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Question 1
Incorrect
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A 21-year-old female presents for a follow-up after a medical termination of pregnancy at 8 weeks gestation. She is considering getting a Nexplanon implant. When is it appropriate to insert Nexplanon in this situation?
Your Answer: After 12 weeks
Correct Answer: Immediately
Explanation:Implanon and Nexplanon are subdermal contraceptive implants that slowly release the progestogen hormone etonogestrel to prevent ovulation and thicken cervical mucus. Nexplanon is the newer version and has a redesigned applicator to prevent deep insertions and is radiopaque for easier location. It is highly effective with a failure rate of 0.07/100 women-years and lasts for 3 years. It does not contain estrogen, making it suitable for women with a past history of thromboembolism or migraine. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraceptive methods are required for the first 7 days if not inserted on days 1 to 5 of a woman’s menstrual cycle.
The main disadvantage of these implants is irregular and heavy bleeding, which can be managed with a co-prescription of the combined oral contraceptive pill. Other adverse effects include headache, nausea, and breast pain. Enzyme-inducing drugs such as certain antiepileptic and rifampicin may reduce the efficacy of Nexplanon, and women should switch to a method unaffected by enzyme-inducing drugs or use additional contraception until 28 days after stopping the treatment.
There are also contraindications for using these implants, such as ischaemic heart disease/stroke, unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Current breast cancer is a UKMEC 4 condition, which represents an unacceptable risk if the contraceptive method is used. Overall, these implants are a highly effective and long-acting form of contraception, but they require careful consideration of the potential risks and contraindications.
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This question is part of the following fields:
- Reproductive Medicine
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Question 2
Correct
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You encounter the mother of a 9-month-old baby who was born premature (at 30 weeks) and has recently been discharged from hospital after being admitted for 'breathing difficulties'. During the hospital stay, the baby received an injection called palivizumab, but the mother cannot remember the purpose of this medication. Can you explain the medication and its indication?
Your Answer: Monoclonal antibody used to prevent respiratory syncytial virus (RSV)
Explanation:To prevent respiratory syncytial virus (RSV) in children who are at a higher risk of severe disease, palivizumab, a monoclonal antibody, is administered. Infants who are premature, have lung or heart abnormalities, or are immunocompromised are among those at risk of developing RSV.
Bronchiolitis is a condition where the bronchioles become inflamed, and it is most commonly caused by respiratory syncytial virus (RSV). This virus is responsible for 75-80% of cases, with other causes including mycoplasma and adenoviruses. Bronchiolitis is most prevalent in infants under one year old, with 90% of cases occurring in those aged 1-9 months. The condition is more serious in premature babies, those with congenital heart disease or cystic fibrosis. Symptoms include coryzal symptoms, dry cough, increasing breathlessness, and wheezing. Hospital admission is often necessary due to feeding difficulties associated with increasing dyspnoea.
Immediate referral is recommended if the child has apnoea, looks seriously unwell, has severe respiratory distress, central cyanosis, or persistent oxygen saturation of less than 92% when breathing air. Clinicians should consider referral if the child has a respiratory rate of over 60 breaths/minute, difficulty with breastfeeding or inadequate oral fluid intake, or clinical dehydration. Immunofluorescence of nasopharyngeal secretions may show RSV, and management is largely supportive. Humidified oxygen is given via a head box if oxygen saturations are persistently low, and nasogastric feeding may be necessary if children cannot take enough fluid/feed by mouth. Suction may also be used for excessive upper airway secretions. NICE released guidelines on bronchiolitis in 2015 for more information.
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This question is part of the following fields:
- Paediatrics
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Question 3
Incorrect
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In a 20-year-old man with primary generalised epilepsy, what is the most suitable initial oral treatment option?
Your Answer: Carbamazepine
Correct Answer: Valproate
Explanation:First-Line Treatments for Seizures: A Guide to Medications
When it comes to treating seizures, there are several medications available. However, not all medications are suitable for every type of seizure. Here is a breakdown of some commonly used medications and their recommended uses:
Valproate: This medication is recommended as a first-line treatment for children, young people, and adults with newly diagnosed generalized tonic-clonic seizures. However, it is important to be aware of the teratogenic and developmental risks associated with valproate.
Carbamazepine: This medication is recommended as a first-line treatment for new-onset focal seizures, but not for generalized seizures.
Topiramate: While topiramate is not routinely used as a first-line treatment for any type of seizure, it can be used as an adjunct.
Phenytoin: This medication is useful as a rescue medication in status epilepticus, but should not be considered first-line for any seizure type due to troublesome long-term side effects.
Phenobarbital: This medication is now rarely used for seizures due to its unacceptable side effects when compared to more modern alternatives.
Overall, the first-choice treatments for primary generalized epilepsy are lamotrigine and valproate. For partial (localization-related) epilepsy, carbamazepine, valproate, lamotrigine, and oxcarbazepine are all reasonable first choices.
In summary, it is important to work closely with a healthcare provider to determine the best medication for an individual’s specific type of seizure.
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This question is part of the following fields:
- Neurology
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Question 4
Correct
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A 38-year-old man complains of dyspepsia without any alarm symptoms. He has no significant medical history and this is his first episode. The plan is to use a test-and-treat approach. What is the most suitable test to detect Helicobacter pylori?
Your Answer: 13C-urea breath test
Explanation:The urea breath test is a non-invasive, highly specific and sensitive method. Therefore, there is no need for an endoscopy. Instead, an alternative option is to use stool antigen instead of culture.
Tests for Helicobacter pylori
There are several tests available to diagnose Helicobacter pylori infection. One of the most common tests is the urea breath test, where patients consume a drink containing carbon isotope 13 (13C) enriched urea. The urea is broken down by H. pylori urease, and after 30 minutes, the patient exhales into a glass tube. Mass spectrometry analysis calculates the amount of 13C CO2, which indicates the presence of H. pylori. However, this test should not be performed within four weeks of treatment with an antibacterial or within two weeks of an antisecretory drug.
Another test is the rapid urease test, also known as the CLO test. This involves mixing a biopsy sample with urea and a pH indicator. If there is a color change, it indicates the presence of H. pylori urease activity. Serum antibody tests can also be used, but they remain positive even after eradication. Culture of gastric biopsy can provide information on antibiotic sensitivity, while histological evaluation alone can be done through gastric biopsy. Lastly, the stool antigen test has a sensitivity of 90% and specificity of 95%.
Overall, these tests have varying levels of sensitivity and specificity, and the choice of test depends on the patient’s clinical presentation and the availability of resources.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 5
Correct
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A 28-year-old female visited her doctor complaining of a 3-week history of excessive malodorous vaginal discharge. Microscopy revealed the presence of clue cells, and she was diagnosed with Gardnerella vaginalis-induced bacterial vaginosis.
What would be the appropriate treatment option?Your Answer: Metronidazole
Explanation:Common Antibiotics and Antifungals: Uses and Dosages
Metronidazole, Azithromycin, Co-amoxiclav, Fluconazole, and Nystatin are common antibiotics and antifungals used to treat various infections. Metronidazole is recommended for bacterial vaginosis and can be taken orally or applied topically. Azithromycin is used for Chlamydia, gonorrhea, and chancroid. Co-amoxiclav is a broad-spectrum antibiotic used for respiratory and urinary tract infections, among others. Fluconazole is an oral antifungal used for severe oral and vaginal candidiasis. Nystatin is an antifungal used for oral candidiasis. Dosages and treatment durations vary depending on the specific infection being treated.
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This question is part of the following fields:
- Infectious Diseases
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Question 6
Incorrect
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A 21-year-old male patient visits his GP complaining of visible blood in his urine for the past day. He reports no pain while urinating or abdominal pain. He has no significant medical history and is not taking any regular medications. He had a mild cold four days ago. Upon analysis, his urine shows positive for blood and trace amounts of protein, but negative for leucocytes, nitrites, and glucose. What is the most probable diagnosis?
Your Answer: Post-streptococcal glomerulonephritis
Correct Answer: IgA nephropathy
Explanation:The classic presentation of IgA nephropathy is visible haematuria that occurs after a recent upper respiratory tract infection. This patient’s new-onset haematuria following a recent URTI is consistent with a diagnosis of IgA nephropathy, which is the most common cause of haematuria worldwide. IgA nephropathy typically presents acutely in young males, in contrast to post-streptococcal glomerulonephritis, which presents after 2 weeks from an upper or lower respiratory tract infection. Focal segmental glomerulosclerosis and minimal change disease are unlikely diagnoses as they present with proteinuria rather than haematuria. While post-streptococcal glomerulonephritis is a possible differential diagnosis, it differs from this patient’s presentation as it typically presents with haematuria after 2 weeks following an acute infection.
Understanding IgA Nephropathy
IgA nephropathy, also known as Berger’s disease, is the most common cause of glomerulonephritis worldwide. It is characterized by the deposition of IgA immune complexes in the mesangium, leading to mesangial hypercellularity and positive immunofluorescence for IgA and C3. The classic presentation is recurrent episodes of macroscopic hematuria in young males following an upper respiratory tract infection. Unlike post-streptococcal glomerulonephritis, IgA nephropathy is not associated with low complement levels and typically does not present with nephrotic range proteinuria or renal failure.
Management of IgA nephropathy depends on the severity of proteinuria and renal function. Isolated hematuria with no or minimal proteinuria and normal GFR requires only follow-up to monitor renal function. Persistent proteinuria with normal or slightly reduced GFR can be treated with ACE inhibitors. If there is active disease or failure to respond to ACE inhibitors, immunosuppression with corticosteroids may be necessary. The prognosis of IgA nephropathy varies, with 25% of patients developing ESRF. Factors associated with a poor prognosis include male gender, proteinuria, hypertension, smoking, hyperlipidemia, and ACE genotype DD, while frank hematuria is a marker of good prognosis.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 7
Correct
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A 55-year-old man presented to his GP with two instances of painless visible haematuria. He was subsequently referred to urology for biopsy and flexible cystoscopy, which revealed a transitional cell carcinoma of the bladder. What is the most significant risk factor associated with this condition?
Your Answer: Smoking
Explanation:Risk Factors for Bladder Cancer
Bladder cancer is a type of cancer that affects the bladder, and there are different types of bladder cancer. The most common type is urothelial (transitional cell) carcinoma, and the risk factors for this type of bladder cancer include smoking, exposure to aniline dyes, rubber manufacture, and cyclophosphamide. Smoking is the most important risk factor in western countries, with a hazard ratio of around 4. Exposure to aniline dyes, such as working in the printing and textile industry, can also increase the risk of bladder cancer. Rubber manufacture and cyclophosphamide are also risk factors for urothelial carcinoma.
On the other hand, squamous cell carcinoma of the bladder has different risk factors. Schistosomiasis and smoking are the main risk factors for this type of bladder cancer. Schistosomiasis is a parasitic infection that can cause inflammation and damage to the bladder, which can increase the risk of developing squamous cell carcinoma. Smoking is also a risk factor for squamous cell carcinoma, as it can cause changes in the cells of the bladder lining that can lead to cancer.
In summary, the risk factors for bladder cancer depend on the type of cancer. Urothelial carcinoma is mainly associated with smoking, exposure to aniline dyes, rubber manufacture, and cyclophosphamide, while squamous cell carcinoma is mainly associated with schistosomiasis and smoking. It is important to be aware of these risk factors and take steps to reduce your risk of developing bladder cancer.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 8
Incorrect
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A 56-year-old female presents with an acutely painful hand. She has a history of hypertension, Raynaud's phenomenon, and has smoked twenty cigarettes a day since she was twenty-two years old. She describes the pain as 'different from her usual Raynaud's,' there has been no relief of symptoms despite wearing gloves and making sure her hands are warm.
Upon examination, her blood pressure is 158/80 mmHg, her right hand is blanched white and feels cold, and the colour of her forearm is normal. The radial pulse is not palpable at the wrist. What is the most likely explanation for her symptoms?Your Answer: Raynaud's phenomenon
Correct Answer: Buerger's disease
Explanation:If a patient with extremity ischaemia is diagnosed with Raynaud’s phenomenon, Buerger’s disease should be considered as a possible underlying condition. Buerger’s disease is a condition where the small and medium arteries in the hands and feet become inflamed and thrombosed, leading to acute or chronic progressive ischaemic changes and potentially gangrene. It is strongly associated with smoking. Osteoarthritis, on the other hand, presents with joint pain and swelling, typically in the wrist, knee, hip, or thumb base, and is more common with age. Radial artery dissection is unlikely in the given scenario as there is no history of traumatic injury. Raynaud’s phenomenon, which is characterised by transient vasospasm of the digits triggered by cold, is usually treated conservatively with warmth and sometimes calcium channel blockers in severe cases. It is mostly idiopathic but can be associated with underlying connective tissue disease.
Understanding Buerger’s Disease
Buerger’s disease, also known as thromboangiitis obliterans, is a type of vasculitis that affects the small and medium-sized blood vessels. This condition is strongly linked to smoking and can cause a range of symptoms, including extremity ischemia, intermittent claudication, ischaemic ulcers, superficial thrombophlebitis, and Raynaud’s phenomenon.
Individuals with Buerger’s disease may experience reduced blood flow to their limbs, which can lead to pain, numbness, and tingling sensations. This can make it difficult to walk or perform other activities, and may even result in the development of ulcers or sores on the skin.
Superficial thrombophlebitis, or inflammation of the veins close to the surface of the skin, is another common symptom of Buerger’s disease. This can cause redness, swelling, and tenderness in the affected area.
Raynaud’s phenomenon, which is characterized by the narrowing of blood vessels in the fingers and toes, is also associated with Buerger’s disease. This can cause the affected areas to turn white or blue and feel cold and numb.
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This question is part of the following fields:
- Cardiovascular
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Question 9
Incorrect
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A 45-year-old woman comes to the clinic with a complaint of dyspnoea on exertion and a non-productive cough that has been bothering her for the past 4 months. During the examination, the doctor notices clubbing and crepitations at the lung bases. Lung function tests reveal a decreased vital capacity and an elevated FEV1:FVC ratio. What is the most probable diagnosis?
Your Answer: Bronchiectasis
Correct Answer: Fibrosing alveolitis
Explanation:Understanding Cryptogenic Fibrosing Alveolitis
Cryptogenic fibrosing alveolitis, also known as idiopathic pulmonary fibrosis, is a disorder that typically affects individuals between the ages of 50 and 70 years, with a slightly higher incidence in men than women. The condition is characterized by progressive breathlessness on exertion, dry cough, and a restrictive pattern on pulmonary function tests. While excessive sputum production is uncommon in the early stages, constitutional symptoms such as weight loss and lethargy may occur. Finger clubbing is a common finding in patients with cryptogenic fibrosing alveolitis.
While haemoptysis is rare, it may suggest the development of lung malignancy, which occurs with an increased risk in patients with this condition. It is important to note that the risk of lung cancer does not exclude the possibility of cryptogenic fibrosing alveolitis. Chest pain is uncommon in this condition.
There is no definitive treatment for cryptogenic fibrosing alveolitis, and the average survival from the time of diagnosis is 3 years. However, the course of the disease can be highly variable, and up to 20% of patients survive for more than 5 years from diagnosis.
In summary, cryptogenic fibrosing alveolitis is a progressive lung disorder that presents with breathlessness on exertion, dry cough, and a restrictive pattern on pulmonary function tests. While there is no definitive treatment, early diagnosis and management can improve outcomes for patients.
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This question is part of the following fields:
- Respiratory Medicine
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Question 10
Correct
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A 75-year-old female with a history of acromegaly presents to the respiratory clinic with her husband for a routine follow-up. She has recently been diagnosed with obstructive sleep apnoea and has made several lifestyle changes such as losing weight and exercising regularly. However, she still complains of feeling tired after work and experiencing restless sleep with loud snoring that disturbs her husband. What further steps should be taken in managing her obstructive sleep apnoea?
Your Answer: Continuous positive airway pressure (CPAP)
Explanation:After losing weight, the recommended initial treatment for moderate/severe obstructive sleep apnoea is CPAP.
CPAP is the most widely used treatment for obstructive sleep apnoea (OSA) and is effective for both moderate and severe cases. However, lifestyle changes such as weight loss, quitting smoking, and avoiding alcohol should be attempted first. Although oral appliances can be used, they are not as effective as CPAP. Surgical treatments for OSA are not the first choice and have limited evidence.
Understanding Obstructive Sleep Apnoea/Hypopnoea Syndrome
Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) is a condition where the upper airway becomes partially or completely blocked during sleep, leading to interrupted breathing and reduced oxygen levels in the body. There are several predisposing factors for OSAHS, including obesity, macroglossia, large tonsils, and Marfan’s syndrome. The condition is often characterized by excessive snoring and periods of apnoea, which can be reported by the patient’s partner.
OSAHS can have several consequences, including daytime somnolence, compensated respiratory acidosis, and hypertension. To assess sleepiness, healthcare professionals may use tools such as the Epworth Sleepiness Scale or the Multiple Sleep Latency Test. Diagnostic tests for OSAHS include sleep studies, ranging from monitoring pulse oximetry to full polysomnography.
Management of OSAHS typically involves weight loss and continuous positive airway pressure (CPAP) as the first line of treatment for moderate or severe cases. Intra-oral devices may be used if CPAP is not tolerated or for patients with mild OSAHS. It is important to inform the DVLA if OSAHS is causing excessive daytime sleepiness. While there is limited evidence to support the use of pharmacological agents, healthcare professionals may consider them in certain cases.
Overall, understanding OSAHS and its management is crucial for improving the quality of life for patients with this condition.
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This question is part of the following fields:
- Respiratory Medicine
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Question 11
Incorrect
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A 70-year-old male has been admitted to the cardiology ward following his presentation to the emergency department with palpitations and dyspnoea. After further investigations, he was diagnosed with atrial fibrillation and prescribed digoxin for rate control. What is the recommended frequency for routine drug monitoring in this case?
Your Answer:
Correct Answer: No routine monitoring required
Explanation:Digoxin levels do not require regular monitoring, unless there is suspicion of toxicity. As this patient is commencing digoxin and has no signs of toxicity, routine monitoring is unnecessary. It is not necessary to measure digoxin levels every month until they have stabilized, nor is it appropriate to monitor the drug every 2 weeks for the first 3 months. Routine monitoring is also not required annually throughout the course of treatment.
Understanding Digoxin and Its Toxicity
Digoxin is a medication used for rate control in atrial fibrillation and for improving symptoms in heart failure patients. It works by decreasing conduction through the atrioventricular node and increasing the force of cardiac muscle contraction. However, it has a narrow therapeutic index and requires monitoring for toxicity.
Toxicity may occur even when the digoxin concentration is within the therapeutic range. Symptoms of toxicity include lethargy, nausea, vomiting, anorexia, confusion, yellow-green vision, arrhythmias, and gynaecomastia. Hypokalaemia is a classic precipitating factor, as it allows digoxin to more easily bind to the ATPase pump and increase its inhibitory effects. Other factors that may contribute to toxicity include increasing age, renal failure, myocardial ischaemia, electrolyte imbalances, hypoalbuminaemia, hypothermia, hypothyroidism, and certain medications such as amiodarone, quinidine, and verapamil.
Management of digoxin toxicity involves the use of Digibind, correction of arrhythmias, and monitoring of potassium levels. It is important to recognize the potential for toxicity and monitor patients accordingly to prevent adverse outcomes.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 12
Incorrect
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A 28-year-old woman is referred by her General Practitioner due to irregular and unpredictable menstrual cycle and headaches. Magnetic resonance imaging of the brain shows a midline lesion. Further investigations reveal that her prolactin level is 2314 ng/ml (normal range: 2â29 ng/ml). To reduce the prolactin level, which mediator is manipulated for medical treatment?
Your Answer:
Correct Answer: Dopamine
Explanation:Targeting Hormones in Prolactinoma Treatment
Prolactinoma is a pituitary lesion that results in excessive prolactin secretion. To reduce prolactin levels, dopamine agonists like bromocriptine are used to target dopamine receptors in the anterior pituitary. While increased prolactin can indirectly decrease gonadotropin-releasing hormone (GnRH) secretion, GnRH receptors are not a therapeutic target in prolactin disorders. Corticotropin-releasing hormone (CRH) increases adrenocorticotropic hormone secretion and is not a target in prolactin disorders. Somatostatin decreases thyroid-stimulating hormone (TSH) and growth hormone secretion but does not affect prolactin levels. Thyrotropin-releasing hormone (TRH) increases prolactin and TSH release, but its use is limited due to side-effects on thyroid regulation and the superiority of dopamine agonists.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 13
Incorrect
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A middle-aged business executive presents with a red hot, swollen and very painful right big toe. Joint aspiration reveals no organisms, but there are numerous neutrophils containing long needle-shaped crystals.
Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Gouty arthritis
Explanation:Gout is a crystal arthropathy caused by hyperuricaemia, most commonly affecting middle-aged men. Diagnosis is confirmed by aspiration and examination of joint fluid. Treatment is with high-dose NSAIDs or coxibs initially, followed by allopurinol in the long term. RA presents as an acute monoarticular arthritis in only 10% of cases, and is more common in women between the ages of 35 and 55. Septic arthritis and gonococcal arthritis are bacterial infections that present with a hot, red, swollen joint and constitutional symptoms. Reactive arthritis is a sterile arthritis occurring following an infection, usually presenting as an acute, asymmetrical lower limb arthritis.
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This question is part of the following fields:
- Musculoskeletal
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Question 14
Incorrect
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A 44 year old patient is undergoing quadruple therapy (rifampicin, isoniazid, ethambutol and pyrazinamide) for a confirmed diagnosis of pulmonary tuberculosis. During a respiratory follow up, the patient reports a decline in vision, particularly a decrease in the vibrancy of colors. What modification would you suggest for the medication?
Your Answer:
Correct Answer: Stop ethambutol
Explanation:The use of ethambutol has been linked to optic neuropathy and the onset of color blindness. If these symptoms occur, the medication should be stopped. To prevent these adverse effects, pyridoxine (vitamin B6) is often administered alongside ethambutol in medical settings.
Side-Effects and Mechanism of Action of Tuberculosis Drugs
Rifampicin is a drug that inhibits bacterial DNA dependent RNA polymerase, which prevents the transcription of DNA into mRNA. However, it is a potent liver enzyme inducer and can cause hepatitis, orange secretions, and flu-like symptoms.
Isoniazid, on the other hand, inhibits mycolic acid synthesis. It can cause peripheral neuropathy, which can be prevented with pyridoxine (Vitamin B6). It can also cause hepatitis and agranulocytosis. Additionally, it is a liver enzyme inhibitor.
Pyrazinamide is converted by pyrazinamidase into pyrazinoic acid, which in turn inhibits fatty acid synthase (FAS) I. However, it can cause hyperuricaemia, leading to gout, as well as arthralgia, myalgia, and hepatitis.
Lastly, Ethambutol inhibits the enzyme arabinosyl transferase, which polymerizes arabinose into arabinan. It can cause optic neuritis, so it is important to check visual acuity before and during treatment. Additionally, the dose needs adjusting in patients with renal impairment.
In summary, these tuberculosis drugs have different mechanisms of action and can cause various side-effects. It is important to monitor patients closely and adjust treatment accordingly to ensure the best possible outcomes.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 15
Incorrect
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During a cardiorespiratory exam, a 5-year-old boy is found to have pectus excavatum and pulmonary stenosis. What is the probable diagnosis?
Your Answer:
Correct Answer: Noonan syndrome
Explanation:Noonan syndrome is diagnosed in a young boy who exhibits a webbed neck, pulmonary stenosis, ptosis, and short stature, despite having a normal karyotype.
Childhood syndromes are a group of medical conditions that affect children and are characterized by a set of common features. Patau syndrome, also known as trisomy 13, is a syndrome that is characterized by microcephaly, small eyes, cleft lip/palate, polydactyly, and scalp lesions. Edward’s syndrome, also known as trisomy 18, is characterized by micrognathia, low-set ears, rocker bottom feet, and overlapping of fingers. Fragile X syndrome is characterized by learning difficulties, macrocephaly, long face, large ears, and macro-orchidism. Noonan syndrome is characterized by a webbed neck, pectus excavatum, short stature, and pulmonary stenosis. Pierre-Robin syndrome is characterized by micrognathia, posterior displacement of the tongue, and cleft palate. Prader-Willi syndrome is characterized by hypotonia, hypogonadism, and obesity. William’s syndrome is characterized by short stature, learning difficulties, friendly, extrovert personality, and transient neonatal hypercalcaemia. Cri du chat syndrome, also known as chromosome 5p deletion syndrome, is characterized by a characteristic cry, feeding difficulties and poor weight gain, learning difficulties, microcephaly and micrognathism, and hypertelorism. It is important to note that Treacher-Collins syndrome is similar to Pierre-Robin syndrome, but it is autosomal dominant and usually has a family history of similar problems.
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This question is part of the following fields:
- Paediatrics
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Question 16
Incorrect
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A 7-year-old boy presents to the emergency department with a non-painful, partially rigid erection. He mentions noticing it after playing at school in the morning but did not inform anyone. His mother noticed the erection while helping him get ready for his evening soccer practice. The child has no medical or surgical history and is not on any regular medications. What is the initial investigation that should be performed in this case?
Your Answer:
Correct Answer: Cavernosal blood gas
Explanation:Cavernosal blood gas analysis is a crucial investigation for patients presenting with priapism. In this case, the patient has a partially erect, non-painful penis that has persisted for over 4 hours, indicating non-ischaemic priapism. This type of priapism is caused by large volume arterial inflow to the penis from trauma or congenital malformation. Confirming whether the priapism is ischaemic or non-ischaemic through cavernosal blood gas analysis is essential for appropriate management. Ischaemic priapism is a medical emergency that requires aspiration of blood from the cavernosa, while non-ischaemic priapism can be managed with observation initially. In paediatric patients, a doppler ultrasound may be a better alternative to cavernosal blood gases due to the potential trauma of the procedure.
A CT pelvis is not recommended in this case as it would expose the child to unnecessary radiation. Instead, a doppler ultrasound can be used to investigate the arterial/venous blood flow in the penis. A clotting screen may be useful if the patient has a history of bleeding problems or a family history of haemoglobinopathies. However, it should not delay cavernosal blood gas analysis as it is crucial to confirm the type of priapism. Testicular ultrasound is not a useful imaging modality for investigating priapism. If an imaging modality is required to assess penile blood flow, a doppler ultrasound is the preferred option.
Understanding Priapism: Causes, Symptoms, and Management
Priapism is a medical condition characterized by a persistent penile erection that lasts longer than four hours and is not associated with sexual stimulation. There are two types of priapism: ischaemic and non-ischaemic, each with a different pathophysiology. Ischaemic priapism is caused by impaired vasorelaxation, resulting in reduced vascular outflow and trapping of de-oxygenated blood within the corpus cavernosa. Non-ischaemic priapism, on the other hand, is due to high arterial inflow, often caused by fistula formation due to congenital or traumatic mechanisms.
Priapism can affect individuals of all ages, with a bimodal distribution of age at presentation, with peaks between 5-10 years and 20-50 years of age. The incidence of priapism has been estimated at up to 5.34 per 100,000 patient-years. There are various causes of priapism, including idiopathic, sickle cell disease or other haemoglobinopathies, erectile dysfunction medication, trauma, and drug use (both prescribed and recreational).
Patients with priapism typically present acutely with a persistent erection lasting over four hours and pain localized to the penis. A history of haemoglobinopathy or medication use may also be present. Cavernosal blood gas analysis and Doppler or duplex ultrasonography can be used to differentiate between ischaemic and non-ischaemic priapism and assess blood flow within the penis. Treatment for ischaemic priapism is a medical emergency and includes aspiration of blood from the cavernosa, injection of a saline flush, and intracavernosal injection of a vasoconstrictive agent. Non-ischaemic priapism, on the other hand, is not a medical emergency and is usually observed as a first-line option.
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This question is part of the following fields:
- Reproductive Medicine
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Question 17
Incorrect
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A 67-year-old man attending the respiratory clinic receives a suspected diagnosis of chronic obstructive pulmonary disease.
Which of the following is the most appropriate investigation to confirm diagnosis?Your Answer:
Correct Answer: Spirometry
Explanation:Investigations for COPD: Spirometry is Key
COPD is a chronic obstructive airway disease that is diagnosed through a combination of clinical history, signs, and investigations. While several investigations may be used to support a diagnosis of COPD, spirometry is the most useful and important tool. A spirometer is used to measure functional lung volumes, including forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC). The FEV1:FVC ratio provides an estimate of the severity of airflow obstruction, with a normal ratio being 75-80%. In patients with COPD, the ratio is typically <0.7 and FEV1 <80% predicted. Spirometry is essential for establishing a baseline for disease severity, monitoring disease progression, and assessing the effects of treatment. Other investigations, such as echocardiography, chest radiography, ECG, and peak flow, may be used to exclude other pathologies or assess comorbidities, but spirometry remains the key investigation for diagnosing and managing COPD.
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This question is part of the following fields:
- Respiratory Medicine
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Question 18
Incorrect
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As a general practice doctor, you see a 35-year-old plumber who complains of shooting pains down his left leg for the past 3 weeks. The pain has been increasing in intensity and over the counter analgesia has not helped. The patient has no past medical history and takes no regular medications. During examination, you find normal power in both legs but altered sensation over the great toe on his left. There are no urinary symptoms or perianal sensation issues. An MRI scan of his lumbar spine shows a small left paracentral L4/5 disc prolapse causing compression of the transiting L5 nerve root. There is no compression of the cauda equina with CSF visible around all nerve roots. What is the most appropriate next step in managing this patient?
Your Answer:
Correct Answer: Start treatment with NSAIDs and refer for physiotherapy
Explanation:Most cases of sciatica can be resolved within 3 months through conservative treatment, and specialist referral is rarely necessary. However, if the pain persists after 4-6 weeks of physiotherapy and anti-neuropathic medication, referral to spinal surgery may be considered. Discharging the patient without proper intervention is not recommended as there is a risk of symptoms worsening and developing cauda equina syndrome. Patients should be advised to seek emergency care if they experience peri-anal or saddle sensory changes, difficulty urinating, or symptoms affecting both legs. Opiates are not recommended for neuropathic pain and may lead to dependence. Instead, a more appropriate and effective pain reliever for the patient’s age would be a non-steroidal anti-inflammatory drug (NSAID) like naproxen.
Understanding Prolapsed Disc and its Features
A prolapsed lumbar disc is a common cause of lower back pain that can lead to neurological deficits. It is characterized by clear dermatomal leg pain, which is usually worse than the back pain. The pain is often aggravated when sitting. The features of the prolapsed disc depend on the site of compression. For instance, L3 nerve root compression can cause sensory loss over the anterior thigh, weak quadriceps, reduced knee reflex, and a positive femoral stretch test. On the other hand, L4 nerve root compression can lead to sensory loss in the anterior aspect of the knee, weak quadriceps, reduced knee reflex, and a positive femoral stretch test.
The management of prolapsed disc is similar to that of other musculoskeletal lower back pain. It involves analgesia, physiotherapy, and exercises. According to NICE, the first-line treatment for back pain without sciatica symptoms is NSAIDs +/- proton pump inhibitors, rather than neuropathic analgesia. If the symptoms persist after 4-6 weeks, referral for consideration of MRI is appropriate. Understanding the features of prolapsed disc can help in the diagnosis and management of this condition.
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This question is part of the following fields:
- Musculoskeletal
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Question 19
Incorrect
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A 35-year-old para 2, gravida 3 is in labour in the delivery ward. The labour is progressing normally until the midwife calls the obstetrician to assess the patient. The cervix is dilated to 6 cm, and the baby's position is 2 cm above the ischial spine. The cardiotocography shows a slow but steady heartbeat. The obstetrician decides to perform an emergency category 2 caesarian section. What is the maximum time allowed between this decision and the delivery of the baby, given the indication?
Your Answer:
Correct Answer: 75 minutes
Explanation:Category 2 caesarean sections should be performed within 75 minutes of the decision being made. This is because these cases involve maternal or fetal compromise that is not immediately life-threatening, allowing the medical team to manage the emergency and plan the surgery to minimize risks to both the mother and the baby. A timeframe of 2 hours is incorrect as it would delay the necessary intervention. On the other hand, a timeframe of 30 minutes is only applicable to category 1 caesarean sections, where there is an immediate threat to the life of the mother or baby. A timeframe of 5 minutes is too short and may increase the risk of errors during the procedure.
Caesarean Section: Types, Indications, and Risks
Caesarean section, also known as C-section, is a surgical procedure that involves delivering a baby through an incision in the mother’s abdomen and uterus. In recent years, the rate of C-section has increased significantly due to an increased fear of litigation. There are two main types of C-section: lower segment C-section, which comprises 99% of cases, and classic C-section, which involves a longitudinal incision in the upper segment of the uterus.
C-section may be indicated for various reasons, including absolute cephalopelvic disproportion, placenta praevia grades 3/4, pre-eclampsia, post-maturity, IUGR, fetal distress in labor/prolapsed cord, failure of labor to progress, malpresentations, placental abruption, vaginal infection, and cervical cancer. The urgency of C-section may be categorized into four categories, with Category 1 being the most urgent and Category 4 being elective.
It is important for clinicians to inform women of the serious and frequent risks associated with C-section, including emergency hysterectomy, need for further surgery, admission to intensive care unit, thromboembolic disease, bladder injury, ureteric injury, and death. C-section may also increase the risk of uterine rupture, antepartum stillbirth, placenta praevia, and placenta accreta in subsequent pregnancies. Other complications may include persistent wound and abdominal discomfort, increased risk of repeat C-section, readmission to hospital, haemorrhage, infection, and fetal lacerations.
Vaginal birth after C-section (VBAC) may be an appropriate method of delivery for pregnant women with a single previous C-section delivery, except for those with previous uterine rupture or classical C-section scar. The success rate of VBAC is around 70-75%.
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This question is part of the following fields:
- Reproductive Medicine
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Question 20
Incorrect
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What is a true statement about trigeminal neuralgia? Choose one option from the list provided.
Your Answer:
Correct Answer: Carbamazepine is the first-line treatment
Explanation:Trigeminal Neuralgia: Diagnosis and Treatment
Trigeminal neuralgia is a condition characterized by sharp, shooting pain in the distribution of one or more branches of the trigeminal nerve. While the cause is unknown, it can be due to compression of the nerve as it exits the foramen. The pain is intermittent and often exacerbated by light touch, eating, talking, or exposure to the cold.
Carbamazepine is the first-line treatment for trigeminal neuralgia, with an initial dose of 100 mg up to twice daily. The dosage can be increased in increments of 100-200 mg every 2 weeks until the pain is under control.
Contrary to popular belief, trigeminal neuralgia usually affects the face unilaterally, with only 3% of cases being bilateral. A CT scan of the head is not recommended for all patients with the diagnosis of trigeminal neuralgia, but may be necessary if red flag symptoms are present.
It is important to note that patients with trigeminal neuralgia do not typically experience constant pain, as the pain is episodic in frequency. Tramadol is not the first-line treatment for trigeminal pain, carbamazepine is.
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This question is part of the following fields:
- Neurology
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Question 21
Incorrect
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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:
Correct 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.
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This question is part of the following fields:
- ENT
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Question 22
Incorrect
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Which of the following types of anti-anginal medication do patients frequently develop tolerance to?
Your Answer:
Correct Answer: Standard release isosorbide mononitrate
Explanation:Angina pectoris is a condition that can be managed through various methods, including lifestyle changes, medication, percutaneous coronary intervention, and surgery. In 2011, NICE released guidelines for the management of stable angina. Medication is an important aspect of treatment, and all patients should receive aspirin and a statin unless there are contraindications. Sublingual glyceryl trinitrate can be used to abort angina attacks. The first-line medication should be either a beta-blocker or a calcium channel blocker, depending on the patient’s comorbidities, contraindications, and preferences. If a calcium channel blocker is used as monotherapy, a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker should be used. Beta-blockers should not be prescribed concurrently with verapamil due to the risk of complete heart block. If the initial treatment is not effective, medication should be increased to the maximum tolerated dose. If a patient is still symptomatic after monotherapy with a beta-blocker, a calcium channel blocker can be added, and vice versa. If a patient cannot tolerate the addition of a calcium channel blocker or a beta-blocker, other drugs such as long-acting nitrates, ivabradine, nicorandil, or ranolazine can be considered. Nitrate tolerance is a common issue, and patients who take standard-release isosorbide mononitrate should use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimize the development of nitrate tolerance. This effect is not seen in patients who take once-daily modified-release isosorbide mononitrate. If a patient is taking both a beta-blocker and a calcium-channel blocker, a third drug should only be added while awaiting assessment for PCI or CABG.
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This question is part of the following fields:
- Cardiovascular
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Question 23
Incorrect
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A 28-year-old law student visits his primary care physician complaining of ear pain. He suspects that this is related to the same issue causing dryness in his scalp and beard, as well as eczema-like patches in his nasolabial folds. He has been using non-prescription topical treatments to manage these symptoms but seeks guidance for his earache. What is the probable diagnosis that connects all of this patient's symptoms?
Your Answer:
Correct Answer: Seborrhoeic dermatitis
Explanation:Seborrhoeic dermatitis can lead to common complications such as otitis externa and blepharitis. The patient is experiencing eczema-like plaques and dry skin in areas rich in sebum, which he has been treating with over-the-counter antifungal shampoos. However, his complaint of earache may be due to otitis externa, which is associated with seborrhoeic dermatitis. A full ear examination should be performed to rule out other diagnoses. Contact dermatitis is unlikely to present in this distribution and would not cause otalgia. Eczema herpeticum is a severe primary infection by herpes-simplex-virus 1 or 2, commonly seen in children with atopic eczema. Guttate psoriasis commonly affects children after Streptococcal upper respiratory tract infection and will clear over the course of ,3 months without treatment. Irritant dermatitis is unlikely to cause such focal areas of irritation.
Understanding Seborrhoeic Dermatitis in Adults
Seborrhoeic dermatitis is a chronic skin condition that affects around 2% of the general population. It is caused by an inflammatory reaction related to the overgrowth of a fungus called Malassezia furfur, which is a normal inhabitant of the skin. The condition is characterized by eczematous lesions that appear on the sebum-rich areas of the body, such as the scalp, periorbital, auricular, and nasolabial folds. It can also lead to the development of otitis externa and blepharitis.
Seborrhoeic dermatitis is often associated with other medical conditions, such as HIV and Parkinson’s disease. The management of the condition depends on the affected area. For scalp disease, over-the-counter preparations containing zinc pyrithione and tar are usually the first-line treatment. If these are not effective, ketoconazole is the preferred second-line agent. Selenium sulphide and topical corticosteroids may also be useful.
For the face and body, topical antifungals such as ketoconazole and topical steroids are often used. However, it is important to use steroids for short periods only to avoid side effects. Seborrhoeic dermatitis can be difficult to treat, and recurrences are common. Therefore, it is important to work closely with a healthcare provider to manage the condition effectively.
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This question is part of the following fields:
- Dermatology
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Question 24
Incorrect
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A 50-year-old man presents to the clinic with painful red eyes and blurred vision. Upon examination, the eye appears red and tender with decreased visual acuity. There is no inflammation or discharge from the eyelids, and the anterior chamber is normal. The patient has a history of rheumatoid arthritis but is currently not receiving treatment. What is the probable diagnosis?
Your Answer:
Correct Answer: Scleritis
Explanation:Blepharitis is a condition characterized by inflammation of the margins of the eyelids, typically caused by the growth of eyelashes inwards. Symptoms include discomfort, redness, and dryness of the eyes, but no visual impairment. Urgent referral to ophthalmology is necessary if suspected. Treatment involves conservative measures such as regular eye care using warm compresses.
Understanding Scleritis: Causes, Symptoms, and Treatment
Scleritis is a condition that involves inflammation of the sclera, which is the white outer layer of the eye. This condition is typically non-infectious and can cause a red, painful eye. The most common risk factor associated with scleritis is rheumatoid arthritis, but it can also be linked to other conditions such as systemic lupus erythematosus, sarcoidosis, and granulomatosis with polyangiitis.
Symptoms of scleritis include a red eye, which is often accompanied by pain and discomfort. Patients may also experience watering and photophobia, as well as a gradual decrease in vision.
Treatment for scleritis typically involves the use of oral NSAIDs as a first-line treatment. In more severe cases, oral glucocorticoids may be used. For resistant cases, immunosuppressive drugs may be necessary, especially if there is an underlying associated disease. With proper treatment, most patients with scleritis can achieve relief from their symptoms and prevent further complications.
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This question is part of the following fields:
- Ophthalmology
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Question 25
Incorrect
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A 28-year-old G1P0 woman attends her routine antenatal appointment at 12 weeks gestation and reports experiencing burning retrosternal pain. Omeprazole is prescribed, and a urine sample is taken. The urinalysis shows trace protein with no haematuria, nitrates, or white cells, and the patient denies any urinary symptoms. During the appointment, her blood pressure is measured at 135/88 mmHg. Upon further testing, the urine sample is found to have scant growth of Escherichia coli. What is the most appropriate course of action?
Your Answer:
Correct Answer: Prescribe a 7 day course of nitrofurantoin
Explanation:Asymptomatic bacteriuria in pregnant women should be treated promptly with antibiotics. The recommended treatment is a 7-day course of nitrofurantoin. This is important to prevent the development of symptomatic urinary tract infection or pyelonephritis. Nitrofurantoin is safe to use in the first and second trimester, but should be avoided in the third trimester due to the risk of neonatal haemolysis. The patient’s blood pressure is within normal range and does not require treatment. The trace of protein in her urine is likely related to her asymptomatic bacteriuria and should be monitored with subsequent urine dips. Antihypertensive treatment is not necessary based on the trace of protein alone. Prescribing a 7-day course of trimethoprim is not recommended as it is contraindicated in the first trimester of pregnancy due to the increased risk of neural-tube defects. Prescribing aspirin, labetalol, and a 7-day course of nitrofurantoin is not necessary as the patient does not meet the diagnostic criteria for pre-eclampsia or pregnancy-induced hypertension. Similarly, prescribing aspirin, labetalol, and a 7-day course of trimethoprim is not recommended for the same reasons.
Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. The management of UTIs depends on various factors such as the patient’s age, gender, and pregnancy status. For non-pregnant women, local antibiotic guidelines should be followed if available. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. However, if the patient is aged over 65 years or has visible or non-visible haematuria, a urine culture should be sent. Pregnant women with UTIs should be treated with nitrofurantoin, amoxicillin, or cefalexin for seven days. Trimethoprim should be avoided during pregnancy as it is teratogenic in the first trimester. Asymptomatic bacteriuria in pregnant women should also be treated to prevent progression to acute pyelonephritis. Men with UTIs should be offered a seven-day course of trimethoprim or nitrofurantoin unless prostatitis is suspected. A urine culture should be sent before antibiotics are started. Catheterised patients should not be treated for asymptomatic bacteria, but if symptomatic, a seven-day course of antibiotics should be given. Acute pyelonephritis requires hospital admission and treatment with a broad-spectrum cephalosporin or quinolone for 10-14 days. Referral to urology is not routinely required for men who have had one uncomplicated lower UTI.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 26
Incorrect
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A 10-year-old boy presents to the General Practitioner with his father who reports that he has been falling behind at school. His teachers have noticed that multiple times during lessons he appears to be 'staring into space' for about ten seconds at a time, during which there is twitching of his arms. He does not remember these episodes. He is referred for an electroencephalography (EEG) which shows spike-and-wave complexes during an episode. He is started on a new medication.
Which of the following is the most likely treatment?Your Answer:
Correct Answer: Ethosuximide
Explanation:When it comes to treating absence seizures, ethosuximide is the preferred first-line option for women and girls who may become pregnant. Boys and men can be treated with either ethosuximide or sodium valproate. Absence seizures are most common in children and young people, and are characterized by brief episodes of fixed gaze and possible arm or leg movements. An EEG can confirm the presence of spike-and-wave complexes during an attack. Sodium valproate may be used for boys and men, but should be avoided in women of childbearing potential due to the risk of birth defects. Carbamazepine is not effective for absence seizures, but is the first-line treatment for focal seizures. Lamotrigine may be used as a second-line option if other treatments are not effective or well-tolerated. In cases of status epilepticus, intravenous lorazepam is the preferred treatment in a hospital setting, but buccal midazolam or rectal diazepam can be used if intravenous access is not available.
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This question is part of the following fields:
- Neurology
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Question 27
Incorrect
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A 65-year-old man presented to the GP surgery multiple times with a persistent conjunctivitis in one eye. Despite being treated with chloramphenicol and steroid eye drops, the symptoms did not improve. After three weeks, he visited the eye casualty with a constantly teary, painless, and red right eye. Upon examination, it was found that he had decreased visual acuity and mild proptosis in the affected eye. What is the probable diagnosis for this patient?
Your Answer:
Correct Answer: Orbital lymphoma
Explanation:If a patient has chronic unilateral conjunctivitis that is not responding to treatment, it could be a sign of orbital lymphoma.
Orbital lymphoma typically has a slow onset of symptoms, which is why it is the most appropriate answer in this situation. If the red eye persists despite treatment, it is important to investigate further to rule out any serious underlying conditions. The other options listed are not applicable as they are associated with a painful red eye.
Conjunctivitis is a common eye problem that is often seen in primary care. It is characterized by red, sore eyes with a sticky discharge. There are two types of infective conjunctivitis: bacterial and viral. Bacterial conjunctivitis is identified by a purulent discharge and eyes that may be stuck together in the morning. On the other hand, viral conjunctivitis is characterized by a serous discharge and recent upper respiratory tract infection, as well as preauricular lymph nodes.
In most cases, infective conjunctivitis is a self-limiting condition that resolves without treatment within one to two weeks. However, topical antibiotic therapy is often offered to patients, such as Chloramphenicol drops given every two to three hours initially or Chloramphenicol ointment given four times a day initially. Alternatively, topical fusidic acid can be used, especially for pregnant women, and treatment is twice daily.
For contact lens users, topical fluoresceins should be used to identify any corneal staining, and treatment should be the same as above. During an episode of conjunctivitis, contact lenses should not be worn, and patients should be advised not to share towels. School exclusion is not necessary.
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This question is part of the following fields:
- Ophthalmology
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Question 28
Incorrect
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A newborn girl born 4 hours ago has an APGAR score of 10. She is not cyanosed, has a pulse of 150, cries on stimulation, her arms and legs resist extension and she has a good cry. However, she appears jaundiced. What should be done in this situation?
Your Answer:
Correct Answer: Measure and record the serum bilirubin level urgently.
Explanation:Jaundice in newborns can occur within the first 24 hours of life and is always considered pathological. The causes of jaundice during this period include rhesus and ABO haemolytic diseases, hereditary spherocytosis, and glucose-6-phosphodehydrogenase deficiency. On the other hand, jaundice in neonates from 2-14 days is common and usually physiological, affecting up to 40% of babies. This type of jaundice is due to a combination of factors such as more red blood cells, fragile red blood cells, and less developed liver function. Breastfed babies are more likely to develop this type of jaundice.
If jaundice persists after 14 days (21 days for premature babies), a prolonged jaundice screen is performed. This includes tests for conjugated and unconjugated bilirubin, direct antiglobulin test, thyroid function tests, full blood count and blood film, urine for MC&S and reducing sugars, and urea and electrolytes. Prolonged jaundice can be caused by biliary atresia, hypothyroidism, galactosaemia, urinary tract infection, breast milk jaundice, prematurity, and congenital infections such as CMV and toxoplasmosis. Breast milk jaundice is more common in breastfed babies and is thought to be due to high concentrations of beta-glucuronidase, which increases the intestinal absorption of unconjugated bilirubin. Prematurity also increases the risk of kernicterus.
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This question is part of the following fields:
- Paediatrics
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Question 29
Incorrect
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A 45 year-old-woman of African origin is diagnosed with type II diabetes by her General Practitioner. Her haemoglobin A1c was found to be 58 mmol/mol (normal range < 48 mmol/mol) on routine bloods for her annual hypertension review. Her body mass index (BMI) is 30 kg/m2.
Along with Metformin (an oral hypoglycaemic agent), which of the following is the most appropriate dietary recommendation for this patient?Your Answer:
Correct Answer: Low-fat dairy and oily fish
Explanation:Dietary Recommendations for Type II Diabetes Management
Managing type II diabetes requires a comprehensive approach that includes lifestyle modifications and medication. One crucial aspect of diabetes management is a healthy, balanced diet. The National Institute for Health and Care Excellence (NICE) provides guidelines on dietary recommendations for people with type II diabetes.
Low-fat dairy and oily fish are recommended to control the intake of saturated and trans fatty acids. Oily fish contains Omega-3 fatty acids, which are cardio-protective. High-fibre foods with carbohydrates with a low glycaemic index, such as fruits, vegetables, whole grains, and pulses, are also recommended.
Sucrose-containing foods should be limited, and care should be taken to avoid excess energy intake. NICE discourages the use of foods marketed specifically for people with type II diabetes, as they are often higher in calories.
Weight loss is an essential aspect of diabetes management, particularly for overweight individuals. NICE recommends a weight loss target of 5-10% for overweight adults with type II diabetes. Those who achieve a weight loss of 10% or more in the first five years after diagnosis have the greatest chance of seeing their disease go into remission.
In summary, a healthy, balanced diet that includes low-fat dairy, oily fish, high-fibre foods with low glycaemic index carbohydrates, and limited sucrose-containing foods is crucial for managing type II diabetes. Weight loss is also an essential aspect of diabetes management, particularly for overweight individuals.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 30
Incorrect
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Which of the following is not an absolute contraindication to using combined oral contraceptive pills for women?
Your Answer:
Correct Answer: Breast feeding a 10-week-old baby
Explanation:Breastfeeding is classified as UKMEC category 4 if done for less than 6 weeks after giving birth, but it is categorized as UKMEC category 2 if done after this period.
The decision to prescribe the combined oral contraceptive pill is now based on the UK Medical Eligibility Criteria (UKMEC), which categorizes potential contraindications and cautions on a four-point scale. UKMEC 1 indicates no restrictions for use, while UKMEC 2 suggests that the benefits outweigh the risks. UKMEC 3 indicates that the disadvantages may outweigh the advantages, and UKMEC 4 represents an unacceptable health risk. Examples of UKMEC 3 conditions include controlled hypertension, a family history of thromboembolic disease in first-degree relatives under 45 years old, and current gallbladder disease. Examples of UKMEC 4 conditions include a history of thromboembolic disease or thrombogenic mutation, breast cancer, and uncontrolled hypertension. Diabetes mellitus diagnosed over 20 years ago is classified as UKMEC 3 or 4 depending on severity. In 2016, breast feeding between 6 weeks and 6 months postpartum was changed from UKMEC 3 to UKMEC 2.
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This question is part of the following fields:
- Reproductive Medicine
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Question 31
Incorrect
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A 57-year-old man presents with papilloedema during examination. What could be the possible cause?
Your Answer:
Correct Answer: Hypercapnia
Explanation:In emergency situations, inducing hypocapnia through hyperventilation may be employed as a means to decrease intracranial pressure.
Understanding Papilloedema: Optic Disc Swelling Caused by Increased Intracranial Pressure
Papilloedema is a condition characterized by swelling of the optic disc due to increased pressure within the skull. This condition is typically bilateral and can be identified through fundoscopy. During this examination, venous engorgement is usually the first sign observed, followed by loss of venous pulsation, blurring of the optic disc margin, elevation of the optic disc, loss of the optic cup, and the presence of Paton’s lines, which are concentric or radial retinal lines cascading from the optic disc.
There are several potential causes of papilloedema, including space-occupying lesions such as tumors or vascular abnormalities, malignant hypertension, idiopathic intracranial hypertension, hydrocephalus, and hypercapnia. In rare cases, papilloedema may also be caused by hypoparathyroidism and hypocalcaemia, or vitamin A toxicity.
Overall, understanding papilloedema is important for identifying potential underlying conditions and providing appropriate treatment to prevent further complications.
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This question is part of the following fields:
- Ophthalmology
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Question 32
Incorrect
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A 52-year-old woman with a body mass index (BMI) of 32 was diagnosed with type 2 diabetes mellitus during a routine check-up six months ago. Despite being advised about a low-energy, weight-reducing diet and exercise, she has not followed through with these recommendations and her postprandial blood glucose concentration is 13.8 mmol/l (reference range <11.1 mmol/l). What would be the drug of choice in this case?
Your Answer:
Correct Answer: Metformin
Explanation:Medications for Type 2 Diabetes
Metformin: The Initial Drug Treatment of Choice
For adults with type 2 diabetes, standard-release metformin is the recommended initial drug treatment. The dose should be gradually increased to avoid gastrointestinal side effects. If significant GI side effects occur, modified-release metformin can be tried. Metformin reduces hepatic gluconeogenesis and increases insulin sensitivity, leading to an increase in peripheral glucose uptake. However, caution should be exercised when using metformin in patients with renal failure, and it should be stopped if the estimated glomerular filtration rate is less than 30 ml/min per 1.73m2.Tolbutamide and Chlorpropamide: First-Generation Sulfonylureas
Tolbutamide and chlorpropamide are first-generation sulfonylureas that are no longer routinely used in the treatment of type 2 diabetes due to a higher incidence of side effects compared to newer, second-generation sulfonylureas. Chlorpropamide is not available in the UK.Insulin: Considered for Dual Therapy
Insulin-based treatment should be considered in type 2 diabetes patients who have not achieved optimal glycated haemoglobin control with dual therapy using metformin and another oral drug. Metformin should continue to be offered to patients without contraindications or intolerance.Pioglitazone: An Alternative Second-Line Agent
Pioglitazone can be considered as an alternative second-line agent for patients with type 2 diabetes who cannot take metformin or have not tolerated it well. It can also be used in dual therapy for first intensification of treatment. -
This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 33
Incorrect
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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:
Correct 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.
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This question is part of the following fields:
- Psychiatry
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Question 34
Incorrect
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A 25-year-old woman is referred to the clinic for evaluation. She is in her first month of pregnancy and has been experiencing excessive morning sickness. Her routine blood work revealed an ALT level of 64 iu/l (reference range 20â60 iu/l) and a total bilirubin level of 30 ÎŒmol/l (reference range < 20 ÎŒmol/l). Additionally, her potassium level was 3.4 (reference range 3.5â5.0 mEq/l) and her urea level was 7.5 (reference range 2.5â7.1 mmol/l). What is the most likely diagnosis based on these findings?
Your Answer:
Correct Answer: Hyperemesis gravidarum
Explanation:Liver Disorders in Pregnancy: Differential Diagnosis
During pregnancy, various liver disorders can occur, each with its own set of symptoms and potential complications. Here are some of the most common liver disorders that can occur during pregnancy and their distinguishing features:
1. Hyperemesis gravidarum: This is the most severe form of nausea and vomiting in pregnancy, which can lead to weight loss, dehydration, and electrolyte imbalances. It is characterised by persistent nausea and vomiting, and may require hospitalisation.
2. Acute fatty liver of pregnancy: This is a rare but serious complication that can occur in the third trimester. It is characterised by microvesicular steatosis in the liver, which can lead to liver insufficiency. Symptoms include malaise, nausea and vomiting, right upper quadrant and epigastric pain, and acute renal failure.
3. Intrahepatic cholestasis of pregnancy: This is the most common pregnancy-related liver disorder, characterised by generalised itching, particularly in the palms and soles, and jaundice. It is caused by hormonal changes and can lead to fetal complications if not treated promptly.
4. Pre-eclampsia: This is a disorder of widespread vascular malfunction that occurs after 20 weeks of gestation. It is characterised by hypertension and proteinuria, with or without oedema.
5. Biliary tract disease: This is a broad spectrum of disorders ranging from asymptomatic gallstones to cholecystitis and choledocholithiasis. Symptoms include biliary colic, inflammation of the gall bladder wall, and obstruction of the common bile duct.
It is important to differentiate between these liver disorders in pregnancy, as each requires a different approach to management and treatment. Consultation with a healthcare provider is recommended for proper diagnosis and management.
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This question is part of the following fields:
- Reproductive Medicine
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Question 35
Incorrect
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A 54-year-old man presents to his General Practitioner with a three-day history of blurring of vision. He has a past medical history of hypertension, managed with amlodipine, ramipril, and indapamide, and type II diabetes mellitus, which is well controlled with metformin.
On examination, his visual acuity is 6/18 in both eyes with a reduction in colour vision. There is no relative afferent pupillary defect. On direct fundoscopy, the optic disc's margins are ill-defined and seem to be raised in both eyes. There are also some cotton-wool spots scattered around the retina in both eyes.
What is the most likely diagnosis?Your Answer:
Correct Answer: Hypertensive retinopathy
Explanation:Differentiating Hypertensive Retinopathy from Other Eye Conditions
Hypertensive retinopathy is a serious condition that can lead to vision loss if left untreated. A grade 4 hypertensive retinopathy, as classified by the Keith-Wagener-Barker system, is characterized by bilateral optic disc swelling and cotton-wool spots. This condition can cause a reduction in visual acuity and color vision due to optic neuropathy secondary to hypertension.
It is important to differentiate hypertensive retinopathy from other eye conditions that may present with similar symptoms. Proliferative diabetic retinopathy, for example, is unlikely if the patient’s type II diabetes is well-controlled. The presence of cotton-wool spots does not indicate diabetic retinopathy.
An intracranial space-occupying lesion is also not indicated in the patient’s history. Optic neuritis, while it can present with loss of optic nerve function, is more likely to present unilaterally and without cotton-wool spots.
Pre-proliferative diabetic retinopathy is also unlikely in this case, as the patient’s diabetes is well-controlled. In diabetic retinopathy, optic discs will not be raised.
In summary, a thorough understanding of the patient’s medical history and symptoms is necessary to accurately diagnose hypertensive retinopathy and differentiate it from other eye conditions.
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This question is part of the following fields:
- Ophthalmology
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Question 36
Incorrect
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A 26-year-old woman in her first pregnancy visits her GP at 12 weeks gestation complaining of dysuria. Apart from this, she is healthy and her pregnancy has been uneventful so far. Upon urine dip, leucocytes, nitrates, blood, and protein are detected. What is the most suitable course of treatment?
Your Answer:
Correct Answer: Nitrofurantoin
Explanation:Although UTI in pregnancy may not show any symptoms, it still needs to be treated promptly to prevent the development of pyelonephritis. The common medications used to treat UTIs are nitrofurantoin and trimethoprim. Nitrofurantoin can be used during pregnancy, but it should be avoided at term as it can cause neonatal haemolysis. Trimethoprim should be avoided in the first trimester of pregnancy. Penicillins and cephalosporins are safe to use during pregnancy, but sulfonamides (such as sulfasalazine) and quinolones (such as ciprofloxacin) should be avoided.
Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. The management of UTIs depends on various factors such as the patient’s age, gender, and pregnancy status. For non-pregnant women, local antibiotic guidelines should be followed if available. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. However, if the patient is aged over 65 years or has visible or non-visible haematuria, a urine culture should be sent. Pregnant women with UTIs should be treated with nitrofurantoin, amoxicillin, or cefalexin for seven days. Trimethoprim should be avoided during pregnancy as it is teratogenic in the first trimester. Asymptomatic bacteriuria in pregnant women should also be treated to prevent progression to acute pyelonephritis. Men with UTIs should be offered a seven-day course of trimethoprim or nitrofurantoin unless prostatitis is suspected. A urine culture should be sent before antibiotics are started. Catheterised patients should not be treated for asymptomatic bacteria, but if symptomatic, a seven-day course of antibiotics should be given. Acute pyelonephritis requires hospital admission and treatment with a broad-spectrum cephalosporin or quinolone for 10-14 days. Referral to urology is not routinely required for men who have had one uncomplicated lower UTI.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 37
Incorrect
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A 21-year-old man visits his GP with complaints of increased thirst throughout the day and difficulty performing everyday tasks. He was recently treated for a UTI with ciprofloxacin. His father has a history of diabetes, but is unsure of the type. He drinks about 8 units of alcohol per week. Fasting plasma glucose is 17.1 mmol/L (3.9-5.6), ketone bodies are 0.4 mmol/L (< 0.6 mmol/L), and C-peptide level is 2.87 ng/mL (0.51-2.72). What is the most likely diagnosis based on the patient's presentation?
Your Answer:
Correct Answer: Type 2 diabetes
Explanation:Distinguishing between type 1 and type 2 diabetes can be achieved through the measurement of C-peptide levels and diabetes-specific autoantibodies.
Diagnosis of Type 1 Diabetes Mellitus
Type 1 diabetes mellitus (T1DM) is typically diagnosed through symptoms and signs that are similar to those seen in diabetic ketoacidosis (DKA), although the diagnosis may take longer. Symptoms of DKA include abdominal pain, polyuria, polydipsia, dehydration, Kussmaul respiration, and an acetone-smelling breath. To confirm a diagnosis, urine should be dipped for glucose and ketones, and fasting glucose and random glucose levels should be measured. C-peptide levels are typically low in patients with T1DM, and diabetes-specific autoantibodies can be useful in distinguishing between type 1 and type 2 diabetes. Antibodies to glutamic acid decarboxylase (anti-GAD), islet cell antibodies (ICA), insulin autoantibodies (IAA), and insulinoma-associated-2 autoantibodies (IA-2A) are commonly used.
The diagnostic criteria for T1DM include a fasting glucose level greater than or equal to 7.0 mmol/l or a random glucose level greater than or equal to 11.1 mmol/l if the patient is symptomatic. If the patient is asymptomatic, the criteria must be demonstrated on two separate occasions. To distinguish between type 1 and type 2 diabetes, age of onset, speed of onset, weight of the patient, and symptoms should be considered. NICE recommends further investigation for adults suspected of having T1DM if the clinical presentation includes atypical features. Conversely, for patients suspected of having type 2 diabetes, if they respond well to oral hypoglycaemic agents and are over the age of 40 years, further testing for T1DM may not be necessary.
Example scenarios include a 15-year-old with weight loss and lethargy, a 38-year-old obese man with polyuria, a 52-year-old woman with polyuria and polydipsia, and a 59-year-old obese man with polyuria. The appropriate diagnostic tests should be conducted based on the patient’s symptoms and risk factors.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 38
Incorrect
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A 25-year-old male patient visits the GP clinic with a history of deteriorating vision in both eyes for the past 3 years. He complains of a gradual loss of peripheral vision, as if viewing through a tunnel. He is unable to play basketball due to difficulty seeing the ball. Additionally, he is experiencing increasing difficulty with his vision in low light conditions, causing him to avoid driving at night. Apart from this, he reports feeling healthy. There is no significant medical history to note. What is the probable diagnosis?
Your Answer:
Correct Answer: Retinitis pigmentosa
Explanation:Retinitis pigmentosa is responsible for causing tunnel vision, as reported by the patient who is experiencing a gradual decline in their peripheral vision and difficulty seeing at night. These symptoms are typical of retinitis pigmentosa. However, central vision loss is associated with Best disease and juvenile retinoschisis, not retinitis pigmentosa. Glaucoma is improbable in this age range.
Understanding Tunnel Vision and Its Causes
Tunnel vision is a condition where the visual fields become smaller and more concentrated. This means that the person affected can only see what is directly in front of them, while the peripheral vision is diminished. There are several causes of tunnel vision, including papilloedema, glaucoma, retinitis pigmentosa, choroidoretinitis, optic atrophy secondary to tabes dorsalis, and hysteria.
Papilloedema is a condition where there is swelling of the optic nerve head, which can cause pressure on the surrounding tissues. Glaucoma is a condition where there is damage to the optic nerve, which can lead to vision loss. Retinitis pigmentosa is a genetic disorder that affects the retina, causing progressive vision loss. Choroidoretinitis is an inflammation of the choroid and retina, which can cause vision loss. Optic atrophy secondary to tabes dorsalis is a condition where there is damage to the optic nerve due to syphilis. Hysteria is a psychological condition that can cause physical symptoms, including tunnel vision.
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This question is part of the following fields:
- Ophthalmology
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Question 39
Incorrect
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A 51-year-old male visits his doctor due to a rise in his blood pressure. He regularly checks it because of his bilateral renal artery stenosis. During the clinic visit, his blood pressure is measured at 160/101 mmHg. He reports feeling fine and not taking any medications regularly. Which antihypertensive medication should be avoided in this patient?
Your Answer:
Correct Answer: Enalapril
Explanation:Enalapril is an ACE inhibitor drug that inhibits the conversion of angiotensin I to angiotensin II. However, it is contraindicated in patients with bilateral renal artery stenosis as it can cause a significant increase in creatinine levels due to the constriction of the efferent arteriole by angiotensin II. Although ACE inhibitors can sometimes be used to treat hypertension caused by renal artery stenosis, close monitoring is necessary to prevent severe renal impairment. Amlodipine, a calcium channel blocker, is a suitable alternative for this patient as it has no contraindications for renovascular disease. Bendroflumethiazide, a thiazide diuretic, increases sodium excretion and urine volume by interfering with transfer across cell membranes, reducing blood volume. Indapamide, a thiazide-like diuretic, can also be used in this patient, although it is not typically the first-line treatment.
Angiotensin-converting enzyme (ACE) inhibitors are commonly used as the first-line treatment for hypertension and heart failure in younger patients. However, they may not be as effective in treating hypertensive Afro-Caribbean patients. These inhibitors are also used to treat diabetic nephropathy and for secondary prevention of ischaemic heart disease. The mechanism of action of ACE inhibitors is to inhibit the conversion of angiotensin I to angiotensin II. They are metabolized in the liver through phase 1 metabolism.
ACE inhibitors may cause side effects such as cough, which occurs in around 15% of patients and may occur up to a year after starting treatment. This is thought to be due to increased bradykinin levels. Angioedema may also occur up to a year after starting treatment. Hyperkalaemia and first-dose hypotension are other potential side effects, especially in patients taking diuretics. ACE inhibitors should be avoided during pregnancy and breastfeeding, and caution should be exercised in patients with renovascular disease, aortic stenosis, or hereditary or idiopathic angioedema.
Patients receiving high-dose diuretic therapy (more than 80 mg of furosemide a day) are at an increased risk of hypotension when taking ACE inhibitors. Before initiating treatment, urea and electrolytes should be checked, and after increasing the dose, a rise in creatinine and potassium may be expected. Acceptable changes include an increase in serum creatinine up to 30% from baseline and an increase in potassium up to 5.5 mmol/l. Patients with undiagnosed bilateral renal artery stenosis may experience significant renal impairment. The current NICE guidelines provide a flow chart for the management of hypertension.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 40
Incorrect
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A 30-year-old male is brought to the emergency department after being found unconscious on the street with a syringe and used pack of oxycodone and alprazolam nearby. Upon examination, he is lethargic with pinpoint pupils, reduced bowel sounds, and fresh needle marks on his right arm. His vital signs are: blood pressure 110/70 mmHg, heart rate 55/min, oxygen saturation of 95% on room air, temperature 36ÂșC, and respiratory rate of 5 breaths per minute. His blood glucose level is 8 mmol/L. What is the most appropriate management for this patient?
Your Answer:
Correct Answer: Naloxone
Explanation:The individual displays classic symptoms of acute opioid overdose, including slow breathing, constricted pupils, and changes in consciousness.
The management of overdoses and poisonings involves specific treatments for each toxin. For paracetamol overdose, activated charcoal is recommended if ingested within an hour, followed by N-acetylcysteine or liver transplantation if necessary. Salicylate overdose can be managed with urinary alkalinization using IV bicarbonate or haemodialysis. Opioid/opiate overdose can be treated with naloxone, while benzodiazepine overdose can be treated with flumazenil in severe cases. Tricyclic antidepressant overdose may require IV bicarbonate to reduce the risk of seizures and arrhythmias, but class 1a and class Ic antiarrhythmics should be avoided. Lithium toxicity may respond to volume resuscitation with normal saline or haemodialysis in severe cases. Warfarin overdose can be treated with vitamin K or prothrombin complex, while heparin overdose can be treated with protamine sulphate. Beta-blocker overdose may require atropine or glucagon. Ethylene glycol poisoning can be managed with fomepizole or ethanol, while methanol poisoning can be treated with the same. Organophosphate insecticide poisoning can be treated with atropine, and digoxin overdose can be treated with digoxin-specific antibody fragments. Iron overdose can be managed with desferrioxamine, and lead poisoning can be treated with dimercaprol or calcium edetate. Carbon monoxide poisoning can be managed with 100% oxygen or hyperbaric oxygen, while cyanide poisoning can be treated with hydroxocobalamin or a combination of amyl nitrite, sodium nitrite, and sodium thiosulfate.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 41
Incorrect
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A 60-year-old woman has blood tests done by her primary care physician during a routine check-up. The results show a decline in her renal function. Upon further examination, she reports experiencing ankle swelling and increased fatigue. The renal team suspects she may have amyloidosis. What diagnostic test could be used to confirm this diagnosis?
Your Answer:
Correct Answer: Renal biopsy
Explanation:Diagnostic Methods for Renal Amyloidosis
Renal amyloidosis is a condition that can be challenging to diagnose. It is caused by the accumulation of proteinaceous material in tissues, which can be identified through a biopsy. Congo-red staining extracellular fibrillar material is a characteristic feature of amyloid protein in the kidney. While a urine dip may show proteinuria, a renal biopsy is necessary for a definitive diagnosis as proteinuria can be caused by other conditions. A bone marrow biopsy can confirm amyloidosis if there is suspicion of bone marrow infiltration. CT scans of the abdomen may reveal abnormalities in the kidneys or lymph nodes, but a renal biopsy is still required for a definitive diagnosis. As amyloidosis can affect other organs, a lung biopsy may not be the most targeted approach for diagnosing renal amyloidosis. Overall, a renal biopsy is the most reliable method for diagnosing renal amyloidosis.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 42
Incorrect
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Concurrent use of which one of the following would decrease the effectiveness of the combined oral contraceptive pill for a 25-year-old woman?
Your Answer:
Correct Answer: Carbamazepine
Explanation:P450 Enzyme System and its Inducers and Inhibitors
The P450 enzyme system is responsible for metabolizing drugs in the body. Induction of this system usually requires prolonged exposure to the inducing drug, unlike P450 inhibitors, which have rapid effects. Some drugs that induce the P450 system include antiepileptics like phenytoin and carbamazepine, barbiturates such as phenobarbitone, rifampicin, St John’s Wort, chronic alcohol intake, griseofulvin, and smoking, which affects CYP1A2 and is the reason why smokers require more aminophylline.
On the other hand, some drugs inhibit the P450 system, including antibiotics like ciprofloxacin and erythromycin, isoniazid, cimetidine, omeprazole, amiodarone, allopurinol, imidazoles such as ketoconazole and fluconazole, SSRIs like fluoxetine and sertraline, ritonavir, sodium valproate, and acute alcohol intake. It is important to be aware of these inducers and inhibitors as they can affect the metabolism and efficacy of drugs in the body. Proper dosing and monitoring can help ensure safe and effective treatment.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 43
Incorrect
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A 62-year-old woman complains of blood in her stool and unintentional weight loss. During rectal examination, you notice a suspicious lesion below the pectinate line, which raises concern for cancer. You proceed to check for any signs of lymphadenopathy.
Where would you anticipate discovering enlarged lymph nodes?Your Answer:
Correct Answer: Inguinal
Explanation:Lymph Node Drainage in the Pelvic Region
The lymphatic drainage in the pelvic region is an important aspect of the body’s immune system. There are several lymph nodes in this area that drain different parts of the body. Here is a breakdown of the lymph node drainage in the pelvic region:
1. Inguinal: The inguinal lymph nodes drain the anal canal inferior to the pectinate line. These nodes then drain into the lateral pelvic nodes.
2. External iliac: The external iliac nodes drain the adductor region of the upper thigh, glans, clitoris, cervix, and upper bladder.
3. Inferior mesenteric: The inferior mesenteric nodes drain the sigmoid, upper rectum, and descending colon.
4. Internal iliac: The internal iliac nodes drain the rectum and the part of the anal canal superior to the pectinate line.
5. Superior mesenteric: The superior mesenteric nodes drain parts of the upper gastrointestinal tract, specifically the duodenum and jejunum.
Understanding the lymph node drainage in the pelvic region is important for diagnosing and treating certain conditions. By knowing which lymph nodes drain which parts of the body, healthcare professionals can better identify the source of an infection or cancer and provide appropriate treatment.
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This question is part of the following fields:
- Immunology/Allergy
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Question 44
Incorrect
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A mother brings her 14-year-old daughter to the general practice with concerns about her delayed onset of periods. During the examination, the daughter is found to be in the 9th percentile for her age in terms of height, has short ring fingers, poor breast development, and a high arched palate. While listening to her heart, a crescendo-decrescendo murmur is heard on the upper right sternal border that radiates to the carotids. What is the probable cause of this murmur?
Your Answer:
Correct Answer: Bicuspid valve
Explanation:A 16-year-old girl presents with symptoms of shortness of breath, chest pain, and fatigue. Upon examination, a heart murmur is detected in the aortic region, which is described as a crescendo-decrescendo murmur. The possible causes of this murmur are considered, including aortic stenosis, aortic valve calcification, rheumatic heart disease, and Tetralogy of Fallot. However, based on the patient’s age and symptoms, aortic stenosis is the most likely diagnosis.
Understanding Turner’s Syndrome
Turner’s syndrome is a genetic disorder that affects approximately 1 in 2,500 females. It is caused by the absence of one sex chromosome (X) or a deletion of the short arm of one of the X chromosomes. This condition is denoted as 45,XO or 45,X.
The features of Turner’s syndrome include short stature, a shield chest with widely spaced nipples, a webbed neck, a bicuspid aortic valve (15%), coarctation of the aorta (5-10%), primary amenorrhea, cystic hygroma (often diagnosed prenatally), a high-arched palate, a short fourth metacarpal, multiple pigmented naevi, lymphoedema in neonates (especially feet), and elevated gonadotrophin levels. Hypothyroidism is much more common in Turner’s syndrome, and there is also an increased incidence of autoimmune disease (especially autoimmune thyroiditis) and Crohn’s disease.
In summary, Turner’s syndrome is a chromosomal disorder that affects females and can cause a range of physical features and health issues. Early diagnosis and management can help individuals with Turner’s syndrome lead healthy and fulfilling lives.
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This question is part of the following fields:
- Paediatrics
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Question 45
Incorrect
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A 19-year-old woman goes to a family planning clinic to talk about contraception options. She has been experiencing migraine with aura for the past year and a half. According to the UK Medical Eligibility Criteria, which contraceptive method is considered safe to use without caution or contraindication in this situation?
Your Answer:
Correct Answer: Copper intrauterine device
Explanation:The use of combined oral contraceptive pills is completely contraindicated in patients with migraine with aura due to an increased risk of ischaemic stroke (UKMEC class 4). However, progestogen-based contraception methods and the levonorgestrel-releasing intrauterine device are considered safe (UKMEC 2) as the benefits of using these methods outweigh the potential risks. The copper intrauterine device is the only form of contraception recommended by UKMEC as having no contraindication in this condition (UKMEC 1).
Intrauterine contraceptive devices include copper IUDs and levonorgestrel-releasing IUS. Both are over 99% effective. The IUD prevents fertilization by decreasing sperm motility, while the IUS prevents endometrial proliferation and thickens cervical mucus. Potential problems include heavier periods with IUDs and initial bleeding with the IUS. There is a small risk of uterine perforation, ectopic pregnancy, and infection. New IUS systems, such as JaydessÂź and KyleenaÂź, have smaller frames and less levonorgestrel, resulting in lower serum levels and different rates of amenorrhea.
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This question is part of the following fields:
- Reproductive Medicine
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Question 46
Incorrect
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A 56-year-old man with hypertension presents to the clinic with a complaint of ankle swelling that has developed over the past two months. Which medication is the most probable cause of this symptom?
Your Answer:
Correct Answer: Amlodipine
Explanation:Calcium channel blockers may cause adverse effects such as headaches, flushing, and swelling in the ankles.
Understanding Calcium Channel Blockers
Calcium channel blockers are medications primarily used to manage cardiovascular diseases. These blockers target voltage-gated calcium channels present in myocardial cells, cells of the conduction system, and vascular smooth muscle cells. The different types of calcium channel blockers have varying effects on these three areas, making it crucial to differentiate their uses and actions.
Verapamil is an example of a calcium channel blocker used to manage angina, hypertension, and arrhythmias. However, it is highly negatively inotropic and should not be given with beta-blockers as it may cause heart block. Verapamil may also cause side effects such as heart failure, constipation, hypotension, bradycardia, and flushing.
Diltiazem is another calcium channel blocker used to manage angina and hypertension. It is less negatively inotropic than verapamil, but caution should still be exercised when patients have heart failure or are taking beta-blockers. Diltiazem may cause side effects such as hypotension, bradycardia, heart failure, and ankle swelling.
On the other hand, dihydropyridines such as nifedipine, amlodipine, and felodipine are calcium channel blockers used to manage hypertension, angina, and Raynaud’s. These blockers affect the peripheral vascular smooth muscle more than the myocardium, resulting in no worsening of heart failure but may cause ankle swelling. Shorter-acting dihydropyridines such as nifedipine may cause peripheral vasodilation, resulting in reflex tachycardia and side effects such as flushing, headache, and ankle swelling.
In summary, understanding the different types of calcium channel blockers and their effects on the body is crucial in managing cardiovascular diseases. It is also important to note the potential side effects and cautions when prescribing these medications.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 47
Incorrect
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A 32-year-old man visits his GP complaining of a sore throat, runny nose, cough, feeling feverish and generally unwell for the past week. He reports no difficulty eating or drinking.
Upon examination, his temperature is 37.2°C, and his chest is clear, but he has a dry cough. His tonsils are inflamed, but there is no exudate. He has no significant medical history.
Based on his Fever PAIN score, what would be the most appropriate course of action?Your Answer:
Correct Answer: Advise her that antibiotics are not indicated at this point and to return in one week if there is no improvement
Explanation:Using the FeverPAIN Score to Determine Antibiotic Use for Pharyngitis
When a patient presents with symptoms of pharyngitis, it can be difficult to determine whether antibiotics are necessary. The FeverPAIN Score for Streptococcus pharyngitis was developed to help assess which patients have streptococcal pharyngitis and therefore require antibiotics.
The score assigns points based on the presence of fever, pus, quick attenuation of symptoms, inflamed tonsils, and cough.
Fever PAIN score
Fever – 1
Pus – 1
Attenuates quickly – 1
Inflamed tonsils – 1
No cough – 1
A score of 0-1 is associated with a low likelihood of streptococcal infection and does not require antibiotics. A score of 2-3 may warrant a delayed antibiotic prescription, while a score of 4 or more may require immediate antibiotics.In the case of a patient with a low FeverPAIN score, it is important to advise against antibiotics and instead recommend a follow-up visit in one week if there is no improvement. Safety netting should also be provided to ensure the patient is aware of potential warning signs of deterioration. By using the FeverPAIN score, healthcare providers can reduce inappropriate antibiotic use in pharyngitis and promote more effective treatment.
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This question is part of the following fields:
- ENT
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Question 48
Incorrect
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A 25-year-old man who is typically healthy presents with joint pain and swelling that has been ongoing for 2 weeks. During the examination, you observe a rash on his nose and detect 2+ protein in his urine upon dipping. What is the probable diagnosis?
Your Answer:
Correct Answer: Systemic Lupus Erythematosus
Explanation:The symptoms exhibited by this individual are indicative of Systemic Lupus Erythematosus (SLE), as evidenced by the presence of the butterfly rash, joint pain, and proteinuria. In SLE, the impaired kidney function is responsible for the proteinuria. It is worth noting that SLE is more prevalent in females, with a ratio of 9:1 compared to males.
Understanding Systemic Lupus Erythematosus
Systemic lupus erythematosus (SLE) is an autoimmune disorder that affects multiple systems in the body. It is more common in women and people of Afro-Caribbean origin, and typically presents in early adulthood. The general features of SLE include fatigue, fever, mouth ulcers, and lymphadenopathy.
SLE can also affect the skin, causing a malar (butterfly) rash that spares the nasolabial folds, discoid rash in sun-exposed areas, photosensitivity, Raynaud’s phenomenon, livedo reticularis, and non-scarring alopecia. Musculoskeletal symptoms include arthralgia and non-erosive arthritis.
Cardiovascular manifestations of SLE include pericarditis and myocarditis, while respiratory symptoms may include pleurisy and fibrosing alveolitis. Renal involvement can lead to proteinuria and glomerulonephritis, with diffuse proliferative glomerulonephritis being the most common type.
Finally, neuropsychiatric symptoms of SLE may include anxiety and depression, as well as more severe manifestations such as psychosis and seizures. Understanding the various features of SLE is important for early diagnosis and management of this complex autoimmune disorder.
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This question is part of the following fields:
- Musculoskeletal
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Question 49
Incorrect
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A 6-year-old girl has a 2-year history of progressive weakness, finding it more difficult to stand from a sitting position at home and climb stairs at school. She had measles when she was 3-years-old and received all her childhood immunisations as normal. Apparently, her maternal grandmother suffered from a similar condition but died in a car accident at the age of 28. On examination, the girl is of normal height and appearance. Cranial nerves and higher mental function are normal. She has normal tone and reflexes in her limbs, with weakness proximally in her arms and legs. On repeated stimulation, there is no change. Cranial nerve and sensory examinations are entirely normal.
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Beckerâs muscular dystrophy
Explanation:The patient is likely suffering from Becker’s muscular dystrophy, a milder form of the condition compared to Duchenne muscular dystrophy (DMD). Both conditions are caused by mutations in the DMD gene, but Becker’s tends to present later in childhood or adolescence with slower progression of symptoms. The patient’s normal childhood development followed by slow onset of proximal weakness fits the typical picture of Becker’s. Limb-girdle muscular dystrophy (LGMD) is a possibility, but less likely given the patient’s presentation. DMD is unlikely as it typically presents in early childhood with rapid progression of symptoms. Facioscapulohumeral dystrophy is characterized by weakness and wasting of the face, scapula, and upper arms, and would not typically present with gait disturbance or lower limb weakness in childhood. Myasthenia gravis is also unlikely given the patient’s history.
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This question is part of the following fields:
- Neurology
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Question 50
Incorrect
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As a general practice registrar, you are reviewing a patient who was referred to ENT and has a history of acoustic neuroma on the right side. The patient, who is in their mid-50s, returned 2 months ago with pulsatile tinnitus in the left ear and was diagnosed with a left-sided acoustic neuroma after undergoing an MRI scan. Surgery is scheduled for later this week. What is the probable cause of this patient's recurrent acoustic neuromas?
Your Answer:
Correct Answer: Neurofibromatosis type 2
Explanation:Neurofibromatosis type 2 is commonly linked to bilateral acoustic neuromas (vestibular schwannomas). Additionally, individuals with this condition may also experience benign neurological tumors and lens opacities.
Understanding Vestibular Schwannoma (Acoustic Neuroma)
Vestibular schwannoma, also known as acoustic neuroma, is a type of brain tumor that accounts for 5% of intracranial tumors and 90% of cerebellopontine angle tumors. The condition is characterized by a combination of symptoms such as vertigo, hearing loss, tinnitus, and an absent corneal reflex. The affected cranial nerves can predict the features of the condition. For instance, cranial nerve VIII can cause vertigo, unilateral sensorineural hearing loss, and unilateral tinnitus. On the other hand, cranial nerve V can lead to an absent corneal reflex, while cranial nerve VII can cause facial palsy.
Bilateral vestibular schwannomas are often seen in neurofibromatosis type 2. The diagnosis of vestibular schwannoma is made through an MRI of the cerebellopontine angle, and audiometry is also important since only 5% of patients have a normal audiogram.
The management of vestibular schwannoma involves surgery, radiotherapy, or observation. The choice of treatment depends on the size and location of the tumor, the patient’s age and overall health, and the severity of symptoms. In conclusion, understanding vestibular schwannoma is crucial in managing the condition effectively.
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This question is part of the following fields:
- ENT
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Question 51
Incorrect
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A 45-year-old man of Afro-Caribbean descent has been diagnosed with hypertension after ruling out secondary causes. What is the best initial medication for treatment?
Your Answer:
Correct Answer: Amlodipine
Explanation:For black African or African-Caribbean patients newly diagnosed with hypertension, a calcium channel blocker should be added as first-line treatment instead of ACE inhibitors, which have shown lower effectiveness in this population.
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.
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This question is part of the following fields:
- Cardiovascular
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Question 52
Incorrect
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An 80-year-old woman comes in for a routine eye exam and is found to have a reproducible peripheral vision defect in her left eye. She reports no noticeable changes in her vision. Tonometry shows intraocular pressure of 17 mmHg in the left eye and 19 mmHg in the right eye (normal range is 10-21 mmHg). Direct ophthalmoscopy reveals a cup-to-disc ratio of 0.8 (increased) in the left eye. Gonioscopy is normal and she has no significant medical history. What is the most likely diagnosis?
Your Answer:
Correct Answer: Chronic open-angle glaucoma
Explanation:The correct diagnosis for this patient is chronic open-angle glaucoma, which can sometimes occur even with normal intraocular pressure. The patient’s symptoms, such as gradual peripheral vision loss, and the increased cup-to-disc ratio seen on investigations point towards this diagnosis. Gonioscopy also revealed a normal drainage angle, confirming that this is open-angle glaucoma.
Dry age-related macular degeneration is an incorrect diagnosis in this case, as it typically presents with central vision loss and drusen on ophthalmoscopy, not changes in the cup-to-disc ratio.
Hypertensive retinopathy is also an unlikely diagnosis, as it is often asymptomatic and associated with a medical history of hypertension. Additionally, it has a characteristic appearance on ophthalmoscopy that does not include changes in the cup-to-disc ratio.
Optic neuritis is another incorrect diagnosis, as it typically presents with painful vision loss and other symptoms such as loss of color vision or acuity. It is also often associated with multiple sclerosis, which would present with additional symptoms such as sensory or motor deficits or other cranial nerve palsies.
Glaucoma is a condition where the optic nerve is damaged due to increased pressure in the eye. Primary open-angle glaucoma (POAG) is a type of glaucoma where the peripheral iris is clear of the trabecular meshwork, which is important in draining aqueous humour from the eye. POAG is more common in older individuals and those with a family history of the condition. It may present insidiously with symptoms such as peripheral visual field loss, decreased visual acuity, and optic disc cupping. Diagnosis is made through a series of investigations including automated perimetry, slit lamp examination, applanation tonometry, central corneal thickness measurement, and gonioscopy. It is important to assess the risk of future visual impairment based on factors such as IOP, CCT, family history, and life expectancy. Referral to an ophthalmologist is typically done through a GP.
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This question is part of the following fields:
- Ophthalmology
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Question 53
Incorrect
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A 19-year-old male arrives at the emergency department with complaints of hand pain after punching a wall. He reports swelling and pain on the ulnar side of his hand. Based on his injury mechanism, what is the most probable diagnosis?
Your Answer:
Correct Answer: 5th metacarpal 'Boxer's' fracture
Explanation:When a person punches a hard surface, they may suffer from a ‘Boxer fracture’, which is a type of 5th metacarpal fracture that is usually only slightly displaced.
Boxer fracture is a type of fracture that occurs in the fifth metacarpal bone. It is usually caused by punching a hard surface, such as a wall, and results in a minimally displaced fracture. This means that the bone is broken but the pieces are still in alignment and have not moved significantly out of place. The injury is named after boxers because it is a common injury in this sport, but it can also occur in other activities that involve punching or striking objects. Proper treatment and management of a boxer fracture is important to ensure proper healing and prevent long-term complications.
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This question is part of the following fields:
- Musculoskeletal
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Question 54
Incorrect
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A 25-year-old woman who is 14 weeks pregnant complains of worsening acne that is causing her distress. Despite using topical benzyl peroxide, she has noticed limited improvement. During examination, non-inflammatory lesions and pustules are observed on her face. What would be the most suitable next course of action?
Your Answer:
Correct Answer: Oral erythromycin
Explanation:If treatment for acne is required during pregnancy, oral erythromycin is a suitable option, as the other medications are not recommended.
Acne vulgaris is a common skin condition that typically affects adolescents, with the face, neck, and upper trunk being the most commonly affected areas. It is characterized by the obstruction of hair follicles with keratin plugs, leading to the formation of comedones, inflammation, and pustules. The severity of acne can be classified as mild, moderate, or severe, depending on the presence and extent of inflammatory lesions, papules, and pustules.
The management of acne vulgaris typically involves a step-up approach, starting with single topical therapy such as topical retinoids or benzoyl peroxide. If this is not effective, topical combination therapy may be used, which includes a topical antibiotic, benzoyl peroxide, and topical retinoid. Oral antibiotics such as tetracyclines may also be prescribed, but they should be avoided in pregnant or breastfeeding women and children under 12 years of age. Erythromycin may be used in pregnancy, while minocycline is now considered less appropriate due to the possibility of irreversible pigmentation. Oral antibiotics should be used for a maximum of three months and always co-prescribed with a topical retinoid or benzoyl peroxide to reduce the risk of antibiotic resistance.
Combined oral contraceptives (COCP) are an alternative to oral antibiotics in women, and Dianette (co-cyrindiol) may be used as it has anti-androgen properties. However, it has an increased risk of venous thromboembolism compared to other COCPs, so it should generally be used second-line and for only three months. Oral isotretinoin is a potent medication that should only be used under specialist supervision, and it is contraindicated in pregnancy. Finally, there is no evidence to support dietary modification in the management of acne vulgaris.
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This question is part of the following fields:
- Dermatology
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Question 55
Incorrect
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A 78-year-old man visits his doctor with worries about his wife. He reports that in the past year, she has become increasingly forgetful and confused. He has observed her talking to their deceased dog, 'Buddy', and has noticed that she has been falling more frequently and moving around the house at a slower pace. What is the most probable diagnosis?
Your Answer:
Correct Answer: Lewy-Body Dementia
Explanation:To differentiate between the possible answers, it is crucial to analyze the patient’s symptoms. Considering his age and the duration of one year, the decline in cognitive function indicates a potential dementia condition. Additionally, the presence of visual hallucinations involving an animal strongly suggests Lewy-body dementia. Furthermore, the decrease in mobility and higher frequency of falls may indicate parkinsonism, further supporting the correct answer of Lewy-body dementia.
Understanding Lewy Body Dementia
Lewy body dementia is a type of dementia that is becoming more recognized as a cause of cognitive impairment, accounting for up to 20% of cases. It is characterized by the presence of alpha-synuclein cytoplasmic inclusions, known as Lewy bodies, in certain areas of the brain. While there is a complicated relationship between Parkinson’s disease and Lewy body dementia, with dementia often seen in Parkinson’s disease, the two conditions are distinct. Additionally, up to 40% of patients with Alzheimer’s disease have Lewy bodies.
The features of Lewy body dementia include progressive cognitive impairment, which typically occurs before parkinsonism, but both features usually occur within a year of each other. Unlike other forms of dementia, cognition may fluctuate, and early impairments in attention and executive function are more common than memory loss. Other features include parkinsonism, visual hallucinations, and sometimes delusions and non-visual hallucinations.
Diagnosis of Lewy body dementia is usually clinical, but single-photon emission computed tomography (SPECT) can be used to confirm the diagnosis. Management of Lewy body dementia involves the use of acetylcholinesterase inhibitors and memantine, similar to Alzheimer’s disease. However, neuroleptics should be avoided as patients with Lewy body dementia are extremely sensitive and may develop irreversible parkinsonism. It is important to carefully consider the use of medication in these patients to avoid worsening their condition.
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This question is part of the following fields:
- Neurology
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Question 56
Incorrect
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A 35-year-old woman presents to the hospital with diarrhea and abdominal pain. She has a history of depression and takes citalopram, smokes 20 cigarettes per day, and drinks 20 units of alcohol per week. During ileocolonoscopy, Crohn's disease is diagnosed, and she is treated with glucocorticoid therapy. What is the most crucial step to decrease the likelihood of future episodes?
Your Answer:
Correct Answer: Stop smoking
Explanation:Managing Crohn’s Disease: Guidelines and Treatment Options
Crohn’s disease is a type of inflammatory bowel disease that can affect any part of the digestive tract. To manage this condition, the National Institute for Health and Care Excellence (NICE) has published guidelines that provide recommendations for inducing and maintaining remission, as well as treating complications. One of the most important steps in managing Crohn’s disease is to advise patients to quit smoking, as this can worsen the condition. Additionally, some medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and the combined oral contraceptive pill, may increase the risk of relapse, although the evidence is not conclusive.
To induce remission, glucocorticoids are often used, either orally, topically, or intravenously. Budesonide is an alternative for some patients. Enteral feeding with an elemental diet may also be used, especially in young children or when there are concerns about the side effects of steroids. Second-line treatments for inducing remission include 5-ASA drugs like mesalazine, as well as azathioprine or mercaptopurine, which may be used in combination with other medications. Methotrexate is another option. Infliximab is useful for refractory disease and fistulating Crohn’s, and patients may continue on azathioprine or methotrexate.
To maintain remission, stopping smoking is a priority, and azathioprine or mercaptopurine is used first-line. TPMT activity should be assessed before starting these medications. Methotrexate is used second-line. Surgery may be necessary for around 80% of patients with Crohn’s disease, depending on the location and severity of the disease. Complications of Crohn’s disease include small bowel cancer, colorectal cancer, and osteoporosis. Perianal fistulae and abscesses require specific treatments, such as oral metronidazole, anti-TNF agents like infliximab, or a draining seton. By following these guidelines and treatment options, patients with Crohn’s disease can better manage their condition and improve their quality of life.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 57
Incorrect
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A 55-year-old woman with a history of diabetes complains of left-sided ear pain and discharge. During examination, her temperature is recorded at 37.9ÂșC and there is red discharge in the ear canal. The tympanic membrane is partially visible and appears normal. Despite visiting the out of hours clinic twice and using different ear drops for two weeks, her symptoms persist. What course of treatment should be recommended?
Your Answer:
Correct Answer: Referral to secondary care
Explanation:It is probable that the patient is suffering from malignant otitis externa, a condition that affects individuals with weakened immune systems like those with diabetes. This condition is characterized by osteomyelitis of the temporal bone. Despite receiving several rounds of antibiotic drops, the patient’s symptoms have not improved. It is recommended that the patient be referred to an ENT specialist for a CT scan of the temporal bones and treated with an extended course of intravenous antibiotics.
Understanding Otitis Externa: Causes, Features, and Management
Otitis externa is a common condition that often prompts patients to seek medical attention. It is characterized by ear pain, itch, and discharge, and is caused by various factors such as infection, seborrhoeic dermatitis, and contact dermatitis. Swimming is also a common trigger of otitis externa. Upon examination, the ear canal appears red, swollen, or eczematous.
The recommended initial management of otitis externa involves the use of topical antibiotics or a combination of topical antibiotics with a steroid. However, if the tympanic membrane is perforated, aminoglycosides are traditionally not used. In cases where there is canal debris, removal may be necessary, while an ear wick may be inserted if the canal is extensively swollen. Second-line options include oral antibiotics, taking a swab inside the ear canal, and empirical use of an antifungal agent.
It is important to note that if a patient fails to respond to topical antibiotics, referral to an ENT specialist may be necessary. Malignant otitis externa is a more serious condition that is more common in elderly diabetics. It involves the extension of infection into the bony ear canal and the soft tissues deep to the bony canal, and may require intravenous antibiotics.
Overall, understanding the causes, features, and management of otitis externa is crucial in providing appropriate care and preventing complications.
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This question is part of the following fields:
- ENT
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Question 58
Incorrect
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A 28-year-old male came to the emergency department complaining of shortness of breath during exertion. He had no medical history to report. During the examination, a midsystolic murmur was detected, which was most audible at the left lower sternal border. The murmur became louder when the Valsalva manoeuvre was performed. An echocardiogram revealed mitral regurgitation, asymmetric hypertrophy, systolic anterior motion of the anterior mitral valve leaflet, and left ventricular outflow tract obstruction. What medication should be avoided in this patient?
Your Answer:
Correct Answer: Ramipril
Explanation:Patients with HOCM should avoid ACE-inhibitors.
The correct answer is Ramipril. In patients with hypertrophic obstructive cardiomyopathy (HOCM) and left ventricular outflow tract (LVOT) obstruction, ACE inhibitors are not recommended. This is because ACE inhibitors can decrease afterload, which may exacerbate the LVOT gradient. The patient in this case has echocardiographic evidence of HOCM, including asymmetric hypertrophy, systolic anterior motion of the anterior mitral valve leaflet, and mitral regurgitation.
However, amiodarone, atenolol, disopyramide, and verapamil are all viable treatment options for HOCM.
Hypertrophic obstructive cardiomyopathy (HOCM) is a genetic disorder that affects muscle tissue and is inherited in an autosomal dominant manner. It is estimated to have a prevalence of 1 in 500. The condition is caused by defects in the genes that encode contractile proteins.
The management of HOCM involves several approaches. Amiodarone is a medication that can be used to treat the condition. Beta-blockers or verapamil may also be prescribed to alleviate symptoms. In some cases, a cardioverter defibrillator or dual chamber pacemaker may be necessary. It is important to note that certain drugs, such as nitrates, ACE-inhibitors, and inotropes, should be avoided in patients with HOCM. Additionally, endocarditis prophylaxis may be recommended, although the 2008 NICE guidelines should be consulted for specific recommendations.
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This question is part of the following fields:
- Cardiovascular
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Question 59
Incorrect
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A 38-year-old homeless man presents to the emergency department after collapsing on the street. He reports feeling increasingly lethargic over the past week and has been coughing up green sputum. He has a history of alcoholic pancreatitis.
His vital signs are as follows:
- Temperature: 38.4ÂșC
- Heart rate: 122 bpm
- Blood pressure: 106/54 mmHg
- Respiratory rate: 22 breaths/min
- Oxygen saturations: 94% on 2L nasal cannulae
Upon examination, coarse crackles are heard in the left upper lobe. His heart sounds are normal and his abdomen is soft and nontender.
What is the most likely causative organism?Your Answer:
Correct Answer: Klebsiella pneumoniae
Explanation:Klebsiella pneumoniae is a gram-negative rod that commonly causes a cavitating pneumonia in the upper lobes, particularly in individuals with a history of diabetes and alcoholism. The presence of upper zone crackles is a sign of Klebsiella pneumoniae infection, while a history of alcoholic pancreatitis suggests chronic alcohol use.
Legionella pneumophila causes Legionnaire’s disease, an atypical pneumonia that typically spreads through contaminated water sources, such as air conditioner vents. Symptoms include fever, cough, and myalgia, with bilateral chest symptoms being more common. Other extra-pulmonary symptoms, such as hyponatremia and hepatitis, may also be present.
Mycoplasma pneumoniae is another cause of atypical pneumonia, with symptoms including coryza and a dry cough. This form of pneumonia is associated with extra-pulmonary symptoms such as haemolytic anaemia and erythema multiforme, which are not present in this case.
Staphylococcus aureus is the most likely cause of pneumonia following influenza virus infection. However, since there is no history of preceding coryza and the patient has upper zone crackles and alcoholism, Staphylococcus aureus is less likely to be the cause of this patient’s pneumonia.
Klebsiella Pneumoniae: A Gram-Negative Rod Causing Infections in Humans
Klebsiella pneumoniae is a type of Gram-negative rod that is typically found in the gut flora of humans. Although it is a normal part of the body’s microbiome, it can also cause a variety of infections in humans, including pneumonia and urinary tract infections. This bacterium is more commonly found in individuals who have diabetes or who consume alcohol regularly. In some cases, Klebsiella pneumoniae infections can occur following aspiration.
One of the distinctive features of Klebsiella pneumoniae infections is the presence of red-currant jelly sputum. This type of sputum is often seen in patients with pneumonia caused by this bacterium. Additionally, Klebsiella pneumoniae infections tend to affect the upper lobes of the lungs.
Unfortunately, Klebsiella pneumoniae infections can be quite serious and even life-threatening. They commonly lead to the formation of lung abscesses and empyema, and the mortality rate for these infections is between 30-50%. It is important for healthcare providers to be aware of the potential for Klebsiella pneumoniae infections, particularly in patients who are at higher risk due to underlying health conditions.
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This question is part of the following fields:
- Respiratory Medicine
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Question 60
Incorrect
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You are assessing a 55-year-old man who has been admitted with pneumonia. His medical history indicates that he consumes approximately 70-80 units of alcohol per week. Which medication would be the most suitable to administer to prevent the onset of alcohol withdrawal symptoms?
Your Answer:
Correct Answer: Chlordiazepoxide
Explanation:Alcohol withdrawal occurs when an individual who has been consuming alcohol chronically suddenly stops or reduces their intake. Chronic alcohol consumption enhances the inhibitory effects of GABA in the central nervous system, similar to benzodiazepines, and inhibits NMDA-type glutamate receptors. However, alcohol withdrawal leads to the opposite effect, resulting in decreased inhibitory GABA and increased NMDA glutamate transmission. Symptoms of alcohol withdrawal typically start at 6-12 hours and include tremors, sweating, tachycardia, and anxiety. Seizures are most likely to occur at 36 hours, while delirium tremens, which includes coarse tremors, confusion, delusions, auditory and visual hallucinations, fever, and tachycardia, peak at 48-72 hours.
Patients with a history of complex withdrawals from alcohol, such as delirium tremens, seizures, or blackouts, should be admitted to the hospital for monitoring until their withdrawals stabilize. The first-line treatment for alcohol withdrawal is long-acting benzodiazepines, such as chlordiazepoxide or diazepam, which are typically given as part of a reducing dose protocol. Lorazepam may be preferable in patients with hepatic failure. Carbamazepine is also effective in treating alcohol withdrawal, while phenytoin is said to be less effective in treating alcohol withdrawal seizures.
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This question is part of the following fields:
- Psychiatry
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