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Question 1
Incorrect
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A 70-year-old man comes in for his routine psychiatric follow-up appointment. He has a history of schizophrenia that has been difficult to manage, but has been stable for the past 5 years on various antipsychotic medications. He also has type II diabetes. During the appointment, he reports experiencing repetitive, involuntary movements of his lips and tongue, including lip smacking and grimacing. Which medication is the most likely culprit for these symptoms?
Your Answer: Risperidone
Correct Answer: Haloperidol
Explanation:Understanding Tardive Dyskinesia and its Association with Antipsychotic Drugs
Tardive dyskinesia is a disorder characterized by involuntary and repetitive movements, including lip puckering, excessive blinking, and pursing of the lips. This condition is commonly associated with the use of typical (older generation) antipsychotics such as haloperidol, prochlorperazine, and flupentixol. However, newer generation (atypical) antipsychotics like olanzapine, quetiapine, risperidone, and clozapine have a lower risk of causing tardive dyskinesia.
If tardive dyskinesia is diagnosed, the causative drug should be discontinued. It is important to note that the dyskinesia may persist for months after drug withdrawal and may even be permanent. Metformin is not linked to tardive dyskinesia.
Risperidone is an atypical antipsychotic used to treat schizophrenia, bipolar disorder, and autism. Current evidence suggests that the risk of developing tardive dyskinesia is lower than with typical antipsychotic use. To prevent tardive dyskinesia in chronic psychoses, it is recommended to use the lowest effective dose for the shortest possible time, while balancing the fact that increased doses are more beneficial to prevent recurrence.
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This question is part of the following fields:
- Psychiatry
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Question 2
Correct
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A 25-year-old rugby player injured his shoulder after a heavy tackle during a match. He arrived at the Emergency Department in visible discomfort with a deformed right shoulder that appeared flattened and drooped lower than his left. An X-ray revealed an anterior dislocation.
What is the name of the nerve that passes around the surgical neck of the humerus?Your Answer: Anterior branch of the axillary nerve
Explanation:Nerve Branches and their Innervations in the Upper Limb
The upper limb is innervated by various nerves that originate from the brachial plexus. Each nerve has specific branches that innervate different muscles and areas of the arm. Here are some important nerve branches and their innervations in the upper limb:
1. Anterior branch of the axillary nerve: This nerve branch winds around the surgical neck of the humerus and innervates the teres minor, deltoid, glenohumeral joint, and skin over the inferior part of the deltoid.
2. Median nerve: This nerve passes through the carpal tunnel and innervates the muscles of the anterior forearm, as well as the skin over the palmar aspect of the hand.
3. Lateral cutaneous nerve: This nerve is a continuation of the posterior branch of the axillary nerve and sweeps around the posterior border of the deltoid, innervating the skin over the lateral aspect of the arm.
4. Posterior interosseous nerve: This nerve is a branch of the radial nerve and does not wind around the surgical neck of the humerus. It innervates the muscles of the posterior forearm.
5. Radial nerve: This nerve winds around the midshaft of the humerus and innervates the muscles of the posterior arm and forearm, as well as the skin over the posterior aspect of the arm and forearm.
Understanding the innervations of these nerve branches is important in diagnosing and treating upper limb injuries and conditions.
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This question is part of the following fields:
- Orthopaedics
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Question 3
Correct
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A 22-year-old woman, a known type 1 diabetic, visited the GP clinic.
Your GP placement supervisor requested you to conduct a dilated direct fundoscopy on her eyes. During the examination, you observed a few dot haemorrhages and hard exudates.
What is the probable diagnosis of the patient's eye condition?Your Answer: Background diabetic retinopathy
Explanation:Understanding the Different Stages of Diabetic Retinopathy
Diabetic retinopathy is a condition that affects the eyes of people with diabetes. It is important to understand the different stages of diabetic retinopathy to ensure timely diagnosis and treatment.
Background diabetic retinopathy is the earliest stage, characterized by a few dot haemorrhages and microaneurysms. Pre-proliferative diabetic retinopathy is marked by intraretinal microvascular abnormalities, venous beading or loops, large blot haemorrhages, and cotton-wool spots.
Diabetic maculopathy occurs when these features affect the macula, which is responsible for central vision. Proliferative diabetic retinopathy is a more advanced stage, with new vessels forming at the disc or elsewhere in the retina.
Finally, proliferative diabetic retinopathy with maculopathy combines the features of pre-proliferative retinopathy, new vessel formation, and diabetic maculopathy. By understanding these stages, individuals with diabetes can work with their healthcare providers to manage their condition and prevent vision loss.
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This question is part of the following fields:
- Ophthalmology
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Question 4
Incorrect
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Which one of the following statements regarding toddler spasms is incorrect?
Your Answer: Causes characteristic 'salaam' attacks
Correct Answer: Carries a good prognosis
Explanation:Understanding Infantile Spasms
Infantile spasms, also known as West syndrome, is a form of epilepsy that typically occurs in infants between 4 to 8 months old, with a higher incidence in male infants. This condition is often associated with a serious underlying condition and has a poor prognosis. The characteristic feature of infantile spasms is the salaam attacks, which involve the flexion of the head, trunk, and arms followed by the extension of the arms. These attacks last only 1-2 seconds but can be repeated up to 50 times.
Infants with infantile spasms may also experience progressive mental handicap. To diagnose this condition, an EEG is typically performed, which shows hypsarrhythmia in two-thirds of infants. Additionally, a CT scan may be used to identify any diffuse or localized brain disease, which is present in 70% of cases, such as tuberous sclerosis.
Unfortunately, infantile spasms carry a poor prognosis. However, there are treatment options available. Vigabatrin is now considered the first-line therapy, and ACTH is also used.
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This question is part of the following fields:
- Paediatrics
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Question 5
Incorrect
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A 48-year-old woman is referred for further evaluation after an abnormal routine mammogram. Biopsy of a left breast mass shows high-grade malignant ductal epithelial cells with dark staining nuclei and several mitotic figures visible under high-power field. Necrosis and central calcification are noted and the basement membrane appears intact.
Based on the biopsy findings, which one of the following is the most likely diagnosis?Your Answer: Lobular carcinoma in situ
Correct Answer: Comedocarcinoma
Explanation:Breast Cancer Subtypes and Histological Findings
Breast cancer can present in various subtypes, each with unique histological findings and prognoses. Comedocarcinoma is a high-grade ductal carcinoma in situ that often presents with calcification and necrosis due to rapid cellular proliferation. Mucinous carcinoma is a subtype of invasive ductal carcinoma characterized by a large amount of mucin-producing cells and a slightly better prognosis than inflammatory carcinoma. Lobular carcinoma in situ is characterized by malignant cells in the terminal duct lobules that rarely progress to invasive lobular carcinoma. Anaplastic carcinoma is another subtype of invasive ductal carcinoma with a slightly better prognosis than inflammatory carcinoma. Inflammatory carcinoma is characterized by dermal lymphatic invasion of malignant cells and is associated with poor prognosis. Understanding the different subtypes and histological findings of breast cancer can aid in diagnosis and treatment planning.
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This question is part of the following fields:
- Breast
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Question 6
Correct
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A 29-year-old woman presents with two episodes of post-coital bleeding. She reports that she noticed some red spotting immediately after intercourse, which settled shortly afterwards. She is on the combined oral contraceptive pill, with a regular partner, and does not use barrier contraception.
Examination reveals a malodorous, green, frothy discharge and an erythematosus cervix with small areas of exudation. High vaginal and endocervical swabs were performed.
Given the most likely diagnosis, which of the following is the most appropriate management?Your Answer: Metronidazole 400–500 mg twice daily for 5–7 days
Explanation:Treatment Options for Sexually Transmitted Infections
Sexually transmitted infections (STIs) can cause a range of symptoms in women, including post-coital bleeding, vaginal discharge, cervicitis, and more. Here are some common treatment options for STIs:
– Metronidazole: This medication is used to treat Trichomonas vaginalis infections. Patients typically take 400-500 mg twice daily for 5-7 days. It’s important to treat the partner simultaneously and abstain from sex for at least one week.
– Referral for colposcopy: If symptoms persist after treatment, patients may be referred for colposcopy to rule out cervical carcinoma.
– Azithromycin or doxycycline: These medications are used to treat uncomplicated genital Chlamydia infections. Most women with a chlamydial infection remain asymptomatic.
– Ceftriaxone and azithromycin: This combination is the treatment of choice for gonorrhoea infections. Symptoms may include increased vaginal discharge, lower abdominal pain, dyspareunia, and dysuria.
– No treatment is required: This is not an option for symptomatic patients with T vaginalis, as it is a sexually transmitted infection that requires treatment.It’s important to seek medical attention if you suspect you have an STI, as early treatment can prevent complications and transmission to others.
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This question is part of the following fields:
- Gynaecology
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Question 7
Incorrect
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A 4-week old baby is seen by the GP. The baby was born in breech position at 38+4 weeks gestation without any complications during delivery. However, two days after birth, the baby developed jaundice and was treated with phototherapy. The newborn physical examination was normal. The mother has a medical history of anaemia, asthma, and coeliac disease. The baby is currently thriving and is on the 45th centile. What investigations should the GP consider referring the baby for based on their medical history?
Your Answer: Serum bilirubin levels
Correct Answer: Ultrasounds of pelvis
Explanation:Developmental dysplasia of the hip (DDH) is a condition that affects 1-3% of newborns and is more common in females, firstborn children, and those with a positive family history or breech presentation. It used to be called congenital dislocation of the hip (CDH). DDH is more often found in the left hip and can be bilateral in 20% of cases. Screening for DDH is recommended for infants with certain risk factors, and all infants are screened using the Barlow and Ortolani tests at the newborn and six-week baby check. Clinical examination includes testing for leg length symmetry, restricted hip abduction, and knee level when hips and knees are flexed. Ultrasound is used to confirm the diagnosis if clinically suspected, but x-ray is the first line investigation for infants over 4.5 months. Management includes the use of a Pavlik harness for children under 4-5 months and surgery for older children with unstable hips.
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This question is part of the following fields:
- Paediatrics
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Question 8
Correct
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An 80-year-old man is brought to the Emergency Department by his daughter after being found collapsed at home by his caregiver. He is complaining of a headache and appears confused. The patient has a history of an irregular heartbeat and takes digoxin and warfarin. On examination, there is no evidence of trauma or injury. The patient is confused with a Mini Mental score of 24/30 and is slightly drowsy but can be easily awakened. He has mild weakness in his left arm and leg, and the left plantar response is extensor. Urgent blood tests reveal a haemoglobin level of 111 g/l (normal range: 135-175 g/l), an INR of 5.7 (usual range for this patient: 2-3), and a urea level of 9.6 mmol/l (normal range: 2.5-6.5 mmol/l). An urgent CT scan is ordered. What is the most likely finding on the CT scan?
Your Answer: Right sided acute subdural haematoma
Explanation:Different Types of Intracranial Bleeding and Their Causes
Intracranial bleeding can occur in various forms, each with its own causes and symptoms. Here are some of the different types of intracranial bleeding and their associated factors:
1. Right Sided Acute Subdural Haematoma
This type of bleeding can occur in elderly patients who are on anticoagulation therapy, especially if their INR levels are higher than the therapeutic limits. The symptoms include fluctuating confusion and conscious level, and a history of trauma is not always necessary.2. Intraparenchymal Haematoma in the Right Temporal Lobe with Mass Effect
This type of bleeding is usually caused by trauma, hypertension, or an underlying neoplastic lesion. It is less common than subdural haematoma.3. Right Sided Extradural Haematoma
Extradural haematoma is associated with significant head trauma.4. Right Sided Chronic Subdural Haematoma
Chronic subdural haematoma has a longer, insidious course and is often accompanied by headache, impaired conscious level, and focal signs. Over-anticoagulation can increase the likelihood of this type of bleeding.5. Right Sided Subarachnoid Haemorrhage
Subarachnoid haemorrhage is usually caused by significant trauma or a ruptured aneurysm.Overall, the elderly are more at risk of subdural haematomas due to factors such as thinner cortical bridging veins, increased subdural space, and increased probability of falls and use of medications that alter blood clotting.
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This question is part of the following fields:
- Neurosurgery
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Question 9
Incorrect
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A 9-year-old patient is brought to the general practitioner by his parents because he has been disruptive at school. His teachers report that he does not pay attention in class, bullies other classmates and takes their food during lunchtime without their permission. One teacher also reported that the patient was seen hurting the class hamster.
What is the most probable diagnosis for this patient?Your Answer: Antisocial disorder
Correct Answer: Conduct disorder
Explanation:Differentiating between Conduct Disorder, Major Depression, Oppositional Defiant Disorder, Antisocial Disorder, and Manic Episode
Conduct Disorder, Major Depression, Oppositional Defiant Disorder, Antisocial Disorder, and Manic Episode are all mental health conditions that can present with similar symptoms. However, each disorder has its own unique characteristics that differentiate it from the others.
Conduct Disorder is a disorder that affects individuals under the age of 18 and is associated with disruptive, bullying behavior and often torture of animals. It is characterized by repetitive behavior that violates the rights of others.
Major Depression is associated with depressed mood, in addition to five of the following symptoms: sleep changes, loss of interest in previous hobbies or activities, guilt, decreased energy, difficulty concentrating, changes in appetite, sluggishness, and suicidal thoughts persisting for 2 weeks.
Oppositional Defiant Disorder is characterized by behavior in opposition to authority, but there is no violation of the rights of others or extreme behavior such as bullying or animal cruelty.
Antisocial Disorder is diagnosed in individuals who are 18 or older and exhibit signs of Conduct Disorder. It is characterized by a disregard for the rights of others and a lack of empathy.
Manic Episode is associated with elevated mood lasting for 7 days. These patients feel as though they have increased energy, do not need sleep, engage in risky sexual activity and sometimes illicit behavior, feel above the law or invincible, are easily distractible, have flight of fancy, are agitated, and have pressured speech.
It is important to differentiate between these disorders to ensure that individuals receive the appropriate treatment and support for their specific condition.
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This question is part of the following fields:
- Psychiatry
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Question 10
Correct
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As the orthopaedic foundation year doctor, you have been requested by the nurse in charge to assess a patient who is experiencing acute shortness of breath and right-sided chest pain 8 days after undergoing total knee replacement surgery. The patient is a 66-year-old builder with a medical history of COPD and high cholesterol. He has a BMI of 35 and currently smokes 30 cigarettes per day. His vital signs are as follows: regular heart rate of 115 beats per minute, blood pressure of 135/60 mmHg, and oxygen saturation of 91% on room air. What is the most effective diagnostic test to perform on this patient?
Your Answer: CT pulmonary angiogram
Explanation:Diagnosing Pulmonary Embolism in Postoperative Patients
In postoperative patients who become acutely unwell, pulmonary embolism (PE) must be considered and excluded as a crucial diagnosis. After initial resuscitation, diagnostic tests such as arterial blood gas sampling, full blood count, and C-reactive protein count are likely to be performed. However, these tests cannot confirm a specific diagnosis and may be abnormal in various conditions such as PE, pneumonia, acute respiratory distress syndrome (ARDS), pneumothorax, or cardiac events.
D-dimer is often used to assess the risk of PE, but in patients with major risk factors such as surgery and minor risk factors such as obesity, a negative D-dimer cannot rule out PE. Chest X-ray can reveal underlying chest pathology, but it is rarely diagnostic for PE. The wedge-shaped infarcts that are often associated with PE are not common. However, a chest X-ray can determine whether a ventilation-perfusion (V/Q) scan is possible or whether a computed tomography pulmonary angiography (CTPA) is required.
In patients with chronic obstructive pulmonary disease (COPD), there is already an underlying V/Q mismatch, making it difficult to diagnose PE with a low probability result. Therefore, a CTPA is necessary to confirm or exclude the diagnosis of PE. Patients with suspected PE should be placed on a direct oral anticoagulant (DOAC) until a definitive diagnosis is made. In conclusion, clinicians must have a high degree of suspicion for PE in postoperative patients and use a diagnostic rationale to exclude other potential diagnoses.
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This question is part of the following fields:
- Emergency Medicine
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Question 11
Incorrect
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A 35-year-old male patient complains of a painless lump in his right testicle. What is the strongest association of testicular cancer?
Your Answer: Smoking
Correct Answer: Infertility
Explanation:Men with infertility have a threefold increased risk of developing testicular cancer.
Understanding Testicular Cancer
Testicular cancer is a type of cancer that commonly affects men between the ages of 20 and 30. Germ-cell tumors are the most common type of testicular cancer, accounting for around 95% of cases. These tumors can be divided into seminomas and non-seminomas, which include embryonal, yolk sac, teratoma, and choriocarcinoma. Other types of testicular cancer include Leydig cell tumors and sarcomas. Risk factors for testicular cancer include infertility, cryptorchidism, family history, Klinefelter’s syndrome, and mumps orchitis.
The most common symptom of testicular cancer is a painless lump, although some men may experience pain. Other symptoms may include hydrocele and gynaecomastia, which occurs due to an increased oestrogen:androgen ratio. Tumor markers such as hCG, AFP, and beta-hCG may be elevated in germ cell tumors. Ultrasound is the first-line diagnostic tool for testicular cancer.
Treatment for testicular cancer depends on the type and stage of the tumor. Orchidectomy, chemotherapy, and radiotherapy may be used. Prognosis for testicular cancer is generally excellent, with a 5-year survival rate of around 95% for seminomas and 85% for teratomas if caught at Stage I. It is important for men to perform regular self-examinations and seek medical attention if they notice any changes or abnormalities in their testicles.
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This question is part of the following fields:
- Surgery
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Question 12
Correct
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A 45-year-old woman presented with abdominal swelling, pain and constipation for 5 days. She also complained of generalised aches and pains and feelings of thirst. She had recently been diagnosed with metastatic breast cancer which had recurred. She has a past medical history of irritable bowel syndrome and hypothyroidism. Her regular medications include paracetamol and thyroxine. Her general practitioner (GP) had started her on codeine yesterday. On examination, she appeared dehydrated and had a soft, but mildly distended, abdomen. Thyroid function tested 2 weeks ago was normal.
What is the most likely cause of her presentation?Your Answer: Hypercalcaemia
Explanation:Hypercalcaemia is a medical emergency that can occur in patients with cancer, especially those with metastatic cancer and osteolytic lesions. Breast, lung, and multiple myeloma are the most common cancers that cause hypercalcaemia. Symptoms include lethargy, anorexia, nausea, constipation, dehydration, polyuria, polydipsia, renal stones, confusion, and generalised aches. Treatment involves intravenous fluid resuscitation and bisphosphonates. Codeine can cause constipation, but if it lasts for more than five days, it may not be the cause. Hypothyroidism and irritable bowel syndrome can also lead to constipation, but the patient’s thyroid function test is normal, and there are no other symptoms of irritable bowel syndrome. Malignant bowel obstruction causes absolute constipation, a distended abdomen, and vomiting.
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This question is part of the following fields:
- Clinical Biochemistry
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Question 13
Incorrect
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A 30-year-old woman visits her psychiatrist for a follow-up after receiving treatment for a moderate depressive episode. Based on the patient's history, the psychiatrist identifies early morning awakening as the most distressing symptom currently affecting the patient.
What term best describes this particular symptom?Your Answer: Core depression symptom
Correct Answer: Somatic symptom
Explanation:Screening and Assessment for Depression
Depression is a common mental health condition that affects many people worldwide. Screening and assessment are important steps in identifying and managing depression. The screening process involves asking two simple questions to determine if a person is experiencing symptoms of depression. If the answer is yes to either question, a more in-depth assessment is necessary.
Assessment tools such as the Hospital Anxiety and Depression (HAD) scale and the Patient Health Questionnaire (PHQ-9) are commonly used to assess the severity of depression. The HAD scale consists of 14 questions, seven for anxiety and seven for depression. Each item is scored from 0-3, producing a score out of 21 for both anxiety and depression. The PHQ-9 asks patients about nine different problems they may have experienced in the last two weeks and scores each item from 0-3. The severity of depression is then graded based on the score.
The DSM-IV criteria are also used to grade depression, with nine different symptoms that must be present for a diagnosis. Subthreshold depressive symptoms may have fewer than five symptoms, while mild depression has few symptoms in excess of the five required for diagnosis. Moderate depression has symptoms or functional impairment between mild and severe, while severe depression has most symptoms and significantly interferes with functioning.
In conclusion, screening and assessment are crucial in identifying and managing depression. Healthcare professionals can use various tools to assess the severity of depression and determine the appropriate treatment plan. Early identification and intervention can help individuals with depression receive the necessary support and treatment to improve their quality of life.
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This question is part of the following fields:
- Psychiatry
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Question 14
Incorrect
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A 70-year-old woman was recently diagnosed with essential hypertension and started on a medication to lower her blood pressure. She then stopped taking the medication as she reported ankle swelling. Her blood pressure readings usually run at 160/110 mmHg. She denies any headache, palpitation, chest pain, leg claudication or visual problems. She was diagnosed with osteoporosis with occasional back pain and has been admitted to the hospital for a hip fracture on two occasions over the last 3 years. There is no history of diabetes mellitus, coronary artery disease or stroke. She has no known drug allergy. Her vital signs are within normal limits, other than high blood pressure. The S1 is loud. The S2 is normal. There is an S4 sound without a murmur, rub or gallop. The peripheral pulses are normal and symmetric. The serum electrolytes (sodium, potassium, calcium and chloride), creatinine and urea nitrogen are within normal range.
What is the most appropriate antihypertensive medication for this patient?Your Answer: Enalapril
Correct Answer: Indapamide
Explanation:The best medication for the patient in the scenario would be indapamide, a thiazide diuretic that blocks the Na+/Cl− cotransporter in the distal convoluted tubules, increasing calcium reabsorption and reducing the risk of osteoporotic fractures. Common side-effects include hyponatraemia, hypokalaemia, hypercalcaemia, hyperglycaemia, hyperuricaemia, gout, postural hypotension and hypochloraemic alkalosis. Prazosin is used for benign prostatic hyperplasia, enalapril is not preferred for patients over 55 years old and can increase osteoporosis risk, propranolol is not a preferred initial treatment for hypertension, and amlodipine can cause ankle swelling and should be avoided in patients with myocardial infarction and symptomatic heart failure.
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This question is part of the following fields:
- Cardiology
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Question 15
Correct
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A 24-year-old woman who is 36 weeks pregnant arrives at the delivery suite with complaints of feeling generally unwell. Upon examination, a 32 week size foetus is noted. Her blood pressure is measured at 160/100 mmHg and 2+ protein is detected in her urine. While being examined, she experiences a seizure, leading you to suspect eclampsia. What is the first medication that should be administered?
Your Answer: Magnesium sulphate
Explanation:The primary concern in eclampsia is to manage seizures, which can be prevented and treated with magnesium sulphate as the first-line treatment. If magnesium sulphate is not available or ineffective, benzodiazepines like midazolam can be considered. Additionally, due to high blood pressure, antihypertensive drugs like Labetalol, Hydralazine, and Nifedipine are administered during pregnancy as they are effective and have low teratogenicity. Starting low dose aspirin before 16 weeks of gestation has been shown to significantly reduce the risk of pre-eclampsia.
Understanding Eclampsia and its Treatment
Eclampsia is a condition that occurs when seizures develop in association with pre-eclampsia, a pregnancy-induced hypertension that is characterized by proteinuria and occurs after 20 weeks of gestation. To prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop, magnesium sulphate is commonly used. However, it is important to note that this medication should only be given once a decision to deliver has been made. In cases of eclampsia, an IV bolus of 4g over 5-10 minutes should be given, followed by an infusion of 1g/hour. During treatment, it is crucial to monitor urine output, reflexes, respiratory rate, and oxygen saturations. Respiratory depression can occur, and calcium gluconate is the first-line treatment for magnesium sulphate-induced respiratory depression. Treatment should continue for 24 hours after the last seizure or delivery, as around 40% of seizures occur post-partum. Additionally, fluid restriction is necessary to avoid the potentially serious consequences of fluid overload.
In summary, understanding the development of eclampsia and its treatment is crucial in managing this potentially life-threatening condition. Magnesium sulphate is the primary medication used to prevent and treat seizures, but it should only be given once a decision to deliver has been made. Monitoring vital signs and urine output is essential during treatment, and calcium gluconate should be readily available in case of respiratory depression. Finally, fluid restriction is necessary to avoid complications associated with fluid overload.
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This question is part of the following fields:
- Obstetrics
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Question 16
Correct
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A 50-year-old man is worried about pain control during his upcoming radical prostatectomy. The consultant goes over various options, including general and regional anesthesia. What is a definite reason to avoid using regional anesthesia, such as spinal, epidural, or plexus block?
Your Answer: Concurrent administration of therapeutic dose of warfarin
Explanation:The use of regional anesthesia is not recommended for patients undergoing therapeutic anticoagulation due to the potential risk of bleeding and the severity of hematoma formation within the central nervous system. To prepare for surgery, warfarin is typically discontinued five days prior and replaced with a Low Molecular Weight Heparin, with the dosage determined by the individual’s thrombosis risk stratification (such as CHADs score or time from pulmonary embolism). Additionally, the patient’s INR should be monitored and ideally kept below 1.4, while also ensuring there are no other coagulation abnormalities present.
Pain management can be achieved through various methods, including the use of analgesic drugs and local anesthetics. The World Health Organisation (WHO) recommends a stepwise approach to pain management, starting with peripherally acting drugs such as paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs). If pain control is not achieved, weak opioid drugs such as codeine or dextropropoxyphene can be introduced, followed by strong opioids such as morphine as a final option. Local anesthetics can also be used to provide pain relief, either through infiltration of a wound or blockade of plexuses or peripheral nerves.
For acute pain management, the World Federation of Societies of Anaesthesiologists (WFSA) recommends a similar approach, starting with strong analgesics in combination with local anesthetic blocks and peripherally acting drugs. The use of strong opioids may no longer be required once the oral route can be used to deliver analgesia, and peripherally acting agents and weak opioids can be used instead. The final step is when pain can be controlled by peripherally acting agents alone.
Local anesthetics can be administered through infiltration of a wound with a long-acting agent such as Bupivacaine, providing several hours of pain relief. Blockade of plexuses or peripheral nerves can also provide selective analgesia, either for surgery or postoperative pain relief. Spinal and epidural anesthesia are other options, with spinal anesthesia providing excellent analgesia for lower body surgery and epidural anesthesia providing continuous infusion of analgesic agents. Transversus Abdominal Plane block (TAP) is a technique that uses ultrasound to identify the correct muscle plane and injects local anesthetic to block spinal nerves, providing a wide field of blockade without the need for indwelling devices.
Patient Controlled Analgesia (PCA) allows patients to administer their own intravenous analgesia and titrate the dose to their own end-point of pain relief using a microprocessor-controlled pump. Opioids such as morphine and pethidine are commonly used, but caution is advised due to potential side effects and toxicity. Non-opioid analgesics such as paracetamol and NSAIDs can also be used, with NSAIDs being more useful for superficial pain and having relative contraindications for certain medical conditions.
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This question is part of the following fields:
- Pharmacology
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Question 17
Correct
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After reviewing a patient with chronic obstructive pulmonary disease (COPD) in clinic, the respiratory consultant discusses the anatomy of the lungs with a group of undergraduate students.
With regard to the lungs, which one of the following statements is accurate?Your Answer: The lungs receive a dual blood supply
Explanation:Facts about the Anatomy of the Lungs
The lungs are a vital organ responsible for respiration. Here are some important facts about their anatomy:
– The lungs receive a dual blood supply from the pulmonary artery and the bronchial arteries. A pulmonary embolus may only result in infarction when the circulation is already inadequate.
– The left lung has two lobes, while the right lung has three. The horizontal fissure is present only in the right lung.
– Each lung has ten bronchopulmonary segments, which can be selectively removed surgically if diseased.
– The right bronchus is shorter, wider, and more vertical than the left bronchus, making it more likely for foreign bodies to enter it. Aspiration pneumonia and abscess formation are common in the apical segment of the right lower lobe.Important Facts about the Anatomy of the Lungs
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This question is part of the following fields:
- Respiratory
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Question 18
Correct
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A medical registrar is obtaining consent from a 42-year-old patient with longstanding ulcerative colitis who is listed for a surveillance colonoscopy that afternoon.
Regarding consent, which one of the following statements is correct?Your Answer: Therapeutic privilege can allow you to withhold information from a patient in certain, very specific situations
Explanation:Therapeutic privilege allows doctors to withhold information from patients in certain situations where disclosure could cause serious harm or if the patient is not emotionally stable enough to handle the information. It is important to discuss these situations with senior colleagues and document the reasons for withholding information. Contrary to popular belief, patients should be informed of common and serious complications of treatment, regardless of the likelihood of occurrence. A signed consent form does not protect doctors from negligence claims, as they have a duty of care to inform patients. In emergency situations, such as an appendectomy for a child, consent may not be required, but it is still preferable to discuss the case with all parties involved. Patients who are heavily intoxicated may not have the capacity to refuse life-saving treatment, and it is necessary to wait until they are sober to discuss treatment options or proceed with urgent treatment.
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This question is part of the following fields:
- Ethics And Legal
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Question 19
Correct
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A 10-month-old infant is brought to the emergency department by her mother. She has had a barking cough for the past 2 days and her mother says she has been eating poorly for the past 3 days. During examination, the infant appears calm and is easily entertained by her toys. The barking cough is audible even at rest and there is slight sternal retraction. Vital signs are stable. The diagnosis is croup and treatment is initiated. What is the most appropriate initial treatment for this infant?
Your Answer: Oral dexamethasone
Explanation:The infant’s condition is stable.
If oral administration is not possible, IV hydrocortisone may be required, but it is not the preferred option.
Antibiotics are not the primary treatment for croup as it is mostly caused by a viral infection.Understanding Croup: A Respiratory Infection in Infants and Toddlers
Croup is a type of upper respiratory tract infection that commonly affects infants and toddlers. It is characterized by a barking cough, fever, and coryzal symptoms, and is caused by a combination of laryngeal oedema and secretions. Parainfluenza viruses are the most common cause of croup. The condition typically peaks between 6 months and 3 years of age, and is more prevalent during the autumn season.
The severity of croup can be graded based on the presence of symptoms such as stridor, cough, and respiratory distress. Mild cases may only have occasional barking cough and no audible stridor at rest, while severe cases may have frequent barking cough, prominent inspiratory stridor at rest, and marked sternal wall retractions. Children with moderate or severe croup, those under 6 months of age, or those with known upper airway abnormalities should be admitted to the hospital.
Diagnosis of croup is usually made based on clinical presentation, but a chest x-ray may show subglottic narrowing, commonly referred to as the steeple sign. Treatment for croup typically involves a single dose of oral dexamethasone or prednisolone, regardless of severity. In emergency situations, high-flow oxygen and nebulized adrenaline may be necessary.
Understanding croup is important for parents and healthcare providers alike, as prompt recognition and treatment can help prevent complications and improve outcomes for affected children.
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This question is part of the following fields:
- Paediatrics
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Question 20
Correct
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A 62-year-old man visits the anticoagulation clinic for his regular INR check-up as he is taking warfarin for chronic atrial fibrillation. During the test, he informs the healthcare provider that he has been incorporating more fruits into his diet and has started consuming cranberry juice.
The INR reading shows a value of 6, but the patient is asymptomatic and not experiencing any bleeding.
What should be the subsequent course of action in managing this patient?Your Answer: Stop warfarin and recheck INR
Explanation:Managing Elevated INR Levels in Patients on Warfarin
When a patient on warfarin presents with an INR level above the therapeutic range, the management approach depends on the severity of the situation. Here are some possible courses of action:
Stop Warfarin and Recheck INR: If the INR is between 6.0 and 8.0 and there is no bleeding, warfarin should be stopped, and the INR rechecked. Once the INR drops below 5.0, warfarin can be restarted. Patients should also be advised to avoid cranberry juice, which can interfere with warfarin metabolism.
Stop Warfarin, Commence Prothrombin Complex Concentrate (PCC) and Recheck INR: If the patient has major bleeding, warfarin should be stopped, and the patient managed in a hospital setting. PCC or fresh frozen plasma can be administered to reverse the effects of warfarin. The INR should be rechecked after treatment.
Continue Warfarin and Recheck INR: If the INR is only slightly elevated and there is no bleeding, warfarin can be continued, and the INR rechecked.
Stop Warfarin, Commence Vitamin K and Recheck INR: If the INR is above 8.0 and there is minor or no bleeding, warfarin should be stopped, and vitamin K administered orally or intravenously. The INR should be rechecked, and a second dose of vitamin K given if necessary.
Reduce Warfarin and Recheck INR: If the INR is only slightly elevated (0.5 above range or less than 6.0) and there is no bleeding, the doctor may choose to reduce the warfarin dose or omit a few doses. The INR should be rechecked a few days later.
In all cases, the management approach should be tailored to the individual patient’s situation and needs.
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This question is part of the following fields:
- Pharmacology
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Question 21
Correct
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A 25-year-old man arrives in the resuscitation area of the Emergency Department with significant burns to his face, torso, and hands after throwing petrol on a bonfire. According to the rule of nines, he has 31.5% burns. He weighs 95 kg.
What would be the appropriate amount of fluid resuscitation based on the Parkland formula?Your Answer: 12L, with 6L given in the first 8 h followed by 6L over the next 16 h
Explanation:Understanding Fluid Resuscitation in Major Burns
Fluid resuscitation is a crucial aspect of treating patients with major burns. The goal is to replace fluid losses and maintain tissue perfusion to prevent the spread of tissue damage. The Parkland formula is a guide used to calculate the total fluid requirement in 24 hours, based on the patient’s body weight and the percentage of burn surface area. The formula recommends giving 50% of the total fluid requirement in the first 8 hours and the remaining 50% over the next 16 hours.
However, caution should be exercised to avoid overly aggressive fluid resuscitation, which can worsen tissue oedema and hypoxia. The aim is to achieve a urine output of 0.5-1.0 ml/kg/hour in adults. Children require maintenance fluid in addition to the calculated fluid requirement.
It’s important to note that the Parkland formula is a guide, and the fluid requirement may vary depending on the patient’s condition. The initial shift of fluid from the intravascular compartment to the interstitial tissues can lead to hypotension, and burns to the skin can reduce the body’s ability to regulate fluid losses and temperature. Therefore, careful monitoring and adjustment of fluid resuscitation are necessary to ensure optimal outcomes for patients with major burns.
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This question is part of the following fields:
- Plastics
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Question 22
Correct
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A 6-week-old baby girl is brought to her pediatrician's office by her mother who is worried about her poor feeding over the past 24 hours. The mother has noticed that the baby feels warm but has not observed any signs of cough or cold. The baby is scheduled to receive her vaccinations next week. She has had a wet and dirty diaper today and her urine has a strong odor.
During the examination, the baby has a fever of 38.9ºC and is fussy, but her chest and abdomen appear normal.
What is the most appropriate course of action for this infant?Your Answer: Admit same day to the paediatrics ward for assessment
Explanation:If a child under 3 months old is suspected to have a UTI, it is important to refer them to specialist paediatrics services. In the case of a baby with a persistent fever and no clear source of infection, a urine sample should be collected to check for a UTI. It is important to note that a raised temperature alone is considered a red sign according to NICE guidance for assessing fever in children, and the child should be referred for urgent paediatric assessment. It would be inappropriate to reassure the mother that this is just a virus and can be managed at home, and using paracetamol to manage the fever would not be acceptable in this case. While antibiotics may treat the infection, waiting a week for a review could be dangerous for an unwell child who may deteriorate rapidly. Referring the child for a routine review with paediatrics would also not be appropriate, as urgent attention is required. While a health visitor may be helpful for feeding issues, the short history of poor feeding and fever suggests that the baby is struggling to feed due to illness, and this would not address the current presentation.
Urinary tract infections (UTI) are more common in boys until 3 months of age, after which the incidence is substantially higher in girls. Presentation in childhood depends on age, with infants showing poor feeding, vomiting, and irritability, younger children showing abdominal pain, fever, and dysuria, and older children showing dysuria, frequency, and haematuria. NICE guidelines recommend checking urine samples in children with symptoms or signs suggestive of a UTI, unexplained fever of 38°C or higher, or an alternative site of infection but who remain unwell. Urine collection should be done through clean catch or urine collection pads, and invasive methods should only be used if non-invasive methods are not possible. Management includes referral to a paediatrician for infants less than 3 months old, admission to hospital for children aged more than 3 months old with an upper UTI, and oral antibiotics for 3-10 days for children aged more than 3 months old with a lower UTI. Antibiotic prophylaxis is not given after the first UTI but should be considered with recurrent UTIs.
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This question is part of the following fields:
- Paediatrics
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Question 23
Correct
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A 72-year-old man with a history of smoking and high blood pressure arrives at the Emergency Department complaining of sudden-onset abdominal pain. He reports that the pain is severe and radiates to his back. Upon examination, a pulsatile mass is detected in his abdomen. The patient is currently stable and able to communicate without difficulty. The medical team suspects an abdominal aortic aneurysm (AAA).
Which layers of the abdominal aortic wall are expected to be dilated in this patient?Your Answer: Intima, media and adventitia
Explanation:Understanding the Layers of an Abdominal Aortic Aneurysm
An abdominal aortic aneurysm (AAA) is a serious condition that involves the enlargement of the abdominal aorta, the main blood vessel that supplies blood to the lower body. To understand this condition better, it is important to know the three layers of the aortic wall: the intima, media, and adventitia.
In a true AAA, all three layers of the aortic wall are affected, with most occurring in the infrarenal segment. This means that the diameter of the aorta is greater than 3 cm or has increased by over 50% from the baseline. The intima and media are pathologically more affected, but the adventitia is also involved.
A false aneurysm or pseudoaneurysm, on the other hand, only affects the intima and media layers. It is important to note that a true AAA always involves all three layers of the aortic wall.
It is physically impossible to have an aneurysm only in the outer layer of the aortic wall, as blood would have to pass through the intima and media to cause the destruction of elastin and collagen in the adventitia. Similarly, the intima is the innermost layer of the aortic wall and is certainly affected in an aneurysm, but it is not the only layer involved.
Understanding the layers of an AAA is crucial in diagnosing and treating this condition. Regular check-ups and screenings can help detect an AAA early, which can improve the chances of successful treatment.
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This question is part of the following fields:
- Trauma
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Question 24
Correct
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A patient in their 60s with severe intermittent claudication undergoes an axillo-bifemoral bypass. Two days after the operation, they develop pain in the leg. Examination reveals a warm, erythaematous swelling in the groin.
What complication has occurred?Your Answer: The graft has become infected
Explanation:Possible Complications of a Graft Procedure
Graft procedures are commonly performed to improve blood flow in patients with peripheral arterial disease. However, like any surgical intervention, there are potential complications that may arise. One possible complication is an infected graft, which can cause swelling and abscess formation. Another possibility is graft occlusion, which may occur if there is a surgical error and can lead to the recurrence of claudication symptoms. An anastomotic aneurysm is another rare but serious complication that may cause pulsatile swelling. Embolism is more likely to occur in patients with aneurysmal disease and can present with acute limb ischaemia or petechiae. Finally, an anastomotic leak is an extremely rare complication that may cause sudden pain and swelling at the site of the graft. It is important for patients to be aware of these potential complications and to seek medical attention if they experience any concerning symptoms after a graft procedure.
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This question is part of the following fields:
- Surgery
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Question 25
Correct
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A 30-year-old woman presents with a 3-week history of episodes of postcoital bleeding. She has had some lower abdominal pain but no tenderness or urinary symptoms. She is sexually active, with regular periods and her last menstrual cycle was one week ago. Her temperature is 37.1 °C and she has no systemic symptoms. She is a smoker and takes the oral contraceptive pill. Her last smear test was two years ago.
What is the most appropriate initial investigation?Your Answer: Speculum examination of the cervix
Explanation:Investigating Postcoital Bleeding: The Role of Speculum Examination and Other Tests
Postcoital bleeding can be caused by various abnormalities of the cervix, including cervical ectropion, polyps, infection, or cervical cancer. In women presenting with postcoital bleeding, cervical cancer should be suspected if there are other symptoms such as vaginal discharge, pelvic pain, or dyspareunia. Risk factors for cervical cancer include smoking, oral contraceptive use, HPV infection, HIV infection, immunosuppression, and family history.
The primary screening tool for cervical cancer is a cervical smear, which should be done every three years for women aged 25-49. If a patient presents with postcoital bleeding, the first step is to perform a speculum examination to visualize the cervix, which can detect over 80% of cervical cancers. If the cervix appears normal, a smear may be taken if it is due, and swabs can be taken for STI testing and pregnancy testing. If symptoms persist, referral to colposcopy may be necessary.
Other tests such as blood tests, urine dipstick, and high vaginal swab may be useful in certain cases, but they are not the primary investigation for postcoital bleeding. Blood tests may be indicated later, while urine dipstick and high vaginal swab are secondary investigations following visualisation of the cervix.
In summary, speculum examination is the key initial investigation for postcoital bleeding, and cervical smear is the primary screening tool for cervical cancer. Other tests may be useful in specific situations, but they should not replace the essential role of speculum examination and cervical smear in the evaluation of postcoital bleeding.
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This question is part of the following fields:
- Gynaecology
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Question 26
Incorrect
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A 60-year-old man with a past medical history of obesity, hypertension and hyperlipidaemia presents to the Emergency Department complaining of sudden-onset chest pain. After your initial history and examination, you conclude that there is a 40% chance that this patient is experiencing an acute myocardial infarction. An electrocardiogram (ECG) and cardiac enzymes are performed to further evaluate his condition.
This estimate (40%) is defined as which of the following?Your Answer: Odds ratio
Correct Answer: Prior probability
Explanation:Understanding Key Probability Terms in Medical Diagnosis
Prior probability refers to the initial estimation of the likelihood of a disease in a patient before any additional data is obtained. On the other hand, posterior probability is the updated probability of an event occurring after new data is considered. This is calculated using Bayes’ theorem.
Odds ratio is the ratio of the chance of an event occurring in one population compared to another population. For instance, the odds of lung cancer in smokers compared to non-smokers.
Likelihood ratio is the probability of an observation in patients with a disease divided by the probability of the same observation in patients without the disease.
Prevalence is the proportion of people in a given population who have a disease at a particular point in time. Understanding these key probability terms is crucial in medical diagnosis.
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This question is part of the following fields:
- Statistics
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Question 27
Correct
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You are a Foundation Year 2 in general practice and a 32-year-old lady comes in who is pregnant with her first child. She feels unwell, has upper abdominal pain near her epigastrium, and thinks that her ankle swelling has been much worse over the last few days. You assess her and your findings are as follows:
Symphysis–fundal height (SFH): 39 cm
Presentation: breech
Lie: longitudinal
Blood pressure (BP): 152/93
Fetal movements: not palpable
Which of these investigations is most likely to lead you to a diagnosis?Your Answer: Urine dipstick
Explanation:Diagnosis and Management of Pre-eclampsia in Pregnancy
Pre-eclampsia is a serious condition that can occur during pregnancy, characterized by hypertension, proteinuria, and edema. It can lead to various complications and is a leading cause of maternal death. Risk factors include nulliparity, previous history of pre-eclampsia, family history, and certain medical conditions. Diagnosis is made by testing for proteinuria and monitoring blood pressure. Treatment involves close monitoring, medication, and delivery of the baby. Complications can include HELLP syndrome and eclampsia. Testing for liver function and performing a CTG can aid in management, but will not lead to the diagnosis. Early identification and management are crucial in preventing adverse outcomes.
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This question is part of the following fields:
- Obstetrics
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Question 28
Correct
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You are the out-of-hours General Practitioner (GP) on call. You receive a call from the relative of an 85-year-old woman with palliative breast cancer and a complete Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order. The relative believes she has passed away and is not sure what to do. You offer your condolences and arrange a home visit to confirm death.
Which of the following should be confirmed in order to diagnose death?Your Answer: No response to verbal/painful stimuli, absence of carotid pulse, absence of breath sounds for more than three minutes, absence of heart sounds for more than two minutes, pupils fixed and dilated
Explanation:Assessing for Death: Signs and Symptoms
When diagnosing death, it is important to look for signs of life initially, including skin color, signs of respiratory effort, and response to verbal/painful stimuli. Painful stimuli can be assessed using various methods, such as fingernail bed pressure, supraorbital pressure, or trapezius squeeze. Pupils should be assessed using a pen torch, as they become fixed and dilated after death. A central pulse, such as the carotid pulse, should be palpated, and doctors should listen for heart sounds for at least two minutes and breath sounds for at least three minutes. Exact durations may vary, but a minimum of five minutes of auscultation should be conducted to confirm irreversible cardiorespiratory arrest.
However, assessing for a gag reflex is not a routine part of diagnosing death, and the absence of a gag reflex may not necessarily indicate death. Instead, the absence of a corneal reflex can be used to diagnose death.
It is important to note that one minute of auscultation for breath and heart sounds would be insufficient to diagnose death. Additionally, assessing for a peripheral pulse, such as the radial pulse, would not be accurate, as it can be lost in peripherally shut down or hypotensive patients. Confirmation of death requires the absence of a central pulse, such as the carotid pulse, and the absence of breath and heart sounds for an adequate amount of time, along with fixed and dilated pupils.
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This question is part of the following fields:
- Palliative Care
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Question 29
Incorrect
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A mother brings her 6-year-old daughter to see you at the General Practice surgery where you are working as a Foundation Year 2 doctor. The daughter had a runny nose and sore throat for the past few days but then developed bright red rashes on both her cheeks. She now has a raised itchy rash on her chest, that has a lace-like appearance, but feels well. She has no known long-term conditions and has been developing normally.
What is the most likely diagnosis?Your Answer:
Correct Answer: Parvovirus infection
Explanation:Common Skin Rashes and Infections: Symptoms and Characteristics
Parvovirus Infection: Also known as ‘slapped cheek syndrome’, this mild infection is characterized by a striking appearance. However, it can lead to serious complications in immunocompromised patients or those with sickle-cell anaemia or thalassaemia.
Pityriasis Rosea: This rash starts with an oval patch of scaly skin and is followed by small, scaly patches that spread across the body.
Impetigo: A superficial infection caused by Staphylococcus or Streptococcus bacteria, impetigo results in fluid-filled blisters or sores that burst and leave a yellow crust.
Scarlet Fever: This rash is blotchy and rough to the touch, typically starting on the chest or abdomen. Patients may also experience headache, sore throat, and high temperature.
Urticaria: This itchy, raised rash is caused by histamine release due to an allergic reaction, infection, medications, or temperature changes. It usually settles within a few days.
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This question is part of the following fields:
- Paediatrics
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Question 30
Incorrect
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What category of hypersensitivity is characterized by immune system dysregulation in systemic lupus erythematosus (SLE), an inflammatory disorder affecting multiple systems?
Your Answer:
Correct Answer: Type 3 hypersensitivity
Explanation:SLE is classified as a type 3 hypersensitivity reaction, which is characterized by the formation of antigen-antibody complexes. The development of SLE involves the transfer of cellular remnants containing nuclear material to lymphatic tissues, where they are presented to T cells. This, in turn, stimulates B cells to produce autoantibodies. These IgG autoantibodies are specifically targeted to attack DNA and other nuclear material, leading to the formation of antigen-antibody complexes that cause damage in various parts of the body.
Systemic Lupus Erythematosus: Epidemiology and Pathophysiology
Systemic lupus erythematosus (SLE) is an autoimmune disease that is much more common in females, with a ratio of 9:1. It is also more prevalent in Afro-Caribbeans and Asian communities. The onset of SLE usually occurs between the ages of 20-40 years, and the incidence has risen substantially during the past 50 years. The pathophysiology of SLE involves a type 3 hypersensitivity reaction, which is associated with HLA B8, DR2, DR3. The disease is thought to be caused by immune system dysregulation leading to immune complex formation. These immune complexes can affect any organ, including the skin, joints, kidneys, and brain.
It is interesting to note that the incidence of SLE in black Africans is much lower than in black Americans, although the reasons for this are unclear. The rise in incidence of SLE over the past 50 years may be due to changes in environmental factors or lifestyle habits. The dysregulation of the immune system in SLE leads to the formation of immune complexes, which can deposit in various organs and cause damage. This can result in a wide range of symptoms, including joint pain, skin rashes, and kidney problems. Understanding the epidemiology and pathophysiology of SLE is crucial for developing effective treatments and improving patient outcomes.
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This question is part of the following fields:
- Musculoskeletal
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