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  • Question 1 - A 65-year-old man, who was recently diagnosed with atrial fibrillation but has not...

    Correct

    • A 65-year-old man, who was recently diagnosed with atrial fibrillation but has not yet started any anticoagulant medication, presents with new-onset weakness on the left side of his body. He is also experiencing difficulty speaking and has lost vision on the left side. He contacts emergency services and is transported to the hospital where he undergoes an urgent CT head and MR angiogram. The results confirm a proximal anterior circulation occlusive stroke that occurred approximately 3 hours ago.

      What is the most definitive course of action for managing this patient?

      Your Answer: Arrange thrombectomy AND thrombolysis as soon as possible

      Explanation:

      For patients with an acute ischaemic stroke who present within 4.5 hours, it is recommended to arrange both thrombolysis and thrombectomy as soon as possible. This is in line with NICE guidelines, which suggest offering both treatments to patients diagnosed with an acute proximal anterior circulation occlusive stroke confirmed on CT or MR angiogram. Thrombectomy alone can be offered up to 6 hours post-presentation. Giving a stat dose of aspirin is also part of the acute treatment of ischaemic stroke, but it is not a definitive treatment option. Starting apixaban for atrial fibrillation is not appropriate in the initial management of acute ischaemic stroke, as anticoagulant treatment is usually delayed for at least 2 weeks to reduce the risk of haemorrhagic transformation.

      The Royal College of Physicians (RCP) and NICE have published guidelines on the diagnosis and management of patients following a stroke. The management of acute stroke includes maintaining normal levels of blood glucose, hydration, oxygen saturation, and temperature. Blood pressure should not be lowered in the acute phase unless there are complications. Aspirin should be given as soon as possible if a haemorrhagic stroke has been excluded. Anticoagulants should not be started until brain imaging has excluded haemorrhage. Thrombolysis with alteplase should only be given if administered within 4.5 hours of onset of stroke symptoms and haemorrhage has been definitively excluded. Mechanical thrombectomy is a new treatment option for patients with an acute ischaemic stroke. NICE recommends thrombectomy for people who have acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography or magnetic resonance angiography. Secondary prevention includes the use of clopidogrel and dipyridamole. Carotid artery endarterectomy should only be considered if carotid stenosis is greater than 70% according to ECST criteria or greater than 50% according to NASCET criteria.

    • This question is part of the following fields:

      • Neurology
      14.2
      Seconds
  • Question 2 - A 35-year-old woman with a history of eczema presents with itchy, red patches...

    Correct

    • A 35-year-old woman with a history of eczema presents with itchy, red patches on her inner elbows, back of knees, and thighs. The skin on her right thigh is oozing. She reports feeling fatigued and wonders if she has had a fever. Her vital signs are within normal limits. Based on your assessment, you diagnose her with moderately severe eczema.
      What is the best course of action for managing her condition?

      Your Answer: Regular Diprobase® ointment and once-daily betamethasone valerate 0.025% cream plus 10 days of oral flucloxacillin

      Explanation:

      Treatment Regime for Moderately Severe Eczema with Superimposed Infection

      Moderately severe eczema with evidence of superimposed infection requires a specific treatment regime. The severity of eczema is categorized into four categories: clear, mild, moderate, and severe. In this case, the patient has small areas of dry skin mainly in the flexures, and there is evidence of superimposed infection with the erythematous, weeping patch of skin in the lateral thigh, indicating infected eczema/cellulitis.

      The treatment regime should include a regular emollient ointment, such as Diprobase®, applied generously to the skin multiple times a day. Additionally, a moderately potent topical corticosteroid, such as betamethasone valerate 0.025% or clobetasone butyrate 0.05%, should be used sparingly on the inflamed areas once a day. The patient must be advised to apply the steroid first and allow 15–20 min for it to be absorbed before applying the emollient. Treatment should last 7–14 days and should continue until 48 h after the eczematous patches have cleared.

      Furthermore, oral antibiotics are necessary for the treatment of infected eczema. Oral flucloxacillin is considered first-line, and treatment usually lasts for a 10-day period.

      It is important to note that hydrocortisone 1% cream is only a mild steroid and not indicated in the initial management of moderate eczema. Betamethasone valerate 1% cream is a potent topical corticosteroid and should be reserved for the management of acute flare-ups of severe eczema. Oral flucloxacillin alone is not sufficient for treatment, and there is a need for a moderately potent topical corticosteroid as well to settle the inflammation.

      In conclusion, a combination of regular emollient ointment, moderately potent topical corticosteroid, and oral antibiotics is necessary for the effective treatment of moderately severe eczema with superimposed infection.

    • This question is part of the following fields:

      • Dermatology
      41.9
      Seconds
  • Question 3 - A 35-year-old woman and her partner visit their GP with concerns about their...

    Incorrect

    • A 35-year-old woman and her partner visit their GP with concerns about their inability to conceive. Despite having regular unprotected intercourse for 12 months, they have not been successful in getting pregnant. The husband's semen analysis came back normal. The GP decides to order a serum progesterone test to assess ovulation.
      At what point should the blood test be conducted?

      Your Answer: On the first day of her next menstrual period

      Correct Answer: 7 days before her next expected period

      Explanation:

      To confirm ovulation in patients struggling to conceive, a serum progesterone level should be taken 7 days prior to the expected next period. This timing coincides with ovulation and is the most accurate way to confirm it. Taking the test 14 days before the next expected period or on the first day of the next period would not be timed correctly. It is also important to note that the timing of intercourse does not affect the confirmation of ovulation through serum progesterone testing.

      Infertility is a common issue that affects approximately 1 in 7 couples. It is important to note that around 84% of couples who have regular sexual intercourse will conceive within the first year, and 92% within the first two years. The causes of infertility can vary, with male factor accounting for 30%, unexplained causes accounting for 20%, ovulation failure accounting for 20%, tubal damage accounting for 15%, and other causes accounting for the remaining 15%.

      When investigating infertility, there are some basic tests that can be done. These include a semen analysis and a serum progesterone test. The serum progesterone test is done 7 days prior to the expected next period, typically on day 21 for a 28-day cycle. The interpretation of the serum progesterone level is as follows: if it is less than 16 nmol/l, it should be repeated and if it remains consistently low, referral to a specialist is necessary. If the level is between 16-30 nmol/l, it should be repeated, and if it is greater than 30 nmol/l, it indicates ovulation.

      It is important to counsel patients on lifestyle factors that can impact fertility. This includes taking folic acid, maintaining a healthy BMI between 20-25, and advising regular sexual intercourse every 2 to 3 days. Additionally, patients should be advised to quit smoking and limit alcohol consumption to increase their chances of conceiving.

    • This question is part of the following fields:

      • Reproductive Medicine
      20.2
      Seconds
  • Question 4 - A 6-week-old baby is seen in surgery with decreased feeding and a temperature...

    Incorrect

    • A 6-week-old baby is seen in surgery with decreased feeding and a temperature of 38.8°C.
      Which of the following is the appropriate action?

      Your Answer: Start oral antibiotics

      Correct Answer: Refer to the paediatric on-call team

      Explanation:

      Management of Fever in a High-Risk Child

      When managing a child with fever, it is important to consider their age and any accompanying symptoms. According to the NICE guideline on ‘Fever in under 5s’, children aged <3 months with a temperature of 38°C are at high risk for serious illness. In such cases, it is recommended to refer the child urgently to a paediatric specialist. Encouraging fluids may be useful, but it should not be relied upon to rule out serious underlying illness. Similarly, antipyretics may be given before the child is seen by the paediatric team, but it is important to consult the NICE guideline for appropriate dosages. Blind prescription of oral antibiotics or IM benzylpenicillin is not recommended without a clear source of infection and discussion with the on-call paediatric team. Therefore, it is crucial to refer high-risk children to the paediatric on-call team for further management.

    • This question is part of the following fields:

      • Paediatrics
      21.9
      Seconds
  • Question 5 - A 51-year-old man comes to see the GP complaining of leg twitching and...

    Correct

    • A 51-year-old man comes to see the GP complaining of leg twitching and cramps that have been going on for a year. He also reports difficulty swallowing both liquids and food. The patient has no prior medical history. During the examination, the GP observes tongue fasciculations and hypophonia. Based on these findings, what conditions should be considered for further investigation?

      Your Answer: Motor neuron disease

      Explanation:

      Bulbar onset motor neuron disease can be identified by the presence of tongue fasciculations.

      While benign fasciculation syndrome can also cause tongue fasciculations, the overall clinical picture suggests a more serious underlying condition. Other factors may be misleading in making a diagnosis.

      Understanding Motor Neuron Disease: Signs and Diagnosis

      Motor neuron disease is a neurological condition that affects both upper and lower motor neurons. It is a rare condition that usually presents after the age of 40 and can manifest in different patterns such as amyotrophic lateral sclerosis, progressive muscular atrophy, and bulbar palsy. The diagnosis of motor neuron disease is based on clinical features, including the presence of fasciculations, the absence of sensory signs, and the combination of upper and lower motor neuron signs. Wasting of the small hand muscles and tibialis anterior is also common.

      Other features that can help diagnose motor neuron disease include the absence of external ocular muscle involvement, the absence of cerebellar signs, and preserved abdominal reflexes. Sphincter dysfunction, if present, is usually a late feature. While vague sensory symptoms may occur early in the disease, sensory signs are typically absent.

      Nerve conduction studies can help exclude a neuropathy, while electromyography shows a reduced number of action potentials with increased amplitude. MRI is usually performed to exclude other conditions such as cervical cord compression and myelopathy. Understanding the signs and diagnosis of motor neuron disease is crucial for early detection and management of the condition.

    • This question is part of the following fields:

      • Neurology
      12.6
      Seconds
  • Question 6 - A previously healthy 27-year-old man presents with abdominal discomfort and shortness of breath....

    Correct

    • A previously healthy 27-year-old man presents with abdominal discomfort and shortness of breath. He has been experiencing a dry cough for the past two weeks. He works as a full-time accountant, does not smoke, and drinks approximately 15 units of alcohol per week. He recently went on a trip to Amsterdam with some friends. He has also noticed a widespread skin rash with pink rings and pale centers. Upon admission, his blood work shows low sodium levels, normal potassium levels, elevated urea levels, and high creatinine levels. His chest x-ray reveals diffuse reticular infiltrates and a small pleural effusion on the right side. What is the most likely organism responsible for his symptoms?

      Your Answer: Mycoplasma pneumoniae

      Explanation:

      Typical presentation of mycoplasma pneumonia includes flu-like symptoms that progressively worsen and a dry cough. During examination, the patient may exhibit erythema multiforme, indicating the presence of the infection. This type of pneumonia is commonly acquired within the community. Although Streptococcus pneumoniae is also a possible cause, it is not the focus of this particular case.

      Mycoplasma pneumoniae: A Cause of Atypical Pneumonia

      Mycoplasma pneumoniae is a type of bacteria that causes atypical pneumonia, which is more common in younger patients. This disease is associated with various complications such as erythema multiforme and cold autoimmune haemolytic anaemia. Epidemics of Mycoplasma pneumoniae typically occur every four years. It is important to recognize atypical pneumonia because it may not respond to penicillins or cephalosporins due to the bacteria lacking a peptidoglycan cell wall.

      The disease usually has a gradual onset and is preceded by flu-like symptoms, followed by a dry cough. X-rays may show bilateral consolidation. Complications may include cold agglutinins, erythema multiforme, erythema nodosum, meningoencephalitis, Guillain-Barre syndrome, bullous myringitis, pericarditis/myocarditis, and gastrointestinal and renal problems.

      Diagnosis is generally made through Mycoplasma serology and a positive cold agglutination test. Management involves the use of doxycycline or a macrolide such as erythromycin or clarithromycin.

      In comparison to Legionella pneumonia, which is caused by a different type of bacteria, Mycoplasma pneumoniae has a more gradual onset and is associated with different complications. It is important to differentiate between the two types of pneumonia to ensure appropriate treatment.

    • This question is part of the following fields:

      • Infectious Diseases
      21.4
      Seconds
  • Question 7 - A 50-year-old woman comes to her GP with bloody discharge from her left...

    Correct

    • A 50-year-old woman comes to her GP with bloody discharge from her left nipple. She is extremely worried as she has discovered a small lump on the same breast while examining it after noticing the discharge. She has no medical history and does not take any regular medication. She mentions that her sister had breast cancer a few years ago. She denies any injury to the area. She has never given birth and still has regular periods. What is the probable diagnosis?

      Your Answer: Duct papilloma

      Explanation:

      The presence of blood-stained discharge and a small lumpy mass in this patient suggests that they may have duct papilloma. This condition typically affects middle-aged women and develops in the lactiferous ducts beneath the nipple, causing a lumpy mass and bloody discharge. While fat necrosis can also occur in women with large breasts, it is less likely in this case as the patient has not reported any trauma. Fibroadenoma, on the other hand, is not associated with bloody nipple discharge and is typically found in younger women as a firm, non-tender mass. Fibroadenosis, which causes painful and lumpy breasts, is most commonly seen in middle-aged women and may worsen before menstruation.

      Breast Disorders: Common Features and Characteristics

      Breast disorders are a common occurrence among women of all ages. The most common breast disorders include fibroadenoma, fibroadenosis, breast cancer, Paget’s disease of the breast, mammary duct ectasia, duct papilloma, fat necrosis, and breast abscess. Fibroadenoma is a non-tender, highly mobile lump that is common in women under the age of 30. Fibroadenosis, on the other hand, is characterized by lumpy breasts that may be painful, especially before menstruation. Breast cancer is a hard, irregular lump that may be accompanied by nipple inversion or skin tethering. Paget’s disease of the breast is associated with a reddening and thickening of the nipple/areola, while mammary duct ectasia is characterized by dilatation of the large breast ducts, which may cause a tender lump around the areola and a green nipple discharge. Duct papilloma is characterized by local areas of epithelial proliferation in large mammary ducts, while fat necrosis is more common in obese women with large breasts and may mimic breast cancer. Breast abscess, on the other hand, is more common in lactating women and is characterized by a red, hot, and tender swelling. Lipomas and sebaceous cysts may also develop around the breast tissue.

      Common Features and Characteristics of Breast Disorders

      Breast disorders are a common occurrence among women of all ages. The most common breast disorders include fibroadenoma, fibroadenosis, breast cancer, Paget’s disease of the breast, mammary duct ectasia, duct papilloma, fat necrosis, and breast abscess. Each of these disorders has its own unique features and characteristics that can help identify them. Understanding these features and characteristics can help women identify potential breast disorders and seek appropriate medical attention. It is important to note that while some breast disorders may be benign, others may be malignant or premalignant, and further investigation is always warranted. Regular breast exams and mammograms can also help detect breast disorders early, increasing the chances of successful treatment.

    • This question is part of the following fields:

      • Haematology/Oncology
      21
      Seconds
  • Question 8 - Which of the following is the least probable cause of snoring in adolescents?...

    Incorrect

    • Which of the following is the least probable cause of snoring in adolescents?

      Your Answer: Obesity

      Correct Answer: Kallman's syndrome

      Explanation:

      Snoring is not a symptom of Kallman’s syndrome, which is a condition that leads to delayed puberty due to hypogonadotrophic hypogonadism.

      Snoring in Children: Possible Causes

      Snoring in children can be caused by various factors. One of the common causes is obesity, which can lead to the narrowing of the airways and difficulty in breathing during sleep. Another possible cause is nasal problems such as polyps, deviated septum, and hypertrophic nasal turbinates, which can also obstruct the airways and cause snoring. Recurrent tonsillitis can also contribute to snoring, as the inflamed tonsils can block the air passages.

      In some cases, snoring in children may be associated with certain medical conditions such as Down’s syndrome and hypothyroidism. These conditions can affect the structure and function of the respiratory system, leading to snoring and other breathing difficulties.

      It is important to identify the underlying cause of snoring in children and seek appropriate treatment to prevent potential health complications. Parents should consult a healthcare professional if their child snores regularly or experiences other symptoms such as daytime sleepiness, difficulty concentrating, or behavioral problems.

    • This question is part of the following fields:

      • Paediatrics
      3.6
      Seconds
  • Question 9 - At what age do most children attain urinary incontinence during the day and...

    Correct

    • At what age do most children attain urinary incontinence during the day and at night?

      Your Answer: 3-4 years old

      Explanation:

      Reassurance and advice can be provided to manage nocturnal enuresis in children under the age of 5 years.

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

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

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

    • This question is part of the following fields:

      • Paediatrics
      4
      Seconds
  • Question 10 - As a foundation doctor in the emergency decisions unit, you assess a 28-year-old...

    Correct

    • As a foundation doctor in the emergency decisions unit, you assess a 28-year-old intravenous drug user who complains of pyrexia and malaise. Upon examination, the patient appears cachectic, pale, and is coughing. A soft murmur is detected, and mild erythematous macular lesions are observed on both palms. Although the patient is experiencing general aches, there is no specific tenderness reported. Can you identify the probable diagnosis and explain the significance of the lesions?

      Your Answer: Janeway lesions

      Explanation:

      Janeway lesions are painless, red, and bloody lesions that appear on the palms and soles. They are typically associated with infective endocarditis.

      Based on the patient’s history of intravenous drug use, fever, and heart murmur, it is likely that he has infective endocarditis. Both janeway lesions (caused by septic emboli) and osler nodes (caused by immune complex deposition) can be present in endocarditis. However, in this case, the lesions are more likely to be janeway lesions as they are not painful.

      Roth spots are retinal hemorrhages that can also be seen in endocarditis, but they would be detected during a fundoscopy exam.

      If the patient had meningitis, the rash would not be limited to the palms and would not disappear when pressed.

      Aetiology of Infective Endocarditis

      Infective endocarditis is a condition that affects patients with previously normal valves, rheumatic valve disease, prosthetic valves, congenital heart defects, intravenous drug users, and those who have recently undergone piercings. The strongest risk factor for developing infective endocarditis is a previous episode of the condition. The mitral valve is the most commonly affected valve.

      The most common cause of infective endocarditis is Staphylococcus aureus, particularly in acute presentations and intravenous drug users. Historically, Streptococcus viridans was the most common cause, but this is no longer the case except in developing countries. Streptococcus mitis and Streptococcus sanguinis are the two most notable viridans streptococci, commonly found in the mouth and dental plaque. Coagulase-negative Staphylococci such as Staphylococcus epidermidis are the most common cause of endocarditis in patients following prosthetic valve surgery.

      Streptococcus bovis is associated with colorectal cancer, with the subtype Streptococcus gallolyticus being most linked to the condition. Non-infective causes of endocarditis include systemic lupus erythematosus and malignancy. Culture negative causes may be due to prior antibiotic therapy or infections caused by Coxiella burnetii, Bartonella, Brucella, or HACEK organisms (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella).

    • This question is part of the following fields:

      • Infectious Diseases
      20
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Neurology (2/2) 100%
Dermatology (1/1) 100%
Reproductive Medicine (0/1) 0%
Paediatrics (1/3) 33%
Infectious Diseases (2/2) 100%
Haematology/Oncology (1/1) 100%
Passmed