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Question 1
Incorrect
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A 20-year-old woman presents to the clinic with complaints of breakthrough bleeding while taking her combined oral contraceptive pill containing 30 mcg ethinylestradiol with levonorgestrel. She started the pill two cycles ago and takes 21 active pills with a seven day pill-free interval. Although she is not currently sexually active, she plans to be in the near future. She reports no missed pills, recent illnesses, or other medication use. What is the probable cause of her breakthrough bleeding?
Your Answer: Normal finding
Correct Answer: Chlamydia infection
Explanation:Breakthrough Bleeding and the Combined Pill
Breakthrough bleeding is a common issue that can occur when taking the combined pill. It is important to first check compliance with pill usage, as missed pills or erratic usage can lead to bleeding problems. Other factors such as intercurrent illness or the use of other medications should also be considered. Pregnancy should be ruled out with a test, especially if any pills have been missed or pill efficacy has been compromised. Additionally, sexually transmitted infections should be considered and appropriate tests performed.
For women who have recently started using the combined pill, breakthrough bleeding is a common occurrence in the first few months of use. It is important to discuss this with a healthcare provider and be reassured that it usually settles with time. If breakthrough bleeding persists, a change in approach may be necessary. Lower dose pills (20 mcg ethinyloestradiol) are more likely to cause breakthrough bleeding, and switching to a higher dose pill (30 mcg) may be an option. Overall, it is important to address breakthrough bleeding promptly to ensure the effectiveness and safety of the combined pill.
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This question is part of the following fields:
- Gynaecology And Breast
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Question 2
Correct
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A 29-year-old male attends surgery with his wife to ask your advice.
He has neurofibromatosis and they are thinking about starting a family. He tells you that his father had the same condition and he is worried about passing it on to their children. His wife has no significant family history of genetic problems and no personal history of any medical problems.
What should you tell them?Your Answer: The risk of their child inheriting the conditionis 50% regardless of the sex of the child
Explanation:Neurofibromatosis: An Inherited Condition
Neurofibromatosis is a genetic condition that is inherited in an autosomal dominant manner. This means that both males and females can be affected, and there is no carrier state. If an individual inherits the faulty gene, they will have the condition. If one parent has the condition, there is a 50% chance of passing it on to their offspring.
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This question is part of the following fields:
- Genomic Medicine
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Question 3
Incorrect
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A 68-year-old man has developed diplopia.
Which finding would suggest a third nerve palsy?Your Answer: Convergent strabismus
Correct Answer: Pupil unreactive to light
Explanation:Common Symptoms of Nerve Palsies
A nerve palsy is a condition that affects the function of a specific nerve. There are different types of nerve palsies, each with their own set of symptoms. Here are some common symptoms associated with different types of nerve palsies:
Third Nerve Palsy: This type of palsy is characterized by ptosis (drooping of the eyelid), a dilated and unreactive pupil, and downward and outward displacement of the eyeball. The affected eye may also have a divergent squint.
Seventh Nerve Palsy: In this type of palsy, increased lacrimation (tearing) may be seen. The affected eye may also have difficulty closing, resulting in dryness and irritation.
Horner’s Syndrome: This type of palsy is characterized by enophthalmos (sunken appearance of the eye) and miosis (constriction of the pupil). Other symptoms may include ptosis and decreased sweating on one side of the face.
By understanding the common symptoms associated with different types of nerve palsies, individuals can seek appropriate medical attention and treatment.
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This question is part of the following fields:
- Eyes And Vision
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Question 4
Incorrect
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A 29-year-old woman presents to you with concerns about her current medication for depression. She is currently taking reboxetine but is experiencing over-energization and only sleeping for 4.5-5 hours per night. After discussing her options, you both agree that switching to sertraline may be the best course of action.
What advice would you give her regarding the switch to sertraline?Your Answer: The dose of reboxetine should be slowly reduced while the sertraline dose is increased
Correct Answer: A washout period of two weeks between drugs is needed
Explanation:Switching from Reboxetine to Sertraline
When switching from reboxetine to sertraline, it is recommended to start sertraline immediately but gradually increase the dose as the reboxetine dose is reduced. It is important to note that reboxetine is metabolized by CYP3A4, which means that taking inhibitors such as macrolides and antifungals like fluconazole may increase its effects by raising plasma concentration. Therefore, caution should be exercised when taking these medications together. Proper management and monitoring of the switch from reboxetine to sertraline can help ensure a smooth transition and minimize potential adverse effects.
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This question is part of the following fields:
- Mental Health
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Question 5
Incorrect
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A childminder brings a boy for his routine 18 month vaccinations. The boy's father is at work and has provided a letter stating that he consents for his son to be vaccinated. The practice nurse is unsure whether it is appropriate to administer the vaccine without the father being present. What should be the nurse's course of action?
Your Answer: The parent needs to be phoned prior to giving the vaccine to give verbal consent
Correct Answer: The child can have the vaccine
Explanation:Other Aspects of Immunisation
Consent is an important aspect of immunisation, and the Greenbook provides useful information on this topic. Written consent is not required, and a person with parental responsibility may give consent on behalf of a child who is not competent to give or withhold consent. Parental responsibility is defined by the Children Act 1989, and unmarried fathers can acquire it if they are named on the child’s birth certificate. If parents disagree, immunisation cannot go ahead without specific court approval. A person with parental responsibility doesn’t need to be present at the time of immunisation, but the healthcare provider must be satisfied that consent has been given in advance.
Vaccine storage is also crucial to ensure the effectiveness of immunisation. Vaccines should be stored in a fridge at +2ÂșC to +8ÂșC and kept in their original packaging to protect them from UV light. The temperature of the refrigerator should be monitored using a maximum-minimum thermometer and recorded daily. Ordinary domestic refrigerators should not be used, and surgeries should keep no more than 2 to 4 weeks’ supply of vaccines at any time. By following these guidelines, healthcare providers can ensure that vaccines are stored properly and administered safely to patients.
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This question is part of the following fields:
- Children And Young People
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Question 6
Correct
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A 67-year-old man presents for follow-up. He has a medical history of small cell lung cancer and ischemic heart disease. His cancer was detected five months ago and he recently finished a round of chemotherapy. In terms of his heart health, he experienced a heart attack two years ago and underwent primary angioplasty with stent placement. He has not had any angina since then.
Over the past week, he has been experiencing increasing shortness of breath, particularly at night, and has an occasional non-productive cough. He has also noticed that his wedding ring feels tight. Upon examination, his chest appears normal, but he does have distended neck veins and periorbital edema. What is the most probable diagnosis?Your Answer: Superior vena cava obstruction
Explanation:Understanding Superior Vena Cava Obstruction
Superior vena cava obstruction is a medical emergency that occurs when the superior vena cava, a large vein that carries blood from the upper body to the heart, is compressed. This condition is commonly associated with lung cancer, but it can also be caused by other malignancies, aortic aneurysm, mediastinal fibrosis, goitre, and SVC thrombosis. The most common symptom of SVC obstruction is dyspnoea, but patients may also experience swelling of the face, neck, and arms, headache, visual disturbance, and pulseless jugular venous distension.
The management of SVC obstruction depends on the underlying cause and the patient’s individual circumstances. Endovascular stenting is often the preferred treatment to relieve symptoms, but certain malignancies may require radical chemotherapy or chemo-radiotherapy instead. Glucocorticoids may also be given, although the evidence supporting their use is weak. It is important to seek advice from an oncology team to determine the best course of action for each patient.
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This question is part of the following fields:
- Cardiovascular Health
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Question 7
Incorrect
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A woman visits her GP for a check-up of her type 2 diabetes. She is taking metformin at the maximum tolerated dose. Her most recent HbA1c reading is 64 mmol/mol.
The GP prescribes gliclazide and schedules another HbA1c test in 3 months.
What is the new target HbA1c for this patient?Your Answer: 68
Correct Answer: 53
Explanation:The target HbA1c for patients taking a drug that may cause hypoglycaemia, such as gliclazide, is 53 mmol/mol or below. This target applies to adults who are prescribed a single hypoglycaemic agent or two or more antidiabetic drugs in combination. For adults with type 2 diabetes who are managed by diet and lifestyle alone or a single antidiabetic drug not associated with hypoglycaemia, the target HbA1c is 48 mmol/mol. Therefore, the correct answer for the HbA1c target for a patient starting on gliclazide is 53 mmol/mol. The answers 58 mmol/mol and 63 mmol/mol are incorrect.
NICE has updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022 to reflect advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. For the average patient taking metformin for T2DM, lifestyle changes and titrating up metformin to aim for a HbA1c of 48 mmol/mol (6.5%) is recommended. A second drug should only be added if the HbA1c rises to 58 mmol/mol (7.5%). Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates, controlling intake of saturated fats and trans fatty acids, and initial target weight loss of 5-10% in overweight individuals.
Individual HbA1c targets should be agreed upon with patients to encourage motivation, and HbA1c should be checked every 3-6 months until stable, then 6 monthly. Targets should be relaxed on a case-by-case basis, with particular consideration for older or frail adults with type 2 diabetes. Metformin remains the first-line drug of choice, and SGLT-2 inhibitors should be given in addition to metformin if the patient has a high risk of developing cardiovascular disease (CVD), established CVD, or chronic heart failure. If metformin is contraindicated, SGLT-2 monotherapy or a DPP-4 inhibitor, pioglitazone, or sulfonylurea may be used.
Further drug therapy options depend on individual clinical circumstances and patient preference. Dual therapy options include adding a DPP-4 inhibitor, pioglitazone, sulfonylurea, or SGLT-2 inhibitor (if NICE criteria are met). If a patient doesn’t achieve control on dual therapy, triple therapy options include adding a sulfonylurea or GLP-1 mimetic. GLP-1 mimetics should only be added to insulin under specialist care. Blood pressure targets are the same as for patients without type 2 diabetes, and ACE inhibitors or ARBs are first-line for hypertension. Antiplatelets should not be offered unless a patient has existing cardiovascular disease, and only patients with a 10-year cardiovascular risk > 10% should be offered a statin.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 8
Incorrect
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A 38-year-old teacher is undergoing treatment for moderate depression with citalopram 20 mg daily. She initially sought help due to a recent break-up and stress at work caused by a difficult colleague. This is her first experience with depression and she has been taking medication for three months. She has a supportive family, including her parents and sister who live nearby.
At her last appointment one month ago, she reported still feeling sad when alone with her thoughts and not fully recovered. However, at her most recent appointment, she reported feeling like her usual self again. She has resolved the work issues with her colleague and is enjoying her social life with friends. She has also started practicing yoga and is interested in tapering off her medication.
Based on her current progress, when is the earliest appropriate time for her to consider tapering off her medication?Your Answer: He can tail off now that he has recovered
Correct Answer: He can tail off in six months
Explanation:Duration of Antidepressant Treatment
This patient, a relatively young individual who has experienced a first episode of depression, has successfully recovered without any lingering issues that would indicate a high risk of recurrence. It is recommended that he continue taking his antidepressants for at least six more months. While there are situations where treatment may need to be extended, such as for older adults or those at a high risk of relapse, this patient is eager to reduce his medication. Therefore, six months is the earliest opportunity for reducing the dose.
It is common for patients to want to stop taking their medication once they feel better. However, it is important to remind them that depression can be a recurrent condition. Continuing treatment for the recommended period can help prevent relapse and will not result in addiction to the medication.
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This question is part of the following fields:
- Mental Health
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Question 9
Correct
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A 6 week-old infant is presented to your clinic as the mother has observed a white spot in the baby's mouth. Upon examination, a small white papule of around 1 mm size is visible on the lower gum. The baby is being breastfed and feeding without any issues. What is the probable diagnosis?
Your Answer: Epstein's pearl
Explanation:Understanding Epstein’s Pearl
Epstein’s pearl is a type of cyst that is present in the mouth from birth. It is commonly found on the hard palate, but can also be seen on the gums. Parents may mistake it for a tooth that is about to erupt. However, there is no need for concern as it tends to resolve on its own within a few weeks. Treatment is not usually required.
In summary, Epstein’s pearl is a harmless cyst that is commonly found in the mouth of newborns. It is important for parents to be aware of its presence and not mistake it for a dental issue. With time, it will naturally disappear without any intervention.
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This question is part of the following fields:
- Children And Young People
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Question 10
Correct
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A new case of Chickenpox has been reported at the daycare yesterday. A mother attends with her 4-year-old son and is anxious because she is going away for a weekâs holiday on the next day. She wonders how soon her son will develop symptoms.
Select from the list the option within which the incubation period for Chickenpox lies.Your Answer: Medium (7-21 days)
Explanation:Understanding Incubation Periods and Latent Periods in Diseases
Incubation period refers to the time between exposure to a pathogenic organism and the onset of symptoms. This period can range from minutes to even 30 years, depending on the disease. Latent period, on the other hand, is the time from infection to infectiousness. While the two terms may be synonymous, a distinction is sometimes made between them.
Examples of diseases with short incubation periods include norovirus, influenza, and scarlet fever. Diseases with medium incubation periods include roseola, measles, and pertussis. Mumps, erythema infectiosum, and rubella have long incubation periods, while infectious mononucleosis and hepatitis A have extra-long incubation periods. Hepatitis B has an incubation period greater than six weeks.
Clinical latency occurs in diseases like AIDS, where people infected with HIV may not show any symptoms or signs of AIDS despite having a large viral load. It is important to understand incubation and latent periods in diseases to prevent their spread and manage their symptoms effectively.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 11
Incorrect
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A psychology student conducts a study amongst her peers investigating the effect of age on memory. She found that participants over the age of 50 showed significantly worse memory performance compared to participants under the age of 50 with a significance level of p<0.05. Later on in her project, she conducts a systematic review which finds no significant effect of age on memory.
What statistical mistake is the student likely to have made in her initial study?Your Answer: False negative
Correct Answer: Type I error
Explanation:In statistical hypothesis testing, a type I error occurs when the null hypothesis is rejected when it is actually true. This is also known as a false positive. For example, if a student found a significant effect of previous covid-19 infection on task performance when there actually was no effect, this would be a type I error.
A false negative, on the other hand, is when no significant result is found when there actually is one. This is the same as a type II error. For instance, if the student found no effect of previous covid-19 infection on task performance when actually there was an effect, this would be a false negative or a type II error.
Sampling errors can occur when there is a systematic error in recruiting research participants, resulting in a sample population that is not representative of the population to which the results will be applied. However, there is no indication that this is the case in this scenario.
A type II error occurs when the null hypothesis is accepted when it is actually false. In this case, if the student found no effect of previous covid-19 infection on task performance when later research demonstrates there is an effect, this would be a type II error.
Finally, a type III error is not commonly used. It occurs when the null hypothesis is rejected correctly but for the wrong reason.
Significance tests are used to determine the likelihood of a null hypothesis being true. The null hypothesis states that two treatments are equally effective, while the alternative hypothesis suggests that there is a difference between the two treatments. The p value is the probability of obtaining a result by chance that is at least as extreme as the observed result, assuming the null hypothesis is true. Two types of errors can occur during significance testing: type I, where the null hypothesis is rejected when it is true, and type II, where the null hypothesis is accepted when it is false. The power of a study is the probability of correctly rejecting the null hypothesis when it is false, and it can be increased by increasing the sample size.
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This question is part of the following fields:
- Evidence Based Practice, Research And Sharing Knowledge
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Question 12
Correct
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A 14-year-old boy presents with swollen legs and proteinuria (> 3.5g/24 hours). After referral and kidney biopsy, a diagnosis of focal segmental glomerulosclerosis is made.
Select from the list the single correct statement about this condition.Your Answer: It may present as a nephritic syndrome
Explanation:Understanding Glomerulonephritis: Types, Symptoms, and Causes
Glomerulonephritis is a group of immune-mediated disorders that cause inflammation in the glomerulus and other parts of the kidney. It can be primary or secondary, and may present with various symptoms such as haematuria, proteinuria, nephrotic syndrome, nephritic syndrome, acute or chronic renal failure.
Primary glomerulonephritis can be classified based on clinical syndrome, histopathological appearance, or underlying aetiology. One common type is focal segmental glomerulosclerosis, which causes segmental scarring and podocyte fusion in the glomerulus. It often leads to nephrotic syndrome and may progress to end-stage renal failure, but can be treated with corticosteroids.
Another type is IgA nephropathy, which is characterised by IgA antibody deposition in the glomerulus and is the most common type of glomerulonephritis in adults worldwide. It usually presents with macroscopic haematuria but can also cause nephrotic syndrome.
Interstitial nephritis, on the other hand, affects the area between the nephrons and can be acute or chronic. The most common cause is a drug hypersensitivity reaction.
In summary, understanding the types, symptoms, and causes of glomerulonephritis is crucial in diagnosing and managing this group of kidney disorders.
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This question is part of the following fields:
- Kidney And Urology
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Question 13
Incorrect
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A 65-year-old woman with poorly controlled type 2 diabetes presents with burning pains in both feet that have been ongoing for several months. On examination, she has easily palpable pedal pulses but reduced light touch sensation in both feet up to her ankles. Her blood pressure is 130/80 mmHg. Recent blood tests reveal an HbA1c of 76 mmol/mol (9.1%) with normal full blood count, renal and liver function. She is currently taking metformin 500 mg TDS, gliclazide 80 mg OD, aspirin 75 mg OD, ramipril 10 mg OD, and simvastatin 40 mg ON. You discuss the importance of tighter glycemic control and potential medications that may help alleviate her symptoms. What is the most appropriate first-line treatment for her burning foot pain?
Your Answer: Duloxetine
Correct Answer: Lamotrigine
Explanation:NICE Guidelines for Neuropathic Pain Management
The National Institute for Health and Care Excellence (NICE) has released guidelines for the pharmacological management of neuropathic pain in non-specialist settings. The key points include offering a choice of amitriptyline, duloxetine, gabapentin, or pregabalin as initial treatment for all neuropathic pain (except trigeminal neuralgia). If the initial treatment is not effective or not tolerated, one of the remaining three drugs should be offered, with consideration for switching again if necessary. Tramadol should only be considered for acute rescue therapy, and capsaicin cream may be used for localized neuropathic pain. Nortriptyline is no longer recommended as an alternative to amitriptyline, and lamotrigine and venlafaxine are not recommended in non-specialized settings. It is important to note that there are many plausible options for medication, but the test is to select the one listed in the options.
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This question is part of the following fields:
- Neurology
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Question 14
Incorrect
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A 42-year-old man with known asthma visits your clinic with complaints of worsening wheezing over the past few hours. He seldom attends asthma clinic. During previous consultations, his best peak flow measurements have been 500 L/min. What is the indication of acute severe asthma in this patient?
Your Answer: Heart rate 115/min
Correct Answer: Heart rate 105/min
Explanation:Assessment and Severity of Acute Asthma
The British Thoracic Society provides clear guidance on the assessment and management of acute asthma. It is important to familiarize oneself with this document, as questions about the assessment and severity of acute asthma are common in exams.
Indicators of acute severe asthma include a peak expiratory flow rate of 33-50% of the patient’s best or predicted rate, a respiratory rate of 25 or greater, a heart rate of 110/min or greater, or the inability to complete sentences in one breath. The goal of oxygen therapy is to maintain SpO2 levels between 94-98%.
It is important to note that there is no fixed numerical peak flow rate for all patients to determine the severity of their asthma. It depends on their personal best reading or predicted peak flow reading. If their actual peak flow is 33-50% of this figure, it is a marker of an acute severe attack.
For example, a peak flow rate of 400 L/min in a patient with a personal best of 500 L/min equates to 80% of their best and would not be considered a marker of an acute severe attack. However, a pulse of 115 would be considered a marker of acute severe asthma because the threshold is 110/min or greater.
If any of these features of an acute severe asthma attack persist after initial treatment, the patient should be admitted.
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This question is part of the following fields:
- Urgent And Unscheduled Care
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Question 15
Incorrect
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A 45-year-old man visits his GP clinic seeking sildenafil (Viagra) as he is nervous every time he is intimate with his new partner. He can still achieve his own erections and has morning erections. His recent NHS health screening blood tests were all normal, and he has normal blood pressure. The GP examines his medication history and advises him against using sildenafil. Which of the following medications listed below is not recommended to be used with sildenafil?
Your Answer: All of the above
Correct Answer: Isosorbide mononitrate (ISMN)
Explanation:When considering treatment options for this patient, it is important to note that PDE 5 inhibitors such as sildenafil are contraindicated when used in conjunction with nitrates and nicorandil. This is due to the potential for severe hypotension. Therefore, alternative treatment options should be explored and discussed with the patient.
Phosphodiesterase type V inhibitors are medications used to treat erectile dysfunction and pulmonary hypertension. They work by increasing cGMP, which leads to relaxation of smooth muscles in blood vessels supplying the corpus cavernosum. The most well-known PDE5 inhibitor is sildenafil, also known as Viagra, which is taken about an hour before sexual activity. Other examples include tadalafil (Cialis) and vardenafil (Levitra), which have longer-lasting effects and can be taken regularly. However, these medications have contraindications, such as not being safe for patients taking nitrates or those with hypotension. They can also cause side effects such as visual disturbances, blue discolouration, and headaches. It is important to consult with a healthcare provider before taking PDE5 inhibitors.
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This question is part of the following fields:
- Cardiovascular Health
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Question 16
Incorrect
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You see a 75-year-old male patient with back pain. He reports having lower back pain for the past year, which has gradually worsened. The pain now radiates bilaterally to his buttocks, thighs, and legs, with the left leg being worse than the right. He describes the pain as 'cramping' and 'burning'. Walking for more than a few minutes causes weakness and numbness in his legs, which improves when he sits down and leans forward. Standing exacerbates the symptoms, and he has lost his independence and now uses a walking aid. His wife has noticed a more stooped posture than 12 months ago.
The patient's medical history includes hypertension, which is controlled with medication. He has never smoked and has a normal BMI. On examination, he has a wide-based gait, and neurological examination of his lower limbs is normal. Peripheral pulses feel normal.
What is the most likely diagnosis based on the patient's presentation and examination findings?Your Answer: Ankylosing spondylitis
Correct Answer: Spinal stenosis
Explanation:A patient who experiences gradual leg and back pain, weakness, and numbness while walking, with a normal clinical examination, is most likely suffering from spinal stenosis. This condition is characterized by symptoms that are relieved by sitting and leaning forward, and worsened by walking, especially on flat surfaces. Although physical examination findings are often normal in patients with lumbar spinal stenosis, it is important to rule out other conditions such as vascular claudication. Sciatica, which typically presents with unilateral leg pain, is less likely to be the cause of these symptoms.
Treatment for Lumbar Spinal Stenosis
Laminectomy is a surgical procedure that is commonly used to treat lumbar spinal stenosis. It involves the removal of the lamina, which is the bony arch that covers the spinal canal. This procedure is done to relieve pressure on the spinal cord and nerves, which can help to alleviate the symptoms of lumbar spinal stenosis.
Laminectomy is typically reserved for patients who have severe symptoms that do not respond to conservative treatments such as physical therapy, medication, and epidural injections. The procedure is performed under general anesthesia and involves making an incision in the back to access the affected area of the spine. The lamina is then removed, and any other structures that are compressing the spinal cord or nerves are also removed.
After the procedure, patients may need to stay in the hospital for a few days to recover. They will be given pain medication and will be encouraged to walk as soon as possible to prevent blood clots and promote healing. Physical therapy may also be recommended to help patients regain strength and mobility.
Overall, laminectomy is a safe and effective treatment for lumbar spinal stenosis. However, as with any surgery, there are risks involved, including infection, bleeding, and nerve damage. Patients should discuss the risks and benefits of the procedure with their doctor before making a decision.
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This question is part of the following fields:
- Musculoskeletal Health
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Question 17
Correct
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A 65-year-old woman presents with a painful face that started gradually over the past day and has now become severe. The pain is localized around one of her lower molars, which is tender to touch and sensitive to temperature. Upon examination, an abscess is visible around the affected tooth and the surrounding tissues are inflamed. The patient has a temperature of 37.1 ÂșC and is otherwise healthy with no medication use or allergies.
What is the initial treatment approach for this patient?Your Answer: Advise the patient to see her dentist today
Explanation:Brant Daroff exercises
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 18
Incorrect
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Immunodeficiency is most likely to result from which of the following conditions? Please select one option.
Your Answer: Polycythaemia rubra vera
Correct Answer: Nephrotic syndrome
Explanation:Causes of Secondary Immunodeficiency
Secondary immunodeficiency can be caused by various factors such as lymphoreticular malignancy, drugs, viruses, malnutrition, metabolic disorders, trauma or major surgery, and protein loss. Lymphoma, myeloma, cytotoxic drugs, and immunosuppressants like corticosteroids are some of the common causes of secondary immunodeficiency. HIV is also a significant cause of secondary immunodeficiency. Malnutrition, particularly protein calorie deficiency, is the most common cause of secondary immunodeficiency worldwide. Metabolic disorders like renal disease requiring peritoneal dialysis can also lead to secondary immunodeficiency. Trauma or major surgery and protein loss due to nephrotic syndrome or ulcerative or erosive gastrointestinal disease can also cause secondary immunodeficiency. While heart failure, lung cancer, and polycythemia are consequences of HIV infection, sarcoidosis has been reported to occur in patients with common variable immunodeficiency.
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This question is part of the following fields:
- Allergy And Immunology
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Question 19
Incorrect
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You are evaluating a 28-year-old female patient who has been experiencing deteriorating migraines over the last half-year. She usually experiences aura before the onset of the headache. During the history-taking process, what is the maximum duration of aura that NICE and the British Association for the Study of Headache (BASH) consider to be normal?
Your Answer: 2 hours
Correct Answer: 1 hour
Explanation:The typical duration of an aura is from 5 to 60 minutes.
Migraine is a neurological condition that affects a significant portion of the population. The International Headache Society has established diagnostic criteria for migraine without aura, which includes at least five attacks lasting between 4-72 hours, with at least two of the following characteristics: unilateral location, pulsating quality, moderate or severe pain intensity, and aggravation by routine physical activity. During the headache, there must be at least one of the following: nausea and/or vomiting, photophobia, and phonophobia. The headache cannot be attributed to another disorder. In children, attacks may be shorter-lasting, headache is more commonly bilateral, and gastrointestinal disturbance is more prominent.
Migraine with aura, which is seen in around 25% of migraine patients, tends to be easier to diagnose with a typical aura being progressive in nature and may occur hours prior to the headache. Typical aura include a transient hemianopic disturbance or a spreading scintillating scotoma (‘jagged crescent’). Sensory symptoms may also occur. NICE criteria suggest that migraines may be unilateral or bilateral and give more detail about typical auras, which may occur with or without headache and are fully reversible, develop over at least 5 minutes, and last 5-60 minutes. Atypical aura symptoms, such as motor weakness, double vision, visual symptoms affecting only one eye, poor balance, and decreased level of consciousness, may prompt further investigation or referral.
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This question is part of the following fields:
- Neurology
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Question 20
Incorrect
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A 6-year-old child is brought to your clinic by their parents due to concerns about bruising and nosebleeds. The child's medical history shows only a previous case of croup as a toddler. The parents report a cold one week prior to the current symptoms. On examination, the child appears healthy and active, but there is significant bruising and purpura on the trunk and legs. There is no enlargement of lymph nodes or liver and spleen, and a dipstick test of urine is normal. What is the most probable diagnosis?
Your Answer: Henoch-Schönlein purpura
Correct Answer: Immune-mediated thrombocytopenic purpura
Explanation:Immune-Mediated Thrombocytopenic Purpura in Children
This child is experiencing immune-mediated thrombocytopenic purpura, which is the most common cause of low platelets in children. It occurs due to immune-mediated platelet destruction and typically affects children between 2 and 10 years old, usually after a viral infection. Symptoms include purpura, bruising, nosebleeds, and mucosal bleeding. While intracranial hemorrhage is a rare complication, it can be serious. However, in most cases, ITP is self-limiting and acute.
While abnormal bruising can also be a symptom of acute lymphoblastic leukemia (ALL), the child’s history and clinical features are more consistent with ITP. ALL typically presents with malaise, recurrent infections, pallor, hepatosplenomegaly, and lymphadenopathy, none of which are present in this case.
Other conditions that can cause purpura include haemolytic uraemic syndrome, Henoch-Schönlein purpura, and meningococcal septicaemia. However, these conditions have distinct symptoms and presentations that differ from ITP.
In summary, immune-mediated thrombocytopenic purpura is a common cause of low platelets in children, typically occurring after a viral infection. While it can cause purpura and bruising, it is usually self-limiting and acute. Other conditions that can cause purpura have distinct symptoms and presentations that differ from ITP.
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This question is part of the following fields:
- Haematology
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Question 21
Correct
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A 26-year-old man presents to your emergency clinic with worsening pain in his right ear. He had previously been diagnosed with otitis externa and started on antibiotic ear drops by another physician four days ago. However, he reports that the pain has only gotten worse and he has been unable to apply the drops for the past 24 hours due to swelling of the canal. Upon examination, you notice that the right external auditory canal is completely swollen shut and you are unable to see any further. The patient's vital signs are normal.
What is the most appropriate course of action for management?Your Answer: Refer to on-call ENT
Explanation:If topical antibiotics do not provide relief for otitis externa, it is recommended to refer the patient to an ear, nose, and throat (ENT) specialist. This is because the infection can cause swelling and narrowing of the ear canal, making it difficult for antibiotic drops to be effective. In such cases, microsuction and insertion of a pope wick may be necessary, which requires the expertise of an ENT specialist.
Ear syringing should not be performed during an active infection as it will not be helpful.
Steroids are often included in antibiotic ear drops, but they will not be effective if the drops cannot reach the ear canal.
Oral antibiotics, such as ciprofloxacin, may be prescribed alongside topical antibiotics if there is concern of a deep tissue infection. However, this is unlikely in a young and otherwise healthy patient, and the primary treatment remains antibiotic drops.
If necrotising otitis externa is suspected, a CT scan may be helpful, but this would be arranged by an ENT specialist and is not necessary in most cases.
Understanding Otitis Externa: Causes, Features, and Management
Otitis externa is a prevalent condition that often prompts primary care visits in the UK. It is characterized by ear pain, itch, and discharge, and can be caused by bacterial or fungal infections, seborrhoeic dermatitis, or contact dermatitis. Swimming is also a common trigger for otitis externa. Upon examination, the ear canal may appear red, swollen, or eczematous.
The recommended initial management for otitis externa is the use of topical antibiotics or a combination of topical antibiotics with a steroid. However, if the tympanic membrane is perforated, aminoglycosides are traditionally not used. If there is canal debris, removal may be necessary, and if the canal is extensively swollen, an ear wick may be inserted. Second-line options include taking a swab inside the ear canal, considering contact dermatitis secondary to neomycin, or using oral antibiotics such as flucloxacillin if the infection is spreading. Empirical use of an antifungal agent may also be considered.
It is important to note that if a patient fails to respond to topical antibiotics, they should be referred to an ENT specialist. Malignant otitis externa is a more severe form of the condition that is more common in elderly diabetics. It involves the extension of infection into the bony ear canal and the soft tissues deep to the bony canal, and may require intravenous antibiotics. While some ENT doctors disagree, concerns about ototoxicity may arise with the use of aminoglycosides in patients with perforated tympanic membranes.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 22
Incorrect
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A 42-year-old diabetic man is seen in the Diabetes Clinic with decreased visual acuity. When referred to the Eye Clinic, the Ophthalmologist inquires about the patient's risk factors for macular edema.
What is the most significant risk factor? Choose ONE answer only.Your Answer: Peripheral vascular disease
Correct Answer: Proteinuria
Explanation:Factors Associated with Macular Edema in Diabetes
In diabetes, macular edema is a common cause of visual loss and can result from various factors such as macular capillary non-perfusion, vitreous hemorrhage, and distortion or traction detachment of the retina. The severity of diabetic retinopathy, male gender, higher glycosylated hemoglobin, proteinuria, higher systolic and diastolic blood pressure, and smoking history are all associated with a higher incidence of macular edema, according to The Wisconsin Epidemiologic Study of Diabetic Retinopathy.
Contrary to popular belief, low glycosylated hemoglobin is not associated with macular edema. However, hypercholesterolemia and other cardiovascular risk factors can influence the onset and progression of retinopathy and should be monitored. While peripheral vascular disease is a risk factor for diabetes, it is not directly associated with macular edema. Overall, understanding the factors associated with macular edema in diabetes can help healthcare professionals identify and manage patients at risk for this complication.
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This question is part of the following fields:
- Eyes And Vision
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Question 23
Incorrect
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A study testing a new prostate cancer screening tool enrolls 52,820 participants. Among the 8950 participants diagnosed with prostate cancer through histological examination, 8900 had a positive test outcome. Meanwhile, 13,750 healthy participants had a positive screening result. What is the specificity of this novel screening tool?
Your Answer: 99.80%
Correct Answer: 68.70%
Explanation:To calculate specificity, we need to use a 2*2 table with the following values for a sample size of 11,000 participants:
Disease Healthy
Positive TP=8900 FP=13750
Negative FN=50 TN=30120Specificity is the probability of getting a negative test result when the person is healthy/doesn’t have the screened disease. We can calculate specificity using the formula:
Specificity = TN / (TN+FP)
Plugging in the values from our table, we get:
Specificity = 30120 / (30120 + 13750) =
Precision refers to the consistency of a test in producing the same results when repeated multiple times. It is an important aspect of test reliability and can impact the accuracy of the results. In order to assess precision, multiple tests are performed on the same sample and the results are compared. A test with high precision will produce similar results each time it is performed, while a test with low precision will produce inconsistent results. It is important to consider precision when interpreting test results and making clinical decisions.
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This question is part of the following fields:
- Evidence Based Practice, Research And Sharing Knowledge
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Question 24
Incorrect
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You think that an 80-year-old man has dementia.
Which one of the following is more suggestive of vascular dementia than Alzheimer's?Your Answer: Insidious onset normal
Correct Answer: Emotional lability
Explanation:Emotional lability in Vascular Dementia
Emotional lability, which refers to sudden and exaggerated changes in mood or emotions, is a common symptom in patients with vascular dementia. This type of dementia is caused by reduced blood flow to the brain, leading to damage in different areas of the brain. Emotional lability can manifest as sudden outbursts of anger, crying spells, or inappropriate laughter.
On the other hand, other symptoms such as memory loss, confusion, and difficulty with language and communication are more suggestive of Alzheimer’s disease. It is important to differentiate between the two types of dementia as they have different underlying causes and may require different treatment approaches.
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This question is part of the following fields:
- Older Adults
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Question 25
Incorrect
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A 20-year-old woman complains of hearing difficulties over the last six months. She initially suspected it was due to earwax, but her hearing has not improved after ear syringing. You conduct an auditory system examination, including Rinne's and Weber's tests:
Rinne's test: Left ear: air conduction > bone conduction
Right ear: air conduction > bone conduction
Weber's test: Lateralises to the left side
What is the significance of these test results?Your Answer: Right conductive deafness
Correct Answer: Right sensorineural deafness
Explanation:If there is a sensorineural issue, the sound in Weber’s test will be perceived on the healthy side (left), suggesting a problem on the affected side (right).
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:
- Ear, Nose And Throat, Speech And Hearing
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Question 26
Incorrect
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Following NICE guidance, which one of the following patients should undergo screening for hereditary thrombophilia?
Your Answer: A 52-year-old develops a massive pulmonary embolism following an hysterectomy. She has a history of systemic lupus erythematosus
Correct Answer: A 54-year-old woman with an unprovoked deep vein thrombosis. Her sister was diagnosed with a pulmonary embolism three years ago
Explanation:The probability of an underlying hereditary thrombophilia is high in the 54-year-old woman who has an unprovoked deep vein thrombosis and a first-degree relative with the same condition.
Deep vein thrombosis (DVT) is a serious condition that requires prompt diagnosis and management. The National Institute for Health and Care Excellence (NICE) updated their guidelines in 2020, recommending the use of direct oral anticoagulants (DOACs) as first-line treatment for most people with VTE, including as interim anticoagulants before a definite diagnosis is made. They also recommend the use of DOACs in patients with active cancer, as opposed to low-molecular weight heparin as was previously recommended. Routine cancer screening is no longer recommended following a VTE diagnosis.
If a patient is suspected of having a DVT, a two-level DVT Wells score should be performed to assess the likelihood of the condition. If a DVT is ‘likely’ (2 points or more), a proximal leg vein ultrasound scan should be carried out within 4 hours. If the result is positive, then a diagnosis of DVT is made and anticoagulant treatment should start. If the result is negative, a D-dimer test should be arranged. If a proximal leg vein ultrasound scan cannot be carried out within 4 hours, a D-dimer test should be performed and interim therapeutic anticoagulation administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours).
The cornerstone of VTE management is anticoagulant therapy. The big change in the 2020 guidelines was the increased use of DOACs. Apixaban or rivaroxaban (both DOACs) should be offered first-line following the diagnosis of a DVT. Instead of using low-molecular weight heparin (LMWH) until the diagnosis is confirmed, NICE now advocate using a DOAC once a diagnosis is suspected, with this continued if the diagnosis is confirmed. If neither apixaban or rivaroxaban are suitable, then either LMWH followed by dabigatran or edoxaban OR LMWH followed by a vitamin K antagonist (VKA, i.e. warfarin) can be used.
All patients should have anticoagulation for at least 3 months. Continuing anticoagulation after this period is partly determined by whether the VTE was provoked or unprovoked. If the VTE was provoked, the treatment is typically stopped after the initial 3 months (3 to 6 months for people with active cancer). If the VTE was
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This question is part of the following fields:
- Haematology
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Question 27
Incorrect
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A 30-year-old woman presents to your clinic after cutting her hand while preparing dinner. Upon examination, you note a three inch laceration on her left hand which is cleaned and sutured. She recalls receiving a tetanus booster shot approximately 10 years ago and has received a total of five tetanus vaccines throughout her life. What is the appropriate recommendation for tetanus prophylaxis?
Your Answer: She should be given one booster tetanus vaccination
Correct Answer: She should be given tetanus immunoglobulin
Explanation:Tetanus Vaccination Not Required for Low-Risk Wound
This woman’s wound is clean and low-risk, with a very low chance of being contaminated with tetanus bacteria. Fortunately, she has already received five doses of the tetanus vaccine in the past, which means she should not require any further vaccination. It is important to note that tetanus vaccination is crucial for individuals who have not received the vaccine or have not completed the recommended doses. However, in this case, the woman can rest assured that she is protected against tetanus and can focus on proper wound care to promote healing.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 28
Incorrect
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Regarding confounding, which of the following statements is incorrect?
Your Answer: Confounding factors are factors associated with both the exposure the outcome
Correct Answer: In the analytic stage of a study confounding can be controlled for by randomisation
Explanation:Stratification can control for confounding in the analytic stage of a study.
Understanding Confounding in Statistics
Confounding is a term used in statistics to describe a situation where a variable is correlated with other variables in a study, leading to inaccurate or spurious results. For instance, in a case-control study that examines whether low-dose aspirin can prevent colorectal cancer, age could be a confounding factor if the case and control groups are not matched for age. This is because older people are more likely to take aspirin and also more likely to develop cancer. Similarly, in a study that finds a link between coffee consumption and heart disease, smoking could be a confounding factor as it is associated with both drinking coffee and heart disease.
Confounding occurs when there is a non-random distribution of risk factors in the populations being studied. Common causes of confounding include age, sex, and social class. To control for confounding in the design stage of an experiment, randomization can be used to produce an even distribution of potential risk factors in two populations. In the analysis stage, confounding can be controlled for by stratification. Understanding confounding is crucial in ensuring that research findings are accurate and reliable.
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This question is part of the following fields:
- Evidence Based Practice, Research And Sharing Knowledge
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Question 29
Incorrect
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A father brings his 15-month-old daughter to your clinic. He reports that she has had a runny nose and cough for the past 3 days. He is concerned because this morning, her cough sounded like a seal. However, she has been eating and drinking normally. During the examination, the child seems content and plays with toys in the room. She has an occasional barking cough, but there is no audible stridor at rest. There is no intercostal or suprasternal recession, and her chest is clear. Vital signs are within normal limits. What is the most appropriate course of action for you to take in managing this situation?
Your Answer: Regular paracetamol
Correct Answer: Prescribe a single dose of dexamethasone
Explanation:For mild, moderate, or severe croup, a single dose of dexamethasone (0.15 mg/kg) should be taken immediately, according to NICE guidelines. In cases of moderate or severe croup, or if respiratory failure is imminent, immediate admission is recommended by CKS. To manage fever and pain, paracetamol or ibuprofen can be used, but they are not necessary in this scenario as there is no evidence of fever or pain. Tepid sponging is not recommended, and humidified air is not advised.
Croup is a respiratory infection that affects young children, typically those between 6 months and 3 years old. It is most common in the autumn and is caused by parainfluenza viruses. The main symptom is stridor, which is caused by swelling and secretions in the larynx. Other symptoms include a barking cough, fever, and cold-like symptoms. The severity of croup can be graded based on the child’s symptoms, with mild cases having occasional coughing and no audible stridor at rest, and severe cases having frequent coughing, prominent stridor, and significant distress or lethargy. Children with moderate or severe croup should be admitted to the hospital, especially if they are under 6 months old or have other airway abnormalities. Diagnosis is usually made based on clinical symptoms, but a chest x-ray can show subglottic narrowing. Treatment typically involves a single dose of oral dexamethasone or prednisolone, and emergency treatment may include high-flow oxygen or nebulized adrenaline.
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This question is part of the following fields:
- Children And Young People
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Question 30
Correct
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A 3-year-old girl presents with a 2-day history of right sided limp and reluctance to weight bear. She has been distressed, excessively sweaty and febrile overnight. She looks unwell and has a temperature of 38.9ÂșC. She refuses to walk but will lie on the couch to be examined; she is warm to the touch and there is erythema over her right hip. She is distressed when you check the range of movement in the right hip, the left hip examination is unremarkable. Her mother thinks her symptoms started following a fall in the garden 2 days ago. What is the most likely diagnosis?
Your Answer: Septic arthritis
Explanation:The likely diagnosis in this case is septic arthritis, as indicated by the child’s reluctance to bear weight, distress, and fever with sweats. Although the child had a history of injury, this is not a significant factor as falls and accidents are common in toddlers. There is no indication of non-accidental injury, and the mother brought the child in for review due to his sudden illness. Developmental dysplasia of the hip is an unlikely cause of a new onset limp in a previously mobile child, while transient synovitis is uncommon in this age group and typically only causes mild illness.
Causes of Limping in Children Vary by Age
When a child is limping, the cause can vary depending on their age. For younger children, transient synovitis is a common cause. This condition has an acute onset and is often accompanied by viral infections, but the child is usually well or has a mild fever. It is more common in boys aged 2-12 years. On the other hand, septic arthritis/osteomyelitis is a more serious condition that causes a high fever and an unwell child.
Juvenile idiopathic arthritis can also cause a limp, which may be painless. Trauma is usually the cause of a limp in children, and the history of the injury can often diagnose the issue. Development dysplasia of the hip is usually detected in neonates and is six times more common in girls. Perthes disease is more common in children aged 4-8 years and is caused by avascular necrosis of the femoral head. Finally, slipped upper femoral epiphysis is a condition that occurs in children aged 10-15 years and is caused by the displacement of the femoral head epiphysis postero-inferiorly. Understanding the potential causes of a limp in children can help parents and healthcare providers identify and treat the issue promptly.
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This question is part of the following fields:
- Children And Young People
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