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"choices": [
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"answer": false,
"explanation": "Pyrazinamide is not known to cause urine discolouration. Side effects of Pyrazinamide include hepatitis and arthralgia.",
"id": "10035484",
"label": "c",
"name": "Pyrazinamide",
"picture": null,
"votes": 16
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Isoniazid is not known to cause urine discolouration. A more established side effect of Isoniazid in the treatment of TB is peripheral neuropathy.",
"id": "10035483",
"label": "b",
"name": "Isoniazid",
"picture": null,
"votes": 35
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Ethambutol is not known to cause urine discolouration. An important side effect of Ethambutol in the treatment of TB is optic neuritis.",
"id": "10035485",
"label": "d",
"name": "Ethambutol",
"picture": null,
"votes": 31
},
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "A well-established side effect of rifampicin is red/orange discolouration of secretions including tears, urine and semen.",
"id": "10035482",
"label": "a",
"name": "Rifampicin",
"picture": null,
"votes": 1699
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is used to treat travellers’ diarrhoea or hepatic encephalopathy rather than TB. It is poorly absorbed and is not typically used to treat systemic infections.",
"id": "10035486",
"label": "e",
"name": "Rifaximin",
"picture": null,
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}
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"comment": "anyone else not read :(",
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"comment": "aahahha same ",
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"id": "3697",
"name": "Tuberculosis",
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"learningPoint": "Rifampicin can cause red/orange discolouration of urine and other secretions, a common and benign side effect of the medication.",
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"question": "A 47-year-old male complains of urine discolouration. He has recently been started on treatment for tuberculosis following a 6-month history of a chronic cough, night sweats and weight loss. When asked, he describes the urine as red/orange in colour and denies any dysuria or increased urinary frequency.\n\nWhich of the following medications is most likely to have caused this presentation?",
"sbaAnswer": [
"a"
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"totalVotes": 1881,
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173,468,590 | false | 22 | null | 6,495,268 | null | false | [] | null | 19,501 | {
"__typename": "QuestionSBA",
"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "The costophrenic angles are well-defined in the CXR with no obvious effusion.",
"id": "10035489",
"label": "c",
"name": "Pleural effusion",
"picture": null,
"votes": 22
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This history is less suggestive of a malignancy, which would be more likely to present with chronic systemic symptoms.",
"id": "10035488",
"label": "b",
"name": "Adenocarcinoma of the lung",
"picture": null,
"votes": 57
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{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This history is not suggestive of pneumothorax and there is no evidence of pneumothorax seen on this CXR.",
"id": "10035491",
"label": "e",
"name": "Pneumothorax",
"picture": null,
"votes": 24
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a complication of severe pneumonia. Radiolucency over the region of consolidation may instead be seen on CXR.",
"id": "10035490",
"label": "d",
"name": "Cavitating pneumonia",
"picture": null,
"votes": 596
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This history suggests a patient who is at higher risk of aspiration due to the patient’s poor functional baseline and cognitive impairment. The CXR shows a right-sided pneumonia typical of aspiration.",
"id": "10035487",
"label": "a",
"name": "Aspiration pneumonia",
"picture": null,
"votes": 1179
}
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"id": "4389",
"name": "Aspiration Pneumonia",
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"learningPoint": "Aspiration pneumonia commonly occurs in patients with cognitive impairment and poor functional status, leading to increased risk of respiratory infections.",
"likes": 1,
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"question": "An 87-year-old female has a productive cough and appears more confused than normal according to her carers. The carers state that her sputum is green in colour and that the patient seems to be slightly breathless when talking. She has a poor functional baseline and has lived in a care home, since her diagnosis of Alzheimer’s disease 5 years ago.\n\nHer CXR is seen below:\n\n[lightgallery]\n\nWhat is the most likely diagnosis?",
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Alendronic acid has a common side effect of dizziness, however, it is less likely to cause postural hypotension than tamsulosin, as described by the feeling of light-headedness.",
"id": "10035496",
"label": "e",
"name": "Alendronic acid",
"picture": null,
"votes": 47
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Although a common regular medication for older patients, macrogol is unlikely to cause this presentation unless the laxative effect contributes to severe dehydration.",
"id": "10035493",
"label": "b",
"name": "Macrogol",
"picture": null,
"votes": 27
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Atorvastatin is a common regular medication, however, it is unlikely to cause this presentation as it is not known to cause dizziness or postural hypotension.",
"id": "10035495",
"label": "d",
"name": "Atorvastatin",
"picture": null,
"votes": 35
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Aspirin is an anti-platelet agent which is unlikely to cause this presentation as it is not commonly known to cause dizziness or postural hypotension.",
"id": "10035494",
"label": "c",
"name": "Aspirin",
"picture": null,
"votes": 21
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Tamsulosin is an alpha blocker used to treat benign prostatic hyperplasia, a common symptom of which is nocturia. It can commonly cause postural hypotension, classically depicted by dizziness on standing, as outlined in this scenario.",
"id": "10035492",
"label": "a",
"name": "Tamsulosin",
"picture": null,
"votes": 1745
}
],
"comments": [],
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"id": "4044",
"name": "Postural Hypotension",
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"topic": {
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"name": "Geriatrics",
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"learningPoint": "Tamsulosin can cause postural hypotension by blocking alpha-1 adrenergic receptors, which leads to relaxation of smooth muscles in blood vessels and a subsequent drop in blood pressure when standing, increasing the risk of dizziness and falls, especially in elderly patients.",
"likes": 0,
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"question": "A 92-year-old male has a fall when trying to get out of bed to use the toilet in the middle of the night. He describes feeling dizzy and light-headed on standing before falling onto his knees and staying there for a few minutes. He denies hitting his head or any other injury.\n\nOf the following medications, which is the most likely to have caused these symptoms?",
"sbaAnswer": [
"a"
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173,468,592 | false | 24 | null | 6,495,268 | null | false | [] | null | 19,503 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The patient is afebrile without any audible crackles, making this an unlikely option.",
"id": "10035498",
"label": "b",
"name": "Pneumonia",
"picture": null,
"votes": 11
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is a case of delirium, of which constipation is a common cause. Given the patient is afebrile and appears euvolaemic based on her observations and examination, the most likely cause is constipation, which can present with mild lower abdominal tenderness.",
"id": "10035497",
"label": "a",
"name": "Constipation",
"picture": null,
"votes": 1630
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst pain itself can cause delirium, the abdominal pain is described as mild. Additionally, the patient has normal observations, which you may not expect in the case of acute pain. This makes constipation a more likely cause of this patient’s delirium.",
"id": "10035499",
"label": "c",
"name": "Pain",
"picture": null,
"votes": 68
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "As the patient has moist mucous membranes, is not tachycardic and is normotensive for an older female, this is unlikely to be the cause of her delirium. This is however an important cause of delirium that should always be considered.",
"id": "10035501",
"label": "e",
"name": "Dehydration",
"picture": null,
"votes": 86
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "As this patient was acutely confused before medical attention was sought, this is unlikely to have caused her delirium.",
"id": "10035500",
"label": "d",
"name": "Change of environment to a medical setting",
"picture": null,
"votes": 65
}
],
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"id": "4045",
"name": "Delirium",
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"name": "Geriatrics",
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"learningPoint": "Constipation is a common cause of delirium in elderly patients, often presenting with confusion and mild abdominal tenderness.",
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"question": "A 93-year-old female has 2 days of confusion and loss of appetite. She does not answer questions directly when asked and appears drowsy throughout the assessment. She lives with her daughter who states she is much more confused than normal and reports she was otherwise well before this presentation.\n\nObservations:\n\n* Respiratory rate: 14\n* Oxygen saturations: 95% on room air\n* Heart rate: 58\n* Blood pressure: 95/58 with no significant postural drop\n* Temperature: 37.2 degrees celsius\n\nOn examination, she has moist mucous membranes. Her chest is clear and no added heart sounds are heard. Her abdomen is mildly tender on palpation of the left iliac fossa with bowel sounds present.\n\nWhat is the most likely cause of her presentation?",
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"a"
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173,468,593 | false | 25 | null | 6,495,268 | null | false | [] | null | 19,504 | {
"__typename": "QuestionSBA",
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{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Visual hallucinations are not typically seen in Alzheimer’s disease.",
"id": "10035503",
"label": "b",
"name": "Alzheimer’s Disease",
"picture": null,
"votes": 55
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This usually presents in younger patients and will present with features of behaviour change and disinhibition, rather than visual hallucinations.",
"id": "10035504",
"label": "c",
"name": "Fronto-temporal dementia",
"picture": null,
"votes": 44
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is a classic description of Dementia with Lewy Bodies, which presents with memory loss and hallucinations. This patient may go on to develop Parkinsonism.",
"id": "10035502",
"label": "a",
"name": "Dementia with Lewy Bodies",
"picture": null,
"votes": 1690
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This presents with visual hallucinations due to sight loss, it would not normally involve memory loss and cognitive impairment.",
"id": "10035505",
"label": "d",
"name": "Charles-Bonnet syndrome",
"picture": null,
"votes": 54
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Visual hallucinations are not typically seen in Vascular dementia.",
"id": "10035506",
"label": "e",
"name": "Vascular dementia",
"picture": null,
"votes": 16
}
],
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"question": "An 81-year-old male is noted to have memory loss, decreased ability to make decisions and increased drowsiness noted by his wife. She also describes that the patient will sometimes say things about seeing their dog running around, despite her dog having passed away 5 years ago. She is very concerned about her husband and is worried that he may have had a stroke.\n\nWhat is the most likely diagnosis?",
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"a"
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173,468,594 | false | 26 | null | 6,495,268 | null | false | [] | null | 19,505 | {
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"__typename": "QuestionChoice",
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"explanation": "This is a rare disease characterised by fibrosis of the thyroid, which leads to hypothyroidism and a goitre which would typically be painless. In this scenario, the patient describes symptoms of hyperthyroidism and has a painful goitre, making this a less likely option.",
"id": "10035509",
"label": "c",
"name": "Ridel’s thyroiditis",
"picture": null,
"votes": 134
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst Graves' disease is the most common cause of hyperthyroidism in the UK it would not typically present with a tender goitre. The recent viral infection also points towards subacute thyroiditis.",
"id": "10035508",
"label": "b",
"name": "Graves’ disease",
"picture": null,
"votes": 101
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would usually cause a unilateral, pulsatile neck mass and would not cause any symptoms of hyperthyroidism.",
"id": "10035510",
"label": "d",
"name": "Carotid aneurysm",
"picture": null,
"votes": 1
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The patient denied any history of weight loss and this is less likely to cause a painful goitre.",
"id": "10035511",
"label": "e",
"name": "Thyroid adenoma",
"picture": null,
"votes": 15
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is a classic description of a case of subacute thyroiditis in the thyrotoxic phase, with symptoms of hyperthyroidism and a tender goitre. it is a transient inflammation of the thyroid gland which often can be triggered by a viral infection.",
"id": "10035507",
"label": "a",
"name": "Subacute thyroiditis",
"picture": null,
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}
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"learningPoint": "Subacute thyroiditis presents with fever, malaise, and a tender goitre, often following a viral infection, leading to transient hyperthyroid symptoms.",
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"question": "A 53-year-old female has a fever and malaise. She states she has felt more anxious and experienced palpitations in the 3 days. On examination, she has a symmetrical swelling around the midline of her lower neck. It is very tender on palpation. She describes having a sore throat 3 weeks ago but denies any other symptoms including weight loss.\n\nWhat is the most likely diagnosis?",
"sbaAnswer": [
"a"
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173,468,595 | false | 27 | null | 6,495,268 | null | false | [] | null | 19,506 | {
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "This describes a likely case of Addison’s disease, given the presence of risk factors (female patient with autoimmune history) and hyperpigmented lesions. Confirming low cortisol is therefore the most useful initial investigation.",
"id": "10035512",
"label": "a",
"name": "9 AM cortisol",
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"votes": 1125
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is unlikely to be a helpful test in a patient with an established diagnosis of type 1 diabetes. It additionally would not be useful for this specific clinical scenario.",
"id": "10035516",
"label": "e",
"name": "Oral glucose tolerance test",
"picture": null,
"votes": 39
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is used in the diagnosis of Cushing’s syndrome rather than Addison’s disease as it assesses for loss of negative feedback in the HPA axis.",
"id": "10035514",
"label": "c",
"name": "Dexamethasone suppression test",
"picture": null,
"votes": 262
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is usually used as a test for Cushing’s syndrome to show increased urinary cortisol over 24 hours rather than the 9 AM cortisol which is used to investigate Addison’s disease.",
"id": "10035513",
"label": "b",
"name": "24-hour urinary free cortisol",
"picture": null,
"votes": 232
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst hypothyroidism could present with fatigue and is more common in a patient with a pre-existing autoimmune condition, it would more commonly cause weight gain and does not explain the hyperpigmented patches.",
"id": "10035515",
"label": "d",
"name": "Thyroid function tests",
"picture": null,
"votes": 201
}
],
"comments": [
{
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"comment": "9am Cortisol results:\n<100: addison's likely\n100-500: further investigations needed\nOver 500: addison's unlikely\n",
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"comment": "Wouldn't a short synacthen test be better?",
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"comment": "yh but its not an option",
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"explanation": "# Summary\n\nAdrenal insufficiency is a condition where destruction of the adrenal cortex leads to reduced glucocorticoid production. It can be classified as primary (Addison's disease) or secondary, each with different causes. Key signs and symptoms include hypotension, fatigue, weakness, gastrointestinal symptoms, and increased pigmentation. Initial investigations should focus on levels of sodium, potassium, glucose, cortisol, ACTH, renin, and aldosterone, while further tests should be used to establish the underlying cause. Management includes patient education on 'sick day' rules, glucocorticoid and mineralocorticoid replacement, and regular screening for complications like adrenal crisis and osteoporosis.\n\n# Definition\n\nAdrenal insufficiency is a clinical syndrome that arises due to the insufficient production of glucocorticoids and mineralocorticoids from the adrenal cortex. \n\nIt can be categorized as primary, commonly known as Addison's disease, where the cause lies within the adrenal glands themselves, or secondary, where inadequate stimulation of the adrenal glands by the pituitary or hypothalamus is the culprit.\n\n\n# Epidemiology\n\nAdrenal insufficiency is a relatively rare disease. Primary adrenal insufficiency (Addison's disease) affects approximately 100-140 people per million in developed countries. Secondary adrenal insufficiency is considered more common but accurate prevalence rates are difficult to determine.\n\n# Pathophysiology\n\nAdrenal insufficiency can result from damage to the adrenal cortex or disruptions in the hypothalamus-pituitary-adrenal (HPA) axis. The HPA axis regulates adrenal hormone production. In primary adrenal insufficiency (Addison's disease), the adrenal glands are damaged, while secondary adrenal insufficiency is due to dysfunction in the hypothalamus or pituitary. The lack of cortisol then disrupts feedback mechanisms, leading to elevated adrenocorticotropic hormone (ACTH) levels.\n\n\nPrimary adrenal insufficiency (Addison's disease) can be caused by:\n\n- Auto-immune destruction (most common)\n- Surgical removal of the adrenal glands\n- Trauma to the adrenal glands\n- Infectious diseases, such as tuberculosis (more common in developing countries)\n- Haemorrhage (e.g., Waterhouse-Friderichsen syndrome)\n- Infarction\n- Less commonly, neoplasms, sarcoidosis, or amyloidosis\n\nSecondary adrenal insufficiency can occur due to:\n\n- Congenital disorders\n- Fracture of the base of the skull\n- Pituitary or hypothalamic surgery or Neoplasms in the pituitary or hypothalamus\n- Infiltration or infection of the brain\n- Deficiency of corticotropin-releasing hormone (CRH)\n\n# Signs and Symptoms \n\nClinical features of adrenal insufficiency include:\n\n- Hypotension\n- Fatigue and weakness\n- Gastrointestinal symptoms\n- Syncope\n- Skin pigmentation due to increased ACTH which stimulates production of alpha melanocyte stimulating hormone (MSH).\n\n[lightgallery]\n\nIn the case of auto-immune Addison's disease, approximately 60% of patients may also have vitiligo or other autoimmune endocrinopathies.\n\n[lightgallery1]\n\n# Differential Diagnosis\n\nAdrenal insufficiency can be misdiagnosed as several other conditions, including:\n\n- Chronic fatigue syndrome: Presents with persistent fatigue, cognitive difficulties, and other non-specific symptoms\n- Dehydration or septic shock: Hypotension and tachycardia can mimic adrenal insufficiency\n- Primary psychiatric illnesses: Depression or other psychiatric illnesses may present with fatigue, decreased appetite, and weight loss.\n\n# Investigations\n\n* First line investigations are U+E and serum cortisol, where you may find:\n\t* Hyponatraemia (low sodium)\n\t* Hyperkalaemia (high potassium)\n\t* Low serum cortisol\n- Glucose (typically low)\n- Therefore in a patient with Addison's who is acutely unwell, you would expect a blood gas to show a **hyperkalaemic, hyponatraemic, hypoglycaemic metabolic acidosis**\n- ACTH: High in primary insufficiency, low or low-normal in secondary insufficiency\n- Renin (high in Addison's disease)\n- Aldosterone (low in Addison's disease)\n\nAn ACTH (Short Synacthen) test is the gold standard investigation to confirm the diagnosis.\n\nFurther investigations to establish the cause can include:\n\n- Testing for adrenal auto-antibodies\n- Chest X-ray\n- CT scan of the adrenal glands\n- MRI of the brain\n\n# Management\n\n**Management of adrenal insufficiency involves:**\n\n- Patient education on 'sick day' rules, carrying a steroid card, and wearing a medical alert bracelet\n- Doubling the regular steroid medication dose during any intercurrent illness\n- Replacement of both glucocorticoids (typically with hydrocortisone) and mineralocorticoids (typically with fludrocortisone)\n- Regular screening for complications including an adrenal crisis and osteoporosis\n\n**Management of Addisonian Crisis**\n\nAn Addisonian crisis, a life-threatening condition characterized by severe hypotension and electrolyte imbalances, should be managed with:\n\n- Aggressive fluid resuscitation\n- Administration of intravenous/IM (if no access) steroids STAT\n- Glucose administration if hypoglycaemia is present\n\n# Complications\n* Addisonian crisis (life-threatening adrenal crisis)\n* Severe electrolyte imbalances\n* Cardiovascular collapse\n* Hypoglycemia\n* Side effects of long term corticosteroid use e.g. osteoporosis\n\n# NICE Guidelines\n\n[Click here for NICE CKS on Addison's disease](https://cks.nice.org.uk/topics/addisons-disease/)\n",
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"caption": "The appearance of acanthosis nigricans.",
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"learningPoint": "In Addison's disease, a condition characterized by insufficient production of adrenal hormones, a 9 a.m. cortisol level is typically measured to assess adrenal function, as cortisol levels are usually low in affected individuals.",
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"question": "A 32-year-old female has a 6-month history of weight loss and persistent fatigue throughout the day. The fatigue is present regardless of how much sleep she had the night before. She has a past medical history of type 1 diabetes mellitus, which she feels is well-controlled with no recent episodes of hypoglycaemia. On examination, she is noted to have dark patches on the inside of her mouth as well as her palms.\n\nGiven the most likely diagnosis, which initial investigation should be performed?",
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"a"
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173,468,596 | false | 28 | null | 6,495,268 | null | false | [] | null | 19,507 | {
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"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is only recommended for a short course in patients awaiting referral after initial treatment has failed and is therefore not the most appropriate medication to commence.",
"id": "10035519",
"label": "c",
"name": "Tramadol",
"picture": null,
"votes": 19
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Fluoxetine is not recommended for the treatment of neuropathic pain in the UK.",
"id": "10035518",
"label": "b",
"name": "Fluoxetine",
"picture": null,
"votes": 13
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "NICE guidance states that more than one neuropathic pain drug should not be prescribed at the same.",
"id": "10035521",
"label": "e",
"name": "Duloxetine and Amitriptyline",
"picture": null,
"votes": 260
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "NICE guidance states that more than one neuropathic pain drug should not be prescribed at the same time.",
"id": "10035520",
"label": "d",
"name": "Duloxetine and Pregabalin",
"picture": null,
"votes": 164
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "NICE guidance recommends a choice of amitriptyline, duloxetine, gabapentin or pregabalin alone for patients with painful diabetic neuropathy. This is therefore the only appropriate answer.",
"id": "10035517",
"label": "a",
"name": "Duloxetine",
"picture": null,
"votes": 1400
}
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"name": "Diabetic neuropathy",
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"learningPoint": "Duloxetine is an effective treatment option for managing painful diabetic neuropathy in patients with type 2 diabetes mellitus.",
"likes": 0,
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"question": "A 78-year-old male with a history of uncontrolled type 2 diabetes mellitus has burning pain and tingling in his right foot, which has worsened over the last 6 months. On examination, he has objective loss of pinprick sensation and light touch in the L5 dermatome of the right foot. The patient would like to be prescribed a medication which can help with the pain.\n\nGiven the likely diagnosis, which medication would be most appropriate to commence?",
"sbaAnswer": [
"a"
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173,468,597 | false | 29 | null | 6,495,268 | null | false | [] | null | 19,508 | {
"__typename": "QuestionSBA",
"choices": [
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "This describes a case of acromegaly, with the presence of carpal tunnel syndrome, soft tissue swelling and visual field defects. Acromegaly can cause bitemporal hemianopia as a result of compression of the optic chiasm by the pituitary tumour.",
"id": "10035522",
"label": "a",
"name": "Bitemporal hemianopia",
"picture": null,
"votes": 1661
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is usually due to a lesion involving the temporal lobe optic radiations, rather than a pituitary tumour compressing the optic chiasm as in the case of a pituitary tumour in acromegaly.",
"id": "10035525",
"label": "d",
"name": "Superior homonymous hemianopia",
"picture": null,
"votes": 71
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is loss of vision in a single eye, usually caused by retinal or optic nerve damage.",
"id": "10035523",
"label": "b",
"name": "Monocular anopia",
"picture": null,
"votes": 5
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is due to a lesion of the optic tract or the optic cortex and is normally seen in the case of stroke.",
"id": "10035524",
"label": "c",
"name": "Homonymous hemianopia",
"picture": null,
"votes": 70
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is usually due to a lesion involving the parietal lobe optic radiations, rather than a pituitary tumour compressing the optic chiasm as in the case of a pituitary tumour in acromegaly.",
"id": "10035526",
"label": "e",
"name": "Inferior homonymous hemianopia",
"picture": null,
"votes": 51
}
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"name": "Acromegaly",
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"question": "A 45-year-old male has noticed tingling in the lateral aspect of his right hand and finds he is having difficulty doing up his shirt buttons with his right hand. He also states he has noticed that his shoes no longer fit and he has had to buy a larger size. On examination, his visual fields are found to be abnormal.\n\nGiven the likely diagnosis, what is the most likely visual field defect to be elicited on examination?",
"sbaAnswer": [
"a"
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173,468,598 | false | 30 | null | 6,495,268 | null | false | [] | null | 19,509 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be an appropriate first-line option if the patient was unconscious without IV access.",
"id": "10035529",
"label": "c",
"name": "IM glucogen",
"picture": null,
"votes": 44
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is viscous and hypertonic so it is not recommended for the treatment of hypoglycaemia, unlike 10% or 20% glucose.",
"id": "10035531",
"label": "e",
"name": "IV glucose 50%",
"picture": null,
"votes": 6
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not appropriate as the high fat content of biscuits may delay gastric emptying and they have a lower sugar content than oral glucose gel. They are better given as a snack to provide a form of long-acting carbohydrates in patients once their blood glucose increases above 4mmol/L.",
"id": "10035528",
"label": "b",
"name": "Chocolate biscuits",
"picture": null,
"votes": 180
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be an appropriate first-line option if the patient was unconscious and had IV access.",
"id": "10035530",
"label": "d",
"name": "IV glucose 10%",
"picture": null,
"votes": 37
},
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "In a conscious patient, oral glucose gel is the most appropriate first option to manage hypoglycaemia. If this fails after 3 treatment cycles or 30-45 minutes, then IM glucogen or IV glucose should be considered.",
"id": "10035527",
"label": "a",
"name": "Oral glucose gel",
"picture": null,
"votes": 1591
}
],
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"name": "Hypoglycaemia",
"status": null,
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"learningPoint": "For conscious patients with low blood sugar, using oral glucose gel is the best first step to quickly restore blood sugar levels.",
"likes": 1,
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"question": "A 22-year-old female with type 1 diabetes presents to the GP feeling dizzy, flushed and extremely fatigued. She has recently been diagnosed with type 1 diabetes and is still getting used to her insulin regimen. When she checks her blood sugar, it is 2.6mmol/L (normal fasting range 3.5-5.3 mmol/L).\n\nWhat is the most appropriate initial management?",
"sbaAnswer": [
"a"
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"totalVotes": 1858,
"typeId": 1,
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173,468,599 | false | 31 | null | 6,495,268 | null | false | [] | null | 19,510 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst this may explain increased urinary frequency, the chronic history, lack of dysuria/haematuria and the examination findings suggest a malignant process rather than a simple UTI.",
"id": "10035536",
"label": "e",
"name": "Urine MCS",
"picture": null,
"votes": 6
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not an appropriate option as although LUTS might be common in older patients, they have a variety of causes, some of which are serious. Even if caused by BPH, treatment may be considered. This is especially inappropriate based on the examination findings.",
"id": "10035534",
"label": "c",
"name": "Reassure the patient that these are normal symptoms with age",
"picture": null,
"votes": 1
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "If a patient has a prostate which feels malignant on DRE, they should be referred under the suspected cancer pathway. A PSA should not be performed on a patient who had a DRE on the same day and the patient should be referred based on the examination findings alone.",
"id": "10035532",
"label": "a",
"name": "2-week wait referral under suspected cancer pathway",
"picture": null,
"votes": 1720
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A PSA should not be performed on a patient who had a DRE on the same day and the patient should be referred based on the examination findings alone.",
"id": "10035533",
"label": "b",
"name": "Offer same-day PSA testing",
"picture": null,
"votes": 119
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not an appropriate choice as there is no history of haematuria and the examination findings suggest prostate cancer needs to be ruled out before investigating other urological causes.",
"id": "10035535",
"label": "d",
"name": "Refer for cystoscopy",
"picture": null,
"votes": 7
}
],
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"id": "3755",
"name": "Prostate cancer",
"status": null,
"topic": {
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"id": "143",
"name": "Urology",
"typeId": 7
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"topicId": 143,
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"explanation": null,
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"id": "19510",
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"learningPoint": "When a prostate feels suspicious for cancer on digital rectal exam (DRE), referral under the suspected cancer pathway should be made based on the examination alone, without performing a PSA on the same day, as the DRE findings take precedence",
"likes": 0,
"multiAnswer": null,
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"question": "A 67-year-old male complains of a 6-month history of urinary hesitancy and increased urinary frequency. He states he wakes up approximately 3 times every night to pass urine which he is finding increasingly troublesome. He denies any dysuria or haematuria. On digital rectal examination. a hard, irregular mass is felt on the posterior aspect of his prostate gland.\n\nWhat is the most appropriate management of this patient?",
"sbaAnswer": [
"a"
],
"totalVotes": 1853,
"typeId": 1,
"userPoint": null
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173,468,600 | false | 32 | null | 6,495,268 | null | false | [] | null | 19,511 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is a case of paraphimosis, which is a medical emergency as the blood flow to the glans is compromised. It may require surgical decompression if manual decompression fails or is inappropriate. In this case, it likely occurred as the individual who replaced the catheter forgot to replace the foreskin.",
"id": "10035537",
"label": "a",
"name": "Arrange emergency medical admission",
"picture": null,
"votes": 1699
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is inappropriate as paraphimosis is a medical emergency, given the risk of ischaemia.",
"id": "10035541",
"label": "e",
"name": "Advise this is normal in patients who have long-term catheters",
"picture": null,
"votes": 6
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be useful in the case of bacterial balanitis, which would not present with acute pain or these examination findings.",
"id": "10035539",
"label": "c",
"name": "Prescribe an oral antibiotic",
"picture": null,
"votes": 84
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be useful in the case of fungal balanitis, which would not present with acute pain or these examination findings.",
"id": "10035538",
"label": "b",
"name": "Prescribe a topical antifungal",
"picture": null,
"votes": 29
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is inappropriate as this is a medical emergency, which may require circumcision if surgical decompression is needed.",
"id": "10035540",
"label": "d",
"name": "Non-urgent referral for consideration of circumcision",
"picture": null,
"votes": 26
}
],
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"id": "6138",
"name": "Phimosis and paraphimosis",
"status": null,
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"name": "Urology",
"typeId": 7
},
"topicId": 143,
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"id": "19511",
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"learningPoint": "Paraphimosis is a medical emergency in which the foreskin is retracted behind the glans and cannot be returned to its normal position, leading to swelling and restricted blood flow that can cause pain and serious complications if not treated promptly.",
"likes": 0,
"multiAnswer": null,
"pictures": [],
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"question": "An 87-year-old male has significant acute penile pain. He lives in a care home and has a long-term catheter in situ, which was changed 4 hours ago. His carers report he was otherwise well before this incident and normally his catheter changes occur without any issues. On examination, he has an enlarged glans with a retracted, oedematous foreskin. The patient reports extreme pain on palpation of the glans and foreskin.\n\nWhat is the most appropriate management?",
"sbaAnswer": [
"a"
],
"totalVotes": 1844,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,601 | false | 33 | null | 6,495,268 | null | false | [] | null | 19,512 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This should only be offered if IV paracetamol has inadequate analgesic effect.",
"id": "10035545",
"label": "d",
"name": "Oral tramadol",
"picture": null,
"votes": 90
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "NSAIDs are contraindicated in this patient due to his past medical history of peptic ulcer disease with a previous upper GI bleed.",
"id": "10035543",
"label": "b",
"name": "IM diclofenac",
"picture": null,
"votes": 540
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "NICE recommends offering IV paracetamol rather than oral paracetamol if NSAIDs are contraindicated.",
"id": "10035546",
"label": "e",
"name": "Oral paracetamol",
"picture": null,
"votes": 115
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Whilst NSAIDs are usually recommended as first-line treatment for pain in renal colic, they are contraindicated due to the patient’s past medical history of peptic ulcer disease with a previous upper GI bleed. IV paracetamol is therefore a more appropriate initial analgesic agent to offer.",
"id": "10035542",
"label": "a",
"name": "IV paracetamol",
"picture": null,
"votes": 711
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "NSAIDs are contraindicated in this patient due to his past medical history of peptic ulcer disease with a previous upper GI bleed.",
"id": "10035544",
"label": "c",
"name": "PR diclofenac",
"picture": null,
"votes": 406
}
],
"comments": [],
"concept": {
"__typename": "Concept",
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"__typename": "Chapter",
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"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6139",
"name": "Renal colic",
"status": null,
"topic": {
"__typename": "Topic",
"id": "143",
"name": "Urology",
"typeId": 7
},
"topicId": 143,
"totalCards": null,
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"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 6139,
"conditions": [],
"difficulty": 1,
"dislikes": 9,
"explanation": null,
"highlights": [],
"id": "19512",
"isLikedByMe": 0,
"learningPoint": "In patients with a history of peptic ulcer disease, intravenous paracetamol is a safer analgesic choice for managing renal colic pain.",
"likes": 11,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
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"qaAnswer": null,
"question": "A 67-year-old man has severe abdominal pain. He describes it as 7/10 pain which radiates from his right flank down towards his suprapubic area. The patient also states the last few times he has passed urine, it appeared tinged red. He has a past medical history of COPD and peptic ulcer disease, with a previous upper GI bleed 6 years ago.\n\nWhat is the most appropriate analgesia to offer?",
"sbaAnswer": [
"a"
],
"totalVotes": 1862,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,602 | false | 34 | null | 6,495,268 | null | false | [] | null | 19,513 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This typically presents a few weeks following a streptococcal infection with self resolving haematuria.",
"id": "10035549",
"label": "c",
"name": "Post-streptococcal glomerulonephritis",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This clinical picture is more suggestive of renal damage. Acute liver failure would present with jaundice, ascities, abdominal pain and coagulation disturbance.",
"id": "10035550",
"label": "d",
"name": "Acute liver failure",
"picture": null,
"votes": 92
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Membranous nephropathy causes a nephrotic syndrome and can be triggered by medications such as gold and penicillamine but tends to present less acutely with symptoms of proteinuria and peripheral oedema.",
"id": "10035551",
"label": "e",
"name": "Membranous nephropathy",
"picture": null,
"votes": 26
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is another cause of intrinsic renal AKI, which can also be triggered by medications. However, antifreeze consumption is more likely to cause an acute tubular necrosis picture and acute interstitial nephritis would present with a triad of fever, rash and eosinophilia.",
"id": "10035548",
"label": "b",
"name": "Acute interstitial nephritis",
"picture": null,
"votes": 260
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. This is suggestive of a diagnosis of acute kidney injury secondary to acute tubular necrosis which is an intrinsic cause of AKI, whereby ethylene glycol in antifreeze directly damages the cells in the renal tubules.",
"id": "10035547",
"label": "a",
"name": "Acute tubular necrosis.",
"picture": null,
"votes": 1475
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": null,
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},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6140",
"name": "Acute Tubular Necrosis",
"status": null,
"topic": {
"__typename": "Topic",
"id": "142",
"name": "Nephrology",
"typeId": 7
},
"topicId": 142,
"totalCards": null,
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"userNote": null,
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},
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"conditions": [],
"difficulty": 1,
"dislikes": 1,
"explanation": null,
"highlights": [],
"id": "19513",
"isLikedByMe": 0,
"learningPoint": "Acute tubular necrosis can occur following exposure to nephrotoxins, such as ethylene glycol, leading to acute kidney injury and anuria.",
"likes": 1,
"multiAnswer": null,
"pictures": [],
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"presentations": [],
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"question": "A 5-year-old boy is brought to the emergency department after accidentally drinking a significant amount of antifreeze which he mistook for a soft drink. He appears significantly dehydrated and is hypotensive on examination. He is anuric for 6 hours.\n\nWhat is the most likely diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 1853,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,603 | false | 35 | null | 6,495,268 | null | false | [] | null | 19,514 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Malignancy within the bladder may present as painless/ painful haematuria, however, the acuity of the symptoms and the fact that the bladder is not a common site for metastases for NHL render this less likely ( common sites include head and neck and GI tract).",
"id": "10035556",
"label": "e",
"name": "Bladder metastases",
"picture": null,
"votes": 50
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. Cyclophosphamide is well documented to cause hemorrhagic cystitis whereby symptoms of haematuria, and dysuria may occur immediately or years after treatment and persist despite discontinuation.",
"id": "10035552",
"label": "a",
"name": "Cyclophosphamide",
"picture": null,
"votes": 1295
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may cause haematuria, but it is likely to occur immediately post-catheterisation as opposed to 3 days later.",
"id": "10035553",
"label": "b",
"name": "Traumatic catheterisation",
"picture": null,
"votes": 101
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Side effects associated with ciclosporin are more commonly: gingival hyperplasia, hypertension, increased hair growth and peripheral neuropathy. Haematuria is not common.",
"id": "10035555",
"label": "d",
"name": "Ciclosporin",
"picture": null,
"votes": 384
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Renal TB may cause haematuria and treatment with rifampicin may cause red urine, however, the absence of any other general symptoms of infection or TB such as fever, cough, dyspnoea, night sweats etc render this less likely.",
"id": "10035554",
"label": "c",
"name": "Opportunistic TB infection",
"picture": null,
"votes": 17
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": null,
"files": null,
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"id": "2693",
"pictures": [],
"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6141",
"name": "Haematuria",
"status": null,
"topic": {
"__typename": "Topic",
"id": "142",
"name": "Nephrology",
"typeId": 7
},
"topicId": 142,
"totalCards": null,
"typeId": null,
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},
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"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "19514",
"isLikedByMe": 0,
"learningPoint": "Cyclophosphamide, a chemotherapy drug, can cause hemorrhagic cystitis, which typically presents with dysuria and haematuria shortly after starting treatment.",
"likes": 2,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
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"qaAnswer": null,
"question": "A 64-year-old gentleman has recently been diagnosed with Hodgkin’s Lymphoma following lymphadenopathy and weight loss. He was admitted to the oncology ward, catheterised, and commenced on cyclophosphamide and cyclosporin. 3 days later, he complains of dysuria and a nurse notices frank haematuria in his catheter bag.\n\nWhich of the following is the most likely cause of the patient’s haematuria?",
"sbaAnswer": [
"a"
],
"totalVotes": 1847,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,604 | false | 36 | null | 6,495,268 | null | false | [] | null | 19,515 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "NSAIDs should be avoided in such poor renal function and AKI, colchicine is recommended to be avoided in extremely low gfr (<10).",
"id": "10035559",
"label": "c",
"name": "Administer NSAIDs and colchicine",
"picture": null,
"votes": 403
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "NSAIDs should be avoided in such poor renal function and AKI. IVF will undoubtedly form part of the initial management of this patient but he needs acute dialysis.",
"id": "10035561",
"label": "e",
"name": "Administer NSAIDs and intravenous fluids",
"picture": null,
"votes": 353
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. This patient has an acute kidney injury with features of pericarditis and encephalopathy, likely in the context of uraemia. He therefore needs acute dialysis. Other indications include refractory hyperkalaemia, acidosis, overload or toxin ingestion.",
"id": "10035557",
"label": "a",
"name": "Refer for haemodialysis",
"picture": null,
"votes": 1026
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "There is no evidence of a Myocardial infarction at present. The ECG findings suggest pericarditis.",
"id": "10035558",
"label": "b",
"name": "Refer for PCI",
"picture": null,
"votes": 64
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is inappropriate as the patient is very unwell with uraemic pericarditis and encephalopathy.",
"id": "10035560",
"label": "d",
"name": "Discharge with paracetamol",
"picture": null,
"votes": 6
}
],
"comments": [],
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"__typename": "Concept",
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"__typename": "Chapter",
"explanation": null,
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"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6142",
"name": "Emergency management of Acute Kidney Injury (AKI)",
"status": null,
"topic": {
"__typename": "Topic",
"id": "142",
"name": "Nephrology",
"typeId": 7
},
"topicId": 142,
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},
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"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "19515",
"isLikedByMe": 0,
"learningPoint": "Indications for acute dialysis include severe electrolyte imbalances, acute kidney failure with significant fluid overload, uremic symptoms (such as encephalopathy or pericarditis), and poisoning or drug overdose that cannot be managed with other treatments.",
"likes": 6,
"multiAnswer": null,
"pictures": [],
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"qaAnswer": null,
"question": "A 35-year-old attends the emergency department with central chest pain, weakness and lethargy. It is difficult to elicit a history as he is confused. ECG shows widespread saddle-shaped ST elevation and PR depression. Troponin is raised. Urea and electrolytes reveal an eGFR of 8 mmol (>90), a creatinine of 300μmol (59 - 104) and urea of 26mmol (2.5-7.8)\n\nWhat is the most appropriate management?",
"sbaAnswer": [
"a"
],
"totalVotes": 1852,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,605 | false | 37 | null | 6,495,268 | null | false | [] | null | 19,516 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Chlorhexidine mouthwash is useful in a variety of conditions such as ulcers, mucositis and following oral surgery. This option however does not appreciate the urgency of the situation and the need for an HIV specialist.",
"id": "10035565",
"label": "d",
"name": "Commence chlorhexidine mouthwash with topical analgesia",
"picture": null,
"votes": 320
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is very inappropriate given the patient's symptoms, concerns and history.",
"id": "10035566",
"label": "e",
"name": "Discharge and advise improvement in dental hygiene",
"picture": null,
"votes": 33
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Nystatin may be used in oral candidiasis (thrush) where we would expect white patches on gums, tongue and inside the mouth that can be peeled off leaving a raw area. Oesophageal candidiasis can occur in HIV as well but we would expect odynophagia and sometimes dysphagia.",
"id": "10035563",
"label": "b",
"name": "Commence Nystatin suspension",
"picture": null,
"votes": 440
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. The patient is presenting with oral hairy leukoplakia, an EBV infection of the tongue, suggestive of advanced immunocompromise likely on the background of HIV and ulcerative colitis here. This can be an AIDS-defining illness and he needs to be rapidly assessed by an HIV specialist.",
"id": "10035562",
"label": "a",
"name": "Refer to secondary care",
"picture": null,
"votes": 1056
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Antiretrovirals must never be stopped, started or withheld by anyone other than an HIV specialist. In addition, we do not know if the patient is established on them in this case.",
"id": "10035564",
"label": "c",
"name": "Stop the patient’s antiretrovirals",
"picture": null,
"votes": 7
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": null,
"files": null,
"highlights": [],
"id": "2693",
"pictures": [],
"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6143",
"name": "Oral lesions",
"status": null,
"topic": {
"__typename": "Topic",
"id": "136",
"name": "Gastroenterology",
"typeId": 7
},
"topicId": 136,
"totalCards": null,
"typeId": null,
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"userNote": null,
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},
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"conditions": [],
"difficulty": 1,
"dislikes": 2,
"explanation": null,
"highlights": [],
"id": "19516",
"isLikedByMe": 0,
"learningPoint": "Oral hairy leukoplakia, often associated with HIV, requires urgent referral to secondary care for assessment and management.",
"likes": 4,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 48-year-old man comes to the GP concerned about a white patch on the side of his tongue that he is not able to rub off. His past medical history consists of ulcerative colitis, hypertension and HIV.\n\nWhat is the most appropriate management?",
"sbaAnswer": [
"a"
],
"totalVotes": 1856,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,606 | false | 38 | null | 6,495,268 | null | false | [] | null | 19,517 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This normally develops after longstanding GORD which is not described and predisposes to malignancy.",
"id": "10035570",
"label": "d",
"name": "Barrett's oesophagus",
"picture": null,
"votes": 33
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. The patient is presenting with signs and symptoms of oesophageal cancer and his smoking and alcohol history further increase the risk of squamous cell carcinoma.",
"id": "10035567",
"label": "a",
"name": "Oesophageal squamous cell carcinoma",
"picture": null,
"votes": 1033
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not in keeping with the clinical context with no heartburn, indigestion, belching or acid reflux.",
"id": "10035571",
"label": "e",
"name": "Gastro-oesophageal reflux disease",
"picture": null,
"votes": 2
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The progressive dysphagia, age and history are more in keeping with malignancy as opposed to achalasia which is dysphagia to solids and liquids from its onset with sputtering and regurgitation of food which are not described.",
"id": "10035569",
"label": "c",
"name": "Achalasia",
"picture": null,
"votes": 4
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The patient is presenting with signs and symptoms of oesophageal cancer, however adenocarcinoma tends to be associated with longstanding reflux/GORD. Smoking is very strongly associated with squamous cell carcinoma, as is chronic alcohol abuse.",
"id": "10035568",
"label": "b",
"name": "Oesophageal adenocarcinoma",
"picture": null,
"votes": 782
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "naughty\n",
"createdAt": 1737479878,
"dislikes": 0,
"id": "61156",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 19517,
"replies": [],
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"__typename": "User",
"accessLevel": "subscriber",
"displayName": "a1 ramzy",
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"demo": null,
"entitlement": null,
"id": "3985",
"name": "Oesophageal carcinoma",
"status": null,
"topic": {
"__typename": "Topic",
"id": "136",
"name": "Gastroenterology",
"typeId": 7
},
"topicId": 136,
"totalCards": null,
"typeId": null,
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"conditions": [],
"difficulty": 1,
"dislikes": 11,
"explanation": null,
"highlights": [],
"id": "19517",
"isLikedByMe": 0,
"learningPoint": "Oesophageal squamous cell carcinoma is associated with risk factors such as smoking and alcohol consumption, presenting with dysphagia and weight loss.",
"likes": 3,
"multiAnswer": null,
"pictures": [],
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"psaSectionId": null,
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"question": "A 68-year-old man attends the GP practice with a 3-month history of progressive dysphagia and weight loss. He has smoked 20 cigarettes a day for the last 32 years, and used to suffer from alcoholism.\n\nWhat is the most likely diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 1854,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,607 | false | 39 | null | 6,495,268 | null | false | [] | null | 19,518 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This presentation does not appear cardiac in origin.",
"id": "10035576",
"label": "e",
"name": "Urgent two-week wait referral to cardiology",
"picture": null,
"votes": 10
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a recommendation in general practice for the treatment of possible peptic ulcer, however, the priority here is to exclude an upper GI malignancy.",
"id": "10035573",
"label": "b",
"name": "Advise 8-week trial of oral PPI",
"picture": null,
"votes": 175
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. NICE recommends anyone with dysphagia requires urgent assessment to exclude upper GI malignancy.",
"id": "10035572",
"label": "a",
"name": "Urgent two-week wait referral to gastro-enterology",
"picture": null,
"votes": 1456
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a recommendation in general practice for the treatment of possible peptic ulcer, however, the priority here is to exclude an upper GI malignancy.",
"id": "10035574",
"label": "c",
"name": "Test and treat for H.Pylori",
"picture": null,
"votes": 184
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Lifestyle measures such as weight loss and avoiding certain foods may be helpful in dyspepsia but this does not address his dysphagia, which is a red flag symptom for upper GI malignancy.",
"id": "10035575",
"label": "d",
"name": "Reassure and advise lifestyle measures",
"picture": null,
"votes": 23
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": null,
"files": null,
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"id": "2693",
"pictures": [],
"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6144",
"name": "Dysphagia",
"status": null,
"topic": {
"__typename": "Topic",
"id": "136",
"name": "Gastroenterology",
"typeId": 7
},
"topicId": 136,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 6144,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "19518",
"isLikedByMe": 0,
"learningPoint": "Dysphagia warrants urgent referral to gastroenterology to rule out potential upper gastrointestinal malignancy, as per NICE guidelines.",
"likes": 1,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 48-year-old man attends the GP due to troublesome reflux, heartburn and difficulty swallowing for the last three months.\n\nWhat is the most appropriate management?",
"sbaAnswer": [
"a"
],
"totalVotes": 1848,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,608 | false | 40 | null | 6,495,268 | null | false | [] | null | 19,519 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The vignette does mention an alcohol history in this case. This should however be explored. Alcohol abuse would not explain the respiratory symptoms.",
"id": "10035579",
"label": "c",
"name": "Alcoholic cirrhosis",
"picture": null,
"votes": 67
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a disorder of sleep breathing in obese patients which results in daytime hypercapnia and is associated with obstructive sleep apnoea. It would not produce the liver or respiratory findings in this case.",
"id": "10035580",
"label": "d",
"name": "Obesity hypoventilation syndrome",
"picture": null,
"votes": 16
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. The patient has features of chronic liver disease and respiratory symptoms in keeping with obstructive pulmonary disease. The combination in a young non-smoker is typical of alpha 1 anti-trypsin deficiency.",
"id": "10035577",
"label": "a",
"name": "Alpha-1 Antitrypsin Deficiency",
"picture": null,
"votes": 1277
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Chronic myeloid leukaemia may result in hepatomegaly and recurrent respiratory infections. However, it does not explain the other symptoms of chronic liver disease and the patient describes no other symptoms of chronic myeloid leukaemia e.g. pallor, fatigue, easy bleeding and bruising.",
"id": "10035581",
"label": "e",
"name": "Chronic myeloid leukaemia",
"picture": null,
"votes": 9
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may cause chronic liver disease, with obesity commonly predisposing. The patient is however quite young to develop non-alcoholic fatty liver disease and it does not explain the respiratory symptoms.",
"id": "10035578",
"label": "b",
"name": "Non-alcoholic fatty liver disease",
"picture": null,
"votes": 475
}
],
"comments": [],
"concept": {
"__typename": "Concept",
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},
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"demo": null,
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"id": "4593",
"name": "Alpha-1 Antitrypsin Deficiency",
"status": null,
"topic": {
"__typename": "Topic",
"id": "136",
"name": "Gastroenterology",
"typeId": 7
},
"topicId": 136,
"totalCards": null,
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"userChapter": null,
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},
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"conditions": [],
"difficulty": 1,
"dislikes": 3,
"explanation": null,
"highlights": [],
"id": "19519",
"isLikedByMe": 0,
"learningPoint": "Alpha-1 Antitrypsin Deficiency can present with liver disease and respiratory symptoms, particularly in young, non-smoking individuals.",
"likes": 3,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
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"qaAnswer": null,
"question": "A 35-year-old man attends the GP due to skin yellowing. On examination, he has hepatomegaly with jaundiced skin and spider naevi. He reports troublesome cough, breathlessness and wheezing over the last year. He is not a smoker and is obese.\n\nWhat is the most likely underlying diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 1844,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,609 | false | 41 | null | 6,495,268 | null | false | [] | null | 19,520 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is typically delayed until all symptoms have resolved and ERCP has confirmed that the bile duct is clear of gallstones.",
"id": "10035583",
"label": "b",
"name": "Cholecystectomy",
"picture": null,
"votes": 252
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. The patient has features of ascending cholangitis with Charcot's triad of fever, jaundice and right upper quadrant pain. She has presented in shock and will likely require biliary drainage via ERCP alongside IV antibiotics.",
"id": "10035582",
"label": "a",
"name": "Endoscopic retrograde cholangiopancreatography",
"picture": null,
"votes": 1420
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may be required as cases of ascending cholangitis are associated with high morbidity and mortality but the priority is in providing relief of biliary obstruction.",
"id": "10035585",
"label": "d",
"name": "Admit to the intensive care unit",
"picture": null,
"votes": 78
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is inappropriate as the patient is extremely unwell and requires intravenous antibiotics and relief of biliary obstruction.",
"id": "10035586",
"label": "e",
"name": "Reassurance and discharge with oral antibiotics",
"picture": null,
"votes": 5
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The preferred approach is endoscopic as opposed to surgical.",
"id": "10035584",
"label": "c",
"name": "Urgent laparotomy",
"picture": null,
"votes": 82
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": null,
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"id": "2693",
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"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "4652",
"name": "Ascending cholangitis",
"status": null,
"topic": {
"__typename": "Topic",
"id": "136",
"name": "Gastroenterology",
"typeId": 7
},
"topicId": 136,
"totalCards": null,
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},
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"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "19520",
"isLikedByMe": 0,
"learningPoint": "Emergency endoscopic retrograde cholangiopancreatography (within 24 hours) is needed for adults with common bile duct stones and acute cholangitis or acute pancreatitis when indicated",
"likes": 1,
"multiAnswer": null,
"pictures": [],
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"psaSectionId": null,
"qaAnswer": null,
"question": "A 47-year-old woman attends the emergency department with severe right upper abdominal pain. She is hypotensive, tachycardic, jaundiced and febrile on examination. She is fluid resuscitated and initiated on intravenous antibiotics.\n\nWhat is the most appropriate management?",
"sbaAnswer": [
"a"
],
"totalVotes": 1837,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,610 | false | 42 | null | 6,495,268 | null | false | [] | null | 19,521 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Seizures may be seen in cases of brain tumours but are not common in cases of idiopathic intracranial hypertension.",
"id": "10035589",
"label": "c",
"name": "Generalised tonic-clonic seizures",
"picture": null,
"votes": 179
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is more suggestive of a gynaecological pathology or antiphospholipid syndrome.",
"id": "10035588",
"label": "b",
"name": "Recurrent miscarriages",
"picture": null,
"votes": 293
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This finding is not in keeping with a diagnosis of idiopathic intracranial hypertension. Anosmia can be associated with infections and congenital causes.",
"id": "10035590",
"label": "d",
"name": "Loss of sense of smell",
"picture": null,
"votes": 393
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. The patient is presenting with signs and symptoms of idiopathic intracranial hypertension, with a space-occupying lesion excluded. The biggest risk factors for this condition are obesity and the use of tetracyclines, common in the treatment of acne.",
"id": "10035587",
"label": "a",
"name": "Poorly controlled acne vulgaris",
"picture": null,
"votes": 677
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not in keeping with the clinical story with persistent daily headaches and features of focal neurology described as opposed to nasal congestion and discharge and short-lived episodes of intense agony.",
"id": "10035591",
"label": "e",
"name": "Cluster headaches",
"picture": null,
"votes": 302
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Got this question correct for the wrong reasons:( Assumed her raised ICP was due to obesity secondary to PCOS, which patient would likely also have acne due to PCOS",
"createdAt": 1734705943,
"dislikes": 0,
"id": "58651",
"isLikedByMe": 0,
"likes": 8,
"parentId": null,
"questionId": 19521,
"replies": [
{
"__typename": "QuestionComment",
"comment": "dw i thought the same hahah but a win is still a win ",
"createdAt": 1736003110,
"dislikes": 0,
"id": "59641",
"isLikedByMe": 0,
"likes": 1,
"parentId": 58651,
"questionId": 19521,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Axillary RNA",
"id": 31002
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Loose Lung",
"id": 3972
}
}
],
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"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
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"id": "2693",
"pictures": [],
"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6145",
"name": "Idiopathic Intracranial Hypertension",
"status": null,
"topic": {
"__typename": "Topic",
"id": "141",
"name": "Neurology",
"typeId": 7
},
"topicId": 141,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
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},
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"conditions": [],
"difficulty": 1,
"dislikes": 18,
"explanation": null,
"highlights": [],
"id": "19521",
"isLikedByMe": 0,
"learningPoint": "Tetracyclines, especially doxycycline, are associated with an increased risk of idiopathic intracranial hypertension (IIH), which can cause symptoms like headaches and vision changes, and other risk factors include obesity, certain medications, medical conditions like PCOS, and hormonal changes,",
"likes": 10,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 24-year-old obese woman comes to the GP describing a 4-month history of right-sided headaches and blurry vision, worst in the morning.\n\nFundoscopy reveals bilateral papilloedema and a CT Head is reported as normal.\n\nWhich of the following is most likely to be present in her past medical history?",
"sbaAnswer": [
"a"
],
"totalVotes": 1844,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,611 | false | 43 | null | 6,495,268 | null | false | [] | null | 19,522 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Guillan-Barre typically presents with an ascending weakness and paralysis following viral infection, neither of which is described here.",
"id": "10035596",
"label": "e",
"name": "Guillan-Barre syndrome",
"picture": null,
"votes": 26
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. The patient is presenting with signs and symptoms of multiple sclerosis with multiple demyelinating lesions in space and time. The story is in keeping with Uthoff's phenomenon where symptoms worsen in the heat, i.e. during exercising.",
"id": "10035592",
"label": "a",
"name": "Multiple sclerosis",
"picture": null,
"votes": 1400
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Syringomyelia tends to present with loss of pain and temperature sensation, weakness and reflex changes due to damage to the spinothalamic tract. Symptoms vary depending on where the syrinx occurs but are more likely to affect the upper extremities. Syringomyelia would cause a progressively worsening clinical history as opposed to distinct events.",
"id": "10035594",
"label": "c",
"name": "Syringomyelia",
"picture": null,
"votes": 117
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not in keeping with the vignette with no mention of fatigability, eye drooping, or muscle weakness. The incidences appear distinct in time correlating with different lesions in the nervous system more in keeping with multiple sclerosis as opposed to continuously present as would be expected in myasthenia gravis.",
"id": "10035593",
"label": "b",
"name": "Myasthenia Gravis",
"picture": null,
"votes": 188
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This tends to present with bilateral numbness, neck stiffness, and loss of manual dexterity in hands generally in older patients. It would not explain the leg weakness here.",
"id": "10035595",
"label": "d",
"name": "Degenerative cervical myelopathy",
"picture": null,
"votes": 111
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "ok but the symptoms post workout made it sound like myasthenia",
"createdAt": 1736548534,
"dislikes": 2,
"id": "60224",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 19522,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Kawasaki Metabolism",
"id": 15904
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": null,
"files": null,
"highlights": [],
"id": "2693",
"pictures": [],
"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "3745",
"name": "Multiple Sclerosis",
"status": null,
"topic": {
"__typename": "Topic",
"id": "141",
"name": "Neurology",
"typeId": 7
},
"topicId": 141,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
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},
"conceptId": 3745,
"conditions": [],
"difficulty": 1,
"dislikes": 4,
"explanation": null,
"highlights": [],
"id": "19522",
"isLikedByMe": 0,
"learningPoint": "Multiple sclerosis can present with transient neurological symptoms, often exacerbated by heat, as seen in Uthoff's phenomenon.",
"likes": 1,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 29-year-old woman comes to the GP describing two separate instances over the last few months of pins and needles in her left arm and right leg, respectively. She says both of these episodes came on shortly after a gym workout and lasted a few days. In addition, she also experienced weakness in her left leg for almost a day, two weeks ago.\n\nWhat is the most likely diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 1842,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,612 | false | 44 | null | 6,495,268 | null | false | [] | null | 19,523 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would result in anaphylaxis which would likely worsen the clinical picture.",
"id": "10035598",
"label": "b",
"name": "Arrange urgent hospital transfer and administer IM Benzylpenicillin",
"picture": null,
"votes": 186
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not appropriate as bacterial meningitis with septicaemia is a life-threatening emergency. It is to be managed in an inpatient setting.",
"id": "10035600",
"label": "d",
"name": "Arrange assessment in ID clinic within 24 hours",
"picture": null,
"votes": 7
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not appropriate as bacterial meningitis with septicaemia is a life-threatening emergency. This may be advice given in some new suspected cases of TIA.",
"id": "10035599",
"label": "c",
"name": "Arrange assessment in the neurology clinic within 24 hours",
"picture": null,
"votes": 7
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Oral therapy has no role in meningitis, especially not in septicaemia. This advice is dangerous and not appropriate as this is an emergency.",
"id": "10035601",
"label": "e",
"name": "Prescribe 7 days of oral ceftriaxone and re-book appointment for next week",
"picture": null,
"votes": 24
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. The patient is presenting with signs and symptoms of bacterial meningitis with meningococcal septicaemia, a neurological emergency which requires ambulance transport to the nearest hospital. As he is allergic to penicillin, benzylpenicillin is not appropriate. IM Cefotaxime may be administered in GP based on local availability.",
"id": "10035597",
"label": "a",
"name": "Arrange urgent hospital transfer",
"picture": null,
"votes": 1617
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": null,
"files": null,
"highlights": [],
"id": "2693",
"pictures": [],
"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "3751",
"name": "Meningitis",
"status": null,
"topic": {
"__typename": "Topic",
"id": "141",
"name": "Neurology",
"typeId": 7
},
"topicId": 141,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3751,
"conditions": [],
"difficulty": 1,
"dislikes": 4,
"explanation": null,
"highlights": [],
"id": "19523",
"isLikedByMe": 0,
"learningPoint": "Non-blanching rash, fever, and headache in a young adult may indicate meningococcal septicaemia, requiring urgent hospital transfer for immediate treatment.",
"likes": 0,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "An 18-year-old university student comes to the GP with a headache, fever and non-blanching rash. He is truly penicillin allergic.\n\nWhat is the most appropriate course of action?",
"sbaAnswer": [
"a"
],
"totalVotes": 1841,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,613 | false | 45 | null | 6,495,268 | null | false | [] | null | 19,524 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. The patient is presenting with regular narrow complex tachycardia with adverse features, i.e. signs and symptoms of myocardial ischaemia, she therefore urgently requires DC Cardioversion.",
"id": "10035602",
"label": "a",
"name": "Arrange urgent DC Cardioversion",
"picture": null,
"votes": 240
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not appropriate as this is used in broad complex tachycardias. In addition, the patient has adverse features.",
"id": "10035605",
"label": "d",
"name": "Administer 300mg amiodarone",
"picture": null,
"votes": 54
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be the correct second-line approach in the absence of adverse features.",
"id": "10035604",
"label": "c",
"name": "Administer 6mg Adenosine",
"picture": null,
"votes": 102
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be the correct first-line approach to acute narrow complex tachycardias in the absence of adverse features.",
"id": "10035603",
"label": "b",
"name": "Attempt vagal manoeuvres",
"picture": null,
"votes": 541
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The priority is proceeding down the advanced life support tachycardia algorithm, normalising the rate and then subsequently the patient will require a PCI.",
"id": "10035606",
"label": "e",
"name": "Urgent PCI",
"picture": null,
"votes": 906
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "From LITFL:\nNew LBBB in the context of chest pain was once considered a “STEMI-equivalent” and part of the criteria for thrombolysis. However, more up-to-date data suggests that chest pain patients with new LBBB have little increased risk of acute myocardial infarction at the time of presentation.",
"createdAt": 1719238472,
"dislikes": 0,
"id": "53698",
"isLikedByMe": 0,
"likes": 5,
"parentId": null,
"questionId": 19524,
"replies": [
{
"__typename": "QuestionComment",
"comment": "Would be appropriate to have their troponin",
"createdAt": 1737291354,
"dislikes": 0,
"id": "60973",
"isLikedByMe": 0,
"likes": 0,
"parentId": 53698,
"questionId": 19524,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Neutrophillia",
"id": 10669
}
}
],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Serotonin Migraine",
"id": 17304
}
}
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"__typename": "Concept",
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"__typename": "Chapter",
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"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "5886",
"name": "Acute narrow complex tachycardias",
"status": null,
"topic": {
"__typename": "Topic",
"id": "134",
"name": "Cardiology",
"typeId": 7
},
"topicId": 134,
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"userChapter": null,
"userNote": null,
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"conditions": [],
"difficulty": 1,
"dislikes": 31,
"explanation": null,
"highlights": [],
"id": "19524",
"isLikedByMe": 0,
"learningPoint": "In patients with narrow complex tachycardia and signs of myocardial ischaemia, urgent direct current cardioversion is often necessary.",
"likes": 16,
"multiAnswer": null,
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"question": "A 73-year-old woman is admitted to the hospital with palpitations and new onset chest pain. She is normotensive and tachycardic on examination. An ECG demonstrates a narrow complex tachycardia of 150 with a new left bundle branch block in the inferior leads. An initial troponin I is 1200.\n\nWhat is the most appropriate initial course of action?",
"sbaAnswer": [
"a"
],
"totalVotes": 1843,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,614 | false | 46 | null | 6,495,268 | null | false | [] | null | 19,525 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. The patient is presenting with signs and symptoms of metastatic spinal cord compression, an emergency which requires immobilisation, urgent high-dose steroids to limit oedema and urgent spinal imaging to characterise the level and nature of compression.",
"id": "10035607",
"label": "a",
"name": "Immobilise the patient and administer 16mg of dexamethasone",
"picture": null,
"votes": 1347
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would certainly form part of managing this patient but is not the initial priority in the emergency department.",
"id": "10035608",
"label": "b",
"name": "Arrange urgent oncology review",
"picture": null,
"votes": 28
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A whole spine MRI is required urgently within 24 hours to assess for spinal cord compression and to characterise the levels of compression.",
"id": "10035611",
"label": "e",
"name": "Request an emergency lumbar spine MRI",
"picture": null,
"votes": 284
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Surgical options would likely be discussed in a multidisciplinary setting once imaging has characterised any spinal lesions.",
"id": "10035609",
"label": "c",
"name": "Arrange urgent spinal surgical review",
"picture": null,
"votes": 82
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not appropriate as patients with suspected cord compression must be immobilised to stabilise the spinal column after possible injury and thus prevent further spinal cord damage.",
"id": "10035610",
"label": "d",
"name": "Encourage mobilisation and administer 8mg dexamethasone",
"picture": null,
"votes": 96
}
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"question": "A 58-year-old gentleman is brought into the emergency department by ambulance after losing the ability to walk over the last few days. He describes severe lower back pain, incontinence and profound leg weakness bilaterally. On examination, power in his legs is MRC Grade 1/5 bilaterally. He is known to have renal cell carcinoma and is undergoing chemotherapy.\n\nWhat is the most appropriate initial course of action?",
"sbaAnswer": [
"a"
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173,468,615 | false | 47 | null | 6,495,268 | null | false | [] | null | 19,526 | {
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"answer": false,
"explanation": "This may be required in advanced refractory cases but is not immediately indicated at present. Indications for acute dialysis include refractory hyperkalaemia, fluid overload, toxin ingestion, and uraemia.",
"id": "10035613",
"label": "b",
"name": "Arrange urgent haemodialysis",
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is likely to form part of the initial management of his hyperkalaemia but the priority is protecting the heart and administering plenty of fluids to improve the AKI and rhabdomyolysis.",
"id": "10035616",
"label": "e",
"name": "Administer insulin dextrose",
"picture": null,
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},
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. The patient is presenting with signs and symptoms of rhabdomyolysis as suggested by a long lie, hypocalcaemia and severe stage 3 acute kidney injury due to the release of myoglobin from dying muscle cells. Calcium gluconate protects the heart and stabilises the myocardium given the hyperkalaemia.",
"id": "10035612",
"label": "a",
"name": "Aggressive fluid resuscitation and calcium gluconate",
"picture": null,
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"explanation": "This may play a part later on in optimising AEDs to reduce the frequency of seizures (and possible subsequent long lies).",
"id": "10035614",
"label": "c",
"name": "Arrange urgent nephrology review",
"picture": null,
"votes": 22
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"__typename": "QuestionChoice",
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"explanation": "This is not appropriate as this patient is very unwell with a stage 3 AKI and severe hyperkalaemia and he could go into cardiac arrest without appropriate treatment.",
"id": "10035615",
"label": "d",
"name": "Discharge with outpatient nephrology review",
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"question": "A 28-year-old gentleman with poorly controlled epilepsy is brought into hospital by his family following a collapse at home. He was previously last seen by his neighbour a day ago.\n\nBloods demonstrate a Sodium of 134mmol (135-145), K 6.9mmol (3.5-5.2), Urea 19mmol (1.8-7), Creatinine 630μmol (59 - 104) and an adjusted calcium of 1.84mmol (2.2-2.6).\n\nWhat is the most appropriate initial course of action?",
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"a"
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"explanation": "This should be avoided as the patient is on methotrexate. Combining trimethoprim and methotrexate increases the risk of haematological side effects (sometimes fatal).",
"id": "10035619",
"label": "c",
"name": "Trimethoprim for 3 days",
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"explanation": "In men, the recommended treatment is 7 days of oral nitrofurantoin. In non-pregnant women, the duration is a 3-day course.",
"id": "10035618",
"label": "b",
"name": "Nitrofurantoin for 3 days",
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"explanation": "This is not needed at present with no concerning features. This can safely be managed in the community.",
"id": "10035621",
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"explanation": "This should be avoided as the patient is on methotrexate. Combining trimethoprim and methotrexate increases the risk of haematological side effects (sometimes fatal).",
"id": "10035620",
"label": "d",
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"answer": true,
"explanation": "This is correct. The patient is presenting with signs and symptoms of urinary tract infection. In men, the recommended treatment is 7 days of oral nitrofurantoin, trimethoprim or amoxicillin.",
"id": "10035617",
"label": "a",
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"question": "A 47-year-old gentleman attends the GP with burning pain on urination and an increased frequency of urination for the last two days. Urine dip is strongly positive for leucocytes and nitrites. He has rheumatoid arthritis and takes methotrexate.\n\nWhat is the most appropriate course of action?",
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"a"
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173,468,617 | false | 49 | null | 6,495,268 | null | false | [] | null | 19,846 | {
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"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "The vignette suggests a diagnosis of hypertrophic cardiomyopathy and chest X-ray does not play any role in its diagnosis.",
"id": "10037215",
"label": "d",
"name": "Chest X-ray",
"picture": null,
"votes": 64
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"__typename": "QuestionChoice",
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"explanation": "Myocardial scintigraphy is used to diagnose coronary artery disease (CAD). The purpose of myocardial scintigraphy is to detect myocardial ischaemia. It does not play any role in diagnosing HOCM.",
"id": "10037216",
"label": "e",
"name": "Myocardial Scintography",
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"__typename": "QuestionChoice",
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"explanation": "Holter monitoring is an important investigation that is warranted when arrhythmia is suspected but it cannot confirm the diagnosis of HOCM.",
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"explanation": "ECG would be the first line of investigation in the aforementioned scenario and even though there are ECG changes associated with HOCM such as septal Q waves (deep narrow dagger-like Q waves seen in lateral and inferior leads), it cannot confirm the given diagnosis and further investigation is imperative.",
"id": "10037214",
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"id": "10037212",
"label": "a",
"name": "Cardiac MRI",
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}
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{
"__typename": "QuestionComment",
"comment": "how can we rule out wolff parkinson white from the question stem?",
"createdAt": 1720261983,
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"comment": "WPW is usually not inherited, family history is more relevant for HOCM",
"createdAt": 1731625287,
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"comment": "The fact that they put MRI there instead of echo really made me second guess myself... ",
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"comment": "In clinical practice, you would do an echocardiogram ",
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"comment": "Why not ARVC or brugada syndrome, is it that HOCM is the most common and therefor more likely? ",
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"__typename": "QuestionComment",
"comment": "and the positive family history",
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"explanation": "# Summary\r\n\r\nHypertrophic cardiomyopathy (HCM) is an autosomal dominant condition characterised by left ventricular hypertrophy without an apparent cause. It is a common inherited cardiac condition and a significant cause of sudden cardiac death in young adults. HCM is attributed to mutations in genes encoding sarcomere proteins leading to chaotic and disorganized myocytes. HCM may be asymptomatic but can also lead to exertional syncope, dyspnoea, chest pain and heart failure. Definitive diagnosis is made via echocardiogram. Management involves lifestyle modifications, medication for symptom control, surgical or interventional procedures for severe cases, and consideration of implantable cardioverter-defibrillators in those at risk of sudden cardiac death. Prognosis varies, with an annual mortality rate of 1.1%, and a 20-year survival rate estimated at 81% after diagnosis.\r\n\r\n# Definition \r\n\r\nHypetrophic cardiomyopathy (HCM) is an autosomal dominant condition characterised by asymmetrical septal hypertrophy leading to left ventricular hypetrophy and diastolic dysfunction in the absence of an obvious cause (e.g. hypertension). \r\n\r\n# Epidemiology \r\n\r\nHCM is estimated to impact 1 in 500 people. It is the most common inherited cardiac condition. Inheritance of HCM is in an autosomal dominant fashion. However, 50% of cases result due to sporadic mutations. Most of the hypertrophy develops during childhood and adolescent, however, genetic variation means late-onset disease can occur.\r\n\r\n# Pathophysiology\r\n\r\nHCM is attributed to mutations in one or a number of genes that encode for sarcomere proteins. A common mutation is in the beta-myosin heavy chain gene leading to myocyte hypetrophy with chaotic and disorganised myocytes. \r\n\r\n# Symptoms\r\n\r\n* May be asymptomatic \r\n* Or can present with symptoms of left ventricular outflow obstruction, pulmonary congestion or heart failure: \r\n\t* Exertional syncope \r\n\t* Pre-syncope/syncope\r\n\t* Sudden cardiac death \r\n\t* Exertional dyspnoea \r\n\t* Fatigue\r\n\t* Chest pain: may be anginal (due to decreased blood flow through the coronary arteries) or atypical. \r\n\r\n# Signs\r\n\r\nPhysical examination can often be normal or non-specific, however typical findings may include:\r\n\r\n* \"Jerky\" pulse\r\n* Double apex beat\r\n* Harsh ejection systolic murmur\r\n* Apical thrill\r\n* A wave in JVP \r\n\r\n# Differential Diagnoses\r\n\r\n* Aortic Stenosis \r\n\t* Similarities: both may have an ejection systolic murmur and present similarly with chest pain, exertional syncope and dyspnoea. \r\n\t* Differences: can be difficult to delineate clinically, but demographics may be very different. Aortic stenosis tends to affect older patients, whilst HOCM is likely to be found in younger patients. \r\n\r\n* Hypertensive Disease \r\n\t* Similarities: chronic high blood pressure can lead to left ventricular hypertrophy. \r\n\t* Differences: echocardiogram reveals asymmetrical left ventricular hypertrophy in HOCM. Family history and patient demographics may also suggest HOCM over hypertensive disease. \r\n\r\n* Supravalvular Aortic Stenosis: \r\n\t* Similarities: both may have an ejection systolic murmur. \r\n\t* Differences: supravalvular aortic stenosis is a congenital cardiac condition whereas HOCM tends to develop over time. Supravalvular stenosis can be distinguished from HOCM on echocardiography due to the level of obstruction either above or below the aortic valve respectively. \r\n\r\n# Investigations\r\n\r\n**ECG** typically demonstrates: \r\n\r\n* Abnormal Q waves\r\n* Deep T wave inversion \r\n* LVH \r\n\r\n**Echocardiogram: definitive diagnosis** \r\n\r\n* HCM is reliably diagnosed on echocardiogram. \r\n* Findings of HOCM on echocardiogram can be remembered with the mnemonic 'MR SAM ASH'. \r\n\t* **M**itral **R**egurgitation\r\n\t* **S**ystolic **A**nterior **M**otion of the mitral valve leaflets \r\n\t* **A**symmetrical **S**eptal **H**ypertrophy. \r\n\r\n**Genetic testing:** there is a role for genetic testing in HCM in families where there are known cases of HCM. \r\n\r\n# Management\r\n\r\n## Conservative \r\n\r\nMany patients with HCM do not have any symptoms and have a normal life expectancy. They are often counselled on not undertaking particularly stressful exercise or competitive athletics. \r\n\r\n## Medical \r\n\r\nMedical treatment of HCM remains symptoms control. \r\n**1st line: beta-blockers** to reduce palpitations symptoms, ectopic beats and are anti-anginal. \r\n\r\nOther medications that can be used are: non-dihydropyridine calcium channel blockers (verapamil), anti-arrhythmics (amiodarone) and anticoagulation (for AF). \r\n\r\n## Surgical and Interventional\r\n\r\nManagement of the septal hypetrophy in those with severe left ventricular outflow tract obstruction (LVOTO) or symptoms that are refractory to medical management. \r\n\r\n* Surgical septal myectomy\r\n* Alcohol septal ablation\r\n\r\nFor those at significant risk of sudden cardiac death an ICD may be inserted to mitigate this risk. \r\n\r\n# Complications\r\n\r\nThe abnormal morphology of the left ventricle can cause severe consequences for heart function: \r\n\r\n* Left ventricular outflow tract obstruction (LVOTO)\r\n* Diastolic dysfunction: HFpEF\r\n* Ischaemia \r\n* Mitral regurgitation: MR SAM ASH on echocardiogram \r\n\r\n# Prognosis \r\n\r\nThe annual mortality rate for HCM is 1.1% of people per year and the HCM survival rate is estimated to be 81% at 20 years after diagnosis. \r\n\r\n# NICE Guidelines\r\n\n[NICE Guidelines on Non-Surgical Reduction of the Myocardium in HCM](<https://www.nice.org.uk/guidance/ipg40>)\r\n\r\n# References\r\n\r\n[Patient UK HCM Summary](<https://patient.info/doctor/hypertrophic-cardiomyopathy-pro>)\n\r\n[American Heart Association Article on HCM](<https://www.ahajournals.org/doi/full/10.1161/circresaha.116.309348>)",
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"question": "A 25-year-old female presents to the emergency department after collapsing during a football game. She is currently haemodynamically stable. Her father passed away at the age of 42 after a collapse.\n\nWhich of the following investigations would confirm the diagnosis?",
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"explanation": "This would be appropriate for patients with suspected urosepsis. This patient does not present with any features of sepsis e.g. hypotension and therefore does not require a stat dose of gentamicin.",
"id": "10038324",
"label": "e",
"name": "STAT dose IV gentamicin 5mg/kg",
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"__typename": "QuestionChoice",
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"explanation": "The BNF advises that ciprofloxacin be used with caution in patients with G6PD deficiency. Furthermore, this medication would be more appropriate for patients with acute pyelonephritis managed in the community. The lack of additional symptoms in this patient i.e. flank pain or features of sepsis makes acute pyelonephritis unlikely. ",
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"explanation": "According to [NICE CKS guidelines](https://cks.nice.org.uk/topics/urinary-tract-infection-lower-women/management/acute-uti-no-visible-haematuria-not-pregnant-or-catheterized/), this is the second-line antibiotic regimen where nitrofurantoin and trimethoprim are contraindicated (see other explanations), or where there is no improvement in symptoms.",
"id": "10038320",
"label": "a",
"name": "PO Pivmecillinam 400mg initial dose, then 200 mg TDS for three days",
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},
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"__typename": "QuestionChoice",
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"explanation": "Methotrexate is listed as a severe interaction with trimethoprim in the BNF, due to the increased risk of haematological side effects that can be fatal. This is a very important drug interaction to remember.",
"id": "10038322",
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},
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}
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"comment": "So focussed on the G6PD stuff I didn't even see the methotrexate god",
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"explanation": "# Summary \n\nLower urinary tract infections (LUTIs), often manifesting as cystitis, typically involve the infection of the bladder. Primarily caused by transurethral ascent of colonic commensals like E. coli, symptoms include urinary frequency, dysuria, urgency, foul-smelling urine, and suprapubic pain. Investigations are generally limited to a urine dipstick test for leucocytes and nitrites, while management involves oral nitrofurantoin or trimethoprim, and conservative measures. A key differential diagnosis is pyelonephritis, a urinary tract infection affecting the kidneys. Pyelonephritis exhibits more severe symptoms like fever, malaise, loin pain, and vomiting, and requires hospital admission and intravenous antibiotics.\n\n# Definition \n\nA lower urinary tract infection (LUTI) is generally defined as an infection of the bladder, often manifesting as cystitis.\n\n# Aetiology \n\nLUTIs are caused by the transurethral ascent of colonic commensals, most commonly **E. coli**.\n\n# Signs and symptoms\n\nPatients with LUTIs generally present with:\n\n- Urinary frequency\n- Dysuria\n- Urgency\n- Foul-smelling urine\n- Suprapubic pain\n- Clinical examination may be normal or reveal suprapubic tenderness.\n\nRed flag symptoms such as haematuria, loin pain, rigors, nausea, vomiting, and altered mental state may indicate more serious infection, and these patients may have/are at risk of developing pyelonephritis (see below) and likely need referral to A&E.\n\n\n# Investigations\n\nFor LUTIs:\n\n- Urine dipstick is positive for leucocytes and nitrites in most cases.\n- In uncomplicated cases, no further investigations are required.\n- In children, men, and pregnant women a mid-stream urine sample should be sent.\n\nNB: Urine dipstick is unreliable in women aged older than 65 years and those who are catheterised.\n\nIf being managed in secondary care due to red flag symptoms consider:\n\n- If there are signs of systemic upset consider routine blood tests such as FBC, U+E, and CRP.\n- For uncomplicated UTIs, imaging is rarely required, but if there are concerns over antecedents/complications such as urinary retention/obstruction, an USS bladder/kidney scan would be the first port of call.\n\n# Management \n\n[lightgallery]\n\n[lightgallery1]\n\nFor LUTIs:\n\n- First line management is with oral nitrofurantoin or trimethoprim. Antibiotic duration can vary (see below) however in women the standard course length is 3 days.\n- The patient should be advised on conservative measures to reduce the risk of further infection e.g. regular fluid intake, post-coital voiding.\n\n## Specific situations\n\n**UTI in Men:**\n\n- Empirical antibiotic drug treatment (if no cultures with sensitivities) with trimethoprim or nitrofurantoin for **7 days.**\n- Refer to urology if there are ongoing symptoms despite treatment, if there is an underlying risk factor for UTIs (e.g. urinary calculi, suspected obstruction, previous GU surgery), or if there are recurrent episodes of UTI.\n\n**UTI during Pregnancy (with no haematuria):**\n\n- First-line antibiotics are nitrofurantoin (but *avoid at term),* for **7 days.**\n- If nitrofurantoin is not suitable due to e.g. renal function, or there is no improvement in symptoms, consider second-choice antibiotics such as amoxicillin/cefalexin for 7 days.\n\n\n# NICE Guidelines\n\n[Click here for NICE CKS on urinary tract infection (lower) - women](https://cks.nice.org.uk/topics/urinary-tract-infection-lower-women/)\n\n[Click here for NICE CKS on pyelonephritis - acute](https://cks.nice.org.uk/topics/pyelonephritis-acute/)\n",
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"question": "A 55-year-old woman presents to the GP clinic with pain on passing urine for the past three days. She is otherwise well in herself. She has a past medical history of G6PD deficiency and rheumatoid arthritis, for which she takes methotrexate. She does not take any other medication and has no known drug allergies.\n\nShe has a temperature of 36.5 degrees Celsius, pulse 65 bpm, BP 125/86 mmHg.\n\nUrine dipstick shows 2+ leukocytes and 3+ nitrites.\n\nThe GP decides to prescribe a course of antibiotics for this patient. Which is the most appropriate regimen to prescribe?",
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"explanation": "Whilst it would be important to investigate the possibility of Coeliac disease if the CA-125 was normal, Ovarian cancer should be ruled out urgently before investigating other differentials of these symptoms.",
"id": "10035815",
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"question": "A 65-year-old female has a 6-month history of feeling bloated after meals. She has lost 6kg in this period due to decreased appetite and has also experienced fluctuating diarrhoea and constipation. She has a past medical history of hypercholesterolaemia and has two children, born via uncomplicated vaginal delivery. Her last menstrual period was 10 years ago.\n\nOn examination, her abdomen is soft and non-tender, with no evidence of obvious distension, ascites or any palpable masses.\n\nWhat is the most appropriate initial investigation?",
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"explanation": "This is incorrect as adenocarcinomas are a type of non-small cell lung cancer rather than small-cell lung cancer.",
"id": "10035818",
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"name": "A smoking history does not increase the risk of developing adenocarcinoma of the lung",
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"explanation": "This is incorrect as small cell lung cancers are classed as neuroendocrine tumours, adenocarcinomas are a type of non-small cell lung cancer.",
"id": "10035819",
"label": "c",
"name": "Lung adenocarcinomas are classed as neuroendocrine tumours",
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"explanation": "This is incorrect as it describes squamous cell carcinoma, which arises from the flat cells that line the surface of the airways. Adenocarcinomas arise from mucus-producing glands.",
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"label": "d",
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"question": "A 62-year-old male has an 8-month history of cough, haemoptysis and weight loss. He has a background of COPD and a 45-pack-year smoking history. Due to these symptoms, he is referred urgently under the 2-week wait cancer pathway and is subsequently diagnosed with adenocarcinoma of the lung. The patient would like to find out more about his new diagnosis as he is confused by the information he has read online.\n\nWhich of the following statements about adenocarcinoma of the lung is the correct advice to provide?",
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"id": "10035824",
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"explanation": "Whilst previously experiencing severe morning sickness is a risk factor for chemotherapy-related nausea and vomiting, history of pregnancy alone is not itself a risk factor.",
"id": "10035826",
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"explanation": "This is incorrect, as these medications are used to treat chemotherapy-related nausea and vomiting.",
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"question": "A 17-year-old female has recently been diagnosed with acute lymphoblastic leukaemia (ALL) after a 4-week history of extreme fatigue, easy bruising and lymphadenopathy. She is due to undergo induction chemotherapy for her ALL and is concerned about the possibility of nausea and vomiting. The patient would like to know if it is possible to avoid these symptoms and asks if anything increases the risk of nausea and vomiting related to chemotherapy.\n\nWhich of the following is a risk factor for chemotherapy-related nausea and vomiting?",
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"explanation": "The NG tube is sited in the right lower lobe of the lung. Waiting for a day would risk serious consequences without any benefit, as the NG tube will not re-site itself. The appropriate choice in this scenario is to remove the NG tube immediately.",
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"explanation": "This would be incredibly dangerous as the NG tube is seen in the right lower lobe of the lung. Commencing feeding in this scenario could be fatal.",
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"explanation": "The patient followed fasting rules correctly (no solid food for at least 6 hours before the operation, clear fluids up to 2 hours before the operation) and therefore there is no reason to delay the operation.",
"id": "10035833",
"label": "b",
"name": "Delay the operation until 6:00 PM",
"picture": null,
"votes": 126
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Fasting rules outline that a patient should not eat for at least 6 hours before the operation but can have clear fluids (water, black tea/coffee) up to 2 hours before the operation. As the patient had clear fluids 5 hours before the operation, she is completely safe to proceed.",
"id": "10035832",
"label": "a",
"name": "Continue with the operation as planned",
"picture": null,
"votes": 1414
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be incorrect as solid food should be consumed at the latest 6 hours before the operation.",
"id": "10035836",
"label": "e",
"name": "Encourage the patient to keep eating and drinking up until 10:00 AM",
"picture": null,
"votes": 15
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The patient followed fasting rules correctly (no solid food for at least 6 hours before the operation, clear fluids up to 2 hours before the operation) and therefore there is no reason to delay the operation.",
"id": "10035834",
"label": "c",
"name": "Delay the operation until the following morning",
"picture": null,
"votes": 73
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be incorrect as clear fluids can be consumed up until 2 hours before the operation, this would only allow 1.5 hours after consumption of clear fluids.",
"id": "10035835",
"label": "d",
"name": "Bring the operation forward to 8:30 AM",
"picture": null,
"votes": 3
}
],
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"id": "177",
"name": "Anaesthetics and Intensive Care Medicine",
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"learningPoint": "Patients can consume clear fluids, such as black coffee, up to two hours before elective surgery without increasing aspiration risk.",
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"question": "A 57-year-old female is scheduled for an elective laparoscopic cholecystectomy at 12:00 PM. She attends her pre-operative assessment at 8:00 AM, at which she reveals she drank black coffee at 7:00 AM the same morning. She apologises and states she was aware she needed to remain 'nil by mouth' and is now concerned that the operation will need to be cancelled.\n\nWhat is the most appropriate course of action to take?",
"sbaAnswer": [
"a"
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"userPoint": null
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173,468,659 | false | 6 | null | 6,495,272 | null | false | [] | null | 19,571 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an atypical antipsychotic, which has a stronger affinity for 5HT receptors than dopamine receptors, although the antagonistic effect on dopamine receptors still can cause hyperprolactinaemia.",
"id": "10035841",
"label": "e",
"name": "Olanzapine",
"picture": null,
"votes": 237
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "As a partial dopamine agonist, Aripiprazole is least likely to cause galactorrhoea as dopamine normally inhibits prolactin production. All the other medications listed antagonise dopamine receptors and therefore have a greater risk of increasing prolactin production.",
"id": "10035837",
"label": "a",
"name": "Aripiprazole",
"picture": null,
"votes": 1154
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a typical antipsychotic which is a strong dopamine receptor antagonist, therefore greatly increasing the risk of hyperprolactinaemia.",
"id": "10035838",
"label": "b",
"name": "Chlorpromazine",
"picture": null,
"votes": 69
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a typical antipsychotic which is a strong dopamine receptor antagonist, therefore greatly increasing the risk of hyperprolactinaemia.",
"id": "10035839",
"label": "c",
"name": "Prochlorperazine",
"picture": null,
"votes": 77
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an atypical antipsychotic, which has a stronger affinity for 5HT receptors than dopamine receptors. However, the antagonistic effect on dopamine receptors still can cause hyperprolactinaemia.",
"id": "10035840",
"label": "d",
"name": "Quetiapine",
"picture": null,
"votes": 95
}
],
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"question": "A 37-year-old male has painful and swollen breast tissue and has noticed a milky discharge from his nipples. This has been occurring for the past 3 weeks and the patient is finding it to be troublesome and embarrassing. He has a past medical history of schizophrenia and takes haloperidol for this. He is aware that the symptoms he is experiencing are a side effect of his medication and asks whether there is an alternative which he can start taking.\n\nWhich of the below anti-psychotic medications is least likely to cause these symptoms?",
"sbaAnswer": [
"a"
],
"totalVotes": 1632,
"typeId": 1,
"userPoint": null
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173,468,660 | false | 7 | null | 6,495,272 | null | false | [] | null | 19,572 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is the correct answer. SSRIs do not always work for patients with depression but if they have a beneficial effect it will be seen within 4 weeks of starting treatment. It is vital to counsel patients that they may feel worse initially, including worsened suicidal ideation. They should be advised of how to seek urgent review if this is the case.",
"id": "10035842",
"label": "a",
"name": "The medication usually will work within 4 weeks of commencing treatment, but the patient may experience worsening symptoms initially",
"picture": null,
"votes": 1463
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "SSRIs usually have a beneficial effect within 4 weeks of starting treatment but can make patients feel worse initially, especially within the first 2 weeks of starting treatment.",
"id": "10035843",
"label": "b",
"name": "The medication will start to work immediately",
"picture": null,
"votes": 5
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Although a beneficial effect is expected to be seen within the first 4 weeks of treatment, SSRIs must be taken daily.",
"id": "10035846",
"label": "e",
"name": "The medication will be more effective if taken twice a week, with a beneficial effect seen within 4 weeks of starting treatment",
"picture": null,
"votes": 9
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Although SSRIs can make patients feel worse initially, a beneficial effect should be seen within 4 weeks of starting treatment.",
"id": "10035844",
"label": "c",
"name": "The medication will cause a worsening of symptoms for a month and a beneficial effect is normally seen within 6 months",
"picture": null,
"votes": 141
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "SSRIs usually have a beneficial effect within 4 weeks of starting treatment, a year is much too long to wait before trying alternative treatment options.",
"id": "10035845",
"label": "d",
"name": "The medication must be taken for a year before a beneficial effect is seen",
"picture": null,
"votes": 3
}
],
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},
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"id": "6156",
"name": "Depression",
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"__typename": "Topic",
"id": "332",
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"typeId": 7
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"id": "19572",
"isLikedByMe": null,
"learningPoint": "Selective serotonin reuptake inhibitors (SSRIs) like sertraline typically show effects within four weeks, though initial worsening of symptoms may occur.",
"likes": 0,
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"question": "A 23-year-old male has recently been diagnosed with moderate depression after experiencing low mood, anhedonia and fatigue for the past 4 months. He has also been noticing poor focus and sleep, often waking up at 4AM and unable to get back to sleep. He is awaiting an appointment for cognitive behavioural therapy but would like to trial medication and is therefore started on sertraline. The patient would like to know when he will start to see the positive effects of the medication.\n\nWhat is the most appropriate advice to offer?",
"sbaAnswer": [
"a"
],
"totalVotes": 1621,
"typeId": 1,
"userPoint": null
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173,468,661 | false | 8 | null | 6,495,272 | null | false | [] | null | 19,573 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is also known as erotomania, where an individual believes another person (whom they are often unable to interact with directly e.g. celebrities) is infatuated with them. It can be secondary to BPAD or schizophrenia.",
"id": "10035850",
"label": "d",
"name": "De Clarembeut’s syndrome",
"picture": null,
"votes": 83
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is delusional misidentification syndrome, where an individual has a fixed delusion that a person close to them has been replaced by an identical imposter. It is associated with schizophrenia.",
"id": "10035847",
"label": "a",
"name": "Capgras syndrome",
"picture": null,
"votes": 1097
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a syndrome where the patient has a fixed delusion that multiple people are the same person (often a familiar person to the patient) in disguise. This is different to Capgras syndrome where they believe an individual close to them has been replaced by an imposter. De Fregoli syndrome is also associated with schizophrenia.",
"id": "10035848",
"label": "b",
"name": "De Fregoli syndrome",
"picture": null,
"votes": 286
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "These describe nihilistic delusions, where the patient believes they are dead or rotten. It is common in psychotic depression in older patients.",
"id": "10035851",
"label": "e",
"name": "Cotard syndrome",
"picture": null,
"votes": 113
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Ekbom syndrome is also known as delusional parasitosis, where an individual believes they are infested with parasites and often have tactile hallucinations of insects crawling on them. It is associated with a range of conditions.",
"id": "10035849",
"label": "c",
"name": "Ekbom syndrome",
"picture": null,
"votes": 32
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "what is the point in learning eponymous delusion syndromes. It is of no help on the wards, where I spend a lot of my time",
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"learningPoint": "Capgras syndrome is a delusional misidentification disorder where individuals believe a close person has been replaced by an imposter.",
"likes": 0,
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"question": "A 65-year-old male believes that an imposter has replaced his wife. He states this started 4 weeks ago and is unsure who the ‘imposter’ is and their purpose or aim. He has not been engaging with his wife and has attempted to contact the police numerous times. On discussion, he refuses to accept evidence that his wife is the same person, including information that only his wife would know. The patient has a background of schizophrenia and takes olanzapine, although his wife is unsure of how compliant he is with his medication.\n\nWhat is the likely diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 1611,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,662 | false | 9 | null | 6,495,272 | null | false | [] | null | 19,574 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is associated with the individual holding unconventional beliefs and difficulty interacting with others due to social anxiety and paranoia.",
"id": "10035853",
"label": "b",
"name": "Schizotypal personality disorder",
"picture": null,
"votes": 7
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is characterised by intense fluctuating emotions, inability to maintain relationships, feelings of emptiness and often self-harm.",
"id": "10035855",
"label": "d",
"name": "Emotionally unstable personality disorder",
"picture": null,
"votes": 6
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is characterised by inappropriate attention-seeking behaviour and an excessive desire for approval and validation.",
"id": "10035856",
"label": "e",
"name": "Histrionic personality disorder",
"picture": null,
"votes": 122
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is characterised by a lack of empathy and aggressive behaviour towards others and is associated with impulsive behaviour and often substance abuse.",
"id": "10035854",
"label": "c",
"name": "Antisocial personality disorder",
"picture": null,
"votes": 5
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is a classic description of narcissistic personality disorder, where the individual believes themselves to be superior and acts in a manipulative manner, often to get admiration.",
"id": "10035852",
"label": "a",
"name": "Narsicistic personality disorder",
"picture": null,
"votes": 1462
}
],
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"learningPoint": "Narcissistic personality disorder is characterised by an inflated sense of self-importance and a constant need for admiration from others.",
"likes": 2,
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"question": "A 27-year-old female often gets into disagreements with her colleagues. She believes herself to be the best employee in the company and thinks others have ideas which are unimportant or meaningless. She will constantly seek praise from her boss and enjoys having interns she can influence. She frequently lies about missing deadlines to ensure she is presented in the best possible way at work.\n\nWhich of the following is the most likely diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 1602,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,663 | false | 10 | null | 6,495,272 | null | false | [] | null | 19,575 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Clomipramine is the only TCA which is licencsed to treat OCD. Amitriptyline is therefore an incorrect answer.",
"id": "10035858",
"label": "b",
"name": "Amitriptyline",
"picture": null,
"votes": 17
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an antipsychotic which is not licensed for the treatment of OCD.",
"id": "10035861",
"label": "e",
"name": "Aripiprazole",
"picture": null,
"votes": 9
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is the only medication listed here which is licensed to treat OCD, characterised by intrusive obsessions and ritualistic compulsions. It may be required at a higher dose than used when treating depression.",
"id": "10035857",
"label": "a",
"name": "Sertraline",
"picture": null,
"votes": 1520
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an antipsychotic which is not licensed for the treatment of OCD.",
"id": "10035859",
"label": "c",
"name": "Olanzapine",
"picture": null,
"votes": 43
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an antipsychotic which is not licensed for the treatment of OCD.",
"id": "10035860",
"label": "d",
"name": "Haloperidol",
"picture": null,
"votes": 13
}
],
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"learningPoint": "Sertraline is an effective first-line medication for treating obsessive-compulsive disorder (OCD), targeting intrusive thoughts and compulsive behaviours.",
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"question": "A 32-year-old male complains of persistently distressing thoughts and images. This has been occurring for the last 6 months and he finds them worsening when he is stressed. He finds the only way to deal with the stress created by these thoughts is repeatedly turning his bedside lamp on and off, or doing the same with his phone torch. He would like to try medication to improve his symptoms.\n\nWhich of the following medications should be offered?",
"sbaAnswer": [
"a"
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"userPoint": null
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173,468,664 | false | 11 | null | 6,495,272 | null | false | [] | null | 19,576 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is the management of regular, broad complex tachycardias without life-threatening features. The rhythm seen here is an irregular, broad complex tachycardia.",
"id": "10035863",
"label": "b",
"name": "IV amiodarone",
"picture": null,
"votes": 486
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is the management of irregular, narrow complex tachycardias without life-threatening features. The rhythm seen here is an irregular, broad complex tachycardia.",
"id": "10035866",
"label": "e",
"name": "IV diltiazem",
"picture": null,
"votes": 4
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is an irregular, broad complex rhythm in keeping with Torsades des Pointes (polymorphic ventricular tachycardia). Lithium is a risk factor for QTc prolongation which can predispose to Torsades des Pointes. Magnesium is the correct medical treatment for this if no life-threatening features are present.",
"id": "10035862",
"label": "a",
"name": "IV magnesium",
"picture": null,
"votes": 995
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is the second line management of regular, narrow complex tachycardias without life-threatening features after vagal manoeuvres have been tried. The rhythm seen here is an irregular, broad complex tachycardia.",
"id": "10035864",
"label": "c",
"name": "IV adenosine",
"picture": null,
"votes": 45
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is the first line of management of regular, narrow complex tachycardias without life-threatening features. The rhythm seen here is an irregular, broad complex tachycardia.",
"id": "10035865",
"label": "d",
"name": "Vagal manoeuvres",
"picture": null,
"votes": 82
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "the only reason i didnt put magnesium was because i thought they were tryin to trick me out without putting the sulphate part, its been a long day man ",
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"learningPoint": "Torsades de Pointes is a polymorphic ventricular tachycardia often associated with QTc prolongation, and IV magnesium is the first-line treatment.",
"likes": 3,
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"question": "A 57-year-old male with a background of bipolar disorder experiences palpitations. He said this commenced when he was walking his dog 30 minutes ago and he also feels lightheaded. He denies any chest pain, syncope or dyspnoea and states that the symptoms have not worsened or changed in the last 30 minutes. An urgent ECG is carried out which is seen below:\n\n[lightgallery]\n\nGiven the likely diagnosis, what is the most appropriate management?",
"sbaAnswer": [
"a"
],
"totalVotes": 1612,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,665 | false | 12 | null | 6,495,272 | null | false | [] | null | 19,577 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Although naloxone is the correct treatment for opioid toxicity, it is given IV, IM or via intranasal administration.",
"id": "10035868",
"label": "b",
"name": "Oral naloxone",
"picture": null,
"votes": 56
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is the reversal agent for ethylene glycol toxicity rather than opioid overdose. Opioid overdose is suggested here by low GCS, low RR and pinpoint pupils.",
"id": "10035870",
"label": "d",
"name": "Fomepizil",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is the reversal agent for benzodiazepine toxicity. Although benzodiazepine toxicity also would present with a reduced GCS, dilated pupils are more likely than pinpoint pupils. Additionally, flumazenil is only licensed for reversal in anaesthesia or ICU, rather than overdoses in the community.",
"id": "10035869",
"label": "c",
"name": "IV flumazenil",
"picture": null,
"votes": 12
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is a likely case of opioid toxicity; suggested by the low respiratory rate, pinpoint pupils and low GCS. The correct treatment for opioid toxicity is naloxone. This is given IV, IM or via intranasal administration.",
"id": "10035867",
"label": "a",
"name": "IV naloxone",
"picture": null,
"votes": 1534
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is used for paracetamol overdose rather than opioid overdose. Paracetamol toxicity would instead likely present with nausea, vomiting, headache and jaundice (in some severe or cases of delayed presentation).",
"id": "10035871",
"label": "e",
"name": "N-acetyl cysteine",
"picture": null,
"votes": 7
}
],
"comments": [],
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"__typename": "Concept",
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"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6161",
"name": "Opioid toxicity",
"status": null,
"topic": {
"__typename": "Topic",
"id": "199",
"name": "Emergency Medicine",
"typeId": 7
},
"topicId": 199,
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"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "19577",
"isLikedByMe": null,
"learningPoint": "Opioid toxicity presents with respiratory depression, pinpoint pupils, and altered consciousness; naloxone is the antidote of choice.",
"likes": 0,
"multiAnswer": null,
"pictures": [],
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"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 25-year-old male is found collapsed. The only collateral history was provided by a passerby who found the patient was unresponsive and called an ambulance.\n\nOn assessment:\n\n* A: No obvious angioedema, trachea central. Patient groaning occasionally\n* B: Equal but slow chest expansion, no added sounds. RR 6, SpO2 91% on room air\n* C: Regular pulse with warm peripheries. HS I + II + 0. HR 112, BP 108/60, Temperature 37.3 degrees, Urine Output unknown.\n* D: GCS 7/15. Pinpoint pupils. Glucose within normal limits.\n* E: No obvious rashes. Abdomen soft and non-tender\n\nWhich of the following is the most appropriate medication to prescribe?",
"sbaAnswer": [
"a"
],
"totalVotes": 1609,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,666 | false | 13 | null | 6,495,272 | null | false | [] | null | 19,578 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Back blows and abdominal thrusts should be carried out when the patient is conscious, with severe airway obstruction (e.g. ineffective cough). If the patient falls unconscious, CPR should be carried out.",
"id": "10035876",
"label": "e",
"name": "A further cycle of 5 abdominal thrusts and 5 back blows",
"picture": null,
"votes": 40
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not an appropriate choice, in the scenario of choking where the patient falls unconscious, CPR should be started.",
"id": "10035875",
"label": "d",
"name": "Lay the patient in the recovery position",
"picture": null,
"votes": 53
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "As outlined by the BLS choking algorithm, once the patient is unconscious then CPR should be started rather than abdominal thrusts or back blows.",
"id": "10035874",
"label": "c",
"name": "5 further abdominal thrusts",
"picture": null,
"votes": 5
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "As per the BLS choking algorithm, if the patient falls unconscious then CPR should be started. Ideally, help should be sought early but if an ambulance had not already been called it should be now.",
"id": "10035872",
"label": "a",
"name": "Call an ambulance and start CPR",
"picture": null,
"votes": 1427
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "As outlined by the BLS choking algorithm, once the patient is unconscious then CPR should be started rather than abdominal thrusts or back blows.",
"id": "10035873",
"label": "b",
"name": "5 back blows",
"picture": null,
"votes": 83
}
],
"comments": [],
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"__typename": "Concept",
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"__typename": "Chapter",
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"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6162",
"name": "Choking (adults)",
"status": null,
"topic": {
"__typename": "Topic",
"id": "199",
"name": "Emergency Medicine",
"typeId": 7
},
"topicId": 199,
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},
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"conditions": [],
"difficulty": 1,
"dislikes": 1,
"explanation": null,
"highlights": [],
"id": "19578",
"isLikedByMe": 0,
"learningPoint": "In cases of suspected choking leading to unconsciousness, initiate CPR immediately and call for emergency medical assistance.",
"likes": 1,
"multiAnswer": null,
"pictures": [],
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"question": "A 47-year-old female is out for a steak dinner with her colleagues. She starts gesturing towards her throat and cannot answer when asked what is wrong. Her colleagues believe she is choking and start performing abdominal thrusts. After a few minutes of abdominal thrusts, she falls unconscious, with no response to voice or pain.\n\nWhat is the appropriate management?",
"sbaAnswer": [
"a"
],
"totalVotes": 1608,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,667 | false | 14 | null | 6,495,272 | null | false | [] | null | 19,579 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect as the history is highly suggestive of idiopathic intracranial hypertension, the LP would help confirm the diagnosis whilst potentially also improving symptoms. The patient should be advised on weight loss, a low-sodium diet and stopping antibiotics. They may also be given acetazolamide.",
"id": "10035878",
"label": "b",
"name": "Discharge with simple analgesia, no investigations required",
"picture": null,
"votes": 358
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient had idiopathic intracranial hypertension; as classically described by signs of raised ICP (vomiting, blurry vision and severe headaches). She also has some significant risk factors for this condition (obesity and use of tetracycline antibiotics). As her CT head is normal, carrying out an LP to show raised opening pressure is the next most appropriate step.",
"id": "10035877",
"label": "a",
"name": "Lumbar puncture",
"picture": null,
"votes": 1127
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "EEG is usually used in the diagnosis of epilepsy or other seizure disorders. The history here is suggestive of idiopathic intracranial hypertension (morning headaches and blurred vision) and the patient has significant risk factors for this condition (obesity and use of tetracycline antibiotics).",
"id": "10035880",
"label": "d",
"name": "EEG",
"picture": null,
"votes": 71
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst meningitis is an important differential for severe headaches, the month-long history and absence of photophobia, neck stiffness and fevers make an infective cause much less likely.",
"id": "10035879",
"label": "c",
"name": "Commence IV ceftriaxone",
"picture": null,
"votes": 8
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is usually used in the diagnosis of neuromuscular abnormalities such as MND, myasthenia gravis or myositis. The history here is suggestive of idiopathic intracranial hypertension (morning headaches and blurred vision) and the patient has significant risk factors for this condition (obesity and use of tetracycline antibiotics).",
"id": "10035881",
"label": "e",
"name": "EMG",
"picture": null,
"votes": 42
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "are LPs not contraindicated due to the features of raised ICP?",
"createdAt": 1716112337,
"dislikes": 0,
"id": "49965",
"isLikedByMe": 0,
"likes": 9,
"parentId": null,
"questionId": 19579,
"replies": [
{
"__typename": "QuestionComment",
"comment": "think normal head imaging showing no obvious space occupying lesions means u can do LP",
"createdAt": 1716235360,
"dislikes": 0,
"id": "50172",
"isLikedByMe": 0,
"likes": 11,
"parentId": 49965,
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}
}
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"user": {
"__typename": "User",
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"displayName": "Contusion Kawasaki",
"id": 29356
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"entitlement": null,
"id": "6163",
"name": "Idiopathic Intracranial Hypertension",
"status": null,
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"__typename": "Topic",
"id": "199",
"name": "Emergency Medicine",
"typeId": 7
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"topicId": 199,
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"conditions": [],
"difficulty": 1,
"dislikes": 4,
"explanation": null,
"highlights": [],
"id": "19579",
"isLikedByMe": 0,
"learningPoint": "A lumbar puncture is performed in cases of idiopathic intracranial hypertension (IIH) to measure the opening pressure of the cerebrospinal fluid (CSF) and to analyze the fluid for abnormalities",
"likes": 2,
"multiAnswer": null,
"pictures": [],
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"question": "A 27-year-old female has a frequent severe headache, often worse on waking. She describes the pain as 9/10 and ‘pressure-like’ in nature. Since the headaches started 1 month ago, she has experienced dizziness and blurry vision. She denies any fevers, photophobia or neck stiffness. She is very concerned she has a brain tumour. She has a past medical history of type 2 diabetes, obesity and acne (for which she takes lymecycline).\n\nShe has a CT head which is reported as normal.\n\nWhat is the most appropriate next step?",
"sbaAnswer": [
"a"
],
"totalVotes": 1606,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,668 | false | 15 | null | 6,495,272 | null | false | [] | null | 19,580 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Resus council guidance now states IM adrenaline alone should be given initially in anaphylaxis. Steroids and antihistamines are no longer mentioned in the guidance. Antihistamines may help with an urticarial rash although this is often only given once the patient has been stabilised.",
"id": "10035885",
"label": "d",
"name": "IM adrenaline and chlorphenamine",
"picture": null,
"votes": 75
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "PO adrenaline cannot be used in anaphylaxis as it is broken down and digested and does not have any systemic beneficial effects.",
"id": "10035884",
"label": "c",
"name": "PO adrenaline alone",
"picture": null,
"votes": 1
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Resus council guidance now states IM adrenaline alone should be given initially in anaphylaxis. Steroids and antihistamines are no longer mentioned in the guidance.",
"id": "10035882",
"label": "a",
"name": "IM adrenaline alone",
"picture": null,
"votes": 1464
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "An IV adrenaline infusion is given in the treatment of refractory anaphylaxis (no response after 2 x IM adrenaline) and can only be initiated in a critical care setting.",
"id": "10035883",
"label": "b",
"name": "IV adrenaline alone",
"picture": null,
"votes": 20
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Resus council guidance now states IM adrenaline alone should be given initially in anaphylaxis. Steroids and antihistamines are no longer mentioned in the guidance. Antihistamines may help with an urticarial rash although this is often only given once the patient has been stabilised.",
"id": "10035886",
"label": "e",
"name": "IM adrenaline and IV hydrocortisone",
"picture": null,
"votes": 48
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": null,
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"id": "2693",
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"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "4090",
"name": "Emergency management of anaphylaxis",
"status": null,
"topic": {
"__typename": "Topic",
"id": "199",
"name": "Emergency Medicine",
"typeId": 7
},
"topicId": 199,
"totalCards": null,
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"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "19580",
"isLikedByMe": 0,
"learningPoint": "In cases of anaphylaxis, administer intramuscular adrenaline as the first-line treatment to rapidly counteract severe allergic reactions; steroids and antihistamines are not first-line treatments and should not replace adrenaline.",
"likes": 1,
"multiAnswer": null,
"pictures": [],
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"psaSectionId": null,
"qaAnswer": null,
"question": "A 6-year-old boy has difficulty breathing after eating cake at a friend’s birthday party.\n\nOn examination, his lips and tongue are swollen and he has a diffuse urticarial rash.\n\nWhich of the following medications should be given initially?",
"sbaAnswer": [
"a"
],
"totalVotes": 1608,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,669 | false | 16 | null | 6,495,272 | null | false | [] | null | 19,581 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a nuclear medicine scan primarily used to diagnose neuroendocrine tumours. Nuclear medicine scans have a role in diagnosing osteomyelitis and technetium and indium scintigraphy scans may be used in the workup of osteomyelitis.",
"id": "10035891",
"label": "e",
"name": "PET-CT Ga-68 Dotatate scan",
"picture": null,
"votes": 21
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is less accurate in diagnosing osteomyelitis with reduced sensitivity and specificity compared to MRI.",
"id": "10035888",
"label": "b",
"name": "Plain radiograph",
"picture": null,
"votes": 182
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This has low overall sensitivity and specificity in diagnosing osteomyelitis but is superior in delineating the bony margins of the foot.",
"id": "10035889",
"label": "c",
"name": "CT",
"picture": null,
"votes": 60
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. This is suggestive of a diagnosis of osteomyelitis which is much more common in diabetic patients with non-healing foot ulcers. MRI is the most sensitive imaging modality to confirm osteomyelitis.",
"id": "10035887",
"label": "a",
"name": "Magnetic resonance imaging",
"picture": null,
"votes": 1179
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This has little role in the direct assessment of osteomyelitis, as it is unable to visualise within the bone.",
"id": "10035890",
"label": "d",
"name": "Ultrasound",
"picture": null,
"votes": 161
}
],
"comments": [],
"concept": {
"__typename": "Concept",
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"__typename": "Chapter",
"explanation": null,
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"id": "2693",
"pictures": [],
"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6164",
"name": "Osteomyelitis",
"status": null,
"topic": {
"__typename": "Topic",
"id": "145",
"name": "Orthopaedics",
"typeId": 7
},
"topicId": 145,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 6164,
"conditions": [],
"difficulty": 1,
"dislikes": 3,
"explanation": null,
"highlights": [],
"id": "19581",
"isLikedByMe": 0,
"learningPoint": "Osteomyelitis frequently complicates diabetic foot ulcers, and MRI is the most sensitive imaging modality for its diagnosis.",
"likes": 2,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 67-year-old man with poorly controlled diabetes attends the emergency department with fever and severe pain overlying his left first toe. A diabetic foot ulcer is noted on inspection with surrounding erythema.\n\nWhat is the most appropriate imaging modality in this case?",
"sbaAnswer": [
"a"
],
"totalVotes": 1603,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,670 | false | 17 | null | 6,495,272 | null | false | [] | null | 19,582 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Osteomyelitis may present with severe systemic upset and it is possible the procedure introduced an infection, however, the absence of focal pain, fever, tachycardia and hypotension render septic shock secondary to osteomyelitis a less likely differential in this case.",
"id": "10035896",
"label": "e",
"name": "Osteomyelitis",
"picture": null,
"votes": 82
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an excellent differential in this case with acute onset breathlessness following surgery but the acute onset confusion and rash render this less likely. Some massive pulmonary emboli are associated with consumptive coagulopathy presenting as disseminated intravascular coagulation which could present as a diffuse petechial rash. The absence of bleeding and chest pain makes this less likely.",
"id": "10035893",
"label": "b",
"name": "Pulmonary embolism",
"picture": null,
"votes": 82
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is unlikely in this young gentleman with the absence of any chest pain and would not commonly present with any of the symptoms described in the vignette.",
"id": "10035895",
"label": "d",
"name": "ST Elevation Myocardial Infarction",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. This is suggestive of a diagnosis of fat embolism which may occur following trauma to the long bones and presents with a triad of hypoxia, confusion and petechial rash. It is treated with urgent thrombectomy.",
"id": "10035892",
"label": "a",
"name": "Fat embolism",
"picture": null,
"votes": 1419
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may well have occurred in the road traffic accident but should have been picked up in the primary survey and would not explain the confusion or rash.",
"id": "10035894",
"label": "c",
"name": "Traumatic pneumothorax",
"picture": null,
"votes": 11
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": null,
"files": null,
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"id": "2693",
"pictures": [],
"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6165",
"name": "Fat embolism",
"status": null,
"topic": {
"__typename": "Topic",
"id": "145",
"name": "Orthopaedics",
"typeId": 7
},
"topicId": 145,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 6165,
"conditions": [],
"difficulty": 1,
"dislikes": 1,
"explanation": null,
"highlights": [],
"id": "19582",
"isLikedByMe": 0,
"learningPoint": "Fat embolism syndrome typically presents with hypoxia, confusion, and a petechial rash following long bone fractures.",
"likes": 1,
"multiAnswer": null,
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"question": "A 23-year-old man is brought in by ambulance following a road traffic accident during which he fractured both femurs. He undergoes surgical fixation and is admitted to the orthopaedic ward where two days later he becomes suddenly dyspneoic and hypoxic, profoundly confused with a widespread petechial rash.\n\nWhat is the most likely diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 1594,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,671 | false | 18 | null | 6,495,272 | null | false | [] | null | 19,583 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be expected in ulnar nerve injury. Supracondylar fractures tend to cause radial nerve injuries which may present with wrist drop and sensory deficits.",
"id": "10035900",
"label": "d",
"name": "Ulnar claw on examination",
"picture": null,
"votes": 153
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would certainly be expected in cases of compartment syndrome in the lower limb, however, this child has sustained a supracondylar fracture, a common fracture in the upper limb in children therefore would not impact the lower limb.",
"id": "10035898",
"label": "b",
"name": "Pain on passive flexion of toes",
"picture": null,
"votes": 409
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is more in keeping with a fat embolism following a long bone fracture in an orthopaedic context.",
"id": "10035901",
"label": "e",
"name": "Petechial rash on examination",
"picture": null,
"votes": 42
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. This is suggestive of a diagnosis of compartment syndrome in the arm. In children, anxiety associated with increasing analgesic requirements, often necessitating opioid medications, is a reliable indicator of compartment syndrome which most commonly occurs following trauma and presents with severe pain, pallor, paraesthesia and in severe cases paralysis.",
"id": "10035897",
"label": "a",
"name": "Excessive use of breakthrough analgesia",
"picture": null,
"votes": 700
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may well occur in the late stages of compartment syndrome in the lower limb but the injury here is in the upper limb.",
"id": "10035899",
"label": "c",
"name": "Absence of dorsalis pedis pulse",
"picture": null,
"votes": 303
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": null,
"files": null,
"highlights": [],
"id": "2693",
"pictures": [],
"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "3903",
"name": "Compartment syndrome",
"status": null,
"topic": {
"__typename": "Topic",
"id": "145",
"name": "Orthopaedics",
"typeId": 7
},
"topicId": 145,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
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"conditions": [],
"difficulty": 1,
"dislikes": 15,
"explanation": null,
"highlights": [],
"id": "19583",
"isLikedByMe": 0,
"learningPoint": "Anxiety and increased analgesic requirements in a child after limb trauma may indicate compartment syndrome.",
"likes": 10,
"multiAnswer": null,
"pictures": [],
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"psaSectionId": null,
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"question": "A 7-year-old boy is brought to the emergency department following a road traffic accident with a traumatic supracondylar fracture. The fracture is reduced and a cast is placed. A few hours later he appears anxious and in pain. Examination demonstrates pallor and paraesthesia.\n\nWhich of the following is most likely to be observed in this patient?",
"sbaAnswer": [
"a"
],
"totalVotes": 1607,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,672 | false | 19 | null | 6,495,272 | null | false | [] | null | 19,584 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incredibly unlikely in this chronic case of joint pain and stiffness with no systemic upset.",
"id": "10035904",
"label": "c",
"name": "Septic arthritis",
"picture": null,
"votes": 2
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. This is suggestive of a diagnosis of frozen shoulder with shoulder pain, stiffness and limitations in primarily external rotation in a middle-aged diabetic.",
"id": "10035902",
"label": "a",
"name": "Adhesive capsulitis",
"picture": null,
"votes": 1476
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an excellent differential producing pain and reduced range of motion over a similar timeframe to adhesive capsulitis. Rotator cuff injuries are more likely in occupations where the arm is likely to be overused e.g. carpenter. The key distinction is that patients with rotator cuff injuries can typically lift their arms by themselves whereas patients with frozen shoulders typically need assistance.",
"id": "10035903",
"label": "b",
"name": "Supraspinatus tendinopathy",
"picture": null,
"votes": 108
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "An important differential to consider in chronic bone pain, however this typically occurs in younger patients and would not tend to cause such profound \"freezing\".",
"id": "10035906",
"label": "e",
"name": "Osteosarcoma",
"picture": null,
"votes": 10
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would likely occur acutely and secondary to trauma and would present with intense pain and a visible deformity.",
"id": "10035905",
"label": "d",
"name": "Anterior shoulder dislocation",
"picture": null,
"votes": 0
}
],
"comments": [],
"concept": {
"__typename": "Concept",
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"__typename": "Chapter",
"explanation": null,
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"id": "2693",
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"typeId": 7
},
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"entitlement": null,
"id": "4391",
"name": "Frozen shoulder",
"status": null,
"topic": {
"__typename": "Topic",
"id": "145",
"name": "Orthopaedics",
"typeId": 7
},
"topicId": 145,
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"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "19584",
"isLikedByMe": 0,
"learningPoint": "Adhesive capsulitis, or frozen shoulder, commonly presents with pain and stiffness, particularly in diabetics, affecting daily activities such as dressing.",
"likes": 1,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
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"psaSectionId": null,
"qaAnswer": null,
"question": "A 43-year-old diabetic woman attends the GP with a six-month history of left shoulder pain and stiffness with increasing difficulty in bathing and dressing on the left side, now requiring daily assistance. She denies trauma and works as a receptionist.\n\nWhich of the following is the most likely diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 1596,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,673 | false | 20 | null | 6,495,272 | null | false | [] | null | 19,585 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This case is likely to require assessment by orthopaedics and will likely require surgical washout, but the initial priority is joint aspiration.",
"id": "10035909",
"label": "c",
"name": "Surgical irrigation and debridement",
"picture": null,
"votes": 9
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Septic arthritis is an orthopaedic emergency and can cause permanent and severe damage to joints. Oral antibiotics are not appropriate and intravenous ones are required.",
"id": "10035911",
"label": "e",
"name": "Oral antibiotics",
"picture": null,
"votes": 8
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a last resort and not indicated at present.",
"id": "10035910",
"label": "d",
"name": "Above knee amputation",
"picture": null,
"votes": 3
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. This is suggestive of a diagnosis of septic arthritis with an acute red hot swollen joint. The sample is sent for culture, microscopy, gram staining and sensitivities.",
"id": "10035907",
"label": "a",
"name": "Joint aspirate",
"picture": null,
"votes": 1367
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "These will need to be initiated following joint aspirate.",
"id": "10035908",
"label": "b",
"name": "Intravenous antibiotics",
"picture": null,
"votes": 216
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Joint aspiration is not management, it is an investigation.",
"createdAt": 1737200469,
"dislikes": 1,
"id": "60859",
"isLikedByMe": 0,
"likes": 5,
"parentId": null,
"questionId": 19585,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Amnesia Contusion",
"id": 79228
}
},
{
"__typename": "QuestionComment",
"comment": "Wouldn't you complete sepsis 6 first? Especially if joint aspiration will delay abx?",
"createdAt": 1737986351,
"dislikes": 0,
"id": "61659",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 19585,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "rockinrobyn9",
"id": 28439
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"demo": null,
"entitlement": null,
"id": "4189",
"name": "Septic arthritis",
"status": null,
"topic": {
"__typename": "Topic",
"id": "145",
"name": "Orthopaedics",
"typeId": 7
},
"topicId": 145,
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"conditions": [],
"difficulty": 1,
"dislikes": 5,
"explanation": null,
"highlights": [],
"id": "19585",
"isLikedByMe": 0,
"learningPoint": "Septic arthritis presents with a warm, erythematous joint; joint aspiration is crucial for diagnosis and management.",
"likes": 1,
"multiAnswer": null,
"pictures": [],
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"qaAnswer": null,
"question": "A 75-year-old woman attends the emergency department with severe pain in her right knee with fever, lethargy and nausea. On examination, the knee joint is warm and erythematous.\n\nWhat is the most appropriate initial management?",
"sbaAnswer": [
"a"
],
"totalVotes": 1603,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,674 | false | 21 | null | 6,495,272 | null | false | [] | null | 19,586 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is the typical advice given for causes of postpartum mastitis not requiring antibiotics such as those not complicated by a nipple fissure.",
"id": "10035915",
"label": "d",
"name": "Encourage breastfeeding and expressing milk",
"picture": null,
"votes": 768
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. Cases of mastitis with a nipple fissure require antibiotic presentation.",
"id": "10035912",
"label": "a",
"name": "Prescribe flucloxacillin",
"picture": null,
"votes": 664
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This scenario is one of mastitis and does not warrant a two-week wait referral for suspected cancer at present. If the mastitis fails to improve with antibiotic treatment, breast cancer should be considered.",
"id": "10035914",
"label": "c",
"name": "Urgent two-week wait referral to a breast specialist",
"picture": null,
"votes": 58
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may form part of the management of a breast abscess. There is currently no evidence of an abscess developing.",
"id": "10035913",
"label": "b",
"name": "Urgent hospital admission for drainage",
"picture": null,
"votes": 69
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not appropriate as this case warrants treatment.",
"id": "10035916",
"label": "e",
"name": "Reassure",
"picture": null,
"votes": 38
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": null,
"files": null,
"highlights": [],
"id": "2693",
"pictures": [],
"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6090",
"name": "Mastitis",
"status": null,
"topic": {
"__typename": "Topic",
"id": "151",
"name": "Breast Disease",
"typeId": 7
},
"topicId": 151,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 6090,
"conditions": [],
"difficulty": 1,
"dislikes": 8,
"explanation": null,
"highlights": [],
"id": "19586",
"isLikedByMe": 0,
"learningPoint": "Mastitis in postpartum women, especially with nipple fissures, is commonly treated with flucloxacillin to address potential bacterial infection.",
"likes": 4,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 24-year-old woman comes to the GP with a painful erythematous left breast. She is 2 weeks postpartum. Inspection shows erythema and a nipple fissure in the left breast.\n\nWhat is the most appropriate management?",
"sbaAnswer": [
"a"
],
"totalVotes": 1597,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,675 | false | 22 | null | 6,495,272 | null | false | [] | null | 19,587 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may form part of the management of suspected breast cancer. The NICE guidelines recommend a two-week wait referral for suspected breast cancer for an unexplained breast lump in patients aged 30 or above.",
"id": "10035918",
"label": "b",
"name": "Urgent 2-week wait referral to a breast specialist",
"picture": null,
"votes": 260
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Some large fibroadenomas may be excised as per the patient's wishes.",
"id": "10035921",
"label": "e",
"name": "Refer for excision",
"picture": null,
"votes": 65
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. Fibroadenomas are common benign tumours of breast duct tissue. They are typically small and mobile within the breast tissue, and are not concerning. [NICE guidance](https://cks.nice.org.uk/topics/breast-cancer-recognition-referral/) advises to **consider** non-urgent referral in people aged under 30 years with an unexplained breast lump with or without pain, though not all lumps will be referred",
"id": "10035917",
"label": "a",
"name": "Reassure",
"picture": null,
"votes": 1262
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may be required in cases of mastitis which do not self-resolve or in which a nipple fissure is present.",
"id": "10035920",
"label": "d",
"name": "Prescribe oral antibiotics",
"picture": null,
"votes": 2
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may form part of the management of a breast abscess in primary care.",
"id": "10035919",
"label": "c",
"name": "Urgent same-day referral for incision and drainage",
"picture": null,
"votes": 1
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "I thought you send all possible fibroadenomas to 2ww and let the breast surgeons sort it out?",
"createdAt": 1717611576,
"dislikes": 2,
"id": "52032",
"isLikedByMe": 0,
"likes": 6,
"parentId": null,
"questionId": 19587,
"replies": [
{
"__typename": "QuestionComment",
"comment": "<30yr with breast lump is a routine referral",
"createdAt": 1719019063,
"dislikes": 0,
"id": "53472",
"isLikedByMe": 0,
"likes": 2,
"parentId": 52032,
"questionId": 19587,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Ambiguous Genitalia",
"id": 23718
}
},
{
"__typename": "QuestionComment",
"comment": "sba routine isnt an option - reassure\n",
"createdAt": 1736898129,
"dislikes": 0,
"id": "60620",
"isLikedByMe": 0,
"likes": 2,
"parentId": 52032,
"questionId": 19587,
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Malignant Syndrome",
"id": 15952
}
}
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"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Transplant Retrograde",
"id": 21860
}
},
{
"__typename": "QuestionComment",
"comment": "Refer no one has x ray eyes to just reassure this is a safety issue ",
"createdAt": 1719157745,
"dislikes": 0,
"id": "53628",
"isLikedByMe": 0,
"likes": 1,
"parentId": null,
"questionId": 19587,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Tyrosine Sclerosis",
"id": 31655
}
}
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"__typename": "Concept",
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"__typename": "Chapter",
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},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6166",
"name": "Fibroadenoma",
"status": null,
"topic": {
"__typename": "Topic",
"id": "151",
"name": "Breast Disease",
"typeId": 7
},
"topicId": 151,
"totalCards": null,
"typeId": null,
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"userNote": null,
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},
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"conditions": [],
"difficulty": 1,
"dislikes": 13,
"explanation": null,
"highlights": [],
"id": "19587",
"isLikedByMe": 0,
"learningPoint": "According to NICE guidelines, fibroadenomas should be assessed with clinical examination and imaging, and if they are asymptomatic and stable, routine monitoring is usually recommended, while biopsy or surgical removal may be considered for large, painful, or uncertain cases.",
"likes": 2,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 24-year-old woman comes to the GP worried about a breast lump. Examination reveals a smooth, round 1cm lump in the left breast which is mobile and painless.\n\nWhat is the most appropriate management?",
"sbaAnswer": [
"a"
],
"totalVotes": 1590,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,676 | false | 23 | null | 6,495,272 | null | false | [] | null | 19,588 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. This scenario describes rapid breast changes with a \"peau d'orange\" appearance most in keeping with inflammatory breast cancer, a fast-growing, aggressive form of breast cancer.",
"id": "10035922",
"label": "a",
"name": "Inflammatory breast cancer",
"picture": null,
"votes": 1422
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "These are benign breast lumps which are small, mobile and painless.",
"id": "10035925",
"label": "d",
"name": "Fibroadenoma",
"picture": null,
"votes": 20
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Inflammatory breast cancer is often misdiagnosed as mastitis, which more typically affects younger lactating women. The appearances in the vignette are more in keeping with breast cancer as opposed to mastitis. In equivocal cases, inflammatory breast cancer should be considered in cases of mastitis which do not respond to antibiotics.",
"id": "10035923",
"label": "b",
"name": "Mastitis",
"picture": null,
"votes": 111
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is breast pain that is associated with the menstrual cycle due to hormonal variation and can cause lumpiness and breast swelling but this would follow a menstrual history and would not cause the profound appearance changes that are described.",
"id": "10035924",
"label": "c",
"name": "Cyclical mastalgia",
"picture": null,
"votes": 12
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "These are benign tumours of fat (adipose) tissue which can occur in the breasts and tend to be painless, and mobile with no skin changes.",
"id": "10035926",
"label": "e",
"name": "Lipoma",
"picture": null,
"votes": 19
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": null,
"files": null,
"highlights": [],
"id": "2693",
"pictures": [],
"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "3779",
"name": "Breast Cancer",
"status": null,
"topic": {
"__typename": "Topic",
"id": "151",
"name": "Breast Disease",
"typeId": 7
},
"topicId": 151,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3779,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "19588",
"isLikedByMe": null,
"learningPoint": "Inflammatory breast cancer presents with rapid swelling, skin dimpling, erythema, and oedema, often resembling \"peau d'orange\".",
"likes": 0,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 48-year-old woman attends the GP worried about a swelling in her left breast which started a week ago. Inspection reveals a swollen painful left breast with significant skin dimpling and erythema with overlying oedema and nipple inversion.\n\nWhat is the most likely diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 1584,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,677 | false | 24 | null | 6,495,272 | null | false | [] | null | 19,589 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. Case-control studies are the most efficient design for rare diseases to investigate exposures as known cases of DiGeorge syndrome can be matched to controls and retrospectively investigated.",
"id": "10035927",
"label": "a",
"name": "Case-Control study",
"picture": null,
"votes": 754
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Cohort studies are not efficient as they involve splitting people by exposures and following them up over time to assess whether a given outcome occurs. If a disease occurs very infrequently, you would have to follow a large group of people for a long period to accrue enough incident cases to study, which is both very time- and resource-intensive.",
"id": "10035928",
"label": "b",
"name": "Cohort study",
"picture": null,
"votes": 576
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This study design involves surveying people at a particular point in time to gather a range of opinions on a particular topic and would not be suitable for assessing temporal exposures.",
"id": "10035930",
"label": "d",
"name": "Cross-sectional study",
"picture": null,
"votes": 213
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an interventional study design which splits cases of interest into treatment and control groups and follows them over time to assess outcomes. This study design is not an observational study.",
"id": "10035929",
"label": "c",
"name": "Randomised controlled trial",
"picture": null,
"votes": 43
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Expert opinions may well prove valuable in guiding study design but are very low down the hierarchy of evidence and there may exist significant disagreement before the development of rigorous studies.",
"id": "10035931",
"label": "e",
"name": "Expert witness interviewing",
"picture": null,
"votes": 12
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": null,
"files": null,
"highlights": [],
"id": "2693",
"pictures": [],
"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6167",
"name": "Study Design",
"status": null,
"topic": {
"__typename": "Topic",
"id": "335",
"name": "Social and population health",
"typeId": 7
},
"topicId": 335,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 6167,
"conditions": [],
"difficulty": 1,
"dislikes": 1,
"explanation": null,
"highlights": [],
"id": "19589",
"isLikedByMe": 0,
"learningPoint": "Case-control studies are ideal for investigating rare diseases like DiGeorge syndrome by comparing known cases with matched controls for exposure history.",
"likes": 1,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A researcher is attempting to design a study which investigates gestational risk factors for the development of DiGeorge syndrome, which has an incidence of 1 in 6000.\n\nWhat is the most optimal study design in this case?",
"sbaAnswer": [
"a"
],
"totalVotes": 1598,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,678 | false | 25 | null | 6,495,272 | null | false | [] | null | 19,590 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "NICE advises sending an urgent CA-125 and/or performing ultrasound in cases of new onset IBS, early satiety, abdominal bloating, pelvic pain and urinary frequency. In cases of ascites, an urgent two-week wait referral is the priority as the likelihood of cancer is increased.",
"id": "10035933",
"label": "b",
"name": "Urgent CA-125",
"picture": null,
"votes": 782
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. This scenario is suspicious for ovarian cancer with abdominal bloating and pelvic pain. The presence of ascites on initial examination circumvents the need for an initial CA-125 before referral (although it would likely be performed alongside the referral in practice).",
"id": "10035932",
"label": "a",
"name": "Urgent 2-week wait gynaecology referral",
"picture": null,
"votes": 660
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This scenario is more suspicious for ovarian pathology than malignancy within the renal tract which is more likely to present with haematuria.",
"id": "10035935",
"label": "d",
"name": "Urgent renal tract imaging",
"picture": null,
"votes": 8
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is very inappropriate as the patient has signs and symptoms which are concerning of possible metastatic ovarian malignancy and needs urgent investigation.",
"id": "10035936",
"label": "e",
"name": "Reassure",
"picture": null,
"votes": 2
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "NICE advises sending an urgent CA-125 and/or performing ultrasound in cases of new onset IBS, early satiety, abdominal bloating, pelvic pain and urinary frequency. In cases of ascites, an urgent two-week wait referral is the priority as the likelihood of cancer is increased.",
"id": "10035934",
"label": "c",
"name": "Urgent abdominal ultrasound",
"picture": null,
"votes": 137
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": null,
"files": null,
"highlights": [],
"id": "2693",
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"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6168",
"name": "Ovarian Cancer",
"status": null,
"topic": {
"__typename": "Topic",
"id": "333",
"name": "Obstetrics and Gynaecology",
"typeId": 7
},
"topicId": 333,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 6168,
"conditions": [],
"difficulty": 1,
"dislikes": 28,
"explanation": null,
"highlights": [],
"id": "19590",
"isLikedByMe": 0,
"learningPoint": "Abdominal bloating, pelvic pain, and ascites in women over 50 warrant urgent gynaecology referral due to potential ovarian cancer.",
"likes": 7,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 54-year-old woman attends the GP with abdominal bloating, pelvic pain and urinary frequency. She reports these symptoms have been bothersome for the last two months. Examination reveals abdominal distension with shifting dullness, with no masses felt.\n\nWhat is the most appropriate management?",
"sbaAnswer": [
"a"
],
"totalVotes": 1589,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,679 | false | 26 | null | 6,495,272 | null | false | [] | null | 19,591 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a deformity of the hand due to thickening and fibrosis of the palmar aponeurosis and eventual contracture of the 4th and 5th digits. It is not associated with brachial plexus injury but is more commonly associated with alcoholism.",
"id": "10035939",
"label": "c",
"name": "Duputyren's contracture",
"picture": null,
"votes": 11
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is characterised by the extension of the second and third fingers and the abduction of the first finger, typically resulting from a median nerve injury affecting finger flexion. Shoulder dystocia is most commonly associated with Erb's palsy.",
"id": "10035940",
"label": "d",
"name": "Hand of benediction",
"picture": null,
"votes": 37
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. The most common kind of brachial plexus injury in shoulder dystocia is Erb's Palsy, an upper brachial plexus injury affecting C5/6. Erb's palsy presents with a flexed and adducted wrist and, extended and internally rotated arm, due to loss of the lateral rotators of the shoulder, arm flexors, and hand extensor muscles.",
"id": "10035937",
"label": "a",
"name": "Waiter's tip appearance",
"picture": null,
"votes": 1267
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "In partial ulnar claw, only certain fingers exhibit the characteristic claw-like deformity, typically the fourth and fifth fingers. This occurs due to weakness or paralysis of the intrinsic hand muscles supplied by the ulnar nerve, leading to the inability to extend these fingers fully.",
"id": "10035938",
"label": "b",
"name": "Partial claw hand",
"picture": null,
"votes": 88
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Wrist drop is a condition characterised by the inability to extend the wrist and fingers due to radial nerve palsy, resulting in a partially flexed wrist and difficulty with hand movements. Shoulder dystocia is most commonly associated with Erb's palsy.",
"id": "10035941",
"label": "e",
"name": "Wrist drop",
"picture": null,
"votes": 181
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": null,
"files": null,
"highlights": [],
"id": "2693",
"pictures": [],
"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6169",
"name": "Shoulder dystocia",
"status": null,
"topic": {
"__typename": "Topic",
"id": "333",
"name": "Obstetrics and Gynaecology",
"typeId": 7
},
"topicId": 333,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 6169,
"conditions": [],
"difficulty": 1,
"dislikes": 2,
"explanation": null,
"highlights": [],
"id": "19591",
"isLikedByMe": 0,
"learningPoint": "Erb's Palsy, a common complication of shoulder dystocia, results in a characteristic 'waiter's tip' arm position due to upper brachial plexus injury.",
"likes": 0,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 30-year-old primigravida woman goes into labour in the delivery suite. The delivery is difficult and the labour is prolonged. The head is delivered but, shortly thereafter, the anterior shoulder is stuck.\n\nWhich of the following is the baby at risk of developing?",
"sbaAnswer": [
"a"
],
"totalVotes": 1584,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,680 | false | 27 | null | 6,495,272 | null | false | [] | null | 19,592 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The patient would like oral contraceptives which have higher success rates than barrier methods.",
"id": "10035946",
"label": "e",
"name": "Advise barrier methods",
"picture": null,
"votes": 100
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The patient does not want long-term options. IUC can be safely inserted immediately after birth (within 10 minutes of delivery of the placenta) or within the first 48 hours after uncomplicated caesarean section or vaginal birth as per the FSRH.",
"id": "10035945",
"label": "d",
"name": "Offer intrauterine device insertion",
"picture": null,
"votes": 19
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The Lactational Amenorrhea Method is suitable for fully or almost fully breastfeeding mothers who experience amenorrhea. It relies on exclusive breastfeeding to suppress ovulation. It can be highly effective but relies on factors such as strict adherence to breastfeeding alone. In this case, this patient has asked for contraception.",
"id": "10035944",
"label": "c",
"name": "Advise no contraception is needed until 6 months due to breastfeeding",
"picture": null,
"votes": 271
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "As per the FSRH, the combined hormonal contraceptive pill should not be restarted until 6 weeks postpartum in breastfeeding women.",
"id": "10035943",
"label": "b",
"name": "Offer the combined hormonal contraceptive pill",
"picture": null,
"votes": 110
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. According to the FSRH, the progesterone-only pill can be started at any time after childbirth, including immediately after delivery. No contraception is required in the first three weeks after birth.",
"id": "10035942",
"label": "a",
"name": "Offer the progesterone-only pill",
"picture": null,
"votes": 1082
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "if she has said she wants to combined oral contraceptive .. would you still give the POP? ",
"createdAt": 1738433732,
"dislikes": 0,
"id": "62089",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 19592,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Hypertension Kinase",
"id": 8318
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": null,
"files": null,
"highlights": [],
"id": "2693",
"pictures": [],
"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6170",
"name": "Post-partum contraception",
"status": null,
"topic": {
"__typename": "Topic",
"id": "333",
"name": "Obstetrics and Gynaecology",
"typeId": 7
},
"topicId": 333,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 6170,
"conditions": [],
"difficulty": 1,
"dislikes": 8,
"explanation": null,
"highlights": [],
"id": "19592",
"isLikedByMe": 0,
"learningPoint": "The progesterone-only pill is the recommended contraceptive method for breastfeeding women postpartum, as it can be initiated anytime after childbirth.",
"likes": 2,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 30-year-old woman attends the GP enquiring about postpartum contraception as she gave birth three weeks ago. She is breastfeeding and does not want any long-term contraceptive options. She was on the combined oral contraceptive pill before conceiving and tolerated it well and would like to restart it.\n\nWhat is the most appropriate management?",
"sbaAnswer": [
"a"
],
"totalVotes": 1582,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,681 | false | 28 | null | 6,495,272 | null | false | [] | null | 19,593 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Cases of cord prolapse require emergency caesarean section due to the risk of foetal compromise.",
"id": "10035948",
"label": "b",
"name": "Take to theatre for assisted delivery",
"picture": null,
"votes": 96
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. This is a case of cord prolapse which has a high morbidity and mortality with potential foetal compromise. The presenting part should be elevated to relieve cord compression and an immediate C-section performed.",
"id": "10035947",
"label": "a",
"name": "Emergency caesarean section",
"picture": null,
"votes": 1465
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an option for induction of labour and is not appropriate here when urgent intervention is required.",
"id": "10035950",
"label": "d",
"name": "Insert prostaglandin pessary",
"picture": null,
"votes": 4
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incredibly inappropriate in this maternal and foetal emergency.",
"id": "10035951",
"label": "e",
"name": "Reassure and discharge",
"picture": null,
"votes": 2
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is inappropriate. The CTG findings are extremely concerning and this is an obstetric emergency which needs to be acted upon promptly to minimise risk to the foetus.",
"id": "10035949",
"label": "c",
"name": "Continue CTG monitoring and await events",
"picture": null,
"votes": 6
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": null,
"files": null,
"highlights": [],
"id": "2693",
"pictures": [],
"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6171",
"name": "Cord Prolapse",
"status": null,
"topic": {
"__typename": "Topic",
"id": "333",
"name": "Obstetrics and Gynaecology",
"typeId": 7
},
"topicId": 333,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 6171,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "19593",
"isLikedByMe": 0,
"learningPoint": "Cord prolapse occurs when the umbilical cord slips ahead of or alongside the baby during delivery, which can compress the cord and reduce blood and oxygen supply to the baby, making an emergency C-section necessary to prevent complications.",
"likes": 3,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 32-year-old G2P1 pregnant woman, at 39 weeks gestation, presents to the maternity assessment unit ward with sudden onset severe vaginal discomfort. On examination, the umbilical cord is palpable alongside the presenting part of the foetus. CTG reveals sudden onset foetal bradycardia.\n\nWhat is the most appropriate management?",
"sbaAnswer": [
"a"
],
"totalVotes": 1573,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,682 | false | 29 | null | 6,495,272 | null | false | [] | null | 19,594 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "These are screening blood tests which can help inform whether invasive test is needed. AFP and PAPP-a are typically lower in Down's Syndrome pregnancies and serum HCG is typically higher.",
"id": "10035956",
"label": "e",
"name": "AFP, PAPP-a and serum HCG",
"picture": null,
"votes": 375
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a screening test which measures the thickness of a fluid-filled space at the back of the baby's neck during the first-trimester ultrasound. An increased translucency measurement may indicate a higher risk of certain chromosomal abnormalities, prompting further diagnostic testing such as chorionic villus sampling (CVS) or amniocentesis for confirmation.",
"id": "10035955",
"label": "d",
"name": "Nuchal translucency scan",
"picture": null,
"votes": 159
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Later in pregnancy, this may give evidence related to congenital heart defects related to Down's Syndrome, but would not be diagnostic in and of itself.",
"id": "10035954",
"label": "c",
"name": "Echocardiogram",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. This an invasive test to definitively diagnose Down's Syndrome by taking a small sample of placental tissue (chorionic villi) from the uterus, usually through the cervix or the abdomen. It is performed between 11 and 14 weeks.",
"id": "10035952",
"label": "a",
"name": "Chorionic villous sampling",
"picture": null,
"votes": 704
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an invasive test to definitively diagnose Down's Syndrome by inserting a thin needle through the abdomen into the uterus to withdraw a small amount of amniotic fluid surrounding the foetus, which is then analysed. It is performed after 15 weeks of gestation.",
"id": "10035953",
"label": "b",
"name": "Amniocentesis",
"picture": null,
"votes": 345
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": null,
"files": null,
"highlights": [],
"id": "2693",
"pictures": [],
"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6172",
"name": "Down's Syndrome",
"status": null,
"topic": {
"__typename": "Topic",
"id": "333",
"name": "Obstetrics and Gynaecology",
"typeId": 7
},
"topicId": 333,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 6172,
"conditions": [],
"difficulty": 1,
"dislikes": 3,
"explanation": null,
"highlights": [],
"id": "19594",
"isLikedByMe": 0,
"learningPoint": "Chorionic villus sampling is an invasive procedure used for definitive prenatal diagnosis of Down's Syndrome between 11 and 14 weeks of gestation.",
"likes": 1,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 45-year-old multigravida presents to the antenatal clinic worried about the risk of her child developing Down’s Syndrome. She would like a definitive test performed. She is 13 weeks pregnant.\n\nWhich of the following is the most appropriate investigation to order?",
"sbaAnswer": [
"a"
],
"totalVotes": 1583,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,683 | false | 30 | null | 6,495,272 | null | false | [] | null | 19,595 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst bisphosphonates may well be used in the treatment of bone metastases, stopping the patient's pain relief is unnecessary and agonising for the patient",
"id": "10035960",
"label": "d",
"name": "Stop all pain relief and start pamidronate",
"picture": null,
"votes": 51
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The current regimen is not sufficient to control her pain as she has used 5 breakthrough doses in a day, it needs to be increased.",
"id": "10035961",
"label": "e",
"name": "Continue with the same dose of morphine",
"picture": null,
"votes": 12
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst radiotherapy is a treatment option for bone metastases, this will likely require careful planning and may not occur immediately, stopping the patient's pain relief is unnecessary and agonising for the patient.",
"id": "10035959",
"label": "c",
"name": "Stop all pain relief and refer for radiotherapy",
"picture": null,
"votes": 98
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may be overzealous at this stage as we are more than doubling her current pain relief and we must titrate up to find the optimal regimen for the patient. High doses of opioids can be associated with greater side effects profile including respiratory depression.",
"id": "10035958",
"label": "b",
"name": "Increase morphine sulfate to 120mg BD with 40mg oramorph breakthrough dose",
"picture": null,
"votes": 117
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. The patient's regular analgesia regimen is not strong enough. The patient has used 60mg + 6(10mg = 1/6th of her total 120mg for breakthrough dose)= 120mg in a day. Therefore her new regimen should include 120mg as regular pain relief with a breakthrough dose of 1/6th of 120=20mg of oramorph.",
"id": "10035957",
"label": "a",
"name": "Increase morphine sulfate to 60mg BD with 20mg oramorph breakthrough dose",
"picture": null,
"votes": 1289
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "I thought you're meant to increase by 30-50%",
"createdAt": 1736720005,
"dislikes": 0,
"id": "60378",
"isLikedByMe": 0,
"likes": 5,
"parentId": null,
"questionId": 19595,
"replies": [],
"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Medstudent01",
"id": 67545
}
}
],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": null,
"files": null,
"highlights": [],
"id": "2693",
"pictures": [],
"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6029",
"name": "WHO Pain Ladder",
"status": null,
"topic": {
"__typename": "Topic",
"id": "225",
"name": "Oncology and Palliative Care",
"typeId": 7
},
"topicId": 225,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 6029,
"conditions": [],
"difficulty": 1,
"dislikes": 6,
"explanation": null,
"highlights": [],
"id": "19595",
"isLikedByMe": 0,
"learningPoint": "Breakthrough analgesia should typically be dosed at 1/6th of the total daily dose of the patient’s regular pain medication to provide relief for episodes of severe pain between regular doses.",
"likes": 2,
"multiAnswer": null,
"pictures": [],
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"qaAnswer": null,
"question": "A 69-year-old woman with metastatic breast cancer is admitted to the oncology ward due to new bony metastases causing her an incredible degree of pain. She is commenced on co-codamol, ibuprofen and morphine sulfate (Continus) 30mg BD. She has used 6 breakthrough doses in the last 24 hours.\n\nWhat is the most appropriate management of her pain relief?",
"sbaAnswer": [
"a"
],
"totalVotes": 1567,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,684 | false | 31 | null | 6,495,272 | null | false | [] | null | 19,596 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not appropriate or required here. Variable rate infusion is typically used peri-operatively or in medical patients who are not eating and drinking with erratic blood sugars.",
"id": "10035966",
"label": "e",
"name": "Switch to variable rate insulin infusion",
"picture": null,
"votes": 421
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Insulin may need to be continued depending on his blood sugar control, this should be explored as opposed to immediately stopped.",
"id": "10035963",
"label": "b",
"name": "Stop all diabetic medications",
"picture": null,
"votes": 285
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. The guidance related to diabetic management in end-of-life is primarily focused on symptom control as opposed to preventing long-term complications. Therefore, oral hypoglycaemics can be stopped and stopping insulin should be considered based on how erratic the control is. It is important to avoid symptomatic hyperglycaemia in end-of-life patients as this can be bothersome.",
"id": "10035962",
"label": "a",
"name": "Stop all oral hypoglycaemics and consider whether insulin can be stopped",
"picture": null,
"votes": 795
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is important to endeavour to honour patient wishes when the guidelines allow you to, particularly in palliative patients at the end of their life.",
"id": "10035965",
"label": "d",
"name": "Continue all diabetic medications",
"picture": null,
"votes": 42
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not in keeping with guidance related to diabetes management at the end of life which advises stopping oral hypoglycaemics.",
"id": "10035964",
"label": "c",
"name": "Stop insulin but continue oral hypoglycaemics",
"picture": null,
"votes": 37
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "So continue giving the dying man his insulin despite him not wanting it? Will I hold him down while we give it? ",
"createdAt": 1719257081,
"dislikes": 3,
"id": "53717",
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"id": "6094",
"name": "End of Life Care Medications",
"status": null,
"topic": {
"__typename": "Topic",
"id": "225",
"name": "Oncology and Palliative Care",
"typeId": 7
},
"topicId": 225,
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"learningPoint": "In palliative care, it is often recommended to stop all oral hypoglycemics and consider whether insulin therapy can be discontinued, as the focus shifts to comfort and quality of life rather than strict blood glucose control.",
"likes": 0,
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"question": "A 76-year-old gentleman with metastatic colon cancer is dying in the oncology ward and in his last few days of life. He has poorly controlled type 2 diabetes mellitus and takes multiple medications including insulin and asks if his diabetic medications can be stopped.\n\nWhat is the most appropriate management?",
"sbaAnswer": [
"a"
],
"totalVotes": 1580,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,685 | false | 32 | null | 6,495,272 | null | false | [] | null | 19,597 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This presentation of an indolent, incidentally-diagnosed haematological malignancy presenting with an acute illness is characteristic of Richter's transformation of CLL to non-Hodgkin lymphoma (typically diffuse large B cell lymphoma). The history of being diagnosed with a haematological malignancy incidentally that was not actively treated is not typical of an initial diagnosis of acute leukaemia.",
"id": "10035969",
"label": "c",
"name": "Acute Lymphocytic Leukaemia (ALL)",
"picture": null,
"votes": 19
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "While hairy cell leukaemia is indolent and is usually not actively treated, it rarely transforms into an acute lymphoma/leukaemia. This presentation of an indolent, incidentally-diagnosed haematological malignancy presenting with an acute illness is characteristic of Richter's transformation of CLL to a non-Hodgkin lymphoma (typically diffuse large B cell lymphoma).",
"id": "10035971",
"label": "e",
"name": "Hairy cell leukaemia",
"picture": null,
"votes": 26
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This presentation of an indolent, incidentally-diagnosed haematological malignancy presenting with an acute illness is characteristic of Richter's transformation of CLL to a non-Hodgkin lymphoma (typically diffuse large B cell lymphoma). The history of being diagnosed with a haematological malignancy incidentally that was not actively treated is not typical of an initial diagnosis of acute leukaemia.",
"id": "10035970",
"label": "d",
"name": "Acute Myeloid Leukaemia (AML)",
"picture": null,
"votes": 78
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This presentation of an indolent, incidentally-diagnosed haematological malignancy presenting with an acute illness is characteristic of Richter's transformation of CLL to a non-Hodgkin lymphoma (typically diffuse large B cell lymphoma). This patient requires hospital admission and treatment with chemotherapy.",
"id": "10035967",
"label": "a",
"name": "Chronic Lymphocytic Leukaemia (CLL)",
"picture": null,
"votes": 851
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "While CML can enter the blast phase and transform into acute myeloid leukaemia, it would not be typical for a patient with CML to receive no treatment; a JAK inhibitor such as imatinib would usually be prescribed. This presentation of an indolent, incidentally-diagnosed haematological malignancy presenting with an acute illness is characteristic of Richter's transformation of CLL to a non-Hodgkin lymphoma (typically diffuse large B cell lymphoma). This patient requires hospital admission and treatment with chemotherapy.",
"id": "10035968",
"label": "b",
"name": "Chronic Myeloid Leukaemia (CML)",
"picture": null,
"votes": 603
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "anyone have any mnemonics to remember all cml etc\n\n",
"createdAt": 1720277019,
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"__typename": "QuestionComment",
"comment": "This may sound stupid but: ALL is ALL kids (the most common in childhood), AML= acute in nature, and if you inverse the M it looks like a W so AW (AWr rods or Auer rods), CLL contains Smudge cells (if your write cll in lower case it can look non-descript/smudged) and you want to put the RICH(ters) in a CeLL (richters transformation). ",
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"name": "Chronic Lymphocytic Leukaemia (CLL)",
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"__typename": "Topic",
"id": "157",
"name": "Haematology",
"typeId": 7
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"learningPoint": "Chronic Lymphocytic Leukaemia can transform into aggressive non-Hodgkin lymphoma, presenting with acute symptoms like fever and weight loss.",
"likes": 5,
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"question": "A 79-year-old man visits his general practitioner with fevers and significant weight loss after returning from a prolonged stay in Asia. He reports that he was diagnosed with a type of 'blood cancer' three years ago after a routine blood test, but has been very well and has not received any treatment for his condition.\n\nOn examination, he looks unwell and is cachectic. Firm, rubbery lymph nodes are palpated in the mandible and his spleen is enlarged.\n\nWhich haematological malignancy is he most likely to have been initially diagnosed with?",
"sbaAnswer": [
"a"
],
"totalVotes": 1577,
"typeId": 1,
"userPoint": null
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173,468,686 | false | 33 | null | 6,495,272 | null | false | [] | null | 19,598 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has a macrocytic anaemia that is likely multifactorial given her B12 deficiency, folate deficiency, history of alcohol use, and liver disease. She requires correction of her B12 and folate levels to help with her symptoms. B12 should be repleted before folic acid is administered due to the small risk of precipitating subacute combined degeneration of the spinal cord or worsening peripheral neuropathy.",
"id": "10035972",
"label": "a",
"name": "Start B12 supplements",
"picture": null,
"votes": 1329
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Macrocytosis and haematinic deficiencies are common in gastroenterology/hepatology settings. Unless the patient fails to respond to therapy or there are other concerns, a haematology referral is not warranted.",
"id": "10035976",
"label": "e",
"name": "Refer to haematology",
"picture": null,
"votes": 116
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may be a useful step in the holistic management of her chronic liver disease, but is not the most appropriate next step.",
"id": "10035975",
"label": "d",
"name": "Refer to dieticians",
"picture": null,
"votes": 15
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "While the patient is anaemic, she has multifactorial macrocytic anaemia and normal ferritin levels. There is currently no evidence of iron deficiency. She should be prescribed vitamin B12, followed by folic acid.",
"id": "10035974",
"label": "c",
"name": "Start iron supplements",
"picture": null,
"votes": 4
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has a macrocytic anaemia that is likely multifactorial given her B12 deficiency, folate deficiency, history of alcohol use, and liver disease. She requires correction of her B12 and folate levels to help with her symptoms. B12 should be repleted before folic acid is administered due to the small risk of precipitating subacute combined degeneration of the spinal cord or worsening peripheral neuropathy.",
"id": "10035973",
"label": "b",
"name": "Start folate supplements",
"picture": null,
"votes": 107
}
],
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},
"chapterId": 2693,
"demo": null,
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"id": "6174",
"name": "Macrocytic Anaemia",
"status": null,
"topic": {
"__typename": "Topic",
"id": "157",
"name": "Haematology",
"typeId": 7
},
"topicId": 157,
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"dislikes": 2,
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"id": "19598",
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"learningPoint": "Macrocytic anaemia in patients with alcohol-related liver disease often indicates deficiencies in vitamin B12 and folate, necessitating appropriate supplementation.",
"likes": 0,
"multiAnswer": null,
"pictures": [],
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"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 43-year-old female is seen in an outpatient clinic for a follow-up of her alcohol-related liver disease. She reports being abstinent from alcohol for three months and has not experienced any episodes of decompensation. However, she reports feeling tired all the time.\n\nExamination of her gastrointestinal system is normal. Routine blood tests show:\n\n| | | |\n| -------------- | :-------: | --------------- |\n| Haemoglobin | 98 g/L | (M) 130 - 170, (F) 115 - 155 |\n| White Cell Count | 4.3 x10<sup>9</sup>/L | 3.0 - 10.0 |\n| Platelets | 72 x10<sup>9</sup>/L | 150 - 400 |\n| Mean Cell Volume (MCV) | 112 fL | 80 - 96 |\n\n| | | |\n| --------------------------- | :-------: | ------------------------------ |\n| Serum Vitamin B12 | 50 ng/L | 160 - 925 |\n| Serum Folate | 1.9 μg/L | (3 - 15 |\n| Ferritin | 173 μg/L | 12 - 200 |\n\nWhat is the most appropriate next step in management?",
"sbaAnswer": [
"a"
],
"totalVotes": 1571,
"typeId": 1,
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} | MarksheetMark |
173,468,687 | false | 34 | null | 6,495,272 | null | false | [] | null | 19,599 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Acute cholangitis may rarely cause a mild coagulopathy due to cholestasis, however, the history of an infection causing sepsis and profound coagulopathy is more in keeping with DIC.",
"id": "10035981",
"label": "e",
"name": "Liver dysfunction",
"picture": null,
"votes": 24
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "HELLP (Haemolysis, Elevated Liver enzymes and Low Platelets) syndrome is a life-threatening pregnancy complication that may occur in the late second/third trimesters of pregnancy. It is often associated with pre-eclampsia/eclampsia.",
"id": "10035980",
"label": "d",
"name": "HELLP syndrome",
"picture": null,
"votes": 28
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Evolving coagulopathy and oozing at line sites/mucosal bleeding in the context of an acute illness should raise suspicions of DIC. A blood film, d-dimer, and fibrinogen levels would be useful to confirm the diagnosis.",
"id": "10035977",
"label": "a",
"name": "Disseminated intravascular coagulation (DIC)",
"picture": null,
"votes": 1422
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "HUS causes microangiopathic haemolytic anaemia like DIC, however, it often presents after infection with a Shiga-toxin-associated E. coli strain. Patients with HUS may present with bloody diarrhoea. Sepsis followed by coagulopathy is more typical of DIC than HUS.",
"id": "10035979",
"label": "c",
"name": "Haemolytic uraemic syndrome (HUS)",
"picture": null,
"votes": 50
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "TTP causes microangiopathic haemolytic anaemia like DIC, however it often presents with renal dysfunction and neurological signs. Intercurrent sepsis makes DIC a more likely diagnosis. Further, deranged PT/APTT are more commonly seen in DIC than TTP.",
"id": "10035978",
"label": "b",
"name": "Thrombotic thrombocytopenic purpura (TTP)",
"picture": null,
"votes": 47
}
],
"comments": [],
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"__typename": "Chapter",
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},
"chapterId": 2693,
"demo": null,
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"id": "6175",
"name": "Disseminated intravascular coagulation (DIC)",
"status": null,
"topic": {
"__typename": "Topic",
"id": "157",
"name": "Haematology",
"typeId": 7
},
"topicId": 157,
"totalCards": null,
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"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "19599",
"isLikedByMe": null,
"learningPoint": "Disseminated intravascular coagulation (DIC) presents with coagulopathy and bleeding in the context of severe systemic illness.",
"likes": 0,
"multiAnswer": null,
"pictures": [],
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"psaSectionId": null,
"qaAnswer": null,
"question": "An 82-year-old man is admitted to hospital with right upper quadrant pain, jaundice, and fevers. A CT abdomen shows evidence of cholangitis and he is admitted for antibiotics and a planned ERCP.\n\nRoutine clotting studies show a mildly prolonged prothrombin time and mild thrombocytopenia.\n\nOver the day, he becomes profoundly septic and it is noted that he is bleeding from his cannula site. Repeat blood tests show worsening thrombocytopenia and coagulopathy, as well as new anaemia.\n\nWhat is the most likely diagnosis?",
"sbaAnswer": [
"a"
],
"totalVotes": 1571,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,688 | false | 35 | null | 6,495,272 | null | false | [] | null | 19,600 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "As direct pressure and ice packs have not resolved the bleeding, the next step would be to insert a nasal pack to tamponade the bleeding. As a bleeding point cannot be visualised, direct cautery is not appropriate. If packing fails to stem the bleeding or the patient becomes unstable, more invasive management (e.g. arterial ligation/embolisation) may be required.",
"id": "10035982",
"label": "a",
"name": "Anterior nasal packing",
"picture": null,
"votes": 1397
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "As direct pressure and ice packs have not resolved the bleeding, the next step would be to insert a nasal pack to tamponade the bleeding. If packing fails to stem the bleeding or the patient becomes unstable, more invasive management (e.g. arterial ligation/embolisation) may be required.",
"id": "10035983",
"label": "b",
"name": "Embolisation of the sphenopalatine artery",
"picture": null,
"votes": 33
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "As no bleeding point can be identified, there is currently no target to cauterise. A nasal pack should be inserted to tamponade the bleeding.",
"id": "10035984",
"label": "c",
"name": "Silver nitrate cautery",
"picture": null,
"votes": 114
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "As direct pressure and ice packs have not resolved the bleeding, the next step would be to insert a nasal pack to tamponade the bleeding. If packing fails to stem the bleeding or the patient becomes unstable, more invasive management (e.g. arterial ligation/embolisation) may be required.",
"id": "10035986",
"label": "e",
"name": "Ligation of the anterior ethmoidal artery",
"picture": null,
"votes": 21
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is unlikely to help as she has already applied pressure for over 30 minutes. A nasal pack should be inserted to tamponade the bleeding.",
"id": "10035985",
"label": "d",
"name": "Apply increased pressure for 30 minutes",
"picture": null,
"votes": 10
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "How long do we wait for the bleeding to stop after anterior nasal packing?",
"createdAt": 1735329510,
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"id": "6176",
"name": "Epistaxis",
"status": null,
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"__typename": "Topic",
"id": "138",
"name": "Ear, Nose & Throat",
"typeId": 7
},
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"highlights": [],
"id": "19600",
"isLikedByMe": null,
"learningPoint": "In cases of persistent epistaxis where the bleeding point is not visible, anterior nasal packing is the appropriate management step.",
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"question": "A 14-year-old girl is sent to the emergency department by her GP with a continuous nosebleed. She is advised to apply pressure on the way to the hospital and an ice pack is also applied in the waiting area, but she is still bleeding 30 minutes later.\n\nShe looks well and observations are normal. She has no past medical history, and takes no regular medications.\n\nOn examination with a nasal speculum, a bleeding point cannot be confidently identified.\n\nWhat is the most appropriate next step to take?",
"sbaAnswer": [
"a"
],
"totalVotes": 1575,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,689 | false | 36 | null | 6,495,272 | null | false | [] | null | 19,601 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "While imaging is required to exclude a more sinister cause of sensorineural hearing loss, the most appropriate modality would be an MRI. In the first instance, however, steroids should be prescribed, and this is therefore the most appropriate first step to take.",
"id": "10035989",
"label": "c",
"name": "Arrange a CT scan of the brain",
"picture": null,
"votes": 66
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This gentleman's clinical presentation and examination findings are consistent with sudden idiopathic sensorineural hearing loss. Imaging (an MRI of the cerebellopontine angle/acoustic meatus) should be undertaken to exclude a more serious pathology e.g. a space-occupying mass, however, the most appropriate next step is to initiate high-dose oral steroids as arranging a scan can take some time.",
"id": "10035990",
"label": "d",
"name": "Arrange an MRI scan of the cerebellopontine angle and auditory meatus",
"picture": null,
"votes": 747
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is inappropriate; the patient requires further work-up and management of his sensorineural hearing loss.",
"id": "10035988",
"label": "b",
"name": "Discharge with reassurance and follow-up",
"picture": null,
"votes": 36
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This gentleman's clinical presentation and examination findings are consistent with sudden idiopathic sensorineural hearing loss. Imaging (an MRI of the cerebellopontine angle/acoustic meatus) should be undertaken to exclude a more serious pathology e.g. a mass, however the most appropriate next step is to initiate high-dose oral steroids.",
"id": "10035987",
"label": "a",
"name": "Oral prednisolone",
"picture": null,
"votes": 618
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Pure tone audiometry would be more appropriate to assess this patient's hearing quantitatively; the otoacoustic emissions test is usually used in newborn hearing screening. In this scenario, the patient is likely suffering from idiopathic sudden-onset sensorineural hearing loss, for which steroids should be commenced.",
"id": "10035991",
"label": "e",
"name": "Arrange an otoacoustic emissions test",
"picture": null,
"votes": 107
}
],
"comments": [],
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"__typename": "Concept",
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"__typename": "Chapter",
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},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "4111",
"name": "Sensorineural Hearing Loss",
"status": null,
"topic": {
"__typename": "Topic",
"id": "138",
"name": "Ear, Nose & Throat",
"typeId": 7
},
"topicId": 138,
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"conditions": [],
"difficulty": 1,
"dislikes": 31,
"explanation": null,
"highlights": [],
"id": "19601",
"isLikedByMe": 0,
"learningPoint": "First-line treatment options for idiopathic sudden idiopathic sensorineural hearing loss can include oral steroids, intra-tympanic steroid injections or a combination of both.",
"likes": 5,
"multiAnswer": null,
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"question": "A 46-year-old man is referred to the emergency ENT clinic as he has been struggling to hear in his right ear for the past 3 days. He has no past medical history and takes no medications. He cannot think of any events that have precipitated this episode.\n\nA full neurological examination and otoscopy are normal. He does not report any other symptoms.\n\nThe results of the initial screening are as follows:\n\nWeber's test: Lateralises to the left ear\nRinne's test: Positive (air conduction > bone conduction) bilaterally.\n\nWhat is the most appropriate next step in management?",
"sbaAnswer": [
"a"
],
"totalVotes": 1574,
"typeId": 1,
"userPoint": null
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173,468,690 | false | 37 | null | 6,495,272 | null | false | [] | null | 19,602 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The patient appears to have the capacity to make decisions in this case. Seeking consent from the patient's next of kin is not the best course of action in this case.",
"id": "10035994",
"label": "c",
"name": "Seek consent to proceed from the patient's next of kin",
"picture": null,
"votes": 11
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may be required if there are disagreements regarding whether the patient has capacity, but is unlikely to be the next best step to take.",
"id": "10035996",
"label": "e",
"name": "Seek advice from the hospital's legal department",
"picture": null,
"votes": 87
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "While this would be useful to establish, a lasting power of attorney's decision-making role is only invoked if a patient lacks the capacity to make decisions about their medical treatment. In this case, the patient appears to have the capacity to refuse surgery, so the best course of action is to respect their wishes.",
"id": "10035995",
"label": "d",
"name": "Establish if a lasting power of attorney has been appointed",
"picture": null,
"votes": 262
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A DOLS application is required when a patient who lacks capacity is being deprived of their liberty (e.g. kept in hospital, subjected to 1-1 nursing or physical restraints) in their best interests. This is not applicable in this case.",
"id": "10035993",
"label": "b",
"name": "Apply for a deprivation of liberty safeguard (DOLS)",
"picture": null,
"votes": 64
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Despite the patient's Alzheimer's disease, the question stem suggests they have the capacity to decide to not undergo surgery. A detailed assessment would of course be required to confirm this is the case. It is important to remember that capacity is decision and time-specific and that a disorder of the mind/brain does not automatically mean a patient lacks capacity.",
"id": "10035992",
"label": "a",
"name": "Respect the patient's choice",
"picture": null,
"votes": 1153
}
],
"comments": [],
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"__typename": "Concept",
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"id": "2693",
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},
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"demo": null,
"entitlement": null,
"id": "5799",
"name": "Criteria for assessing capacity in adults",
"status": null,
"topic": {
"__typename": "Topic",
"id": "184",
"name": "Ethics and Law",
"typeId": 7
},
"topicId": 184,
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"isLikedByMe": 0,
"learningPoint": "Respecting a patient's autonomy is crucial, even in the presence of cognitive impairment, provided they demonstrate understanding and capacity regarding their treatment choices.",
"likes": 2,
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"question": "An 89-year-old patient with a history of Alzheimer's dementia is admitted to hospital after sustaining a fall at home. A trauma-protocol CT scan shows a displaced left humeral fracture.\n\nThe patient is adamant that they do not want to be operated on despite the orthopaedic team's recommendations. They express a strong wish for conservative management and appear to understand the consequences of not having surgery.\n\nWhat is the most appropriate next step to take?",
"sbaAnswer": [
"a"
],
"totalVotes": 1577,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,691 | false | 38 | null | 6,495,272 | null | false | [] | null | 19,603 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Since 2015, there has been a legal duty for healthcare professionals to report suspected cases of FGM in girls under the age of 18 to the police for further investigation within 28 days of discovery. This should, of course, be done sensitively, and safeguarding processes (if relevant) should also be commenced.",
"id": "10035997",
"label": "a",
"name": "The doctor has a legal duty to inform the police of their findings",
"picture": null,
"votes": 1510
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "When considering whether to breach confidentiality, it is always best to discuss reasoning with the patient and gain consent to do so. However, there is a legal duty for doctors to disclose possible FGM to the police, and they do not need consent to do so.",
"id": "10036000",
"label": "d",
"name": "The doctor must have the patient's consent to disclose this information to the police",
"picture": null,
"votes": 45
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect. While there would be a plausible defence to disclose this information (e.g. protecting any siblings of the patient), since 2015, there has been a legal duty for healthcare professionals to report suspected cases of FGM in girls under the age of 18 to the police for further investigation within 28 days of discovery. This should, of course, be done sensitively, and safeguarding processes (if relevant) should also be commenced.",
"id": "10035998",
"label": "b",
"name": "The doctor does not have a legal duty to inform the police but should do so as they have a legal defence",
"picture": null,
"votes": 7
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "When considering whether to breach confidentiality, it is always best to discuss reasoning with the patient (and their families if appropriate/if there are no safeguarding concerns) and gain consent to do so. However, there is a legal duty for doctors to disclose possible FGM to the police, and they do not need consent to do so.",
"id": "10036001",
"label": "e",
"name": "The doctor must have the patient's parent/guardian's consent to disclose this information to the police",
"picture": null,
"votes": 6
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect; since 2015, there has been a legal duty for healthcare professionals to report suspected cases of FGM in girls under the age of 18 to the police for further investigation within 28 days of discovery. This should, of course, be done sensitively, and safeguarding processes (if relevant) should also be commenced.",
"id": "10035999",
"label": "c",
"name": "The doctor should not provide the requested information to the police as there is no legal duty to do so",
"picture": null,
"votes": 2
}
],
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"name": "Legal duty vs legal defence",
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"id": "19603",
"isLikedByMe": null,
"learningPoint": "Healthcare professionals must report suspected cases of female genital mutilation in under-18s to the police within 28 days of discovery.",
"likes": 0,
"multiAnswer": null,
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"question": "A 14-year-old girl visits her GP complaining of heavy, painful periods. She is otherwise well with no past medical or surgical history.\n\nOn examination, the GP is concerned that there are signs of previous female genital mutilation (FGM).\n\nWhich statement best describes the current legal position on disclosing this information to the police?",
"sbaAnswer": [
"a"
],
"totalVotes": 1570,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,692 | false | 39 | null | 6,495,272 | null | false | [] | null | 19,604 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This knee radiograph shows chondrocalcinosis. The likely diagnosis given this finding and the clinical information given is pseudogout (calcium pyrophosphate dihydrate crystal deposition). Osteoarthritis is a risk factor for this condition. Other risk factors include hyperparathyroidism, haemochromatosis, hypercalcaemia, and osteoporosis.",
"id": "10036002",
"label": "a",
"name": "Osteoarthritis of the knee",
"picture": null,
"votes": 150
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The most likely diagnosis is pseudogout given the clinical history and chondrocalcinosis evident on the knee radiograph. Kidney disease is more of a risk factor for gout (due to reduced urate clearance) than pseudogout.",
"id": "10036003",
"label": "b",
"name": "Chronic kidney disease",
"picture": null,
"votes": 475
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The most likely diagnosis is pseudogout given the clinical history and chondrocalcinosis evident on the knee radiograph. Thiazide use is more of a risk factor for gout (due to reduced urate clearance) than pseudogout.",
"id": "10036005",
"label": "d",
"name": "Thiazide diuretic use",
"picture": null,
"votes": 801
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The most likely diagnosis is pseudogout given the clinical history and chondrocalcinosis evident on the knee radiograph. NSAIDs are used to treat pseudogout and are not a risk factor for developing the condition.",
"id": "10036006",
"label": "e",
"name": "NSAID use",
"picture": null,
"votes": 57
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The most likely diagnosis is pseudogout given the clinical history and chondrocalcinosis evident on the knee radiograph. Increased, rather than decreased, levels of vitamin D are a risk factor for ectopic calcium deposition.",
"id": "10036004",
"label": "c",
"name": "Hypovitaminosis D",
"picture": null,
"votes": 90
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "thiazide diuretics are associated with chondrocalcinosis though",
"createdAt": 1738340323,
"dislikes": 0,
"id": "62003",
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"likes": 0,
"parentId": null,
"questionId": 19604,
"replies": [
{
"__typename": "QuestionComment",
"comment": "I think it's more so associated with increasing uric acid so gout no?",
"createdAt": 1738452592,
"dislikes": 1,
"id": "62110",
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"likes": 0,
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}
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"accessLevel": "subscriber",
"displayName": "Vaccine Complement",
"id": 17667
}
}
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"id": "6178",
"name": "Crystal arthropathies",
"status": null,
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"__typename": "Topic",
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"name": "Rheumatology",
"typeId": 7
},
"topicId": 146,
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"id": "19604",
"isLikedByMe": 0,
"learningPoint": "Osteoarthritis increases the risk of pseudogout due to calcium pyrophosphate crystal deposition in damaged/ degenerated joints.",
"likes": 5,
"multiAnswer": null,
"pictures": [
{
"__typename": "Picture",
"caption": null,
"createdAt": 1713536139,
"id": "2793",
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"question": "A 78-year-old man is referred to the acute medical unit with a red, warm, swollen right knee. He is systemically well; observations and blood test results are all within normal limits.\n\nAn x-ray taken of the knee is shown below:\n\n[lightgallery]\n\nWhich of the following conditions is a risk factor for this presentation?",
"sbaAnswer": [
"a"
],
"totalVotes": 1573,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,693 | false | 40 | null | 6,495,272 | null | false | [] | null | 19,605 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "While antiphospholipid syndrome can be associated with inflammatory arthropathies and other autoimmune conditions, this is not the most likely association of the options presented.",
"id": "10036009",
"label": "c",
"name": "Antiphospholipid syndrome",
"picture": null,
"votes": 11
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient's radiograph shows the classic 'pencil in cup' appearance, which along with the dactylitis and involvement of the distal interphalangeal joints suggests a diagnosis of psoriatic arthritis. Rheumatoid arthritis would usually show features of proximal interphalangeal and metacarpophalangeal joint (especially those of the index and middle fingers) involvement.",
"id": "10036008",
"label": "b",
"name": "Rheumatoid arthritis",
"picture": null,
"votes": 218
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient's radiograph shows the classic 'pencil in cup' appearance, which along with the dactylitis and involvement of the distal interphalangeal joints suggests a diagnosis of psoriatic arthritis, which may be associated with cutaneous psoriasis.",
"id": "10036007",
"label": "a",
"name": "Psoriasis",
"picture": null,
"votes": 1246
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "While lupus can be associated with inflammatory arthropathies and other autoimmune conditions, this is not the most likely association of the options presented. Psoriasis would be a more likely association.",
"id": "10036011",
"label": "e",
"name": "Systemic lupus erythematosus",
"picture": null,
"votes": 58
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "While some patients with psoriatic arthritis may develop Sjögren's syndrome, this is not the most likely association of the options presented. Psoriasis would be a more likely association.",
"id": "10036010",
"label": "d",
"name": "Sjögren's syndrome",
"picture": null,
"votes": 37
}
],
"comments": [],
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"__typename": "Concept",
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},
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"demo": null,
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"id": "3767",
"name": "Psoriatic arthritis",
"status": null,
"topic": {
"__typename": "Topic",
"id": "146",
"name": "Rheumatology",
"typeId": 7
},
"topicId": 146,
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"conditions": [],
"difficulty": 1,
"dislikes": 3,
"explanation": null,
"highlights": [],
"id": "19605",
"isLikedByMe": 0,
"learningPoint": "Psoriatic arthritis often presents with dactylitis and distal interphalangeal joint involvement, commonly associated with cutaneous psoriasis.",
"likes": 0,
"multiAnswer": null,
"pictures": [
{
"__typename": "Picture",
"caption": null,
"createdAt": 1713536139,
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"psaSectionId": null,
"qaAnswer": null,
"question": "A 32-year-old woman is referred to the urgent rheumatology clinic with dactylitis and a one month history of early-morning joint pain. X-rays of the hands are performed, which show:\n\n[lightgallery]\n\nGiven the most likely diagnosis, which other medical condition is she most likely to have?",
"sbaAnswer": [
"a"
],
"totalVotes": 1570,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,694 | false | 41 | null | 6,495,272 | null | false | [] | null | 19,606 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It would be important to take blood cultures in a patient who is febrile with a suspected infection, however, the most urgent task to perform is a joint aspiration for diagnostic purposes.",
"id": "10036014",
"label": "c",
"name": "Take blood cultures",
"picture": null,
"votes": 176
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient likely has a septic joint. Colchicine may be used to help manage pain in an acute monoarthritis, but is not typically used in septic arthritis. The most important step to take is to obtain a joint aspirate.",
"id": "10036016",
"label": "e",
"name": "Commence colchicine",
"picture": null,
"votes": 70
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The likely diagnosis in this case is septic arthritis given the acute red hot swollen joint and fever. Patients with sickle cell anaemia are susceptible to overwhelming infections, and there is a link between sickle cell anaemia and septic arthritis caused by salmonella. An urgent joint aspirate should be obtained for diagnostic purposes and to ascertain microbial sensitivities.",
"id": "10036012",
"label": "a",
"name": "Joint aspiration",
"picture": null,
"votes": 1192
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be inappropriate; the patient has an acute monoarthritis with a fever and septic arthritis must be considered.",
"id": "10036015",
"label": "d",
"name": "Discharge with NSAIDs",
"picture": null,
"votes": 15
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The most likely diagnosis is septic arthritis. The first step that should be undertaken is a diagnostic joint aspirate. An arthroscopy and washout may be required further down the line if the infection is severe or is not responding to antibiotics.",
"id": "10036013",
"label": "b",
"name": "Arthroscopy and washout",
"picture": null,
"votes": 121
}
],
"comments": [],
"concept": {
"__typename": "Concept",
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"__typename": "Chapter",
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"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "5804",
"name": "Septic arthritis",
"status": null,
"topic": {
"__typename": "Topic",
"id": "146",
"name": "Rheumatology",
"typeId": 7
},
"topicId": 146,
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},
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"conditions": [],
"difficulty": 1,
"dislikes": 3,
"explanation": null,
"highlights": [],
"id": "19606",
"isLikedByMe": 0,
"learningPoint": "Patients with sickle cell anaemia are at increased risk of septic arthritis, often caused by Salmonella, requiring prompt joint aspiration for diagnosis.",
"likes": 1,
"multiAnswer": null,
"pictures": [],
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"qaAnswer": null,
"question": "A 23-year-old patient with sickle cell anaemia develops a fever and a red, hot swollen elbow. On examination, they are in excruciating pain on active and passive movement of the joint.\n\nA radiograph of the elbow is normal. The patient's observations are as follows:\n\n* Heart rate: 112 beats/minute\n* Blood pressure: 102/69 mmHg\n* Respiratory rate: 17 breaths/minute\n* Temperature: 38.7 degrees\n* Oxygen saturations (room air): 98%\n\nWhat is the next most appropriate step?",
"sbaAnswer": [
"a"
],
"totalVotes": 1574,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,695 | false | 42 | null | 6,495,272 | null | false | [] | null | 19,607 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Post-exposure prophylaxis for infants born to HIV-positive mothers is recommended in all cases. Raltegravir, however, is not recommended for this indication. Standard PEP for very low and low-risk babies is zidovudine monotherapy for 2-4 weeks. Combination antiretroviral therapy is recommended in high-risk babies (i.e. those born to mothers with a viral load >50 copies/mL)",
"id": "10036020",
"label": "d",
"name": "Raltegravir administered to the baby (post-delivery)",
"picture": null,
"votes": 178
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "As this patient's HIV viral load is undetectable, a vaginal delivery is acceptable. Elective Caesarean section deliveries were more common before the introduction of highly active antiretroviral therapy.",
"id": "10036021",
"label": "e",
"name": "Elective caesarean section",
"picture": null,
"votes": 541
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The British HIV Association and Royal College of Obstetricians and Gynaecologists recommend women avoid breastfeeding post-partum, regardless of their viral load and CD4 count, to reduce the risk of vertical transmission. If a woman does decide to breastfeed with an undetectable viral load, they should stop doing so if they develop any nipple bleeding or infections.",
"id": "10036017",
"label": "a",
"name": "Avoid breastfeeding",
"picture": null,
"votes": 593
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Intrapartum antiretrovirals are indicated for women with a viral load of >1000 RNA copies/mL plasma, untreated HIV-positive patients, and can be considered if the viral load is 50-100 copies/mL plasma. This does not apply in this case as the patient has an undetectable viral load. Further, the antiretroviral of choice for this situation would be zidovudine.",
"id": "10036018",
"label": "b",
"name": "Intrapartum emtricitabine",
"picture": null,
"votes": 41
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Intrapartum antiretrovirals are indicated for women with a viral load of >1000 RNA copies/mL plasma, untreated HIV-positive patients, and can be considered if the viral load is 50-100 copies/mL plasma. This does not apply in this case. Further, the antiretroviral of choice for this situation would be zidovudine.",
"id": "10036019",
"label": "c",
"name": "Intrapartum tenofovir",
"picture": null,
"votes": 228
}
],
"comments": [],
"concept": {
"__typename": "Concept",
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"__typename": "Chapter",
"explanation": null,
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"pictures": [],
"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6179",
"name": "HIV mother-to-child transmission",
"status": null,
"topic": {
"__typename": "Topic",
"id": "163",
"name": "Genitourinary medicine",
"typeId": 7
},
"topicId": 163,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 6179,
"conditions": [],
"difficulty": 1,
"dislikes": 9,
"explanation": null,
"highlights": [],
"id": "19607",
"isLikedByMe": 0,
"learningPoint": "To minimise vertical transmission of HIV, mothers should avoid breastfeeding, regardless of viral load or CD4 count.",
"likes": 2,
"multiAnswer": null,
"pictures": [],
"prescribeAnswer": null,
"presentations": [],
"psaSectionId": null,
"qaAnswer": null,
"question": "A 30-year-old primigravida at 32 weeks gestation is discussing childbirth with her midwife. She is known to be HIV positive, and is taking antiretroviral therapy. Her latest blood tests show an undetectable HIV viral load and a normal CD4 count.\n\nWhat is the best strategy to reduce vertical transmission of HIV?",
"sbaAnswer": [
"a"
],
"totalVotes": 1581,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,696 | false | 43 | null | 6,495,272 | null | false | [] | null | 19,608 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The diagnosis in this case is non-gonococcal urethritis (NGU). Common organisms implicated are _Chlamydia_ and _Mycoplasma_ species. Doxycycline (or azithromycin as a 2nd line option) are recommended in the first instance. If NGU recurs, metronidazole may be prescribed with azithromycin.",
"id": "10036025",
"label": "d",
"name": "Metronidazole",
"picture": null,
"votes": 698
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Benzathine benzylpenicillin is the first-line antibiotic of choice for syphilis. The diagnosis in this case is non-gonococcal urethritis (NGU). Common organisms implicated are _Chlamydia_ and _Mycoplasma_ species. Doxycycline (or azithromycin as a 2nd line option) are recommended in the first instance.",
"id": "10036024",
"label": "c",
"name": "Benzathine benzylpenicillin",
"picture": null,
"votes": 304
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Fluconazole is usually used in the treatment of candidiasis. The diagnosis in this case is non-gonococcal urethritis (NGU). Common organisms implicated are _Chlamydia_ and _Mycoplasma_ species. Doxycycline (or azithromycin as a 2nd line option) are recommended in the first instance.",
"id": "10036026",
"label": "e",
"name": "Fluconazole",
"picture": null,
"votes": 78
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The diagnosis in this case is non-gonococcal urethritis (NGU). Common organisms implicated are _Chlamydia_ and _Mycoplasma_ species. Doxycycline (or azithromycin as a 2nd line option) are recommended in the first instance.",
"id": "10036022",
"label": "a",
"name": "Doxycycline",
"picture": null,
"votes": 423
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The diagnosis, in this case, is non-gonococcal urethritis (NGU). Common organisms implicated are _Chlamydia_ and _Mycoplasma_ species. Doxycycline (or azithromycin as a 2nd line option) are recommended in the first instance.",
"id": "10036023",
"label": "b",
"name": "Clarithromycin",
"picture": null,
"votes": 75
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Am I being stupid- his urine NAAT was negative for chlamydia, are we assuming it's mycoplasma then and so giving doxycycline?",
"createdAt": 1718642735,
"dislikes": 1,
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{
"__typename": "QuestionComment",
"comment": "can this not be trichomoniasis? ",
"createdAt": 1734433599,
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"__typename": "QuestionComment",
"comment": "thats what i thought\n",
"createdAt": 1734965478,
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"id": "3846",
"name": "Urethral discharge",
"status": null,
"topic": {
"__typename": "Topic",
"id": "163",
"name": "Genitourinary medicine",
"typeId": 7
},
"topicId": 163,
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"likes": 1,
"multiAnswer": null,
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"question": "A 23-year-old man visits a sexual health clinic with dysuria and purulent urethral discharge. He reports two episodes of unprotected sexual intercourse with a casual female partner three weeks ago.\n\nA nucleic acid amplification test of his urine is negative for chlamydia and gonorrhoea. Microscopy performed on a sample of the discharge shows 19 neutrophils/high power microscopic field (normal < 5 neutrophils/high power microscopic field).\n\nWhat is the most appropriate antimicrobial to prescribe?",
"sbaAnswer": [
"a"
],
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} | MarksheetMark |
173,468,697 | false | 44 | null | 6,495,272 | null | false | [] | null | 19,609 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Postpartum sepsis is an absolute contraindication (UKMEC 4) to IUD insertion due to infection risk.",
"id": "10036027",
"label": "a",
"name": "Postpartum sepsis",
"picture": null,
"votes": 455
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Insertion of an IUD in a patient with fibroids NOT distorting the uterine cavity is UKMEC 1 (no restriction), however, if uterine distortion is present, this would be UKMEC category 3 (risks usually outweigh advantages). In both cases, fibroids are not an absolute contraindication to IUD use.",
"id": "10036031",
"label": "e",
"name": "Uterine fibroids (not distorting uterine cavity)",
"picture": null,
"votes": 172
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Insertion of an IUD in patients with sickle cell disease is UKMEC category 2 (advantages generally outweigh risks) rather than UKMEC 4 (contraindicated)",
"id": "10036030",
"label": "d",
"name": "Sickle cell disease",
"picture": null,
"votes": 106
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Obesity is not a contraindication to IUD insertion. It is, however, a consideration with hormonal methods.",
"id": "10036029",
"label": "c",
"name": "BMI >35 kg/m^2",
"picture": null,
"votes": 40
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Copper IUD insertion is UKMEC category 3 (risks usually outweigh advantages) between 48 hours and 4 weeks postpartum, rather than UKMEC 4 (contraindicated). Copper IUD insertion is UKMEC category 1 (no restriction) <48 hours and >4 weeks postpartum.",
"id": "10036028",
"label": "b",
"name": "Vaginal delivery within 3 weeks",
"picture": null,
"votes": 793
}
],
"comments": [],
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"__typename": "Concept",
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"__typename": "Chapter",
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},
"chapterId": 2693,
"demo": null,
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"id": "6180",
"name": "Intrauterine device",
"status": null,
"topic": {
"__typename": "Topic",
"id": "163",
"name": "Genitourinary medicine",
"typeId": 7
},
"topicId": 163,
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},
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"conditions": [],
"difficulty": 1,
"dislikes": 21,
"explanation": null,
"highlights": [],
"id": "19609",
"isLikedByMe": 0,
"learningPoint": "Postpartum sepsis is an absolute contraindication for copper intrauterine device insertion due to the increased risk of infection.",
"likes": 4,
"multiAnswer": null,
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"question": "A 31-year-old woman visits her GP after giving birth to discuss contraceptive options. She has done extensive reading and would like a highly effective method that does not involve hormonal therapy. A copper intrauterine device (IUD) is suggested.\n\nWhat would be an absolute contraindication to IUD insertion?",
"sbaAnswer": [
"a"
],
"totalVotes": 1566,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,698 | false | 45 | null | 6,495,272 | null | false | [] | null | 19,610 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The most likely diagnosis is caput succedaneum, a self-limiting and benign condition characterised by scalp oedema after childbirth. Attempting to aspirate any fluid/blood would be inappropriate.",
"id": "10036036",
"label": "e",
"name": "Diagnostic aspiration",
"picture": null,
"votes": 11
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The most likely diagnosis is caput succedaneum, a self-limiting and benign condition characterised by scalp oedema after childbirth. No further investigations are required in this case. Baseline blood tests should be considered for other causes of head swelling e.g. subgaleal haemorrhages.",
"id": "10036033",
"label": "b",
"name": "Full blood count and clotting profile",
"picture": null,
"votes": 42
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The most likely diagnosis is caput succedaneum, a self-limiting and benign condition characterised by scalp oedema after childbirth. No further investigations are required in this case.",
"id": "10036034",
"label": "c",
"name": "Cranial ultrasound scan",
"picture": null,
"votes": 290
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The most likely diagnosis is caput succedaneum, a self-limiting and benign condition characterised by scalp oedema after childbirth. No further investigations are required in this case. Imaging may be considered for other conditions e.g. craniosynostosis.",
"id": "10036035",
"label": "d",
"name": "Skull x-ray",
"picture": null,
"votes": 26
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The most likely diagnosis is caput succedaneum, a self-limiting and benign condition characterised by scalp oedema after childbirth. This can occur in unassisted deliveries due to external pressure from the birth canal but is made more likely by vacuum or forceps-assisted births.",
"id": "10036032",
"label": "a",
"name": "No further investigations are required",
"picture": null,
"votes": 1188
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Would you not want to double check that your diagnosis is right though lol",
"createdAt": 1737201377,
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{
"__typename": "QuestionComment",
"comment": "why is a subgaleal haematoma not a concern?",
"createdAt": 1737979692,
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"id": "61648",
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"displayName": "Syndrome Hematoma",
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"name": "Caput succedaneum",
"status": null,
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"id": "153",
"name": "Paediatrics",
"typeId": 7
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"conditions": [],
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"dislikes": 2,
"explanation": null,
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"isLikedByMe": 0,
"learningPoint": "Caput succedaneum is a benign, self-limiting scalp swelling in newborns, often resulting from vacuum-assisted deliveries. It typically resolves within a few days without treatment.",
"likes": 0,
"multiAnswer": null,
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"question": "The mother of a 12-hour-old baby in the post-natal observation unit is concerned about a swelling on her baby's head. She had a vacuum-assisted delivery but suffered no intrapartum or postpartum complications.\n\nOn examination, there is a boggy diffuse swelling with poorly defined margins around the occiput. It appears to cross the suture lines.\n\nWhat is the best next step to take?",
"sbaAnswer": [
"a"
],
"totalVotes": 1557,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,699 | false | 46 | null | 6,495,272 | null | false | [] | null | 19,611 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The combination of advanced maternal age and the findings of the combined test suggest that the foetus may have Down's syndrome (trisomy 21). The most common cardiovascular anomaly occurring in Down's syndrome is atrioventricular septal defect. Tetralogy of Fallot has a weaker association with Down's syndrome, and is also associated with Alagille syndrome and DiGeorge syndrome.",
"id": "10036039",
"label": "c",
"name": "Tetralogy of Fallot",
"picture": null,
"votes": 155
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The combination of advanced maternal age and the findings of the combined test suggest that the foetus may have Down's syndrome (trisomy 21). The most common cardiovascular anomaly occurring in Down's syndrome is atrioventricular septal defect.",
"id": "10036038",
"label": "b",
"name": "Patent foramen ovale",
"picture": null,
"votes": 54
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The combination of advanced maternal age and the findings of the combined test suggest that the foetus may have Down's syndrome (trisomy 21). The most common cardiovascular anomaly occurring in Down's syndrome is atrioventricular septal defect.",
"id": "10036040",
"label": "d",
"name": "Total anomalous pulmonary venous return",
"picture": null,
"votes": 9
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The combination of advanced maternal age and the findings of the combined test suggest that the foetus may have Down's syndrome (trisomy 21). The most common cardiovascular anomaly occurring in Down's syndrome is atrioventricular septal defect. Aortic coarctation is commonly associated with Turner syndrome.",
"id": "10036041",
"label": "e",
"name": "Coarctation of the aorta",
"picture": null,
"votes": 95
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The combination of advanced maternal age and the findings of the combined test suggest that the foetus may have Down's syndrome (trisomy 21). The most common cardiovascular anomaly occurring in Down's syndrome is atrioventricular septal defect.",
"id": "10036037",
"label": "a",
"name": "Atrioventricular septal defect",
"picture": null,
"votes": 1242
}
],
"comments": [],
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"__typename": "Concept",
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"__typename": "Chapter",
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},
"chapterId": 2693,
"demo": null,
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"id": "4603",
"name": "Down's Syndrome",
"status": null,
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"id": "153",
"name": "Paediatrics",
"typeId": 7
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"topicId": 153,
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"conditions": [],
"difficulty": 1,
"dislikes": 2,
"explanation": null,
"highlights": [],
"id": "19611",
"isLikedByMe": 0,
"learningPoint": "Atrioventricular septal defect is the most common cardiac anomaly associated with Down's syndrome.",
"likes": 1,
"multiAnswer": null,
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"psaSectionId": null,
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"question": "A 41-year-old pregnant lady is referred to a materno-foetal medicine unit after a cardiovascular anomaly was found on a routine foetal ultrasound scan. A combined screening test in the first trimester showed increased nuchal thickness, a high serum beta-HCG level, and a low Pregnancy-associated plasma protein-A (PAPP-A) level. She opted not to proceed with further pre-natal diagnostics.\n\nWhat is the most likely cardiovascular anomaly detected?",
"sbaAnswer": [
"a"
],
"totalVotes": 1555,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,700 | false | 47 | null | 6,495,272 | null | false | [] | null | 19,612 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The most likely diagnosis is croup, for which steroids should be administered in the first instance. Nebulised (not injected) adrenaline can be considered as a second-line treatment until steroids take effect.",
"id": "10036044",
"label": "c",
"name": "Intramuscular adrenaline",
"picture": null,
"votes": 9
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The most likely diagnosis is croup, which is generally caused by a viral infection. Steroids should be administered immediately to help reduce airway oedema.",
"id": "10036045",
"label": "d",
"name": "Intravenous antibiotics",
"picture": null,
"votes": 61
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Given that croup primarily affects the upper respiratory tract (which does not contain smooth muscle), salbutamol is unlikely to be of benefit. Oral dexamethasone should be administered immediately.",
"id": "10036043",
"label": "b",
"name": "Inhaled salbutamol",
"picture": null,
"votes": 59
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The most likely diagnosis is croup, for which steroids should be administered in the first instance. Nebulised adrenaline can be considered as a second-line treatment until steroids take effect.",
"id": "10036046",
"label": "e",
"name": "Nebulised adrenaline",
"picture": null,
"votes": 97
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The most likely diagnosis is croup. The next best step to take is to administer steroids to help control inflammation. First-line treatment is oral dexamethasone (0.15 mg/kg), however, if the child is too unwell to take this, they can be given inhaled budesonide or parenteral dexamethasone.",
"id": "10036042",
"label": "a",
"name": "Oral dexamethasone",
"picture": null,
"votes": 1333
}
],
"comments": [],
"concept": {
"__typename": "Concept",
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"__typename": "Chapter",
"explanation": null,
"files": null,
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"id": "2693",
"pictures": [],
"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "4401",
"name": "Croup",
"status": null,
"topic": {
"__typename": "Topic",
"id": "153",
"name": "Paediatrics",
"typeId": 7
},
"topicId": 153,
"totalCards": null,
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},
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"conditions": [],
"difficulty": 1,
"dislikes": 3,
"explanation": null,
"highlights": [],
"id": "19612",
"isLikedByMe": 0,
"learningPoint": "Croup is characterised by a barking cough and stridor, often requiring oral dexamethasone for inflammation management.",
"likes": 2,
"multiAnswer": null,
"pictures": [],
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"psaSectionId": null,
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"question": "An 8-month-old girl is brought to the emergency department by her parents after developing a loud cough on a background of coryzal symptoms. They have also noticed a harsh high-pitched sound when she breathes in. Her observations are within normal limits except for a mild fever. She has mild stridor at rest. Her parents have given her oral paracetamol.\n\nWhat is the best next step in management?",
"sbaAnswer": [
"a"
],
"totalVotes": 1559,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,701 | false | 48 | null | 6,495,272 | null | false | [] | null | 19,613 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This child requires 1740ml fluid/day (i.e. 72 ml/hour) according to the Holliday-Segar formula ( (100x10) + (50x10) + 20x12) ). NICE recommends administering isotonic crystalloids that contain sodium in the range of 131–154 mmol/litre in the first instance. Glucose may also be included.",
"id": "10036047",
"label": "a",
"name": "72 ml/hour 0.9% sodium chloride with 5% glucose",
"picture": null,
"votes": 1125
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Although this child requires 1740ml fluid/day according to the Holliday-Segar formula, NICE recommends administering isotonic crystalloids that contain sodium in the range of 131–154 mmol/litre in the first instance. Administering only 5% glucose may result in hyponatraemia.",
"id": "10036048",
"label": "b",
"name": "1740 ml/day 5% glucose solution",
"picture": null,
"votes": 285
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be an inappropriate choice; while a fluid bolus of 10-20 ml/kg can be considered for resuscitation in shocked patients, there is no indication that this is currently the case.",
"id": "10036051",
"label": "e",
"name": "640 ml over 15 minutes 0.9% sodium chloride solution",
"picture": null,
"votes": 52
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This child requires 1740ml fluid/day (i.e. 72 ml/hour) according to the Holliday-Segar formula. NICE recommends administering isotonic crystalloids that contain sodium in the range of 131–154 mmol/litre in the first instance. Glucose may also be included.",
"id": "10036049",
"label": "c",
"name": "145 ml/hour Hartmann's solution",
"picture": null,
"votes": 57
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be an inappropriate choice; while a fluid bolus of 10-20 ml/kg can be considered for resuscitation in shocked patients, there is no indication that this is currently the case. Furthermore, 5% glucose is an inappropriate choice for fluid resuscitation.",
"id": "10036050",
"label": "d",
"name": "320 ml over 15 minutes 5% glucose solution",
"picture": null,
"votes": 33
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "i just gave the patient 2 litres of sugar ",
"createdAt": 1719173127,
"dislikes": 0,
"id": "53652",
"isLikedByMe": 0,
"likes": 8,
"parentId": null,
"questionId": 19613,
"replies": [],
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"__typename": "User",
"accessLevel": "subscriber",
"displayName": "C.difficult",
"id": 60900
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}
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"__typename": "Concept",
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"__typename": "Chapter",
"explanation": null,
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"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6182",
"name": "Fluid prescription in children",
"status": null,
"topic": {
"__typename": "Topic",
"id": "153",
"name": "Paediatrics",
"typeId": 7
},
"topicId": 153,
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"difficulty": 1,
"dislikes": 1,
"explanation": null,
"highlights": [],
"id": "19613",
"isLikedByMe": 0,
"learningPoint": "For children requiring maintenance fluids, use the Holliday-Segar formula to calculate daily fluid needs and consider isotonic crystalloids.",
"likes": 1,
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"question": "An 8-year-old boy weighing 32kg is admitted to the paediatric ward with acute appendicitis. He is awaiting an appendectomy and has been made nil by mouth so requires maintenance fluids.\n\nWhat is the most appropriate 24hr fluid regime to prescribe?",
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"explanation": "The most likely diagnosis is transient tachypnoea of the newborn, which is the most common aetiology of neonatal respiratory distress. The chest radiograph shows features of fluid congestion in the lungs with a trace seen within the right horizontal fissure. Caesarean section is a significant risk factor for transient tachypnoea of the newborn, as the neonate is not subject to the compressive forces of the vaginal canal during delivery which would aid in fluid absorption.",
"id": "10036052",
"label": "a",
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"explanation": "The most likely diagnosis is transient tachypnoea of the newborn, which is the most common aetiology of neonatal respiratory distress. Maternal sepsis may predispose the newborn to neonatal sepsis, however this would not present immediately after delivery.",
"id": "10036053",
"label": "b",
"name": "Maternal sepsis",
"picture": null,
"votes": 79
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"explanation": "Meconium aspiration syndrome is a differential in this case, however, The most likely diagnosis is transient tachypnoea of the newborn, which is the most common aetiology of neonatal respiratory distress. This is due to the clinical history (Caesarean section delivery and no mention of meconium staining) and the radiographic findings of fluid overload.",
"id": "10036054",
"label": "c",
"name": "Meconium stained liquor",
"picture": null,
"votes": 288
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"explanation": "The most likely diagnosis is transient tachypnoea of the newborn, which is the most common aetiology of neonatal respiratory distress. Prematurity is a risk factor for the condition, however, in this case, the baby has been delivered at 39 weeks' gestation. Caesarean section is a significant risk factor for transient tachypnoea of the newborn, as the neonate is not subject to the compressive forces of the vaginal canal during delivery which would aid in fluid absorption.",
"id": "10036055",
"label": "d",
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"explanation": "The most likely diagnosis is transient tachypnoea of the newborn, which is the most common aetiology of neonatal respiratory distress. Caesarean section delivery is the greatest risk factor in this particular case. Maternal cardiac disorders are not linked to the development of the condition.",
"id": "10036056",
"label": "e",
"name": "Maternal cardiac disease",
"picture": null,
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"comment": "whers the fluid consolidation?\n",
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"question": "A neonate born at 39 weeks gestation by elective Caesarean section is noted to be tachypnoeic and in respiratory distress shortly after delivery.\n\nObservations:\n\n* Heart rate: 187 beats/minute (100 - 205 beats/minute)\n* Respiratory rate: 67 breaths/minute (30 - 50 breaths/minute)\n* Oxygen saturations (room air): 98%\n\nA chest x-ray was performed:\n\n[lightgallery]\n\nGiven the most likely diagnosis, which of the following is the greatest risk factor for this condition in this case?",
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"explanation": "The history and examination is consistent with an inhaled foreign body. The immediate management is a rigid bronchoscopy to remove it. Foreign body inhalations are often unwitnessed in children and it is an important differential for anyone presenting with stridor and respiratory distress. Although not common practice, this question has appeared in previous writers' MLA AKT exams so we have included it in our bank.",
"id": "10035732",
"label": "a",
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"explanation": "Bronchoconstriction can cause respiratory distress in infants, however a wheeze rather than stridor would be found on examintation. The history and examination is more consistent with an inhaled foreign body.",
"id": "10035733",
"label": "b",
"name": "Nebulised salbutamol",
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"explanation": "Croup is a common cause of stridor in children and can also cause respiratory distress, this would be treated with steroids. However, the onset would not be so sudden and there is usually a history of low grade fever and coryzal illness. The history and examination is more consistent with an inhaled foreign body.",
"id": "10035734",
"label": "c",
"name": "Dexamethasone, STAT dose",
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"explanation": "The sudden onset and lack of temperature in this patient is not consistent with an infectious cause of respiratory distress. The history and examination is more consistent with an inhaled foreign body.",
"id": "10035736",
"label": "e",
"name": "Amoxicillin",
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"explanation": "Anaphylaxis is an important differential for respiratory distress and stridor, however is is accompanied by hypotension, and allergic symptoms such as angioedema. The history and examination is more consistent with an inhaled foreign body.",
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"comment": "Would CXR be indicated at all?",
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"comment": "If it's already suspected that the kiddy has eaten the forbidden plastic chocolate brick then you are already there with the grabber to remove it with a bronchoscopy. A CXR would only confirm the diagnosis but exposure them to extra radiation and you would still need to go in with the scope. Hope this helps / makes sense :D ",
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"comment": "thanks uncs",
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"explanation": "# Summary\n\nForeign Body Ingestion (FBI) refers to the swallowing of objects that are not intended to be ingested. Clinical manifestations vary from being asymptomatic to significant morbidity, including esophageal obstruction or perforation, depending on the type and location of the foreign body. Most instances can be managed conservatively, but high-risk objects may necessitate invasive interventions such as endoscopy or open surgery. High-risk objects include batteries, large objects, absorbent materials, magnets swallowed with metal objects, lead-based objects, and objects containing toxins.\n\n# Definition\n\nForeign Body Ingestion is a common pediatric complaint and involves the swallowing of objects not intended for ingestion. While most foreign bodies pass harmlessly through the gastrointestinal tract, some can cause significant complications.\n\n# Epidemiology\n\nForeign Body Ingestion is a prevalent issue among children, particularly those between the ages of six months to three years. This high incidence is attributed to their oral exploratory behavior. Most ingested objects pass spontaneously without causing complications, but a subset may pose a significant health risk.\n\n# Aetiology\n\nObjects often ingested include coins, toys, jewelry, batteries, and food items. The list of potentially ingestible items is virtually limitless but varies based on cultural, environmental, and individual factors. High-risk objects include batteries, large objects that may become trapped at the pylorus, absorbent materials that may cause obstruction, magnets swallowed with metal objects, lead-based objects, and objects containing toxins.\n\n# Signs and Symptoms\n\nThe clinical presentation can range from asymptomatic to significant morbidity. Symptoms include, but are not limited to:\n\n- Drooling\n- Difficulty swallowing or painful swallowing\n- Refusal to eat\n- Chest, throat, or abdominal pain\n- Vomiting\n- Blood in the stool\n\nThe onset and type of symptoms can be influenced by the size, shape, location, and nature of the foreign body.\n\n# Differential Diagnosis\n\nConsider the following conditions in a patient presenting with symptoms suggestive of foreign body ingestion:\n\n- Gastroenteritis: Characterized by nausea, vomiting, diarrhea, abdominal pain.\n- Esophagitis or Gastritis: These could present with similar symptoms of painful swallowing, refusal to eat, and abdominal pain.\n- Appendicitis: Presents with abdominal pain, loss of appetite, nausea, and vomiting.\n- Esophageal stricture or tumor: Can present with difficulty swallowing, chest pain, weight loss, and regurgitation of food or fluids.\n\n# Investigations\n\nInvestigations are unnecessary in an asymptomatic child with a low-risk ingestion. In symptomatic patients or those who have ingested high-risk objects, investigations may include:\n\n- Plain radiography: Most commonly used and can detect radio-opaque objects.\n- Computed Tomography (CT): Offers better sensitivity and specificity for detecting radiolucent foreign bodies.\n- Direct visualization with endoscopy: Useful when there is a high index of suspicion, even if radiological studies are negative.\n\n# Management\n\nThe majority of foreign bodies that are swallowed can be managed conservatively, including observation and symptomatic treatment. High-risk objects such as batteries, sharp objects, or large objects may require endoscopic or surgical removal. Clinicians should provide clear discharge instructions regarding potential complications and when to seek immediate medical attention.\n\n# References\n\n[BMJ Best Practice: Foreign Body Ingestion](https://bestpractice.bmj.com/topics/en-gb/1050)",
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"question": "A 10-month old girl is rushed into the Emergency Department with sudden onset cough, respiratory distress, and noisy breathing. This started 20 minutes ago whilst at a playdate, and she had previously been well. On examination she is making a high-pitched inspiratory sound whilst breathing and is coughing ineffectively. There is no wheeze, rash, or angioedema. Her respiratory rate is elevated at 48 (30-40) and she is tachycardic at 152 bpm (80-140), her other vital signs are normal.\n\nWhat is the most appropriate management?",
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"__typename": "QuestionChoice",
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"explanation": "Bisoprolol may be used to rate control atrial fibrillation (AF). However, as this is her first presentation of AF, she is young and symptomatic, and she has presented to the emergency department, rhythm control would be more favourable in the first instance.\n\nIn primary care, rate control may be initiated rather than cardioversion, depending on patient preference and clinical judgement",
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"explanation": "We can be fairly certain that this woman's onset of atrial fibrillation is less than 48 hours, and since she's presented to an acute medical unit, DC cardioversion would be the most appropriate management. Factors favouring rhythm control over rate control in this case include being symptomatic, the first presentation of atrial fibrillation, and her age. She may require anticoagulation prior to cardioversion.\n\nHad this patient presented to the GP, management in primary care could also be considered, depending on patient preferences and clinical judgement",
"id": "31753",
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"explanation": "TOEs may sometimes be used to exclude a left atrial appendage thrombus before cardioversion if the onset of AF was more than 48 hours prior to the planned cardioversion, as an alternative to anticoagulation",
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"explanation": "Anticoagulation is indicated if her CHA<sub>2</sub>DS<sub>2</sub>-VASc score is 2 or more. She only has a score of 1 for being female",
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"label": "c",
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"__typename": "QuestionComment",
"comment": "hello everyone - good luck for all your exams xoxo",
"createdAt": 1655059775,
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"comment": "you too!! good luck :)",
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"comment": "Thank you!",
"createdAt": 1682170430,
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"comment": "Would you not rate control and DC cardiovert as OP? She's 95bpm and no other evidence of haemodynamic compromise? Or is this because it's her first presentation you hit her with DCCV??",
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"comment": "If presenting with very recently started AF you cardiovert, if it is longer standing or there is doubt about onset then either rate control or delayed cardioversion with anticoagulation",
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"comment": "There is no evidence that she is symptomatic or haemodynamically unstable. She has presented <48 hours and so rhythm or rate control can be used. Does this question require re-writing?",
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"comment": "She IS symptomatic, she's come in to A&E with palpitations. Since the history is <48 hours, her risk of clots is low so she can be cardioverted straight away, as is preferred.",
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"comment": "in what world is she asymptomatic with palpitations? ",
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"comment": "What would be mx if she presented to GP?",
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"comment": "“ In primary care, rate control may be initiated rather than cardioversion, depending on patient preference and clinical judgement”",
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"explanation": "# Summary \r\n\r\nAtrial fibrillation (AF) is the most common arrhythmia characterised by irregular and uncoordinated atrial contraction at a rate of 300-600 beats per minute. Its prevalence increases with age, and it can be caused by various cardiac and non-cardiac factors. Symptoms of AF include palpitations, chest pain, shortness of breath, lightheadedness, and syncope. Diagnosis is confirmed by an ECG showing the absence of p waves and an irregularly irregular rhythm. Management depends on the acute or chronic nature of the AF and involves rate or rhythm control strategies. Anticoagulation is essential to mitigate the risk of stroke in chronic AF. Complications include heart failure, embolism, and bleeding. With appropriate management, AF has a favourable prognosis.\r\n\r\n# Definition \r\n\r\nAtrial fibrillation (AF) is characterised by irregular, uncoordinated atrial contraction usually at a rate of 300-600 beats per minute. Delay at the AVN means that only some of the atrial impulses are conducted to the ventricles, resulting in an irregular ventricular response.\r\n\r\n# Epidemiology \r\n\r\nAF is the commonest sustained cardiac arrhythmia. The prevalence of AF roughly doubles with each advancing decade of age, from 0.5% at age 50 years to almost 9% at age 80 years.\r\n\r\n# Pathophysiology\r\n\r\nThe exact pathophysiology of AF is unclear, but factors that cause atrial dilatation through inflammation and fibrosis leads to disorganised electrical impulses (which originate near the pulmonary veins) that overwhelm the SAN. These disorganised electrical impulses are usually at a rate of 300-600 beats per minute and are intermittently conducted through the AVN leading to irregular activation of the ventricles. \r\n\r\n# Classification \r\n\r\n* Acute: lasts <48 hours\r\n* Paroxysmal: lasts <7 days and is intermittent\r\n* Persistent: lasts >7 days but is amenable to cardioversion\r\n* Permanent: lasts >7 days and is not amenable to cardioversion\r\n\r\nAtrial fibrillation can also be classified as to whether it is 'fast' or 'slow'. Fast AF refers to AF that is at a rate of =>100bpm. Slow AF refers to AF that is at a rate of <=60bpm. \r\n\r\n# Causes \r\n\r\nCardiac:\r\n\r\n* Ischaemic heart disease: most common cause in the UK. \r\n* Hypertension\r\n* Rheumatic heart disease (typically affecting the mitral valve): most common cause in less developed countries.\r\n* Peri-/myocarditis\r\n\r\nNon-cardiac:\r\n\r\n* Dehydration\r\n* Endocrine causes e.g. hyperthyroidism\r\n* Infective causes e.g. sepsis \r\n* Pulmonary causes e.g. pneumonia or pulmonary embolism\r\n* Environmental toxins e.g. alcohol abuse\r\n* Electrolyte disturbances e.g. hypokalaemia, hypomagnesaemia \r\n\r\n# Symptoms\r\n\r\n* Palpitations\r\n* Chest pain\r\n* Shortness of breath\r\n* Lightheadedness\r\n* Syncope\r\n\r\n# Signs\r\n\r\n* Irregularly irregular pulse rate with a variable volume pulse.\r\n* A single waveform on the jugular venous pressure (due to loss of the a wave - this normally represents atrial contraction).\r\n* An apical to radial pulse deficit (as not all atrial impulses are mechanically conducted to the ventricles).\r\n* On auscultation there may be a variable intensity first heart sound.\r\n* Features suggestive of the underlying cause e.g. hyperthyroidism, alcohol excess, sepsis\r\n* Features suggestive of complications resulting from the AF e.g. heart failure.\r\n\r\n# Differential Diagnoses \r\n\r\nImportant differentials for atrial fibrillation include other common causes of narrow and broad complex tachycardias. Tachycardias may present with palpitations, shortness of breath, and dyspnoea. \r\n\r\n* **Atrial Flutter** \r\n\t* **Similarities**: atrial flutter may have a regular peripheral pulse or may be irregularly irregular if the flutter has variable block. Atrial fibrillation leads to an irregularly irregular peripheral pulse on palpation.\r\n\t* **Differences**: distinguishing between the two requires an ECG. Atrial fibrillation on ECG shows a fibrillating baseline with no visible p waves. Atrial flutter characteristically has a sawtooth baseline. \r\n\r\n* **Supraventricular Tachycardia**\r\n\t* **Similarities**: atrial flutter is a type of SVT, and other types including AVNRT and AVRT may present identically. \r\n\t* **Differences**: distinguishing between different types of SVT requires an ECG. \r\n\r\n* **Ventricular Tachycardia**\r\n\t* **Similarities**:both may present similarly. \r\n\t* **Differences**: the ECG patterns differ tremendously. \r\n\r\nFor palpitation histories, it is also important to consider whether the presentation is being driven by anxiety. However, it is important as a rule of thumb to rule out organic causes first. \r\n\r\n# Investigations\r\n\r\n## Bedside\r\n\r\n**Definitive diagnosis: 12-lead ECG** shows absence of p waves with an irregularly irregular rhythmn. \r\n\r\n[lightgallery]\n\n- If a person has a suspected diagnosis of paroxysmal AF which is not detected on standard ECG, arrange ambulatory electrocardiography or cardiology referral, depending on the frequency and duration of symptoms and local referral pathways\r\n\r\n## Bloods \r\n\r\nRoutine bloods: to look for reversible causes including infection (raised WCC or CRP), hyperthyroidism (raised T3/T4) or alcohol use (raised MCV and GGT).\r\n\r\n## Imaging\r\n\r\nEchocardiogram: can be used to see if there is a cardiac cause of the AF e.g. left atrial dilatation secondary to mitral valve disease. \r\n\r\n# Management\n\nConsider emergency admission or Cardiology referral if a patient presents with:\n\n- New-onset AF within the past 48 hours and is haemodynamically unstable\n- Severe symptoms of AF due to rapid (bpm > 150 ) or very slow (bpm < 40) ventricular rate\n- Concomitant acute decompensated heart failure\n- Complications of AF, such as TIA/stroke\n- An acute, potentially reversible trigger such as pneumonia/sepsis or thyrotoxicosis\n\nIf they do not require acute management or emergency admission, they can be considered for anticoagulation and rate-control treatment in primary care.\r\n\r\n## Management of Acute or New-onset Atrial Fibrillation\r\n\r\nFor emergencies, always follow an A-E structure. Identify reversible causes (dyselectrolytaemias, drugs, cardiac causes etc.) \r\n\r\n*If there are adverse signs (e.g. shock, syncope, heart failure, myocardial ischaemia):* \r\n\r\n* **1st line** = **synchronised DC cardioversion +/- amiodarone.**\r\n\r\n*If there are no adverse signs:* and the rhythm is irregular it is likely atrial fibrillation. \r\n\r\n* **If the patient is stable and onset of AF <48 hours**: \r\n\t* Rate or rhythmn control.\r\n\t* Rhythm control with DC cardioversion (+ sedation) or pharmacological anti-arrhythmics (fleicanide if no structural heart disease, amiodarone if history of structural heart disease). \r\n\t* If DC cardioversion is delayed then heparin will be required to anticoagulate the patient. \r\n\r\n* **If the patient is stable and onset of AF >48 hours/unclear time of onset**: \r\n\t* Rate control only. \r\n\t* Rate control with beta-blockers, diltiazem or digoxin. \r\n\t* Need to anticoagulate for 3/52 prior to attempting cardioversion due to the risk of throwing off a clot. You can also perform a TOE to exclude a mural thrombus. \r\n\r\nIf AF persists or reversible causes are not present then decisions should be made about rate control, rhythm control or electrical cardioversion.\r\n\r\n## Management of Chronic AF \r\n\r\nThe cornerstones of managing chronic AF are related to symptom control and mitigating stroke risk. \r\n\r\n## Symptom Management of Chronic AF \r\n\r\n### Rate vs. Rhythm Control \r\n\r\n#### Rate-Control\r\n\r\nThe aim of rate control is to reduce a patient's heart rate in order to reduce symptoms.\r\n \r\n* First line in most patients. See below for patients who should undergo rhythm control. \r\n* **1st line medications:** beta-blocker (bisoprolol) or rate-limiting calcium channel blocker (diltiazem). \r\n* **2nd line medications**: dual therapy (under specialist guidance) \r\n* Digoxin monotherapy may be considered in those with non-paroxysmal AF who are sedentary. \r\n \r\n#### Rhythm Control\r\n\r\nThe aim of rhythm control is to revert a patient back into sinus rhythm. \r\n \r\nRhythm control should be offered to patients who have: \r\n\r\n* AF secondary to a reversible cause\r\n* Heart failure thought to be caused by AF\r\n* New-onset AF\r\n* Or those for whom a rhythm control strategy would be more suitable based on clinical judgement. \r\n\r\nRhythm control can be achieved via two methods:\r\n\r\n* Electrical cardioversion\r\n* Pharmacological cardioversion: amiodarone, fleicanide or sotalol. \r\n\r\nThe moment of return to sinus rhythm poses the highest stroke risk. Therefore, rhythm control should only be attempted if the onset of AF <48 hours, a patient has undergone 3/52 of anticoagulation or has had a TOE to exclude a mural thrombus. \r\n\r\nNote that patients in chronic AF or those who have failed cardioversion before are unlikely to be successfully cardioverted so this would not be considered in most of these cases.\r\n\r\n#### Catheter Ablation \r\n\r\nA final option for rhythm control is catheter ablation of the arrhythmogenic focus between the pulmonary veins and left atrium. Even if teh foci is ablated, this does not reduce stroke risk and the patient must be anticoagulated. There is a high risk of recurrence (50% have recurrent AF). \r\n\r\n## Medications used for Rate Control \r\n\r\n### Beta-blockers\r\n\r\n* The most commonly used beta-blocker in AF is bisoprolol.\r\n* Commonly used medication for acute treatment and chronic management.\r\n* Technically it is contraindicated in COPD and asthma (in reality unless the conditions are considered _brittle_ it is not a problem). \r\n* Cannot be used in hypotension because it will drop blood pressure.\r\n* Note that sotalol CANNOT be used as a rate control agent because of its rhythm control action.\r\n\r\n### Non-dihydropyridine calcium channel blockers\r\n\r\n* Calcium channel blockers used in AF are diltiazem or verapamil.\r\n* They are not frequently used in hospital settings because they are negatively ionotropic and therefore they are contraindicated in heart failure.\r\n\r\n### Digoxin\r\n\r\n* Usual for patients who are hypotensive or who have co-existent heart failure.\r\n* Should be avoided in younger patients because it increases cardiac mortality.\r\n* Often used second-line in conjunction with beta-blockers if fast AF remains refractory.\r\n\r\n## Medications used for Rhythm Control\r\n\r\n* Flecainide\r\n * Can be either given regularly or as a \"pill in the pocket\" when symptoms come on.\r\n * Is preferred in _young patients_ who have _structurally normal hearts_ because it can induce fatal arrhythmias in those with structural heart disease.\r\n\r\n* Amiodarone\r\n * Extremely effective drug in controlling both rate and rhythm.\r\n * However it comes with a massive list of significant side-effects so should normally only be given to _older, sedentary patients_.\r\n\r\n* Sotalol\r\n * This is a beta blocker with additional K channel blocker action.\r\n * Used for those that don't meet the demographics for either flecainide or amiodarone.\r\n\r\n## Mitigating Stroke Risk in Chronic AF \r\n\r\nIn atrial fibrillation, the lack of organised atrial contraction can lead to blood stasis in the left atrium. Due to the left atrial appendage, blood clots easily here and if part of this clot embolises it can lead to a stroke. Therefore, if a patient has any history of atrial fibrillation or atrial flutter the need for anticoagulation must be considered. \r\n\r\nPatients need to be considered according to their stroke risk (CHADS2VASc score) and their bleeding risk (ORBIT score) to determine whether anticoagulation is appropriate. \r\n\r\n### CHADS2VASc Score\r\n\r\nPatients should be risk stratified using the CHADS2VASc score:\r\n\r\n* C: 1 point for congestive cardiac failure.\r\n* H: 1 point for hypertension.\r\n* A2: 2 points if the patient is aged 75 or over.\r\n* D: 1 point if the patient has diabetes mellitus.\r\n* S2: 2 points if the patient has previously had a stroke or transient ischaemic attack (TIA).\r\n* V: 1 point if the patient has known vascular disease.\r\n* A: 1 point if the patient is aged 65-74.\r\n* Sc: 1 point if the patient is female.\r\n\r\n#### Interpretation of the CHADS2VASc score\r\n\r\nThe minimum score is 0 (associated with 0% annual stroke risk) and maximum score is 9 (15% annual stroke risk).\r\nMales who score 1 or more or females who score 2 or more should be anticoagulated (as long as the risk of stroke outweighs the risk of bleeding). \r\n\r\n#### ORBIT Score\r\n\r\nRisks of anticoagulation also need to be considered. Historically the HASBLED score stratified bleeding risk:\r\n\r\n* H: Hypertension 1 point\r\n* A: Abnormal renal or liver function 2 points if both are present\r\n* S: Stroke (previous) 1 point\r\n* B: Major bleed (previous) 1 point\r\n* L: Labile INR 1 point\r\n* E: Elderly (>65) 1 point\r\n* D: Drugs/alcohol 1 point for drug or alcohol use (2 points if both are present)\r\n\r\nIn their 2021 AF guidelines NICE suggested the use of the ORBIT score which takes into account:\r\n\r\n* Sex\r\n* Haemoglobin (<13mg/Dl in males, <12mg<dL in females) 2 points\r\n* Age (>74) 1 point\r\n* Bleeding history 2 points\r\n* Renal function (eGFR <60) 1 point\r\n* Concomitant use of anti-platelets 1 point\r\n\r\n#### Interpretation of the HASBLED and ORBIT scores\r\n\r\nIn reality very little guidance exists about how to weigh up the stroke and bleeding risks when making a decision on anticoagulation. Choice of long term anticoagulation is generally a decision led by patient choice and clinical judgement.\r\n\r\n### Anticoagulation options in AF\r\n\r\n* **Direct oral anticoagulants (DOACs)**:\r\n * Considered first line for anticoagulation in AF. \r\n * Examples of DOACs are edoxaban, apixaban, rivaroxaban & dabigatran\r\n * **Do not** require monitoring\r\n * Generally associated with fewer bleeding risks compared to warfarin.\r\n * Most have approximately 12 hour half-lives therefore if a patient misses a dose they are not covered.\r\n\r\n* **Warfarin**:\r\n * Requires cover with LMWH for 5 days when initiating treatment (because warfarin is initially _prothrombotic_).\r\n * Requires regular INR monitoring.\r\n * INR can be affected by a whole host of drugs and foods.\r\n * Has 40 hour half-life therefore anticoagulant effect lasts days.\r\n * Is the only oral anticoagulant licenced for **valvular AF**.\r\n* **Low Molecular Weight Heparin (LMWH)**:\r\n * An example of a LMWH is enoxaparin.\r\n * A rare option in patients who cannot tolerate oral treatment.\r\n * Involves daily _treatment dose_ injections.\r\n\r\n# Complications\r\n\r\nMost complications are either from uncontrolled heart rate, embolism or from anticoagulation. They include:\r\n\r\n* Heart failure\r\n* Systemic emboli:\r\n * Ischaemic Stroke\r\n * Mesenteric ischaemia\r\n * Acute limb ischaemia\r\n* Bleeding:\r\n * GI\r\n * Intracranial\r\n \r\n# Prognosis \r\n\r\nIf patients are anticoagulated and are on either rhythm or rate control AF can remain a benign cardiac arrhythmia. \r\n\r\n# NICE Guidelines\r\n\n[Click here to see information on NICE CKS guidance for AF](https://cks.nice.org.uk/topics/atrial-fibrillation/)\r\n\r\n# References\r\n \r\n[Live Life in the Fast Lane AF ECG Summary](https://litfl.com/atrial-fibrillation-ecg-library/)",
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"question": "A 62-year-old woman presents to the Accident and Emergency department with a sudden onset of palpitations 6 hours earlier. In the department, her ECG shows atrial fibrillation at a rate of 95 beats per minute. She has a past medical history of asthma, and had an NHS Health Check the day before, where she was noted to be in sinus rhythm.\n\nWhich of the following is the most suitable next step in the management of this patient?",
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"explanation": "There is no indication of ST-elevation on this ECG. A STEMI will cause ST elevation acutely, but it is important to note that the ECG changes will evolve over time",
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"explanation": "This ECG shows left ventricular hypertrophy (increased amplitude of the QRS complex, particularly noticeable in V1-V4) and non-specific T-wave inversion. In an otherwise young, healthy person, the most likely cause of left ventricular hypertrophy is HCM. This would also explain his symptoms of chest pain and shortness of breath on exertion. He should be referred for an urgent cardiology review for consideration of an implantable cardioverter-defibrillator (ICD)",
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"comment": "can't see all of the ecg\n",
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"comment": "Doesnt seem like an LVH on ecg",
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"comment": "agreed - should be deep S waves in V1/V2 and tall R waves in V5/V6",
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"explanation": "# Summary\r\n\r\nHypertrophic cardiomyopathy (HCM) is an autosomal dominant condition characterised by left ventricular hypertrophy without an apparent cause. It is a common inherited cardiac condition and a significant cause of sudden cardiac death in young adults. HCM is attributed to mutations in genes encoding sarcomere proteins leading to chaotic and disorganized myocytes. HCM may be asymptomatic but can also lead to exertional syncope, dyspnoea, chest pain and heart failure. Definitive diagnosis is made via echocardiogram. Management involves lifestyle modifications, medication for symptom control, surgical or interventional procedures for severe cases, and consideration of implantable cardioverter-defibrillators in those at risk of sudden cardiac death. Prognosis varies, with an annual mortality rate of 1.1%, and a 20-year survival rate estimated at 81% after diagnosis.\r\n\r\n# Definition \r\n\r\nHypetrophic cardiomyopathy (HCM) is an autosomal dominant condition characterised by asymmetrical septal hypertrophy leading to left ventricular hypetrophy and diastolic dysfunction in the absence of an obvious cause (e.g. hypertension). \r\n\r\n# Epidemiology \r\n\r\nHCM is estimated to impact 1 in 500 people. It is the most common inherited cardiac condition. Inheritance of HCM is in an autosomal dominant fashion. However, 50% of cases result due to sporadic mutations. Most of the hypertrophy develops during childhood and adolescent, however, genetic variation means late-onset disease can occur.\r\n\r\n# Pathophysiology\r\n\r\nHCM is attributed to mutations in one or a number of genes that encode for sarcomere proteins. A common mutation is in the beta-myosin heavy chain gene leading to myocyte hypetrophy with chaotic and disorganised myocytes. \r\n\r\n# Symptoms\r\n\r\n* May be asymptomatic \r\n* Or can present with symptoms of left ventricular outflow obstruction, pulmonary congestion or heart failure: \r\n\t* Exertional syncope \r\n\t* Pre-syncope/syncope\r\n\t* Sudden cardiac death \r\n\t* Exertional dyspnoea \r\n\t* Fatigue\r\n\t* Chest pain: may be anginal (due to decreased blood flow through the coronary arteries) or atypical. \r\n\r\n# Signs\r\n\r\nPhysical examination can often be normal or non-specific, however typical findings may include:\r\n\r\n* \"Jerky\" pulse\r\n* Double apex beat\r\n* Harsh ejection systolic murmur\r\n* Apical thrill\r\n* A wave in JVP \r\n\r\n# Differential Diagnoses\r\n\r\n* Aortic Stenosis \r\n\t* Similarities: both may have an ejection systolic murmur and present similarly with chest pain, exertional syncope and dyspnoea. \r\n\t* Differences: can be difficult to delineate clinically, but demographics may be very different. Aortic stenosis tends to affect older patients, whilst HOCM is likely to be found in younger patients. \r\n\r\n* Hypertensive Disease \r\n\t* Similarities: chronic high blood pressure can lead to left ventricular hypertrophy. \r\n\t* Differences: echocardiogram reveals asymmetrical left ventricular hypertrophy in HOCM. Family history and patient demographics may also suggest HOCM over hypertensive disease. \r\n\r\n* Supravalvular Aortic Stenosis: \r\n\t* Similarities: both may have an ejection systolic murmur. \r\n\t* Differences: supravalvular aortic stenosis is a congenital cardiac condition whereas HOCM tends to develop over time. Supravalvular stenosis can be distinguished from HOCM on echocardiography due to the level of obstruction either above or below the aortic valve respectively. \r\n\r\n# Investigations\r\n\r\n**ECG** typically demonstrates: \r\n\r\n* Abnormal Q waves\r\n* Deep T wave inversion \r\n* LVH \r\n\r\n**Echocardiogram: definitive diagnosis** \r\n\r\n* HCM is reliably diagnosed on echocardiogram. \r\n* Findings of HOCM on echocardiogram can be remembered with the mnemonic 'MR SAM ASH'. \r\n\t* **M**itral **R**egurgitation\r\n\t* **S**ystolic **A**nterior **M**otion of the mitral valve leaflets \r\n\t* **A**symmetrical **S**eptal **H**ypertrophy. \r\n\r\n**Genetic testing:** there is a role for genetic testing in HCM in families where there are known cases of HCM. \r\n\r\n# Management\r\n\r\n## Conservative \r\n\r\nMany patients with HCM do not have any symptoms and have a normal life expectancy. They are often counselled on not undertaking particularly stressful exercise or competitive athletics. \r\n\r\n## Medical \r\n\r\nMedical treatment of HCM remains symptoms control. \r\n**1st line: beta-blockers** to reduce palpitations symptoms, ectopic beats and are anti-anginal. \r\n\r\nOther medications that can be used are: non-dihydropyridine calcium channel blockers (verapamil), anti-arrhythmics (amiodarone) and anticoagulation (for AF). \r\n\r\n## Surgical and Interventional\r\n\r\nManagement of the septal hypetrophy in those with severe left ventricular outflow tract obstruction (LVOTO) or symptoms that are refractory to medical management. \r\n\r\n* Surgical septal myectomy\r\n* Alcohol septal ablation\r\n\r\nFor those at significant risk of sudden cardiac death an ICD may be inserted to mitigate this risk. \r\n\r\n# Complications\r\n\r\nThe abnormal morphology of the left ventricle can cause severe consequences for heart function: \r\n\r\n* Left ventricular outflow tract obstruction (LVOTO)\r\n* Diastolic dysfunction: HFpEF\r\n* Ischaemia \r\n* Mitral regurgitation: MR SAM ASH on echocardiogram \r\n\r\n# Prognosis \r\n\r\nThe annual mortality rate for HCM is 1.1% of people per year and the HCM survival rate is estimated to be 81% at 20 years after diagnosis. \r\n\r\n# NICE Guidelines\r\n\n[NICE Guidelines on Non-Surgical Reduction of the Myocardium in HCM](<https://www.nice.org.uk/guidance/ipg40>)\r\n\r\n# References\r\n\r\n[Patient UK HCM Summary](<https://patient.info/doctor/hypertrophic-cardiomyopathy-pro>)\n\r\n[American Heart Association Article on HCM](<https://www.ahajournals.org/doi/full/10.1161/circresaha.116.309348>)",
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"question": "An 18 year old man attends to his GP with chest pain and shortness of breath on exertion. He has no significant past medical history. An ECG is performed:\n\n[lightgallery]\n\nWhich of the following is the most likely to account for the ECG findings?",
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"explanation": "An NSTEMI, by definition, does not produce ST elevation on an ECG. ECG changes in an NSTEMI include ST-segment depression and T wave flattening or inversion, and can be differentiated from unstable angina by raised cardiac enzymes 8-12 after the onset of symptoms",
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"explanation": "# Summary\r\n\r\nAcute coronary syndrome (ACS) refers to a set of symptoms and signs that occur due to reduced blood flow to the heart at rest. It encompasses 3 distinct diagnoses: unstable angina, non-ST elevation myocardial infarction (NSTEMI), and ST elevation myocardial infarction (STEMI). In the case of infarction, this is a medical emergency requiring urgent treatment. ACS is most commonly caused by the rupture of atherosclerotic plaques in coronary arteries leading to further narrowing, and potentially complete occlusion, of these critical blood vessels. Diagnosis involves clinical evaluation, ECGs, and troponin levels. Treatment strategies differ for STEMI and NSTEMI/unstable angina but include oxygen therapy if hypoxic, antiplatelet medication, glyceryl trinitrates, morphine, and percutaneous coronary intervention (PCI). Post-MI management includes aspirin, dual antiplatelet therapy, beta-blockers, ACE inhibitors, high-dose statins, and cardiac rehabilitation. There are many complications to be aware of post-ACS and these include arrhythmias, heart failure, and cardiac tamponade, and others.\r\n\r\n# Definition \r\n\r\nAcute coronary syndrome is a set of symptoms and signs that occur due to decreased blood flow to the heart at rest. It broadly refers to three distinct diagnoses: unstable angina, non-ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI). \r\n\r\n# Epidemiology \r\n\r\nIn the UK, there are over 80,000 hospital admissions due to ACS every year. Coronary artery disease remains the largest cause of death in the UK. \r\n\r\n# Pathophysiology\r\n\r\nCoronary artery disease refers to the narrowing of coronary arteries by atherosclerosis and plaque formation. In stable angina, when the demand for myocardial oxygen increases with exertion, narrowed coronary arteries cannot meet this increased demand leading to myocardial ischaemia and pain. Conversely, in ACS, the symptoms occur at rest. This is because there is sudden plaque rupture and clot formation in the narrowed coronary arteries. If there is partial occlusion of the coronary artery this leads to ischaemia and chest pain at rest (unstable angina). If the coronary artery becomes more occluded or fully occluded this leads to significant hypoperfusion of the myocardium and ultimately leads to infarction (death) of the myocardial tissue (NSTEMI or STEMI). \r\n\r\n# Risk Factors\r\n\r\nCoronary artery disease and the development of plaques can be attributed to non-modifiable and modifiable risk factors. Modifiable risk factors must be addressed in the management of IHD. \r\n\r\n* Non-modifiable:\r\n * Age\r\n * Male sex\r\n * Family history\r\n * Ethnicity (particularly South Asians)\r\n* Modifiable:\r\n * Smoking\r\n * Hypertension\r\n * Hyperlipidaemia\r\n * Hypercholesterolaemia\r\n * Obesity\r\n * Diabetes\r\n * Stress\r\n * High fat diets\r\n * Physical inactivity\r\n\r\n# Classification \r\n\r\nAcute coronary syndrome can be split up into three distinct diagnoses: \r\n\r\n1. **Unstable angina**: caused by partial occlusion of a coronary artery. Troponin negative chest pain with normal/abnormal ECG signs. \r\n2. **Non-ST Elevation Myocardial Infarction**: caused by severe but incomplete occlusion of a coronary artery. Troponin positive chest pain without ST elevation. \r\n3. **ST-Elevation Myocardial Infarction**: caused by complete occlusion of a coronary artery. Troponin positive chest pain with ST elevation on ECG. \r\n\r\n*Myocardial Ischaemia vs. Myocardial Infarction and the Release of Troponin*\r\n\r\nIt is important at this stage to distinguish between angina (stable angina is on exertion and unstable angina is at rest) and myocardial infarction. Angina refers to myocardial ischaemia that causes chest pain but does not lead to the death of myocardial tissue and does not lead to a troponin rise. In myocardial infarction, the hypoperfusion of the myocardium is so profound that it leads to the death of myocardial tissue. It is when there is myocardial tissue death that troponin is released into the bloodstream and a troponin rise is found on blood tests.\r\n\r\n*Type 2 Myocardial Infarction* \r\n\r\nIt is also important to mention that some patient may have myocardial infarctions due to cardiac hypoperfusion for other reasons (e.g. severe sepsis, hypotension, hypovolaemia or coronary artery spasm). These are usually termed type 2 myocardial infarctions and may not require the conventional treatment outlined below. \r\n\r\n# Symptoms and Signs\r\n\r\n* Chest pain - the classical presentation can be considered in terms of the SOCRATES mnemonic:\r\n * Site - Central/left sided\r\n * Onset - Sudden\r\n * Character - Crushing ('like someone is sitting on your chest')\r\n * Radiation - Left arm, neck and jaw\r\n * Associated symptoms - Nausea, sweating, clamminess, shortness of breath, sometimes vomiting or syncope\r\n * Timing - Constant\r\n * Exacerbating/relieving factors - Worsened by exercise/exertion and may be improved by GTN\r\n * Severity - Often extremely severe\r\n* Atypical presentations may include:\r\n * Epigastric pain\r\n * No pain (more common in elderly and **patients with diabetes**):\r\n * Acute breathlessness\r\n * Palpitations\r\n * Acute confusion\r\n * Diabetic hyperglycaemic crises\r\n * Syncope\r\n\r\n# Differential Diagnoses\r\n\r\nIt is important to remember that there are non-MI causes of chest pain and these should be considered when making a diagnosis:\r\n\r\n* Cardiac\r\n * Myocarditis\r\n * Pericarditis\r\n * Cardiomyopathy\r\n * Valvular disease\r\n * Cardiac trauma\r\n* Pulmonary\r\n * PE\r\n * Pneumonia\r\n * Pneumothorax\r\n* Vascular\r\n * Aortic dissection\r\n* GI\r\n * Oesophageal spasm\r\n * Oesophagitis\r\n * Peptic ulcer\r\n * Pancreatitis\r\n * Cholecystitis\r\n* MSK\r\n * Rib fracture\r\n * Costochondritis\r\n * Muscle injury\r\n * Herpes zoster\r\n\r\n# Diagnosis of ACS \r\n\r\nDiagnosis depends on a combination of clinical, ECG and biochemical findings which helps distinguish between the various types of ACS.\r\n\r\n* Unstable angina - cardiac chest pain at rest + abnormal/normal ECG + **normal troponin**.\r\n* NSTEMI - cardiac chest pain at rest + abnormal/normal ECG (but not ST-elevation) + **raised troponin**\r\n* STEMI - cardiac chest pain at rest + **persistent ST-elevation/new LBBB** (note that there is no need for a troponin in this case).\r\n\r\n## Diagnosis of STEMI\r\n\r\n* ST segment elevation **>2mm** in adjacent chest leads\r\n* ST segment elevation **>1mm** in adjacent limb leads\r\n* New left bundle branch block (LBBB) with chest pain or suspicion of MI\r\n\r\n## Diagnosis of NSTEMI\r\n\r\nDiagnosis of NSTEMI requires two of the following:\r\n\r\n* Cardiac chest pain\r\n* Newly abnormal ECG which does not demonstrate ST-elevation e.g. ST depression, T wave inversion or non-specific changes. \r\n* Raised troponin (with no other reasonable explanation)\r\n\r\n# Investigations\r\n\r\n## Bedside \r\n\r\n* ECG \r\n\t* Looking for ST-elevation, LBBB or other ST abnormalities\r\n\t* This is the most important investigation and should not be delayed for other investigations (e.g. bloods) because this will define immediate management.\r\n\t* If an ECG shows STEMI then troponin is essentially irrelevant and the patient requires immediate treatment.\r\n\r\n## Bloods \r\n\r\n* Troponin: performed **at least 3 hours** after pain starts. It will also need to be repeated (usually 6 hours after the first level) in order to demonstrate a dynamic troponin rise. \r\n* Renal function: good renal function is required for coronary angiogram +/- PCI due to the use of contrast. \r\n* HbA1c and lipid profile: looking for modifiable risk factors for coronary artery disease. \r\n* FBC and CRP - rule out infectious causes of chest pain\r\n* D-dimer - may be used in _appropriate_ patients to rule out PE. *Be very careful about who you do a D-dimer on!*\r\n\r\n## Imaging \r\n\r\n* CXR: should be completed in all those presenting with a chest symptoms. It will help to rule out other causes of chest pain (e.g. pneumothorax) and look for complications of a large MI (e.g. pulmonary oedema in acute heart failure). \r\n\r\n# ECG Interpretation - Cardiac Territories and Affected Vessels\r\n\r\nThe importance of a 12-lead ECG is that it allows one to view electrical activity of the heart from different \"views\". In MI (particularly STEMI) this allows you to understand which territory (and therefore which vessel) is being affected.\r\n\r\n| Location of ST elevation | Area of myocardium | Coronary artery |\r\n| -------------------------- | ------------------ | -------------------- |\r\n| II, III, aVF | Inferior | RCA |\r\n| V1-2 | Septal | Proximal LAD |\r\n| V3-4 | Anterior | LAD |\r\n| V5-6 | Apex | Distal LAD/ LCx/ RCA |\r\n| I, aVL | Lateral | Lcx |\r\n| V7-V9 (ST depression V1-3) | Posterolateral | RCA/ LCx |\r\n\r\n\r\nRCA: right coronary artery, LAD: left anterior descending, LCx: Left circumflex\r\n\r\n[lightgallery]\r\n\r\n[lightgallery2]\r\n\r\n[lightgallery3]\r\n\r\n[lightgallery4]\r\n\r\n\r\nNSTEMIs may also show T wave abnormalities (such as ST depression and T wave inversions) in vascular territories as above. However, changes can also often not include all the specific leads of that territory in an NSTEMI.\r\n\r\n# Troponin Interpretation\r\n\r\nTroponin is a myocardial protein that is released into the bloodstream when cardiac myocytes are damaged. Serum levels typically rise **3 hours** after myocardial infarction begins.\r\n\r\nDifferent hospitals have differing guidelines (and assays) for interpretations of results. In general there are three groups of troponin levels:\r\n\r\n* Low - definitely no myocardial cell death. The patient is not having an MI although they may be experiencing unstable angina.\r\n* Mildly raised - This is an equivocal result and may be due to other non-MI related factors (see below). These patients usually need a <u>6-12 hour repeat test</u>.\r\n * If repeat troponin is raised on the repeat they are having an MI.\r\n * If repeat troponin is stable or falling then they are unlikely to be having an MI.\r\n* Definitely raised with sequential dynamic troponin rises - MI confirmed (be aware of the possibility of a Type 2 MI)\r\n\r\n## Non-ACS causes of a raised troponin\r\n\r\nAlthough troponin is often used diagnose myocardial infarction, there are in fact many causes of a raised troponin:\r\n\r\n* Myocardial infarction\r\n* Pericarditis\r\n* Myocarditis\r\n* Arrythmias\r\n* Defibrillation\r\n* Acute heart failure\r\n* Pulmonary embolus\r\n* Type A aortic dissection\r\n* Chronic kidney disease\r\n* Prolonged strenuous exercise\r\n* Sepsis\r\n\r\nIt is therefore critical to have good clinical grounds to test a troponin in order to avoid unnecessary treatments and investigations.\r\n\r\n# Management\r\n\r\nAcute management depends on the type of acute coronary syndrome. It is broadly split into the management of STEMI and the management of NSTEMI/unstable angina. \r\n\r\n# Management of STEMI\r\n\r\n[lightgallery5]\r\n\r\nFor emergencies, always follow A-E structure. \r\n\r\n1. Targeted oxygen therapy (aiming for sats >90%)\r\n2. Loading dose of **PO aspirin 300mg**\r\n - Note that some hospital protocols will also call for a loading dose of a second anti-platelet agent such as clopidogrel (300mg) or ticagrelor (180mg)\r\n - For those going on to have PCI, NICE guidance suggests adding prasugrel (if not on anti-coagulation) or clopidogrel (if on anti-coagulation)\r\n3. **Sublingual GTN spray** - for symptom relief\r\n4. **IV morphine/diamorphine** - in addition this causes vasodilation reducing preload on the heart\r\n5. Primary percutaneous coronary intervention (PPCI) for those who:\r\n - Present **within 12 hours of onset of pain** AND\r\n - Are **<2 hours** since <u>first medical contact</u>\r\n\r\nRemember that (particularly in STEMI) _time is heart_ therefore urgent treatment, escalation, and delivery of PPCI is critical to good outcomes.\r\n\r\n# Management of NSTEMI/Unstable Angina\r\n\r\n[lightgallery6]\r\n\r\nFor emergencies, always follow A-E structure. \r\n\r\n1. Targeted oxygen therapy (aiming for sats >90%)\r\n2. Loading dose of **PO aspirin 300mg** and fondaparinux\r\n * Patients should have their 6 month mortality score (often the GRACE score) calculated as early as possible - all those who are anything other than lowest risk should also be given **prasugrel or ticagrelor** unless they have a high risk of bleeding where **PO clopidogrel 300mg** is more appropriate.\r\n3. **Sublingual GTN spray** - for symptom relief\r\n4. **IV morphine/diamorphine** - in addition this causes vasodilation reducing preload on the heart\r\n5. Start antithrombin therapy such as **treatment dose low molecular weight heparin** or **fondaparinux** if they are for an immediate angiogram\r\n6. Patients with <u>high 6 month risk of mortality</u> should be offered an angiogram within 96 hours of symptom onset.\r\n\r\nNote that management of unstable angina is similar to that of NSTEMI with aspirin for all patients and fondaparinux and early angiography for those at high risk.\r\n\r\n# Post-MI management\r\n\r\n[lightgallery7]\r\n\r\n* ALL patients post-MI patients should be started on the following 5 drugs:\r\n 1. **Aspirin 75mg OM** + second anti-platelet (**clopidogrel 75mg OD** or **ticagrelor 90mg OD**)\r\n 2. **Beta blocker (normally bisoprolol)**\r\n 3. **ACE-inhibitor (normally ramipril)**\r\n 4. **High dose statin (e.g. Atorvastatin 80mg ON)**\r\n* All patients should have an **ECHO** performed to assess systolic function and any evidence of heart failure should be treated.\r\n* All patients should be referred to **cardiac rehabilitation**.\r\n* Patients who have been treated without angiography should be considered for ischaemia testing to assess for inducible ischaemia. \r\n\r\n# Complications\r\n\r\n* Ventricular arrhythmia\r\n* Recurrent ischaemia/infarction/angina\r\n* Acute mitral regurgitation\r\n* Congestive heart failure\r\n* 2nd, 3rd degree heart block\r\n* Cardiogenic shock\r\n* Cardiac tamponade\r\n* Ventricular septal defects\r\n* Left ventricular thrombus/aneurysm\r\n* Left/right ventricular free wall rupture\r\n* Dressler's Syndrome\r\n* Acute pericarditis\r\n\r\n## Ventricular Arrhythmias\r\n\r\n* Ventricular arrhythmias can occur as a consequence of MI, during cardiac catheterisation, or after reperfusion.\r\n* Most post-MI ventricular arrhythmias are short lived and self-resolve.\r\n* However if sustained VT or VF occurs they should be treated as per the Advanced Life Support protocols.\r\n\r\n## Recurrent Ischaemia/Infarction/Angina\r\n\r\n* Occasionally inserted stents can thrombose requiring reintervention.\r\n* New infarcts can occur in different vascular territories - this is less likely in the age of PCI where all territory are imaged during the procedure.\r\n* Angina and chest pain can continue for some time after an MI and is more common in NSTEMI patients.\r\n\r\n## Congestive Heart Failure\r\n\r\n* Heart failure can occur as a consequence of impairment heart muscle function secondary to ischaemia.\r\n* It should be treated as any other acute heart failure.\r\n* Ventricular function may improve over months as the heart muscle recovers.\r\n\r\n## Heart Block\r\n\r\n* Various levels of heart block are common - particularly following **inferior** infarcts (because the right coronary artery supplies the SAN).\r\n* These may be treated with:\r\n * Simple observation (as many will revert back to sinus rhythm)\r\n * Transcutaneous/venous pacing (if symptomatic)\r\n * Permanent pacing (if failing to resolve)\r\n\r\n## Left Ventricular Thrombus/Aneurysm\r\n\r\n* Aneurysm can occur following an anterior MI where the myocardium can be susceptible to wall stress leading to an aneurysm.\r\n* It may be silent, cause arrhythmias or embolic events.\r\n* It is definitely diagnosed on ECHO but ECG may show persisting ST elevation.\r\n* Thrombus can form either within an above described aneurysm or around hypokinetic regions of the myocardium.\r\n* Thrombi can embolise causing complications such as stroke, acute limb ischaemia and mesenteric ischaemia.\r\n\r\n## Left/Right Ventricular Free Wall Rupture\r\n\r\n* Necrosis of the free walls of either ventricle can lead to rupture allowing blood into the pericardial space.\r\n* This leads to a rapid tamponade and normally leads to cardiac arrest/death within seconds.\r\n* Treatment includes pericardiocentesis and surgery but prognosis is extremely poor.\r\n\r\n## Acute Mitral Regurgitation\r\n\r\n* This can occur because of papillary muscle rupture and carries a poor prognosis. Occurs commonly due to infero-osterior MI. \r\n* This presents with:\r\n * Pansystolic murmur heard best at the apex\r\n * Severe and sudden heart failure\r\n* It is diagnosed on echocardiogram and may require surgical correction.\r\n\r\n## Ventricular Septal Defect\r\n\r\n* Interventricular septal rupture is a short-term complications of myocardial infarction.\r\n* Rupture caused by an anterior infarct is generally apical and simple.\r\n* Rupture caused by an inferior infarct is generally basal and more complex.\r\n* Without reperfusion, septal rupture typically occurs within the first week after the infarction.\r\n* Features of septal rupture include:\r\n * Shortness of breath\r\n * Chest pain\r\n * Heart failure\r\n * Hypotension\r\n * Harsh, loud pan-systolic murmur along the left sternal border.\r\n * Palpable parasternal thrill.\r\n* Diagnosis is with echocardiogram.\r\n* Patients are managed with emergency cardiac surgery.\r\n\r\n## Dressler's syndrome\r\n\r\n* Dressler's syndrome or post-infarction pericarditis typically presents with persistent fever and pleuritic chest pain **2-3 weeks** or up to a few months after an MI.\r\n* Note that patients can get pericarditis immediately following MI which is NOT considered Dressler's syndrome.\r\n* Symptoms usually resolve after several days.\r\n* Occasionally it can also present with features of pericardial effusion and has become relatively uncommon since the introduction of PCI.\r\n* Management: **high dose aspirin**\r\n\r\n# Prognosis \r\n\r\nDue to the development of PPCI and post-MI care (cardiac rehabilitation) the mortality rates following myocardial infarction continue to decline. Those patients who go on to develop heart failure after myocardial infarction have a significantly worse prognosis than those who do not. \r\n\r\n# NICE Guidelines\r\n\n[NICE Guidelines for Unstable Angina and NSTEMI](https://www.nice.org.uk/guidance/cg94)\r\n\n[NICE Guidelines for STEMI](https://www.nice.org.uk/guidance/cg167)\r\n\r\n# References\r\n\r\n[Patient UK Information on Acute Coronary Syndrome](<https://patient.info/doctor/acute-coronary-syndrome-pro>)",
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"explanation": "# Summary\r\n\r\nHeart failure (HF) is a clinical syndrome characterised by the heart's inability to pump enough blood to meet the body's needs. It is a common condition primarily affecting the elderly population. HF can be classified based on various factors, such as the type of dysfunction (systolic or diastolic), the onset (acute or chronic), and the severity of symptoms (NYHA classification). The clinical features of HF differ depending on whether it primarily affects the left or right ventricle, but broadly include fatigue, shortness of breath, and peripheral oedema. Diagnosis involves evaluating symptoms, NT-pro-BNP levels, and echocardiography. Management includes lifestyle modifications, medical therapy, and, in some severe cases, cardiac resynchronisation therapy. The prognosis for HF varies, but approximately 50% of those diagnosed are alive at 5 years.\r\n\r\n# Definition \r\n\r\nHeart failure (HF), also known as congestive heart failure (CHF) and congestive cardiac failure (CCF), is defined as the failure of the heart to generate sufficient cardiac output to meet the metabolic demands of the body.\r\n\r\n# Epidemiology \r\n\r\n* HF is common: the prevalence in the UK is estimated at 1-2%.\r\n\r\n* HF primarily affects the elderly population: the average age of diagnosis is 75 years old. The incidence of HF has been increasing with the ageing population.\r\n\r\n* In Europe and North America the most common causes are coronary artery disease, hypertension, and valvular disease.\r\n\r\n* Although Chagas disease is a rare cause in Europe and North America, it is a significant cause of heart failure in Central/South America.\r\n\r\n# Pathophysiology\r\n\r\nThe pathophysiology for HF is diverse and depends on the aetiology of the HF. \r\n\r\n# Classification \r\n\r\nHF can be classified in different ways. It can be classified as being low output vs. high output HF, predominantly systolic or diastolic dysfunction, whether the process has been acute or chronic, or by the severity of symptoms (and consideration for predominantly left or right ventricle features). \r\n\r\n## Low-output HF vs. High-output HF \r\n\r\nLow-output HF is much more common than high-output HF. Low-output HF occurs when cardiac output is reduced due to a primary problem with the heart and the heart is unable to meet the body's needs. Conversely, high-output HF refers to a heart that has a normal cardiac output, but there is an increase in peripheral metabolic demands that the heart is unable to meet. \r\n\r\nThe common causes of low-output HF will be further discussed below. Common causes of high-output HF include: \r\n\r\n* Anaemia\r\n* Arteriovenous malformation\r\n* Paget's disease\r\n* Pregnancy\r\n* Thyrotoxicosis\r\n* Thiamine deficiency (wet Beri-Beri)\r\n\r\nThese can be remembered with the AAPPTT mnemonic. \r\n\r\n## Systolic vs. Diastolic HF\r\n\r\nSystolic dysfunction refers to an impairment of ventricular contraction. The ventricles are able to fill well, but the heart is unable to pump the blood sufficiently out of the ventricle due to impaired myocardial contraction during systole (reduced ejection fraction). Common causes include: ischaemic heart disease, dilated cardiomyopathy, myocarditis or infiltration (haemochromatosis or sarcoidosis). \r\n\r\nIn comparison, diastolic dysfunction refers to the inability of the ventricles to relax and fill normally, hence the heart is still able to pump well but pumps out less blood per contraction due to reduced diastolic filling (preserved ejection fraction). Common causes include: uncontrolled chronic hypertension (significant left ventricular hypertrophy reduces filling of the left ventricle), hypertrophic cardiomyopathy, cardiac tamponade, and constrictive pericarditis. \r\n\r\n## Acute vs. Chronic HF \r\n\r\nHF can also be classified according to the time of onset. Acute HF occurs with new-onset HF symptoms (acute mitral regurgitation following an MI) or an acute deterioration in a patient with known, chronic HF. In comparison, chronic HF progresses more slowly and may take many years to develop. \r\n\r\n## Severity of Symptoms\r\n\r\n**New York Heart Association (NYHA) Classification of HF**\r\n\r\nThe NYHA Classification system is used to classify HF through the severity of symptoms. It runs from Class I (no limitation) to Class IV (discomfort at rest). \r\n\r\n* Class I - no limitation in physical activity, and activity does not cause undue fatigue, palpitations or dyspnoea.\r\n* Class II - slight limitation of physical activity, and comfort at rest. Ordinary physical activity causes fatigue, palpitations and/or dyspnoea.\r\n* Class III - marked limitation in physical activity, but comfort at rest. Minimal physical activity causes fatigue (less than ordinary).\r\n* Class IV - inability to carry on any physical activity without discomfort, with symptoms occurring at rest. If any activity takes place, discomfort increases.\r\n\r\n# Symptoms and Signs\r\n\r\nThe clinical features of HF can be considered according to the ventricle most impacted. However, a common presenting complaint for all types of heart failure is **fatigue**. \r\n\r\n\r\n## Clinical features of left heart failure (LHF)\r\n\r\nLHF, or left ventricular failure (LVF), causes pulmonary congestion (pressure builds up in the LHS of the heart and there is backpressure to the lungs) and systemic hypoperfusion.\r\n\r\n### Symptoms \r\n\r\n* Shortness of breath on exertion\r\n* Orthopnoea\r\n* Paroxysmal nocturnal dyspnoea\r\n* Nocturnal cough (± pink frothy sputum)\r\n* **Fatigue**\r\n\r\n### Signs \r\n\r\n* Tachypnoea\r\n* Bibasal fine crackles on auscultation of the lungs\r\n* Cyanosis\r\n* Prolonged capillary refill time \r\n* Hypotension\r\n* Less common signs: pulsus alternans (alternating strong and weak pulse), S3 gallop rhythm (produced by large amounts of blood striking compliant left ventricle), features of functional mitral regurgitation. \r\n\r\n## Clinical features of right heart failure \r\n\r\nRight heart failure causes venous congestion (pressure builds up behind the right heart) and pulmonary hypoperfusion (reduced right heart output).\r\n\r\n### Symptoms \r\n\r\n* Ankle swelling \r\n* Weight gain \r\n* Abdominal swelling and discomfort \r\n* Anorexia and nausea \r\n\r\n### Signs\r\n\r\n* Raised JVP\r\n* Pitting peripheral oedema (ankle to thighs to sacrum)\r\n* Tender smooth hepatomegaly\r\n* Ascites\r\n* Transudative pleural effusions (typically bilaterally)\r\n\r\n*NB. Sometimes left-sided heart failure can lead to pulmonary congestion which in turn also pushes the right ventricle into failure. In these cases, signs and symptoms of both left and right-sided heart failure may be present. This is congestive cardiac failure.* \r\n\r\n# Differential Diagnoses\r\n\r\n* **Chronic Obstructive Pulmonary Disease (COPD)** \r\n\t* **Similarities**: both may present with dyspnoea (and significant respiratory distress) and fatigue. \r\n\t* **Differences**: in heart failure, the shortness of breath is typically worse on lying flat (orthopnoea) and may be accompanied by paroxysmal nocturnal dyspnoea and peripheral oedema. Shortness of breath in COPD tends to be worse with exertion and is likely accompanied by other symptoms including chronic productive cough, wheeze and a significant smoking history. \r\n\r\n* **Acute Respiratory Distress Syndrome** \r\n\t* **Similarities**: both may present with shortness of breath, tachypnoea and respiratory distress. Both lead to the accumulation of fluid in the lungs and impaired gaseous exchange leading to hypoxaemia. \r\n\t* **Differences**: the underlying pathology between the two is different. Heart failure is a result of raised pressures in pulmonary capillaries, whereas ARDS is usually due to increased pressures in pulmonary capillaries secondary to a large insult (e.g. pneumonia, aspiration, or trauma). They can be distinguished by taking pulmonary capillary wedge pressures. \r\n\r\n* **Renal Failure** \r\n\t* **Similarities**: fluid retention and peripheral overload. \r\n\t* **Differences**: other signs and symptoms will allow distinction between HF and renal failure. In the latter, you may find uraemic symptoms(nausea, anorexia, uraemic flap) and potentially signs of renal replacement therapy. \r\n\r\n* **Liver Failure** \r\n\t* **Similarities**: fluid retention and peripheral overload especially ascites. \r\n\t* **Differences**: liver failure patients will present with other signs and symptoms including jaundice, hepatic encephalopathy and chronic liver disease signs (gynaecomastia, spider naevi, and excoriations). \r\n\r\n\r\n# Investigations\r\n\r\nIf a stable patient is presenting to the GP with suspected chronic heart failure, investigations should be carried out as per NICE guidelines. \r\n\r\n**1st line = NT-pro-BNP level**\r\n\r\nNT-pro-BNP is released by the ventricles in response to myocardial stretch. It has a high negative predictive value.\r\n\r\nInterpret NT-pro-BNP results as follows: \r\n\r\n* >2000ng/L (236pmol/L): refer urgently for specialist assessment and TTE <2 weeks. \r\n* 400-2000ng/L (47-236pmol/L): refer for specialist assessment and TTE <6 weeks. \r\n* If <400ng/L: diagnosis of heart failure is less likely. \r\n\r\n**Arrange a 12-lead ECG in all patients** \r\n\r\nECG may be normal or hint at underlying aetiology (ischaemic changes or arrhythmias). \r\n\r\n**Transthoracic echocardiogram (TTE)**\r\n\r\nAn echocardiogram will confirm the presence and degree of ventricular dysfunction.\r\n\r\n* Ventricular dysfunction is normally measured by the ejection fraction (EF). \r\n * EF <40% = HF with reduced ejection fraction (HFrEF, systolic dysfunction). \r\n * EF >40% but with raised BNP = HF with preserved ejection fraction (HFpEF, diastolic dysfunction).\r\n * EF 50-70% with normal BNP = normal. \r\n\r\n**Other Investigations:** \r\n\r\n* **Bloods**: U&E (renal function for medication and hyponatraemia), LFTS (deranged LFTs suggest hepatic congestion), TFTs (hyperthyroidism and high-output HF), glucose and lipid profile (modifiable CV risk factors)\r\n\r\n* **CXR**: CXR findings in heart HF can be remembered by the ABCDEF mnemonic:\r\n * A: **Alveolar** oedema (with 'batwing' perihilar shadowing)\r\n * B: **Kerley B** lines (caused by interstitial oedema)\r\n * C: **Cardiomegaly** (cardiothoracic ratio >0.5)\r\n * D: upper lobe blood **diversion**\r\n * E: **Pleural effusions** (typically bilateral transudates)\r\n * F: **Fluid in the horizontal fissure**\r\n\r\n[lightgallery]\r\n\r\n[lightgallery1] \r\n\r\n# Management\r\n\r\n## Conservative management\r\n\r\n* Weight loss if BMI >30. \r\n* Smoking cessation \r\n* Salt and fluid restriction - improves mortality\r\n* Supervised exercise-based group rehabilitation programme for people with heart failure. \r\n\r\nOffer annual influenza and one-off pneumococcal vaccinations for patients diagnosed with heart failure. \r\n\r\n## Medical management\r\n\r\n**Symptom management**: \r\n\r\n* For fluid overload, prescribe loop diuretics (e.g. furosemide or bumetanide). These do not affect overall mortality from heart failure. \r\n\r\n\r\n**Management which improves mortality**:\r\n \r\n1st line = ACE-I and beta-blocker \r\n\r\n* Consider ARB if intolerant to ACE-I. \r\n* Consider hydralazine if intolerant to ACE-I/ARB. \r\n\r\nIf symptoms persist and NYHA Class 3 or 4 consider adding:\r\n\r\n* Aldosterone antagonists = spironolactone or eplerenone. \r\n* Hydralazine and a nitrate for Afro-Caribbean patients. \r\n* Ivabradine if in sinus rhythm and impaired EF. \r\n* Digoxin = useful in those with AF. This <u>worsens</u> mortality but improves morbidity.\r\n\r\nNICE also advices seeking specialist guidance for prescribing **SGLT2 inhibitors** (dapagliflozin or empagliflozin). These should be given in symptomatic chronic heart failure with preserved or reduced ejection fraction, or as an add-on for patients already optimised with ACE-i/ARB/sacubitril-valsartan (i.e. combination), beta-blockers and aldosterone antagonists.\r\n\r\n**BASH Mnemonic**\r\n\r\n* BASH medications demonstrate a mortality benefit in patients with HFrEF = Beta-blockers, ACE-inhibitors/ARB, Spironolactone and Hydralazine. \r\n* There are no medications that improve mortality in diastolic heart failure. \r\n\r\n[lightgallery2]\r\n\r\n# Surgical/Interventional management \r\n\r\n* Cardiac resynchronisation therapy\r\n* Implantable cardiac defibrillators (ICDs) are indicated if the following criteria are fulfilled: \r\n * QRS interval <120ms, high risk sudden cardiac death, NYHA class I-III\r\n * QRS interval 120-149ms without LBBB, NYHA class I-III\r\n * QRS interval 120-149ms with LBBB, NYHA class I\r\n\r\n## Adverse effects of heart failure medications\r\n\r\nThe common side-effects for different heart failure medications are listed below\r\n\r\n* **Beta blockers**: Bradycardia, hypotension, fatigue, dizziness\r\n* **ACE inhibitors**: Hyperkalaemia, renal impairment, dry cough, lightheadedness, fatigue, GI disturbances, angioedema\r\n* **Spironolactone**: Hyperkalaemia, renal impairment, gynaecomastia, breast tenderness/hair growth in women, changes in libido\r\n* **Furosemide**: Hypotension, hyponatraemia/kalaemia,\r\n* **Hydralazine/nitrates**: Headache, palpitations, flushing\r\n* **Digoxin**: Dizziness, blurred vision, GI disturbances\n* **SGLT-2 inhibitors:** Thrush, UTIs, DKA in patients with pre-existing diabetes\r\n\r\n# Prognosis \r\n\r\nIt is estimated that >50% of people diagnosed with HF will survive after 5 years. Approximately 35% will be alive in 10 years. \r\n\r\n# NICE Guidelines\r\n\r\n[NICE Guidelines on Acute Heart Failure](https://www.nice.org.uk/guidance/cg187/chapter/1-Recommendations)\n\n[NICE Guidelines on Chronic Heart Failure](https://cks.nice.org.uk/topics/heart-failure-chronic)\r\n\r\n# References \r\n\r\n[2022 Stat Pearls Summary of Congestive Heart Failure](https://www.ncbi.nlm.nih.gov/books/NBK430873)",
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"question": "A 60-year-old lady presents to the emergency department with confusion. She has the following blood tests:\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Sodium|136 mmol/L|135 - 145|\n|Potassium|4 mmol/L|3.5 - 5.3|\n|Urea|6 mmol/L|2.5 - 7.8|\n|Creatinine|300 µmol/L|60 - 120|\n|eGFR|15 mL/min/1.73m<sup>2</sup>|> 60|\n\n\nHer previous blood tests from 2 months ago suggest that her baseline creatinine is approximately 70umol/L.\n\n\nThere is no information on the computer system about her medications but you find the following medications in her bag: trimethoprim, nitrofurantoin, bisoprolol, ramipril, and atorvastatin.\n\n\nWhich of the following medications would lead to a falsely low estimated glomerular filtration rate (eGFR)?",
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"explanation": "Stevens-Johnson syndrome typically produces a maculopapular rash with target lesions. There is normally mucosal involvement, as can be seen in the image above. Stevens-Johnson syndrome is usually drug-induced. This will require a hospital admission for treatment",
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"label": "a",
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"explanation": "Pyoderma gangrenosum usually manifests as a painful pustule or nodule with rapid progression. There is normally just one nodule, and is usually on the lower limbs. There is no mucosal involvement. It can sometimes be accompanied by fever and systemic symptoms",
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"explanation": "# Summary\n\nStevens-Johnson syndrome (SJS) is a serious, immune-complex-mediated hypersensitivity disorder often triggered by medication or, less commonly, viral, bacterial, or fungal infections. Clinically, it's characterized by symptoms resembling an upper respiratory tract infection, followed by erythematous macules and mucosal ulceration, affecting less than 10% of the body surface. Diagnosis is usually clinical, supplemented by skin biopsy. Management is largely supportive, with a focus on skin and eye care.\n\n# Definition\n\nStevens-Johnson syndrome (SJS) is an immune-complex-mediated hypersensitivity disorder. It ranges from mild to severe forms, part of a spectrum that includes toxic epidermal necrolysis (TEN) at its most severe end.\n\n# Epidemiology\n\nSJS is a rare disorder, with an incidence estimated between 2.6 to 6.1 cases per million people annually. It affects both genders and all age groups, although some studies suggest a slightly higher incidence in females and middle-aged adults.\n\n# Pathophysiology\n\nThe predominant cause of SJS is adverse drug reactions, most commonly from sulfonamides, beta-lactams (penicillins and cephalosporins), antiepileptics, allopurinol, and NSAIDs. Infectious agents, particularly viral pathogens like herpes simplex virus, Epstein-Barr virus, HIV, influenza, and hepatitis, can also trigger SJS. Bacterial and fungal infections are much less common causes.\n\n# Signs and Symptoms\n\n- SJS often presents within a week of medication intake, initially resembling an upper respiratory tract infection with symptoms such as cough, cold, fever, and sore throat.\n- Erythematous macules, later becoming target-shaped, appear after a few days.\n- Flaccid blisters develop and the Nikolsky sign is positive.\n- SJS affects less than 10% of the body surface, in contrast to TEN, which involves more than 30% of the skin.\n- Mucosal ulceration is seen in at least two of the following: conjunctiva, mouth, urethra, pharynx, or gastrointestinal tract. \n\nSJS has a 10% mortality rate, primarily due to dehydration, infection, or disseminated intravascular coagulation. In comparison, TEN has a 30% mortality rate.\n\n[lightgallery]\n\n# Differential Diagnosis\n\nThe differential diagnosis of SJS includes:\n\n- Erythema Multiforme: Characterized by target lesions, typically on the hands and feet, and less severe mucosal involvement.\n- Drug Rash with Eosinophilia and Systemic Symptoms (DRESS): Presents with fever, rash, and internal organ involvement, often with a delay of 2-6 weeks after drug exposure.\n- Acute Generalized Exanthematous Pustulosis (AGEP): Noted for the rapid development of numerous small non-follicular sterile pustules on a background of edematous erythema.\n\n# Investigations\n\nThe diagnosis of SJS is primarily clinical but can be supported by a skin biopsy, which can reveal necrotic keratinocytes and a sparse lymphocytic infiltrate.\n\n# Management\n\nManagement of SJS is largely supportive, focusing on skin care and prevention of ocular complications through timely ophthalmology referrals. Patients may require hospitalization for fluid and electrolyte management, pain control, and potential treatment of secondary infections.\n\n# References\n\n[Click here for more information on Stevens-Johnson syndrome](https://patient.info/doctor/stevens-johnson-syndrome)",
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"question": "A 40-year-old man presents to the accident and emergency department with a painful rash which has established quickly over the last few hours. He is pyrexial and reports general arthralgia. He was started on a course of amoxicillin for sinusitis the preceding day. He has no significant past medical or dermatological history.\n\nHis rash can be seen below.\n\n[lightgallery]\n\nWhich of the following is the most likely diagnosis in this patient?",
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"explanation": "The glomerular basement membrane is the kidneys - there will be IgG/C3 deposition in glomerulonephritis (eg. post-infectious)",
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"explanation": "### Summary\n\nBullous Pemphigoid and Pemphigus Vulgaris are both autoimmune blistering disorders with different blister locations and antigens involved. The clinical features, investigations, and treatments are similar, with steroids forming the mainstay of treatment. \n\n### Bullous Pemphigoid\n\n#### Definition\n\nOne of the autoimmune blistering disorders characterised by tense subepidermal blisters\n\n#### Pathophysiology\n\n- Autoantibodies targeting the hemidesmosomes that bind the basal keratinocytes of the epidermis to the basement membrane. The antigens are the BP180 and BP230 components of hemidesmosomes\n- This causes the development of tense, sub-epidermal blisters that are not readily deroofed\n- On immunoflouresence, this produces a linear pattern of immunoflouresence along the basement membrane\n- Autoantibodies may also be identified in the circulation\n- May sometimes represent a paraneoplastic process, so a careful history and examination is important\n- Other associations include drugs (PD-1 inhibitors in melanoma, ACEi and penicillamine), psoriasis treatment (phototherapy), injury to skin, neurological disease, and genetics\n\n#### Clinical Features\n\n- Usually affects older people\n- Prodrome of itch, irritation, erythematous, eczematous, urticarial skin changes, followed by tense subepidermal blisters\n- Nikolsky's sign is negative\n- The mucous membrane's are spared, except for the cicatrial variant (characterised by marked scarring and predilection for the mucous membranes) \n\n[lightgallery]\n\n#### Investigations\n\n- Biopsy for immunoflouresence from lesion edge\n- Anti BP180/BP230 antibodies circulating\n\n#### Treatment\n\n- Topical potent steroids at onset of symptoms e.g. itch\n- Doxycycline for anti-inflammatory effect\n- Systemic steroids (0.5-1mg/kg of prednisolone), continued until no further lesions for one year. Then tapered very gradually over many, many months\n- Steroid sparing agents include azathioprine and mycophenolate if relapse during steroid withdrawal\n- The cicatrial variant is particularly difficult to treat \n\n### Pemphigus Vulgaris\n\n#### Definition\n\nOne of the autoimmune blistering skin conditions characterised by flaccid intra-epidermal blisters.\n\n#### Pathophysiology\n\n- IgG autoantibodies are targeted against desmosomes, structures that link keratinocytes to other keratinocytes within the epidermis\n- The specific antigens are desmoglein 1 and desmoglein 3\n- This leads to the development of blisters within the epidermis, which are flaccid and often deroofed\n- Immunoflouresence shows a fish-net/chicken-wire pattern of staining within the epidermis\n- Drug triggers have been noted (such as ACEi and penicillamine), and it may be associated with an underlying malignancy as a paraneoplastic phenomenon\n\n#### Clinical Features\n\n- Flaccid, thin walled blisters leading to erosions across the body \n- Mucous membranes may be involved\n- Nikolsky's sign is positive\n- Patients can be quite unwell with pemphigus vulgaris and mortality is high without treatment\n\n[lightgallery1]\n\n#### Investigations\n\n- Biopsy for immunoflouresence from the edge of the lesion\n- Detection of autoantibodies against desmoglein 1 and desmoglein 3 using indirect immunofluorescence (IIF) or enzyme-linked immunosorbent assay (ELISA)\n\n#### Treatment\n\n- Treatment is very similar to Bullous Pemphigoid, with oral predniosolone\n- Risk of secondary bacterial infections is high and these often need treating with antibiotics \n\n### Memory Aid\n\nPemphigu**s** = **s**uperficial blisters, pemphigoi**d** = **d**eep blisters\n\nHere's a table comparing the two conditions:\n\n| | Bullous pemphigoid | Pemphigus vulgaris |\n| ------------- |:-------------:| :-----:|\n| Pathophysiology | IgG antibodies against hemidesmosomal proteins, primarily BP180 and BP230 | IgG antibodies against desmoglein 1 and desmoglein 3|\n| Clinical features | Tense, subepidermal blisters, rarely mucous membrane involvement | Painful, fragile blisters and erosions, mucous membrane involvement (oral membranes almost always)|\n| Investigation findings | Direct immunofluorescence (DIF) demonstrates linear IgG and complement along the basement membrane zone; Indirect immunofluorescence (IIF) or ELISA detects circulating antibodies against BP180 and BP230 | DIF demonstrates intercellular IgG deposits in the epidermis; IIF or ELISA identifies antibodies against desmoglein 1 and desmoglein 3 |\nTreatment | High-potency topical corticosteroids for local disease, oral corticosteroids for extensive involvement; immunosuppressive medications (AZT, MMF) for severe or refractory cases | High-dose systemic corticosteroids to induce remission, topical steroids for mucous membranes; adjunctive immunosuppressive agents (AZT, MMF, rituximab) to reduce corticosteroid dependence|\n\n\n\n### References\n[Bullous pemphigoid - DermNet NZ](https://dermnetnz.org/topics/bullous-pemphigoid)\n\n[Pemphigus vulgaris - DermNet NZ](https://dermnetnz.org/topics/pemphigus-vulgaris)\n",
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"question": "A patient presents with blistering of the skin. Bullous pemphigoid is suspected. Direct immunofluorescence is carried out and detects IgG and C3 in a linear pattern.\n\nIn what location would the IgG and C3 be located to confirm a diagnosis of bullous pemphigoid?",
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"explanation": "This is a topical antibiotic and is not indicated for acne vulgaris. It may be used to treat a skin infection however",
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"id": "31818",
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"name": "Add in oral lymecycline, in addition to current therapy",
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"explanation": "Oral antibiotics should be prescribed along with benzoyl peroxide and/or a topical retinoid to reduce the risk of antibiotic resistance",
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"explanation": "This is a topical steroid and is not indicated in acne vulgaris",
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"comment": "I understand fusidic acid is not the abx of choice. But are you not supposed to add topical abx before going for oral?",
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"comment": "yes but its not an option out of the 5??",
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"comment": "Also the acne is quite extensive (face and back) - therefore systemic abx are more appropriate in combination with the topical ",
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"comment": "How does it reduce the risk of antibiotic resistance?",
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"explanation": "# Summary\n\nAcne vulgaris is a common chronic disorder of the pilo-sebaceous unit, resulting in blockage of the follicle, formation of comedones and inflammation. Key signs and symptoms include open/closed comedones, inflammatory papules and pustules, and in severe cases, nodules and cysts. The disorder predominantly affects the face, neck, chest, and back, and has a significant psychological impact due to altered physical appearance. Acne is primarily diagnosed clinically, with further investigations necessary only in uncertain cases or prior to commencing certain treatments like isotretinoin. Treatment is guided by severity and may involve topical or systemic therapy based on the NICE guidelines. Potential complications include post-inflammatory hyperpigmentation, hypopigmentation, erythema, psycho/social/sexual dysfunction, and scarring.\n\n\n# Definition\n\n- A a chronic disorder of the skin affecting the pilo-sebaceous unit, in which there is blockage of the follicle leading to comedones and inflammation. \n- Vulgaris translates as \"common\", which is true as this condition affects over 80% of adolescents.\n\n# Epidemiology\n\n* It is one of the most common dermatological conditions globally, affecting individuals of all ethnicities and ages.\n* Prevalence is highest in adolescents and young adults, with up to 80% of individuals experiencing some degree of acne during their lifetime.\n* While most common in adolescents, adult-onset acne can occur, affecting people well into their 30s and beyond.\n* Acne affects both males and females, but the prevalence and severity may vary between genders.\n* The psychological impact of acne can be significant, affecting self-esteem and overall quality of life.\n\n# Risk Factors\n\nSeveral factors contribute to the development and exacerbation of acne, including:\n\n* Hormonal changes (e.g. during puberty, menstrual cycle, polycystic ovary syndrome)\n* Increased sebum (oil) production\n* Blockage of hair follicles and sebaceous glands by keratin and sebum\n* Bacterial colonization (Propionibacterium acnes)\n* Family history of acne\n* Certain medications (e.g. corticosteroids, hormonal treatments)\n\n# Pathophysiology\n\n- In normal skin, skin cells in the stratum corneum of the epidermis (corneocytes) desquamate successfully without blocking pilo-sebaceous units.\n- In acne, the corneocytes are excessively cohesive. They do not detach successfully.\n- Because of this, the keratin rich corneocytes accumulate and block off hair follicles causing follicular hyperkeratinisation.\n- Sebum is trapped in the hair follicle since it cannot be drained away. Androgens may also contribute to this causing sebaceous gland hyperplasia and increased sebum production. \n- This combination of sebum and keratin forms micro-comedones - the earliest feature of acne vulgaris. This is only visible under a microscope.\n- Gradually, the follicle becomes more distended with keratin and sebum, and the micro-comedone enlarges to become a comedone. \n- Initially, these are closed comedones, referred to as whiteheads. The contents are not exposed to the skin surface or oxygen, and therefore appear as fleshy/white papules. \n- Eventually, closed comedones become open comedones. As their contents become exposed to oxygen, they oxidise which causes black discolouration. Open comedones are therefore referred to as blackheads.\n- Comedones are then colonised with a gram positive bacillus called Propionibacterium (Cutibacterium) acnes. This is a commensal organism (part of the normal skin flora) but leads to an inflammatory response in the right conditions of the comedone, in a predisposed patient. \n- The comedone is subsequently transformed into an inflammatory papule, which is now associated with erythema. A papule is a solid, raised lesion less than 0.5cm in diameter. \n- As things progress and more neutrophils accumulate, the inflammatory papule becomes a pustule; this is a lesion less than 0.5cm in diameter that contains pus. \n- Eventually, the inflammatory papule or pustule becomes so distended that it ruptures into the dermis, triggering a marked and deep seated inflammatory response. \n- This leads to the formation of nodules/cysts, which are painful and red. A nodule is a solid lesion larger than 0.5cm, and cysts are walled off fluid containing structures. \n\n[lightgallery]\n\n# Classification\n\n- Non-inflammatory: blackheads and whiteheads.\n- Inflammatory: inflammatory papules, pustules, and nodules (cysts.)\n- Mild acne: predominantly non-inflammatory lesions. \n- Moderate acne: predominantly inflammatory papules and pustules. \n- Severe acne: nodules (cysts), scarring, acne fulminans, and acne conglobata. \n\n# Clinical Features\n\n- Open/closed Comedones, inflammatory papules and pustules, nodules, and cysts may be present.\n- The face is most often affected. The neck, chest and back may also be affected.\n- Psychological dysfunction due to changes physical appearance\n- Scarring: associated with inflammatory acne. Hypertrophic and keloid scars are more common in darker skin tones. \n\t- Atrophic: flat or indented, such as ice-pick, box-car, or rolling scars.\n\t- Hypertrophic: raised scars.\n\t- Keloid: raised scars that extend beyond the initial boundaries of the injury. \n- Post-inflammatory hyperpigmentation and hypopigmentation: associated with inflammatory acne. \n- Post inflammatory erythema: associated with inflammatory acne.\n- Acne fulminans: an uncommon but severe, serious acne presentation. \n\t- Inflammatory nodules/cysts that are painful, ulcerating, and haemorrhagic appear, with associated systemic upset (raised white cell count, joint pain, fever, fatigue.) \n\t- These patients should be reviewed urgently within 24 hours. It usually affects teenage male patients.\n- Acne conglobata: another uncommon presentation of severe nodular/cystic acne with interconnecting sinus tracts and extensive scaring. \n\n[lightgallery1]\n\n[lightgallery2]\n\n# Investigations\n\n- Acne is a clinical diagnosis and investigations are not usually needed. \n- Swabs may be indicated if the diagnosis is uncertain (e.g. if ruling out infectious pustules.)\n- Investigations will be required prior to commencing isotretinoin if indicated.\n- In some particular presentations where an endocrine cause is suspected, there may be endocrinological investigations (hyperandrogenic states such as PCOS or androgen secreting tumours.)\n\n# Treatment\n\nManagement of acne is multifaceted including education, topical/oral treatments and lifestyle modifications. \n\n- Each treatment combination is given as a 12 week course. \n- Combination therapies help reduce antimicrobial resistance. \n- Antibiotics are used predominantly since they have anti-inflammatory effects, rather than for their antimicrobial effects.\n- **Mild-moderate acne** is treated with any 2 of the following in combination:\n\t- Topical benzoyl peroxide.\n\t- Topical antibiotics (clindamycin)\n\t- Topical retinoids (tretinoin/adapalene)\n- **Moderate-severe acne** is treated with a 12-week coures of the following first line options:\n\t- Topical retinoids (tretinoin/adapelene) + topical benzoyl peroxide.\n\t- Topical retinoids + topical antibiotics (clindamycin)\n\t- Topical benzoyl peroxide + topical retinoid (tretinoin/adapelene) + oral antibiotic (lymecycline/doxycycline.) \n\t- Topical azelaic acid + oral antibiotic (lymecycline/doxycycline) \n\t- Second line oral antibiotics: trimethoprim and erythromycin e.g. in pregnant/breast-feeding women where tetracyclines are contra-indicated. \n\t- Combined oral contraceptives (COCPs) (if not contraindicated) in combination with topical agents can be considered as an alternative to systemic antibiotics in women\n\nNB: topical retinoids and oral tetracyclines are contraindicated during pregnancy and when planning a pregnancy, and so women of childbearing potential will need to use effective contraception, or choose an alternative treatment to these options.\n\t\n- As per NICE guidelines, referral to specialist Dermatology is indicated in the case of:\n\t- Acne fulminans.\n\t- Mild-moderate acne not responding to two 12 week courses of treatment as above.\n\t- Moderate-severe acne not responding to one 12 week course of treatment as above, including an oral antibiotic.\n\t- Psychological distress/mental health disorder contributed to by acne.\n\t- Acne with persistent pigmentary changes.\n\t- Acne with scarring.\n- Other available agents:\n\t- Co-cyprindiol: anti-androgenic contraceptive agent - may be trialled in primary care on female patients, but usually second line COCP due to increased risk of venous thromboembolism, and can only be given for 3 months. \n\t- Spironolactone: anti-androgenic - not often used. Not for male patients. \n\t- **Isotretinoin (oral retinoid):** the usual next step if the standard treatment fails and is prescribed by a dermatologist. \n\t\t* Notable adverse effects: dry skin/mouth/eyes/lips (most common), teratogenecity, photosensitivity, low mood, nose bleeds, hair thinning, raised triglycerides, intracranial hypertension \n\t\t* Isotretinoin is a well established teratogen that results in miscarriages and severe birth defects. As a result, the manufacturer recommends that all female patients taking isotretinoin are also using two forms of contraception from one month before until one month after use. For this reason a pregnancy test should also be done before initiating treatment\n\t\t* There is a controversial association between isotretinoin and depression/suicide. Recent research has shown that concerns about links between isotretinoin and depression or suicide are not established. This has now been included into the NICE guidelines. However it is still important to screen for depression/suicidal ideation before prescribing and during treatment.\n\t\n\t\n# Complications\n\n- Post-inflammatory erythema\n- Post-inflammatory hyper- and hypo- pigmentation\n- Psycho/social/sexual dysfunction \n- Scars (atrophic, hypertrophic, keloid)\n\t- Keloid scars: over-proliferating scar tissue/collagen extending beyond the boundaries of the lesion. Takes 3-4 weeks typically to develop after injury. They can cause itch and pain. It is fleshy, smooth, firm, and does not regress with time. The original injury may be minor, for example piercing or insect bite. Treatment is usually with intralesional steroids (triamcinolone). Cryotherapy and laser may also be used. Surgical resection is unlikely to be successful due to further scarring. Risk factors include:\n\t\t- Darker skin/Chinese/Hispanic origin \n\t\t- Less than 30 years of age\n\t\t- Previous keloid scarring \n\t- These are distinct from hypetrophic scars, which are thick and raised but remain within the injured boundary and tend to improve over time. \n\n# NICE Guidelines\n\n[NICE CKS for Acne Vulgaris](https://cks.nice.org.uk/topics/acne-vulgaris/)",
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"explanation": "# Summary\r\n\r\nBradycardia is defined as a heart rate <60bpm. It may be physiological or pathological. Bradycardic patients may present with fatigue, lightheadedness and/or syncope. Diagnosis of a bradycardia is made on ECG. It a patient has an acute bradycardia and adverse features then this is a medical emergency requiring immediate treatment. Emergency management is according to the Resus Council Algorithm and may involve atropine administration and transcutaneous/transvenous pacing. Longer-term management involves the insertion of a permanent pacemaker. \r\n\r\n# Definition \r\n\r\nBradycardia is defined as a heart rate <60bpm. If a patient has an acute bradycardia and adverse features (shock, syncope, heart failure or evidence of myocardial ischaemia) then this is a medical emergency requiring immediate treatment. \r\n\r\n# Epidemiology \r\n\r\nThe most common cause of pathological bradycardia is sick sinus syndrome and is estimated to have an incidence of 1 in 600 peopel over the age of 65. It affects both sexes equally. \r\n\r\n# Pathophysiology\r\n\r\nThe pathophysiology of bradycardias depends on the cause. The most common cause of bradycardia is sick sinus syndrome and this is due to the dysfunction of pacmemaker cells within the sinoatrial node (physiological pacemaker) as a person gets older. \r\n\r\n# Classification\r\n\r\nBradycardia can be classified according to cause: \r\n\r\n* Physiological: common in younger populations, athletes and during sleep. \r\n\r\n* Cardiac: \r\n * Sick sinus syndrome: disorder of the sinoatrial node. \r\n * Heart block: disorder of the atrioventricular node. \r\n * Post-myocardial infarction: post-inferior myocardial infarction. The right coronary artery supplies the SAN (pacemaker of the heart). \r\n * Aortic valve disease: the right coronary artery origin is disrupted just above the aortic valve. \r\n\r\n* Non-cardiac: \r\n * Vasovagal \r\n * Endocrinological: hypothyroidism. \r\n * Hypothermia \r\n * Electrolyte abnormalities\r\n * Cushing's triad of raised ICP: bradycardia, irregular breathing and hypertension. \r\n * Medications: beta-blockers, calcium channel blockers, digoxin etc. \r\n\r\n# Symptoms and signs\r\n\r\n## Symptoms\r\n\r\n* Lightheadedness \r\n* Syncope\r\n* Fatigue \r\n* Shortness of breath\r\n\r\n## Signs \r\n\r\n* Nil signs apart from bradycardia \r\n\r\n# Investigations\r\n\r\n## Bedside\r\n\r\n* **ECG**: help indicate underlying cause for the bradyarrhythmia. E.g. sick sinus syndrome with severe bradycardia and long pauses vs. heart block with prolonged PR interval. \r\n\r\n## Bloods \r\n\r\n* If considering a non-cardiac cause of the bradyarrhythmia (e.g. heart block).\r\n\r\n## Imaging \r\n\r\n* TTE: if considering causes such as post-MI (looking for regional wall motion abnormalities) or aortic valve disease. \r\n\r\n# Management\r\n\r\n## Initial management\r\n\r\nFor emergencies, always follow an A-E structure. Identify reversible causes (dyselectrolytaemias, drugs, cardiac causes etc.) \r\n\r\n*If there are adverse signs (e.g. shock, syncope, heart failure, myocardial ischaemia):* \r\n\r\n* **1st line** = **500 micrograms atropine IV**\r\n * Atropine blocks the vagal nerve which increases firing rate of the SAN. \r\n* **2nd line** = if the first dose of atropine is not working can consider giving additional doses of atropine 500mcg up to 3mg until response. Alternatively, **transcutaenous pacing** or **isoprenaline** or **adrenaline** or **alternative drugs** including aminophylline, adrenaline, glucagon (in beta-blocker or calcium channel blocker overdose). \r\n\r\n*If there are no adverse signs but a risk of asystole, or a satisfactory response to 500mcg atropine:*\r\n\r\n* Risk of asystole: recent asystole, mobitz type II block, complete heart block + broad QRS, ventricular pauses >3s. \r\n* **1st line** = administer **500 micrograms atropine IV**. Alternatively, **transcutaenous pacing** or **isoprenaline** or **adrenaline** or **alternative drugs** including aminophylline, adrenaline, glucagon (in beta-blocker or calcium channel blocker overdose). \r\n\r\n*If there are no adverse signs and there is no risk of asystole*\r\n\r\n* Observe\r\n\r\n## Further management \r\n\r\nTranscutaneous pacing may be used as an interim measure whilst awaiting expert help for transvenous pacing/permanent pacemaker insertion. \r\n\r\n# NICE Guidelines\r\n\r\n[NICE Guidelines for Symptomatic Bradycardias](https://www.nice.org.uk/guidance/ta88/ifp/chapter/what-is-symptomatic-bradycardia)\r\n\r\n# References\r\n\r\n[Click here to see the algorithm on the Resus Council website on management of bradycardia](https://www.resus.org.uk/library/2015-resuscitation-guidelines/peri-arrest-arrhythmias)",
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"question": "A 75 year old is brought to the emergency department by his son who believes he has taken an intentional overdose of his bisoprolol. On arrival to the department he has a reduced GCS, a blood pressure of 88/58 mmHg, and a heart rate of 40 beats per minute. He is initially given atropine, but his heart rate only increases to 50 beats per minute and he remains hypotensive.\n\nWhich of the following is the next best step in the management of this patient's bisoprolol overdose?",
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"explanation": "This is unlikely if her abdomen is soft and non-tender. Metabolic acidosis may occur in patients with peritonitis secondary to a perforated appendix, but they would almost certainly have a tender and rigid abdomen if this was the case",
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"explanation": "This is likely euglycaemic DKA. Although this is a rare phenomenon, one of the most known causes is SGLT2 inhibitors. These are typical symptoms associated with DKA, and her blood tests are all typical of DKA, with the exception of the normal glucose. Therefore, this is euglycaemic DKA. She should be treated with the local DKA protocol",
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"name": "Diabetic ketoacidosis (DKA)",
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"explanation": "Gastroenteritis is unlikely to cause polyuria and acidosis such as this",
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"explanation": "HHS leads to a significantly elevated glucose and not such a significant acidosis",
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"explanation": "Pyelonephritis is associated with dysuria and urinary frequency, not polyuria. It may cause nausea and vomiting. It would not normally cause an acidosis such as this",
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"comment": "Hiiiiiigh yield fam",
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"comment": "such a great question but. like so many things it tests. impressed I am. ",
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"comment": "wouldnt you expect hyperglycaemia in this case?",
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"comment": "SGLT2 inhibitors (-flozin) can cause euglycaemic DKA where they are in diabetic ketoacidosis but with normal range serum glucose",
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"comment": "SGLT2 inhibitors (-flozin) are known to cause ketoacidosis that is euglycaemic, so the serum glucose is normal",
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"comment": "why would you get DKA though with T2DM? Thought it was typically T1DM that you get DKA?",
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"comment": "DKA and euglycemic DKA are not the same bloody thing",
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"comment": "feel like it would have been easier if they put euglycaemic DKA as an answer option yea",
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"explanation": "# Summary\n \nDiabetic ketoacidosis (DKA) is a life-threatening medical emergency characterised by hyperglycemia, acidosis and ketosis. DKA may be triggered by infection, dehydration or fasting, or may be the initial presentation of Type 1 diabetes. Symptoms include a 'fruity' breath odour, vomiting, dehydration, abdominal pain and altered mental state. Key investigations include blood glucose and ketones, urea and electrolytes and a venous blood gas to check pH. Management involves IV fluids and a fixed rate insulin infusion, with close monitoring both clinically and biochemically. Important complications that should be monitored for include cerebral oedema, hypoglycaemia and hypokalaemia. \n\n# Definition\n \nDiabetic ketoacidosis (DKA) is a medical emergency characterised by the triad of:\n \n - Hyperglycemia (blood glucose >11 mmol/L)\n - Ketosis (blood ketones >3 mmol/L or urinary ketones ++ or higher)\n - Acidosis (pH <7.3 or bicarbonate <15 mmol/L)\n - Note: patients on SGLT-2 inhibitors may present with euglycemic DKA (where glucose is normal)\n \n\n# Epidemiology\n \nDKA is most common in individuals with Type 1 diabetes (T1DM) but around a third of cases occur in patients with Type 2 diabetes. The incidence of DKA is highest in young people aged 18-24. \n\nDKA is the leading cause of death in people aged under 58 years old with T1DM, with cerebral oedema the most common cause of mortality. However, mortality in the UK is still <1%.\n \n\n# Aetiology \n\n- DKA occurs due to insulin deficiency (absolute or relative) leading to hyperglycaemia\n- Ketones, including acetone, 3-beta-hydroxybutyrate, and acetoacetate, are produced from ketogenesis, whereby fatty acids are metabolised as an alternative energy source\n- These ketones are responsible for the acidosis seen\n- Hyperglycaemia causes an osmotic diuresis that contributes to severe dehydration as well as electrolyte imbalance\n- Vomiting and decreased fluid intake secondary to altered mental state also exacerbate dehydration\n\n**10-20% of presentations of DKA represent a first presentation of Type 1 Diabetes**\n\n**Common triggers for DKA include:**\n\n- Infections\n- Dehydration and fasting\n- Missing doses of insulin\n- Medications e.g. steroid treatment or diuretics\n- Surgery\n- Stroke or myocardial infarction\n- Alcohol excess or illicit drug use\n- Pancreatitis\n\n# Classification\n\nPatients with at least one of the following may be classified as having **severe DKA**, which should prompt consideration of referral for higher dependency care:\n\n- Blood ketones > 6mmol/L\n- Bicarbonate < 5mmol/L\n- Blood pH < 7\n- Anion gap above 16\n- Hypokalaemia on admission\n- GCS less than 12\n- Oxygen saturations < 92% in air\n- Systolic BP < 90mmHg\n- Brady or tachycardia (heart rate < 60 or > 100bpm)\n\n\n# Signs and Symptoms\n \n**Symptoms:**\n\n- Nausea and vomiting\n- Abdominal pain\n- Polyuria\n- Polydipsia\n- Weakness\n\n**Signs:**\n\n- Dry mucous membranes\n- Hypotension\n- Tachycardia\n- Altered mental state (drowsiness, confusion, coma)\n- Kussmaul's breathing (deep, sighing breathing to compensate for metabolic acidosis by blowing off carbon dioxide)\n- Fruit-like smelling breath (due to ketosis)\n\n# Investigations\n \n**Bedside tests:**\n \n - Capillary blood glucose\n - Blood or urinary ketones\n - Urine dip +/- MSU (looking for evidence of a urinary tract infection which may precipitate DKA)\n - ECG (for ischaemic changes which may precipitate DKA, or changes secondary to electrolyte imbalance e.g. hypokalaemia)\n\n**Blood tests:**\n\n- Venous blood gas (for acid-base balance)\n- Urea and electrolytes (for electrolyte imbalance and AKI)\n- Full blood count and CRP (for infection markers) \n- Blood cultures (if infection is suspected)\n- HbA1c (to assess diabetic control over recent months)\n\n**Imaging:**\n\n- Consider chest X-ray as part of septic screen (if signs of infection as a trigger for DKA)\n\n# Management\n\n**Initial management:** \n\n- Initial **A to E assessment**\n - Drowsy patients may require airway protection and an **NG tube** to prevent aspiration\n - Ensure adequate IV access\n - If hypotensive give up to 1L in **fluid boluses** then seek urgent senior input if not resolved\n - Consider urinary catheterisation and monitor fluid balance\n- **IV fluid replacement with normal saline**\n - A regimen of large volumes of IV fluid replacement given relatively quickly initially then over longer durations should be followed\n - Slower infusion rates should be considered in young adults, the elderly, those with heart or kidney failure or other serious comorbidities\n - An example in a healthy adult would be 1L over 1 hour, then 2x 1L over 2 hours, then 2x 1L over 4 hours, then 1L over 6 hours\n - **Potassium replacement** should be added after the first bag, depending on serum potassium levels, bearing in mind potassium can be infused at a maximum of 10mmol/h:\n\n| Potassium level (mmol/L) | Potassium replacement mmol/L of next infusion | \n| :---------------: | :----------------: \n| > 5.5 | Nil | \n| 3.5 - 5.5 | 40 mmol/L | \n| < 3.5 | senior review – additional potassium required | \n \n \n- After IV fluids have started, a **fixed rate insulin infusion** should be set up \n- This is provided as an infusion of 50 units of Actrapid in 50ml of 0.9% NaCl, at a rate of 0.1 units/kg/hour\n- Continue long-acting insulin if the patient is already on this \n- Investigation and management of any underlying triggers (e.g. septic screen and start antibiotics if evidence of infection)\n- Ensure **VTE prophylaxis** with low molecular weight heparin is prescribed as patients are at high risk of developing clots due to dehydration\n\n**Ongoing emergency management:**\n\n- Patients should be closely monitored with hourly blood glucose and ketones\n - The aim is for ketones to fall by > 0.5mmol/L/hour\n - Blood glucose should fall by 3 mmol/L/hour\n - If these targets are not met, the rate of insulin infusion should be continued\n- Once blood glucose is below 14, a **10% glucose infusion** should be started alongside ongoing saline and insulin\n- Regular venous blood gases should also be done to monitor potassium, bicarbonate and pH\n- DKA is considered resolved once ketones are less than 0.6 mmol/L and pH is over 7.3 \n - If at this point they are able to eat and drink, a subcutaneous regimen of insulin should be started (usually with the input of a specialist diabetes team)\n - The insulin infusion should be stopped half an hour after the first dose of subcutaneous short acting insulin has been given \n\n# References\n \n[ABCD Guidelines: The Management of Diabetic\nKetoacidosis in Adults](https://abcd.care/sites/default/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf)\n\n[RCEM - Diabetic Ketoacidosis](https://www.rcemlearning.co.uk/reference/diabetic-ketoacidosis/#1635853037528-05d8fa0f-621f)\n\n[Patient UK - Diabetic ketoacidosis](https://patient.info/doctor/diabetic-ketoacidosis#presentation)",
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"question": "A 30-year-old female presents to the Emergency Department with a one-week history of polyuria, reduced appetite, nausea and vomiting. On examination, her abdomen is soft and non-tender. She has the following blood tests:\n\n||||\n|---------------------------|:-------:|------------------------------|\n|Non-fasting Glucose|5.8 mmol/L|< 6.1|\n|Bicarbonate|17.5 mmol/L|22 - 29|\n|pH|7.26|7.35 - 7.45|\n|Anion gap|20 mEq/L|6 - 12|\n\n\nShe has a background of type 2 diabetes, for which she takes dapagliflozin and metformin.\n\n\nWhich of the following is the most likely diagnosis in this patient?",
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"answer": false,
"explanation": "Paget's disease classically causes a raised ALP level",
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"name": "Paget's disease",
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"explanation": "A T-score between -1.0 and -2.5 is consistent with a diagnosis of osteopenia",
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"label": "a",
"name": "Osteopenia",
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"explanation": "A T-score of <-2.5 is the threshold for a diagnosis of osteoporosis",
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"explanation": "Advanced osteoarthritis can, in fact, produce a higher than normal T-score on DEXA scan due to osteophytes and disc narrowing, making the bone appear denser than it is. This patient has a low T-score",
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"name": "Osteoarthritis",
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"explanation": "Osteomalacia classically causes low vitamin D levels, low calcium, low phosphate, and a raised alkaline phosphate. This is not the case in this patient who has normal levels for all of these investigations",
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"comment": "thought a low t score + fragility fracture = osteoporosis?",
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"comment": "<-2.5 = osteoporosis, between -1-1.5= osteopenia",
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"comment": "Wouldn't osteopenia have deranged blood test?",
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"comment": "is this not a fragility fractur e= instant osteoporosis",
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"explanation": "# Summary \r\n\r\nOsteoporosis is a chronic condition characterised by low bone density and increased propensity to sustain fragility fractures. It is diagnosed with a dual-energy X-ray absorptiometry (DEXA) scan if a patient's T-score is less than -2.5. It is very common in older patients, especially post-menopausal women, with other risk factors including long-term corticosteroid use, low body weight and immobility. Other key investigations include checking calcium and vitamin D levels as these may require supplementation if low. Treatment is with bone-sparing treatment, with bisphosphonates being the first-line option in the majority of patients. Lifestyle changes such as smoking cessation, taking regular exercise and maintaining a healthy diet are important. Falls risk assessment is also key to reducing the risk of fragility fractures, especially in older patients. \r\n\r\n# Definition\r\n\r\nOsteoporosis refers to a state of low bone density with structural deterioration of bones. This causes bones to weaken, increasing the risk of fragility fractures (defined as a fracture sustained due to a fall from standing or without any trauma). \r\n\r\nPatients are defined as having osteoporosis if their bone mineral density (BMD) is at least 2.5 standard deviations below the mean peak mass of young healthy adults. This is measured with a dual-energy X-ray absorptiometry (DEXA) scan which gives BMD for the lumbar vertebrae and the femur. \r\n\r\n# Epidemiology\r\n\r\n- In the UK, around 2 million people are estimated to have osteoporosis\r\n- Post-menopausal women are particularly at risk due to accelerated bone loss secondary to decreased oestrogen production\r\n- Prevalence also increases significantly with age\r\n- Almost 50% of 80 year old women have osteoporosis\r\n- White ethnicity is also a risk factor\r\n- There are approximately 300,000 fragility fractures per year in the UK, with osteoporosis often being undiagnosed at the time of presentation\r\n\r\n# Aetiology\r\n\r\nRisk of fragility fractures increases as bone density declined, however there are many other factors that increase fracture risk:\r\n\r\n| Risk factors reducing bone density | Risk factors that do not reduce bone density |\r\n|----------|----------|\r\n| Low body weight | Older age |\r\n| Menopause | Inflammatory arthritis (e.g. rheumatoid arthritis) |\r\n| Immobility | Prolonged use of oral corticosteroids |\r\n| Chronic disease e.g. chronic kidney disease, chronic obstructive pulmonary disease, chronic liver disease | Smoking |\r\n| Malabsorption e.g. coeliac disease, inflammatory bowel disease, pancreatic insufficiency | Alcohol excess |\r\n| Endocrine disease e.g. hyperparathyroidism, hyperthyroidism | History of fragility fracture |\r\n| Certain medications (proton pump inhibitors, selective serotonin reuptake inhibitors, carbamazepine) - mixed evidence | Parental hip fracture |\r\n\r\n# Signs and Symptoms\r\n\r\nOsteoporosis itself is asymptomatic and so is usually diagnosed either with screening of people at high risk (e.g. those on long-term corticosteroids) or when someone presents with a fragility fracture.\r\n\r\nThe most common fragility fractures seen are:\r\n\r\n- Vertebral body\r\n- Neck of femur (hip)\r\n- Distal radius\r\n- Proximal humerus\r\n- Pelvis\r\n\r\nSome osteoporotic fractures (e.g. vertebral fractures) may also be asymptomatic acutely. Loss of height and kyphosis may occur due to multiple vertebral fractures, with severe kyphosis leading to reduced mobility and function.\r\n\r\nOther common symptoms of fragility fractures include acute severe pain, difficulty weight-bearing (e.g. for a hip fracture) and mobilising. \r\n\r\nSigns include deformities, such as a shortened and externally rotated leg due to a hip fracture or a \"dinner fork\" deformity in a Colles' wrist fracture.\r\n\r\nThe area around the fracture may be bruised, swollen and tender to touch. \r\n\r\n# Differential Diagnosis\r\n\r\n- **Bone metastases** may lead to pathological fractures, either in patients with known malignancies or as a first presentation of cancer (especially lung, prostate, breast, kidney and thyroid)\r\n- **Osteomalacia** usually occurs secondary to severe vitamin D deficiency and increases fracture risk due to bone weakening; other symptoms include bone pain, muscle pain and proximal weakness with a waddling gait\r\n- **Multiple myeloma** also is associated with pathological fractures, as well as hypercalcaemia, renal impairment, anaemia and bone pain\r\n- **Paget's disease** increases the risk of fracture due to abnormal bone remodelling, leading to features of bone pain and bowing of the long bones\r\n- **Osteogenesis imperfecta** is a genetic condition that commonly presents in childhood with fragility fractures, bowing of the long bones, short stature and blue sclera\r\n- **Avascular necrosis** may mimic a spontaneous fracture with severe pain after no or minimal trauma, commonly affecting the femoral head\r\n\r\n# Investigations\r\n\r\n- The diagnostic investigation for osteoporosis is a **dual-energy X-ray absorptiometry scan (DEXA)**\r\n- This measures **bone mineral density (BMD)**\r\n- A T-score of -2.5 or less is considered diagnostic of osteoporosis\r\n- If the T-score is between -1 and -2.5 this is referred to as osteopenia\r\n- Z-score is also reported (this compares bone density to a age, sex and ethnicity matched population rather than healthy young adults) - below -2 is low for their age\r\n- The following patients should be offered a DEXA scan as the initial step in assessment\r\n- Aged over 50 presenting with a fragility fracture\r\n- Aged under 40 with a major risk factor for fragility fracture (e.g. long-term steroids) \r\n- Those about to start treatment that will rapidly decrease bone density (e.g. hormone deprivation in breast cancer) - consider\r\n- All other patients with risk factors should have their fracture risk assessed as the initial step\r\n- **QFracture** and **FRAX** are the two online assessment tools used\r\n- These both predict a patient's 10-year risk of hip and major osteoporotic fractures\r\n- QFracture is interpreted based on whether the risk score is greater or less than 10%\r\n- FRAX plots fracture risk versus age on a graph that stratifies people into low/intermediate/high risk\r\n- With QFracture, those at approximately 10% risk or more at 10 years should have a DEXA scan \r\n- With FRAX, patients at intermediate or high risk of fracture should have a DEXA\r\n- In women over the age of 75 with a history of fragility fractures, a clinical diagnosis of osteoporosis may be appropriate (if a DEXA is unfeasible)\r\n\r\nOther investigations required in all patients include:\r\n\r\n- **Vitamin D** to check for deficiency; this is needed prior to starting bisphosphonate treatment\r\n- **Bone profile** to check serum calcium as this may also require supplementation\r\n- **X-rays** or other imaging modalities (e.g. CT or MRI) may be required to diagnose and assess fragility fractures\r\n\r\nIf an underlying cause is suspected, the following investigations may be appropriate:\r\n\r\n- **Full blood count** which may show anaemia in malabsorption or malignancy, and leukocytosis in malignancy or inflammatory disease\r\n- **Liver function tests** for chronic liver disease\r\n- **U&Es** for chronic kidney disease\r\n- **ESR** or **CRP** which may be raised in inflammatory disease or malignancy\r\n- **Thyroid function tests** if hyperthyroidism is suspected\r\n- **Testosterone** and **sex hormone-binding globulin** if hypogonadism is suspected in men\r\n- **Anti-TTG antibodies** for coeliac disease if there is evidence of malabsorption\r\n\r\n# Management\r\n\r\n**Conservative management:**\r\n\r\n- Identification and treatment of any underlying condition contributing to osteoporosis\r\n- Optimisation of risk factors e.g. smoking cessation, alcohol reduction\r\n- Advise patients to take regular weight-bearing exercise to improve muscle strength, including walking, strength training and balance and flexibility training\r\n- Advise patients to eat a balanced diet and assess their calcium intake\r\n- Assess falls risk and consider measures to reduce this, including referral to multidisciplinary falls teams \r\n- Referral to specialist services for patients with very high fracture risk (e.g. T score less than -3.5, multiple vertebral fractures)\r\n\r\n**Medical management:**\r\n\r\n- Prescribing vitamin D supplementation for patients not exposed to adequate sunlight\r\n- Prescribing calcium supplements to patients with an inadequate dietary calcium intake\r\n- For patients at high risk of fragility fracture, prescribe bone-sparing treatment\r\n- Treatment should be started promptly after a fragility fracture to reduce the risk of another fracture\r\n- Oral bisphosphonates are the first-line treatment in the majority of patients \r\n- Options include alendronate and risedronate, which can be given either daily or weekly\r\n\t- These must be taken on an empty stomach, at least 30 minutes before food or other medications\r\n\t- Tablets need to be swallowed whole with a glass of water whilst the patient is upright; they should stay upright for at least 30 minutes after this\r\n\t- Common side effects include nausea, dyspepsia, gastritis, abdominal pain and musculoskeletal pains\r\n\t- Rarer side effects include oesophagitis or ulceration, stricturing or erosions, osteonecrosis of the jaw or external auditory canal and atypical stress fractures\r\n\t- To minimise risk of osteonecrosis of the jaw, patients with poor dentition or malignancy should have a dental check-up (and any work required performed) before starting bisphosphonates\r\n\t- They should also continue to have routine dental checks and maintain good oral hygiene during treatment \r\n\t- Contraindications include severe chronic kidney disease, hypocalcaemia or vitamin D deficiency, and oesophageal abnormalities such as stricture or achalasia \r\n\t- Patients with recent peptic ulceration, upper gastrointestinal bleeding or surgery, dysphagia, gastritis or duodenitis should be prescribed bisphosphonates with caution\r\n- If oral bisphosphonates are not tolerated or unsuitable, options for bone-sparing treatment include:\r\n\t- Parenteral bisphosphonates (e.g. zoledronate)\r\n\t- Denosumab\r\n\t- Raloxifene hydrochloride\r\n\t- Strontium ranelate\r\n\t- Hormone replacement therapy should be considered for younger women experiencing menopausal symptoms as this will also reduce their fragility fracture risk\r\n\t- Teriparatide and romosozumab are other bone-sparing treatments that may be recommended first-line in women with severe osteoporosis - these are then followed by bisphosphonate treatment\r\n\r\n**Surgical management:**\r\n\r\n- Fragility fractures may require surgical fixation or joint replacement (e.g. hip arthroplasty for a fractured neck of femur)\r\n\r\n# Complications\r\n\r\n- Hip fractures are high-consequence injuries and lead to permanent disability in 50% and death in 20% of patients \r\n- Vertebral fractures may lead to disabling and painful kyphosis which may in turn cause difficulty breathing and gastrointestinal problems such as dyspepsia\r\n- Wrist fractures can significantly affect independence and functional ability\r\n- Many patients experience a \"fracture cascade\" where further fractures occur in the years following the initial one\r\n- Pain from fractures can lead to poor sleep, low mood and reduced quality of life\r\n- Complications of treatment may be significant (e.g. osteonecrosis of the jaw or oesophageal ulceration with bisphosphonates)\r\n\r\n# Prognosis\r\n\r\n- There is no cure for osteoporosis\r\n- In general however, prognosis is good with effective treatment\r\n- Bisphosphonate treatment should be reviewed after 3-5 years\r\n- If patients remain at high risk of fracture it may be continued for up to 7-10 years\r\n- Patients with previous hip or vertebral fractures, those aged 70 or older or those who sustain another fragility fracture whilst on bone protection often require longer durations of treatment\r\n- Repeat DEXA may be appropriate to aid decision making\r\n- If bone protection is stopped, fracture risk should be reassessed 18 months to 3 years later\r\n\r\n# NICE Guidelines\r\n\r\n[NICE CKS: Osteoporosis - prevention of fragility fractures](https://cks.nice.org.uk/topics/osteoporosis-prevention-of-fragility-fractures/)\r\n\r\n[NICE - Osteoporosis: assessing the risk of fragility fracture](https://www.nice.org.uk/guidance/cg146)\r\n\r\n# References\r\n\r\n[National Osteoporosis Guideline Group - Prevention and Treatment of Osteoporosis](https://www.nogg.org.uk/full-guideline)\r\n\r\n[BNF Treatment Summary - Osteoporosis](https://bnf.nice.org.uk/treatment-summaries/osteoporosis/)\r\n\r\n[Radiopaedia - Dual-energy x-ray absorptiometry](https://radiopaedia.org/articles/dual-energy-x-ray-absorptiometry-1?lang=gb)\r\n\r\n[WHO - Fragility fractures](https://www.who.int/news-room/fact-sheets/detail/fragility-fractures)\r\n\r\n[International Longevity Centre UK report on Osteoporosis](https://ilcuk.org.uk/wp-content/uploads/2018/10/OsteoporosisUK.pdf)\r\n\r\n\r\n",
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"explanation": "# Summary\n\nNephrotic syndrome refers to the clinical triad of proteinuria, hypoalbuminemia and peripheral oedema. It occurs due to increased permeability of the glomerular basement membrane, which occurs either due to a variety of both primary (idiopathic) or secondary diseases. Renal biopsy is the key investigation to differentiate between causes and should be considered in all adults. Other investigations include a urine dip and protein:creatinine ratio, LFTs for albumin and investigations for an underlying cause such as myeloma or diabetes. First-line management is usually with steroids; other immunosuppressants may need to be added. Management options for oedema include lifestyle changes (low salt diet, fluid restriction) and/or diuretics.\n\n# Definition\n\nNephrotic syndrome occurs when there is excessive loss of protein in the urine, leading to hypoalbuminemia and peripheral oedema. Other resulting features include hyperlipidaemia, abnormal coagulation and immunodeficiency. \n\n# Aetiology\n\nThe common underlying pathology leading to nephrotic syndrome is damage to the glomerular basement membrane leading to excessive leakage of protein into the urine.\n\nThere are a wide variety of conditions that may lead to nephrotic syndrome which may be classified as either primary (idiopathic) or secondary (due to another underlying disease) - these include:\n\n- **Minimal change disease** causes the majority of cases of nephrotic syndrome in young children\n- It is usually idiopathic but may rarely be associated with lymphoma or NSAID use\n- Glomeruli are normal under light microscopy\n- Electron microscopy shows diffuse effacement of the podocyte food processes\n- Steroid responsiveness is characteristic\n- **Focal segmental glomerulosclerosis** may be primary or secondary to conditions including HIV, extensive nephron loss or drugs (e.g. heroin)\n- Biopsy shows sclerosis of segments of the glomerular tuft, only affecting some glomeruli\n- **Membranous nephropathy** is the leading cause of nephrotic syndrome in older people\n- Biopsy shows thickening of the glomerular basement membrane without cellular proliferation\n- A classic \"spike and dome\" appearance is described where subepithelial immune deposits are interspersed with new basement membrane growth\n- Most cases are primary; usually associated with PLA2R antibodies\n- Others may be secondary to malignancy, infections, autoimmune disease or drugs\n- **Membranoproliferative glomerulonephritis** is also referred to as membranoproliferative glomerulonephritis\n- It can present with nephrotic or nephritic syndrome\n- It may be idiopathic or secondary to infections such as hepatitis C or systemic lupus erythematosus\n- **Diabetic nephropathy** may affect patients with longstanding type 1 or 2 diabetes\n- It tends to be a progression from microalbuminuria, especially if untreated\n- Patients are at risk of end-stage renal disease\n- Biopsy shows thickening of the glomerular basement membrane, mesangial expansion and Kimmelstiel-Wilson nodules\n- **Amyloidosis**, especially AA amyloid due to chronic inflammation\n- AL amyloid (due to light chain deposition) and hereditary amyloidosis can also cause nephropathy\n- On biopsy, amyloid deposits stain with Congo red and display apple green birefringence under polarized light\n- **Multiple myeloma** can present with a variety of renal manifestations, with proteinuria and renal insufficiency the most common\n- Nephrotic syndrome occurs in a minority of cases and may be due to a number of underlying mechanisms\n- **Lupus nephritis** i.e. renal involvement due to systemic lupus erythematosus\n- Class V (membranous lupus nephritis) is the most likely to cause nephrotic syndrome\n- This is characterised histologically by subepithelial immune complex deposition\n- **Medications** are a rarer cause of nephrotic syndrome, including:\n- Bisphosphonates\n- NSAIDs\n- D-penicillamine\n- Probenecid\n- Tolbutamide\n\n# Classification\n\nThe diagnosis of nephrotic syndrome requires the presence of all of:\n\n- Proteinuria > 3.5 grams/24 hours\n- Serum albumin < 30 grams/litre\n- Peripheral oedema\n\n# Signs and Symptoms\n\n**Symptoms include:**\n\n- Frothy urine due to proteinuria\n- Swelling of the face and body\n- Weight gain due to fluid retention\n- Fatigue\n- Lethargy\n- Anorexia\n\n**Signs include:**\n\n- Oedema - typically peripheral and periorbital\n- Muehrcke's lines refers to paired white transverse lines across the nails that may occur secondary to hypoalbuminemia\n- Signs of hyperlipidaemia such as xanthelasma (yellow plaques over the eyelids)\n- Signs of pleural effusion e.g. dull bases to percussion with decreased air entry\n\nPatients may also present with signs and symptoms of complications e.g. infection, thrombosis.\n\n# Differential Diagnosis\n\n- **Heart failure** is a common cause of peripheral oedema; typically however patients cannot lie flat due to breathlessness and so facial oedema is unusual; proteinuria is not a feature\n- **Cirrhosis** is commonly complicated by fluid accumulation, usually in the form of ascites; although ascites may occur in nephrotic syndrome it is less common than fluid accumulation in the peripheries and face; proteinuria is not a feature\n- **Chronic kidney disease** may present with fluid retention, especially in patients with end-stage renal disease - it may coexist with nephrotic syndrome however renal function is often preserved\n- **Medications** may cause peripheral oedema including calcium channel blockers, NSAIDs and corticosteroids\n\n# Investigations\n\n**Bedside tests:**\n\n- **Urine dipstick** looking for proteinuria; glycosuria may be present in diabetes but haematuria is not usually seen\n- **Urine protein:creatinine ratio** should be over 2 or **24 hour urine collection** should show proteinuria >3.5g/day\n\n**Blood tests:**\n\n- **LFTs** to confirm hypoalbuminemia\n- **U&Es** for renal function (significant impairment is unusual)\n- **FBC** may show anaemia in persistent nephrotic syndrome\n- **Vitamin D** may be low as this is lost in urine\n- **Bone profile** may show hypocalcemia secondary to decreased calcium absorption due to vitamin D deficiency\n- **Coagulation screen** is usually normal although there is a hypercoagulable state wiht increased risk of thromboembolism\n- **HbA1c** or **fasting glucose** for diabetes\n- **Lipid profile** often shows dyslipidemia\n- **CRP** and **ESR** may be raised due to an underlying inflammatory, malignant or infectious process\n- **Myeloma screen** i.e. immunoglobulins and serum protein electrophoresis if myeloma is suspected\n- **Autoimmune screen** e.g. for suspected systemic lupus erythematosus (antinuclear antibody, complement levels etc.)\n- **Infection screen** i.e. hepatitis B and C serology, HIV testing\n\n**Imaging tests:**\n\n- **Chest X-ray** if there are clinical signs of pleural effusion\n- **US KUB** (kidneys, ureters and bladder) if there is renal impairment to assess for obstruction and any structural abnormalities of the kidneys\n- Imaging may be required to diagnose complications, such as a **CT pulmonary angiogram** for suspected pulmonary embolism or **doppler ultrasound** of the limbs for suspected deep vein thrombosis\n\n**Special tests:**\n\n- **Renal biopsy** is the key investigation to diagnose the cause of nephrotic syndrome - this is important both for prognosis and to guide management \n- Biopsy is usually indicated in adults, however in children there are specific indications e.g. if not responsive to steroids\n\n# Management\n\n**Conservative:**\n\n- Restrict salt intake to <2g/day\n- Fluid restriction to <1.5L/day \n- Weight should be monitored, with a target of 1-2 kg weight loss per day until the patient reaches their predicted \"dry weight\" (i.e. weight when not oedematous)\n- Dietary changes (e.g. avoiding a high protein diet, limiting fat intake) may be advised and dietician input may be indicated\n- Mechanical thromboprophylaxis (TEDS) to reduce risk of venous thromboembolism\n\n**Medical:**\n\n- **Corticosteroids** are usually first-line for management of nephrotic syndrome - these should be weaned after remission is achieved\n- Other immunosuppressive drugs (e.g. ciclosporin, cyclophosphamide, mycophenolate mofetil or rituximab) may be added as steroid sparing agents or for severe or refractory cases\n- Diuretics are used to treat significant peripheral oedema, usually furosemide but potassium sparing and thiazide diuretics may be added as adjuncts\n- Risk of thromboembolism should be assessed and prophylactic anticoagulation considered\n- Antihypertensives may be required to maintain a normal blood pressure; ACE inhibitors and angiotensin II receptor blockers may also help to reduce proteinuria\n- Ensure patients are up to date with vaccinations (however live vaccines should not be given to patients who are immunocompromised)\n- In some cases hyperlipidaemia may require treatment with statins \n- Patients taking steroids may require co-administration of proton pump inhibitors for gastric protection and consideration of bone protection\n\n**Surgical:**\n\n- If nephrotic syndrome results in end-stage renal failure, renal replacement therapy may be required either with dialysis or renal transplantation\n\n# Complications\n\n- **Increased risk of infection** as immunoglobulins are lost in urine\n- **Venous thromboembolism** due to urinary loss of anti-thrombotic proteins such as antithrombin III\n- **Hyperlipidaemia** due to increased hepatic production of lipoproteins to compensate for hypoalbuminemia - this may also present with lipiduria (which may cause urine to appear milky) \n- **Acute kidney injury** may occur due to excessive diuresis or renal vein thrombosis\n- **Chronic kidney disease** may occur secondary to the underlying cause of nephrotic syndrome (e.g. diabetes, amyloidosis)\n- **Medication side-effects** especially with chronic steroid use (e.g. osteoporosis, psychiatric effects)\n- **Hypothyroidism** due to urinary losses of T4 and T3 with their binding proteins\n- **Vitamin D deficiency** as this is also lost in urine\n- **Anaemia** may result from persistent nephrotic syndrome as iron bound to transferrin and erythropoietin are lost in urine\n\n# Prognosis\n\nPrognosis varies between subtypes, for example minimal change disease rarely progresses to end-stage renal failure (1% of cases), whereas 50% of patients with FSGS will do over 5-10 years.\n\nMortality has been greatly reduced with the use of steroids and immunosuppression.\n\nRelapses are common and may require repeated courses of steroids or escalation to other immunosuppressive medications.\n\n# References\n\n[KDIGO Guidelines on Glomerular Diseases](https://kdigo.org/guidelines/gd/)\n\n[Patient UK - Nephrotic syndrome](https://patient.info/doctor/nephrotic-syndrome-pro)\n\n[Radiopaedia - Nephrotic syndrome](https://radiopaedia.org/articles/nephrotic-syndrome?lang=gb)",
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"explanation": "# Summary\n\nSecondary causes of type 2 diabetes mellitus (T2DM) encompass a variety of conditions and factors that can induce or exacerbate hyperglycemia. These range from pancreatic and endocrine disorders to specific medications and glycogen storage diseases. It's important to consider these in patients with new-onset diabetes that presents atypically or doesn't respond to typical management.\n\n# Definition\n\nSecondary diabetes refers to forms of the disease where there is a clear causative factor aside from the typical insulin resistance or pancreatic β-cell failure associated with T2DM.\n\n# Epidemiology\n\nThe prevalence of secondary diabetes varies based on the causative condition. While some causes such as pancreatic cancer are relatively common, others, like glycogen storage disorders, are quite rare.\n\n# Aetiology\n\nSecondary causes of T2DM include:\n\n**Pancreatic Causes**\n\n- Cystic fibrosis: An autosomal recessive disorder leading to mucus accumulation in various organs including the pancreas, resulting in fibrosis and loss of exocrine and endocrine function.\n- Chronic pancreatitis: Long-standing inflammation of the pancreas can result in damage to islet cells, leading to diabetes.\n- Haemochromatosis: Iron overload can lead to deposition in various organs including the pancreas, leading to diabetes.\n- Cancer: Pancreatic neoplasms can destroy the islet cells, leading to diabetes.\n\n**Endocrine Causes**\n\n- Cushing's syndrome/disease: Elevated cortisol levels increase insulin resistance.\n- Acromegaly: Excess growth hormone leads to insulin resistance.\n- Pheochromocytoma: These rare adrenal tumors can induce diabetes through chronic catecholamine-induced glucose intolerance.\n- Thyrotoxicosis: Thyroid hormone excess can enhance hepatic gluconeogenesis and glycogenolysis and impair insulin secretion.\n\n**Drug Causes**\n\n- Steroids: Chronic use can lead to glucose intolerance and diabetes due to increased insulin resistance.\n- Atypical neuroleptics: These medications can lead to weight gain and increased insulin resistance.\n- Thiazides: These diuretics may impair glucose tolerance, possibly by reducing insulin secretion.\n- Beta-blockers: They can impair glycemic control through inhibition of insulin secretion and promoting insulin resistance.\n\n**Glycogen Storage Disorders**\n\n- Glycogen Storage Disease Type 1 (von Gierke's disease): The inability to perform gluconeogenesis can lead to hypoglycemia and secondary hyperglycemia.\n- Glycogen Storage Disease Type 2 (Pompe disease): It affects the heart and skeletal muscles more than it causes diabetes, but can present with variable symptoms.\n\n# Management\n\nManagement primarily involves addressing the underlying condition responsible for secondary diabetes. In cases where this is difficult/not possible, for example, pancreatic cancer, patients may require insulin therapy to manage hyperglycemia.\n\n\n\n# NICE Guidelines\n\n[NICE CKS on type 2 diabetes](https://cks.nice.org.uk/topics/diabetes-type-2/)",
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"explanation": "# Summary\n\nCrohn's disease (CD) is a chronic, relapsing inflammatory bowel disease (IBD) characterized by transmural granulomatous inflammation. Key signs and symptoms include gastrointestinal and systemic symptoms, such as crampy abdominal pain, diarrhoea, weight loss, and fever. The disease is diagnosed primarily through blood tests and endoscopy with imaging. Management strategies include monotherapy with glucocorticoids, azathioprine, mercaptopurine, and biological agents for severe cases. Surgical management is rarely curative and should be maximally conservative.\n\n# Definition\n\nCrohn's disease (CD) is a chronic relapsing inflammatory bowel disease (IBD). It is characterised by transmural granulomatous inflammation which can affect any part of the gastrointestinal tract ('from mouth to anus', most commonly the terminal ileum, leading to fistula formation or stricturing.\n\n# Aetiology\n\nThe exact cause is unknown, but it is thought to be an inappropriate reaction to gut flora in a susceptible person. Important risk factors include:\n\n- Family history - 10-25% of patients have a first-degree relative who also suffers from Crohn's disease\n- **Smoking** - x3 increased risk\n- Diets high in refined carbohydrates and fats have been implicated\n\n# Epidemiology\n\nIn Europe the incidence of Crohn's disease is 5.6 per 100, 000 at ages 15-64. The disease is more common in northern climates and developed countries. In the last 60 years the incidence of Crohn's disease has increased in Europe and North America, and is now approximately equal to that of ulcerative colitis.\n\nCrohn's disease has a bimodal age of onset: the most common age of onset is between 15 and 40 years old, but there is a smaller secondary peak between 60-80 years.\n\nCrohn's disease is more common in Caucasian people than in Asian and black people. Ashkenazi Jews have a 2-4 fold higher risk of Crohn's disease.\n\n\n# Signs and Symptoms\n\nSymptoms: \n\n- Gastrointestinal symptoms (crampy abdominal pain and non-bloody diarrhoea)\n- Up to 50% have perianal disease\n- Systemic symptoms (weight loss and fever)\n\nSigns: \n\n- General appearance: cachectic and pale (secondary to anaemia), clubbing.\n- Abdominal examination: aphthous ulcers in the mouth, right lower quadrant tenderness and a right iliac fossa mass.\n- PR examination to check for perianal skin tags, fistulae, or perianal abscess.\n\n[lightgallery] \n\n**Extra-gastrointestinal manifestations include:**\n\nDermatological manifestations:\n\n- Erythema nodosum (painful erythematous nodules/plaques on the shins)\n- Pyoderma gangrenosum (a well-defined ulcer with a purple overhanging edge)\n\n[lightgallery1] [lightgallery2]\n\nOcular manifestations:\n\n- Anterior uveitis (painful red eye with blurred vision and photophobia)\n- Episcleritis (painless red eye).\n\nMusculoskeletal manifestation:\n\n- Enteropathic arthropathy (symmetrical, non-deforming)\n- Axial spondyloarthropathy (sacro-iliitis), \n\nHepatobiliary manifestations:\n\n- Gallstones (these are more common in Crohn's disease than in ulcerative colitis) - reduced bile acid reabsorption and increased calcium loss predisposes to gallstones\n\nHaematological and renal manifestations:\n\n- AA amyloidosis (secondary to chronic inflammation) and renal stones (more common in Crohn's disease than in ulcerative colitis)\n\n# Investigations \n\n- Bedside:\n\t- Stool culture is necessary to exclude infection (MC&S and ovas/cysts/parasite).\n\t- **Faecal calprotectin** (an antigen produced by neutrophils) will be raised (this helps distinguish inflammatory bowel disease from irritable bowel syndrome).\n\n- Blood tests:\n - Raised white cell count\n - Raised ESR/CRP\n - Thrombocytosis\n - Anaemia (secondary to chronic inflammation)\n - Low albumin (secondary to malabsorption)\n - Haematinics and iron studies including (B12, folate) due to terminal ileum involvement\n\n\n- Imaging:\n\t- Endoscopy with imaging is required for diagnosis. Small bowel video capsule endoscopy can be used for proximal disease\n\t- MRI can be used for suspected small bowel disease.\n\t- Upper GI series may show the 'string sign of Kantour'. This is used to describe the string-like appearance of contrast-filled narrowed terminal ileum, and is suggestive of Crohn's disease.\n\t- Colonoscopy with biopsy will reveal:\n\t\t- Intermittent inflammation **('skip lesions')**\n\t\t- Cobblestone mucosa (due to ulceration and mural oedema)\n\t\t- Rose-thorn ulcers (due to transmural inflammation), ± fistulae or abscesses.\n\t\t- Non-caseating granulomas\n\n# Management\n\n- As a general management point, it is paramount to advise patients with Crohn's who are smokers to **stop smoking** as this is known to strongly impact disease activity\n\n## Inducing remission\n\n- The first step of treatment is inducing remission in patients having a flare\n- Patients should be offered monotherapy with glucocorticoids (oral prednisolone, or IV hydrocortisone if first presentation is severe flare necessitating admission).\n- There is an increasing role for biologics for acute management of severe flares\n\n## Maintaining remission\n\n- Azathioprine or mercaptopurine may be added on to induce remission if there are 2 or more exacerbations in a 12-month period or the glucocorticoid cannot be tapered.\n\n - It is important to assess for thiopurine methyltransferase (TPMT) activity before offering azathioprine or mercaptopurine. If there is underactivity, this greatly increases the risk of profound bone marrow suppression if the above medications are given\n\n- Methotrexate may be considered in patients who are intolerant/have a contraindication to azathioprine or mercaptopurine or who do not respond to azathioprine or mercaptopurine monotherapy.\n- Biological agents (such as infliximab or adalimumab) are recommended in patients with severe Crohn's disease who fail to respond to the above.\n\t- These patients should have a CXR before treatment initiation due to the risk of re-activation of latent TB\n\n\n## Surgical management\n\nSurgical management is rarely curative in Crohn's disease (unlike in ulcerative colitis) because disease can occur anywhere along the GI tract, however 50-80% of Crohn’s patients end up requiring surgery at some point.\n\nSurgical options will depend on the part of the GI tract that is affected, and is indicated in those who have failed medical therapy or in those with severe stricturing or fistulating disease:\n\r\n-\tControl fistulae \r\n-\tResection of strictures\r\n-\tRest/defunctioning of the bowel\r\n\n\n### Management of peri-anal fistulae\n\n- Drainage seton is the management of choice for high (trans-sphincteric) fistulae. A seton is a thread passed through the fistula tract, forming a ring between the internal and external openings. It is used in the management of high trans-sphincteric fistulae, to prevent division of the anal sphincter muscles and incontinence. Closure of the fistula occurs by the formation of granulation tissue.\n- Fistulotomy is the management of choice for low (submucosal) fistulae. Fistulotomy involves dissecting the superficial tissue and opening the fistula tract. This is not a treatment option for high fistulae due to the risk of incontinence.\n- 'Sphincter saving' methods include fibrin glue and fistula plug - these are still under investigation and have not yet been approved in mainstream management.\n\n### Management of peri-anal abscess\n\n- The patient should be started on intravenous antibiotics e.g. ceftriaxone + metronidazole.\n- Patients typically require examination under anaesthetic and incision and drainage. An incision is made in the affected region, the pus is broken up, the infected tissue material is excised, and anti-septic soaked packs are inserted. Healing occurs by secondary intention.\n\n# Complications\n\n- **Fistulas:**\n - Formation of abnormal connections between different parts of the digestive tract or between the digestive tract and other organs.\n - Commonly involves the small intestine and other structures like the bladder or skin.\n\n- **Strictures:**\n - Narrowing or tightening of the intestinal walls.\n - Can lead to bowel obstruction and difficulties with the passage of stool.\n\n- **Abscesses:**\n - Collection of pus within the abdomen, often near areas of inflammation.\n - Presents with localized pain, swelling, and may require drainage.\n\n- **Malabsorption:**\n - Impaired absorption of nutrients due to inflammation and damage to the intestinal lining.\n - Can lead to nutritional deficiencies and weight loss.\n\n- **Perforation:**\n - Formation of a hole or tear in the intestinal wall.\n - Can result in peritonitis, a serious and potentially life-threatening condition.\n\n- **Nutritional Deficiencies:**\n - Chronic inflammation can affect nutrient absorption.\n - Common deficiencies include vitamin B12, vitamin D, and iron.\n\n- **Increased Risk of Colon Cancer:**\n - Prolonged inflammation may elevate the risk of developing colorectal cancer, particularly in long-standing disease involving the colon.\n\n- **Osteoporosis:**\n - Reduced bone density due to chronic inflammation and corticosteroid use.\n - Increases the risk of fractures.\n\n- **Intestinal Obstruction andToxic Megacolon:**\n - Severe inflammation can lead to the dilation of the colon.\n - Presents as abdominal distension, fever, and can be a medical emergency.\n\n\n# Comparison with Ulcerative Colitis\n\nPlease see below a summary table comparing Crohn's disease and Ulcerative colitis:\n\n| Characteristic | Crohn's Disease | Ulcerative Colitis |\n|------------------------------------|---------------------------------------|-------------------------------------|\n| **Location** | Any part of the digestive tract, from the mouth to the anus (most commonly affects the terminal ileum and colon) | Limited to the colon and rectum |\n| **Inflammation Pattern** | Patchy, skip lesions | Continuous, involves the entire colon|\n| **Depth of Inflammation** | Full thickness (transmural) | Limited to the inner lining (mucosa and submucosa)|\n| **Symptoms** | Abdominal pain, non-bloody diarrhoea, weight loss | Bloody diarrhoea, abdominal cramps |\n| **Complications** | Fistulas, strictures, abscesses | Toxic megacolon, colon cancer risk |\n| **Extraintestinal Manifestations** | Joint pain, skin problems, eye inflammation | Joint pain, skin problems, eye inflammation |\n| **Endoscopy Findings** | Cobblestone appearance, deep ulcers | Continuous colonic inflammation, ulcers |\n| **Diagnostic Imaging** | Transmural inflammation visible on imaging (e.g, MRI) | Limited to the colonic mucosa and submucosa, visible on colonoscopy |\n| **Treatment Approach** | Individualised, may involve medications (e.g. steroids, immunosuppressants) and surgery | Medications (e.g. aminosalicylates, steroids, immunosuppressants), surgery (in severe cases) |\n| **Prognosis** | Variable, chronic condition with periods of remission and exacerbation | Variable, can be chronic with periods of remission, may require surgery in some cases |\n\n\n# NICE Guidelines\n\n[Click here to see information on NICE CKS on Crohn's disease](https://cks.nice.org.uk/topics/crohns-disease/)\n\n",
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is associated with type I AIH. Anti-smooth muscle antibodies are also associated with type I AIH",
"id": "31923",
"label": "a",
"name": "Anti-nuclear antibodies (ANA)",
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"votes": 4161
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"explanation": "This antibody is associated with rheumatoid arthritis",
"id": "31926",
"label": "d",
"name": "Anti-cyclic citrullinated peptide antibody",
"picture": null,
"votes": 328
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"explanation": "This is associated with myositis (e.g. dermatomyositis)",
"id": "31927",
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"comment": "ANA Loves Smooth Liver\" to remember that Anti-Nuclear Antibodies (ANA) and Anti-Smooth Muscle Antibodies are associated with Type I Autoimmune Hepatitis (AIH).",
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"explanation": "# Summary\n\nAutoimmune hepatitis is a condition typically seen in young and middle-aged women, characterised by inflammation of the liver caused by an autoimmune response. Key signs and symptoms include jaundice, fatigue, hepatomegaly, and abdominal pain. Key investigations include liver function tests which often show a hepatic pattern of disease and hypergammaglobulinemia. The main types of autoimmune hepatitis are Type I, II, and III, identified by different antibody profiles. Management strategies often depend on the severity of symptoms and disease, and typically include steroid induction therapy followed by maintenance therapy with azathioprine.\n\n# Definition\n\nAutoimmune hepatitis is a chronic, inflammatory disease of the liver that occurs when the body's immune system attacks liver cells leading to inflammation and damage. It is classified into three main types based on the presence of specific antibodies.\n\n# Epidemiology\n\nAutoimmune hepatitis is most frequently observed in young and middle-aged women. There is a notable association with other autoimmune disorders, including: pernicious anaemia, ulcerative colitis, Hashimoto’s/Grave’s, autoimmune haemolytic anaemia, primary sclerosing cholangitis.\n\n# Aetiology\n\nAutoimmune hepatitis occurs due to an abnormal autoimmune reaction against hepatocyte surface antigen, with HLA-B8 and DR3 most frequently implicated. Specifically, there are 3 different types of autoimmune hepatitis:\n\nType 1) ANA positive, with anti-smooth muscle antibodies\n\nType 2) anti-liver/kidney mitochondrial type 1 antibodies (LKM1) – can be remembered as ‘Little Kids’ – children predominantly get Type 2\n\nType 3) Antibodies directed against soluble liver-kidney Antigen \n\n# Signs and Symptoms\n\n- Can present as an acute hepatitis - fever, jaundice, malaise, abdominal pain urticarial rash, polyarthritis, pulmonary infilitration, glomerulonephritis\n- It can also present as chronic liver disease - ascites, jaundice, leuconychia, spider naevi \n\nOther signs and symptoms include:\n\n- Fatigue\n- Anorexia\n- Hepatomegaly\n- Splenomegaly\n\n\n# Differential Diagnosis\n\nThe main differentials for autoimmune hepatitis are other causes of:\n\n- Acute hepatitis e.g. viral A/E/B, drugs (paracetamol poisoning), ischaemia\n- Chronic liver disease e.g. alcohol, NAFLD, hepatitis B and C\n\n\n# Investigations\n\n- Bloods: Abnormal liver function tests often indicate autoimmune hepatitis, showing a hepatic pattern of disease, such as raised ALT and bilirubin with normal or mildly raised ALP. \n- Additionally, patients may present with an IgG predominant hypergammaglobulinemia. \n- The presence of specific antibodies helps to differentiate between the three types of autoimmune hepatitis:\n\t- Type I: Characterised by raised levels of anti-smooth muscle antibodies (80%) and possibly positive antinuclear antibodies (10%).\n\t- Type II: Less common and often more severe, typically positive for anti liver/kidney microsomal antibodies type 1.\n\t- Type III: Also less common, often positive for anti-soluble liver antigen.\n\n# Management\n\n* Management of autoimmune hepatitis is largely dependent on the severity of symptoms and the severity of disease, as determined by blood results and liver biopsy. \n* Initial treatment of acute episodes involves steroid (prednisolone) induction therapy, followed by maintenance therapy with azathioprine, which is effective in most cases. \n* For patients who do not respond to standard treatment, second-line treatment with other immunosuppressants can be considered.\n* In patients presenting with chronic liver disease with decompensated cirrhosis or those who have failed to respond to immunosuppression, liver transplantation is the only management option.\n\n# References\n\n[British Society of Gastroenterology - Management of AIH](https://www.bsg.org.uk/clinical-resource/bsg-guidelines-for-the-management-of-autoimmune-hepatitis/)",
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"question": "A 20-year-old female presents to the emergency department with fever and jaundice. Their LFTs are deranged, and their liver viral screen is negative. Autoimmune hepatitis (AIH) is suspected.\n\nThe presence of which of the following antibodies is classically associated with Type I AIH?",
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173,468,789 | false | 16 | null | 6,495,278 | null | false | [] | null | 6,386 | {
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is correct. Neutrophils will be raised in bacterial peritonitis due to the localised inflammatory response. Positive ascitic fluid bacterial cultures will also confirm. E.coli is the most common bacteria grown",
"id": "31928",
"label": "a",
"name": "Neutrophil count of more than 250/mm3",
"picture": null,
"votes": 6038
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is associated with malignancy or haemorrhagic pancreatitis. In SBP, the ascitic fluid may appear cloudy, but there should not be any visible blood",
"id": "31929",
"label": "b",
"name": "Bloody appearance to ascitic fluid",
"picture": null,
"votes": 67
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Ascitic amylase is typically raised in pancreatic ascites and is usually normal in SBP",
"id": "31932",
"label": "e",
"name": "Raised amylase",
"picture": null,
"votes": 128
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Ascitic glucose is typically normal in SBP and low in secondary bacterial peritonitis. However, a normal glucose would not **confirm** a diagnosis of SBP",
"id": "31930",
"label": "c",
"name": "Low glucose",
"picture": null,
"votes": 1465
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "An ascitic pH of <7.0 suggests bacterial infection but will not confirm a diagnosis",
"id": "31931",
"label": "d",
"name": "pH 7.1",
"picture": null,
"votes": 412
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"__typename": "QuestionComment",
"comment": "SBP: High neutrophils, normal glucose\nCSF: Low Glucose - bacteria eats the sugar\nSecondary Peritonitis due to e.g. dialysis or something: Low glucose",
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"explanation": "# Summary\n\nAscites is the accumulation of fluid within the peritoneal cavity, commonly seen in patients with cirrhosis. Key signs and symptoms include abdominal distension, discomfort, and dyspnea. The primary investigation is an ascitic tap to analyse the fluid's content, and the Serum Ascites Albumin Gradient (SAAG) helps determine the cause. Management strategies target the underlying cause, dietary restrictions, and diuretic therapy. Refractory cases may require regular therapeutic paracentesis.\n\n# Definition\n\nAscites is defined as the abnormal accumulation of fluid within the peritoneal cavity. This condition is typically associated with liver disease, particularly cirrhosis, but can also occur due to other medical conditions affecting the heart, kidneys, or peritoneum.\n\n# Epidemiology\n\nAscites is a common complication of cirrhosis and represents a key landmark in the natural history of chronic liver disease. The prevalence and incidence of ascites depend significantly on the severity and duration of liver disease.\n\n# Aetiology\n\nThe mechanism of ascites formation is complex and not fully understood. It is thought to involve portal hypertension causing increased hydrostatic pressure, leading to the transudation of fluid into the peritoneal cavity.\n\nCauses include liver disorders (cirrhosis, acute liver failure, liver metastases), cardiac causes (right heart failure) and others such as Budd-Chiari, Portal vein thrombosis etc. (see below).\n\nOther types of ascites can form due to reduced oncotic pressure (nephrotic syndrome, Kwashiorkor), or due to malignancy (peritoneal carcinomatosis, or peritoneal metastasis), or infection (increased permeability – TB), and other causes of 3rd spacing (acute pancreatitis).\n\n# Signs and Symptoms\n\n\n- Abdominal distension\n- Abdominal discomfort or pain\n- Dyspnea\n- Reduced mobility\n- Anorexia and early satiety due to pressure on the stomach\n- Tense abdomen\n- Shifting dullness\n- Stigmata of the underlying cause (see below)\n\n# Differential Diagnosis\n\nThe differential diagnosis for ascites includes conditions like:\n\n- Cirrhosis: jaundice, spider angioma, palmar erythema, hepatic encephalopathy\n- Heart failure: dyspnea, orthopnoea, lower extremity oedema\n- Budd Chiari syndrome: abdominal pain, liver enlargement, jaundice\n- Constrictive pericarditis: dyspnea, peripheral oedema, raised jugular venous pressure\n- Hepatic failure: jaundice, coagulopathy, mental status changes\n- Peritoneal cancer: abdominal pain, weight loss, changes in bowel habits\n- Tuberculosis: fever, night sweats, weight loss, cough\n- Pancreatitis: severe abdominal pain, nausea, vomiting\n- Nephrotic syndrome: proteinuria, hypoalbuminaemia, edema\n\n# Investigations\n\n- The primary investigation for ascites is an ascitic tap, which can provide valuable information about the content of the ascitic fluid. This is usually done under USS guidance to avoid e.g. perforating bowel.\n- The SAAG can help to determine the cause of ascites. It is calculated by subtracting the albumin concentration of the ascitic fluid from the serum albumin concentration.\n- Bloods (to help determine the underlying cause) - FBC, U+E, LFTs, CRP\n- Imaging - CT abdomen, CXR (looking for signs of right-sided heart failure)\n\n[lightgallery]\n\n\n\n# Serum ascites albumin gradient (SAAG)calculation\n\nThe **serum ascites albumin gradient** (SAAG) can help to determine the cause of ascites.\n\nCalculation: serum albumin concentration – ascites albumin concentration\n\n## Causes of a high SAAG (>11g/L)\n\n- Cirrhosis\n- Heart failure\n- Budd Chiari syndrome\n- Constrictive pericarditis\n- Hepatic failure\n\nA high SAAG (>11g/L) suggests that the cause of the ascites is due to raised portal pressure. Raised hydrostatic pressure forces water into the peritoneal cavity whilst albumin remains within the vessels, thus resulting in a higher difference in the albumin concentration between the serum and ascitic fluid.\n\n## Causes of a low SAAG (<11g/L)\n\n- Cancer of the peritoneum, metastatic disease\n- Tuberculosis, peritonitis and other infections\n- Pancreatitis\n- Hypoalbuminaemia - nephrotic syndrome, Kwashiokor\n\n# Management\n\nThe management of ascites primarily involves:\n\n- Addressing the underlying cause\n- High SAAG - implementing a salt-restricted diet and fluid restriction\n- Administering **spironolactone** is first line. Providing adjunctive diuretic therapy such as furosemide if spironolactone is insufficient.\n- Conducting regular therapeutic paracentesis for patients with ascites refractory to medical management, whereby the fluid is drained from the abdomen over a few hours. These patients require replacement with human albumin solution (HAS) in order to avoid the ascites re-accumulating.\n- If the ascitic tap shows neutrophils >250mm<sup>3</sup>, this is diagnostic of **spontaneous bacterial peritonitis**, a serious complication of ascites. This is treated with intravenous piperacillin-tazobactam.\n\t- Prophylactic antibiotics – 1st line = ciprofloxacin (indication if cirrhotic with ascites and ascites protein <15g/L, until ascites has resolved OR previous SBP OR hepato-renal syndrome OR child pugh C)\n- For refractory ascites in portal hypertension, a TIPS (transjugular intrahepatic portosystemic) shunt procedure can be considered.\n\n# References\n\n[British Society of Gastroenterology - Management of Ascites in Cirrhosis](https://www.bsg.org.uk/clinical-resource/guidelines-on-the-management-of-ascites-in-cirrhosis/)\n",
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"learningPoint": "A neutrophil count exceeding 250/mm³ in ascitic fluid indicates spontaneous bacterial peritonitis in patients with liver disease.",
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"question": "A 50-year-old female with known non-alcoholic fatty liver disease (NAFLD) and associated ascites presents to the emergency department unwell. She is pyrexial and has generalised abdominal pain. Paracentesis is performed.\n\nWhich of the following results from the ascitic fluid would confirm a diagnosis of spontaneous bacterial peritonitis (SBP)?",
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "According to the modified KCC, an arterial lactate of >3.5mmol/L on admission or >3.0mmol/L 24 hours after paracetamol ingestion or after fluid resuscitation meets the criteria for possible liver transplantation",
"id": "31937",
"label": "e",
"name": "Arterial lactate of 3.1mmol/L",
"picture": null,
"votes": 223
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "According to the modified KCC, hepatic encephalopathy grade III or IV and serum creatinine concentration >300umol/L and prothrombin time >100 seconds meets the criteria for possible liver transplantation",
"id": "31936",
"label": "d",
"name": "Prothrombin time of 80 seconds",
"picture": null,
"votes": 1956
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "According to the modified KCC, hepatic encephalopathy grade III or IV and serum creatinine concentration >300umol/L and prothrombin time >100 seconds meets the criteria for possible liver transplantation",
"id": "31934",
"label": "b",
"name": "Hepatic encephalopathy grade II",
"picture": null,
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "According to the modified KCC, an arterial pH of <7.3 is criteria for possible liver transplantation",
"id": "31933",
"label": "a",
"name": "Arterial pH of 7.2",
"picture": null,
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},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "According to the modified KCC, hepatic encephalopathy grade III or IV and serum creatinine concentration >300umol/L and prothrombin time >100 seconds meets the criteria for possible liver transplantation",
"id": "31935",
"label": "c",
"name": "Serum creatinine of 200umol/L",
"picture": null,
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"__typename": "QuestionComment",
"comment": "Isn't it arterial pH <7.3 if 24h after ingestion ",
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"comment": "Oh shut up, you got it wrong stop crying ",
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"comment": "hw can i rmeber this\nTo remember the modified King's College Criteria (KCC) for liver transplantation, you can use a mnemonic or a story. Here's a mnemonic that might help:\n\n\"PHLaSH\":\n\nP: pH < 7.3\n\nH: Hepatic encephalopathy (Grade III or IV)\n\nL: Lactate > 3.5 mmol/L (early) or > 3.0 mmol/L (after resuscitation)\n\nS: Serum creatinine > 300 µmol/L\n\nH: Prothrombin Time (PT) > 100 seconds",
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"explanation": "# Summary\n \nParacetamol overdose accounts for 44% of all adult self-poisoning cases in the UK and results in approximately 150,000 hospital admissions annually. Some patients may be asymptomatic, or present with nausea, vomiting, abdominal pain, jaundice or altered mental state. Investigations should include baseline bloods including a clotting and a blood gas, as well as a paracetamol level. Management depends on the dose taken, timing of ingestion and the patient's clinical condition, with N-acetylcysteine being the mainstay of treatment. The decision to treat is often guided by a nomogram although in certain situations N-acetylcysteine should be started immediately.\n \n# Definition \n \nParacetamol overdose refers to when a potentially toxic dose of paracetamol is taken, either accidentally or in the context of a self-harm or suicide attempt. \n \n# Epidemiology \n \nParacetamol is the most common agent ingested in the context of intentional self-harm in the UK. Paracetamol overdose accounts for 44% of all adult self-poisoning cases in the UK, with approximately 150,000 people admitted to hospital each year due to poisoning.\n \n\n# Aetiology\n \n- The pathophysiology of paracetamol toxicity involves the build-up of its toxic metabolite NAPQI (N-acetyl-p-benzoquinone-imine). \n- Normally, NAPQI is inactivated by glutathione in the blood, but in a paracetamol overdose, glutathione stores are rapidly depleted. \n- NAPQI therefore accumulates, unmetabolised, and binds to cellular proteins, causing cell death.\n- This causes both severe hepatotoxicity and nephrotoxicity that can lead to liver and kidney failure. \n\n# Classification\n \n - **Acute overdose** - excessive paracetamol taken in less than 1 hour, usually in the context of self-harm\n - **Staggered overdose** - excessive paracetamol ingested over longer than 1 hour, usually in the context of self harm\n - **Therapeutic excess** - excessive paracetamol taken with the intent to treat pain or fever and without self-harm intent, ingested at a dose greater than 75mg/kg/24 hours.\n\n\n# Signs and Symptoms\n \n- These depend on how long has passed since the overdose was taken\n- In the first 24 hours patients may be asymptomatic or have nausea and vomiting\n- After this, up to around 72 hours, right upper quadrant pain and hypotension may develop\n- From 72 to 96 hours patients may develop liver and renal failure with resulting metabolic acidosis, encephalopathy and coagulopathy, with symptoms of:\n - Confusion\n - Drowsiness\n - Reduced urine output\n - Loin pain\n - Jaundice\n - Bleeding diathesis\n\n# Differential Diagnosis \n\n - **Acute gastroenteritis:** has similar symptoms of nausea, vomiting and abdominal pain; may have diarrhoea and history of unwell contacts\n - **Renal colic:** may also present with haematuria, nausea and vomiting; pain more likely to be \"loin to groin\" rather than right upper quadrant\n - **Decompensation of chronic liver disease:** can present with jaundice, abdominal pain and encephalopathy\n - **Sepsis:** can lead to a lactic acidosis and acute kidney injury; patients are often febrile and may have localising signs or symptoms of infection\n \n# Investigations\n \nBlood tests for paracetamol levels should be taken at least 4 hours after ingestion, as this is when plasma paracetamol concentration peaks so an earlier blood test may underestimate levels\n\nOther important blood tests include:\n \n - Full Blood Count (FBC)\n - Urea and Electrolytes\n - Clotting Screen\n - Liver Function Tests\n - Venous Blood Gas (may show metabolic acidosis)\n - Blood glucose (could also do a bedside capillary blood glucose)\n - Salicylate levels (to look for a mixed overdose with aspirin)\n\n# Management\n \n**Conservative:**\n\n- Weigh patient (important for determining dose of paracetamol taken per kg and to calculate N-acetylcysteine dosing)\n- Consider if any other substances may have been taken with paracetamol\n- If overdose was intentional, refer to liaison psychiatry for a mental health assessment\n - Consider if 1:1 observations are required for high-risk patients\n - Assess risk to self and ongoing suicidal ideation\n - Discharge planning and assess need for ongoing psychiatric input\n- Treat any other self-harm\n\n**Medical:**\n\nDecisions on medical treatment are guided by a nomogram which plots paracetamol levels against time from ingestion. \n\nThe management of paracetamol overdose is dependent on the timing of ingestion, the dose taken, and the patient's clinical condition:\n \n - **Ingestion less than 1 hour ago + dose >150mg/kg**: Administer activated charcoal\n - **Ingestion 1-4 hours ago**: Wait until 4 hours to take a level and treat with N-acetylcysteine (NAC) based on level\n - **Ingestion within 4-8 hours + dose >150mg/kg**: Start NAC immediately if there is going to be a delay of ≥8 hours in obtaining the paracetamol level, otherwise wait for level and treat if level high (above the treatment line on the nomogram)\n - **Ingestion within 8-24 hours + dose >150mg/kg**: Start NAC immediately\n - **Ingestion >24 hours ago**: Start NAC immediately if the patient has jaundice, right upper quadrant tenderness, elevated ALT, INR >1.3 or if the paracetamol concentration is detectable\n - **Staggered overdose**: Start NAC immediately\n \nNAC is given as an IV medication - it acts by increasing glutathione levels thereby preventing toxicity. \n\nThere are two ways to give NAC:\n\n- Standard regimen of 3 consecutive infusions totalling 21 hours in duration \n- The newer SNAP protocol (now recommended by Royal College of Emergency Medicine as standard) where the same dose of NAC is given over 12 hours in two infusions\n- If after either of these are completed, bloods show deranged LFTs, clotting or renal function NAC infusions should be continued and the patient discussed with local liver transplant services\n- Anaphylactoid reactions are a common side effect of NAC, characterised by urticaria, angioedema, nausea and vomiting, tachycardia and bronchospasm but rarely shock\n- These are managed by suspending treatment and giving chlorphenamine and salbutamol nebulisers before restarting (possibly at a slower rate)\n \n**Surgical:**\n\nPatients who develop acute liver failure may require an urgent liver transplant as a life-saving measure - the following groups of patients should be transferred to a liver transplant centre:\n\n- INR > 3 at 48 hours or > 4.5 at any time\n- Oliguric or creatinine > 200\n- pH < 7.3 despite fluid resuscitation\n- Hypotension (systolic blood pressure < 80mmHg)\n- Severe thrombocytopenia\n- Encephalopathy\n \nThe King's College Criteria is used to predict mortality from paracetamol overdose and to identify those patients who would potentially benefit from liver transplantation. It advises consideration of liver transplantation if:\n \n- Blood pH < 7.3\n \n\nOr **all** of:\n \n- Serum creatinine > 300 µmol/L\n- INR > 6.5 (Prothrombin time > 100s)\n- Grade III or IV hepatic encephalopathy\n\n# NICE Guidelines\n\n[NICE CKS - Poisoning or overdose](https://cks.nice.org.uk/topics/poisoning-or-overdose/)\n\n# References\n\n[BNF - Poisoning](https://bnf.nice.org.uk/treatment-summary/poisoning-emergency-treatment.html)\n\n[MHRA - Treating paracetamol overdose with intravenous acetylcysteine](https://www.gov.uk/drug-safety-update/treating-paracetamol-overdose-with-intravenous-acetylcysteine-new-guidance)\n\n[RCEM - SNAP Protocol Position Statement](https://rcem.ac.uk/wp-content/uploads/2021/11/Use_of_SNAP_for_Treatment_of_Paracetamol_Toxicity_Nov_2021.pdf)\n\n[Life in the Fast Lane - liver transplanation for paracetamol toxicity](https://litfl.com/liver-transplantation-for-paracetamol-toxicity/)",
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"question": "A 25-year-old female presents to the emergency department with a paracetamol overdose. She has hepatic encephalopathy grade II.\n\n\nShe has the following blood tests:\n\n\n||||\n|--------------|:-------:|------------------|\n|pH|7.2|7.35 - 7.45|\n|Creatinine|200 µmol/L|60 - 120|\n|Prothrombin Time (PT)|80 seconds|10 - 12|\n|Lactate|3.1 mmol/L|0.6 - 1.4|\n\n\nWhich of the following means that she is a candidate for liver transplantation according to the modified King's College Criteria (KCC)?",
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"comment": "I thought 2 consecutive BP readings were needed showing HTN? 3 months is definitely more appropriate than slamming meds",
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"comment": "I thought ARBs where better for diabetics than ACEi?",
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"comment": "No ACE is for type 2 diabetics. Remember ACEi is renal protective",
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"comment": "Surely you would take it more than once? How do you know it’s not white coat syndrome?",
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"comment": "honestly thought they were hinting at White Coat Syndrome too :(\n\nBP readings from Mon-Weds seem fine but is 155/100 when examined *in the practice* ",
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"comment": "100 diastolic pressure in practice and at home is not fine, it classes as 2nd stage hypertension which is what the question is hinting at hope that helps.",
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"explanation": "# Summary\r\n\r\nPrimary hypertension, accounting for approximately 90-95% of cases of hypertension, is characterised by persistently elevated blood pressure due to age-related pathophysiological changes. It is a major risk factor for cardiovascular disease, cerebrovascular disease, chronic kidney disease, and peripheral vascular disease. Diagnosis is based on ambulatory blood pressure monitoring (ABPM) readings of 135/85mmHg or higher. Classification is determined by the severity of the hypertension. Management depends on the classification of the hypertension and involves lifestyle modifications and pharmacological anithypertensives according to NICE guidelines. Effective management, through lifestyle changes and medications, significantly reduces the associated risks and improves outcomes for individuals with hypertension.\r\n\r\n# Definition \r\n\r\nA 'normal' blood pressure ranges between 90/60mmHg to 140/90mmHg. The definition of hypertension is a 24h ambulatory blood pressure average reading (ABPM) that is more than or equal to 135/85mmHg. \r\n\r\n# Epidemiology\r\n\r\nIn 2015, it was reported that high blood pressure affected more than 1 in 4 adults in England (31% of men; 26% of women). In England, it is estimated that primary hypertension affects around 13.5 million people and contributed to 75,000 deaths.\r\n\r\n# Pathophysiology\r\n\r\nPrimary hypertension is as a result of a series of complex physiological changes as we age. Hypertension often occurs as a result of reduced elasticity of large arteries, age-related and atherosclerosis-related calcification, and degradation of arterial elastin. It may also be present in conditions associated with increased cardiac output, such as anaemia, hyperthyroidism and aortic regurgitation.\r\n\r\nAlthough the risk of cardiovascular disease increases progressively with increasing systolic and diastolic blood pressure, raised systolic pressure is more important than raised diastolic pressure as a risk factor for cardiovascular and renal disease.\r\n\r\n# Classification \r\n\r\nHypertension can be classified according to how high a patient's blood pressure is. \r\n\r\n* Stage 1: Clinic => 140/90mmHg; ABPM => 135/85mmHg \r\n* Stage 2: Clinic => 160/100mmHg; ABPM =>150/95mmHg \r\n* Stage 3: Clinic systolic BP (SBP) => 180 or diastolic BP (DBP) =>120mmHg\r\n\r\n\r\n# Symptoms and Signs\r\n\r\nHypertension, unless malignant, is asymptomatic and does not have any clinical signs. It is diagnosed with ABPM and further investigations should focus on diagnosing end-organ complications of hypertension. \r\n\r\n# Investigations\r\n\r\n[lightgallery]\r\n\r\n* Hypertensive patients are commonly first identified at GP appointments or during hospital admissions. Due to the prominence of 'white coat hypertension', ABPM is now required for the diagnosis of hypertension. \r\n* Hypertension should be suspected in a patient who has a clinic blood pressure of =>140/90mmHg. \r\n* **1st line: ABPM** or home blood pressure monitoring if ABPM is not tolerated or declined. \r\n* Alongside ABPM: assessment for end-organ damage and assessment of cardiovascular risk (QRISK2 scores). \r\n * Urine dip and albumin:creatinine level\r\n * Blood glucose, lipids and renal function\r\n * Fundoscopy for evidence of hypertensive retinopathy\r\n * ECG: look for evidence of LV hypertrophy\r\n\r\n\r\nN.B. if presentation is suspicious for secondary hypertension refer and investigate as appropriate (see section). \r\n\r\nN.B. Referral for same-day specialist assessment should be arranged for people with: \r\n\r\n* Clinic blood pressure of 180/120mmHg and higher with signs of retinal haemorrhage or papilloedema (accelerated hypertension) or life-threatening symptoms (e.g. new onset confusion, chest pain, heart failure signs or AKI). \r\n\r\n# Management\r\n\r\n## Principles of Management \r\n\r\n### Conservative Management \r\n\r\nControlling risk factors for cardiovascular disease:\r\n\r\n* Weight loss\r\n* Healthy diet (reduce salt and saturated fats)\r\n* Reduce alcohol and caffeine\r\n* Reduce stress\r\n* Stop smoking\r\n\r\n### Medical Management\r\n\r\nIndications to start pharmacological management of primary hypertension:\r\n\r\n* Stage 1 hypertensive patients who are <80 years old with end organ damage, CVS disease, renal disease, diabetes or 10-year CVS risk >10% OR\r\n* Anyone with stage 2 hypertension\r\n\r\n### 2019 NICE Guidelines for Pharmacological Management of Primary Hypertension \r\n\r\n[lightgallery1]\r\n\r\n* Step 1: \r\n\t* **ACE-inhibitor** (e.g. Ramipril) if <=55 years old\r\n\t* **DHP-Calcium Channel Blocker** (e.g. Amlodipine) if >55 years old OR African or Caribbean ethnicity\r\n\t* If unable to tolerate ACE-inhibitor then switch to _Angiotensin Receptor Blocker_ (e.g. Candesartan)\r\n* Step 2: \r\n\t* (If maximal dose of Step 1 has failed or not tolerated)\r\n\t* **Combine CCB and ACE-I/ARB**\r\n* Step 3:\r\n\t* (If maximal doses of Step 2 has failed or not tolerated)\r\n\t* **Add thiazide-like diuretic** (e.g. Indapamide)\r\n* Step 4: *Resistant Hypertension*\r\n\t* If blood potassium <4.5mmol/L then add **spironolactone**\r\n\t* If >4.5mmol/L **increase thiazide-like diuretic dose**\r\n\t* Other options at this point if the potassium is >4.5mmol/L include:\r\n\t\t* Alpha blocker (e.g. Doxazosin)\r\n\t\t* Beta blocker (e.g. Atenolol)\r\n\t\t* Referral to cardiology for further advice\r\n\r\n**ABPM Targets:**\r\n \r\n* Age <80 ABPM target <135/85\r\n* Age >80 ABPM target <145/85 (due to risk of postural drop and falls)\r\n* T1DM with end-organ damage <130/80\r\n\r\n# Complications\r\n\r\n* Increased risk of morbidity and mortality from all causes\r\n* Coronary artery disease\r\n* Heart failure\r\n* Renal failure\r\n* Stroke\r\n* Peripheral vascular disease\r\n\r\n# Prognosis \r\n\r\nHypertension remains one of the biggest risk factors for cardiovascular disease and its associated disabilities. Management of hypertension (with lifestyle modifications or pharmacological therapies) has been shown to reduce these risks significantly. \r\n\r\n# NICE Guidelines\r\n> <https://cks.nice.org.uk/topics/hypertension/> \r\n\r\n# References \r\n\r\n<https://patient.info/heart-health/high-blood-pressure-hypertension>\r\n<https://www.ahajournals.org/doi/full/10.1161/01.CIR.101.3.329> ",
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"question": "A 65 year old man presents to his general practice for a routine blood pressure check. He does not appear confused and he denies chest pain or cough.\n\nHe has a blood pressure monitor at home and presents a piece of paper with his recordings on it:\n\n- Monday AM: 132/95mmHg\n- Monday PM: 136/92mmHg\n- Tuesday AM: 142/105mmHg\n- Tuesday PM: 135/95mmHg\n- Wednesday AM: 143/105mmHg\n- Wednesday PM: 139/101mmHg\n\nThe patient currently takes the following medications:\n\n- Ramipril 10mg OD\n- Amlodipine 10mg OD\n- Metformin 500mg BD\n\nA fundoscopy examination is normal. At the practice, his blood pressure is 155/100mmHg.\n\nWhat is the next best step in the management of this patient?",
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"explanation": "This patient likely has Alzheimer's disease. Donepazil is an acetylcholinesterase inhibitor which can prolong the QT-interval (QTc). Therefore it is important to perform a 12 lead ECG and document baseline heart rhythm and QTc interval prior to initiation",
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"comment": "Before starting the patient on an alzheimers medication, shouldnt a CT scan be done to rule out organic causes? I see why we should do an ECG before commencing the medication, but there is no formal diagnosis of dementia so surely the correct answer is CT?",
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"comment": "My guess is because the neuro exam was entirely normal and the Hx/symptoms are very much in line with Alzheimer's so no need for a CT? But I agree think a CT would be appropriate",
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"comment": "no focal neurology therefore: no",
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"explanation": "# Summary\n\nAlzheimer's disease, the most common form of dementia, is a progressive neurodegenerative disorder that leads to cognitive decline, memory impairment, and a range of behavioural and psychological symptoms. Its impact extends beyond the individual, affecting families and healthcare systems worldwide. This comprehensive guide explores the key aspects of Alzheimer's disease, from its definition and pathophysiology to clinical features, diagnostic considerations, management approaches, and prognosis. Adherence to NICE guidelines ensures evidence-based care for patients with this challenging condition.\n\n# Definition\n\nAlzheimer's disease is a chronic, neurodegenerative disorder characterized by the progressive accumulation of abnormal protein deposits, primarily amyloid plaques and tau tangles, in the brain. This leads to the deterioration of cognitive function, memory loss, and various behavioural and psychological symptoms.\n\n\n# Epidemiology\n\nAlzheimer's disease is a global health concern, with an increasing prevalence as the population ages. It is estimated that millions of individuals worldwide are affected, with higher incidence rates in older age groups. Women are more commonly affected than men, and several genetic and environmental factors influence disease risk.\n\n\n# Pathophysiology\n\n\nAlzheimer's disease is a complex and progressive neurodegenerative disorder characterized by distinct pathophysiological hallmarks. These hallmarks are responsible for the gradual decline in cognitive function and the characteristic clinical features observed in affected individuals.\n\n1. **Amyloid Plaques:** The accumulation of beta-amyloid protein fragments outside nerve cells in the form of plaques is a hallmark feature. These abnormal protein deposits are believed to disrupt neuronal communication, trigger inflammation, and ultimately lead to cell death.\n\n2. **Tau Tangles:** Inside nerve cells, abnormal tau protein accumulates, forming neurofibrillary tangles. These tangles interfere with the transport of essential nutrients within neurons, contributing to their dysfunction and eventual demise.\n\n3. **Neuronal Loss and Brain Atrophy:** As the disease progresses, significant neuronal loss occurs, particularly in brain regions responsible for memory and cognitive function, such as the hippocampus and the cerebral cortex. This loss is associated with brain atrophy, visible on imaging studies.\n\n4. **Neurotransmitter Imbalance:** Alzheimer's disease disrupts the balance of neurotransmitters, particularly acetylcholine, which plays a crucial role in memory and learning. Reduced acetylcholine levels further contribute to cognitive decline.\n\n5. **Inflammatory Response:** Chronic neuroinflammation, characterized by the activation of microglia and astrocytes, is a prominent feature in Alzheimer's disease. Inflammation may exacerbate neuronal damage and contribute to the progression of the disease.\n\n# Risk Factors\n\nSeveral factors influence an individual's risk of developing Alzheimer's disease. These include:\n\n- **Age:** Advanced age is the most significant risk factor, with the incidence of Alzheimer's disease increasing exponentially after the age of 65.\n\n- **Genetic Predisposition:** Mutations in specific genes, such as the apolipoprotein E (APOE) gene, increase the risk of developing Alzheimer's disease. Additionally, individuals with Down's syndrome are at a higher risk due to a triplication of chromosome 21, which carries the amyloid precursor protein (APP) gene.\n\n- **Family History:** Having a first-degree relative with Alzheimer's disease can increase one's susceptibility.\n\n- **Cardiovascular Risk Factors:** Conditions like hypertension, diabetes, obesity, and hypercholesterolemia have been associated with an elevated risk of Alzheimer's disease.\n\n- **Lifestyle Factors:** Physical inactivity, smoking, and a diet high in saturated fats may contribute to increased risk.\n\n- **Traumatic Brain Injury:** A history of head injuries, particularly repeated concussions, has been linked to a higher risk of developing Alzheimer's disease.\n\n- **Low Educational Attainment:** Lower levels of education may be associated with an increased risk.\n\nUnderstanding these risk factors and their relationship to the disease's pathophysiology is crucial for early identification, prevention, and management of Alzheimer's disease.\n\n# Clinical Features\n\nAlzheimer's disease is characterized by a constellation of cognitive and behavioural symptoms, which may include:\n\n* **Memory Impairment:** Early in the disease, individuals often experience difficulties in recalling recent events and conversations.\n* **Language Impairment:** This may manifest as difficulty finding words, struggling to express oneself, and, in later stages, aphasia.\n* **Executive Dysfunction:** Impaired ability to plan, organize, and carry out tasks, leading to difficulties in activities of daily living.\n* **Behavioural Changes:** Individuals may exhibit agitation, aggression, or apathy, sometimes accompanied by mood swings and irritability.\n* **Psychological Symptoms:** Hallucinations, delusions, and paranoia can occur, particularly in later stages of the disease.\n* **Disorientation:** Affected individuals may become disoriented in familiar surroundings, unable to recognize places or people.\n* **Loss of Motor Skills:** In advanced stages, motor skills decline, leading to difficulties with mobility and self-care.\n\n# Differential Diagnosis\n\n\n1. **Vascular Dementia:** Cognitive impairment in vascular dementia often presents suddenly and is associated with a history of cerebrovascular events.\n\n2. **Lewy Body Dementia:** Visual hallucinations and fluctuating cognitive impairment are more common in Lewy body dementia.\n\n3. **Frontotemporal Dementia:** This condition typically presents with profound behavioural and personality changes, often affecting social conduct.\n\n4. **Mild Cognitive Impairment (MCI):** MCI is a transitional state between normal cognitive aging and dementia. Unlike Alzheimer's, MCI may not significantly impact daily functioning.\n\n5. **Normal Age-Related Cognitive Decline:** Age-related cognitive changes are common but do not interfere significantly with daily activities.\n\n# Investigations\n\nDiagnosing Alzheimer's disease may involve a series of assessments, including:\n\n- **History** - including a functional history, which may be informed using a structured instrument such as the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) or the Functional Activities Questionnaire (FAQ). A collateral history may be necessary, and a risk assessment should also be taken.\n- Assess cognitive decline using an approved scoring tool such as MMSE, MOCA, 10-point Cognitive Screener (10-CS), 6-item Cognitive Impairment Test (6-CIT), 6-item Screener, Memory Impairment Screen (MIS), Mini-Cog, Test Your Memory (TYM) \n- **Examination** - physical examination including a full neurological examination looking for abnormaliities in coordination, gait, sensation and motor signs.\n- **Blood tests** - to rule out reversible causes, this is known as a confusion screen and is often done in primary care. It includes FBC, U&E, LFTs, CRP/ESR, Ca2+, TFTs, B12, folate, syphilis, HIV. If there is an acute onset of symptoms delirium should be considered as this is a different pathway.\n- Once reversible causes are ruled out and a diagnosis of dementia is still suspected, refer to a specialist dementia diagnostic service (such as a memory clinic or community old age psychiatry service. Here, a full functional assessment is carried out and the patient will be referred for **neuroimaging**, such as CT or MRI.\n\t- **Brain Imaging:** Magnetic resonance imaging (MRI) and positron emission tomography (PET) scans can reveal brain atrophy and the presence of amyloid plaques.\n\t- **Cerebrospinal Fluid Analysis:** May be used to detect specific biomarkers associated with Alzheimer's disease.\n\n# Management\n\n- **Non-Pharmacological Approaches:** Psychological interventions, cognitive stimulation therapy, and occupational therapy can help manage behavioural and psychological symptoms.\n\n- **Support for Caregivers:** Education and support for family members and caregivers are vital to help them navigate the challenges of providing care.\n\n- **Patient-Centered Care:** Tailoring interventions to the individual's needs and preferences, while ensuring their safety and well-being.\n- **Pharmacological Intervention:** Medications, such as cholinesterase inhibitors (e.g. donepezil) and N-methyl-D-aspartate (NMDA) receptor antagonists (e.g. memantine), may be prescribed to manage cognitive symptoms.\n\t- Pharmacological treatments may have modest benefits, and include the cholinesterase inhibitors rivastigamine, galantamine, and donpezil in mild-moderate dementia, and the NMDA inhibitor memantine in severe dementia (as classified using the MMSE score: severe: <10; moderate: 10-20; mild: 21-26/30. \n\t- If there is evidence of behavioral and psychological symptoms of dementia (BPSD), low-dose risperidone may be started\n\n\n# NICE Guidelines\n\n[NICE CKS - Dementia](https://cks.nice.org.uk/topics/dementia/)\n\n# References\n\n[NHS UK - Alzheimer's Disease](https://www.nhs.uk/conditions/alzheimers-disease/)\n\n[Alzheimer's Association](https://www.alz.org/alzheimers-dementia/what-is-alzheimers)\n\n\n\n\n\n",
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"question": "A 85 year old man is seen at the neurology clinic with his daughter. The daughter reports that he has been increasingly forgetful, has a shortened attention span compared to his usual self and has become very clumsy. She says that this has been a gradual decline over several months. The patient denies any changes in mood or any suicidal ideation.\n\nHis only significant past medical history is chronic obstructive pulmonary disease (COPD) for which he takes salbutamol PRN. He has no significant psychiatric history.\n\nOn examination, he has normal tone of his upper and lower limbs, a normal gait, and normal power throughout.\n\nThe neurologist decides to start him on Donepazil. Which investigation should be performed prior to commencing this medication?",
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"comment": "weird question. I think very niche too - not high yield memorising Rx of haemolytic anaemia in pt with G6PD",
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"comment": "Does routine HIV testing post-diagnosis of TB not extend to other Mycobacterium infections?",
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"comment": "i tried looking this up and there doesn't seem to be much evidence in favour of TB association with leprosy. however, if you have both, the leprosy might flare more (i guess reasonably so because of the diminished immune response). but there's no guidance to test everyone (i got it wrong as well tho)",
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"explanation": "# Summary\n \n \nLeprosy is a disease endemic in many developing countries. The disease can manifest in various ways depending on host immunology and bacterial virulence. The two main forms are multibacillary (lepromatous) and paucibacillary (tuberculoid) leprosy. Differential diagnoses to consider include inherited diseases, endocrine disorders, and other conditions such as AL amyloidosis. Diagnosis is primarily based on clinical assessment and the presence of acid-fast bacilli in biopsies or smears. Management involves the use of medications such as dapsone, rifampicin, and clofazimine, with close monitoring for potential side effects and immunological complications. \n \n \n# Definition\n \n \nLeprosy is a mycobacterial disease caused by *Mycobacterium leprae* which typically presents with dermatological and neurological manifestations.\n \n# Epidemiology\n \nLeprosy is endemic in a number of developing countries across the world. Most new cases occur in Southeast Asia.\n \nIt is associated with severe morbidity, reduced psychosocial functioning and stigmatisation. While difficult to transmit, it is thought to be spread by the respiratory route via nasal discharge.\n \n# Aetiology\n \n - Leprosy is spread through droplets from the respiratory tract. Prolonged close contact (over months) is required to transmit the disease.\n - Leprosy manifests in a number of different ways owing to a range of factors, the most important being host immunology and bacterial virulence/initial infectious load\n - *M. leprae* grows best at 27–33° so it prefers to grow at **cooler** areas of the body (eg. skin, nerves close to the skin, mucous membranes)\n - There are five types, but broadly it can be classified as lepromatous and tuberculoid leprosy\n - In disseminated lepromatous/multibacillary leprosy, bacteria become widely disseminated due to poor Th1 cell-mediated responses. This causes symmetrical peripheral nerve damage through demyelination of peripheral nerves, as well as classical skin changes.\n - In tuberculoid/paucibacillary leprosy, there is a robust Th1 cell-mediated response, leading to better control by the immune system and milder clinical manifestations.\n \n# Symptoms & Signs\n \nThe clinical features of leprosy exist on a spectrum. At one end is **disseminated lepromatous/multibacillary leprosy**:\n \n - Coppery or hypopigmented anaesthetic patches; ≥5\n - Classic facial changes include nose destruction and ear swellings – leonine faces\n - Nerve thickening may be felt on palpation, with the most commonly affected nerves being the ulnar, median, radial cutaneous, greater auricular, common peroneal and posterior tibial nerves to control of the infection\n \nClinical features of **tuberculoid/paucibacillary leprosy** include a milder form of nerve damage and dermatological manifestations (<5 lesions)\n \nNerve damage in all forms can lead to contractures, ulceration and deformity in the long term\n \n# Differential diagnosis\n \n \nThe differential diagnosis for other causes of thickened peripheral nerves include:\n \n - **Inherited diseases** – Charcot–Marie–Tooth disease, Refsum's disease and neurofibromatosis. These can also cause peripheral neuropathies and cutaneous manifestations alongside a family history.\n - **Acromegaly** - coarsening features & nerve compression (especially carpal tunnel syndrome). Symptoms are more generalised and complications such as diabetes mellitus can develop.\n - **AL amyloidosis** - may be associated with symptoms of multiple myeloma (hypercalcaemia, renal dysfunction, anaemia, bone pain).\n - **Peripheral neuropathy** secondary to diabetes mellitus, alcohol use or, more acutely, Guillain-Barré syndrome. This is usually preceded by poorly controlled diabetes or alcoholism, or by a recent infection (precipitating GBS)\n \n \n# Diagnosis\n \nLeprosy is diagnosed with one or more of the following clinical features and laboratory tests:\n \n - Loss of sensation in a hypopigmented or reddened skin patch\n - Thickened peripheral nerve and sensory loss/weakness in the area supplied by the nerve\n - Slit-skin smear demonstrating acid-fast bacilli with a special stain\n \n \n# Treatment\n \nEarly diagnosis and treatment can reduce illness severity and long-term sequelae.\n \n - Treatment of multibacillary leprosy involves the use of dapsone, rifampicin and clofazimine (an immunosuppressive agent) for at least 12–24 months\n - Patients commenced on medications need to be monitored closely throughout the course of their treatment for immunological complications known as type I and II (erythema nodosum lepromum) reactions, which require hospital inpatient treatment. Treatment should continue with the addition of prednisolone, aspirin or thalidomide under specialist guidance.\n - Side effects of dapsone include methaemoglobinaemia, agranulocytosis, Stevens–Johnson Syndrome and the DRESS syndrome; it can also trigger a haemolytic crisis in G6PD deficiency\n - Clofozamine can cause abnormal skin pigmentation\n - Rifampicin can cause orange secretions and is a cytochrome P450 inducer, hence has several drug interactions\n - Treatment of paucibacillary leprosy involves rifampicin and dapsone for 6 months\n \n \n# References \n \n [BNF: Leprosy treatment summary](https://bnf.nice.org.uk/treatment-summaries/leprosy/#:~:text=Paucibacillary%20leprosy%20should%20be%20treated,is%20sufficient%20to%20treat%20tuberculosis.)\n \n [Click here for the WHO page on leprosy](https://www.who.int/news-room/fact-sheets/detail/leprosy)\n \n \n [Leprosy: review of the epidemiological, clinical, and etiopathogenic aspects - Part 1 - PMC (nih.gov)](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4008049/)",
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"question": "A 55 year old man presents to his GP with a 6 month history of multiple hypopigmented patches over his torso. He also has multiple burn marks on his hands from accidentally touching hot pans whilst cooking. Nerve conduction studies reveal reduced conduction velocity in the ulnar and median nerves. He is diagnosed with leprosy and started on dapsone.\n\nWhich one of the following tests should be performed before starting treatment?",
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Subsets and Splits