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  • Question 1 - You see a 4-year-old child in surgery with his mother. He has been...

    Correct

    • You see a 4-year-old child in surgery with his mother. He has been diagnosed with molluscum contagiosum and she is keen to have him treated.
      Which of the following statements about molluscum contagiosum is true?

      Your Answer: The condition resolves spontaneously

      Explanation:

      Molluscum Contagiosum: Myths and Facts

      Molluscum contagiosum is a common skin infection caused by a poxvirus. However, there are several myths surrounding this condition that need to be debunked. Firstly, it is not true that the condition resolves spontaneously. While most cases do clear up on their own within 6-9 months, some can last up to 4 years. Secondly, molluscum contagiosum is highly infectious and can be transmitted through contact with infected persons or objects, including swimming pools. Sexual transmission is also possible.

      Another myth is that patients can treat themselves by squeezing the spots. This is not recommended as it can lead to scarring. Additionally, molluscum contagiosum is not limited to children. While it does present mainly in young children, there is also a later peak in young adults, some of which is attributable to sexual transmission.

      Finally, piercing the lesions with an orange stick dipped in phenol is not the treatment of choice. In fact, the condition usually requires no treatment and resolves on its own. Treatment may be recommended for adults or older children with particularly unsightly spots or in the immunosuppressed, where it can take several years to resolve. Topical applications such as benzyl peroxide or potassium hydroxide, as well as curettage and cryotherapy, can be used to treat the condition.

      In conclusion, it is important to separate fact from fiction when it comes to molluscum contagiosum. While it is a common and often harmless condition, it is important to seek medical advice if you have concerns or if the spots are causing discomfort or affecting your quality of life.

    • This question is part of the following fields:

      • Dermatology
      25.9
      Seconds
  • Question 2 - A 29-year-old female of Afro-Caribbean descent visits the oncology clinic after being referred...

    Incorrect

    • A 29-year-old female of Afro-Caribbean descent visits the oncology clinic after being referred by her primary care physician. She has observed some painless, asymmetrical lymphadenopathy lumps on her neck. She reports experiencing more night sweats lately and has noticed some discomfort when consuming alcohol.
      What characteristic is linked to a negative prognosis for the most probable diagnosis?

      Your Answer: Asymmetrical lymphadenopathy

      Correct Answer: Night sweats

      Explanation:

      Experiencing fever above 38ºC and night sweats in the past 6 months is linked to a poor prognosis if at least one of these ‘B’ symptoms is present. While acute lymphoblastic leukemia has a worse prognosis in individuals of Afro-Caribbean descent, Hodgkin’s lymphoma does not typically present with bone marrow failure and is more common in children. Alcohol-induced pain may be present in some cases of Hodgkin’s lymphoma, but it does not indicate a poor prognosis. While female sex is not linked to a poor prognosis, some studies suggest that males may have a worse outcome. Asymmetrical lymphadenopathy is a characteristic of Hodgkin’s lymphoma but has not been associated with a worse prognosis.

      Understanding Hodgkin’s Lymphoma: Histological Classification and Prognosis

      Hodgkin’s lymphoma is a type of cancer that affects the lymphocytes and is characterized by the presence of Reed-Sternberg cells. It is most commonly seen in individuals in their third and seventh decades of life. The histological classification of Hodgkin’s lymphoma is based on the type of cells present and their frequency. The most common type is nodular sclerosing, which is more common in women and has a good prognosis. Mixed cellularity is the second most common type and is associated with a large number of Reed-Sternberg cells. Lymphocyte predominant is a rare type with the best prognosis, while lymphocyte depleted is the rarest and has the worst prognosis.

      In addition to the histological classification, there are other factors that can affect the prognosis of Hodgkin’s lymphoma. The presence of B symptoms, such as weight loss, fever, and night sweats, is associated with a poor prognosis. Other factors identified in a 1998 NEJM paper include age over 45 years, stage IV disease, low hemoglobin levels, low lymphocyte count, male gender, low albumin levels, and high white blood cell count. Understanding the histological classification and prognosis of Hodgkin’s lymphoma can help guide treatment decisions and improve outcomes for patients.

    • This question is part of the following fields:

      • Haematology/Oncology
      19.9
      Seconds
  • Question 3 - A primigravid 44 year-old woman, who is at 28 weeks gestation, arrives at...

    Incorrect

    • A primigravid 44 year-old woman, who is at 28 weeks gestation, arrives at the maternity unit with regular weak contractions. Upon examination, her cervix is found to be 3 cm dilated and her membranes are intact. What is the most suitable course of action?

      Your Answer: Admit and administer syntocinon

      Correct Answer: Admit and administer tocolytics and steroids

      Explanation:

      At present, the woman is experiencing premature labour, but it is still in its early stages as she is only 3 cm dilated. As a result, tocolytic medication may be used to halt the labour. However, if the labour persists and delivery becomes necessary, steroids will be administered beforehand to aid in the development of the foetal lungs. Antibiotics are unnecessary since there is no evidence of an infection. The Syntocinon injection contains oxytocin, which increases the strength of uterine contractions.

      Risks Associated with Prematurity

      Prematurity is a condition that poses several risks to the health of newborns. The risk of mortality increases with decreasing gestational age. Premature babies are at risk of developing respiratory distress syndrome, intraventricular haemorrhage, necrotizing enterocolitis, chronic lung disease, hypothermia, feeding problems, infection, jaundice, and retinopathy of prematurity. Retinopathy of prematurity is a significant cause of visual impairment in babies born before 32 weeks of gestation. The cause of this condition is not fully understood, but it is believed that over oxygenation during ventilation can lead to the proliferation of retinal blood vessels, resulting in neovascularization. Screening for retinopathy of prematurity is done in at-risk groups. Premature babies are also at risk of hearing problems.

    • This question is part of the following fields:

      • Reproductive Medicine
      23.5
      Seconds
  • Question 4 - Which one of the following statements regarding pancreatic cancer is true? ...

    Correct

    • Which one of the following statements regarding pancreatic cancer is true?

      Your Answer: High-resolution CT scanning is the diagnostic investigation of choice

      Explanation:

      Pancreatic cancer is best diagnosed through high-resolution CT scanning. Although chronic pancreatitis increases the risk, neither alcohol nor gallstone disease are significant independent risk factors. Radiotherapy is not effective for surgical resection. Unfortunately, most patients are diagnosed with unresectable lesions.

      Understanding Pancreatic Cancer: Risk Factors, Symptoms, and Management

      Pancreatic cancer is a type of cancer that is often diagnosed late due to its non-specific symptoms. Adenocarcinomas, which occur at the head of the pancreas, make up over 80% of pancreatic tumors. Risk factors for pancreatic cancer include increasing age, smoking, diabetes, chronic pancreatitis, hereditary non-polyposis colorectal carcinoma, and genetic mutations such as BRCA2 and KRAS.

      Symptoms of pancreatic cancer can include painless jaundice, pale stools, dark urine, pruritus, anorexia, weight loss, epigastric pain, loss of exocrine and endocrine function, and atypical back pain. Migratory thrombophlebitis, also known as Trousseau sign, is more common in pancreatic cancer than in other cancers.

      Diagnosis of pancreatic cancer can be made through ultrasound or high-resolution CT scanning, which may show the double duct sign – simultaneous dilatation of the common bile and pancreatic ducts. However, less than 20% of patients are suitable for surgery at diagnosis. A Whipple’s resection, or pancreaticoduodenectomy, may be performed for resectable lesions in the head of the pancreas. Adjuvant chemotherapy is usually given following surgery, and ERCP with stenting may be used for palliation.

      In summary, pancreatic cancer is a serious disease with non-specific symptoms that can be difficult to diagnose. Understanding the risk factors and symptoms can help with early detection and management.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      9.8
      Seconds
  • Question 5 - A 25-year-old woman is seen by her general practitioner. She has lost 8...

    Correct

    • A 25-year-old woman is seen by her general practitioner. She has lost 8 kg in weight; her previous weight was 70 kg, and she now weighs 60 kg. She has a fear of gaining weight, but no further symptoms are elicited. On examination, she appears underweight and her skin looks dry; there is evidence of thin, soft, unpigmented hair on her back; her blood pressure is 110/70 mmHg, and her heart rate is 65 bpm.
      What is your preferred diagnosis?

      Your Answer: Anorexia nervosa

      Explanation:

      Differentiating Anorexia Nervosa from Other Mental Disorders

      Anorexia nervosa (AN) is a mental disorder characterized by deliberate weight loss induced and sustained by the patient. In this scenario, a woman presents with a fear of gaining weight and has lost more than 15% of her body weight, suggesting a diagnosis of AN. Other physical symptoms such as dry skin, lanugo hair, hypotension, and bradycardia help confirm the diagnosis. However, a more detailed history, a full assessment of her mental state, and clinical investigations are necessary to confirm the diagnosis and inform management.

      While weight loss can also be present in other mental disorders such as generalized anxiety disorder (GAD), depression, schizophrenia, and bulimia nervosa (BN), they are not accompanied by a fear of gaining weight. Patients with GAD experience persistent anxiety that affects several aspects of their lives, while depression is characterized by a persistent feeling of sadness and hopelessness. Schizophrenia involves self-neglect and/or delusional beliefs around food, while BN is characterized by episodes of binge eating followed by purging behaviors.

      It is worth noting that eating disorders have the highest mortality among all mental disorders, with AN being no exception. The excess mortality is explained by the associated physical complications and increased risk of suicide. Psychological interventions are the mainstay of treatment for all eating disorders, but antidepressants have a role in some types (e.g., BN), and a multidisciplinary approach is recommended in any case.

    • This question is part of the following fields:

      • Psychiatry
      10.8
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  • Question 6 - A 67-year-old woman presents with blistering lesions on her leg and is suspected...

    Incorrect

    • A 67-year-old woman presents with blistering lesions on her leg and is suspected to have bullous pemphigoid. What would be the most suitable course of action for management?

      Your Answer: Trial of topical corticosteroids and review in 2 weeks

      Correct Answer: Refer to secondary care

      Explanation:

      Understanding Bullous Pemphigoid

      Bullous pemphigoid is an autoimmune disease that causes blistering of the skin due to the development of antibodies against hemidesmosomal proteins BP180 and BP230. This condition is more common in elderly patients and is characterized by itchy, tense blisters that typically appear around flexures. However, the blisters usually heal without scarring, and there is usually no mucosal involvement.

      To diagnose bullous pemphigoid, a skin biopsy is necessary, and immunofluorescence shows IgG and C3 at the dermoepidermal junction. Treatment for this condition involves referral to a dermatologist for biopsy and confirmation of diagnosis, as well as the use of oral corticosteroids as the mainstay of treatment. Topical corticosteroids, immunosuppressants, and antibiotics may also be used.

      It is worth noting that while mucosal involvement is seen in some patients, it is not a classic feature of bullous pemphigoid and is therefore not always mentioned in exam questions. Overall, understanding the symptoms, diagnosis, and treatment of bullous pemphigoid is crucial for healthcare professionals to provide appropriate care for patients with this condition.

    • This question is part of the following fields:

      • Dermatology
      11.2
      Seconds
  • Question 7 - A 42-year-old patient with ankylosing spondylitis complains of sudden pain in the right...

    Incorrect

    • A 42-year-old patient with ankylosing spondylitis complains of sudden pain in the right eye and blurry vision. During examination, you observe redness around the cornea and a constricted pupil. Ophthalmoscopy reveals difficulty in visualizing the retina due to the patient's intolerance to bright light, but you do notice a fluid level at the front of the eye. What is the probable diagnosis?

      Your Answer: Scleritis

      Correct Answer: Anterior uveitis

      Explanation:

      Anterior uveitis, also known as iritis, is a type of inflammation that affects the iris and ciliary body in the front part of the uvea. It is a common cause of red eye and is associated with HLA-B27, which may also be linked to other conditions. Symptoms of anterior uveitis include sudden onset of eye discomfort and pain, small or irregular pupils, intense sensitivity to light, blurred vision, redness, tearing, and the presence of pus and inflammatory cells in the front part of the eye. This condition may be associated with ankylosing spondylitis, reactive arthritis, ulcerative colitis, Crohn’s disease, Behcet’s disease, and sarcoidosis. Urgent review by an ophthalmologist is necessary, and treatment may involve the use of cycloplegics and steroid eye drops.

    • This question is part of the following fields:

      • Ophthalmology
      19.9
      Seconds
  • Question 8 - A 30-year-old female arrives at the Emergency Department after intentionally overdosing on paracetamol....

    Correct

    • A 30-year-old female arrives at the Emergency Department after intentionally overdosing on paracetamol. What is the most significant indicator of an ongoing high risk of suicide?

      Your Answer: Made efforts to avoid herself being found by friends and family

      Explanation:

      Although deliberate self-harm is more prevalent among females, completed suicide is more prevalent among males.

      Suicide Risk Factors and Protective Factors

      Suicide risk assessment is a common practice in psychiatric care, with patients being stratified into high, medium, or low risk categories. However, there is a lack of evidence on the positive predictive value of individual risk factors. A review in the BMJ concluded that such assessments may not be useful in guiding decision-making, as 50% of suicides occur in patients deemed low risk. Nevertheless, certain factors have been associated with an increased risk of suicide, including male sex, history of deliberate self-harm, alcohol or drug misuse, mental illness, depression, schizophrenia, chronic disease, advancing age, unemployment or social isolation, and being unmarried, divorced, or widowed.

      If a patient has attempted suicide, there are additional risk factors to consider, such as efforts to avoid discovery, planning, leaving a written note, final acts such as sorting out finances, and using a violent method. On the other hand, there are protective factors that can reduce the risk of suicide, such as family support, having children at home, and religious belief. It is important to consider both risk and protective factors when assessing suicide risk and developing a treatment plan.

    • This question is part of the following fields:

      • Psychiatry
      22
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  • Question 9 - A 36-year-old patient arrives at the emergency department experiencing confusion and vomiting. Upon...

    Correct

    • A 36-year-old patient arrives at the emergency department experiencing confusion and vomiting. Upon further inquiry, she reports six months of weight loss, fatigue, and dizziness upon standing. Blood tests reveal the following results: Na+ 126 mmol/L (135 - 145), K+ 5.6 mmol/L (3.5 - 5.0), Urea 6.8 mmol/L (2.0 - 7.0), and Creatinine 95 µmol/L (55 - 120). After stabilization, she undergoes additional testing and is prescribed a daily maintenance regimen of 20 mg hydrocortisone and 100mcg fludrocortisone. In the event of an acute illness, such as an infection, what dosage of medication should she take?

      Your Answer: 40mg hydrocortisone, 100mcg fludrocortisone

      Explanation:

      To manage this patient with Addison’s disease who is experiencing an intercurrent illness, it is recommended to increase the glucocorticoid dose by double while keeping the fludrocortisone dose the same. The patient’s symptoms, including vomiting, confusion, fatigue, weight loss, and postural hypotension, suggest adrenal insufficiency. Blood tests reveal hyponatremia and hyperkalemia due to aldosterone deficiency. Aldosterone normally regulates sodium and potassium levels in the body, and its absence leads to sodium loss and potassium elevation. The prescribed steroid replacement regimen is appropriate for intercurrent illness, as it mimics the body’s natural response by increasing glucocorticoid secretion while maintaining mineralocorticoid secretion. The patient’s hydrocortisone dose has been doubled from 20mg to 40mg, while the fludrocortisone dose remains at 100mcg.

      Addison’s disease is a condition that requires patients to undergo both glucocorticoid and mineralocorticoid replacement therapy. This treatment usually involves taking a combination of hydrocortisone and fludrocortisone. Hydrocortisone is typically given in 2 or 3 divided doses, with patients requiring 20-30 mg per day, mostly in the first half of the day. Patient education is crucial, and it is essential to emphasize the importance of not missing glucocorticoid doses. Additionally, patients should consider wearing MedicAlert bracelets and steroid cards, and they should be provided with hydrocortisone for injection with needles and syringes to treat an adrenal crisis.

      During an intercurrent illness, it is crucial to manage the glucocorticoid dose properly. In simple terms, the glucocorticoid dose should be doubled, while the fludrocortisone dose should remain the same. The Addison’s Clinical Advisory Panel has produced guidelines that detail specific scenarios, and patients should refer to these guidelines for more information. It is essential to discuss how to adjust the glucocorticoid dose during an intercurrent illness with a healthcare professional. Proper management of Addison’s disease is crucial to ensure that patients can lead healthy and fulfilling lives.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      24
      Seconds
  • Question 10 - A 40-year-old woman undergoing treatment for rheumatoid arthritis complains of nephrotic syndrome.
    Which...

    Incorrect

    • A 40-year-old woman undergoing treatment for rheumatoid arthritis complains of nephrotic syndrome.
      Which medication is the probable cause of this issue?

      Your Answer: Methotrexate

      Correct Answer: Penicillamine

      Explanation:

      Overview of Medications Used in the Treatment of Rheumatoid Arthritis

      Rheumatoid arthritis is a chronic autoimmune disease that affects the joints and can lead to disability. There are several medications used in the management of this condition, each with their own benefits and potential side effects.

      Penicillamine is a drug commonly used in the treatment of rheumatoid arthritis, but it can also cause secondary membranous nephropathy, a condition characterized by proteinuria. Hydroxychloroquine is another medication that can be used for active rheumatoid arthritis, but its main complication is ocular toxicity. Sulfasalazine is primarily used for ulcerative colitis, but can also be used for rheumatoid arthritis under expert advice. Cyclophosphamide is rarely used for rheumatoid arthritis and is associated with the rare but serious complication of haemorrhagic cystitis. Methotrexate is a commonly used medication for severe Crohn’s disease and moderate to severe rheumatoid arthritis, but its main complication is bone marrow suppression.

      It is important for patients to work closely with their healthcare providers to determine the most appropriate medication for their individual needs and to monitor for potential side effects.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      13.1
      Seconds
  • Question 11 - A 35-year-old woman with a history of gallstones is scheduled for a laparoscopic...

    Incorrect

    • A 35-year-old woman with a history of gallstones is scheduled for a laparoscopic cholecystectomy in two months. She is currently taking Microgynon 30 (combined oral contraceptive pill) and is concerned about the increased risk of blood clots. What advice should be given to the patient in this scenario?

      Your Answer: She should stop Microgynon 7 days before the procedure

      Correct Answer: She should stop Microgynon 28 days before the procedure

      Explanation:

      Venous thromboembolism (VTE) is a serious condition that can lead to severe health complications and even death. However, it is preventable. The National Institute for Health and Care Excellence (NICE) has updated its guidelines for 2018 to provide recommendations for the assessment and management of patients at risk of VTE in hospital. All patients admitted to the hospital should be assessed individually to identify risk factors for VTE development and bleeding risk. The department of health’s VTE risk assessment tool is recommended for medical and surgical patients. Patients with certain risk factors, such as reduced mobility, surgery, cancer, and comorbidities, are at increased risk of developing VTE. After assessing a patient’s VTE risk, healthcare professionals should compare it to their risk of bleeding to decide whether VTE prophylaxis should be offered. If indicated, VTE prophylaxis should be started as soon as possible.

      There are two types of VTE prophylaxis: mechanical and pharmacological. Mechanical prophylaxis includes anti-embolism stockings and intermittent pneumatic compression devices. Pharmacological prophylaxis includes fondaparinux sodium, low molecular weight heparin (LMWH), and unfractionated heparin (UFH). The choice of prophylaxis depends on the patient’s individual risk factors and bleeding risk.

      In general, medical patients deemed at risk of VTE after individual assessment are started on pharmacological VTE prophylaxis, provided that the risk of VTE outweighs the risk of bleeding and there are no contraindications. Surgical patients at low risk of VTE are treated with anti-embolism stockings, while those at high risk are treated with a combination of stockings and pharmacological prophylaxis.

      Patients undergoing certain surgical procedures, such as hip and knee replacements, are recommended to receive pharmacological VTE prophylaxis to reduce the risk of VTE developing post-surgery. For fragility fractures of the pelvis, hip, and proximal femur, LMWH or fondaparinux sodium is recommended for a month if the risk of VTE outweighs the risk of bleeding.

      Healthcare professionals should advise patients to stop taking their combined oral contraceptive pill or hormone replacement therapy four weeks before surgery and mobilize them as soon as possible after surgery. Patients should also ensure they are hydrated. By following these guidelines, healthcare professionals can help prevent VTE and improve patient outcomes.

    • This question is part of the following fields:

      • Reproductive Medicine
      34
      Seconds
  • Question 12 - A 60-year-old man comes in with complaints of nocturia, hesitancy, and terminal dribbling....

    Incorrect

    • A 60-year-old man comes in with complaints of nocturia, hesitancy, and terminal dribbling. During prostate examination, a moderately enlarged prostate with no irregular features and a well-defined median sulcus is found. Blood tests reveal a PSA level of 1.3 ng/ml.

      What is the best course of action for management?

      Your Answer: Urgent referral to urology

      Correct Answer: Alpha-1 antagonist

      Explanation:

      First-line treatment for benign prostatic hyperplasia involves the use of alpha-1 antagonists.

      Benign prostatic hyperplasia (BPH) is a common condition that affects older men, with around 50% of 50-year-old men showing evidence of BPH and 30% experiencing symptoms. The risk of BPH increases with age, with around 80% of 80-year-old men having evidence of the condition. BPH typically presents with lower urinary tract symptoms (LUTS), which can be categorised into voiding symptoms (obstructive) and storage symptoms (irritative). Complications of BPH can include urinary tract infections, retention, and obstructive uropathy.

      Assessment of BPH may involve dipstick urine tests, U&Es, and PSA tests. A urinary frequency-volume chart and the International Prostate Symptom Score (IPSS) can also be used to assess the severity of LUTS and their impact on quality of life. Management options for BPH include watchful waiting, alpha-1 antagonists, 5 alpha-reductase inhibitors, combination therapy, and surgery. Alpha-1 antagonists are considered first-line treatment for moderate-to-severe voiding symptoms, while 5 alpha-reductase inhibitors may be indicated for patients with significantly enlarged prostates and a high risk of progression. Combination therapy and antimuscarinic drugs may also be used in certain cases. Surgery, such as transurethral resection of the prostate (TURP), may be necessary in severe cases.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      15.6
      Seconds
  • Question 13 - A 82-year-old man comes to the clinic complaining of sudden loss of vision...

    Correct

    • A 82-year-old man comes to the clinic complaining of sudden loss of vision in his left eye since this morning. He denies any associated eye pain or headaches and is otherwise feeling well. His medical history includes ischaemic heart disease. Upon examination, the patient has no vision in his left eye. The left pupil shows poor response to light, but the consensual light reaction is normal. Fundoscopy reveals a red spot over a pale and opaque retina. What is the most probable diagnosis?

      Your Answer: Central retinal artery occlusion

      Explanation:

      Central Retinal Artery Occlusion: A Rare Cause of Sudden Vision Loss

      Central retinal artery occlusion is a rare condition that can cause sudden, painless loss of vision in one eye. It is typically caused by a blood clot or inflammation in the artery that supplies blood to the retina. This can be due to atherosclerosis or arteritis, such as temporal arteritis. Symptoms may include a relative afferent pupillary defect and a cherry red spot on a pale retina. Unfortunately, the prognosis for this condition is poor, and management can be difficult. Treatment may involve identifying and addressing any underlying conditions, such as intravenous steroids for temporal arteritis. In some cases, intraarterial thrombolysis may be attempted, but the results of this treatment are mixed. Overall, central retinal artery occlusion is a serious condition that requires prompt medical attention.

    • This question is part of the following fields:

      • Ophthalmology
      17.9
      Seconds
  • Question 14 - A 45-year-old teacher who was previously healthy was discovered unconscious on the ground....

    Correct

    • A 45-year-old teacher who was previously healthy was discovered unconscious on the ground. Upon admission, assessment showed weakness on the right side of their body, with their leg more affected than their arm and face, and significant difficulty with speech. What is the most probable diagnosis?

      Your Answer: An occlusion of the left middle cerebral artery (MCA)

      Explanation:

      A blockage in the left middle cerebral artery (MCA) is a common cause of cerebral infarction. The symptoms experienced will depend on the extent of the infarct and which hemisphere of the brain is dominant. In right-handed individuals, over 95% have left-sided dominance. Symptoms may include weakness on the opposite side of the body, particularly in the face and arm, as well as sensory loss and homonymous hemianopia. If the left MCA is affected, the patient may experience expressive dysphasia in the anterior MCA territory (Broca’s area) if it is their dominant side, or neglect if it is their non-dominant side. A tumour in the left cerebral hemisphere or thalamus would have a more gradual onset of symptoms, while an occlusion of the right anterior cerebral artery would produce left-sided weakness. The region affected and presentation of each type of artery involvement is summarized in a table.

    • This question is part of the following fields:

      • Neurology
      12.8
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  • Question 15 - A 56-year-old woman with a history of rheumatoid arthritis complains of bloody diarrhoea,...

    Correct

    • A 56-year-old woman with a history of rheumatoid arthritis complains of bloody diarrhoea, accompanied by fever and abdominal pain for the past week. She is on methotrexate for her rheumatoid arthritis, which is usually well-controlled. Upon testing her stool sample, Campylobacter jejuni is detected. What is the best course of action for treatment?

      Your Answer: Fluids + clarithromycin

      Explanation:

      Campylobacter: The Most Common Bacterial Cause of Intestinal Disease in the UK

      Campylobacter is a Gram-negative bacillus that is responsible for causing infectious intestinal disease in the UK. The bacteria is primarily spread through the faecal-oral route and has an incubation period of 1-6 days. Symptoms of Campylobacter infection include a prodrome of headache and malaise, diarrhoea (often bloody), and abdominal pain that may mimic appendicitis.

      In most cases, Campylobacter infection is self-limiting and does not require treatment. However, the British National Formulary (BNF) recommends treatment with antibiotics if the patient is immunocompromised or if symptoms are severe (high fever, bloody diarrhoea, or more than eight stools per day) and have lasted for more than one week. The first-line antibiotic for Campylobacter infection is clarithromycin, although ciprofloxacin is an alternative. It is important to note that strains with decreased sensitivity to ciprofloxacin are frequently isolated.

      Complications of Campylobacter infection may include Guillain-Barre syndrome, reactive arthritis, septicaemia, endocarditis, and arthritis. It is important to seek medical attention if symptoms are severe or persist for an extended period of time.

    • This question is part of the following fields:

      • Infectious Diseases
      23.2
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  • Question 16 - A 52-year-old man has recently been diagnosed with type 2 diabetes mellitus. He...

    Correct

    • A 52-year-old man has recently been diagnosed with type 2 diabetes mellitus. He was prescribed medication but a few days later he complained of stomach cramps and loose stools.
      Which of the following medications is most likely responsible for these symptoms?

      Your Answer: Metformin

      Explanation:

      Side Effects of Common Oral Diabetic Medications

      Managing diabetes often involves the use of oral medications to help control blood sugar levels. However, these medications can come with side effects that need to be considered when choosing a treatment plan. Here are some common side effects of four oral diabetic medications:

      Metformin: The most common side effects of metformin are abdominal pain, anorexia, diarrhea, nausea, taste disturbance, and vomiting. There is also a risk of developing lactic acidosis, particularly in patients with a history of heart failure and concomitant use of drugs that can acutely impair renal function.

      Furosemide: Furosemide is a less likely option due to its potential to exacerbate diabetes and cause hypokalemia, which can be dangerous in certain patients. It can also cause urinary retention in patients with enlarged prostates.

      Gliclazide: Gliclazide can encourage weight gain and may cause hypoglycemia if the dosage is excessive.

      Pioglitazone: Pioglitazone should be used with caution in patients with cardiovascular disease or in combination with insulin due to an increased risk of heart failure, particularly in elderly people.

      It is important to be familiar with these side effects to ensure patient compliance with medication and to choose the most appropriate treatment plan for each individual.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      33.9
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  • Question 17 - A 60-year-old man presents to his GP with a three month history of...

    Correct

    • A 60-year-old man presents to his GP with a three month history of intermittent pain and numbness in his fourth and fifth fingers.
      Which of the following is the most likely cause of his symptoms?

      Your Answer: Ulnar nerve entrapment

      Explanation:

      Common Hand and Wrist Conditions: Symptoms and Characteristics

      Ulnar Nerve Entrapment
      Ulnar neuropathy is a common condition where the ulnar nerve is compressed at or near the elbow. Patients experience numbness and tingling in the fifth finger and ulnar half of the fourth finger, along with weakness of grip and potential muscle wasting. In severe cases, a claw hand deformity may occur.

      De Quervain’s Tenosynovitis
      Also known as mother’s wrist, this condition is caused by tendinitis in the tendons of the first dorsal compartment of the wrist. Patients experience pain during thumb and wrist movement, along with tenderness and thickening at the radial styloid. Finkelstein’s test causes sharp pain at the first dorsal compartment, and a prominent radial styloid may be visible. There is no associated sensory loss.

      Carpal Tunnel Syndrome
      This condition occurs when the median nerve is compressed as it passes through the carpal tunnel at the wrist. Symptoms include numbness and tingling in the thumb and radial fingers, aching and pain in the anterior wrist and forearm, and potential weakness and clumsiness in the hand. Risk factors include female sex, pregnancy, hypothyroidism, connective tissue disease, obesity, trauma, dialysis, and repetitive stress.

      Dupuytren’s Contracture
      This progressive fibrous tissue contracture of the palmar fascia mainly affects men over 40 with a family history. Patients experience difficulty with manual dexterity, palmar nodules, and eventually flexion contractures in the fourth and fifth fingers. There is no sensory deficit. Risk factors include smoking, alcohol, heavy manual labor, trauma, and diabetes.

      Radial Nerve Palsy
      Radial nerve palsy results in wrist drop and loss of triceps reflex, along with potential sensory loss in the dorsal thumb and forearm. The radial nerve does not supply sensory innervation to the fourth and fifth fingers.

    • This question is part of the following fields:

      • Neurology
      11.7
      Seconds
  • Question 18 - A 56-year-old man with a history of type 2 diabetes mellitus complains of...

    Correct

    • A 56-year-old man with a history of type 2 diabetes mellitus complains of right shoulder pain and limited movement in all directions. What is the probable diagnosis?

      Your Answer: Adhesive capsulitis

      Explanation:

      The development of adhesive capsulitis is more likely in individuals with diabetes mellitus.

      Understanding Adhesive Capsulitis (Frozen Shoulder)

      Adhesive capsulitis, commonly known as frozen shoulder, is a prevalent cause of shoulder pain that primarily affects middle-aged women. The exact cause of this condition is not yet fully understood. However, studies have shown that up to 20% of diabetics may experience an episode of frozen shoulder. Symptoms typically develop over several days, with external rotation being more affected than internal rotation or abduction. Both active and passive movement are affected, and patients usually experience a painful freezing phase, an adhesive phase, and a recovery phase. In some cases, the condition may affect both shoulders, which occurs in up to 20% of patients. The episode typically lasts between 6 months and 2 years.

      Diagnosis of adhesive capsulitis is usually clinical, although imaging may be necessary for atypical or persistent symptoms. Unfortunately, no single intervention has been proven to improve the outcome in the long-term. However, there are several treatment options available, including nonsteroidal anti-inflammatory drugs (NSAIDs), physiotherapy, oral corticosteroids, and intra-articular corticosteroids.

    • This question is part of the following fields:

      • Musculoskeletal
      5.1
      Seconds
  • Question 19 - A 25-year-old man comes to you complaining of severe, stabbing pain in his...

    Incorrect

    • A 25-year-old man comes to you complaining of severe, stabbing pain in his right eye that has been occurring once a day for the past few weeks. The pain lasts for about 30 minutes and he is often seen pacing around and shouting during these episodes. His wife reports that his right eye appears red and he has clear nasal discharge during the episodes. Based on this presentation, what advice would you give the patient to prevent further episodes?

      Your Answer: Excessive exercise

      Correct Answer: Alcohol

      Explanation:

      Cluster headaches are often triggered by alcohol, and they typically affect individuals of a certain age and gender.

      Cluster headaches are a type of headache that is known to be extremely painful. They are called cluster headaches because they tend to occur in clusters that last for several weeks, usually once a year. These headaches are more common in men and smokers, and alcohol and sleep patterns may trigger an attack. The pain typically occurs once or twice a day, lasting between 15 minutes to 2 hours. The pain is intense and sharp, usually around one eye, and is accompanied by redness, lacrimation, lid swelling, and nasal stuffiness. Some patients may also experience miosis and ptosis.

      To manage cluster headaches, 100% oxygen or subcutaneous triptan can be used for acute treatment, with response rates of 80% and 75% respectively within 15 minutes. Verapamil is the drug of choice for prophylaxis, and a tapering dose of prednisolone may also be effective. It is recommended to seek specialist advice from a neurologist if a patient develops cluster headaches, especially with respect to neuroimaging. Some neurologists use the term trigeminal autonomic cephalgia to group a number of conditions including cluster headache, paroxysmal hemicrania, and short-lived unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT). Patients with these conditions should be referred for specialist assessment as specific treatment may be required, such as indomethacin for paroxysmal hemicrania.

    • This question is part of the following fields:

      • Ophthalmology
      18.7
      Seconds
  • Question 20 - A 55-year-old woman presents to the hypertension clinic for review. She has a...

    Correct

    • A 55-year-old woman presents to the hypertension clinic for review. She has a past medical history of depression and gout. The patient was initiated on lisinopril for hypertension two months ago, with gradual titration of the dose and monitoring of her urea and electrolytes. During today's visit, she reports a dry cough that has been progressively worsening over the past four weeks. The cough is described as really annoying and is causing sleep disturbance. The patient is a non-smoker, and a chest x-ray performed six weeks ago during an Emergency Department visit was normal. What is the most appropriate course of action regarding her antihypertensive medications?

      Your Answer: Switch her to an angiotensin II receptor blocker

      Explanation:

      A dry cough is a common side effect experienced by patients who begin taking an ACE inhibitor. However, in this case, the patient has been suffering from this symptom for four weeks and it is affecting her sleep. Therefore, it is advisable to switch her to an angiotensin II receptor blocker.

      Angiotensin II receptor blockers are a type of medication that is commonly used when patients cannot tolerate ACE inhibitors due to the development of a cough. Examples of these blockers include candesartan, losartan, and irbesartan. However, caution should be exercised when using them in patients with renovascular disease. Side-effects may include hypotension and hyperkalaemia.

      The mechanism of action for angiotensin II receptor blockers is to block the effects of angiotensin II at the AT1 receptor. These blockers have been shown to reduce the progression of renal disease in patients with diabetic nephropathy. Additionally, there is evidence to suggest that losartan can reduce the mortality rates associated with CVA and IHD in hypertensive patients.

      Overall, angiotensin II receptor blockers are a viable alternative to ACE inhibitors for patients who cannot tolerate the latter. They have a proven track record of reducing the progression of renal disease and improving mortality rates in hypertensive patients. However, as with any medication, caution should be exercised when using them in patients with certain medical conditions.

    • This question is part of the following fields:

      • Respiratory Medicine
      55.9
      Seconds
  • Question 21 - A 40-year-old woman presents to your clinic with concerns about her heavy periods....

    Correct

    • A 40-year-old woman presents to your clinic with concerns about her heavy periods. She has been trying to conceive for the past 10 months without success. She has noticed that her periods have been getting progressively heavier over the past year, and she has experienced episodes of flooding. She initially attributed this to getting older, but now it has become unmanageable. During the examination, you palpate a supra-pubic mass. What is the most probable diagnosis?

      Your Answer: Fibroids

      Explanation:

      The patient’s symptoms of menorrhagia, subfertility, and an abdominal mass strongly suggest the presence of fibroids. While ectopic pregnancy should be ruled out, it is less likely due to the absence of severe pain. Endometriosis and endometrial cancer are also unlikely causes of an abdominal mass. Although ovarian cancer cannot be completely ruled out, it is not the most probable diagnosis. Fibroids are benign tumors that commonly occur in the myometrium. Symptoms include heavy menstrual bleeding, pain (if the fibroid twists), and subfertility. As fibroids grow larger, they can cause additional symptoms such as dysuria, hydronephrosis, constipation, and sciatica. Initial treatment typically involves medications such as tranexamic acid, NSAIDs, or progesterones to manage menorrhagia, but surgery is often necessary for persistent fibroids.

      Understanding Uterine Fibroids

      Uterine fibroids are non-cancerous growths that develop in the uterus. They are more common in black women and are thought to occur in around 20% of white women in their later reproductive years. Fibroids are usually asymptomatic, but they can cause menorrhagia, which can lead to iron-deficiency anaemia. Other symptoms include lower abdominal pain, bloating, and urinary symptoms. Fibroids may also cause subfertility.

      Diagnosis is usually made through transvaginal ultrasound. Asymptomatic fibroids do not require treatment, but periodic monitoring is recommended. Menorrhagia secondary to fibroids can be managed with various treatments, including the levonorgestrel intrauterine system, NSAIDs, tranexamic acid, and hormonal therapies.

      Medical treatment to shrink or remove fibroids may include GnRH agonists or ulipristal acetate, although the latter is not currently recommended due to concerns about liver toxicity. Surgical options include myomectomy, hysteroscopic endometrial ablation, hysterectomy, and uterine artery embolization.

      Fibroids generally regress after menopause, but complications such as subfertility and iron-deficiency anaemia can occur. Red degeneration, which is haemorrhage into the tumour, is a common complication during pregnancy.

    • This question is part of the following fields:

      • Reproductive Medicine
      47.8
      Seconds
  • Question 22 - What is the most accurate description of a characteristic of irritable bowel syndrome...

    Incorrect

    • What is the most accurate description of a characteristic of irritable bowel syndrome (IBS)?

      Your Answer: Weight loss becomes more evident as the disease runs a chronic course

      Correct Answer: A low FODMAP diet is often prescribed for treatment of the syndrome

      Explanation:

      Understanding Irritable Bowel Syndrome: Diagnosis and Management

      Irritable Bowel Syndrome (IBS) is a functional gastrointestinal disorder that presents with abdominal pain, bloating, and altered bowel habits. While there is no specific organic pathology associated with IBS, it can significantly impact a patient’s quality of life. Management of IBS involves providing psychological support and recommending dietary measures such as fibre supplementation, increased water intake, and avoiding trigger foods. A low FODMAP diet, which involves avoiding consumption of garlic, onion, high fructose fruits, wheat, alcohol, and dairy, may also be helpful. Pharmacological treatment is adjunctive and should be directed at symptoms. However, if there are ‘red flag’ symptoms such as bleeding, anemia, chronic diarrhea, older age, history of colon polyps, cancer in the patient or first-degree relatives, or constitutional symptoms such as anorexia or weight loss, lower gastrointestinal endoscopy should be performed. Nocturnal symptoms are not consistent with IBS, and weight loss is a ‘red flag’ symptom that should alert the clinician to the possibility of an organic pathology.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      22.6
      Seconds
  • Question 23 - A 35-year-old man visits the clinic with complaints of decreased hearing and ringing...

    Correct

    • A 35-year-old man visits the clinic with complaints of decreased hearing and ringing in his right ear, which feels congested, and he experiences frequent bouts of vertigo lasting up to a few hours at a time. There are no abnormalities found during the neurological examination.

      What is the most probable diagnosis?

      Your Answer: Ménière’s disease

      Explanation:

      Differentiating Vertigo Conditions: Ménière’s Disease, Benign Paroxysmal Positional Vertigo, Central Vertigo, Labyrinthitis, and Vestibular Neuronitis

      Vertigo is a common symptom that can be caused by various conditions. Ménière’s disease, for instance, is characterized by fluctuant hearing loss, vertigo, tinnitus, and aural fullness. Patients are advised to undergo vestibular rehabilitation and avoid risky activities. Prochlorperazine is recommended for acute attacks, while betahistine is used for preventive treatment. Benign paroxysmal positional vertigo, on the other hand, presents with brief episodes of vertigo triggered by movement, without tinnitus, hearing loss, or ear fullness. Central vertigo has a sudden onset, constant symptoms, and possible neurological abnormalities, requiring urgent hospital admission. Labyrinthitis causes acute vertigo and hearing loss, but the presence of ear fullness suggests Ménière’s disease. Vestibular neuronitis, caused by viral infection, results in isolated and prolonged episodes of vertigo without tinnitus or ear fullness. Accurate diagnosis and appropriate management are crucial in addressing vertigo and its underlying conditions.

    • This question is part of the following fields:

      • ENT
      26
      Seconds
  • Question 24 - A 27-year-old woman arrives at the emergency department complaining of sudden abdominal pain...

    Incorrect

    • A 27-year-old woman arrives at the emergency department complaining of sudden abdominal pain and vaginal bleeding. She had her last period 6 weeks ago and is sexually active without using any hormonal contraception. She has no significant medical history. Upon examination, she has a heart rate of 84 bpm and a blood pressure of 128/78 mmHg. There is tenderness in the left iliac fossa. A pregnancy test confirms that she is pregnant, and further investigations reveal a 40 mm left adnexal mass with no heartbeat. The serum b-hCG level is 6200 IU/L. What is the most appropriate course of action for her management?

      Your Answer: Vaginal misoprostol and monitoring

      Correct Answer: Laparoscopic salpingectomy and monitoring

      Explanation:

      For women with no other risk factors for infertility, salpingectomy is the first-line treatment for ectopic pregnancy requiring surgical management, rather than salpingotomy. In the case of a patient with acute-onset abdominal pain and vaginal bleeding after 6-8 weeks following her last period, a positive pregnancy test, and ultrasound findings confirming an ectopic pregnancy, laparoscopic salpingectomy and monitoring is the correct course of action. This is especially true if the size of the ectopic pregnancy is greater than 35 mm and the beta-hCG levels are higher than 5000 IU/L. Salpingotomy may require further treatment with methotrexate and may not remove the ectopic pregnancy entirely, making salpingectomy the preferred method. Expectant management and monitoring, laparoscopic salpingotomy and monitoring, and methotrexate and monitoring are all inappropriate for this patient’s case.

      Ectopic pregnancy is a serious condition that requires prompt investigation and management. Women who are stable are typically investigated and managed in an early pregnancy assessment unit, while those who are unstable should be referred to the emergency department. The investigation of choice for ectopic pregnancy is a transvaginal ultrasound, which will confirm the presence of a positive pregnancy test.

      There are three ways to manage ectopic pregnancies: expectant management, medical management, and surgical management. The choice of management will depend on various criteria, such as the size of the ectopic pregnancy, whether it is ruptured or not, and the patient’s symptoms and hCG levels. Expectant management involves closely monitoring the patient over 48 hours, while medical management involves giving the patient methotrexate and requires follow-up. Surgical management can involve salpingectomy or salpingotomy, depending on the patient’s risk factors for infertility.

      Salpingectomy is the first-line treatment for women with no other risk factors for infertility, while salpingotomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingotomy require further treatment, such as methotrexate and/or a salpingectomy. It is important to carefully consider the patient’s individual circumstances and make a decision that will provide the best possible outcome.

    • This question is part of the following fields:

      • Reproductive Medicine
      24.1
      Seconds
  • Question 25 - What is a true statement about trigeminal neuralgia? Choose one option from the...

    Incorrect

    • What is a true statement about trigeminal neuralgia? Choose one option from the list provided.

      Your Answer: Trigeminal neuralgia is usually bilateral

      Correct Answer: Carbamazepine is the first-line treatment

      Explanation:

      Trigeminal Neuralgia: Diagnosis and Treatment

      Trigeminal neuralgia is a condition characterized by sharp, shooting pain in the distribution of one or more branches of the trigeminal nerve. While the cause is unknown, it can be due to compression of the nerve as it exits the foramen. The pain is intermittent and often exacerbated by light touch, eating, talking, or exposure to the cold.

      Carbamazepine is the first-line treatment for trigeminal neuralgia, with an initial dose of 100 mg up to twice daily. The dosage can be increased in increments of 100-200 mg every 2 weeks until the pain is under control.

      Contrary to popular belief, trigeminal neuralgia usually affects the face unilaterally, with only 3% of cases being bilateral. A CT scan of the head is not recommended for all patients with the diagnosis of trigeminal neuralgia, but may be necessary if red flag symptoms are present.

      It is important to note that patients with trigeminal neuralgia do not typically experience constant pain, as the pain is episodic in frequency. Tramadol is not the first-line treatment for trigeminal pain, carbamazepine is.

    • This question is part of the following fields:

      • Neurology
      27.4
      Seconds
  • Question 26 - A 35-year-old man presents to his General Practitioner (GP) with concerns about a...

    Correct

    • A 35-year-old man presents to his General Practitioner (GP) with concerns about a mole on his leg. He has noticed over the past few months that it has increased in size. On examination, the mole is 7 mm in diameter and has an irregular border but is a consistent colour.
      What is the most appropriate management option for this patient?

      Your Answer: 2-week wait referral to dermatology

      Explanation:

      Understanding Referral Guidelines for Suspicious Pigmented Lesions

      When assessing pigmented lesions, the National Institute of Health and Care Excellence (NICE) recommends using the 7-point scoring system.
      The 7-point checklist includes:
      Major features (2 points each):
      change in size
      irregular shape or border
      irregular colour.
      Minor features (1 point each):
      > 7 mm at greatest diameter
      inflammation
      oozing or crusting
      change in sensation including itch.

      Lesions scoring 3 or more or with other suspicious features of melanoma should be referred urgently via the cancer fast-track pathway to dermatology.

      For lesions with a low suspicion of melanoma, a photo should be taken with a ruler and the patient advised to return in eight weeks for review. However, lesions scoring 5 on the checklist, like those with a change in size, irregular shape or border, and irregular color, should be referred urgently to a dermatologist to avoid any delay in diagnosis and subsequent treatment.

      Excision of lesions suspicious of melanoma should be avoided in primary care as this can delay treatment, and incomplete excision is more common. Routine referral to dermatology would be suitable for a pigmented lesion which scores less than 3 on the 7-point checklist if there are no other features to suggest melanoma. Referral to genetics is recommended if three or more family members have been diagnosed with melanoma.

      It is important to understand these referral guidelines to ensure timely and appropriate management of suspicious pigmented lesions.

    • This question is part of the following fields:

      • Dermatology
      45.6
      Seconds
  • Question 27 - A 50-year-old woman presents with complaints of hot flashes that occur randomly and...

    Incorrect

    • A 50-year-old woman presents with complaints of hot flashes that occur randomly and are affecting her work as a lawyer, especially during court sessions. She is hesitant to try hormone replacement therapy due to its side effects and is seeking alternative options. What medication can be prescribed to alleviate her symptoms?

      Your Answer: Folic acid

      Correct Answer: Fluoxetine

      Explanation:

      According to NICE guidelines, women experiencing vasomotor symptoms during menopause can be prescribed fluoxetine, a selective serotonin uptake inhibitor (SSRI). While clonidine is also approved for treating these symptoms, its effectiveness is not well-established and it can cause side effects such as dry mouth, sedation, depression, and fluid retention. Gabapentin is being studied for its potential to reduce hot flushes, but more research is needed.

      Managing Menopause: Lifestyle Modifications, Hormone Replacement Therapy, and Non-Hormone Replacement Therapy

      Menopause is a natural biological process that marks the end of a woman’s reproductive years. It is diagnosed when a woman has not had a period for 12 consecutive months. Menopausal symptoms are common and can last for up to 7 years, with varying degrees of severity and duration. The management of menopause can be divided into three categories: lifestyle modifications, hormone replacement therapy (HRT), and non-hormone replacement therapy.

      Lifestyle modifications can help manage menopausal symptoms such as hot flushes, sleep disturbance, mood changes, and cognitive symptoms. Regular exercise, weight loss, stress reduction, and good sleep hygiene are recommended. For women who cannot or do not want to take HRT, non-hormonal treatments such as fluoxetine, citalopram, or venlafaxine for vasomotor symptoms, vaginal lubricants or moisturizers for vaginal dryness, and cognitive behavior therapy or antidepressants for psychological symptoms can be prescribed.

      HRT is a treatment option for women with moderate to severe menopausal symptoms. However, it is contraindicated in women with current or past breast cancer, any estrogen-sensitive cancer, undiagnosed vaginal bleeding, or untreated endometrial hyperplasia. HRT brings certain risks, including venous thromboembolism, stroke, coronary heart disease, breast cancer, and ovarian cancer. Women should be advised of these risks and the fact that symptoms typically last for 2-5 years.

      When stopping HRT, it is important to gradually reduce the dosage to limit recurrence of symptoms in the short term. However, in the long term, there is no difference in symptom control. Women who experience ineffective treatment, ongoing side effects, or unexplained bleeding should be referred to secondary care. Overall, managing menopause requires a personalized approach that takes into account a woman’s medical history, preferences, and individual symptoms.

    • This question is part of the following fields:

      • Reproductive Medicine
      17.9
      Seconds
  • Question 28 - A 58-year-old man is recuperating on the ward after an emergency laparotomy and...

    Correct

    • A 58-year-old man is recuperating on the ward after an emergency laparotomy and ileocolic resection for Crohn's disease. The nursing staff has raised concerns about his abdominal wound on the fifth day post-operation. Upon review, you observe a clear wound dehiscence in the central area of his laparotomy incision, with a small portion of the bowel visible.

      What are the initial steps that should be taken in this situation?

      Your Answer: Cover the wound with sterile saline-soaked gauze and administer antibiotics while awaiting a senior review

      Explanation:

      When an abdominal wound reopens after surgery, it is called wound dehiscence. This can happen for various reasons, including infection, poor surgical technique, and malnutrition. As a junior doctor, it is important to know how to manage this emergency situation. The initial steps involve administering broad-spectrum antibiotics intravenously, covering the wound with sterile gauze soaked in sterile saline to prevent the abdominal contents from drying out, and arranging for the patient to undergo wound repair in the operating theatre. It is not advisable to attempt to close the wound on the ward, as this can be unsafe and increase the risk of infection or bowel injury. A nasogastric tube is not necessary, and simply redressing the wound without moist gauze can lead to fluid loss from the abdominal contents. It is also not necessary to arrange a CT scan, as the problem is evident and requires immediate management. While antibiotics and surgery are necessary, leaving the wound open and uncovered can lead to fluid loss and infection.

      Abdominal wound dehiscence is a serious issue that surgeons who perform abdominal surgery frequently encounter. It occurs when all layers of an abdominal mass closure fail, resulting in the protrusion of the viscera externally. This condition is associated with a 30% mortality rate and can be classified as either superficial or complete, depending on the extent of the wound failure.

      Several factors increase the risk of abdominal wound dehiscence, including malnutrition, vitamin deficiencies, jaundice, steroid use, major wound contamination (such as faecal peritonitis), and poor surgical technique. To prevent this condition, the preferred method is the mass closure technique, also known as the Jenkins Rule.

      When sudden full dehiscence occurs, the wound should be covered with saline impregnated gauze, and the patient should receive IV broad-spectrum antibiotics, analgesia, and IV fluids. Arrangements should also be made for a return to the operating theatre.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      16.6
      Seconds
  • Question 29 - A 58-year-old man presents to his doctor with concerns about his chest. He...

    Incorrect

    • A 58-year-old man presents to his doctor with concerns about his chest. He feels embarrassed and believes that he is developing breast tissue. Upon examination, bilateral gynaecomastia is the only abnormal finding. The patient has a medical history of hypertension, high cholesterol, type 2 diabetes, and benign prostatic hyperplasia. Which medication is the most probable cause of this condition?

      Your Answer: Metformin

      Correct Answer: Finasteride

      Explanation:

      Gynaecomastia in males can have various underlying causes, some of which may be serious, such as endocrine disorders, liver failure, kidney failure, or malignancy. Additionally, medication-related causes should be considered, as in the case of this patient who was taking finasteride, which is known to cause gynaecomastia. Finasteride functions by inhibiting 5-alpha-reductase, which reduces dihydrotestosterone production and shrinks the prostate. However, it can also lead to side effects such as sexual dysfunction and gynaecomastia.

      Understanding Finasteride: Its Uses and Side Effects

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

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

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      17.5
      Seconds
  • Question 30 - A 9-year-old girl comes to the GP with her father. Her father explains...

    Incorrect

    • A 9-year-old girl comes to the GP with her father. Her father explains that she is still experiencing bed-wetting almost every night. She has undergone thorough investigations in the past year for this issue and has no physical abnormalities to explain her enuresis. She is otherwise healthy and active.

      Her father has attempted to limit her fluid intake before bedtime, encourage regular and timely toileting, and wake her up during the night, but none of these methods have been successful.

      What is the most appropriate course of action to manage her enuresis?

      Your Answer:

      Correct Answer: Enuresis alarm

      Explanation:

      Withholding fluids for 2 hours before bedtime is not recommended as part of enuresis management. While limiting fluid intake throughout the day and before bedtime, especially caffeinated drinks, is advised, completely withholding fluids is not recommended. Referring the patient for sleep studies is not the most appropriate management at this stage, although other conditions that can worsen enuresis, such as sleep-disordered breathing, should be considered. Desmopressin, an analogue of anti-diuretic hormone (ADH), is not indicated at this stage and is only used when general advice and enuresis alarm have failed. The primary goal of management is to achieve dry nights at follow-up.

      Nocturnal enuresis, or bedwetting, is when a child involuntarily urinates during the night. Most children achieve continence by the age of 3 or 4, so enuresis is defined as the involuntary discharge of urine in a child aged 5 or older without any underlying medical conditions. Enuresis can be primary, meaning the child has never achieved continence, or secondary, meaning the child has been dry for at least 6 months before.

      When managing bedwetting, it’s important to look for any underlying causes or triggers, such as constipation, diabetes mellitus, or recent onset UTIs. General advice includes monitoring fluid intake and encouraging regular toileting patterns, such as emptying the bladder before sleep. Reward systems, like star charts, can also be helpful, but should be given for agreed behavior rather than dry nights.

      The first-line treatment for bedwetting is an enuresis alarm, which has a high success rate. These alarms have sensor pads that detect wetness and wake the child up to use the toilet. If short-term control is needed, such as for sleepovers, or if the alarm is ineffective or not acceptable to the family, desmopressin may be prescribed. Overall, managing bedwetting involves identifying any underlying causes and implementing strategies to promote continence.

    • This question is part of the following fields:

      • Paediatrics
      0
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SESSION STATS - PERFORMANCE PER SPECIALTY

Dermatology (1/3) 33%
Haematology/Oncology (0/1) 0%
Reproductive Medicine (2/5) 40%
Gastroenterology/Nutrition (2/3) 67%
Psychiatry (2/2) 100%
Ophthalmology (1/3) 33%
Endocrinology/Metabolic Disease (1/1) 100%
Renal Medicine/Urology (0/2) 0%
Neurology (2/2) 100%
Infectious Diseases (1/1) 100%
Pharmacology/Therapeutics (2/2) 100%
Musculoskeletal (1/1) 100%
Respiratory Medicine (1/1) 100%
ENT (1/1) 100%
Paediatrics (1/1) 100%
Passmed