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Question 1
Incorrect
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A 32-year-old male patient visits the sexual health clinic complaining of a recent genital lesion. The patient reports experiencing severe pain and first noticed the lesion one week ago. He admits to engaging in unprotected sexual activity with multiple partners within the past three months. Upon examination, a deep ulcer with a ragged border is observed on the penis shaft, accompanied by tenderness and inguinal lymphadenopathy. What is the probable diagnosis?
Your Answer: Lymphogranuloma venereum
Correct Answer: Chancroid
Explanation:The man’s ulcer appears to be caused by chancroid, which is known for causing deep and painful genital ulcers accompanied by inguinal lymphadenopathy. Gonorrhoea is an unlikely diagnosis as it typically presents with penile discharge and no ulceration. Herpes simplex can also cause painful genital ulcers, but they are usually multiple and superficial, and inguinal lymphadenopathy is not as common as with chancroid. Lymphogranuloma venereum causes painless ulceration that heals quickly, while primary syphilis causes a painless ulcer called a chancre.
Understanding Chancroid: A Painful Tropical Disease
Chancroid is a disease that is commonly found in tropical regions and is caused by a bacterium called Haemophilus ducreyi. This disease is characterized by the development of painful genital ulcers that are often accompanied by painful swelling of the lymph nodes in the groin area. The ulcers themselves are typically easy to identify, as they have a distinct border that is ragged and undermined.
Chancroid is a disease that can be quite painful and uncomfortable for those who are affected by it.
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This question is part of the following fields:
- Infectious Diseases
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Question 2
Correct
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A 50-year-old-man comes to the emergency department with a 10-hour history of colicky abdominal pain, abdominal distension, constipation and an inability to pass flatus. He reports feeling nauseous but has not vomited.
What should not be done in the management of this patient?Your Answer: IV metoclopramide
Explanation:Metoclopramide should be avoided in cases of bowel obstruction due to its prokinetic properties that can worsen the condition and even lead to perforation. Moclobemide, an antidepressant, may cause gastrointestinal upset but is not contraindicated in suspected bowel obstruction. Conservative management for bowel obstruction includes NG tube insertion, catheterization, and IV fluid resuscitation. Ondansetron, an antiemetic, can be useful in managing nausea. Opioid-based analgesia, such as pethidine and diamorphine, is effective in relieving obstruction-related pain despite its potential to reduce bowel motility. Intravenous fluids, such as Hartmann’s solution, are crucial in countering hypovolemia caused by fluid hypersecretion into the obstructed bowel lumen.
Metoclopramide is a medication that is commonly used to manage nausea. It works by blocking D2 receptors in the chemoreceptor trigger zone, which helps to alleviate feelings of sickness. In addition to its antiemetic properties, metoclopramide also has other uses, such as treating gastro-oesophageal reflux disease and gastroparesis caused by diabetic neuropathy. It is often combined with analgesics to treat migraines, which can cause gastroparesis and slow the absorption of pain medication.
However, metoclopramide can have some adverse effects, such as extrapyramidal effects, acute dystonia, diarrhoea, hyperprolactinaemia, tardive dyskinesia, and parkinsonism. These side effects are particularly problematic in children and young adults. It is important to note that metoclopramide should not be used in cases of bowel obstruction, but it may be helpful in cases of paralytic ileus.
Although metoclopramide primarily works as a D2 receptor antagonist, its mechanism of action is quite complex. It also acts as a mixed 5-HT3 receptor antagonist and 5-HT4 receptor agonist. The antiemetic effects of metoclopramide are due to its D2 receptor antagonist activity in the chemoreceptor trigger zone, while its gastroprokinetic effects are mediated by both D2 receptor antagonist and 5-HT4 receptor agonist activity. At higher doses, the 5-HT3 receptor antagonist activity also comes into play.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 3
Correct
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A 67-year-old man contacts emergency services due to experiencing central crushing chest pain that spreads to his left arm and jaw. Upon arrival at the emergency department, his heart rate is recorded at 50/min. An ECG is conducted, revealing ST elevation and bradycardia with a 1st-degree heart block. Based on the provided information, which leads are expected to display the ST elevation?
Your Answer: II, III and aVF
Explanation:An ST-elevated myocardial infarction affecting the inferior leads (II, III, aVF) can cause arrhythmias due to the involvement of the right coronary artery, which supplies blood to the AV node. This is evidenced by the patient’s presentation with 1st-degree heart block following the MI.
Anteroseptal changes in V1-V4 indicate involvement of the left anterior descending artery. Inferior changes in II, III, and aVF suggest the right coronary artery is affected. Anterolateral changes in V1-6, I, and aVL indicate the proximal left anterior descending artery is involved. Lateral changes in I, aVL, and possibly V5-6 suggest the left circumflex artery is affected. Posterior changes in V1-3 may indicate a posterior infarction, which is confirmed by ST elevation and Q waves in posterior leads (V7-9). This type of infarction is usually caused by the left circumflex artery, but can also be caused by the right coronary artery. Reciprocal changes of STEMI are typically seen as horizontal ST depression, tall and broad R waves, upright T waves, and a dominant R wave in V2. It is important to note that a new left bundle branch block (LBBB) may indicate acute coronary syndrome.
Overall, understanding the correlation between ECG changes and coronary artery territories is crucial in diagnosing acute coronary syndrome. By identifying the specific changes in the ECG, medical professionals can determine which artery is affected and provide appropriate treatment. Additionally, recognizing the reciprocal changes of STEMI and the significance of a new LBBB can aid in making an accurate diagnosis.
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This question is part of the following fields:
- Cardiovascular
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Question 4
Incorrect
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A 60-year-old African American male presents with widespread bone pain and muscle weakness. Upon investigation, the following results were obtained:
Calcium 2.05 mmol/l
Phosphate 0.68 mmol/l
ALP 340 U/l
What is the probable diagnosis?Your Answer: Paget's disease
Correct Answer: Osteomalacia
Explanation:Osteomalacia may be indicated by bone pain, tenderness, and proximal myopathy (resulting in a waddling gait), as well as low levels of calcium and phosphate and elevated alkaline phosphatase.
Understanding Osteomalacia
Osteomalacia is a condition that occurs when the bones become soft due to low levels of vitamin D, which leads to a decrease in bone mineral content. This condition is commonly seen in adults, while in growing children, it is referred to as rickets. The causes of osteomalacia include vitamin D deficiency, malabsorption, lack of sunlight, chronic kidney disease, drug-induced factors, inherited conditions, liver disease, and coeliac disease.
The symptoms of osteomalacia include bone pain, muscle tenderness, fractures, especially in the femoral neck, and proximal myopathy, which may lead to a waddling gait. To diagnose osteomalacia, blood tests are conducted to check for low vitamin D levels, low calcium and phosphate levels, and raised alkaline phosphatase levels. X-rays may also show translucent bands known as Looser’s zones or pseudofractures.
The treatment for osteomalacia involves vitamin D supplementation, with a loading dose often needed initially. Calcium supplementation may also be necessary if dietary calcium intake is inadequate. Understanding the causes, symptoms, and treatment options for osteomalacia is crucial in managing this condition effectively.
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This question is part of the following fields:
- Musculoskeletal
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Question 5
Correct
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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: 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 6
Correct
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A 54-year-old woman complains of facial asymmetry. She noticed that the right corner of her mouth was drooping while brushing her teeth this morning. She is in good health but experienced pain behind her right ear yesterday and reports dryness in her right eye. Upon examination, she exhibits complete paralysis of the facial nerve on the right side, from the forehead to the mouth. There are no abnormalities found during ear, nose, and throat examination or clinical examination of the peripheral nervous system. What is the probable diagnosis?
Your Answer: Bell's palsy
Explanation:The diagnosis of an ear infection is unlikely based on the patient’s symptoms and the results of their ear exam.
Understanding Bell’s Palsy
Bell’s palsy is a sudden, one-sided facial nerve paralysis of unknown cause. It is more common in individuals aged 20-40 years and pregnant women. The condition is characterized by lower motor neuron facial nerve palsy, which affects the forehead. Unlike upper motor neuron lesions, the upper face is spared. Patients may also experience post-auricular pain, altered taste, dry eyes, and hyperacusis.
The management of Bell’s palsy has been a subject of debate. However, it is now widely accepted that all patients should receive oral prednisolone within 72 hours of onset. The addition of antiviral medications is still a matter of discussion, but it may be beneficial for severe facial palsy. Eye care is also crucial to prevent exposure keratopathy, and patients should be prescribed artificial tears and eye lubricants. If they are unable to close their eyes at bedtime, they should tape them closed using microporous tape.
If the paralysis shows no sign of improvement after three weeks, an urgent referral to ENT is necessary. Patients with long-standing weakness may require a referral to plastic surgery. The prognosis for Bell’s palsy is generally good, with most patients making a full recovery within 3-4 months. However, untreated patients may experience permanent moderate to severe weakness in around 15% of cases.
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This question is part of the following fields:
- Neurology
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Question 7
Correct
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A 12-month-old boy is brought into morning surgery by a concerned first-time mother. She reports several episodes of her baby crying inconsolably and drawing his legs towards his chest since last night. Today he passed some bright red jelly-like blood in his nappy without any stool.
Which of the following is the likely cause?
Your Answer: Intussusception
Explanation:Understanding Intussusception: A Common Cause of Abdominal Pain in Children
Intussusception is a medical condition where one segment of the bowel invaginates into another, causing obstruction and compromise to the blood supply of that part of the bowel. This can lead to symptoms such as colicky abdominal pains, vomiting, and passing of redcurrant stools. It is a common cause of abdominal pain in children and requires immediate medical attention.
Gastroenteritis, appendicitis, constipation, and volvulus are all conditions that can cause abdominal pain in children, but they are not likely to present with the specific symptoms of intussusception. Any child with suspected intussusception should be admitted to the hospital immediately for further investigation and observation.
Understanding the symptoms and causes of intussusception can help parents and caregivers recognize the condition and seek prompt medical attention for their child.
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This question is part of the following fields:
- Paediatrics
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Question 8
Incorrect
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A geriatric patient presents to the Emergency Department with a fast, irregular pulse, chest pain, weakness and palpitations. Upon arrival, investigations were carried out, including the following:
Investigation Result Normal value
PaO2 11.9 kPa
pH 7.35 7.40 ± 0.05
PaCO2 27 mmHg
Sodium (Na+) 125 mmol
Potassium (K+) 6.7 mmol
HCO3− 15 mmol
Chloride (Cl−) 107 mmol
Normal anion gap 10–18 mmol/l
With which of the following are the results consistent?Your Answer: Excessive thiazide treatment
Correct Answer: Addisonian crisis
Explanation:Causes of Metabolic Acidosis with Normal Anion Gap
Metabolic acidosis with a normal anion gap can be caused by various medical conditions. One such condition is an Addisonian crisis, which occurs due to severe adrenal insufficiency. This results in reduced activity of aldosterone, causing sodium loss and potassium retention, leading to hyperkalaemia and metabolic acidosis with a normal anion gap.
Burns can also cause hyperkalaemia due to rhabdomyolysis, resulting in a raised anion gap metabolic acidosis. Diabetic ketoacidosis is another condition that presents with hyperkalaemia and metabolic acidosis, but with an increased anion gap due to ketone bodies.
Diarrhoea can cause hypokalaemia, hyponatraemia, loss of bicarbonate, and metabolic acidosis with a normal anion gap. However, excessive thiazide treatment would result in hypokalaemia and not hyperkalaemia.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 9
Correct
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An older gentleman patient presents with arthritic pains. At the end of the consultation, he mentions that he recently visited a doctor at the memory clinic who diagnosed him with Alzheimer's dementia. However, he cannot recall why he was not prescribed any medication for this condition.
Which of the following factors would be a potential relative contraindication to prescribing donepezil for this patient?Your Answer: Resting bradycardia
Explanation:Managing Alzheimer’s Disease: Non-Pharmacological and Pharmacological Approaches
Alzheimer’s disease is a type of dementia that progressively affects the brain and is the most common form of dementia in the UK. To manage this condition, there are both non-pharmacological and pharmacological approaches available.
Non-pharmacological management involves offering a range of activities that promote wellbeing and are tailored to the patient’s preferences. Group cognitive stimulation therapy is recommended for patients with mild to moderate dementia, while group reminiscence therapy and cognitive rehabilitation are also options to consider.
Pharmacological management involves the use of medications. The three acetylcholinesterase inhibitors (donepezil, galantamine, and rivastigmine) are options for managing mild to moderate Alzheimer’s disease. Memantine, an NMDA receptor antagonist, is considered a second-line treatment and is recommended for patients with moderate Alzheimer’s who are intolerant of or have a contraindication to acetylcholinesterase inhibitors. It can also be used as an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer’s or as monotherapy in severe Alzheimer’s.
When managing non-cognitive symptoms, NICE does not recommend antidepressants for mild to moderate depression in patients with dementia. Antipsychotics should only be used for patients at risk of harming themselves or others or when the agitation, hallucinations, or delusions are causing them severe distress.
It is important to note that donepezil is relatively contraindicated in patients with bradycardia, and adverse effects may include insomnia. By utilizing both non-pharmacological and pharmacological approaches, patients with Alzheimer’s disease can receive comprehensive care and management.
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This question is part of the following fields:
- Neurology
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Question 10
Correct
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A 50-year-old woman with known ovarian cancer presented to the emergency department complaining of severe right leg pain since yesterday. She had a hysterectomy 1 month ago.
Which of the following is the most likely cause of her symptoms?
Your Answer: DVT (deep-vein thrombosis)
Explanation:After undergoing surgery, a woman presents with leg pain. Several potential causes are considered, including deep-vein thrombosis (DVT), acute limb ischaemia, air embolus, lumbar disc herniation, and paradoxical embolus. Based on the patient’s risk factors and symptoms, DVT is deemed the most likely diagnosis. Other causes are ruled out due to lack of relevant history or low probability. Understanding the possible causes of leg pain after urological surgery can help healthcare providers make an accurate diagnosis and provide timely treatment.
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This question is part of the following fields:
- Haematology/Oncology
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Question 11
Correct
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A 28-year-old professional basketball player presents with complaints of feeling lightheaded during exercise. Upon physical examination, a laterally displaced apical impulse is noted. Auscultation reveals a 2/6 mid-systolic murmur in the mitral area that increases upon sudden standing. The ECG shows LVH and Q waves in V1–4 leads.
What is the most probable diagnosis?Your Answer: Hypertrophic cardiomyopathy
Explanation:Differential Diagnosis for a Patient with Dyspnoea and a Murmur: Hypertrophic Cardiomyopathy
Hypertrophic cardiomyopathy is a condition that can lead to sudden death in young athletes and is characterized by dyspnoea, LVH, and a loud S4. The systolic murmur associated with hypertrophic cardiomyopathy does not radiate to the carotids and can be differentiated from aortic stenosis, which causes a crescendo-decrescendo murmur that does radiate to the carotids. Young-onset hypertension is unlikely to cause a murmur, and acute myocardial infarction would show ST elevation or depression on ECG, but not LVH. Atrial septal defect is usually picked up in newborn checks and presents with a brief murmur in early systole and early diastole, while hypertrophic cardiomyopathy presents with a double or triple apical impulse and a characteristic jerky carotid pulse. It is important to recognize the symptoms and signs of hypertrophic cardiomyopathy to prevent sudden death in young athletes.
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This question is part of the following fields:
- Cardiovascular
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Question 12
Correct
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A 68-year-old woman is brought to her General Practitioner by her daughter who is concerned that she has been experiencing a few falls recently. She reveals that she has been getting confused and forgetful for the past two weeks. She has been complaining of dizziness and has vomited on a couple of occasions in the same time period. Her past medical history includes type 2 diabetes, hypertension and osteoporosis.
Which of the following is the most likely diagnosis?
Your Answer: Chronic subdural haematoma (SDH)
Explanation:Differentiating between types of intracranial hemorrhage
Intracranial hemorrhage can have various causes and presentations. Here are some key points to differentiate between different types of intracranial hemorrhage:
Chronic subdural hematoma (SDH): This type of hemorrhage can be spontaneous or caused by head trauma. Symptoms tend to develop gradually and may fluctuate. They include headache, vomiting, personality changes, memory disturbances, and loss of consciousness. Patients with a history of AF and recurrent falls are at high risk of developing a chronic SDH.
Subarachnoid hemorrhage (SAH): This type of hemorrhage occurs when blood accumulates in the space between the arachnoid and pia mater. The most common cause is rupture of a Berry aneurysm in the Circle of Willis. The classical presentation of SAH is a sudden-onset, severe ‘thunderclap’ headache often accompanied by vomiting and meningism. The presentation is usually acute.
Acute subdural hematoma (SDH): This type of hemorrhage occurs due to tearing of cortical bridging veins leading to bleeding into the subdural space. An acute SDH usually follows a significant head injury. Loss of consciousness may occur immediately or a few hours after the injury.
Extradural hemorrhage: This type of hemorrhage is caused by the rupture of one of the meningeal arteries that run between the dura and the skull. It usually occurs following a significant head injury often in younger patients. There is classically a lucid interval following the injury, followed several hours later by rapid deterioration resulting in loss of consciousness.
Ischemic cerebrovascular accident (CVA): This type of event occurs due to a lack of blood flow to the brain. Patients with risk factors such as AF and hypertension are at higher risk. Classical CVA symptoms include sudden-onset unilateral weakness, speech difficulties, or visual loss which do not resolve within 24 hours. However, the patient’s symptoms in this case are not typical for a CVA.
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This question is part of the following fields:
- Neurology
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Question 13
Correct
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An 81-year-old man who is a resident in a nursing home reports feeling tired and cold all the time. Blood tests are arranged which show the following:
Investigation Result Normal value
Thyroid-stimulating hormone (TSH) 12.8 mU/l 0.25–4.0 mU/l
Free T4 (thyroxine) 6.8 pmol/l 12.0-22.0 pmol/l
Free T3 (triiodothyronine) 2.6 pmol/l 3.1–6.8 pmol/l
Which of the following is the best action to take?
Select the SINGLE best action from the list below.Your Answer: Start levothyroxine 25 µg once daily
Explanation:Managing Hypothyroidism in an Elderly Patient: Recommended Treatment and Monitoring
For an elderly patient with overt hypothyroidism, immediate treatment is recommended by the National Institute for Health and Care Excellence (NICE). The recommended starting dose of levothyroxine is 25 µg once daily, with regular monitoring of response every 3-4 weeks until a stable TSH has been achieved. After that, a blood test should be performed at 4-6 months and annually thereafter. The goal of treatment is to resolve symptoms and signs of hypothyroidism, normalize TSH and T3/T4 levels, and avoid overtreatment, especially in elderly patients who are at risk of developing cardiac disease. Inappropriate treatments, such as carbimazole or radio-iodine therapy, should be avoided. It is crucial to avoid overtreatment, as it can worsen the patient’s condition and put them at risk of developing myxoedema coma, which can be life-threatening.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 14
Incorrect
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A 45-year-old woman is referred to Rheumatology Outpatients by her General Practitioner with a history of symptoms that highly resemble rheumatoid arthritis.
Which one of the following X-ray findings would indicate a diagnosis of rheumatoid arthritis?
Your Answer: Subchondral sclerosis
Correct Answer: Juxta-articular osteoporosis
Explanation:Common X-Ray Findings in Arthritis
Arthritis is a condition that affects the joints, causing pain, stiffness, and inflammation. X-rays are often used to diagnose and monitor arthritis, as they can reveal changes in the bones and joints. Here are some common X-ray findings in arthritis:
Juxta-articular osteoporosis/osteopenia: This is an early X-ray feature of rheumatoid arthritis, characterized by a loss of bone density around the joints.
Loss of joint space: Both osteoarthritis and rheumatoid arthritis can cause joint space narrowing, which occurs when the cartilage no longer keeps the bones a normal distance apart. This can be painful, as the bones rub or put too much pressure on each other.
Osteophytes: These are bony lumps (bone spurs) that grow on the bones of the spine or around the joints. They often form next to joints affected by osteoarthritis.
Subchondral cysts: This is a feature of a degenerative process (osteoarthritis). A subchondral cyst is a fluid-filled space inside a joint that extends from one of the bones that form the joint.
Subchondral sclerosis: This is a thickening of bone that happens in joints affected by osteoarthritis.
Overall, X-rays can provide valuable information about the progression of arthritis and help guide treatment decisions.
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This question is part of the following fields:
- Musculoskeletal
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Question 15
Incorrect
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A 62-year-old woman presents to her General Practitioner with a history of worsening painless muscle weakness of six months’ duration. She reports difficulty rising from a chair, climbing stairs, and combing her hair. On examination, mild tenderness is noted in her upper arms and thighs. Her thyroid function tests, full blood count, and glycosylated haemoglobin are normal. Serum antinuclear antibodies (ANAs) and rheumatoid factor (RF) are positive, and her creatine kinase (CK) is markedly raised. What is the most likely diagnosis?
Your Answer: Polymyalgia rheumatica
Correct Answer: Polymyositis
Explanation:Autoimmune Conditions: Differentiating Polymyositis from Other Disorders
Polymyositis is an inflammatory myopathy that causes gradual, symmetrical proximal muscle weakness, which is rarely painful. However, other autoimmune conditions can present with similar symptoms, making it important to differentiate between them. Here are some key differences:
Systemic sclerosis: This condition causes abnormal growth of connective tissue, leading to vascular damage and fibrosis. Proximal muscle weakness is not a feature of systemic sclerosis, but patients may experience calcinosis, Raynaud’s phenomenon, oesophageal dysmotility, sclerodactyly, and telangiectasia.
Polymyalgia rheumatica: This inflammatory condition causes bilateral pain and stiffness of proximal muscles, particularly the shoulders and pelvic girdle. However, painless proximal muscle weakness is not typical of polymyalgia rheumatica, and positive RF or ANA are not seen in this condition.
Sjögren syndrome: This autoimmune condition is characterized by lymphocytic infiltration of exocrine glands, leading to dry eyes and dry mouth. While ANAs and RF may be positive in this condition, proximal myopathy is not a feature.
Systemic lupus erythematosus (SLE): This multi-system autoimmune condition usually presents in women of childbearing age with remitting and relapsing symptoms. While ANA antibodies are often positive in SLE, CK is not usually raised, and painless proximal muscle weakness is not typical. The presence of anti-double-stranded deoxyribonucleic acid antibodies or low complement levels are more specific markers of SLE.
In summary, while these autoimmune conditions may share some symptoms, careful evaluation can help differentiate between them and lead to appropriate treatment.
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This question is part of the following fields:
- Musculoskeletal
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Question 16
Incorrect
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A 67-year-old man arrives at the emergency department with a history of severe chest pain, scoring 9 out of 10, that began an hour ago. He is a smoker and is currently taking amlodipine for his hypertension. Following an ECG and troponin testing, he is diagnosed with NSTEMI. Using the GRACE score, his predicted 6-month mortality is 2%, and he is not at high risk of bleeding. However, the nearest primary percutaneous intervention unit is over an hour away. What is the appropriate management plan for this patient?
Your Answer: Aspirin, clopidogrel and fondaparinux
Correct Answer: Aspirin, ticagrelor and fondaparinux
Explanation:Managing Acute Coronary Syndrome: A Summary of NICE Guidelines
Acute coronary syndrome (ACS) is a common and serious medical condition that requires prompt management. The management of ACS has evolved over the years, with the development of new drugs and procedures such as percutaneous coronary intervention (PCI). The National Institute for Health and Care Excellence (NICE) has updated its guidelines on the management of ACS in 2020.
ACS can be classified into three subtypes: ST-elevation myocardial infarction (STEMI), non ST-elevation myocardial infarction (NSTEMI), and unstable angina. The management of ACS depends on the subtype. However, there are common initial drug therapies for all patients with ACS, such as aspirin and nitrates. Oxygen should only be given if the patient has oxygen saturations below 94%, and morphine should only be given for severe pain.
For patients with STEMI, the first step is to assess eligibility for coronary reperfusion therapy, which can be either PCI or fibrinolysis. Patients with NSTEMI/unstable angina require a risk assessment using the Global Registry of Acute Coronary Events (GRACE) tool to determine whether they need coronary angiography (with follow-on PCI if necessary) or conservative management.
This summary provides an overview of the NICE guidelines for managing ACS. The guidelines are complex and depend on individual patient factors, so healthcare professionals should review the full guidelines for further details. Proper management of ACS can improve patient outcomes and reduce the risk of complications.
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This question is part of the following fields:
- Cardiovascular
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Question 17
Correct
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You are having a consultation with a 49-year-old man for his initial diabetes review. Following 3 months of metformin treatment, his HbA1c has shown improvement. Unfortunately, he hasn't been able to make any lifestyle modifications. You are content with the management of his type 2 diabetes mellitus. However, the patient reports experiencing significant gastrointestinal (GI) adverse effects due to metformin.
What would be your approach to managing this patient?Your Answer: Switch to a modified-release formulation of metformin
Explanation:If the patient experiences GI side-effects with metformin, it is recommended to try a modified-release formulation before considering switching to a second-line agent. Modified-release formulations are known to cause fewer GI side-effects compared to other formulations. It is advisable to continue with metformin as it is effective for the patient rather than trying another medication that may not work as well.
Continuing with the same formulation of metformin is not a suitable solution as the patient is experiencing significant GI side-effects. Modified-release formulations can help manage diabetes while reducing these side-effects.
Discontinuing all antidiabetic medications is not recommended as the patient has not made any lifestyle changes and requires medical support to manage their diabetes.
While second-line agents like sulfonylureas may be effective in managing diabetes and reducing GI side-effects, they may not be as effective as metformin and may cause their own set of side-effects. These medications should be considered only when combination therapy is required.
GLP-1 receptor antagonists are effective antidiabetic medications, but they are expensive and inconvenient as they require injection. Therefore, other medications should be tried before considering these.
Metformin is a medication commonly used to treat type 2 diabetes mellitus. It belongs to a class of drugs called biguanides and works by activating the AMP-activated protein kinase (AMPK), which increases insulin sensitivity and reduces hepatic gluconeogenesis. Additionally, it may decrease the absorption of carbohydrates in the gastrointestinal tract. Unlike other diabetes medications, such as sulphonylureas, metformin does not cause hypoglycemia or weight gain, making it a first-line treatment option, especially for overweight patients. It is also used to treat polycystic ovarian syndrome and non-alcoholic fatty liver disease.
While metformin is generally well-tolerated, gastrointestinal side effects such as nausea, anorexia, and diarrhea are common and can be intolerable for some patients. Reduced absorption of vitamin B12 is also a potential side effect, although it rarely causes clinical problems. In rare cases, metformin can cause lactic acidosis, particularly in patients with severe liver disease or renal failure. However, it is important to note that lactic acidosis is now recognized as a rare side effect of metformin.
There are several contraindications to using metformin, including chronic kidney disease, recent myocardial infarction, sepsis, acute kidney injury, severe dehydration, and alcohol abuse. Additionally, metformin should be discontinued before and after procedures involving iodine-containing x-ray contrast media to reduce the risk of contrast nephropathy.
When starting metformin, it is important to titrate the dose slowly to reduce the incidence of gastrointestinal side effects. If patients experience intolerable side effects, modified-release metformin may be considered as an alternative.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 18
Correct
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A 25-year-old male visits a dermatology clinic after being referred by his physician due to a mole that has changed color. When asked, he mentions that he always burns and never tans when exposed to sunlight. He has fair skin and red hair. What is the appropriate Fitzpatrick grade for this skin type?
Your Answer: Fitzpatrick type 1
Explanation:Skin type 1 according to the Fitzpatrick classification is characterized by pale skin with features like blue eyes, red hair, and freckles. Individuals with this skin type always experience burning and never tanning. The classification system ranges from type 1, which is most prone to burning, to type 6, which is Afro-Caribbean skin that never burns.
Skin type is a crucial factor in determining the risk of developing skin cancer. The Fitzpatrick classification system is commonly used to categorize skin types based on their response to UV radiation. This system divides skin types into six categories, ranging from those who always burn and never tan to those who never burn and always tan.
Type I skin is the most sensitive to UV radiation and is characterized by red hair, freckles, and blue eyes. These individuals never tan and always burn when exposed to the sun. Type II skin usually tans but always burns, while Type III skin always tans but may sometimes burn. Type IV skin always tans and rarely burns, and Type V skin burns and tans after extreme UV exposure. Finally, Type VI skin, which is common in individuals of African descent, never tans and never burns.
Understanding your skin type is essential in protecting yourself from skin cancer. Those with fair skin, such as Type I and II, are at a higher risk of developing skin cancer and should take extra precautions when exposed to the sun. On the other hand, those with darker skin, such as Type V and VI, may have a lower risk of skin cancer but should still take measures to protect their skin from UV radiation. By knowing your skin type and taking appropriate precautions, you can reduce your risk of developing skin cancer.
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This question is part of the following fields:
- Dermatology
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Question 19
Incorrect
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A 35-year-old man attends his cousin's bachelor party where they go to a seafood buffet. After consuming eight plates of food, he finally feels full and they head to a nearby bar.
Four hours later, he is at a dart tournament when he suddenly feels sick and starts vomiting uncontrollably. He goes home and the vomiting stops overnight. The next day, he feels better and is relieved that he did not experience any diarrhea.
What is the probable organism responsible for his illness?Your Answer: Escherichia coli
Correct Answer: Staphylococcus aureus
Explanation:Gastroenteritis can occur either at home or while traveling, known as travelers’ diarrhea. This condition is characterized by at least three loose to watery stools in 24 hours, accompanied by abdominal cramps, fever, nausea, vomiting, or blood in the stool. The most common cause of travelers’ diarrhea is Escherichia coli. Acute food poisoning is another pattern of illness that results in sudden onset of nausea, vomiting, and diarrhea after ingesting a toxin. Staphylococcus aureus, Bacillus cereus, or Clostridium perfringens are typically responsible for acute food poisoning.
There are several types of infections that can cause gastroenteritis, each with its own typical presentation. Escherichia coli is common among travelers and causes watery stools, abdominal cramps, and nausea. Giardiasis results in prolonged, non-bloody diarrhea, while cholera causes profuse, watery diarrhea and severe dehydration leading to weight loss. Shigella causes bloody diarrhea, vomiting, and abdominal pain, while Staphylococcus aureus results in severe vomiting with a short incubation period. Campylobacter typically starts with a flu-like prodrome and progresses to crampy abdominal pains, fever, and diarrhea, which may be bloody and mimic appendicitis. Bacillus cereus can cause two types of illness, vomiting within six hours, typically due to rice, or diarrheal illness occurring after six hours. Amoebiasis has a gradual onset of bloody diarrhea, abdominal pain, and tenderness that may last for several weeks.
The incubation period for gastroenteritis varies depending on the type of infection. Staphylococcus aureus and Bacillus cereus have an incubation period of 1-6 hours, while Salmonella and Escherichia coli have an incubation period of 12-48 hours. Shigella and Campylobacter have an incubation period of 48-72 hours, while Giardiasis and Amoebiasis have an incubation period of more than seven days.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 20
Incorrect
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A 57-year-old woman comes to the clinic complaining of a sudden onset of vision loss in her left eye. She reports no pain associated with the loss of vision. The patient explains that the loss of vision began as a dense shadow that started at the edges of her vision and moved towards the centre. She has a history of myopia and wears corrective glasses but has no other significant medical history. What is the probable diagnosis?
Your Answer: Central retinal vein occlusion
Correct Answer: Retinal detachment
Explanation:The sudden painless loss of vision described in the history is most likely caused by retinal detachment. The classic symptom of a dense shadow starting from the periphery and progressing towards the center, along with the patient’s history of myopia, are highly suggestive of this condition. Urgent corrective surgery is necessary to address this issue.
Central retinal artery occlusion is less likely to be the diagnosis as there are no risk factors mentioned for thromboembolism or arteritis. Similarly, central retinal vein occlusion is a possibility but given the lack of risk factors and the patient’s history, retinal detachment is still the more likely cause.
It is important to note that vitreous detachment is not a direct cause of vision loss, although it may precede retinal detachment. Its symptoms typically involve floaters or flashes of light that do not usually interfere with daily activities.
Sudden loss of vision can be a scary symptom for patients, as it may indicate a serious issue or only be temporary. Transient monocular visual loss (TMVL) is a term used to describe a sudden, brief loss of vision that lasts less than 24 hours. The most common causes of sudden, painless loss of vision include ischaemic/vascular issues (such as thrombosis, embolism, and temporal arteritis), vitreous haemorrhage, retinal detachment, and retinal migraine.
Ischaemic/vascular issues, also known as ‘amaurosis fugax’, have a wide range of potential causes, including large artery disease, small artery occlusive disease, venous disease, and hypoperfusion. Altitudinal field defects are often seen, and ischaemic optic neuropathy can occur due to occlusion of the short posterior ciliary arteries. Central retinal vein occlusion is more common than arterial occlusion and can be caused by glaucoma, polycythaemia, or hypertension. Central retinal artery occlusion is typically caused by thromboembolism or arteritis and may present with an afferent pupillary defect and a ‘cherry red’ spot on a pale retina.
Vitreous haemorrhage can be caused by diabetes, bleeding disorders, or anticoagulants and may present with sudden visual loss and dark spots. Retinal detachment may be preceded by flashes of light or floaters, which are also common in posterior vitreous detachment. Differentiating between posterior vitreous detachment, retinal detachment, and vitreous haemorrhage can be challenging, but each has distinct features such as photopsia and floaters for posterior vitreous detachment, a dense shadow that progresses towards central vision for retinal detachment, and large bleeds causing sudden visual loss for vitreous haemorrhage.
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This question is part of the following fields:
- Ophthalmology
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Question 21
Correct
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A 6-month-old infant is brought to his General Practitioner by his concerned mother. He has been crying after every feed for several weeks and regurgitating milk. He has also been failing to gain weight.
Which of the following is the most likely diagnosis?Your Answer: Gastro-oesophageal reflux disease (GORD)
Explanation:The child’s symptoms suggest that they may have gastro-oesophageal reflux disease (GORD), which is characterized by regurgitation of milk after feeds and crying due to abdominal pain. This can lead to failure to gain weight or even weight loss. Infantile colic is less likely as it would not cause these symptoms. Intussusception, a condition where part of the bowel invaginates into another, causing colicky abdominal pain, vomiting, and passing of redcurrant stools, requires immediate hospitalization. Pyloric stenosis, which presents with projectile vomiting, dehydration, and faltering growth, is less likely as the child does not have projectile vomiting. Volvulus, a complete twisting of an intestinal loop, could present with bilious vomiting, signs of shock, peritonitis, and blood per rectum, and typically occurs in the first year of life.
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This question is part of the following fields:
- Paediatrics
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Question 22
Correct
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As a junior doctor in an inpatient psychiatric unit, you have assessed a 25-year-old patient who has recently been diagnosed with paranoid schizophrenia. Your consultant has initiated treatment with olanzapine and baseline blood tests have been conducted. According to NICE guidelines, what further investigation is recommended for this patient?
Your Answer: ECG
Explanation:Patients starting antipsychotic medications should have a baseline ECG, along with weight, waist circumference, pulse and BP measurements, blood tests (including fasting glucose, HbA1c, lipids and prolactin), assessment of movement disorders and nutritional status. An ECG may also be necessary if the medication’s summary of product characteristics recommends it, if the patient has a high risk of cardiovascular disease, has a personal history of cardiovascular disease, or is being admitted as an inpatient. As olanzapine is a second-generation antipsychotic that can cause QT prolongation, an ECG is particularly important for this patient because she is currently hospitalized.
Monitoring patients who are taking antipsychotic medication is a crucial aspect of their treatment. In addition to regular clinical follow-ups, extensive monitoring is required to ensure the safety and effectiveness of the medication. The British National Formulary (BNF) recommends a range of tests and assessments to be carried out at various intervals. At the start of therapy, a full blood count (FBC), urea and electrolytes (U&E), and liver function tests (LFT) should be conducted. Clozapine, in particular, requires more frequent monitoring of FBC, initially on a weekly basis. Lipids and weight should be measured at the start of therapy, after three months, and annually thereafter. Fasting blood glucose and prolactin levels should be checked at the start of therapy, after six months, and annually thereafter. Blood pressure should be measured at baseline and frequently during dose titration. An electrocardiogram should be conducted at baseline, and cardiovascular risk assessment should be carried out annually. For more detailed information, please refer to the BNF, which also provides specific recommendations for individual drugs.
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This question is part of the following fields:
- Psychiatry
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Question 23
Correct
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A 32-year-old female with rheumatoid arthritis visits her GP for advice on starting a family. She and her partner are eager to conceive and she has been taking folic acid for the past four weeks. The patient has no other medical history and is currently taking methotrexate, paracetamol, ibuprofen, and lansoprazole. She is aware that her sister had to stop some of her rheumatoid arthritis medications before getting pregnant and wants to know if she needs to do the same.
What is the appropriate management advice for this patient?Your Answer: Stop methotrexate at least six months before conception
Explanation:When it comes to methotrexate, it is important to discontinue the drug at least six months before attempting to conceive, regardless of gender. This is because methotrexate can potentially harm sperm in males and cause early abortion in females. By allowing for a full wash-out period, the risk of DNA changes in both gametes can be minimized. While some studies suggest that paternal exposure to methotrexate within 90 days before pregnancy may not lead to congenital malformations, stillbirths, or preterm births, current guidelines recommend avoiding the drug for six months to ensure proper folic acid repletion. Therefore, options suggesting stopping methotrexate for only one or three months before conception are incorrect.
Managing Rheumatoid Arthritis During Pregnancy
Rheumatoid arthritis (RA) is a condition that commonly affects women of reproductive age, making issues surrounding conception and pregnancy a concern. While there are no official guidelines for managing RA during pregnancy, expert reviews suggest that patients with early or poorly controlled RA should wait until their disease is more stable before attempting to conceive.
During pregnancy, RA symptoms tend to improve for most patients, but only a small minority experience complete resolution. After delivery, patients often experience a flare-up of symptoms. It’s important to note that certain medications used to treat RA are not safe during pregnancy, such as methotrexate and leflunomide. However, sulfasalazine and hydroxychloroquine are considered safe.
Interestingly, studies have shown that the use of TNF-α blockers during pregnancy does not significantly increase adverse outcomes. However, many patients in these studies stopped taking the medication once they found out they were pregnant. Low-dose corticosteroids may also be used to control symptoms during pregnancy.
NSAIDs can be used until 32 weeks, but should be withdrawn after that due to the risk of early closure of the ductus arteriosus. Patients with RA should also be referred to an obstetric anaesthetist due to the risk of atlanto-axial subluxation. Overall, managing RA during pregnancy requires careful consideration and consultation with healthcare professionals.
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This question is part of the following fields:
- Reproductive Medicine
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Question 24
Correct
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A 16-year-old female from Nigeria comes to the clinic with a swelling near her earlobe. She had her ears pierced three months ago and has noticed a gradual development of an erythematous swelling. Upon examination, a keloid scar is observed. What is the best course of action for management?
Your Answer: Refer for intralesional triamcinolone
Explanation:Understanding Keloid Scars
Keloid scars are abnormal growths that develop from the connective tissue of a scar and extend beyond the boundaries of the original wound. They are more common in people with dark skin and tend to occur in young adults. Keloids are most frequently found on the sternum, shoulder, neck, face, extensor surface of limbs, and trunk.
To prevent keloid scars, incisions should be made along relaxed skin tension lines. However, if keloids do develop, early treatment with intra-lesional steroids such as triamcinolone may be effective. In some cases, excision may be necessary, but this should be approached with caution as it can potentially lead to further keloid scarring.
It is important to note that the historical use of Langer lines to determine optimal incision lines has been shown to produce worse cosmetic results than following skin tension lines. Understanding the predisposing factors and treatment options for keloid scars can help individuals make informed decisions about their care.
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This question is part of the following fields:
- Dermatology
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Question 25
Incorrect
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A 63-year-old woman who is undergoing treatment for bladder cancer presents to the Emergency Department because she has noticed that the urine in her catheter is blood-stained.
On examination, the urine is pink in colour. Her observations are normal.
What would be the next most appropriate step in this patient’s management?
Select the SINGLE most likely option.
Your Answer: Flush the urinary catheter using normal saline
Correct Answer: Arrange a full blood count
Explanation:Management of a Patient with Suspected Bladder Tumour and Bleeding
When managing a patient with suspected bladder tumour and bleeding, it is important to consider the appropriate steps to take. Here are some options and their potential outcomes:
1. Arrange a full blood count: This test can help assess the degree of blood loss and guide the urgency of treatment.
2. Transfuse two units of O-negative blood: While patients with bladder tumours can bleed extensively, it is important to first assess the need for transfusion through a full blood count.
3. Flush the urinary catheter using normal saline: This step is appropriate for a blocked catheter, but not for a patient with active bleeding.
4. Remove the urinary catheter: This step can cause blood clots and urinary retention, and is not indicated for this patient.
5. Transfer to theatre for resection of tumour: While this may be necessary in cases of catastrophic bleeding, it is important to first assess the patient’s stability and obtain blood tests before planning definitive management.
In summary, careful consideration of the appropriate steps is crucial in managing a patient with suspected bladder tumour and bleeding.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 26
Correct
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A 35-year-old woman presents for review at her local general practice surgery. She has noticed a number of patches of pale skin on her hands over the past few weeks. The patient has tried using emollients and topical clotrimazole with no result.
On examination, a number of depigmented patches on the dorsum of both hands are noted. Her past medical history includes thyrotoxicosis for which she takes carbimazole and thyroxine.
Given the likely diagnosis, which of the following is most appropriate before starting treatment?
Select the SINGLE best option from the list below.
Select ONE option only.Your Answer: No further testing required
Explanation:Understanding Vitiligo: Diagnosis and Testing
Vitiligo is an autoimmune condition that causes depigmentation of the skin due to the loss of melanocytes. It is usually diagnosed based on clinical features, such as well-demarcated patches of depigmented skin. While there are no specific diagnostic tests for vitiligo, a punch biopsy may be used to obtain a skin sample for histological analysis in cases of suspected skin cancer or inflammatory skin disease. However, skin patch testing and skin prick testing are not useful in diagnosing vitiligo.
It is important to note that vitiligo is commonly associated with other autoimmune conditions, such as type I diabetes mellitus, Addison’s disease, thyroid disorders, pernicious anemia, and alopecia areata. While it can affect individuals of any age, it often arises before the age of 20 years and is equally prevalent in men and women. Itching and other symptoms are rare, and the changes may be more noticeable in individuals with light skin during the summer months.
In contrast, a radioallergosorbent test (RAST) is unsuitable for diagnosing vitiligo as it is used to determine the amount of immunoglobulin E (IgE) that reacts with suspected or known allergens. RAST is useful for diagnosing food allergies, inhaled allergens, and venom allergies. Blood tests may be used when skin prick tests are not suitable, such as when the patient is taking antihistamines or has extensive eczema.
In summary, vitiligo is a clinical diagnosis that does not require further testing. While a punch biopsy may be used in certain cases, skin patch testing and skin prick testing are not useful in diagnosing vitiligo. It is important to be aware of the potential association with other autoimmune conditions and to monitor for any changes in skin pigmentation.
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This question is part of the following fields:
- Dermatology
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Question 27
Incorrect
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A 72-year-old man is being investigated for unexplained weight loss. He reports experiencing abdominal pain, dyspepsia, and nausea. He has a history of pernicious anaemia. What is the probable diagnosis based on these symptoms?
Your Answer: Pancreatic cancer
Correct Answer: Stomach cancer
Explanation:Dyspepsia, abdominal pain, nausea, and anorexia are among the early signs of stomach cancer. This type of cancer is uncommon and is more likely to occur in individuals over the age of 50, particularly those with pernicious anemia. Pancreatic cancer is linked to the onset of diabetes. Bone pain is a typical symptom of myeloma. Recurrent infections, bleeding, and bruising are common symptoms of acute leukemia.
Management of Dyspepsia and Referral for Possible Cancer
Dyspepsia is a common symptom that can be caused by various factors, including medication and lifestyle choices. However, it can also be a sign of underlying conditions such as stomach or oesophageal cancer. The 2015 NICE guidelines provide updated advice on when urgent referral for endoscopy is necessary. Patients with dysphagia or an upper abdominal mass consistent with stomach cancer should be referred urgently. Patients aged 55 years or older with weight loss and upper abdominal pain, reflux, or dyspepsia should also be referred urgently. Non-urgent referrals include patients with haematemesis or those with treatment-resistant dyspepsia, upper abdominal pain with low haemoglobin levels, or raised platelet count with other symptoms.
For patients with undiagnosed dyspepsia, a step-wise approach is recommended. First, medications should be reviewed for possible causes. Lifestyle advice should also be given. If symptoms persist, a trial of full-dose proton pump inhibitor for one month or a ‘test and treat’ approach for H. pylori can be tried. If symptoms persist after either approach, the alternative should be attempted. Testing for H. pylori infection can be done using a carbon-13 urea breath test, stool antigen test, or laboratory-based serology. If symptoms resolve following test and treat, there is no need to check for H. pylori eradication. However, if repeat testing is required, a carbon-13 urea breath test should be used.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 28
Incorrect
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A 32-year-old woman who is 8 weeks pregnant is curious about the anomaly scan after hearing about a friend's experience. She wants to know the earliest possible time she can have the scan.
When can the anomaly scan be done at the earliest?Your Answer: 11 weeks
Correct Answer: 18 weeks
Explanation:The earliest possible time for an anomaly scan is at 18 weeks, with the latest being at 20 weeks and 6 days. For a dating scan, the earliest possible time is at 8 weeks. As for a nuchal scan, it can be done at the earliest at 11 weeks.
NICE guidelines recommend 10 antenatal visits for first pregnancies and 7 for subsequent pregnancies if uncomplicated. The purpose of each visit is outlined, including booking visits, scans, screening for Down’s syndrome, routine care for blood pressure and urine, and discussions about labour and birth plans. Rhesus negative women are offered anti-D prophylaxis at 28 and 34 weeks. The guidelines also recommend discussing options for prolonged pregnancy at 41 weeks.
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This question is part of the following fields:
- Reproductive Medicine
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Question 29
Correct
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A 35-year-old woman is experiencing heavy menstrual bleeding but refuses an intrauterine system due to negative mood effects from hormonal therapies in the past. What alternative treatment should be considered?
Your Answer: Tranexamic acid or NSAID
Explanation:If the woman does not approve of hormonal treatments, alternatives such as tranexamic acid or NSAIDs can be utilized according to NICE CG44.
Managing Heavy Menstrual Bleeding
Heavy menstrual bleeding, also known as menorrhagia, is a condition where a woman experiences excessive blood loss during her menstrual cycle. While it was previously defined as total blood loss of over 80 ml per cycle, the management of menorrhagia now depends on the woman’s perception of what is excessive. In the past, hysterectomy was a common treatment for heavy periods, but the approach has changed significantly since the 1990s.
To manage menorrhagia, a full blood count should be performed in all women. If symptoms suggest a structural or histological abnormality, a routine transvaginal ultrasound scan should be arranged. For women who do not require contraception, mefenamic acid or tranexamic acid can be used. If there is no improvement, other drugs can be tried while awaiting referral.
For women who require contraception, options include the intrauterine system (Mirena), combined oral contraceptive pill, and long-acting progestogens. Norethisterone can also be used as a short-term option to rapidly stop heavy menstrual bleeding. The flowchart below shows the management of menorrhagia.
[Insert flowchart here]
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This question is part of the following fields:
- Reproductive Medicine
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Question 30
Incorrect
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A 65-year-old man visits his GP for a medication review. He has been diagnosed with stable congestive heart failure. As you review his repeat prescriptions, you consider his new diagnosis. The patient has type 2 diabetes mellitus, osteoarthritis, and erectile dysfunction. What is the most crucial medication to avoid in patients with chronic heart failure among his current medications?
Your Answer: Gliclazide
Correct Answer: Diclofenac
Explanation:Patients with heart failure should exercise caution when using NSAIDs as they have the potential to worsen the condition by causing fluid retention, particularly diclofenac.
Medications to Avoid in Patients with Heart Failure
Heart failure is a serious condition that requires careful management of medications. Some medications can exacerbate heart failure and should be avoided. Thiazolidinediones, such as pioglitazone, are contraindicated as they cause fluid retention. Verapamil has a negative inotropic effect and should be used with caution. NSAIDs and glucocorticoids can also cause fluid retention and should be used with caution. However, low-dose aspirin is an exception as many patients with heart failure also have coexistent cardiovascular disease and the benefits of taking aspirin easily outweigh the risks. Class I antiarrhythmics, such as flecainide, have a negative inotropic and proarrhythmic effect and should be avoided. It is important for healthcare providers to be aware of these medications and to carefully consider their use in patients with heart failure.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 31
Incorrect
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An 80-year-old man is receiving treatment at the Haematology Clinic for multiple myeloma (MM). He is a newly diagnosed non-transplant candidate.
Various blood tests are being conducted to monitor response to treatment and determine prognosis.
What is considered the most crucial factor for predicting survival and prognosis?Your Answer: Lactate dehydrogenase (LDH)
Correct Answer: Beta-2 microglobulin
Explanation:Prognostic Factors in Multiple Myeloma
Multiple myeloma is a type of cancer that affects plasma cells in the bone marrow. Prognostic factors are important in determining the severity of the disease and predicting survival rates. Here are some key factors to consider:
Beta-2 microglobulin: This protein is found on the surface of all nucleated cells and is associated with the human leukocyte antigen (HLA)–histocompatibility complex. Elevated levels of serum beta-2 microglobulin are linked to poor prognosis in multiple myeloma patients.
Serum creatinine: High levels of creatinine indicate renal impairment, which is common in multiple myeloma patients and is associated with a poor prognosis.
Albumin: Low levels of albumin are related to the extent of myeloma proliferation and are therefore of diagnostic and prognostic importance. An albumin level of 29.0 g/l or less is a sign of advanced disease.
C-Reactive protein (CRP): Elevated CRP levels before autologous stem-cell transplantation (ASCT) are associated with worse overall survival in multiple myeloma patients, especially those who had a transplant more than 12 months after diagnosis.
Lactate dehydrogenase (LDH): High LDH levels at the time of diagnosis are a marker of poor prognosis in multiple myeloma patients. Increased LDH is associated with worse overall survival, progression-free survival, aggressive disease, and high tumor burden.
Understanding these prognostic factors can help healthcare providers make informed decisions about treatment options and provide patients with more accurate information about their disease.
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This question is part of the following fields:
- Haematology/Oncology
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Question 32
Correct
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A mother who refused regular prenatal check-ups delivers a male infant. During delivery, a defect is observed on the side of the belly button, revealing the intestines.
What could be the possible diagnosis?Your Answer: Gastroschisis
Explanation:Gastroschisis is a bowel condition where the intestines are exposed and not encased by a sac. It is not associated with cardiac and kidney diseases, unlike exomphalos. It can be diagnosed through routine ultrasound, but may be missed if the mother does not engage in antenatal care. It is not a normal variant and is not necessarily associated with prematurity.
Gastroschisis and exomphalos are both types of congenital visceral malformations. Gastroschisis refers to a defect in the anterior abdominal wall located just beside the umbilical cord. In contrast, exomphalos, also known as omphalocoele, involves the protrusion of abdominal contents through the anterior abdominal wall, which are covered by an amniotic sac formed by amniotic membrane and peritoneum.
When it comes to managing gastroschisis, vaginal delivery may be attempted, but newborns should be taken to the operating theatre as soon as possible after delivery, ideally within four hours. As for exomphalos, a caesarean section is recommended to reduce the risk of sac rupture. In cases where primary closure is difficult due to lack of space or high intra-abdominal pressure, a staged repair may be undertaken. This involves allowing the sac to granulate and epithelialise over several weeks or months, forming a shell. As the infant grows, the sac contents will eventually fit within the abdominal cavity, at which point the shell can be removed and the abdomen closed.
Overall, both gastroschisis and exomphalos require careful management to ensure the best possible outcome for the newborn. By understanding the differences between these two conditions and the appropriate steps to take, healthcare professionals can provide effective care and support to both the infant and their family.
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This question is part of the following fields:
- Paediatrics
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Question 33
Incorrect
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An 85-year-old woman presents with a history of falls. She has a medical history of osteoporosis, constipation, frequent urinary tract infections, ischaemic heart disease, and urge incontinence. Upon conducting a comprehensive assessment, you determine that her falls are likely due to a combination of physical frailty, poor balance, and medication burden. Which medication should be discontinued first?
Your Answer: Alendronic acid
Correct Answer: Oxybutynin
Explanation:To avoid the risk of falls, it is not recommended to administer oxybutynin to frail elderly individuals. Instead, safer alternatives such as solifenacin and tolterodine should be considered. Mirabegron, a newer medication, may also be a viable option as it is believed to have fewer anti-cholinergic side effects. Discontinuing laxatives may not be helpful if the patient is still experiencing constipation. However, prescribing alendronic acid for osteoporosis and aspirin for ischaemic heart disease is appropriate given the patient’s medical history and risk of falls. While the use of trimethoprim as long-term prophylaxis for urinary tract infections is controversial, it should not be the first intervention to be discontinued.
Understanding Urinary Incontinence: Causes, Classification, and Management
Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.
Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.
In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 34
Incorrect
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Samantha, a 56-year-old teacher, visits you for a check-up regarding her angina. Despite taking the highest dosage of bisoprolol, she experiences chest pain during physical activity, which hinders her daily routine as she frequently needs to take breaks and rest after walking short distances. Her pain never occurs while at rest, and she has no known allergies or drug sensitivities. What is the recommended course of action for managing Samantha's condition?
Your Answer: Admit to the emergency department
Correct Answer: Add amlodipine
Explanation:According to NICE guidelines (2019), if a beta-blocker is not effectively controlling angina, a long-acting dihydropyridine calcium-channel blocker (CCB) like amlodipine should be added. It is important to ensure that the patient is taking the highest tolerated dose of their current medications before adding new ones.
Ramipril is not the best treatment option for this patient as there is no evidence of hypertension in their medical history. While ACE inhibitors like ramipril can be effective in preventing myocardial infarction and stroke in patients with angina and hypertension, they are not indicated in this case.
Verapamil is a CCB that can be used to manage angina, but it should not be used in combination with a beta-blocker as this can increase the risk of severe bradycardia and heart failure.
As the patient is not displaying any signs of unstable angina, such as pain at rest or rapidly progressing symptoms, admission to the emergency department is not necessary.
If there is evidence of extensive ischaemia on an electrocardiograph (ECG) or the patient is not responding well to an optimised drug treatment, referral to cardiology for angioplasty may be necessary.
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 35
Incorrect
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A 45-year-old woman develops a deep vein thrombosis (DVT) during the second trimester of pregnancy.
Which of the following treatments is she likely to be managed with?
Your Answer: Unfractionated heparin
Correct Answer: Low-molecular-weight heparin (eg. Clexane®)
Explanation:Anticoagulant Therapy for Deep Vein Thrombosis in Pregnancy
Deep vein thrombosis (DVT) is a serious condition that can occur during pregnancy. Any woman with symptoms or signs suggestive of DVT should undergo objective testing and receive treatment with low-molecular-weight heparin (LMWH) immediately until the diagnosis is excluded. LMWH should be given in doses titrated against the woman’s weight and can be administered once daily or in two divided doses. It does not cross the placenta and has a lower risk of bleeding and heparin-induced osteoporosis compared to unfractionated heparin (UH). Fondaparinux, argatroban, or r-hirudin may be considered for pregnant women who cannot tolerate heparin.
Aspirin is not recommended for thromboprophylaxis in obstetric patients, except for pregnant women with a known history of antiphospholipid syndrome. Intravenous UH is the preferred initial treatment for massive pulmonary embolism with cardiovascular compromise during pregnancy and the puerperium. Warfarin should not be used for antenatal DVT treatment due to its adverse effects on the fetus. Postnatal therapy can be with LMWH or oral anticoagulants, but regular blood tests are needed to monitor warfarin.
Compression duplex ultrasonography should be performed when there is clinical suspicion of DVT. D-dimer testing should not be used in the investigation of acute DVT in pregnancy. Before anticoagulant therapy is started, blood tests should be taken for a full blood count, coagulation screen, urea and electrolytes, and liver function tests. Thrombophilia screening before therapy is not recommended.
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This question is part of the following fields:
- Reproductive Medicine
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Question 36
Correct
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An 83-year-old man who resides in a nursing home arrives at the Emergency Department with symptoms of diarrhoea and vomiting. He has been experiencing 8 watery bowel movements per day for the past 3 days and seems disoriented and dehydrated. The patient has a medical history of atrial fibrillation, type II diabetes, and dementia. His heart rate is elevated at 110/min, and his electrocardiogram displays noticeable U waves. What is the probable reason for his ECG alterations?
Your Answer: Hypokalaemia
Explanation:The ECG changes observed in this scenario are most likely due to hypokalaemia. The patient’s electrolyte balance has been disrupted by vomiting and loose stools, resulting in a depletion of potassium that should be rectified through intravenous replacement. While hypocalcaemia and hypothermia can also cause U waves, they are less probable in this case. Non-ischaemic ST elevation changes may be caused by hyponatraemia. QT prolongation is a common effect of tricyclic antidepressant toxicity.
ECG Features of Hypokalaemia
Hypokalaemia is a condition characterized by low levels of potassium in the blood. This condition can be detected through an electrocardiogram (ECG) which shows specific features. The ECG features of hypokalaemia include U waves, small or absent T waves, prolonged PR interval, ST depression, and long QT. The U waves are particularly noticeable and are accompanied by a borderline PR interval.
To remember these features, one registered user suggests the following rhyme: In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT. It is important to detect hypokalaemia early as it can lead to serious complications such as cardiac arrhythmias and even cardiac arrest. Therefore, regular monitoring of potassium levels and ECGs is crucial for individuals at risk of hypokalaemia.
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This question is part of the following fields:
- Cardiovascular
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Question 37
Correct
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A 10-year-old girl presents to the Emergency Department after suffering a head injury falling from a tree. She has remained conscious and her Glasgow Coma Score (GCS) has been 15 since the accident. She is not vomiting.
On examination, there is no focal neurological deficit. An area of bruising is seen behind her left ear and she has a headache. No other injuries are observed.
What is the most appropriate initial investigation for this patient?Your Answer: Computed tomography (CT) head
Explanation:The patient requires a CT head scan within an hour of the accident, as per NICE guidelines. A basal skull fracture, which can be fatal, may be caused by high-impact mechanisms and can present with symptoms such as bruising behind the ear, bruising around the eyes, blood behind the eardrum, or cerebral spinal fluid rhinorrhoea. Optic-nerve entrapment may also occur if the fracture is displaced, leading to changes in vision. Patients are at an increased risk of developing meningitis. An MRI head is not the primary investigation of choice for acute clinically important brain injuries due to safety, logistic, and resource reasons. A lateral cervical spine X-ray may be required for a thorough assessment of the C-spine, but a CT head and neck would be easier to perform if imaging of the neck is necessary. A plain skull X-ray may be used for non-accidental brain injury in children to avoid high-dose radiation from a CT scan, but it should not be used to diagnose brain trauma without consulting a neuroscience unit. If red flags are present, a CT head is necessary to exclude severe intracranial pathology.
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This question is part of the following fields:
- Paediatrics
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Question 38
Incorrect
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A 9-year-old girl comes to the GP with her father. Her father explains that she is still experiencing bed-wetting almost every night. She has undergone thorough investigations in the past year for this issue and has no physical abnormalities to explain her enuresis. She is otherwise healthy and active.
Her father has attempted to limit her fluid intake before bedtime, encourage regular and timely toileting, and wake her up during the night, but none of these methods have been successful.
What is the most appropriate course of action to manage her enuresis?Your Answer: Trial desmopressin
Correct Answer: Enuresis alarm
Explanation:Withholding fluids for 2 hours before bedtime is not recommended as part of enuresis management. While limiting fluid intake throughout the day and before bedtime, especially caffeinated drinks, is advised, completely withholding fluids is not recommended. Referring the patient for sleep studies is not the most appropriate management at this stage, although other conditions that can worsen enuresis, such as sleep-disordered breathing, should be considered. Desmopressin, an analogue of anti-diuretic hormone (ADH), is not indicated at this stage and is only used when general advice and enuresis alarm have failed. The primary goal of management is to achieve dry nights at follow-up.
Nocturnal enuresis, or bedwetting, is when a child involuntarily urinates during the night. Most children achieve continence by the age of 3 or 4, so enuresis is defined as the involuntary discharge of urine in a child aged 5 or older without any underlying medical conditions. Enuresis can be primary, meaning the child has never achieved continence, or secondary, meaning the child has been dry for at least 6 months before.
When managing bedwetting, it’s important to look for any underlying causes or triggers, such as constipation, diabetes mellitus, or recent onset UTIs. General advice includes monitoring fluid intake and encouraging regular toileting patterns, such as emptying the bladder before sleep. Reward systems, like star charts, can also be helpful, but should be given for agreed behavior rather than dry nights.
The first-line treatment for bedwetting is an enuresis alarm, which has a high success rate. These alarms have sensor pads that detect wetness and wake the child up to use the toilet. If short-term control is needed, such as for sleepovers, or if the alarm is ineffective or not acceptable to the family, desmopressin may be prescribed. Overall, managing bedwetting involves identifying any underlying causes and implementing strategies to promote continence.
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This question is part of the following fields:
- Paediatrics
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Question 39
Correct
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A 28-year-old woman is seeking screening for sexually transmitted infections due to starting a new relationship. What is the most frequently diagnosed sexually transmitted infection in the UK?
Your Answer: Chlamydia
Explanation:Chlamydia is a common sexually transmitted infection caused by Chlamydia trachomatis. It is prevalent in the UK, with approximately 1 in 10 young women affected. The incubation period is around 7-21 days, but many cases are asymptomatic. Symptoms in women include cervicitis, discharge, and bleeding, while men may experience urethral discharge and dysuria. Complications can include epididymitis, pelvic inflammatory disease, and infertility.
Traditional cell culture is no longer widely used for diagnosis, with nuclear acid amplification tests (NAATs) being the preferred method. Testing can be done using urine, vulvovaginal swab, or cervical swab. Screening is recommended for sexually active individuals aged 15-24 years, and opportunistic testing is common.
Doxycycline is the first-line treatment for Chlamydia, with azithromycin as an alternative if doxycycline is contraindicated or not tolerated. Pregnant women may be treated with azithromycin, erythromycin, or amoxicillin. Patients diagnosed with Chlamydia should be offered partner notification services, with all contacts since the onset of symptoms or within the last six months being notified and offered treatment.
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This question is part of the following fields:
- Infectious Diseases
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Question 40
Incorrect
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Sophie, 16, has come to her doctor's office to ask for the combined oral contraceptive pill (COCP). As per the guidelines of the Faculty of Sexual and Reproductive Healthcare (FSRH), what is an absolute contraindication for the COCP?
Your Answer: First degree relative with venous thromboembolism aged 25
Correct Answer: Migraine with aura
Explanation:The FSRH uses a scale of 1 to 4 to categorize risk factors for contraceptive methods. A rating of 1 indicates no restrictions on use, while a rating of 4 indicates a condition that poses an unacceptable risk if the contraceptive method is used. Migraine with aura is the only absolute contraindication among the answer options. Ratings of 2 and 3 indicate that the advantages and risks of the contraceptive method should be carefully considered and evaluated by a clinical expert.
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 41
Correct
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A 47-year-old heavy smoker presents with a persistent cough and occasional wheezing. The chest radiograph reveals hyperinflation but clear lung fields.
What is the next step to assist in making a diagnosis?Your Answer: Spirometry
Explanation:Spirometry: The Best Diagnostic Tool for COPD
Chronic obstructive pulmonary disease (COPD) is a common respiratory condition that can significantly impact a patient’s quality of life. To diagnose COPD, spirometry is the best diagnostic tool. According to NICE guidelines, a diagnosis of COPD should be made based on symptoms and signs, but supported by spirometry results. Post-bronchodilator spirometry should be performed to confirm the diagnosis. Airflow obstruction is confirmed by a forced expiratory volume in 1 s (FEV1):forced vital capacity (FVC) ratio of <0.7 and FEV1 <80% predicted. Other diagnostic tools, such as CT of the chest, serial peak flow readings, and trials of beclomethasone or salbutamol, may have a role in the management of COPD, but they are not used in the diagnosis of the condition. CT of the chest may be used to investigate symptoms that seem disproportionate to the spirometric impairment, to investigate abnormalities seen on a chest radiograph, or to assess suitability for surgery. Serial peak flow readings may be appropriate if there is some doubt about the diagnosis, in order to exclude asthma. Inhaled corticosteroids and short-acting beta agonists may be used in the management of COPD for breathlessness/exercise limitation, but they are not used in the diagnosis of COPD. In summary, spirometry is the best diagnostic tool for COPD, and other diagnostic tools may have a role in the management of the condition.
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This question is part of the following fields:
- Respiratory Medicine
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Question 42
Correct
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A 19-year-old young woman is enjoying a meal at a Chinese restaurant to celebrate her birthday. Despite having a nut allergy, the restaurant has taken precautions to ensure her safety. However, while trying a friend's chicken dish, she unknowingly ingested peanuts and experiences a severe allergic reaction, including difficulty breathing and facial swelling. Thankfully, her friend has an EpiPen® and administers it before calling for an ambulance. Although her symptoms improve, she remains unwell and struggling to breathe. Her friend remembers that a second EpiPen® can be used if necessary. When is it appropriate to administer the second dose of adrenaline?
Your Answer: 5 minutes
Explanation:Adrenaline can be administered every 5 minutes in the management of anaphylaxis. It is recommended that individuals with a history of anaphylaxis carry two auto-injectors with them in case a second dose is needed.
Anaphylaxis is a severe and potentially life-threatening allergic reaction that affects the entire body. It can be caused by various triggers, including food, drugs, and insect venom. The symptoms of anaphylaxis typically occur suddenly and progress rapidly, affecting the airway, breathing, and circulation. Common signs include swelling of the throat and tongue, hoarse voice, respiratory wheeze, dyspnea, hypotension, and tachycardia. In addition, around 80-90% of patients experience skin and mucosal changes, such as generalized pruritus, erythematous rash, or urticaria.
The management of anaphylaxis requires prompt and decisive action, as it is a medical emergency. The Resuscitation Council guidelines recommend intramuscular adrenaline as the most important drug for treating anaphylaxis. The recommended doses of adrenaline vary depending on the patient’s age, ranging from 100-150 micrograms for infants under 6 months to 500 micrograms for adults and children over 12 years. Adrenaline can be repeated every 5 minutes if necessary, and the best site for injection is the anterolateral aspect of the middle third of the thigh. In cases of refractory anaphylaxis, IV fluids and expert help should be sought.
Following stabilisation, patients may be given non-sedating oral antihistamines to manage persisting skin symptoms. It is important to refer all patients with a new diagnosis of anaphylaxis to a specialist allergy clinic and provide them with an adrenaline injector as an interim measure before the specialist assessment. Patients should also be prescribed two adrenaline auto-injectors and trained on how to use them. A risk-stratified approach to discharge should be taken, as biphasic reactions can occur in up to 20% of patients. The Resus Council UK recommends a fast-track discharge for patients who have had a good response to a single dose of adrenaline and complete resolution of symptoms, while those who require two doses of IM adrenaline or have a history of biphasic reaction should be observed for at least 12 hours following symptom resolution.
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This question is part of the following fields:
- Immunology/Allergy
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Question 43
Correct
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A 10-year-old boy presents to you with his mother, reporting pain in his left hip. He is typically healthy, but he recently saw another doctor for a viral upper respiratory tract infection. The pain began two days ago, and he is hesitant to put weight on his left leg.
What is the probable underlying condition?Your Answer: Transient synovitis of the hip
Explanation:A possible diagnosis for a child experiencing hip pain, limp, and a recent infection could be transient synovitis.
Transient synovitis, also known as irritable hip, is a common cause of hip pain in children aged 3-8 years. It typically occurs following a recent viral infection and presents with symptoms such as groin or hip pain, limping or refusal to weight bear, and occasionally a low-grade fever. However, a high fever may indicate other serious conditions such as septic arthritis, which requires urgent specialist assessment. To exclude such diagnoses, NICE Clinical Knowledge Summaries recommend monitoring children in primary care with a presumptive diagnosis of transient synovitis, provided they are aged 3-9 years, well, afebrile, mobile but limping, and have had symptoms for less than 72 hours. Treatment for transient synovitis involves rest and analgesia, as the condition is self-limiting.
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This question is part of the following fields:
- Paediatrics
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Question 44
Incorrect
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Which of the following outcomes confirms a diagnosis of diabetes mellitus?
Your Answer: Glycosuria +++
Correct Answer: Symptomatic patient with random glucose 12.0 mmol/L on one occasion
Explanation:To diagnose diabetes mellitus, fasting blood glucose levels should be above 7.0 or random blood glucose levels should be above 11.1. If the patient is asymptomatic, two readings are required for confirmation.
Type 2 diabetes mellitus can be diagnosed through a plasma glucose or HbA1c sample. The diagnostic criteria vary depending on whether the patient is experiencing symptoms or not. If the patient is symptomatic, a fasting glucose level of 7.0 mmol/l or higher or a random glucose level of 11.1 mmol/l or higher (or after a 75g oral glucose tolerance test) indicates diabetes. If the patient is asymptomatic, the same criteria apply but must be demonstrated on two separate occasions.
In 2011, the World Health Organization released supplementary guidance on the use of HbA1c for diagnosing diabetes. A HbA1c level of 48 mmol/mol (6.5%) or higher is diagnostic of diabetes mellitus. However, a HbA1c value of less than 48 mmol/mol (6.5%) does not exclude diabetes and may not be as sensitive as fasting samples for detecting diabetes. For patients without symptoms, the test must be repeated to confirm the diagnosis. It is important to note that increased red cell turnover can cause misleading HbA1c results.
There are certain conditions where HbA1c cannot be used for diagnosis, such as haemoglobinopathies, haemolytic anaemia, untreated iron deficiency anaemia, suspected gestational diabetes, children, HIV, chronic kidney disease, and people taking medication that may cause hyperglycaemia (such as corticosteroids).
Impaired fasting glucose (IFG) is defined as a fasting glucose level of 6.1 mmol/l or higher but less than 7.0 mmol/l. Impaired glucose tolerance (IGT) is defined as a fasting plasma glucose level less than 7.0 mmol/l and an OGTT 2-hour value of 7.8 mmol/l or higher but less than 11.1 mmol/l. People with IFG should be offered an oral glucose tolerance test to rule out a diagnosis of diabetes. A result below 11.1 mmol/l but above 7.8 mmol/l indicates that the person does not have diabetes but does have IGT.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 45
Correct
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A 28-year-old female presents to the hospital with palpitations. On ECG, a shortened PR interval and wide QRS complexes are observed, along with a slurred upstroke in lead II. What is the definitive treatment for this condition?
Your Answer: Accessory pathway ablation
Explanation:The definitive treatment for this patient’s Wolff-Parkinson White syndrome is ablation of the accessory pathway.
Understanding Wolff-Parkinson White Syndrome
Wolff-Parkinson White (WPW) syndrome is a condition that occurs due to a congenital accessory conduction pathway between the atria and ventricles, leading to atrioventricular re-entry tachycardia (AVRT). This condition can cause AF to degenerate rapidly into VF as the accessory pathway does not slow conduction. The ECG features of WPW include a short PR interval and wide QRS complexes with a slurred upstroke, also known as a delta wave. The left or right axis deviation depends on the location of the accessory pathway.
WPW syndrome is associated with several conditions, including HOCM, mitral valve prolapse, Ebstein’s anomaly, thyrotoxicosis, and secundum ASD. The definitive treatment for WPW syndrome is radiofrequency ablation of the accessory pathway. Medical therapy options include sotalol, amiodarone, and flecainide. However, sotalol should be avoided if there is coexistent atrial fibrillation as it may increase the ventricular rate and potentially deteriorate into ventricular fibrillation.
In summary, WPW syndrome is a condition caused by a congenital accessory conduction pathway that can lead to rapid degeneration of AF into VF. The ECG features include a short PR interval and a delta wave. WPW syndrome is associated with several conditions, and the definitive treatment is radiofrequency ablation of the accessory pathway. Medical therapy options are available, but sotalol should be avoided in certain cases.
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This question is part of the following fields:
- Cardiovascular
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Question 46
Incorrect
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A 32-year-old female patient comes to the clinic with a chief complaint of headaches. During the examination, it is observed that when a light is shone in her right eye, both pupils constrict, but when the light is immediately moved to the left eye, both pupils appear to dilate. What is the probable diagnosis?
Your Answer: Right Holmes-Adie pupil
Correct Answer: Left optic neuritis
Explanation:The ‘swinging light test’ can detect a relative afferent pupillary defect, which is indicated by less constriction of the pupils on one side. In this case, the left side is affected, suggesting an underlying condition such as multiple sclerosis causing optic neuritis. Symptoms of optic neuritis may include a dull ache around the eye that worsens with movement, which is common in patients of this age group.
Understanding Relative Afferent Pupillary Defect
A relative afferent pupillary defect, also known as the Marcus-Gunn pupil, is a condition that can be identified through the swinging light test. This condition is caused by a lesion that is located anterior to the optic chiasm, which can be found in the optic nerve or retina.
When conducting the swinging light test, the affected eye will appear to dilate when light is shone on it, while the normal eye will not. This is due to the fact that the afferent pathway of the pupillary light reflex is disrupted. The pathway starts from the retina, then goes through the optic nerve, lateral geniculate body, and midbrain. The efferent pathway, on the other hand, starts from the Edinger-Westphal nucleus in the midbrain and goes through the oculomotor nerve.
There are various causes of relative afferent pupillary defect, such as retina detachment and optic neuritis, which is commonly associated with multiple sclerosis. Understanding this condition is important in diagnosing and treating patients who may be experiencing vision problems.
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This question is part of the following fields:
- Ophthalmology
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Question 47
Correct
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A 29-year-old woman visits the genitourinary medicine clinic with four fleshy, pigmented lesions on her vulva after starting a new relationship. What is the best initial course of action?
Your Answer: Topical podophyllum
Explanation:For the treatment of genital warts, topical podophyllum is recommended for multiple, non-keratinised warts, while cryotherapy is recommended for solitary, keratinised warts. Cryotherapy can also be used as an initial treatment for genital warts.
Understanding Genital Warts
Genital warts, also known as condylomata accuminata, are a common reason for visits to genitourinary clinics. These warts are caused by various types of the human papillomavirus (HPV), with types 6 and 11 being the most common culprits. It is important to note that HPV, particularly types 16, 18, and 33, can increase the risk of cervical cancer.
The warts themselves are small, fleshy protrusions that are typically 2-5mm in size and may be slightly pigmented. They can cause discomfort, itching, and even bleeding. Treatment options for genital warts include topical podophyllum or cryotherapy, depending on the location and type of lesion. Topical agents are generally used for multiple, non-keratinised warts, while solitary, keratinised warts respond better to cryotherapy. Imiquimod, a topical cream, is often used as a second-line treatment. It is important to note that genital warts can be resistant to treatment, and recurrence is common. However, most anogenital HPV infections clear up on their own within 1-2 years without intervention.
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This question is part of the following fields:
- Reproductive Medicine
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Question 48
Incorrect
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A 20-year-old woman presents to your clinic seeking emergency contraception after forgetting to take 2 doses of her regular contraceptive pill. She reports engaging in sexual activity approximately 48 hours ago. Her medical history includes eczema and severe asthma. Although she missed her pill, she is hesitant to switch to a different form of contraception as she typically has no issues with her current pill but simply forgot to bring it with her while staying at her boyfriend's for the weekend. What is the most suitable emergency contraception option to suggest to her?
Your Answer: Ulipristal (EllaOne)
Correct Answer: Levonorgestrel
Explanation:Levonorgestrel is the correct choice, as the patient has expressed reluctance to try a different form of contraception. It is important to prioritize pregnancy prevention while also discussing the benefits of long-acting reversible contraception and allowing the patient time to consider it. While ulipristal and levonorgestrel are both oral options, ulipristal should be used cautiously in patients with severe asthma. As the patient is still within the 72-hour window for levonorgestrel use and has missed two doses of her oral contraceptive pill, levonorgestrel is the preferred option.
Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, while ulipristal primarily inhibits ovulation. Levonorgestrel should be taken as soon as possible after unprotected sexual intercourse, within 72 hours, and is 84% effective when used within this time frame. The dose should be doubled for those with a BMI over 26 or weight over 70kg. Ulipristal should be taken within 120 hours of intercourse and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which can be inserted within 5 days of unprotected intercourse or up to 5 days after the likely ovulation date. It may inhibit fertilization or implantation and is 99% effective regardless of where it is used in the cycle. Prophylactic antibiotics may be given if the patient is at high risk of sexually transmitted infection.
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This question is part of the following fields:
- Reproductive Medicine
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Question 49
Correct
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A 28-year-old woman visits her doctor concerned about her family's history of inherited illnesses. Her grandmother experienced vision loss at the age of 70, while her mother began to have similar symptoms at the age of 50. What is the genetic mechanism responsible for the earlier age of onset in each generation?
Your Answer: Anticipation
Explanation:Genetic Phenomena: Anticipation, Incomplete Penetrance, Genetic Imprinting, Mosaicism, and Translocation of a Chromosome
Genetics is a complex field that involves the study of inherited traits and conditions. There are several genetic phenomena that can occur, each with its own unique characteristics and implications.
Anticipation is a term used to describe inherited conditions that become more severe and have an earlier onset in subsequent generations. This is often associated with trinucleotide repeats of DNA bases, which can lead to an expansion of the repeat and an increase in severity.
Incomplete penetrance refers to the likelihood of a condition being present in individuals with a certain trait. In some cases, only some people who inherit a certain trait will develop the associated condition, while others will not.
Genetic imprinting involves the silencing of one copy of an allele, which can lead to conditions such as Angelman and Prader-Willi syndromes.
Mosaicism is the presence of two cell lines with different genetic compositions within the same individual. This can occur in conditions such as mosaic trisomy 21.
Translocation of a chromosome involves the exchange of genetic material between non-homologous chromosomes. This can lead to conditions such as chronic myeloid leukemia, which is associated with the Philadelphia chromosome resulting from a translocation between chromosomes 9 and 22.
Understanding these genetic phenomena is important for diagnosing and treating inherited conditions, as well as for predicting the likelihood of certain conditions in future generations.
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This question is part of the following fields:
- Genetics
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Question 50
Correct
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A 25-year-old individual is being examined after experiencing an anaphylactic reaction believed to be caused by a wasp sting. What is the most suitable initial test to investigate the reason for the reaction?
Your Answer: Radioallergosorbent test (RAST)
Explanation:Performing a skin prick test would not be appropriate due to the patient’s history of anaphylaxis.
Types of Allergy Tests
Allergy tests are used to determine if a person has an allergic reaction to a particular substance. There are several types of allergy tests available, each with its own advantages and limitations. The most commonly used test is the skin prick test, which is easy to perform and inexpensive. Drops of diluted allergen are placed on the skin, and a needle is used to pierce the skin. A wheal will typically develop if a patient has an allergy. This test is useful for food allergies and pollen.
Another type of allergy test is the radioallergosorbent test (RAST), which determines the amount of IgE that reacts specifically with suspected or known allergens. Results are given in grades from 0 (negative) to 6 (strongly positive). This test is useful for food allergies, inhaled allergens (e.g. pollen), and wasp/bee venom.
Skin patch testing is useful for contact dermatitis. Around 30-40 allergens are placed on the back, and irritants may also be tested for. The patches are removed 48 hours later, and the results are read by a dermatologist after a further 48 hours. Blood tests may be used when skin prick tests are not suitable, for example if there is extensive eczema or if the patient is taking antihistamines. Overall, allergy tests are an important tool in diagnosing and managing allergies.
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This question is part of the following fields:
- Immunology/Allergy
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