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  • Question 1 - A 72-year-old man is being investigated for unexplained weight loss. He reports experiencing...

    Correct

    • A 72-year-old man is being investigated for unexplained weight loss. He reports experiencing abdominal pain, dyspepsia, and nausea. He has a history of pernicious anaemia. What is the probable diagnosis based on these symptoms?

      Your Answer: Stomach cancer

      Explanation:

      Dyspepsia, abdominal pain, nausea, and anorexia are among the early signs of stomach cancer. This type of cancer is uncommon and is more likely to occur in individuals over the age of 50, particularly those with pernicious anemia. Pancreatic cancer is linked to the onset of diabetes. Bone pain is a typical symptom of myeloma. Recurrent infections, bleeding, and bruising are common symptoms of acute leukemia.

      Management of Dyspepsia and Referral for Possible Cancer

      Dyspepsia is a common symptom that can be caused by various factors, including medication and lifestyle choices. However, it can also be a sign of underlying conditions such as stomach or oesophageal cancer. The 2015 NICE guidelines provide updated advice on when urgent referral for endoscopy is necessary. Patients with dysphagia or an upper abdominal mass consistent with stomach cancer should be referred urgently. Patients aged 55 years or older with weight loss and upper abdominal pain, reflux, or dyspepsia should also be referred urgently. Non-urgent referrals include patients with haematemesis or those with treatment-resistant dyspepsia, upper abdominal pain with low haemoglobin levels, or raised platelet count with other symptoms.

      For patients with undiagnosed dyspepsia, a step-wise approach is recommended. First, medications should be reviewed for possible causes. Lifestyle advice should also be given. If symptoms persist, a trial of full-dose proton pump inhibitor for one month or a ‘test and treat’ approach for H. pylori can be tried. If symptoms persist after either approach, the alternative should be attempted. Testing for H. pylori infection can be done using a carbon-13 urea breath test, stool antigen test, or laboratory-based serology. If symptoms resolve following test and treat, there is no need to check for H. pylori eradication. However, if repeat testing is required, a carbon-13 urea breath test should be used.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      20.3
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  • Question 2 - A 28-year-old woman visits her doctor concerned about her family's history of inherited...

    Correct

    • A 28-year-old woman visits her doctor concerned about her family's history of inherited illnesses. Her grandmother experienced vision loss at the age of 70, while her mother began to have similar symptoms at the age of 50. What is the genetic mechanism responsible for the earlier age of onset in each generation?

      Your Answer: Anticipation

      Explanation:

      Genetic Phenomena: Anticipation, Incomplete Penetrance, Genetic Imprinting, Mosaicism, and Translocation of a Chromosome

      Genetics is a complex field that involves the study of inherited traits and conditions. There are several genetic phenomena that can occur, each with its own unique characteristics and implications.

      Anticipation is a term used to describe inherited conditions that become more severe and have an earlier onset in subsequent generations. This is often associated with trinucleotide repeats of DNA bases, which can lead to an expansion of the repeat and an increase in severity.

      Incomplete penetrance refers to the likelihood of a condition being present in individuals with a certain trait. In some cases, only some people who inherit a certain trait will develop the associated condition, while others will not.

      Genetic imprinting involves the silencing of one copy of an allele, which can lead to conditions such as Angelman and Prader-Willi syndromes.

      Mosaicism is the presence of two cell lines with different genetic compositions within the same individual. This can occur in conditions such as mosaic trisomy 21.

      Translocation of a chromosome involves the exchange of genetic material between non-homologous chromosomes. This can lead to conditions such as chronic myeloid leukemia, which is associated with the Philadelphia chromosome resulting from a translocation between chromosomes 9 and 22.

      Understanding these genetic phenomena is important for diagnosing and treating inherited conditions, as well as for predicting the likelihood of certain conditions in future generations.

    • This question is part of the following fields:

      • Genetics
      1035.4
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  • Question 3 - A 58-year-old woman complains of developing urinary incontinence. She reports no urinary urgency...

    Correct

    • A 58-year-old woman complains of developing urinary incontinence. She reports no urinary urgency or pain, but experiences leakage of urine when she coughs or laughs. What is the best initial approach to manage this condition?

      Your Answer: Pelvic floor muscle training

      Explanation:

      The initial treatment for urinary incontinence differs depending on the type. For urge incontinence, bladder retraining is the recommended first-line approach. On the other hand, for stress incontinence, pelvic floor muscle training is the preferred initial treatment.

      Understanding Urinary Incontinence: Causes, Classification, and Management

      Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

      Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.

      In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.

    • This question is part of the following fields:

      • Renal Medicine/Urology
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  • Question 4 - A 20-year-old girl presented at the age of 5 years with progressive ataxia....

    Incorrect

    • A 20-year-old girl presented at the age of 5 years with progressive ataxia. She is now wheelchair-bound. On examination, she is now dysarthric, with bilateral optic atrophy. There is ataxia in both upper limbs. Reflexes in her lower limbs are absent, with bilateral extensor plantar response. She has absent vibration and impaired joint position in both feet. Bilateral pes cavus is apparent. An electrocardiogram (ECG) shows inverted T waves. Echocardiogram reveals left ventricular hypertrophy.
      Which of the following is the most likely diagnosis?
      Select the SINGLE most appropriate diagnosis from the list below. Select ONE option only.

      Your Answer: Huntington’s disease

      Correct Answer: Friedreich’s ataxia

      Explanation:

      Friedreich’s ataxia is a common inherited progressive ataxia in the UK that typically presents in childhood or adolescence. The earliest symptom is gait ataxia, followed by limb ataxia, absent lower limb reflexes, and later weakness and wasting of the limbs. Other common features include reduced or absent vibration sense and proprioception, spasticity, dysarthria, dysphagia, cardiac abnormalities, scoliosis, pes cavus, equinovarus, sleep apnea, and urinary frequency/urgency. The history is classic for this condition, and the ECG may show left ventricular hypertrophy. Charcot-Marie-Tooth disease, Huntington’s disease, and multiple sclerosis are not consistent with this history, while vitamin B12 deficiency may cause similar symptoms but is generally a condition of adults and does not fit the clinical picture as well as Friedreich’s ataxia.

    • This question is part of the following fields:

      • Neurology
      98.4
      Seconds
  • Question 5 - A 32-year-old man with cystic fibrosis (CF) has been experiencing a significant increase...

    Incorrect

    • A 32-year-old man with cystic fibrosis (CF) has been experiencing a significant increase in productive cough with large amounts of sputum, occasional haemoptysis and difficulty breathing for the past few months.
      What is the most probable diagnosis?

      Your Answer: Interstitial lung disease

      Correct Answer: Bronchiectasis

      Explanation:

      Identifying Bronchiectasis in a Patient with Cystic Fibrosis

      Cystic Fibrosis (CF) is a genetic disorder that can lead to the development of bronchiectasis. Bronchiectasis is a condition characterized by dilated, thick-walled bronchi, which can result from continual or recurrent infection and inflammation caused by thick, difficult to expectorate mucus in patients with CF. In contrast, bronchiolitis is an acute lower respiratory infection that occurs in children aged <2 years, while asthma typically presents with variable wheeze, cough, breathlessness, and chest tightness. Chronic obstructive pulmonary disease (COPD) typically develops in smokers aged >40, and interstitial lung disease generally affects patients aged >45 and is associated with persistent breathlessness on exertion and cough. Therefore, in a patient with CF presenting with symptoms such as cough, breathlessness, and chest infections, bronchiectasis should be considered as a possible diagnosis.

    • This question is part of the following fields:

      • Respiratory Medicine
      40.9
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  • Question 6 - A 25-year-old male patient visits the GP clinic complaining of left ear pain...

    Incorrect

    • A 25-year-old male patient visits the GP clinic complaining of left ear pain that has been present for 3 days. The patient is new to the clinic and there is no medical history available on the system. Upon examination, you observe the patient's facial features, which include upslanting palpebral fissures, prominent epicanthic folds, low-set ears, and a protruding tongue. Otoscopy examination of the left ear reveals a bulging tympanic membrane. What is the probable diagnosis?

      Your Answer: Otitis media with effusion

      Correct Answer: Acute otitis media

      Explanation:

      Acute otitis media can be indicated by a bulging tympanic membrane, which is a common occurrence in individuals with Down’s syndrome. Lesions in the attic area of the tympanic membrane are typically associated with cholesteatoma. Otitis externa does not typically result in a bulging otitis media, while otitis media with effusion is characterized by a retracted tympanic membrane and a feeling of fullness in the ear.

      Vision and Hearing Issues in Down’s Syndrome

      Individuals with Down’s syndrome are prone to experiencing vision and hearing problems. In terms of vision, they are more likely to have refractive errors, which can cause blurred vision. Strabismus, a condition where the eyes do not align properly, is also common in 20-40% of individuals with Down’s syndrome. Cataracts, both congenital and acquired, are more prevalent in this population, as well as recurrent blepharitis, an inflammation of the eyelids. Glaucoma, a condition that damages the optic nerve, is also a potential issue.

      Regarding hearing, otitis media and glue ear are very common in individuals with Down’s syndrome, which can lead to hearing problems. Otitis media is an infection of the middle ear, while glue ear is a buildup of fluid in the middle ear that can cause temporary hearing loss. It is important for individuals with Down’s syndrome to receive regular vision and hearing screenings to detect and address any potential issues.

    • This question is part of the following fields:

      • Paediatrics
      1409.5
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  • Question 7 - A 56-year-old man has been experiencing fatigue and bone pain, prompting his regular...

    Correct

    • A 56-year-old man has been experiencing fatigue and bone pain, prompting his regular GP to conduct investigations. Blood tests revealed an elevated paraprotein level, leading to further investigations to rule out multiple myeloma as the primary differential. What other potential cause could result in a raised paraprotein level?

      Your Answer: MGUS (Monoclonal gammopathy of undetermined significance)

      Explanation:

      MGUS is a possible differential diagnosis for elevated paraproteins in the blood.

      Thrombocytopenia is a characteristic feature of haemolytic uraemic syndrome.

      The presence of paraproteins in the blood is an abnormal finding and not a normal variant.

      While a viral infection may cause neutropenia, it would not typically result in the presence of paraproteins in the blood.

      Paraproteinaemia is a medical condition characterized by the presence of abnormal proteins in the blood. There are various causes of paraproteinaemia, including myeloma, monoclonal gammopathy of uncertain significance (MGUS), benign monoclonal gammopathy, Waldenstrom’s macroglobulinaemia, amyloidosis, CLL, lymphoma, heavy chain disease, and POEMS. Benign monoclonal gammopathy can also cause paraproteinaemia, as well as non-lymphoid malignancy (such as colon or breast cancer), infections (such as CMV or hepatitis), and autoimmune disorders (such as RA or SLE).

      Paraproteinaemia is a medical condition that is characterized by the presence of abnormal proteins in the blood. This condition can be caused by various factors, including myeloma, MGUS, benign monoclonal gammopathy, Waldenstrom’s macroglobulinaemia, amyloidosis, CLL, lymphoma, heavy chain disease, and POEMS. Additionally, benign monoclonal gammopathy, non-lymphoid malignancy (such as colon or breast cancer), infections (such as CMV or hepatitis), and autoimmune disorders (such as RA or SLE) can also cause paraproteinaemia. It is important to identify the underlying cause of paraproteinaemia in order to determine the appropriate treatment plan.

    • This question is part of the following fields:

      • Haematology/Oncology
      14.5
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  • Question 8 - A 43-year-old Nigerian woman comes to the clinic with complaints of heavy menstrual...

    Incorrect

    • A 43-year-old Nigerian woman comes to the clinic with complaints of heavy menstrual bleeding and pelvic discomfort for the past 3 months. During the physical examination, a solid, non-painful abdominal mass is detected, which originates from the pelvis. The pelvic ultrasound confirms the presence of a sizable uterine fibroid. The medical team decides to perform a hysterectomy. What medication should be administered to prepare her for the surgery?

      Your Answer: Combined oral contraceptive pill

      Correct Answer: GnRH agonist e.g. Leuprolide

      Explanation:

      GnRH agonists can be effective in reducing the size of uterine fibroids, but their use is typically limited to short-term treatment. It is important to note that these agonists are primarily used to decrease the size of the uterus prior to surgery, as the risk of post-operative blood loss is directly related to the size of the uterus. Progesterone receptor inhibitors, on the other hand, do not have an impact on overall uterine size and are therefore not useful in preparing for surgery. However, they can be helpful in reducing the severity of fibroid-related bleeding. It is also important to avoid taking COCP 4-6 weeks prior to major surgery due to an increased risk of venous thromboembolism, and to avoid antiplatelet drugs such as Ibuprofen before surgery. While antifibrinolytics like tranexamic acid can be useful in reducing the severity of uterine bleeding, they are not helpful in preparing for surgery.

      Understanding Uterine Fibroids

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

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

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

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

    • This question is part of the following fields:

      • Reproductive Medicine
      10.7
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  • Question 9 - Which one of the following statements regarding pancreatic cancer is true? ...

    Correct

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

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

      Explanation:

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

      Understanding Pancreatic Cancer: Risk Factors, Symptoms, and Management

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

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

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

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

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      1111.7
      Seconds
  • Question 10 - A 25-year-old man with sickle cell anaemia complains of fatigue, paleness and a...

    Correct

    • A 25-year-old man with sickle cell anaemia complains of fatigue, paleness and a headache. Laboratory findings reveal Hb of 66 g/L and reticulocytes of 0.8%. The patient is suspected to have contracted parvovirus. What is the probable diagnosis?

      Your Answer: Aplastic crisis

      Explanation:

      An aplastic crisis, often caused by parvovirus infection, is characterized by a sudden decrease in haemoglobin levels without a corresponding increase in reticulocytes.

      Sickle cell anaemia is a condition that involves periods of good health with intermittent crises. There are several types of crises that can occur, including thrombotic or painful crises, sequestration, acute chest syndrome, aplastic, and haemolytic. Thrombotic crises, also known as painful crises or vaso-occlusive crises, are triggered by factors such as infection, dehydration, and deoxygenation. These crises are diagnosed clinically and can result in infarcts in various organs, including the bones, lungs, spleen, and brain.

      Sequestration crises occur when sickling occurs within organs such as the spleen or lungs, leading to pooling of blood and worsening of anaemia. This type of crisis is associated with an increased reticulocyte count. Acute chest syndrome is caused by vaso-occlusion within the pulmonary microvasculature, resulting in infarction in the lung parenchyma. Symptoms include dyspnoea, chest pain, pulmonary infiltrates on chest x-ray, and low pO2. Management involves pain relief, respiratory support, antibiotics, and transfusion.

      Aplastic crises are caused by infection with parvovirus and result in a sudden fall in haemoglobin. Bone marrow suppression leads to a reduced reticulocyte count. Haemolytic crises are rare and involve a fall in haemoglobin due to an increased rate of haemolysis. It is important to recognise and manage these crises promptly, as they can lead to serious complications and even death.

    • This question is part of the following fields:

      • Haematology/Oncology
      576.1
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  • Question 11 - A 30-year-old runner complains of anterior groin pain accompanied by hip snapping. The...

    Correct

    • A 30-year-old runner complains of anterior groin pain accompanied by hip snapping. The pain is described as sharp and aggravated after prolonged sitting. During the examination, the patient displays limited range of motion and experiences pain when the hip is adducted and internally rotated while flexed to 90 degrees. What is the probable diagnosis?

      Your Answer: Femoroacetabular impingement

      Explanation:

      Anterior groin pain in active young adults is often caused by femoroacetabular impingement (FAI), which is a common condition that can lead to persistent hip pain. Symptoms include hip/groin pain that worsens with prolonged sitting and is often accompanied by snapping, clicking, or locking of the hip. FAI is typically associated with prior hip pathology, such as Perthes disease in childhood, and is caused by an abnormality in hip anatomy that results in abnormal contact between the femur and acetabulum rim. Over time, this can cause soft tissue damage, including labral tears. Snapping hip syndrome, on the other hand, is characterized by a snapping or clunking sound as tendons move over the hip bones during flexion and extension. This condition is usually painless unless there is an associated labral tear. Stress fractures, in contrast, typically improve with rest rather than worsening. Osteonecrosis of the femoral head is usually associated with other risk factors, such as steroid use, alcohol consumption, or autoimmune conditions. Initially, pain occurs during activity, but it can become constant as the condition progresses.

      Causes of Hip Pain in Adults

      Hip pain in adults can be caused by a variety of conditions. Osteoarthritis is a common cause, with pain that worsens with exercise and improves with rest. Reduced internal rotation is often the first sign, and risk factors include age, obesity, and previous joint problems. Inflammatory arthritis can also cause hip pain, with pain typically worse in the morning and accompanied by systemic features and raised inflammatory markers. Referred lumbar spine pain may be caused by femoral nerve compression, which can be tested with a positive femoral nerve stretch test. Greater trochanteric pain syndrome, or trochanteric bursitis, is caused by repeated movement of the iliotibial band and is most common in women aged 50-70 years. Meralgia paraesthetica is caused by compression of the lateral cutaneous nerve of the thigh and typically presents as a burning sensation over the antero-lateral aspect of the thigh. Avascular necrosis may have gradual or sudden onset and may follow high dose steroid therapy or previous hip fracture or dislocation. Pubic symphysis dysfunction is common in pregnancy and presents with pain over the pubic symphysis with radiation to the groins and medial aspects of the thighs, often with a waddling gait. Transient idiopathic osteoporosis is an uncommon condition sometimes seen in the third trimester of pregnancy, with groin pain and limited range of movement in the hip, and patients may be unable to weight bear. ESR may be elevated in this condition.

    • This question is part of the following fields:

      • Musculoskeletal
      1121.5
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  • Question 12 - A 57-year-old male presents to eye casualty with a one-day history of a...

    Correct

    • A 57-year-old male presents to eye casualty with a one-day history of a painful red eye. He has a past medical history of hypertension and type II diabetes mellitus. He wears glasses for his hypermetropia.

      Upon examination of the right eye, a ciliary injection accompanies a fixed mid-dilated pupil. The pain is exacerbated when assessing pupillary reaction, which is non-reactive. His visual acuity is markedly reduced in his right eye compared to his left.

      Gonioscopy was performed, and the trabecular meshwork was not visualised. What is the first-line management for this likely diagnosis?

      Your Answer: Administer pilocarpine, timolol, and brimonidine eye drops

      Explanation:

      The appropriate treatment for a patient with acute angle closure glaucoma (AACG) is to administer pilocarpine, timolol, and brimonidine eye drops. This condition is characterized by ocular pain, decreased visual acuity, worsened symptoms with mydriasis, and haloes around lights. AACG is more common in individuals with hypermetropia. The presence of a fixed mid-dilated pupil and inability to visualize the trabecular meshwork are consistent with AACG. Pilocarpine, timolol, and brimonidine are all used to reduce intra-ocular pressure (IOP) and protect the optic nerve.

      Administering gentamicin eye drops is not appropriate for this patient as it is an antibiotic used to treat eye infections such as microbial keratitis. The patient does not have risk factors for an eye infection and the examination findings are more consistent with AACG.

      Prescribing prednisolone eye drops is also not appropriate as it is a steroid used to manage inflammatory eye diseases such as anterior uveitis. While anterior uveitis may present with a painful red eye, the examination findings for this patient are more suggestive of angle closure.

      Similarly, prescribing cyclopentolate eye drops is not appropriate as it is a mydriatic eye drop that may worsen the patient’s symptoms by reducing the angle. Mydriatic eye drops may be used in the management of anterior uveitis, but the examination findings for this patient are more consistent with AACG.

      Glaucoma is a group of disorders that cause optic neuropathy due to increased intraocular pressure (IOP). However, not all patients with raised IOP have glaucoma, and vice versa. Acute angle-closure glaucoma (AACG) is a type of glaucoma where there is a rise in IOP due to impaired aqueous outflow. Factors that increase the risk of AACG include hypermetropia, pupillary dilatation, and lens growth associated with age. Symptoms of AACG include severe pain, decreased visual acuity, haloes around lights, and a hard, red-eye. Management of AACG is an emergency and requires urgent referral to an ophthalmologist. Emergency medical treatment is necessary to lower the IOP, followed by definitive surgical treatment once the acute attack has subsided.

      There are no specific guidelines for the initial medical treatment of AACG, but a combination of eye drops may be used, including a direct parasympathomimetic, a beta-blocker, and an alpha-2 agonist. Intravenous acetazolamide may also be administered to reduce aqueous secretions. Definitive management of AACG involves laser peripheral iridotomy, which creates a small hole in the peripheral iris to allow aqueous humour to flow to the angle. It is important to seek medical attention immediately if symptoms of AACG are present to prevent permanent vision loss.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 13 - A 58-year-old man with chronic obstructive pulmonary disease (COPD) experiences an exacerbation of...

    Correct

    • A 58-year-old man with chronic obstructive pulmonary disease (COPD) experiences an exacerbation of breathlessness and a productive cough with green sputum.
      What is the most appropriate treatment option for him?

      Your Answer: Doxycycline and prednisolone

      Explanation:

      Treatment Options for COPD Exacerbations: Antibiotics and Corticosteroids

      COPD exacerbations are characterized by a sudden worsening of symptoms beyond the patient’s usual stable state. These symptoms include increased breathlessness, cough, sputum production, and changes in sputum color. To treat exacerbations, a combination of antibiotics and corticosteroids is often used.

      Oral corticosteroids, such as prednisolone, should be prescribed for five days to patients experiencing a significant increase in breathlessness that interferes with daily activities. Antibiotics are recommended for exacerbations associated with purulent sputum, with first-line agents including amoxicillin, doxycycline, and clarithromycin.

      It is important to follow local microbiologist guidance when initiating empirical antibiotic treatment. Flucloxacillin and clindamycin are not useful in treating COPD exacerbations and are recommended for other conditions such as skin infections and bacterial vaginosis, respectively. Nitrofurantoin and trimethoprim are used for urinary tract infections and may be considered as first or second-line agents depending on antibiotic resistance and previous sensitivity.

    • This question is part of the following fields:

      • Respiratory Medicine
      6.7
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  • Question 14 - A 60-year-old man comes in with complaints of nocturia, hesitancy, and terminal dribbling....

    Incorrect

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

      What is the best course of action for management?

      Your Answer: 5 alpha-reductase inhibitor

      Correct Answer: Alpha-1 antagonist

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Renal Medicine/Urology
      1375.9
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  • Question 15 - You are evaluating a 23-year-old man who has just been diagnosed with type...

    Correct

    • You are evaluating a 23-year-old man who has just been diagnosed with type 1 diabetes mellitus. He works as a software engineer and has no other medical conditions. What should be his initial target for HbA1c?

      Your Answer: 48 mmol/mol

      Explanation:

      Managing Type 1 Diabetes: NICE Guidelines

      The management of type 1 diabetes is a complex process that involves the collaboration of various healthcare professionals. It is crucial to monitor the condition regularly as it can reduce life expectancy by 13 years and lead to micro and macrovascular complications. In 2015, NICE released guidelines on the diagnosis and management of type 1 diabetes, which provide valuable information for clinicians caring for patients with this condition.

      One of the key recommendations is to monitor HbA1c levels every 3-6 months, with a target of 48 mmol/mol (6.5%) or lower for adults. However, other factors such as daily activities, comorbidities, and history of hypoglycemia should also be considered. Self-monitoring of blood glucose is also essential, with a minimum of four tests per day, including before meals and bedtime. Blood glucose targets should be between 5-7 mmol/l on waking and 4-7 mmol/l before meals at other times of the day.

      NICE recommends multiple daily injection basal-bolus insulin regimens as the preferred choice for adults with type 1 diabetes, rather than twice-daily mixed insulin regimens. Rapid-acting insulin analogues should be used before meals instead of rapid-acting soluble human or animal insulins. Metformin may also be considered if the patient’s BMI is 25 kg/m² or higher.

      In summary, managing type 1 diabetes requires a comprehensive approach that considers various factors. NICE guidelines provide a useful framework for clinicians to ensure optimal care for their patients with type 1 diabetes.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      7
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  • Question 16 - A 61-year-old man presents to his GP with increasing mild confusion over the...

    Correct

    • A 61-year-old man presents to his GP with increasing mild confusion over the past 2 weeks. His husband has also noticed a decline in his mental state. The patient's medical history includes a road traffic accident 8 weeks ago, where he sustained a head injury but was discharged from the emergency department with no significant injuries. He denies any current symptoms of headache, nausea, or changes in vision. On examination, there are no focal neurological deficits, and both ocular and mental state exams are unremarkable. What is the most likely cause of this man's presentation?

      Your Answer: Subdural haematoma

      Explanation:

      Understanding Subdural Haemorrhage

      A subdural haemorrhage is a condition where blood collects deep to the dural layer of the meninges. This collection of blood is not within the brain substance and is referred to as an ‘extra-axial’ or ‘extrinsic’ lesion. Subdural haematomas can be classified based on their age, which includes acute, subacute, and chronic. Although they occur within the same anatomical compartment, acute and chronic subdurals have significant differences in terms of their mechanisms, associated clinical features, and management.

      An acute subdural haematoma is a collection of fresh blood within the subdural space and is commonly caused by high-impact trauma. This type of haematoma is associated with high-impact injuries, and there is often other underlying brain injuries. Symptoms and presentation vary depending on the size of the compressive acute subdural haematoma and the associated injuries. CT imaging is the first-line investigation, and surgical options include monitoring of intracranial pressure and decompressive craniectomy.

      On the other hand, a chronic subdural haematoma is a collection of blood within the subdural space that has been present for weeks to months. Elderly and alcoholic patients are particularly at risk of subdural haematomas since they have brain atrophy and therefore fragile or taut bridging veins. Infants also have fragile bridging veins and can rupture in shaken baby syndrome. If the chronic subdural is an incidental finding or if it is small in size with no associated neurological deficit, it can be managed conservatively. However, if the patient is confused, has an associated neurological deficit, or has severe imaging findings, surgical decompression with burr holes is required.

    • This question is part of the following fields:

      • Neurology
      11.3
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  • Question 17 - A 28-year-old woman comes to the Endocrine Clinic with a history of hyperthyroidism....

    Incorrect

    • A 28-year-old woman comes to the Endocrine Clinic with a history of hyperthyroidism. Her blood tests confirm that she is currently experiencing thyrotoxicosis. She is hoping to conceive and wants to discuss her treatment options.
      What is the most suitable treatment for her condition in this scenario?

      Your Answer: 12–18 months of carbimazole

      Correct Answer: Thyroidectomy

      Explanation:

      Treatment Options for Hyperthyroidism in Women Planning a Pregnancy

      When it comes to treating hyperthyroidism in women who are planning a pregnancy, there are several options to consider. Definitive treatment, such as thyroidectomy, is the preferred option as it eliminates the risk of thyrotoxicosis during pregnancy and the need for medication that could harm the fetus. However, following thyroidectomy, the patient will need thyroxine replacement and should wait until she is euthyroid before trying to conceive.

      Propylthiouracil and thyroxine are not recommended for use during pregnancy due to the risk of fetal goitre or hypothyroidism. Carbimazole is teratogenic and should not be started in women planning a pregnancy. Propylthiouracil can be used in low doses if there is no other suitable alternative.

      Radioactive iodine is highly effective but is contraindicated in women planning a pregnancy within six months. This option can be considered if the patient is willing to continue contraception until six months after treatment. Ultimately, the best course of action will depend on the individual patient’s needs and preferences, and should be discussed with a healthcare provider.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      8
      Seconds
  • Question 18 - A 30-year-old presents to the emergency department following an altercation. He reports being...

    Correct

    • A 30-year-old presents to the emergency department following an altercation. He reports being involved in a physical altercation while under the influence of alcohol at a bar. His recollection of the event is unclear, but he recalls being hit in the face and bitten on his hand. Upon examination, there is significant bruising around the left eye and a bite wound on the outer aspect of the left hand. What antibiotic should be administered for the bite?

      Your Answer: Co-amoxiclav

      Explanation:

      When it comes to treating human bites, it is recommended to use co-amoxiclav, which is also used for treating animal bites. This medication is effective in targeting the primary organisms that are commonly associated with human bites, such as Streptococcus, Staphylococcus, Eikenella, Corynebacterium, and other anaerobes. It is important to note that even if there are no visible signs of infection, antibiotics should still be prescribed.

      Animal and Human Bites: Causes and Management

      Animal and human bites are common injuries that can lead to infections caused by various microorganisms. Dogs and cats are the most common animals involved in bites, with Pasteurella multocida being the most commonly isolated organism. On the other hand, human bites can cause infections from both aerobic and anaerobic bacteria, including Streptococci spp., Staphylococcus aureus, Eikenella, Fusobacterium, and Prevotella.

      To manage animal and human bites, it is important to cleanse the wound thoroughly. Puncture wounds should not be sutured closed unless there is a risk of cosmesis. The current recommendation for treatment is co-amoxiclav, but if the patient is allergic to penicillin, doxycycline and metronidazole are recommended. It is also important to consider the risk of viral infections such as HIV and hepatitis C in human bites.

      In summary, animal and human bites can lead to infections caused by various microorganisms. Proper wound cleansing and appropriate antibiotic treatment are essential in managing these injuries. Additionally, healthcare providers should consider the risk of viral infections in human bites.

    • This question is part of the following fields:

      • Infectious Diseases
      578.8
      Seconds
  • Question 19 - A 70-year-old male, who migrated to the UK from India 8 years ago,...

    Incorrect

    • A 70-year-old male, who migrated to the UK from India 8 years ago, presents to the respiratory clinic with a persistent cough and recent episodes of haemoptysis. The patient has never smoked and there are no notable findings on physical examination. A chest X-ray reveals a crescent of air partially outlining a cavitating mass in the right upper lobe. A CT scan of the chest is performed in both supine and prone positions, demonstrating movement of the mass within the cavity. The patient has not previously been screened for tuberculosis. What is the most probable cause of the mass?

      Your Answer: Tuberculosis

      Correct Answer: Aspergilloma

      Explanation:

      Cavitating lung lesions can be caused by various factors, including infections and malignancies. In this case, the absence of a smoking history makes small cell and squamous cell lung cancers less likely. Small cell lung cancers typically affect the hilar or peri-hilar areas, while squamous cell lung cancers may present with pulmonary symptoms or paraneoplastic syndromes.

      An aspergilloma is a fungal ball that forms in an existing lung cavity, often caused by conditions such as tuberculosis, lung cancer, or cystic fibrosis. While it may not cause any symptoms, it can lead to coughing and severe haemoptysis (coughing up blood). Diagnosis can be made through a chest x-ray, which will show a rounded opacity with a possible crescent sign, as well as high levels of Aspergillus precipitins. In some cases, a CT scan may also be necessary to confirm the presence of the aspergilloma.

    • This question is part of the following fields:

      • Respiratory Medicine
      2.9
      Seconds
  • Question 20 - A 25-year-old man presents with sudden onset of pain in his right elbow...

    Correct

    • A 25-year-old man presents with sudden onset of pain in his right elbow and left Achilles tendon. He reports dysuria, conjunctivitis, and fever, and recently returned from a trip to the Far East where he had unprotected sex. He has also developed macules and pustules on his hands. What is the most likely diagnosis?

      Your Answer: Reactive arthritis

      Explanation:

      Reactive arthritis is a type of arthritis that occurs after an infection, typically dysentery or a sexually transmitted disease. It affects 1-2% of patients who have had these infections, with Salmonella, Shigella, and Yersinia causing diarrheal illness that can lead to reactive arthritis, and Chlamydia trichomonas and Ureaplasma urealyticum causing STDs. Those who are HLA-B27-positive are at a higher risk of developing reactive arthritis. Symptoms include acute, asymmetrical lower limb arthritis, enthesitis causing plantar fasciitis or Achilles tendinosis, and back pain from sacroiliitis and spondylosis. Other symptoms may include acute anterior uveitis, circinate balanitis, keratoderma blenorrhagia, nail dystrophy, mouth ulcers, and bilateral conjunctivitis. The classic triad of conjunctivitis, urethritis, and arthritis may also be present. In this scenario, the patient’s symptoms and history of unprotected sexual intercourse suggest reactive arthritis as the correct diagnosis. Other potential diagnoses, such as UTI, HIV, psoriatic arthritis, and syphilitic arthritis, can be ruled out based on the patient’s symptoms and history.

    • This question is part of the following fields:

      • Musculoskeletal
      16.8
      Seconds
  • Question 21 - A 72-year-old male presents to the emergency department with complaints of new-onset pain...

    Correct

    • A 72-year-old male presents to the emergency department with complaints of new-onset pain in his left groin. Upon examination, a large, warm, non-reducible mass located inferolateral to the pubic tubercle is observed, accompanied by erythema of the overlying skin. The patient reports vomiting twice and passing stools with blood mixed in them once. He appears to be in pain and is sweating profusely. His medical history includes peptic ulcer disease, which is managed with omeprazole. What is the most likely diagnosis?

      Your Answer: Strangulated femoral hernia

      Explanation:

      A femoral hernia can lead to the serious complication of strangulation. In this case, the patient has a non-reducible mass located below the pubic tubercle, which is typical of a femoral hernia. However, the accompanying symptoms of vomiting, bloody stools, and a toxic appearance suggest that the hernia has become strangulated, meaning that the blood supply to the herniated tissue has been compromised and may lead to tissue death.

      An incarcerated femoral hernia would also present as a non-reducible mass below the pubic tubercle, but without the symptoms of strangulation.

      In contrast, an incarcerated inguinal hernia would present as a non-reducible mass above and towards the middle of the pubic tubercle, and would not cause symptoms of strangulation.

      A perforated peptic ulcer would cause pain in the upper abdomen, syncope, and possibly vomiting blood, which is different from the patient’s symptoms.

      Similarly, a strangulated inguinal hernia would cause similar symptoms, but the mass would be located above and towards the middle of the pubic tubercle, rather than below it.

      Understanding Femoral Hernias

      Femoral hernias occur when a part of the bowel or other abdominal organs pass through the femoral canal, which is a potential space in the anterior thigh. This can result in a lump in the groin area that is mildly painful and typically non-reducible. Femoral hernias are less common than inguinal hernias, accounting for only 5% of abdominal hernias, and are more prevalent in women, especially those who have had multiple pregnancies. Diagnosis is usually clinical, but ultrasound may be used to confirm the presence of a femoral hernia and exclude other possible causes of a lump in the groin area.

      Complications of femoral hernias include incarceration, where the herniated tissue cannot be reduced, and strangulation, which is a surgical emergency. The risk of strangulation is higher with femoral hernias than with inguinal hernias and increases over time. Bowel obstruction and bowel ischaemia may also occur, leading to significant morbidity and mortality for the patient.

      Surgical repair is necessary for femoral hernias, and it can be done laparoscopically or via a laparotomy. Hernia support belts or trusses should not be used for femoral hernias due to the risk of strangulation. In an emergency situation, a laparotomy may be the only option. It is essential to distinguish femoral hernias from inguinal hernias, as they have different locations and require different management approaches.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      14.3
      Seconds
  • Question 22 - A 25-year-old homeless person is brought into the general practice surgery, having been...

    Correct

    • A 25-year-old homeless person is brought into the general practice surgery, having been found nearby in a disoriented state.
      On examination, they have neck stiffness and a non-blanching rash on their arms. Their vital signs are stable except for fever and tachycardia. They score 13/15 on the Glasgow Coma Scale. An ambulance has been called to transfer them to the hospital.
      Which of the following is the most appropriate action to perform while awaiting the ambulance?

      Your Answer: Administer a dose of parenteral benzylpenicillin

      Explanation:

      Appropriate Actions for Suspected Bacterial Meningitis with Non-Blanching Rash

      When a patient presents with suspected bacterial meningitis and a non-blanching rash, it is crucial to take appropriate actions promptly. Administering a single dose of parenteral benzylpenicillin at the earliest opportunity is recommended, but this should not delay the transfer to the hospital. It is also important to notify the regional Public Health consultant about the suspected case.

      While administering paracetamol for fever and starting the patient on high-flow oxygen may be necessary in some cases, they would not take priority over the administration of parenteral benzylpenicillin. Additionally, an IV fluid bolus is not indicated unless the patient’s vital signs are unstable. By taking these appropriate actions, healthcare providers can help ensure the best possible outcome for patients with suspected bacterial meningitis and non-blanching rash.

    • This question is part of the following fields:

      • Infectious Diseases
      526.6
      Seconds
  • Question 23 - An 18-year-old woman who is sexually active presents to her General Practitioner (GP)...

    Correct

    • An 18-year-old woman who is sexually active presents to her General Practitioner (GP) complaining of dysuria and abdominal pain. A urine dipstick test is positive for leukocytes and a pregnancy test is negative. The GP prescribes a course of trimethoprim, but the patient returns one week later with persistent symptoms. Despite negative results from a high vaginal swab and urine culture taken during the first visit, what is the most likely cause of her symptoms?

      Your Answer: Chlamydia trachomatis

      Explanation:

      Differential Diagnosis of a Female Patient with Dysuria and Abdominal Pain

      A female patient presents with dysuria and abdominal pain, but a negative urine culture and lack of response to trimethoprim suggest an alternative diagnosis to urinary tract infection. Here are some possible differential diagnoses:

      Chlamydia trachomatis: This sexually transmitted micro-organism can cause cervicitis, salpingitis, endometritis, and urethritis. Many carriers are asymptomatic, but nucleic acid amplification can diagnose the infection from a urine sample, endocervical or vulvovaginal swab.

      Trichomonas vaginalis: This protozoan causes trichomoniasis, a sexually transmitted infection that commonly presents with abnormal vaginal discharge, odour, itching, burning, soreness, and dyspareunia. Abdominal pain and dysuria are not typical symptoms.

      Escherichia coli: This bacterium is the most common cause of uncomplicated UTIs, but negative urine cultures and trimethoprim resistance suggest an alternative diagnosis.

      Candida albicans: This fungus can cause vulvovaginal thrush, which may present with dysuria and vulval pruritus, but not abdominal pain. A high vaginal swab can diagnose the infection.

      Bacterial vaginosis: This overgrowth of bacteria in the vagina affects vaginal pH and causes a fishy smelling discharge, but not abdominal pain or dysuria. A high vaginal swab can diagnose the condition.

    • This question is part of the following fields:

      • Infectious Diseases
      26
      Seconds
  • Question 24 - A 67-year-old woman presents to the Memory Clinic with a 9-month history of...

    Correct

    • A 67-year-old woman presents to the Memory Clinic with a 9-month history of cognitive decline. Her daughter mentions that she has difficulty remembering basic tasks and is becoming more confused and forgetful than usual. Her daughter noticed a change in her personality and has caught her leaving the stove on and wandering outside alone on multiple occasions.
      Given the likely diagnosis, which of the following is the most appropriate initial step in this patient’s management?
      Select the SINGLE most appropriate management from the list below.

      Your Answer: Stop drugs that may be exacerbating memory problems or confusion (anticholinergics, central nervous system drugs)

      Explanation:

      Managing Frontotemporal Dementia: Treatment Options and Referrals

      Frontotemporal dementia (FTD) is a progressive neurodegenerative disorder that affects behavior, language, and executive function. While there is no cure for FTD, management strategies can help alleviate symptoms and provide support for patients and their families.

      One important step in managing FTD is to stop any drugs that may be exacerbating memory problems or confusion, such as anticholinergics or central nervous system drugs. Multidisciplinary health and social care is also crucial, involving referrals to geriatric medicine, psychiatry, psychology, social work, occupational therapy, speech and language therapy, physiotherapy, and community nursing.

      However, certain treatment options should be avoided or used with caution in FTD patients. Benzodiazepines, for example, are associated with cognitive worsening and fall-related injuries. Anticholinesterase inhibitors, typically used in mild to moderate Alzheimer’s disease, have shown disappointing results in FTD patients who do not have cholinergic loss. Memantine, used in moderate to severe Alzheimer’s disease, has not been shown to be effective in FTD and may even have a detrimental effect on cognition in some individuals.

      Antipsychotics should only be used cautiously and when other options have failed, as FTD patients are at higher risk of extrapyramidal side effects. Overall, a personalized and coordinated approach to FTD management is essential for optimizing patient outcomes.

    • This question is part of the following fields:

      • Neurology
      12.3
      Seconds
  • Question 25 - A 25-year-old gymnast complains of experiencing pain in her lateral forearm that worsens...

    Incorrect

    • A 25-year-old gymnast complains of experiencing pain in her lateral forearm that worsens when she straightens her wrist or fingers. Additionally, she occasionally feels a peculiar sensation in her hand similar to pins and needles. During the examination, she displays tenderness below the common extensor origin, with no pain over the lateral epicondyle itself. What is the probable reason for her forearm pain?

      Your Answer: Lateral epicondylitis

      Correct Answer: Radial tunnel syndrome

      Explanation:

      Radial tunnel syndrome and lateral epicondylitis have similar presentations, but radial tunnel syndrome causes pain distal to the epicondyle and worsens with elbow extension and forearm pronation. This can make it challenging to differentiate between the two conditions. Radial tunnel syndrome is more common in athletes who frequently hyperextend their wrists or perform supination/pronation movements, such as gymnasts, racquet players, and golfers. Patients may also experience hand paraesthesia or wrist aching. Cubital tunnel syndrome, on the other hand, causes tingling and numbness in the 4th and 5th fingers, while olecranon bursitis results in swelling over the posterior elbow.

      Understanding Lateral Epicondylitis

      Lateral epicondylitis, commonly known as tennis elbow, is a condition that often occurs after engaging in activities that the body is not accustomed to, such as painting or playing tennis. It is most prevalent in individuals aged 45-55 years and typically affects the dominant arm. The primary symptom of this condition is pain and tenderness localized to the lateral epicondyle. The pain is often exacerbated by wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended. Episodes of lateral epicondylitis can last between 6 months and 2 years, with patients experiencing acute pain for 6-12 weeks.

      To manage lateral epicondylitis, it is essential to avoid muscle overload and engage in simple analgesia. Steroid injections and physiotherapy are also viable options for managing the condition. By understanding the symptoms and management options for lateral epicondylitis, individuals can take the necessary steps to alleviate pain and discomfort associated with this condition.

    • This question is part of the following fields:

      • Musculoskeletal
      9.3
      Seconds
  • Question 26 - A 25-year-old female patient complains of red, itchy, and sore eyelids with crusts...

    Correct

    • A 25-year-old female patient complains of red, itchy, and sore eyelids with crusts on the eyelashes and a gritty feeling in both eyes. What is the primary treatment for this condition?

      Your Answer: Eyelid hygiene with warm compresses, lid massage and lid margin cleaning

      Explanation:

      The initial step in treating blepharitis is to apply hot compresses to the affected area. This is followed by eyelid hygiene, which involves cleaning the lid margins and massaging them. If this does not work, chloramphenicol eye drops and oral antibiotics may be prescribed. Oily tear eye drops can be used to prevent rapid evaporation of tears caused by blepharitis. While an omega-3 rich diet may help improve the condition, it is not considered a first-line treatment.

      Blepharitis is a condition where the eyelid margins become inflamed. This can be caused by dysfunction of the meibomian glands (posterior blepharitis) or seborrhoeic dermatitis/staphylococcal infection (anterior blepharitis). It is more common in patients with rosacea. The meibomian glands secrete oil to prevent rapid evaporation of the tear film, so any problem affecting these glands can cause dryness and irritation of the eyes. Symptoms of blepharitis are usually bilateral and include grittiness, discomfort around the eyelid margins, sticky eyes in the morning, and redness of the eyelid margins. Styes and chalazions are also more common in patients with blepharitis, and secondary conjunctivitis may occur.

      Management of blepharitis involves softening the lid margin with hot compresses twice a day and practicing lid hygiene to remove debris from the lid margins. This can be done using cotton wool buds dipped in a mixture of cooled boiled water and baby shampoo or sodium bicarbonate in cooled boiled water. Artificial tears may also be given for symptom relief in people with dry eyes or an abnormal tear film.

    • This question is part of the following fields:

      • Ophthalmology
      2690.5
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  • Question 27 - A 67-year-old man arrives at the emergency department with haematemesis. Upon reviewing his...

    Correct

    • A 67-year-old man arrives at the emergency department with haematemesis. Upon reviewing his medical history, it is discovered that he has been taking dabigatran since being diagnosed with pulmonary embolism. Due to the severity of the bleeding, it is necessary to reverse the effects of the anticoagulant. What medication is used for this purpose?

      Your Answer: Idarucizumab

      Explanation:

      Understanding Direct Oral Anticoagulants

      Direct oral anticoagulants (DOACs) are medications used for various indications such as preventing stroke in non-valvular atrial fibrillation, preventing venous thromboembolism (VTE) after hip or knee surgery, and treating deep vein thrombosis (DVT) and pulmonary embolism (PE). To be prescribed DOACs for stroke prevention in non-valvular AF, certain risk factors must be present, such as prior stroke or transient ischaemic attack, age 75 years or older, hypertension, diabetes mellitus, or heart failure.

      There are four DOACs available, namely dabigatran, rivaroxaban, apixaban, and edoxaban, which differ in their mechanism of action and excretion. Dabigatran is a direct thrombin inhibitor, while rivaroxaban, apixaban, and edoxaban are direct factor Xa inhibitors. The majority of dabigatran is excreted through the kidneys, while rivaroxaban is metabolized in the liver, and apixaban and edoxaban are excreted through the feces.

      In terms of reversal agents, idarucizumab is available for dabigatran, while andexanet alfa is available for rivaroxaban and apixaban. However, there is currently no authorized reversal agent for edoxaban, although andexanet alfa has been studied. Understanding the differences between DOACs is important for healthcare professionals to make informed decisions when prescribing these medications.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      12.1
      Seconds
  • Question 28 - A 65-year-old man with a history of type 2 diabetes, angina, and erectile...

    Correct

    • A 65-year-old man with a history of type 2 diabetes, angina, and erectile dysfunction presents with complaints of rectal pain. During a per rectum examination, the patient experiences discomfort and an anal ulceration is discovered. What is the most probable cause of this man's symptoms?

      Your Answer: Nicorandil

      Explanation:

      Nicorandil, a medication used for angina, can lead to anal ulceration as a potential adverse effect. GTN spray may cause headaches, dizziness, and low blood pressure. Gastric discomfort is a possible side effect of both metformin and ibuprofen. Excessive use of paracetamol can result in liver damage.

      Nicorandil is a medication that is commonly used to treat angina. It works by activating potassium channels, which leads to vasodilation. This process is achieved by stimulating guanylyl cyclase, which increases the levels of cGMP in the body. However, there are some adverse effects associated with the use of nicorandil, including headaches, flushing, and the development of ulcers in the skin, mucous membranes, and eyes. Additionally, nicorandil can cause gastrointestinal ulcers, including anal ulceration. It is important to note that nicorandil should not be used in patients with left ventricular failure.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      20.2
      Seconds
  • Question 29 - A 50-year-old alcoholic patient begins to have a seizure in the waiting area....

    Incorrect

    • A 50-year-old alcoholic patient begins to have a seizure in the waiting area. You quickly position him in the recovery stance and provide oxygen. However, after 5 minutes, the seizure persists. What is the best medication to give in this situation?

      Your Answer: Rectal diazepam 5 mg

      Correct Answer: Rectal diazepam 10 mg

      Explanation:

      Managing Seizures: Basic Steps and Medication Dosages

      Seizures can be a frightening experience for both the patient and those around them. While most seizures will stop on their own, prolonged seizures can be life-threatening. Therefore, it is important to know how to manage seizures in case of an emergency.

      The first step in managing a seizure is to check the patient’s airway and provide oxygen if necessary. It is also important to place the patient in the recovery position to prevent choking or aspiration. If the seizure is prolonged, benzodiazepines may be necessary. The recommended dose for rectal diazepam varies depending on the patient’s age and condition. For neonates, the dose is 1.25-2.5 mg, while for adults, it is 10-20 mg (max. 30 mg). The dose may be repeated once after 10-15 minutes if necessary.

      Another medication that may be used is midazolam oromucosal solution. However, it is important to note that this medication is unlicensed for use in neonates and children under 2 months old. The recommended dose for midazolam oromucosal solution also varies depending on the patient’s age and condition. For example, the dose for a child aged 1-4 years is 5 mg, while for an adult, it is 10 mg.

      In summary, managing seizures involves basic steps such as checking the airway and placing the patient in the recovery position. If the seizure is prolonged, benzodiazepines such as rectal diazepam or midazolam oromucosal solution may be necessary. It is important to follow the recommended dosage based on the patient’s age and condition.

    • This question is part of the following fields:

      • Neurology
      10.6
      Seconds
  • Question 30 - A 76-year-old male with a history of COPD and metastatic lung cancer is...

    Incorrect

    • A 76-year-old male with a history of COPD and metastatic lung cancer is admitted with worsening shortness of breath. After consulting with family, it is determined that active treatment, including fluids and antibiotics, will be withdrawn as this admission is likely a terminal event. However, two days later, the patient becomes restless and agitated. What is the best course of action in managing this situation?

      Your Answer: Intramuscular haloperidol

      Correct Answer: Subcutaneous midazolam

      Explanation:

      Palliative Care Prescribing for Agitation and Confusion

      When dealing with agitation and confusion in palliative care patients, it is important to identify and treat any underlying causes such as hypercalcaemia, infection, urinary retention, or medication. If these specific treatments fail, medication can be used to manage symptoms. Haloperidol is the first choice for treating agitation and confusion, with chlorpromazine and levomepromazine as alternative options. In the terminal phase of the illness, midazolam is the preferred medication for managing agitation or restlessness. Proper management of these symptoms can greatly improve the quality of life for palliative care patients.

    • This question is part of the following fields:

      • Haematology/Oncology
      12.2
      Seconds
  • Question 31 - A 49 year-old woman visits her doctor complaining of urinary incontinence that has...

    Correct

    • A 49 year-old woman visits her doctor complaining of urinary incontinence that has been going on for nine months. Upon examination, her abdomen appears normal and urinalysis results are normal. The doctor diagnoses her with detrusor muscle over-activity and prescribes oxybutynin. What is the mechanism of action of oxybutynin?

      Your Answer: Anti-muscarinic

      Explanation:

      The detrusor muscle’s contraction is regulated by muscarinic cholinergic receptors, and oxybutynin acts as a direct antimuscarinic agent. Sympathetic control, which decreases detrusor muscle activity, is influenced by serotonin and noradrenaline. The bladder does not contain GABAergic or estrogen receptors.

      Understanding Urinary Incontinence: Causes, Classification, and Management

      Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

      Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.

      In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      6
      Seconds
  • Question 32 - A 45-year-old woman visits her primary care physician after being bitten by a...

    Incorrect

    • A 45-year-old woman visits her primary care physician after being bitten by a tick. She explains that the tick was removed by her husband using tweezers and is worried about the potential for Lyme disease. She reports no symptoms such as rash, headache, fever, lethargy, or joint pain. Her vital signs are normal and a full physical examination reveals no abnormalities. What is the best course of action for management?

      Your Answer: Request an ELISA for Borrelia burgdorferi antibodies

      Correct Answer: Re-assure the patient and provide safety netting advice

      Explanation:

      If a patient has been bitten by a tick but shows no signs of Lyme disease, such as erythema migrans or systemic malaise, prophylactic antibiotics are not necessary. According to NICE guidelines, asymptomatic patients with tick bites do not require ELISA investigation or antibiotic treatment. Referral to secondary care is also unnecessary in this case. The best course of action is to provide reassurance to the patient and advise them to be aware of potential symptoms of Lyme disease.

      Understanding Lyme Disease

      Lyme disease is a bacterial infection caused by Borrelia burgdorferi and is transmitted through tick bites. The early symptoms of Lyme disease include erythema migrans, a characteristic bulls-eye rash that appears at the site of the tick bite. This rash is painless, slowly increases in size, and can be more than 5 cm in diameter. Other early symptoms include headache, lethargy, fever, and joint pain.

      If erythema migrans is present, Lyme disease can be diagnosed clinically, and antibiotics should be started immediately. The first-line test for Lyme disease is an enzyme-linked immunosorbent assay (ELISA) to detect antibodies to Borrelia burgdorferi. If the ELISA is negative but Lyme disease is still suspected, it should be repeated 4-6 weeks later. If Lyme disease is suspected in patients who have had symptoms for 12 weeks or more, an immunoblot test should be done.

      Tick bites can cause significant anxiety, but routine antibiotic treatment is not recommended by NICE. If the tick is still present, it should be removed using fine-tipped tweezers, and the area should be washed. In cases of suspected or confirmed Lyme disease, doxycycline is the preferred treatment for early disease, while ceftriaxone is used for disseminated disease. A Jarisch-Herxheimer reaction may occur after initiating therapy, which can cause fever, rash, and tachycardia.

      In summary, Lyme disease is a bacterial infection transmitted through tick bites. Early symptoms include erythema migrans, headache, lethargy, fever, and joint pain. Diagnosis is made through clinical presentation and ELISA testing, and treatment involves antibiotics. Tick bites do not require routine antibiotic treatment, and ticks should be removed using fine-tipped tweezers.

    • This question is part of the following fields:

      • Infectious Diseases
      1971.6
      Seconds
  • Question 33 - A 55-year-old man presents to his General Practitioner after experiencing buzzing sounds in...

    Correct

    • A 55-year-old man presents to his General Practitioner after experiencing buzzing sounds in both ears intermittently over the past two weeks. He claims that this occurs suddenly, lasts for a few seconds and is not associated with his pulse. He reports no change in his hearing or other symptoms. Ear and cranial nerve examinations are unremarkable.
      Which of the following investigations are necessary?

      Your Answer: Audiogram

      Explanation:

      Investigating Tinnitus: Guidelines and Recommendations

      Tinnitus, the perception of sounds in the ears or head that do not come from an outside source, affects around 1 in 10 people at some point in their life. While it is sometimes considered a minor symptom of ringing in the ears, it can be distressing and may indicate a serious underlying condition. Here are some guidelines and recommendations for investigating tinnitus:

      Audiological Assessment: The National Institute for Health and Care Excellence (NICE) recommends that all patients with tinnitus should be offered an audiological assessment.

      Psychoacoustic Testing: Acoustic reflex testing and psychoacoustic testing are not recommended as part of the investigation of tinnitus.

      Imaging: Imaging should not be offered to people with symmetrical non-pulsatile tinnitus with no associated neurological, audiological, otological or head-and-neck signs and symptoms. If they are unable to have this, a contrast-enhanced CT scan of the internal auditory meatus should be offered. An MR scan of the internal auditory meatus should only be offered to people with unilateral or asymmetrical non-pulsatile tinnitus, or non-pulsatile tinnitus with associated neurological, otological or head-and-neck signs and symptoms.

      Otoacoustic Emissions: Otoacoustic emission testing should only be considered if there are other indicative symptoms and signs. All patients with tinnitus should be offered an audiological assessment.

    • This question is part of the following fields:

      • ENT
      10.7
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  • Question 34 - As the GPST1 in the emergency department, you are requested to assess a...

    Correct

    • As the GPST1 in the emergency department, you are requested to assess a 34-year-old woman who fell and struck her head while drinking three hours ago. Your consultant instructs you to confirm the absence of any clinical indications of a base of skull fracture. Which of the following is not linked to a base of skull injury?

      Your Answer: Stellwag's sign

      Explanation:

      The base of the skull is made up of three bony fossae: the anterior, middle, and posterior. These structures provide support for various internal structures within the cranium. If these bones are fractured, it can result in damage to associated neurovascular structures, which can have external manifestations in areas such as the nasal cavity or auditory canal. Bleeding from ruptured vessels can lead to haemotympanum or Battle’s sign in the mastoid area, while ruptured CSF spaces can cause CSF rhinorrhoea and otorrhoea. Stellwag’s sign, on the other hand, is not related to base of skull trauma and refers to reduced blinking.

      Patients with head injuries should be managed according to ATLS principles and extracranial injuries should be managed alongside cranial trauma. There are different types of traumatic brain injuries, including extradural hematoma, subdural hematoma, and subarachnoid hemorrhage. Primary brain injury may be focal or diffuse, and secondary brain injury can occur due to cerebral edema, ischemia, infection, or herniation. Management may include IV mannitol/frusemide, decompressive craniotomy, and ICP monitoring. Pupillary findings can provide information on the location and severity of the injury.

    • This question is part of the following fields:

      • ENT
      14.7
      Seconds
  • Question 35 - A 52-year-old man is on a flupentixol depot for schizophrenia. The patient presents...

    Correct

    • A 52-year-old man is on a flupentixol depot for schizophrenia. The patient presents to his General Practitioner with severe restlessness.
      Which of the following side-effects of antipsychotic medication is present?

      Your Answer: Akathisia

      Explanation:

      Understanding Extrapyramidal Side-Effects of Antipsychotic Medications

      One common extrapyramidal side-effect of antipsychotic medications is akathisia, which is characterized by a subjective feeling of restlessness and an inability to sit still. This is often seen in the legs and can be caused by first-generation typical antipsychotics like flupentixol. Treatment involves reducing or switching the medication dose.

      Neuroleptic malignant syndrome is another potential side-effect that occurs within days of starting antipsychotic medication. It presents with symptoms such as pyrexia, muscle rigidity, autonomic lability, and confusion. Rapid diagnosis and treatment with fluids, cooling, benzodiazepines, and dantrolene are necessary.

      Acute dystonic reactions, such as torticollis, oculogyric crises, and trismus, can occur within hours to days of taking antipsychotic medications. These extrapyramidal side-effects are more common in first-generation typical antipsychotics due to their increased anti-dopaminergic activity. Treatment may involve anticholinergic drugs like procyclidine.

      Parkinsonism refers to features associated with antipsychotic medication that are essentially the same as iatrogenic Parkinsonism, including joint rigidity, bradykinesia, and tremor. These symptoms are more common in first-generation typical antipsychotics.

      Finally, tardive dyskinesia is a late-onset movement disorder that can occur after long-term use of antipsychotics. It presents with involuntary movements such as lip-smacking and grimacing. While this patient may have been on flupentixol for a long time, they do not present with these symptoms.

    • This question is part of the following fields:

      • Psychiatry
      11.1
      Seconds
  • Question 36 - A 75-year-old woman comes to the clinic with a painful swelling on the...

    Correct

    • A 75-year-old woman comes to the clinic with a painful swelling on the left side of her neck below the jaw angle that has been bothering her for the past 5 days. She also reports a bad taste in her mouth. During the physical examination, the patient has a temperature of 37.8ºC and a tender submandibular mass measuring 4x5cm. Additionally, there is tender lymphadenopathy. What is the probable diagnosis?

      Your Answer: Sialadenitis

      Explanation:

      This woman is experiencing sialadenitis, which is inflammation of the salivary gland. It is likely caused by a stone blocking the duct. The submandibular gland is located below the jawline and its duct drains into the floor of the mouth. When there is a discharge from this duct, it can cause a bad taste in the mouth. There are three main salivary glands: the parotid glands, which are located in front of and below each ear, the submandibular glands, which are located below the jawline, and the sublingual glands, which are located beneath the tongue. Disorders of these glands can be caused by infection, inflammation, obstruction, or malignancy. Swelling of the submandibular gland can be caused by a stone or a tumor, which can be either benign or malignant.

      Salivary Glands and Their Pathologies

      Salivary glands are responsible for producing saliva, which aids in digestion and protects the mouth from harmful bacteria. There are three pairs of salivary glands: parotid, submandibular, and sublingual. The parotid gland is the most common site for tumors, while the submandibular gland is most commonly affected by stones.

      Tumors in the salivary glands are rare, but when they do occur, 80% of them are found in the parotid gland. Of these, 80% are pleomorphic adenomas, which are benign. These tumors typically grow slowly and are painless, but surgical removal carries a risk of damage to the facial nerve (CN VII). Warthin’s tumor is another benign tumor that affects the salivary glands, but it is less common than pleomorphic adenomas.

      Stones in the salivary glands can cause recurrent pain and swelling, especially when eating. They are most commonly found in the submandibular gland and can lead to infection if left untreated. Other causes of salivary gland enlargement include viral or bacterial infections, as well as autoimmune disorders like Sjogren’s syndrome. Proper diagnosis and treatment are important for managing these conditions and preventing complications.

    • This question is part of the following fields:

      • ENT
      6.1
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  • Question 37 - A 68-year-old psychiatric patient is brought to the Emergency Room, complaining of excessive...

    Correct

    • A 68-year-old psychiatric patient is brought to the Emergency Room, complaining of excessive thirst. He is carrying multiple shopping bags and has spent a significant amount of money. Blood tests reveal a urea level of 20.5 mmol/l (reference range 2.5–7.1 mmol/l), a creatinine level of 190 μmol/l (reference range 53–106 μmol/l) and a sodium level of 144 mmol/l (reference range 135–145 mmol/l). Urinary osmolality is low.
      What is the most likely diagnosis based on this clinical presentation?

      Your Answer: Nephrogenic diabetes insipidus (DI)

      Explanation:

      Medical Conditions Explained: Nephrogenic Diabetes Insipidus, Cranial Diabetes Insipidus, Chronic Reflux Nephropathy, Syndrome of Inappropriate Antidiuretic Hormone Secretion, and Psychogenic Polydipsia

      Nephrogenic Diabetes Insipidus (DI)
      Nephrogenic DI is a condition where the kidneys are unable to concentrate urine due to resistance to the action of antidiuretic hormone (ADH). This can be caused by lithium toxicity, which is commonly used to treat bipolar affective disorder. Symptoms include passing large volumes of dilute urine and a urinary specific gravity of 1.005 or less. Treatment involves replacing fluid losses with dextrose and water or hypo-osmolar intravenous fluids, as well as a low-protein, low-sodium diet. Alternative medication to lithium may be considered after consultation with a psychiatrist.

      Cranial Diabetes Insipidus
      Cranial DI, also known as central or neurogenic DI, is caused by decreased secretion of ADH, resulting in polyuria and polydipsia. Urine osmolality will be less than 300 mOsm/kg after a water deprivation test, and will rise to over 750 mOsm/kg after ADH administration.

      Chronic Reflux Nephropathy
      Reflux nephropathy is a condition where urine flows back from the bladder to the kidneys, causing renal damage. It is typically seen in children with urinary tract abnormalities, but can also occur with conditions that obstruct urine flow. Symptoms include those of nephrotic syndrome and urinary tract infections, but this diagnosis is not consistent with the clinical presentation in this scenario.

      Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)
      SIADH is characterized by hyponatremia and hypo-osmolality due to excessive secretion or action of ADH, resulting in impaired water excretion. However, the patient in this scenario is presenting with hypernatremia, which is not consistent with SIADH.

      Psychogenic Polydipsia
      Psychogenic polydipsia is excessive fluid intake without physiological stimuli, often caused by psychiatric disorders such as schizophrenia or bipolar affective disorder. It is accompanied by the sensation of dry mouth.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      349.3
      Seconds
  • Question 38 - A 68-year-old male visits his primary care physician with a complaint of persistent...

    Correct

    • A 68-year-old male visits his primary care physician with a complaint of persistent left-sided ear pain for over a month. He reports no hearing loss or discharge and feels generally healthy. He has a history of hypertension and currently smokes 15 cigarettes a day. Otoscopy reveals no abnormalities in either ear. What is the best course of action to take?

      Your Answer: Refer to ENT under 2-week wait

      Explanation:

      If a person experiences unexplained ear pain on one side for more than 4 weeks and there are no visible abnormalities during an otoscopy, it is important to refer them for further investigation under the 2-week wait. This is particularly crucial for individuals who smoke, as they are at a higher risk for head and neck cancer. Using topical antibiotic/steroid drops or nasal steroid sprays without identifying any underlying pathology is not recommended. While amitriptyline may provide relief for symptoms, it should not be used as a substitute for proper diagnosis and treatment. Referring the patient for further evaluation is necessary to rule out the possibility of malignancy.

      Understanding Head and Neck Cancer

      Head and neck cancer is a broad term that encompasses various types of cancer, including oral cavity cancers, pharynx cancers, and larynx cancers. Symptoms of head and neck cancer may include a neck lump, hoarseness, persistent sore throat, and mouth ulcers.

      To ensure prompt diagnosis and treatment, the National Institute for Health and Care Excellence (NICE) has established suspected cancer pathway referral criteria. For instance, individuals aged 45 and over with persistent unexplained hoarseness or an unexplained lump in the neck may be referred for an appointment within two weeks to assess for laryngeal cancer. Similarly, those with unexplained ulceration in the oral cavity lasting for more than three weeks or a persistent and unexplained lump in the neck may be referred for an appointment within two weeks to assess for oral cancer.

      Dentists may also play a role in identifying potential cases of oral cancer. Individuals with a lump on the lip or in the oral cavity or a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia may be urgently referred for assessment within two weeks. Finally, individuals with an unexplained thyroid lump may be referred for an appointment within two weeks to assess for thyroid cancer. By following these guidelines, healthcare providers can help ensure timely diagnosis and treatment of head and neck cancer.

    • This question is part of the following fields:

      • ENT
      20.1
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  • Question 39 - A 30-year-old woman presents with neck pain and swelling. She reports having symptoms...

    Correct

    • A 30-year-old woman presents with neck pain and swelling. She reports having symptoms of an upper respiratory tract infection followed by neck pain and swelling for the past 2 weeks. During examination, she appears anxious, her heart rate is 98/min, and her thyroid gland is tender and diffusely swollen.
      Her blood tests reveal the following results:
      Thyroid-stimulating hormone (TSH) 0.4 mU/L (0.5-5.5)
      Free thyroxine (T4) 42 pmol/L (9.0 - 18)
      ESR 65 mm/h (1-20)
      What is the most likely diagnosis?

      Your Answer: Subacute thyroiditis (de Quervain's thyroiditis)

      Explanation:

      Subacute (De Quervain’s) thyroiditis is the likely diagnosis for this woman who presents with hyperthyroidism and a tender goitre following an upper respiratory tract infection. This condition is characterized by high ESR and painful thyroid gland. Graves’ disease, Hashimoto’s thyroiditis, and thyroid cancer are less likely causes as they do not present with these specific symptoms.

      Subacute Thyroiditis: A Self-Limiting Condition with Four Phases

      Subacute thyroiditis, also known as De Quervain’s thyroiditis or subacute granulomatous thyroiditis, is a condition that is believed to occur after a viral infection. It is characterized by hyperthyroidism, a painful goitre, and raised ESR during the first phase, which lasts for 3-6 weeks. The second phase, which lasts for 1-3 weeks, is characterized by euthyroidism. The third phase, which can last for weeks to months, is characterized by hypothyroidism. Finally, in the fourth phase, the thyroid structure and function return to normal.

      To diagnose subacute thyroiditis, thyroid scintigraphy is used to show a globally reduced uptake of iodine-131. However, most patients do not require treatment as the condition is self-limiting. Thyroid pain may respond to aspirin or other NSAIDs, but in more severe cases, steroids may be used, particularly if hypothyroidism develops.

      It is important to note that subacute thyroiditis is just one of the many causes of thyroid dysfunction. A Venn diagram can be used to show how different causes of thyroid dysfunction may manifest. It is interesting to note that many causes of hypothyroidism may have an initial thyrotoxic phase. Proper diagnosis and management of thyroid dysfunction are crucial to ensure optimal patient outcomes.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      18
      Seconds
  • Question 40 - You are conducting a neurological examination on a thirty-five-year-old patient who presents with...

    Incorrect

    • You are conducting a neurological examination on a thirty-five-year-old patient who presents with recent onset of blurred vision, speech disturbance, pronounced reflexes, and upward plantars upon attempting the Babinski reflex. The patient denies any history of headache and fundoscopy reveals normal findings. What is the probable diagnosis?

      Your Answer: Amyotrophic lateral sclerosis

      Correct Answer: Multiple sclerosis

      Explanation:

      The presence of Babinski sign suggests the presence of a condition affecting the upper motor neurons. When the sole of the foot is stimulated with a blunt object, an atypical reflex is observed where the toes move upwards.

      When ankle jerks are absent and extensor plantars are present, it is usually due to a lesion that affects both the upper and lower motor neurons. This can be caused by various conditions such as subacute combined degeneration of the cord, motor neuron disease, Friedreich’s ataxia, syringomyelia, taboparesis (syphilis), or a lesion in the conus medullaris. These conditions can lead to a loss of reflexes in the ankle and a specific type of reflex in the foot that indicates damage to both the upper and lower motor neurons. It is important to identify the underlying cause of these symptoms in order to provide appropriate treatment and management.

    • This question is part of the following fields:

      • Neurology
      3295.3
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  • Question 41 - A 24-year-old teacher attends her first cervical smear appointment. She has never been...

    Incorrect

    • A 24-year-old teacher attends her first cervical smear appointment. She has never been pregnant before, but she had pelvic inflammatory disease that was treated 3 years ago. Currently, she has an intrauterine device in place. She has no other significant medical or social history. During the appointment, she asks what the test is for.
      How would you explain it to her?

      Your Answer: The sample will always have HPV testing AND cytology done

      Correct Answer: The sample is tested for high-risk HPV first

      Explanation:

      The human papillomavirus (HPV) is a common sexually transmitted infection that can lead to cervical cancer. There are over 100 types of HPV, with types 16 and 18 being high-risk types that are responsible for the majority of cervical cancers. Types 6 and 11 are low-risk types that typically cause benign genital warts. Although not part of the screening process, the Gardasil vaccine can protect against both HPV types 6 and 11.

      Contrary to popular belief, not all samples undergo both HPV testing and cytology. Only samples that test positive for high-risk HPV undergo cytology testing. Samples that test negative for high-risk HPV do not require further testing.

      In the past, samples were first examined under a microscope (cytology) before HPV testing. However, research has shown that testing for high-risk HPV first is more effective. If a woman tests positive for HPV, she will receive a single letter informing her of her HPV status and whether any abnormal cells were detected.

      The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.

    • This question is part of the following fields:

      • Reproductive Medicine
      421.6
      Seconds
  • Question 42 - A 5-year-old boy presents to the emergency department with generalised facial swelling. He...

    Correct

    • A 5-year-old boy presents to the emergency department with generalised facial swelling. He recently recovered from viral pharyngitis. He is otherwise healthy and meeting developmental milestones.

      Upon examination, he is alert and not experiencing any respiratory distress. There is pitting edema in his face and legs.

      Urinalysis reveals 4+ protein and no hematuria. Blood tests show a hemoglobin level of 180 g/L (normal range for males: 135-180, females: 115-160), platelets at 450 * 109/L (normal range: 150-400), WBC at 8.0 * 109/L (normal range: 4.0-11.0), bilirubin at 12 µmol/L (normal range: 3-17), ALP at 60 u/L (normal range: 30-100), ALT at 35 u/L (normal range: 3-40), γGT at 32 u/L (normal range: 8-60), and albumin at 10 g/L (normal range: 35-50).

      What is the recommended first-line treatment option for this likely diagnosis?

      Your Answer: Prednisolone

      Explanation:

      The most appropriate treatment for minimal change glomerulonephritis, which is likely the cause of this patient’s facial edema, hypoalbuminemia, and proteinuria, is prednisolone. This medication is a corticosteroid and is considered the mainstay of therapy for this condition. Adrenaline, albumin infusion, and furosemide are not appropriate treatments for this patient’s condition. While albumin infusion may be used as adjunctive therapy, its effects will only be temporary. Adrenaline is used to treat anaphylaxis and would not be effective in treating minimal change disease. Furosemide may be used as adjunctive therapy, but its effects will also be temporary.

      Minimal change disease is a condition that typically presents as nephrotic syndrome, with children accounting for 75% of cases and adults accounting for 25%. While most cases are idiopathic, around 10-20% have a known cause, such as certain drugs, Hodgkin’s lymphoma, thymoma, or infectious mononucleosis. The pathophysiology of the disease involves T-cell and cytokine-mediated damage to the glomerular basement membrane, resulting in polyanion loss and reduced electrostatic charge, which increases glomerular permeability to serum albumin. The disease is characterized by nephrotic syndrome, normotension (hypertension is rare), and highly selective proteinuria, with only intermediate-sized proteins such as albumin and transferrin leaking through the glomerulus. Renal biopsy shows normal glomeruli on light microscopy, but electron microscopy reveals fusion of podocytes and effacement of foot processes.

      Management of minimal change disease typically involves oral corticosteroids, which are effective in 80% of cases. For steroid-resistant cases, cyclophosphamide is the next step. The prognosis for the disease is generally good, although relapse is common. Approximately one-third of patients have just one episode, one-third have infrequent relapses, and one-third have frequent relapses that stop before adulthood.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      904.6
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  • Question 43 - A 63-year-old woman with metastatic breast cancer complains of worsening dyspnea. She is...

    Incorrect

    • A 63-year-old woman with metastatic breast cancer complains of worsening dyspnea. She is undergoing chemotherapy treatment. During the physical examination, a third heart sound is heard and the apex beat is displaced to the anterior axillary line in the 6th intercostal space. Which chemotherapy drug is most likely causing these symptoms?

      Your Answer: Docetaxel

      Correct Answer: Doxorubicin

      Explanation:

      Cardiomyopathy can be caused by anthracyclines such as doxorubicin.

      Cytotoxic agents are drugs that are used to kill cancer cells. There are several types of cytotoxic agents, each with their own mechanism of action and adverse effects. Alkylating agents, such as cyclophosphamide, work by causing cross-linking in DNA. However, they can also cause haemorrhagic cystitis, myelosuppression, and transitional cell carcinoma. Cytotoxic antibiotics, like bleomycin, degrade preformed DNA and can lead to lung fibrosis. Anthracyclines, such as doxorubicin, stabilize the DNA-topoisomerase II complex and inhibit DNA and RNA synthesis, but can also cause cardiomyopathy. Antimetabolites, like methotrexate, inhibit dihydrofolate reductase and thymidylate synthesis, leading to myelosuppression, mucositis, liver fibrosis, and lung fibrosis. Fluorouracil (5-FU) is a pyrimidine analogue that induces cell cycle arrest and apoptosis by blocking thymidylate synthase, but can also cause myelosuppression, mucositis, and dermatitis. Cytarabine is a pyrimidine antagonist that interferes with DNA synthesis specifically at the S-phase of the cell cycle and inhibits DNA polymerase, but can also cause myelosuppression and ataxia. Drugs that act on microtubules, like vincristine and vinblastine, inhibit the formation of microtubules and can cause peripheral neuropathy, paralytic ileus, and myelosuppression. Docetaxel prevents microtubule depolymerisation and disassembly, decreasing free tubulin, but can also cause neutropaenia. Topoisomerase inhibitors, like irinotecan, inhibit topoisomerase I which prevents relaxation of supercoiled DNA, but can also cause myelosuppression. Other cytotoxic drugs, such as cisplatin, cause cross-linking in DNA and can lead to ototoxicity, peripheral neuropathy, and hypomagnesaemia. Hydroxyurea (hydroxycarbamide) inhibits ribonucleotide reductase, decreasing DNA synthesis, but can also cause myelosuppression.

    • This question is part of the following fields:

      • Haematology/Oncology
      1062.9
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  • Question 44 - A 50-year-old woman who recently finished a round of chemotherapy reports experiencing tingling...

    Incorrect

    • A 50-year-old woman who recently finished a round of chemotherapy reports experiencing tingling sensations and difficulty using her hands. Additionally, she has noticed hesitancy in her urinary function. Which specific cytotoxic medication is the likely culprit for these symptoms?

      Your Answer: Methotrexate

      Correct Answer: Vincristine

      Explanation:

      Peripheral neuropathy is a known side effect of Vincristine. Additionally, bladder atony may cause urinary hesitancy.

      Cytotoxic agents are drugs that are used to kill cancer cells. There are several types of cytotoxic agents, each with their own mechanism of action and adverse effects. Alkylating agents, such as cyclophosphamide, work by causing cross-linking in DNA. However, they can also cause haemorrhagic cystitis, myelosuppression, and transitional cell carcinoma. Cytotoxic antibiotics, like bleomycin, degrade preformed DNA and can lead to lung fibrosis. Anthracyclines, such as doxorubicin, stabilize the DNA-topoisomerase II complex and inhibit DNA and RNA synthesis, but can also cause cardiomyopathy. Antimetabolites, like methotrexate, inhibit dihydrofolate reductase and thymidylate synthesis, leading to myelosuppression, mucositis, liver fibrosis, and lung fibrosis. Fluorouracil (5-FU) is a pyrimidine analogue that induces cell cycle arrest and apoptosis by blocking thymidylate synthase, but can also cause myelosuppression, mucositis, and dermatitis. Cytarabine is a pyrimidine antagonist that interferes with DNA synthesis specifically at the S-phase of the cell cycle and inhibits DNA polymerase, but can also cause myelosuppression and ataxia. Drugs that act on microtubules, like vincristine and vinblastine, inhibit the formation of microtubules and can cause peripheral neuropathy, paralytic ileus, and myelosuppression. Docetaxel prevents microtubule depolymerisation and disassembly, decreasing free tubulin, but can also cause neutropaenia. Topoisomerase inhibitors, like irinotecan, inhibit topoisomerase I which prevents relaxation of supercoiled DNA, but can also cause myelosuppression. Other cytotoxic drugs, such as cisplatin, cause cross-linking in DNA and can lead to ototoxicity, peripheral neuropathy, and hypomagnesaemia. Hydroxyurea (hydroxycarbamide) inhibits ribonucleotide reductase, decreasing DNA synthesis, but can also cause myelosuppression.

    • This question is part of the following fields:

      • Haematology/Oncology
      9.4
      Seconds
  • Question 45 - A 50-year-old man with a persistent chest infection visits the clinic for evaluation....

    Incorrect

    • A 50-year-old man with a persistent chest infection visits the clinic for evaluation. Despite two rounds of antibiotics, there has been no significant improvement. The medical team decides to conduct a chest x-ray and screening blood tests. When analyzing the blood tests, which of the following markers is typically not elevated in response to an acute infection?

      Your Answer: ESR

      Correct Answer: Albumin

      Explanation:

      A decrease in albumin levels is frequently observed after an acute phase response.

      Acute phase proteins are a group of proteins that are produced by the liver in response to inflammation or infection. These proteins are involved in various physiological processes such as immune response, blood clotting, and iron metabolism. Examples of acute phase proteins include CRP, procalcitonin, ferritin, fibrinogen, alpha-1 antitrypsin, caeruloplasmin, serum amyloid A, serum amyloid P component, haptoglobin, and complement.

      During the acute phase response, the liver decreases the production of other proteins known as negative acute phase proteins. These proteins include albumin, transthyretin, transferrin, retinol binding protein, and cortisol binding protein. The levels of acute phase proteins, particularly CRP, are commonly measured in acutely unwell patients. Elevated levels of CRP are indicative of inflammation or infection, and levels greater than 150 at 48 hours post-surgery suggest the development of complications.

      It is important to note that while acute phase proteins play a significant role in humans, some of these proteins, such as serum amyloid P component, have a more significant role in other mammals like mice. Overall, the production of acute phase proteins is a crucial part of the body’s response to inflammation or infection, and monitoring their levels can aid in the diagnosis and management of various medical conditions.

    • This question is part of the following fields:

      • Infectious Diseases
      9.2
      Seconds
  • Question 46 - A 26-year-old woman presents to her GP with worsening lower abdominal pain over...

    Correct

    • A 26-year-old woman presents to her GP with worsening lower abdominal pain over the past 48 hours. The pain is located in the suprapubic area and slightly to the left. She experienced some vaginal bleeding this morning, which she describes as light. The patient also reports shoulder pain that started after playing tennis. Her last menstrual period was seven weeks ago and was normal. She has a history of Chlamydia infection and admits to not practicing safe sex. On examination, she is tender in the left iliac fossa. Her blood pressure is 98/62 mmHg, and her pulse is 100/min. What is the most likely diagnosis?

      Your Answer: Ruptured ectopic pregnancy

      Explanation:

      Ectopic pregnancy presents with amenorrhoea, abdominal pain, vaginal bleeding, and shoulder tip pain indicating peritoneal bleeding.

      Understanding Ectopic Pregnancy

      Ectopic pregnancy occurs when a fertilized egg implants outside the uterus. This condition is characterized by lower abdominal pain and vaginal bleeding, typically occurring 6-8 weeks after the start of the last period. The pain is usually constant and may be felt on one side of the abdomen due to tubal spasm. Vaginal bleeding is usually less than a normal period and may be dark brown in color. Other symptoms may include shoulder tip pain, pain on defecation/urination, dizziness, fainting, or syncope. Breast tenderness may also be reported.

      During examination, abdominal tenderness and cervical excitation may be observed. However, it is not recommended to examine for an adnexal mass due to the risk of rupturing the pregnancy. Instead, a pelvic examination to check for cervical excitation is recommended. In cases of pregnancy of unknown location, serum bHCG levels >1,500 may indicate an ectopic pregnancy. It is important to seek medical attention immediately if ectopic pregnancy is suspected as it can be life-threatening.

    • This question is part of the following fields:

      • Reproductive Medicine
      5.4
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  • Question 47 - An 82-year-old woman is brought to see you by her daughter who complains...

    Incorrect

    • An 82-year-old woman is brought to see you by her daughter who complains that she has to repeat everything multiple times for her mother to understand. An audiogram confirms sensorineural hearing loss.
      What is the most probable cause?

      Your Answer: Otosclerosis

      Correct Answer: Presbyacusis

      Explanation:

      Causes of Hearing Loss in Adults: Understanding the Differences

      As we age, our hearing abilities may decline, leading to a condition known as presbyacusis. This age-related hearing loss affects high-frequency sounds and can be detected through an audiogram that shows reduced hearing for both air and bone conduction at higher frequencies in the affected ear.

      Another cause of hearing loss is otosclerosis, which is a form of conductive hearing loss caused by problems with the ossicular chain. An audiogram would show a wide air-bone gap, indicating a gap between the hearing level for both air and bone conduction.

      While multiple sclerosis can cause sensorineural hearing loss in adults, it is a rare occurrence and not the most likely option in most cases. Barotrauma, on the other hand, is a conductive cause of hearing loss that can lead to drum perforation. An audiogram would show a wide air-bone gap on the affected ear.

      Ménière’s disease is another cause of sensorineural hearing loss, but it is less common than presbyacusis. It typically presents with symptoms of tinnitus, vertigo, and a fullness in the ear. Infections such as measles and mumps, or ototoxic medications, would usually present earlier. Barotrauma and otosclerosis are causes of conductive deafness.

      In summary, understanding the differences between these various causes of hearing loss can help individuals and healthcare professionals identify the most likely cause and determine the appropriate treatment plan.

    • This question is part of the following fields:

      • ENT
      7.4
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  • Question 48 - A 49-year-old man goes for a routine medical check-up for his new job....

    Incorrect

    • A 49-year-old man goes for a routine medical check-up for his new job. He has no complaints and his physical examination is unremarkable. Blood tests are conducted and all results are normal except for:
      Uric acid 0.66 mmol/l (0.18-0.48 mmol/l)
      After reading online, the patient is concerned about his chances of developing gout. What treatment should be initiated based on this finding?

      Your Answer: Colchicine

      Correct Answer: No treatment

      Explanation:

      NICE does not recommend treating asymptomatic hyperuricaemia as a means of preventing gout. While high levels of serum uric acid are associated with gout, it is possible to have hyperuricaemia without experiencing any symptoms. NICE has found that attempting to prevent gout in this way is not cost-effective or beneficial for patients. Instead, lifestyle changes such as reducing consumption of red meat, alcohol, and sugar can help lower uric acid levels without the need for medication. The other options listed may be appropriate for treating gout, but are not recommended in the absence of symptoms.

      Understanding Hyperuricaemia

      Hyperuricaemia is a condition characterized by elevated levels of uric acid in the blood. This can be caused by either increased cell turnover or reduced renal excretion of uric acid. While some patients may not experience any symptoms, hyperuricaemia may be associated with hyperlipidaemia, hypertension, and the metabolic syndrome.

      There are several factors that can contribute to increased uric acid synthesis, including Lesch-Nyhan disease, myeloproliferative disorders, a diet rich in purines, exercise, psoriasis, and cytotoxics. On the other hand, decreased excretion of uric acid can be caused by drugs such as low-dose aspirin, diuretics, and pyrazinamide, as well as pre-eclampsia, alcohol consumption, renal failure, and lead exposure.

      It is important to understand the underlying causes of hyperuricaemia in order to properly manage and treat the condition. By identifying and addressing the contributing factors, healthcare professionals can help prevent complications such as gout and kidney stones.

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 49 - A 56-year-old man is recuperating after experiencing his initial bout of gout. He...

    Incorrect

    • A 56-year-old man is recuperating after experiencing his initial bout of gout. He continues to experience some persistent discomfort in his big toe. He has no predisposing factors for gout and no signs of gouty tophi upon examination. At what point would it be appropriate to initiate uric acid-lowering treatment?

      Your Answer: Immediately

      Correct Answer: Once his symptoms of acute gout have resolved

      Explanation:

      It is now recommended to offer allopurinol to all patients after their first gout attack, without delay. However, it is advised to wait until the inflammation has subsided before discussing urate-lowering therapy with the patient. If the attacks are too frequent, allopurinol can be considered even before the inflammation has completely settled. These recommendations are provided by the 2017 British Society for Rheumatology and NICE Clinical Knowledge Summaries.

      Gout is caused by chronic hyperuricaemia and is managed acutely with NSAIDs or colchicine. Urate-lowering therapy (ULT) is recommended for patients with >= 2 attacks in 12 months, tophi, renal disease, uric acid renal stones, or prophylaxis if on cytotoxics or diuretics. Allopurinol is first-line ULT, with an initial dose of 100 mg od and titrated to aim for a serum uric acid of < 300 µmol/l. Lifestyle modifications include reducing alcohol intake, losing weight if obese, and avoiding high-purine foods. Consideration should be given to stopping precipitating drugs and losartan may be suitable for patients with coexistent hypertension.

    • This question is part of the following fields:

      • Musculoskeletal
      13
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  • Question 50 - A 55-year-old man presents with a daytime-average ABPM reading of 162/100 mmHg and...

    Incorrect

    • A 55-year-old man presents with a daytime-average ABPM reading of 162/100 mmHg and a calculated QRISK-3 score of 13.8%. He has no significant past medical history and is of Pakistani background. What initial pharmacological management should be offered, in addition to lifestyle advice?

      Your Answer:

      Correct Answer: A statin and a calcium-channel blocker

      Explanation:

      NICE Guidelines for Managing Hypertension

      Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of a calcium channel blocker or thiazide-like diuretic in addition to an ACE inhibitor or angiotensin receptor blocker.

      The guidelines also provide a flow chart for the diagnosis and management of hypertension. Lifestyle advice, such as reducing salt intake, caffeine intake, and alcohol consumption, as well as exercising more and losing weight, should not be forgotten and is frequently tested in exams. Treatment options depend on the patient’s age, ethnicity, and other factors, and may involve a combination of drugs.

      NICE recommends treating stage 1 hypertension in patients under 80 years old if they have target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For patients with stage 2 hypertension, drug treatment should be offered regardless of age. The guidelines also provide step-by-step treatment options, including adding a third or fourth drug if necessary.

      New drugs, such as direct renin inhibitors like Aliskiren, may have a role in patients who are intolerant of more established antihypertensive drugs. However, trials have only investigated the fall in blood pressure and no mortality data is available yet. Patients who fail to respond to step 4 measures should be referred to a specialist. The guidelines also provide blood pressure targets for different age groups.

    • This question is part of the following fields:

      • Cardiovascular
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ENT (4/5) 80%
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