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Question 1
Correct
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A 14-month-old girl presents with rash and high fever.
A diagnosis of measles is suspected.
Which one of the following statements is true concerning measles infection?Your Answer: The erythematous maculopapular rash usually starts on the hands
Explanation:Measles: Key Points to Remember
– Prophylactic antibiotics are not effective in treating measles.
– Koplik spots are a unique symptom of measles.
– Erythromycin doesn’t reduce the duration of measles.
– The MMR vaccine is typically given to children between 12-15 months of age.
– The rash associated with measles is widespread and different from the vesicular rash of Chickenpox.Measles is a highly contagious viral infection that can cause serious complications, particularly in young children. It is important to remember that prophylactic antibiotics are not effective in treating measles, and erythromycin doesn’t shorten the duration of the illness. One unique symptom of measles is the presence of Koplik spots, which are small white spots that appear on the inside of the mouth. The MMR vaccine is the most effective way to prevent measles and is typically given to children between 12-15 months of age. Finally, it is important to note that the rash associated with measles is widespread and different from the vesicular rash of Chickenpox.
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This question is part of the following fields:
- Children And Young People
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Question 2
Incorrect
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One of your receptionists has tested positive for pertussis. Her GP has given her clarithromycin today.
She feels well enough to work, but with regard to her infectivity, when could she start back at work?Your Answer: 48 hours
Correct Answer: When her cough subsides
Explanation:Pertussis Guidance for Healthcare Workers
According to the latest guidance from Public Health England (PHE), healthcare workers (HCWs) suspected of having pertussis should be excluded from work until 48 hours of appropriate antibiotic treatment is completed or for 21 days from onset if not treated. This is a change from earlier advice to exclude for 5 days. Hospitalized patients with pertussis should be placed in respiratory isolation until 48 hours of treatment is completed or for 21 days from onset if not treated. HCWs looking after patients with pertussis should wear appropriate personal protective equipment (PPE).
It is important for GPs to understand and implement key national guidelines that influence healthcare provision for respiratory problems, as stated in the RCGP Curriculum Statement 3.19. Public Health England has published comprehensive guidelines on the symptoms, diagnosis, management, surveillance, and epidemiology of pertussis, including updated sub-documents. Staying up to date with the latest guidance is crucial for providing safe and effective care to patients and protecting the health of healthcare workers.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 3
Incorrect
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A 25-year-old male presented with a paranoid psychosis accompanied by visual hallucinations which resolved over the next three days.
Which one of the following is the most likely diagnosis?Your Answer: Heroin withdrawal
Correct Answer: Diazepam dependence
Explanation:Understanding Alcohol Withdrawal and Hallucinations
The key points in the history are that the patient is experiencing visual hallucinations that resolve over 72 hours. Based on the given options, alcohol withdrawal is the most likely cause, especially since the patient also has paranoid psychosis. Symptoms of alcohol withdrawal typically appear 6-12 hours after cessation and include insomnia, tremors, anxiety, and nausea, among others. Alcoholic hallucinosis can also occur, which includes visual, auditory, and tactile hallucinations. Withdrawal seizures and delirium tremens can also occur, with the latter having a mortality rate of approximately 35% without treatment. It’s important to note that benzodiazepines can cause a protracted withdrawal syndrome, while fluoxetine overdose, heroin withdrawal, and cannabis use have their own distinct symptoms and effects. Understanding the signs and symptoms of alcohol withdrawal and hallucinations can help in proper diagnosis and treatment.
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This question is part of the following fields:
- Mental Health
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Question 4
Correct
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A 25-year-old man comes to see you to discuss his father’s recent diagnosis of Huntington’s disease. He is particularly concerned about the possibility that he could develop the disease himself, and that he could pass it on to his children.
Select the single correct statement concerning Huntington's disease.Your Answer: The condition is an autosomal dominant trait, giving a 50% risk of passing the disease on to children
Explanation:Huntington’s Disease: A Progressive Neurodegenerative Disorder
Huntington’s disease is an autosomal dominant disorder caused by a gene on chromosome 4. It can present at any age from 20 years to old age and is associated with cell loss in the basal ganglia and cortex. The disease is characterized by a distinct phenotype, including chorea and dystonia, incoordination, cognitive decline, and behavioral problems, ultimately leading to death.
There is often a prodromal phase of mild psychotic and behavioral symptoms that can last up to 10 years before the development of chorea. Unfortunately, drug therapy has no effect on the progression of disability, and while hyperkinesia and psychiatric symptoms may respond to pharmacotherapy, neuropsychological deficits and dementia remain untreatable.
Management of Huntington’s disease is supportive, and a predictive diagnosis is possible in offspring of affected individuals if they wish it.
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This question is part of the following fields:
- Genomic Medicine
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Question 5
Correct
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You come across a 27-year-old male patient who complains of a painful red right eye. He mentions that the eye has been watering and he feels that his vision has worsened in the right eye. The pain has been persistent for approximately 4 days now, and he recalls that it started with a rash around his eye. He has no regular medication and is generally healthy. He wears glasses and doesn't use contact lenses.
Upon examination, you observe that the acuity in the right eye has decreased and it appears diffusely red. The pupils are equal and reactive. You notice some crusted lesions along the lid margin. After staining the eye, you see a dendritic looking lesion which is enhanced by the staining.
What is the most probable diagnosis?Your Answer: Herpes simplex ophthalmicus
Explanation:The most probable diagnosis for a patient with a red, painful eye with discharge, decreased acuity, and a dendritic ulcer on staining is herpes simplex ophthalmicus. It is crucial to refer all suspected cases of ophthalmic herpes to an ophthalmology clinic for immediate evaluation.
Although a corneal abrasion could also cause staining, the presence of lesions on the eyelid makes a dendritic ulcer more likely to be caused by herpes infection.
Blepharitis, which causes eyelid inflammation, typically presents with burning and itching, and both eyelids sticking together. There would be no abnormality on staining the eye.
Episcleritis, characterized by segmental redness, normal vision, normal pupil reactions, and no abnormality on corneal staining, is another possible differential diagnosis.
Anterior uveitis, which causes inflammation in the anterior segment of the eye, presents with a red, painful eye, reduced vision, flashes/floaters, and abnormal pupil shape or size. The presence of cells in the aqueous humour is a characteristic sign. The pain is not as severe as scleritis.
Understanding the Causes of Red Eye
Red eye is a common condition that can be caused by various factors. It is important to identify the underlying cause of red eye to determine the appropriate treatment. Some causes of red eye require urgent referral to an ophthalmologist. Here are some key distinguishing features of different causes of red eye:
Acute angle closure glaucoma is characterized by severe pain, decreased visual acuity, and a semi-dilated pupil. The patient may also see haloes and have a hazy cornea.
Anterior uveitis has an acute onset and is accompanied by pain, blurred vision, and photophobia. The pupil is small and fixed, and there may be ciliary flush.
Scleritis is characterized by severe pain and tenderness, which may be worse on movement. It may be associated with an underlying autoimmune disease such as rheumatoid arthritis.
Conjunctivitis may be bacterial or viral. Bacterial conjunctivitis is characterized by purulent discharge, while viral conjunctivitis has a clear discharge.
Subconjunctival haemorrhage may be caused by trauma or coughing bouts.
Endophthalmitis typically occurs after intraocular surgery and is characterized by a red eye, pain, and visual loss.
By understanding the different causes of red eye and their distinguishing features, healthcare professionals can provide appropriate treatment and referral when necessary.
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This question is part of the following fields:
- Eyes And Vision
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Question 6
Incorrect
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A 45-year-old male office worker is on quetiapine for his bipolar disorder and visits your clinic alone after driving himself. He has had a stable condition for the past year with no manic or depressive episodes. He reports experiencing flight-of-ideas, pressured speech, and difficulty sleeping.
What advice should you give him regarding his ability to drive?Your Answer: No action required
Correct Answer: Must stop driving for at least 3 months and inform the DVLA
Explanation:Patients diagnosed with bipolar disease are required to inform the DVLA if they experience manic episodes, as this will prevent them from driving. The duration of the driving ban depends on whether the patient has stable or unstable disease. If the patient has stable disease, they must stop driving for a minimum of 3 months. However, if they have unstable disease, they must stop driving for at least 6 months. Before being allowed to drive again, patients must adhere to their treatment plan, regain insight, be free from any medication effects that could impair driving, and receive a favorable specialist report. During a manic episode, patients must stop driving, but they can continue to drive if they inform the DVLA. If a patient experiences a manic episode without informing the DVLA, they must stop driving for 6 months.
Understanding Bipolar Disorder
Bipolar disorder is a mental health condition that is characterized by alternating periods of mania/hypomania and depression. It typically develops in the late teen years and has a lifetime prevalence of 2%. There are two types of bipolar disorder: type I, which involves mania and depression, and type II, which involves hypomania and depression.
Mania and hypomania both refer to abnormally elevated mood or irritability. Mania is more severe and involves functional impairment or psychotic symptoms for 7 days or more, while hypomania involves decreased or increased function for 4 days or more. Psychotic symptoms, such as delusions of grandeur or auditory hallucinations, suggest mania.
Management of bipolar disorder involves psychological interventions specifically designed for the condition, as well as medication. Lithium is the mood stabilizer of choice, with valproate as an alternative. Antipsychotic therapy may be used for mania/hypomania, while fluoxetine is the antidepressant of choice for depression. Co-morbidities, such as diabetes, cardiovascular disease, and COPD, should also be addressed.
If symptoms suggest hypomania, routine referral to the community mental health team (CMHT) is recommended. If there are features of mania or severe depression, an urgent referral to the CMHT should be made. Understanding bipolar disorder and its management is crucial for healthcare professionals to provide appropriate care and support for individuals with this condition.
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This question is part of the following fields:
- Mental Health
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Question 7
Correct
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A 40-year-old man comes to the General Practice Surgery with a six-month history of persistent fatigue. He has no medical problems and takes no regular medication. He briefly injected heroin when he was younger but has not done so for the last ten years.
What is the most probable diagnosis? Choose ONE option only.Your Answer: Hepatitis C
Explanation:Blood-Borne Infections Commonly Associated with Intravenous Drug Use
Intravenous (IV) drug use is a major risk factor for acquiring blood-borne infections. The most common infections associated with IV drug use are hepatitis C, human immunodeficiency virus (HIV), and hepatitis B. Syphilis and tetanus are also possible, but less common, infections.
Hepatitis C is the most prevalent blood-borne virus among IV drug users, affecting up to 50% of users in the UK and 67% worldwide. Acute infection is usually asymptomatic or presents with vague symptoms, but can progress to chronic hepatitis C in the majority of cases. Cirrhosis and liver failure are potential long-term complications.
HIV is present in up to 15% of IV drug users and is transmitted through shared needles. Acute infection presents with flu-like symptoms, followed by an asymptomatic period until the CD4 count drops enough to allow for opportunistic infections.
Hepatitis B is less common than hepatitis C among IV drug users, but still poses a risk. Acute infection presents with flu-like symptoms and can progress to chronic infection, which increases the risk of hepatocellular carcinoma.
Syphilis is a sexually transmitted infection that can also be transmitted through direct contact with skin lesions or mucous membranes. Primary infection presents with a painless ulcer, followed by a generalised rash and lymphadenopathy. Latent syphilis can be asymptomatic, but is not associated with IV drug use.
Tetanus is rare in the UK due to immunisation programs, but can occur if spores enter an open wound. It presents with muscle stiffness and spasms, but is not associated with a prolonged asymptomatic period or IV drug use.
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This question is part of the following fields:
- Smoking, Alcohol And Substance Misuse
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Question 8
Correct
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A study was conducted to investigate whether individuals with lower socioeconomic status were at a higher risk of developing gastric cancer. The study tracked participants for 35 years and discovered that those with lower socioeconomic status had a significantly greater likelihood of developing gastric cancer. The researchers concluded that there was a strong correlation between lower socioeconomic status and gastric cancer development. However, an independent committee reviewing the study later discovered that individuals with lower socioeconomic status were also more likely to smoke.
What type of potential bias is likely to be present in this study design?Your Answer: Confounding bias
Explanation:Confounding bias arises when an unaccounted factor has a causal relationship with the main outcome, leading to a distorted effect of the exposure of interest. In the case of the study mentioned, the association between lower socioeconomic status and gastric cancer is confounded by smoking, which is more prevalent among people with lower socioeconomic status. Berkson bias occurs when cases and controls are selected from hospitals instead of the general population, while measurement bias arises from systematically distorted information gathering. Recall bias occurs when those exposed have a greater sensitivity for recalling exposure, and selection bias arises from a poorly devised method of recruiting participants, leading to nonrandom assignment to study groups.
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 9
Correct
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A 37-year-old woman presents with new-onset facial weakness. She had been in excellent health until last summer when, after a hiking trip, she noticed an expanding erythematous rash on her abdomen, ultimately about 8 inches in diameter and lasting about three weeks. This improved following treatment with an oral cephalosporin, but she developed six weeks of diffuse arthralgias and headaches.
She has developed acute right facial paralysis, evolving over 24 hours, with retro auricular pain, hyperacusis and a decreased sense of taste. On examination, a complete, right lower motor neurone, seventh nerve palsy is noted.
What is the most likely diagnosis?Your Answer: Lyme disease
Explanation:Possible Diagnoses for Facial Paralysis and Other Symptoms After a Walking Holiday
Facial paralysis is a common neurological manifestation of Lyme disease, which is a possible diagnosis for a patient with no specific history of tick bite but with a rash and arthralgias after a walking holiday. Sarcoidosis can also cause facial palsy but fits less well with the story. Bell’s palsy is consistent with a complete lower motor neurone seventh nerve palsy, hyperacusis, and retroarticular pain, but doesn’t explain the preceding symptoms. Multiple sclerosis is characterized by symptomatic neurological episodes that occur months or years apart and affect different anatomical locations, which doesn’t fit with a single episode of seventh nerve palsy. Ramsay Hunt syndrome would cause pain and a vesicular eruption in and around the ear and the facial palsy but not the other features, and is unlikely without the characteristic rash.
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This question is part of the following fields:
- Neurology
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Question 10
Correct
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A 6-year-old boy is seen by his doctor for inadequate asthma management. He is currently on a daily steroid inhaler (Clenil - 50 mcg, two puffs twice a day) and uses a salbutamol inhaler as needed. What should be the next course of action in his treatment plan?
Your Answer: Trial of a leukotriene receptor antagonist
Explanation:If a child under the age of 5 has asthma that is not being effectively managed with a combination of a short-acting beta agonist and a low-dose inhaled corticosteroid, it is recommended by NICE guidelines to try adding a leukotriene receptor antagonist to their treatment plan.
Managing Asthma in Children: NICE Guidelines
The National Institute for Health and Care Excellence (NICE) released guidelines in 2017 for the management of asthma in children aged 5-16. These guidelines follow a stepwise approach, with treatment options based on the severity of the child’s symptoms. For newly-diagnosed asthma, short-acting beta agonists (SABA) are recommended. If symptoms persist or worsen, a combination of SABA and paediatric low-dose inhaled corticosteroids (ICS) may be used. Leukotriene receptor antagonists (LTRA) and long-acting beta agonists (LABA) may also be added to the treatment plan.
For children under 5 years old, clinical judgement plays a greater role in diagnosis and treatment. The stepwise approach for this age group includes an 8-week trial of paediatric moderate-dose ICS for newly-diagnosed asthma or uncontrolled symptoms. If symptoms persist, a combination of SABA and paediatric low-dose ICS with LTRA may be used. If symptoms still persist, referral to a paediatric asthma specialist is recommended.
It is important to note that NICE doesn’t recommend changing treatment for patients with well-controlled asthma simply to adhere to the latest guidelines. Additionally, maintenance and reliever therapy (MART) may be used for combined ICS and LABA treatment, but only for LABAs with a fast-acting component. The definitions for low, moderate, and high-dose ICS have also changed, with different definitions for children and adults.
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This question is part of the following fields:
- Children And Young People
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Question 11
Incorrect
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A 4-week-old boy comes for his 4-week check. You wish to examine for developmental dysplasia of the hip.
Which of the following options is most suggestive of developmental dysplasia in the hip when being examined?Your Answer: Abduction of 90° with the hip flexed
Correct Answer: Hip movement is felt when forward pressure is applied to the femoral head
Explanation:Understanding Developmental Dysplasia of the Hip (DDH) Tests
Developmental dysplasia of the hip (DDH) is a condition where the hip joint is not properly formed, leading to instability and potential dislocation. There are several tests used to diagnose DDH, including the Ortolani and Barlow tests. The Ortolani test involves applying forward pressure to the femoral head, which can cause a palpable ‘clunk’ as the hip moves over the posterior rim of the acetabulum. The Barlow test involves applying backward pressure to the femoral head. Both tests are typically negative by three months of age.
Contrary to popular belief, the leg tends to be externally rotated in DDH, rather than internally rotated. Limitation of hip abduction is the most reliable sign of DDH after eight weeks, with significant limitation being 60° or less. Benign hip clicks are common during testing and result from soft tissues snapping over bony prominences.
In addition to these tests, a discrepancy in limb length (Galeazzi sign) may be noted when the child lies supine with the hip and knee flexed to 90°. Leg shortening occurs on the affected side in DDH.
Understanding these tests and signs can aid in the early diagnosis and treatment of DDH, which is crucial for proper hip joint development and long-term mobility.
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This question is part of the following fields:
- Children And Young People
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Question 12
Correct
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An 80-year-old patient passes away in a nursing home. You were familiar with her and are requested to fill out the death certificate. She has been experiencing a gradual decline over the past few weeks and died peacefully in her sleep. What could be a possible cause of death under certain conditions?
Your Answer: Old age
Explanation:Old age or frailty due to old age can only be listed as the cause of death if specific criteria are fulfilled. These include personally caring for the deceased over a long period, observing a gradual decline in their health and functioning, not being aware of any identifiable disease or injury contributing to the death, being certain that there is no other reason to report the death to the procurator fiscal, and the patient being 80 years or older. Other options such as terminal events or vague phrases like cardiovascular event are not appropriate as they do not identify a specific disease or pathological process.
Death Certification in the UK
There are no legal definitions of death in the UK, but guidelines exist to verify it. According to the current guidance, a doctor or other qualified personnel should verify death, and nurse practitioners may verify but not certify it. After a patient has died, a doctor needs to complete a medical certificate of cause of death (MCCD). However, there is a list of circumstances in which a doctor should notify the Coroner before completing the MCCD.
When completing the MCCD, it is important to note that old age as 1a is only acceptable if the patient was at least 80 years old. Natural causes is not acceptable, and organ failure can only be used if the disease or condition that led to the organ failure is specified. Abbreviations should be avoided, except for HIV and AIDS.
Once the MCCD is completed, the family takes it to the local Registrar of Births, Deaths, and Marriages office to register the death. If the Registrar decides that the death doesn’t need reporting to the Coroner, he/she will issue a certificate for Burial or Cremation and a certificate of Registration of Death for Social Security purposes. Copies of the Death Register are also available upon request, which banks and insurance companies expect to see. If the family wants the burial to be outside of England, an Out of England Order is needed from the coroner.
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This question is part of the following fields:
- End Of Life
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Question 13
Incorrect
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A 25-year-old man presents to you with concerns that he may be losing his mind. He reports experiencing peculiar odors (such as burnt rubber) and frequently feeling jamais vu. No one else detects any unusual smells during these episodes. He remains fully conscious and has excellent recall of the events. What is the probable diagnosis?
Your Answer: Complex partial seizure
Correct Answer: Schizophreniform attack
Explanation:Understanding Simple Partial Seizures
A simple partial seizure is a type of seizure where consciousness is usually not lost during the attack. However, other symptoms such as muscle twitching, numbness, or tingling sensations may occur. This type of seizure is considered simple because it only affects a small part of the brain.
It is important to note that if consciousness is impaired during the seizure, it is then classified as a complex partial seizure. It is crucial to understand the difference between the two types of seizures as they may require different treatment approaches.
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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 10-year-old girl comes to her General Practitioner with her mother, complaining of a plantar wart on the sole of her foot. It has been there for a few months, is increasing in size, and is causing discomfort while walking.
What is the most suitable initial treatment choice for this situation?
Your Answer: No treatment required
Correct Answer: Cryotherapy
Explanation:Treatment Options for Plantar Warts
Plantar warts can be a painful and persistent problem, and while they may eventually resolve on their own, treatment is often necessary. Cryotherapy and salicylic acid treatments are commonly used, but may require multiple courses and can cause local pain and irritation. Laser therapy may be used for resistant cases, while surgical excision may be necessary if other treatments fail. However, topical terbinafine is not indicated for plantar wart treatment. It is important to seek medical advice for proper diagnosis and treatment.
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This question is part of the following fields:
- Dermatology
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Question 15
Incorrect
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A 23 year old female comes to you seeking treatment for her moderate acne. She has attempted using benzoyl peroxide from the drugstore. She discloses that she is presently attempting to get pregnant. Which of the subsequent acne treatments would be appropriate for this patient?
Your Answer: Oral lymecycline
Correct Answer: Oral erythromycin
Explanation:Pregnancy poses a challenge when it comes to treating acne as many treatments can be harmful to the developing foetus. It is important to consider this issue before starting any treatment, especially in women of childbearing age who may not yet know they are pregnant.
Retinoids, such as isotretinoin and adapalene, are not safe for use during pregnancy due to their teratogenic effects. Dianette, a contraceptive pill, is not suitable for this patient who is trying to conceive. Antibiotics like oxytetracycline, tetracycline, lymecycline, and doxycycline can accumulate in growing bones and teeth, making them unsuitable for use during pregnancy. Erythromycin, on the other hand, is considered safe for use during pregnancy.
Acne vulgaris is a common skin condition that usually affects teenagers and is characterized by the obstruction of hair follicles with keratin plugs, resulting in comedones, inflammation, and pustules. The severity of acne can be classified as mild, moderate, or severe, depending on the number and type of lesions present. Treatment for acne typically involves a step-up approach, starting with single topical therapy and progressing to combination therapy or oral antibiotics if necessary. Tetracyclines are commonly used but should be avoided in certain populations, and a topical retinoid or benzoyl peroxide should always be co-prescribed to reduce the risk of antibiotic resistance. Combined oral contraceptives can also be used in women, and oral isotretinoin is reserved for severe cases under specialist supervision. Dietary modification has no role in the management of acne.
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This question is part of the following fields:
- Dermatology
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Question 16
Incorrect
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A 55-year-old woman has newly diagnosed diabetes. You examine her retina.
Which of the following represents the earliest sign of diabetic retinopathy?Your Answer: Cotton wool spots
Correct Answer: Dot haemorrhage
Explanation:Understanding the Stages of Diabetic Retinopathy
Diabetic retinopathy is a condition that affects the eyes of individuals with diabetes. While the exact mechanism behind its development is not fully understood, it is known that microvascular occlusion leads to retinal ischaemia, which in turn causes arteriovenous shunts and neovascularisation. This process results in the characteristic features seen at various stages of diabetic retinopathy.
The earliest lesions to be detected in diabetic retinopathy are usually dot haemorrhages, which are capillary microaneurysms. Cotton-wool spots and hard exudates usually appear later than microaneurysms. Cotton-wool spots are due to a build-up of axonal debris, while hard exudates are precipitates of lipoproteins and other proteins leaking from retinal blood vessels that form well-defined yellow patches.
New blood vessels on the optic disc characterise proliferative retinopathy. They are an attempt by the residual healthy retina to re-vascularise hypoxic retinal tissue. However, these vessels are poorly and hastily built, and they bleed spontaneously or with minimal trauma. Advanced disease then follows with pre-retinal haemorrhage, vitreous haemorrhage, retinal detachment, macular oedema, and ischaemic maculopathy.
Venous loops and venous beading frequently occur adjacent to areas of non-perfusion. They indicate increasing retinal ischaemia, and their occurrence is a significant predictor of progression to proliferative diabetic retinopathy.
Understanding the stages of diabetic retinopathy is crucial for early detection and treatment. Regular eye exams are recommended for individuals with diabetes to monitor their eye health and prevent vision loss.
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This question is part of the following fields:
- Eyes And Vision
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Question 17
Incorrect
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A young adult with psoriasis manages his flare-ups at home using potent topical steroids. He is aware of the potential side effects of continuous topical steroid use and asked about the recommended duration of break between courses of treatment according to NICE guidelines.
Your Answer: Aim for a break of 4 weeks
Correct Answer: Aim for a break of 8 weeks
Explanation:Managing Psoriasis with Topical Treatments
Psoriasis patients are advised by NICE to take a break of at least 4 weeks between courses of treatment with potent or very potent corticosteroids. During this period, patients should consider using topical treatments that are not steroid-based, such as vitamin D or vitamin D analogues, or coal tar to maintain psoriasis disease control. These topical treatments can help manage psoriasis symptoms and prevent flare-ups. It is important for patients to work closely with their healthcare provider to determine the best treatment plan for their individual needs. By incorporating non-steroid topical treatments into their psoriasis management plan, patients can achieve better control of their symptoms and improve their overall quality of life.
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This question is part of the following fields:
- Dermatology
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Question 18
Correct
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A 25-year-old soldier who returned from a tour of Iraq 3 months ago comes to the clinic with a painless ulcer on his forearm. He explains that it began as a small bump and has been growing in size. Upon examination, there is a 4 cm ulcer with a sunken center and a raised firm border. The patient is healthy otherwise and has no other medical issues.
What is the probable diagnosis?Your Answer: Cutaneous leishmaniasis
Explanation:Based on the patient’s travel history to Afghanistan and the presence of a painless single lesion, the most probable diagnosis is cutaneous leishmaniasis. Although primary syphilis can also present with a painless lesion, the size and location of the lesion on the back of the hand is atypical. Pyoderma gangrenosum typically causes pain and presents more acutely. While a buruli ulcer can also present similarly, it is rare, mostly found in children, and has not been reported in the Middle East.
Source: WHO fact sheets on leishmaniasis
Cutaneous leishmaniasis is transmitted by sandflies and usually manifests as an erythematous patch or papule that gradually enlarges and becomes an ulcer with a raised indurated border. In dry forms, the lesion is crusted with a raised edge. It is usually painless unless a secondary bacterial infection is present. Afghanistan has particularly high levels of cutaneous leishmaniasis.Leishmaniasis: A Disease Caused by Sandfly Bites
Leishmaniasis is a disease caused by the protozoa Leishmania, which are transmitted through the bites of sandflies. There are three main forms of the disease: cutaneous, mucocutaneous, and visceral. Cutaneous leishmaniasis is characterized by a crusted lesion at the site of the bite, which may be accompanied by an underlying ulcer. It is typically diagnosed through a punch biopsy from the edge of the lesion. Mucocutaneous leishmaniasis can spread to involve the mucosae of the nose, pharynx, and other areas. Visceral leishmaniasis, also known as kala-azar, is the most severe form of the disease and is characterized by fever, sweats, rigors, massive splenomegaly and hepatomegaly, poor appetite, weight loss, and grey skin. The gold standard for diagnosis is bone marrow or splenic aspirate. Treatment is necessary for cutaneous leishmaniasis acquired in South or Central America due to the risk of mucocutaneous leishmaniasis, while disease acquired in Africa or India can be managed more conservatively.
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This question is part of the following fields:
- Dermatology
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Question 19
Correct
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A 25-year-old woman presented to the Emergency Department from her workplace, for the second time in the span of three months, after experiencing a syncopal episode. She also reported feeling extremely fatigued for the past few months and having bouts of dizziness. Upon examination, she appeared slender and sun-kissed, with a blood pressure of 112/72 mmHg while lying down, but it dropped to 87/63 mmHg upon standing. Her baseline serum cortisol was low (<100 nmol/l) and her free thyroxine (T4) level was also low.
What is the most appropriate diagnosis for the clinical presentation described above? Choose ONE option only.Your Answer: Primary hypoadrenalism
Explanation:Diagnosis of Primary Hypoadrenalism: A Case Study
A woman presents with a marked postural drop in blood pressure, increased pigmentation, and low cortisol levels, indicating primary hypoadrenalism as the most likely diagnosis. The high adrenocorticotropic hormone (ACTH) level causes pigmentation, and autoimmune destruction of the adrenal glands is responsible for 80% of cases. Hyponatremia and hyperkalemia are common in established cases. The National Institute for Health and Care Excellence recommends hospital admission for serum cortisol levels below 100 nmol/l and referral to an endocrinologist for levels between 100 and 500 nmol/l. Hypovolemia, HIV, hypothyroidism, and psychiatric symptoms are unlikely causes based on the case history.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 20
Incorrect
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A 39-year-old woman presents with pain and swelling of the metacarpo-phalangeal joints and the proximal inter-phalangeal joints of both hands. She reports that the symptoms are worse in the morning and her hands are very stiff. The symptoms have been present for eight weeks. Her rheumatoid factor is reported as weakly positive.
What is the most suitable course of action for a general practitioner? Choose ONE option only.Your Answer: Methotrexate
Correct Answer: Urgent referral
Explanation:Urgent Referral for Suspected Rheumatoid Arthritis
If a patient presents with persistent synovitis of unknown cause, it is important to consider the possibility of rheumatoid arthritis. According to the National Institute for Health and Care Excellence, an urgent referral to a rheumatologist is necessary if the small joints of the hands or feet are affected, more than one joint is affected, or symptoms have been present for three months or longer before presentation. This referral should be made even if the patient’s erythrocyte sedimentation rate is normal and they are negative for rheumatoid factor and anticyclic citrullinated peptide.
While a non-steroidal anti-inflammatory drug may be prescribed by a general practitioner for pain control, the urgent referral to a rheumatologist is the most appropriate option. In secondary care, a disease-modifying anti-rheumatic drug (DMARD) such as methotrexate, leflunomide, or sulfasalazine should be started as soon as possible, ideally within three months of the onset of persistent symptoms. Short-term bridging treatment with glucocorticoids may also be considered when starting the DMARD.
In summary, an urgent referral to a rheumatologist is necessary for suspected rheumatoid arthritis, even if certain diagnostic markers are negative. Prompt treatment with a DMARD is crucial for managing the disease and preventing long-term joint damage.
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This question is part of the following fields:
- Musculoskeletal Health
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Question 21
Correct
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A 75-year-old male has just begun taking Pramipexole for his restless legs.
Which of the following parameters should be monitored during his treatment?Your Answer: Blood pressure
Explanation:Monitoring and Counseling for Pramipexole Use
When using Pramipexole, it is important to monitor blood pressure due to the risk of postural hypotension, especially during initiation. However, there is no need to check pulses, serum calcium, or liver function. Although renal function is not listed as an option, it is important to note that dosage adjustments or discontinuation may be necessary in the presence of reduced or abnormal renal function. Additionally, patients should be counseled about the potential for sudden onset of sleep and hypotensive reactions, which may affect their ability to operate machinery or drive. Proper monitoring and counseling can help ensure safe and effective use of Pramipexole.
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This question is part of the following fields:
- Improving Quality, Safety And Prescribing
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Question 22
Incorrect
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You wish to investigate an outbreak of atypical pneumonia cases in the elderly population and determine if there has been exposure to a particular risk factor.
Which study design would be most appropriate?Your Answer: Cohort
Correct Answer: Case-control
Explanation:The most appropriate study design to investigate an infectious outbreak is a case-control study. This study design allows for the retrospective identification of patients who have developed the disease and compares their past exposure to suspected causal factors with controls who do not have the disease. A cohort study, which follows patients into the future, is not suitable for this scenario as the aim is to trace the cause of the outbreak. A cross-sectional study provides a snapshot of the condition and exposures in the overall population at a set time, but it is not suitable for finding the cause of the outbreak. Randomized controlled trials are not appropriate as there are no interventions being studied. Meta-analysis is not applicable as there is no mention of other research to review.
There are different types of studies that researchers can use to investigate various phenomena. One of the most rigorous types of study is the randomised controlled trial, where participants are randomly assigned to either an intervention or control group. However, practical or ethical issues may limit the use of this type of study. Another type of study is the cohort study, which is observational and prospective. Researchers select two or more groups based on their exposure to a particular agent and follow them up to see how many develop a disease or other outcome. The usual outcome measure is the relative risk. Examples of cohort studies include the Framingham Heart Study.
On the other hand, case-control studies are observational and retrospective. Researchers identify patients with a particular condition (cases) and match them with controls. Data is then collected on past exposure to a possible causal agent for the condition. The usual outcome measure is the odds ratio. Case-control studies are inexpensive and produce quick results, making them useful for studying rare conditions. However, they are prone to confounding. Lastly, cross-sectional surveys provide a snapshot of a population and are sometimes called prevalence studies. They provide weak evidence of cause and effect.
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This question is part of the following fields:
- Evidence Based Practice, Research And Sharing Knowledge
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Question 23
Correct
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A mother brings her 18-month-old daughter in for review. She started walking three months ago. The mother has noticed that her daughter seems to be 'bow-legged' when she walks.
Examination of the knees and hips is unremarkable with a full range of movement. Leg length is equal. On standing the intercondylar distance is around 7cm.
What is the most appropriate action?Your Answer: Reassure that it is a normal variant and likely to resolve by the age of 4 years
Explanation:It is common for children under the age of 3 to have bow legs, which is considered a normal variation. Typically, this condition resolves on its own by the time the child reaches 4 years old.
Common Variations in Lower Limb Development in Children
Parents may become concerned when they notice what appears to be abnormalities in their child’s lower limbs. This often leads to a visit to the primary care physician and a referral to a specialist. However, many of these variations are actually normal and will resolve on their own as the child grows.
One common variation is flat feet, where the medial arch is absent when the child is standing. This is typically seen in children of all ages and usually resolves between the ages of 4-8 years. Orthotics are not recommended, and parental reassurance is appropriate.
Another variation is in-toeing, which can be caused by metatarsus adductus, internal tibial torsion, or femoral anteversion. In most cases, these will resolve on their own, but severe or persistent cases may require intervention such as serial casting or surgical intervention. Out-toeing is also common in early infancy and usually resolves by the age of 2 years.
Bow legs, or genu varum, are typically seen in the first or second year of life and are characterized by an increased intercondylar distance. This variation usually resolves by the age of 4-5 years. Knock knees, or genu valgum, are seen in the third or fourth year of life and are characterized by an increased intermalleolar distance. This variation also typically resolves on its own.
In summary, many variations in lower limb development in children are normal and will resolve on their own. However, if there is concern or persistent symptoms, intervention may be appropriate.
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This question is part of the following fields:
- Children And Young People
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Question 24
Incorrect
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You review the results of a DEXA scan for a 70-year-old man who was referred due to a family history of femoral fracture. His past medical history includes hypertension, for which he takes lisinopril. He is a non-smoker, drinks 5 units of alcohol per week and eats a healthy balanced diet. His T-score is -2.5. Blood results are shown below.
Hb 140g/L 120-160g/L
WCC 7.0x109/l 4.0-11x109/l
Na+ 137mmol/L 135-145mmol/L)
K+ 4.2mmol/L 3.5-5.3mmol/L
Ca2+ 2.3mmol/L 2.2-2.6mmol/L (adjusted)
Vitamin D 60nmol/L >50nmol/L
What is the most appropriate action?Your Answer: Alendronate + calcium + vitamin D
Correct Answer: Alendronate
Explanation:The most appropriate prescription for this patient with osteoporosis is alendronate, a bisphosphonate therapy. Calcium and vitamin D supplementation is not necessary as both levels are replete and the patient has a balanced diet. Calcium should only be prescribed if dietary intake is inadequate. Hormone replacement therapy is not recommended for older postmenopausal women with osteoporosis, as the risk vs benefit ratio is unfavourable.
Bisphosphonates: Uses, Adverse Effects, and Patient Counselling
Bisphosphonates are drugs that mimic the action of pyrophosphate, a molecule that helps prevent bone demineralization. They work by inhibiting osteoclasts, the cells responsible for breaking down bone tissue. Bisphosphonates are commonly used to prevent and treat osteoporosis, hypercalcemia, Paget’s disease, and pain from bone metastases.
However, bisphosphonates can cause adverse effects such as oesophageal reactions, osteonecrosis of the jaw, and an increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate. Patients may also experience an acute phase response, which includes fever, myalgia, and arthralgia following administration. Hypocalcemia may also occur due to reduced calcium efflux from bone, but this is usually clinically unimportant.
To minimize the risk of adverse effects, patients taking oral bisphosphonates should swallow the tablets whole with plenty of water while sitting or standing. They should take the medication on an empty stomach at least 30 minutes before breakfast or another oral medication and remain upright for at least 30 minutes after taking the tablet. Hypocalcemia and vitamin D deficiency should be corrected before starting bisphosphonate treatment. However, calcium supplements should only be prescribed if dietary intake is inadequate when starting bisphosphonate treatment for osteoporosis. Vitamin D supplements are usually given.
The duration of bisphosphonate treatment varies depending on the level of risk. Some experts recommend stopping bisphosphonates after five years if the patient is under 75 years old, has a femoral neck T-score of more than -2.5, and is at low risk according to FRAX/NOGG.
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This question is part of the following fields:
- Musculoskeletal Health
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Question 25
Incorrect
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You see a 50-year-old type one diabetic patient who has come to see you regarding his erectile dysfunction. He reports a gradual decline in his ability to achieve and maintain erections over the past 6 months. After reviewing his medications and discussing treatment options, you suggest he try a phosphodiesterase (PDE-5) inhibitor and prescribe him sildenafil.
What advice should you give this patient regarding taking a PDE-5 inhibitor?Your Answer: Of the available PDE-5 inhibitors, this patient can only get sildenafil on an NHS prescription
Correct Answer: Sexual stimulation is required to facilitate an erection
Explanation:PDE-5 inhibitors do not cause an erection on their own, but rather require sexual stimulation to assist in achieving an erection. They are typically the first choice for treating erectile dysfunction, as long as there are no contraindications.
The primary cause of ED is often vasculogenic, such as cardiovascular disease, which means that the same lifestyle and risk factors that apply to CVD also apply to ED. Treatment for ED typically involves a combination of lifestyle changes and medication. It is important to advise patients to lose weight, quit smoking, reduce alcohol consumption, and increase exercise. Lifestyle changes and risk factor modification should be implemented before or alongside treatment.
Generic sildenafil is available on the NHS without restrictions. Additionally, other PDE-5 inhibitors may be prescribed on the NHS for certain medical conditions, such as diabetes.
For most men, as-needed treatment with a PDE-5 inhibitor is appropriate. The frequency of treatment will depend on the individual.
Sildenafil should be taken one hour before sexual activity and requires sexual stimulation to facilitate an erection.
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 26
Correct
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A woman you are treating for tuberculosis mentions that she has observed her urine turning orange since commencing treatment. Which medication is causing this change?
Your Answer: Rifampicin
Explanation:One of the peculiar side effects of rifampicin, a medication used in TB treatment, is the discoloration of bodily secretions to orange. However, the other medications used in TB treatment do not cause such a side effect. The notes below provide information on the side effects of these medications.
Tuberculosis is a bacterial infection that can be treated with a combination of drugs. Each drug has a specific mechanism of action and can also cause side-effects. Rifampicin works by inhibiting bacterial DNA dependent RNA polymerase, which prevents the transcription of DNA into mRNA. However, it is a potent liver enzyme inducer and can cause hepatitis, orange secretions, and flu-like symptoms.
Isoniazid, on the other hand, inhibits mycolic acid synthesis. It can cause peripheral neuropathy, which can be prevented with pyridoxine (Vitamin B6). It can also cause hepatitis and agranulocytosis, but it is a liver enzyme inhibitor.
Pyrazinamide is converted by pyrazinamidase into pyrazinoic acid, which inhibits fatty acid synthase (FAS) I. However, it can cause hyperuricaemia, leading to gout, as well as arthralgia and myalgia. It can also cause hepatitis.
Finally, Ethambutol inhibits the enzyme arabinosyl transferase, which polymerizes arabinose into arabinan. However, it can cause optic neuritis, so it is important to check visual acuity before and during treatment. The dose also needs adjusting in patients with renal impairment.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 27
Correct
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A 65-year-old male presents to your clinic with a suspected fungal toenail infection. The infection has been gradually developing, causing discoloration of the nail unit with white/yellow streaks and distorting the nail bed. The severity of the infection is moderate. During his last visit, nail scrapings were taken for microscopy and culture, which recently confirmed dermatophyte infection. The patient is experiencing discomfort while walking and is seeking treatment for the fungal infection.
What is the most suitable treatment option for this patient?Your Answer: Oral terbinafine
Explanation:Oral terbinafine is recommended for treating dermatophyte nail infections.
Fungal Nail Infections: Causes, Symptoms, and Treatment
Fungal nail infections, also known as onychomycosis, can affect any part of the nail or the entire nail unit. However, toenails are more susceptible to infection than fingernails. The primary cause of fungal nail infections is dermatophytes, with Trichophyton rubrum being the most common. Yeasts, such as Candida, and non-dermatophyte molds can also cause fungal nail infections. Risk factors for developing a fungal nail infection include increasing age, diabetes mellitus, psoriasis, and repeated nail trauma.
The most common symptom of a fungal nail infection is thickened, rough, and opaque nails. Patients may present with unsightly nails, which can be a source of embarrassment. Differential diagnoses include psoriasis, repeated trauma, lichen planus, and yellow nail syndrome. To confirm a fungal nail infection, nail clippings or scrapings of the affected nail should be examined under a microscope and cultured. However, the false-negative rate for cultures is around 30%, so repeat samples may be necessary if clinical suspicion is high.
Asymptomatic fungal nail infections do not require treatment unless the patient is bothered by the appearance. Topical treatment with amorolfine 5% nail lacquer is recommended for limited involvement, while oral terbinafine is the first-line treatment for more extensive involvement due to a dermatophyte infection. Fingernail infections require 6 weeks to 3 months of therapy, while toenails should be treated for 3 to 6 months. Oral itraconazole is recommended for more extensive involvement due to a Candida infection, with pulsed weekly therapy being the preferred method.
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This question is part of the following fields:
- Dermatology
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Question 28
Incorrect
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A 28-year-old woman contacts the clinic seeking guidance. She has missed taking her Cerazette contraceptive pill yesterday. Based on your calculation, it has been approximately 48 hours since she last took a Cerazette pill. She is typically diligent in taking her pills and has not missed any other pills in the last half-year. Her last sexual activity was eight days ago. What is the best advice to provide her?
Your Answer: Take two pills now + use condoms for 7 days + needs emergency contraception
Correct Answer: Take two pills now + use condoms for 2 days
Explanation:Cerazette has a wider time frame for taking the pill than traditional progestogen only pills, but if a pill is missed, the user should take two pills immediately and use additional contraception for two days.
The progestogen only pill (POP) has simpler rules for missed pills compared to the combined oral contraceptive pill. It is important to not confuse the two. For traditional POPs such as Micronor, Noriday, Norgeston, and Femulen, as well as Cerazette (desogestrel), if a pill is less than 3 hours late, no action is required and pill taking can continue as normal. However, if a pill is more than 3 hours late (i.e. more than 27 hours since the last pill was taken), action is needed. If a pill is less than 12 hours late, no action is required. But if a pill is more than 12 hours late (i.e. more than 36 hours since the last pill was taken), action is needed.
If action is needed, the missed pill should be taken as soon as possible. If more than one pill has been missed, only one pill should be taken. The next pill should be taken at the usual time, which may mean taking two pills in one day. Pill taking should continue with the rest of the pack. Extra precautions, such as using condoms, should be taken until pill taking has been re-established for 48 hours.
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This question is part of the following fields:
- Maternity And Reproductive Health
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Question 29
Correct
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A 5-year-old boy presents with his first febrile convulsion.
Which of the following is appropriate information for his parents?Your Answer: Most cases happen between 6 months and 3 years of age
Explanation:Febrile Convulsions: A Common Occurrence in Young Children
Febrile convulsions are a relatively common occurrence in young children, with a prevalence of 5% between the ages of 6 months and 5 years. Clinical experience has shown that most of these convulsions occur before the age of three. The convulsions are typically tonic-clonic in nature, and most children (75%) will only experience one seizure. A strong family history of febrile seizures is the most important factor in predicting whether a child will develop further seizures.
Fortunately, epilepsy develops in only approximately 2% of children who experience febrile convulsions. After the first seizure, no treatment is required other than symptomatic care. It is important for parents and caregivers to be aware of the signs and symptoms of febrile convulsions and to seek medical attention if they occur. With proper management and care, most children will recover fully from febrile convulsions without any long-term effects.
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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 32-year-old woman presents with complaints of constant fatigue for the past few months. She reports having missed her period for six months and experiences dizziness in the morning. Addison's disease is being considered as a possible diagnosis.
Which of the following clinical manifestations is the most specific for Addison's disease?
Choose ONE answer only.Your Answer: Pigmentation of the palms
Explanation:Symptoms of Hypoadrenalism and Hypopituitarism
Hypoadrenalism, also known as Addison’s disease, can be caused by autoimmune destruction of the adrenal cortex, granulomatous disorders, tuberculosis, tumours, or infections. Glucocorticoid deficiency, commonly seen in Addison’s disease, can cause pigmentation of the palms due to elevated levels of melanocyte-stimulating hormone (MSH) and adrenocorticotropic hormone (ACTH).
Hypopituitarism can cause a variety of symptoms, including pallor due to normochromic, normocytic anaemia, postural hypotension related to glucocorticoid deficiency, and visual-field defects from pressure on the optic nerve caused by a pituitary tumour. Lack of body hair and amenorrhoea are also features of hypogonadism in hypopituitarism.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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