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Question 1
Incorrect
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A 5-year-old girl comes to the GP with her father. He reports that she has had a fever and a sore throat for the past 3 days and now has a rash all over her trunk and legs. During the examination, the child appears lethargic, flushed, and has a rough-textured erythematosus rash on her trunk and legs. The doctor observes a swollen red tongue and cervical lymphadenopathy during throat examination. What is the diagnosis?
Your Answer: Kawasaki disease
Correct Answer: Scarlet Fever
Explanation:The child’s symptoms are consistent with scarlet fever, which is characterized by a sandpaper-like rash, swollen tongue, and lymphadenopathy. Treatment with a 10-day course of penicillin V is recommended, and the child should stay home from school for 24 hours after starting antibiotics. Public health should also be notified. Kawasaki disease, rubella, and parvovirus are unlikely diagnoses based on the child’s presentation.
Scarlet fever is a condition caused by erythrogenic toxins produced by Group A haemolytic streptococci, usually Streptococcus pyogenes. It is more prevalent in children aged 2-6 years, with the highest incidence at 4 years. The disease spreads through respiratory droplets or direct contact with nose and throat discharges, especially during sneezing and coughing. The incubation period is 2-4 days, and symptoms include fever, malaise, headache, nausea/vomiting, sore throat, ‘strawberry’ tongue, and a rash that appears first on the torso and spares the palms and soles. The rash has a rough ‘sandpaper’ texture and desquamation occurs later in the course of the illness, particularly around the fingers and toes.
To diagnose scarlet fever, a throat swab is usually taken, but antibiotic treatment should be initiated immediately, rather than waiting for the results. Management involves administering oral penicillin V for ten days, while patients with a penicillin allergy should be given azithromycin. Children can return to school 24 hours after commencing antibiotics, and scarlet fever is a notifiable disease. Although usually a mild illness, scarlet fever may be complicated by otitis media, rheumatic fever, acute glomerulonephritis, or rare invasive complications such as bacteraemia, meningitis, or necrotizing fasciitis, which may present acutely with life-threatening illness.
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This question is part of the following fields:
- Paediatrics
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Question 2
Correct
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A 82-year-old female is brought to the emergency department following a fall at her nursing home. She has a medical history of osteoporosis, dementia, and is considered clinically frail. During examination, her left leg is found to be shortened and her hip externally rotated. An X-ray reveals a displaced intracapsular fracture. What is the most suitable course of action for this patient?
Your Answer: Hemiarthroplasty
Explanation:For patients with a displaced hip fracture, hemiarthroplasty or total hip replacement is the recommended treatment. In this case, the patient has a confirmed intracapsular fracture of the neck of femur, which carries a high risk of avascular necrosis. Hemiarthroplasty or total hip replacement is preferred for patients over 70 years old, with hemiarthroplasty being the better option for those with serious comorbidities, dementia, or immobility. Therefore, the patient should be managed with a hemiarthroplasty. The use of a dynamic hip screw, internal fixation, or Intramedullary nail is not appropriate for this type of fracture.
Hip fractures are a common occurrence, particularly in elderly women with osteoporosis. The femoral head’s blood supply runs up the neck, making avascular necrosis a potential risk in displaced fractures. Symptoms of a hip fracture include pain and a shortened and externally rotated leg. Patients with non-displaced or incomplete neck of femur fractures may still be able to bear weight. Hip fractures can be classified as intracapsular or extracapsular, with the Garden system being a commonly used classification system. Blood supply disruption is most common in Types III and IV fractures.
Intracapsular hip fractures can be treated with internal fixation or hemiarthroplasty if the patient is unfit. Displaced fractures are recommended for replacement arthroplasty, such as total hip replacement or hemiarthroplasty, according to NICE guidelines. Total hip replacement is preferred over hemiarthroplasty if the patient was able to walk independently outdoors with the use of a stick, is not cognitively impaired, and is medically fit for anesthesia and the procedure. Extracapsular hip fractures can be managed with a dynamic hip screw for stable intertrochanteric fractures or an intramedullary device for reverse oblique, transverse, or subtrochanteric fractures.
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This question is part of the following fields:
- Musculoskeletal
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Question 3
Correct
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A 35-year-old woman visits the gynaecology clinic with a history of endometriosis diagnosed 3 years ago after laparoscopic surgery. She complains of chronic pelvic pain that intensifies during her menstrual cycle and deep dyspareunia. Despite trying ibuprofen, the progesterone-only pill, and the combined oral contraceptive pill, she has not found relief. The patient has no medical history, allergies, or current desire to conceive. What would be the recommended course of action for treatment?
Your Answer: Trial a gonadotrophin-releasing hormone agonist
Explanation:If a patient with endometriosis is not experiencing relief from their symptoms with a combination of non-steroidal anti-inflammatories and the combined oral contraceptive pill, they may be prescribed gonadotrophin-releasing hormone agonists (GnRH agonists) as a second-line medical management option. progesterone-only contraception may also be offered in this stage of treatment. GnRH agonists work by down-regulating GnRH receptors, which reduces the production of oestrogen and androgen. This reduction in hormones can alleviate the symptoms of endometriosis, as oestrogen thickens the uterine lining. The copper intrauterine device is not an appropriate treatment option, as it does not contain hormones and may actually worsen symptoms. NICE does not recommend the use of opioids in the management of endometriosis, as there is a high risk of adverse effects and addiction. Amitriptyline may be considered as a treatment option for chronic pain, but it is important to explore other medical and surgical options for endometriosis before prescribing it, as it comes with potential side effects and risks.
Understanding Endometriosis
Endometriosis is a common condition where endometrial tissue grows outside of the uterus. It affects around 10% of women of reproductive age and can cause chronic pelvic pain, painful periods, painful intercourse, and subfertility. Other symptoms may include urinary problems and painful bowel movements. Diagnosis is typically made through laparoscopy, and treatment options depend on the severity of symptoms.
First-line treatments for symptomatic relief include NSAIDs and/or paracetamol. If these do not help, hormonal treatments such as the combined oral contraceptive pill or progestogens may be tried. If symptoms persist or fertility is a priority, referral to secondary care may be necessary. Secondary treatments may include GnRH analogues or surgery. For women trying to conceive, laparoscopic excision or ablation of endometriosis plus adhesiolysis is recommended, as well as ovarian cystectomy for endometriomas.
It is important to note that there is poor correlation between laparoscopic findings and severity of symptoms, and that there is little role for investigation in primary care. If symptoms are significant, referral for a definitive diagnosis is recommended.
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This question is part of the following fields:
- Gynaecology
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Question 4
Correct
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A 55-year-old male patient has been diagnosed with acromegaly. What is the most suitable treatment option for him?
Your Answer: Trans-sphenoidal hypophysectomy
Explanation:Treatment Options for Acromegaly
Acromegaly is a condition characterized by the excessive production of growth hormone (GH) in adults. The most effective treatment for this condition is surgery, which may prove curative. Although somatostatin therapy can reduce GH levels, it is not recommended for young patients like this man, as it requires lifelong therapy. On the other hand, radiotherapy can take a long time to be effective, and surgical resection is the preferred option. Therefore, surgery is the most appropriate treatment for acromegaly in this man, as it offers the best chance of a cure. Proper treatment can help manage the symptoms of acromegaly and improve the patient’s quality of life.
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This question is part of the following fields:
- Endocrinology
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Question 5
Incorrect
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An 85-year-old woman attends her general practice for a medication review. She is currently taking aspirin, simvastatin, atenolol, captopril and furosemide. The general practitioner (GP) performs an examination and notes an irregular pulse with a rate of 100 bpm. The GP makes a referral to the Cardiology Department with a view to establishing whether this woman’s atrial fibrillation (AF) is permanent or paroxysmal and to obtaining the appropriate treatment for her.
Which of the following is the most recognised risk factor for the development of AF?Your Answer: Obesity
Correct Answer: Alcohol
Explanation:Understanding Risk Factors for Atrial Fibrillation
Atrial fibrillation (AF) is a common cardiac arrhythmia that can lead to palpitations, shortness of breath, and fatigue. It is most commonly associated with alcohol consumption, chest disease, and hyperthyroidism. Other risk factors include hypertension, pericardial disease, congenital heart disease, cardiomyopathy, valvular heart disease, and coronary heart disease. AF can be classified as paroxysmal, persistent, or permanent, and may be diagnosed incidentally through an electrocardiogram (ECG) finding.
Once diagnosed, management includes investigating with a 12-lead ECG, echocardiogram, and thyroid function tests. The main objectives are rate control, rhythm control, and reducing the risk of thromboembolic disease. Rhythm control can be achieved through electrical cardioversion or drug therapy, while rate control is managed using medications such as digoxin, β-blockers, or rate-limiting calcium antagonists. Warfarin is indicated for patients with risk factors for stroke, and the risk of ischaemic stroke is calculated using the CHADS2vasc scoring system. Novel oral anticoagulants are also available as an alternative to warfarin in certain patients.
While hyperthyroidism is a recognized risk factor for AF, obesity and smoking are also associated with an increased risk of developing the condition. Pneumothorax, however, is not a recognized risk factor for AF. Understanding these risk factors can help individuals take steps to reduce their risk of developing AF and manage the condition if diagnosed.
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This question is part of the following fields:
- Cardiology
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Question 6
Correct
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A 35-year-old woman comes to the General Practitioner complaining of a painful red photophobic eye with some blurred vision. She reports no discharge, headache, nausea or vomiting. She has a medical history of inflammatory bowel disease but is otherwise healthy.
What is the probable diagnosis?Your Answer: Uveitis
Explanation:Common Eye Inflammations and Their Symptoms
Uveitis, a condition that can affect people of all ages, is often associated with systemic diseases like inflammatory bowel disease, sarcoidosis, and seronegative arthritis. It typically presents as a painful red eye with photophobia, but there is usually no discharge. Upon examination, signs of intraocular inflammation such as cells in the anterior chamber will be present. Urgent referral to ophthalmology is necessary, and treatment may involve cycloplegics and steroid eye drops.
Conjunctivitis, on the other hand, is characterized by a red, sore eye with discharge that can be mucopurulent or clear depending on the cause. Tarsal conjunctiva inflammation is also likely.
Episcleritis, which affects mostly women and younger people, is self-limiting and causes mild pain, watering, and very mild photophobia. It does not cause any visual symptoms.
Acute glaucoma is an ophthalmological emergency that requires urgent referral to ophthalmology. Patients with this condition will present with an acutely painful red eye and systemic symptoms like nausea and vomiting. Medications to reduce intraocular pressure are necessary.
Keratitis, which refers to inflammation of the cornea, has many different causes, with infection being the most common, especially in contact lens wearers. While the symptoms may initially appear similar to uveitis, keratitis is unlikely to be associated with inflammatory bowel disease and will show abnormalities of the cornea upon examination.
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This question is part of the following fields:
- Ophthalmology
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Question 7
Correct
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A 70-year-old man, with a history of atrial fibrillation, hypertension and type 2 diabetes mellitus, presents to the Emergency Department with a sudden painless loss of vision in his left eye that lasted for a few minutes. He describes the loss of vision as a curtain coming into his vision, and he could not see anything out of it for a few minutes before his vision returned to normal.
Upon examination, his acuity is 6/9 in both eyes. On dilated fundoscopy, there is a small embolus in one of the vessels in the left eye. The rest of the fundus is normal in both eyes.
What is the most likely diagnosis?Your Answer: Amaurosis fugax
Explanation:Differentiating Causes of Vision Loss: Amaurosis Fugax, Anterior Ischaemic Optic Neuropathy, CRAO, CRVO, and Retinal Detachment
When a patient presents with vision loss, it is important to differentiate between various causes. In the case of a transient and painless loss of vision, a typical diagnosis is amaurosis fugax. This is often seen in patients with atrial fibrillation and other vascular risk factors, and a small embolus may be present on fundoscopy. Treatment involves addressing the underlying cause and treating it as an eye transischaemic attack (TIA).
Anterior ischaemic optic neuropathy, on the other hand, is caused by giant-cell arthritis and presents with a sudden, painless loss of vision. However, there is no evidence of this in the patient’s history.
Central retinal artery occlusion (CRAO) is another potential cause of vision loss, but it does not present as a transient loss of vision. Instead, it causes long-lasting damage and may be identified by a cherry-red spot at the macula. The small embolus seen on fundoscopy is not causing a CRAO.
Similarly, central retinal vein occlusion (CRVO) presents with multiple flame haemorrhages, which are not present in this case.
While the patient did mention a curtain-like loss of vision, this does not necessarily indicate retinal detachment. Retinal detachment typically presents with flashes and floaters, and vision is worse if the detachment is a macula-off detachment.
In summary, careful consideration of the patient’s history and fundoscopic findings can help differentiate between various causes of vision loss.
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This question is part of the following fields:
- Ophthalmology
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Question 8
Incorrect
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A 65-year-old woman presents with abdominal pain that occurs after eating. She also reports weight loss due to her abdominal pain preventing her from eating large amounts. Her medical history includes stable angina and intermittent claudication caused by peripheral arterial disease. Upon examination, there are no visible abnormalities on the abdomen, but there is general tenderness upon palpation, no signs of organ enlargement, and normal bowel sounds. Routine blood tests, including full blood count, urea and electrolytes, and liver function tests, are normal. CT angiography shows an obstructed coeliac trunk and a stenosed but patent superior mesenteric artery. Which organ is most likely to be ischemic and contributing to this patient's symptoms?
Your Answer: Jejunum
Correct Answer: Stomach
Explanation:Understanding Chronic Mesenteric Ischaemia and Organ Involvement
Chronic mesenteric ischaemia is a condition that occurs when there is reduced blood flow to the intestines due to the narrowing or blockage of major mesenteric vessels. Patients with this condition often present with postprandial abdominal pain, weight loss, and concurrent vascular co-morbidities. To develop symptoms, at least two of the major mesenteric vessels must be affected, with one of these two occluded.
The coeliac trunk is one of the major mesenteric vessels, and when it is occluded, the organs it supplies are at risk. These organs include the stomach, spleen, liver, gallbladder, pancreas, duodenum, and abdominal portion of the oesophagus.
The jejunum is supplied directly by the superior mesenteric artery, but it is less likely to be the cause of symptoms than a foregut structure supplied by the coeliac trunk. The transverse colon is supplied by the right and middle colic arteries and the left colic artery, but it is unlikely to be the cause of symptoms if neither the superior nor the inferior mesenteric artery is completely occluded. The descending colon is supplied by the left colic artery, but it is unlikely to be the organ causing symptoms if this artery is neither occluded nor stenosed. The ileum is also supplied by the superior mesenteric artery, but it is less likely to be the cause of symptoms than a foregut structure.
In summary, understanding the involvement of different organs in chronic mesenteric ischaemia can help in the diagnosis and management of this condition.
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This question is part of the following fields:
- Gastroenterology
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Question 9
Correct
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Sarah is a 3-month-old baby who was brought in by her father. He is extremely worried as his baby is generally unwell. Sarah has not been feeding well over the past 24 hours and has been very irritable. Her father had noted a fever of 38.5ºC this morning and this prompted him to seek medical attention. Her nappies continued to appear wet over this time and her father noted she had vomited once at home. No other symptoms were noted without cough.
On examination, Sarah's general tone is maintained and she does not appear to display any signs of hypotonia. She is moving all 4 limbs equally. The chest remains clear. An area of non-blanching petechiae was noted.
A lumbar puncture was performed with the following results:
Parameter Value Normal range
White cell count 200 cells <3
Neutrophils 180 cells 0
Lymphocytes 20 cells <22
Protein 1.8g/L <1g/L
CSF: serum glucose ratio 0.3 >=0.6
What is the appropriate treatment for Sarah's likely diagnosis?Your Answer: IV cefotaxime and IV amoxicillin
Explanation:Investigation and Management of Meningitis in Children
Meningitis is a serious condition that can affect children. When investigating meningitis, it is important to note any contraindications to lumbar puncture, such as signs of raised intracranial pressure, focal neurological signs, papilloedema, significant bulging of the fontanelle, disseminated intravascular coagulation, or signs of cerebral herniation. For patients with meningococcal septicaemia, a lumbar puncture is contraindicated, and blood cultures and PCR for meningococcal should be obtained instead.
The management of meningitis in children involves administering antibiotics, such as IV amoxicillin (or ampicillin) and IV cefotaxime for children under three months, and IV cefotaxime (or ceftriaxone) for children over three months. Steroids should be considered if the lumbar puncture reveals certain findings, such as purulent cerebrospinal fluid, a high white blood cell count, or bacteria on Gram stain. Fluids should be administered to treat shock, and cerebral monitoring should be conducted, including mechanical ventilation if necessary.
It is also important to notify public health authorities and administer antibiotic prophylaxis to contacts. Ciprofloxacin is now preferred over rifampicin for this purpose. Overall, prompt and appropriate management of meningitis in children is crucial for ensuring the best possible outcomes.
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This question is part of the following fields:
- Paediatrics
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Question 10
Incorrect
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A 7-year-old boy who attends a regular school has been brought to the clinic due to his short stature. He measures 3 cm below the third centile for his age and weighs 800 grams less than the third centile. His bone age is 4.5 years. The boy's mother and father have heights on the 30th and 60th centiles, respectively.
Which of the following statements is true?Your Answer: Physiological (constitutional) short stature is unlikely
Correct Answer: Findings of poorly felt femoral pulses suggest that chromosome analysis might be required
Explanation:Factors to Consider in Evaluating Growth and Puberty Delay
When evaluating a child’s growth and puberty delay, it is important to consider the family history of delayed growth and puberty. A single measurement of growth is not enough to determine if there is a growth hormone deficiency or thyroid disease. It is also important to check for poorly felt femoral pulses, which may indicate coarctation and Turner’s syndrome.
Constitutional short stature is the most common reason for growth delay. To assess growth velocity, another measurement of growth is necessary. It is important to take into account all of these factors when evaluating a child’s growth and puberty delay to ensure an accurate diagnosis and appropriate treatment plan. Proper evaluation and management can help prevent potential complications and improve the child’s overall health and well-being.
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This question is part of the following fields:
- Endocrinology
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Question 11
Correct
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A 55-year-old man presented with non-specific abdominal discomfort lasting for 8 months. Physical examination revealed no lymphadenopathy, abdominal masses or organomegaly, and bowel sounds were present. A stool sample tested negative for occult blood. Imaging with abdominal CT revealed a 22-cm retroperitoneal soft tissue mass that was obstructing the left psoas muscle. What is the most probable neoplasm in this case?
Your Answer: Liposarcoma
Explanation:Liposarcoma is a type of sarcoma that commonly affects adults in their 40s to 60s. It typically develops in the deep soft tissues of the proximal extremities and retroperitoneum and can grow into large tumors. There are different histological variants of liposarcoma, with varying degrees of malignancy. All types of liposarcoma have a high likelihood of recurring locally unless completely removed.
Adenocarcinoma is a type of cancer that originates from glandular tissue in organs such as the oesophagus, pancreas, prostate, cervix, stomach, colorectal, and lungs. It does not arise in soft tissues.
Melanoma is a type of skin cancer that can occur in younger patients and often arises from pre-existing moles. Suspicious signs include changes in size, shape, color, itching, crusting, bleeding, inflammation, or sensory changes. Melanomas can metastasize.
Hamartoma is a benign neoplasm that consists of normal tissues in a disorganized mass. The most common type is pulmonary hamartoma, which grows at the same rate as surrounding tissue.
Lymphoma is a type of cancer that results from the malignant proliferation of lymphocytes. It typically presents with lymphadenopathy and constitutional symptoms, and may also involve organs such as the liver and spleen. Matted nodes of this size are unlikely to be caused by lymphoma.
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This question is part of the following fields:
- Oncology
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Question 12
Incorrect
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A 25-year-old female comes to see her GP with concerns about her mood during her menstrual cycle. She has been experiencing symptoms for the past 8 months despite making lifestyle changes. The week before her period, she notices a significant change in her mood, feeling extremely low and anxious with poor concentration. Her irritability is starting to affect her work as a primary school teacher. She has no other physical symptoms and feels like her usual self for the rest of the month. She has a medical history of migraine with aura.
What is the most appropriate treatment for this patient, given the likely diagnosis?Your Answer: Combined oral contraceptive pill (COCP)
Correct Answer: Fluoxetine
Explanation:Understanding Premenstrual Syndrome (PMS)
Premenstrual syndrome (PMS) is a condition that affects women during the luteal phase of their menstrual cycle. It is characterized by emotional and physical symptoms that can range from mild to severe. PMS only occurs in women who have ovulatory menstrual cycles and does not occur before puberty, during pregnancy, or after menopause.
Emotional symptoms of PMS include anxiety, stress, fatigue, and mood swings. Physical symptoms may include bloating and breast pain. The severity of symptoms varies from woman to woman, and management options depend on the severity of symptoms.
Mild symptoms can be managed with lifestyle advice, such as getting enough sleep, exercising regularly, and avoiding smoking and alcohol. Specific advice includes eating regular, frequent, small, balanced meals that are rich in complex carbohydrates.
Moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP), such as Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg). Severe symptoms may benefit from a selective serotonin reuptake inhibitor (SSRI), which can be taken continuously or just during the luteal phase of the menstrual cycle (for example, days 15-28, depending on the length of the cycle). Understanding PMS and its management options can help women better cope with this common condition.
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This question is part of the following fields:
- Gynaecology
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Question 13
Correct
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A 48-year-old patient has requested a consultation to discuss the outcome of her recent cervical screening test. The test showed normal cytology and was negative for high-risk human papillomavirus (hrHPV). In her previous screening test 18 months ago, she had normal cytology but tested positive for hrHPV. What guidance should you provide to the patient based on her latest screening test result?
Your Answer: Return to routine recall in 3 years time
Explanation:If the result of the first repeat smear for cervical cancer screening at 12 months is negative for high-risk human papillomavirus (hrHPV), the patient can resume routine recall. This means they should undergo screening every 3 years from age 25-49 years or every 5 years from age 50-64 years. However, if the repeat test is positive again, the patient should undergo another HPV test in 12 months. If there is dyskaryosis on a cytology sample, the patient should be referred for colposcopy.
The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.
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This question is part of the following fields:
- Gynaecology
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Question 14
Incorrect
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You are requested to assess an infant in the neonatal unit. The baby was delivered at 39 weeks gestation without any complications. The parents are hesitant to give their consent for vitamin K administration, citing their preference for a more natural approach. How would you advise the parents on the recommended practice for neonatal vitamin K?
Your Answer: IM vitamin K at day 1 and day 8
Correct Answer: Once-off IM injection
Explanation:Vitamin K is crucial in preventing haemorrhagic disease in newborns and can be administered orally or intramuscularly. While both methods are licensed for neonates, it is advisable to recommend the IM route to parents due to concerns about compliance and the shorter duration of treatment (one-off injection). The oral form is not recommended for healthy neonates as there is a risk of inadequate dosage due to forgetfulness or the baby vomiting up the medication.
Haemorrhagic Disease of the Newborn: Causes and Prevention
Newborn babies have a relatively low level of vitamin K, which can lead to the development of haemorrhagic disease of the newborn (HDN). This condition occurs when the production of clotting factors is impaired, resulting in bleeding that can range from minor bruising to intracranial haemorrhages. breastfed babies are particularly at risk, as breast milk is a poor source of vitamin K. Additionally, the use of antiepileptic medication by the mother can increase the risk of HDN in the newborn.
To prevent HDN, all newborns in the UK are offered vitamin K supplementation. This can be administered either intramuscularly or orally. By providing newborns with adequate levels of vitamin K, the risk of HDN can be significantly reduced. It is important for parents and healthcare providers to be aware of the risk factors for HDN and to take steps to prevent this potentially serious condition.
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This question is part of the following fields:
- Paediatrics
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Question 15
Correct
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A 55-year-old woman arrives at the emergency department complaining of a severe headache that has been ongoing for 2 hours. Despite taking paracetamol, she has not experienced any relief. She also reports experiencing photophobia, neck stiffness, and nausea.
The patient has a medical history of hypertension and polycystic kidney disease. She has a 30-year history of smoking and drinks 2 standard drinks per night.
What initial investigation would be most appropriate?Your Answer: Non-contrast CT head
Explanation:Meningeal irritation can be a symptom of SAH.
A subarachnoid haemorrhage (SAH) is a type of bleeding that occurs within the subarachnoid space of the meninges in the brain. It can be caused by head injury or occur spontaneously. Spontaneous SAH is often caused by an intracranial aneurysm, which accounts for around 85% of cases. Other causes include arteriovenous malformation, pituitary apoplexy, and mycotic aneurysms. The classic symptoms of SAH include a sudden and severe headache, nausea and vomiting, meningism, coma, seizures, and ECG changes.
The first-line investigation for SAH is a non-contrast CT head, which can detect acute blood in the basal cisterns, sulci, and ventricular system. If the CT is normal within 6 hours of symptom onset, a lumbar puncture is not recommended. However, if the CT is normal after 6 hours, a lumbar puncture should be performed at least 12 hours after symptom onset to check for xanthochromia and other CSF findings consistent with SAH. If SAH is confirmed, referral to neurosurgery is necessary to identify the underlying cause and provide urgent treatment.
Management of aneurysmal SAH involves supportive care, such as bed rest, analgesia, and venous thromboembolism prophylaxis. Vasospasm is prevented with oral nimodipine, and intracranial aneurysms require prompt intervention to prevent rebleeding. Most aneurysms are treated with a coil by interventional neuroradiologists, but some require a craniotomy and clipping by a neurosurgeon. Complications of aneurysmal SAH include re-bleeding, hydrocephalus, vasospasm, and hyponatraemia. Predictive factors for SAH include conscious level on admission, age, and amount of blood visible on CT head.
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This question is part of the following fields:
- Surgery
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Question 16
Correct
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A 65-year-old smoker presents with a persistent cough and chest pain. A plain chest x-ray examination suggests bronchial carcinoma. However, before a tissue diagnosis can be made, the patient unexpectedly dies in the hospital due to a large haemoptysis. With the consent of the family, a post-mortem examination is conducted, which reveals that the patient had tuberculosis and not carcinoma. Is there a requirement to report this to a specific authority, and if so, which one?
Your Answer: Consultant in Communicable Diseases Control
Explanation:Doctors in England and Wales have a legal obligation to report suspected cases of certain infectious diseases to the Proper Officer of the Local Authority or local Health Protection Unit. The Proper Officer is usually the local Consultant in Communicable Disease Control. The diseases that are notifiable include anthrax, cholera, diphtheria, measles, tuberculosis, and yellow fever, among others. The attending doctor should fill out a notification certificate immediately on diagnosis of a suspected notifiable disease and should not wait for laboratory confirmation. The certificate should be sent to the Proper Officer within three days or verbally within 24 hours if the case is considered urgent.
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This question is part of the following fields:
- Miscellaneous
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Question 17
Correct
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A 29-year-old nulliparous woman who is at 39 weeks gestation goes into spontaneous labour. You are summoned to aid in the vaginal delivery. During delivery, you observe the head retracting against the perineum. Downward traction is ineffective in delivering the anterior shoulder. What is a true statement about shoulder dystocia?
Your Answer: Immediately after shoulder dystocia is recognised, additional help should be called
Explanation:When managing shoulder dystocia, it is important to call for extra assistance immediately. Avoid using fundal pressure and note that an episiotomy may not always be required. Inducing labor at term can lower the occurrence of shoulder dystocia in women with gestational diabetes. The McRoberts manoeuvre is the preferred initial intervention due to its simplicity, speed, and effectiveness in most cases. These guidelines are based on the RCOG Green-top guideline no. 42 from March 2012 on Shoulder Dystocia.
Shoulder dystocia is a complication that can occur during vaginal delivery when the body of the fetus cannot be delivered after the head has already been delivered. This is usually due to the anterior shoulder of the fetus becoming stuck on the mother’s pubic bone. Shoulder dystocia can cause harm to both the mother and the fetus. Risk factors for shoulder dystocia include fetal macrosomia, high maternal body mass index, diabetes mellitus, and prolonged labor.
If shoulder dystocia is identified, it is important to call for senior help immediately. The McRoberts’ maneuver is often performed, which involves flexing and abducting the mother’s hips to increase the angle of the pelvis and facilitate delivery. An episiotomy may be performed to provide better access for internal maneuvers, but it will not relieve the bony obstruction. Symphysiotomy and the Zavanelli maneuver are not recommended as they can cause significant maternal morbidity. Oxytocin administration is not indicated for shoulder dystocia.
Complications of shoulder dystocia can include postpartum hemorrhage and perineal tears for the mother, and brachial plexus injury and neonatal death for the fetus. It is important to manage shoulder dystocia promptly and appropriately to minimize the risk of these complications.
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This question is part of the following fields:
- Obstetrics
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Question 18
Correct
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A 68-year-old man is 2 days post-op for a laparoscopic prostatectomy and experiences difficulty breathing. He has been unable to move around since his surgery and is experiencing poorly managed pain. He has no significant medical history.
During the examination, he is lying flat in bed and his oxygen saturation is at 95% on room air. His calves are soft and non-tender. A chest X-ray reveals basal atelectasis.
What immediate measures should be taken to improve his breathing?Your Answer: Reposition the patient to an upright position
Explanation:If the patient’s oxygen saturation levels remain low, administering high flow oxygen would not be appropriate as it is not an emergency situation. Instead, it would be more reasonable to begin with 1-2L of oxygen and reevaluate the need for further oxygen therapy, as weaning off oxygen could potentially prolong the patient’s hospital stay.
Atelectasis is a frequent complication that can occur after surgery, where the collapse of the alveoli in the lower part of the lungs can cause breathing difficulties. This condition is caused by the blockage of airways due to the accumulation of bronchial secretions. Symptoms of atelectasis may include shortness of breath and low oxygen levels, which typically appear around 72 hours after surgery. To manage this condition, patients may be positioned upright and undergo chest physiotherapy, which includes breathing exercises.
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This question is part of the following fields:
- Medicine
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Question 19
Incorrect
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You are the out-of-hours General Practitioner (GP) on call. You receive a call from the relative of an 85-year-old woman with palliative breast cancer and a complete Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order. The relative believes she has passed away and is not sure what to do. You offer your condolences and arrange a home visit to confirm death.
Which of the following should be confirmed in order to diagnose death?Your Answer: No response to verbal/painful stimuli, absence of radial pulse, absence of breath sounds for more than one minute, absence of heart sounds for more than one minute, pupils fixed and dilated
Correct Answer: No response to verbal/painful stimuli, absence of carotid pulse, absence of breath sounds for more than three minutes, absence of heart sounds for more than two minutes, pupils fixed and dilated
Explanation:Assessing for Death: Signs and Symptoms
When diagnosing death, it is important to look for signs of life initially, including skin color, signs of respiratory effort, and response to verbal/painful stimuli. Painful stimuli can be assessed using various methods, such as fingernail bed pressure, supraorbital pressure, or trapezius squeeze. Pupils should be assessed using a pen torch, as they become fixed and dilated after death. A central pulse, such as the carotid pulse, should be palpated, and doctors should listen for heart sounds for at least two minutes and breath sounds for at least three minutes. Exact durations may vary, but a minimum of five minutes of auscultation should be conducted to confirm irreversible cardiorespiratory arrest.
However, assessing for a gag reflex is not a routine part of diagnosing death, and the absence of a gag reflex may not necessarily indicate death. Instead, the absence of a corneal reflex can be used to diagnose death.
It is important to note that one minute of auscultation for breath and heart sounds would be insufficient to diagnose death. Additionally, assessing for a peripheral pulse, such as the radial pulse, would not be accurate, as it can be lost in peripherally shut down or hypotensive patients. Confirmation of death requires the absence of a central pulse, such as the carotid pulse, and the absence of breath and heart sounds for an adequate amount of time, along with fixed and dilated pupils.
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This question is part of the following fields:
- Palliative Care
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Question 20
Correct
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A 27-year-old Asian woman complains of palpitations, shortness of breath on moderate exertion and a painful and tender knee. During auscultation, a mid-diastolic murmur with a loud S1 is heard. Echocardiography reveals valvular heart disease with a normal left ventricular ejection fraction.
What is the most probable valvular disease?Your Answer: Mitral stenosis
Explanation:Differentiating Heart Murmurs: Causes and Characteristics
Heart murmurs are abnormal sounds heard during a heartbeat and can indicate underlying heart conditions. Here are some common causes and characteristics of heart murmurs:
Mitral Stenosis: This condition is most commonly caused by rheumatic fever in childhood and is rare in developed countries. Patients with mitral stenosis will have a loud S1 with an associated opening snap. However, if the mitral valve is calcified or there is severe stenosis, the opening snap may be absent and S1 soft.
Mitral Regurgitation and Ventricular Septal Defect: These conditions cause a pan-systolic murmur, which is not the correct option for differentiating heart murmurs.
Aortic Regurgitation: This condition leads to an early diastolic murmur.
Aortic Stenosis: Aortic stenosis causes an ejection systolic murmur.
Ventricular Septal Defect: As discussed, a ventricular septal defect will cause a pan-systolic murmur.
By understanding the causes and characteristics of different heart murmurs, healthcare professionals can better diagnose and treat underlying heart conditions.
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This question is part of the following fields:
- Cardiology
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Question 21
Incorrect
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A 32-year-old man presents with upper abdominal pain and is diagnosed with Helicobacter pylori infection. He is treated with appropriate eradication therapy and advised to follow up with his general practitioner for testing of eradication.
What would be the most suitable method for testing eradication in this patient?Your Answer: Helicobacter immunoassay on a stool sample
Correct Answer: The 13C urea breath test
Explanation:Methods for Detecting and Confirming Eradication of H. pylori Infection
There are several methods available for detecting and confirming eradication of H. pylori infection. Serologic testing for antibodies to H. pylori in the blood or saliva is a cheap and simple initial detection method with high sensitivity and specificity. However, it is not useful for follow-up as patients may continue to have antibodies for several months after eradication therapy. Stool sample analysis may also be used for initial detection, but the 13C urea breath test is currently the only recommended method for confirming eradication following treatment. Histological examination of tissue biopsy samples is an invasive procedure and not recommended for eradication testing. The CLO test, which is carried out on biopsied tissue at endoscopy, can provide immediate results but is also an invasive procedure and not appropriate for confirming eradication. Overall, the 13C urea breath test is the most reliable method for confirming eradication of H. pylori infection.
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This question is part of the following fields:
- Gastroenterology
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Question 22
Incorrect
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A 47-year-old woman presents with a 4-month history of low mood, fatigue, and weight gain. She has constantly felt cold during this time. This is her first presentation with these symptoms and she has noticed them after starting a new medication for her hypertension.
She has a past medical history of hypertension and takes amlodipine, lisinopril, and hydrochlorothiazide.
Investigations are performed:
Thyroid-stimulating hormone (TSH) 19.2 mU/L (0.5 - 5.5)
Free T4 1.8 pmol/L (9-18)
What is the most appropriate step in her management?Your Answer: Add levothyroxine and change amiodarone to flecainide
Correct Answer: Add levothyroxine and continue amiodarone
Explanation:Levothyroxine can be added to continue amiodarone in cases of amiodarone-induced hypothyroidism. This patient is exhibiting symptoms of hypothyroidism, which can occur in around 1 in 6 patients taking amiodarone. Amiodarone’s high iodine content can inhibit thyroxine production, leading to hypothyroidism. However, amiodarone can usually be continued alongside levothyroxine to counteract this effect. As the patient’s AF is currently being effectively controlled by amiodarone, it would be inappropriate to switch to digoxin, dronedarone, or flecainide, as these medications would require a period of re-titration and assessment that could increase the risk of stroke due to the AF. Additionally, amiodarone is preferred in patients with structural heart disease, which this patient has due to her heart failure.
Amiodarone and Thyroid Dysfunction
Amiodarone is a medication used to treat heart rhythm disorders. However, around 1 in 6 patients taking amiodarone develop thyroid dysfunction. This can manifest as either amiodarone-induced hypothyroidism (AIH) or amiodarone-induced thyrotoxicosis (AIT).
The pathophysiology of AIH is thought to be due to the high iodine content of amiodarone causing a Wolff-Chaikoff effect. This is an autoregulatory phenomenon where thyroxine formation is inhibited due to high levels of circulating iodide. Despite this, amiodarone may be continued if desirable.
On the other hand, AIT may be divided into two types: type 1 and type 2. Type 1 is caused by excess iodine-induced thyroid hormone synthesis, while type 2 is caused by amiodarone-related destructive thyroiditis. In patients with AIT, amiodarone should be stopped if possible.
It is important for healthcare professionals to monitor patients taking amiodarone for any signs of thyroid dysfunction and adjust treatment accordingly.
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This question is part of the following fields:
- Pharmacology
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Question 23
Incorrect
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An 81-year-old man comes to your clinic with his wife. He has been experiencing memory loss for recent events and has gotten lost while out shopping. His cognitive abilities seem to fluctuate frequently, but overall, they appear to be declining. Additionally, he reports seeing small, fairy-like creatures running around, although he knows they are not real. He has also had several unexplained falls. Apart from increased muscle tone in all limbs, there are no other neurological symptoms. What is the most probable diagnosis?
Your Answer: Pick’s disease
Correct Answer: Dementia with Lewy bodies
Explanation:Different Types of Dementia: Symptoms and Diagnosis
Dementia is a progressive cognitive impairment that affects millions of people worldwide. There are several types of dementia, each with its own set of symptoms and diagnostic criteria. Here are some of the most common types of dementia:
Dementia with Lewy bodies
This type of dementia is characterized by a progressive decline in cognitive function, with a particular emphasis on memory loss and disorientation. It is caused by the presence of Lewy bodies in the brain, which are distributed more widely than in Parkinson’s disease. Diagnosis requires the presence of dementia, as well as two out of three core features: fluctuating attention and concentration, recurrent visual hallucinations, and spontaneous parkinsonism.Huntington’s disease
Huntington’s disease is a genetic disorder that typically presents in middle age. It causes a deterioration in mental ability and mood, as well as uncoordinated movements and jerky, random motions. Diagnosis is made through genetic testing.Multi-infarct dementia
This type of dementia is caused by a history of interrupted blood supply to the brain, such as multiple strokes. Risk factors include hypertension, diabetes, smoking, hypercholesterolemia, and cardiovascular disease.Pick’s disease
Also known as fronto-temporal dementia, Pick’s disease is characterized by a loss of inhibitions and other behavioral changes.Alzheimer’s disease
The most common type of dementia, Alzheimer’s is characterized by a gradual decline in cognitive function, including memory loss and disorientation. However, the presence of visual hallucinations, parkinsonism, and a fluctuating course may indicate dementia with Lewy bodies instead.In conclusion, understanding the different types of dementia and their symptoms is crucial for accurate diagnosis and appropriate treatment.
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This question is part of the following fields:
- Neurology
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Question 24
Incorrect
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A 28-year-old woman who works in a factory presents with lower back pain. She says that she has had the pain for past two years and that it started gradually. The patient has no past medical history. There is no evidence or history of trauma. Upon examination the patient has normal power in the lower and upper limbs, and sensation is intact. She denies any fever or weight loss and has no significant family history. She is discharged with analgesia.
What is the most appropriate next step?Your Answer: MRI lumbar spine
Correct Answer: Mobilisation
Explanation:Management of Lower Back Pain: Explained
Lower back pain is a common complaint among patients seeking medical attention. In managing lower back pain, it is important to identify the cause and provide appropriate treatment. In this case, the patient’s back pain is most likely mechanical in nature. Mobilisation has been shown to be effective in reducing back pain, and bed rest is not advised as it can worsen the pain and affect the patient’s daily activities. A lumbar X-ray is not necessary unless there is suspicion of a fracture. Referral to physiotherapy or alternative therapies may be considered if initial management is not effective. An MRI would be indicated if there are any ‘red flags’ in the history.
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This question is part of the following fields:
- Orthopaedics
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Question 25
Incorrect
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You are urgently called to the Surgical Ward to assess a 45-year-old man who has just returned from Theatre after a stoma reversal. The nursing staff have reported that he appears drowsy, and on assessment, his blood pressure is 70/42 mmHg, heart rate is 120 bpm, respiratory rate is 22 breaths/minute, oxygen saturation is 98%, and temperature is 36.7 °C. On examination, he is difficult to rouse and has a thready pulse. Chest sounds are clear, with normal heart sounds and soft calves. He groans when you palpate his abdomen. What is the most appropriate initial investigation?
Your Answer: Chest X-ray
Correct Answer: Bloods, including full blood count and crossmatch
Explanation:Appropriate Investigations for a Patient with Post-Operative Shock
Post-operative shock can occur for various reasons, including blood loss, infection, and pulmonary embolism. In this scenario, a patient has undergone extensive abdominal surgery and is experiencing significant hypotension and tachycardia, making a post-operative bleed highly likely. Here are some appropriate investigations for this patient:
Bloods, including full blood count and crossmatch: A full blood count can help identify a drop in hemoglobin, while crossmatch is necessary as the patient may require a transfusion.
Chest X-ray: This investigation is not necessary as there is no indication of chest-related issues.
Computerised tomography (CT) of abdomen: If the patient can be stabilized, a CT scan can help determine if there is an intra-abdominal cause for the deterioration.
D-dimer: This investigation is not necessary as there is no strong suspicion of pulmonary embolism.
Return to Theatre for diagnostic laparotomy: This is a possibility if the patient cannot be stabilized on the ward and there is a strong suspicion of an intra-abdominal bleed. However, baseline bloods, including crossmatch, would be required before surgery.
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This question is part of the following fields:
- Surgery
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Question 26
Incorrect
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A 84-year-old woman visits her GP with a complaint of persistent, heightened vaginal discharge. She reports that this has been going on for approximately a month and the odor is so unpleasant that she needs to change pads every 2 hours. During the examination, her abdomen is soft and painless. There is a small amount of fecal matter on the pad. A digital rectal examination reveals normal perianal sensation and an empty rectal vault. What is the probable cause of her symptom?
Your Answer: Cauda equina syndrome
Correct Answer: Diverticular disease
Explanation:The woman’s symptoms of diverticulitis and passing of faeces or flatus through the vaginal passage suggest the presence of a colovaginal fistula, which is a complication of diverticular disease. This abnormal connection between the colon and vagina can occur during or after episodes of diverticulitis, leading to continuous leakage of faecal matter through the vagina. This condition can be diagnosed even in the absence of active infection or inflammation. Digital rectal examination will not reveal any findings as diverticulosis does not occur in the rectum. Age-related faecal incontinence is not a valid explanation as it is not a normal part of ageing and always has an underlying cause. Bacterial vaginosis and cauda equina syndrome are not relevant to this case.
Understanding Diverticulitis
Diverticulitis is a condition where an outpouching of the intestinal mucosa becomes infected. This outpouching is called a diverticulum and the presence of these pouches is known as diverticulosis. Diverticula are common and are thought to be caused by increased pressure in the colon. They usually occur in the sigmoid colon and are more prevalent in Westerners over the age of 60. While only a quarter of people with diverticulosis experience symptoms, 75% of those who do will have an episode of diverticulitis.
Risk factors for diverticulitis include age, lack of dietary fiber, obesity, and a sedentary lifestyle. Patients with diverticular disease may experience intermittent abdominal pain, bloating, and changes in bowel habits. Those with acute diverticulitis may experience severe abdominal pain, nausea, vomiting, changes in bowel habits, and urinary symptoms. Complications may include colovesical or colovaginal fistulas.
Signs of diverticulitis include low-grade fever, tachycardia, tender lower left quadrant of the abdomen, and possibly a palpable mass. Imaging tests such as an erect CXR, AXR, and CT scans can help diagnose diverticulitis. Treatment may involve oral antibiotics, a liquid diet, and analgesia for mild cases. Severe cases may require hospitalization for IV antibiotics. Colonoscopy should be avoided initially due to the risk of perforation.
Overall, understanding the symptoms, risk factors, and signs of diverticulitis can help with early diagnosis and treatment. Proper management can help prevent complications and improve outcomes for patients.
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This question is part of the following fields:
- Surgery
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Question 27
Incorrect
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A 42-year-old man comes in after being found unconscious. He smells strongly of alcohol.
When considering withdrawal from this substance, which of the following statements is correct?Your Answer: Flumazenil is routinely used as part of the detoxification process
Correct Answer: Hypophosphataemia is commonly seen
Explanation:Misconceptions about Alcohol Withdrawal: Debunked
Alcohol withdrawal is a common condition that can lead to serious complications if not managed properly. However, there are several misconceptions about alcohol withdrawal that can lead to inappropriate treatment and poor outcomes. Let’s debunk some of these misconceptions:
1. Hypophosphataemia is commonly seen: This is true. Hypophosphataemia is a common electrolyte abnormality in alcohol withdrawal due to malnutrition.
2. Visual hallucinations suggest a coexisting psychiatric disorder: This is false. Visual hallucinations in alcohol withdrawal are usually related to alcohol withdrawal and not necessarily a coexisting psychiatric disorder.
3. Flumazenil is routinely used as part of the detoxification process: This is false. Flumazenil is not routinely used in alcohol detoxification but may be useful in benzodiazepine overdose.
4. Seizures are rare: This is false. Seizures in alcohol withdrawal are common and can lead to serious complications if not managed properly.
5. All patients who have a seizure should be started on an antiepileptic: This is false. Withdrawal seizures generally do not require antiepileptic treatment and may even increase the risk of further seizures and other medical problems.
In summary, it is important to understand the true nature of alcohol withdrawal and its associated complications to provide appropriate and effective treatment.
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This question is part of the following fields:
- Gastroenterology
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Question 28
Incorrect
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A survey is conducted to determine the number of people in a retirement community suffering from arthritis. The community's population is 25 000 people. The total number of people found to have a confirmed diagnosis of arthritis is 125.
According to the result of this survey, what is the prevalence of arthritis in this population?Your Answer: 5%
Correct Answer: 0.50%
Explanation:Understanding Prevalence: Calculating and Interpreting Disease Burden in a Population
Prevalence is a measure of disease burden in a population at a specific point in time. It is calculated by dividing the number of people with a particular condition by the total number of people in the sample. Unlike incidence, which measures the number of new cases over a period of time, prevalence takes into account both new and existing cases.
It is important to note that prevalence is dependent on both the rate at which new cases arise (incidence) and the average length of time that people survive after acquiring the condition. An overestimate or underestimate of prevalence can have significant implications for public health interventions and resource allocation.
Therefore, accurate calculation and interpretation of prevalence is crucial for understanding the burden of disease in a population.
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This question is part of the following fields:
- Statistics
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Question 29
Correct
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A 27-year-old G4P3 woman presents with a lump in the breast, having ceased breastfeeding her youngest child two weeks prior. Her past medical history is significant for previous episodes of mastitis when breastfeeding her older children. On examination the lump is in the right breast at the six o'clock position, 3 cm from the nipple. The lump is non-tender and the overlying skin seems unaffected. Her observations are as follows:
Heart rate: 90,
Respiratory rate: 14,
Blood pressure: 112/72 mmHg,
Oxygen saturation: 99%,
Temperature: 37.5 Cº.
What is the probable diagnosis, and what is the most appropriate next step in investigation?Your Answer: Galactocele, no further investigation necessary
Explanation:Galactocele and breast abscess can be distinguished based on clinical history and examination findings, without the need for further investigation.
Recent discontinuation of breastfeeding is a risk factor for both mastitis/abscess formation and galactocele formation. Galactoceles are distinguishable from breast abscesses because they are painless and non-tender upon examination, and there are no signs of infection locally or systemically.
Although the patient’s history of mastitis increases the likelihood of a breast abscess, the clinical presentation strongly suggests a galactocele (i.e. painless lump, no localized redness, and absence of fever).Understanding Galactocele
Galactocele is a condition that commonly affects women who have recently stopped breastfeeding. It occurs when a lactiferous duct becomes blocked, leading to the accumulation of milk and the formation of a cystic lesion in the breast. Unlike an abscess, galactocele is usually painless and does not cause any local or systemic signs of infection.
In simpler terms, galactocele is a type of breast cyst that develops when milk gets trapped in a duct. It is not a serious condition and can be easily diagnosed by a doctor. Women who experience galactocele may notice a lump in their breast, but it is usually painless and does not require any treatment. However, if the lump becomes painful or infected, medical attention may be necessary. Overall, galactocele is a common and harmless condition that can be managed with proper care and monitoring.
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This question is part of the following fields:
- Obstetrics
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Question 30
Incorrect
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A 35-year-old woman presents to her Accident and Emergency with visual loss. She has known persistently uncontrolled hypertension, previously managed in the community. Blood tests are performed as follows:
Investigation Patient Normal value
Sodium (Na+) 148 mmol/l 135–145 mmol/l
Potassium (K+) 2.7 mmol/l 3.5–5.0 mmol/l
Creatinine 75 μmol/l 50–120 µmol/
Chloride (Cl–) 100 mEq/l 96–106 mEq/l
What is the next most appropriate investigation?Your Answer: Aldosterone levels
Correct Answer: Aldosterone-to-renin ratio
Explanation:Investigating Hypertension in a Young Patient: The Importance of Aldosterone-to-Renin Ratio
Hypertension in a young patient with hypernatraemia and hypokalaemia can be caused by renal artery stenosis or an aldosterone-secreting adrenal adenoma. To determine the cause, measuring aldosterone levels alone is not enough. Both renin and aldosterone levels should be measured, and the aldosterone-to-renin ratio should be evaluated. If hyperaldosteronism is confirmed, CT or MRI of the adrenal glands is done to locate the cause. If both are normal, adrenal vein sampling may be performed. MR angiogram of renal arteries is not a first-line investigation. Similarly, CT angiogram of renal arteries should not be the first choice. 24-hour urine metanephrine levels are not useful in this scenario. The electrolyte abnormalities point towards elevated aldosterone levels, not towards a phaeochromocytoma.
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This question is part of the following fields:
- Cardiology
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