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  • Question 1 - You assess a 50-year-old woman who has developed a dependence on temazepam, which...

    Incorrect

    • You assess a 50-year-old woman who has developed a dependence on temazepam, which was initially prescribed as a sleep aid. She expresses a desire to overcome her addiction to temazepam and seeks assistance. Her current dosage is 20 mg per day. What would be the most suitable approach?

      Your Answer: Switch to the equivalent zopiclone dose then slowly withdraw over the next 2 weeks

      Correct Answer: Switch to the equivalent diazepam dose then slowly withdraw over the next 2 months

      Explanation:

      Benzodiazepines are drugs that enhance the effect of the neurotransmitter GABA, which inhibits brain activity. They are used for various purposes, including sedation, anxiety relief, muscle relaxation, and seizure prevention. However, patients can develop a tolerance and dependence on these drugs, so they should only be prescribed for a short period of time. When withdrawing from benzodiazepines, it is important to do so gradually to avoid withdrawal symptoms, which can include insomnia, anxiety, and seizures. Barbiturates are another type of drug that affect GABA, but they work differently than benzodiazepines by increasing the duration of chloride channel opening.

    • This question is part of the following fields:

      • Psychiatry
      86.6
      Seconds
  • Question 2 - A 42-year-old-woman, who rarely visits the clinic, complains of heartburn and acid reflux...

    Correct

    • A 42-year-old-woman, who rarely visits the clinic, complains of heartburn and acid reflux for the past 3 weeks. She comes back after taking a PPI for 1 week with some relief. Her BMI is 27 kg/m2. What is the most suitable next step in her treatment?

      Your Answer: Continue the PPI and review in 2 weeks

      Explanation:

      Management of New-Onset Dyspepsia in a Middle-Aged Patient

      When a middle-aged patient presents with new-onset dyspepsia, it is important to take a thorough clinical history to rule out more serious conditions such as malignancy. A 4-week course of full-dose PPI is typically recommended, although there is no clear evidence on whether this or Helicobacter pylori testing should be done first. If PPIs are used, a 2-week washout period is necessary before testing for H. pylori to avoid false-negative results.

      While alginate preparations like Gaviscon® can be used to inhibit gastric acid reflux, it may be more appropriate to increase the PPI dose if the patient has already experienced some improvement with this medication. However, if the patient exhibits ‘red flag’ symptoms like gastrointestinal bleeding, anorexia, weight loss, dysphagia, or the presence of an epigastric mass, urgent endoscopy is necessary. Endoscopy is also recommended for patients over 55 with persistent, unexplained dyspepsia that has not responded well to PPIs.

      Finally, while this patient’s BMI is on the higher end of the healthy range, referral to a dietician is unlikely to be necessary unless there are specific concerns about weight loss measures. Overall, a comprehensive approach to managing new-onset dyspepsia in middle-aged patients involves careful consideration of symptoms, medication options, and potential underlying conditions.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      34.5
      Seconds
  • Question 3 - A 42-year-old man with schizophrenia is brought to the clinic by one of...

    Correct

    • A 42-year-old man with schizophrenia is brought to the clinic by one of his caregivers. He is currently taking clozapine and procyclidine. The caregiver reports that he seems more fatigued than usual and generally not feeling well. She also suspects that he may have gained weight. What is the most crucial examination to conduct?

      Your Answer: Full blood count

      Explanation:

      Monitoring FBC is crucial to detect agranulocytosis/neutropenia, a potentially fatal adverse reaction of clozapine. Additionally, patients taking this medication often experience weight gain.

      Atypical antipsychotics are now recommended as the first-line treatment for patients with schizophrenia, as per the 2005 NICE guidelines. These medications have the advantage of significantly reducing extrapyramidal side-effects. However, they can also cause adverse effects such as weight gain, hyperprolactinaemia, and in the case of clozapine, agranulocytosis. The Medicines and Healthcare products Regulatory Agency has issued warnings about the increased risk of stroke and venous thromboembolism when antipsychotics are used in elderly patients. Examples of atypical antipsychotics include clozapine, olanzapine, risperidone, quetiapine, amisulpride, and aripiprazole.

      Clozapine, one of the first atypical antipsychotics, carries a significant risk of agranulocytosis and requires full blood count monitoring during treatment. Therefore, it should only be used in patients who are resistant to other antipsychotic medication. The BNF recommends introducing clozapine if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs, one of which should be a second-generation antipsychotic drug, each for at least 6-8 weeks. Adverse effects of clozapine include agranulocytosis, neutropaenia, reduced seizure threshold, constipation, myocarditis, and hypersalivation. Dose adjustment of clozapine may be necessary if smoking is started or stopped during treatment.

    • This question is part of the following fields:

      • Psychiatry
      37.1
      Seconds
  • Question 4 - A 10-year-old child with a history of infective diarrhoea presents with fever, hypertension,...

    Correct

    • A 10-year-old child with a history of infective diarrhoea presents with fever, hypertension, haematuria and bloody stools two weeks later. What could be a potential diagnosis?

      Your Answer: Haemolytic uraemic syndrome

      Explanation:

      Haemolytic uraemic syndrome (HUS) is a condition that causes progressive kidney failure and is associated with microangiopathic haemolytic anaemia and thrombocytopenia. There are two main types of HUS, one of which is associated with Shiga-like toxin (Stx) and is commonly seen in children who have had diarrhoea. The classic form of Stx-HUS is often caused by E. coli O157:H7 and is characterized by a history of gastroenteritis, fever, bloody diarrhoea, oedema, and hypertension. Henoch-Schönlein purpura is an acute disorder that affects small blood vessels in various parts of the body, including the skin, gastrointestinal tract, kidneys, and joints. It is characterized by a rash with bullae and ulcers, which typically appears in crops. Post-infectious glomerulonephritis is a condition that occurs after a streptococcal infection and is characterized by haematuria, proteinuria, red blood cell casts in the urine, oedema, and hypertension. Membranoproliferative glomerulonephritis is a rare cause of chronic nephritis that occurs primarily in children and young adults and may be idiopathic or secondary in aetiology. Acute interstitial nephritis is a condition that causes sudden kidney dysfunction, fever, and occasionally a rash, and is often associated with drug use.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      28.5
      Seconds
  • Question 5 - A 32-year-old female patient complains of gradual tingling and numbness in her right...

    Incorrect

    • A 32-year-old female patient complains of gradual tingling and numbness in her right hand's 4th and 5th fingers. The symptoms were occasional at first, but now they are persistent. She observes that the discomfort intensifies when she rests her right elbow on a surface. She remembers hitting her elbow against a door a while back. What is the probable diagnosis?

      Your Answer: Carpal tunnel syndrome

      Correct Answer: Cubital tunnel syndrome

      Explanation:

      Cubital tunnel syndrome is a condition that occurs when the ulnar nerve is compressed, resulting in tingling and numbness in the fourth and fifth fingers.

      The correct answer is cubital tunnel syndrome. The ulnar nerve passes through the cubital tunnel, and when it is compressed, it can cause the symptoms described, such as tingling and numbness in the fourth and fifth fingers. Treatment for this condition may involve conservative measures, but surgery may be necessary in some cases.

      Carpal tunnel syndrome, on the other hand, is caused by compression of the median nerve at the wrist, leading to pain and tingling in the hand and wrist, rather than specific fingers.

      De Quervain’s tenosynovitis presents differently, with pain occurring during movement of the thumb and wrist, and the radial styloid may become thickened and hardened.

      Medial epicondylitis, or golfer’s elbow, causes pain in the medial elbow area, near the cubital tunnel, but it is a tendinopathy rather than nerve compression. The pain is localized to the affected area.

      Understanding Cubital Tunnel Syndrome

      Cubital tunnel syndrome is a condition that occurs when the ulnar nerve is compressed as it passes through the cubital tunnel. This can cause a range of symptoms, including tingling and numbness in the fourth and fifth fingers, which may start off intermittent but eventually become constant. Over time, patients may also experience weakness and muscle wasting. Pain is often worse when leaning on the affected elbow, and there may be a history of osteoarthritis or prior trauma to the area.

      Diagnosis of cubital tunnel syndrome is usually made based on clinical features, although nerve conduction studies may be used in selected cases. Management of the condition typically involves avoiding aggravating activities, undergoing physiotherapy, and receiving steroid injections. In cases where these measures are not effective, surgery may be necessary. By understanding the symptoms and treatment options for cubital tunnel syndrome, patients can take steps to manage their condition and improve their quality of life.

    • This question is part of the following fields:

      • Musculoskeletal
      49.9
      Seconds
  • Question 6 - A 55-year-old woman complains of urine leakage issues for the past six months....

    Incorrect

    • A 55-year-old woman complains of urine leakage issues for the past six months. She reports frequent urination and difficulty reaching the toilet in time. She denies experiencing urine loss during coughing or sneezing. What is the best initial treatment option?

      Your Answer: Trial of oxybutynin

      Correct Answer: Bladder retraining

      Explanation:

      The initial treatment for urinary incontinence differs depending on the type. For urge incontinence, bladder retraining is the recommended first-line approach. On the other hand, for stress incontinence, pelvic floor muscle training is the preferred initial treatment.

      Understanding Urinary Incontinence: Causes, Classification, and Management

      Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

      Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.

      In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      66.4
      Seconds
  • Question 7 - A 57-year-old woman with a long history of sun exposure presents to the...

    Correct

    • A 57-year-old woman with a long history of sun exposure presents to the accident and emergency department after a fracture of her right femur associated with a minor fall. On reviewing the films with the on-call radiographer you are concerned about a lytic lesion possibly being related to the fracture.
      Which of the following primary tumours most commonly metastasises to bone?

      Your Answer: Bronchial carcinoma

      Explanation:

      Metastasis Patterns of Common Carcinomas

      Carcinomas are malignant tumors that can spread to other parts of the body through a process called metastasis. The patterns of metastasis vary depending on the type of carcinoma. Here are some common carcinomas and their typical metastasis patterns:

      Bronchial Carcinoma: This type of carcinoma often spreads to the bone or brain. Symptoms may include difficulty breathing, coughing, chest pain, weight loss, and fatigue.

      Brain Carcinoma: Primary malignant brain tumors rarely spread to other parts of the body, but they can spread to surrounding areas of the brain and spinal cord.

      Renal Carcinoma: Renal cancers commonly metastasize to the lungs, producing lesions that appear like cannonballs on a chest X-ray. They can also spread to the bone, causing osteolytic lesions.

      Gastric Carcinoma: Gastric cancers tend to spread to the liver, lung, and peritoneum. Tumors that have a preference for bone metastasis include those of the lung, prostate, breast, kidney, and thyroid.

      Colorectal Carcinoma: Colorectal cancers commonly metastasize to the liver, lung, and peritoneum. Tumors that have a preference for bone metastasis include those of the lung, prostate, breast, kidney, and thyroid.

      Understanding the patterns of metastasis for different types of carcinomas can help with early detection and treatment. If you experience any symptoms or have concerns, it’s important to speak with your healthcare provider.

    • This question is part of the following fields:

      • Haematology/Oncology
      34.3
      Seconds
  • Question 8 - A 45-year-old woman presents to the Emergency Department with a 2-month history of...

    Correct

    • A 45-year-old woman presents to the Emergency Department with a 2-month history of dull abdominal pain. It is central and occasionally radiates to her back. However, this is not always present and it seems to get worse half an hour after a meal. She denies any vomiting or diarrhoea but confirms that painful episodes are accompanied by nausea.
      The patient does not have any past medical history but admits that she has been drinking a glass of wine every night for the past 15 years. An abdominal X-ray is done.
      Given the likely diagnosis, which of the following findings are most likely to be seen on the abdominal X-ray?
      Select the SINGLE most likely finding from the list below.

      Your Answer: Pancreatic calcifications

      Explanation:

      The patient’s symptoms of dull, central abdominal pain that worsens after meals and radiates to the back, along with a history of regular alcohol consumption, suggest a diagnosis of chronic pancreatitis. Imaging studies, such as an abdominal X-ray or CT scan, may reveal pancreatic calcifications, which are a common finding in chronic pancreatitis. If imaging is inconclusive, a faecal elastase test may be used to assess pancreatic exocrine function. The presence of the football sign, air under the diaphragm, dilated loops of small bowel, or the Rigler sign on an abdominal X-ray would suggest other conditions such as gastrointestinal perforation or bowel obstruction, which do not fit the patient’s presentation.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      28.8
      Seconds
  • Question 9 - A 28-year-old female comes to the clinic with a skin rash under her...

    Incorrect

    • A 28-year-old female comes to the clinic with a skin rash under her new bracelet. The possibility of a nickel allergy is being considered. What is the most appropriate test to confirm the diagnosis?

      Your Answer: Serum IgE

      Correct Answer: Skin patch test

      Explanation:

      Understanding Nickel Dermatitis

      Nickel dermatitis is a type of allergic contact dermatitis that is commonly caused by exposure to nickel. This condition is an example of a type IV hypersensitivity reaction, which means that it is caused by an immune response to a specific substance. In the case of nickel dermatitis, the immune system reacts to nickel, which is often found in jewelry such as watches.

      To diagnose nickel dermatitis, a skin patch test is typically performed. This involves applying a small amount of nickel to the skin and monitoring the area for any signs of an allergic reaction. Symptoms of nickel dermatitis can include redness, itching, and swelling of the affected area.

    • This question is part of the following fields:

      • Dermatology
      13.8
      Seconds
  • Question 10 - A 63-year-old man presents to the haematology clinic with fatigue, significant weight loss,...

    Correct

    • A 63-year-old man presents to the haematology clinic with fatigue, significant weight loss, and easy bruising over the past 2 years. His blood test results are as follows:
      - Hemoglobin: 90 g/L (normal range for males: 135-180 g/L; females: 115-160 g/L)
      - Platelets: 85 * 109/L (normal range: 150-400 * 109/L)
      - White blood cells: 70.5 * 109/L (normal range: 4.0-11.0 * 109/L)
      - Neutrophils: 61.8 * 109/L (normal range: 2.0-7.0 * 109/L)
      - Lymphocytes: 1.2 * 109/L (normal range: 1.0-3.5 * 109/L)
      - Monocytes: 3.0 * 109/L (normal range: 0.2-0.8 * 109/L)
      - Eosinophils: 2.5 * 109/L (normal range: 0.0-0.4 * 109/L)
      The blood film shows obvious leucocytosis with eosinophilia and basophilia visible. There are also large numbers of immature granulocytes, but no blast cells are visible. What is the most appropriate first-line treatment for this patient?

      Your Answer: Imatinib

      Explanation:

      The patient’s history and blood results suggest that they have chronic myeloid leukaemia (CML), which is characterized by a high white cell count due to an excess of myeloid cells and a chronic presentation. The absence of blast cells indicates that this is not acute leukaemia. The patient’s anaemia and thrombocytopenia are likely due to bone marrow dysfunction caused by myelofibrosis, indicating a need for treatment. The first-line treatment for CML is imatinib, a tyrosine kinase inhibitor that is taken as a daily tablet and has shown excellent results in treating CML.

      Given the patient’s signs of bone marrow dysfunction, conservative management is not appropriate. While there may be a role for no treatment in early disease detected incidentally on a blood test, this patient requires treatment at this point.

      It is important to note that fludarabine and cyclophosphamide are chemotherapy agents used in treating chronic lymphocytic leukaemia (CLL) and have no role in managing CML. The blood test abnormalities expected in CLL are similar to those seen in CML, but with a differential showing normal or low neutrophil and high lymphocyte counts.

      Prednisolone, a glucocorticoid used to treat various conditions, is often used in treating different forms of lymphoma but is not effective in managing CML.

      Understanding Chronic Myeloid Leukaemia and its Management

      Chronic myeloid leukaemia (CML) is a type of cancer that affects the blood and bone marrow. It is characterized by the presence of the Philadelphia chromosome in more than 95% of patients. This chromosome is formed due to a translocation between chromosomes 9 and 22, resulting in the fusion of the ABL proto-oncogene and the BCR gene. The resulting BCR-ABL gene produces a fusion protein that has excessive tyrosine kinase activity.

      CML typically affects individuals between 60-70 years of age and presents with symptoms such as anaemia, weight loss, sweating, and splenomegaly. The condition is also associated with an increase in granulocytes at different stages of maturation and thrombocytosis. In some cases, CML may undergo blast transformation, leading to acute myeloid leukaemia (AML) or acute lymphoblastic leukaemia (ALL).

      The management of CML involves various treatment options, including imatinib, which is considered the first-line treatment. Imatinib is an inhibitor of the tyrosine kinase associated with the BCR-ABL defect and has a very high response rate in the chronic phase of CML. Other treatment options include hydroxyurea, interferon-alpha, and allogenic bone marrow transplant. With proper management, individuals with CML can lead a normal life.

    • This question is part of the following fields:

      • Haematology/Oncology
      54.9
      Seconds
  • Question 11 - A 62-year-old woman presents to the clinic with a 6-month history of chest...

    Incorrect

    • A 62-year-old woman presents to the clinic with a 6-month history of chest pain that occurs during physical activity and is relieved with rest. She has a medical history of hypercholesterolemia and asthma, drinks 8 units of alcohol per week, and has never smoked. Her vital signs are within normal limits and an ECG shows sinus rhythm. What is the most suitable medication to prescribe for preventing future episodes, considering the probable diagnosis?

      Your Answer: Amlodipine

      Correct Answer: Verapamil

      Explanation:

      To prevent angina attacks, the first-line treatment is either a beta-blocker or a calcium channel blocker. If a person experiences chest pain that feels like squeezing during physical activity but goes away with rest, it is likely stable angina. Having high cholesterol levels increases the risk of developing this condition. A normal electrocardiogram (ECG) indicates that there is no ongoing heart attack.

      Angina pectoris is a condition that can be managed through various methods, including lifestyle changes, medication, percutaneous coronary intervention, and surgery. In 2011, NICE released guidelines for the management of stable angina. Medication is an important aspect of treatment, and all patients should receive aspirin and a statin unless there are contraindications. Sublingual glyceryl trinitrate can be used to abort angina attacks. The first-line medication should be either a beta-blocker or a calcium channel blocker, depending on the patient’s comorbidities, contraindications, and preferences. If a calcium channel blocker is used as monotherapy, a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker should be used. Beta-blockers should not be prescribed concurrently with verapamil due to the risk of complete heart block. If the initial treatment is not effective, medication should be increased to the maximum tolerated dose. If a patient is still symptomatic after monotherapy with a beta-blocker, a calcium channel blocker can be added, and vice versa. If a patient cannot tolerate the addition of a calcium channel blocker or a beta-blocker, other drugs such as long-acting nitrates, ivabradine, nicorandil, or ranolazine can be considered. Nitrate tolerance is a common issue, and patients who take standard-release isosorbide mononitrate should use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimize the development of nitrate tolerance. This effect is not seen in patients who take once-daily modified-release isosorbide mononitrate. If a patient is taking both a beta-blocker and a calcium-channel blocker, a third drug should only be added while awaiting assessment for PCI or CABG.

    • This question is part of the following fields:

      • Cardiovascular
      40.1
      Seconds
  • Question 12 - A 45-year-old woman presents with a 3-day history of cough, fever and left-sided...

    Correct

    • A 45-year-old woman presents with a 3-day history of cough, fever and left-sided pleuritic pain. On examination she has a temperature of 38.5 °C, a respiratory rate of 37/min, a blood pressure of 110/80 mm/Hg and a pulse rate of 110/min. Oxygen saturations are 95%. She has basal crepitations and dullness to percussion at the left lung base.
      Which of the following is the most likely diagnosis?

      Your Answer: Bronchopneumonia

      Explanation:

      Differential Diagnosis for a Patient with Cough and Fever: Bronchopneumonia vs. Other Conditions

      Bronchopneumonia is a common condition that presents with a cough and fever, along with other symptoms such as sputum production, dyspnea, and pleuritic pain. Examination findings may include decreased breath sounds and focal chest signs. A chest radiograph can confirm the diagnosis. In primary care, a CRB-65 score is used to assess mortality risk and determine where to treat the patient: one point each for acute confusion, respiratory rate (RR) ≥30/min, systolic blood pressure (BP) <90 mmHg or diastolic BP <60 mmHg, age >65 years).
      CRB-65 score Mortality risk (%) – Where to treat
      0 <1 At home
      1-2 1-10 Hospital advised, particularly score of 2
      3-4 >10 Hospital advised, may require stay in intensive therapy unit (ITU).

      Other conditions that may present with similar symptoms include pneumothorax, pulmonary embolism, malignant mesothelioma, and tuberculosis. However, these conditions have distinct features that differentiate them from bronchopneumonia. For example, pneumothorax involves partial or full collapse of a lung, while pulmonary embolism results from obstruction of one or more of the pulmonary arteries. Malignant mesothelioma is a cancer that affects the pleura and peritoneum, and tuberculosis usually presents with a persistent productive cough, weight loss, night sweats, fevers, lymphadenopathy, and general malaise.

      It is important to consider these differentials when evaluating a patient with cough and fever, and to use appropriate diagnostic tools to confirm the diagnosis and determine the best course of treatment.

    • This question is part of the following fields:

      • Respiratory Medicine
      47.2
      Seconds
  • Question 13 - A 65-year-old man comes to your clinic complaining of myalgia in the shoulder...

    Incorrect

    • A 65-year-old man comes to your clinic complaining of myalgia in the shoulder girdle and low-grade fevers that have persisted for three weeks. He also mentions experiencing a brief loss of vision in his left eye. Based on the probable diagnosis, what laboratory test would be the most effective for diagnosis?

      Your Answer: Creatinine kinase

      Correct Answer: Erythrocyte sedimentation rate

      Explanation:

      The diagnosis of polymyalgia rheumatica primarily relies on the detection of elevated inflammatory markers.

      Among the laboratory tests, the most valuable in diagnosing PMR is the measurement of ESR levels.
      Although CK and electromyography are commonly used in diagnosing muscle disorders, they may not be helpful in detecting PMR.
      While CPR and white cell count may show increased levels in PMR, they are not specific enough to confirm the diagnosis.

      Polymyalgia Rheumatica: A Condition of Muscle Stiffness in Older People

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

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

    • This question is part of the following fields:

      • Musculoskeletal
      41.8
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  • Question 14 - A 30-year-old female patient comes in for her initial cervical screening. What is...

    Correct

    • A 30-year-old female patient comes in for her initial cervical screening. What is the primary causative factor responsible for cervical cancer?

      Your Answer: Human papilloma virus 16 & 18

      Explanation:

      The most significant risk factor for cervical cancer is infection with human papillomavirus, specifically types 16, 18, and 33, among others.

      Understanding Cervical Cancer: Risk Factors and Mechanism of HPV

      Cervical cancer is a type of cancer that affects the cervix, which is the lower part of the uterus. It is most commonly diagnosed in women under the age of 45, with the highest incidence rates occurring in those aged 25-29. The cancer can be divided into two types: squamous cell cancer and adenocarcinoma. Symptoms may include abnormal vaginal bleeding, postcoital bleeding, intermenstrual bleeding, or postmenopausal bleeding, as well as vaginal discharge.

      The most important factor in the development of cervical cancer is the human papillomavirus (HPV), particularly serotypes 16, 18, and 33. Other risk factors include smoking, human immunodeficiency virus, early first intercourse, many sexual partners, high parity, and lower socioeconomic status. While the association between combined oral contraceptive pill use and cervical cancer is sometimes debated, a large study published in the Lancet confirmed the link.

      The mechanism by which HPV causes cervical cancer involves the production of oncogenes E6 and E7 by HPV 16 and 18, respectively. E6 inhibits the p53 tumour suppressor gene, while E7 inhibits the RB suppressor gene. Understanding the risk factors and mechanism of HPV in the development of cervical cancer is crucial for prevention and early detection. Regular cervical cancer screening is recommended for all women.

    • This question is part of the following fields:

      • Reproductive Medicine
      8.7
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  • Question 15 - A 28-year-old woman comes to your clinic for a check-up. She is currently...

    Incorrect

    • A 28-year-old woman comes to your clinic for a check-up. She is currently 16 weeks pregnant and has had no complications so far. During her visit, she mentions that her 4-year-old son was recently diagnosed with chickenpox. The patient is concerned about the potential impact on her pregnancy as she cannot recall if she had chickenpox as a child. What would be the appropriate course of action for this patient?

      Your Answer: Arrange a blood test for varicella antibodies, then immediately commence varicella-zoster immunoglobulin (VZIG) and adjust once the result arrives

      Correct Answer: Arrange a blood test for varicella antibodies and await the result

      Explanation:

      In cases where a pregnant woman is exposed to chickenpox and her immunity status is uncertain, it is recommended to conduct a blood test to check for varicella antibodies. If she is found to be not immune and is over 20 weeks pregnant, either VZIG or aciclovir can be given. However, VZIG is the only option for those under 20 weeks pregnant and not immune. It is important to note that VZIG is effective up to 10 days post-exposure, so there is no need to administer it immediately after the blood test. Prescribing medication without confirming the patient’s immunity status is not recommended. Similarly, reassuring the patient and sending her away without following proper prophylaxis protocol is not appropriate. It is also important to note that the varicella-zoster vaccine is not currently part of the UK’s vaccination schedule and does not play a role in the management of pregnant women.

      Chickenpox exposure in pregnancy can pose risks to both the mother and fetus, including fetal varicella syndrome. Post-exposure prophylaxis (PEP) with varicella-zoster immunoglobulin (VZIG) or antivirals should be given to non-immune pregnant women, with timing dependent on gestational age. If a pregnant woman develops chickenpox, specialist advice should be sought and oral aciclovir may be given if she is ≥ 20 weeks and presents within 24 hours of onset of the rash.

    • This question is part of the following fields:

      • Reproductive Medicine
      27
      Seconds
  • Question 16 - A 45-year-old woman complains of a gritty sensation in her eyes and a...

    Correct

    • A 45-year-old woman complains of a gritty sensation in her eyes and a dry mouth of several months’ duration. She has vague joint pains in her knees and ankles. Her husband mentions that she is also dyspnoeic on exertion and cannot keep up with him during their hikes.
      Which of the following is the most likely diagnosis?

      Your Answer: Sjögren syndrome

      Explanation:

      Sjögren syndrome is a condition characterized by dry eyes (keratoconjunctivitis sicca) and dryness in other areas such as the mouth, skin, or vagina. Enlargement of the salivary or parotid glands may also be present. Primary Sjögren syndrome occurs without any other autoimmune disease and is associated with HLA-B8/DR3 in about 50% of cases. Secondary Sjögren syndrome occurs in the presence of other autoimmune disorders, commonly rheumatoid arthritis (RA). Other symptoms may include arthralgia, Raynaud’s phenomenon, oesophageal dysmotility, vasculitis, polyneuropathy, and pulmonary diffusion defects and fibrosis. Diagnosis is based on the Schirmer tear test, Rose Bengal staining, and lab tests showing raised immunoglobulin levels, circulating immune complexes, and autoantibodies. Treatment is symptomatic with artificial tear and saliva replacement solutions, hydroxychloroquine, and corticosteroids if needed. Polymyositis, polyarteritis nodosa (PAN), mixed connective tissue disease (MCTD), and rheumatoid arthritis are other conditions that may present with similar symptoms but do not fit the clinical picture in this case.

    • This question is part of the following fields:

      • Musculoskeletal
      30.2
      Seconds
  • Question 17 - You assess a 65-year-old man with chronic obstructive pulmonary disease (COPD) who receives...

    Incorrect

    • You assess a 65-year-old man with chronic obstructive pulmonary disease (COPD) who receives approximately 7-8 rounds of oral prednisolone annually to manage infectious exacerbations of his condition. What is one of the potential negative consequences associated with prolonged steroid use?

      Your Answer: Osteomalacia

      Correct Answer: Avascular necrosis

      Explanation:

      Osteopaenia and osteoporosis are associated with prolonged use of corticosteroids, not osteomalacia.

      Understanding Corticosteroids and Their Side-Effects

      Corticosteroids are commonly prescribed therapies used to replace or augment the natural activity of endogenous steroids. They can be administered systemically or locally, depending on the condition being treated. However, the usage of corticosteroids is limited due to their numerous side-effects, which are more common with prolonged and systemic therapy.

      Glucocorticoid side-effects include impaired glucose regulation, increased appetite and weight gain, hirsutism, hyperlipidaemia, Cushing’s syndrome, moon face, buffalo hump, striae, osteoporosis, proximal myopathy, avascular necrosis of the femoral head, immunosuppression, increased susceptibility to severe infection, reactivation of tuberculosis, insomnia, mania, depression, psychosis, peptic ulceration, acute pancreatitis, glaucoma, cataracts, suppression of growth in children, intracranial hypertension, and neutrophilia.

      On the other hand, mineralocorticoid side-effects include fluid retention and hypertension. It is important to note that patients on long-term steroids should have their doses doubled during intercurrent illness. Longer-term systemic corticosteroids suppress the natural production of endogenous steroids, so they should not be withdrawn abruptly as this may precipitate an Addisonian crisis. The British National Formulary suggests gradual withdrawal of systemic corticosteroids if patients have received more than 40mg prednisolone daily for more than one week, received more than three weeks of treatment, or recently received repeated courses.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      21.2
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  • Question 18 - A 32-year-old female patient comes to the clinic complaining of intermittent bloating and...

    Correct

    • A 32-year-old female patient comes to the clinic complaining of intermittent bloating and loose stools that have been going on for 5 months. She reports no blood in her stool but has lost a few kilograms in weight. Recently, she has noticed some itchy, vesicular rashes on her knees that have been persistent. Routine blood tests were ordered and all came back normal except for one positive result. What is the name of the dermatological condition she is experiencing?

      Your Answer: Dermatitis herpetiformis

      Explanation:

      Understanding Dermatitis Herpetiformis

      Dermatitis herpetiformis is a skin condition that is linked to coeliac disease and is caused by the deposition of IgA in the dermis. It is an autoimmune blistering disorder that is characterized by itchy, vesicular skin lesions that appear on the extensor surfaces of the body, such as the elbows, knees, and buttocks.

      To diagnose dermatitis herpetiformis, a skin biopsy is required, which will show the deposition of IgA in a granular pattern in the upper dermis. This condition can be managed by following a gluten-free diet and taking dapsone medication.

      It is important to understand the symptoms and management of dermatitis herpetiformis to ensure that proper treatment is given. By following a gluten-free diet and taking medication, individuals with this condition can manage their symptoms and improve their quality of life.

    • This question is part of the following fields:

      • Dermatology
      26.8
      Seconds
  • Question 19 - A 32-year-old woman with a past medical history of kidney stones awaiting elective...

    Incorrect

    • A 32-year-old woman with a past medical history of kidney stones awaiting elective lithotripsy attends the general practice surgery complaining of fever, fatigue and acute abdominal pain. On examination, she has a temperature of 38.5 °C, a heart rate 118 bpm, yellow sclera and her abdomen is soft but tender on palpation of the right upper quadrant.
      Which of the following is the most likely diagnosis?

      Your Answer: Acute cholecystitis

      Correct Answer: Acute cholangitis

      Explanation:

      Acute cholangitis is a serious infection of the biliary tract that can lead to significant health complications. Symptoms typically include fever, abdominal pain (specifically in the upper right quadrant), and jaundice, which is known as Charcot’s triad. This patient is displaying all of these symptoms and has a history of gallstones, making acute cholangitis the most likely diagnosis. Treatment for acute cholangitis depends on the severity of the infection, as determined by the TG13 guideline. Patients will require intravenous fluids and antibiotics, and may need biliary drainage or intensive care support if the disease is severe. Influenza, acute cholecystitis, acute viral hepatitis, and biliary colic are all potential differential diagnoses, but do not match this patient’s symptoms and medical history.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      53.5
      Seconds
  • Question 20 - A 35-year-old man complains of pain in his left ear. He was using...

    Incorrect

    • A 35-year-old man complains of pain in his left ear. He was using cotton buds to clean his ears earlier today and experienced a sharp pain during the process. He now has slightly reduced hearing in his left ear. The patient reports no discharge and is in good health otherwise.

      All of the patient's vital signs are normal. Upon examination of the left ear, a small perforation in the tympanic membrane is observed. There is no discharge or redness in the ear, and the ear canal is dry. The cranial nerve examination is unremarkable.

      What is the next best course of action for managing this patient's condition?

      Your Answer: Refer patient to ENT

      Correct Answer: Reassure patient and review in 4 weeks

      Explanation:

      If a patient has an uncomplicated tympanic membrane perforation that is dry, they can be managed with watchful waiting for a month without needing to see an ENT specialist. These perforations can occur due to various reasons such as blunt trauma, penetrating injuries, or barotrauma. Typically, the perforation will heal on its own within 4-8 weeks. However, patients should schedule a follow-up appointment after 4 weeks to ensure that the perforation is healing properly. If the patient experiences increasing ear pain, discharge, or worsening hearing loss, they should see their GP. During the examination, the patient should undergo a full examination, including otoscopy, cranial nerve examination, and Rinne/Weber tests. If there are any cranial nerve deficits, the patient should discuss them with an ENT specialist. Patients should keep their ears clean and dry, and topical antibiotics are not recommended for clean, dry perforations. If there are any signs of infection or contamination, topical antibiotics may be given. In cases where the patient has more complex issues such as temporal bone fractures or slowly healing perforations, they may need to be reviewed by an ENT specialist in an emergency clinic. If the perforation does not heal, surgical intervention may be necessary.

      Perforated Tympanic Membrane: Causes and Management

      A perforated tympanic membrane, also known as a ruptured eardrum, is a condition where there is a tear or hole in the thin tissue that separates the ear canal from the middle ear. The most common cause of this condition is an infection, but it can also be caused by barotrauma or direct trauma. When left untreated, a perforated tympanic membrane can lead to hearing loss and increase the risk of otitis media.

      In most cases, no treatment is needed as the tympanic membrane will usually heal on its own within 6-8 weeks. During this time, it is important to avoid getting water in the ear. However, if the perforation occurs following an episode of acute otitis media, antibiotics may be prescribed. This approach is supported by the 2008 Respiratory tract infection guidelines from the National Institute for Health and Care Excellence (NICE).

      If the tympanic membrane does not heal by itself, myringoplasty may be performed. This is a surgical procedure where a graft is used to repair the hole in the eardrum.

    • This question is part of the following fields:

      • ENT
      46.6
      Seconds
  • Question 21 - A 45-year-old woman reports leakage of urine, which is happening more often. She...

    Correct

    • A 45-year-old woman reports leakage of urine, which is happening more often. She is unable to control her urine when she feels the urge to go and has had a few instances where she couldn't make it to the bathroom in time. There is no pain during urination and her urine dipstick test is negative. Which of the following is the most probable diagnosis?

      Your Answer: Urge incontinence

      Explanation:

      Urinary incontinence is a common problem that affects more women than men and increases with age. There are different types of urinary incontinence, each with its own set of symptoms. Functional incontinence occurs when a person is unable to hold urine due to reasons other than lower urinary tract dysfunction, such as delirium or impaired mobility. Mixed incontinence is a combination of stress and urge incontinence, while overflow incontinence occurs when the bladder is overdistended and urine overflows despite the absence of detrusor contraction. Stress incontinence is characterized by urine loss during periods of increased intra-abdominal pressure, while urge incontinence is associated with a sudden and intense desire to void that cannot be prevented. Symptoms of urge incontinence include urinary frequency and nocturia. Treatment is directed at the underlying cause of the incontinence.

    • This question is part of the following fields:

      • Reproductive Medicine
      19.7
      Seconds
  • Question 22 - A 5-year-old girl is brought to the pediatrician's office by her father, who...

    Correct

    • A 5-year-old girl is brought to the pediatrician's office by her father, who is concerned about a red rash on her arms and chest. She has been feeling sick, with cold-like symptoms preceding the rash. The rash is erythematous, macular and symmetrical to both arms and chest and is non-blanching. She is currently without fever and appears to be in good health.
      What is the most probable cause?

      Your Answer: Henoch–Schönlein purpura

      Explanation:

      Distinguishing Between Different Skin Conditions: A Guide for Healthcare Professionals

      Henoch–Schönlein purpura, eczema, intertrigo, meningococcal disease, and systemic lupus erythematosus are all skin conditions that can present with various rashes and symptoms. It is important for healthcare professionals to be able to distinguish between these conditions in order to provide appropriate treatment.

      Henoch–Schönlein purpura is an autoimmune hypersensitivity vasculitis that presents with a non-blanching rash, joint and abdominal pain, and nephritis. Eczema is characterized by areas of erythema that are blanching, dry skin with fine scales, and excoriations. Intertrigo primarily affects the flexures with erythematous patches that may progress to intense inflammation. Meningococcal disease presents with a non-blanching rash that rapidly progresses to purpura and requires immediate treatment. Systemic lupus erythematosus is rare in children and presents with a malar or butterfly rash on the face, joint pain, fever, or weight loss.

      By understanding the unique features of each condition, healthcare professionals can accurately diagnose and treat their patients.

    • This question is part of the following fields:

      • Dermatology
      25.9
      Seconds
  • Question 23 - A 60-year-old woman comes to the clinic complaining of a gradual loss of...

    Incorrect

    • A 60-year-old woman comes to the clinic complaining of a gradual loss of hearing and ringing in her right ear for the past 4 weeks. Upon examination, her ear canal and tympanic membrane appear normal. Rinne's test shows air conduction is better than bone conduction on both sides, but Weber's test reveals that the sound is heard best in her left ear. What is the probable diagnosis?

      Your Answer: Otosclerosis

      Correct Answer: Acoustic neuroma

      Explanation:

      Understanding Vestibular Schwannoma (Acoustic Neuroma)

      Vestibular schwannoma, also known as acoustic neuroma, is a type of brain tumor that accounts for 5% of intracranial tumors and 90% of cerebellopontine angle tumors. The condition is characterized by a combination of symptoms such as vertigo, hearing loss, tinnitus, and an absent corneal reflex. The affected cranial nerves can predict the features of the condition. For instance, cranial nerve VIII can cause vertigo, unilateral sensorineural hearing loss, and unilateral tinnitus. On the other hand, cranial nerve V can lead to an absent corneal reflex, while cranial nerve VII can cause facial palsy.

      Bilateral vestibular schwannomas are often seen in neurofibromatosis type 2. The diagnosis of vestibular schwannoma is made through an MRI of the cerebellopontine angle, and audiometry is also important since only 5% of patients have a normal audiogram.

      The management of vestibular schwannoma involves surgery, radiotherapy, or observation. The choice of treatment depends on the size and location of the tumor, the patient’s age and overall health, and the severity of symptoms. In conclusion, understanding vestibular schwannoma is crucial in managing the condition effectively.

    • This question is part of the following fields:

      • Neurology
      34.8
      Seconds
  • Question 24 - A 55-year-old woman seeks guidance on managing her menopausal symptoms. She has experienced...

    Incorrect

    • A 55-year-old woman seeks guidance on managing her menopausal symptoms. She has experienced cessation of her menstrual cycle and is bothered by hot flashes and night sweats. Due to her sister's breast cancer, she is not interested in hormone replacement therapy. What is the most suitable treatment option to suggest?

      Your Answer: Evening primrose oil

      Correct Answer: Citalopram

      Explanation:

      Managing Menopause: Lifestyle Modifications, Hormone Replacement Therapy, and Non-Hormone Replacement Therapy

      Menopause is a natural biological process that marks the end of a woman’s reproductive years. It is diagnosed when a woman has not had a period for 12 consecutive months. Menopausal symptoms are common and can last for up to 7 years, with varying degrees of severity and duration. The management of menopause can be divided into three categories: lifestyle modifications, hormone replacement therapy (HRT), and non-hormone replacement therapy.

      Lifestyle modifications can help manage menopausal symptoms such as hot flushes, sleep disturbance, mood changes, and cognitive symptoms. Regular exercise, weight loss, stress reduction, and good sleep hygiene are recommended. For women who cannot or do not want to take HRT, non-hormonal treatments such as fluoxetine, citalopram, or venlafaxine for vasomotor symptoms, vaginal lubricants or moisturizers for vaginal dryness, and cognitive behavior therapy or antidepressants for psychological symptoms can be prescribed.

      HRT is a treatment option for women with moderate to severe menopausal symptoms. However, it is contraindicated in women with current or past breast cancer, any estrogen-sensitive cancer, undiagnosed vaginal bleeding, or untreated endometrial hyperplasia. HRT brings certain risks, including venous thromboembolism, stroke, coronary heart disease, breast cancer, and ovarian cancer. Women should be advised of these risks and the fact that symptoms typically last for 2-5 years.

      When stopping HRT, it is important to gradually reduce the dosage to limit recurrence of symptoms in the short term. However, in the long term, there is no difference in symptom control. Women who experience ineffective treatment, ongoing side effects, or unexplained bleeding should be referred to secondary care. Overall, managing menopause requires a personalized approach that takes into account a woman’s medical history, preferences, and individual symptoms.

    • This question is part of the following fields:

      • Reproductive Medicine
      36.5
      Seconds
  • Question 25 - A 28-year-old man undergoes surgical resection of the terminal ileum for stricturing Crohn's...

    Correct

    • A 28-year-old man undergoes surgical resection of the terminal ileum for stricturing Crohn's disease. His gastroenterologist decides to begin azathioprine for remission maintenance after the surgery. What is the crucial enzyme level to test before starting this treatment?

      Your Answer: Thiopurine S-methyltransferase (TPMT)

      Explanation:

      Azathioprine is a medication that is broken down into mercaptopurine, which is an active compound that inhibits the production of purine. To determine if someone is at risk for azathioprine toxicity, a test for thiopurine methyltransferase (TPMT) may be necessary. Adverse effects of this medication include bone marrow depression, which can be detected through a full blood count if there are signs of infection or bleeding, as well as nausea, vomiting, pancreatitis, and an increased risk of non-melanoma skin cancer. It is important to note that there is a significant interaction between azathioprine and allopurinol, so lower doses of azathioprine should be used in conjunction with allopurinol. Despite these potential side effects, azathioprine is generally considered safe to use during pregnancy.

    • This question is part of the following fields:

      • Musculoskeletal
      43.2
      Seconds
  • Question 26 - A 32-year-old woman is brought to the Emergency Department after fainting. She is...

    Incorrect

    • A 32-year-old woman is brought to the Emergency Department after fainting. She is now conscious and able to provide a medical history. The patient mentions having a condition, but cannot recall the name. She shows the doctor the medication she takes, which is a somatostatin analogue.
      What medical condition can be treated with somatostatin analogues?

      Your Answer: Conn syndrome

      Correct Answer: Acromegaly

      Explanation:

      Acromegaly is a condition caused by excessive secretion of growth hormone from an anterior pituitary tumor, resulting in enlarged hands, feet, and jaw, as well as other symptoms. While surgery is the preferred treatment, somatostatin analogues such as octreotide and lanreotide can be used if surgery fails. Somatostatin is an inhibitory hormone that can suppress growth hormone release. However, it can also cause side effects such as bradycardia, hypothyroidism, and hypoglycemia. Cushing’s disease, caused by excess adrenocorticotropic hormone, can be treated with pituitary gland removal, radiotherapy, or cortisol-inhibiting medications. Conn syndrome, or primary aldosteronism, is usually treated with surgery. Type I diabetes is treated with insulin, while Type II diabetes is treated with insulin and oral hypoglycemic agents. Parathyroid adenomas are also treated surgically.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      52.7
      Seconds
  • Question 27 - A 14-year-old boy comes to the clinic with complaints of sudden jerking movements...

    Correct

    • A 14-year-old boy comes to the clinic with complaints of sudden jerking movements of his neck, causing his head to move involuntarily from left to right. He has been experiencing these symptoms for a few years, but lately, he has been feeling embarrassed as he involuntarily utters swear words in social situations. These symptoms worsen when he is under stress. What is the most probable diagnosis for this patient?

      Your Answer: Tourette’s syndrome

      Explanation:

      Differentiating between Mental Disorders: Tourette’s Syndrome, Malingering, Conduct Disorder, Dissocial Personality Disorder, and Schizophrenia

      Tourette’s Syndrome is a tic disorder that usually develops in childhood or adolescence, characterized by multiple motor tics and one or more vocal tics. The vocal tics need not be complete words or phrases and are often throat-clearing and grunting. Anti-psychotics such as pimozide, risperidone, and sulpiride have been shown to be of benefit.

      Malingering is the act of fabricating symptoms for some sort of secondary gain, such as financial, manipulative, avoidance of school, obtaining drugs, or gaining sympathy or attention.

      Conduct Disorder is a mental disorder diagnosed before or after the age of 10, characterized by a persistent and repetitive pattern of behavior that violates either the basic rights of others or goes against age-developmental norms. Childhood onset disorder can be linked to attention deficit/hyperactivity disorder (ADHD) type symptoms.

      Dissocial Personality Disorder is characterized by a long-term disregard for others or the violation of others. Its precursor is conduct disorder. Antisocial personality disorder can be diagnosed when the patient reaches the age of 18 and has a history of conduct disorder in childhood or adolescence.

      Schizophrenia does not typically present with involuntary movements. There is also no history of hallucinations, auditory or visual, or confused thinking.

    • This question is part of the following fields:

      • Psychiatry
      14.6
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  • Question 28 - A 28-year-old presents to his General Practitioner with a 2-month history of pain...

    Incorrect

    • A 28-year-old presents to his General Practitioner with a 2-month history of pain in his right elbow. His GP suspects that the patient has lateral epicondylitis.
      What examination findings would confirm the diagnosis?

      Your Answer: Pain is aggravated by wrist flexion and pronation

      Correct Answer: Pain worse on resisted wrist extension with the elbow extended

      Explanation:

      Common Elbow Pain Symptoms and Their Features

      Elbow pain can be caused by various conditions, each with its own set of symptoms. Here are some common elbow pain symptoms and their features:

      1. Lateral Epicondylitis (Tennis Elbow)
      – Pain and tenderness localized to the lateral epicondyle
      – Pain worsens on resisted wrist extension with the elbow extended or supination of the forearm with the elbow extended
      – Episodes typically last between six months and two years; patients tend to have acute pain for 6-12 weeks
      – Pain aggravated by wrist flexion and pronation

      2. Medial Epicondylitis (Golfer’s Elbow)
      – Pain and tenderness localized to the medial epicondyle
      – Pain aggravated by wrist flexion and pronation
      – Symptoms may be accompanied by numbness/tingling in the fourth and fifth fingers due to ulnar-nerve involvement

      3. Cubital Tunnel Syndrome
      – Initially intermittent tingling in the fourth and fifth fingers
      – Pain worsens when the elbow is resting on a firm surface or flexed for extended periods
      – Later numbness in the fourth and fifth fingers with associated weakness

      4. Carpal Tunnel Syndrome
      – Pain worsens when the wrists are in complete flexion for at least 30 seconds
      – The Phalen test is done to investigate its presence

      5. Olecranon Bursitis
      – Swelling over the posterior aspect of the elbow with associated pain, warmth, and erythema
      – Typically affects middle-aged male patients

      Understanding Common Symptoms of Elbow Pain

    • This question is part of the following fields:

      • Musculoskeletal
      32.6
      Seconds
  • Question 29 - A 35-year-old man with type 1 diabetes visits his GP for a check-up...

    Incorrect

    • A 35-year-old man with type 1 diabetes visits his GP for a check-up on his blood sugar levels. He has been monitoring his daily blood glucose readings and the GP calculates an average of 7.8 mmol/L, indicating the need for better control. However, his HbA1c level is 41.5 mmol/mol (5.9%), indicating good glycaemic control. What could be causing this inconsistency?

      Your Answer: Iron-deficiency anaemia

      Correct Answer: Sickle-cell anaemia

      Explanation:

      Individuals with sickle cell anaemia and other haemoglobinopathies may have inaccurate HbA1c readings due to the shortened lifespan of their red blood cells, resulting in lower than actual levels. Conversely, conditions such as splenectomy, iron-deficiency anaemia, B12 deficiency, and alcoholism can lead to falsely elevated HbA1c levels. The accuracy of HbA1c as a measure of average blood glucose concentration is dependent on the lifespan of red blood cells.

      Understanding Glycosylated Haemoglobin (HbA1c) in Diabetes Mellitus

      Glycosylated haemoglobin (HbA1c) is a commonly used measure of long-term blood sugar control in diabetes mellitus. It is produced when glucose attaches to haemoglobin in the blood at a rate proportional to the glucose concentration. The level of HbA1c is influenced by the lifespan of red blood cells and the average blood glucose concentration. However, certain conditions such as sickle-cell anaemia, GP6D deficiency, and haemodialysis can interfere with accurate interpretation of HbA1c levels.

      HbA1c is believed to reflect the blood glucose levels over the past 2-4 weeks, although it is generally thought to represent the previous 3 months. It is recommended that HbA1c be checked every 3-6 months until stable, then every 6 months. The Diabetes Control and Complications Trial (DCCT) has studied the complex relationship between HbA1c and average blood glucose. The International Federation of Clinical Chemistry (IFCC) has developed a new standardised method for reporting HbA1c in mmol per mol of haemoglobin without glucose attached.

      Understanding HbA1c is crucial in managing diabetes mellitus and achieving optimal blood sugar control.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      53.2
      Seconds
  • Question 30 - A 50-year-old woman with type 1 diabetes mellitus is seen in the diabetes...

    Incorrect

    • A 50-year-old woman with type 1 diabetes mellitus is seen in the diabetes clinic. Her blood tests from three months ago showed:
      K+ 4.5 mmol/l
      Creatinine 116 µmol/l
      eGFR 47 ml/min
      She was started on lisinopril to manage hypertension and protect her kidneys. The medication was titrated up to the treatment dose. Her current blood results are:
      K+ 4.9 mmol/l
      Creatinine 123 µmol/l
      eGFR 44 ml/min
      What is the most appropriate action to take in this situation?

      Your Answer: Switch to a angiotensin 2 receptor blocker

      Correct Answer: No action

      Explanation:

      The slight alterations in creatinine and eGFR are within acceptable limits and do not warrant discontinuation of ACE inhibitors.

      Hypertension Management in Chronic Kidney Disease

      Chronic kidney disease (CKD) patients often require more than two drugs to manage hypertension. The first-line treatment is ACE inhibitors, which are particularly effective in proteinuric renal disease such as diabetic nephropathy. However, these drugs may cause a small decrease in glomerular filtration pressure (GFR) and a rise in creatinine. According to NICE guidelines, a decrease in eGFR of up to 25% or a rise in creatinine of up to 30% is acceptable, but any increase should prompt careful monitoring and exclusion of other causes such as NSAIDs. A rise greater than this may indicate underlying renovascular disease.

      Furosemide is a useful antihypertensive drug in CKD patients, especially when the GFR falls below 45 ml/min. It also helps to lower serum potassium levels. However, high doses are usually required, and if the patient becomes dehydrated due to conditions such as gastroenteritis, the drug should be temporarily stopped. The NKF K/DOQI guidelines suggest a lower cut-off of less than 30 ml/min. Overall, hypertension management in CKD patients requires careful monitoring and individualized treatment plans.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      47.6
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SESSION STATS - PERFORMANCE PER SPECIALTY

Psychiatry (2/3) 67%
Gastroenterology/Nutrition (2/3) 67%
Renal Medicine/Urology (1/3) 33%
Musculoskeletal (2/5) 40%
Haematology/Oncology (2/2) 100%
Dermatology (2/3) 67%
Cardiovascular (0/1) 0%
Respiratory Medicine (1/1) 100%
Reproductive Medicine (2/4) 50%
Endocrinology/Metabolic Disease (0/3) 0%
ENT (0/1) 0%
Neurology (0/1) 0%
Passmed