00
Correct
00
Incorrect
00 : 00 : 00
Session Time
00 : 00
Average Question Time ( Secs)
  • Question 1 - A 55-year-old female patient arrived at the emergency department complaining of intense pain...

    Incorrect

    • A 55-year-old female patient arrived at the emergency department complaining of intense pain in her left eye, along with redness and sensitivity to light. Upon examination, her intraocular pressure was found to be elevated at 30 mmHg, and her pupil was mid-dilated. After diagnosing her with acute angle closure glaucoma, you promptly administered IV acetazolamide and topical pilocarpine. What is the definitive treatment for this condition?

      Your Answer: Topical carbonic anhydrase inhibitors in both eyes

      Correct Answer: Laser peripheral iridotomy in both eyes

      Explanation:

      The definitive treatment for acute angle-closure glaucoma is laser peripheral iridotomy, which creates an additional pathway in the iris for aqueous to flow from the posterior chamber to the anterior chamber and be drained into the angle. While topical beta blockers, alpha agonists, prostaglandin analogues, and carbonic anhydrase inhibitors can all help control intraocular pressure in glaucoma patients, they are not considered definitive treatments for AACG.

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

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

    • This question is part of the following fields:

      • Ophthalmology
      45.2
      Seconds
  • Question 2 - A 67-year-old man comes to the clinic complaining of generalised weakness that has...

    Incorrect

    • A 67-year-old man comes to the clinic complaining of generalised weakness that has been ongoing for the past six months. During the examination, fasciculation and weakness are observed in both arms with absent reflexes. Additionally, increased tone and exaggerated reflexes are noted in the lower limbs. Sensation is normal and there are no cerebellar signs. Based on these findings, what is the most probable diagnosis?

      Your Answer: Syringomyelia

      Correct Answer: Amyotrophic lateral sclerosis

      Explanation:

      If you experience fasciculations, it may be a sign of motor neuron disease, specifically amyotrophic lateral sclerosis, which is the most prevalent type.

      Understanding Motor Neuron Disease: Signs and Diagnosis

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

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

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

    • This question is part of the following fields:

      • Neurology
      81.4
      Seconds
  • Question 3 - A 79-year-old man with a medical history of prostate cancer, asthma, and COPD...

    Incorrect

    • A 79-year-old man with a medical history of prostate cancer, asthma, and COPD presents to the emergency department with complaints of abdominal pain, bone pain, and general weakness. During investigations, a shortened QT interval is noted on his ECG. What is the initial management approach for this complication in this patient?

      Your Answer:

      Correct Answer: IV 0.9% N saline

      Explanation:

      Understanding the Causes of Hypercalcaemia

      Hypercalcaemia is a medical condition characterized by high levels of calcium in the blood. In most cases, two conditions account for 90% of hypercalcaemia cases. The first is primary hyperparathyroidism, which is the most common cause in non-hospitalized patients. The second is malignancy, which is the most common cause in hospitalized patients. Malignancy-related hypercalcaemia may be due to various processes, including PTHrP from the tumor, bone metastases, and myeloma. For this reason, measuring parathyroid hormone levels is crucial when investigating patients with hypercalcaemia.

      Other causes of hypercalcaemia include sarcoidosis, tuberculosis, histoplasmosis, vitamin D intoxication, acromegaly, thyrotoxicosis, milk-alkali syndrome, drugs such as thiazides and calcium-containing antacids, dehydration, Addison’s disease, and Paget’s disease of the bone. It is important to note that hypercalcaemia may occur with prolonged immobilization in patients with Paget’s disease of the bone, although this condition is usually normal.

      In summary, hypercalcaemia can be caused by various medical conditions, with primary hyperparathyroidism and malignancy being the most common. Measuring parathyroid hormone levels is essential in investigating patients with hypercalcaemia. Other causes of hypercalcaemia include sarcoidosis, tuberculosis, histoplasmosis, vitamin D intoxication, acromegaly, thyrotoxicosis, milk-alkali syndrome, drugs, dehydration, Addison’s disease, and Paget’s disease of the bone.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      0
      Seconds
  • Question 4 - In a patient with parkinsonian features, what is the single most appropriate feature...

    Incorrect

    • In a patient with parkinsonian features, what is the single most appropriate feature that supports the diagnosis of progressive supranuclear palsy (PSP) over idiopathic Parkinson's disease (PD)?

      Your Answer:

      Correct Answer: Early postural instability

      Explanation:

      Differentiating Progressive Supranuclear Palsy from Other Movement Disorders

      Progressive Supranuclear Palsy (PSP) is a neurodegenerative condition that typically affects individuals over the age of 50, with a higher incidence in men. Early postural instability is a hallmark feature of PSP, often leading to falls within the first year of onset. The Clinical Criteria for the Diagnosis of Progressive Supranuclear Palsy developed by the National Institute for Neurological Disorders and Society for PSP (NINDS-SPSP) suggests that a poor or absent response to levodopa is indicative of PSP.

      Unlike Parkinson’s disease (PD), PSP is not associated with Internuclear Ophthalmoplegia (INO) and does not typically present with marked tremors. Instead, PSP is characterized by supranuclear gaze dysfunction, rigidity, bradykinesia, dysarthria, and dysphagia. Symptoms are usually symmetrical, and unilateral onset is more suggestive of idiopathic PD.

      In summary, early postural instability, poor response to levodopa, absence of INO, and lack of marked tremors are key features that can help differentiate PSP from other movement disorders.

    • This question is part of the following fields:

      • Neurology
      0
      Seconds
  • Question 5 - A 65-year-old female presents to her GP with a 4-week history of bilateral...

    Incorrect

    • A 65-year-old female presents to her GP with a 4-week history of bilateral shoulder pain. She also experiences stiffness in her shoulders in the morning which improves throughout the day. She reports feeling generally fatigued. No other joints are affected. The patient has a history of osteoarthritis in her left knee.

      During examination, the patient's observations are normal. There is no swelling or redness in the shoulders, and she has a full range of motion bilaterally. Upper limb power is 5/5 bilaterally with normal sensation.

      Based on the patient's history and examination, what is the most likely diagnosis?

      Your Answer:

      Correct Answer: Polymyalgia rheumatica

      Explanation:

      The patient’s symptoms are suggestive of polymyalgia rheumatica (PMR), which is a common inflammatory condition in older adults. The sudden onset of pain and stiffness in the shoulders and hips, along with systemic symptoms such as fatigue and anorexia, are typical of PMR. Osteoarthritis, fibromyalgia, hypothyroidism, and adhesive capsulitis are less likely diagnoses, as they do not typically present with acute onset of symptoms or systemic involvement. However, it is important to rule out hypothyroidism by checking thyroid function. Frozen shoulder may cause shoulder pain and stiffness, but it is usually associated with restricted range of motion and does not typically cause systemic symptoms.

      Polymyalgia Rheumatica: A Condition of Muscle Stiffness in Older People

      Polymyalgia rheumatica (PMR) is a common condition that affects older people. It is characterized by muscle stiffness and elevated inflammatory markers. Although it is closely related to temporal arteritis, the underlying cause is not fully understood, and it does not appear to be a vasculitic process. PMR typically affects patients over the age of 60 and has a rapid onset, usually within a month. Patients experience aching and morning stiffness in proximal limb muscles, along with mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, and night sweats.

      To diagnose PMR, doctors look for raised inflammatory markers, such as an ESR of over 40 mm/hr. Creatine kinase and EMG are normal. Treatment for PMR involves prednisolone, usually at a dose of 15mg/od. Patients typically respond dramatically to steroids, and failure to do so should prompt consideration of an alternative diagnosis.

    • This question is part of the following fields:

      • Musculoskeletal
      0
      Seconds
  • Question 6 - A 68-year-old woman is referred with fatigue. Her primary care physician observes that...

    Incorrect

    • A 68-year-old woman is referred with fatigue. Her primary care physician observes that she has jaundice and suspects liver disease. She also presents with angular cheilitis. She has a history of taking steroid inhalers for asthma, but no other significant medical history. A blood smear shows signs of megaloblastic anemia, and her serum bilirubin level is elevated, but her other laboratory results are normal. There are no indications of gastrointestinal (GI) issues.
      What is the most appropriate diagnosis for this clinical presentation?

      Your Answer:

      Correct Answer: Pernicious anaemia

      Explanation:

      Differential Diagnosis of Anaemia: Understanding the Causes

      Anaemia is a common condition that can be caused by a variety of factors. Here, we will discuss some of the possible causes of anaemia and their corresponding laboratory findings.

      Pernicious Anaemia: This type of anaemia is caused by a deficiency in vitamin B12 due to impaired intrinsic factor (IF) production. It is usually seen in adults aged 40-70 years and is characterized by megaloblastic changes in rapidly dividing cells. Anti-parietal cell antibodies are present in 90% of patients with pernicious anaemia. The Schilling test is useful in confirming the absence of IF. Treatment involves parenteral administration of cyanocobalamin or hydroxycobalamin.

      Chronic Myeloid Leukaemia: CML is a myeloproliferative disorder that results in increased proliferation of granulocytic cells. Symptoms include fatigue, anorexia, weight loss, and hepatosplenomegaly. Mild to moderate anaemia is usually normochromic and normocytic. Diagnosis is based on histopathological findings in the peripheral blood and Philadelphia chromosome in bone marrow cells.

      Iron Deficiency Anaemia: This type of anaemia is primarily a laboratory diagnosis and is characterized by microcytic and hypochromic erythropoiesis. It is caused by chronic iron deficiency and can be due to multiple causes, including chronic inflammation, iron malabsorption, chronic blood loss, and malabsorption of vitamin B12 or folate.

      Crohn’s Disease: This chronic inflammatory process can affect any part of the GI tract and can cause anaemia due to chronic inflammation, iron malabsorption, chronic blood loss, and malabsorption of vitamin B12 or folate. However, the lack of GI symptoms in the clinical scenario provided is not consistent with a history of inflammatory bowel disease.

      Autoimmune Hepatitis: This chronic disease is characterized by continuing hepatocellular inflammation and necrosis, with a tendency to progress to cirrhosis. Elevated serum aminotransferase levels are present in 100% of patients at initial presentation. Anaemia, if present, is usually normochromic. However, this clinical picture and laboratory findings are not consistent with the scenario given.

      In conclusion, understanding the different causes of anaemia and their corresponding laboratory findings is crucial in making an accurate diagnosis and providing appropriate treatment.

    • This question is part of the following fields:

      • Haematology/Oncology
      0
      Seconds
  • Question 7 - You are conducting a medication review for a 67-year-old man who has a...

    Incorrect

    • You are conducting a medication review for a 67-year-old man who has a history of cerebrovascular disease (having suffered a stroke 3 years ago), depression, and knee osteoarthritis. He is currently taking the following medications:
      - Clopidogrel 75 mg once daily
      - Simvastatin 20 mg once daily
      - Amlodipine 5mg once daily
      - Ramipril 10mg once daily
      - Diclofenac 50mg as needed
      - Sertraline 50mg once daily

      What changes would you recommend to his medication regimen?

      Your Answer:

      Correct Answer: Switch diclofenac for an alternative NSAID

      Explanation:

      The use of diclofenac is now prohibited for individuals with any type of cardiovascular ailment.

      MHRA Guidance on Diclofenac and Cardiovascular Safety

      The MHRA has updated its guidance on diclofenac, a nonsteroidal anti-inflammatory drug (NSAID), after a Europe-wide review of cardiovascular safety. While it has been known for some time that NSAIDs may increase the risk of cardiovascular events, the evidence base has become clearer. Diclofenac is associated with a significantly higher risk of cardiovascular events compared to other NSAIDs. Therefore, it is contraindicated in patients with ischaemic heart disease, peripheral arterial disease, cerebrovascular disease, and congestive heart failure (New York Heart Association classification II-IV). Patients should switch from diclofenac to other NSAIDs such as naproxen or ibuprofen, except for topical diclofenac. Studies have shown that naproxen and low-dose ibuprofen have the best cardiovascular risk profiles of the NSAIDs.

      The MHRA’s updated guidance on diclofenac and cardiovascular safety highlights the increased risk of cardiovascular events associated with this NSAID compared to other NSAIDs. Patients with certain conditions are advised to avoid diclofenac and switch to other NSAIDs. This guidance is important for healthcare professionals to consider when prescribing NSAIDs to patients with cardiovascular risk factors.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      0
      Seconds
  • Question 8 - A 48-year-old woman is contemplating hormone replacement therapy but is concerned about the...

    Incorrect

    • A 48-year-old woman is contemplating hormone replacement therapy but is concerned about the potential risk of developing breast cancer. She began menstruating at the age of 11 and experienced premature menopause at 45. She has three children, all of whom she breastfed, and has never used oral contraceptives. Apart from hormone replacement therapy, which of the following factors is most strongly linked to an elevated risk of breast cancer?

      Your Answer:

      Correct Answer: Early menarche

      Explanation:

      Breast cancer risk is increased by HRT, early menarche, late menopause, and COCP, while it is reduced by multiple pregnancy and breastfeeding.

      Breast Cancer Risk Factors: Understanding the Predisposing Factors

      Breast cancer is a complex disease that can be influenced by various factors. Some of these factors are considered predisposing factors, which means they increase the likelihood of developing breast cancer. One of the most well-known predisposing factors is the presence of BRCA1 and BRCA2 genes, which can increase a person’s lifetime risk of breast and ovarian cancer by 40%. Other predisposing factors include having a first-degree relative with premenopausal breast cancer, nulliparity, having a first pregnancy after the age of 30, early menarche, late menopause, combined hormone replacement therapy, combined oral contraceptive use, past breast cancer, not breastfeeding, ionizing radiation, p53 gene mutations, obesity, and previous surgery for benign disease.

      To reduce the risk of developing breast cancer, it is important to understand these predisposing factors and take steps to minimize their impact. For example, women with a family history of breast cancer may choose to undergo genetic testing to determine if they carry the BRCA1 or BRCA2 genes. Women who have not yet had children may consider having their first child before the age of 30, while those who have already had children may choose to breastfeed. Additionally, women who are considering hormone replacement therapy or oral contraceptives should discuss the potential risks and benefits with their healthcare provider. By understanding these predisposing factors and taking proactive steps to reduce their impact, women can help protect themselves against breast cancer.

    • This question is part of the following fields:

      • Reproductive Medicine
      0
      Seconds
  • Question 9 - Samantha is a 55-year-old woman who has been experiencing difficulty breathing. She undergoes...

    Incorrect

    • Samantha is a 55-year-old woman who has been experiencing difficulty breathing. She undergoes a spirometry evaluation with the following findings: a decrease in forced vital capacity (FVC), an increase in the forced expiratory volume in one second to forced vital capacity ratio (FEV1:FVC ratio), and a decrease in the transfer factor for carbon monoxide (TLCO), indicating impaired gas exchange. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Pulmonary fibrosis

      Explanation:

      Understanding Idiopathic Pulmonary Fibrosis

      Idiopathic pulmonary fibrosis (IPF) is a chronic lung condition that causes progressive fibrosis of the interstitium of the lungs. Unlike other causes of lung fibrosis, IPF has no underlying cause. It is typically seen in patients aged 50-70 years and is more common in men.

      The symptoms of IPF include progressive exertional dyspnoea, dry cough, clubbing, and bibasal fine end-inspiratory crepitations on auscultation. Diagnosis is made through spirometry, impaired gas exchange tests, and imaging such as chest x-rays and high-resolution CT scans.

      Management of IPF includes pulmonary rehabilitation, but very few medications have been shown to be effective. Some evidence suggests that pirfenidone, an antifibrotic agent, may be useful in selected patients. Many patients will eventually require supplementary oxygen and a lung transplant.

      The prognosis for IPF is poor, with an average life expectancy of around 3-4 years. CT scans can show advanced pulmonary fibrosis, including honeycombing. While there is no cure for IPF, early diagnosis and management can help improve quality of life and potentially prolong survival.

    • This question is part of the following fields:

      • Respiratory Medicine
      0
      Seconds
  • Question 10 - A 38-year-old woman comes to you with a sudden onset of right-sided facial...

    Incorrect

    • A 38-year-old woman comes to you with a sudden onset of right-sided facial weakness, which appears to be a lower motor neuron palsy. There are no other neurological symptoms on examination, and her ears appear normal. You diagnose her with Bell's palsy and prescribe prednisolone. What is the crucial next step in managing her condition?

      Your Answer:

      Correct Answer: Prescribe artifical tears and advise eye taping at night

      Explanation:

      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.

    • This question is part of the following fields:

      • Neurology
      0
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Ophthalmology (0/1) 0%
Neurology (0/1) 0%
Passmed