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Question 1
Correct
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A 57-year-old male patient with a history of type 2 diabetes mellitus and hypertension is admitted to a surgical ward for a routine cholecystectomy. He is currently taking metformin 500mg BD, gliclazide 120 mg BD, ramipril 5mg, and atorvastatin 20 mg. The nurse on the morning drug round asks the doctor if they should administer the morning dose of gliclazide, as the surgery is scheduled for 9 am. What should the doctor advise the nurse?
Your Answer: The morning dose of gliclazide should be held but the afternoon dose can be given
Explanation:On the day of surgery, sulfonylureas should be omitted, except for patients who take them twice a day. In this case, the morning dose should be withheld, and the afternoon dose given after the surgery. This is because there is a risk of hypoglycemia in the fasted state before surgery. Withholding both doses or withholding for 24 or 48 hours is incorrect. The BNF website provides a comprehensive guide for managing diabetic patients on insulin and anti-diabetic drugs during surgery, including information on when to introduce variable rate insulin infusions and withholding anti-diabetic medications.
Preparation for surgery varies depending on whether the patient is undergoing an elective or emergency procedure. For elective cases, it is important to address any medical issues beforehand through a pre-admission clinic. Blood tests, urine analysis, and other diagnostic tests may be necessary depending on the proposed procedure and patient fitness. Risk factors for deep vein thrombosis should also be assessed, and a plan for thromboprophylaxis formulated. Patients are advised to fast from non-clear liquids and food for at least 6 hours before surgery, and those with diabetes require special management to avoid potential complications. Emergency cases require stabilization and resuscitation as needed, and antibiotics may be necessary. Special preparation may also be required for certain procedures, such as vocal cord checks for thyroid surgery or bowel preparation for colorectal cases.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 2
Incorrect
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A 30-year-old man presents to the emergency department following a motor vehicle collision where he was the driver. A lorry in front lost control and caused significant damage to his car, resulting in the dashboard and footwell being pushed forward. The patient is currently stable but complains of severe pain in his right leg. Upon examination, his right leg is internally rotated, slightly flexed, adducted, and shortened compared to the left. What is the likely diagnosis?
Your Answer:
Correct Answer: Posterior hip dislocation
Explanation:When a person has a posterior hip dislocation, their leg will appear shortened and internally rotated. This type of injury often occurs during car accidents, especially when the driver slams on the brakes to avoid a collision. The impact from the front of the car is then transferred through the leg to the hip joint, causing the femoral head to move behind the acetabulum. Pelvic fractures, on the other hand, typically cause pain when walking or touching the area, as well as instability, nerve or blood vessel damage in the leg, and signs of injury to pelvic organs such as bleeding from the rectum or blood in the urine. Anterior hip dislocations are less common than posterior ones, but they can cause the leg to appear abducted and externally rotated, with a noticeable bulge in the femoral head. These types of dislocations are often associated with hip prostheses. Finally, femoral shaft fractures can cause swelling, deformity, and shortening of the leg. Because such fractures require a significant amount of force to occur, there is usually also damage to the surrounding soft tissues and bleeding.
Understanding Hip Dislocation: Types, Management, and Complications
Hip dislocation is a painful condition that occurs when the ball and socket joint of the hip are separated. This is usually caused by direct trauma, such as road traffic accidents or falls from a significant height. The force required to cause hip dislocation can also result in other fractures and life-threatening injuries. Therefore, prompt diagnosis and appropriate management are crucial to reduce morbidity.
There are three types of hip dislocation: posterior, anterior, and central. Posterior dislocation is the most common, accounting for 90% of cases. It causes the affected leg to be shortened, adducted, and internally rotated. On the other hand, anterior dislocation results in abduction and external rotation of the affected leg, with no leg shortening. Central dislocation is rare and occurs when the femoral head is displaced in all directions.
The management of hip dislocation follows the ABCDE approach, which includes ensuring airway, breathing, circulation, disability, and exposure. Analgesia is also given to manage the pain. A reduction under general anaesthetic is performed within four hours to reduce the risk of avascular necrosis. Long-term management involves physiotherapy to strengthen the surrounding muscles.
Complications of hip dislocation include nerve injury, avascular necrosis, osteoarthritis, and recurrent dislocation due to damage to supporting ligaments. The prognosis is best when the hip is reduced less than 12 hours post-injury and when there is less damage to the joint. It takes about two to three months for the hip to heal after a traumatic dislocation.
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This question is part of the following fields:
- Musculoskeletal
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Question 3
Incorrect
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A 32-year-old female patient comes in seeking emergency contraception after having unprotected sex with her ex-partner four days ago. She is determined to prevent a pregnancy. The patient has a history of ectopic pregnancy four years ago, which led to a salpingectomy. She is currently on day 14 of a 28-day cycle. What is the best course of action among the available options?
Your Answer:
Correct Answer: Insert an intrauterine device
Explanation: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 4
Incorrect
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A 42-year-old woman with diagnosed irritable bowel syndrome (IBS) is currently taking loperamide, movicol and hyoscine butylbromide (Buscopan) for management. However, she is still experiencing bloating and abdominal pain.
What would be the next treatment option from the list below?Your Answer:
Correct Answer: Tricyclic antidepressant (eg amitriptyline)
Explanation:Understanding and Managing Irritable Bowel Syndrome (IBS)
Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder that affects 10-20% of the population, with women being more susceptible than men. It is characterized by abdominal pain, bloating, and altered bowel habits without any specific organic pathology. Diagnosis is based on the presence of symptoms for at least 6 months, and physical examination and investigations are used to exclude other differential diagnoses.
Management of IBS involves psychological support and dietary measures, such as fibre supplementation, low FODMAP diets, increased water intake, and avoiding trigger foods. Pharmacological treatment is adjunctive and should be directed at symptoms. Antispasmodics, antidiarrhoeals, and antidepressants may have a positive effect on symptoms. However, the choice of medication should be based on the nature and severity of symptoms, with the option of single or combination medication determined by the predominant symptom(s).
It is important to note that certain medications, such as aspirin and NSAIDs, can worsen IBS symptoms, and laxatives like lactulose should be discouraged. Patients should be made aware of these potential risks and advised accordingly. Overall, a multidisciplinary approach involving healthcare professionals and patients is essential for the effective management of IBS.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 5
Incorrect
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A 25-year-old woman with a history of type 1 diabetes mellitus presents at the emergency department complaining of vomiting and abdominal pain. Upon examination, she appears dehydrated. The following are some of her blood test results:
pH 7.23 (7.35-7.45)
pCO2 2.1 kPa (4.5-6.0)
pO2 11.2 kPa (10-14)
Na+ 135 mmol/L (135-145)
K+ 3.1 mmol/L (3.5-5.0)
Bicarbonate 13 mmol/L (22-28)
Glucose 22.4 mmol/L (<11.1)
Ketones 3.6 mmol/L (<0.6)
Question: What should be done with her regular insulin during her treatment?Your Answer:
Correct Answer: Continue long-acting insulin and stop short-acting insulin
Explanation:In the management of DKA, it is important to continue the patient’s regular long-acting insulin while stopping their short-acting insulin. Fixed-rate insulin and fluids should also be administered. Continuing short-acting insulin may lead to hypoglycaemia, so it should be stopped until the patient is stable. Increasing the dose of both long-acting and short-acting insulin is not recommended.
Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes mellitus, accounting for around 6% of cases. It can also occur in rare cases of extreme stress in patients with type 2 diabetes mellitus. However, mortality rates have decreased from 8% to under 1% in the past 20 years. DKA is caused by uncontrolled lipolysis, resulting in an excess of free fatty acids that are ultimately converted to ketone bodies. The most common precipitating factors of DKA are infection, missed insulin doses, and myocardial infarction. Symptoms include abdominal pain, polyuria, polydipsia, dehydration, Kussmaul respiration, and acetone-smelling breath. Diagnostic criteria include glucose levels above 13.8 mmol/l, pH below 7.30, serum bicarbonate below 18 mmol/l, anion gap above 10, and ketonaemia.
Management of DKA involves fluid replacement, insulin, and correction of electrolyte disturbance. Most patients with DKA are depleted around 5-8 litres, and isotonic saline is used initially, even if the patient is severely acidotic. Insulin is administered through an intravenous infusion, and correction of electrolyte disturbance is necessary. Long-acting insulin should be continued, while short-acting insulin should be stopped. DKA resolution is defined as pH above 7.3, blood ketones below 0.6 mmol/L, and bicarbonate above 15.0mmol/L. Complications may occur from DKA itself or the treatment, such as gastric stasis, thromboembolism, arrhythmias, acute respiratory distress syndrome, acute kidney injury, and cerebral oedema. Children and young adults are particularly vulnerable to cerebral oedema following fluid resuscitation in DKA and often need 1:1 nursing to monitor neuro-observations.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 6
Incorrect
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What is a true statement about trigeminal neuralgia?
Your Answer:
Correct Answer: The pain is commonly triggered by touching the skin
Explanation:Understanding Trigeminal Neuralgia
Trigeminal neuralgia is a type of pain syndrome that is characterized by severe pain on one side of the face. While most cases are idiopathic, some may be caused by compression of the trigeminal roots due to tumors or vascular problems. According to the International Headache Society, trigeminal neuralgia is defined as a disorder that causes brief electric shock-like pains that are limited to one or more divisions of the trigeminal nerve. The pain is often triggered by light touch, such as washing, shaving, or brushing teeth, and can occur spontaneously. Certain areas of the face, such as the nasolabial fold or chin, may be more susceptible to pain. The pain may also remit for varying periods.
Red flag symptoms and signs that suggest a serious underlying cause include sensory changes, ear problems, a history of skin or oral lesions that could spread perineurally, pain only in the ophthalmic division of the trigeminal nerve, optic neuritis, a family history of multiple sclerosis, and onset before the age of 40.
The first-line treatment for trigeminal neuralgia is carbamazepine. If there is a failure to respond to treatment or atypical features are present, such as onset before the age of 50, referral to neurology is recommended. Understanding the symptoms and management of trigeminal neuralgia is important for proper diagnosis and treatment.
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This question is part of the following fields:
- Neurology
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Question 7
Incorrect
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A 75-year-old woman presents with post-menopausal bleeding. She has experienced multiple episodes over the past 6 months. The bleeding is heavy enough to require sanitary pads, but she denies any clots. She reports no bowel or urinary symptoms and has not experienced any weight loss. She went through menopause at 50 years old and took hormone replacement therapy for 2 years to alleviate hot flashes and mood swings. She has one child who was born via spontaneous vaginal delivery 45 years ago. There is no family history of gynaecological issues. What is the most probable diagnosis?
Your Answer:
Correct Answer: Endometrial cancer
Explanation:When women experience postmenopausal bleeding (PMB), it is important to rule out the possibility of endometrial cancer. The first step is to conduct a speculum examination to check for any visible abnormalities. For women over 40 years old, an endometrial biopsy and hysteroscopy should be performed to diagnose endometrial cancer. Risk factors for this type of cancer include advanced age, never having given birth, using unopposed estrogen therapy, starting menstruation at an early age and experiencing menopause later in life, being overweight, and having submucosal fibroids that typically calcify after menopause.
Endometrial cancer is a type of cancer that is commonly found in women who have gone through menopause, but it can also occur in around 25% of cases before menopause. The prognosis for this type of cancer is usually good due to early detection. There are several risk factors associated with endometrial cancer, including obesity, nulliparity, early menarche, late menopause, unopposed estrogen, diabetes mellitus, tamoxifen, polycystic ovarian syndrome, and hereditary non-polyposis colorectal carcinoma. Postmenopausal bleeding is the most common symptom of endometrial cancer, which is usually slight and intermittent initially before becoming more heavy. Pain is not common and typically signifies extensive disease, while vaginal discharge is unusual.
When investigating endometrial cancer, women who are 55 years or older and present with postmenopausal bleeding should be referred using the suspected cancer pathway. The first-line investigation is trans-vaginal ultrasound, which has a high negative predictive value for a normal endometrial thickness (< 4 mm). Hysteroscopy with endometrial biopsy is also commonly used for investigation. The management of localized disease involves total abdominal hysterectomy with bilateral salpingo-oophorectomy, while patients with high-risk disease may have postoperative radiotherapy. Progestogen therapy is sometimes used in frail elderly women who are not considered suitable for surgery. It is important to note that the combined oral contraceptive pill and smoking are protective against endometrial cancer.
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This question is part of the following fields:
- Reproductive Medicine
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Question 8
Incorrect
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You perform a routine examination on a 6-month-old baby with newly diagnosed Down syndrome. The mother mentions 'white speckles on his eyes'. Upon examination, you find a bilateral red reflex and no abnormalities. What is the mother describing?
Your Answer:
Correct Answer: Brushfield spots
Explanation:Brushfield spots, which are small grey or brown spots found on the outer edge of the iris, are commonly observed in individuals with Down syndrome. Cataracts, on the other hand, involve clouding of the lens and are not likely present in this patient as their red reflex appears normal. Coloboma, a congenital defect that causes a gap in the lens, iris, or retina, is associated with Patau syndrome rather than Down syndrome. While there have been links between Down syndrome and congenital glaucoma, the patient’s history does not suggest this condition. A squint, or deviation in the gaze of an eye, is a separate issue altogether.
Down’s syndrome is a genetic disorder that is characterized by various clinical features. These features include an upslanting of the palpebral fissures, epicanthic folds, Brushfield spots in the iris, a protruding tongue, small low-set ears, and a round or flat face. Additionally, individuals with Down’s syndrome may have a flat occiput, a single palmar crease, and a pronounced sandal gap between their big and first toe. Hypotonia, congenital heart defects, duodenal atresia, and Hirschsprung’s disease are also common in individuals with Down’s syndrome.
Cardiac complications are also prevalent in individuals with Down’s syndrome, with multiple cardiac problems potentially present. The most common cardiac defect is the endocardial cushion defect, also known as atrioventricular septal canal defects, which affects 40% of individuals with Down’s syndrome. Other cardiac defects include ventricular septal defect, secundum atrial septal defect, tetralogy of Fallot, and isolated patent ductus arteriosus.
Later complications of Down’s syndrome include subfertility, learning difficulties, short stature, repeated respiratory infections, hearing impairment from glue ear, acute lymphoblastic leukaemia, hypothyroidism, Alzheimer’s disease, and atlantoaxial instability. Males with Down’s syndrome are almost always infertile due to impaired spermatogenesis, while females are usually subfertile and have an increased incidence of problems with pregnancy and labour.
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This question is part of the following fields:
- Paediatrics
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Question 9
Incorrect
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Sarah, a 26 year old female with treatment resistant schizophrenia, was started on clozapine 2 weeks ago. Prior to this she was prescribed risperidone, which was reduced down prior to commencement of clozapine. She also takes fluoxetine for depression. Her psychiatric symptoms have improved since starting clozapine, however she is now feeling unwell, reporting a sore throat, and on examination is found to have a temperature of 38.5 degrees. Which of the following blood tests would be the most beneficial in this scenario?
Your Answer:
Correct Answer: FBC
Explanation:Monitoring is crucial for detecting the life-threatening side effect of clozapine, which is agranulocytosis/neutropenia.
Atypical antipsychotics are now recommended as the first-line treatment for patients with schizophrenia, as per the 2005 NICE guidelines. These medications have the advantage of significantly reducing extrapyramidal side-effects. However, they can also cause adverse effects such as weight gain, hyperprolactinaemia, and in the case of clozapine, agranulocytosis. The Medicines and Healthcare products Regulatory Agency has issued warnings about the increased risk of stroke and venous thromboembolism when antipsychotics are used in elderly patients. Examples of atypical antipsychotics include clozapine, olanzapine, risperidone, quetiapine, amisulpride, and aripiprazole.
Clozapine, one of the first atypical antipsychotics, carries a significant risk of agranulocytosis and requires full blood count monitoring during treatment. Therefore, it should only be used in patients who are resistant to other antipsychotic medication. The BNF recommends introducing clozapine if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs, one of which should be a second-generation antipsychotic drug, each for at least 6-8 weeks. Adverse effects of clozapine include agranulocytosis, neutropaenia, reduced seizure threshold, constipation, myocarditis, and hypersalivation. Dose adjustment of clozapine may be necessary if smoking is started or stopped during treatment.
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This question is part of the following fields:
- Psychiatry
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Question 10
Incorrect
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A 75-year-old woman who has undergone a total hip replacement (THR) comes for evaluation because of discomfort on the side of her prosthesis. What is the primary cause for a revision surgery in a patient who has had a THR?
Your Answer:
Correct Answer: Aseptic loosening of the implant
Explanation:The primary cause for the revision of total hip replacements is aseptic loosening, followed by pain and dislocation.
Osteoarthritis (OA) of the hip is a prevalent condition, with the knee being the only joint more commonly affected. It is particularly prevalent in older individuals, and women are twice as likely to develop it. Obesity and developmental dysplasia of the hip are also risk factors. The condition is characterized by chronic groin pain that is exacerbated by exercise and relieved by rest. However, if the pain is present at rest, at night, or in the morning for more than two hours, it may indicate an alternative cause. The Oxford Hip Score is a widely used tool to assess the severity of the condition.
If the symptoms are typical, a clinical diagnosis can be made. Otherwise, plain x-rays are the first-line investigation. Management of OA of the hip includes oral analgesia and intra-articular injections, which provide short-term relief. However, total hip replacement is the definitive treatment.
Total hip replacement is a common operation in the developed world, but it is not without risks. Perioperative complications include venous thromboembolism, intraoperative fracture, nerve injury, surgical site infection, and leg length discrepancy. Postoperatively, posterior dislocation may occur during extremes of hip flexion, presenting with a clunk, pain, and inability to weight bear. Aseptic loosening is the most common reason for revision, and prosthetic joint infection is also a potential complication.
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This question is part of the following fields:
- Musculoskeletal
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Question 11
Incorrect
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A 30-year-old woman visits her GP with a query regarding oral contraception. She gave birth to her fourth child 2 weeks ago and believes that her family is complete. After weighing the options, she has decided to begin taking the combined contraceptive pill. She has no significant medical history and only takes regular vitamin supplements without any allergies. She is not breastfeeding at the moment.
What is the earliest possible time for her to start taking her preferred contraceptive?Your Answer:
Correct Answer: Commence 3 weeks post-partum
Explanation:Women need to start using contraception only 21 days after giving birth during the post-partum period. It is recommended that they begin taking the combined contraceptive pill three weeks after delivery. However, if they are breastfeeding, they should wait for six weeks before starting the pill.
After giving birth, women need to use contraception after 21 days. The progestogen-only pill (POP) can be started at any time postpartum, according to the FSRH. Additional contraception should be used for the first two days after day 21. A small amount of progestogen enters breast milk, but it is not harmful to the infant. On the other hand, the combined oral contraceptive pill (COCP) is absolutely contraindicated (UKMEC 4) if breastfeeding is less than six weeks post-partum. If breastfeeding is between six weeks and six months postpartum, it is a UKMEC 2. The COCP may reduce breast milk production in lactating mothers. It should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum. After day 21, additional contraception should be used for the first seven days. The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after four weeks.
The lactational amenorrhoea method (LAM) is 98% effective if the woman is fully breastfeeding (no supplementary feeds), amenorrhoeic, and less than six months post-partum. It is important to note that an inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birth weight, and small for gestational age babies.
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This question is part of the following fields:
- Reproductive Medicine
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Question 12
Incorrect
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You are seeing a 5-year-old boy in your clinic who has a history of multiple wheezy episodes over the past 4 years and was diagnosed with asthma. He was admitted to the hospital 5 months ago with shortness-of-breath and wheeze and was diagnosed with a viral exacerbation of asthma. The paediatric team prescribed him a Clenil (beclometasone dipropionate) inhaler 50mcg bd and salbutamol 100mcg prn via a spacer before his discharge. His mother reports that he has a persistent night-time cough and is regularly using his salbutamol inhaler. On clinical examination, his chest appears normal. What would be the most appropriate next step in managing this patient?
Your Answer:
Correct Answer: Add a leukotriene receptor antagonist
Explanation:Managing Asthma in Children: NICE Guidelines
Asthma management in children has been updated by NICE in 2017, following the 2016 BTS guidelines. The new guidelines for children aged 5-16 are similar to those for adults, with a stepwise approach for treatment. For newly-diagnosed asthma, short-acting beta agonist (SABA) is recommended. If symptoms persist, a combination of SABA and paediatric low-dose inhaled corticosteroid (ICS) is used. Leukotriene receptor antagonist (LTRA) is added if symptoms still persist, followed by long-acting beta agonist (LABA) if necessary. Maintenance and reliever therapy (MART) is used as a combination of ICS and LABA for daily maintenance therapy and symptom relief. For children under 5 years old, clinical judgement plays a greater role in diagnosis. The stepwise approach is similar to that for older children, with an 8-week trial of paediatric moderate-dose ICS before adding LTRA. If symptoms persist, referral to a paediatric asthma specialist is recommended.
It should be noted that NICE does not recommend changing treatment for well-controlled asthma patients simply to adhere to the latest guidelines. The definitions of low, moderate, and high-dose ICS have also changed, with different definitions for adults and children. For children, <= 200 micrograms budesonide or equivalent is considered a paediatric low dose, 200-400 micrograms is a moderate dose, and > 400 micrograms is a high dose. Overall, the new NICE guidelines provide a clear and concise approach to managing asthma in children.
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This question is part of the following fields:
- Paediatrics
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Question 13
Incorrect
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A 42-year-old woman presents to her General Practitioner with a diagnosis of primary biliary cholangitis (PBC). She initially complained of abdominal pain and itching, but is now asymptomatic except for significant fatigue. What medication should be prescribed for this patient? Choose the most likely option.
Your Answer:
Correct Answer: Ursodeoxycholic acid (UDCA)
Explanation:Treatment Options for Primary Biliary Cholangitis
Primary biliary cholangitis (PBC) is a liver disease that can lead to cirrhosis if left untreated. Ursodeoxycholic acid (UDCA) is the main treatment for PBC, as it can prevent or delay the development of cirrhosis. UDCA increases bile flow, inhibits toxic bile acid production, prevents hepatocyte apoptosis, and reduces the liver’s immune response. However, UDCA may cause side effects such as diarrhea, nausea, and thinning hair.
Spironolactone is a diuretic that can be useful for end-stage liver disease with ascites, but it is not indicated for treating fatigue in PBC patients. Aspirin and ibuprofen should be avoided by PBC patients, as they can worsen liver disease. Cholestyramine is used for cholestatic itching, but it should not be taken with UDCA as it can prevent UDCA absorption.
In summary, UDCA is the primary treatment for PBC, and other medications should be used with caution and only for specific symptoms or complications.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 14
Incorrect
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A 38-year-old woman presents with menorrhagia and is diagnosed with a 1.5 cm uterine fibroid that is not distorting the uterine cavity. She has two children and desires ongoing contraception, but is currently relying solely on condoms. What is the recommended initial treatment for her menorrhagia?
Your Answer:
Correct Answer: Intrauterine system
Explanation:Medical treatment can be attempted for uterine fibroids that are smaller than 3 cm and do not distort the uterine cavity. This may include options such as an intrauterine system, tranexamic acid, or COCP. The NICE Clinical Knowledge Summaries suggest starting with an intrauterine system, which can also serve as a form of contraception.
Understanding Uterine Fibroids
Uterine fibroids are non-cancerous growths that develop in the uterus. They are more common in black women and are thought to occur in around 20% of white women in their later reproductive years. Fibroids are usually asymptomatic, but they can cause menorrhagia, which can lead to iron-deficiency anaemia. Other symptoms include lower abdominal pain, bloating, and urinary symptoms. Fibroids may also cause subfertility.
Diagnosis is usually made through transvaginal ultrasound. Asymptomatic fibroids do not require treatment, but periodic monitoring is recommended. Menorrhagia secondary to fibroids can be managed with various treatments, including the levonorgestrel intrauterine system, NSAIDs, tranexamic acid, and hormonal therapies.
Medical treatment to shrink or remove fibroids may include GnRH agonists or ulipristal acetate, although the latter is not currently recommended due to concerns about liver toxicity. Surgical options include myomectomy, hysteroscopic endometrial ablation, hysterectomy, and uterine artery embolization.
Fibroids generally regress after menopause, but complications such as subfertility and iron-deficiency anaemia can occur. Red degeneration, which is haemorrhage into the tumour, is a common complication during pregnancy.
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This question is part of the following fields:
- Reproductive Medicine
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Question 15
Incorrect
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A new father is curious as to when his toddler will be receiving her vaccines. He is particularly interested in the six-in-one vaccine which he has heard about from some friends at playgroup. When is the six-in-one vaccine given to toddlers?
Your Answer:
Correct Answer: 8, 12, and 16 weeks
Explanation:Childhood Vaccination Schedule in the UK
In the UK, childhood vaccinations are an important part of ensuring the health and wellbeing of children. Here is a breakdown of the vaccination schedule:
8, 12, and 16 weeks: The 6-in-1 vaccine is given as a single injection to protect against diphtheria, hepatitis B, Haemophilus influenza B, polio, tetanus, and pertussis. This vaccine is given at eight, 12, and 16 weeks old.
One year: At one year, children receive the MMR vaccine, Hib/Men C vaccine, and third dose of the meningitis B and pneumococcal vaccines.
8, 12, and 16 months: There are three doses given, however at eight, 12, and 16 weeks of age, not months.
24 months: From 2-9 years old, children will receive the annual flu vaccine via nasal spray.
It is important to follow the vaccination schedule to ensure that children are protected against serious illnesses. Talk to your healthcare provider for more information.
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This question is part of the following fields:
- Immunology/Allergy
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Question 16
Incorrect
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A 35-year-old man presents with malaise, fever, backache and joint pains of 1-week duration. On examination, arthritis is present asymmetrically in the lower limbs, involving the knees and metatarsophalangeal (MTP) and toe joints. An eye examination reveals conjunctival congestion, and there is a vesicular crusting lesion on his left sole. Investigations reveal an erythrocyte sedimentation rate (ESR) of 60 mm/h (normal <20 mm/h) and C-reactive protein (CRP) of 50 u/l (normal <5 u/l). Rheumatoid factor is negative and HLA-B27 positive.
Which of the following is the most likely diagnosis?
Select the SINGLE most appropriate diagnosis from the list below. Select ONE option only.Your Answer:
Correct Answer: Reactive arthritis
Explanation:Reactive arthritis is a type of joint inflammation that occurs after an infection, often caused by dysentery or a sexually transmitted infection. It is more common in men who have the HLA-B27 gene. Reactive arthritis is part of a group of diseases called spondyloarthropathies, which also includes ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis, and undifferentiated arthritis. Unlike rheumatoid arthritis, reactive arthritis is not associated with rheumatoid factor. Symptoms of reactive arthritis include sudden, asymmetrical lower limb joint pain, which can occur a few days to weeks after the initial infection. Enthesitis, or inflammation where tendons and ligaments attach to bones, is also common and can cause plantar fasciitis or Achilles tendonitis. In some cases, reactive arthritis can also cause back pain and inflammation of the sacroiliac joint, as well as a sterile conjunctivitis. Treatment involves addressing the initial infection and may include medications such as sulfasalazine or methotrexate for relapsing cases. It is important to trace and treat sexual partners if necessary. Gout, rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis are other types of joint inflammation that have different symptoms and causes.
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This question is part of the following fields:
- Musculoskeletal
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Question 17
Incorrect
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A 32-year-old woman visits her doctor worried that she may have been in contact with a child who has chickenpox. She is currently 20 weeks pregnant and unsure if she has ever had chickenpox before. Upon examination, no rash is present. Her blood test results show that she is Varicella Zoster IgG negative. What is the best course of action to take next?
Your Answer:
Correct Answer: Give varicella-zoster immunoglobulin (VZIG)
Explanation:If a pregnant woman is exposed to chickenpox before 20 weeks and has a negative IgG test, it indicates that she is not immune to the virus or has not been previously exposed to it. In such cases, it is recommended to administer varicella-zoster immunoglobulin (VZIG) as soon as possible, which can be effective up to 10 days after exposure. It is not necessary to inform public health as chickenpox is not a notifiable disease.
If a pregnant woman develops a chickenpox rash, VZIG has no therapeutic benefit and should not be used. However, antiviral agents like aciclovir can be given within 24 hours of the rash onset. It is important to note that antiviral agents are recommended for post-exposure prophylaxis for immunosuppressed individuals.
Women who are not immune to varicella-zoster can receive the vaccine before pregnancy or after delivery, but it should not be administered during pregnancy. Therefore, option D cannot be correct in any situation.
Chickenpox exposure in pregnancy can pose risks to both the mother and fetus, including fetal varicella syndrome. Post-exposure prophylaxis (PEP) with varicella-zoster immunoglobulin (VZIG) or antivirals should be given to non-immune pregnant women, with timing dependent on gestational age. If a pregnant woman develops chickenpox, specialist advice should be sought and oral aciclovir may be given if she is ≥ 20 weeks and presents within 24 hours of onset of the rash.
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This question is part of the following fields:
- Reproductive Medicine
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Question 18
Incorrect
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A 29-year-old male patient informs you that he has Long QT syndrome and you are contemplating prescribing an antibiotic. Which antibiotic should you avoid prescribing to him?
Your Answer:
Correct Answer: Erythromycin
Explanation:A prolonged QT interval may be caused by Erythromycin.
Understanding Long QT Syndrome
Long QT syndrome (LQTS) is a genetic condition that causes delayed repolarization of the ventricles, which can lead to ventricular tachycardia and sudden death. The most common types of LQTS are caused by defects in the alpha subunit of the slow delayed rectifier potassium channel. A normal corrected QT interval is less than 430 ms in males and 450 ms in females.
There are various causes of a prolonged QT interval, including congenital factors, drugs, and other medical conditions. Some drugs that can prolong the QT interval include amiodarone, tricyclic antidepressants, and selective serotonin reuptake inhibitors. Electrolyte imbalances, acute myocardial infarction, and subarachnoid hemorrhage can also cause a prolonged QT interval.
LQTS may be picked up on routine ECG or following family screening. The symptoms and events associated with LQTS can vary depending on the type of LQTS. Long QT1 is usually associated with exertional syncope, while Long QT2 is often associated with syncope following emotional stress or exercise. Long QT3 events often occur at night or at rest.
Management of LQTS involves avoiding drugs that prolong the QT interval and other precipitants if appropriate. Beta-blockers may be used, and in high-risk cases, implantable cardioverter defibrillators may be necessary. It is important to recognize and manage LQTS to prevent sudden cardiac death.
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This question is part of the following fields:
- Cardiovascular
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Question 19
Incorrect
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A 14-year-old boy presents with difficulty in walking and foot drop. There is weakness of dorsiflexion and eversion of the right foot, with a small area of sensory loss over the dorsum of that foot.
Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Common peroneal nerve lesion
Explanation:The common peroneal nerve is a branch of the sciatic nerve that provides motor and sensory innervation to the lateral and anterior compartments of the leg, as well as the dorsum of the foot. Damage to this nerve, often caused by fibular neck fracture, results in footdrop and sensory loss in the affected areas.
The sciatic nerve, which originates from the lumbosacral plexus, innervates the posterior compartment of the thigh and indirectly innervates the posterior leg/calf muscles and some intrinsic muscles of the feet. It also provides sensory innervation to the posterolateral leg, lateral foot, and sole of the foot. Sciatica, a common condition that causes pain radiating down the leg, is often caused by irritation of the sciatic nerve root.
The posterior tibial nerve, another branch of the sciatic nerve, supplies motor innervation to the posterior compartment of the leg and sensory innervation to the posterolateral leg, lateral foot, and sole of the foot. Damage to this nerve, often caused by compression or trauma, results in ankle and sole of foot paraesthesiae.
The L5 root innervates muscles responsible for ankle and great toe dorsiflexion, hip abduction, and sensory innervation to the buttocks, posterolateral thigh, and lateral calf. L5 radiculopathy, which causes pain radiating from the lower back to the foot, is a common condition associated with damage to this root.
The deep peroneal nerve, a branch of the common peroneal nerve, innervates the muscles responsible for foot dorsiflexion and provides sensory innervation to the area between the first and second toes. Damage to this nerve, often caused by conditions such as LMD or diabetes, results in footdrop with minimal sensory loss and preserved eversion.
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This question is part of the following fields:
- Neurology
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Question 20
Incorrect
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A 35-year-old man who is generally healthy visits his doctor to discuss planning a second child. His main concern is that his first child has sickle cell anemia. Both he and his partner have had genetic testing and are both carriers of the sickle cell trait.
Which of the following best describes the likelihood of his next child having sickle cell anemia?Your Answer:
Correct Answer: 25%
Explanation:Understanding the Inheritance of Cystic Fibrosis
Cystic fibrosis (CF) is an autosomal-recessive condition that affects many individuals worldwide. To understand the inheritance of CF, it is important to know that a child inherits one copy of the gene from each parent. If both parents are carriers of the faulty gene, there is a 1 in 4 chance of their child being affected by the condition.
If the child inherits one normal and one abnormal gene, they become a carrier of CF. The chance of this happening is 50%. If the child inherits two normal genes, they will not be affected nor be a carrier of CF, and the chance of this happening is 25%. However, if the child inherits two copies of the faulty gene, they will be affected by the condition, and the chance of this happening is also 25%.
It is important to note that the fact that the first child has CF does not affect the risk to subsequent children. The risk remains the same for each child, as each child inherits a copy of the gene from each parent. Understanding the inheritance of CF can help individuals make informed decisions about family planning and genetic testing.
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This question is part of the following fields:
- Genetics
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