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Question 1
Correct
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A 65-year-old patient reports to their physician with a complaint of taste loss. After taking a thorough medical history, the doctor notes no recent infections. However, the patient does mention being able to taste normally when only using the tip of their tongue, such as when licking ice cream.
Which cranial nerve is impacted in this situation?Your Answer: Glossopharyngeal nerve
Explanation:The loss of taste in the posterior third of the tongue is due to a problem with the glossopharyngeal nerve (CN IX). This is because the patient can taste when licking the ice cream, indicating that the anterior two-thirds of the tongue are functioning normally. The facial nerve also provides taste sensation, but only to the anterior two-thirds of the tongue, so it is not responsible for the loss of taste in the posterior third. The hypoglossal nerve is not involved in taste sensation, but rather in motor innervation of the tongue. The olfactory nerve innervates the nose, not the tongue, and there is no indication of a problem with the patient’s sense of smell.
Cranial nerves are a set of 12 nerves that emerge from the brain and control various functions of the head and neck. Each nerve has a specific function, such as smell, sight, eye movement, facial sensation, and tongue movement. Some nerves are sensory, some are motor, and some are both. A useful mnemonic to remember the order of the nerves is Some Say Marry Money But My Brother Says Big Brains Matter Most, with S representing sensory, M representing motor, and B representing both.
In addition to their specific functions, cranial nerves also play a role in various reflexes. These reflexes involve an afferent limb, which carries sensory information to the brain, and an efferent limb, which carries motor information from the brain to the muscles. Examples of cranial nerve reflexes include the corneal reflex, jaw jerk, gag reflex, carotid sinus reflex, pupillary light reflex, and lacrimation reflex. Understanding the functions and reflexes of the cranial nerves is important in diagnosing and treating neurological disorders.
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This question is part of the following fields:
- Neurological System
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Question 2
Incorrect
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Which statement about steroid receptors is accurate?
Your Answer: Receptors have a transmembrane spanning domain
Correct Answer: Receptors have a DNA binding domain
Explanation:Steroid Receptors
Steroid receptors are composed of three main domains: ligand binding, DNA binding, and transcription activation. These receptors are typically found in the cytoplasm and are only translocated to the nucleus after binding with a ligand. However, the oestrogen receptor is an exception to this rule, as it is constitutively found in the nucleus.
In summary, steroid receptors are essential for the regulation of gene expression. They are composed of three domains and are typically found in the cytoplasm. However, the oestrogen receptor is an exception to this rule, as it is always found in the nucleus. the function of steroid receptors is crucial for developing treatments for various diseases.
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This question is part of the following fields:
- Pharmacology
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Question 3
Incorrect
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A 23-year-old man presents to an after-hours medical clinic following his return from a backpacking trip in Southeast Asia. He complains of abdominal pain, diarrhoea, and healing sores on the soles of his feet. Additionally, he has developed a new and extremely itchy rash that began in the perianal area and has spread to his buttocks over the last two hours. His vital signs include a respiratory rate of 18 breaths per minute, a heart rate of 92 beats per minute, and a blood pressure of 124/86 mmHg. He is not running a fever. What is the probable pathogen responsible for this presentation?
Your Answer: Pinworm
Correct Answer: Strongyloides stercoralis
Explanation:Helminths are a group of parasitic worms that can infect humans and cause various diseases. Nematodes, also known as roundworms, are one type of helminth. Strongyloides stercoralis is a type of roundworm that enters the body through the skin and can cause symptoms such as diarrhea, abdominal pain, and skin lesions. Treatment for this infection typically involves the use of ivermectin or benzimidazoles. Enterobius vermicularis, also known as pinworm, is another type of roundworm that can cause perianal itching and other symptoms. Diagnosis is made by examining sticky tape applied to the perianal area. Treatment typically involves benzimidazoles.
Hookworms, such as Ancylostoma duodenale and Necator americanus, are another type of roundworm that can cause gastrointestinal infections and anemia. Treatment typically involves benzimidazoles. Loa loa is a type of roundworm that is transmitted by deer fly and mango fly and can cause red, itchy swellings called Calabar swellings. Treatment involves the use of diethylcarbamazine. Trichinella spiralis is a type of roundworm that can develop after eating raw pork and can cause fever, periorbital edema, and myositis. Treatment typically involves benzimidazoles.
Onchocerca volvulus is a type of roundworm that causes river blindness and is spread by female blackflies. Treatment involves the use of ivermectin. Wuchereria bancrofti is another type of roundworm that is transmitted by female mosquitoes and can cause blockage of lymphatics and elephantiasis. Treatment involves the use of diethylcarbamazine. Toxocara canis, also known as dog roundworm, is transmitted through ingestion of infective eggs and can cause visceral larva migrans and retinal granulomas. Treatment involves the use of diethylcarbamazine. Ascaris lumbricoides, also known as giant roundworm, can cause intestinal obstruction and occasionally migrate to the lung. Treatment typically involves benzimidazoles.
Cestodes, also known as tapeworms, are another type of helminth. Echinococcus granulosus is a tapeworm that is transmitted through ingestion of eggs in dog feces and can cause liver cysts and anaphylaxis if the cyst ruptures
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This question is part of the following fields:
- General Principles
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Question 4
Incorrect
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A 32-year-old woman injures her sympathetic trunk and experiences Horner's syndrome. When sympathetic pathways are damaged, Horner's syndrome can occur. Which receptors are associated with her symptoms?
Your Answer: Muscarinic acetylcholine receptors to the eye
Correct Answer: Muscarinic acetylcholine receptors of sudomotor neurons to the sweat gland
Explanation:Acetylcholine is exclusively present in the postganglionic sympathetic fibers that lead to sweat glands.
Although muscarinic receptors can be activated by the vagus nerve to the heart, this is a component of the parasympathetic nervous system.
Muscarinic acetylcholine receptors in the salivary glands and the eye are both instances of muscarinic acetylcholine receptors in the parasympathetic nervous system.
The neuromuscular junction employs nicotinic acetylcholine receptors, but this is not a part of the sympathetic nervous system.
Acetylcholine (ACh) is a crucial neurotransmitter in the somatic nervous system and plays a significant role in the autonomic nervous system. It is the primary neurotransmitter in all pre- and postganglionic parasympathetic neurons, all preganglionic sympathetic neurons, and postganglionic sympathetic fibers, including sudomotor neurons that regulate sweat glands. Acetylcholinesterase is an enzyme that breaks down acetylcholine. In conditions such as myasthenia gravis, where there is a deficiency of functioning acetylcholine receptors, acetylcholinesterase inhibitors are used.
In the central nervous system, acetylcholine is synthesized in the basal nucleus of Meynert. Alzheimer’s disease is associated with decreased levels of acetylcholine in the basal nucleus of Meynert. Therefore, acetylcholine plays a crucial role in the functioning of the nervous system, and its deficiency can lead to various neurological disorders.
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This question is part of the following fields:
- General Principles
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Question 5
Correct
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An old woman on your ward is experiencing abdominal pain and has vomited twice today. She has not had a bowel movement for three days. During your examination, you notice that her abdomen is distended and her rectum is empty.
What is the most appropriate initial treatment?Your Answer: Give IV fluids and pass a nasogastric tube for decompression
Explanation:The initial management of small bowel obstruction involves administering IV fluids and performing gastric decompression through the use of a nasogastric tube, also known as ‘drip-and-suck’. Diagnostic laparoscopy is not necessary at this stage, unless there are signs of sepsis or peritonitis. Giving a laxative such as Senna is not recommended and requesting a surgical review is not necessary at this point.
Small bowel obstruction occurs when the small intestines are blocked, preventing the passage of food, fluids, and gas. The most common causes of this condition are adhesions resulting from previous surgeries and hernias. Symptoms include diffuse, central abdominal pain, nausea and vomiting (often bilious), constipation, and abdominal distension. Tinkling bowel sounds may also be present in early stages of obstruction. Abdominal x-ray is typically the first imaging test used to diagnose small bowel obstruction, showing distended small bowel loops with fluid levels. CT is more sensitive and considered the definitive investigation, particularly in early stages of obstruction. Management involves NBM, IV fluids, and a nasogastric tube with free drainage. Conservative management may be effective for some patients, but surgery is often necessary.
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This question is part of the following fields:
- Gastrointestinal System
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Question 6
Incorrect
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You are administering lidocaine to numb the skin of a young patient before a minor procedure. What is a true statement about this medication?
Your Answer: Is not affected by hepatic insufficiency
Correct Answer: Can be used to treat ventricular tachycardia
Explanation:Lidocaine: Characteristics and Uses
Lidocaine is a medication that is quickly broken down by the liver, making it unsuitable for oral administration. Its effects last for only 20 minutes, but this can be extended to approximately 90 minutes when combined with the vasoconstrictor adrenaline. However, this combination should not be used in areas where there is a risk of ischaemia.
Lidocaine is a potent antiarrhythmic drug that falls under class I, as it prolongs the action potential. It can be used to treat ventricular tachycardia, although it is not included in the ALS algorithm and should only be administered by a specialist.
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This question is part of the following fields:
- Pharmacology
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Question 7
Correct
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A 56-year-old man presents to his GP complaining of numbness and tingling in his thumb, middle, and index fingers for the past 8 months. This is beginning to interfere with his work as a financial analyst. He has a history of hypothyroidism for which he takes 100 micrograms of thyroxine daily.
Which nerves are involved in this condition?Your Answer: Median nerve
Explanation:To identify the affected nerve, it is crucial to accurately diagnose the underlying condition. The patient’s symptoms, such as numbness and tingling in the thumb and middle finger (and possibly the radial half of the ring finger), suggest carpal tunnel syndrome. Additionally, the patient’s occupation involving computer use and hypothyroidism are risk factors for this condition.
Carpal tunnel syndrome occurs when the median nerve is compressed at the carpal tunnel as it passes through the wrist.
Carpal tunnel syndrome is a condition that occurs when the median nerve in the carpal tunnel is compressed. This can cause pain and pins and needles sensations in the thumb, index, and middle fingers. In some cases, the symptoms may even travel up the arm. Patients may shake their hand to alleviate the discomfort, especially at night. During an examination, weakness in thumb abduction and wasting of the thenar eminence may be observed. Tapping on the affected area may also cause paraesthesia, and flexing the wrist can trigger symptoms.
There are several potential causes of carpal tunnel syndrome, including idiopathic factors, pregnancy, oedema, lunate fractures, and rheumatoid arthritis. Electrophysiology tests may reveal prolongation of the action potential in both motor and sensory nerves. Treatment options may include a six-week trial of conservative measures such as wrist splints at night or corticosteroid injections. If symptoms persist or are severe, surgical decompression may be necessary, which involves dividing the flexor retinaculum.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 8
Incorrect
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A 25-year-old patient arrives at the emergency department with a head injury after a night of heavy drinking. All his vital signs are normal, and his pupils react to light equally. A CT scan of his head shows no abnormalities. He reports feeling thirsty and experiencing excessive urination.
What is causing his polyuria?Your Answer: The sugar in alcoholic drinks leads to osmotic diuresis
Correct Answer: Inhibition of posterior pituitary gland
Explanation:Excessive alcohol consumption can result in the suppression of ADH in the posterior pituitary gland, which can lead to polyuria.
Normally, dehydration causes an increase in plasma osmolality, which triggers the release of vasopressin (antidiuretic hormone) from the posterior pituitary gland. This hormone increases the insertion of aquaporin 2 channels in the distal convoluted tubules and collecting duct in the kidney, which in turn increases water reabsorption. This leads to a decrease in plasma osmolality and a reduction in the volume of urine produced, i.e., antidiuretic.
However, alcohol inhibits this mechanism, resulting in polyuria and dehydration. Polyuria can then cause thirst, i.e., polydipsia.
It is important to note that the sugars in alcohol do not typically cause osmotic diuresis unless there is an underlying condition such as diabetes and hyperglycemia.
Polyuria, or excessive urination, can be caused by a variety of factors. A recent review in the BMJ categorizes these causes by their frequency of occurrence. The most common causes of polyuria include the use of diuretics, caffeine, and alcohol, as well as diabetes mellitus, lithium, and heart failure. Less common causes include hypercalcaemia and hyperthyroidism, while rare causes include chronic renal failure, primary polydipsia, and hypokalaemia. The least common cause of polyuria is diabetes insipidus, which occurs in less than 1 in 10,000 cases. It is important to note that while these frequencies may not align with exam questions, understanding the potential causes of polyuria can aid in diagnosis and treatment.
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This question is part of the following fields:
- Renal System
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Question 9
Incorrect
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A 56-year-old woman undergoes a serum calcium test. If her renal function is normal, what percentage of calcium filtered by the glomerulus will be reabsorbed by the renal tubules?
Your Answer: 50%
Correct Answer: 95%
Explanation:Maintaining Calcium Balance in the Body
Calcium ions are essential for various physiological processes in the body, and the largest store of calcium is found in the skeleton. The levels of calcium in the body are regulated by three hormones: parathyroid hormone (PTH), vitamin D, and calcitonin.
PTH increases calcium levels and decreases phosphate levels by increasing bone resorption and activating osteoclasts. It also stimulates osteoblasts to produce a protein signaling molecule that activates osteoclasts, leading to bone resorption. PTH increases renal tubular reabsorption of calcium and the synthesis of 1,25(OH)2D (active form of vitamin D) in the kidney, which increases bowel absorption of calcium. Additionally, PTH decreases renal phosphate reabsorption.
Vitamin D, specifically the active form 1,25-dihydroxycholecalciferol, increases plasma calcium and plasma phosphate levels. It increases renal tubular reabsorption and gut absorption of calcium, as well as osteoclastic activity. Vitamin D also increases renal phosphate reabsorption in the proximal tubule.
Calcitonin, secreted by C cells of the thyroid, inhibits osteoclast activity and renal tubular absorption of calcium.
Although growth hormone and thyroxine play a small role in calcium metabolism, the primary regulation of calcium levels in the body is through PTH, vitamin D, and calcitonin. Maintaining proper calcium balance is crucial for overall health and well-being.
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This question is part of the following fields:
- Neurological System
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Question 10
Correct
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You are requested to evaluate a 25-year-old woman who was brought in by the emergency medical services after reporting a bee sting. She has no known allergies but experienced sudden breathlessness and observed swelling of her lips.
Currently, the patient is feeling improved and can converse with you without difficulty. She believes that the medication administered to her during transportation is responsible for her progress.
What is the probable reason for the prompt amelioration of this patient's condition?Your Answer: Intramuscular 0.5ml 1:1000 adrenaline
Explanation:The most crucial drug to administer in cases of anaphylaxis is adrenaline. Hydrocortisone and chlorphenamine are no longer prescribed. It is probable that the patient experienced an anaphylactic reaction due to the bee sting, which is a common trigger for susceptible individuals.
The correct dosage in this scenario is 0.5ml of 1:1000 adrenaline via the intramuscular route. Adrenaline is essential in reducing mast cell degranulation and facilitating bronchodilation and blood pressure maintenance by acting on alpha and beta receptors.
Administering 1ml of 1:10,000 adrenaline subcutaneously is incorrect as this dosage is intended for cardiac arrest and the delivery method is not appropriate.
1ml of 1:1000 adrenaline via the intravenous route is also incorrect as the dosage is excessive, and intramuscular injection is the preferred method.
Chlorphenamine and hydrocortisone are no longer recommended for emergency anaphylaxis management due to insufficient evidence supporting their efficacy.
Anaphylaxis is a severe and potentially life-threatening allergic reaction that affects the entire body. It can be caused by various triggers, including food, drugs, and insect venom. The symptoms of anaphylaxis typically develop suddenly and progress rapidly, affecting the airway, breathing, and circulation. Swelling of the throat and tongue, hoarse voice, and stridor are common airway problems, while respiratory wheeze and dyspnea are common breathing problems. Hypotension and tachycardia are common circulation problems. Skin and mucosal changes, such as generalized pruritus and widespread erythematous or urticarial rash, are also present in around 80-90% of patients.
The most important drug in the management of anaphylaxis is intramuscular adrenaline, which should be administered as soon as possible. The recommended doses of adrenaline vary depending on the patient’s age, with the highest dose being 500 micrograms for adults and children over 12 years old. Adrenaline can be repeated every 5 minutes if necessary. If the patient’s respiratory and/or cardiovascular problems persist despite two doses of IM adrenaline, IV fluids should be given for shock, and expert help should be sought for consideration of an IV adrenaline infusion.
Following stabilisation, non-sedating oral antihistamines may be given to patients with persisting skin symptoms. Patients with a new diagnosis of anaphylaxis should be referred to a specialist allergy clinic, and an adrenaline injector should be given as an interim measure before the specialist allergy assessment. Patients should be prescribed two adrenaline auto-injectors, and training should be provided on how to use them. A risk-stratified approach to discharge should be taken, as biphasic reactions can occur in up to 20% of patients. The Resus Council UK recommends a fast-track discharge for patients who have had a good response to a single dose of adrenaline and have been given an adrenaline auto-injector and trained how to use it. Patients who require two doses of IM adrenaline or have had a previous biphasic reaction should be observed for a minimum of 6 hours after symptom resolution, while those who have had a severe reaction requiring more than two doses of IM adrenaline or have severe asthma should be observed for a minimum of 12 hours after symptom resolution. Patients who present late at night or in areas where access to emergency care may be difficult should also be observed for a minimum of 12
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This question is part of the following fields:
- General Principles
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Question 11
Incorrect
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A 39-year-old woman is being evaluated for progressive dyspnea and is found to have primary pulmonary hypertension. She is prescribed bosentan. What is the mode of action of bosentan?
Your Answer: Phosphodiesterase type 5 inhibitors
Correct Answer: Endothelin receptor antagonist
Explanation:Bosentan is an antagonist of the endothelin-1 receptor.
Pulmonary arterial hypertension (PAH) is a condition where the resting mean pulmonary artery pressure is equal to or greater than 25 mmHg. The pathogenesis of PAH is thought to involve endothelin. It is more common in females and typically presents between the ages of 30-50 years. PAH is diagnosed in the absence of chronic lung diseases such as COPD, although certain factors increase the risk. Around 10% of cases are inherited in an autosomal dominant fashion.
The classical presentation of PAH is progressive exertional dyspnoea, but other possible features include exertional syncope, exertional chest pain, peripheral oedema, and cyanosis. Physical examination may reveal a right ventricular heave, loud P2, raised JVP with prominent ‘a’ waves, and tricuspid regurgitation.
Management of PAH should first involve treating any underlying conditions. Acute vasodilator testing is central to deciding on the appropriate management strategy. If there is a positive response to acute vasodilator testing, oral calcium channel blockers may be used. If there is a negative response, prostacyclin analogues, endothelin receptor antagonists, or phosphodiesterase inhibitors may be used. Patients with progressive symptoms should be considered for a heart-lung transplant.
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This question is part of the following fields:
- Cardiovascular System
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Question 12
Incorrect
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A genetics clinic receives a family with a father and 2 of their 3 children (1 boy and 1 girl) who are all experiencing short stature, short fingers and toes, trident hands, and large heads. The affected members are identified as heterozygotes for a particular mutation, while the mother and the unaffected daughter do not possess this mutation. What is the inheritance pattern demonstrated in this case?
Your Answer: Autosomal dominant with variable penetrance
Correct Answer: Autosomal dominant with complete penetrance
Explanation:The example presented showcases achondroplasia, but it is not necessary to have prior knowledge of this condition for pre-clinical studies. The crucial aspect to focus on is the pattern of inheritance.
The affected individuals are identified as heterozygotes, indicating that the mutation is in the autosomal dominant form. This is further supported by the fact that the mother does not carry the mutation, ruling out the possibility of it being a recessive mutation.
Therefore, we can conclude that the pattern of inheritance is autosomal dominant, but we need to determine whether it is complete or variable penetrance. Complete penetrance means that all individuals who carry the mutation express the associated characteristics, while variable penetrance means that some individuals may carry the mutation but not exhibit the characteristics.
In this case, all individuals who carry the mutation express the characteristics, indicating that it is complete penetrance.
Autosomal Dominant Conditions: A List of Inherited Disorders
Autosomal dominant conditions are genetic disorders that are passed down from one generation to the next through a dominant gene. Unlike autosomal recessive conditions, which require two copies of a mutated gene to cause the disorder, autosomal dominant conditions only require one copy of the mutated gene. While some autosomal dominant conditions are considered structural, such as Marfan’s syndrome and osteogenesis imperfecta, others are considered metabolic, such as hyperlipidemia type II and hypokalemic periodic paralysis.
The following is a list of autosomal dominant conditions:
– Achondroplasia
– Acute intermittent porphyria
– Adult polycystic disease
– Antithrombin III deficiency
– Ehlers-Danlos syndrome
– Familial adenomatous polyposis
– Hereditary haemorrhagic telangiectasia
– Hereditary spherocytosis
– Hereditary non-polyposis colorectal carcinoma
– Huntington’s disease
– Hyperlipidaemia type II
– Hypokalaemic periodic paralysis
– Malignant hyperthermia
– Marfan’s syndromes
– Myotonic dystrophy
– Neurofibromatosis
– Noonan syndrome
– Osteogenesis imperfecta
– Peutz-Jeghers syndrome
– Retinoblastoma
– Romano-Ward syndrome
– Tuberous sclerosis
– Von Hippel-Lindau syndrome
– Von Willebrand’s disease*It’s important to note that while most types of von Willebrand’s disease are inherited as autosomal dominant, type 3 von Willebrand’s disease is inherited as an autosomal recessive trait.
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This question is part of the following fields:
- General Principles
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Question 13
Incorrect
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At 28 years old, Gwen seeks pre-conception advice from her haematologist regarding her Von Willebrand Disease (VWD). She is concerned about the potential risks of bleeding during pregnancy and childbirth, as well as the likelihood of passing on her condition to her child. Gwen is a carrier of VWD, while her partner Dylan does not have the condition. What is the probability of their child inheriting VWD?
Your Answer: 25%
Correct Answer: 50%
Explanation:The offspring of Gwen and Dylan will have the Vv allele combination, resulting in inheriting VWD with a probability of 50%.
Autosomal Dominant Inheritance: Characteristics and Complicating Factors
Autosomal dominant diseases are genetic disorders that are inherited in an autosomal dominant pattern. This means that both homozygotes and heterozygotes manifest the disease, and there is no carrier state. Both males and females can be affected, and only affected individuals can pass on the disease. The disease is passed on to 50% of children, and it normally appears in every generation. The risk remains the same for each successive pregnancy.
However, there are complicating factors that can affect the inheritance of autosomal dominant diseases. One of these factors is non-penetrance, which refers to the lack of clinical signs and symptoms despite having an abnormal gene. For example, 40% of individuals with otosclerosis may not show any symptoms. Another complicating factor is spontaneous mutation, which occurs when there is a new mutation in one of the gametes. This means that 80% of individuals with achondroplasia have unaffected parents.
In summary, autosomal dominant inheritance is characterized by certain patterns of inheritance, but there are also complicating factors that can affect the expression of the disease. Understanding these factors is important for genetic counseling and for predicting the risk of passing on the disease to future generations.
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This question is part of the following fields:
- General Principles
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Question 14
Incorrect
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You opt to obtain an arterial blood gas from the radial artery. Where should the needle be inserted to obtain the sample?
Your Answer:
Correct Answer: Mid inguinal point
Explanation:The femoral artery can be located using the mid inguinal point, which is positioned halfway between the anterior superior iliac spine and the symphysis pubis.
Understanding the Anatomy of the Femoral Triangle
The femoral triangle is an important anatomical region located in the upper thigh. It is bounded by the inguinal ligament superiorly, the sartorius muscle laterally, and the adductor longus muscle medially. The floor of the femoral triangle is made up of the iliacus, psoas major, adductor longus, and pectineus muscles, while the roof is formed by the fascia lata and superficial fascia. The superficial inguinal lymph nodes and the long saphenous vein are also found in this region.
The femoral triangle contains several important structures, including the femoral vein, femoral artery, femoral nerve, deep and superficial inguinal lymph nodes, lateral cutaneous nerve, great saphenous vein, and femoral branch of the genitofemoral nerve. The femoral artery can be palpated at the mid inguinal point, making it an important landmark for medical professionals.
Understanding the anatomy of the femoral triangle is important for medical professionals, as it is a common site for procedures such as venipuncture, arterial puncture, and nerve blocks. It is also important for identifying and treating conditions that affect the structures within this region, such as femoral hernias and lymphadenopathy.
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This question is part of the following fields:
- Gastrointestinal System
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Question 15
Incorrect
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A seven-year-old boy is being investigated for recurrent urinary tract infections. Imaging reveals abnormal fusion of the inferior poles of both kidneys, leading to a diagnosis of horseshoe kidney. During fetal development, what structure traps horseshoe kidneys as they ascend anteriorly?
Your Answer:
Correct Answer: Inferior mesenteric artery
Explanation:During fetal development, horseshoe kidneys become trapped under the inferior mesenteric artery as they ascend from the pelvis, resulting in their remaining low in the abdomen. This can lead to complications such as renal stones, infections, and hydronephrosis, including urteropelvic junction obstruction.
Understanding Horseshoe Kidney Abnormality
Horseshoe kidney is a condition that occurs during the embryonic development of the kidneys, where the lower poles of the kidneys fuse together, resulting in a U-shaped kidney. This abnormality is relatively common, affecting approximately 1 in 500 people in the general population. However, it is more prevalent in individuals with Turner’s syndrome, affecting 1 in 20 individuals with the condition.
The fused kidney is typically located lower than normal due to the root of the inferior mesenteric artery, which prevents the anterior ascent. Despite this abnormality, most people with horseshoe kidney do not experience any symptoms. It is important to note that this condition does not typically require treatment unless complications arise. Understanding this condition can help individuals with horseshoe kidney and their healthcare providers manage any potential health concerns.
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This question is part of the following fields:
- Renal System
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Question 16
Incorrect
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A 45-year-old patient is hospitalized for suspected typhoid fever and started on an antibiotic. After a week, she experiences extreme fatigue and blood tests show anaemia, neutropenia, and thrombocytopenia. Which antibiotic is the most probable cause of these symptoms?
Your Answer:
Correct Answer: Chloramphenicol
Explanation:Aplastic anaemia is a severe side effect of chloramphenicol, which is often used to treat typhoid fever. Ciprofloxacin can increase the risk of tendon rupture and lower the seizure threshold. Clindamycin is known to cause C. difficile diarrhoea, while doxycycline can lead to discolouration of teeth and photosensitivity.
Antibiotics that inhibit protein synthesis work by targeting specific components of the bacterial ribosome, which is responsible for translating genetic information into proteins. Aminoglycosides bind to the 30S subunit of the ribosome, causing errors in the reading of mRNA. Tetracyclines also bind to the 30S subunit, but block the binding of aminoacyl-tRNA. Chloramphenicol and clindamycin both bind to the 50S subunit, inhibiting different steps in the process of protein synthesis. Macrolides also bind to the 50S subunit, but specifically inhibit the movement of tRNA from the acceptor site to the peptidyl site.
While these antibiotics can be effective in treating bacterial infections, they can also have adverse effects. Aminoglycosides are known to cause nephrotoxicity and ototoxicity, while tetracyclines can cause discolouration of teeth and photosensitivity. Chloramphenicol is associated with a rare but serious side effect called aplastic anaemia, and clindamycin is a common cause of C. difficile diarrhoea. Macrolides can cause nausea, especially erythromycin, and can also inhibit the activity of certain liver enzymes (P450) and prolong the QT interval. Despite these potential side effects, these antibiotics are still commonly used in clinical practice, particularly in patients who are allergic to penicillin.
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This question is part of the following fields:
- General Principles
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Question 17
Incorrect
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A 62-year-old patient with multiple comorbidities, including atrial fibrillation, type 2 diabetes mellitus, mild arthritis of the knees, gastric oesophageal reflux disease and high cholesterol, is on several medications. The patient underwent a kidney transplant a few weeks ago and is now visiting the general practitioner with concerns about a persistent rise in blood sugar levels, blurry vision, increased thirst, and fatigue. Which medication is most likely responsible for these symptoms?
Your Answer:
Correct Answer: Tacrolimus
Explanation:Tacrolimus: An Immunosuppressant for Transplant Rejection Prevention
Tacrolimus is an immunosuppressant drug that is commonly used to prevent transplant rejection. It belongs to the calcineurin inhibitor class of drugs and has a similar action to ciclosporin. The drug works by reducing the clonal proliferation of T cells by decreasing the release of IL-2. It binds to FKBP, forming a complex that inhibits calcineurin, a phosphatase that activates various transcription factors in T cells. This is different from ciclosporin, which binds to cyclophilin instead of FKBP.
Compared to ciclosporin, tacrolimus is more potent, resulting in a lower incidence of organ rejection. However, it is also associated with a higher risk of nephrotoxicity and impaired glucose tolerance. Despite these potential side effects, tacrolimus remains an important drug in preventing transplant rejection and improving the success of organ transplantation.
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This question is part of the following fields:
- General Principles
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Question 18
Incorrect
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A 36-year-old man with a history of psoriasis presents with pain in his left knee, middle finger, and heel. He reports a family history of psoriasis. During examination, red, inflamed, and silvery plaques are observed on his elbows and scalp. Additionally, there is tenderness and swelling in the affected joints. What HLA haplotype is linked to his joint pain?
Your Answer:
Correct Answer: HLA-B27
Explanation:Psoriatic arthritis is often observed in individuals who possess the HLA-B27 antigen, as evidenced by the presence of asymmetrical and oligoarticular arthritis with enthesitis in the left heel, along with a history of psoriasis and a familial predisposition to the condition.
HLA Associations: Diseases and Antigens
HLA antigens are proteins encoded by genes on chromosome 6. There are two classes of HLA antigens: class I (HLA A, B, and C) and class II (HLA DP, DQ, and DR). Diseases can be strongly associated with certain HLA antigens. For example, HLA-A3 is associated with haemochromatosis, HLA-B51 with Behcet’s disease, and HLA-B27 with ankylosing spondylitis, reactive arthritis, and acute anterior uveitis. Coeliac disease is associated with HLA-DQ2/DQ8, while narcolepsy and Goodpasture’s are associated with HLA-DR2. Dermatitis herpetiformis, Sjogren’s syndrome, and primary biliary cirrhosis are associated with HLA-DR3. Finally, type 1 diabetes mellitus is associated with HLA-DR3 but more strongly associated with HLA-DR4, specifically the DRB1 gene (DRB1*04:01 and DRB1*04:04).
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This question is part of the following fields:
- General Principles
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Question 19
Incorrect
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What is the most probable cause of a macrocytic anaemia that is non-megaloblastic in nature?
Your Answer:
Correct Answer: Chronic liver disease
Explanation:The Relationship Between Chronic Diseases and Blood Cell Formation
Chronic liver disease, coeliac disease, and Crohn’s disease can all affect the formation of red blood cells in different ways. In chronic liver disease, cholesterol and lipids build up in the membrane of red blood cells, causing them to increase in size. However, DNA maturation is not impaired, so the nucleus is still ejected normally. Coeliac disease can lead to villous atrophy in the small intestine, which impairs the absorption of folic acid. Folate is necessary for DNA replication, and its deficiency can result in the formation of immature, large red cells with impaired DNA maturation. Crohn’s disease typically affects the terminal ileum, where vitamin B12 is absorbed. Vitamin B12 is important for the recycling of folate, which is essential for DNA synthesis. Without intrinsic factor, a co-factor in vitamin B12 absorption secreted by gastric parietal cells, vitamin B12 deficiency can occur. Chemotherapeutic agents that affect DNA synthesis can also lead to the formation of megaloblasts, as normal DNA maturation is impaired. Overall, these chronic diseases can have significant impacts on the formation of red blood cells and the body’s ability to produce healthy blood.
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This question is part of the following fields:
- Haematology And Oncology
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Question 20
Incorrect
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Which of the following anatomical structures is located in the spiral groove of the humerus?
Your Answer:
Correct Answer: Radial nerve
Explanation:Fractures involving the shaft can compromise the radial nerve, which is located in this groove.
The humerus is a long bone that runs from the shoulder blade to the elbow joint. It is mostly covered by muscle but can be felt throughout its length. The head of the humerus is a smooth, rounded surface that connects to the body of the bone through the anatomical neck. The surgical neck, located below the head and tubercles, is the most common site of fracture. The greater and lesser tubercles are prominences on the upper end of the bone, with the supraspinatus and infraspinatus tendons inserted into the greater tubercle. The intertubercular groove runs between the two tubercles and holds the biceps tendon. The posterior surface of the body has a spiral groove for the radial nerve and brachial vessels. The lower end of the humerus is wide and flattened, with the trochlea, coronoid fossa, and olecranon fossa located on the distal edge. The medial epicondyle is prominent and has a sulcus for the ulnar nerve and collateral vessels.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 21
Incorrect
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A 49-year-old male presents to the emergency department with severe back pain. He rates this pain as 7/10. His past medical history includes asthma, for which he takes salbutamol inhalers, and constipation. Although he usually takes laxatives, these were stopped following a few recent episodes of bloody diarrhoea. A significant family history exists for cardiovascular disease, and he neither smokes nor drinks alcohol. On examination, there is symmetrical, ascending weakness in the lower limbs. No further abnormalities were identified on examination.
Which organism is most likely associated with his current condition?Your Answer:
Correct Answer: Campylobacter jejuni
Explanation:Guillain-Barre syndrome is most commonly triggered by Campylobacter jejuni infection. It is important to suspect Guillain-Barre syndrome in patients with back pain, preceding gastrointestinal infection, and symmetrical, ascending weakness on examination. In addition to Guillain-Barre syndrome, Campylobacter jejuni is also associated with reactive arthritis. The other options listed may cause bloody diarrhea but are not typically associated with Guillain-Barre syndrome. Clostridium difficile is associated with antibiotic use, EHEC is associated with undercooked meat, and Entamoeba histolytica is associated with recent travel abroad.
Understanding Guillain-Barre Syndrome and Miller Fisher Syndrome
Guillain-Barre syndrome is a condition that affects the peripheral nervous system and is often triggered by an infection, particularly Campylobacter jejuni. The immune system attacks the myelin sheath that surrounds nerve fibers, leading to demyelination. This results in symptoms such as muscle weakness, tingling sensations, and paralysis.
The pathogenesis of Guillain-Barre syndrome involves the cross-reaction of antibodies with gangliosides in the peripheral nervous system. Studies have shown a correlation between the presence of anti-ganglioside antibodies, particularly anti-GM1 antibodies, and the clinical features of the syndrome. In fact, anti-GM1 antibodies are present in 25% of patients with Guillain-Barre syndrome.
Miller Fisher syndrome is a variant of Guillain-Barre syndrome that is characterized by ophthalmoplegia, areflexia, and ataxia. This syndrome typically presents as a descending paralysis, unlike other forms of Guillain-Barre syndrome that present as an ascending paralysis. The eye muscles are usually affected first in Miller Fisher syndrome. Studies have shown that anti-GQ1b antibodies are present in 90% of cases of Miller Fisher syndrome.
In summary, Guillain-Barre syndrome and Miller Fisher syndrome are conditions that affect the peripheral nervous system and are often triggered by infections. The pathogenesis of these syndromes involves the cross-reaction of antibodies with gangliosides in the peripheral nervous system. While Guillain-Barre syndrome is characterized by muscle weakness and paralysis, Miller Fisher syndrome is characterized by ophthalmoplegia, areflexia, and ataxia.
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This question is part of the following fields:
- Neurological System
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Question 22
Incorrect
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In response to cigarette smoke, does the respiratory epithelium undergo metaplasia and if so, what type of epithelial cell does it form?
Your Answer:
Correct Answer: Stratified squamous
Explanation:Epithelial Tissue and its Metaplasia
Epithelial tissue is a type of tissue that lines the surfaces of organs and structures in the body. Respiratory epithelium, which is made up of pseudostratified, ciliated columnar cells, can undergo a process called metaplasia. This is when the tissue transforms into a different type of tissue. In the case of respiratory epithelium, it can transform into stratified squamous epithelium. This transformation occurs when the cilia on the columnar cells are lost, and the cells become squamous in shape.
This transformation can be problematic, as the squamous cells can become dysplastic and lead to the development of squamous cell carcinoma in the lungs. Small cell carcinoma is another type of cancer that affects epithelial tissue, but its exact origin is not clear.
Different types of epithelial tissue can be found in various parts of the body. Simple columnar epithelium, for example, is commonly found in the stomach. Simple cuboidal epithelium lines the reproductive organs, such as the ovaries and testes. Small cell epithelium lines the large and small intestines, while transitional epithelium can be found in the bladder.
the different types of epithelial tissue and their potential for metaplasia can help in the diagnosis and treatment of various diseases and conditions.
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This question is part of the following fields:
- Clinical Sciences
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Question 23
Incorrect
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What is the definition of kwashiorkor?
Your Answer:
Correct Answer: Inadequate protein intake
Explanation:Malnutrition: Types and Causes
Malnutrition is a condition that can refer to both overnutrition (obesity) and undernutrition, but it is commonly used to describe the latter. Undernutrition can take different forms, with protein-energy malnutrition (PEM) being the most common. PEM can be further classified into kwashiorkor and marasmus, which are characterized by protein deficiency and inadequate consumption of both energy and protein, respectively. Kwashiorkor is associated with oedema, abdominal swelling, and fat accumulation in the liver, while marasmus leads to emaciation without oedema or abdominal swelling.
Despite being distinct clinical scenarios, kwashiorkor and marasmus are both types of protein-energy undernutrition. It is not clear why some patients develop one form of undernutrition over the other, even when they have similar diets. Malnutrition can also result from isolated vitamin or mineral deficiencies. the different types and causes of malnutrition is crucial in addressing this global health issue.
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This question is part of the following fields:
- Clinical Sciences
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Question 24
Incorrect
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A 39-year-old male visits his GP for a routine check-up of his high blood pressure. Despite being on a maximum dose of ramipril, amlodipine, and spironolactone, his blood pressure remains consistently at or above 160/100 mmHg. During the consultation, the patient reveals that he has been experiencing episodes of intense anxiety, sweating, palpitations, and fear about twice a week for the past six months.
What is the source of the hormone responsible for the symptoms experienced by this man?Your Answer:
Correct Answer: Adrenal medulla
Explanation:The patient’s symptoms suggest a phaeochromocytoma, which is caused by a tumor in the adrenal medulla that leads to the release of excess epinephrine. This results in refractory hypertension and severe episodes of sweating, palpitations, and anxiety.
While the pituitary gland produces hormones like thyroid-stimulating hormone and adrenocorticotropic hormone, these hormones do not directly cause the symptoms seen in this patient. Additionally, excess ACTH production is associated with Cushing’s syndrome, which does not fit the clinical picture.
The adrenal cortex has three distinct zones, each responsible for producing different hormones. The zona fasciculata produces glucocorticoids like cortisol, which can lead to Cushing’s syndrome. The zona glomerulosa produces mineralocorticoids like aldosterone, which can cause uncontrolled hypertension and electrolyte imbalances. The zona reticularis produces androgens like testosterone. However, none of these conditions match the symptoms seen in this patient.
The renin-angiotensin-aldosterone system is a complex system that regulates blood pressure and fluid balance in the body. The adrenal cortex is divided into three zones, each producing different hormones. The zona glomerulosa produces mineralocorticoids, mainly aldosterone, which helps regulate sodium and potassium levels in the body. Renin is an enzyme released by the renal juxtaglomerular cells in response to reduced renal perfusion, hyponatremia, and sympathetic nerve stimulation. It hydrolyses angiotensinogen to form angiotensin I, which is then converted to angiotensin II by angiotensin-converting enzyme in the lungs. Angiotensin II has various actions, including causing vasoconstriction, stimulating thirst, and increasing proximal tubule Na+/H+ activity. It also stimulates aldosterone and ADH release, which causes retention of Na+ in exchange for K+/H+ in the distal tubule.
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This question is part of the following fields:
- Renal System
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Question 25
Incorrect
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A 73-year-old woman is admitted to the acute surgical unit with profuse vomiting. Admission bloods show the following:
Na+ 131 mmol/l
K+ 2.2 mmol/l
Urea 3.1 mmol/l
Creatinine 56 mol/l
Glucose 4.3 mmol/l
What ECG feature is most likely to be seen in this patient?Your Answer:
Correct Answer: U waves
Explanation:Hypokalaemia, a condition characterized by low levels of potassium in the blood, can be detected through ECG features. These include the presence of U waves, small or absent T waves (which may occasionally be inverted), a prolonged PR interval, ST depression, and a long QT interval. The ECG image provided shows typical U waves and a borderline PR interval. To remember these features, one user suggests the following rhyme: In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT.
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This question is part of the following fields:
- Cardiovascular System
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Question 26
Incorrect
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Which section of an antibody is targeted by immune cells?
Your Answer:
Correct Answer: Fc region
Explanation:Cells of the immune system attach to the fragment crystallizable (Fc) region of immunoglobulins during crystallization.
Antibodies, also known as immunoglobulins, can be categorized into two primary pairs:
1. Fab region, which is responsible for binding to antigens
2. Fc region, which is the tail end of an antibody that interacts with receptors on the surface of cells.Immunoglobulins, also known as antibodies, are proteins produced by the immune system to help fight off infections and diseases. There are five types of immunoglobulins found in the body, each with their own unique characteristics.
IgG is the most abundant type of immunoglobulin in blood serum and plays a crucial role in enhancing phagocytosis of bacteria and viruses. It also fixes complement and can be passed to the fetal circulation.
IgA is the most commonly produced immunoglobulin in the body and is found in the secretions of digestive, respiratory, and urogenital tracts and systems. It provides localized protection on mucous membranes and is transported across the interior of the cell via transcytosis.
IgM is the first immunoglobulin to be secreted in response to an infection and fixes complement, but does not pass to the fetal circulation. It is also responsible for producing anti-A, B blood antibodies.
IgD’s role in the immune system is largely unknown, but it is involved in the activation of B cells.
IgE is the least abundant type of immunoglobulin in blood serum and is responsible for mediating type 1 hypersensitivity reactions. It provides immunity to parasites such as helminths and binds to Fc receptors found on the surface of mast cells and basophils.
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This question is part of the following fields:
- General Principles
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Question 27
Incorrect
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A 55-year-old man presents to the ENT clinic with a 10-week history of progressive dysphagia and a persistent sore throat. He reports no fever or cough, but has lost around 5kg in weight over the past 8 weeks.
During the examination, non-tender palpable cervical lymphadenopathy is observed. Upon oropharyngeal examination, an ill-defined ulcerated lesion is found at the back of the mouth. Biopsies are taken.
What is the most significant risk factor for the likely presentation of this patient?Your Answer:
Correct Answer: Human papillomavirus 16/18
Explanation:Understanding Oncoviruses and Their Associated Cancers
Oncoviruses are viruses that have the potential to cause cancer. These viruses can be detected through blood tests and prevented through vaccination. There are several types of oncoviruses, each associated with a specific type of cancer.
The Epstein-Barr virus, for example, is linked to Burkitt’s lymphoma, Hodgkin’s lymphoma, post-transplant lymphoma, and nasopharyngeal carcinoma. Human papillomavirus 16/18 is associated with cervical cancer, anal cancer, penile cancer, vulval cancer, and oropharyngeal cancer. Human herpes virus 8 is linked to Kaposi’s sarcoma, while hepatitis B and C viruses are associated with hepatocellular carcinoma. Finally, human T-lymphotropic virus 1 is linked to tropical spastic paraparesis and adult T cell leukemia.
It is important to understand the link between oncoviruses and cancer so that appropriate measures can be taken to prevent and treat these diseases. Vaccination against certain oncoviruses, such as HPV, can significantly reduce the risk of developing associated cancers. Regular screening and early detection can also improve outcomes for those who do develop cancer as a result of an oncovirus.
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This question is part of the following fields:
- General Principles
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Question 28
Incorrect
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A 60-year-old man visits his GP with worries about his hearing in recent months. He has difficulty understanding conversations in noisy environments and his spouse has commented on his need for the television to be turned up to maximum volume.
During the examination, the GP conducts some basic tests and finds:
Rinne's Test - Air conduction > bone conduction in both ears
Weber's Test - Lateralises to the left ear
What can be inferred from these test results?Your Answer:
Correct Answer: Left sensorineural hearing loss
Explanation:The patient has left sensorineural hearing loss, as indicated by the normal Rinne result (air conduction > bone conduction bilaterally) and abnormal Weber result (lateralising to the unaffected ear). In contrast, if the patient had conductive hearing loss, Rinne’s test would show bone conduction > air conduction, and Weber’s test would localise to the worse ear in bilateral conductive hearing loss or the affected ear in unilateral conductive hearing loss. For right sensorineural hearing loss, Rinne’s test would be normal, but Weber’s test would localise to the left ear.
Rinne’s and Weber’s Test for Differentiating Conductive and Sensorineural Deafness
Rinne’s and Weber’s tests are used to differentiate between conductive and sensorineural deafness. Rinne’s test involves placing a tuning fork over the mastoid process until the sound is no longer heard, then repositioning it just over the external acoustic meatus. A positive test indicates that air conduction (AC) is better than bone conduction (BC), while a negative test indicates that BC is better than AC, suggesting conductive deafness.
Weber’s test involves placing a tuning fork in the middle of the forehead equidistant from the patient’s ears and asking the patient which side is loudest. In unilateral sensorineural deafness, sound is localized to the unaffected side, while in unilateral conductive deafness, sound is localized to the affected side.
The table below summarizes the interpretation of Rinne and Weber tests. A normal result indicates that AC is greater than BC bilaterally and the sound is midline. Conductive hearing loss is indicated by BC being greater than AC in the affected ear and AC being greater than BC in the unaffected ear, with the sound lateralizing to the affected ear. Sensorineural hearing loss is indicated by AC being greater than BC bilaterally, with the sound lateralizing to the unaffected ear.
Overall, Rinne’s and Weber’s tests are useful tools for differentiating between conductive and sensorineural deafness, allowing for appropriate management and treatment.
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This question is part of the following fields:
- Respiratory System
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Question 29
Incorrect
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At 39 weeks, a fetus is diagnosed with transverse lie and despite undergoing External Cephalic Version at 37 weeks, the position remains unchanged. With only a few days left until the due date, what is the recommended mode of delivery for a fetus in transverse position?
Your Answer:
Correct Answer: Caesarean section
Explanation:When a fetus is in transverse lie, it means that its longitudinal axis is perpendicular to the long axis of the uterus. If an ECV has been attempted to change this position and has been unsuccessful, it is advisable to schedule an elective Caesarean section. This is because attempting a natural delivery would be pointless as the baby cannot fit through the pelvis in this position, which could result in a cord prolapse, hypoxia, and ultimately, death.
Transverse lie is an abnormal foetal presentation where the foetal longitudinal axis is perpendicular to the long axis of the uterus. It occurs in less than 0.3% of foetuses at term and is more common in women who have had previous pregnancies, have fibroids or other pelvic tumours, are pregnant with twins or triplets, have prematurity, polyhydramnios, or foetal abnormalities. Diagnosis is made during routine antenatal appointments through abdominal examination and ultrasound scan. Complications include pre-term rupture membranes and cord-prolapse. Management options include active management through external cephalic version or elective caesarian section. The decision to perform caesarian section over ECV will depend on various factors.
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This question is part of the following fields:
- Reproductive System
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Question 30
Incorrect
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A 25-year-old male presents with a painless swelling of the testis. Histologically the stroma has a lymphocytic infiltrate. What is the most likely diagnosis?
Seminoma is the most common type of testicular tumor and is frequently seen in males aged between 25-40 years. The classical subtype is the most prevalent, and histology shows a lymphocytic stromal infiltrate. Other subtypes include spermatocytic, anaplastic, and syncytiotrophoblast giant cells. A teratoma is more common in males aged 20-30 years.Your Answer:
Correct Answer: Classical seminoma
Explanation:The most prevalent form of testicular tumor is seminoma, which is typically found in males between the ages of 30 and 40. The classical subtype of seminoma is the most common and is characterized by a lymphocytic stromal infiltrate. Other subtypes include spermatocytic, which features tumor cells that resemble spermatocytes and has a favorable prognosis, anaplastic, and syncytiotrophoblast giant cells, which contain β HCG. Teratoma, on the other hand, is more frequently observed in males between the ages of 20 and 30.
Overview of Testicular Disorders
Testicular disorders can range from benign conditions to malignant tumors. Testicular cancer is the most common malignancy in men aged 20-30 years, with germ-cell tumors accounting for 95% of cases. Seminomas are the most common subtype, while non-seminomatous germ cell tumors include teratoma, yolk sac tumor, choriocarcinoma, and mixed germ cell tumors. Risk factors for testicular cancer include cryptorchidism, infertility, family history, Klinefelter’s syndrome, and mumps orchitis. The most common presenting symptom is a painless lump, but pain, hydrocele, and gynecomastia may also be present.
Benign testicular disorders include epididymo-orchitis, which is an acute inflammation of the epididymis often caused by bacterial infection. Testicular torsion, which results in testicular ischemia and necrosis, is most common in males aged between 10 and 30. Hydrocele presents as a mass that transilluminates and may occur as a result of a patent processus vaginalis in children. Treatment for these conditions varies, with orchidectomy being the primary treatment for testicular cancer. Surgical exploration is necessary for testicular torsion, while epididymo-orchitis and hydrocele may require medication or surgical procedures depending on the severity of the condition.
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This question is part of the following fields:
- Renal System
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