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  • Question 1 - A 20-year-old man presents to the emergency department with a recent history of...

    Incorrect

    • A 20-year-old man presents to the emergency department with a recent history of myoclonic seizures and limb weakness. A neurologist performs a variety of investigations, including a muscle biopsy which confirms the diagnosis of a mitochondrial disease. The patient's mother and two siblings also have experienced some similar symptoms, but to varying degrees of severity. The neurologist explains that this is a characteristic of mitochondrial disorders, where there is variable disease expression within a family due to the presence of both normal and mutated mitochondrial DNA (mtDNA) within a cell.

      What characteristic of mitochondrial disorders is the neurologist referring to?

      Your Answer: Anticipation

      Correct Answer: Heteroplasmy

      Explanation:

      The correct term is heteroplasmy, which refers to the presence of multiple types of organellar genome (such as mitochondrial DNA or plastid DNA) within an individual or cell. This can result in variable expression of mitochondrial disease. Anticipation, on the other hand, is a phenomenon seen in trinucleotide repeat disorders where there is increased severity or earlier onset of disease in successive generations, but it is not observed in mitochondrial diseases. Homoplasmy, which refers to a cell having a uniform collection of mtDNA (either completely normal or abnormal), is not the correct answer.

      Mitochondrial diseases are caused by a small amount of double-stranded DNA present in the mitochondria, which encodes protein components of the respiratory chain and some special types of RNA. These diseases are inherited only via the maternal line, as the sperm contributes no cytoplasm to the zygote. None of the children of an affected male will inherit the disease, while all of the children of an affected female will inherit it. Mitochondrial diseases generally encode rare neurological diseases, and there is poor genotype-phenotype correlation due to heteroplasmy, which means that within a tissue or cell, there can be different mitochondrial populations. Muscle biopsy typically shows red, ragged fibers due to an increased number of mitochondria. Examples of mitochondrial diseases include Leber’s optic atrophy, MELAS syndrome, MERRF syndrome, Kearns-Sayre syndrome, and sensorineural hearing loss.

    • This question is part of the following fields:

      • General Principles
      17.7
      Seconds
  • Question 2 - A team of researchers explore the activation mechanisms of the lectin complement pathway...

    Incorrect

    • A team of researchers explore the activation mechanisms of the lectin complement pathway by group A streptococci. Using CRISPR-Cas9 knockout, they genetically modify wild-type group A streptococci to create a new strain with modified cell surface antigens.

      In their investigation, the scientists find that the removal of a specific monosaccharide antigen impedes the activation of the lectin complement pathway in mice.

      Which pathogenic antigen triggers the activation of this complement pathway?

      Your Answer: Ribose

      Correct Answer: Mannose

      Explanation:

      The correct answer is mannose, as it is a hexose monosaccharide found on the surface of bacteria and is recognized as a PAMP by the human immune system. When mannose-binding lectin (MBL) binds to these carbohydrates, it triggers the lectin complement pathway. Fucose, galactose, and lactulose are not involved in this pathway and do not activate it.

      Overview of Complement Pathways

      Complement pathways are a group of proteins that play a crucial role in the body’s immune and inflammatory response. These proteins are involved in various processes such as chemotaxis, cell lysis, and opsonisation. There are two main complement pathways: classical and alternative.

      The classical pathway is initiated by antigen-antibody complexes, specifically IgM and IgG. The proteins involved in this pathway include C1qrs, C2, and C4. On the other hand, the alternative pathway is initiated by polysaccharides found in Gram-negative bacteria and IgA. The proteins involved in this pathway are C3, factor B, and properdin.

      Understanding the complement pathways is important in the diagnosis and treatment of various diseases. Dysregulation of these pathways can lead to autoimmune disorders, infections, and other inflammatory conditions. By identifying the specific complement pathway involved in a disease, targeted therapies can be developed to effectively treat the condition.

    • This question is part of the following fields:

      • General Principles
      18.4
      Seconds
  • Question 3 - As a doctor in the emergency department, you are presented with a 72-year-old...

    Incorrect

    • As a doctor in the emergency department, you are presented with a 72-year-old woman who has been brought in by her carers due to a large erythematous area on her lower leg. Upon questioning, the patient reveals that she scratched her leg while gardening at her assisted living facility last week.

      Upon examination, you notice a clearly demarcated erythematous area on the lateral aspect of her right lower leg. The area is hot to touch, but the patient is comfortable at rest and not experiencing any breathlessness. Upon auscultation, her chest is clear. Her chart shows a temperature of 37.6ºC.

      The carers inform you that the patient has no allergies but has a history of type 2 diabetes. Based on the likely diagnosis, what medication should you administer immediately?

      Your Answer: Apixaban

      Correct Answer: Flucloxacillin

      Explanation:

      It is highly unlikely that the patient has a pulmonary embolism as acute-onset breathlessness is not a common symptom of individuals with a PE. Additionally, the presence of a well-demarcated lesion on the calf and a history of skin trauma supports a diagnosis of cellulitis instead. Therefore, treatment with apixaban is not appropriate. Azithromycin would be a suitable alternative if the patient is allergic to penicillin. Although cellulitis can cause pain, providing analgesia such as paracetamol is not a primary concern.

      Understanding Cellulitis: Symptoms, Diagnosis, and Treatment

      Cellulitis is a common skin infection caused by Streptococcus pyogenes or Staphylococcus aureus. It is characterized by inflammation of the skin and subcutaneous tissues, usually on the shins, accompanied by erythema, pain, swelling, and sometimes fever. The diagnosis of cellulitis is based on clinical features, and no further investigations are required in primary care. However, bloods and blood cultures may be requested if the patient is admitted and septicaemia is suspected.

      To guide the management of patients with cellulitis, NICE Clinical Knowledge Summaries recommend using the Eron classification. Patients with Eron Class III or Class IV cellulitis, severe or rapidly deteriorating cellulitis, very young or frail patients, immunocompromised patients, patients with significant lymphoedema, or facial or periorbital cellulitis (unless very mild) should be admitted for intravenous antibiotics. Patients with Eron Class II cellulitis may not require admission if the facilities and expertise are available in the community to give intravenous antibiotics and monitor the patient.

      The first-line treatment for mild/moderate cellulitis is flucloxacillin, while clarithromycin, erythromycin (in pregnancy), or doxycycline is recommended for patients allergic to penicillin. Patients with severe cellulitis should be offered co-amoxiclav, cefuroxime, clindamycin, or ceftriaxone. Understanding the symptoms, diagnosis, and treatment of cellulitis is crucial for effective management and prevention of complications.

    • This question is part of the following fields:

      • General Principles
      25.5
      Seconds
  • Question 4 - A 42-year-old woman presents with symptoms of fatigue, palpitations, and shortness of breath...

    Incorrect

    • A 42-year-old woman presents with symptoms of fatigue, palpitations, and shortness of breath on exertion. She has recently been ill with an upper respiratory tract infection. During the examination, you observe that she has conjunctival pallor, and her sclera are icteric.

      After conducting investigations, a positive Coombs test leads to a diagnosis of autoimmune haemolytic anaemia. This condition results in the breakdown of red blood cells, causing an increase in free haemoglobin levels in the blood.

      What mechanisms will be involved in recycling the elevated levels of this substance?

      Your Answer: Albumin

      Correct Answer: Haptoglobins

      Explanation:

      Haptoglobins are responsible for binding free haemoglobin within the circulation, allowing for the complex to be removed from the circulation by the reticuloendothelial system. Therefore, the correct answer is 2 – haptoglobins. LDH, albumin, and bilirubin do not play a role in recycling free haemoglobin.

      Understanding Haemolytic Anaemias by Site

      Haemolytic anaemias can be classified by the site of haemolysis, either intravascular or extravascular. In intravascular haemolysis, free haemoglobin is released and binds to haptoglobin. As haptoglobin becomes saturated, haemoglobin binds to albumin forming methaemalbumin, which can be detected by Schumm’s test. Free haemoglobin is then excreted in the urine as haemoglobinuria and haemosiderinuria. Causes of intravascular haemolysis include mismatched blood transfusion, red cell fragmentation due to heart valves, TTP, DIC, HUS, paroxysmal nocturnal haemoglobinuria, and cold autoimmune haemolytic anaemia.

      On the other hand, extravascular haemolysis occurs when red blood cells are destroyed by macrophages in the spleen or liver. This type of haemolysis is commonly seen in haemoglobinopathies such as sickle cell anaemia and thalassaemia, hereditary spherocytosis, haemolytic disease of the newborn, and warm autoimmune haemolytic anaemia.

      It is important to understand the site of haemolysis in order to properly diagnose and treat haemolytic anaemias. While both intravascular and extravascular haemolysis can lead to anaemia, the underlying causes and treatment approaches may differ.

    • This question is part of the following fields:

      • Haematology And Oncology
      25.1
      Seconds
  • Question 5 - A 23 years old male presents to his GP with a complaint of...

    Incorrect

    • A 23 years old male presents to his GP with a complaint of inability to flex his left elbow. During examination, the GP observes significant weakness in flexion of his left elbow and supination of his forearm. Which nerve is most likely to be damaged in this case?

      Your Answer: Ulnar nerve

      Correct Answer: Musculocutaneous nerve

      Explanation:

      The musculocutaneous nerve provides innervation to the Bicep, Brachialis, and Coracobrachialis muscles in the upper arm, which are responsible for elbow flexion and forearm supination. If a patient has weak elbow flexion and supination, it may indicate damage to the musculocutaneous nerve. The radial nerve innervates the tricep brachii and extensor muscles in the forearm, while the median nerve is responsible for the anterior compartment of the forearm and does not innervate any arm muscles. The ulnar nerve innervates two forearm muscles and intrinsic hand muscles, excluding the thenar muscles and two lateral lumbricals.

      Upper limb anatomy is a common topic in examinations, and it is important to know certain facts about the nerves and muscles involved. The musculocutaneous nerve is responsible for elbow flexion and supination, and typically only injured as part of a brachial plexus injury. The axillary nerve controls shoulder abduction and can be damaged in cases of humeral neck fracture or dislocation, resulting in a flattened deltoid. The radial nerve is responsible for extension in the forearm, wrist, fingers, and thumb, and can be damaged in cases of humeral midshaft fracture, resulting in wrist drop. The median nerve controls the LOAF muscles and can be damaged in cases of carpal tunnel syndrome or elbow injury. The ulnar nerve controls wrist flexion and can be damaged in cases of medial epicondyle fracture, resulting in a claw hand. The long thoracic nerve controls the serratus anterior and can be damaged during sports or as a complication of mastectomy, resulting in a winged scapula. The brachial plexus can also be damaged, resulting in Erb-Duchenne palsy or Klumpke injury, which can cause the arm to hang by the side and be internally rotated or associated with Horner’s syndrome, respectively.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
      8.8
      Seconds
  • Question 6 - A 67-year-old man is admitted to the geriatric ward following a recent fall....

    Correct

    • A 67-year-old man is admitted to the geriatric ward following a recent fall. As the on-call psychiatrist, you have been asked to review his medication. He has a medical history of Parkinson's disease, major depression, diverticulosis, and recurrent falls. Despite this, he reports feeling well. The patient's current medication list includes paracetamol, aspirin, phenelzine, codeine, naproxen, fluoxetine, lactulose, and senna.

      What changes, if any, may need to be made to his medication regimen?

      Your Answer: Remove phenelzine

      Explanation:

      Due to the increased risk of central serotonin syndrome, fluoxetine should not be prescribed alongside phenelzine, a non-selective and irreversible monoamine oxidase inhibitor (MAOI).

      As the patient is not experiencing nausea or vomiting, there is no need to prescribe metoclopramide. Additionally, metoclopramide is not suitable for this patient with Parkinson’s disease as it can worsen their symptoms as a dopamine antagonist.

      The patient’s senna should not be discontinued as it is likely necessary for regular bowel movements due to their history of diverticulosis. Lactulose may also be needed for this purpose.

      As the patient is not reporting any pain, there is no need to increase their pain relief at this time.

      Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for depression, with citalopram and fluoxetine being the preferred options. They should be used with caution in children and adolescents, and patients should be monitored for increased anxiety and agitation. Gastrointestinal symptoms are the most common side-effect, and there is an increased risk of gastrointestinal bleeding. Citalopram and escitalopram are associated with dose-dependent QT interval prolongation and should not be used in certain patients. SSRIs have a higher propensity for drug interactions, and patients should be reviewed after 2 weeks of treatment. When stopping a SSRI, the dose should be gradually reduced over a 4 week period. Use of SSRIs during pregnancy should be weighed against the risks and benefits.

    • This question is part of the following fields:

      • Psychiatry
      33.4
      Seconds
  • Question 7 - A 27-year-old Afro-Caribbean woman visits her GP with concerns about well-defined patches of...

    Incorrect

    • A 27-year-old Afro-Caribbean woman visits her GP with concerns about well-defined patches of significantly lighter skin. At first, this was only on her hands, but she has recently noticed similar patches on her face. She has a medical history of Hashimoto's thyroid disease and takes levothyroxine.

      During the examination, the GP observes well-demarcated areas of hypopigmentation on her hands, arms, and face. Based on the most probable diagnosis, which layer of the epidermis is affected?

      Your Answer: Stratum granulosum

      Correct Answer: Stratum germinativum

      Explanation:

      The deepest layer of the epidermis is called the stratum germinativum, which is responsible for producing keratinocytes and contains melanocytes. Vitiligo, a condition characterized by depigmented patches, affects this layer by causing the loss of melanocytes.

      The stratum corneum is the topmost layer of the epidermis, consisting of dead cells filled with keratin.

      The stratum granulosum is where keratin production occurs in the epidermis.

      The stratum lucidum is only present in the palms of the hands and soles of the feet.

      The Layers of the Epidermis

      The epidermis is the outermost layer of the skin and is made up of a stratified squamous epithelium with a basal lamina underneath. It can be divided into five layers, each with its own unique characteristics. The first layer is the stratum corneum, which is made up of flat, dead, scale-like cells filled with keratin. These cells are continually shed and replaced with new ones. The second layer, the stratum lucidum, is only present in thick skin and is a clear layer. The third layer, the stratum granulosum, is where cells form links with their neighbors. The fourth layer, the stratum spinosum, is the thickest layer of the epidermis and is where squamous cells begin keratin synthesis. Finally, the fifth layer is the stratum germinativum, which is the basement membrane and is made up of a single layer of columnar epithelial cells. This layer gives rise to keratinocytes and contains melanocytes. Understanding the layers of the epidermis is important for understanding the structure and function of the skin.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
      20
      Seconds
  • Question 8 - Can you rephrase this inquiry and adjust the age a bit while maintaining...

    Correct

    • Can you rephrase this inquiry and adjust the age a bit while maintaining the same paragraph format?

      Your Answer: Flexor digitorum brevis

      Explanation:

      The tibial nerve supplies the flexor digitorum.

      The common peroneal nerve originates from the dorsal divisions of the sacral plexus, specifically from L4, L5, S1, and S2. This nerve provides sensation to the skin and fascia of the anterolateral surface of the leg and dorsum of the foot, as well as innervating the muscles of the anterior and peroneal compartments of the leg, extensor digitorum brevis, and the knee, ankle, and foot joints. It is located laterally within the sciatic nerve and passes through the lateral and proximal part of the popliteal fossa, under the cover of biceps femoris and its tendon, to reach the posterior aspect of the fibular head. The common peroneal nerve divides into the deep and superficial peroneal nerves at the point where it winds around the lateral surface of the neck of the fibula in the body of peroneus longus, approximately 2 cm distal to the apex of the head of the fibula. It is palpable posterior to the head of the fibula. The nerve has several branches, including the nerve to the short head of biceps, articular branch (knee), lateral cutaneous nerve of the calf, and superficial and deep peroneal nerves at the neck of the fibula.

    • This question is part of the following fields:

      • Neurological System
      21.8
      Seconds
  • Question 9 - A senior citizen presents with a squamous cell carcinoma involving the lobule of...

    Incorrect

    • A senior citizen presents with a squamous cell carcinoma involving the lobule of their ear. Which lymph node is the most probable site of metastasis?

      Your Answer: Deep cervical nodes

      Correct Answer: Superficial cervical nodes

      Explanation:

      The superficial cervical nodes receive drainage from the lobule.

      Lymphatic Drainage of the Auricle

      The auricle, also known as the outer ear, has a specific pattern of lymphatic drainage. The upper half of the lateral surface drains to the superficial parotid lymph nodes, while the cranial surface of the superior half drains to the mastoid nodes and deep cervical lymph nodes. On the other hand, the lower half and lobule of the auricle drain into the superficial cervical lymph nodes. This means that lymphatic fluid from different parts of the auricle is directed to different lymph nodes in the body. Understanding this pattern of drainage is important for medical professionals who may need to assess and treat conditions affecting the ear and surrounding tissues. By knowing which lymph nodes are involved, they can better diagnose and manage any issues that may arise.

    • This question is part of the following fields:

      • Haematology And Oncology
      8.1
      Seconds
  • Question 10 - A patient's ECG displays broad complex QRS complexes, indicating a possible ventricular origin...

    Correct

    • A patient's ECG displays broad complex QRS complexes, indicating a possible ventricular origin issue or aberrant conduction. What is the typical resting membrane potential of ventricular contractile fibers in the heart?

      Your Answer: -90mV

      Explanation:

      Understanding the Cardiac Action Potential and Conduction Velocity

      The cardiac action potential is a series of electrical events that occur in the heart during each heartbeat. It is responsible for the contraction of the heart muscle and the pumping of blood throughout the body. The action potential is divided into five phases, each with a specific mechanism. The first phase is rapid depolarization, which is caused by the influx of sodium ions. The second phase is early repolarization, which is caused by the efflux of potassium ions. The third phase is the plateau phase, which is caused by the slow influx of calcium ions. The fourth phase is final repolarization, which is caused by the efflux of potassium ions. The final phase is the restoration of ionic concentrations, which is achieved by the Na+/K+ ATPase pump.

      Conduction velocity is the speed at which the electrical signal travels through the heart. The speed varies depending on the location of the signal. Atrial conduction spreads along ordinary atrial myocardial fibers at a speed of 1 m/sec. AV node conduction is much slower, at 0.05 m/sec. Ventricular conduction is the fastest in the heart, achieved by the large diameter of the Purkinje fibers, which can achieve velocities of 2-4 m/sec. This allows for a rapid and coordinated contraction of the ventricles, which is essential for the proper functioning of the heart. Understanding the cardiac action potential and conduction velocity is crucial for diagnosing and treating heart conditions.

    • This question is part of the following fields:

      • Cardiovascular System
      10.5
      Seconds
  • Question 11 - A study examines the effectiveness of amoxicillin in treating acute sinusitis in patients...

    Incorrect

    • A study examines the effectiveness of amoxicillin in treating acute sinusitis in patients aged 50 and above compared to a placebo. The study yielded the following results:

      Total number of patients Number who achieved resolution of symptoms at 7 days
      Amoxicillin 100 60
      Placebo 75 30

      What is the odds ratio of a patient aged 50 and above achieving symptom resolution at 7 days if they take amoxicillin compared to placebo?

      Your Answer: 1.5

      Correct Answer: 2.25

      Explanation:

      The concept of odds involves comparing the number of people who experience a certain outcome to those who do not, rather than comparing it to the total number of people. For example, the odds of symptom resolution with amoxicillin would be calculated by dividing the number of people who experienced symptom resolution by the number who did not, resulting in a ratio of 60 to 40, or 1.5. Similarly, the odds of symptom resolution with a placebo would be calculated by dividing the number of people who experienced symptom resolution by the number who did not, resulting in a ratio of 30 to 45, or 2/3. To determine the odds ratio, the odds of symptom resolution with amoxicillin would be divided by the odds of symptom resolution with placebo, resulting in a ratio of 2.25.

      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.

    • This question is part of the following fields:

      • General Principles
      34.5
      Seconds
  • Question 12 - Samantha, a 23-year-old female, arrives at the emergency department after falling on her...

    Correct

    • Samantha, a 23-year-old female, arrives at the emergency department after falling on her outstretched hand during a volleyball game. She reports experiencing pain in her left shoulder.

      After assessing her neurovascular status, the attending physician orders an x-ray which reveals a surgical neck fracture of the left humerus.

      Which muscles are expected to have decreased movement based on the nerve most likely affected by this fracture?

      Your Answer: Teres minor and deltoid

      Explanation:

      The axillary nerve is responsible for supplying the teres minor and deltoid muscles. It is composed of nerve fibers from C5 and C6 of the brachial plexus and originates in the axilla. The nerve exits the axilla through the quadrangular space, located at the lower border of the subscapularis muscle. It then travels medially to the surgical neck of the humerus, making it vulnerable to injury in cases of surgical neck fractures. Other muscles innervated by the axillary nerve include the teres major and trapezius, which are supplied by the lower subscapular and accessory nerves, respectively.

      Upper limb anatomy is a common topic in examinations, and it is important to know certain facts about the nerves and muscles involved. The musculocutaneous nerve is responsible for elbow flexion and supination, and typically only injured as part of a brachial plexus injury. The axillary nerve controls shoulder abduction and can be damaged in cases of humeral neck fracture or dislocation, resulting in a flattened deltoid. The radial nerve is responsible for extension in the forearm, wrist, fingers, and thumb, and can be damaged in cases of humeral midshaft fracture, resulting in wrist drop. The median nerve controls the LOAF muscles and can be damaged in cases of carpal tunnel syndrome or elbow injury. The ulnar nerve controls wrist flexion and can be damaged in cases of medial epicondyle fracture, resulting in a claw hand. The long thoracic nerve controls the serratus anterior and can be damaged during sports or as a complication of mastectomy, resulting in a winged scapula. The brachial plexus can also be damaged, resulting in Erb-Duchenne palsy or Klumpke injury, which can cause the arm to hang by the side and be internally rotated or associated with Horner’s syndrome, respectively.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
      12.2
      Seconds
  • Question 13 - A 30-year-old man needs a urethral catheter before his splenectomy. At what point...

    Incorrect

    • A 30-year-old man needs a urethral catheter before his splenectomy. At what point will the catheter encounter its first resistance during insertion?

      Your Answer: Bladder neck

      Correct Answer: Membranous urethra

      Explanation:

      The external sphincter surrounding the membranous urethra causes it to be the least distensible part of the urethra.

      Urethral Anatomy: Differences Between Male and Female

      The anatomy of the urethra differs between males and females. In females, the urethra is shorter and more angled than in males. It is located outside of the peritoneum and is surrounded by the endopelvic fascia. The neck of the bladder is subject to intra-abdominal pressure, and any weakness in this area can lead to stress urinary incontinence. The female urethra is surrounded by the external urethral sphincter, which is innervated by the pudendal nerve. It is located in front of the vaginal opening.

      In males, the urethra is much longer and is divided into four parts. The pre-prostatic urethra is very short and lies between the bladder and prostate gland. The prostatic urethra is wider than the membranous urethra and contains several openings for the transmission of semen. The membranous urethra is the narrowest part of the urethra and is surrounded by the external sphincter. The penile urethra travels through the corpus spongiosum on the underside of the penis and is the longest segment of the urethra. The bulbo-urethral glands open into the spongiose section of the urethra.

      The urothelium, which lines the inside of the urethra, is transitional near the bladder and becomes squamous further down the urethra. Understanding the differences in urethral anatomy between males and females is important for diagnosing and treating urological conditions.

    • This question is part of the following fields:

      • Gastrointestinal System
      11.4
      Seconds
  • Question 14 - A patient in his late 40s visits his GP complaining of intense shoulder...

    Incorrect

    • A patient in his late 40s visits his GP complaining of intense shoulder pain that radiates to the scapula area. Despite a thorough shoulder examination revealing no joint issues, the patient is referred for additional tests. Imaging studies reveal a bronchogenic apical lung tumor that has caused lesions in the brachial plexus and extends towards the superior cervical and stellate ganglia. If these two structures are compressed, what signs are most likely to occur?

      Your Answer: Hoarseness of voice

      Correct Answer: Ptosis, miosis, anhydrosis

      Explanation:

      The superior cervical ganglion (SCG) is a component of the sympathetic nervous system that solely innervates the head and neck. Its functions include innervating eye structures, and damage or compression of the SCG can lead to Horner’s syndrome, which is characterized by ptosis, miosis, and anhydrosis. This syndrome occurs due to the unopposed action of the parasympathetic system on the eye, as the sympathetic innervation is impaired.

      Damage to the external laryngeal nerve, a branch of the superior laryngeal nerve, can result in a monotonous voice. However, this nerve does not originate from the SCG, so it is unlikely to affect the voice.

      As the SCG is part of the sympathetic nervous system, its damage impairs sympathetic responses and leads to unopposed parasympathetic innervation. This can cause miosis (constriction) of the eye, not mydriasis (dilation).

      Sweating is caused by the action of the sympathetic nervous system, so damage to the SCG would most likely result in anhydrosis (lack of sweat) of the face, rather than hyperhidrosis (excessive sweating).

      Hoarse voice can result from damage to the recurrent laryngeal nerve, which is not related to the SCG, so it is unlikely to affect the voice.

      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.

    • This question is part of the following fields:

      • Neurological System
      21.3
      Seconds
  • Question 15 - A baby is born prematurely at 28 weeks, increasing the likelihood of delayed...

    Incorrect

    • A baby is born prematurely at 28 weeks, increasing the likelihood of delayed closure of the ductus venosus. What are the structures that the ductus venosus connects in the fetus?

      Your Answer: Umbilical vein and umbilical artery

      Correct Answer: IVC and umbilical vein

      Explanation:

      During fetal development, the ductus venosus redirects blood flow from the left umbilical vein directly to the inferior vena cava, enabling oxygenated blood from the placenta to bypass the fetal liver. Typically, the ductus closes and becomes the ligamentum venosum between day 3 and 7. However, premature infants are more susceptible to delayed closure.

      During cardiovascular embryology, the heart undergoes significant development and differentiation. At around 14 days gestation, the heart consists of primitive structures such as the truncus arteriosus, bulbus cordis, primitive atria, and primitive ventricle. These structures give rise to various parts of the heart, including the ascending aorta and pulmonary trunk, right ventricle, left and right atria, and majority of the left ventricle. The division of the truncus arteriosus is triggered by neural crest cell migration from the pharyngeal arches, and any issues with this migration can lead to congenital heart defects such as transposition of the great arteries or tetralogy of Fallot. Other structures derived from the primitive heart include the coronary sinus, superior vena cava, fossa ovalis, and various ligaments such as the ligamentum arteriosum and ligamentum venosum. The allantois gives rise to the urachus, while the umbilical artery becomes the medial umbilical ligaments and the umbilical vein becomes the ligamentum teres hepatis inside the falciform ligament. Overall, cardiovascular embryology is a complex process that involves the differentiation and development of various structures that ultimately form the mature heart.

    • This question is part of the following fields:

      • Cardiovascular System
      13.8
      Seconds
  • Question 16 - What respiratory disorder is identified by the existence of Curschmann's spirals and Charcot-Leyden...

    Incorrect

    • What respiratory disorder is identified by the existence of Curschmann's spirals and Charcot-Leyden crystals?

      Your Answer: Bronchiectasis

      Correct Answer: Asthma

      Explanation:

      Respiratory Pathologies and Their Pathological Features

      Asthma is a respiratory pathology that is characterized by an excessive inflammatory response of the small bronchial airways to harmless stimuli. This response involves the infiltration of eosinophils, which can aggregate and form Charcot-Leyden crystals. The accumulation of mucus in the airways can lead to the formation of Curschmann spirals. Bronchiectasis is another respiratory pathology that involves the progressive dilation of the small airways. COPD shares similar features with chronic asthma, but with more marked smooth muscle hyperplasia. Cystic fibrosis has pathological features similar to bronchiectasis, but it predominantly affects the upper lobes. Pulmonary fibrosis is a pathological term for the deposition of excess connective and fibrous tissue in the pulmonary interstitial space. Although there are multiple causes, the underlying pathology is the same.

      In summary, respiratory pathologies can have different pathological features, but they all involve some form of inflammation or structural damage to the airways. Asthma, bronchiectasis, COPD, cystic fibrosis, and pulmonary fibrosis are some of the most common respiratory pathologies. their underlying pathology is crucial for developing effective treatments and improving patient outcomes.

    • This question is part of the following fields:

      • Clinical Sciences
      12.7
      Seconds
  • Question 17 - A 30-year-old patient presents with complaints of recurrent bloody diarrhoea and symptoms of...

    Correct

    • 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.

    • This question is part of the following fields:

      • Rheumatology
      24.7
      Seconds
  • Question 18 - A 48-year-old smoker visits his doctor to discuss his smoking habit. He has...

    Incorrect

    • A 48-year-old smoker visits his doctor to discuss his smoking habit. He has been smoking 15 cigarettes a day for the past 25 years and wants to know how much more likely he is to develop lung cancer compared to a non-smoker. The doctor searches PubMed and finds a recent case-control study that provides the following data:

      Lung cancer No lung cancer
      Smokers 300 2700
      Non-smokers 50 8950

      What is the relative risk of smoking on lung cancer based on this data?

      Your Answer: 500

      Correct Answer: 15

      Explanation:

      Understanding Relative Risk in Clinical Trials

      Relative risk (RR) is a measure used in clinical trials to compare the risk of an event occurring in the experimental group to the risk in the control group. It is calculated by dividing the experimental event rate (EER) by the control event rate (CER). If the resulting ratio is greater than 1, it means that the event is more likely to occur in the experimental group than in the control group. Conversely, if the ratio is less than 1, the event is less likely to occur in the experimental group.

      To calculate the relative risk reduction (RRR) or relative risk increase (RRI), the absolute risk change is divided by the control event rate. This provides a percentage that indicates the magnitude of the difference between the two groups. Understanding relative risk is important in evaluating the effectiveness of interventions and treatments in clinical trials. By comparing the risk of an event in the experimental group to the control group, researchers can determine whether the intervention is beneficial or not.

    • This question is part of the following fields:

      • General Principles
      36.7
      Seconds
  • Question 19 - These thyroid function tests were obtained on a 55-year-old female who has recently...

    Incorrect

    • These thyroid function tests were obtained on a 55-year-old female who has recently been treated for hypertension:
      Free T4 28.5 pmol/L (9.8-23.1)
      TSH <0.02 mU/L (0.35-5.5)
      Free T3 10.8 pmol/L (3.5-6.5)
      She now presents with typical symptoms of hyperthyroidism.
      Which medication is likely to have caused this?

      Your Answer: Amlodipine

      Correct Answer: Amiodarone

      Explanation:

      Amiodarone and its Effects on Thyroid Function

      Amiodarone is a medication that can have an impact on thyroid function, resulting in both hypo- and hyperthyroidism. This is due to the high iodine content in the drug, which contributes to its antiarrhythmic effects. Atenolol, on the other hand, is a beta blocker that is commonly used to treat thyrotoxicosis. Warfarin is another medication that is used to treat atrial fibrillation.

      There are two types of thyrotoxicosis that can be caused by amiodarone. Type 1 results in excess thyroxine synthesis, while type 2 leads to the release of excess thyroxine but normal levels of synthesis. It is important for healthcare professionals to monitor thyroid function in patients taking amiodarone and adjust treatment as necessary to prevent complications.

    • This question is part of the following fields:

      • Cardiovascular System
      18.8
      Seconds
  • Question 20 - As a medical student in general practice, you come across a patient with...

    Incorrect

    • As a medical student in general practice, you come across a patient with poorly controlled hypertension. The decision is made to initiate Bendroflumethiazide therapy. What could be a possible contraindication for starting this medication?

      Your Answer: Refractory hyperkalaemia

      Correct Answer: Gout

      Explanation:

      Gout may be a potential side effect of thiazides.

      It is important to note that spironolactone and bendroflumethiazide belong to different drug classes, so being allergic to one does not necessarily mean the other cannot be prescribed.

      Bendroflumethiazide is a type of diuretic that causes the body to lose potassium, so it may actually be prescribed in cases of refractory hyperkalemia rather than being avoided.

      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.

    • This question is part of the following fields:

      • Cardiovascular System
      6.9
      Seconds
  • Question 21 - A 6-year-old girl visits her GP with her parents as they have noticed...

    Incorrect

    • A 6-year-old girl visits her GP with her parents as they have noticed a localized area of red and blistered swelling on her forehead. The GP suspects a superficial skin infection and prescribes appropriate antibiotics.

      What is the most common microorganism associated with this condition, based on the likely diagnosis?

      Your Answer: Enterococcus faecium

      Correct Answer: Streptococcus pyogenes

      Explanation:

      Streptococcus pyogenes is the primary cause of erysipelas, a localized skin infection. However, Staphylococcus aureus can also be a culprit. Haemophilus influenzae type B used to be a common cause before vaccination was available. Diphtheria, which can lead to serious renal and nervous system complications if left untreated, is caused by Corynebacterium diphtheriae. Enterococcus faecium, a gut bacterium, may also be involved in meningitis and endocarditis.

      Understanding Erysipelas: A Superficial Skin Infection

      Erysipelas is a skin infection that is caused by Streptococcus pyogenes. It is a less severe form of cellulitis, which is a more widespread skin infection. Erysipelas is a localized infection that affects the skin’s upper layers, causing redness, swelling, and warmth. The infection can occur anywhere on the body, but it is most commonly found on the face, arms, and legs.

      The treatment of choice for erysipelas is flucloxacillin, an antibiotic that is effective against Streptococcus pyogenes. Other antibiotics may also be used, depending on the severity of the infection and the patient’s medical history.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
      13.3
      Seconds
  • Question 22 - A 56-year-old man comes to the ER with a red and painful leg....

    Correct

    • A 56-year-old man comes to the ER with a red and painful leg. During this process, known as leucocyte extravasation, his innate immune system is activated, causing white blood cells (leucocytes) to migrate out of the circulation system and towards the infection site.

      What are the four stages involved in this process?

      Your Answer: Chemoattraction, rolling, tight adhesion, transmigration

      Explanation:

      Leucocyte extravasation involves four stages: chemoattraction, rolling, tight adhesion, and transmigration. The process of opsonization marks foreign particles for phagocytosis, while cell lysis breaks down cell membranes. Agglutination clusters pathogens together using antibodies to facilitate phagocytosis. These three processes are all part of the complement system. During phagocytosis, a cell, such as a macrophage, engulfs a solid particle.

      Leucocyte Extravasation: The Process of White Blood Cells Leaving Blood Vessels

      Leucocyte extravasation is a process that involves the movement of white blood cells from the bloodstream to the affected tissue. This process occurs in four stages: chemoattraction, rolling, tight adhesion, and transmigration. During chemoattraction and rolling, macrophages in the affected tissue release cytokines that attract circulating white blood cells and cause the endothelium to express cellular adhesion molecules. In the tight adhesion stage, white blood cells express integrins in response to the cytokines, which bind to ICAM proteins on endothelial cells. Finally, in the transmigration stage, PECAM proteins on both endothelial cells and white blood cells interact and facilitate the migration of the white blood cells through the endothelium. This process is crucial for the immune response to infections and injuries.

    • This question is part of the following fields:

      • General Principles
      19.9
      Seconds
  • Question 23 - What is the leading reason for hypoglycemia in adults? ...

    Correct

    • 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.

    • This question is part of the following fields:

      • Clinical Sciences
      16.8
      Seconds
  • Question 24 - A 49-year-old woman visits her GP complaining of low mood, fatigue, constipation, and...

    Correct

    • A 49-year-old woman visits her GP complaining of low mood, fatigue, constipation, and urinary frequency. The doctor orders a standard blood test to investigate the possible cause. After reviewing the results, the GP diagnosis the woman with primary hyperparathyroidism.

      What blood test results are expected for this patient?

      Your Answer: Raised calcium, low phosphate

      Explanation:

      Parathyroid hormone (PTH) is responsible for increasing plasma calcium levels and decreasing plasma phosphate levels. Hyperparathyroidism is a condition where there is an excess of PTH, either due to an overactive parathyroid gland (primary) or a low serum calcium level (secondary). Primary hyperparathyroidism results in raised calcium levels and low phosphate levels, while secondary hyperparathyroidism is typically seen in chronic kidney disease. PTH acts by increasing calcium reabsorption in the kidneys and digestive tract, as well as increasing bone resorption. This helps to prevent the formation of calcium phosphate crystals, which can cause renal stones. Symptoms of hyperparathyroidism include constipation and low mood, which are typical of hypercalcaemia.

      Hormones Controlling Calcium Metabolism

      Calcium metabolism is primarily controlled by two hormones, parathyroid hormone (PTH) and 1,25-dihydroxycholecalciferol (calcitriol). Other hormones such as calcitonin, thyroxine, and growth hormone also play a role. PTH increases plasma calcium levels and decreases plasma phosphate levels. It also increases renal tubular reabsorption of calcium, osteoclastic activity, and renal conversion of 25-hydroxycholecalciferol to 1,25-dihydroxycholecalciferol. On the other hand, 1,25-dihydroxycholecalciferol increases plasma calcium and plasma phosphate levels, renal tubular reabsorption and gut absorption of calcium, osteoclastic activity, and renal phosphate reabsorption. It is important to note that osteoclastic activity is increased indirectly by PTH as osteoclasts do not have PTH receptors. Understanding the actions of these hormones is crucial in maintaining proper calcium metabolism in the body.

    • This question is part of the following fields:

      • General Principles
      13.6
      Seconds
  • Question 25 - At what age is a ventricular septal defect typically diagnosed, and what cardiovascular...

    Incorrect

    • At what age is a ventricular septal defect typically diagnosed, and what cardiovascular structure is responsible for its development due to embryological failure?

      Your Answer: Foramen ovale

      Correct Answer: Endocardial cushions

      Explanation:

      The heart’s development starts at approximately day 18 in the embryo, originating from a group of cells in the cardiogenic area of the mesoderm. The underlying endoderm signals the formation of the cardiogenic cords, which fuse together to create the primitive heart tube.

      Around day 22, the primitive heart tube develops into five regions: the truncus arteriosus, bulbus cordis, primitive ventricle, primitive atrium, and sinus venosus. These regions eventually become the ascending aorta and pulmonary trunk, right and left ventricles, anterior atrial walls and appendages, and coronary sinus and sino-atrial node, respectively.

      Over the next week, the heart undergoes morphogenesis, twisting and looping from a vertical tube into a premature heart with atrial and ventricular orientation present by day 28. The endocardial cushions, thickenings of mesoderm in the inner lining of the heart walls, appear and grow towards each other, dividing the atrioventricular canal into left and right sides. Improper development of the endocardial cushions can result in a ventricular septal defect.

      By the end of the fifth week, the four heart chamber positions are complete, and the atrioventricular and semilunar valves form between the fifth and ninth weeks.

      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.

    • This question is part of the following fields:

      • Cardiovascular System
      13
      Seconds
  • Question 26 - A 32-year-old woman arrives at the emergency department complaining of sudden shortness of...

    Incorrect

    • A 32-year-old woman arrives at the emergency department complaining of sudden shortness of breath and a sharp pain on the right side of her chest that worsens with inspiration. Upon examination, the doctor observes hyper-resonance and reduced breath sounds on the right side of her chest.

      What is a risk factor for this condition, considering the probable diagnosis?

      Your Answer: Female sex

      Correct Answer: Cystic fibrosis

      Explanation:

      Pneumothorax can be identified by reduced breath sounds and a hyper-resonant chest on the same side as the pain. Cystic fibrosis is a significant risk factor for pneumothorax due to the frequent chest infections, lung remodeling, and air trapping associated with the disease. While tall, male smokers are also at increased risk, Marfan’s syndrome, not Turner syndrome, is a known risk factor.

      Pneumothorax: Characteristics and Risk Factors

      Pneumothorax is a medical condition characterized by the presence of air in the pleural cavity, which is the space between the lungs and the chest wall. This condition can occur spontaneously or as a result of trauma or medical procedures. There are several risk factors associated with pneumothorax, including pre-existing lung diseases such as COPD, asthma, cystic fibrosis, lung cancer, and Pneumocystis pneumonia. Connective tissue diseases like Marfan’s syndrome and rheumatoid arthritis can also increase the risk of pneumothorax. Ventilation, including non-invasive ventilation, can also be a risk factor.

      Symptoms of pneumothorax tend to come on suddenly and can include dyspnoea, chest pain (often pleuritic), sweating, tachypnoea, and tachycardia. In some cases, catamenial pneumothorax can be the cause of spontaneous pneumothoraces occurring in menstruating women. This type of pneumothorax is thought to be caused by endometriosis within the thorax. Early diagnosis and treatment of pneumothorax are crucial to prevent complications and improve outcomes.

    • This question is part of the following fields:

      • Respiratory System
      25.4
      Seconds
  • Question 27 - A 42-year-old male patient is experiencing acute renal failure, fever, weight loss, and...

    Incorrect

    • A 42-year-old male patient is experiencing acute renal failure, fever, weight loss, and livedo reticularis. Upon renal biopsy, there is evidence of neutrophilic and eosinophilic infiltration in artery walls with fibrinoid necrosis. What is the most probable circulating antibody present in this patient?

      Your Answer: AMA

      Correct Answer: ANCA

      Explanation:

      Polyarteritis Nodosa and Associated Antibodies

      Polyarteritis nodosa (PAN) is a type of vasculitis that affects medium-sized arteries, particularly those in the renal vasculature. Patients with PAN may experience vague symptoms such as malaise, weight loss, anemia, fever, and non-specific pains. However, more specific features of PAN include acute renal failure with beading of the renal vessel on angiography, livedo reticularis, the presence of pANCA in the blood, and granulomas with eosinophilic infiltrate on biopsy. While the majority of PAN cases are idiopathic, it can also be associated with hepatitis B virus infection.

      In addition to PAN, there are other autoimmune or inflammatory conditions that may be associated with specific antibodies. For example, anti-mitochondrial antibody (AMA) is strongly associated with primary biliary cirrhosis, while Antinuclear antibodies (ANA) are non-specific and may be present in conditions such as SLE, autoimmune hepatitis, post-infection, and inflammatory bowel disease. Therefore, the presence of certain antibodies can aid in the diagnosis and management of these conditions.

    • This question is part of the following fields:

      • Clinical Sciences
      10.6
      Seconds
  • Question 28 - A 67-year-old woman presents with 6 months of gradually increasing abdominal distension, abdominal...

    Incorrect

    • A 67-year-old woman presents with 6 months of gradually increasing abdominal distension, abdominal pain and feeling full quickly. She has also experienced recent weight loss. Upon examination, her abdomen is distended with signs of ascites. Her cancer antigen 125 (CA-125) level is elevated (550 IU/mL). An abdominal ultrasound reveals a mass in the left ovary. What is the most frequent histological subtype of the mass, based on the most probable diagnosis?

      Your Answer: Endometrioid

      Correct Answer: Serous

      Explanation:

      Understanding Ovarian Cancer: Risk Factors, Symptoms, and Management

      Ovarian cancer is a type of cancer that affects women, with the peak age of incidence being 60 years. It is the fifth most common malignancy in females and carries a poor prognosis due to late diagnosis. Around 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas. Interestingly, recent studies suggest that the distal end of the fallopian tube is often the site of origin of many ‘ovarian’ cancers.

      There are several risk factors associated with ovarian cancer, including a family history of mutations of the BRCA1 or the BRCA2 gene, early menarche, late menopause, and nulliparity. Clinical features of ovarian cancer are notoriously vague and can include abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms, early satiety, and diarrhea.

      To diagnose ovarian cancer, a CA125 test is usually done initially. If the CA125 level is raised, an urgent ultrasound scan of the abdomen and pelvis should be ordered. However, a CA125 should not be used for screening for ovarian cancer in asymptomatic women. Diagnosis is difficult and usually involves diagnostic laparotomy.

      Management of ovarian cancer usually involves a combination of surgery and platinum-based chemotherapy. The prognosis for ovarian cancer is poor, with 80% of women having advanced disease at presentation and the all stage 5-year survival being 46%. It is traditionally taught that infertility treatment increases the risk of ovarian cancer, as it increases the number of ovulations. However, recent evidence suggests that there is not a significant link. The combined oral contraceptive pill reduces the risk (fewer ovulations) as does having many pregnancies.

    • This question is part of the following fields:

      • Reproductive System
      16.6
      Seconds
  • Question 29 - As a junior doctor, you are taking the medical history of a patient...

    Correct

    • As a junior doctor, you are taking the medical history of a patient who is scheduled for an elective knee replacement. During the physical examination, you hear a diastolic murmur and observe a collapsing pulse while checking the heart rate. Upon examining the hands, you notice pulsations of red coloration on the nail beds. Other than these findings, the examination appears normal.

      What could be the probable reason behind these examination results if the patient is slightly older?

      Your Answer: Aortic regurgitation

      Explanation:

      The patient’s examination findings suggest aortic regurgitation, which is characterized by an early diastolic, high-pitched, blowing murmur that is louder when the patient sits forward and at the left sternal edge. Aortic regurgitation can also cause a collapsing pulse, dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, and visible pulsing red colouration of the nails (quincke’s sign).

      It is important to note that aortic stenosis does not cause a diastolic murmur or collapsing pulse. Instead, it typically produces an ejection systolic murmur that is louder on expiration and may cause a slow rising pulse.

      Similarly, mitral regurgitation does not cause a diastolic murmur or collapsing pulse. It typically produces a pansystolic murmur.

      Mitral stenosis causes a mid-late diastolic murmur but does not commonly cause a collapsing pulse.

      Pulmonary stenosis causes an ejection systolic murmur but does not commonly cause a collapsing pulse or diastolic murmur.

      Aortic regurgitation is a condition where the aortic valve of the heart leaks, causing blood to flow in the opposite direction during ventricular diastole. This can be caused by disease of the aortic valve or by distortion or dilation of the aortic root and ascending aorta. The most common causes of AR due to valve disease include rheumatic fever, calcific valve disease, and infective endocarditis. On the other hand, AR due to aortic root disease can be caused by conditions such as aortic dissection, hypertension, and connective tissue diseases like Marfan’s and Ehler-Danlos syndrome.

      The features of AR include an early diastolic murmur, a collapsing pulse, wide pulse pressure, Quincke’s sign, and De Musset’s sign. In severe cases, a mid-diastolic Austin-Flint murmur may also be present. Suspected AR should be investigated with echocardiography.

      Management of AR involves medical management of any associated heart failure and surgery in symptomatic patients with severe AR or asymptomatic patients with severe AR who have LV systolic dysfunction.

    • This question is part of the following fields:

      • Cardiovascular System
      16.3
      Seconds
  • Question 30 - A 49-year-old woman comes to the Emergency Department complaining of colicky abdominal pain....

    Incorrect

    • A 49-year-old woman comes to the Emergency Department complaining of colicky abdominal pain. She states that she has been having on-and-off pain in the upper right quadrant for the past few months, especially after consuming fatty foods.

      Which cells are accountable for generating the hormone linked to this presentation?

      Your Answer: G cells

      Correct Answer: I cells

      Explanation:

      The correct answer is I cells, which are located in the upper small intestine. This patient’s symptoms are consistent with biliary colic, which occurs when the gallbladder contracts against an obstruction, typically a gallstone. Fatty foods stimulate the production of cholecystokinin (CCK) from the I cells in the duodenum, which promotes gallbladder contractility and the release of bile into the small intestine to aid in lipid emulsification.

      B cells are not involved in promoting gallbladder contractility and are instead part of the adaptive immune response. D cells release somatostatin, which decreases insulin production, and are found in the stomach, small intestine, and pancreas. G cells are located in the stomach and secrete gastrin to promote acid secretion by the parietal cells of the stomach.

      Overview of Gastrointestinal Hormones

      Gastrointestinal hormones play a crucial role in the digestion and absorption of food. These hormones are secreted by various cells in the stomach and small intestine in response to different stimuli such as the presence of food, pH changes, and neural signals.

      One of the major hormones involved in food digestion is gastrin, which is secreted by G cells in the antrum of the stomach. Gastrin increases acid secretion by gastric parietal cells, stimulates the secretion of pepsinogen and intrinsic factor, and increases gastric motility. Another hormone, cholecystokinin (CCK), is secreted by I cells in the upper small intestine in response to partially digested proteins and triglycerides. CCK increases the secretion of enzyme-rich fluid from the pancreas, contraction of the gallbladder, and relaxation of the sphincter of Oddi. It also decreases gastric emptying and induces satiety.

      Secretin is another hormone secreted by S cells in the upper small intestine in response to acidic chyme and fatty acids. Secretin increases the secretion of bicarbonate-rich fluid from the pancreas and hepatic duct cells, decreases gastric acid secretion, and has a trophic effect on pancreatic acinar cells. Vasoactive intestinal peptide (VIP) is a neural hormone that stimulates secretion by the pancreas and intestines and inhibits acid secretion.

      Finally, somatostatin is secreted by D cells in the pancreas and stomach in response to fat, bile salts, and glucose in the intestinal lumen. Somatostatin decreases acid and pepsin secretion, decreases gastrin secretion, decreases pancreatic enzyme secretion, and decreases insulin and glucagon secretion. It also inhibits the trophic effects of gastrin and stimulates gastric mucous production.

      In summary, gastrointestinal hormones play a crucial role in regulating the digestive process and maintaining homeostasis in the gastrointestinal tract.

    • This question is part of the following fields:

      • Gastrointestinal System
      14.8
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SESSION STATS - PERFORMANCE PER SPECIALTY

General Principles (2/7) 29%
Haematology And Oncology (0/2) 0%
Musculoskeletal System And Skin (1/4) 25%
Psychiatry (1/1) 100%
Neurological System (1/2) 50%
Cardiovascular System (2/6) 33%
Gastrointestinal System (0/2) 0%
Clinical Sciences (1/3) 33%
Rheumatology (1/1) 100%
Respiratory System (0/1) 0%
Reproductive System (0/1) 0%
Passmed