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Question 1
Correct
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A 42-year-old man with irritable bowel syndrome (IBS) is struggling to manage his symptoms through dietary changes alone. He is primarily bothered by abdominal discomfort and bloating.
What is the most suitable next step in his treatment plan?Your Answer: Mebeverine hydrochloride
Explanation:Pharmacological Management of Irritable Bowel Syndrome
Irritable bowel syndrome (IBS) is a common gastrointestinal disorder that affects 10-20% of the population, with women being more susceptible than men. The condition is characterized by abdominal pain, bloating, and altered bowel habits without any specific organic pathology. Management of IBS involves psychological support, dietary measures, and pharmacological treatment for symptom relief.
Antispasmodics, such as mebeverine hydrochloride, are commonly used to alleviate pain and bloating in IBS patients. Loperamide is the first choice of antimotility agent for diarrhea, while laxatives are recommended for constipation. Tricyclic antidepressants (TCAs), such as amitriptyline, are considered a second-line treatment option for IBS patients who do not respond to other medications. However, the use of opioids, such as tramadol, is not recommended due to the risk of constipation, dependence, and tolerance.
In conclusion, pharmacological management of IBS should be tailored to the individual patient’s symptoms and needs, with a focus on providing relief from pain, bloating, and altered bowel habits. Regular review and adjustment of medication dosages are necessary to ensure optimal treatment outcomes.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 2
Correct
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A 31-year-old pilot comes in for his yearly physical examination. He has no significant medical history, does not take any regular medication, and reports no concerning symptoms. He maintains a healthy lifestyle and enjoys participating in ultramarathons as a runner.
During the physical examination, an ECG is conducted, which was normal during his last check-up the previous year. What would be the most worrisome ECG characteristic?Your Answer: Left bundle branch block (LBBB)
Explanation:A new left bundle branch block on an ECG is always a sign of pathology and not a normal variant. It indicates a delay in the left half of the conducting system, which can be caused by conditions such as aortic stenosis, cardiomyopathy, or ischaemia. However, other findings on an ECG, such as J-waves, left axis deviation, second-degree heart block (Mobitz I), or a short QT interval, may be normal variants in a healthy individual and not a cause for concern unless accompanied by symptoms of arrhythmias.
Left Bundle Branch Block: Causes and Diagnosis
Left bundle branch block (LBBB) is a cardiac condition that can be diagnosed through an electrocardiogram (ECG). The ECG shows typical features of LBBB, including a ‘W’ in V1 and a ‘M’ in V6. It is important to note that new LBBB is always pathological and can be caused by various factors such as myocardial infarction, hypertension, aortic stenosis, and cardiomyopathy. However, diagnosing a myocardial infarction for patients with existing LBBB can be difficult. In such cases, the Sgarbossa criteria can be used to aid in diagnosis.
Other rare causes of LBBB include idiopathic fibrosis, digoxin toxicity, and hyperkalaemia. It is crucial to identify the underlying cause of LBBB to determine the appropriate treatment plan. Therefore, patients with LBBB should undergo further evaluation and testing to determine the cause of their condition. By identifying the cause of LBBB, healthcare professionals can provide appropriate treatment and management to improve the patient’s overall health and well-being.
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This question is part of the following fields:
- Cardiovascular
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Question 3
Incorrect
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A woman in her early stages of pregnancy seeks guidance on whether it is safe to consume alcohol. What advice aligns with the current NICE guidelines?
Your Answer: Avoid first and second trimester. If then chooses to drink 1 to 4 units no more than twice per week
Correct Answer: Avoid alcohol throughout pregnancy
Explanation:Antenatal care guidelines were issued by NICE in March 2008, which included specific points for the care of healthy pregnant women. Nausea and vomiting can be treated with natural remedies such as ginger and acupuncture on the ‘p6’ point, as recommended by NICE. Antihistamines, with promethazine as the first-line option according to the BNF, can also be used. Adequate vitamin D intake is crucial for the health of both the mother and baby, and women should be informed about this at their booking appointment. The Chief Medical Officer advises all pregnant and breastfeeding women to take a daily supplement containing 10 micrograms of vitamin D, with particular care taken for those at risk. In 2016, new guidelines were proposed by the Chief Medical Officer regarding alcohol consumption during pregnancy. The government now advises pregnant women not to drink any alcohol to minimize the risk of harm to the baby.
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This question is part of the following fields:
- Reproductive Medicine
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Question 4
Correct
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A 21-year-old female medical student, who is an insulin-dependent diabetic, went on a weekend trip to visit some friends at another university. She forgot to pack her insulin. When she returned, she went to visit her General Practitioner. Which of the following blood results would be expected?
Your Answer: Unchanged haemoglobin A1c (HbA1c)
Explanation:Insulin-dependent diabetes patients rely on insulin to regulate their blood glucose levels. Without insulin, several physiological changes occur. However, these changes do not happen immediately. Here are some effects of insulin absence in insulin-dependent diabetes patients:
Unchanged HbA1c levels – Correct: HbA1c levels do not change significantly over two to three days without insulin. Changes in HbA1c levels are observed over weeks and months.
Below normal fatty acid levels – Incorrect: In the absence of insulin, triglyceride hydrolysis and increased release from adipose tissue occur, giving raised fatty acid levels. Fatty acids are utilised to synthesise ketones.
Below normal glucagon levels – Incorrect: The body responds to the absence of insulin by increasing glucagon levels. In a healthy individual, this raised glucagon would raise glucose levels in the bloodstream, providing target organs with utilisable glucose. However, in a diabetic patient, the absence of insulin means target organs are still not able to utilise this resource.
Hypoglycaemia – Incorrect: In the absence of insulin, hyperglycaemia would be expected to develop. Ketones are generated by the body as an alternative energy source to glucose, since to utilise glucose, insulin is required.
Undetectable ketones – Incorrect: A diabetic patient who is normally dependent on insulin is at risk of developing diabetic ketoacidosis (DKA) even with only a weekend of missed insulin doses.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 5
Incorrect
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A 64-year-old woman presents to her GP complaining of worsening dyspnea. Upon taking a detailed medical history and conducting a thorough physical examination, the GP orders an outpatient chest CT scan. The results reveal lung fibrosis as the likely cause of the patient's symptoms. The patient has a medical history of gout and rheumatoid arthritis. Which medication prescribed to the patient is most likely responsible for causing lung fibrosis?
Your Answer:
Correct Answer: Sulfasalazine
Explanation:Drugs that can lead to lung fibrosis
Lung fibrosis is a condition where the lung tissue becomes scarred and thickened, making it difficult for the lungs to function properly. There are several drugs that can cause lung fibrosis as a side effect. These drugs include amiodarone, which is used to treat heart rhythm problems, cytotoxic agents such as busulphan and bleomycin, which are used to treat cancer, and anti-rheumatoid drugs like methotrexate and sulfasalazine. Nitrofurantoin, an antibiotic used to treat urinary tract infections, and ergot-derived dopamine receptor agonists like bromocriptine, cabergoline, and pergolide, which are used to treat Parkinson’s disease, can also cause lung fibrosis. It is important to be aware of the potential side effects of these drugs and to discuss any concerns with a healthcare provider. Proper monitoring and management can help prevent or minimize the risk of lung fibrosis.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 6
Incorrect
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A 50-year-old woman comes in for a check-up. She has recently noticed several areas of pale skin on her hands. Despite using an emollient and topical hydrocortisone, there has been no improvement. During the examination, you observe multiple depigmented patches on the back of both hands. The patient's medical history includes a previous diagnosis of thyrotoxicosis, for which she is currently taking carbimazole and thyroxine. What is the probable reason for her symptoms?
Your Answer:
Correct Answer: Vitiligo
Explanation:Patients with autoimmune conditions like thyrotoxicosis are more likely to have vitiligo, but there are no other indications in the medical history that point towards Addison’s disease.
Understanding Vitiligo
Vitiligo is a condition that affects the skin, resulting in the loss of melanocytes and causing depigmentation. It is an autoimmune disorder that affects approximately 1% of the population, with symptoms typically appearing between the ages of 20-30 years. The condition is characterized by well-defined patches of depigmented skin, with the peripheries being the most affected. Trauma can also trigger new lesions, known as the Koebner phenomenon.
Vitiligo is often associated with other autoimmune disorders such as type 1 diabetes mellitus, Addison’s disease, autoimmune thyroid disorders, pernicious anemia, and alopecia areata. Management of the condition includes the use of sunblock for affected areas of skin, camouflage make-up, and topical corticosteroids, which may reverse the changes if applied early. There may also be a role for topical tacrolimus and phototherapy, although caution needs to be exercised with light-skinned patients.
In summary, vitiligo is a condition that affects the skin, resulting in depigmentation. It is an autoimmune disorder that can be managed with various treatments, including sunblock, make-up, and topical corticosteroids. It is often associated with other autoimmune disorders, and caution should be exercised when using certain treatments.
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This question is part of the following fields:
- Dermatology
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Question 7
Incorrect
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A 50-year-old woman presents to the GP clinic with complaints of heavy vaginal bleeding. She reports having regular menstrual cycles and denies any intermenstrual or postcoital bleeding. The patient has no significant gynaecological history and is not on any regular medications. She is not in a committed relationship and uses condoms for contraception. Additionally, she has no desire to have children. What is the recommended initial treatment option?
Your Answer:
Correct Answer: Intrauterine system
Explanation:For the treatment of menorrhagia, the first-line option would be the intrauterine system. Specifically, the Mirena, which contains levonorgestrel, is highly effective in treating menorrhagia and also serves as a long-acting reversible contraceptive. While the combined oral contraceptive pill, tranexamic acid, and mefenamic acid may provide relief from symptoms, they are not the preferred initial treatment. On the other hand, the intrauterine device would not be suitable for addressing this patient’s menorrhagia.
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 8
Incorrect
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A 30-year-old male presents with progressive weakness and fatigue over the past year. He reports difficulty achieving and maintaining an erection with his new partner, which is a new symptom for him. Laboratory tests reveal elevated ferritin levels. The patient is started on a treatment plan that involves regular phlebotomies.
What is the most effective way to monitor the patient's response to treatment?Your Answer:
Correct Answer: Ferritin and transferrin saturation
Explanation:To monitor treatment in haemochromatosis, the most effective combination of iron tests is ferritin and transferrin saturation. These tests can track the response to treatment by measuring total iron stores and the amount of serum iron bound to proteins in the blood. However, serum transferrin and serum iron are not reliable indicators of treatment response as they fluctuate throughout the day and are affected by diet and phlebotomies. Therefore, using ferritin and serum transferrin or serum iron would not be the most useful combination for monitoring haemochromatosis. Similarly, using serum iron and serum transferrin together would not provide any insight into treatment monitoring. The most appropriate and effective combination is ferritin and transferrin saturation.
Understanding Haemochromatosis: Investigation and Management
Haemochromatosis is a genetic disorder that causes iron accumulation in the body due to mutations in the HFE gene on both copies of chromosome 6. The best investigation to screen for haemochromatosis is still a topic of debate. For the general population, transferrin saturation is considered the most useful marker, while genetic testing for HFE mutation is recommended for testing family members. Diagnostic tests include molecular genetic testing for the C282Y and H63D mutations and liver biopsy with Perl’s stain. A typical iron study profile in a patient with haemochromatosis includes high transferrin saturation, raised ferritin and iron, and low TIBC.
The first-line treatment for haemochromatosis is venesection, which involves removing blood from the body to reduce iron levels. Transferrin saturation should be kept below 50%, and the serum ferritin concentration should be below 50 ug/l to monitor the adequacy of venesection. If venesection is not effective, desferrioxamine may be used as a second-line treatment. Joint x-rays may show chondrocalcinosis, which is a characteristic feature of haemochromatosis. It is important to note that there are rare cases of families with classic features of genetic haemochromatosis but no mutation in the HFE gene.
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This question is part of the following fields:
- Haematology/Oncology
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Question 9
Incorrect
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A mother brings her 8-year-old daughter to her General Practitioner, who is acutely unwell and has a high temperature, runny nose and inflamed eyes. The mother explains that her daughter has not had her vaccinations as she is worried about the long-term effects of the measles, mumps and rubella (MMR) jab.
Which of the following best reflects the current understanding of measles infection?Your Answer:
Correct Answer: It is more dangerous in overcrowded households
Explanation:Measles: Symptoms, Complications, and Prevention
Measles is a highly contagious viral infection that can lead to serious respiratory complications such as pneumonia, bronchiolitis, and bronchiectasis. While it does not cause recurrent pneumothoraces, severe infection from prolonged exposure to infected siblings in overcrowded households can be fatal.
Koplik’s spots, small red spots with bluish-white centers, are a characteristic late sign of measles infection that may appear on the mucous membranes of the mouth 1-2 days before the rash appears.
Contrary to popular belief, lifelong immunity is often established after natural infection with measles. This is also the mechanism by which the MMR vaccine prevents measles infection in later life.
Measles can also lead to corneal ulceration, especially in cases of vitamin A deficiency. High-dose oral vitamin A supplementation is recommended for all children with measles in developing countries to prevent this complication.
Overall, prevention through vaccination is the best way to avoid the serious complications of measles.
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This question is part of the following fields:
- Infectious Diseases
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Question 10
Incorrect
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A 68-year-old woman with chronic osteoarthritis to multiple joints has been managed on morphine modified-release for several months. She currently takes 30 mg morphine modified-release twice daily. She has also been using Oramorph 10 mg four times daily for the past week because the twice-daily, 30-mg morphine modified-release has not been helping. You decide to increase the total dose of modified-release morphine.
Which of the following is the most appropriate dose of morphine modified-release?
Select the SINGLE most appropriate dose from the list below. Select ONE option only.Your Answer:
Correct Answer: Morphine modified-release 50 mg twice daily
Explanation:Understanding Opioid Conversion and Dosage Adjustments
When managing pain in patients with advanced and progressive disease, strong opioids such as morphine are often used. However, as the patient’s condition changes, adjustments to the dosage and type of opioid may be necessary.
For example, if a patient is using a total of 100 mg of morphine in 24 hours and requires increased use of Oramorph PRN, it may be appropriate to increase the total daily dose of morphine modified-release. To calculate the new dose, simply add the total amount of morphine used in 24 hours and divide by 2, which gives a twice-daily dose for morphine modified-release.
It is important to note that transdermal patch formulations should not be routinely offered to patients for whom oral opioids are suitable. If a patient requires additional pain relief, other options such as adding a fentanyl patch may be considered.
When converting between different opioids, it is important to consult the BNF or local guidance for equi-analgesic potencies. For example, 10 mg of oral morphine is equivalent to 100 mg of codeine phosphate or dihydrocodeine, 1.3 mg of hydromorphone, 5 mg of oxycodone, 25 mg of tapentadol, or 67 mg of tramadol.
Dosage adjustments should always be undertaken with specialist advice, especially when converting to or from methadone. Transdermal opioids also require careful consideration, with buprenorphine and fentanyl patches available in various strengths and corresponding oral morphine equivalents.
In summary, understanding opioid conversion and dosage adjustments is crucial for effective pain management in patients with advanced and progressive disease.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 11
Incorrect
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A 25-year-old woman visits the GP clinic seeking emergency contraception after having unprotected sex last night, 14 days after giving birth. What is the most appropriate course of action?
Your Answer:
Correct Answer: Advice the patient that she does not require emergency contraception
Explanation:After giving birth, women need to use contraception only after 21 days.
As the woman in the question is only 14 days post-partum, she does not need emergency contraception. Therefore, the advice to her would be that emergency contraception is not necessary.
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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A 28-year-old woman comes to the doctor complaining of lower abdominal pain, pain during sexual intercourse, and an abnormal vaginal discharge. A vaginal swab reveals a positive chlamydia infection. She has no known allergies and is generally healthy. What is the most appropriate next step in managing this patient?
Your Answer:
Correct Answer: Prescribe a 7-day course of doxycycline
Explanation:Treatment Options for Chlamydia Infections
Chlamydia trachomatis is a common sexually transmitted infection that can be effectively treated with antibiotics. The National Institute for Health and Care Excellence (NICE) provides guidance on the appropriate antimicrobial prescribing for chlamydia infections.
The first-line treatment for chlamydia is a 7-day course of doxycycline. This medication is highly effective against Chlamydia trachomatis and is well-tolerated by most patients. If doxycycline cannot be used, such as in cases of pregnancy or allergy, a 7-day course of azithromycin can be given as a second-line option.
It is important for patients to complete their full course of antibiotics and to avoid sexual intercourse until treatment is complete. If the treatment is completed, there is no need for a test of cure to be carried out.
Other antibiotics, such as oral penicillin and cefalexin, are not effective against chlamydia infections. A one-off dose of intramuscular ceftriaxone is the treatment of choice for gonorrhoea infections, but it is not indicated for the treatment of chlamydia.
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This question is part of the following fields:
- Infectious Diseases
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Question 13
Incorrect
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A teenage boy presents with bizarre delusions, a blunted affect and tangential thought processes.
Which one of the following characteristics would indicate an unfavourable prognosis?
Your Answer:
Correct Answer: A prolonged premorbid history of social withdrawal
Explanation:Understanding Prognostic Factors in Schizophrenia
Schizophrenia is a complex mental illness that can have a significant impact on a person’s life. While there is no cure for schizophrenia, early diagnosis and treatment can help manage symptoms and improve outcomes. Understanding prognostic factors can also be helpful in predicting the course of the illness and developing appropriate treatment plans.
One important factor to consider is the premorbid history of the patient. A prolonged history of social withdrawal is predictive of more severe and long-lasting psychopathology. Additionally, a family history of schizophrenia in first-degree relatives can have a negative impact on prognosis, while a history in second-degree relatives has little significance.
The onset of illness is also an important factor to consider. In schizophrenia, a sudden onset of illness has a more favourable prognosis than an insidious one. However, if the patient presents with catatonic symptoms, this is actually an indicator of a relatively good prognosis.
Finally, MRI changes are associated with more severe symptoms and clinical course in people with schizophrenia. While it is not fully clear whether these changes are fixed or progress over time, they can be an important factor to consider in developing a treatment plan.
Overall, understanding these prognostic factors can help clinicians develop appropriate treatment plans and provide better support for patients with schizophrenia.
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This question is part of the following fields:
- Psychiatry
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Question 14
Incorrect
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A 6-month-old infant is presented to the emergency department by their caregiver. The infant is exhibiting a fever, lethargy, and decreased muscle tone. Additionally, a non-blanching rash is observed on the right arm of the infant. What is the best course of treatment?
Your Answer:
Correct Answer: IV ceftriaxone
Explanation:For an unwell child with suspected meningitis who is over 3 months old, the recommended initial empirical therapy is IV 3rd generation cephalosporin, such as ceftriaxone. IV cefuroxime, a 2nd generation cephalosporin, is not recommended for this purpose. IV cefotaxime + amoxicillin is recommended for babies at risk of jaundice, but as the child in this case is 4 months old, this is not necessary. IV co-amoxiclav and piperacillin do not provide adequate coverage for meningitis and are not suitable for central nervous system infections.
Investigation and Management of Meningitis in Children
Meningitis is a serious condition that can affect children. When investigating meningitis, it is important to note any contraindications to lumbar puncture, such as signs of raised intracranial pressure, focal neurological signs, papilloedema, significant bulging of the fontanelle, disseminated intravascular coagulation, or signs of cerebral herniation. For patients with meningococcal septicaemia, a lumbar puncture is contraindicated, and blood cultures and PCR for meningococcus should be obtained instead.
The management of meningitis in children involves administering antibiotics, such as IV amoxicillin (or ampicillin) and IV cefotaxime for children under three months, and IV cefotaxime (or ceftriaxone) for children over three months. Steroids should be considered if the lumbar puncture reveals certain findings, such as purulent cerebrospinal fluid, a high white blood cell count, or bacteria on Gram stain. Fluids should be administered to treat shock, and cerebral monitoring should be conducted, including mechanical ventilation if necessary.
It is also important to notify public health authorities and administer antibiotic prophylaxis to contacts. Ciprofloxacin is now preferred over rifampicin for this purpose. Overall, prompt and appropriate management of meningitis in children is crucial for ensuring the best possible outcomes.
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This question is part of the following fields:
- Paediatrics
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Question 15
Incorrect
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Which of the following is most commonly associated with the syndrome of inappropriate ADH secretion?
Your Answer:
Correct Answer: Small cell lung cancer
Explanation:SIADH is a frequent endocrine complication associated with small cell lung cancer.
SIADH is a condition where the body retains too much water, leading to low sodium levels in the blood. This can be caused by a variety of factors, including malignancies such as small cell lung cancer, neurological conditions like stroke or meningitis, infections such as tuberculosis or pneumonia, and certain drugs like sulfonylureas and SSRIs. Other causes may include positive end-expiratory pressure and porphyrias. Treatment for SIADH involves slowly correcting the sodium levels to avoid complications like central pontine myelinolysis. This can be done through fluid restriction, the use of demeclocycline to reduce responsiveness to ADH, or the use of ADH receptor antagonists. It is important to note that certain drugs, such as glimepiride and glipizide, have been reported to cause SIADH according to the BNF.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 16
Incorrect
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A 45-year-old man presents to the Emergency Department with a rash and feeling generally unwell. He has a history of epilepsy and recently started taking phenytoin three weeks ago. He developed mouth ulcers, malaise, and a cough about a week ago. Two days ago, he developed a widespread red rash that has now formed large fluid-filled blisters, covering approximately 30% of his body area. The lesions separate when slight pressure is applied. Upon examination, his temperature is 38.3ºC and pulse is 126/min. Blood results reveal:
Na+ 144 mmol/l
K+ 4.2 mmol/l
Bicarbonate 19 mmol/l
Urea 13.4 mmol/l
Creatinine 121 µmol/l
What is the most likely diagnosis?Your Answer:
Correct Answer: Toxic epidermal necrolysis
Explanation:Understanding Toxic Epidermal Necrolysis
Toxic epidermal necrolysis (TEN) is a severe skin disorder that can be life-threatening and is often caused by a reaction to certain drugs. It is characterized by extensive scalding of the skin, and is considered by some experts to be the most severe form of a range of skin disorders that includes erythema multiforme and Stevens-Johnson syndrome. Symptoms of TEN include fever, rapid heartbeat, and a positive Nikolsky’s sign, which means that the epidermis separates easily with slight lateral pressure.
The most effective way to manage TEN is to stop the use of the drug that caused the reaction. Supportive care is also necessary, and patients are often treated in an intensive care unit to monitor for potential complications such as electrolyte imbalances and fluid loss. Intravenous immunoglobulin is a commonly used first-line treatment for TEN, and has been shown to be effective. Other treatment options include immunosuppressive agents like ciclosporin and cyclophosphamide, as well as plasmapheresis.
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This question is part of the following fields:
- Dermatology
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Question 17
Incorrect
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A 20-year-old male patient visits his GP complaining of bloating, intermittent abdominal pain, weight loss, and diarrhoea. The serology test shows positive results for IgA anti-tissue transglutaminase (anti-TTG) antibodies. What test is most likely to confirm the diagnosis?
Your Answer:
Correct Answer: Jejunal biopsy
Explanation:If coeliac disease is suspected based on serology results, endoscopic intestinal biopsy should be performed in all patients as it is considered the most reliable method for diagnosis, even if the patient exhibits typical symptoms and has tested positive for anti-TTG antibodies which are highly specific and sensitive.
Investigating Coeliac Disease
Coeliac disease is a condition caused by sensitivity to gluten, which can lead to villous atrophy and malabsorption. It is often associated with other conditions such as dermatitis herpetiformis and autoimmune disorders. Diagnosis of coeliac disease is made through a combination of serology and endoscopic intestinal biopsy. The gold standard for diagnosis is the biopsy, which should be performed in all patients with suspected coeliac disease to confirm or exclude the diagnosis. The biopsy traditionally takes place in the duodenum, but jejunal biopsies are also sometimes performed. Findings supportive of coeliac disease include villous atrophy, crypt hyperplasia, an increase in intraepithelial lymphocytes, and lamina propria infiltration with lymphocytes. Serology tests for coeliac disease include tissue transglutaminase antibodies and endomyseal antibodies, while anti-gliadin antibodies are not recommended. Patients who are already on a gluten-free diet should reintroduce gluten for at least six weeks prior to testing. Rectal gluten challenge is not widely used. A gluten-free diet can reverse villous atrophy and immunology in patients with coeliac disease.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 18
Incorrect
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A 65-year-old woman arrives at the Emergency Department complaining of breathlessness and a dry cough that has persisted for three weeks. She is a non-smoker and consumes 10 units of alcohol per week. The patient has a target rash on both of her lower limbs, and her chest x-ray reveals reticulonodular shadowing on the left lung. The medical team diagnoses her with bacterial pneumonia. What is the probable causative agent responsible for her symptoms?
Your Answer:
Correct Answer: Mycoplasma pneumoniae
Explanation:Based on the dry cough, symmetrical target-shaped rash with a central blister (erythema multiforme), and radiological findings, it is likely that the woman has Mycoplasma. While pneumococcal pneumonia is the most common type of pneumonia in the community, it would typically present with lobar consolidation on an x-ray and a productive cough, rather than a dry one. Klebsiella pneumonia is more common in alcoholics, but the woman’s drinking habits, while exceeding the recommended limit for women (14 units per week), are not severe enough to increase her risk of Klebsiella. Additionally, Klebsiella pneumonia typically causes a cavitating pneumonia in the upper lobes.
Mycoplasma pneumoniae: A Cause of Atypical Pneumonia
Mycoplasma pneumoniae is a type of bacteria that causes atypical pneumonia, which is more common in younger patients. This disease is associated with various complications such as erythema multiforme and cold autoimmune haemolytic anaemia. Epidemics of Mycoplasma pneumoniae typically occur every four years. It is important to recognize atypical pneumonia because it may not respond to penicillins or cephalosporins due to the bacteria lacking a peptidoglycan cell wall.
The disease usually has a gradual onset and is preceded by flu-like symptoms, followed by a dry cough. X-rays may show bilateral consolidation. Complications may include cold agglutinins, erythema multiforme, erythema nodosum, meningoencephalitis, Guillain-Barre syndrome, bullous myringitis, pericarditis/myocarditis, and gastrointestinal and renal problems.
Diagnosis is generally made through Mycoplasma serology and a positive cold agglutination test. Management involves the use of doxycycline or a macrolide such as erythromycin or clarithromycin.
In comparison to Legionella pneumonia, which is caused by a different type of bacteria, Mycoplasma pneumoniae has a more gradual onset and is associated with different complications. It is important to differentiate between the two types of pneumonia to ensure appropriate treatment.
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This question is part of the following fields:
- Infectious Diseases
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Question 19
Incorrect
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A 55-year-old man is found to have an irregularly irregular pulse during a routine check-up. An ECG reveals absent P waves and irregular R-R intervals. The patient has moderate renal impairment.
What is the most appropriate treatment option?Your Answer:
Correct Answer: Warfarin
Explanation:Understanding Anticoagulation Treatment for Atrial Fibrillation: A CHADS-VASc Scoring System Overview
Atrial fibrillation (AF) is a common rhythm disturbance that can increase the risk of stroke. To determine the appropriate treatment for primary prevention of stroke, healthcare professionals use the CHADS-VASc scoring system. This system assigns points based on various risk factors, including age, sex, hypertension, diabetes, previous stroke or transient ischemic attack, and vascular disease.
For women aged <65 with a score of 0 or men with a score of 1, anticoagulation treatment may not be necessary. However, women aged >65 with a score of 2 or men with a score of 2 or higher should be treated with warfarin or a novel anticoagulant (NOAC) to prevent stroke.
Aspirin is not recommended for primary prevention of stroke in patients with AF, but may be used for secondary prevention after a stroke. Clexane, a low-molecular-weight heparin, is not used for long-term treatment of AF. Dipyridamole may be used in combination with clopidogrel or aspirin for stroke treatment, but not for prevention in AF patients.
It is important to accurately identify AF and assess the patient’s risk using the CHADS-VASc scoring system to determine the appropriate anticoagulation treatment. NOACs are only licensed for non-valvular AF, so patients with valvular AF should be treated with warfarin or seek advice from a specialist.
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This question is part of the following fields:
- Cardiovascular
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Question 20
Incorrect
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As a foundation doctor in general practice, you have a patient who is a sexually active sixteen-year-old seeking advice about her contraceptive patch. She typically changes the patch on Saturday mornings but forgot to do so this week. What guidance should you provide?
Your Answer:
Correct Answer: Change the patch now, use barrier contraceptives for seven days and consider emergency contraception
Explanation:To ensure the effectiveness of the contraceptive patch, it should be applied to clean, dry skin on a weekly basis for three weeks, followed by a patch-free week to stimulate a withdrawal bleed. However, if the patch change is delayed for more than 48 hours, it is important to change it immediately and use a barrier method of contraception for the next 7 days. In case of unprotected intercourse, emergency contraceptives should be considered.
The Evra patch is the only contraceptive patch that is approved for use in the UK. The patch cycle lasts for four weeks, during which the patch is worn every day for the first three weeks and changed weekly. During the fourth week, the patch is not worn, and a withdrawal bleed occurs.
If a woman delays changing the patch at the end of week one or two, she should change it immediately. If the delay is less than 48 hours, no further precautions are necessary. However, if the delay is more than 48 hours, she should change the patch immediately and use a barrier method of contraception for the next seven days. If she has had unprotected sex during this extended patch-free interval or in the last five days, emergency contraception should be considered.
If the patch removal is delayed at the end of week three, the woman should remove the patch as soon as possible and apply a new patch on the usual cycle start day for the next cycle, even if withdrawal bleeding is occurring. No additional contraception is needed.
If patch application is delayed at the end of a patch-free week, additional barrier contraception should be used for seven days following any delay at the start of a new patch cycle. For more information, please refer to the NICE Clinical Knowledge Summary on combined hormonal methods of contraception.
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This question is part of the following fields:
- Reproductive Medicine
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Question 21
Incorrect
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A 32-year-old woman with epilepsy complains of acne and bleeding gums. Which medication is most likely responsible for these symptoms?
Your Answer:
Correct Answer: Phenytoin
Explanation:Side Effects of Common Anticonvulsants
Anticonvulsants are medications used to treat seizures and epilepsy. However, they commonly have side effects that patients should be aware of. Here are some of the common or more serious side effects reported for some of the most commonly prescribed anticonvulsants:
Phenytoin: This medication can cause paraesthesia, gingival hypertrophy, tiredness, acne, hirsutism, coarsening of facial appearance, peripheral neuropathy, Steven-Johnson syndrome, and blood dyscrasias (such as aplastic anaemia and megaloblastic anaemia).
Sodium valproate (Epilim®): Side effects of this medication may include weight gain, thrombocytopenia, transient hair loss, aggression and behavioural changes, ataxia and tremors.
Carbamazepine: Dry mouth, fatigue, hyponatraemia, blood dyscrasia (such as aplastic anaemia), thrombocytopenia, haemolytic anaemia, eosinophilia, dermatitis, gynaecomastia, male infertility, hepatitis, and restlessness are all possible side effects of this medication.
Lamotrigine (Lamictal®): Skin rash and hypersensitivity, blurred vision, dizziness, sleep disturbance, and joint pains are some of the side effects that may occur with this medication.
Levetiracetam (Keppra®): Weight change and anorexia, abdominal pains, nausea, diarrhoea, and anxiety are all possible side effects of this medication.
It’s important to note that gingival hypertrophy and tenderness are common effects of phenytoin, but not the other medications listed. Patients taking phenytoin should be encouraged to maintain good oral hygiene. Overall, patients should be aware of the potential side effects of their anticonvulsant medication and discuss any concerns with their healthcare provider.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 22
Incorrect
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A social worker in their 40s has been diagnosed with hepatitis C infection.
Which test will conclusively establish the presence of this infection?Your Answer:
Correct Answer: HCV RNA
Explanation:Hepatitis C Testing Methods
Hepatitis C is a viral infection that affects the liver. There are several testing methods available to diagnose and monitor hepatitis C infection.
Quantitative HCV RNA tests measure the amount of hepatitis C virus in the blood, which is also known as the viral load. This test is the most sensitive and accurate way to confirm a hepatitis C diagnosis, especially when viral loads are low.
Screening tests for co-infection with other viruses, such as hepatitis B or HIV, may be done but do not assist in the diagnosis of hepatitis C infection itself.
Anti-hepatitis C virus (HCV) serologic screening involves an enzyme immunoassay (EIA) that can detect antibodies to the virus. However, this test cannot distinguish between acute and chronic infection and may yield false-positive results.
HCV genotyping is a helpful tool for predicting the likelihood of response and duration of treatment. It is used in adult, non-immunocompromised patients with known chronic HCV infection.
Immunoglobulin M (IgM) anti-HAV screening tests for co-infection with hepatitis A virus may be done but do not assist in the diagnosis of hepatitis C infection itself.
Hepatitis C Testing Methods
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This question is part of the following fields:
- Immunology/Allergy
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Question 23
Incorrect
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A 48-year-old male patient visits the GP clinic with a history of hip and back pain that has been getting worse over the past 3 years. The patient reports that the hip pain is more severe when bearing weight and improves with rest. During the examination, you observe frontal bossing and leg bowing.
What is the initial treatment option that should be considered for this patient's condition?Your Answer:
Correct Answer: Alendronate
Explanation:Bisphosphonates are the primary treatment for Paget’s disease of the bone.
Replacing vitamin D is not an effective treatment for Paget’s disease.
Radiotherapy is used to treat osteosarcoma, not Paget’s disease.
Cinacalcet is used to treat hypercalcemia caused by hyperparathyroidism, not Paget’s disease.Understanding Paget’s Disease of the Bone
Paget’s disease of the bone is a condition characterized by increased and uncontrolled bone turnover. It is believed to be caused by excessive osteoclastic resorption followed by increased osteoblastic activity. Although it is a common condition, affecting 5% of the UK population, only 1 in 20 patients experience symptoms. The most commonly affected areas are the skull, spine/pelvis, and long bones of the lower extremities. Predisposing factors include increasing age, male sex, northern latitude, and family history.
Symptoms of Paget’s disease include bone pain, particularly in the pelvis, lumbar spine, and femur. The stereotypical presentation is an older male with bone pain and an isolated raised alkaline phosphatase (ALP). Classical, untreated features include bowing of the tibia and bossing of the skull. Diagnosis is made through blood tests, which show raised ALP, and x-rays, which reveal osteolysis in early disease and mixed lytic/sclerotic lesions later.
Treatment is indicated for patients experiencing bone pain, skull or long bone deformity, fracture, or periarticular Paget’s. Bisphosphonates, either oral risedronate or IV zoledronate, are the preferred treatment. Calcitonin is less commonly used now. Complications of Paget’s disease include deafness, bone sarcoma (1% if affected for > 10 years), fractures, skull thickening, and high-output cardiac failure.
Overall, understanding Paget’s disease of the bone is important for early diagnosis and management of symptoms and complications.
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This question is part of the following fields:
- Musculoskeletal
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Question 24
Incorrect
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As a foundation doctor on the neonatal ward, you conduct a newborn examination on a six hour old infant. The baby was delivered vaginally at 38 weeks with no risk factors for sepsis and no maternal concerns. The baby was born in a healthy condition, with good tone. However, you observe cyanosis in the peripheries, while the rest of the examination appears normal. Pre and post ductal oxygen saturations are at 97%. What is the probable diagnosis?
Your Answer:
Correct Answer: Acrocyanosis
Explanation:Cyanosis, a bluish discoloration of the skin, is a common occurrence in newborns. Peripheral cyanosis, which affects the hands and feet, is often seen in the first 24 hours of life and can be caused by crying or illness. Central cyanosis, on the other hand, is a more serious condition that occurs when the concentration of reduced hemoglobin in the blood exceeds 5g/dl. To differentiate between cardiac and non-cardiac causes of central cyanosis, doctors may use the nitrogen washout test, which involves giving the infant 100% oxygen for ten minutes and then measuring arterial blood gases. A pO2 of less than 15 kPa indicates cyanotic congenital heart disease, which can be caused by conditions such as tetralogy of Fallot, transposition of the great arteries, and tricuspid atresia.
If cyanotic congenital heart disease is suspected, initial management involves supportive care and the use of prostaglandin E1, such as alprostadil, to maintain a patent ductus arteriosus in ductal-dependent congenital heart defects. This can serve as a temporary measure until a definitive diagnosis is made and surgical correction is performed.
Acrocyanosis, a type of peripheral cyanosis, is a benign condition that is often seen in healthy newborns. It is characterized by bluish discoloration around the mouth and extremities, such as the hands and feet, and is caused by vasomotor changes that result in peripheral vasoconstriction and increased tissue oxygen extraction. Unlike other causes of peripheral cyanosis that may indicate significant pathology, such as septic shock, acrocyanosis occurs immediately after birth in healthy infants and typically resolves within 24 to 48 hours.
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This question is part of the following fields:
- Paediatrics
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Question 25
Incorrect
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A 45-year-old woman, who is a non-smoker, presents with back pain. A bone scan shows multiple lesions highly suggestive of metastases. Clinical examination is normal apart from unilateral axillary lymphadenopathy. Excision biopsy of an affected lymph node shows adenocarcinoma. Which of the following investigations should be prioritised to find the site of the primary?
Your Answer:
Correct Answer: Mammography
Explanation:When a patient presents with metastatic bone disease from an unknown primary, it is important to identify the primary source in order to guide treatment and determine prognosis. Tumours that commonly metastasize to bone include those of the lungs, prostate, breast, kidney, and thyroid.
In cases where the patient has unilateral axillary lymphadenopathy, metastatic breast carcinoma is highly likely. Other potential causes of unilateral axillary lymphadenopathy include lymphoma, primary malignancy, melanoma, or metastases from non-breast primary malignancy.
While there are various investigations that can be performed, mammography should be the first examination of choice. If the mammogram is negative, other investigations may be pursued to identify alternative occult sites.
It is important to note that identifying the primary source is useful even in cases of metastatic disease, as it can guide treatment and provide insight into prognosis. Therefore, mammography plays a crucial role in the diagnosis of metastatic breast cancer.
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This question is part of the following fields:
- Haematology/Oncology
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Question 26
Incorrect
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Which factors affect water excretion in the kidneys?
Your Answer:
Correct Answer: Vasopressin
Explanation:The Renal Tubules: Functions and Regulation
The kidneys play a crucial role in maintaining the body’s fluid and electrolyte balance. This is achieved through the intricate workings of the renal tubules, which are responsible for filtering and reabsorbing various substances from the blood.
Vasopressin, also known as antidiuretic hormone, regulates water excretion in the distal convoluted tubule and collecting ducts. Its receptor, vasopressin 2, triggers the insertion of aquaporin-2 channels, allowing water to be reabsorbed down an osmotic gradient.
The distal convoluted tubule regulates pH by absorbing bicarbonate and secreting protons, as well as controlling sodium and potassium levels through aldosterone-mediated ion transport. It also participates in calcium regulation by reabsorbing it in response to parathyroid hormone.
The proximal convoluted tubule reabsorbs the majority of ions and water in the urinary space back into the body.
The ascending limb of the loop of Henle is impermeable to water, but actively reabsorbs sodium, potassium, and chloride ions. This generates a positive electrochemical potential difference in the lumen, driving more paracellular reabsorption of sodium and other cations.
The collecting ducts continue the work of water reabsorption and electrolyte balance initiated in the collecting tubules. Progenitor cells within the collecting duct epithelium respond to tubular injury by proliferating and expanding the principal cell population to maintain epithelial integrity, or by committing to a myofibroblastic phenotype and forming peritubular collars in response to increased intraluminal pressure.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 27
Incorrect
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A 6-year-old girl is diagnosed with haemolytic uraemic syndrome (HUS), after a recent Salmonella infection. She is admitted to the hospital and blood tests demonstrate a platelet count of 85 × 109/l as well as a haemoglobin of 9 g/dl. She is maintaining good oral intake and her observations are normal.
What would be the next most appropriate step in this patient’s management?
Your Answer:
Correct Answer: Supportive treatment with intravenous fluids
Explanation:Treatment Options for Haemolytic Uraemic Syndrome
Haemolytic uraemic syndrome (HUS) is a condition that can lead to acute renal failure and even chronic renal failure if left untreated. The main treatment for HUS is supportive care, which often involves intravenous fluids to prevent renal damage and decline in renal function. Oral rehydration medications may be useful for patients with ongoing diarrhoea, but intravenous fluids are preferred for inpatients. Intravenous immunoglobulins are not used in the acute treatment of HUS, and transfusion of red blood cells and platelets is only necessary if the patient’s levels are significantly low. Intravenous steroids are not a viable treatment option for HUS.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 28
Incorrect
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A 4-year-old boy is brought to the Paediatric Emergency Department with a fever of one week. On evaluation, the child appears unwell, erythema of the palms and soles are noted, along with bilateral conjunctivitis. Examination of the oral cavity reveals cracked lips.
In addition to the above findings, which one of the following features would prompt an urgent referral for echocardiography?Your Answer:
Correct Answer: Rash on the trunk and extremities
Explanation:Clinical Features and Differential Diagnoses of Kawasaki Disease
Kawasaki disease is a rare but serious condition that primarily affects children under the age of five. To diagnose Kawasaki disease, a patient must have a fever for at least five days and four out of five classical features: bilateral, non-exudative conjunctival injection, changes in lips and oral cavity, oedema and erythema in the hands and feet, polymorphous rash, and cervical lymphadenopathy. However, tonsillar exudate, leukopenia, neck stiffness, and small submental lymph nodes are not classical features of Kawasaki disease and should prompt consideration of other differential diagnoses. Patients with confirmed Kawasaki disease should undergo echocardiographic examination to detect potential coronary artery aneurysms. Early diagnosis and treatment are crucial to prevent serious complications.
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This question is part of the following fields:
- Musculoskeletal
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Question 29
Incorrect
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A 55-year-old woman has been prescribed simvastatin for primary prevention of cardiovascular disease (CVD).
Which of the following should be the NEXT step?Your Answer:
Correct Answer: Check LFTs and lipid profiles at 3 months
Explanation:Monitoring Statin Therapy: Recommended Blood Tests and Timing
Statin therapy is a common treatment for patients with high cholesterol levels, both for primary and secondary prevention of cardiovascular disease. However, regular monitoring is necessary to ensure the treatment is effective and safe. Here are some recommended blood tests and their timing for monitoring statin therapy:
Recommended Blood Tests and Timing for Monitoring Statin Therapy
Check LFTs and lipid profiles at 3 months
Within three months of starting high-intensity statin treatment, it is recommended to measure total cholesterol, HDL-cholesterol, and non-HDL cholesterol. The aim is to achieve a >40% reduction in non-HDL-cholesterol. LFTs should also be checked at this time and again at 12 months, unless clinically indicated.
Check LFTs and lipid profiles at 12 months
Both LFTs and the lipid profile should be checked at 12 months, but it is important to assess whether a suitable cholesterol level reduction has been achieved earlier in the process. This allows for discussion of adherence to medication, diet, and lifestyle measures, and consideration of increasing the dose.
Check LFTs at 1 week
Checking LFTs within a week of starting treatment is not necessary, as any liver abnormalities would be unlikely to develop so soon without the patient experiencing symptoms of acute liver disease.
Check the lipid profiles at 1 month
It takes approximately 6-8 weeks for a stable result in lipid reduction to be seen after starting a statin, so checking the lipid profile at 1 month is not appropriate.
Check TFTs at 3 months
There is no need to check thyroid function tests during statin therapy for monitoring purposes. However, patients with other conditions that justify TFTs should have them done as clinically appropriate.
Regular monitoring of statin therapy through blood tests is crucial for ensuring the treatment is effective and safe for patients with high cholesterol levels.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 30
Incorrect
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A 28-year-old male patient visits his GP with complaints of progressive tunnel vision and difficulty seeing at night for the past year. He recalls his grandfather experiencing similar symptoms but is unsure of the cause. During fundus examination, bone-spicule pigmentation is observed in the peripheral retina. What is the probable diagnosis?
Your Answer:
Correct Answer: Retinitis pigmentosa
Explanation:The presence of black bone-spicule pigmentation on fundoscopy is a classic sign of retinitis pigmentosa, an inherited retinal disorder that causes tunnel vision and night blindness by affecting the peripheral retina.
Understanding Retinitis Pigmentosa
Retinitis pigmentosa is a condition that primarily affects the peripheral retina, leading to tunnel vision. The initial sign of this condition is often night blindness, which can progress to a loss of peripheral vision. Fundoscopy, a diagnostic test, reveals black bone spicule-shaped pigmentation in the peripheral retina and mottling of the retinal pigment epithelium. Retinitis pigmentosa is often associated with other diseases such as Refsum disease, Usher syndrome, abetalipoproteinemia, Lawrence-Moon-Biedl syndrome, Kearns-Sayre syndrome, and Alport’s syndrome.
To better understand retinitis pigmentosa, it is important to know that it is a genetic disorder that affects the retina’s ability to respond to light. This condition can lead to the death of photoreceptor cells in the retina, which are responsible for detecting light and transmitting visual information to the brain. As a result, individuals with retinitis pigmentosa may experience difficulty seeing in low light conditions, loss of peripheral vision, and, in severe cases, complete blindness.
In summary, retinitis pigmentosa is a genetic condition that primarily affects the peripheral retina, leading to tunnel vision. It is often associated with other diseases and can cause night blindness, loss of peripheral vision, and, in severe cases, complete blindness. Early diagnosis and management are crucial in preventing further vision loss.
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This question is part of the following fields:
- Ophthalmology
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