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Question 1
Correct
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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.
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This question is part of the following fields:
- Reproductive Medicine
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Question 2
Correct
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A 38-year-old woman with rheumatoid arthritis visits her doctor every three months for blood tests. Which of the following blood tests is necessary for monitoring the use of methotrexate?
Your Answer: FBC, U&Es, LFTs
Explanation:Importance of Drug Monitoring in Primary Care
Patients on methotrexate require regular monitoring of their blood tests to prevent severe side effects. The three essential blood tests that need monitoring are FBC, U&Es, and LFTs. Methotrexate can cause blood dyscrasias, liver cirrhosis, and kidney failure, making it crucial to monitor these tests every 2-3 months once therapy has stabilized. Patients should report any symptoms of infection, bruising, mouth ulcers, abdominal discomfort, dark urine, and shortness of breath. They should also avoid self-medication with over-the-counter aspirin or ibuprofen.
Thyroid function is not affected by methotrexate, and regular monitoring is not necessary unless there is another medical condition that justifies it. However, patients on methotrexate should report any signs of blood disorders such as ecchymosis and telangiectasia.
Drug monitoring is becoming increasingly common in primary care, especially for patients under shared care with secondary/specialty care. Some examples of drug monitoring in primary care include amiodarone, azathioprine, lithium, and methotrexate. Each drug requires specific blood tests, and the frequency of monitoring varies. For instance, patients on methotrexate require FBC, U&Es, and LFTs every 2-3 months.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 3
Correct
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Which of the following causes of diarrhea has the briefest incubation period?
Your Answer: Bacillus cereus
Explanation:Gastroenteritis can occur either at home or while traveling, known as travelers’ diarrhea. This condition is characterized by at least three loose to watery stools in 24 hours, accompanied by abdominal cramps, fever, nausea, vomiting, or blood in the stool. The most common cause of travelers’ diarrhea is Escherichia coli. Acute food poisoning is another pattern of illness that results in sudden onset of nausea, vomiting, and diarrhea after ingesting a toxin. Staphylococcus aureus, Bacillus cereus, or Clostridium perfringens are typically responsible for acute food poisoning.
There are several types of infections that can cause gastroenteritis, each with its own typical presentation. Escherichia coli is common among travelers and causes watery stools, abdominal cramps, and nausea. Giardiasis results in prolonged, non-bloody diarrhea, while cholera causes profuse, watery diarrhea and severe dehydration leading to weight loss. Shigella causes bloody diarrhea, vomiting, and abdominal pain, while Staphylococcus aureus results in severe vomiting with a short incubation period. Campylobacter typically starts with a flu-like prodrome and progresses to crampy abdominal pains, fever, and diarrhea, which may be bloody and mimic appendicitis. Bacillus cereus can cause two types of illness, vomiting within six hours, typically due to rice, or diarrheal illness occurring after six hours. Amoebiasis has a gradual onset of bloody diarrhea, abdominal pain, and tenderness that may last for several weeks.
The incubation period for gastroenteritis varies depending on the type of infection. Staphylococcus aureus and Bacillus cereus have an incubation period of 1-6 hours, while Salmonella and Escherichia coli have an incubation period of 12-48 hours. Shigella and Campylobacter have an incubation period of 48-72 hours, while Giardiasis and Amoebiasis have an incubation period of more than seven days.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 4
Incorrect
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As a foundation doctor in general surgery, you are assisting your consultant in a surgical exploration of a suspected testicular torsion in a patient with a bell clapper deformity. The patient, who is in his early twenties, has been experiencing symptoms for six hours. Upon examination, the surgery confirms the presence of testicular torsion.
What is the appropriate course of action for the surgeon to take in this situation?Your Answer: Unilateral orchiectomy
Correct Answer: Fixation of both testicles
Explanation:To prevent future torsion of the other testicle, it is recommended that both testes be fixed during testicular torsion surgery. While manual rotation may be successful in some cases, it is not appropriate once surgery has begun. If a bell clapper deformity is present, both testes should be fixed if they are still viable. Given the short duration of symptoms (only six hours), it is unlikely that surgical removal (orchiectomy) will be necessary.
Testicular Torsion: Causes, Symptoms, and Treatment
Testicular torsion is a medical condition that occurs when the spermatic cord twists, leading to testicular ischaemia and necrosis. This condition is most common in males aged between 10 and 30, with a peak incidence between 13 and 15 years. The symptoms of testicular torsion are sudden and severe pain, which may be referred to the lower abdomen. Nausea and vomiting may also be present. On examination, the affected testis is usually swollen, tender, and retracted upwards, with reddened skin. The cremasteric reflex is lost, and elevation of the testis does not ease the pain (Prehn’s sign).
The treatment for testicular torsion is urgent surgical exploration. If a torted testis is identified, both testes should be fixed, as the condition of bell clapper testis is often bilateral.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 5
Incorrect
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As a junior doctor on the postnatal ward, you perform a newborn examination on a twelve-hour-old baby delivered vaginally. During the examination, you observe a scalp swelling that has poorly defined margins and crosses suture lines. The swelling is soft and pitted on pressure. The mother reports that the swelling has been present since birth. What is the probable diagnosis?
Your Answer: Subgaleal haematoma
Correct Answer: Caput succedaneum
Explanation:Scalp edema known as caput seccedaneum can be identified by its ability to extend beyond the suture lines during examination.
Understanding Caput Succedaneum
Caput succedaneum is a condition that refers to the swelling of the scalp at the top of the head, usually at the vertex. This swelling is caused by the mechanical trauma that occurs during delivery, particularly in prolonged deliveries or those that involve the use of vacuum delivery. The condition is characterized by soft, puffy swelling due to localized edema that crosses suture lines.
Compared to cephalohaematoma, which is a collection of blood under the scalp, caput succedaneum is caused by edema. While cephalohaematoma is limited to a specific area and does not cross suture lines, caput succedaneum can affect a larger area and cross suture lines. Fortunately, no treatment is needed for caput succedaneum, as the swelling usually resolves on its own within a few days.
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This question is part of the following fields:
- Paediatrics
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Question 6
Incorrect
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A 63-year-old man presents to the haematology clinic with fatigue, significant weight loss, and easy bruising over the past 2 years. His blood test results are as follows:
- Hemoglobin: 90 g/L (normal range for males: 135-180 g/L; females: 115-160 g/L)
- Platelets: 85 * 109/L (normal range: 150-400 * 109/L)
- White blood cells: 70.5 * 109/L (normal range: 4.0-11.0 * 109/L)
- Neutrophils: 61.8 * 109/L (normal range: 2.0-7.0 * 109/L)
- Lymphocytes: 1.2 * 109/L (normal range: 1.0-3.5 * 109/L)
- Monocytes: 3.0 * 109/L (normal range: 0.2-0.8 * 109/L)
- Eosinophils: 2.5 * 109/L (normal range: 0.0-0.4 * 109/L)
The blood film shows obvious leucocytosis with eosinophilia and basophilia visible. There are also large numbers of immature granulocytes, but no blast cells are visible. What is the most appropriate first-line treatment for this patient?Your Answer: Fludarabine and cyclophosphamide
Correct Answer: Imatinib
Explanation:The patient’s history and blood results suggest that they have chronic myeloid leukaemia (CML), which is characterized by a high white cell count due to an excess of myeloid cells and a chronic presentation. The absence of blast cells indicates that this is not acute leukaemia. The patient’s anaemia and thrombocytopenia are likely due to bone marrow dysfunction caused by myelofibrosis, indicating a need for treatment. The first-line treatment for CML is imatinib, a tyrosine kinase inhibitor that is taken as a daily tablet and has shown excellent results in treating CML.
Given the patient’s signs of bone marrow dysfunction, conservative management is not appropriate. While there may be a role for no treatment in early disease detected incidentally on a blood test, this patient requires treatment at this point.
It is important to note that fludarabine and cyclophosphamide are chemotherapy agents used in treating chronic lymphocytic leukaemia (CLL) and have no role in managing CML. The blood test abnormalities expected in CLL are similar to those seen in CML, but with a differential showing normal or low neutrophil and high lymphocyte counts.
Prednisolone, a glucocorticoid used to treat various conditions, is often used in treating different forms of lymphoma but is not effective in managing CML.
Understanding Chronic Myeloid Leukaemia and its Management
Chronic myeloid leukaemia (CML) is a type of cancer that affects the blood and bone marrow. It is characterized by the presence of the Philadelphia chromosome in more than 95% of patients. This chromosome is formed due to a translocation between chromosomes 9 and 22, resulting in the fusion of the ABL proto-oncogene and the BCR gene. The resulting BCR-ABL gene produces a fusion protein that has excessive tyrosine kinase activity.
CML typically affects individuals between 60-70 years of age and presents with symptoms such as anaemia, weight loss, sweating, and splenomegaly. The condition is also associated with an increase in granulocytes at different stages of maturation and thrombocytosis. In some cases, CML may undergo blast transformation, leading to acute myeloid leukaemia (AML) or acute lymphoblastic leukaemia (ALL).
The management of CML involves various treatment options, including imatinib, which is considered the first-line treatment. Imatinib is an inhibitor of the tyrosine kinase associated with the BCR-ABL defect and has a very high response rate in the chronic phase of CML. Other treatment options include hydroxyurea, interferon-alpha, and allogenic bone marrow transplant. With proper management, individuals with CML can lead a normal life.
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This question is part of the following fields:
- Haematology/Oncology
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Question 7
Incorrect
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You are evaluating a 67-year-old patient in the renal clinic who has been undergoing haemodialysis for chronic kidney disease for the last 6 years. What is the leading cause of mortality in this patient population?
Your Answer: Dialysis related sepsis
Correct Answer: Ischaemic heart disease
Explanation:Causes of Chronic Kidney Disease
Chronic kidney disease is a condition that affects the kidneys, causing them to gradually lose their ability to function properly. There are several common causes of this condition, including diabetic nephropathy, chronic glomerulonephritis, chronic pyelonephritis, hypertension, and adult polycystic kidney disease.
Diabetic nephropathy is a complication of diabetes that occurs when high blood sugar levels damage the small blood vessels in the kidneys. Chronic glomerulonephritis is a condition in which the glomeruli, the tiny filters in the kidneys, become inflamed and damaged over time. Chronic pyelonephritis is a type of kidney infection that can cause scarring and damage to the kidneys. Hypertension, or high blood pressure, can also damage the kidneys over time. Finally, adult polycystic kidney disease is an inherited condition in which cysts form in the kidneys, causing them to enlarge and lose function.
It is important to identify the underlying cause of chronic kidney disease in order to properly manage the condition and prevent further damage to the kidneys. Treatment may involve medications, lifestyle changes, and in some cases, dialysis or kidney transplant.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 8
Incorrect
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A 42-year-old woman visits her GP clinic with a blistering rash around her right eye that developed overnight. Upon examination, the eye appears to be unaffected. The GP promptly contacts the nearby hospital rapid access eye clinic for guidance.
What is the most suitable course of treatment?Your Answer:
Correct Answer: Oral aciclovir
Explanation:Herpes Zoster Ophthalmicus: Symptoms, Treatment, and Complications
Herpes zoster, commonly known as shingles, is a reactivation of the varicella-zoster virus that causes chickenpox. Herpes zoster ophthalmicus (HZO) occurs when the virus affects the trigeminal nerve, resulting in eye involvement in about 50% of cases. Symptoms include patchy erythema and grouped herpetiform vesicles, which may extend to the tip of the nose. Other ophthalmic manifestations include conjunctivitis, scleritis, keratitis, and optic neuritis. Urgent referral to ophthalmology is necessary in the presence of eye involvement, as it poses a risk to vision. Treatment involves oral aciclovir and topical aciclovir for severe eye infection. There is no recommendation for the use of carbamazepine in the management of post-herpetic neuralgia. Topical steroids are not indicated for herpes zoster infection. Complications of HZO include post-herpetic neuralgia and scarring. Aggressive treatment and follow-up monitoring are required for HZO due to the possibility of eye involvement.
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This question is part of the following fields:
- Ophthalmology
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Question 9
Incorrect
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A 28-year-old man with ankylosing spondylitis (AS) comes in with photophobia and a painful red eye.
What is the most probable diagnosis?Your Answer:
Correct Answer: Uveitis
Explanation:Understanding Eye Conditions Associated with Ankylosing Spondylitis
Ankylosing spondylitis (AS) is a chronic inflammatory disorder that primarily affects the sacroiliac joints and axial skeleton. However, it can also lead to various eye conditions. Uveitis, also known as iritis or iridocyclitis, is the most common extra-articular manifestation of AS, occurring in 20-30% of patients. Acute anterior uveitis is often unilateral and presents with symptoms such as a painful red eye, photophobia, and blurred vision. Patients with uveitis may also have or develop other spondyloarthropathies, including reactive arthritis, undifferentiated spondyloarthropathy, and psoriatic arthritis.
Acute angle-closure glaucoma, on the other hand, is not associated with AS. It is a medical emergency that needs immediate treatment to prevent vision loss. Conjunctivitis, which is responsible for approximately 30% of all eye complaints, is usually benign and self-limited. Herpes zoster ophthalmicus and keratoconus are also not associated with AS.
It is important for patients with AS to be aware of these potential eye conditions and seek urgent ophthalmological assessment if they experience any symptoms. Early diagnosis and treatment can prevent vision loss and improve outcomes.
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This question is part of the following fields:
- Ophthalmology
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Question 10
Incorrect
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A young librarian seeks therapy as he is lonely and unhappy. He describes a solitary life cataloguing books all day and then remaining alone all night and on weekends. He declines invitations for dinners, as he feels anxious when other people are around.
Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Social phobia
Explanation:Differentiating Anxiety Disorders: A Vignette Analysis
The following vignette describes a patient with symptoms of anxiety in a social situation. To properly diagnose the patient, it is important to differentiate between various anxiety disorders.
Social Phobia: This disorder is characterized by anxiety in public, particularly when feeling scrutinized. It typically starts in adolescence and is equally prevalent in men and women. Some patients have a specific social phobia, while others have a more diffuse type. Treatment is mainly with psychological interventions.
Generalized Anxiety Disorder (GAD): GAD is characterized by non-specific and persistent anxiety. Patients feel anxious most days for periods of at least several weeks, and may experience a variety of worries that are not objectively warranted by their circumstances. Autonomic and motor overactivity are also common.
Panic Disorder: Panic attacks are recurrent episodes of severe anxiety that occur unpredictably and under unrestricted circumstances. A diagnosis of panic disorder can be given only if several panic attacks have occurred in about 1 month in situations that do not pose an objective danger, in unrestricted circumstances and with relative freedom from symptoms of anxiety between attacks.
Separation Anxiety Disorder: This disorder is mainly diagnosed in children, although an adult form has been increasingly recognized. Symptoms include anxiety and fear when separated from emotionally attached individuals, and avoidance of being alone.
Conduct Disorder: This disorder is a precursor to dissocial personality disorder and presents as a persistent and repetitive pattern of dissocial behavior beyond the expected mischief and rebelliousness of childhood and adolescence.
In the vignette, the patient’s anxiety is specific to certain situations and therefore predictable, which excludes the diagnosis of panic disorder. The patient’s symptoms do not fit the criteria for GAD or separation anxiety disorder. The most likely diagnosis is social phobia, which is characterized by anxiety in public situations.
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This question is part of the following fields:
- Psychiatry
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Question 11
Incorrect
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Cataracts are usually not associated with which of the following conditions? Please select only one option from the list below.
Your Answer:
Correct Answer: Thyrotoxicosis
Explanation:Common Causes of Cataracts and Their Associated Symptoms
Cataracts are a common eye condition that can cause visual impairment. While ageing is the most common cause, there are several other factors that can contribute to cataract development. Here are some of the common causes of cataracts and their associated symptoms:
1. Thyrotoxicosis: This condition involves excess synthesis and secretion of thyroid hormones, leading to the hypermetabolic condition of thyrotoxicosis. Symptoms include sympathetic activation in younger patients and cardiovascular symptoms and unexplained weight loss in older patients. Approximately 50% of patients with Graves-thyrotoxicosis have mild thyroid ophthalmopathy, which can cause periorbital edema, conjunctival edema, poor lid closure, extraocular muscle dysfunction, and proptosis.
2. Diabetes mellitus: Patients with diabetes are at risk of developing several ophthalmic complications, including cataracts. Epidemiological studies have shown that cataracts are the most common cause of visual impairment in patients with older-onset diabetes. Hyperglycemia is associated with loss of lens transparency, and rapid decline of serum glucose levels in patients with marked hyperglycemia may induce temporary lens opacification and swelling.
3. Myotonic dystrophy: This chronic genetic disorder affects muscle function and can cause gradually worsening muscle atrophy and weakness. Other symptoms include cataracts, intellectual disability, and heart conduction abnormalities. Myotonic dystrophy may cause a cortical cataract with a blue dot appearance or a posterior subcapsular cataract.
4. Rubella: Congenital cataracts are usually diagnosed at birth and can be associated with ocular abnormalities, trauma, or intrauterine infection, particularly rubella. Congenital rubella infection may result in growth delay, learning disability, hearing loss, congenital heart disease, and eye, endocrinological, and neurological abnormalities.
5. Hypoparathyroidism: This condition is characterized by hypocalcemia, hyperphosphatemia, and low or inappropriately normal levels of parathyroid hormone. Patients may present with hypocalcemia, mental changes, and neuromuscular excitability or tetany. Anatomical abnormalities, although not readily apparent, include deposition of calcium in soft tissues, including intracranial calcifications and cataract formation.
In addition to these causes, cataracts can also be caused by trauma
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This question is part of the following fields:
- Ophthalmology
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Question 12
Incorrect
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A 25-year-old actress visits your clinic seeking advice on contraception. She expresses concern about weight gain as she needs to maintain her figure for her profession. Which contraceptive method has been linked to weight gain?
Your Answer:
Correct Answer: Depo Provera (Medroxyprogesterone acetate)
Explanation:Weight gain is a known side effect of the Depo Provera contraceptive method. Additionally, it may take up to a year for fertility to return after discontinuing use, and there is an increased risk of osteoporosis and irregular bleeding. Other contraceptive methods such as the combined pill, progesterone only pill, and subdermal implant do not have a proven link to weight gain.
Injectable Contraceptives: Depo Provera
Injectable contraceptives are a popular form of birth control in the UK, with Depo Provera being the main option available. This contraceptive contains 150mg of medroxyprogesterone acetate and is administered via intramuscular injection every 12 weeks. It can be given up to 14 weeks after the last dose without the need for extra precautions. The primary method of action is by inhibiting ovulation, while secondary effects include cervical mucus thickening and endometrial thinning.
However, there are some disadvantages to using Depo Provera. Once the injection is given, it cannot be reversed, and there may be a delayed return to fertility of up to 12 months. Adverse effects may include irregular bleeding and weight gain, and there is a potential increased risk of osteoporosis. It should only be used in adolescents if no other method of contraception is suitable.
It is important to note that there are contraindications to using Depo Provera, such as current breast cancer (UKMEC 4) or past breast cancer (UKMEC 3). While Noristerat is another injectable contraceptive licensed in the UK, it is rarely used in clinical practice and is given every 8 weeks. Overall, injectable contraceptives can be an effective form of birth control, but it is important to weigh the potential risks and benefits before deciding on this method.
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This question is part of the following fields:
- Reproductive Medicine
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Question 13
Incorrect
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A 49-year-old man comes to the emergency department complaining of dizziness and shortness of breath on exertion for the past 3 days. He reports experiencing palpitations during this time but denies any chest pain or cough. The patient has a history of hypertension and angina, for which he takes amlodipine and GTN spray, respectively. Upon examination, he appears alert and oriented, but his vital signs reveal a heart rate of 170 BPM, respiratory rate of 25 breaths/min, and blood pressure of 72/50 mmHg. An ECG shows a narrow complex irregular tachycardia without P waves. What is the most crucial next step in management?
Your Answer:
Correct Answer: Electrical cardioversion
Explanation:In the case of an acute presentation of atrial fibrillation with signs of haemodynamic instability such as hypotension or heart failure, the correct treatment is electrical cardioversion. This is because the patient is at risk of going into cardiac arrest and needs to be returned to normal sinus rhythm immediately to prevent end organ damage. Giving a bolus of IV saline is not recommended as it will not push more blood into the ventricles and could even be harmful. Starting high dose aspirin or bisoprolol is not appropriate in this situation. Digoxin is only considered as a second line treatment for stable patients, so pharmacologic therapies are not considered until after cardioversion has been attempted and blood pressure returns to normal.
Atrial fibrillation (AF) is a condition that requires careful management to prevent complications. The latest guidelines from NICE recommend that patients presenting with AF should be assessed for haemodynamic instability, and if present, electrically cardioverted. For haemodynamically stable patients, the management depends on how acute the AF is. If the AF has been present for less than 48 hours, rate or rhythm control may be considered. However, if it has been present for 48 hours or more, or the onset is uncertain, rate control is recommended. If long-term rhythm control is being considered, cardioversion should be delayed until the patient has been maintained on therapeutic anticoagulation for at least 3 weeks.
Rate control is the first-line treatment strategy for AF, except in certain cases. Medications such as beta-blockers, calcium channel blockers, and digoxin can be used to control the heart rate. However, digoxin is no longer considered first-line as it is less effective at controlling the heart rate during exercise. Rhythm control agents such as beta-blockers, dronedarone, and amiodarone can be used to maintain sinus rhythm in patients with a history of AF. Catheter ablation is recommended for those who have not responded to or wish to avoid antiarrhythmic medication.
The aim of catheter ablation is to ablate the faulty electrical pathways that are causing AF. The procedure is performed percutaneously, typically via the groin, and can use radiofrequency or cryotherapy to ablate the tissue. Anticoagulation should be used 4 weeks before and during the procedure. It is important to note that catheter ablation controls the rhythm but does not reduce the stroke risk, so patients still require anticoagulation as per their CHA2DS2-VASc score. Complications of catheter ablation can include cardiac tamponade, stroke, and pulmonary vein stenosis. The success rate of the procedure is around 50% for early recurrence within 3 months, and around 55% of patients who’ve had a single procedure remain in sinus rhythm after 3 years. Of patients who’ve undergone multiple procedures, around 80% are in sinus rhythm.
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This question is part of the following fields:
- Cardiovascular
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Question 14
Incorrect
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A 75 year-old woman comes to the clinic with a non-healing skin area on her ankle. She had a deep vein thrombosis 15 years ago after a hip replacement surgery. She is currently taking Adcal D3 and no other medications. During the examination, a superficial ulcer is observed in front of the medial malleolus. Apart from this, she is in good health. What test would be the most beneficial in deciding the next course of action?
Your Answer:
Correct Answer: Ankle-brachial pressure index
Explanation:The patient exhibits typical signs of a venous ulcer and appears to be in good overall health without any indications of infection. The recommended treatment for venous ulcers involves the use of compression dressings, but it is crucial to ensure that the patient’s arterial circulation is sufficient to tolerate some level of compression.
Venous Ulceration and its Management
Venous ulceration is a type of ulcer that is commonly seen above the medial malleolus. To assess for poor arterial flow that could impair healing, an ankle-brachial pressure index (ABPI) is important in non-healing ulcers. A normal ABPI is usually between 0.9 – 1.2, while values below 0.9 indicate arterial disease. Interestingly, values above 1.3 may also indicate arterial disease, particularly in diabetics, due to false-negative results caused by arterial calcification.
The only treatment that has been shown to be of real benefit for venous ulceration is compression bandaging, usually four-layer. Oral pentoxifylline, a peripheral vasodilator, can also improve the healing rate. There is some small evidence supporting the use of flavonoids, but little evidence to suggest benefit from hydrocolloid dressings, topical growth factors, ultrasound therapy, and intermittent pneumatic compression. Proper management of venous ulceration is crucial to promote healing and prevent complications.
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This question is part of the following fields:
- Dermatology
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Question 15
Incorrect
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A 43-year-old patient presents to the emergency department with complaints of feeling generally unwell. He reports experiencing body aches and waking up in a cold sweat at night. Upon examination, you observe injection marks on the antecubital fossa. His vital signs reveal a temperature of 38.1ºC, heart rate of 122 bpm, blood pressure of 110/90 mmHg, respiratory rate of 18/min, and oxygen saturation of 98%. You urgently order blood cultures and an echocardiogram. Based on the diagnosis, which site is most likely affected?
Your Answer:
Correct Answer: Tricuspid valve
Explanation:The tricuspid valve is the valve most commonly affected by infective endocarditis in intravenous drug users.
Aetiology of Infective Endocarditis
Infective endocarditis is a condition that affects patients with previously normal valves, rheumatic valve disease, prosthetic valves, congenital heart defects, intravenous drug users, and those who have recently undergone piercings. The strongest risk factor for developing infective endocarditis is a previous episode of the condition. The mitral valve is the most commonly affected valve.
The most common cause of infective endocarditis is Staphylococcus aureus, particularly in acute presentations and intravenous drug users. Historically, Streptococcus viridans was the most common cause, but this is no longer the case except in developing countries. Streptococcus mitis and Streptococcus sanguinis are the two most notable viridans streptococci, commonly found in the mouth and dental plaque. Coagulase-negative Staphylococci such as Staphylococcus epidermidis are the most common cause of endocarditis in patients following prosthetic valve surgery.
Streptococcus bovis is associated with colorectal cancer, with the subtype Streptococcus gallolyticus being most linked to the condition. Non-infective causes of endocarditis include systemic lupus erythematosus and malignancy. Culture negative causes may be due to prior antibiotic therapy or infections caused by Coxiella burnetii, Bartonella, Brucella, or HACEK organisms (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella).
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This question is part of the following fields:
- Infectious Diseases
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Question 16
Incorrect
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A 25-year-old female student attends the blood transfusion service wishing to donate blood. She is currently well, has never had a serious illness and weighs 60 kg. About three months ago she spent the summer doing voluntary work in Nigeria. She also had her ears pierced three years ago and had a tattoo put on her left arm one year ago. She is not acceptable as a donor.
Which of the following is the reason for her rejection to donate blood in the UK?Your Answer:
Correct Answer: Recent travel to an endemic area
Explanation:Blood Donation Eligibility Criteria: Factors to Consider
When it comes to donating blood, there are several factors to consider to ensure the safety of both the donor and the recipient. Here are some examples:
Recent travel to an endemic area: If a person has recently traveled to a country with a high risk of infectious diseases, they may have to wait a certain period before donating blood. For instance, if someone has returned from Nigeria, they must wait at least six months before donating blood in the UK.
Underweight: A person must weigh at least 50 kg to donate blood. If they weigh less than that, they may not have enough blood volume to spare.
Body piercing: If someone has had a body piercing within the last 12 months, they should inform the staff before donating blood. They may have to wait for at least four months before donating.
Tattoo: Similarly, if someone has had a tattoo within the last 12 months, they should inform the staff before donating blood. They may have to wait for at least four months before donating.
Age: To donate blood, a person must be between 17 and 66 years old (or 70 if they have donated blood before). If they are over 70, they can still donate if they have donated blood in the last two years.
By considering these factors, blood donation centers can ensure that the blood they collect is safe and suitable for transfusion.
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This question is part of the following fields:
- Haematology/Oncology
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Question 17
Incorrect
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A 25-year-old female patient visits the GP office complaining of occasional finger pain. She reports that her fingers turn pale, become painful and numb, and then return to normal after a few minutes. This is causing her significant distress, and she wishes to start treatment. She has a 10-pack-year smoking history, no other medical problems, and no other notable symptoms. What is the best course of action to take next?
Your Answer:
Correct Answer: Oral nifedipine
Explanation:Raynaud’s disease can be managed with non-pharmacological measures such as keeping warm, avoiding cold temperatures, wearing gloves, and quitting smoking. However, if symptoms persist, a first-line pharmacological option such as nifedipine, a dihydropyridine calcium channel blocker, can be considered. Intravenous epoprostenol is an option but not the first line due to potential adverse effects. Diltiazem, a non-dihydropyridine calcium channel blocker, should be avoided in this case. Beta-blockers such as metoprolol and propranolol should also be avoided as they can worsen Raynaud’s phenomenon.
Understanding Raynaud’s Phenomenon
Raynaud’s phenomenon is a condition where the digital arteries and cutaneous arteriole overreact to cold or emotional stress, causing an exaggerated vasoconstrictive response. It can be classified as primary or secondary. Primary Raynaud’s disease is more common in young women and presents with bilateral symptoms. On the other hand, secondary Raynaud’s phenomenon is associated with underlying connective tissue disorders such as scleroderma, rheumatoid arthritis, and systemic lupus erythematosus, among others.
Factors that suggest an underlying connective tissue disease include onset after 40 years, unilateral symptoms, rashes, presence of autoantibodies, and digital ulcers. Management of Raynaud’s phenomenon involves referral to secondary care for patients with suspected secondary Raynaud’s phenomenon. First-line treatment includes calcium channel blockers such as nifedipine. In severe cases, IV prostacyclin (epoprostenol) infusions may be used, and their effects may last for several weeks or months.
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This question is part of the following fields:
- Musculoskeletal
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Question 18
Incorrect
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A 7-year-old boy who has recently arrived from India complains of fever. During examination, extensive cervical lymphadenopathy is observed and a grey coating is seen surrounding the tonsils. What is the probable diagnosis?
Your Answer:
Correct Answer: Diphtheria
Explanation:Understanding Diphtheria: Causes, Symptoms, and Treatment
Diphtheria is a bacterial infection caused by the Gram positive bacterium Corynebacterium diphtheriae. The pathophysiology of this disease involves the release of an exotoxin encoded by a β-prophage, which inhibits protein synthesis by catalyzing ADP-ribosylation of elongation factor EF-2. This toxin commonly causes a ‘diphtheric membrane’ on tonsils, resulting in a grey, pseudomembrane on the posterior pharyngeal wall. Systemic distribution may produce necrosis of myocardial, neural, and renal tissue.
Possible presentations of diphtheria include sore throat with a ‘diphtheric membrane’, bulky cervical lymphadenopathy, and neuritis of cranial nerves. It may also result in a ‘bull neck’ appearance and heart block. People who have recently visited Eastern Europe, Russia, or Asia are at a higher risk of contracting this disease.
To diagnose diphtheria, a culture of throat swab is taken using tellurite agar or Loeffler’s media. The treatment for diphtheria involves intramuscular penicillin and diphtheria antitoxin.
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This question is part of the following fields:
- Infectious Diseases
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Question 19
Incorrect
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A 68-year-old woman comes to the emergency department complaining of fatigue and difficulty breathing for the past 2 days. She has a medical history of hypertension, a heart attack 3 years ago, heart failure, and a recent chest infection that was successfully treated with antibiotics. During the examination, the patient has bibasal crepitations and an elevated JVP. Her temperature is 37ºC, oxygen saturation is 95% on air, heart rate is 95 beats per minute, respiratory rate is 26 breaths per minute, and blood pressure is 129/86 mmHg.
What is the most appropriate course of treatment?Your Answer:
Correct Answer: IV furosemide
Explanation:The recommended treatment for acute pulmonary oedema in this patient is IV loop diuretic, specifically furosemide. This is because the patient is experiencing acute decompensated heart failure, which causes pulmonary oedema. IV loop diuretic has a prompt diuretic effect, reducing ventricular filling pressures and improving symptoms within 30 minutes.
IV dobutamine is not necessary for this patient as they are not in shock and dobutamine is typically reserved for patients with severe left ventricular dysfunction who have potentially reversible cardiogenic shock.
IV morphine is not recommended for acute heart failure as it may increase morbidity in patients with acute pulmonary oedema.
Oral furosemide is not the preferred route of administration for this patient as IV furosemide has a faster onset of diuresis.
Heart failure requires acute management, with recommended treatments for all patients including IV loop diuretics such as furosemide or bumetanide. Oxygen may also be necessary, with guidelines suggesting oxygen saturations be kept at 94-98%. Vasodilators such as nitrates should not be routinely given to all patients, but may have a role in cases of concomitant myocardial ischaemia, severe hypertension, or regurgitant aortic or mitral valve disease. However, hypotension is a major side-effect/contraindication. Patients with respiratory failure may require CPAP, while those with hypotension or cardiogenic shock may require inotropic agents like dobutamine or vasopressor agents like norepinephrine. Mechanical circulatory assistance such as intra-aortic balloon counterpulsation or ventricular assist devices may also be necessary. Regular medication for heart failure should be continued, with beta-blockers only stopped in certain circumstances. Opiates should not be routinely offered to patients with acute heart failure due to potential increased morbidity.
In summary, acute management of heart failure involves a range of treatments depending on the patient’s specific condition. It is important to carefully consider the potential side-effects and contraindications of each treatment, and to continue regular medication for heart failure where appropriate. Opiates should be used with caution, and only in cases where they are likely to reduce dyspnoea/distress without causing harm. With appropriate management, patients with acute heart failure can receive the care they need to improve their outcomes and quality of life.
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This question is part of the following fields:
- Respiratory Medicine
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Question 20
Incorrect
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A 65-year-old woman comes to you with complaints of feeling low and having trouble sleeping. Upon further discussion and administering a validated symptom measure, you diagnose her with moderate depression. She has a medical history of ischemic heart disease and is currently on aspirin, ramipril, and simvastatin. What would be the best course of action in this situation?
Your Answer:
Correct Answer: Start sertraline + lansoprazole
Explanation:Selective serotonin reuptake inhibitors (SSRIs) are commonly used as the first-line treatment for depression. Citalopram and fluoxetine are the preferred SSRIs, while sertraline is recommended for patients who have had a myocardial infarction. However, caution should be exercised when prescribing SSRIs to children and adolescents. Gastrointestinal symptoms are the most common side-effect, and patients taking SSRIs are at an increased risk of gastrointestinal bleeding. Patients should also be aware of the possibility of increased anxiety and agitation after starting a SSRI. Fluoxetine and paroxetine have a higher propensity for drug interactions.
The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning regarding the use of citalopram due to its association with dose-dependent QT interval prolongation. As a result, citalopram and escitalopram should not be used in patients with congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval. The maximum daily dose of citalopram is now 40 mg for adults, 20 mg for patients older than 65 years, and 20 mg for those with hepatic impairment.
When initiating antidepressant therapy, patients should be reviewed by a doctor after 2 weeks. Patients under the age of 25 years or at an increased risk of suicide should be reviewed after 1 week. If a patient responds well to antidepressant therapy, they should continue treatment for at least 6 months after remission to reduce the risk of relapse. When stopping a SSRI, the dose should be gradually reduced over a 4 week period, except for fluoxetine. Paroxetine has a higher incidence of discontinuation symptoms, including mood changes, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms, and paraesthesia.
When considering the use of SSRIs during pregnancy, the benefits and risks should be weighed. Use during the first trimester may increase the risk of congenital heart defects, while use during the third trimester can result in persistent pulmonary hypertension of the newborn. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester.
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This question is part of the following fields:
- Psychiatry
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Question 21
Incorrect
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A 46-year-old male patient presented to the emergency department with sudden onset of pain, photophobia, and redness in his left eye. During examination, an irregularly sized left pupil and hypopyon in the anterior chamber were observed. The patient has a history of a condition marked by stiffness and back pain. What is the most probable diagnosis for his eye issue?
Your Answer:
Correct Answer: Anterior uveitis
Explanation:Anterior uveitis is frequently observed in conditions linked to HLA-B27, such as ankylosing spondylitis, reactive arthritis, and psoriatic arthritis. This type of uveitis can cause an irregular pupil due to the formation of posterior synechiae, which occurs when inflammation within the eye causes the iris to stick to the anterior lens surface. However, intermediate and posterior uveitis are not associated with HLA-B27 and do not typically cause pain, irregular pupil size, or hypopyon. Scleritis and episcleritis also do not present with an irregular pupil or hypopyon.
Anterior uveitis, also known as iritis, is a type of inflammation that affects the iris and ciliary body in the front part of the uvea. It is a common cause of red eye and is associated with HLA-B27, which may also be linked to other conditions. Symptoms of anterior uveitis include sudden onset of eye discomfort and pain, small or irregular pupils, intense sensitivity to light, blurred vision, redness, tearing, and the presence of pus and inflammatory cells in the front part of the eye. This condition may be associated with ankylosing spondylitis, reactive arthritis, ulcerative colitis, Crohn’s disease, Behcet’s disease, and sarcoidosis. Urgent review by an ophthalmologist is necessary, and treatment may involve the use of cycloplegics and steroid eye drops.
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This question is part of the following fields:
- Ophthalmology
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Question 22
Incorrect
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A 28-year-old man with a history of ulcerative colitis presents to the hospital with a flare-up of his condition. He has been experiencing up to five bloody stools per day for the past three days, and has developed abdominal pain and a low-grade fever in the last 24 hours. His blood work shows the following results:
- Hemoglobin: 13.9 g/dL
- Platelets: 422 * 10^9/L
- White blood cells: 10.1 * 10^9/L
- Erythrocyte sedimentation rate: 88 mm/hr
- C-reactive protein: 198 mg/L
What is the most crucial investigation to conduct next?Your Answer:
Correct Answer: Abdominal x-ray
Explanation:It is possible that this individual has developed toxic megacolon, which is characterized by a transverse colon diameter exceeding 6 cm and accompanying symptoms of systemic distress. Treatment for toxic megacolon typically involves intensive medical intervention for a period of 24-72 hours. If there is no improvement in the patient’s condition during this time, a colectomy may be necessary.
Understanding Ulcerative Colitis Flares
Ulcerative colitis is a chronic inflammatory bowel disease that can cause flares or periods of worsening symptoms. While most flares occur without a clear trigger, there are several factors that are often associated with them. These include stress, certain medications such as NSAIDs and antibiotics, and even quitting smoking.
Flares of ulcerative colitis can be classified as mild, moderate, or severe based on the frequency and severity of symptoms. Mild flares may involve fewer than four stools a day with or without blood, while moderate flares may include four to six stools a day with minimal systemic disturbance. Severe flares, on the other hand, may involve more than six stools a day containing blood, as well as evidence of systemic disturbance such as fever, tachycardia, abdominal tenderness, distension, reduced bowel sounds, anemia, and hypoalbuminemia.
Patients with evidence of severe disease should be admitted to the hospital for close monitoring and treatment. Understanding the triggers and symptoms of ulcerative colitis flares can help patients manage their condition and seek appropriate medical care when necessary.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 23
Incorrect
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The cardiac arrest team is summoned to the bedside of a 68-year-old male patient, 3 days post-myocardial infarction. Two nurses are currently administering chest compressions and a manual defibrillator has just been connected. Chest compressions are momentarily halted to analyze the rhythm, which reveals pulseless electrical activity. What actions should be taken in this situation?
Your Answer:
Correct Answer: Adrenaline should be commenced immediately
Explanation:In the case of a non-shockable rhythm, it is crucial to administer adrenaline as soon as possible according to the ALS protocol. This should be done immediately and during alternate cycles. However, if the rhythm is shockable, adrenaline should be given after the third shock and then during alternate cycles. Amiodarone should be administered after the third shock, and a second dose may be considered after five shocks. Therefore, the other options are not appropriate.
The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken when dealing with patients with shockable and non-shockable rhythms. For both types of patients, chest compressions are a crucial part of the process, with a ratio of 30 compressions to 2 ventilations. Defibrillation is recommended for shockable rhythms, with a single shock for VF/pulseless VT followed by 2 minutes of CPR. Adrenaline and amiodarone are the drugs of choice for non-shockable rhythms, with adrenaline given as soon as possible and amiodarone administered after 3 shocks for VF/pulseless VT. Thrombolytic drugs should be considered if a pulmonary embolus is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Oxygen should be titrated to achieve saturations of 94-98% following successful resuscitation. The Hs and Ts should be considered as potential reversible causes of cardiac arrest.
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This question is part of the following fields:
- Respiratory Medicine
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Question 24
Incorrect
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A 25-year-old woman in her first trimester of pregnancy presents for a check-up. She is experiencing a resurgence of her chronic acne and is interested in finding a solution. What should she steer clear of?
Your Answer:
Correct Answer: Topical isotretinoin
Explanation:Acne vulgaris is a common skin condition that typically affects adolescents, with the face, neck, and upper trunk being the most commonly affected areas. It is characterized by the obstruction of hair follicles with keratin plugs, leading to the formation of comedones, inflammation, and pustules. The severity of acne can be classified as mild, moderate, or severe, depending on the presence and extent of inflammatory lesions, papules, and pustules.
The management of acne vulgaris typically involves a step-up approach, starting with single topical therapy such as topical retinoids or benzoyl peroxide. If this is not effective, topical combination therapy may be used, which includes a topical antibiotic, benzoyl peroxide, and topical retinoid. Oral antibiotics such as tetracyclines may also be prescribed, but they should be avoided in pregnant or breastfeeding women and children under 12 years of age. Erythromycin may be used in pregnancy, while minocycline is now considered less appropriate due to the possibility of irreversible pigmentation. Oral antibiotics should be used for a maximum of three months and always co-prescribed with a topical retinoid or benzoyl peroxide to reduce the risk of antibiotic resistance.
Combined oral contraceptives (COCP) are an alternative to oral antibiotics in women, and Dianette (co-cyrindiol) may be used as it has anti-androgen properties. However, it has an increased risk of venous thromboembolism compared to other COCPs, so it should generally be used second-line and for only three months. Oral isotretinoin is a potent medication that should only be used under specialist supervision, and it is contraindicated in pregnancy. Finally, there is no evidence to support dietary modification in the management of acne vulgaris.
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This question is part of the following fields:
- Dermatology
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Question 25
Incorrect
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A 28-year-old man undergoes a routine electrocardiogram (ECG) as part of an examination at his local general practice surgery.
On examination, his pulse is 64 bpm and his blood pressure is 120/80 mmHg. The clinician notes a delta wave on the ECG and refers him to the Cardiology Department.
What is the most likely cause of this irregularity?Your Answer:
Correct Answer: Wolff-Parkinson-White (WPW) syndrome
Explanation:Wolff-Parkinson-White (WPW) syndrome is a condition where there is an extra electrical pathway in the heart, making the patient more susceptible to developing supraventricular tachycardia (SVT). The presence of delta waves, which are a slurred upstroke in the QRS complex, and a shortened PR interval are characteristic of WPW syndrome. Atrial fibrillation (AF), on the other hand, is an irregularly irregular pulse that is diagnosed by the absence of P waves and irregular QRS complexes on an ECG. Delta waves are not typically seen in AF unless the patient also has WPW syndrome. Sinus arrhythmia, which is an irregular rhythm, does not show delta waves on an ECG. Acute myocardial infarction (MI) is not associated with delta waves, but rather with ST elevation or depression and T wave inversion. Supraventricular tachycardia (SVT) is a regular narrow complex tachycardia that may or may not have delta waves, depending on whether the patient has underlying WPW syndrome.
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This question is part of the following fields:
- Cardiovascular
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Question 26
Incorrect
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A 63-year-old man visits his doctor with a persistent cough that has lasted for 5 weeks. He reports coughing up smelly, green phlegm and experiencing night sweats, left-sided chest pain, and occasional fevers. He denies any weight loss. During the examination, the lower left lung is dull to percussion with low-pitched bronchial breath sounds, and he has a temperature of 38.2°C. The patient has not traveled recently or had any contact with sick individuals. The doctor notes that he was treated for pneumonia 7 weeks ago. What is the most probable cause of this patient's presentation?
Your Answer:
Correct Answer: Lung abscess
Explanation:The most likely diagnosis for this patient is lung abscess, as they are presenting with a subacute productive cough, foul-smelling sputum, and night sweats. The duration of a cough can be categorized as acute, subacute, or chronic, and this patient falls under the subacute category. The patient’s recent history of aspiration pneumonia and examination findings, such as dullness on percussion, bronchial breath sounds, and fever, support the diagnosis of lung abscess.
Lung cancer is not the most likely diagnosis for this patient, as they do not have weight loss and have other findings that point towards lung abscess. Pulmonary fibrosis is also unlikely, as it is rare to have unilateral pulmonary fibrosis, and the patient’s examination findings do not support this diagnosis. Recurrent pneumonia is a good differential, but the presence of bronchial breath sounds and night sweats make lung abscess a more likely diagnosis.
Understanding Lung Abscess
A lung abscess is a localized infection that occurs within the lung tissue. It is commonly caused by aspiration pneumonia, which can be triggered by poor dental hygiene, reduced consciousness, or previous stroke. Other potential causes include haematogenous spread, direct extension, and bronchial obstruction. The infection is typically polymicrobial, with Staphylococcus aureus, Klebsiella pneumonia, and Pseudomonas aeruginosa being the most common monomicrobial causes.
The symptoms of lung abscess are similar to pneumonia, but they tend to develop more slowly over several weeks. Patients may experience fever, productive cough, foul-smelling sputum, chest pain, and dyspnea. Some may also have systemic features such as night sweats and weight loss, while a minority may experience haemoptysis. Physical examination may reveal dull percussion and bronchial breathing, as well as clubbing in some cases.
To diagnose lung abscess, a chest x-ray is usually performed, which shows a fluid-filled space within an area of consolidation. Sputum and blood cultures should also be obtained to identify the causative organism. Treatment typically involves intravenous antibiotics, but if the infection does not resolve, percutaneous drainage or surgical resection may be required in rare cases.
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This question is part of the following fields:
- Respiratory Medicine
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Question 27
Incorrect
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A 42-year-old female presents to her primary care physician with a 2-month history of progressive fatigue. She has a medical history of type-1 diabetes mellitus. Her doctor orders a full blood count, which reveals a low Hb and high mean cell volume. The platelet and WBC counts are within normal limits. Which antibody test should be performed to assist in the diagnosis?
Your Answer:
Correct Answer: Intrinsic-factor antibodies
Explanation:When investigating vitamin B12 deficiency, intrinsic factor antibodies are more useful than gastric parietal cell antibodies due to the low specificity of the latter. Megaloblastic anaemia, characterized by low haemoglobin and raised mean cell volume, can be caused by B12 or folate deficiency and may indicate pernicious anaemia, an autoimmune condition that impairs B12 uptake. Intrinsic factor antibodies are more specific for pernicious anaemia and are commonly used to confirm the diagnosis along with a blood test. Anti-histone antibodies are involved in drug-induced lupus caused by certain drugs. Anti-TTG antibodies are used to screen for coeliac disease, which can cause microcytic anaemia due to iron deficiency from malabsorption. While gastric parietal cell antibodies are linked to pernicious anaemia, their low specificity makes them less reliable for diagnosis compared to intrinsic factor antibodies.
Understanding Pernicious Anaemia
Pernicious anaemia is a condition that results in vitamin B12 deficiency due to an autoimmune disorder affecting the gastric mucosa. The term pernicious means causing harm in a gradual or subtle way, and this is reflected in the often subtle symptoms and delayed diagnosis of the condition. While pernicious anaemia is the most common cause of vitamin B12 deficiency, other causes include atrophic gastritis, gastrectomy, and malnutrition.
The pathophysiology of pernicious anaemia involves antibodies to intrinsic factor and/or gastric parietal cells. These antibodies can bind to intrinsic factor, blocking the vitamin B12 binding site, or reduce acid production and cause atrophic gastritis. This leads to reduced intrinsic factor production and reduced vitamin B12 absorption, which can result in megaloblastic anaemia and neuropathy.
Risk factors for pernicious anaemia include being female, middle to old age, and having other autoimmune disorders such as thyroid disease, type 1 diabetes mellitus, Addison’s, rheumatoid arthritis, and vitiligo. It is also more common in individuals with blood group A.
Symptoms of pernicious anaemia include anaemia features such as lethargy, pallor, and dyspnoea, as well as neurological features such as peripheral neuropathy and subacute combined degeneration of the spinal cord. Neuropsychiatric features such as memory loss, poor concentration, confusion, depression, and irritability may also be present, along with mild jaundice and glossitis.
Diagnosis of pernicious anaemia involves a full blood count, vitamin B12 and folate levels, and testing for antibodies such as anti intrinsic factor antibodies and anti gastric parietal cell antibodies. Treatment involves vitamin B12 replacement, usually given intramuscularly, and folic acid supplementation may also be required. Complications of pernicious anaemia include an increased risk of gastric cancer.
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This question is part of the following fields:
- Haematology/Oncology
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Question 28
Incorrect
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A 87-year-old male presents to the emergency department after collapsing. Upon arrival, an ECG reveals complete heart block with a heart rate of 35 bpm. The patient reports feeling dizzy. Despite receiving 500 micrograms of IV atropine, there is no improvement. This is repeated five more times, but the heart rate remains below 40 bpm even after transcutaneous pacing is attempted. What is the next recommended step according to the Resuscitation Council (UK) guidelines?
Your Answer:
Correct Answer: Transvenous pacing
Explanation:Management of Bradycardia in Peri-Arrest Rhythms
The 2015 Resuscitation Council (UK) guidelines highlight the importance of identifying adverse signs and potential risk of asystole in the management of bradycardia in peri-arrest rhythms. Adverse signs indicating haemodynamic compromise include shock, syncope, myocardial ischaemia, and heart failure. Atropine (500 mcg IV) is the first line treatment in this situation. If there is an unsatisfactory response, interventions such as atropine (up to a maximum of 3mg), transcutaneous pacing, and isoprenaline/adrenaline infusion titrated to response may be used. Specialist help should be sought for consideration of transvenous pacing if there is no response to the above measures.
Furthermore, the presence of risk factors for asystole such as complete heart block with broad complex QRS, recent asystole, Mobitz type II AV block, and ventricular pause > 3 seconds should be considered. Even if there is a satisfactory response to atropine, specialist help is indicated to consider the need for transvenous pacing. Effective management of bradycardia in peri-arrest rhythms is crucial in preventing further deterioration and improving patient outcomes.
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This question is part of the following fields:
- Cardiovascular
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Question 29
Incorrect
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An 80-year-old man visits his GP complaining of a painful lesion on his ear that has been bothering him for a year. The lesion has remained the same for several months but is causing him significant discomfort when he lies down. He reports no other symptoms.
Upon examination, the doctor observes a well-defined, 10mm, flesh-colored nodule on the superior helix of the ear. The nodule is firm, very tender to touch, and covered with some scales.
What is the most probable diagnosis?Your Answer:
Correct Answer: Chondrodermatitis nodularis helicis
Explanation:Chondrodermatitis nodularis helicis is a painful, non-cancerous nodule that commonly occurs on the ear, particularly in men. Based on the patient’s level of pain and the stable nature of the lesion, this is the most likely diagnosis. While squamous cell carcinoma is a possible differential, it typically progresses more rapidly than this lesion. Similarly, basal cell carcinoma usually develops gradually and is not typically associated with significant pain. Although actinic keratosis can cause a scaly lesion on the ear, it is usually not as painful as chondrodermatitis nodularis helicis and tends to progress slowly over time.
Understanding Chondrodermatitis Nodularis Helicis
Chondrodermatitis nodularis helicis (CNH) is a harmless condition that is characterized by the formation of a painful nodule on the ear. It is believed to be caused by various factors such as continuous pressure on the ear, trauma, or exposure to cold. This condition is more prevalent in men and tends to occur more frequently as one ages.
To manage CNH, it is essential to reduce pressure on the ear. This can be achieved by using foam ear protectors while sleeping. Other treatment options include cryotherapy, steroid injection, and collagen injection. However, surgical treatment may be necessary in some cases, although there is a high likelihood of recurrence.
Overall, understanding CNH is crucial in managing this condition effectively. By taking the necessary precautions and seeking appropriate treatment, individuals can alleviate the pain and discomfort associated with CNH.
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This question is part of the following fields:
- Dermatology
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Question 30
Incorrect
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A 24-year-old female presents to the emergency department with a complaint of left leg weakness that started 2 hours ago. She reports no weakness in her face or upper limbs, and her speech is normal. She has no medical history and takes no regular medications.
Upon examination, the emergency physician suspects a non-organic cause. The patient is placed in a supine position and asked to raise her right leg against resistance while keeping it straight. The physician places his hand under the left heel and feels pressure under his hand.
What is the name of this clinical sign or test?Your Answer:
Correct Answer: Hoover's sign
Explanation:Hoover’s sign is a useful clinical tool that can quickly differentiate between organic and non-organic leg paresis. In cases of non-organic paresis, pressure is felt under the affected leg when the unaffected leg is lifted against pressure. This is due to involuntary contralateral hip extension.
Based on this scenario, the likely diagnosis is a conversion disorder, which is characterized by the loss of motor function in the leg without any organic cause. The positive result of Hoover’s sign supports this diagnosis.
Babinski’s sign is a reflex that involves dorsiflexion of the big toe upon plantar stimulation. It is indicative of an upper motor neuron lesion of the corticospinal tract.
Brudziński’s sign is a reflex that involves the flexion of the hips with forced flexion of the neck. It is typically associated with meningitis but can also be present in patients with subarachnoid hemorrhage and encephalitis.
The glabellar tap sign, also known as Myerson’s sign, involves tapping the area above the nose and between the eyebrows (glabella) repeatedly. Healthy patients usually blink in response to the first 2-3 taps, but if a patient is unable to resist blinking beyond this, it can be indicative of early Parkinson’s disease.
The straight leg raise test, also known as Lasègue’s sign, involves raising the straight leg to reproduce radiating leg pain. A positive result indicates a likely lumbar disc herniation.
Psychiatric Terms for Unexplained Symptoms
There are various psychiatric terms used to describe patients who exhibit symptoms for which no organic cause can be found. One such disorder is somatisation disorder, which involves the presence of multiple physical symptoms for at least two years, and the patient’s refusal to accept reassurance or negative test results. Another disorder is illness anxiety disorder, which is characterized by a persistent belief in the presence of an underlying serious disease, such as cancer, despite negative test results.
Conversion disorder is another condition that involves the loss of motor or sensory function, and the patient does not consciously feign the symptoms or seek material gain. Patients with this disorder may be indifferent to their apparent disorder, a phenomenon known as la belle indifference. Dissociative disorder, on the other hand, involves the process of ‘separating off’ certain memories from normal consciousness, and may manifest as amnesia, fugue, or stupor. Dissociative identity disorder (DID) is the most severe form of dissociative disorder and was previously known as multiple personality disorder.
Factitious disorder, also known as Munchausen’s syndrome, involves the intentional production of physical or psychological symptoms. Finally, malingering is the fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain. Understanding these psychiatric terms can help healthcare professionals better diagnose and treat patients with unexplained symptoms.
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This question is part of the following fields:
- Psychiatry
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