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"comment": "Why is the title \"in pregnancy\"?",
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"comment": "Isn't CCB contraindicated with beta blocker?",
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"comment": "only rate limiting CCB like verapamil, diltiazem as it works on coronary arteries ",
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"comment": "Why is an ACE not correct in this senario?\n",
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"comment": "Contraindicated in those with risk of bronchospasm",
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"explanation": "# Summary\n\n\nChronic hypertension and gestational hypertension are common conditions that may affect pregnant women. They are defined by consistently high blood pressure readings over a certain threshold. Typical signs and symptoms include elevated blood pressure readings, with gestational hypertension specifically presenting after 20 weeks of gestation with no proteinuria. Differential diagnosis may include preeclampsia and chronic kidney disease. Investigations primarily focus on blood pressure monitoring and urinalysis. Management strategies include the use of safe anti-hypertensive medications, such as labetalol, methyldopa, and nifedipine, and regular monitoring.\n\n\n# Definition\n\n\nChronic hypertension refers to high blood pressure that predates pregnancy or is diagnosed before 20 weeks of gestation. Gestational hypertension, on the other hand, is the onset of high blood pressure after 20 weeks gestation without the presence of proteinuria.\n\n\n# Epidemiology\n\n\nBoth chronic and gestational hypertension are common conditions amongst pregnant women. It is crucial to manage these conditions effectively to prevent complications such as preeclampsia and low birth weight.\n\n\n# Aetiology\n\n\nThe causes of chronic and gestational hypertension are multifactorial, often involving genetic predisposition, lifestyle factors, and physiological changes during pregnancy.\n\n\n# Signs and Symptoms\n\n\nThey are primarily asymptomatic but are detected through elevated blood pressure readings. Gestational hypertension specifically presents after 20 weeks of gestation with no proteinuria.\n\n\n# Differential Diagnosis\n\n\n- Preeclampsia: Characterized by high blood pressure and damage to another organ system, most often the liver and kidneys, after 20 weeks of gestation.\n- Chronic Kidney Disease: Typically presents with proteinuria, haematuria, and a rise in serum creatinine.\n\n# Investigations\n\nInvestigations primarily focus on blood pressure monitoring and urinalysis. Regular monitoring and testing are recommended to track the course of the condition and evaluate the effectiveness of treatments.\n\n# Management\n\nManagement strategies for chronic and gestational hypertension in pregnancy include:\n\n- Discontinuation of some anti-hypertensive medications (particularly ACE inhibitors or ARBs) and switching to pregnancy-safe alternatives such as labetalol.\n- Regular blood pressure monitoring.\n- For gestational hypertension above 140/90 mmHg, offer pharmacological treatment; first line management is oral labetalol.\n- If labetalol is not tolerated, alternatives include methyldopa and nifedipine.\n- Regular urinalysis is recommended for all women.\n\n# NICE Guidelines\n\n[NICE - Hypertension in\npregnancy: diagnosis and\nmanagement](https://www.nice.org.uk/guidance/ng133/resources/hypertension-in-pregnancy-diagnosis-and-management-pdf-66141717671365)\n\n",
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"question": "Case Presentation: A 62-year-old white gentleman returns to his GP to receive the results of his ambulatory blood pressure monitoring. It is determined to be 158/97mmHg. His estimated 10-year risk of cardiovascular disease is 7%.\n\n\n\n\n## PH\n\n\nAllergic rhinitis, Migraine\n\n\n## DH\n\n\nFexofenadine hydrochloride 120mg PO OD PRN, Propranolol 80mg PO BD (NKDA)\n\n\n## On examination\n\n\nAlert and oriented. Neurological examination normal. Fundoscopy normal.\n\n\nTemperature 36.0°C, HR 72, RR 14, BP 161/94, O<sub>2</sub> 100% RA, GCS 15, Weight 82kg\n\n\n## Investigations\n\n\nUrine dipstick negative\n\n\nBM: 5.2 mmol/L (normal range 3.5-5.5 mmol/L)\n\n\n# Prescribing Request\n\n\nWrite a prescription for one drug that is most appropriate for treating his condition.",
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"comment": "why isn't prednisolone right? he already has salbutamol prescribed, so isn't the assumption that he has already tried salbutamol?",
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"comment": "Here he has salbutamol prescribed but as an inhaler for at home use, they would need to prescribe it again in the nebulised form as the dose is different. You're right that prednisolone would be used afterwards ( but it wouldn't be once off duration which is the clue)",
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"explanation": "# Summary\n \n\nAcute exacerbations of asthma in children are primarily triggered by allergens such as dust, pollution, animal hair, or smoke, leading to a type 1 (IgE-mediated) hypersensitivity reaction. This triggers bronchoconstriction and bronchial oedema. Signs of a severe episode may include respiratory distress, tachycardia, and significantly reduced peak expiratory flow rate. Key differentials include pneumothorax, anaphylaxis, foreign body inhalation, and cardiac arrhythmia. Investigations involve a stepwise approach to managing acute exacerbations according to the British Thoracic Society and Scottish Intercollegiate Guidelines Network, including the use of high-flow oxygen, inhaled and intravenous salbutamol, and steroids.\n \n\n# Definition\n \n\nAcute exacerbations of asthma in children are episodes where symptoms of asthma, a chronic inflammatory disease of the airways, are significantly intensified. This is typically due to triggers such as exposure to certain allergens, leading to a type 1 (IgE-mediated) hypersensitivity reaction, which results in bronchoconstriction and bronchial oedema.\n \n\n# Epidemiology\n \n\n - Asthma is a common condition, affecting millions of children globally.\n - Asthma can start at any age, but it most commonly begins during childhood.\n - Asthma exacerbations are among the most common reasons for hospitalisation in children.\n \n\n# Aetiology\n \n\nAcute exacerbations of asthma in children can be triggered by a variety of factors including:\n \n\n - Allergens: Dust, pollution, animal hair, smoke\n - Respiratory infections: Viruses such as the common cold\n - Exercise: Especially in cold weather\n - Emotional stress: This can lead to hyperventilation and symptoms of an asthma attack.\n\n \nRisk factors for severe acute asthma include:\n\n- Background of severe asthma (previous near-fatal asthma, or admissions to hospital/PICU)\n- Exposure to second-hand smoke, air pollution or pollen \n- Inadequately controlled asthma \n \n\n# Signs and Symptoms\n \n \n## Features of moderate acute asthma \n\n- Peak flow >50% predicted \n- Tachypnoea but respiratory rate less than 40/minute if 1-5 years old or less than 30/minute if over 5 years \n- Tachycardia but <140/minute if 1-5 years old or <125 if over 5 years \n- SpO2 >2%\n- The child is still able to speak in complete sentences \n\n## Features of acute severe asthma\n \n\n - Respiratory distress: use of accessory muscles of respiration, breathlessness resulting in an inability to complete sentences, tachypnoea with a respiratory rate > 30/min if over 5yrs, > 40 if under 5yrs\n - Heart rate > 125/min if over 5yrs, > 140/min if under 5yrs\n - Peak expiratory flow rate 33-50% of predicted\n \n\n## Features of life-threatening asthma \n \n\n - Peak expiratory flow rate <33% predicted\n - Oxygen saturations <92%\n - Silent chest on auscultation\n - Weak or no respiratory effort\n - Hypotension\n - Exhaustion\n - Confusion/altered conscious level\n \n\n# Differential Diagnosis\n \n\nImportant differentials include:\n \n\n - **Pneumothorax**: Very sudden onset, chest pain, possible deviation of the trachea\n - **Anaphylaxis**: Very sudden onset, associated with antigen exposure, may be associated with rash and angioedema\n - **Inhalation of a foreign body**: Unilateral chest signs\n - **Cardiac arrhythmia**: Chest pain or palpitations, tachycardia or changes in blood pressure\n \n\n# Investigations\n\nThe diagnosis of an acute asthma exacerbation is primarily clinical, based on the presenting symptoms and history. Important investigations may include:\n \n - Peak flow meter: to estimate PEFR \n - Spirometry: Reduction in peak expiratory flow rate and FEV1 which improves with treatment confirms the diagnosis\n - Blood tests: To evaluate the inflammatory response and rule out other causes\n - Chest X-ray: In severe cases or when the diagnosis is uncertain\n - ABG may be used if there is a poor response to initial treatment\n \n\n# Management\n \n\nThe management of acute exacerbations of asthma in children, according to the British Thoracic Society and Scottish Intercollegiate Guidelines Network, follows a stepwise approach:\n \n\n - Maintain oxygen saturations between 94-98% with high flow oxygen if necessary.\n - Administer inhaled salbutamol with a pressurised metered dose inhaler and spacer \n - Proceed to nebulised salbutamol (2.5-5 mg) if necessary\n - Add nebulised ipratropium bromide\n - All patients should receive steroids, given IV only if the patient is unable to take the dose orally\n - 20 mg oral prednisolone for children aged 2-5 years\n - 40 mg oral prednisolone for children over 5 years \n - If not tolerating oral, IV hydrocortisone 4 mg/kg every 4 hours can be used \n - Steroids are given for 3 days \n - If the patient is not responding to salbutamol or ipratropium, consult with a senior clinician \n - For consideration of IV magnesium, IV salbutamol or aminophylline\n \nModerate asthma may be managed using oral prednisolone and beta 2 bronchodilator therapy as an outpatient. \n\nIf there are signs of severe or life-threatening asthma, refer to PICU urgently. \n \nDischarge criteria:\n\n- Child stable on their normal salbutamol inhalers every 3-4 hours \n- Peak Expiratory Flow (PEF) or Forced Expiratory Volume in first second of expiration (FEV1) > 75% best or predicted\n- Oxygen saturations >94% on room air\n\n\nFollow-up after discharge:\n \n - The child should be reviewed by their GP within 2 working days to update or create an asthma action plan, check inhaler technique and adherence\n - The child should be discharged on inhaled corticosteroid-containing controller treatment or on an increased dose compared to their pre-existing dose \n - If a child has a near-fatal attack, they will require specialist supervision \n\n# Complications\n\n- Fatigue\n- Pneumothorax \n- Aspiration pneumonia \n- Respiratory failure requiring intubation and ventilation \n- Hypokalaemia and cardiac arrhythmias related to treatment used\n- Hypoxic-ischaemic brain injury \n\n# Prognosis \n\nUnfortunately, outcomes in the UK are some of the worst in Europe, with approximately 25-30 children per year dying of asthma. 90% of these deaths are thought to be preventable with better care and tackling the deprivation that contributes to poor outcomes. \n \n# NICE Guidelines\n \n [BNFc Guidelines for Acute Asthma](https://bnfc.nice.org.uk/treatment-summaries/asthma-acute/) \n \n\n# References\n \n\n [British Thoracic Society Guidelines](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiL-dbLtOPrAhUXQEEAHbUKAEcQFjACegQIAhAB&url=https%3A%2F%2Fwww.brit-thoracic.org.uk%2Fdocument-library%2Fguidelines%2Fasthma%2Fbtssign-asthma-guideline-quick-reference-guide-2019%2F&usg=AOvVaw0ZD19J5kUP75tRHs2_eoUU)\n \n [Resuscitation Council UK Paediatric emergency algorithms & resources](https://www.resus.org.uk/sites/default/files/2022-03/RCUK%20Paediatric%20emergency%20algorithms%20and%20resources%20Mar%2022%20V1.pdf) \n \n [Patient Info Acute Severe Asthma and Status Asthmaticus](https://patient.info/doctor/acute-severe-asthma-and-status-asthmaticus) \n \n [BMJ Best Practice Acute Asthma in Children](https://bestpractice.bmj.com/topics/en-gb/1098/treatment-algorithm#)",
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"explanation": "# Drug choice feedback\n\nAny short-acting beta-2 agonist is appropriate as first line agent for the treatment of acute asthma. These include salbutamol and terbutaline sulphate, although the former is more commonly prescribed as it is less expensive but no different in efficacy.\n\n# Dose/Route/Frequency/Duration feedback\n\nThe correct dose is 2.5mg-5mg for nebulised salbutamol and 5mg-10mg for nebulised terbutaline sulphate respectively. The nebulised route is most preferred in the initial stages of asthma management.",
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"question": "Case Presentation: A 19-year-old gentleman is brought to the Emergency Department with a sudden-onset 2-hour history of shortness of breath and wheezing\n\n\n\n\n## PH\n\n\nAsthma\n\n\n## DH\n\n\nSalbutamol metered dose inhaler 200 mcg/dose INH PRN, Beclometasone inhalation powder 200 mcg/dose INH BD (NKDA)\n\n\n## On examination\n\n\nAppears distressed, barely able to answer in full sentences. Wheeze heard throughout both lung fields, no crackles. Use of accessory muscles seen. No cyanosis.\n\n\nTemperature 36.6°C, HR 105, RR 29, BP 110/78, O2 95% RA, GCS 15, Weight 67kg\n\n\n## Investigations\n\n\n||||\n|--------------|:-------:|------------------|\n|pH|7.41|7.35 - 7.45|\n|PaO₂|16 kPa|11 - 15|\n|PaCO₂|3.8 kPa|4.6 - 6.4|\n|Bicarbonate|25 mmol/L|22 - 30|\n\nCXR normal\n\n\n# Prescribing Request\n\n\nWrite a prescription for one drug that is most appropriate to treat his bronchospasm.",
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173,458,560 | false | 3 | null | 6,494,964 | null | false | [] | null | 6,757 | {
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"__typename": "QuestionComment",
"comment": "Make spaces for drug names e.g. dalteparin sodium as 2 words (with a space) correct answers. ",
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"comment": "BNF just has it as dalteparin - should give marks for it pls",
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"comment": "what about Fondaparinux?",
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"comment": "Why not apixaban because in the BNF it is used post surgery for this specific surgery of the hip\n",
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"comment": "Surely enoxaparin 150mg/mL is correct too if its 40mg dose?",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "# Drug choice feedback\n\nApart from mechanical means, administration of a low-molecular weight heparin should be offered to all surgical patients in whom the risk of venous thromboembolism outweighs the risk of bleeding. In certain situations, such as in high-risk patients and/or those undergoing orthopaedic procedures, DOACs can also be given as prophylaxis, as per the BNF.\n\n# Dose/Route/Frequency/Duration feedback\n\nThe correct dose depends on the individual low-molecular weight heparin offered. This can only be given subcutaneously and once-daily. It should be continued until mobility is no longer reduced (generally 5-7 days) and reviewed at discharge.",
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"question": "Case Presentation: A 52-year-old woman has been admitted to the orthopaedic ward for observation after an elective hip replacement. \r\n\r\n\r\n## PH\r\n\r\nFibroids, hypertension, previous facial squamous cell carcinoma\r\n\r\n## DH\r\n\r\nNifedipine (extended-release) 30mg PO OD\r\n\r\n## On examination\r\n\r\nAppears well and oriented to time and place. Bedbound - awaiting her first physiotherapy assessment. Anti-embolism stockings seen.\r\n\r\nTemperature 36.3°C, HR 72, RR 13, BP 135/78, O2 98% RA, GCS 15, Weight 82kg\r\n\r\n## Investigations\r\n\r\nFBC: Hb 139, WCC 11.3, Plts 278\r\n\r\nU&Es: Na<sup>+</sup> 142, K<sup>+</sup> 4.7, Cl<sup>-</sup> 105, Ur 7.2, Cr 69, eGFR >90mL/min/1.73m<sup>2</sup>\r\n\r\nClotting: normal\r\n\r\n# Prescribing Request\r\n\r\nWrite a prescription for one drug that is most appropriate for prophylaxis of venous thromboembolism in this patient.",
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"comment": "Excessive respiratory secretions in palliative care \nBy subcutaneous injection\n\nAdult\n20 mg every 4 hours if required, adjusted according to response to up to 20 mg every 1 hour.\nBy subcutaneous infusion\n\nAdult\n20–120 mg/24 hours.",
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"comment": "In a syringe driver 1.2mg in 24 hours would mean 50 micrograms per hour. So why is the correct answer not hyoscine hydrobromide 400 micrograms/mL injection, 50 micrograms SC every hour, continuous? ",
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"comment": "why 5mg per hour ? : ) ",
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"comment": "I did the same but I think because the BNF says '20 mg every 4 hours if required' so its 5 mg in one hour. Mean question but I can see what they're going for",
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"comment": "marked wrong if you prescribe it as 1 mL of 400 micrograms/mL because you should put \"400 micrograms\" but in the other mock it was the other way around, so frustrating",
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"comment": "Why not 20mg per hour as per bnf?",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "# Drug choice feedback\n\nA trial of medicine to treat noisy respiratory secretions should be considered if they are causing distress to the family of the patient at the end-of-life. They can be treated using anticholinergics such as those given above, at their starting doses, before uptitrating. Atropine can also be used as recommended by NICE but it is used off-label.\n\n# Dose/Route/Frequency/Duration feedback\n\nIf the patient continues to have significant secretions not managed with PRN subcutaneous doses, the addition of these medications to the syringe driver can be considered.",
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"question": "Case Presentation: A 91-year-old gentleman has been admitted to the hospice for end-of-life care after being diagnosed with end-stage pancreatic cancer 1 year ago. The nurses looking after him has reported increased noisy respiratory secretions which is causing the family distress.\n\n\n## PH\n\nPancreatic cancer, Hypertension, Chronic Kidney Disease, Type 2 Diabetes Mellitus.\n\n## DH\n\nCurrent: Morphine 30mg SC, cyclizine 150mg SC, midazolam 20mg SC via a syringe driver diluted with sterile water given over 24 hours. Discontinued: Ramipril 5mg PO OD, Bendroflumethiazide 2.5mg PO OD, Metformin 1g BD PO (NKDA)\n\n## On examination\n\nAppears comatose, noisy respiratory secretions audible from the bedside.\n\n# Prescribing Request\n\nWrite a prescription for one additional drug that is most appropriate for treating his noisy respiratory secretions",
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173,458,562 | false | 5 | null | 6,494,964 | null | false | [] | null | 6,761 | {
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"__typename": "QuestionComment",
"comment": "Can it not be famciclovir?",
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"comment": "me getting it wrong because I wrote 1 week duration instead of 7 days...",
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"explanation": "# Summary \n\nShingles is a reactivation of the varicella zoster virus which can lie dormant in nerve ganglia following primary infection (chickenpox). It commonly occurs in the elderly and shingles in young adults should prompt investigation for an underlying immune condition. Management normally includes oral antivirals, but intravenous antiviral medications can be used if severe or if the patient is immunocompromised.\n\n# Signs & Symptoms\n\nShingles can manifest first as a tingling feeling in a dermatomal distribution. Progresses to erythematous papules occurring along one or more dermatomes within a few days, which develop into fluid-filled vesicles which then crust over and heal. May be associated with viral symptoms e.g. fever, headache, malaise.\n\n[lightgallery]\n\n[lightgallery1]\n\n**Herpes zoster ophthalmicus (HZO)** presents with symptoms including a painful red eye, fever, malaise, and headache, followed by an erythematous vesicular rash over the trigeminal division of the ophthalmic nerve. A lesion on the nose, known as **Hutchinson's sign,** may suggest ocular involvement.\n\n\n\n# Management\n\n- Oral antiviral (e.g. valaciclovir 1g three times per day for 7 days) within 72h of rash onset if immunocompromised (and infection is not severe) or moderate/severe rash or moderate/severe pain, or non-truncal involvement.\n- Admit to hospital for IV antivirals if severe disease or immunocompromise, ophthalmic symptoms or suspicion of meningitis/encaphalitis/myelitis\n- Advise avoiding contact with pregnant women, babies and those who are immunocompromised until the lesions are fully crusted over, as transmission can occur via skin contact\n- Pain can be managed with NSAIDs (e.g. ibuprofen). If unsuccessful, consider offering amitriptyline (off-label use), duloxetine (off-label use), gabapentin, or pregabalin\n\n# Shingles vaccine\n\nThere is a one-off vaccine available for shingles that is typically advised for those in their 70s.\n\n# Complications\n\n- Secondary bacterial infection of skin lesions\n- Corneal ulcers, scarring and blindness if eye involved\n- Post-herpetic neuralgia\n - Pain occurring at site of healed shingles infection\n - Can cause neuropathic type pain (burning, pins and needles)\n - Can cause allodynia (perception of pain from a normally non-painful stimulus e.g. light touch)\n\n# NICE Guidelines\n\n[NICE Clinical Knowledge Summary (CKS): Shingles](https://cks.nice.org.uk/topics/shingles/)\n\n[NICE Treatment Summary: Varicella-zoster vaccine](https://bnf.nice.org.uk/treatment-summary/varicella-zoster-vaccine-2.html)",
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"explanation": "# Drug choice feedback\n\nThis patient is suffering from shingles, the appropriate treatment of which is aciclovir, an anti-viral effective against the Herpes simplex family.\n\n# Dose/Route/Frequency/Duration feedback\n\nThe optimal dose is 800mg, and should be given five times a day for 7 days, as licensed. Although the intravenous route exists, this is not required as the patient is generally well and is in the community setting.",
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"question": "Case Presentation: A 51-year-old gentleman sees his GP with a 12-hour history of a painful rash that appeared overnight which was preceded by a mild flu-like illness and itch in the same area. She mentions she has been facing increased stress at work recently.\n\n\n## PH\n\nType 2 Diabetes Mellitus\n\n## DH\n\nMetformin 500mg BD PO (NKDA)\n\n## On examination\n\nAppears well, oriented to time and place. Vesicular rash seen along dermatome T5 on the torso. Otherwise normal.\n\nTemperature 36.1°C, HR 72, RR 13, BP 130/80, O2 96% RA, GCS 15, Weight 82kg\n\n## Prescribing Request\n\nWrite a prescription for one drug that is most appropriate for treating her rash.",
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173,458,563 | false | 6 | null | 6,494,964 | null | false | [] | null | 6,778 | {
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"id": "2711",
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"id": "13",
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"explanation": "1. Common drugs that are stopped prior to surgeries include NSAIDs, diuretics, ACEi and ARBs. ACEi and ARBs are stopped due to the increased risk of peri- and postoperative hypotension. Bisoprolol and calcium channel blockers (amlodipine) are safe and have potential benefits when taken preoperatively. Anticoagulants are also stopped when the surgical bleeding risk outweighs the individual’s thromboembolic risk . Bisoprolol is also generally continued due to the additional risk of ischemia following acute withdrawal. The use of beta blockers cause a sympathetic blockade, which lead to an upregulation of beta receptors and an increase in its responsiveness to circulating catecholamines. Catecholamine levels are elevated during surgery, this results in an increase in myocardial oxygen demand and an exacerbation of ischaemic events. NSAIDs are generally stopped due to its antiplatelet effects (via the inhibition of COX-1 and decreased production of thromboxane A2, preventing platelet aggregation). This increases the bleeding risk perioperatively. Diuretics are stopped due to concerns of hypokalaemia, which increases the risk of perioperative arrhythmia and hypovolaemia, which, in addition to the vasodilating effect of anaesthetic agents can lead to hypotension. Analgesia apart from NSAIDs are generally continued pre-operatively.\nb) Paracetamol is the first step in the WHO analgesic ladder and is commonly used for pain relief. Paracetamol tablets are available in 500mg and 1g tablets but the maximum dose per day is 4g spread evenly over 6 hours or four times a day. The dose prescribed for this patient is likely to represent a transcription error of 6-hrly to 4-hrly.",
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{
"__typename": "QuestionComment",
"comment": "why is co-careldopa not written 25/100mg?",
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"comment": "is that not a whopping dose of digoxin??\n",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"name": "Dosing error & drugs worsening Parkinson’s",
"status": null,
"topic": {
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"id": "74",
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"typeId": 5
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"explanation": "1. Both metoclopramide and prochlorperazine are dopamine D2 receptor antagonists that can precipitate and worsen parkinsonian symptoms. Hence, BNF advises that they should be used with caution in patients already diagnosed with Parkinson’s disease.\n2. The maintenance dose of digoxin for atrial fibrillation is 125–250 micrograms daily. Hence, the dose prescribed is likely to be a transcription error of the micrograms to mg.",
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"question": "Case presentation: A 75-year old man attends the Parkinson clinic with increasing frequencies of involuntary movement. PH: Parkinson’s disease, Atrial fibrillation, Congestive Heart Failure, Migraine, Schizophrenia DH: His current regular prescriptions are listed below\n\n\n**On examination**: Pill-rolling resting tremor seen on right hand, cog-wheel rigidity, bradykinesia, micrographia\n**Vital signs**: BP 122/78, Temperature 36.5°C, HR 80, O2 Sat 99% (room air), RR 18\n\nQuestion 1: Select the TWO prescriptions that are most likely to be a cause for the worsening of his Parkinson’s signs and symptoms? (mark them with a tick in column A).\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B)",
"sbaAnswer": null,
"totalVotes": 0,
"typeId": 3,
"userPoint": null
} | MarksheetMark |
173,458,565 | false | 8 | null | 6,494,964 | null | false | [] | null | 6,796 | {
"__typename": "QuestionMultiA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33916",
"label": "b",
"name": "Metformin hydrochloride;500 mg;Oral (PO);Three times daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33918",
"label": "d",
"name": "Pioglitazone;45 mg;Oral (PO);Daily",
"picture": null,
"votes": 0
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33917",
"label": "c",
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"picture": null,
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33921",
"label": "g",
"name": "Senna;15 mg;Oral (PO);Nightly",
"picture": null,
"votes": 0
},
{
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"answer": false,
"explanation": null,
"id": "33920",
"label": "f",
"name": "Alendronic acid;70 mg;Oral (PO);Once weekly",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33919",
"label": "e",
"name": "Omeprazole;20mg;Oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33915",
"label": "a",
"name": "Mirtazapine;30 mg;Oral (PO);Daily",
"picture": null,
"votes": 0
}
],
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"comment": "mirtazapine only causes drowsiness at lower doses ",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "1. Mirtazapine is a presynaptic alpha2-adrenoreceptor antagonist that is used to treat depression. It works by increasing central noradrenergic and serotonergic neurotransmission. Weight gain is a common or very common side effect of mirtazapine. Gliclazide is a sulfonylurea that works by increasing insulin secretion. Gliclazide is also known to cause weight gain. Pioglitazone is a peroxisome proliferator-activated receptor gamma (PPAR-γ) agonist that works by reducing peripheral insulin resistance. Weight gain is a common or very common side effect of pioglitazone.\n2. Drowsiness is a common or very common side effect of mirtazapine. Drowsiness is also listed as an uncommon side effect of omeprazole in BNF.",
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"question": "Case presentation: A 56-year old woman visits her GP for medication review. She reports that she has been putting on weight despite following a healthy diet and exercising regularly. She also complains of feeling drowsy PH: Type 2 Diabetes Mellitus, Depression, GORD, Osteoporosis, Constipation DH: Her current regular prescriptions are listed below\n\n\n**On examination**: Chest is clear with no added lung sounds. Heart sounds I + II + 0. Abdomen soft and non tender.\n\n**Investigation**:\n\n- Weight 71kg (66kg 6 months ago)\n- BMI: 27\n- HbA1c: 53 mmol/mol\n\nQuestion 1: Select the THREE prescriptions that are most likely to be contributing to the weight gain (mark them with a tick in column A)\nQuestion 2: Select the ONE prescription that is most likely be contributing to the drowsiness (mark it with a tick in column B)",
"sbaAnswer": null,
"totalVotes": 0,
"typeId": 3,
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} | MarksheetMark |
173,458,566 | false | 9 | null | 6,494,964 | null | false | [] | null | 6,797 | {
"__typename": "QuestionMultiA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33922",
"label": "a",
"name": "Chlorpromazine hydrochloride;150 mg;Oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33923",
"label": "b",
"name": "Metformin hydrochloride;500 mg;Oral (PO);Three times daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33925",
"label": "d",
"name": "Ibuprofen;400mg;Oral (PO);4-hourly when required",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
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"explanation": null,
"id": "33924",
"label": "c",
"name": "Fluoxetine;40 mg;Oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33927",
"label": "f",
"name": "Omeprazole;20mg;Oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33928",
"label": "g",
"name": "Allopurinol;100 mg;Oral (PO);Daily",
"picture": null,
"votes": 0
},
{
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"answer": false,
"explanation": null,
"id": "33926",
"label": "e",
"name": "Metoclopramide hydrochloride;100mg;Oral (PO);8-hourly when required",
"picture": null,
"votes": 0
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "4-hourly ibuprofen is also a significant dosing error??",
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"comment": "So is 8-hourly 100mg metoclopramide no...?",
"createdAt": 1735819197,
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"demo": null,
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"id": "2730",
"name": "Hyperprolactinaemia & dosing error",
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"topic": {
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"name": "Obstetrics and Gynaecology",
"typeId": 5
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"explanation": "1. Hyperprolactinaemia is a common or very common side effect of chlorpromazine and an uncommon side effect of metoclopramide. Both chlorpromazine and metoclopramide have dopamine D2 receptor antagonistic property, leading to disinhibition of excessive prolactin production. Hyperprolactinaemia is also rare or very rare side effect of all selective serotonin reuptake inhibitors (SSRI). A SSRI like fluoxetine is thought to cause hyperprolactinaemia by inducing a 5HT receptor–mediated stimulation of prolactin secretion.\n2. The correct dose of metoclopramide for acute migraine should be 10mg and not 100mg.",
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"question": "Case presentation: A 35-year old woman presents to her GP with amenorrhoea. She reports that she has missed her period and that her menstrual cycle has been irregular for the past few months. She also notices white, milky discharge from her breasts. Besides that, she also informs that she has been trying to conceive for two years but is not successful. PH: Type 2 Diabetes Mellitus, Schizophrenia, Depression, Migraine, GORD, Gout DH: Her current regular prescriptions are listed below\n\n\n\n\n **On examination**:\nChest is clear with no added lung sounds. Heart sounds I + II + 0. Abdomen soft and non tender. Normal pelvic examination, normal breast examination\n\n\n **Investigation:**\nNegative human chorionic gonadotrophin (HCG) pregnancy test\nSerum prolactin: 850 mIU/L (<500)\n\n\nQuestion 1: Select the THREE prescriptions that are most likely to be contributing to the hyperprolactinaemia (mark them with a tick in column A)\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B)",
"sbaAnswer": null,
"totalVotes": 0,
"typeId": 3,
"userPoint": null
} | MarksheetMark |
173,458,567 | false | 10 | null | 6,494,964 | null | false | [] | null | 6,785 | {
"__typename": "QuestionMultiA",
"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33836",
"label": "e",
"name": "Tamsulosin hydrochloride;400mg;oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33832",
"label": "a",
"name": "Citalopram;20mg;oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33835",
"label": "d",
"name": "Paracetamol;1g;oral (PO);6-hourly",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33837",
"label": "f",
"name": "Ramipril;2.5mg;oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33838",
"label": "g",
"name": "Amoxicillin;500mg;oral (PO);8-hourly",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33834",
"label": "c",
"name": "Omeprazole;20mg;oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33833",
"label": "b",
"name": "Colecalciferol (Vitamin D3);800 units;oral (PO);Daily",
"picture": null,
"votes": 0
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Woww fell for the mg/microgram thing again",
"createdAt": 1703609989,
"dislikes": 0,
"id": "36896",
"isLikedByMe": 0,
"likes": 7,
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"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"id": "2718",
"name": "Thrombocytopenia & dosing error",
"status": null,
"topic": {
"__typename": "Topic",
"id": "13",
"name": "Neurosurgery",
"typeId": 5
},
"topicId": 13,
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"dislikes": 0,
"explanation": "1. Penicillin (amoxicillin) commonly or very commonly cause thrombocytopenia. PPI and paracetamol also cause thrombocytopenia but are significantly less common\n2. Tamsulosin, an alpha blocker that is prescribed for benign prostatic hyperplasia, is given in 400 micrograms daily, not in milligrams.",
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"question": "Case presentation: A 55-year-old gentleman presents to his GP with repeated episodes of epistaxis. PH Mild depressive episodes, Osteoarthritis of right knee, Vitamin D deficiency, GORD, Benign Prostatic Hyperplasia, HTN. DH His current regular medicines are listed (below).\n\n\n\n\n **Investigation**\nPlatelet count 100 x 109/L (Normal value 150-400 x 109/L )\n\n\nQuestion 1: Select the ONE prescriptions that are most likely to be contributing to the low platelet count (mark them with a tick in column A)\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).",
"sbaAnswer": null,
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} | MarksheetMark |
173,458,568 | false | 11 | null | 6,494,964 | null | false | [] | null | 6,802 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The patient is clearly fluid overloaded and requires immediate diuresis with a powerful loop diuretic like furosemide",
"id": "33955",
"label": "a",
"name": "Furosemide 40mg IV",
"picture": null,
"votes": 5043
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This novel drug combination is used in the chronic medical management of CCF with reduced ejection fraction and has no role in treating acute fluid overload",
"id": "33959",
"label": "e",
"name": "Sacubitril/valsartan 49/51mg PO",
"picture": null,
"votes": 16
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Digoxin is a cardiac glycoside that increases myocardial contractility and decreases AV node conduction. It is a useful adjunct in patients with CCF and concomitant AF",
"id": "33957",
"label": "c",
"name": "Digoxin 750 micrograms PO",
"picture": null,
"votes": 13
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be an option in acute pulmonary oedema unresponsive to initial medical therapy",
"id": "33956",
"label": "b",
"name": "CPAP therapy",
"picture": null,
"votes": 60
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A glyceryl trinitrate infusion can be a useful adjunct treatment in fluid overload secondary to CCF. The patient’s blood pressure must be monitored closely due to its potent vasodilatory effects",
"id": "33958",
"label": "d",
"name": "Glyceryl trinitrate 100 micrograms/kg IV",
"picture": null,
"votes": 74
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Patient has low sats with 92% - treat what kills first, patient should receive CPAP first",
"createdAt": 1675100290,
"dislikes": 2,
"id": "17451",
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"comment": "Correct! But the reason this patients sats are low is because of the pulmonary oedema. The fluid within the interstitial spaces is reducing gas exchange, hence the hypoxaemia. The only way to fix this is to get the fluid out of the lungs! \nCPAP would help and is indicated for cardiogenic pulmonary oedema - but it splints the airways open allowing for more gas exchange in the alveoli by preventing them from collapsing. This would be a temporary solution only (often used for patients who don't respond to medical treatment) and giving furosemide would actually likely solve the problem all together :) \nThis is why furosemide is indicated first. Hope this helps!",
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"comment": "can PE be excluded in this case?",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case Presentation: A 72 year old woman presents to A&E with acute shortness of breath and chest pain. **PH** congestive cardiac failure, recurrent DVTs, osteoporosis. **DH** bisoprolol fumarate 7.5mg PO OD, lisinopril 40mg PO OD, spironolactone 50mg PO OD, warfarin sodium 8mg PO OD, alendronic acid 70mg PO once weekly, calcichew D3.\n\n\n**O/E**\n\nHR 98, RR 36, BP 149/97, Temperature 37.2°C, O2 92% RA. HS I + II + ?III, bibasal fine creps. Pitting oedema to buttocks.\n\nShe has been sat upright and started on 6L O2 via simple face mask.\n\n**Investigations**\n\nECG: sinus tachycardia\n\nQuestion: Select the most appropriate management at this stage.",
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "In treating type 2 diabetes, it is recommended that a second antidiabetic drug be added following an inadequate response to maximal therapy with metformin",
"id": "34055",
"label": "a",
"name": "Add gliclazide 40mg PO OD to his current prescription",
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"__typename": "QuestionChoice",
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"explanation": "Repaglinide is an oral antidiabetic medication used to treat type 2 diabetes. It is less preferred than sulfonylureas",
"id": "34057",
"label": "c",
"name": "Add repaglinide 500 micrograms PO with meals to his current prescription",
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"explanation": "This prescription would exceed the recommended maximum dose of metformin which is 2g per day",
"id": "34058",
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"name": "Change his prescription to metformin hydrochloride 1g PO TDS",
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"explanation": "The patient is already receiving 2g of metformin hydrochloride and as such this prescription would not effect any significant change to the overall medical treatment this patient is currently receiving",
"id": "34059",
"label": "e",
"name": "Change his prescription to metformin hydrochloride modified release 2g PO OD",
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"id": "34056",
"label": "b",
"name": "Add exenatide 5 micrograms SC BD to his current prescription",
"picture": null,
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"__typename": "QuestionComment",
"comment": "but isn't his glucose control improving?\n",
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"comment": "HbA1c >58mmol/L warrants the addition of another diabetic medication",
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"comment": "I don't think it's as black and white as that. The point is that after 3 months his glucose has barely improved at all. Were it 59 mmol/L, I suspect you wouldn't add another drug. Someone can correct me if I'm wrong though.",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case Presentation: A 54 year old man attends a follow-up appointment at his GP. Six months ago, he was previously diagnosed with type 2 diabetes and started on metformin hydrochloride 500mg PO OD. This has since been up-titrated to 500mg PO TDS, then 500mg PO QDS.\n\n\n**Investigations**\n\nHbA1C (3 months ago): 64 mmol/mol\n\nHbA1C (now): 61 mmol/mol\n\nUrine dipstick: NAD\n\nQuestion: Select the most appropriate management at this stage.",
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"explanation": "This is a medicated mouthwash with anti-inflammatory and analgesic properties. It has no role in the acute management of oral candidiasis",
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"picture": null,
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"explanation": "Itraconazole may be an option for oral candidiasis that has not responded to first-line treatments",
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"name": "Itraconazole oral solution 100mg PO BD",
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"comment": "Thought it was itraconzole... if you're unsure of what the first line med is, and there's no treatment summary, any other way you can find out using bnf? ",
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"comment": "if you go into Oropharyngeal fungal infections in medicine complete appears, and itraconazole will be used if fluconazole or 1st line treatment dont work",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case Presentation: An 83 year old man is on the geriatric ward being treated for a grade III pressure sore. Today he is complaining of a foul taste in his mouth and some associated throat discomfort. **PH** hypertension, hyperlipidaemia, bilateral hemiarthroplasties. **DH** ramipril 2.5mg PO OD, amlodipine 10mg PO OD, simvastatin 40mg PO ON, paracetamol 1g PO QDS, senna 7.5mg PO BD, lactulose 15ml PO OD. NKDA\n\n\n**O/E**\n\nDry oral mucous membranes with halitosis. Visible white patches covering proximal 2/3rds of tongue that slough off when scraped with wooden depressor.\n\nQuestion: Select the most appropriate management at this stage.",
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173,458,571 | false | 14 | null | 6,494,964 | null | false | [] | null | 6,803 | {
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"explanation": "Linezolid is a very broad spectrum oxazolidinone antibiotic with powerful anti Gram-positive activity and is used to treat severe skin and soft tissue infections. It should not be initiated without specialist microbiology input",
"id": "33962",
"label": "c",
"name": "Linezolid 600mg PO BD",
"picture": null,
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Flucloxacillin would be the first-line agent to treat cellulitis, but should not be used in view of the patient’s previous adverse reaction to penicillin",
"id": "33961",
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"explanation": "Vancomycin is an aminoglycoside antibiotic with anti-MRSA activity and is used to treat severe skin and soft tissue infections. Due to its narrow therapeutic range and side effects it is not a first-line agent to treat cellulitis",
"id": "33964",
"label": "e",
"name": "Vancomycin 15mg/kg IV BD",
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"__typename": "QuestionChoice",
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"explanation": "Phenoxymethylpenicillin is sometimes used as prophylaxis against skin and soft tissue infections in some patients, but should not be used to treat cellulitis as it likely has limited activity against Staphylococcus species",
"id": "33963",
"label": "d",
"name": "Phenoxymethylpenicillin 500mg PO QDS",
"picture": null,
"votes": 6
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "Clarithromycin is a second-line agent to treat cellulitis in patients who are penicillin-allergic",
"id": "33960",
"label": "a",
"name": "Clarithromycin 500mg PO BD",
"picture": null,
"votes": 3581
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"__typename": "QuestionComment",
"comment": "The reaction to tazocin should be listed under allergies to make this question clear and fair that it is in fact an allergy.",
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"comment": " clarithromycin is second line if allergy not clindamycin",
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"comment": "clindamyin is first line for severe infection which i think it what they're trying to get at (although could be much clearer)",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case Presentation: A 45 year old man attends A&E with a painful swollen left calf. **PH** type 2 diabetes, previous myocardial infarction. **DH** metformin hydrochloride 500mg PO TDS, glimepiride 4mg PO OD, aspirin 75mg PO OD, bisoprolol fumarate 5mg PO OD, ramipril 5mg PO OD. Previous adverse drug reaction to Tazocin – urticarial rash.\n\n\n**O/E**\n\nLarge erythematous patch on left calf, very tender to touch. Temperature 38.0°C. All other observations stable.\n\n**Investigations**\n\nWCC 15.9, CRP 89. Blood cultures pending.\n\nQuestion: Select the most appropriate management at this stage.",
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"explanation": "Fluoxetine is licensed for the treatment of depression in young children. It has no role in treating ADHD alone",
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an alternative treatment for ADHD if there is inadequate response to first line treatments",
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an alternative treatment for ADHD, but is unlicensed for that indication and is less preferred than first line options",
"id": "34012",
"label": "c",
"name": "Dexamfetamine sulfate 2.5mg PO TDS",
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is recommended first line to treat ADHD. Lisdexamfetamine mesilate is an alternative first line treatment",
"id": "34010",
"label": "a",
"name": "Methylphenidate hydrochloride 5mg PO OD",
"picture": null,
"votes": 6513
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"__typename": "QuestionChoice",
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"explanation": "Risperidone may be used to manage behavioural problems associated with ADHD but would not be initiated as a first line treatment",
"id": "34014",
"label": "e",
"name": "Risperidone 250 micrograms PO OD",
"picture": null,
"votes": 13
}
],
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{
"__typename": "QuestionComment",
"comment": "As this patient is a child - and methylphenidate hydrochloride causes growth retardation in children - would it still be recommended to give?",
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"comment": "If in doubt, check the BNFc and that's what it says here! \n",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case Presentation: A 7 year old boy attends a specialist paediatric assessment after being referred via his family GP. He has been reported to have significant difficulty concentrating in school and at home, often disrupting entire class lessons and refusing to sit still for longer than 5 minutes. His mother is now worried about allowing him to play outdoors as he tends towards climbing high objects like trees and fences, and has fallen from them on a number of occasions. His teachers feel that he does exhibit some difficulty in understanding instructions when spoken to, and sometimes makes inappropriate comments in reply to them.\n\n\n**Investigations**\n\nHe has not had any significant developmental delay and has received all his scheduled childhood vaccinations. Baseline ECG normal sinus rhythm. Weight and height on 70th centile for his age and gender. He weighs 30kg.\n\nQuestion: Select the most appropriate management at this stage.",
"sbaAnswer": [
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173,458,573 | false | 16 | null | 6,494,964 | null | false | [] | null | 6,848 | {
"__typename": "QuestionSBA",
"choices": [
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"__typename": "QuestionChoice",
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"explanation": "The starting dose of carbimazole will be reduced gradually once the patients have become euthyroid. Patients will usually be started on a dose of 15-40 mg daily, taken divided into 2-3 doses a day. This may then be reduced after 4-8 weeks to a lower maintenance dose of 5-15 mg, taken once daily",
"id": "34188",
"label": "d",
"name": "She would be started on a low dose before the dose gets titrated upwards in a gradual manner in order to reduce risk of side effects",
"picture": null,
"votes": 50
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Haemolytic anaemia is a rare side effect of carbimazole",
"id": "34189",
"label": "e",
"name": "Haemolytic anaemia is a common side effect of carbimazole",
"picture": null,
"votes": 14
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "As the bone marrow disorder may happen at any time during the course of treatment, NICE currently does not recommend monitoring white blood cell count on a regular basis. Instead, white blood cell count will only be performed if there is any clinical evidence of infection",
"id": "34186",
"label": "b",
"name": "A white blood cell count should be performed before the treatment and then three monthly throughout the course of treatment",
"picture": null,
"votes": 70
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Carbimazole is a medication that is used to treat hyperthyroidism. A rare but serious side effect of carbimazole is bone marrow suppression leading to agranulocytosis. As the bone marrow disorder may happen at any time during the course of treatment, NICE currently does not recommend monitoring white blood cell count on a regular basis. Instead, white blood cell count will only be performed if there is any clinical evidence of infection. Hence, patients are advised to report immediately any signs and symptoms such as sore throat and infection",
"id": "34185",
"label": "a",
"name": "She should immediately report to her doctor if sore throat develops",
"picture": null,
"votes": 4294
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Patients who are women of childbearing age are encouraged to use effective contraception during treatment because carbimazole is linked to an increased risk of congenital malformations during pregnancy",
"id": "34187",
"label": "c",
"name": "It is safe for her to attempt to get pregnant during treatment",
"picture": null,
"votes": 7
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"demo": null,
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"id": "2780",
"name": "Carbimazole",
"status": null,
"topic": {
"__typename": "Topic",
"id": "92",
"name": "General Practice",
"typeId": 5
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"topicId": 92,
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"question": "Case presentation: A 35-year-old woman attends her GP with a two-month history of weight loss, heat intolerance and sweating. \n\n\nPMH: Vitiligo\nInvestigations:\n\n\n||||\n|---------------------------|:-------:|------------------------------|\n|Thyroid Stimulating Hormone|0.1 mU/L|0.3 - 4.2|\n|Free T4|30 pmol/L|9 - 25|\n\n - TSH receptor antibodies - Positive\n\n#\nThe patient is advised to commence treatment with carbimazole 15mg PO daily.\n\n\nQuestion: Select the most appropriate information that should be provided for this patient.",
"sbaAnswer": [
"a"
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"totalVotes": 4435,
"typeId": 1,
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173,458,574 | false | 17 | null | 6,494,964 | null | false | [] | null | 6,844 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Intrauterine device (IUD) is a small device made from copper and plastic that is inserted into the uterus by a trained health professional. The copper alters the cervical mucus and makes it harder for sperms to get through the cervix to fertilise the ovum. It also prevents the implantation of fertilised ovum by altering the endometrial lining",
"id": "34166",
"label": "b",
"name": "IUD works by preventing ovulation through the release of gonadotropins",
"picture": null,
"votes": 33
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "IUD can be fitted at any time during the menstrual cycle and it offers instantaneous protection once it is inserted",
"id": "34168",
"label": "d",
"name": "She needs to use an additional barrier contraception during the first 7 days of the IUD insertion because IUD takes time to reach its full protective effect",
"picture": null,
"votes": 225
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Breast cancer is not a contraindication to IUD. It is classified by UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) as a Category 1 condition. UKMEC defines category 1 condition as “a condition for which there is no restriction for the use of the method”",
"id": "34167",
"label": "c",
"name": "Breast cancer is an absolute contraindication",
"picture": null,
"votes": 69
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Intrauterine device (IUD) is a small device made from copper and plastic that is inserted into the uterus by a trained health professional. It is important to highlight to patients that they might experience heavier, longer or more painful periods, especially in the first few months after insertion. They should report this to their doctors so that a discussion about an alternative contraceptive method can take place",
"id": "34165",
"label": "a",
"name": "She might experience heavier, longer or more painful periods",
"picture": null,
"votes": 2359
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "IUD does not contain any hormones, so it is not associated with hormonal side effects such as weight gain, acne or breast tenderness",
"id": "34169",
"label": "e",
"name": "Weight gain is a common side effect of IUD",
"picture": null,
"votes": 24
}
],
"comments": [
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"__typename": "QuestionComment",
"comment": "Is this on the bnf?",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"id": "2776",
"name": "IUD",
"status": null,
"topic": {
"__typename": "Topic",
"id": "76",
"name": "Obstetrics and Gynaecology",
"typeId": 5
},
"topicId": 76,
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"question": "Case presentation: A 27-year-old woman attends the sexual health clinic to discuss about emergency contraception. She had unprotected sexual intercourse yesterday and the first day of her last menstrual period was 15 days ago. She is not on any regular forms of contraception. She dislikes the notion of having hormonal pills. \r\n\nPhysical examination: HS 1+11 + 0, chest clear with no added lung sounds, abdomen SNT, normal neurological exam\nShe is advised to use intrauterine device (IUD)\n\nQuestion: Select the most appropriate information that should be provided for this patient.",
"sbaAnswer": [
"a"
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"typeId": 1,
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173,458,575 | false | 18 | null | 6,494,964 | null | false | [] | null | 6,845 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Glyceryl Trinitrate (GTN) is a medication used for prophylaxis and treatment of angina. It converts into nitric oxide, leading to vasodilation and increased blood flow to the heart",
"id": "34171",
"label": "b",
"name": "GTN works by making the heart beat faster and stronger so that more blood can be delivered to meet the body’s demand",
"picture": null,
"votes": 236
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Manufacturer advises against the concurrent use of GTN and sildenafil because it increases the risk of severe hypotension and circulatory collapse",
"id": "34172",
"label": "c",
"name": "GTN can be safely used together with sildenafil",
"picture": null,
"votes": 54
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Restlessness is a rare side effect of GTN",
"id": "34174",
"label": "e",
"name": "Restlessness is a common side effect of GTN",
"picture": null,
"votes": 252
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Patients are advised to repeat the dose at 5 minutes interval if required and to seek immediate medical attention if symptoms have not resolved after 2 doses",
"id": "34170",
"label": "a",
"name": "He should seek immediate medical help if symptoms have not resolved after 2 consecutive doses",
"picture": null,
"votes": 4375
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Patients are advised to repeat the dose at 5 minutes interval if required and to seek immediate medical attention if symptoms have not resolved after 3 doses",
"id": "34173",
"label": "d",
"name": "GTN can be taken at 10 minutes interval if required",
"picture": null,
"votes": 248
}
],
"comments": [],
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"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
"files": null,
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"demo": null,
"entitlement": null,
"id": "2777",
"name": "Headache following GTN ",
"status": null,
"topic": {
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"id": "92",
"name": "General Practice",
"typeId": 5
},
"topicId": 92,
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"question": "Case presentation: A 63-year-old man attends his GP appointment with a 3-month history of chest pain on exertion. He reports that he sometimes gets out of breath and feels a constricting chest pain when climbing up the stairs. The pain usually goes away a few minutes after he sits down. \r\n\nPMH: Erectile dysfunction\nSH: Retired, lives with his wife\n\nThe patient is advised to take Glyceryl Trinitrate (GTN) spray to relieve the chest pain.\n\nQuestion: Select the most appropriate information that should be provided for this patient.",
"sbaAnswer": [
"a"
],
"totalVotes": 5165,
"typeId": 1,
"userPoint": null
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173,458,576 | false | 19 | null | 6,494,964 | null | false | [] | null | 6,835 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Patients should discuss with their doctors before stopping the medication because an abrupt discontinuation could lead to discontinuation symptoms such as restlessness and irritability. Besides that, sertraline has not been shown to cause addiction problems",
"id": "34122",
"label": "c",
"name": "He should discontinue his medication once he feels better as sertraline is linked to addiction",
"picture": null,
"votes": 14
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Rather than excessive salivation, sertraline more commonly causes dry mouth",
"id": "34123",
"label": "d",
"name": "Sertraline can lead to excessive salivation",
"picture": null,
"votes": 59
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Sertraline is a selective serotonin reuptake inhibitor (SSRI) that works by increasing serotonin levels in the brain. It is important to highlight to the patients about the gradual development of full antidepressant effect of SSRI. Patients should be advised to not stop the medication early on even though they might not have felt an improvement because SSRI usually needs to be taken for up to 6 weeks before the benefit is felt",
"id": "34120",
"label": "a",
"name": "He should continue taking the medication even if he does not feel any improvements in the first 6 weeks",
"picture": null,
"votes": 6357
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Sertraline is a selective serotonin reuptake inhibitor (SSRI) that works by increasing serotonin levels in the brain. An increase in serotonin levels has been shown to bring about an improvement in symptoms",
"id": "34121",
"label": "b",
"name": "Sertraline works by increasing dopamine levels in the brain",
"picture": null,
"votes": 104
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Sertraline is linked to low sex drive and erectile dysfunction",
"id": "34124",
"label": "e",
"name": "Sertraline can lead to increased sex drive",
"picture": null,
"votes": 43
}
],
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"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
"files": null,
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"id": "2768",
"name": "SSRI considerations",
"status": null,
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"id": "90",
"name": "Psychiatry",
"typeId": 5
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"topicId": 90,
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"question": "Case presentation: A 25-year-old man attends his GP with a 3-month history of low mood and energy. He reports that he no can no longer derive joy from gardening which he used to enjoy. He denies having any suicidal ideation. \r\n\nPhysical examination: HS 1+11 + 0, vesicular breathing with no added lung sounds, abdomen SNT, normal neurological exam\nQuestionnaire: Patient Health Questionnaire (PHQ-9) score is 10/27.\nHe has previously tried computerised cognitive behavioural therapy but found it to be less effective. The patient is advised to commence treatment with sertraline 50mg PO daily and attend another appointment in two weeks’ time to review the medication.\n\nQuestion: Select the most important information that should be provided for this patient.",
"sbaAnswer": [
"a"
],
"totalVotes": 6577,
"typeId": 1,
"userPoint": null
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173,458,577 | false | 20 | null | 6,494,964 | null | false | [] | null | 6,846 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": ". In a sudden asthma attack, patients should sit up straight and take one puff of reliever inhaler every 30 seconds up to 10 puffs. They should call 999 for an ambulance if the symptoms still do not resolve after 10 puffs",
"id": "34177",
"label": "c",
"name": "In an asthma attack, he can take salbutamol up to 50 puffs with a time interval of 2 minutes between each puff",
"picture": null,
"votes": 82
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Salbutamol is not associated with oral thrush. Oral thrush is a potential side effect of inhaled corticosteroids that are commonly used in asthma maintenance therapy",
"id": "34178",
"label": "d",
"name": "Salbutamol inhaler increases risk of developing oral thrush",
"picture": null,
"votes": 280
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Salbutamol is a short-acting beta 2 adrenergic receptor agonist that treats bronchoconstriction by opening up the airway muscles. Patients should talk to their doctors if they need to use the inhaler for more than 3 times in a week. This may be a sign that the asthma is still not well controlled and that an adjustment needs to be made to the current regime",
"id": "34175",
"label": "a",
"name": "He should talk to his doctor if he uses his salbutamol inhaler for more than 3 times a week",
"picture": null,
"votes": 4571
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Salbutamol is a short-acting beta 2 adrenergic receptor agonist that treats bronchoconstriction by opening up the airway muscles",
"id": "34176",
"label": "b",
"name": "Salbutamol is an alpha-1-agonist that relieves symptoms of asthma by relaxing the muscles of airway",
"picture": null,
"votes": 85
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Salbutamol can cause potentially serious hypokalaemia not hyperkalaemia. It stimulates the entry of potassium into the cells, thus lowering serum potassium concentration",
"id": "34179",
"label": "e",
"name": "Salbutamol can lead to hyperkalaemia",
"picture": null,
"votes": 126
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "# Summary\n\nAsthma is a common disease of the airways, involving reversible bronchoconstriction, hyperreactivity and chronic inflammation. When bronchoconstriction is triggered (an “asthma attack”), patients experience episodes of wheeze, dyspnoea, cough and chest tightness. Initial investigations for all adults with suspected asthma are fractional exhaled nitric oxide (FeNO) or a full blood count looking for eosinophilia. If neither of these are confirmatory, patients should be assessed with spirometry including bronchodilator reversibility. Management involves a stepwise approach to medications, starting with “reliever therapy” (usually short-acting beta-2 agonists such as salbutamol inhalers) in combination with “preventer therapy” medications including inhaled corticosteroids, leukotriene receptor antagonists and long-acting beta-2 agonist inhalers. Allergen avoidance, smoking cessation, regular peak flow monitoring and inhaler technique are all key to good asthma control.\n\n# Definition\n\nAsthma is a common disease in both adults and children, characterised by intermittent \"asthma attacks\" with wheeze, cough, shortness of breath and chest tightness. There are several underlying mechanisms that centre around reversible bronchoconstriction, hyperreactivity and chronic inflammation.\n\n# Epidemiology\n\nIn the UK, approximately 8 million people have been diagnosed with asthma, of which 5.4 million are on treatment. Onset is usually in childhood and some find symptoms remit with age, although relapse is possible after long periods of being well.\n\nOn average, three people die from an asthma attack each day in the UK. The majority of these deaths are preventable, with an estimated 7/10 people with asthma not receiving basic preventative care such as inhaler technique checks and a personalised asthma plan.\n\nPeople experiencing socioeconomic deprivation are more likely to have asthma and to have worse outcomes (e.g. higher rates of hospitalisation). This is multifactorial, with these groups more likely to be exposed to triggers such as smoking and air pollution, and to have lower health literacy and access to healthcare.\n\n# Pathophysiology\n\nAsthma is often associated with a personal and/or family history of atopy, including the atopic triad of asthma, allergic rhinitis, and eczema. In asthma, there is an exaggerated response to a wide range of triggers. These include:\n\n- Cold air and exercise\n- Pollution and cigarette smoke\n- Allergens such as animal dander, dust mites and pollen\n- Irritants such as perfumes, paints or air fresheners\n- Medications such as NSAIDs or beta-blockers\n\nThese trigger a type 1 hypersensitivity reaction which is mediated by IgE. T Helper 2 cells produce IL4, IL5 and IL13 cytokines which activate the humoral immune system, leading to the proliferation of eosinophils, mast cells and dendritic cells. These cells then produce more inflammatory mediators such as leukotrienes and histamine.\n\nThis inflammation contributes to airway hyperresponsiveness leading to bronchospasm, as well as mucus hypersecretion that also obstructs airways. Over time in severe asthma, airway remodelling mediated by fibroblasts causes chronic obstruction and thickening of smooth muscle.\n\n# Risk factors\n\n- Family history of asthma or atopy\n- Personal history of atopy (eczema, allergic rhinitis, allergic conjunctivitis)\n- Exposure to smoke, including maternal smoking in pregnancy\n- Respiratory infections in infancy\n- Prematurity and low birth weight\n- Obesity\n- Social deprivation\n- Occupational exposures (e.g. flour dust, isocyanates from paint)\n\n# Symptoms\n\n- Wheeze\n- Dyspnoea\n- Cough\n- Chest tightness\n\nThe above symptoms should be episodic and usually show **diurnal variation** (worse at night or in the early morning). The patient may be able to identify specific triggers as listed above.\n\n# Signs\n\nIn between asthma exacerbations, clinical examination may be normal. If asthma is poorly controlled or during an exacerbation, signs include:\n\n- Tachypnoea\n- Increased work of breathing\n- Hyperinflated chest\n- Expiratory polyphonic wheeze throughout the lung fields\n- Decreased air entry (if severe)\n\n\n# Differential diagnosis\n\n- **Bronchiectasis** - usually associated with a productive cough, patients get frequent chest infections and coarse crackles rather than wheeze predominate on examination.\n- **Vocal cord dysfunction** - shares many triggers with asthma, inspiration more difficult than expiration, may have stridor.\n- **Chronic obstructive pulmonary disease** - patients usually >35 years old with a significant smoking history, may overlap with asthma in some.\n- **Gastro-oesophageal reflux disease** - microaspiration of stomach acid due to reflux can cause episodes of cough and wheeze which mimic asthma (although these may coexist and reflux can trigger asthma exacerbations). Symptoms are often postural and related to eating.\n- **Eosinophilic Granulomatosis with Polyangiitis** (Churg-Strauss syndrome) - small vessel vasculitis associated with pANCA, aside from asthma symptoms include nasal polyps, sinusitis, purpuric rashes and peripheral neuropathy.\n\n# Investigations \n\n- **FeNO (fractional exhaled nitric oxide) testing:** offer this **or** blood eosinophil count to all adults to confirm eosinophilic airway inflammation, asthma can be diagnosed if this is >50 parts per billion.\n- **Full blood count** to check **eosinophil count:** offer this **or** FeNO first-line to all adults - asthma can be diagnosed if this is above the normal reference range.\n- If neither of these confirm asthma, **spirometry** with **bronchodilator reversibility** should be offered to confirm airway obstruction (i.e. FEV1/FVC<70%). A bronchodilator (e.g. salbutamol inhaler) is given and spirometry repeated to assess response to treatment. An improvement in FEV1 of 12% or more or 200ml is diagnostic of asthma.\n- If spirometry is delayed or not available, patients may be asked to monitor their peak flow twice a day for 2 weeks and keep a diary of the readings. This is then used to assess **peak flow variability** (the difference between the highest and lowest readings as a percentage of the average PEF). Variability >20% is a positive result.\n- If none of the above are confirmatory, patients may be referred to specialist services for a **direct bronchial challenge test**, where histamine or metacholine is inhaled to trigger bronchoconstriction. Airway hyperresponsiveness is assessed by looking at the concentration of the triggering medication required to cause a 20% decrease in FEV1 - 8mg/ml or less is a positive result.\n\nNote: All of the above tests may be falsely negative in patients treated with inhaled corticosteroids.\n\n# Management of Chronic asthma\n\nThe aim of chronic asthma management is to achieve complete control over symptoms, with no need for rescue medications and no restrictions on physical activity. All patients should have a personalised asthma action plan which should be reviewed at least annually. Components of management include:\n\n## Non-pharmacological\n\n- Teach good inhaler technique and review this regularly\n- Spacer devices can be used to optimise medication delivery\n- Regular peak flow monitoring\n- Smoking cessation\n- Advice on avoiding triggers where possible (e.g. allergens, certain medications)\n- Ensure vaccinations are up to date, including annual influenza vaccination\n- Assess for occupational asthma by asking if symptoms are better when the patient is away from work and arrange specialist referral if this is suspected\n\n## Pharmacological\n\n- Prescribe all patients a combination inhaler with a **long-acting beta-2 agonist** (LABA) i.e. formoterol and a low-dose **inhaled corticosteroid** (ICS) i.e. budesonide to use as a reliever inhaler (i.e. PRN) - this is referred to as anti-inflammatory reliever (AIR) therapy.\n- Patients who do not respond adequately to AIR therapy, who are highly symptomatic at presentation or who present with a severe asthma exacerbation should be started on a low-dose **maintenance and reliever therapy inhaler** (MART). MART is a combination inhaler with ICS and a fast-acting LABA (e.g. beclomethasone + formoterol which is also known as Fostair), which is used as both a reliever inhaler (PRN) and as maintenance treatment (usually twice daily).\n- The next step would be increasing the ICS dose from low to **moderate** in the MART inhaler.\n- At this stage if asthma is not controlled, check FeNO and blood eosinophil count and refer to specialist asthma services if either are raised.\n- If neither are raised, consider adding either a **leukotriene receptor antagonist** (LTRA) such as montelukast (this is a tablet taken every night) or a **long-acting muscarinic agonist** (LAMA) such as tiotropium.\n- One of these should be trialled for 8-12 weeks alongside the moderate-dose MART - if asthma is well-controlled it can be continued.\n- If there is some improvement in control but this is still inadequate, the other medication can be trialled in addition (i.e. moderate dose MART + LTRA + LAMA).\n- If control has not improved, stop the medication and try the other one - if this is not successful refer to specialist services.\n- Options in specialist clinics include therapies such as **biologics** (e.g. omalizumab, which targets IgE).\n\nOther than patients who are not responding to treatment, the following situations shold also prompt a secondary care referral:\n\n- Uncertainty regarding diagnosis\n- Suspected occupational asthma\n- Severe or life-threatening asthma requiring admission to hospital\n- Multiple exacerbations requiring oral steroid treatment per year\n\n# Acute asthma\n\nAcute asthma exacerbations are graded in severity as below:\n\n\n| Severity | Clinical Features |\n|-----------------------|-----------------------------------------------|\n| Moderate | PEFR > 50% of predicted or best |\n| | No features of severe/life-threatening asthma |\n| Severe | PEFR 33-50% of predicted or best |\n| | Heart rate > 110 |\n| | Respiratory rate > 25 |\n| | Unable to complete sentences in one breath. |\n| | Accessory muscle use |\n| Life-threatening | PEFR < 33% of predicted or best |\n| | Oxygen saturation < 92% or cyanosis |\n| | Altered conciousness/confusion |\n| | Exhaustion/poor respiratory effort |\n| | Cardiac arrhythmia |\n| | Hypotension |\n| | Silent chest |\n\n\n## Investigations \n\n- **Peak expiratory flow rate (PEFR)** to help assess severity as per the classification above and monitor response to treatment.\n- **Arterial blood gas** if the patient is hypoxic to assess oxygenation and ventilation in patients - CO2 is expected to be low due to hyperventilation and if this is raised this indicates the asthma attack is near fatal.\n- **Portable chest X-ray** if a trigger such as pneumonia or a complication such as pneumothorax is suspected clinically.\n\n## Management \n\n- Recognise that this may be a medical emergency, assess using an ABCDE approach and escalate early to senior colleagues/critical care if not responding to treatment\n- Titrate oxygen to maintain saturations of 94-98%\n- Nebulised salbutamol driven by oxygen (if out of hospital, give up to 10 puffs of inhaled salbutamol and call an ambulance if not responding)\n- If the attack is severe or life-threatening or if response to salbutamol has been poor, add nebulised ipratropium bromide\n- Give prednisolone 40-50mg orally, or IV hydrocortisone if the patient is unable to swallow\n- Can consider IV magnesium sulphate and/or aminophylline if the patient is not responding to nebulisers\n- If the patient continues to deteriorate despite maximal therapy, they may require intubation and ventilation in an intensive care setting (for example in cases of severe hypoxia or exhaustion)\n\nFollow up after an acute asthma attack is crucial, with NICE guidelines stating that patients should be reviewed within 2 days of discharge from hospital to assess their symptoms, inhaler technique and current management.\n\n# NICE Guidelines\n\n[NICE - Asthma: diagnosis, monitoring and chronic asthma management](https://www.nice.org.uk/guidance/ng245)\n\n# References\n\n[NICE CKS](https://cks.nice.org.uk/topics/asthma/)\n\n[Report on health inequalities and asthma](https://www.asthmaandlung.org.uk/sites/default/files/2023-03/auk-health-inequalities-final.pdf)\n\n[Guideline on severe asthma in primary care](https://www.pcrs-uk.org/sites/default/files/pcru/articles/2019-Autumn-Issue-18-SevereAsthmaReferral.pdf)\n\n\n\n",
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"question": "Case presentation: A 25-year-old man attends his GP appointment with a three-month history of wheeze and chest tightness. He reports that the symptoms usually happen after his morning runs and on exposure to cold air. \r\n\nPMH: Eczema\nExamination: Widespread expiratory polyphonic wheeze\nInvestigation: Fractional exhaled nitric oxide(FENO) > 50 parts per billion (ppb); Forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) < 65%; Expiratory peak flow variability >25%\nThe patient is to be offered a salbutamol inhaler (Ventolin Accuhaler®)as reliever therapy.\n\nQuestion: Select the most appropriate information that should be provided for this patient.",
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"comment": "It is stated that 1mg is administered and then this is repeated a further 3 times. This means 4mg of Adrenaline was given in total meaning the correct answer is 40mL, not 30mL.",
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"comment": "It says the doses were repeated, to a total of 3 times rather than repeated 3 times \n",
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"comment": "im confused I thought 1:10000 meant 1g in 10,000ml ",
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"comment": "you're right - 1g in 10,000mL = 1000mg in 10,000mL (same thing) \njust cancel out the extra 0s from both sides then you get 1mg in 10 mL ",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "The definition of 1:10000 is 1kg in 10000L = 1mg in 0.01L = 1mg in 10mL. Since each dose of adrenaline is 1mg, the corresponding volume given is 10mL. Since three doses of adrenaline were given, the total volume given was 30mL.\n\nConcentration ratios (1:10000 in this case) are based on units of kilogram and litre as they belong to the International System of Units (SI units) which are used by convention.",
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"question": "A 72-year-old patient suffered a cardiac arrest. Once intravenous access was obtained, 1mg of adrenaline was administered. This was repeated and in total, the same dose was given three times until there was return of spontaneous circulation. Adrenaline is available as a 1:10000 solution.\n\n\nWhat was the total volume of adrenaline given?",
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"comment": "this part, '0.11mmol is equivalent to 0.5mL of calcium gluconate 10%' is confusing and needs to be a bit more specific - 0.11 mmol of what?",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "0.5mL of calcium gluconate 10% = 0.11mmol\n\n100mL of calcium gluconate 10% = 22mmol\n\nNow, after diluting 100mL of calcium gluconate 10% in 1 litre of glucose 5%, the total volume is: 100mL + 1L = 1100mL. Since the rate at which the solution is to be given is 50mL/hour, the total amount of time for the volume of 1.1L solution to be infused is: 1100mL ÷ 50ml/hour = 22 hours\n\nTherefore, the dose of calcium gluconate being given is: 22mmol ÷ 22 hours = 1mmol/hour.",
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"question": "A 71-year-old patient is noted to have a severely low corrected calcium level of 1.6mmol/L (normal range 2.2-2.6 mmol/L). As part of emergency management, he has already been given 10mL of 10% calcium gluconate infusion. To prevent recurrence, he is prescribed a further 100mL of calcium gluconate 10% diluted in 1 litre of glucose 5% to be given at 50mL/ hour. 0.11mmol is equivalent to 0.5mL of calcium gluconate 10%.\n\n\n\n\nBased on the information given above, what is the rate at which calcium gluconate is given (in mmol per hour)?",
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"comment": "the way this question is written is vague - the dose of the patch IS 9.5mg. A new one is just applied every day",
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"comment": "2 days as in prescribe for today, tomorrow and the day after, or 2 days as in 48 hrs!!",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "Current dose of rivastigmine a day = 12mg\n12mg PO OD = 9.5mg/24 hours patch.\nTotal dose prescribed for 2 days\n= 9.5mg x 2\n= 19mg",
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"sbaAnswer": null,
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"typeId": 2,
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "Normal dose of prednisolone per day = 5mg\nEquivalent dose of hydrocortisone per day = 20mg\nDouble dose of hydrocortisone in line with sick day rules = 40mg\n\nNote that most patients are given hydrocortisone as this is the most physiological choice of corticosteroid, although adherence might be an issue as this is a thrice-daily regimen. In addition, the reason why hydrocortisone is given instead is because prednisolone cannot be given intravenously.",
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"question": "A 55-year-old patient suffers from Addison's disease and currently takes 5mg of prednisolone as a once-daily regimen. She has recently been taken ill with vomiting and unable to have any oral intake. The doctor decides to administer corticosteroid replacement using intravenous hydrocortisone instead with a view of doubling the normal dose in line with sick-day rules.\n\n\nGiven that 1mg of prednisolone is equivalent to 4mg of hydrocortisone, what is the total dose of hydrocortisone given per day?",
"sbaAnswer": null,
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173,458,582 | false | 25 | null | 6,494,964 | null | false | [] | null | 6,916 | {
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"comment": "it says Tramadol 400mg TDS. So, 1200mg a day?",
"createdAt": 1705585987,
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"comment": "It says that for Ibuprofen not Tramadol.",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "Current dose of tramadol a day = 400mg a day\nNumber of tablets a day\n= 400mg/ 200mg tablets\n= 2 tablets a day\nNumber of tablets for 10 days\n= 2 tablets x 10days\n= 20 tablets for 10 days",
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"question": "A 77- year-old man was admitted to the care of the elderly ward for infective exacerbation of COPD. PMH Mild COPD, Osteoarthritis of left knee. DH Paracetamol 1g QDS, Ibuprofen 400mg TDS PO, Tramadol 200mg BD PO, Ipratropium bromide 40 micrograms INH, Salbutamol 200 micrograms INH QDS\n\n\nTramadol tablets are available in 50mg, 100mg, 150mg and 200mg.\n\nHow many 200mg tablets should the patient be discharged with for a duration of 10days?",
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173,458,583 | false | 26 | null | 6,494,964 | null | false | [] | null | 6,866 | {
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"explanation": "Co-amoxiclav is associated with an increased risk of necrotising enterocolitis in neonates",
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"__typename": "QuestionChoice",
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"explanation": "Co-amoxiclav is not known to discolour the teeth. On the other hand, tetracycline and doxycycline are associated with bone and teeth discolouration",
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"id": "34279",
"label": "e",
"name": "Hepatic failure",
"picture": null,
"votes": 118
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Co-amoxiclav is not known to cause auditory nerve damage. On the other hand, streptomycin is associated with foetal ototoxicity",
"id": "34278",
"label": "d",
"name": "Auditory nerve damage",
"picture": null,
"votes": 19
}
],
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"comment": "Weird q as necrotising enterocolitis is only really a risk when in PPROM. Otherwise BNF says not harmful ",
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"comment": "Yep that's why I didn't choose it either",
"createdAt": 1703610085,
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"comment": "is this the same as pseudomembranous enterocolitis?",
"createdAt": 1738158070,
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"comment": "No, that's caused by Clostridium Difficile",
"createdAt": 1738699890,
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case presentation: A 34-year-old pregnant woman is admitted to hospital for community-acquired pneumonia. She is a primigravida and is currently 22 weeks into her pregnancy. She has hyperemesis gravidarum and is not able to tolerate oral medication well. \r\n\nObservations: Temperature 37.5, Respiratory rate 32, Blood pressure 88/64, Heart rate 76\nOn examination: Coarse crackles at left lung base, normal antenatal examination\nThe junior doctor would like to discuss with the obstetric consultant commencing treatment with Co-amoxiclav 1.2 g TDS because the junior doctor is concerned that co-amoxiclav may increase the risk of a particular neonatal condition.\n\nQuestion: Select the neonatal condition that is most likely to be caused by Co-amoxiclav",
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173,458,584 | false | 27 | null | 6,494,964 | null | false | [] | null | 6,855 | {
"__typename": "QuestionSBA",
"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Co-careldopa does not commonly cause orthostatic hypotension",
"id": "34221",
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"name": "Co-careldopa 25/100 TDS PO",
"picture": null,
"votes": 285
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Carbamazepine does not commonly cause orthostatic hypotension",
"id": "34222",
"label": "c",
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"picture": null,
"votes": 8
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "Tamsulosin, an alpha1-adrenoreceptor blocker is known to cause postural hypotension due to the inhibition of alpha-1 receptors, leading to vascular smooth muscle relaxation and vasodilation the loss of reflex vasoconstriction upon standing",
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"picture": null,
"votes": 3994
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Daleparin does not commonly cause orthostatic hypotension",
"id": "34224",
"label": "e",
"name": "Dalteparin sodium 2500 units SC OD",
"picture": null,
"votes": 4
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Amlodipine can cause dizziness but is not known to commonly cause orthostatic hypotension",
"id": "34223",
"label": "d",
"name": "Amlodipine 5mg PO daily",
"picture": null,
"votes": 741
}
],
"comments": [
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"__typename": "QuestionComment",
"comment": "The question says he has syncope. Syncope is common with bisoprolol.\nOrthostatic hypotension is listed as not common for tamsulosin.",
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"comment": "I'm guessing because the reason for his syncope is due to orthostatic hypotension and not b-blocker related (e.g., bradycardia)",
"createdAt": 1674236583,
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"__typename": "QuestionComment",
"comment": "Why isn't bisoprolol an acceptable answer? Postural hypotension is listed as an uncommon side effect for both bisoprolol and tamsulosin.",
"createdAt": 1706719189,
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"comment": "I think because BNF has a whole caution section for tamsulosin about postural hypotension which bisoprolol doesn't ? ",
"createdAt": 1706821800,
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"__typename": "QuestionComment",
"comment": " postural hypotension is listed in the uncommon side effect section for both bisoprolol and tamsulosin. how are we meant to choose which one",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case Presentation: An 85-year-old man is transferred to the care of the elderly ward following an episode of syncope. PMH Hypertension, BPH, Epilepsy, Parkinson disease. DH His current regular medicines are listed (below).\r\n\r\n\nOn examination\nLying BP 120/85mmHg, HR 80/min; standing BP 90/70mmHg, HR 100/min\n\nQuestion: Select the prescription that is most likely to contribute to his orthostatic hypotension.\n",
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173,458,585 | false | 28 | null | 6,494,964 | null | false | [] | null | 6,870 | {
"__typename": "QuestionSBA",
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Amlodipine is not known to interact with lithium to cause hypokalaemia",
"id": "34296",
"label": "b",
"name": "Amlodipine 10 mg PO OD",
"picture": null,
"votes": 14
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "Indapamide is a thiazide-like diuretic that is used in the treatment of hypertension. It inhibits the Na+/Cl- cotransporter at the distal convoluted tubule of nephron, thereby leading to reduced sodium reabsorption and decreased water retention. It is important to note that it can cause hypokalaemia when given with lithium, thus potentially increasing the risk of torsade de pointes",
"id": "34295",
"label": "a",
"name": "Indapamide 2.5 mg PO daily in the morning",
"picture": null,
"votes": 3903
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"__typename": "QuestionChoice",
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"explanation": "Metformin is not known to interact with lithium to cause hypokalaemia",
"id": "34297",
"label": "c",
"name": "Metformin hydrochloride 500 mg PO TDS",
"picture": null,
"votes": 7
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Simvastatin is not known to interact with lithium to cause hypokalaemia",
"id": "34299",
"label": "e",
"name": "Simvastatin 40 mg PO ON",
"picture": null,
"votes": 28
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Captopril can increase the concentration of lithium but is not known to interact with lithium to cause hypokalaemia. Angiotensin-converting-enzyme inhibitors like captopril are known to cause hyperkalaemia",
"id": "34298",
"label": "d",
"name": "Captopril 75 mg PO BD",
"picture": null,
"votes": 724
}
],
"comments": [],
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case presentation: A 50-year-old woman visits her GP for medication review \n\n\nPMH: Bipolar disoder, Type 2 Diabetes Mellitus, Hypertension, Hypercholesterolaemia\nDH: Her current regular prescriptions, in addition to lithium carbonate 600 mg PO twice daily, are listed in the options below\nInvestigations:\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Sodium|138 mmol/L|135 - 145|\n|Potassium|3.2 mmol/L|3.5 - 5.3|\n|Urea|5 mmol/L|2.5 - 7.8|\n|Creatinine|120 µmol/L|60 - 120|\n|Thyroid Stimulating Hormone|2.5 mU/L|0.3 - 4.2|\n|Total T4|120 nmol/L|60 - 150|\n\n\nQuestion: Select the prescription that is most likely to interact with lithium carbonate to cause the abnormal blood test results?",
"sbaAnswer": [
"a"
],
"totalVotes": 4676,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,586 | false | 29 | null | 6,494,964 | null | false | [] | null | 6,863 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Visual disorders are common or very common side effects of digoxin. Digoxin toxicity should be suspected in a case of xanthopsia (yellow vision). Toxicity is increased by electrolyte disturbances such as hypercalcaemia, hypokalaemia and hypomagnesaemia. Serum electrolytes and renal function tests should be arranged besides plasma-digoxin concentration assay",
"id": "34260",
"label": "a",
"name": "Digoxin 250 micrograms PO OD",
"picture": null,
"votes": 5812
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Gliclazide is not known to cause xanthopsia",
"id": "34262",
"label": "c",
"name": "Gliclazide 40mg PO OD",
"picture": null,
"votes": 92
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Sertraline can cause visual impairment such as blurry vision but is generally less associated with xanthopsia",
"id": "34264",
"label": "e",
"name": "Sertraline 50 mg PO OD",
"picture": null,
"votes": 162
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Blurred vision is a rare or very rare side effect of captopril",
"id": "34263",
"label": "d",
"name": "Captopril 25 mg PO BD",
"picture": null,
"votes": 207
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Metformin is not known to cause xanthopsia",
"id": "34261",
"label": "b",
"name": "Metformin 500 mg PO TDS",
"picture": null,
"votes": 27
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Where can we find signs of digoxin toxicity on BNF?\n",
"createdAt": 1705855242,
"dislikes": 0,
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"likes": 0,
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"__typename": "QuestionComment",
"comment": "its under side effects\n",
"createdAt": 1732367983,
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"displayName": "Axillary Tazocin",
"id": 1823
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"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
"files": null,
"highlights": [],
"id": "2618",
"pictures": [],
"typeId": 2
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"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "2795",
"name": "Digoxin side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "92",
"name": "General Practice",
"typeId": 5
},
"topicId": 92,
"totalCards": null,
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"dislikes": 0,
"explanation": null,
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"qaAnswer": null,
"question": "Case presentation: A 45-year-old man presents to GP with a visual problem. He is concerned that his vision has a yellow tinge. \r\n\nPMH: Diabetes Mellitus, Hypertension, Depression, Atrial fibrillation\nDH: His current regular prescriptions are listed\nObservations: Temperature 36.5, Respiratory rate 14, Blood pressure 128/85, Heart rate 76, Oxygen saturation 100% (on air)\nOn Examination: 6/6 visual acuity\n\nQuestion: Select the prescription that is most likely to be contributing his yellow-tinted vision?",
"sbaAnswer": [
"a"
],
"totalVotes": 6300,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,587 | false | 30 | null | 6,494,964 | null | false | [] | null | 6,869 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Simvastatin is not known to cause NMS",
"id": "34294",
"label": "e",
"name": "Simvastatin 40 mg PO ON",
"picture": null,
"votes": 61
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Sertraline is not associated with NMS but an overdose of sertraline can cause serotonin syndrome, which share some similarities with NMS. Both NMS and serotonin syndrome can bring about hypertension, tachycardia and hyperthermia. However, NMS is different from serotonin syndrome in that it is associated with hyporeflexia, normal pupillary sizes and a gradual onset while serotonin syndrom is characterised by hyperreflexia, myadriasis and a rapid onset",
"id": "34291",
"label": "b",
"name": "Sertraline 50 mg PO OD",
"picture": null,
"votes": 1341
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Lisinopril is not known to casuse NMS",
"id": "34293",
"label": "d",
"name": "Lisinopril 20 mg PO OD",
"picture": null,
"votes": 4
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The clinical picture described above is that of neuroleptic malignant syndrome (NMS). NMS is an uncommon but potentially fatal side effect of all antipsychotic drugs. Antipsychotic medications lead to NMS through their antagonism of dopamine D2 receptors. NMS is characterised by a tetrad of hyperthermia, changed mental status, muscle rigidity and autonomic instability",
"id": "34290",
"label": "a",
"name": "Olanzapine 10 mg PO OD",
"picture": null,
"votes": 4179
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Metformin is not known to casuse NMS",
"id": "34292",
"label": "c",
"name": "Metformin hydrochloride 500 mg PO TDS",
"picture": null,
"votes": 9
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "one day i'll get NMS and serotonin syndrome the right way round ",
"createdAt": 1737741426,
"dislikes": 0,
"id": "61454",
"isLikedByMe": 0,
"likes": 5,
"parentId": null,
"questionId": 6869,
"replies": [
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"__typename": "QuestionComment",
"comment": "\"Neuroepeleptic\" malignant syndrome = antipsychotic bad syndrome.\nIt has rise in CK, muscle ridgity - basically excess of motor side effects of antipsycotics anyway. + confusion and sweating",
"createdAt": 1738205190,
"dislikes": 0,
"id": "61915",
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"displayName": "Lung Metastasis",
"id": 28734
}
}
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"__typename": "User",
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"displayName": "Epidermis Benign",
"id": 25779
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"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
"files": null,
"highlights": [],
"id": "2618",
"pictures": [],
"typeId": 2
},
"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "2801",
"name": "Antipsychotic side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "90",
"name": "Psychiatry",
"typeId": 5
},
"topicId": 90,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 2801,
"conditions": [],
"difficulty": 2,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "6869",
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"likes": 2,
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"psaSectionId": 6,
"qaAnswer": null,
"question": "Case presentation: A 35-year-old man presents to the accident and emergency department with a two-day history of gradual onset confusion and muscle rigidity. He is highly agitated and sweats excessively. \r\n\nPMH: Schizophrenia, Depression, Type 2 Diabetes Mellitus, Hypertension, Hypercholesterolaemia\nDH: Her current regular prescriptions are listed below\nObservations: Temperature 40°C , blood pressure 181/95 mmHg, heart rate 100 bpm, respiratory rate 25; oxygen saturation 100% (on air)\nOn examination: Lead pipe rigidity. Normal pupillary sizes\nInvestigation: Negative urine toxicology screen\n\nQuestion: Select the prescription that is most likely to be contributing to the clinical picture described above?",
"sbaAnswer": [
"a"
],
"totalVotes": 5594,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,588 | false | 31 | null | 6,494,964 | null | false | [] | null | 6,897 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Stress echocardiography may be indicated following a full specialist assessment but is unlikely to be used to demonstrate effectiveness of treatment with bisoprolol",
"id": "34433",
"label": "d",
"name": "Stress echocardiogram",
"picture": null,
"votes": 215
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Her blood pressure is likely to be lowered due to beta blockade and blunting of the sympathetic response, but it is not a useful marker of effective treatment",
"id": "34431",
"label": "b",
"name": "Blood pressure",
"picture": null,
"votes": 156
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "An increase in exercise tolerance due to a reduction in angina symptoms indicates effective treatment with bisoprolol",
"id": "34430",
"label": "a",
"name": "Exercise tolerance",
"picture": null,
"votes": 3252
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Her heart rate is likely to be lowered due to beta blockade and blunting of the sympathetic response, but it is not a useful marker of effective treatment",
"id": "34432",
"label": "c",
"name": "Heart rate",
"picture": null,
"votes": 675
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "An elevation in cardiac enzymes may suggest some ongoing myocardial ischaemia and can be useful in the general clinical setting on a background of acute chest pain, but is of limited usefulness to determine effectiveness of treatment with bisoprolol",
"id": "34434",
"label": "e",
"name": "Troponin",
"picture": null,
"votes": 8
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "in the psa practice papers, it states the best way to assess whether a BB is working is via HR?",
"createdAt": 1675105265,
"dislikes": 0,
"id": "17454",
"isLikedByMe": 0,
"likes": 2,
"parentId": null,
"questionId": 6897,
"replies": [
{
"__typename": "QuestionComment",
"comment": "For AF ",
"createdAt": 1675382825,
"dislikes": 0,
"id": "17657",
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"likes": 3,
"parentId": 17454,
"questionId": 6897,
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"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Swtmess",
"id": 8953
}
},
{
"__typename": "QuestionComment",
"comment": "Agreed re:AF \n+ the way I thought about it was he is in Normal sinus (ignoring AF) he is not tachy. Therefore is not tachy so why would HR help ",
"createdAt": 1678460165,
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"id": "19767",
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"displayName": "Gastro X-linked",
"id": 12891
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"__typename": "User",
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"displayName": "Lipsyncope",
"id": 29478
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"__typename": "QuestionComment",
"comment": "Where can I find this in the BNF?",
"createdAt": 1705935910,
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"id": "39570",
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"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
"files": null,
"highlights": [],
"id": "2618",
"pictures": [],
"typeId": 2
},
"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "2829",
"name": "Beta blocker monitoring",
"status": null,
"topic": {
"__typename": "Topic",
"id": "92",
"name": "General Practice",
"typeId": 5
},
"topicId": 92,
"totalCards": null,
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"difficulty": 2,
"dislikes": 0,
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"highlights": [],
"id": "6897",
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"psaSectionId": 7,
"qaAnswer": null,
"question": "Case Presentation: A 56 year old woman with no significant past medical history attends her GP with intermittent chest pain. The pain is central and constricting with no radiation into her jaw or arms. She only has the pain a few times a week and notices that it comes on when she is either climbing stairs or running for the bus. She denies syncope, sweating, shortness of breath or any other symptoms of ill health.\n\n\n**Investigations**\n\nECG: Normal sinus rhythm\n\nHer GP decides to make a routine referral to the outpatient cardiology clinic and prescribes bisoprolol fumarate 5mg PO OD.\n\nQuestion: Select the most appropriate option to assess the beneficial effects of this treatment.",
"sbaAnswer": [
"a"
],
"totalVotes": 4306,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,589 | false | 32 | null | 6,494,964 | null | false | [] | null | 6,885 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is recommended to measure liver function prior to and at 4-6 weeks after starting this drug as terbinafine is known to be hepatotoxic",
"id": "34372",
"label": "c",
"name": "No routine monitoring is required",
"picture": null,
"votes": 118
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not a necessary monitoring requirement for this drug",
"id": "34373",
"label": "d",
"name": "Platelet count",
"picture": null,
"votes": 13
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "It is recommended to measure liver function prior to and at 4-6 weeks after starting this drug as terbinafine is known to be hepatotoxic",
"id": "34370",
"label": "a",
"name": "Liver function tests",
"picture": null,
"votes": 6031
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is recommended that the dose of terbinafine should be reduced in patients with renal impairment, but routine monitoring of renal function is not necessary",
"id": "34374",
"label": "e",
"name": "Serum creatinine",
"picture": null,
"votes": 28
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not a necessary monitoring requirement for this drug",
"id": "34371",
"label": "b",
"name": "Fasting lipid profile",
"picture": null,
"votes": 7
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
"files": null,
"highlights": [],
"id": "2618",
"pictures": [],
"typeId": 2
},
"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "2817",
"name": "Terbinafine side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "74",
"name": "Elderly Care",
"typeId": 5
},
"topicId": 74,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 2817,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "6885",
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"psaSectionId": 7,
"qaAnswer": null,
"question": "Case Presentation: An 88 year old woman attends a follow-up appointment for review at her GP. One month ago she was seen in the outpatient dermatology clinic for a surgical excision of a basal cell carcinoma. She was incidentally diagnosed at the time with multiple-nail onychomycosis on her left foot and started on terbinafine 250mg PO OD.\n\n\nQuestion: Select the most appropriate option to monitor for adverse effects of this treatment.",
"sbaAnswer": [
"a"
],
"totalVotes": 6197,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,590 | false | 33 | null | 6,494,964 | null | false | [] | null | 6,893 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "While deep-vein thromboses are a well-known adverse effect of taking oestrogen-containing contraception, it is not necessary to rule out an existing DVT prior to starting contraception",
"id": "34412",
"label": "c",
"name": "Venous doppler ultrasound",
"picture": null,
"votes": 20
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is recommended to monitor the blood pressure and weight prior to starting and while taking the COCP",
"id": "34414",
"label": "e",
"name": "No routine monitoring is required",
"picture": null,
"votes": 1317
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A D-dimer is a specific blood test that is useful in helping to guide clinical diagnosis of a DVT. It is not necessary to perform one prior to starting contraception",
"id": "34413",
"label": "d",
"name": "D-dimer",
"picture": null,
"votes": 27
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Hypertension is a common adverse effect of the combined oral contraceptive pill and it is recommended that blood pressure should be checked before and while taking the COCP",
"id": "34410",
"label": "a",
"name": "Blood pressure",
"picture": null,
"votes": 4810
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is not necessary to perform an ECG prior to starting contraception",
"id": "34411",
"label": "b",
"name": "ECG",
"picture": null,
"votes": 60
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "there are no monitoring requirements for blood pressure. Where is that?\n",
"createdAt": 1675291943,
"dislikes": 0,
"id": "17586",
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"likes": 1,
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"replies": [
{
"__typename": "QuestionComment",
"comment": "you do have to measure BP once per year",
"createdAt": 1737648908,
"dislikes": 0,
"id": "61349",
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"likes": 0,
"parentId": 17586,
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"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Vaccine Complement",
"id": 17667
}
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"user": {
"__typename": "User",
"accessLevel": "subscriber",
"displayName": "Fungal Tyrosine",
"id": 22953
}
},
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"__typename": "QuestionComment",
"comment": "its before starting not necessarily monitored",
"createdAt": 1703278067,
"dislikes": 0,
"id": "36709",
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"likes": 2,
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"displayName": "Serotonin Dorsal",
"id": 37313
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"comment": "Is this on the BNF somewhere? I can't find it",
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"comment": "found in oral contraceptives treatment summary, not the drug page",
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"explanation": "# Summary\n \n\nThe combined oral contraceptive pill (COCP) is a long-term contraceptive containing synthetic oestrogen and progestogen. It works by inhibiting ovulation, thickening cervical mucus, and altering the endometrium to prevent fertilisation and implantation. Indications for COCP use include contraception, menstrual cycle regulation, and treatment of dysmenorrhea, menorrhagia, acne, and hirsutism. Contraindications are categorised by UKMEC criteria, detailed in this chapter. \n \n# Definition\n \n\nThe combined oral contraceptive pill (COCP) is a long-term contraceptive. It contains synthetic versions of the female hormones oestrogen and progestogen. \n \n\n# Mechanism of Action\n \n\n* **Inhibition of Ovulation:** The COCP contains synthetic versions of the hormones oestrogen and progestogen. These hormones together suppress the release of gonadotrophins (LH and FSH) from the pituitary gland, preventing the maturation and release of an egg from the ovaries.\n \n\n* **Thickening of Cervical Mucus:** The progestogen component of the COCP increases the viscosity of cervical mucus, making it more difficult for sperm to enter the uterus and fertilise an egg.\n \n\n * **Alteration of the Endometrium:** The COCP induces changes in the lining of the uterus (endometrium), making it less suitable for the implantation of a fertilised egg.\n \n\n# Indications\n \n\nThere are a range of reasons for women to be recommended the oral combined contraceptive pill. For example:\n \n\n* **Contraception:** The COCP works as a long-term contraception. It is taken orally once a day, at around the same time each day. \n * **Menstrual Cycle Regulation:** The COCP can help regulate irregular menstrual cycles. \n * **Dysmenorrhea:** The COCP may be used to reduce menstrual cramps. \n * **Menorrhagia:** The COCP can decrease heavy menstrual bleeding.\n * **Acne and Hirsutism:** The COCP helps in the treatment of acne and excessive hirsutism in women, which may happen in conditions such as polycystic ovary syndrome (PCOS) or other androgen excess conditions.\n * **Premenstrual Syndrome (PMHS**: The COCP can alleviate symptoms of PMS, such as mood swings, bloating, and irritability.\n \n# Contraindications \n \nThere are numerous contra-indications to the Combined Oral Contraceptive Pill. These can be divided into absolute contraindications, known as ''UKMEC 4'', a situation where the disadvantages outweigh the advantages (UKMEC 3), a situation where the advantages outweigh the disadvantages (UKMEC 2), and a situation whereby there is no limit on that choice of contraception (UKMEC 1).\n \n\n## Absolute Contraindications to Contraception (UKMEC 4)\n \n \n * Known or suspected pregnancy\n * Hypertension with SBP ≥160 mmHg or DBP ≥100 mmHg\n * Smoker over the age of 35 who smokes >15 cigarettes a day \n * Current and history of ischaemic heart disease\n * History of stroke (including TIA) \n * Vascular disease\n * History or current VTE\n * Major surgery with prolonged immobilisation\n * Breastfeeding <6 weeks postpartum\n * Not breastfeeding and <3 weeks postpartum with other risk factors for VTE\n * Known thrombogenic mutations \n * Complicated valvular and congenital heart disease\n * Cardiomyopathy with impaired cardiac function\n * Atrial fibrillation \n * Migraine with aura (any age)\n * Current breast cancer \n * Severe (decompensated) cirrhosis \n * Hepatocellular adenoma and hepatocellular carcinoma\n * Positive antiphospholipid antibodies \n \n \n \n## Disadvantages of a contraceptive outweigh the advantages (UKMEC 3)\n \n * Obesity (BMI ≥35 kg/m2)\n * Multiple risk factors for cardiovascular disease (e.g. smoking, diabetes mellitus, hypertension, obesity, dyslipidaemia) \n * Well controlled hypertension, and hypertension with SBP >140-159 mmHg or DBP <90-99 mmHg\n * Smoker over age of 35 who smokes <15 cigarettes a day, or anyone over age of 35 who stopped smoking <1 year ago\n * Family history of thrombosis before 45 years old\n * Not breastfeeding and <3 weeks postpartum without other risk factors for VTE\n * Not breastfeeding and between 3-6 weeks postpartum with other risk factors for VTE\n * Organ transplant with complications (e.g. graft failure, rejection) \n * Immobility (unrelated to surgery)\n * Migraine without aura (any age) [applies to *continuation* of COCP]\n * History (≥5 years ago) of migraine\nwith aura (any age) \n * Undiagnosed breast mass or symptoms [applies to *initiation* of COCP] \n * Carriers of known gene mutations associated with breast cancer\n * Past breat cancer \n * Diabetes mellitus with nephropathy, retinopathy, neuropathy or other vascular complications \n * Symptomatic gall bladder disease treated medically or currently active \n * Past COCP associated cholestasis \n * Acute viral hepatitis [applies to *initiation* of COCP]\n \n \n \n## Advantages of a contraceptive outweigh the disadvantages (UKMEC 2)\n \n * Smokers under the age of 35, and people aged over 35 who stopped smoking over 1 year ago \n * Obesity (BMI ≥30–34 kg/m2) \n * Family history of VTE in first-degree relative aged ≥45 years\n * History of raised blood pressure in pregnancy \n * Breast feeding between 6 weeks-6 months postpartum\n * Not breastfeeding and between 3-6 weeks postpartum without other risk factors for VTE\n * Uncomplicated organ transplant \n * Known dyslipidaemia \n * Major surgery without prolonged immobilisation \n * Superficial venous thrombosis \n * Uncomplicated valvular and congenital heart disease\n * Cardiomyopathy with normal cardiac function \n * Long QT syndrome \n * Non-migrainous headaches [applies to *continuation* of COCP]\n * Migraine without aura [applies to *initiation* of COCP] \n * Idiopathic intracranial hypertension \n * Unexplained vaginal bleeding\n * Cervical cancer \n * Undiagnosed breast mass or symptoms [applies to *continuation* of COCP]\n * Insulin-dependent diabetes mellitus without vascular disease \n * Symptomatic gall bladder disease treated through cholecystectomy, or asymptomatic gall bladder disease, or history of pregnancy-related cholestasis \n * Acute viral hepatitis [applies to *continuation* of COCP]\n * Inflammatory bowel disease \n * Sickle cell disease \n * Rheumatoid arthritis\n * SLE without antiphospholipid antibodies \n \n\n \n\n# Side-effects and Complications\n \n**Common Side-Effects:**\n \n\n * Breast tenderness \n * Abdominal discomfort, nausea diarrhoea \n * Headaches\n * Mood changes\n * Reduced libido \n \n\n**Rare but Serious Side-Effects:**\n \n\n * Embolism or thrombus, including: DVT and PE, stroke, myocardial infarction\n * Increased risk of breast cancer\n * Increased risk of cervical cancer \n \n\n \n\n# Follow-up\n\nArrange follow up 3 months following initial prescription of a COCP, and annually thereafter.\n \n\nAt follow-up, ensure to: \n \n\n * Check blood pressure and BMI. \n * Ask about headaches (including migraine). \n * Check for risk factors that may be contraindicators to COCP (as per UKMEC criteria). \n * Enquire about side-effects. \n * Enquire about how woman is taking the COCP (i.e. adherence). \n \n\n \n\n# Missed Pill Rules\n \n\n**Missed One Pill:**\n \n\n* Advise patient to take the pill as soon as possible, even if it means taking two pills in one day.\n* * Continue taking the rest of the pack as usual.\nNo additional contraception needed if this is the only pill missed in the pack.\n \n\n**Missed Two or More Pills in Week 1 (Days 1-7):**\n \n\n * Advise patient to take the last pill they missed as soon as possible. \n * Continue taking the rest of the pack as usual.\n * Use additional contraception for the next 7 days.\n * If they had unprotected sex during this week, seek emergency contraception.\n \n\n**Missed Two or More Pills in Week 2 (Days 8-14):**\n \n\n * Take the last pill they missed as soon as possible. \n * Continue taking the rest of the pack as usual.\n * No additional contraception needed if they have taken pills correctly for the 7 days prior to the missed pill.\n \n\n**Missed Two or More Pills in Week 3 (Days 15-21):**\n \n\n* Finish the active pills in the current pack, then start a new pack immediately without taking the usual 7-day break.\n* No additional contraception needed if they have taken pills correctly for the 7 days prior to the missed pill.\n \n# NICE Guidelines \n \n\n[Click here to view NICE Guidelines on COCP](https://cks.nice.org.uk/topics/contraception-combined-hormonal-methods/management/combined-oral-contraceptive/)\n \n \n# References\n \n[Click here to see the UKMEC summary sheet on contraception](https://www.fsrh.org/standards-and-guidance/documents/ukmec-2016-summary-sheets/)",
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"question": "A 15 year old girl attends her GP to ask for the combined oral contraceptive pill. During the consultation, her GP is satisfied that there are no safeguarding concerns regarding her partner and that she meets the Fraser guidelines. She is prescribed ethinylestradiol with desogestrel 1 tablet daily for 21 days and a 7-day pill free break.\n\n\nQuestion: Select the most appropriate monitoring option required before starting her contraception.",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case Presentation: A 67 year old man attends a follow-up appointment at his GP after being discharged from hospital. He had been admitted for three days to manage an acute infective exacerbation of COPD, during which it was noted that his recorded blood pressure consistently ran above 150/90mmHg. The medical team have requested the GP to prescribe antihypertensive treatment.\n\n\nThe GP decides to prescribe amlodipine 5mg PO OD and schedules a follow-up appointment in 2 weeks.\n\nQuestion: Select the most appropriate option to monitor for adverse effects of this treatment.",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "# Summary\n \nAcute pulmonary oedema refers to fluid accumulation in the interstitium and alveoli of the lungs, which may be cardiogenic or non-cardiogenic. Symptoms include severe dyspnoea, diaphoresis, paroxysmal noctural dyspnoea, orthopnoea and a cough classically productive of pink frothy sputum. Key investigations include a chest X-ray for diagnosis, an ABG, ECG basic bloods including a troponin and BNP and an echocardiogram. Management involves giving oxygen, IV Furosemide and consider non-invasive or invasive ventilation in patients not responding to treatment.\n \n# Definition\n \nAcute pulmonary oedema is a condition that occurs when excess fluid accumulates in the lungs, particularly within the pulmonary interstitium and alveoli.\n \n# Aetiology\n \nPulmonary oedema can be divided into two main groups: cardiogenic and non-cardiogenic.\n\nCardiogenic pulmonary oedema is associated with raised pulmonary capillary pressures, with the following causes:\n\n- Acute coronary syndrome\n- Decompensation of chronic heart failure (e.g. stopping diuretics, infection, volume overload)\n- Valvular disorders (e.g. acute mitral regurgitation)\n- Acute arrhythmia\n- Acute myopathies (e.g. myocarditis, postpartum cardiomyopathy)\n- Medications e.g. NSAIDs\n- Hypertensive crisis\n\nNon-cardiogenic causes of pulmonary oedema include:\n\n- Acute respiratory distress syndrome\n- Renal artery stenosis\n- Acute kidney injury\n- Iatrogenic fluid overload\n- High altitude\n- Neurogenic pulmonary oedema (e.g. secondary to head injury)\n\n# Signs and Symptoms\n \n**Symptoms include:**\n\n- Severe dyspnoea\n- Orthopnoea\n- Paroxysmal nocturnal dyspnoea (PND)\n- Anxiety\n- Diaphoresis\n- Cough - may be dry or productive of pink frothy sputum\n- Nausea\n\n**On examination, signs include:**\n\n- Respiratory distress\n- Tachypnoea\n- Tachycardia\n- Raised jugular venous pressure (JVP)\n- Inspiratory crepitations on auscultation\n- Gallop rhythm (3rd heart sound)\n- Peripheral oedema and hepatomegaly if secondary to right heart failure\n- Hypotension and oliguria if in cardiogenic shock\n \n\n# Differential Diagnosis\n \n- **Acute exacerbation of chronic obstructive pulmonary disease**: also associated with dyspnoea and cough, usually productive of sputum and symptoms of orthopnoea and PND not present.\n- **Pneumonia**: also causes dyspnoea and cough, patients usually are febrile and may have other symptoms such as chest pain. Can be differentiated on chest X-ray (showing consolidation in pneumonia).\n- **Pulmonary embolism**: also causes sudden dyspnoea, may have haemoptysis and tachycardia. Risk factors e.g. immobility may be present, chest X-ray is typically normal but can co-exist with other pulmonary pathologies.\n\n# Investigations\n\n**Bedside tests:**\n\n- **ECG** to look for causes e.g. ischaemic changes in acute coronary syndrome or an arrhythmia, may show evidence of chronic heart failure e.g. left ventricular hypertrophy\n- **Arterial blood gas** to assess for respiratory failure which is usually type 1 unless consciousness is impaired in severe illness\n\n**Blood tests:**\n\n- **Full blood count** and **CRP** for inflammatory markers as infection may precipitate acute pulmonary oedema\n- **U&Es** and **LFTs** to look for renal or hepatic causes of pulmonary oedema, hyponatraemia may occur\n- **Troponin** to investigate for acute coronary syndrome\n- **BNP** which should be raised in heart failure\n\n**Imaging:**\n\n- **Chest X-ray** classically shows ABCDE signs of pulmonary oedema:\n - **A**lveolar opacification (bilateral perihilar lung shadowing)\n - Kerley **B** lines (thickened subpleural interlobular septa)\n - **C**ardiomegaly\n - Upper lobe **D**iversion\n - Pleural **E**ffusions\n- **Echocardiogram** to assess heart function and look for a cause e.g. valvular disease\n\n [lightgallery]\n \n\n# Management\n \nAn ABCDE approach should be taken and a medical emergency call put out if required:\n\n- **Airway**\n - Position the patient upright\n - Intubation may be required in some cases e.g. reduced GCS secondary to hypercapnia in patients who have tired\n- **Breathing**\n - Give high flow oxygen via a non-rebreather mask\n - Non-invasive ventilation (NIV) may be required e.g. in cases of severe dyspnoea and acidaemia\n- **Circulation**\n - Ensure the patient has adequate IV access\n - Give IV furosemide, usually in boluses of 20-40mg\n - Nitrates should not be used routinely\n - Inotropes or vasopressors may be required in cases of cardiogenic shock\n - Monitor input-output and consider a urinary catheter\n- **Disability**\n - Small doses of morphine may be required for agitation or chest pain but opiates should not be given routinely\n- **Exposure/Everything Else**\n - Review medications - beta-blockers should usually be continued unless the patient is bradycardic or shocked\n - Ensure cardiology are aware in cases of cardiogenic pulmonary oedema\n - Mechanical circulatory support (e.g. a ventricular assist device) is an option in acute severe heart failure \n \n# NICE Guidelines\n\n[NICE - Acute heart failure: diagnosis and management](https://www.nice.org.uk/guidance/cg187/)\n\n# References\n \n[Radiopaedia - Pulmonary Oedema](https://radiopaedia.org/articles/pulmonary-oedema-summary?lang=gb)\n\n[Patient UK - Acute Pulmonary Oedema](https://patient.info/doctor/acute-pulmonary-oedema)\n\n[RCEM Learning - Cardiogenic Pulmonary Oedema](https://www.rcemlearning.co.uk/reference/cardiogenic-pulmonary-oedema/)",
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"explanation": "# Drug choice feedback\n\nAdministration of furosemide, a loop diuretic, is the most appropriate treatment for this gentleman to alleviate his shortness of breath and peripheral oedema. It is an effective and inexpensive choice of diuretic.\n\n# Dose/Route/Frequency/Duration feedback\n\nThe correct dose is 20-50mg intravenously for adults. This can be increased in steps of 20mg every 2 hours if further treatment is required. Furosemide can be given orally or intramuscularly as well, although the intravenous route is preferred in hospital due to more rapid onset of action and it is given that a cannula is in situ.",
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"question": "Case Presentation: A 73-year-old gentleman is brought to the Emergency Department with shortness of breath and ankle swelling. He denies any chest pain.\n\n\n## PH\n\nIschaemic heart disease, Type 2 diabetes mellitus, Hyperlipidaemia\n\n## DH\n\nAspirin 75mg OD PO, Ramipril 5mg OD PO, Metformin 1g BD PO, Empaglifozin 10mg, Bisoprolol 2.5mg PO OD, Atorvastatin 80mg PO OD (NKDA)\n\n## On examination\n\nAppears distressed. CRT 3s, peripheries cool. Cannula in situ. Bilateral peripheral oedema up to the mid-shins. JVP seen just inferior to earlobe.\n\nTemperature 37.3°C, HR 110, RR 18, BP 156/68, O2 93% on 5L oxygen, GCS 14, Weight 79kg\n\n## Investigations\n\nFBC: Hb 152, WCC 5.3, Plts 311\n\nU&Es: Na<sup>+</sup> 141, K<sup>+</sup> 4.2, Cl<sup>-</sup> 102, Ur 10.5, Cr 105, eGFR 64mL/min/1.73m<sup>2</sup>\n\nECG: NSR and left ventricular strain\n\nCXR: cardiomegaly and interstitial oedema\n\n# Prescribing Request\n\nWrite a prescription for one drug that is most appropriate to treat his shortness of breath and peripheral oedema.",
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173,458,629 | false | 2 | null | 6,494,967 | null | false | [] | null | 6,765 | {
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"comment": "why not Mupirocin? ",
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"comment": "good q",
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"comment": "why is 7 days wrong in bnf they say 5-7 days for hydrogen peroxide",
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"comment": "I agree, does anyone know why?",
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"explanation": "# Summary\n \n\nImpetigo is a highly infectious superficial epidermal infection primarily caused by Staphylococcal or Streptococcal bacteria, commonly found in infants and school-aged children. Characteristic clinical signs include erythematous macules that vesiculate or pustulate, followed by superficial erosion with a golden crust. Although the diagnosis is usually clinical, a skin swab may be required in certain circumstances. Management is primarily via topical treatments such as fusidic acid, or oral flucloxacillin, and it's important to limit transmission by avoiding shared items and public places until 48 hours post-antibiotic treatment.\n \n\n# Definition\n \n\nImpetigo is a highly contagious superficial epidermal infection of the skin primarily caused by Staphylococcal and Streptococcal bacteria.\n \n\n# Epidemiology\n \n\nImpetigo most commonly occurs in infants and school-age children, with weekly rates of 84 per 100,000 children aged 0-4 in the UK. However, whilst less common in older individuals, it can affect individuals of any age. It affects boys and girls equally. \n \n\n# Aetiology\n \n\nThe aetiology of impetigo is mainly bacterial infections, specifically:\n \n\n - Staphylococcus aureus (80% of cases)\n - Group A beta haemolytic Streptococcus (Streptococcus pyogenes) (10% of cases)\n - In 10% of cases, both bacteria are present. \n\nThese bacteria can invade the skin through minor cuts, insect bites, or abrasions, leading to infection.\n \nImpetigo is very contagious and is spread through direct contact, with lesions appearing 4-10 days after contact. \n \nBullous lesions are almost exclusively caused by Staphylococcus aureus, as this bacteria produces an exotoxin targeting desmoglein - 1 (an epithelial intercellular adhesion molecule). \n\nRisk factors include:\n\n- Pre-existing skin conditions (i.e. eczema, cuts, burns, scabies)\n- Immunosuppression\n- Direct contact with an infected individual\n- Environmental factors such as crowding, humidity and poor hygiene. \n \n# Classification\n \nImpetigo can be sub-divided into:\n \n - Bullous: The child will have fluid filled lesions greater than 1 cm in diameter\n - Non-bullous: This is more common, and the child will not have bullae\n\nIt can also be divided based on aetiology:\n \n - Primary: Infection occurs in otherwise normal skin. \n - Secondary: Infection is related to an underlying skin condition (i.e. eczema) or breach to the skin barrier (i.e. bite or cut).\n \n\n# Signs and Symptoms\n \n\nThe primary clinical features of impetigo include:\n \n\n - Erythematous macule that vesiculates or pustulates\n - Superficial erosion with a characteristic golden crust\n - Impetigo may be bullous (causing large blisters) or non-bullous (causing sores)\n - Patches may be itchy or painful\n \n\nThese features are typically very infectious, prompting caution regarding close contact and shared items.\n \n\n [lightgallery]\n \n\n# Differential Diagnosis\n \n\n - **Eczema Herpeticum**: Presents with rapid onset of painful, punched-out erosions with or without vesiculation on a background of atopic dermatitis. It may also exhibit systemic symptoms like fever and malaise.\n - **Herpes Simplex Virus (HSV) infection**: This may manifest as grouped vesicles on an erythematous base, usually accompanied by pain and itching. It can also cause systemic symptoms.\n - **Contact Dermatitis**: This involves erythematous, pruritic rash, usually in a pattern suggestive of a contact allergen.\n - **Tinea Corporis (Ringworm)**: Exhibits annular erythematous scaly plaques, often with central clearing.\n \n\n# Investigations\n \n\nWhile the diagnosis of impetigo is often clinical, based on the characteristic signs and symptoms, in certain cases, investigations may be warranted:\n \n\n - A skin swab may be necessary for microscopy, culture, and sensitivity, particularly in cases resistant to treatment or in the context of recurrent infections.\n \n\n# Management\n \n\nImpetigo can typically be managed effectively in primary care. Key management strategies include:\n \n\n - **Localised non-bullous impetigo:** topical treatment with hydrogen peroxide 1% cream (apply two or three times daily for 5 days) is first-line\n - If unsuitable, second-line options include fusidic acid or mupirocin (if fusidic acid resistance)\n - **Widespread non-bullous impetigo:**\n - Topical (fusidic acid/mupirocin) *or* oral antibiotics for 5 days, such as flucloxacillin\n - Clarithromycin (penicillin-allergic) or erythromycin (pregnancy) are alternatives\n - **Bullous impetigo, or impetigo in those systemically unwell or at high risk of complications:**\n - Oral antibiotics as above for up to 7 days\n\n\nAdvise general hygiene measures:\n \n - Avoid scratching the lesions \n - Cover the affected areas and wash hands with soap and water \n - Avoid sharing toys and towels whilst the infection is active \n\n**Children should be off school until all lesions are healed or until 48 hours after starting treatment.** \n\nRefer to secondary care if:\n \n\n * Suspected complications of impetigo (sepsis, glomerulonephritis, or deeper soft tissue infection) \n * The patient is immunocompromised and infection is widespread\n\n# Complications \n\nPossible complications include:\n\n- Worsening or spread of the infection to cellulitis, ecthyma (a deeper form of impetigo), septic arthritis or sepsis\n- Scarring \n- Acute post-streptococcal glomerulonephritis \n \n# Prognosis \n \nInfection will resolve within 1-3 weeks, with this time reduced with proper treatment. Secondary impetigo is most likely to relapse if the underlying cause is chronic.\n\nThe risk of serious complications is low - however, it is most commonly seen in neonates or children with severe immunodeficiency. \n \n\n# NICE Guidelines \n\n[NICE Guidelines - Impetigo](https://cks.nice.org.uk/topics/impetigo/management/bullous-impetigo/)\n\n# References\n\n[NHS Information on Impetigo](https://www.nhs.uk/conditions/impetigo/) \n\n[Patient Info Impetigo](https://patient.info/doctor/impetigo-pro)",
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"explanation": "# Drug choice feedback\n\nThis child is suffering from facial impetigo, an extremely common superficial skin infection usually caused by _Staphylococcus aureus_ or _Streptococcus pyogenes_. As the infection is localised and the patient is systemically well, as well as the infection being non-bullous and not around the eyes, topical hydrogen peroxide 1% is first line as recommended by NICE. Fusidic acid can also be used, and is preferred if there is evidence of impetigo near the eyes. If impetigo were extensive, oral treatment with flucloxacillin would be recommended. \n\n\n# Dose/Route/Frequency/Duration feedback\n\nThe optimal frequency is two-three times a day for a duration of 5 days, as per NICE guidance.",
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"question": "Case Presentation: A 5-year-old girl attends her GP with her mother with non-bullous lesions on her cheeks and chin. They are mildly itchy.\n\n## PH\n\nAtopic Eczema\n\n## DH\n\nNone (Severe allergy to Penicillin - Anaphylaxis)\n\n## On examination\n\nChild looks well and not in distress. The lesions are tiny pustules localised to the face, some have evolved into honey-coloured crusted plaques, most tend to be under 2cm in diameter. MRSA is not clinically suspected.\n\nTemperature 36.7°C, HR 95, RR 25, BP 100/68, O<sub>2</sub> 94% RA, GCS 15, Weight 21kg\n\n## Investigations\n\nNone\n\n## Prescribing Request\n\nWrite a prescription for one topical drug that is most appropriate for treating her condition.",
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173,458,630 | false | 3 | null | 6,494,967 | null | false | [] | null | 6,751 | {
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"comment": "I get insulin but dont you start with saline infusion first?",
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"comment": "oh wait the Q asked high blood glucose levels",
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"comment": "was so confused because you can't write \"per hour\" anywhere",
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"explanation": "# Summary\n \n\nDiabetic ketoacidosis (DKA) is a serious complication often associated with type 1 diabetes, characterised by hyperglycaemia, ketonaemia, and acidosis. Key signs and symptoms include fruity-smelling breath, vomiting, dehydration, abdominal pain, hyperventilation, and altered mental status. Investigations include blood glucose and ketone measurements, blood gas analysis, urea and electrolytes, and possibly blood cultures if infection is suspected. Management strategies largely depend on the patient's condition, including hydration and insulin administration via various routes and in various volumes based on severity. The major complication is cerebral oedema, a rare but potentially fatal condition that might be caused by rapid correction of dehydration with IV fluids.\n \n\n# Definition\n \n\nDiabetic ketoacidosis (DKA) is a severe and life-threatening medical complication characterised by hyperglycaemia, acidosis and ketonaemia.\n\nIt is defined by acidosis (bicarbonate < 15 mmol/l or pH <7.3) and ketones >3.0 mmol/L. \n \n\n# Epidemiology\n \n\nDKA is most commonly seen in individuals with type 1 diabetes. However, it can occur in those with type 2 diabetes under extreme stress or illness. The condition can be the first presentation of diabetes, especially type 1 diabetes in children and young adults.\n\nIt is more common in children under 5. \n \n\n# Aetiology\n \n\nDKA can be precipitated by several factors, including infection, dehydration, stress, burns, fasting, or untreated type 1 diabetes. It is important to note that fever is not a typical part of DKA presentation. A raised temperature could indicate an underlying infection that may have triggered the DKA.\n\nRisk factors include:\n\n- Previous episodes of DKA \n- Peripubertal and adolescent girls \n- Comorbidities including psychiatric disorders\n- Difficult home life\n- Insulin pump therapy \n\n\n# Classification\n\n- Mild: pH 7.1-7.29 or bicarbonate < 15 mmol/L. Dehydration 5%\n- Moderate: pH 7.1-7.19 or bicarbonate < 10 mmol/L. Dehydration 5%\n- Severe: pH <7.1 or bicarbonate < 5 mmol/L\n \n\n# Signs and Symptoms\n \n\nPatients with DKA may present with:\n \n\n - Fruity-smelling breath (due to the presence of acetone)\n - Vomiting\n - Dehydration secondary to polydipsia and polyuria \n - Abdominal pain\n - Deep, sighing respiration (Kussmaul respiration)\n - Signs of hypovolaemic shock\n - Altered mental status, including drowsiness or coma\n \n\n# Differential Diagnosis\n \n\nThe main differential diagnoses for DKA in children include:\n \n - **Lactic Acidosis**: This may present with rapid breathing, abdominal pain, and altered mental status. The patient may have a history of severe illness or sepsis, hepatic failure or metformin use.\n - **Starvation Ketosis**: This usually presents with weight loss, nausea, and clear mental status. The condition is mild, with low-level ketonaemia.\n - **Inborn errors of metabolism**: Tend to present earlier in life with metabolic disturbances or failure to thrive. \n - **Sepsis**: The child will be generally unwell, with a high or low temperature, hypotension and tachycardia. \n \n\n# Investigations\n \n\nDiagnosis of DKA involves assessment of clinical features along with:\n \n\n - Blood glucose (>11.1mmol/L)\n - Blood ketones (>3mmol/L)\n - Urea and electrolytes\n - Blood gas analysis\n - Urinary glucose and ketones\n - Blood cultures (if evidence of infection)\n - Cardiac monitoring/ECG (for any ischaemic changes or changes secondary to hypokalaemia)\n \n\nNote that hyperglycaemia may not always be present in DKA.\n \n\n# Management\n \n\nManagement of DKA should be based on the A to E approach followed by the following treatments: \n\n - IV fluids (initial bolus of 10ml/kg 0.9% NaCl, even if the patient is shocked) given over 15 minutes.\n - Repeat as needed to restore circulation\n - At 40 ml/kg then discuss with a senior for consideration for inotropes \n - Insulin infusion at 0.1 units/kg/hour 1 hour after starting IV fluids\n\n\nFluids:\n\n- Further fluids, following initial boluses should contain 40 mmol/l potassium chloride to protect against hypokalaemia. \n- Total fluid required = deficit + maintenance\n- Hourly rate = [(Deficit - initial bolus) / 48 hours ] + maintenance per hour \n- Deficit \n - A 5% fluid deficit is assumed for children with mild or moderate DKA\n - A 10% fluid deficit is assumed for children with severe DKA\n - Deficit should be replaced over 48 hours alongside maintenance fluids \n- Maintenance \n - Calculated by Holliday-Segar formula: 100 ml/kg/day for the first 10 kg, 50 ml/kg/day for the next 10 kg, and 20 ml/kg/day for each additional kg over 20 kgs. \n \nImportant points to consider: \n\n- Monitoring should include hourly blood glucose and ketones, neurological observations and fluid balance. \n- Investigations should be done to determine the cause of the DKA. \n- Many patients will require HDU-level care. \n- Intravenous insulin infusion should not be stopped until 1 hour after subcutaneous insulin has been given.\n- Long-acting insulin should continue to be given.\n\n\n# Resolving DKA\n\nIVF can be stopped once ketosis is resolving and oral fluids are tolerated without nausea or vomiting. \n\nSubcutaneous insulin can be started once ketosis is resolving and should be started at least 30 minutes before stopping intravenous insulin. \n\nDischarge can be considered once a child is eating and drinking, and stabilised on their subcutaneous insulin regime. \n \n\n# Complications\n\n\nImportant complications to monitor for include:\n\n- Cerebral oedema:\n - Can occur several hours after the onset of DKA due to rapid correction of dehydration with IV fluids. \n - Due to the potential risk, fluid deficit correction is recommended to be performed slowly, over 48 hours. \n - Though rare, this complication is fatal in 1 in 4 children. \n - Risk factors include younger age and longer duration of symptoms. \n - Management includes hypertonic (2.7%) sodium chloride and restriction of IV fluids. \n- Hypokalaemia \n- Aspiration pneumonia \n- Venous thromboembolism \n - Thromboembolic prophylaxis is not recommended in children < 16 years \n- Inadequate resuscitation \n- Hypoglycaemia\n - Blood glucose levels can fall rapidly with intravenous insulin, and if blood glucose falls below 14 mmol/L, IV fluids should include glucose. \n\n# Prognosis\n\nEarly detection and treatment results in good outcomes for patients with DKA, with many children discharged within a few days of DKA. Poorer outcomes are associated with delays in treatment and the development of cerebral oedema. \n\n\n# NICE Guidelines\n\n[BNFC Treatment Summaries: Diabetic hyperglycaemic emergencies](https://bnfc.nice.org.uk/treatment-summaries/diabetic-hyperglycaemic-emergencies/) \n \n\n# References\n \n[BSPED Guidelines for Management of DKA in Children](https://www.bsped.org.uk/media/1959/dka-guidelines.pdf)\n \n[Patient Info: Childhood ketoacidosis](https://patient.info/doctor/childhood-ketoacidosis#ref-2)",
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"explanation": "# Drug choice feedback\n\nAny rapid-acting or short-acting insulin is appropriate for the treatment of diabetic ketoacidosis. Common ones include NovoRapid/Humalog and Actrapid/Humilin S respectively. Prescribing insulin by brand name is acceptable; an exception is made as each brand of insulin may have different formulations even if it belongs to the same class as another.\n\n# Dose/Route/Frequency/Duration feedback\n\nThe dose of insulin to be administered is 0.1units/kg/hour IV. Since the patient's weight is 75kg, the dose is 7.5 units per hour IV. S/C administration is not appropriate for the treatment of DKA.",
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"explanation": "# Summary\n \nMeningitis is a potentially life-threatening condition characterised by the inflammation of the meninges, the membranes enveloping the brain and spinal cord. Its causes span from infectious agents, such as bacteria, viruses, fungi, and parasites, to non-infective causes like malignancy and certain medications. Symptoms are often non-specific, necessitating accurate differential diagnoses and prompt investigations. Timely management, including empirical antibiotics and targeted therapy post-identification of causative agent, is crucial to mitigate complications and improve patient outcomes. \n \n \n# Definition\n \n \nMeningitis is an inflammation of the meninges, which are composed of three layers: the dura mater, arachnoid mater, and pia mater. This inflammation may arise from both infective and non-infective aetiologies. \n \n \n# Epidemiology\n \n \nBacterial meningitis, while not the most common form of meningitis, is particularly significant due to its high morbidity and mortality rates. \n \nViral meningitis, predominantly caused by enteroviruses, is more common but typically less severe. Fungal and parasitic causes are relatively rare, except in immunosuppressed individuals. \n \nIn the United States, the annual incidence of bacterial meningitis is approximately 1.38 cases/100,000 population with a case fatality rate of 14.3%.\n\n# Aetiology\n \n \nInfective causes of meningitis include:\n \n \n - Bacterial: **Streptococcus pneumoniae (most common bacterial cause),** Neisseria meningitidis, Haemophilus influenzae, Listeria monocytogenes, among others.\n - Viral: **Enteroviruses are overall most common** (Echoviruses, Coxsackie viruses A and B, poliovirus), herpes viruses (HSV2, HSV1), Paramyxovirus, measles and rubella viruses, Varicella Zoster Virus, Arboviruses, Rabies virus.\n - Fungal: Particularly Cryptococcus neoformans, mainly affecting the immunosuppressed population.\n - Parasitic: Amoeba (Acanthamoeba), Toxoplasma gondii.\n \n \nNon-infective causes of meningitis encompass:\n \n \n - Malignancies such as leukaemia, lymphoma, and other tumours\n - Chemical meningitis\n - Certain drugs, including NSAIDs and trimethoprim\n - Systemic inflammatory diseases such as sarcoidosis, systemic lupus erythematosus, Behcet's disease.\n \n \n# Signs and Symptoms\n \n \nThe cardinal features of meningitis include:\n \n \n- Headache\n- Fever\n- Neck stiffness\n- Photophobia\n- Nausea and vomiting\n- Focal neurology\n- Seizures\n- Reduced conscious level\n- Features of overwhelming sepsis, such as non-blanching petechial rash indicative of impending Disseminated Intravascular Coagulation (DIC). \n \nSpecific signs suggestive of meningeal irritation (and therefore not specific to meningitis) include:\n \n \n1. **Kernig's sign:** Kernig's sign is a test performed to evaluate the presence of meningeal irritation and stiffness in the hamstrings and lower back. To perform this test, the patient is positioned lying on their back with the hip and knee flexed at 90 degrees. The examiner then attempts to extend the patient's knee. If the patient experiences pain and resistance to knee extension, especially when attempting to straighten the leg, it is considered a positive Kernig's sign. This sign suggests meningeal irritation or inflammation.\n \n \n2. **Brudzinski's sign:** Brudzinski's sign is another manoeuvre used to assess for meningeal irritation. This test involves passive neck flexion, where the examiner gently flexes the patient's neck forward toward the chest while the patient is lying on their back. If the patient involuntarily flexes their hips and knees in response to neck flexion, it is considered a positive Brudzinski's sign. This involuntary movement indicates irritation of the meninges.\n \n \n \n \n# Differential Diagnosis\n \nThe key differentials for meningitis often present with overlapping symptoms. These include:\n \n \n- **Encephalitis**: Headache, fever, altered consciousness, seizures, focal neurological signs, behaviour changes.\n- **Subarachnoid hemorrhage**: Sudden severe headache, nausea and vomiting, neck stiffness, altered consciousness, seizures.\n- **Brain abscess**: Headache, fever, nausea and vomiting, focal neurological deficits, seizures, altered mental status.\n- **Sinusitis**: Headache, fever, facial pain, nasal congestion.\n- **Migraine**: Recurrent headaches, often unilateral and throbbing, accompanied by nausea/vomiting, photophobia, phonophobia.\n \n \n# Investigations\n \n \nDiagnostic investigations for suspected meningitis include:\n \n \n - Blood tests: Full Blood Count, Urea and Electrolytes, Clotting, Glucose, PCT\n - Arterial Blood Gas\n - Blood cultures\n - Bacterial throat swab for meningococcus\n - PCR for meningococcus & pneumococcus\n - HIV test\n - Imaging: CT Head if there are signs of raised intracranial pressure (ICP)\n - Lumbar puncture for Cerebrospinal Fluid (CSF) analysis, once confirmed there are no signs of raised ICP.\n \n \n## CSF Findings \n \n \nAnalysis of the cerebrospinal fluid in acute meningitis can provide important clues as to the underlying aetiology. Once establishing that it is safe to do so, a CSF sample should be taken via lumbar puncture and the opening pressure should be measured.\n \n \nThis can be examined macroscopically, and then sent for haematology, biochemistry, and microbiological microscopy, culture and sensitivities, as well as PCR.\n \n| | **Appearance** | **Predominant cell type** | **Culture** | **Protein** | **Glucose** |\n|---------------------------|-------------------------------------|---------------------------------------------------|--------------------------------------------------------|-------------|-------------|\n| **Bacterial meningitis** | Clear or turbid | **Polymorphonuclear** cells (i.e. neutrophils) | Positive | Raised | **Reduced** |\n| **Aseptic (viral) meningitis** | Clear or slightly turbid | **Lymphocytes** | Negative | Raised | **Normal** |\n| **Tuberculous meningitis** | Clear or slightly turbid ± fibrin web | **Lymphocytes** + polymorphonuclear cells | Negative gram stain; acid-fast bacilli positive (auramine staining) | Raised | **Reduced** |\n\n \nN.b. Cryptococcal meningitis may give any of the above results, so should be considered as a differential in any HIV or immunocompromised patient. Classically the opening pressure is very high, and this is a poor prognostic sign. If suspected, request cryptococcal antigen or India Ink staining.\n \n \n# Management\n \n \n- Empirical antibiotic therapy for suspected bacterial meningitis typically includes 2g of IV ceftriaxone twice daily to ensure CNS penetration, with IV amoxicillin added in patients at age extremes for listeria coverage.\n- In primary care, IM benzylpenicillin or ceftriaxone should be given while awaiting urgent transfer to hospital, especially if meningococcal disease is suspected.\n- Dexamethasone should be given if bacterial meningitis is strongly suspected in the absence of a rash\n\t- This has been shown to reduce neurological sequelae in bacterial meningitis but not meningococcal meningitis\n- In cases of suspected viral encephalitis, IV aciclovir should also be administered. For patients allergic to penicillin, alternatives such as chloramphenicol may be used. \n- It's important to note that any empirical antibiotic regimen should be adjusted based on culture results when available.\n \n **Additional notes**\n \nClose contacts of the patient should receive prophylactic antibiotics. This will be guided by specialists but may be a single dose of oral ciprofloxacin, or rifampicin.\n \nBacterial meningitis is a notifiable disease and any suspected cases should be reported to the local health protection team.\n \n \n# Complications\n \n \nMeningitis may lead to severe complications if not promptly treated, such as:\n \n - Septic shock\n - Disseminated Intravascular Coagulation\n - Coma\n - Subdural effusions\n - Syndrome of inappropriate antidiuretic hormone secretion\n - Seizures\n - Delayed complications: Hearing loss, cranial nerve dysfunction, hydrocephalus, intellectual deficits, ataxia, blindness\n - Death\n \n \n# NICE guidelines\n \n [NICE CKS: Meningitis - bacterial meningitis and meningococcal disease](https://cks.nice.org.uk/topics/meningitis-bacterial-meningitis-meningococcal-disease/)\n \n [NICE: meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management](https://www.nice.org.uk/guidance/ng240/resources/meningitis-bacterial-and-meningococcal-disease-recognition-diagnosis-and-management-pdf-66143949881029)\n \n# References\n \n [BNF: Ciprofloxacin](https://bnf.nice.org.uk/drugs/ciprofloxacin/)",
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"question": "Case Presentation: A 25-year-old lady is brought to the Emergency Department with sudden-onset high fever, headache, photophobia and stiff neck. She is confused and is disoriented to time and place. No seizures reported.\n\n\n\n\n## PH and DH NIL (NKDA)\n\n\n## On examination\n\n\nAppears lethargic and irritable. Refuses food and drink. Photophobia noted. CRT 3s, peripheries cool. No rash, Kernig's and Brudzinski's sign positive. No neurological deficits.\n\n\nTemperature 39.6°C, HR 98, RR 22, BP 110/88, O2 98% RA, GCS 12, Weight 68kg\n\n\n## Investigations\n\n\n||||\n|--------------|:-------:|---------------|\n|Haemoglobin|144 g/L|(M) 130 - 170, (F) 115 - 155|\n|White Cell Count|15.3x10<sup>9</sup>/L|3.0 - 10.0|\n|Platelets|320x10<sup>9</sup>/L|150 - 400|\n|Sodium|139 mmol/L|135 - 145|\n|Potassium|4.2 mmol/L|3.5 - 5.3|\n|Chloride|102 mmol/L|95 - 106|\n|Urea|7.2 mmol/L|2.5 - 7.8|\n|Creatinine|80 µmol/L|60 - 120|\n|eGFR|>90 mL/min/1.73m<sup>2</sup>|> 60|\n|International Normalised Ratio (INR)|1.0|1.0|\n|Non-fasting Glucose|6.2 mmol/L|< 6.1|\n\n\nBlood cultures: pending\n\n\nLumbar puncture: not yet performed\n\n\n# Prescribing Request\n\n\nWrite a prescription for one antibiotic that is most appropriate to treat her condition empirically.",
"sbaAnswer": null,
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173,458,632 | false | 5 | null | 6,494,967 | null | false | [] | null | 6,786 | {
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33839",
"label": "a",
"name": "Pramipexole;2mg;oral (PO);12-hourly",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33840",
"label": "b",
"name": "Atenolol;50mg;oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33845",
"label": "g",
"name": "Paracetamol;1000mg;oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33841",
"label": "c",
"name": "Alendronic acid;70mg;oral (PO);Weekly",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33842",
"label": "d",
"name": "Cholecalciferol 200 units + calcium carbonate 750mg (Adcal D3 ®);2 tablets;oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33844",
"label": "f",
"name": "Metformin;500mg;oral (PO);8-hourly",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33843",
"label": "e",
"name": "Lansoprazole;15mg;oral (PO);Daily",
"picture": null,
"votes": 0
}
],
"comments": [
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"comment": "Oral in frequency... seems like an error too...",
"createdAt": 1664933439,
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"comment": "BNF says common side effect of lansoprazole is insomnia ??",
"createdAt": 1675467761,
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"comment": "1g of paracetamol oral daily isnt right.. surely it would be qds like in every other question Ive seen?",
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"comment": "it's not the maximum dose sure but it isn't a serious dosing error",
"createdAt": 1706823803,
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"comment": "I put the correct answers but was marked incorrect?",
"createdAt": 1706619700,
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"demo": null,
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"id": "2719",
"name": "Sleeping disorder & dosing error",
"status": null,
"topic": {
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"id": "75",
"name": "GP",
"typeId": 5
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"topicId": 75,
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"explanation": "1. Pramipexole, a non-ergoline dopamine agonist and systemic beta blockers (atenolol) commonly cause sleeping disorders. Although excess daytime sleepiness and sleep attacks are recognized side effects of pramipexole, the underlying pathophysiology remained controversial. Beta blockers cause night awakening and nightmares, likely due to the inhibition of melatonin secretion, a hormone that is involved in sleep and the body’s circadian clock\n2. Pramipexole, given for treatment of Parkinson's Disease has a maximum dose of 3.3mg daily. 2mg 12-hrly is more than the recommended maximum dose and alternative adjuncts should be considered instead.",
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"question": "Case presentation: An 80-year-old woman presents to her GP for her medication review, she complains of fatigue due to poor sleep. PH Osteoporosis, Type 2 diabetes, Dyspepsia, Parkinson Disease, hypertension. DH Her current regular medicines are listed (below).\n\n\nQuestion 1: Select the TWO prescriptions that are most likely to be contributing to her sleeping disorders (mark them with a tick in column A)\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).",
"sbaAnswer": null,
"totalVotes": 0,
"typeId": 3,
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} | MarksheetMark |
173,458,633 | false | 6 | null | 6,494,967 | null | false | [] | null | 6,783 | {
"__typename": "QuestionMultiA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33818",
"label": "a",
"name": "Labetalol;80mg;hourly;intravenous (IV)",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33822",
"label": "e",
"name": "Levothyroxine sodium;100mg;Daily;oral (PO)",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33820",
"label": "c",
"name": "Carbamazepine;100mg;12-hourly;oral (PO)",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33821",
"label": "d",
"name": "Gabapentin;300mg;8-hourly;oral (PO)",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33824",
"label": "g",
"name": "Metformin;1g; Daily;oral (PO)",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33819",
"label": "b",
"name": "Fluoxetine;20mg;Daily;oral (PO)",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33823",
"label": "f",
"name": "Aspirin;75mg;Daily;oral (PO)",
"picture": null,
"votes": 0
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "i mean the gabapentin is frequency not known on the bnf so this is just a shit question, better off putting just two options ",
"createdAt": 1706636013,
"dislikes": 0,
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"comment": "The BNF often has 'frequency not known' even for potentially well known side effects. This usually when the drugs are quite old and didnt have the same testing requirements as today.",
"createdAt": 1709755892,
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"id": "2716",
"name": "Dosing error & drugs causing hyponatraemia",
"status": null,
"topic": {
"__typename": "Topic",
"id": "76",
"name": "Obstetrics and Gynaecology",
"typeId": 5
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"explanation": "1. Hyponatremia is a recognised complication of selective serotonin re-uptake inhibitors (fluoxetine), carbamazepine and gabapentin, via syndrome of inappropriate antidiuretic hormone secretion (SIADH).\n2. Maintenance dose of levothyroxine sodium is prescribed as 100-200 micrograms daily, not milligrams.",
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"question": "Case presentation: A 22-week pregnant woman who is 30 years old is admitted to the emergency department with suspected pre-eclampsia. PH Type 2 Diabetes mellitus, Epilepsy, Depression, Hashimoto’s Disease. DH Her current regular medications are listed (below).\n\n\n\n\n **On Examination**\nAbdominal tenderness, bilateral swelling of ankles.\n\n\n **Investigation**\nBP 145/95 mmHg. Na 120 mmol/L (135-145) Urine dipstick ++ protein\n\n\nQuestion 1: Select the THREE prescriptions that are most likely to be contributing to her hyponatremia (mark them with a tick in column A)\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).",
"sbaAnswer": null,
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} | MarksheetMark |
173,458,634 | false | 7 | null | 6,494,967 | null | false | [] | null | 6,780 | {
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"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33798",
"label": "d",
"name": "Acebutolol;400mg;oral (PO);12-hourly",
"picture": null,
"votes": 0
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33800",
"label": "f",
"name": "Dexibuprofen;200mg;oral (PO);8-hourly",
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"votes": 0
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"explanation": null,
"id": "33795",
"label": "a",
"name": "Amlodipine;10mg;oral (PO);Daily",
"picture": null,
"votes": 0
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "33803",
"label": "i",
"name": "Diazepam;2mg;oral (PO);8-hourly",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33802",
"label": "h",
"name": "Co-codamol 8-500mg;1 tablet;oral (PO);6-hourly",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33796",
"label": "b",
"name": "Ramipril;2.5mg;oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33797",
"label": "c",
"name": "Indapamide;1.5mg;oral (PO);Daily",
"picture": null,
"votes": 0
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33801",
"label": "g",
"name": "Omeprazole;40mg;oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33799",
"label": "e",
"name": "Tamsulosin;400micrograms;oral (PO);Daily",
"picture": null,
"votes": 0
}
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{
"__typename": "QuestionComment",
"comment": "diazepam and co codamol can definitely cause confusion in an elderly patient... ",
"createdAt": 1703264452,
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"id": "36681",
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"comment": "this has got an error?! correct explanation but you've marked the wrong answers ",
"createdAt": 1703264498,
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"comment": "BNF says dexibuprofen -> “Patients commonly present with confusion” ?!",
"createdAt": 1721832568,
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"id": "2713",
"name": "Drugs causing confusion and bradycardia",
"status": null,
"topic": {
"__typename": "Topic",
"id": "74",
"name": "Elderly Care",
"typeId": 5
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"explanation": "1. The patient has developed AKI, which can result in a reduction in the clearance of his medication and an increase in adverse effects. The mechanism for confusion caused by benzodiazepine and codeine remains unknown, although the incidence is noted to be higher in the elderly population and in patient with decreased renal function due to a reduction in the clearance of the medication. Similarly, in geriatric patients, the bioavailability of acebutolol and its metabolite increases approximately by two-fold, due to the decrease in first pass metabolism and renal function in the elderly. Retention of codeine (co-codamol), diazepam and acebutolol in this patient may contribute to the patient’s confusion\n2. Acebutolol is a cardio-selective beta-adrenergic antagonist, which acts on the beta-1 receptors in the heart causing a reduction in heart rate and contractility. Ramipril can cause arrythmia but acebutolol, specifically, causes bradycardia.",
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"question": "Case presentation: A 75-year-old man is admitted to the care of the elderly ward following a urinary tract infection. PH Hypertension, Alzheimer’s Disease, BPH, Osteoarthritis, Severe anxiety. DH. His current regular medications are listed (below).\n\n\n\n\n **On Examination**\n\nHR 50/min regular, BP 135/75mmHg. He appears confused.\n\n\n **Investigation**\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Urea|8.5 mmol/L|2.5 - 7.8|\n|Creatinine|125 µmol/L|60 - 120|\n\n\nQuestion 1: Select the THREE prescriptions that are most likely to be contributing to his confusion (mark them with a tick in column A)\n\nQuestion 2: Select the ONE prescriptions that are most likely to be a cause of his bradycardia (mark them with a tick in column B).",
"sbaAnswer": null,
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173,458,635 | false | 8 | null | 6,494,967 | null | false | [] | null | 6,789 | {
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"answer": false,
"explanation": null,
"id": "33865",
"label": "d",
"name": "Omeprazole;20mg;Oral (PO);Daily",
"picture": null,
"votes": 0
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33864",
"label": "c",
"name": "Bendroflumethiazide;2.5 mg;Oral (PO);Daily",
"picture": null,
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "33867",
"label": "f",
"name": "Salmeterol;50 micrograms;Inhaled (INH);12-hourly",
"picture": null,
"votes": 0
},
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "33869",
"label": "h",
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"picture": null,
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "33863",
"label": "b",
"name": "Perindopril erbumine;8 mg;Oral (PO);Daily",
"picture": null,
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},
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "33868",
"label": "g",
"name": "Theophylline (Uniphyllin Continus®);200mg;Oral (PO);12-hourly",
"picture": null,
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},
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"explanation": null,
"id": "33866",
"label": "e",
"name": "Simvastatin;40mg;Oral (PO);Daily",
"picture": null,
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},
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"id": "33862",
"label": "a",
"name": "Amlodipine;5mg;Oral (PO);Daily",
"picture": null,
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}
],
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{
"__typename": "QuestionComment",
"comment": "Budesonide also causes hypokalaemia",
"createdAt": 1643564920,
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"comment": "Hypomagnesaemia (caused by omeprazole) can also precipitate hypokalaemia ",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"id": "2722",
"name": "Myopathy & drugs causing hypokalemia",
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"explanation": "1. Bendroflumethiazide is a thiazide-like diuretic. It inhibits the Na+/Cl- cotransporter at the distal convoluted tubule of nephron, leading to reduced Na+ reabsorption. As a result of the reduced reabsorption, the concentration of Na+ left in the urine increases. The increase in Na+ availability increases the activity of Na+/K+-ATPase in the collecting duct and brings about an increase in excretion of K+ into the urine. Salmeterol is a long-acting β2 adrenergic receptor agonist (LABA). β2 adrenergic receptor agonist decreases the serum K+ level via an inward shift of K+ into the cells. Theophylline is a phosphodiesterase inhibitor. It is also known to cause hypokalaemia. BNF highlights that concomitant treatment of β2 adrenergic receptor agonist with theophylline may potentiate potentially serious hypokalaemia.\n2. Myalgia is a common or very common side effect of simvastatin.",
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"question": "Case presentation: A 49-year old man presents to the emergency walk-in clinic with muscle weakness and constipation. He also complains that he has been having pain in the muscles of his upper arms. PH: Hypertension, Asthma, GORD, Hypercholesterolaemia DH: Her current regular prescriptions are listed below\n\n\n\n\n **On examination**: Chest is clear with no added lung sounds. Heart sounds I + II + 0. Abdomen soft and non tender.\n\n\n **Vital signs**: BP 125/80, Temperature 36.5°C, HR 80, O2 Sat 99% (room air), RR 18\n\n\n **Investigations**:\n\n\n - ECG: Prolonged QT, mild ST depression, presence of U wave\n\n\n||||\n|--------------|:-------:|---------------|\n|Haemoglobin|130 g/L|(M) 130 - 170, (F) 115 - 155|\n|White Cell Count|5x10<sup>9</sup>/L|3.0 - 10.0|\n|Platelets|320x10<sup>9</sup>/L|150 - 400|\n|Mean Cell Volume (MCV)|95 fL|80 - 96|\n|Neutrophils|5x10<sup>9</sup>/L|2.0 - 7.5|\n|Lymphocytes|2x10<sup>9</sup>/L|1.5 - 4.0|\n|Sodium|140 mmol/L|135 - 145|\n|Potassium|3 mmol/L|3.5 - 5.3|\n|Urea|7 mmol/L|2.5 - 7.8|\n|Creatinine|109 µmol/L|60 - 120|\n\n\nQuestion 1: Select the THREE prescriptions that are most likely to be a cause of his hypokalaemia (mark them with a tick in column A)\nQuestion 2: Select the ONE prescription that should be withheld in view of the patient’s myopathy? (mark it with a tick in column B)",
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173,458,636 | false | 9 | null | 6,494,967 | null | false | [] | null | 6,781 | {
"__typename": "QuestionMultiA",
"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33806",
"label": "c",
"name": "Omeprazole;40mg;oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33807",
"label": "d",
"name": "Salbutamol;200 micrograms;inhaled (INH);Daily",
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"votes": 0
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"id": "33804",
"label": "a",
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"id": "33809",
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"name": "Colecalciferol (Vitamin D3);800units;oral (PO);Daily",
"picture": null,
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"id": "33805",
"label": "b",
"name": "Ibuprofen;400mg;oral (PO);8-hourly",
"picture": null,
"votes": 0
},
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"__typename": "QuestionChoice",
"answer": false,
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"id": "33810",
"label": "g",
"name": "Dalteparin sodium;12500 units;subcutaneous (SC);Daily",
"picture": null,
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"label": "e",
"name": "Ipratropium bromide;40micrograms;inhaled (INH);6-hourly",
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}
],
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"comment": "all of these need looking at. ive put the correct answers for both and its marked them wrong.",
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"comment": "my answers got changed as well",
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"comment": "Omeprazole dose for both GORD and NSAID prophylaxis is 20mg OD, ",
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"comment": "How would you know it is a prophylaxis dose and not a treatment dose? Is it just because he is in hospital?",
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"comment": "well salbutamol is wrong surely it should be PRN?",
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"comment": "I thought similarly- with a PMH of severe COPD they're surely not using salbutamol once daily.",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"name": "Drugs causing diarrhoea & dosing error",
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"id": "74",
"name": "Elderly Care",
"typeId": 5
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"explanation": "1. Co-amoxiclav, proton pump inhibitors (omeprazole) commonly cause diarrhea. Oral use of ibuprofen generally do not cause diarrhea.\n2. Dalteparin sodium, given for prophylaxis of DVT in medical patients are prescribed at 5000 units daily. 12 500 units is given as treatment dose for a 60kg patient. The indication of dalteparin in this patient is for prophylactic use, not for treatment.",
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"question": "Case presentation: A 85-year-old man was admitted to the Acute Medical Unit for infective exacerbation of COPD.\n\n\n**PH** Severe COPD, Migraine, GORD, Osteoporosis.\n\n**DH** His current regular medications are listed (below). Weight 60kg.\n\n**On Examination**\nPatient complained of loose stools over the past 3 days. Dry mucous membrane, peripheral CRT 3s.\n\nQuestion 1: Select the TWO prescriptions that are most likely to be contributing to his loose stools (mark them with a tick in column A)\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).",
"sbaAnswer": null,
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173,458,637 | false | 10 | null | 6,494,967 | null | false | [] | null | 6,823 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Tetracyclines are recommended as first line oral agents to treat acne vulgaris that has not responded to topical treatments. NICE recommends combination therapy (as opposed to antibiotic monotherapy), with topical azelaic acid.",
"id": "34060",
"label": "a",
"name": "Topical azelaic acid and Doxycycline 100mg PO OD",
"picture": null,
"votes": 4956
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an alternative topical treatment for acne vulgaris which is less effective than the treatment that the patient is currently using",
"id": "34061",
"label": "b",
"name": "Azelaic acid 20% cream (Skinoren) topical BD",
"picture": null,
"votes": 489
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an alternative oral antibiotic agent used to treat acne vulgaris where first line oral treatments are unsuitable",
"id": "34064",
"label": "e",
"name": "Trimethoprim 300mg PO BD",
"picture": null,
"votes": 40
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an alternative oral antibiotic agent used to treat acne vulgaris where first line oral treatments are unsuitable",
"id": "34062",
"label": "c",
"name": "Erythromycin 500mg PO BD",
"picture": null,
"votes": 527
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Isotretinoin is a retinoid medication used to treat severe acne vulgaris. It should not be prescribed in the primary care setting without specialist assessment",
"id": "34063",
"label": "d",
"name": "Isotretinoin 20mg PO BD",
"picture": null,
"votes": 237
}
],
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case Presentation: A 19 year old man attends a follow-up appointment at his GP. **PH** acne vulgaris. **DH** 3% benzoyl peroxide with 1% clindamycin gel (Duac). He has been using this for twelve weeks following failure to improve his condition with benzoyl peroxide gel alone.\n\n\n**O/E**\n\nHe has a uniform distribution of open and closed comedones with occasional pustules on his face and upper back. No scarring or nodularity present.\n\nQuestion: Select the most appropriate management at this stage.",
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173,458,638 | false | 11 | null | 6,494,967 | null | false | [] | null | 6,815 | {
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Up-titrating doses of SSRIs should be done where there has been an inadequate response to the initial starting dose",
"id": "34022",
"label": "c",
"name": "Maintain his current fluoxetine dose and review after 2 weeks",
"picture": null,
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},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Combination therapy with SSRIs is not routinely recommended due to the increased risk of developing serotonin syndrome",
"id": "34021",
"label": "b",
"name": "Add sertraline 50mg PO OD to his current prescription",
"picture": null,
"votes": 79
},
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"__typename": "QuestionChoice",
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"explanation": "Switching to a non-SSRI antidepressant may be done in the primary care setting by experienced clinicians, but it is recommended to attempt to elicit a beneficial response with at least two SSRIs beforehand",
"id": "34024",
"label": "e",
"name": "Switch his prescription to mirtazapine 15mg PO OD",
"picture": null,
"votes": 379
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Up-titrating doses of SSRIs should be done where there has been an inadequate response to the initial starting dose. The highest dose of fluoxetine that can be prescribed is 60mg",
"id": "34020",
"label": "a",
"name": "Increase the dose of fluoxetine to 40mg PO OD and review after 1 week",
"picture": null,
"votes": 4396
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "SSRIs may be switched where there has been an inadequate response to previously tried SSRIs after up-titration",
"id": "34023",
"label": "d",
"name": "Switch his prescription to citalopram 20mg PO OD",
"picture": null,
"votes": 516
}
],
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{
"__typename": "QuestionComment",
"comment": "SSRIs can take 6 weeks to have an effect so why would we be uptitrating after 4 weeks?",
"createdAt": 1675255816,
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"comment": "The BNF says: Patients should be reviewed every 1–2 weeks at the start of antidepressant treatment. Treatment should be continued for at least 4 weeks (6 weeks in the elderly) before considering whether to switch antidepressant due to lack of efficacy. In cases of partial response, continue for a further 2–4 weeks (elderly patients may take longer to respond).\n\nSo i guess it depends on how you interpret the question as to whether you think it was a partial response or not. Hope this helps!\n",
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"comment": "If there is limited or no improvement with antidepressant medication alone, options include:\nAugmenting with group exercise.\nSwitching to a psychological intervention.\nSee the section on Initial management for more information on choices of psychological intervention.\nIncreasing the antidepressant dose or switching the antidepressant to a drug in the same class or different class.\n\ncan do either?",
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"comment": "I thought the SSRI was causing thoughts of suicide which is why I stopped it",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"name": "Depression Therapy Titration",
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"question": "Case Presentation: A 27 year old man attends a follow-up appointment with his GP. He initially presented one month ago with markedly low mood, loss of interest in his usual activities and feeling tired all the time. His GP diagnosed him with major depressive disorder and prescribed fluoxetine 20mg PO OD.\n\n\n**O/E**\n\nWhen asked about any improvement in his symptoms, the patient reports only a very slight lift to his mood that ‘may as well be the same as before’. He still experiences difficulty sleeping and only leaves the house to work his part-time job as a landscaper, but is finding that increasingly challenging. He says he has infrequent suicidal thoughts, and while he is adamant that he would never act on them in reality, he feels that he really ‘can’t go on like this for much longer’.\n\nQuestion: Select the most appropriate management at this stage.",
"sbaAnswer": [
"a"
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173,458,639 | false | 12 | null | 6,494,967 | null | false | [] | null | 6,821 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Patients with gout who are taking anti-uric acid medications should not switch their drugs during an acute flare as this can worsen symptoms",
"id": "34051",
"label": "b",
"name": "Change allopurinol to febuxostat 120mg PO OD",
"picture": null,
"votes": 13
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Patients with gout who are taking anti-uric acid medications should not discontinue their drugs during an acute flare as this can worsen symptoms",
"id": "34054",
"label": "e",
"name": "Stop allopurinol and prescribe prednisolone 20mg PO for 7 days",
"picture": null,
"votes": 71
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Patients with gout who are taking anti-uric acid medications should continue their drugs and receive treatment with anti-inflammatories. As NSAIDs should be avoided in this patient, colchicine can be given as an alternative",
"id": "34050",
"label": "a",
"name": "Continue allopurinol and prescribe colchicine 500 micrograms PO BD for 3 days",
"picture": null,
"votes": 4354
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Patients with gout who are taking anti-uric acid medications should not discontinue their drugs during an acute flare as this can worsen symptoms",
"id": "34053",
"label": "d",
"name": "Stop allopurinol and prescribe naproxen sodium 500mg PO stat",
"picture": null,
"votes": 343
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Patients with gout who are taking anti-uric acid medications should continue their drugs and receive treatment with anti-inflammatories. NSAIDs are generally recommended first line but this patient has a history of GORD and hence they would not be suitable",
"id": "34052",
"label": "c",
"name": "Continue allopurinol and prescribe diclofenac sodium 75mg PO BD for 7 days",
"picture": null,
"votes": 427
}
],
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"__typename": "QuestionComment",
"comment": "Why should NSAIDs be avoided in this patient?",
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"comment": "GORD, increased GI bleeding",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case Presentation: A 48 year old man presents to his GP with a 48 hour history of pain in his right foot. **PH** type 2 diabetes, GORD, gout. **DH** metformin hydrochloride 500mg PO TDS, sitagliptin 100mg PO OD, esomeprazole 20mg PO OD, allopurinol 200mg PO OD, paracetamol 1g PO QDS.\n\n\n**O/E**\n\nSwollen, erythematous 1st metatarsophalangeal joint on right foot. No other joints involved. Left foot grossly normal.\n\nTemperature 36.4°C.\n\nQuestion: Select the most appropriate management at this stage.",
"sbaAnswer": [
"a"
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"__typename": "QuestionSBA",
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Isotretinoin is a retinoid medication used to treat severe acne vulgaris. It should not be prescribed in the primary care setting or to a woman of childbearing age absent a pregnancy prevention plan due to its potent teratogenic effects",
"id": "34031",
"label": "b",
"name": "Isotretinoin 20mg PO BD",
"picture": null,
"votes": 88
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{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an alternative topical treatment for acne vulgaris",
"id": "34033",
"label": "d",
"name": "Nicotinamide gel topical BD",
"picture": null,
"votes": 15
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{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an oral treatment option for acne vulgaris that has not responded to topical treatments",
"id": "34034",
"label": "e",
"name": "Tetracycline 500mg PO BD",
"picture": null,
"votes": 267
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "For females with PCOS that have not improved following treatment with a first line option such as topical treatments, consider adding ethinylestradiol with cyproterone (co-cyprindiol) and review at 6 months, as per [NICE Guidance.](https://www.nice.org.uk/guidance/ng198/chapter/Recommendations)",
"id": "34030",
"label": "a",
"name": "Co-cyprindiol 2000/35 micrograms PO OD",
"picture": null,
"votes": 2110
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a combined contraceptive pill formulation. This is recommended as second line treatment (though it is unlicensed) for acne in patients with PCOS if co-cyprindiol is ineffective, as per [NICE Guidelance.](https://www.nice.org.uk/guidance/ng198/chapter/Recommendations)",
"id": "34032",
"label": "c",
"name": "Combined oral contraceptive pill",
"picture": null,
"votes": 2737
}
],
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"__typename": "QuestionComment",
"comment": "is co-cyprindiol not regarded as a COCP? im confused",
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"comment": "i think they just want you to be more specific - co-cyprindiol is the best for hirsutism and pcos related symptoms out of all the cocp, and this is an SBA so it's a better answer. can try other formulations afterwards if co-cyprindiol not effective",
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"comment": "the co-cyprindiol guidelines can be found under acne treatment summary and then 'reassessment and further treatment' If anyone was wondering :)",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"id": "2750",
"name": "Polycystic Ovary Syndrome",
"status": null,
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"typeId": 5
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"question": "Case Presentation: A 28 year old woman presents to her GP with a longstanding history of acne. She has tried various topical creams and ointments in the past that have only resulted in very modest improvement, and wonders if there is anything else that can be prescribed. **PH** acne vulgaris. **DH** benzoyl peroxide gel, azelaic acid 20% cream (Skinoren).\n\n\nHer BMI is 28kg/m^2. On further questioning, she also reveals that she has had to engage in waxing her upper lip and chin since the age of 17, and describes erratic menstrual cycles ranging anywhere from 21 days to as long as 90 days. She has never been pregnant before, is sexually active and uses barrier protection as contraception as she is not looking to start a family.\n\nQuestion: Select the most appropriate management at this stage.",
"sbaAnswer": [
"a"
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"typeId": 1,
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"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Palivizumab is a humanised monoclonal antibody that is used to prevent RSV infections in children at higher risk of severe disease. It is not routinely given without specialist paediatric input",
"id": "34003",
"label": "d",
"name": "Palivizumab 15mg IM",
"picture": null,
"votes": 61
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Bronchiolitis is generally managed conservatively unless there is evidence of disease severity (e.g cyanosis, <50% oral intake)",
"id": "34000",
"label": "a",
"name": "No additional treatment is required",
"picture": null,
"votes": 3232
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Phenoxymethylpenicillin may be given to treat streptococcal infections. There is no evidence such an infection is present in the stem",
"id": "34004",
"label": "e",
"name": "Phenoxymethylpenicillin 125mg PO",
"picture": null,
"votes": 143
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Dexamethasone is an anti-inflammatory steroid medication commonly used to treat croup in the paediatric population. It has no role in the acute management of bronchiolitis",
"id": "34002",
"label": "c",
"name": "Dexamethasone 1.5mg PO",
"picture": null,
"votes": 869
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Although fluid resuscitation may be necessary if the child is dehydrated due to reduced oral intake, there is nothing in the stem to support this",
"id": "34001",
"label": "b",
"name": "0.9% normal saline 200ml IV",
"picture": null,
"votes": 532
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Not sure about his hydration level.",
"createdAt": 1647178611,
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"__typename": "QuestionComment",
"comment": "''Although fluid resuscitation may be necessary if the child is dehydrated due to reduced oral intake, there is nothing in the stem to support this'' - dude the stem says reduced oral intake\n\n",
"createdAt": 1647179756,
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"name": "Bronchiolitis",
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"__typename": "Topic",
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"question": "Case Presentation: A 15 month old boy is brought to A&E by his parents with fever, cough and reduced oral intake.\n\n\n**O/E**\n\nTemperature 37.8°C. HR 104, RR 32 with persistent non-productive cough. O2 95% RA. Scattered fine crepitations and audible wheeze on auscultation. Appears pale pink and not cyanosed. Weight 10kg.\n\nHe has been given paracetamol oral suspension (Calpol Infant 120mg/5ml) 120mg PO and started on 4L oxygen wafted via simple face mask.\n\nQuestion: Select the most appropriate management at this stage.",
"sbaAnswer": [
"a"
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"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A pill is considered missed if 24 hours have passed since the time it should be taken",
"id": "34152",
"label": "c",
"name": "A pill is considered missed if it has been more than 12 hours since the time it should be taken",
"picture": null,
"votes": 187
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "She does not need emergency contraception because she would already have been protected against pregnancy if COCO was consistently taken in the previous 7 days",
"id": "34154",
"label": "e",
"name": "She needs emergency contraception if she misses two pills and has unprotected sexual intercourse in week two after hormone free interval",
"picture": null,
"votes": 860
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "If 2 or more pills have been missed in week 3, the patient should take the most recent missed pill, omit the hormone free interval and take the precautionary step of using an additional barrier contraception until 7 consecutive pills have been taken",
"id": "34150",
"label": "a",
"name": "She should omit the upcoming hormone free interval if she misses two or more pills in week three",
"picture": null,
"votes": 1853
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "If a patient starts taking COCP within the first 5 days of period, she will be protected from pregnancy straight away. However, since the patient is in day 9 of her menstrual cycle, she should avoid sexual intercourse or use a barrier method of contraception such as a condom for the first 7 days",
"id": "34151",
"label": "b",
"name": "There is no need for additional contraception as COCP offers immediate protection once taken",
"picture": null,
"votes": 27
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": ". If the patient has missed a pill, she should take the last missed pill (and leave any earlier missed pills if she missed more than 1 pills) immediately, even if this means that she is taking 2 pills in 1 day",
"id": "34153",
"label": "d",
"name": "She should never take a double dose to replace a missed dose",
"picture": null,
"votes": 88
}
],
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"explanation": "# Summary\n \n\nThe combined oral contraceptive pill (COCP) is a long-term contraceptive containing synthetic oestrogen and progestogen. It works by inhibiting ovulation, thickening cervical mucus, and altering the endometrium to prevent fertilisation and implantation. Indications for COCP use include contraception, menstrual cycle regulation, and treatment of dysmenorrhea, menorrhagia, acne, and hirsutism. Contraindications are categorised by UKMEC criteria, detailed in this chapter. \n \n# Definition\n \n\nThe combined oral contraceptive pill (COCP) is a long-term contraceptive. It contains synthetic versions of the female hormones oestrogen and progestogen. \n \n\n# Mechanism of Action\n \n\n* **Inhibition of Ovulation:** The COCP contains synthetic versions of the hormones oestrogen and progestogen. These hormones together suppress the release of gonadotrophins (LH and FSH) from the pituitary gland, preventing the maturation and release of an egg from the ovaries.\n \n\n* **Thickening of Cervical Mucus:** The progestogen component of the COCP increases the viscosity of cervical mucus, making it more difficult for sperm to enter the uterus and fertilise an egg.\n \n\n * **Alteration of the Endometrium:** The COCP induces changes in the lining of the uterus (endometrium), making it less suitable for the implantation of a fertilised egg.\n \n\n# Indications\n \n\nThere are a range of reasons for women to be recommended the oral combined contraceptive pill. For example:\n \n\n* **Contraception:** The COCP works as a long-term contraception. It is taken orally once a day, at around the same time each day. \n * **Menstrual Cycle Regulation:** The COCP can help regulate irregular menstrual cycles. \n * **Dysmenorrhea:** The COCP may be used to reduce menstrual cramps. \n * **Menorrhagia:** The COCP can decrease heavy menstrual bleeding.\n * **Acne and Hirsutism:** The COCP helps in the treatment of acne and excessive hirsutism in women, which may happen in conditions such as polycystic ovary syndrome (PCOS) or other androgen excess conditions.\n * **Premenstrual Syndrome (PMHS**: The COCP can alleviate symptoms of PMS, such as mood swings, bloating, and irritability.\n \n# Contraindications \n \nThere are numerous contra-indications to the Combined Oral Contraceptive Pill. These can be divided into absolute contraindications, known as ''UKMEC 4'', a situation where the disadvantages outweigh the advantages (UKMEC 3), a situation where the advantages outweigh the disadvantages (UKMEC 2), and a situation whereby there is no limit on that choice of contraception (UKMEC 1).\n \n\n## Absolute Contraindications to Contraception (UKMEC 4)\n \n \n * Known or suspected pregnancy\n * Hypertension with SBP ≥160 mmHg or DBP ≥100 mmHg\n * Smoker over the age of 35 who smokes >15 cigarettes a day \n * Current and history of ischaemic heart disease\n * History of stroke (including TIA) \n * Vascular disease\n * History or current VTE\n * Major surgery with prolonged immobilisation\n * Breastfeeding <6 weeks postpartum\n * Not breastfeeding and <3 weeks postpartum with other risk factors for VTE\n * Known thrombogenic mutations \n * Complicated valvular and congenital heart disease\n * Cardiomyopathy with impaired cardiac function\n * Atrial fibrillation \n * Migraine with aura (any age)\n * Current breast cancer \n * Severe (decompensated) cirrhosis \n * Hepatocellular adenoma and hepatocellular carcinoma\n * Positive antiphospholipid antibodies \n \n \n \n## Disadvantages of a contraceptive outweigh the advantages (UKMEC 3)\n \n * Obesity (BMI ≥35 kg/m2)\n * Multiple risk factors for cardiovascular disease (e.g. smoking, diabetes mellitus, hypertension, obesity, dyslipidaemia) \n * Well controlled hypertension, and hypertension with SBP >140-159 mmHg or DBP <90-99 mmHg\n * Smoker over age of 35 who smokes <15 cigarettes a day, or anyone over age of 35 who stopped smoking <1 year ago\n * Family history of thrombosis before 45 years old\n * Not breastfeeding and <3 weeks postpartum without other risk factors for VTE\n * Not breastfeeding and between 3-6 weeks postpartum with other risk factors for VTE\n * Organ transplant with complications (e.g. graft failure, rejection) \n * Immobility (unrelated to surgery)\n * Migraine without aura (any age) [applies to *continuation* of COCP]\n * History (≥5 years ago) of migraine\nwith aura (any age) \n * Undiagnosed breast mass or symptoms [applies to *initiation* of COCP] \n * Carriers of known gene mutations associated with breast cancer\n * Past breat cancer \n * Diabetes mellitus with nephropathy, retinopathy, neuropathy or other vascular complications \n * Symptomatic gall bladder disease treated medically or currently active \n * Past COCP associated cholestasis \n * Acute viral hepatitis [applies to *initiation* of COCP]\n \n \n \n## Advantages of a contraceptive outweigh the disadvantages (UKMEC 2)\n \n * Smokers under the age of 35, and people aged over 35 who stopped smoking over 1 year ago \n * Obesity (BMI ≥30–34 kg/m2) \n * Family history of VTE in first-degree relative aged ≥45 years\n * History of raised blood pressure in pregnancy \n * Breast feeding between 6 weeks-6 months postpartum\n * Not breastfeeding and between 3-6 weeks postpartum without other risk factors for VTE\n * Uncomplicated organ transplant \n * Known dyslipidaemia \n * Major surgery without prolonged immobilisation \n * Superficial venous thrombosis \n * Uncomplicated valvular and congenital heart disease\n * Cardiomyopathy with normal cardiac function \n * Long QT syndrome \n * Non-migrainous headaches [applies to *continuation* of COCP]\n * Migraine without aura [applies to *initiation* of COCP] \n * Idiopathic intracranial hypertension \n * Unexplained vaginal bleeding\n * Cervical cancer \n * Undiagnosed breast mass or symptoms [applies to *continuation* of COCP]\n * Insulin-dependent diabetes mellitus without vascular disease \n * Symptomatic gall bladder disease treated through cholecystectomy, or asymptomatic gall bladder disease, or history of pregnancy-related cholestasis \n * Acute viral hepatitis [applies to *continuation* of COCP]\n * Inflammatory bowel disease \n * Sickle cell disease \n * Rheumatoid arthritis\n * SLE without antiphospholipid antibodies \n \n\n \n\n# Side-effects and Complications\n \n**Common Side-Effects:**\n \n\n * Breast tenderness \n * Abdominal discomfort, nausea diarrhoea \n * Headaches\n * Mood changes\n * Reduced libido \n \n\n**Rare but Serious Side-Effects:**\n \n\n * Embolism or thrombus, including: DVT and PE, stroke, myocardial infarction\n * Increased risk of breast cancer\n * Increased risk of cervical cancer \n \n\n \n\n# Follow-up\n\nArrange follow up 3 months following initial prescription of a COCP, and annually thereafter.\n \n\nAt follow-up, ensure to: \n \n\n * Check blood pressure and BMI. \n * Ask about headaches (including migraine). \n * Check for risk factors that may be contraindicators to COCP (as per UKMEC criteria). \n * Enquire about side-effects. \n * Enquire about how woman is taking the COCP (i.e. adherence). \n \n\n \n\n# Missed Pill Rules\n \n\n**Missed One Pill:**\n \n\n* Advise patient to take the pill as soon as possible, even if it means taking two pills in one day.\n* * Continue taking the rest of the pack as usual.\nNo additional contraception needed if this is the only pill missed in the pack.\n \n\n**Missed Two or More Pills in Week 1 (Days 1-7):**\n \n\n * Advise patient to take the last pill they missed as soon as possible. \n * Continue taking the rest of the pack as usual.\n * Use additional contraception for the next 7 days.\n * If they had unprotected sex during this week, seek emergency contraception.\n \n\n**Missed Two or More Pills in Week 2 (Days 8-14):**\n \n\n * Take the last pill they missed as soon as possible. \n * Continue taking the rest of the pack as usual.\n * No additional contraception needed if they have taken pills correctly for the 7 days prior to the missed pill.\n \n\n**Missed Two or More Pills in Week 3 (Days 15-21):**\n \n\n* Finish the active pills in the current pack, then start a new pack immediately without taking the usual 7-day break.\n* No additional contraception needed if they have taken pills correctly for the 7 days prior to the missed pill.\n \n# NICE Guidelines \n \n\n[Click here to view NICE Guidelines on COCP](https://cks.nice.org.uk/topics/contraception-combined-hormonal-methods/management/combined-oral-contraceptive/)\n \n \n# References\n \n[Click here to see the UKMEC summary sheet on contraception](https://www.fsrh.org/standards-and-guidance/documents/ukmec-2016-summary-sheets/)",
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"name": "Combined Oral Contraceptive Pill",
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"id": "76",
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"typeId": 5
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"question": "Case presentation: A 32-year-old woman visits the GP to discuss about contraception. She is interested in having combined oral contraceptive pill (COCP) after hearing about it from her friends. The first day of her last menstrual period was 9 days ago. The patient is advised to start taking ethinylestradiol 30 micrograms/ levonorgestrel 150 micrograms one tablet PO daily for 21 days of each cycle . She does not have any contraindications to the medication. \r\n\nPhysical examination: HS 1+11 + 0, chest clear with no added lung sounds, abdomen SNT\nShe would like to know if she needs additional contraception if she were to start taking the pill from today and also of the appropriate actions that should be done if she misses her pills.\n\nQuestion: Select the most appropriate information that should be provided for this patient.",
"sbaAnswer": [
"a"
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"typeId": 1,
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173,458,643 | false | 16 | null | 6,494,967 | null | false | [] | null | 6,833 | {
"__typename": "QuestionSBA",
"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Donepezil can be prescribed in the form an orodispersible tablet. The tablet should be placed on the tongue, allowed to disperse and swallowed",
"id": "34112",
"label": "c",
"name": "Donepezil orodispersible tablet should be chewed and placed below the tongue to allow easy absorption",
"picture": null,
"votes": 370
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is important to remind patients to refrain from drinking alcohol while taking donepezil because alcohol can reduce the effectiveness of donepezil and increase the risk of side effects",
"id": "34113",
"label": "d",
"name": "He can drink alcohol while taking donepezil",
"picture": null,
"votes": 21
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Non-steroidal anti-inflammatory drugs (NSAIDs) should be taken with caution because concurrent usage of NSAID and donepezil may increase risk of ulceration",
"id": "34114",
"label": "e",
"name": "He can take over-the-counter anti-inflammatory painkillers such as ibuprofen without consulting a health professional first",
"picture": null,
"votes": 85
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Donepezil is a reversible cholinesterase inhibitor that is used to manage mild to moderate Alzheimer’s disease. It helps to alleviate some symptoms like being forgetful or confused but does not completely cure Alzheimer’s disease",
"id": "34111",
"label": "b",
"name": "Donepezil is a glutamate receptor antagonist that is used to treat mild-to-moderate Alzheimer’s disease",
"picture": null,
"votes": 55
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Most common side effects of donepezil include diarrhoea, headache and nausea. Through accumulation of acetylcholine at muscarinic receptors, donepezil causes diarrhoea by increasing the gastrointestinal motility",
"id": "34110",
"label": "a",
"name": "Diarrhoea is a common side effect of donepezil",
"picture": null,
"votes": 2460
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "The BNF does not mention alcohol.",
"createdAt": 1647178832,
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"comment": "I can't find where it says about NSAIDs and donepezil in the BNF?",
"createdAt": 1674485740,
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"name": "Donepezil",
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"id": "74",
"name": "Elderly Care",
"typeId": 5
},
"topicId": 74,
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"question": "Case presentation: A 65-year-old woman attends the memory clinic with a six-month gradual onset memory decline. Her children report that she has been misplacing items and appears to be disoriented at times. The patient denies being low in mood, feeling tired or having any problems deriving joy from her hobbies. \r\n\nPhysical examination: HS 1+11 + 0, chest clear with no added lung sounds, abdomen SNT, normal neurological exam\nInvestigation: Mini Mental State Examination (MMSE) score is 20/30.\nShe is advised to commence treatment with Donepezil Hydrochloride 5mg PO daily.\n\nQuestion: Select the most important information that should be provided for this patient.",
"sbaAnswer": [
"a"
],
"totalVotes": 2991,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,644 | false | 17 | null | 6,494,967 | null | false | [] | null | 6,829 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Prednisolone is a steroid medication used to reduce inflammation in rheumatological condition such as polymyalgia rheumatica. During sickness, patients are advised to increase the dose of prednisolone for two days before returning to the usual dose. This action aims to mimic the natural response of adrenal glands that increase the production of steroid hormones during illness",
"id": "34090",
"label": "a",
"name": "She should double the dose of prednisolone during sickness",
"picture": null,
"votes": 4729
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Prednisolone is not known to cause hypoglycaemia",
"id": "34094",
"label": "e",
"name": "Prednisolone increases the risk of hypoglycaemia",
"picture": null,
"votes": 144
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Prednisolone could cause insomnia through the release of catecholamines. Hence, patients are usually advised to take prednisolone in the morning so that it does not keep them awake at night",
"id": "34091",
"label": "b",
"name": "She should take prednisolone at night before sleeping",
"picture": null,
"votes": 139
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Dose of prednisolone needs to be reduced gradually before the treatment is stopped completely to reduce the risk of withdrawal symptoms",
"id": "34092",
"label": "c",
"name": "She should immediately stop taking prednisolone once her symptoms have improved to reduce the risk of developing side effects",
"picture": null,
"votes": 59
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Peptic ulcer is a common side effect of all systemic corticosteroids",
"id": "34093",
"label": "d",
"name": "Prednisolone decreases the risk of peptic ulcer",
"picture": null,
"votes": 26
}
],
"comments": [],
"concept": {
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
"files": null,
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"id": "2762",
"name": "Steroid Sick Day Rule",
"status": null,
"topic": {
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"id": "9",
"name": "Internal Medicine",
"typeId": 5
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"topicId": 9,
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"question": "Case presentation: A 60-year-old woman attends the rheumatology clinic with a two-week history of fatigue and morning stiffness in the shoulder. She complains that the stiffness usually lasts more than 1 hour. \n\n\nInvestigations:\n -ESR 45mm/hr [(age+10)/2]\n -CRP 20 mg/l (<10 )\nA diagnosis of polymyalgia rheumatica is made and patient is advised to commence treatment with Prednisolone 10 mg PO daily.\n\n\nQuestion: Select the most important information that should be provided for this patient.",
"sbaAnswer": [
"a"
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"totalVotes": 5097,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,645 | false | 18 | null | 6,494,967 | null | false | [] | null | 6,828 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Gliclazide is usually taken life-long",
"id": "34086",
"label": "b",
"name": "Gliclazide can only be used for short-term treatment to prevent long-term side effects",
"picture": null,
"votes": 17
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Gliclazide can cause weight gain by increasing the concentration of insulin, which is an anabolic hormone that promotes fat storage",
"id": "34089",
"label": "e",
"name": "Gliclazide may cause weight loss",
"picture": null,
"votes": 54
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Gliclazide can sometimes lead to hypoglycaemia due to the increase in insulin synthesis. Hence, patients are advised to avoid missing meals and to carry a source of sugar with them at all times",
"id": "34085",
"label": "a",
"name": "He should avoid missing meals to prevent low blood sugar from happening",
"picture": null,
"votes": 5890
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "If a dose of gliclazide is missed, patients are advised to take the next dose at the usual time. Patients should not take a double dose to make up for the forgotten dose",
"id": "34088",
"label": "d",
"name": "If he has forgotten to take gliclazide the day before, he should take a double dose to make up for the forgotten dose",
"picture": null,
"votes": 9
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Gliclazide is a sulfonylurea that increases the amount of insulin produced by the body",
"id": "34087",
"label": "c",
"name": "Gliclazide is a biguanide that decreases glucose production by liver",
"picture": null,
"votes": 34
}
],
"comments": [],
"concept": {
"__typename": "Concept",
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"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"id": "2761",
"name": "Gliclazide",
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"question": "Case presentation: A 55-year-old man attends the diabetes clinic for review of his diabetic medication. He still complains of thirst and frequent urination despite the up-titration of his metformin dose 3 months ago. \r\n\nPMH: Type 2 Diabetes Mellitus, Hypertension\nDH: Metformin hydrochloride 1g PO BD, Captopril 50mg PO BD\nInvestigations: HbA1c 65 mmol/mol (20-42)\nThe patient is advised to add a new prescription of gliclazide 40mg PO daily to his current treatment regime.\n\nQuestion: Select the most important information that should be provided for this patient.",
"sbaAnswer": [
"a"
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173,458,646 | false | 19 | null | 6,494,967 | null | false | [] | null | 6,825 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Patients are advised to repeat the dose at 5 minutes interval if the pain persists and to call an emergency ambulance if the pain has not gone 5 minutes after taking the second dose",
"id": "34073",
"label": "d",
"name": "He should call an emergency ambulance if the pain has not gone 5 minutes after taking the first dose",
"picture": null,
"votes": 427
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "The correct method of administering GTN is to spray it under the tongue and close the mouth",
"id": "34071",
"label": "b",
"name": "GTN should be sprayed onto the tongue",
"picture": null,
"votes": 85
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Patients are advised to repeat the dose at 5 minutes interval if the pain persists and to call an emergency ambulance if the pain has not gone 5 minutes after taking the second dose",
"id": "34072",
"label": "c",
"name": "He should repeat the dose at 15 minutes interval if the pain has not gone",
"picture": null,
"votes": 125
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Glyceryl Trinitrate (GTN) is a medication used for prophylaxis and treatment of angina. Once in the body, It is converted into nitric oxide, an active metabolite that causes vasodilation and increases blood flow to the heart. Headache is a common side effect of all nitrates",
"id": "34070",
"label": "a",
"name": "GTN spray may cause headache",
"picture": null,
"votes": 2317
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "GTN does not increase the risk of oral thrush",
"id": "34074",
"label": "e",
"name": "GTN spray may increase risk of oral thrush",
"picture": null,
"votes": 23
}
],
"comments": [],
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"__typename": "Concept",
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"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"name": "Headache following GTN ",
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"typeId": 5
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"question": "Case presentation: A 60-year-old man attends the rapid access chest pain clinic with a two-month history of dull, constricting chest pain that is brought upon by exertion and relieved by rest within 5 minutes. He is currently not in any pain and his resting 12-lead ECG is normal. \r\n\nPMH: Hypertension, Hypercholesterolaemia\nDH: Amlodipine 5mg PO OD, Simvastatin 40mg ON\nOne of the medications offered includes a Glyceryl Trinitrate (GTN) spray, which is offered to the patient to relieve episodes of chest pain when they arise.\n\nQuestion: Select the most important information that should be provided for this patient.",
"sbaAnswer": [
"a"
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"totalVotes": 2977,
"typeId": 1,
"userPoint": null
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173,458,647 | false | 20 | null | 6,494,967 | null | false | [] | null | 6,935 | {
"__typename": "QuestionQA",
"choices": [],
"comments": [
{
"__typename": "QuestionComment",
"comment": "If it is 1g twice daily then doesn't that mean 2g a day? Therefore 50% of 2g is 1g. Please correct me if I have missed something.",
"createdAt": 1642265127,
"dislikes": 1,
"id": "6455",
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"replies": [
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"__typename": "QuestionComment",
"comment": "as each dose is 1g - you halve each dose - so it becomes 500mg in the morning and then 500mg in the evening. So the total daily dose will be 1g ",
"createdAt": 1642464905,
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"id": 4050
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"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
"files": null,
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"name": "Calculation of infusion rate",
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"explanation": "After adjusting for renal impairment, the dose to be given is: 50% x 1g = 500mg.\nHence, the rate at which levetiracetam is to be given is: 500mg ÷ 15 minutes = 33.3ml/min ≈ 33mL/min.\nThe volume of 0.9% sodium chloride solution required for dilution is a distraction.",
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"question": "A 47-year-old patient with focal seizures was initially prescribed levetiracetam (Keppra(R)) at a maintenance dose of 1g twice daily. Due to co-existing renal impairment, it has been decided that the dose should be reduced by 50% as per the manufacturer's advice. This is diluted in 100mL of 0.9% sodium chloride solution and given over 15 minutes.\n\n\nWhat is the rate (in mg per minute) of levetiracetam he is to be given at each dose? Round off your answer to the nearest mg per minute.",
"sbaAnswer": null,
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"typeId": 2,
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173,458,648 | false | 21 | null | 6,494,967 | null | false | [] | null | 6,914 | {
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "Dose = 20mg/kg 8-hrly\nWeight = 85kg\nTotal dose= 20mg/kg 8-hrly x 85kg\n= 1.7g 8-hrly\nDrug concentration = 5mg/mL\nMinimum volume required\n= 1700mg/(5mg/mL) = 340mL",
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"question": "A 75-year-old man who was admitted for a severe chest infection developed cellulitis on his third day of admission. He is to be treated with vancomycin 20mg/kg IV 8-hrly. Weight 85kg.\n\nPrior to administration, vancomycin needs to be diluted with sodium chloride 0.9% to a concentration not exceeding 5mg/mL.\n\nWhat is the minimum volume (mL) to which each dose of vancomycin should be diluted?",
"sbaAnswer": null,
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173,458,649 | false | 22 | null | 6,494,967 | null | false | [] | null | 6,913 | {
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"comment": "thats what I thought too and its similar to a question on the official mock where it counts it as 5 mmil\n",
"createdAt": 1706471787,
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"comment": "if youre talking about the PSA mock thats because it says mmol/L, here it just says mmol",
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"comment": "the coorrect answer is 40 mmol the question in the mock that you guys reference used 'mmol/L' as the units as opposed to mmol which is what is used here",
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"comment": "oh that makes sense thank you\n",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "1st hour = 10mmol KCl\nNext 2 hours = 20mmol KCl\nNext 2 hours = (2/8 x 40mmol KCl) = 10mmol KCl\n\nTotal dose of potassium in 5 hours\n= 10 + 20 + 10 mmol KCl\n= 40mmol KCl",
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"question": "A 55-year-old gentleman is admitted to Surgical Assessment Unit with likely acute pancreatitis. Following surgical review, he has been kept NBM and IV fluid has been prescribed. Weight 80kg.\n\n\nHis IV fluid regimen has been prescribed as below:\n\n* IV 0.9% Normal Saline 500mL 10mmol KCl over 1 hour\n* IV 0.9% Normal Saline 1L 20mmol KCl over 2 hours\n* IV 0.18% Normal Saline 4% Dextrose 1L 40mmol KCl over 8 hours\n\nWhat dose (mmol) of potassium will have been administered IV in the first 5 hours?",
"sbaAnswer": null,
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173,458,650 | false | 23 | null | 6,494,967 | null | false | [] | null | 6,920 | {
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "Dose of carbamazepine\n= 500mg BD = 1000mg a day\nSuppositories 125mg =100mg\nNumber of suppositories needed in a day\n= 1000mg /100mg x 125mg\n= 1250mg",
"highlights": [],
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"question": "A 45-year-old patient is admitted to Hyperacute Stroke Unit for left MCA stroke. SALT assessment concluded that he has unsafe swallow and kept him NBM. PMH Focal seizure DH Carbamazepine 500mg PO BD.\n\n\nSuppositories of 125mg may be considered to be approximately equivalent in therapeutic effect to tablets of 100mg but final adjustment should always depend on clinical response.\n\nWhat is the total dose (mg) of carbamazepine in suppositories that is needed in a day?",
"sbaAnswer": null,
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"typeId": 2,
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173,458,651 | false | 24 | null | 6,494,967 | null | false | [] | null | 6,918 | {
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"explanation": "Dose = 0.1units/kg/hr\nWeight = 20kg\nTotal insulin needed/hour\n= 0.1units/kg/hr x20kg = 2units/hr\nTotal insulin needed for a day\n= 2units/hr x 24hrs = 48 units\n= 48units require 48mL of 0.9% sodium chloride.",
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"question": "A 5-year-old boy is admitted to Emergency Department with Kussmaul breathing and ketotic breath following 3 days of polyuria and polydipsia. He was diagnosed with DKA and was started on the appropriate treatment. Fluids was prescribed and fixed rate Actrapid infusion was initiated at a rate of 0.1units/kg/hr. Weight 20kg.\n\n\nFor intravenous infusion of Actrapid, give continuously in Sodium Chloride 0.9% @ 1units in 1mL of 0.9% sodium chloride solution.\n\nWhat is the volume (mL) of 0.9% sodium chloride solution needed for a fixed rate 24 hour Actrapid infusion?",
"sbaAnswer": null,
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"__typename": "QuestionSBA",
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Ibuprofen does not commonly prolongs QT interval",
"id": "34241",
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"name": "Ibuprofen 400mg TDS",
"picture": null,
"votes": 6
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"__typename": "QuestionChoice",
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"explanation": "C0-beneldopa does not commonly prolongs QT interval",
"id": "34243",
"label": "d",
"name": "Co-beneldopa 50mg BD",
"picture": null,
"votes": 21
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"__typename": "QuestionChoice",
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"explanation": "Rotigotine does not commonly prolongs QT interval",
"id": "34244",
"label": "e",
"name": "Rotigotine 8mg OD",
"picture": null,
"votes": 24
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"__typename": "QuestionChoice",
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"explanation": "Paracetamol does not commonly prolongs QT interval",
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"explanation": "Citalopram and escitalopram are examples of drugs that are used for depressive illness. They can commonly cause side effects including prolongation of QT interval especially when other risk factors are present such as age extremity, stress or shock. The exact mechanism of the effect of citalopram on QT interval, however, is not known",
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"name": "Citalopram 40mg OD",
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"__typename": "QuestionComment",
"comment": "Go on BNF and search \"appendix one\", then control F \"QT Prolongation\" and you can see all the drugs that cause it. \n\nAppendix one can also be used for other common electrolyte imbalances ",
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"comment": "this is incredible",
"createdAt": 1736357540,
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case Presentation: A 75-year-old man is recovering on the Orthopaedic Ward following an elective left knee replacement two days ago. Post-operatively, he was prescribed paracetamol, an NSAID and a weak opioid for pain relief. On the second day after his operation, he developed tachycardia. An ECG was performed showing sinus tachycardia with prolongation of QT interval. PMH Severe depression, Parkinson’s disease, IBD. DH Citalopram 40mg OD, Paracetamol 1g QDS PO, Ibuprofen 400mg TDS, Co-beneldopa 50mg BD, Rotigotine 8mg TD OD\r\n\r\n\nQuestion: Select the prescription that is most likely to contribute to the prolongation of his QT interval",
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173,458,653 | false | 26 | null | 6,494,967 | null | false | [] | null | 6,872 | {
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"explanation": "Haemorrhage is a common or very common side effect of warfarin. In a situation where there is minor bleeding and an INR of more than 8, NICE recommends to stop warfarin and give 0.5–1 mg phytomenadione by slow intravenous injection, or 5 mg by mouth",
"id": "34305",
"label": "a",
"name": "Stop warfarin and give phytomenadione 1mg slow IV injection",
"picture": null,
"votes": 4810
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Urgent intravenous treatment with phytomenadione (vitamin K1), and/or dried prothrombin complex concentrate (factors II, VII, IX, and X), or fresh frozen plasma 15mL/kg is only required if there is heavy bleeding",
"id": "34309",
"label": "e",
"name": "Stop warfarin and commence urgent intravenous treatment with phytomenadione and prothrombin complex concentrate",
"picture": null,
"votes": 1567
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Phytomenadione needs to be given if there is bleeding and INR is 8 or more",
"id": "34307",
"label": "c",
"name": "Omit two doses of warfarin and restart thereafter",
"picture": null,
"votes": 163
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Warfarin needs to be stopped. Phytomenadione also needs to be given if there is bleeding and INR is 8 or more",
"id": "34308",
"label": "d",
"name": "Continue with current dose",
"picture": null,
"votes": 15
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Phytomenadione needs to be given if there is bleeding and INR is 8 or more",
"id": "34306",
"label": "b",
"name": "Reduce the dose of warfarin to 5 mg PO OD",
"picture": null,
"votes": 30
}
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"__typename": "QuestionComment",
"comment": "Given the patient has a NOF wouldn't you'd be thinking that there could be more significant internal bleeding... and so you'd go for Fit K and prothrombin complex concentrate... if not why not?",
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"comment": "Yeah I agree, i thought it was a bit strange to just give vit K when he has to go to theatre?",
"createdAt": 1674614099,
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"comment": "We have to only go by what the question says: 'Minor bleeding from a cut on his right hand (and no other bleeding sites)' ",
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"comment": "A tip for anyone doing PSA is to search \"phytomenadione\", and it essentially gives you the treatment for various bleeding severities and INR. Good luck!",
"createdAt": 1706558168,
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"comment": "this person is going to theatre so why would you not give it all",
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"comment": "agree with the theatre people",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"id": "2804",
"name": "Warfarin side effects",
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"id": "9",
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"typeId": 5
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"question": "Case presentation: A 60-year-old man is brought to the accident and emergency department. He had a fall this morning after accidentally walking into a glass door. Besides his prescribed medication, he has been taking some herbal supplements lately. \r\n\nPMH: Atrial fibrillation\nDH: Warfarin Sodium 10 mg PO once daily, Bisoprolol 10 mg PO once daily\nObservations: Temperature 36.5°C , blood pressure 125/80 mmHg, heart rate 80 bpm, respiratory rate 18; oxygen saturation 100% (on air)\nOn examination: Minor bleeding from a cut on his right hand (and no other bleeding sites), cannot weight bear, pain on external rotation of left leg\nInvestigations: Pelvic x-ray: Left Intracapsular neck of femur fracture ; INR: 8.2\n\nQuestion: Select the most appropriate option for the management of this adverse drug event.",
"sbaAnswer": [
"a"
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"totalVotes": 6585,
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173,458,654 | false | 27 | null | 6,494,967 | null | false | [] | null | 6,856 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Clozapine would not be prescribed for nausea and vomiting, and does not commonly cause visual hallucinations",
"id": "34227",
"label": "c",
"name": "Clozapine 12.5mg PO OD",
"picture": null,
"votes": 59
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Cyclizine does not commonly cause visual hallucinations",
"id": "34228",
"label": "d",
"name": "Cyclizine 50mg PO TDS",
"picture": null,
"votes": 568
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Selegiline would not be prescribed for nausea and vomiting, and does not commonly cause visual hallucinations",
"id": "34226",
"label": "b",
"name": "Selegiline hydrochloride 5mg PO OD",
"picture": null,
"votes": 1920
},
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "Haloperidol exert its anti-emetic effect by blocking central dopamine receptors in the chemoreceptor trigger zone in the brain. Its inhibition on D2 receptors, in particular, can worsen the symptoms of LBD as patients with LBD has increased neuroleptic sensitivity and when given typical antipsychotics like haloperidol, they can experience worsening hallucination, cognition and increased parkinsonism",
"id": "34225",
"label": "a",
"name": "Haloperidol 5mg PO BD",
"picture": null,
"votes": 1950
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Ondansetron does not commonly cause visual hallucinations",
"id": "34229",
"label": "e",
"name": "Ondansetron 8mg PO BD",
"picture": null,
"votes": 122
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Under common side effects in the BNF for selegiline hydrochloride it has hallucinations - am I just being dumb, how do you know which one it should be?",
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"comment": "This question requires some clinical reasoning. You are right that Selegilline causes hallucinations, but there is no indication to prescribing Selegilline as it not given for N&V. Haloperidol would go against the Levodopa and is indicated for N&V as per BNF and physiology of acting on the Dopamine receptors in the CTZ.",
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"comment": "hallucinations are not listed as a side effect of haloperidol in the BNF ",
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"comment": "but BNF states the lewy body dementia is a contraindication to giving Haloperiodol",
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"comment": "says visual disorder until side effects",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"id": "2618",
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"demo": null,
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"id": "2788",
"name": "Antipsychotics and Parkinsonism",
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"topic": {
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"id": "74",
"name": "Elderly Care",
"typeId": 5
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"question": "Case Presentation: A 75-year-old man was admitted to the Care of the Elderly Ward following a urinary tract infection 3 days ago. A day after his admission, he felt nauseous and vomited twice in the morning. There was no blood noted in the vomitus. He was prescribed a medication for symptomatic relief of his nausea and vomiting by the on call doctor. However, on the next day, he started experiencing visual hallucinations. PMH Lewy Body Dementia. DH Rivastigmine, Levodopa.\r\n\r\n\nQuestion: Select the prescription that is most likely to contribute to his visual hallucinations.",
"sbaAnswer": [
"a"
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"totalVotes": 4619,
"typeId": 1,
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} | MarksheetMark |
173,458,655 | false | 28 | null | 6,494,967 | null | false | [] | null | 6,854 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Ibuprofen does not commonly cause thrombocytopenia",
"id": "34219",
"label": "e",
"name": "Ibuprofen 400mg PO PRN",
"picture": null,
"votes": 314
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "LMWH (Dalteparin sodium) is common or very commonly associated with immune-mediated, drug induced thrombocytopenia. Heparin, which is negatively charged binds to platelet factor 4 (PF4), a positively charged molecule that is released into the circulation upon the activation of platelets. This heparin-PF4 complex acts as a immunogen, which leads to antibody production and the activation and aggregation of platelets. The clearance of the activated platelets can then lead to thrombocytopenia",
"id": "34215",
"label": "a",
"name": "Dalteparin sodium 2500 units SC OD",
"picture": null,
"votes": 5881
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Furosemide does not commonly cause thrombocytopenia",
"id": "34218",
"label": "d",
"name": "Furosemide 40mg PO OD",
"picture": null,
"votes": 107
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Metformin does not commonly cause thrombocytopenia",
"id": "34216",
"label": "b",
"name": "Metformin 1g BD PO",
"picture": null,
"votes": 24
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Gliclazide does not commonly cause thrombocytopenia",
"id": "34217",
"label": "c",
"name": "Gliclazide 30mg PO OD",
"picture": null,
"votes": 212
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "i selected dalteparin and it changed my answer to gliclazide so i got it wrong...",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"demo": null,
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"id": "2786",
"name": "Dalteparin side effects",
"status": null,
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"__typename": "Topic",
"id": "13",
"name": "Neurosurgery",
"typeId": 5
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"question": "Case Presentation: A 45-year-old man is recovering on the gastroenterology unit following an elective pan proctocolectomy for his UC five days ago. PMH Type 2 diabetes mellitus, Resistant hypertension, Migraine. DH His current regular medicines are listed (below).\n\n\nInvestigation\nPlatelet 100 x 109/L (150-400)\n\n\nQuestion: Select the prescription that is most likely to contribute to his thrombocytopenia.",
"sbaAnswer": [
"a"
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173,458,656 | false | 29 | null | 6,494,967 | null | false | [] | null | 6,880 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Intravenous magnesium is commonly given for severe acute exacerbations of asthma and levels may be monitored during treatment. However it is not being used here",
"id": "34349",
"label": "e",
"name": "Serum magnesium",
"picture": null,
"votes": 137
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient is at risk of hypokalaemia due to repeated salbutamol nebulisers and commencement of an aminophylline infusion. Renal function should be monitored",
"id": "34345",
"label": "a",
"name": "Urea and electrolytes",
"picture": null,
"votes": 3540
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be useful as a baseline as aminophylline is metabolised hepatically. However routine monitoring is not necessary",
"id": "34347",
"label": "c",
"name": "Liver function tests",
"picture": null,
"votes": 424
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be a useful marker of beneficial effects of the treatment rather than adverse effects",
"id": "34348",
"label": "d",
"name": "Respiratory rate",
"picture": null,
"votes": 602
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be a useful marker of beneficial effects of the treatment rather than adverse effects",
"id": "34346",
"label": "b",
"name": "Bedside spirometry",
"picture": null,
"votes": 193
}
],
"comments": [],
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"__typename": "Concept",
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"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
"files": null,
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"id": "2618",
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"demo": null,
"entitlement": null,
"id": "2812",
"name": "Aminophylline side effects",
"status": null,
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"__typename": "Topic",
"id": "9",
"name": "Internal Medicine",
"typeId": 5
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"question": "Case Presentation: A 19 year old man presents to A&E with chest pain and shortness of breath. **PMH** asthma, has had 3x previous A&E attendances for acute exacerbations and 1x hospitalisation stay. **DH** salbutamol 200 micrograms inhaler PRN, beclomethasone with formoterol (Fostair NEXThaler) 100/6 micrograms powder inhaler 2 puffs BD. Allergic to pollen and cat fur – exacerbates asthma.\n\n\n**O/E**\n\nVisibly short of breath with tripoding and use of accessory neck muscles. Sweaty. Peripherals warm and well-perfused. HR 103, RR 29, BP 129/68, O2 100% 15L reservoir mask. Widespread polyphonic wheeze on chest auscultation.\n\n**Investigations**\n\nCXR: No consolidation or pneumothoraces\n\nPEFR: 45% of normal predicted value\n\nHe has been given back to back salbutamol and ipratropium nebulisers and is being started on an aminophylline infusion.\n\nQuestion: Select the most appropriate option to monitor for adverse effects of this treatment.",
"sbaAnswer": [
"a"
],
"totalVotes": 4896,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,657 | false | 30 | null | 6,494,967 | null | false | [] | null | 6,881 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not necessary prior to administering gentamicin",
"id": "34354",
"label": "e",
"name": "Visual fields assessment",
"picture": null,
"votes": 48
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Renal function should be checked at baseline and during ongoing treatment as gentamicin is nephrotoxic",
"id": "34350",
"label": "a",
"name": "Renal function tests",
"picture": null,
"votes": 5353
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not necessary as there is nothing to make one suspicion of any ongoing infection",
"id": "34352",
"label": "c",
"name": "Full blood count",
"picture": null,
"votes": 70
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This may be useful as a baseline but is not routinely done prior to administering gentamicin",
"id": "34353",
"label": "d",
"name": "Liver function tests",
"picture": null,
"votes": 69
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is not necessary as there is nothing to make one suspicion of any inflammatory process or ongoing infection",
"id": "34351",
"label": "b",
"name": "C-reactive protein",
"picture": null,
"votes": 7
}
],
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"id": "2813",
"name": "Gentamicin side effects",
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"typeId": 5
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"question": "Case Presentation: A 65 year old man is admitted to the surgical ward prior to an elective total knee replacement. He is due to receive gentamicin 300mg IV as a one-off dose for surgical prophylaxis prior to the procedure.\n\n\nQuestion: Select the most appropriate option to monitor for adverse effects of this treatment.",
"sbaAnswer": [
"a"
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"totalVotes": 5547,
"typeId": 1,
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} | MarksheetMark |
173,458,658 | false | 31 | null | 6,494,967 | null | false | [] | null | 6,874 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Digoxin levels should be taken no earlier than 6 hours after a dose as this may lead to inaccurate dose adjustments being made from a falsely elevated level",
"id": "34316",
"label": "b",
"name": "Blood levels at 1000 hrs",
"picture": null,
"votes": 36
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Taking digoxin levels more than 6 hours after the initial dose may lead to inaccurate dose adjustments being made from a falsely low level",
"id": "34318",
"label": "d",
"name": "Blood levels immediately before next dose",
"picture": null,
"votes": 260
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Digoxin levels should be taken no earlier than 6 hours after a dose as this may lead to inaccurate dose adjustments being made from a falsely elevated level",
"id": "34319",
"label": "e",
"name": "Blood levels immediately post-dose",
"picture": null,
"votes": 27
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Digoxin levels should be taken no earlier than 6 hours after a dose as this may lead to inaccurate dose adjustments being made from a falsely elevated level",
"id": "34317",
"label": "c",
"name": "Blood levels at 1200 hrs",
"picture": null,
"votes": 127
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is the correct time to take a digoxin level, which is 6 hours after the last dose",
"id": "34315",
"label": "a",
"name": "Blood levels at 1400 hrs",
"picture": null,
"votes": 5297
}
],
"comments": [],
"concept": {
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case Presentation: A 70 year old man is on the acute admissions unit being treated for exacerbation of congestive cardiac failure and new atrial fibrillation. **PMH** CCF, recurrent DVTs. **DH** lisinopril 15mg PO OD, carvedilol 25mg PO BD, spironolactone 50mg PO OD, isosorbide mononitrate 30mg PO BD, warfarin sodium 3mg PO OD. NKDA\n\n\nOn the morning drug round at 0800 hrs, he has been given his usual medications as well as 375 micrograms of digoxin in accordance with the rapid digitalisation protocol.\n\n**Investigations**\n\nU&Es: Na 144, K 3.9, Cl 99, Ur 4.2, Cr 117 (baseline 103), eGFR 52mL/min/1.73m^2\n\nQuestion: Select the most appropriate monitoring option to assess the need for dose adjustments of digoxin in this patient.",
"sbaAnswer": [
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173,458,659 | false | 32 | null | 6,494,967 | null | false | [] | null | 6,876 | {
"__typename": "QuestionSBA",
"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Amiodarone is a potassium channel blocker and as such imbalances in potassium should be corrected prior to starting this drug, rather than sodium",
"id": "34328",
"label": "d",
"name": "Serum sodium",
"picture": null,
"votes": 33
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"__typename": "QuestionChoice",
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"explanation": "An elevation in cardiac enzymes may suggest some ongoing myocardial ischaemia and can be useful in the general clinical setting on a background of acute chest pain, but is of limited usefulness with respect to starting this drug",
"id": "34329",
"label": "e",
"name": "Troponin",
"picture": null,
"votes": 22
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"__typename": "QuestionChoice",
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"explanation": "A potentially severe side effect of amiodarone use is pulmonary fibrosis. Existing lung damage should be ruled out prior to starting this drug",
"id": "34325",
"label": "a",
"name": "Chest X-ray",
"picture": null,
"votes": 6102
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "While blood dyscrasias have been reported with use of amiodarone, these are very rare and as such a full blood count would be useful as a baseline but is not routinely done",
"id": "34327",
"label": "c",
"name": "Full blood count",
"picture": null,
"votes": 119
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Amiodarone is metabolised and excreted by the liver. Renal function would be useful as a baseline but not with respect to starting this drug",
"id": "34326",
"label": "b",
"name": "Creatinine clearance",
"picture": null,
"votes": 141
}
],
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"comment": "Where does it say this in the BNF?",
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"comment": "Search \"Amiodarone Hydrochloride\" -> Find monitoring requirements on the drug monograph -> Under monitoring of patient parameters C&P'd:\n\nMonitoring of patient parameters For amiodarone hydrochloride\nLiver function tests required before treatment and then every 6 months.\nSerum potassium concentration should be measured before treatment.\nChest x-ray required before treatment.\n\nHope that helps!",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case Presentation: A 62 year old man is sent to the rapid access chest pain clinic by his GP following the reported results of a 24 hour ECG holter monitor. **PMH** myocardial infarction with 100% LAD occlusion, hypertension. **DH** aspirin 75mg PO OD, bisoprolol fumarate 2.5mg PO OD, ramipril 5mg PO OD. NKDA\n\n\n**Investigations**\n\n24 hour ECG holter monitor: infrequent runs of ventricular tachycardia lasting 30-40 seconds\n\nThe cardiology consultant recommends starting amiodarone hydrochloride 200mg PO TDS whilst awaiting implantation of an ICD.\n\nQuestion: Select the most appropriate monitoring option required before initiating amiodarone hydrochloride.",
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173,458,660 | false | 33 | null | 6,494,967 | null | false | [] | null | 6,875 | {
"__typename": "QuestionSBA",
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"__typename": "QuestionChoice",
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"explanation": "Dyspepsia is not a known adverse effect associated with warfarin",
"id": "34321",
"label": "b",
"name": "Patient reports new dyspepsia",
"picture": null,
"votes": 91
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"__typename": "QuestionChoice",
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"explanation": "Vitamin K assays are not routinely done in patients taking warfarin as levels will almost certainly be lower and as such this is of negligible clinical usefulness",
"id": "34324",
"label": "e",
"name": "Vitamin K levels",
"picture": null,
"votes": 114
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "The prothrombin time has no role in monitoring either the dosing or adverse effects of warfarin",
"id": "34323",
"label": "d",
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"picture": null,
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"explanation": "Warfarin has no effect on platelets and thus they have no role in monitoring either the dosing or adverse effects of warfarin",
"id": "34322",
"label": "c",
"name": "Platelet count",
"picture": null,
"votes": 93
},
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "When starting anticoagulation treatment it is important for patients to report any new bruising or bleeding as they may be receiving too high a dose",
"id": "34320",
"label": "a",
"name": "Patient reports easy bruising",
"picture": null,
"votes": 3047
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"comment": "WTF\n",
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"comment": "Surely not",
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"comment": "lol its PROthrombin time not TT rip my sanity",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"name": "Warfarin side effects",
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"question": "Case Presentation: A 37 year old woman is referred to the anticoagulation clinic following a hospital admission for a pulmonary embolus. **PMH** systemic lupus erythematosus, antiphospholipid syndrome. **DH** hydroxychloroquine sulfate 300mg PO OD. NKDA **SH** ex-smoker (5 pack years).\n\n\nHer consultant decides that it is appropriate to pursue lifelong anticoagulation with warfarin sodium at a starting dose of 5mg PO OD.\n\nQuestion: Select the most appropriate option to monitor for adverse effects of this treatment in the first few months.",
"sbaAnswer": [
"a"
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173,458,701 | false | 1 | null | 6,494,970 | null | false | [] | null | 9,993 | {
"__typename": "QuestionSBA",
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst PCOS is associated with impaired glucose tolerance and type 2 diabetes, a fasting serum blood glucose would not aid in diagnosing PCOS.",
"id": "49785",
"label": "d",
"name": "Fasting serum blood glucose",
"picture": null,
"votes": 46
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "This woman has features of polycystic ovary syndrome (PCOS). The Rotterdam criteria are used to diagnose PCOS and include (1) oligo- or anovulatory cycles; (2) clinical or biochemical hyperandrogenism and (3) a polycystic appearance of the ovaries on ultrasound. A diagnosis of PCOS can be made if two of the above three criteria are met and other causes of the person's symptoms have been excluded.\n\nThe long and irregular menstrual cycles are likely to be anovulatory cycles. The papulo-pustular rash on her face is likely due to shaving, an indication of troublesome hirsutism caused by hyperandrogenism.",
"id": "49782",
"label": "a",
"name": "Transvaginal ultrasound scan",
"picture": null,
"votes": 1449
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"__typename": "QuestionChoice",
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"explanation": "A 24-hour urinary cortisol would be indicated for the exclusion of Cushing's syndrome, but would not confirm the likely diagnosis of PCOS. Cushing's syndrome results in an excess of glucocorticoids (cortisol). It can present with similar signs such as obesity, acne and hirsutism but is much less common than PCOS.",
"id": "49786",
"label": "e",
"name": "24-hour urinary cortisol",
"picture": null,
"votes": 54
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Serum follicle-stimulating hormone can be measured in conjunction with luteinising hormone (LH). In PCOS, the ratio of LH to FSH is increased (>2). Serum FSH can also help diagnose premature ovarian failure or menopause and is elevated in these conditions. FSH alone would not aid in the diagnosis of PCOS.",
"id": "49783",
"label": "b",
"name": "Serum follicle-stimulating hormone (FSH)",
"picture": null,
"votes": 585
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Mid-luteal serum progesterone is used to confirm ovulation. Whilst this may be useful in the workup for primary infertility, the history of long cycles already suggests anovulatory cycles. A mid-luteal serum progesterone may confirm or refute ovulation, but does not aid in confirming the likely diagnosis of PCOS.",
"id": "49784",
"label": "c",
"name": "Mid-luteal serum progesterone",
"picture": null,
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"explanation": "# Summary\n \n \nPolycystic ovary syndrome (PCOS) is a disorder characterised by hyperandrogenism, ovulation disorders, and polycystic ovarian morphology. It is common among women of child-bearing age. Key signs and symptoms include oligomenorrhoea, hirsutism, acne, and subfertility among others. Investigations such as hormonal assays and imaging techniques are used in diagnosis. Management strategies encompass lifestyle modifications and a range of pharmacological treatments tailored to patient preferences, such as conception.\n \n \n# Definition\n \n \nPolycystic ovary syndrome (PCOS) is a disorder characterised by hyperandrogenism (manifesting as oligomenorrhoea, hirsutism, and acne), ovulation disorders, and polycystic ovarian morphology.\n \n \n# Epidemiology\n \n \nPolycystic ovary syndrome is a common endocrine condition, affecting up to a quarter of women during their reproductive years.\n \n \n# Aetiology\n \n \nThe precise aetiology of PCOS remains undetermined. However, potential hormonal imbalances implicated in this syndrome include hyperandrogenism, insulin resistance, elevated levels of luteinizing hormone (LH) and raised oestrogen levels.\n \n \n# Signs and Symptoms\n \n \nThe clinical presentation of PCOS is largely attributed to the hormonal imbalances, with symptoms including:\n \n \n - Oligomenorrhoea\n - Subfertility\n - Acne\n - Hirsuitism\n - Obesity\n - Mood changes including depression and anxiety\n - Male pattern baldness\n - Acanthosis nigricans (secondary to insulin resistance)\n \n \n# Differential Diagnosis\n \n \nFor accurate diagnosis, other endocrine disorders presenting similar clinical features must be excluded. These include:\n \n \n - Menopause: Characterised by cessation of menstruation, hot flashes, vaginal dryness, mood changes, and sleep problems.\n - Congenital adrenal hyperplasia (CAH): Presenting with signs of androgen excess like hirsutism, acne, and irregular periods. Presents earlier on and can lead to ambiguous genitalia (for affected females). \n - Hyperprolactinaemia: Symptoms include irregular periods, galactorrhoea, and infertility.\n - Androgen-secreting tumours: May cause virilisation, amenorrhoea, and hirsutism.\n - Cushing's syndrome: Characterised by weight gain, purple stretch marks, and easy bruising.\n \n \n# Investigations\n \n \nBiochemical assays and imaging techniques play a pivotal role in the diagnosis of PCOS:\n \n**Bedside:**\n\n- Clinical examination to identify features of hyperandrogenism (e.g. hirsutism) or features of insulin resistance (e.g. acanthosis nigricans, raised BMI)\n\n**Bloods:**\n\n- LH:FSH ratio: An increase (>2) aids in differentiating from menopause where the ratio is normal.\n- Total testosterone: May be normal or slightly elevated.\n- Fasting and oral glucose tolerance tests: Used to diagnose insulin resistance.\n- Other tests may include TFTs (for thyroid dysfunction), 17-hydroxyprogesterone levels (for CAH), prolactin (for hyperprolactinaemia), DHEA-S and free androgen index (for androgen-secreting tumours), and 24-hour urinary cortisol (for Cushing's syndrome).\n\n**Imaging:**\n\n- Transabdominal and transvaginal ultrasound: Reveals increased ovarian volume and multiple cysts. May be important for fulfilling Rotterdam Diagnostic Criteria (See below) \n\n\nNo **invasive tests** are required for diagnosis. \n\n \n **Rotterdam Diagnostic Criteria:**\n \n \nUpon exclusion of other causes, PCOS can be diagnosed if at least two of the following criteria are met:\n \n \n - Polycystic ovaries (defined as a follicle number per ovary of 20 or more in at least one ovary)\n - Oligo-/anovulation\n - Clinical or biochemical features of hyperandrogenism\n \n \n# Management\n \n \nThe management of PCOS primarily focuses on symptom control and prevention of complications, with endometrial cancer risk reduction achieved through regular menstruation.\n \n \n**Conservative:**\n \n \n - Encouragement of weight loss and exercise\n - Education on increased risks of cardiovascular disease, diabetes, and endometrial cancer\n \n \n**Medical, for women not planning pregnancy:**\n \n \n - Co-cyprindrol: Reduces hirsutism and promotes regular menstruation.\n - Combined oral contraceptive pill (COCP): Decreases irregular bleeding and offers protection against endometrial cancer.\n - Metformin: Aids in regularising menstruation, reducing hirsutism, and acne.\n \n \n**Medical, for women wishing to conceive:**\n \n \n - Clomiphene: Induces ovulation and enhances conception rates.\n - Metformin: Can be used alone or in combination with clomiphene to improve chances of pregnancy.\n - Gonadotrophins: Utilised to induce ovulation if clomiphene and metformin prove ineffective.\n\n**Surgical, for women wishing to conceive:**\n\n - Ovarian drilling: A second-line laparoscopic surgical procedure that damages the hormone-producing cells of the ovary. \n \n# Complications\n\n\n- Infertility: Caused by impaired or dysregulated ovulation.\n- Metabolic syndrome and dyslipidaemia: PCOS leads to raised triglycerides and LDL and fall in HDL. \n- Type 2 diabetes: PCOS increases risk of T2DM by approximately two fold as a result of insulin resistance \n- Cardiovascular disease: This is likely a consequence of metabolic complications of PCOS and hormonal alterations. \n- Hypertension: Greater risk of hypertension seen in premenopausal as opposed to postmenopausal women. \n- Obstructive sleep apnoea: This occurs as a result of obesity (usually secondary insulin resistance and metabolic changes). \n\n# NICE Guidelines\n\n[Click here for NICE guidelines on PCOS](https://cks.nice.org.uk/topics/polycystic-ovary-syndrome/)\n\n# References \n\n[BMJ Best Practice](https://bestpractice.bmj.com/topics/en-gb/141)\n\n[RCOG page](https://www.rcog.org.uk/for-the-public/browse-our-patient-information/polycystic-ovary-syndrome-pcos-what-it-means-for-your-long-term-health/)",
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"question": "A 31-year-old woman presents to the general practitioner as she has failed to become pregnant after 18 months of regular intercourse.\n\nShe has an irregular menstrual cycle, which varies between 35-60 days.\n\nOn examination, she is overweight and has a papulopustular folliculitis on her face, particularly on the chin.\n\nWhich single test would most likely to confirm the probable diagnosis?",
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"__typename": "QuestionSBA",
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"explanation": "Pelvic muscle retraining is a first-line management strategy for uncomplicated stress urinary incontinence. Whilst this woman has an element of stress incontinence (urine leakage on coughing), she predominantly has symptoms of urge incontinence, likely caused by vulvovaginal atrophy.",
"id": "49790",
"label": "d",
"name": "Refer for pelvic muscle retraining",
"picture": null,
"votes": 1033
},
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "This postmenopausal woman likely has urge incontinence due to atrophic vulvovaginitis/urethritis caused by oestrogen deficiency. Atrophic vulvovaginitis often results in urinary frequency, urge incontinence and dysuria. Vulval atrophy is evidenced by pallor, and vaginal atrophy is evidenced by the narrowed introitus and inability to insert more than one digit. The treatment of choice is topical oestrogen therapy for at least 14 days. Symptoms can be reassessed at this point.",
"id": "49787",
"label": "a",
"name": "Topical oestrogen therapy for at least 14 days",
"picture": null,
"votes": 595
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Post-void residual urine volume should be measured in people with unexplained urge incontinence to assess for incomplete bladder emptying. This woman has features of vulvovaginal atrophy, so it would be prudent to treat this and reassess. If her symptoms were not resolved with topical oestrogen, an ultrasound scan might be used next.",
"id": "49789",
"label": "c",
"name": "Bladder ultrasound scan for post-void residual urine volume",
"picture": null,
"votes": 347
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "An urgent spinal MRI would be indicated in a patient with recent-onset urinary incontinence accompanied by lower limb weakness, altered perineal sensation or back pain to exclude cauda equina syndrome. This woman does not have an acute onset of urinary incontinence and does not have any other features of cauda equina.",
"id": "49791",
"label": "e",
"name": "Urgent magnetic resonance imaging (MRI) of the spine",
"picture": null,
"votes": 30
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst this woman has features of urinary tract infection (frequency, dysuria and incontinence), her urine dipstick is clear. She also has no fever, and it is unlikely she has had a urinary tract infection for six months.",
"id": "49788",
"label": "b",
"name": "Urine culture and sensitivity",
"picture": null,
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}
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"comment": "Lol",
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"comment": "Let's gooooooooo",
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"comment": "wait what? urge incontinence can be caused by vulvovaginal atrophy?",
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"comment": "i'd never have gotten this ",
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"explanation": "# Summary\n \n \nAtrophic vaginitis, also known as vulvovaginal atrophy, is a condition characterised by inflammation and thinning of genital tissues due to reduced oestrogen levels, most commonly seen after menopause. Key signs and symptoms include thinning of vaginal mucosa, loss of pubic hair, narrowed introitus, and vaginal dryness, among others. Key investigations include clinical examination, transvaginal ultrasound, endometrial biopsy if required, and an infection screen. Management strategies primarily involve hormonal treatments, non-hormonal treatments, and in some cases, transvaginal laser therapy.\n \n \n# Definition\n \n \nAtrophic vaginitis, also known as vulvovaginal atrophy, is characterised by inflammation and thinning of the genital tissues due to a decrease in oestrogen levels. This condition is most common after menopause.\n \n \n \n\n# Aetiology\n \n \nThe primary cause of atrophic vaginitis is a decline in oestrogen levels, which typically occurs post-menopause.\n \n \n# Signs and Symptoms\n \n \n - Thinning of the vaginal mucosa\n - Loss of pubic hair\n - Narrowed introitus\n - Loss of vaginal rugae (folds)\n - Vaginal dryness and itching\n - Dyspareunia\n - Post-coital bleeding\n - Vaginal discharge from inflammation\n - Urinary symptoms such as dysuria and recurrent UTI\n \n \n# Differential Diagnosis\n \n \n- **Endometrial cancer and endometrial hyperplasia:** presents with post-menopausal bleeding. Ruled out with transvaginal USS and possible biopsy.\n- **Sexually transmitted infection:** presents with itching and abnormal discharge. Would have cervical tenderness on bimanual examination and can be diagnosed using vaginal swabs. \n- **Lichen planus:** can cause itchiness and dyspareunia. Would present with pale, dry patches which may be cracked and cause bleeding. \n- **Vaginismus:** also presents with dyspareunia but would not show signs of atrophy on speculum examination. \n\n \n \n# Investigations\n \n **Bedside:**\n \n* Clinical examination, including speculum examination if tolerated, to look for vaginal signs of atrophy. This is usually enough for diagnosis. \n* Vaginal swabs for infection screening if itching of discharge is present. \n \nNo bloods, imaging or invasive tests are required. \n \n\n# Management\n \n \nHormonal treatment:\n \n - Topical oestrogen preparations\n - Systemic hormone-replacement therapy (oral or transdermal)\n\n \nNon-hormonal treatments:\n\n - Lubricants, which provide short-term improvement to vaginal dryness, alleviating symptoms such as dyspareunia\n - Moisturisers, which should be used regularly\n\n \n \n# References\n \n \n [Patient Info](https://patient.info/doctor/atrophic-vaginitis)",
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"question": "A 58-year-old woman presents to her general practitioner with a six-month history of incontinence.\n\nShe feels she needs to pass urine more often and cannot make it to the toilet in time. She often feels a burning sensation when voiding.\n\nHer observations are normal, and a urine dipstick is clear.\n\nShe has a past medical history of well-controlled hypertension, osteoporosis and hypothyroidism. She has had a previous hysterectomy for menorrhagia. She is not sexually active.\n\nOn examination, her abdomen is soft and non-tender. Her vulval skin is pale, and there is a narrowing of the introitus. A single-digit vaginal examination does not reveal any significant pelvic organ prolapse. On coughing, there is a minor leakage of urine.\n\nWhat is the most appropriate management?",
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"explanation": "This woman has features of lichen sclerosus, an inflammatory skin condition that often affects the vulva. It appears as hypopigmentation of the vulval and perianal skin, characteristically appearing in a \"figure of eight\" distribution. In severe cases, thickening and scarring occurs, which can completely obliterate vulval structures such as the labia minora and clitoris. Fissures are common, particularly around the posterior fourchette (the thin, v-shaped tissue joining the labia minora inferiorly). Fissures can easily tear and cause discomfort and bleeding.\n \n\n Vulval biopsy should be performed to confirm the diagnosis of lichen sclerosus. Lichen sclerosus carries an increased risk of vulval intraepithelial neoplasia (VIN) and squamous cell carcinoma. In this case in particular, the distribution of the hypopigmentation is not well-demarcated or symmetrical, raising a concern of pre-cancerous or cancerous changes.",
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"explanation": "A vulvovaginal swab for culture and sensitivity would be indicated if there was any symptoms or signs of infection such as a new vaginal discharge or pelvic pain.",
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"label": "e",
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"explanation": "Topical oestrogen therapy is used to treat vulvovaginal atrophy. Whilst vulvovaginal atrophy presents in a similar way to this woman, the \"figure of eight\" pattern, the \"porcelain white\" appearance and the presence of scarring is more indicative of lichen sclerosus than vulvovaginal atrophy. Atrophy typically presents with thinning of the vulval tissues and does not often cause fusion of vulval structures.",
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"explanation": "Topical ultrapotent steroid cream is the first-line management for lichen sclerosus; however, a biopsy should be performed first to confirm. The patient should have been off steroid therapy for at least three weeks prior to performing a biopsy.",
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"explanation": "Topical ultrapotent steroid cream is the first-line management for lichen sclerosus; however, a biopsy should be performed first to confirm. The patient should have been off steroid therapy for at least three weeks prior to performing a biopsy.",
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"explanation": "# Summary\n \n \nLichen sclerosus is an inflammatory skin condition that predominantly affects the genital and anal areas, characterized by white patches which may scar. It frequently presents itself with symptoms of itchiness and pain, and is more common in females than males. Key investigations for this condition include clinical evaluation, skin biopsy, and possibly blood tests. Management strategies often include topical steroids, avoidance of soaps in affected areas, and use of emollients to alleviate dryness and itching.\n \n \n# Definition\n \n \nLichen sclerosus is an inflammatory dermatological condition. It predominantly affects the genital and anal regions of the body, but it can present elsewhere. There is a noted predilection for this condition in females compared to males. The subtype, vulvar lichen sclerosus, specifically involves the inner vulva.\n \n \n# Aetiology\n \n \nThe cause of lichen sclerosus is currently unknown, but it is likely multifactorial. Potential contributing factors could include autoimmune reactions, genetic predisposition, and hormonal factors. Some studies suggest a possible link with previous skin damage or trauma.\n \n \n# Signs and Symptoms\n \n \n- White patches on the skin which may progress to scarring. \n- Itchiness and pain over patches, which may be exacerbated during urination or sexual intercourse.\n- Bleeding over patches, especially following sexual intercourse or passing of bowel motions. \n \n \n \n \n# Differential Diagnosis\n \n \nThe differential diagnosis for lichen sclerosus includes other dermatological conditions such as:\n \n \n - Lichen planus: Characterised by purple-looking, itchy, flat-topped bumps, and white lacy patches in the mouth or on the skin.\n \n - Psoriasis: Manifests as red patches with silver scales, typically on the scalp, elbows, knees, and lower back.\n \n - Vitiligo: Presents as patchy loss of skin color, usually first on sun-exposed areas of the skin.\n \n \n# Investigations\n \n**Bedside:**\n\n- Vulval examination: This should be enough to diagnose lichen sclerosus, if characteristic lesions are present. \n\n\nNo **blood tests** are required for diagnosis, but may on occasion be used to rule out other autoimmune conditions if there is clinical uncertainty. However, keep in mind that serology for autoimmune conditions often has low specificity. \n\nNo **imaging** is required.\n\n**Invasive:**\n\n- Skin biopsy: May be used to confirm the diagnosis. \n \n \n# Management\n \n \nThe management of lichen sclerosus includes:\n \n **Conservative:**\n \n - Avoidance of soaps in the affected areas to prevent further irritation.\n - Avoid tight clothing, rubbing or scratching. \n - Topical emollients to relieve dryness and soothe itching. \n \n**Medical:**\n\n\n - Topical corticosteroids (most often potent steroids, such as dermovate) to reduce inflammation and itching.\n - Topical cacineurin inhibitors (e.g. Tacrolimus) may be used in addition to steroids. However, they can cause burning and discomfort in the first few days of application. \n - Topical oestrogen cream or pessaries for postmenopausal women affected by atrophic vulvovaginitis, caused or exacerbated by scarring of lesions. \n - Oral treatment with corticosteroids, retinoids, methotrexate or ciclosporin may be indicated in severe cases that do not respond to topical therapies. \n\n**Surgical:**\n\nWhilst surgical management is not usually performed, it can be used in cases of severe adhesions and advanced scarring that impacts continence and sexual intercourse, where conservative and medical measures have not helped.\nSurgery would also be indicated in cases of squamous cell carcinoma (see complications). \n\n\n# Complications\n\n- Infections: Namely Candida albicans, Staphylocuccus aureus, Herpes simplex, predisposed by breaks in the skin. \n- Squamous cell carcinoma: Affects up to 5% of patients with vulval lichen sclerosus. \n- Worsening constipation: Often as a result of pain or discomfort while passing bowel motions. \n \n \n# NICE Guildelines\n\n[Click here for NICE Guildelines on assessment of vulval itching](https://cks.nice.org.uk/topics/pruritus-vulvae/diagnosis/assessment/)\n\n\n# References\n \n \n[BASHH 2014 UK National Guideline on the Management of Vulval Conditions](https://www.bashh.org/documents/UK%20national%20guideline%20for%20the%20management%20of%20vulval%20conditions%202014.pdf)\n\n[DermNet](https://dermnetnz.org/topics/lichen-sclerosus)\n\n[NHS UK](https://www.nhs.uk/conditions/lichen-sclerosus/)",
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"question": "A 66-year-old woman presents with sharp pain on defecation and occasional blood on toilet paper. She denies weight loss or changes in bowel habits.\n\n\nShe has a past medical history of type 2 diabetes which is well-controlled on metformin, hypertension and eczema.\n\nOn examination, her abdomen is soft and non-tender. Genital exam reveals smooth, dry vulva with porcelain-white shiny areas, particularly on the left. The labia minora and clitoris are not visible, and the labia majora are thickened with red patches. Linear lacerations are present at the posterior fourchette and external anal sphincter.\n\n\nDigital vaginal examination is not possible. Digital rectal examination reveals no masses and soft stool in the rectum.\n\n\nWhat is the most appropriate next step?",
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"explanation": "This woman has polycystic ovary syndrome (PCOS). PCOS can be diagnosed using the Rotterdam criteria, where two of the following three are present:\n \n\n - Oligo- or amenorrhoea\n - Clinical or biochemical evidence of hyperandrogenism\n - Polycystic appearance of the ovaries on ultrasound\n \n\n Although her general practitioner has performed multiple hormone blood tests and ordered an ultrasound scan, these are not necessary to provide a diagnosis. She has evidence of oligomenorrhoea (long, irregular cycles) and clinical evidence of hyperandrogenism (acne, hirsutism).\n \n\n PCOS does not cause absolute infertility, as often the woman still ovulates, but less frequently. The advice is to refer to the fertility clinic where a couple has been trying to become pregnant for two years.",
"id": "49802",
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"name": "Advise the woman to continue having unprotected intercourse and ask to be referred to the fertility clinic if she has not become pregnant after 1 year in total",
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"explanation": "BMI is calculated as weight (kg)/height m<sup>2</sup>. Her BMI is 24.9 kg/m<sup>2</sup>, just within the normal range. Women with a BMI over 25kg/m<sup>2</sup> may benefit from weight loss to increase the chances of pregnancy.",
"id": "49803",
"label": "b",
"name": "Advise the woman to lose weight",
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"name": "Advise having sexual intercourse daily to increase the chance of conception",
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"explanation": "BMI is calculated as weight (kg)/height m<sup>2</sup>. Her BMI is 24.9 kg/m<sup>2</sup>, just within the normal range. Women with a BMI over 25kg/m<sup>2</sup> may benefit from weight loss to increase the chances of pregnancy.",
"id": "49805",
"label": "d",
"name": "Advise a trial of combined oral contraception to regulate her periods",
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"explanation": "Referral to the fertility clinic is only warranted where the couple have been trying to conceive for two years.",
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"label": "c",
"name": "Advise the woman's husband to ask for a referral to the fertility clinic for semen analysis",
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"comment": "Could you have not just given us the BMI",
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"explanation": "# Summary\n \n \nSubfertility is defined as the diminished ability of a couple to conceive a child, which may be due to a variety of definable causes or an unexplained failure to conceive over a two-year period. Key signs and symptoms vary based on the underlying cause but generally revolve around the inability to achieve pregnancy despite regular unprotected sexual intercourse. Investigations typically include hormonal studies, semen analysis, and imaging studies. The management of infertility is dependent on the underlying cause and often involves a combination of lifestyle modifications, medical interventions, and assistive reproductive technology. \n \n \n \n# Definition\n \nInfertility is the diminished ability of a couple to conceive a child. This may result from a definable cause such as ovulatory, tubal, or sperm problems, or may be an unexplained failure to conceive over a two-year period despite regular (3-4 times a week) unprotected sexual intercourse.\n \n \n \n# Epidemiology\n \n \nStatistically, a couple stands an 80% chance of conceiving within one year if the woman is younger than 40 years, they do not use contraception, and they have regular intercourse (3-4 times per week). This overall probability increases to 90% if considered over two years.\n \n \n# Aetiology\n\n \nFactors affecting natural fertility include:\n \n - Increasing age\n - Obesity\n - Smoking\n - Tight-fitting underwear (males)\n - Excessive alcohol consumption\n - Anabolic steroid use\n - Illicit drug use\n \n \n\nCauses of infertility can be classified into:\n \n \n - **Genetic causes:** This includes Turner's syndrome (XO) and Kleinfelter's syndrome (XXY).\n - **Ovulation/endocrine disorders:** Examples are polycystic ovary syndrome, pituitary tumours, Sheehan's syndrome, hyperprolactinaemia, Cushing's syndrome, and premature ovarian failure.\n - **Tubal abnormalities:** These can be due to congenital anatomical abnormalities or adhesions secondary to pelvic inflammatory disease (often caused by chlamydia or gonorrhoea).\n - **Uterine abnormalities:** These include bicornate uterus, fibroids, and Asherman's syndrome (uterine adhesions).\n - Endometriosis\n - **Cervical abnormalities:** These include cervical damage after biopsy or LLETZ procedure.\n - **Testicular disorders:** Disorders such as cryptorchidism, varicocele, testicular cancer, and congenital testicular defects fall in this category.\n - **Ejaculatory disorders:** These include obstruction of the ejaculatory system and disorders of ejaculation such as retrograde ejaculation and premature ejaculation.\n \n \n# Investigations\n \n \nInvestigations for infertility are divided into those for men and women. \n\n*For women:*\n\n**Bedside:**\n \n- Thorough history, including past medical history, sexual history and details of past pregnancies. \n- Speculum and bimanual examination: To investigate physical anomalies (e.g. large fibroids). \n- STI screen\n \n \n**Bloods:**\n \n - Serum progesterone testing (performed 7 days before the end of the menstrual cycle): A rise in progesterone indicates that the corpus luteum has formed and is releasing progesterone due to occurrence of ovulation.\n - Prolactin\n - LH/FSH \n - Anti-mullerian hormone (AMH): Measure of ovarian reserve\n - TFTs \n\n \n**Imaging:**\n \n- Transvaginal ultrasound scan: To identify any physical anomalies of the uterus, and check antral follicle count (measure of ovarian reserve)\n- Hysterosalpingography: Assess tubal patency.\n- Laparsocopy and dye: Assess tubal patency in presence of co-morbidities (e.g. PID, ectopic pregnancy, endometriosis). \n\n\n*For men:*\n\n**Bedside:**\n \n- Thorough history, including past medical history, sexual history and details of past pregnancies. \n- Testicular examination: To investigate visible physical anomalies (e.g. varicocele). \n- Semen analysis: To evaluate sperm count, motility, and morphology. \n \n \n**Bloods:**\n \n - Serum testosterone \n - LH/FSH \n - TFTs \n \n \n# Management\n \n \nThe management of infertility is tailored to the underlying cause but may include:\n \n**Conservative:**\n\n - Weight loss\n - Smoking cessation \n - Reduction of alcohol intake\n - Stress-reduction strategies\n\n**Medical:**\n\nMedications may be used for ovulation induction, such as: \n\n - Clomiphene\n - FSH and LH injections\n - GnRH or DA agonists\n\n \n**Surgical:**\n \n - Assisted reproductive technology, including in vitro fertilisation or intracytoplasmic sperm injection.\n\n\nIn addition to all of the above, if an underlying cause of infertility is found (e.g. fibroids, endometriosis), then those causes should be managed. \n\n\n# NICE Guidelines\n\n[Click here for NICE Guidelines on fertility problems](https://www.nice.org.uk/guidance/cg156)\n\n[Click here for NICE Guidelines on infertility](https://cks.nice.org.uk/topics/infertility/)\n\n# References \n\n[BMJ Best Practice](https://bestpractice.bmj.com/topics/en-gb/498)\n\n[Fields et al., 2023 - BMJ](https://www.bmj.com/bmj/section-pdf/187753?path=/bmj/346/7896/Practice.full.pdf)",
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"question": "A 26-year-old woman attends her general practitioner with difficulty conceiving. She has been having regular unprotected intercourse with her 27-year-old husband for six months. She has never taken any hormonal contraception. She describes her periods as \"a bit irregular\" with a 50-75 day cycle.\n\n\n\nOn examination, she is 170cm tall and weighs 72kg. She has notable facial acne and has dark hair on her chin and around her areola.\n\n\n\n\nHer blood tests results are as follows:\n\n\n||||\n|---------------------------|:-------:|------------------------------|\n|Testosterone|1.9 nmol/L|(M) 9.9 - 27.8, (F) 0.2 - 2.9|\n|Androstenedione|15.8 nmol/L|1.3 - 5.8|\n|Luteinising Hormone|9.1 IU/L|1 - 11 (Luteal)|\n|Follicle Stimulating Hormone|5.4 IU/L|2 - 8 (Luteal)|\n|LH/FSH ratio|1.7||\n|Dehydroepiandrosterone sulfate (DHEAS)|6.7 µmol/L|2.7 – 9.2|\n\n\n\nA pelvic ultrasound shows bilateral ovary are enlargement, with multiple peripheral follicles.\n\n\n\nWhat is the most appropriate management?",
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"explanation": "BMI should be recorded and documented prior to initiating combined hormonal contraception in all women, even those who do not appear overweight. Women with a BMI ≥35 kg/m<sup>2</sup> generally should not use combined hormonal contraception.",
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"label": "a",
"name": "Height and weight",
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"__typename": "QuestionChoice",
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"explanation": "Cervical screening starts at age 25 in the UK. Prior to age 25, cervical smears should not be performed.",
"id": "49808",
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"explanation": "As she has been using condoms reliably, there is no need to perform a pregnancy test prior to initiating combined hormonal contraception.",
"id": "49811",
"label": "e",
"name": "High-sensitivity urinary pregnancy test",
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"explanation": "Routine checks for diabetes and impaired glucose tolerance are not required for initiation of combined hormonal contraception, even if there is a family history.",
"id": "49809",
"label": "c",
"name": "Check HbA1c level",
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"explanation": "The use of combined hormonal contraception is acceptable for women with a family history of breast cancer, and genetic tests are not required.",
"id": "49810",
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"name": "Screening for BRCA1 and BRCA2 genes",
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"comment": "her family history of maternal breast cancer entirely excludes the option of the COCP?",
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"comment": "FxHx is UKMEC 1, carrying BRCA mutation is 3, current cancer is 4 and past is 5. Technically she is eligible, it’s also likely that her mother would be aware of BRCA mutations that might need screening, I believe patients are normally told about such potentially hereditary conditions.\n",
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"comment": "Probably a typo, but past breast cancer would be UKMEC 3",
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"comment": "BMI >35 is UKMEC3 though.",
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"explanation": "# Summary\n\nThe combined oral contraceptive pill (COCP) is a long-term contraceptive containing synthetic oestrogen and progestogen. It works by inhibiting ovulation, thickening cervical mucus, and altering the endometrium to prevent fertilisation and implantation. Indications for COCP use include contraception, menstrual cycle regulation, and treatment of dysmenorrhea, menorrhagia, acne, and hirsutism. Contraindications are categorised by UKMEC criteria, detailed in this chapter. \n \n# Definition\n\nThe combined oral contraceptive pill (COCP) is a long-term contraceptive. It contains synthetic versions of the female hormones oestrogen and progestogen. \n\n# Mechanism of Action\n\n* **Inhibition of Ovulation:** The COCP contains synthetic versions of the hormones oestrogen and progestogen. These hormones together suppress the release of gonadotrophins (LH and FSH) from the pituitary gland, preventing the maturation and release of an egg from the ovaries.\n\n* **Thickening of Cervical Mucus:** The progestogen component of the COCP increases the viscosity of cervical mucus, making it more difficult for sperm to enter the uterus and fertilise an egg.\n\n* **Alteration of the Endometrium:** The COCP induces changes in the lining of the uterus (endometrium), making it less suitable for the implantation of a fertilised egg.\n\n# Administration\n\n* Taken orally once daily, ideally at the same time each day\n* Can be taken for 21 days with a 4 or 7 day hormone-free interval (HFI), or tricycled (9 weeks consecutive use with 4 or 7 day HFI)\n\n# Indications\n\nThere are a range of reasons for women to be recommended the oral combined contraceptive pill. For example:\n\n* **Contraception:** The COCP works as a long-term contraception. It is taken orally once a day, at around the same time each day. \n* **Menstrual Cycle Regulation:** The COCP can help regulate irregular menstrual cycles. \n* **Dysmenorrhea:** The COCP may be used to reduce menstrual cramps. \n* **Menorrhagia:** The COCP can decrease heavy menstrual bleeding.\n* **Acne and Hirsutism:** The COCP helps in the treatment of acne and excessive hirsutism in women, which may happen in conditions such as polycystic ovary syndrome (PCOS) or other androgen excess conditions.\n* **Premenstrual Syndrome (PMHS**: The COCP can alleviate symptoms of PMS, such as mood swings, bloating, and irritability.\n \n# Contraindications \n\nThere are numerous contra-indications to the Combined Oral Contraceptive Pill. These can be divided into absolute contraindications, known as ''UKMEC 4'', a situation where the disadvantages outweigh the advantages (UKMEC 3), a situation where the advantages outweigh the disadvantages (UKMEC 2), and a situation whereby there is no limit on that choice of contraception (UKMEC 1).\n\n\n## Absolute Contraindications to Contraception (UKMEC 4)\n \n \n * Known or suspected pregnancy\n * Hypertension with SBP ≥160 mmHg or DBP ≥100 mmHg\n * Smoker over the age of 35 who smokes >15 cigarettes a day \n * Current and history of ischaemic heart disease\n * History of stroke (including TIA) \n * Vascular disease\n * Personal history of or current VTE\n * Major surgery with prolonged immobilisation\n * Breastfeeding <6 weeks postpartum\n * Not breastfeeding and <3 weeks postpartum with other risk factors for VTE\n * Known thrombogenic mutations \n * Complicated valvular and congenital heart disease\n * Cardiomyopathy with impaired cardiac function\n * Atrial fibrillation \n * Migraine with aura (any age)\n * Current breast cancer \n * Severe (decompensated) cirrhosis \n * Hepatocellular adenoma and hepatocellular carcinoma\n * Positive antiphospholipid antibodies \n \n \n \n## Disadvantages of a contraceptive outweigh the advantages (UKMEC 3)\n \n \n * Obesity (BMI ≥35 kg/m2)\n * Multiple risk factors for cardiovascular disease (e.g. smoking, diabetes mellitus, hypertension, obesity, dyslipidaemia) \n * Well controlled hypertension, and hypertension with SBP >140-159 mmHg or DBP <90-99 mmHg\n * Smoker over age of 35 who smokes <15 cigarettes a day, or anyone over age of 35 who stopped smoking <1 year ago\n * Family history of thrombosis in first-degree relative before 45 years old\n * Not breastfeeding and <3 weeks postpartum without other risk factors for VTE\n * Not breastfeeding and between 3-6 weeks postpartum with other risk factors for VTE\n * Organ transplant with complications (e.g. graft failure, rejection) \n * Immobility (unrelated to surgery)\n * Migraine without aura (any age) [applies to *continuation* of COCP]\n * History (≥5 years ago) of migraine\nwith aura (any age) \n * Undiagnosed breast mass or symptoms [applies to *initiation* of COCP] \n * Carriers of known gene mutations associated with breast cancer\n * Past breast cancer \n * Diabetes mellitus with nephropathy, retinopathy, neuropathy or other vascular complications \n * Symptomatic gall bladder disease treated medically or currently active \n * Past COCP associated cholestasis \n * Acute viral hepatitis [applies to *initiation* of COCP]\n \n \n \n## Advantages of a contraceptive outweigh the disadvantages (UKMEC 2)\n \n * Smokers under the age of 35, and people aged over 35 who stopped smoking over 1 year ago \n * Obesity (BMI ≥30–34 kg/m2) \n * Family history of VTE in first-degree relative aged ≥45 years\n * History of raised blood pressure in pregnancy \n * Breast feeding between 6 weeks-6 months postpartum\n * Not breastfeeding and between 3-6 weeks postpartum without other risk factors for VTE\n * Uncomplicated organ transplant \n * Known dyslipidaemia \n * Major surgery without prolonged immobilisation \n * Superficial venous thrombosis \n * Uncomplicated valvular and congenital heart disease\n * Cardiomyopathy with normal cardiac function \n * Long QT syndrome \n * Non-migrainous headaches [applies to *continuation* of COCP]\n * Migraine without aura [applies to *initiation* of COCP] \n * Idiopathic intracranial hypertension \n * Unexplained vaginal bleeding\n * Cervical cancer \n * Undiagnosed breast mass or symptoms [applies to *continuation* of COCP]\n * Insulin-dependent diabetes mellitus without vascular disease \n * Symptomatic gall bladder disease treated through cholecystectomy, or asymptomatic gall bladder disease, or history of pregnancy-related cholestasis \n * Acute viral hepatitis [applies to *continuation* of COCP]\n * Inflammatory bowel disease \n * Sickle cell disease \n * Rheumatoid arthritis\n * SLE without antiphospholipid antibodies \n\n\n# Side-effects and Complications\n \n**Common Side-Effects:**\n\n* Breast tenderness \n* Abdominal discomfort, nausea diarrhoea \n* Headaches\n* Mood changes\n* Reduced libido \n\n\n**Rare but Serious Side-Effects:**\n\n* Embolism or thrombus, including: DVT and PE, stroke, myocardial infarction\n* Increased risk of breast cancer\n* Increased risk of cervical cancer \n\n\n# Follow-up\n\nArrange follow up 3 months following initial prescription of a COCP, and annually thereafter.\n\nAt follow-up, ensure to: \n\n* Check blood pressure and BMI. \n* Ask about headaches (including migraine). \n* Check for risk factors that may be contraindicators to COCP (as per UKMEC criteria). \n* Enquire about side-effects. \n* Enquire about how woman is taking the COCP (i.e. adherence). \n\n\n# Missed Pill Rules\n\n**Missed One Pill:**\n\n* Advise patient to take the pill as soon as possible, even if it means taking two pills in one day.\n* * Continue taking the rest of the pack as usual.\nNo additional contraception needed if this is the only pill missed in the pack.\n\n**Missed Two or More Pills in Week 1 (Days 1-7):**\n\n* Advise patient to take the last pill they missed as soon as possible. \n* Continue taking the rest of the pack as usual.\n* Use additional contraception for the next 7 days.\n* If they had unprotected sex during this week, seek emergency contraception.\n\n**Missed Two or More Pills in Week 2 (Days 8-14):**\n\n* Take the last pill they missed as soon as possible. \n* Continue taking the rest of the pack as usual.\n* No additional contraception needed if they have taken pills correctly for the 7 days prior to the missed pill.\n\n**Missed Two or More Pills in Week 3 (Days 15-21):**\n\n* Finish the active pills in the current pack, then start a new pack immediately without taking the usual 7-day break.\n* No additional contraception needed if they have taken pills correctly for the 7 days prior to the missed pill.\n \n# NICE Guidelines \n\n[Click here to view NICE Guidelines on COCP](https://cks.nice.org.uk/topics/contraception-combined-hormonal-methods/management/combined-oral-contraceptive/)\n \n \n# References\n \n[Click here to see the UKMEC summary sheet on contraception](https://www.fsrh.org/standards-and-guidance/documents/ukmec-2016-summary-sheets/)",
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"question": "A 22-year-old woman attends her general practitioner seeking contraception. She is entering her final year at university and does not wish to become pregnant while studying. She has read a little about contraception and thinks she would like to take a combined oral contraceptive pill. She is currently using condoms every time she has intercourse.\n\nShe has a past medical history of asthma, atopic dermatitis and has recently recovered from a COVID-19 infection. She takes salbutamol as required. She does not appear overweight.\n\nHer mother has type 2 diabetes and recently underwent a left mastectomy for a lobular breast cancer in situ. Her father recently died age 59 of bowel cancer.\n\nWhich of the following should be performed before prescribing the combined oral contraceptive pill?",
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"explanation": "The progestogen-only subdermal implant contains etonogestrel, which, although is less androgenic than levonorgestrel, can also have the side effect of causing or worsening acne. In addition, a common side effect of the contraceptive implant is irregular bleeding, which may be unacceptable to this woman.",
"id": "49819",
"label": "c",
"name": "Progestogen-only subdermal implant",
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"__typename": "QuestionChoice",
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"explanation": "There may be an increased risk of acne worsening with the levonorgestrel-releasing intrauterine system. In addition, the levonorgestrel-releasing intrauterine system is associated with irregular menstrual bleeding or spotting, which may be unacceptable for this woman.",
"id": "49821",
"label": "e",
"name": "Levonorgestrel-releasing intrauterine system",
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"explanation": "Most women with acne find that their skin improves when they take the combined oral contraceptive pill, however different formulations have different effects. Co-cyprindiol (ethinylestradiol and cyproterone) has anti-androgenic properties, and is licenced for treating acne in women who have not responded to antibiotics. Levonorgestrel has androgenic properties and may worsen acne.",
"id": "49817",
"label": "a",
"name": "A combined oral contraceptive pill containing ethinyloestradiol and cyproterone acetate",
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"explanation": "Levonorgestrel has androgenic properties, so may make acne worse. In addition, progestogen-only pills can often result in irregular bleeding. The stem of the question states she started the combined oral contraceptive pill to regulate menstrual bleeding, so this side effect may be unacceptable.",
"id": "49818",
"label": "b",
"name": "A progestogen-only pill containing 30 micrograms levonorgestrel",
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"__typename": "QuestionChoice",
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"explanation": "The copper intrauterine device will not have any effect on acne, as it does not contain any hormones. The copper intrauterine device is associated with increased menstrual blood flow, which may be an unacceptable side effect in a woman who had started the combined oral contraceptive pill for menorrhagia.",
"id": "49820",
"label": "d",
"name": "Copper intrauterine device",
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"explanation": "# Summary\n \n \nPolycystic ovary syndrome (PCOS) is a disorder characterised by hyperandrogenism, ovulation disorders, and polycystic ovarian morphology. It is common among women of child-bearing age. Key signs and symptoms include oligomenorrhoea, hirsutism, acne, and subfertility among others. Investigations such as hormonal assays and imaging techniques are used in diagnosis. Management strategies encompass lifestyle modifications and a range of pharmacological treatments tailored to patient preferences, such as conception.\n \n \n# Definition\n \n \nPolycystic ovary syndrome (PCOS) is a disorder characterised by hyperandrogenism (manifesting as oligomenorrhoea, hirsutism, and acne), ovulation disorders, and polycystic ovarian morphology.\n \n \n# Epidemiology\n \n \nPolycystic ovary syndrome is a common endocrine condition, affecting up to a quarter of women during their reproductive years.\n \n \n# Aetiology\n \n \nThe precise aetiology of PCOS remains undetermined. However, potential hormonal imbalances implicated in this syndrome include hyperandrogenism, insulin resistance, elevated levels of luteinizing hormone (LH) and raised oestrogen levels.\n \n \n# Signs and Symptoms\n \n \nThe clinical presentation of PCOS is largely attributed to the hormonal imbalances, with symptoms including:\n \n \n - Oligomenorrhoea\n - Subfertility\n - Acne\n - Hirsuitism\n - Obesity\n - Mood changes including depression and anxiety\n - Male pattern baldness\n - Acanthosis nigricans (secondary to insulin resistance)\n \n \n# Differential Diagnosis\n \n \nFor accurate diagnosis, other endocrine disorders presenting similar clinical features must be excluded. These include:\n \n \n - Menopause: Characterised by cessation of menstruation, hot flashes, vaginal dryness, mood changes, and sleep problems.\n - Congenital adrenal hyperplasia (CAH): Presenting with signs of androgen excess like hirsutism, acne, and irregular periods. Presents earlier on and can lead to ambiguous genitalia (for affected females). \n - Hyperprolactinaemia: Symptoms include irregular periods, galactorrhoea, and infertility.\n - Androgen-secreting tumours: May cause virilisation, amenorrhoea, and hirsutism.\n - Cushing's syndrome: Characterised by weight gain, purple stretch marks, and easy bruising.\n \n \n# Investigations\n \n \nBiochemical assays and imaging techniques play a pivotal role in the diagnosis of PCOS:\n \n**Bedside:**\n\n- Clinical examination to identify features of hyperandrogenism (e.g. hirsutism) or features of insulin resistance (e.g. acanthosis nigricans, raised BMI)\n\n**Bloods:**\n\n- LH:FSH ratio: An increase (>2) aids in differentiating from menopause where the ratio is normal.\n- Total testosterone: May be normal or slightly elevated.\n- Fasting and oral glucose tolerance tests: Used to diagnose insulin resistance.\n- Other tests may include TFTs (for thyroid dysfunction), 17-hydroxyprogesterone levels (for CAH), prolactin (for hyperprolactinaemia), DHEA-S and free androgen index (for androgen-secreting tumours), and 24-hour urinary cortisol (for Cushing's syndrome).\n\n**Imaging:**\n\n- Transabdominal and transvaginal ultrasound: Reveals increased ovarian volume and multiple cysts. May be important for fulfilling Rotterdam Diagnostic Criteria (See below) \n\n\nNo **invasive tests** are required for diagnosis. \n\n \n **Rotterdam Diagnostic Criteria:**\n \n \nUpon exclusion of other causes, PCOS can be diagnosed if at least two of the following criteria are met:\n \n \n - Polycystic ovaries (defined as a follicle number per ovary of 20 or more in at least one ovary)\n - Oligo-/anovulation\n - Clinical or biochemical features of hyperandrogenism\n \n \n# Management\n \n \nThe management of PCOS primarily focuses on symptom control and prevention of complications, with endometrial cancer risk reduction achieved through regular menstruation.\n \n \n**Conservative:**\n \n \n - Encouragement of weight loss and exercise\n - Education on increased risks of cardiovascular disease, diabetes, and endometrial cancer\n \n \n**Medical, for women not planning pregnancy:**\n \n \n - Co-cyprindrol: Reduces hirsutism and promotes regular menstruation.\n - Combined oral contraceptive pill (COCP): Decreases irregular bleeding and offers protection against endometrial cancer.\n - Metformin: Aids in regularising menstruation, reducing hirsutism, and acne.\n \n \n**Medical, for women wishing to conceive:**\n \n \n - Clomiphene: Induces ovulation and enhances conception rates.\n - Metformin: Can be used alone or in combination with clomiphene to improve chances of pregnancy.\n - Gonadotrophins: Utilised to induce ovulation if clomiphene and metformin prove ineffective.\n\n**Surgical, for women wishing to conceive:**\n\n - Ovarian drilling: A second-line laparoscopic surgical procedure that damages the hormone-producing cells of the ovary. \n \n# Complications\n\n\n- Infertility: Caused by impaired or dysregulated ovulation.\n- Metabolic syndrome and dyslipidaemia: PCOS leads to raised triglycerides and LDL and fall in HDL. \n- Type 2 diabetes: PCOS increases risk of T2DM by approximately two fold as a result of insulin resistance \n- Cardiovascular disease: This is likely a consequence of metabolic complications of PCOS and hormonal alterations. \n- Hypertension: Greater risk of hypertension seen in premenopausal as opposed to postmenopausal women. \n- Obstructive sleep apnoea: This occurs as a result of obesity (usually secondary insulin resistance and metabolic changes). \n\n# NICE Guidelines\n\n[Click here for NICE guidelines on PCOS](https://cks.nice.org.uk/topics/polycystic-ovary-syndrome/)\n\n# References \n\n[BMJ Best Practice](https://bestpractice.bmj.com/topics/en-gb/141)\n\n[RCOG page](https://www.rcog.org.uk/for-the-public/browse-our-patient-information/polycystic-ovary-syndrome-pcos-what-it-means-for-your-long-term-health/)",
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"question": "A 22-year-old woman attends her general practice troubled by acne and hirsutism. On examination, she has significant pustular facial acne and facial hair. She has trialled topical and oral antibiotics; however, she feels her acne has not improved.\n\nShe has been taking a combined oral contraceptive pill containing 30 micrograms ethinyloestradiol and 150 micrograms levonorgestrel for the past six months, which she started to regulate her menstrual cycle and alleviate menorrhagia. She feels her acne has worsened since starting this.\n\nShe asks if there is a different contraceptive that she can switch to, to improve her acne.\n\nWhich of the following contraceptive options is most likely to alleviate acne?",
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"explanation": "Gestational (or pregnancy-induced) hypertension is defined by two blood pressure readings of ≥140/90 mmHg on two occasions (at least 4 hours apart) after 20 weeks gestation in a previously normotensive patient. Gestational hypertension does not have associated proteinuria or other clinical features of pre-eclampsia.",
"id": "49822",
"label": "a",
"name": "Gestational hypertension",
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"__typename": "QuestionChoice",
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"explanation": "Pre-eclampsia is defined as new-onset, persistent hypertension with either proteinuria or evidence of systemic involvement. Whilst headache can be a symptom of pre-eclampsia, the headache this woman is describing sounds more like a tension headache than the classic frontal headache seen in pre-eclampsia.",
"id": "49824",
"label": "c",
"name": "Pre-eclampsia",
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"__typename": "QuestionChoice",
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"explanation": "Eclampsia is the presence of tonic-clonic seizures on a background of pre-eclampsia (new-onset, persistent hypertension with either proteinuria or evidence of systemic involvement).",
"id": "49825",
"label": "d",
"name": "Eclampsia",
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"explanation": "HELLP syndrome is a subtype of severe pre-eclampsia characterised by haemolysis (H), elevated liver enzymes (EL), and low platelets (LP). It is much rarer than gestational hypertension, and there is no suggestion of any of these manifestations.",
"id": "49826",
"label": "e",
"name": "HELLP syndrome",
"picture": null,
"votes": 6
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "The patient is hypertensive but has no past medical history, which suggests the hypertension is new, indicating gestational hypertension rather than chronic hypertension.",
"id": "49823",
"label": "b",
"name": "Chronic hypertension",
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"explanation": "# Summary\n\n\nChronic hypertension and gestational hypertension are common conditions that may affect pregnant women. They are defined by consistently high blood pressure readings over a certain threshold. Typical signs and symptoms include elevated blood pressure readings, with gestational hypertension specifically presenting after 20 weeks of gestation with no proteinuria. Differential diagnosis may include preeclampsia and chronic kidney disease. Investigations primarily focus on blood pressure monitoring and urinalysis. Management strategies include the use of safe anti-hypertensive medications, such as labetalol, methyldopa, and nifedipine, and regular monitoring.\n\n\n# Definition\n\n\nChronic hypertension refers to high blood pressure that predates pregnancy or is diagnosed before 20 weeks of gestation. Gestational hypertension, on the other hand, is the onset of high blood pressure after 20 weeks gestation without the presence of proteinuria.\n\n\n# Epidemiology\n\n\nBoth chronic and gestational hypertension are common conditions amongst pregnant women. It is crucial to manage these conditions effectively to prevent complications such as preeclampsia and low birth weight.\n\n\n# Aetiology\n\n\nThe causes of chronic and gestational hypertension are multifactorial, often involving genetic predisposition, lifestyle factors, and physiological changes during pregnancy.\n\n\n# Signs and Symptoms\n\n\nThey are primarily asymptomatic but are detected through elevated blood pressure readings. Gestational hypertension specifically presents after 20 weeks of gestation with no proteinuria.\n\n\n# Differential Diagnosis\n\n\n- Preeclampsia: Characterized by high blood pressure and damage to another organ system, most often the liver and kidneys, after 20 weeks of gestation.\n- Chronic Kidney Disease: Typically presents with proteinuria, haematuria, and a rise in serum creatinine.\n\n# Investigations\n\nInvestigations primarily focus on blood pressure monitoring and urinalysis. Regular monitoring and testing are recommended to track the course of the condition and evaluate the effectiveness of treatments.\n\n# Management\n\nManagement strategies for chronic and gestational hypertension in pregnancy include:\n\n- Discontinuation of some anti-hypertensive medications (particularly ACE inhibitors or ARBs) and switching to pregnancy-safe alternatives such as labetalol.\n- Regular blood pressure monitoring.\n- For gestational hypertension above 140/90 mmHg, offer pharmacological treatment; first line management is oral labetalol.\n- If labetalol is not tolerated, alternatives include methyldopa and nifedipine.\n- Regular urinalysis is recommended for all women.\n\n# NICE Guidelines\n\n[NICE - Hypertension in\npregnancy: diagnosis and\nmanagement](https://www.nice.org.uk/guidance/ng133/resources/hypertension-in-pregnancy-diagnosis-and-management-pdf-66141717671365)\n\n",
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"explanation": "Whilst chlamydia trachomatis is the most common sexually transmitted infection; it typically does not present with a vulval itch. In most women, chlamydia infection is asymptomatic; however, it can cause an unusual vaginal discharge.",
"id": "49829",
"label": "c",
"name": "Chlamydia trachomatis",
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"explanation": "Lactobacilli are part of the normal vaginal flora. Lack of lactobacilli results in bacterial vaginosis, which presents with a smelly discharge and increased vaginal pH.",
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"explanation": "Trichomonas vaginalis (TV) causes trichomoniasis, which typically presents with a profuse frothy discharge, vaginitis and a raised pH.",
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"id": "49827",
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"name": "Candida albicans",
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"explanation": "# Summary\n \n\nVulvovaginal candidiasis is a common fungal infection primarily caused by Candida Albicans. This infection affects approximately 20% of women annually and presents with key symptoms like itching, white curdy discharge, and a burning sensation. Risk factors include pregnancy, antibiotic use, and immunosuppression. While routine investigations are not generally recommended for uncomplicated cases, microscopy and culture may be required for recurrent instances or ambiguous symptoms. Management primarily involves antifungal treatments such as oral azoles, intravaginal pessaries, or topical creams. The choice of treatment relies on patient factors and preferences.\n \n\n# Definition\n \n\nVulvovaginal candidiasis, often referred to as a yeast infection, is an inflammation of the vagina and the vulva due to an overgrowth of the yeast fungus, primarily Candida Albicans.\n \n\nRecurrent vulvovaginal candidiasis is defined as four or more symptomatic episodes in one year, with at least two episodes confirmed by microscopy or culture when symptomatic.\n \n\n# Epidemiology\n \n\nVulvovaginal candidiasis impacts approximately 20% of women on an annual basis. Despite its high prevalence, the epidemiology of this condition is not well-delineated.\n \n\n# Aetiology\n \n\nCandida Albicans is the main causative organism in 85-90% of vulvovaginal candidiasis cases. Transmission is typically non-sexual.\n \n\n# Risk Factors\n \n\nKey factors that increase the risk of developing a Candida infection include:\n \n\n- Pregnancy\n- Antibiotic use\n- Immunosuppression\n- Type 2 diabetes, use of SGLT-2 inhibitors\n \n\n# Signs and Symptoms\n \n\nClinical features in both men and women include:\n \n\n- **Women**\n- Symptoms: Itching, white curdy or lumpy discharge, sour milk odour, dysuria, superficial dyspareunia, pruritus, tenderness, and a burning sensation.\n- Examination findings: Redness, fissuring, swelling, intertrigo, thick white discharge.\n- **Men**\n- Symptoms: Soreness, pruritus, redness.\n- Examination findings: Dry, dull, red glazed plaques and papules.\n \n\n# Differential Diagnosis\n \n\nThe following conditions can present similarly to vulvovaginal candidiasis and should be considered:\n \n\n- **Bacterial vaginosis**: Characterised by greyish-white discharge, fishy odour, and absence of significant inflammation.\n- **Trichomoniasis**: Presents with yellow-green, frothy discharge, dysuria, and itching.\n- **Chlamydia or Gonorrhoea**: These sexually transmitted infections can cause similar symptoms such as discharge, but often also present with pelvic pain or bleeding.\n- **Genital herpes**: Characterised by painful blisters or open sores in the genital area.\n \n\n# Investigations\n \n\nRoutine investigations are not typically required for acute, uncomplicated vulvovaginal candidiasis cases. However, in instances where the clinical presentation is unclear or recurrent episodes occur, the following investigations may be necessary:\n \n\n- **Microscopy**: Detection of blastospores, pseudohyphae and neutrophils suggests Candida infection.\n- **Culture**: Recommended for recurrent vulvovaginal candidiasis cases to identify the Candida species.\n \n\n# Management\n \n\nVulvovaginal candidiasis is primarily managed with antifungal treatment:\n \n\n- Oral (-azoles) e.g., fluconazole, itraconazole\n- Intravaginal e.g., clotrimazole pessary\n- Vulval e.g., topical clotrimazole cream\n \n\nCommon regimens include:\n \n\n- Fluconazole oral capsule 150mg as a single dose.\n- Clotrimazole intravaginal pessary 500mg as a single dose.\n- Clotrimazole intravaginal cream (10%) 5g as a single dose.\n- Clotrimazole intravaginal pessary 200mg at night for 3 consecutive nights.\n \n\nRecurrent vulvovaginal candidiasis is managed with a induction and maintainence regimen:\n \n\n- Induction with Fluconazole oral capsule 150mg every 72 hours for a total of three doses\n- Maintainence with Fluconazole oral capsule 150mg once weekly for six months\n \n\nThese regimens can be supplemented with topical -azole therapy if vulval symptoms persist. Treatment choice depends on contraindications, drug history, and patient preference. Oral therapies should be avoided in pregnant women, women at risk of pregnancy, and breastfeeding women. Intravaginal and topical treatments may compromise the integrity of latex condoms and diaphragms.\n \n\n# References\n \n\n[Click here to see information on NICE CKS about candidiasis](https://cks.nice.org.uk/topics/candida-female-genital/)\n \n\n[Click here for BASHH guidelines of vulvovaginal candidiasis](https://www.bashhguidelines.org/media/1223/vvc-2019.pdf)",
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"question": "A 16-year-old primiparous woman attends her general practitioner with a 2-week history of unusual vaginal discharge, which started the day after unprotected intercourse with her regular male partner. She describes the discharge as white and associated with vulval discomfort and itch. She is approximately 10 weeks pregnant.\n\nOn examination, the labia minora are coated with a white discharge, and a lumpy white discharge can be observed inside the vaginal vault on speculum examination. There is no noticeable odour.\n\nLitmus paper, applied to the lateral vaginal wall, indicates a pH of around 4.0.\n\nWhat is the most likely causative organism?",
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"explanation": "Mifepristone is an antiprogestogenic steroid used in medical termination of pregnancy. Whilst this woman wishes to proceed with termination of pregnancy, the location of the pregnancy must be confirmed as intrauterine first.",
"id": "49834",
"label": "c",
"name": "Mifepristone",
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"explanation": "This woman currently has a pregnancy of unknown location. Methotrexate is used in the medical management of ectopic pregnancy. Medical management is offered where a woman has an ectopic pregnancy, but there are no indications for surgical management.",
"id": "49833",
"label": "b",
"name": "Methotrexate",
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"explanation": "Misoprostol, a synthetic prostaglandin analogue, is used in a medical termination of pregnancy. Whilst this woman wishes to proceed with termination of pregnancy, the location of the pregnancy must be confirmed as intrauterine first.",
"id": "49836",
"label": "e",
"name": "Misoprostol",
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"explanation": "This woman has a pregnancy of unknown location. As she is haemodynamically stable with mild pelvic pain, she can be managed conservatively.\n\nSerial serum B-hCGs 48 hours apart can help give an indication of the location and prognosis of the pregnancy.\n\n- If the levels fall then it is suggested that the foetus will not develop or there has been a miscarriage.\n- If there is only a slight increase or a plateau in B-hCG levels then this may indicate an ectopic pregnancy.\n- A large increase in B-hCG suggests the foetus is growing normally intrauterine. In this case a repeat transvaginal scan may be performed, and if the pregnancy is confirmed as intrauterine, the woman may proceed with termination of pregnancy.",
"id": "49832",
"label": "a",
"name": "Repeat serum B-hCG in 48 hours",
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"explanation": "Whilst this woman may have an ectopic pregnancy, she is haemodynamically stable, therefore there is no indication for surgery. It may well be an intrauterine pregnancy which is too small to see on a transvaginal ultrasound scan.",
"id": "49835",
"label": "d",
"name": "Admit for an exploratory laparoscopy",
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"comment": "Surely wanting to proceed with termination of pregnancy implies that she wants either medical or surgical intervention and not manage it conservatively",
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"comment": "I assumed this was a question about ectopic pregnancies - but it's about pregnancy of unknown location. In this case, ectopic pregnancy cannot be diagnosed based on the USS, and so they will not treat it yet. The two hCG tests will be done to determine whether this is intrauterine (if it increases by >63%) or not, and then that will guide future management. The pregnancy may be intrauterine, but not yet seen. ",
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"explanation": "# Summary\n \n \nEctopic pregnancy is a gynaecological emergency, referring to a fertilised ovum that has implanted anywhere outside the endometrial cavity. This may present with pelvic pain, shoulder tip pain, abnormal vaginal bleeding, and haemodynamic instability if ruptured. Diagnosis is confirmed by positive pregnancy test and a transvaginal ultrasound that has located the pregnancy outside the uterine cavity. Management strategies include conservative management, medical management with methotrexate, and surgical management, the choice of which depends on the patient's presentation and level of risk.\n \n \n \n# Definition\n \nAn ectopic pregnancy refers to a fertilised ovum that has implanted outside the endometrial cavity, usually in the fallopian tubes. This is a gynaecological emergency. \n \n \n \n \n# Epidemiology\n\n \nThe estimated incidence of ectopic pregnancies in the UK is 1.1%. The risk is higher in women with a history of pelvic inflammatory disease, genital infection, pelvic surgery, an intrauterine device in situ, assisted reproduction, previous ectopic pregnancy, or endometriosis.\n \n \n \n \n# Aetiology \n \n \nEctopic pregnancy usually presents in the 6-8th week of pregnancy, but can occur earlier or later. They can occur anywhere outside the endometrial cavity, but most commonly in the fallopian tube. \n\nRisk of an ectopic increases with conditions that impair the passage of a fertilised egg into the uterine cavity, or with conditions that cause the fertilised egg to implant prematurely. However, most ectopics are not associated with any risk factor. \n \nSpecific risk factors include: \n \n - Pelvic inflammatory disease and previous STIs\n - Pelvic surgery\n - Having an intrauterine device e.g. copper coil or Levonorgestrel-releasing intrauterine system (e.g. Mirena) in situ\n - Assisted reproduction e.g. IVF\n - Previous ectopic pregnancy\n - Endometriosis\n \n \n \n# Signs and Symptoms\n \nClinical features of ectopic pregnancy may include:\n \n \n - Pelvic pain, which may be unilateral to the side of the ectopic\n - Shoulder tip pain - If the ectopic pregnancy bleeds, the blood can irritate the diaphragm causing shoulder tip pain\n - Abnormal vaginal bleeding e.g. missed period or intermenstrual bleeding\n - Haemodynamic instability caused by blood loss if the ectopic ruptures, resulting in syncope/fainting\n - Abdominal examination may reveal unilateral tenderness\n - Cervical tenderness (chandelier sign) on bimanual examination\n \n \n# Differential Diagnosis\n\n1. **Miscarriage:** will also present with bleeding following a positive pregnancy test. However, less likely to have shoulder tip pain, beta-hCG levels will not be as high as in an ectopic (and will fall), and TV USS may show intrauterine pregnancy (if not yet completely expelled). \n\n\n2. **Pelvic inflammatory disease:** presents with abdominal pain and cervical tenderness, and may have bloody vaginal discharge. However, pregnancy test will be negative and inflammatory markers raised. Can be confirmed with positive swab. \n\n\n3. **Ovarian torsion:** also presents with abdominal pain, usually unilateral. Less likely to present with vaginal bleeding and will have negative pregnancy test. \n\n# Investigations\n \nThe investigations for ectopic pregnancy include:\n\n**Bedside**\n\n- Pregnancy test (to confirm pregnancy) \n\n \n**Bloods**\n\n* FBC (check for anaemia)\n* Serum beta-hCG (will help guide management)\n\n**Imaging**\n\n - Transvaginal ultrasound (to locate the pregnancy)\n \n \n# Management\n \n \nThere are three management options for ectopic pregnancy:\n \n \n **Conservative:**\n \n \n - This is an option for a small number of women with an ectopic pregnancy who have minimal or no symptoms, who are considered low risk (usually because there is a plateau or drop in beta-hCG levels indicating self-resolution of the ectopic). \n - These patients require close follow-up with serial repeat b-hCG tests. If the levels do not decrease at a satisfactory rate, medical/surgical management is recommended.\n \n \n**Medical:**\n \n \n - Involves administration of a one-off dose of methotrexate\n - Criteria for methotrexate treatment include: \n - No significant pain\n - Low hCG level (below 1500 IU/L)\n - Unruptured ectopic pregnancy measuring below 35mm and with no visible heartbeat\n - Ability to attend follow-up\n - Adherence to avoiding pregnancy for a period following treatment\n - No intrauterine pregnancy (confirmed on an ultrasound scan). \n - If the initial dose of methotrexate fails to treat the ectopic pregnancy, a second dose of methotrexate or surgical management may be indicated\n \n\n**Surgical:**\n \n - Recommended as first-line option if: \n - Patient is unable to attend follow-up\n - Serum hCG level of 5000 IU/L or higher \n - Adnexal mass of 35mm or greater\n - Foetal heartbeat is visible on ultrasound scan\n - Patient is in significant pain\n - Patient is haemodynamically unstable\n - Also offered second line in cases where medical manamgement has failed \n - The preferred surgical management is a **salpingectomy**, where the fallopian tube containing the ectopic pregnancy is removed. For patients with only one patent fallopian tube (e.g. due to previous PID or ectopic, or past removal of a fallopian tube), a **salpingotomy** may be performed instead, where only the ectopic pregnancy is removed and the ends of the fallopian tube are re-attached. \n - There is a risk with salpingotomy that not all the tissue may have been removed, and so serial serum b-hCG measurements are performed to exclude any remaining trophoblastic tissue within the fallopian tube\n - Offer **anti-D immunoglobulin** to all rhesus-negative women who have had surgical management of ectopic pregnancy. \n \n\n**Borderline Cases: Choosing Between Medical and Surgical Management**\n\n* There are some women who may be offered a choice of either methotrexate or surgical management as first-line.\n* This applies to women who: \n * Have a serum hCG level between 1500 IU/L and 5000 IU/L\n * Are able to return for follow up\n * Have no significant pain\n * Have an unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat.\n * Have no intrauterine pregnancy (confirmed on an ultrasound scan). \n \n\n# NICE Guidelines \n \n [Click here for NICE CKS on ectopic pregnancy ](https://cks.nice.org.uk/topics/ectopic-pregnancy/) \n \n# References\n\n\n[NHS UK - Ectopic pregnancy](https://www.nhs.uk/conditions/ectopic-pregnancy/)\n \n[Patient Info - Ectopic pregnancy](https://patient.info/doctor/ectopic-pregnancy-pro)",
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"question": "A 22-year-old woman attends her general practitioner with a 1-week history of left sided pelvic pain.\n\nOn examination, there is mild tenderness in the left iliac fossa, with no peritonism or guarding. Her observations are normal.\n\nHer last menstrual period was 4 weeks prior.\n\nA urinary pregnancy test is positive, to her surprise.\n\nShe is referred to the early pregnancy assessment unit where a transvaginal ultrasound scan is performed. There is no pregnancy visible within the uterus, and there is no free fluid identified in the pelvis. A serum B-hCG is 315 mIU/mL.\n\nShe wishes to proceed with a termination of pregnancy.\n\nWhat is the most appropriate management?",
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"explanation": "This woman has an obvious abnormality. Although this is likely to be fibroids, intrauterine contraception should only be used in women with fibroids after seeking specialist advice. She has adequate contraception in the form of the progestogen-only pill at present.",
"id": "49838",
"label": "b",
"name": "Insert the Mirena coil and refer to gynaecology",
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"explanation": "This woman has an obvious abnormality and requires referral to gynaecology. In addition, intrauterine contraception should not be inserted where there is a palpable uterus unless under specialist advice.",
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"id": "49841",
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"name": "Prescribe the woman a gonadotropin-releasing hormone (GnRH) analogue and ask her to return for her Mirena coil insertion in six months",
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"explanation": "# Summary\n \n \nFibroids are benign tumours of the myometrium of the uterus, common in women above 30, with peak incidence in perimenopausal years. Fibroids often present with menstrual dysfunction, such as menorrhagia and dysmenorrhoea, and can interfere with fertility if large enough. They are usually diagnosed following a transvaginal ultrasound scan. Management strategies depend on the symptoms and size of the fibroids, ranging from NSAIDs and contraceptive methods to surgical options including myomectomy, ablation, uterine artery embolisation, and hysterectomy.\n \n \n# Definition\n \n \nFibroids, or uterine leiomyomas, are benign smooth muscle tumours originating from the myometrium of the uterus.\n \n \n# Epidemiology\n \n \nUterine fibroids are the most prevalent benign uterine tumours in women and are the leading cause for hysterectomy. The incidence of fibroids increases with age until menopause. \n\nSymptomatic fibroids are less prevalent in women younger than 30 years of age, occurring in 20–50% of women older than 30 years. The peak incidence is observed in women in their 40s, with a crude incidence of 22.5 per 1000 woman-years.\n \n \n# Aetiology\n \n \nThe exact cause of fibroids is unknown but they are thought to be influenced by genetic, hormonal, and environmental factors. Oestrogen and progesterone, the hormones that stimulate the development of the uterine lining during each menstrual cycle in preparation for pregnancy, appear to promote the growth of fibroids. Fibroids contain more oestrogen and progesterone receptors than normal uterine muscle cells.\n \n \n# Signs and Symptoms\n \n \nFibroids can often be asymptomatic, especially when they are small. However, when symptoms do occur, they usually present as:\n \n \n - Menstrual dysfunction, such as menorrhagia and dysmenorrhoea\n - Sub/Infertility, if the fibroid is large enough to distort the uterine cavity\n - Palpable mass on abdominal or pelvic examination if the fibroid is large\n - Abdominal pain, worse during menstruation\n - Urinary frequency if large enough and putting pressure on the bladder\n \n \n# Differential Diagnosis\n \n \nThe main differentials for fibroids include other causes of menorrhagia and dysmenorrhoea. These include:\n \n \n1. **Endometrial polyps:** Present with irregular menstrual bleeding and spotting\n2. **Endometriosis:** Characterised by dysmenorrhoea, deep dyspareunia, chronic pelvic pain, and infertility\n \n \n# Investigations\n \n \n \n**Bedside:**\n\n* Bimanual examination: may feel enlarged uterus \n \n**Bloods**\n\n* Consider FBC if worried about anaemia \n \n**Imaging:**\n \n * Trans-vaginal ultrasound: Used to assess the size and location of the fibroids\n * MRI: Used if ultrasound does not provide enough detail to assess the fibroid for surgery\n \n**Invasive:**\n\n* Biopsy: May be taken if there is any doubt over the diagnosis to differentiate the fibroid from other conditions such as endometrial cancer\n\n\n \n# Management\n \nManagement of fibroids depends on the symptoms and size of the fibroids. It includes:\n \n - Non-surgical management for fibroids causing abnormal bleeding and under 3cm in size with no uterine distortion. This includes NSAIDs, anti-fibrinolytics (tranexamic acid), GnRH analogues, combined hormonal contraception, and Levonorgestrel-releasing intrauterine system (Mirena).\n - Surgical management for fibroids causing symptoms due to their mass effect. This includes myomectomy, ablation, uterine artery embolisation, and hysterectomy.\n\n# Complications\n\n* Recurrence \n* Haemorrhage and anaemia\n* Degeneration, especially during pregnancy (red degeneration)\n* Infertility (especially if large)\n* Torsion\n* Pressure effects (e.g. urinary retention, constipation)\n* Delivery complications (e.g. breech presentation, bleeding) and pregnancy complications, including miscarriage \n\n \n# NICE Guidelines\n \n \n[Click here for NICE CKS on fibroids](https://cks.nice.org.uk/topics/fibroids/)\n \n# References\n\n[Patient Info](https://patient.info/womens-health/periods-and-period-problems/fibroids)",
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"question": "A 44-year-old woman attends the family planning clinic for insertion of a Mirena levonorgestrel-releasing intrauterine system; as she has read that this will help with her heavy periods. She currently takes the progestogen-only pill and is menstruating.\n\nOn routine bimanual examination before inserting the coil, the uterine fundus can be felt around the level of the umbilicus, and it is not possible to ascertain the position of the uterus.\n\nWhat is the most appropriate next step?",
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"explanation": "Women should stop taking combined hormonal contraception over the age of 50.",
"id": "49851",
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"name": "She can continue to take it indefinitely",
"picture": null,
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"__typename": "QuestionChoice",
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"explanation": "She should stop taking it now, as it is contraindicated for women over the age of 50.",
"id": "49850",
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"name": "She should stop taking it in one year's time",
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"id": "49849",
"label": "c",
"name": "She should stop taking it when she no longer has any menstrual bleeding for 1 year",
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"id": "49847",
"label": "a",
"name": "She should stop taking it now and switch to an alternative method of contraception",
"picture": null,
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"id": "49848",
"label": "b",
"name": "She should stop taking it after the age of 55",
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"explanation": "# Summary\n \n \nMenopause is a physiological condition leading to the permanent cessation of menstruation in women (usually aged between 45-55 years). It is caused by ovarian failure and leads to oestrogen deficiency. Key signs and symptoms include vasomotor symptoms (hot flushes and night sweats), sexual dysfunction, and psychological issues. The diagnosis is made clinically. Management strategies include hormone replacement therapy (HRT) for symptom relief and reduced risk of osteoporosis, as well as non-hormonal therapies such as lifestyle changes and cognitive behavioural therapy.\n \n \n# Definition\n \n \n - **Menopause:** This term describes the permanent cessation of menstruation, characterised by at least 12 months of amenorrhoea in otherwise healthy women who are not using hormonal contraception. Menopause typically occurs between the ages of 45 and 55, with the average age in the UK being 52. The underlying reason is ovarian failure, which results in oestrogen deficiency.\n\n \n- Perimenopause: This period begins when symptoms of menopause start and continues until 12 months after the last menstrual period.\n \n \n# Epidemiology\n \n \nMenopause typically occurs between the ages of 45 and 55, with the median age in the UK being 52. \n \n \n# Aetiology\n \n \nMenopause is caused by ovarian failure, which leads to oestrogen deficiency. \n \n \n# Signs and Symptoms\n \n \n - Vasomotor symptoms: hot flushes, night sweats\n - Sexual dysfunction: vaginal dryness, reduced libido, problems with orgasm, dyspareunia\n - Psychological symptoms: depression, anxiety, mood swings, lethargy, reduced concentration\n \n \n# Differential Diagnosis\n \n \nOther medical conditions can cause similar symptoms to menopause and should therefore be considered when diagnosing:\n \n - **Hyperthyroidism:** symptoms can include hot flushes, sweating, palpitations, and changes in menstrual cycle\n - **Depression:** exhibits mood swings, lethargy, reduced concentration. \n - **Premature ovarian insufficiency:** can cause hot flushes, night sweats, vaginal dryness, and reduced libido; however, the woman needs to aged below 40.\n \n \n# Investigations\n \nMenopause is diagnosed **clinically** based on absence of menses for 12 months, meaning that **no investigations are required** as long as the patient is of appropriate age (at least over 40, but usually aged over 45). \n\nIf aged under 40, tests for premature ovarian insufficiency may be indicated, i.e. FSH level testing. \n\nOther indications for FSH testing include:\n\n- Aged over 45 years with atypical symptoms\n- Aged between 40–45 years with menopausal symptoms, including a change in menstrual cycle\n- Over 50 years of age using progestogen-only contraception, including depot medroxyprogesterone acetate \n\n \n# Management\n\n**Conservative:** \n\n - Lifestyle measures: regular exercise, weight loss (if overweight), clothing alterations, stress reduction, avoiding triggers (such as spicy foods, caffeine, smoking, and alcohol), and good sleep hygiene\n\n\n**Medical:** \n \n\n**Hormone replacement therapy (HRT):**\n \n \n - Oestrogens: these overcome oestrogen deficiency and can be given orally, transdermally, or topically.\n - Progestogens: required for endometrial protection from unopposed systemic oestrogens; can be oral, transdermal or intrauterine.\n \nOestrogen-only HRT therapy should only be given to women with a hysterectomy. Otherwise, HRT should include both oestrogen and progesterone. \n \nHRT can be given either cyclically (for perimenopausal women still having periods) or continuously (for postmenopausal women not having periods). Cyclical can include:\n\n- Monthly: Oestrogen every day of the month + progesterone for the last 14 days \n- Every three months: Oestrogen every day for 3 months + progesterone for the last 14 days\n\n \nBenefits of HRT include relief of vasomotor symptoms, relief of urogenital symptoms, and reduced risk of osteoporosis. Risks of oral HRT include increased risks of breast cancer, endometrial cancer (if oestrogen given alone), and venous thromboembolism.\n \nContraindications to HRT:\n\n* Breast cancer (current, past or suspected)\n* Oestrogen-dependent cancer (known or suspected)\n* Vaginal bleeding of unknown cause\n* Endometrial hyperplasia that remains untreated\n* Pregnancy\n* Thrombophilic disorder\n* Venous thromboembolism, including DVTs and PEs (current or previous) - unless on anticoagulant treatment\n* Arterial thromboembolic disease, including angina or MIs (active or recent)\n* Liver disease with abnormal LFTs \n\nHRT should also be prescribed cautiously to those with:\n\n* Diabetes mellitus\n* Those with risk factors for venous thromboembolisms\n* Porphyria cutanea tarda\n* Endometrial hyperplasia\n* Migraines\n* Increased risk of breast cancer \n\n \n**Non-hormonal management:**\n \n\n - Selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs): for vasomotor and mood symptoms\n - Clonidine (an alpha-2 adrenergic receptor agonist): for vasomotor symptoms. \n - Cognitive behavioural therapy (CBT): for vasomotor and mood symptoms\n - Vaginal moisturisers: for urogenital symptoms\n - Vaginal lubricants: for vaginal dryness and consequent dyspareunia. \n\n\n# Complications\n\n\n- **Osteoporosis:** Oestrogens are important for bone maintenance; preventing osteoporosis is a key benefit of HRT.\n- **Cardiovascular disease:** Women are at greater risk of cardiovascular disease from menopause, with exact mechanisms unclear. The evidence for impact of HRT on cardiovascular disease is also unclear. \n- **Dyspareunia:** Occurs as a consequence of vaginal dryness, as a result of reduced oestrogen. Can be managed with vaginal oestrogen creams or lubricants.\n- **Urinary incontinence:** Caused by epithelial thinning as a result of decline in oestrogen. Managed with systemic or topical oestrogen. \n- **Side-effect of HRT**, including: VTE (not a risk if oestrogen is delivered transdermally), stroke, breast tenderness, vaginal bleeding, breast cancer. \n\n \n \n# NICE Guidelines \n\n[NICE Guidance: Menopause](https://www.nice.org.uk/guidance/ng23)\n\n[NICE Clinical Knowledge Summary (CKS): Menopause](https://cks.nice.org.uk/topics/menopause/)\n\n\n# References\n\n[BMJ Best Practice](https://bestpractice.bmj.com/topics/en-gb/194) \n\n[British Menopause Society](https://thebms.org.uk/)",
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"id": "49854",
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"explanation": "# Summary\n\nThe third stage of labour is defined as the period beginning at the delivery of the foetus and ending with the delivery of the placenta and foetal membranes. This stage generally lasts from 30 minutes to an hour naturally, or 5-10 minutes with the administration of oxytocin. Key signs of placental separation and imminent placental delivery include a gush of blood, lengthening of the umbilical cord, and ascension of the uterus in the abdomen. Important management strategies involve the gentle, controlled cord traction to deliver the placenta, with care to avoid complications such as uterine inversion and postpartum haemorrhage.\n\n# Definition\n\nThe third stage of labour is defined as the period that starts at the delivery of the foetus and concludes with the delivery of the placenta and foetal membranes. Typically, this stage lasts between 30 minutes and an hour when allowed to occur naturally, or between 5-10 minutes if expedited with the administration of oxytocin.\n\n# Management\n\nThe third stage of labour is commonly managed by controlled cord traction, a manual method used to deliver the placenta. This procedure must be performed gently to avoid complications such as uterine inversion and postpartum haemorrhage. In cases of a retained placenta, further interventions such as a manual removal or a curettage may be necessary.",
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"question": "A 22-year-old woman has just delivered a live female infant via spontaneous vaginal delivery. She has opted for active management of the third stage of labour.\n\nWhich of the following is involved in active management of the third stage of labour?",
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"explanation": "HELLP (Haemolysis, Elevated Liver enzymes and Low Platelets) syndrome is a severe life-threatening condition in pregnancy. This patient has evidence of haemolysis (low haemoglobin, elevated bilirubin), elevated liver enzymes and low platelets. She is not hypertensive, however this may be accounted for by the fact she is already on labetalol, and she is clinically dehydrated. HELLP syndrome can occur in the absence of hypertension and proteinuria.",
"id": "49857",
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"explanation": "Gestational hypertension is diagnosed where there is new-onset hypertension, without proteinuria or evidence of pre-eclampsia. Whilst this woman does have gestational hypertension, the diagnosis which encompasses all of her findings is HELLP syndrome.",
"id": "49859",
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"explanation": "Hyperemesis gravidarum typically occurs in the first trimester, and whilst it may present with tachycardia and hypotension if profound dehydration, it does not cause thrombocytopenia or deranged liver function tests.",
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"comment": "i aint reading all that \ni'm happy for u tho\nor sorry that happened",
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"comment": "Please i really need some more blood results please please please can you include her thyroid function tests and if you are being so kind maybe a full renal screen.",
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"explanation": "# Summary\n\nHELLP syndrome is a severe pregnancy complication characterized by hemolysis (H), elevated liver enzymes (EL), and low platelets (LP). It typically manifests during the third trimester and is part of a spectrum of hypertensive disorders of pregnancy, including preeclampsia. Key signs and symptoms include headache, nausea/vomiting, epigastric pain, right upper quadrant abdominal pain, blurred vision, and peripheral edema. Investigations may include blood tests and ultrasound scans. The definitive treatment is usually the delivery of the baby, with some mothers also requiring blood transfusions or steroids during pregnancy.\n\n\n# Definition\n\n\nHELLP syndrome is a complication of pregnancy characterized by the presence of hemolysis (H), elevated liver enzymes (EL), and low platelets (LP). It often manifests during the third trimester and is considered part of a spectrum of hypertensive disorders of pregnancy, which also includes preeclampsia.\n\n\n# Epidemiology\n\n\n\nHELLP syndrome is relatively rare, affecting approximately 0.5-0.9% of all pregnancies. However, it is a significant cause of maternal and perinatal morbidity and mortality.\n\n\n# Aetiology\n\n\n\nThe exact cause of HELLP syndrome is unknown. However, it is believed to be related to abnormal placentation, endothelial cell injury, and a generalized inflammatory response. Genetic predisposition and immune maladaptation may also play roles.\n\n\n# Signs and Symptoms\n\n\n\nPatients with HELLP syndrome may present with:\n\n- Headache\n- Nausea and/or vomiting\n- Epigastric pain\n- Right upper quadrant abdominal pain due to liver distension\n- Blurred vision\n- Peripheral edema\n\n\n# Differential Diagnosis\n\n\n\nThe differential diagnoses for HELLP syndrome include acute fatty liver of pregnancy, idiopathic thrombocytopenic purpura, and thrombotic thrombocytopenic purpura. These conditions can also present with similar signs and symptoms such as thrombocytopenia, liver dysfunction, and neurological symptoms.\n\n# Complications\n\nMaternal complications include:\n\n- Organ failure\n- Placental abruption\n- Disseminated intravascular coagulopathy (DIC).\n\nFoetal complications include:\n\n- Intrauterine growth restriction\n- Preterm delivery\n- Neonatal hypoxia\n\n\n# Investigations\n\n\nInvestigations for HELLP syndrome may include:\n\n- Full blood count to assess for low platelet count and evidence of hemolysis\n- Liver function tests to assess for elevated liver enzymes\n- Coagulation studies to evaluate for disseminated intravascular coagulation\n- Ultrasound scans to assess for liver abnormalities and placental abruption\n\n# Management\n\n\nThe definitive treatment for HELLP syndrome is usually the delivery of the baby. In some cases, mothers may also require blood transfusions to manage anemia and thrombocytopenia or steroids to accelerate lung maturation in the fetus prior to delivery. After delivery, supportive care and close monitoring are essential.",
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"question": "A 24-year-old primigravida at 36 weeks gestation presents with 5 days of vomiting and inability to tolerate oral fluids. Her past medical history includes hypothyroidism and gestational hypertension.\nShe takes the following medications:\n\n\n\n - Labetalol 200mg three times daily\n - Levothyroxine 175micrograms once daily\n - Ferrous fumarate 210mg twice daily\n\n\n\nOn examination, she looks clinically dehydrated and has a heart rate of 100 bpm.\n\n\n\nA cardiotocograph is reassuring.\n\n\n\nHer full blood count tests are as follows:\n\n\n||||\n|--------------|:-------:|---------------|\n|Haemoglobin|101 g/L|(M) 130 - 170, (F) 115 - 155|\n|White Cell Count|6.5 x10<sup>9</sup>/L|3.0 - 10.0|\n|Platelets|100x10<sup>9</sup>/L|150 - 400|\n\n\n\n\n\nHer liver function tests are as follows:\n\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Albumin|31 g/L|35 - 50|\n|Alanine Aminotransferase (ALT)|150IU/L|10 - 50|\n|Aspartate Aminotransferase (AST)|120 IU/L|10 - 40|\n|Alkaline Phosphatase (ALP)|210 IU/L|25 - 115|\n|Bilirubin|32 µmol/L|< 17|\n|Gamma Glutamyl Transferase (GGT)|42 U/L|9 - 40|\n|Lactate Dehydrogenase|642 IU/L|70 - 250|\n\n\n\nShe is unable to provide a urine sample for urinalysis.\n\n\n\nWhat is the most likely diagnosis?",
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"__typename": "QuestionSBA",
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Sequential therapy is suitable for women with a uterus. These women require endometrial protection in the form of a progestogen (either oral or via a Mirena coil). This woman does not have a uterus, so she does not require a progestogen.",
"id": "49864",
"label": "c",
"name": "Evorel Sequi (sequential transdermal oestrogen-only hormone replacement therapy) and oral utrogestan for 14 days per month",
"picture": null,
"votes": 139
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Testosterone gel is not first-line therapy for treating symptoms of menopause, and this woman does not require a progestogen as she does not have a uterus.",
"id": "49866",
"label": "e",
"name": "Testogel (transdermal testosterone gel) and oral utrogestan",
"picture": null,
"votes": 33
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"__typename": "QuestionChoice",
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"explanation": "Whilst continuous transdermal oestrogen-only hormone replacement therapy is the correct option, this would be trialled alone before thinking about adding in other options such as testosterone gel.",
"id": "49865",
"label": "d",
"name": "Evorel conti (continuous transdermal oestrogen-only hormone replacement therapy) and Testogel (transdermal testosterone gel)",
"picture": null,
"votes": 356
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{
"__typename": "QuestionChoice",
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"explanation": "Women who have had a hysterectomy should be offered continuous oestrogen-only hormone replacement therapy. Sequential therapy is offered to women with a uterus who are still having menstrual periods, or are within a year of their last menstrual period. Topical vaginal oestrogen pessaries, however, would be a sensible addition to the correct regime.",
"id": "49863",
"label": "b",
"name": "Evorel Sequi (sequential transdermal oestrogen-only hormone replacement therapy) and topical vaginal oestrogen pessaries",
"picture": null,
"votes": 778
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This woman has symptoms of menopause - hot flushes, night sweats, reduced concentration and vulvovaginal symptoms. She would therefore benefit from a trial of hormone replacement therapy. Since she has had her uterus removed, is it is most appropriate to prescribe her a continuous oestrogen-only regime.",
"id": "49862",
"label": "a",
"name": "Evorel Conti (continuous transdermal oestrogen-only hormone replacement therapy)",
"picture": null,
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"__typename": "QuestionComment",
"comment": "low yield af my boy godam",
"createdAt": 1684232925,
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"comment": "Not really tbh...woman without a uterus requires oestrogen only and these are just brand names of HRT...",
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"comment": "Evorel conti is not oestrogen only it has progesterone so all of these options are wrong...?",
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"comment": "oestrogen pessary is necessary due to the dyspareunia surely? ",
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"explanation": "# Summary \n \n \nHormone Replacement Therapy (HRT) is a treatment strategy used to alleviate menopausal symptoms by replacing diminishing hormones. It typically involves small doses of oestrogen and progestogen (if the woman has a uterus) to reduce endometrial cancer risk. HRT may be administered systemically or vaginally and can help manage symptoms such as flushing, insomnia, headaches, vaginal atrophy, and dryness. However, it may also have side effects including breast tenderness, leg cramps, bloating, nausea, and headaches. Key investigations involve assessing the history and physical examination of the patient to decide the need for HRT. Management strategies include careful dose regulation and monitoring for side effects.\n \n \n# Definition \n \n \nHormone replacement therapy (HRT) is a treatment to relieve symptoms of menopause by replacing hormones that decrease as a woman approaches the menopause. It typically involves small doses of oestrogen combined with a progestogen if a woman has a uterus to reduce the risk of endometrial cancer.\n \n \n \n# Indications \n \n \n - Symptomatic relief of vasomotor symptoms such as flushing, insomnia, headaches, vaginal atrophy and dryness\n - Decreases the risk of osteoporosis and colorectal cancer\n - In premature ovarian insufficiency, HRT should be continued until the age of 50. This is to help prevent the development of osteoporosis\n \n \n# Contraindications\n \n \n - Undiagnosed vaginal bleeding\n - Pregnancy\n - Breastfeeding\n - Oestrogen receptor-positive breast cancer\n - Acute liver disease\n - Uncontrolled hypertension\n - History of breast cancer or venous thromboembolism (VTE)\n - Recent stroke, myocardial infarction or angina\n\n\n# Types\n\n\nHRT can be given systemically, either via oral tablets, transdermal patches or gels, or can be given vaginally for urogenital atrophy, in the form of tablets, creams, pessaries or vaginal rings. Transdermal is the preferred route if the woman is at risk of VTE.\n\n\nHormones that can be given as part of HRT are:\n\n\n - **Oestrogens:** oestradiol, estrone and conjugated oestrogen are generally used.\n - **Progestogens:** Medroxyprogesterone, norethisterone, levonorgestrel and drospirenone are typically used. A levonorgestrel-releasing intrauterine system (e.g. Mirena coil) may be used as part of the progestogen component of HRT, so the woman may just take oral oestrogen and have endometrial protection via the intrauterine system\n - **Tibolone:** this is a synthetic compound containing oestrogen, progestogen and androgens.\n\n\nAll women require a combination of oestrogen and progesterone as part of their HRT, unless they have had a hysterectomy, in which case oestrogen-only is enough. This is due to risk of endometrial cancer if oestrogen is given alone. \n\nHRT can be given continuously (for postmenopausal women not having periods) or cyclically (for perimenopausal women still having some periods). Cyclical can include:\n\n- Monthly: Oestrogen every day of the month + progesterone for the last 14 days \n- Every three months: Oestrogen every day for 3 months + progesterone for the last 14 days\n\n\n# Side Effects\n\n\n - Oestrogen: breast tenderness, leg cramps, bloating, nausea, headaches\n - Progestogen: premenstrual syndrome-like symptoms, mood swings, breast tenderness, backache, depression, pelvic pain, fluid retention, weight gain\n - Cholestatic jaundice\n - Increased risk of breast cancer, endometrial cancer, VTE, stroke and ischaemic heart disease\n\n \n# NICE Guidelines\n\n[CLick here for NICE guidelines on HRT](https://cks.nice.org.uk/topics/menopause/prescribing-information/hormone-replacement-therapy-hrt/)\n\n# References\n\n\n[Primary Care Women's Health Forum](https://pcwhf.co.uk/resources/hrt-types-doses-and-regimens/#)\n\n[Hickey & Davison 2012, The BMJ](https://www.bmj.com/content/344/bmj.e763.long)\n\n[NHS Website](https://www.nhs.uk/medicines/hormone-replacement-therapy-hrt/types-of-hormone-replacement-therapy-hrt/)",
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"question": "A 48-year-old woman attends her general practitioner troubled with waking up at night drenched in sweat. She also finds it difficult to concentrate on her work as a statistics professor. She has not had sex with her husband since her hysterectomy as she struggled with low libido postoperatively and now finds it too painful to attempt intercourse.\n\nHer past medical history is significant for a hysterectomy with ovarian preservation age 44 for a large fibroid. She also has Ehlers-Danlos syndrome, which manifests as joint hypermobility with frequent dislocations.\n\nWhich of the following medication regimes is most appropriate?",
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"__typename": "QuestionSBA",
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Intrapartum antibiotics would be indicated if this person's urine had grown a group B streptococcus.",
"id": "49869",
"label": "c",
"name": "Advise intrapartum antibiotics",
"picture": null,
"votes": 54
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be the first-line treatment for symptomatic urinary tract infection in the non-pregnant person. Trimethoprim is not recommended in pregnancy, particularly in the first trimester.",
"id": "49870",
"label": "d",
"name": "Trimethoprim 200mg twice daily for three days",
"picture": null,
"votes": 124
},
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"__typename": "QuestionChoice",
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"explanation": "Unless sensitivities dictate otherwise, oral nitrofurantoin is the first-line antibiotic for asymptomatic bacteriuria in pregnant women.",
"id": "49867",
"label": "a",
"name": "Treat with oral nitrofurantoin 100 mg modified-release tablets twice a day for seven days",
"picture": null,
"votes": 1529
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Asymptomatic bacteriuria should be treated in pregnancy. Without treatment, up to 35% of pregnant women with asymptomatic bacteriuria will develop a symptomatic urinary tract infection or pyelonephritis.",
"id": "49871",
"label": "e",
"name": "Reassure if not symptomatic, the bacteria is a likely contaminant and does not require treatment",
"picture": null,
"votes": 69
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Unless sensitivities dictate otherwise, oral nitrofurantoin is the first-line antibiotic for asymptomatic bacteriuria in pregnant women. A seven-day course is required in pregnancy.",
"id": "49868",
"label": "b",
"name": "Treat with amoxicillin 500 mg three times a day for five days",
"picture": null,
"votes": 198
}
],
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"__typename": "QuestionComment",
"comment": "if it was a 3rd trimester UTI presumably you would give nitrofurantoin?",
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"__typename": "QuestionComment",
"comment": "3rd trimester is amoxicillin i believe ",
"createdAt": 1684950051,
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"comment": "cefalexin methinks",
"createdAt": 1686506616,
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"explanation": "# Summary\n\nAsymptomatic bacteriuria in pregnancy refers to a positive urine culture in pregnancy without symptoms of a urinary tract infection (UTI). It is critical to treat this condition, as it can increase the risk of spontaneous miscarriage and preterm labour. Treatment typically involves antibiotics, such as nitrofurantoin or cefalexin. In cases where group B streptococcal bacteriuria is identified, intrapartum prophylactic antibiotics are necessary to reduce the risk of transmission to the foetus during labour. \n\n\n# Definition\n\n\n\nAsymptomatic bacteriuria in pregnancy is a clinical condition where a significant amount of bacteria is present in the urine of a pregnant woman, without the presence of symptoms indicative of a urinary tract infection. This is characterised by a positive urine culture in the absence of UTI symptoms. \n\n\n# Signs and Symptoms\n\n\n\nAsymptomatic bacteriuria is usually characterised by the absence of symptoms. However, when present, symptoms may be similar to those of a urinary tract infection:\n\n- Frequent urination\n- Discomfort during urination\n- Lower abdominal pain\n- Fever\n- Hematuria\n\n\n# Differential Diagnosis\n\n\nThe main differential diagnoses for asymptomatic bacteriuria in pregnancy include:\n\n- Urinary tract infection: Characterised by dysuria, frequency, urgency, lower abdominal pain, and fever.\n- Pyelonephritis: Characterised by fever, flank pain, nausea, vomiting, and urinary symptoms such as frequency and dysuria.\n- Bladder infection (cystitis): Characterised by dysuria, frequency, urgency, and lower abdominal pain.\n\n\n# Management\n\n \n\nManaging asymptomatic bacteriuria in pregnancy involves treating the condition with antibiotics. Nitrofurantoin and cefalexin are commonly used in this context. If group B streptococcal bacteriuria is identified, the mother will require intrapartum prophylactic antibiotics to reduce the risk of transmission to the foetus during labour.\n\n# External links\n\n[- NICE Clinical Knowledge Summary (CKS): Scenario: Asymptomatic bacteriuria in pregnancy](https://cks.nice.org.uk/topics/urinary-tract-infection-lower-women/management/asymptomatic-bacteriuria-in-pregnancy/).",
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"question": "A 24-year-old woman is asked to provide a repeat urine sample after attending her booking appointment at 12 weeks gestation. Her midwife explains that her first urine sample had grown an e-coli in the culture.\n\nThe woman has no urinary symptoms and is otherwise entirely well.\n\nWhat is the most appropriate management plan if the second sample also shows bacteriuria?",
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"explanation": "# Summary\n \nIrregular menstrual bleeding, which could be physiological or due to an underlying condition, is a common gynaecological presenting complaint. Key signs and symptoms include abnormal bleeding patterns, which can be confirmed through pelvic examination, pregnancy test, ultrasounds, and cervical or endometrial biopsy as required. Management strategies primarily involve hormonal treatments such as the combined oral contraceptive pill, Mirena® intrauterine system, norethisterone, and progestogens, provided there is no underlying pathology.\n \n \n# Definition\n \n \nIrregular menstrual bleeding refers to timings between each menstrual cycle (or period) that are less than 21 days or over 35 days. This condition is common, particularly following menarche, when periods can take 2-3 years to regularise, and when approaching menopause, however, it can also be due to underlying pathology. \n \n \n# Epidemiology\n \n \nWhile irregular menstrual bleeding is common in the general population, it is particularly prevalent among females around the time of menarche and menopause due to the physiological changes occurring during these periods.\n \n \n# Aetiology\n \n \nThe causes of irregular menstrual bleeding can include:\n \n \n - Physiological changes, such as menarche or menopause\n - Polycystic ovarian syndrome \n - Genitourinary infection, e.g., chlamydia\n - Endometrial hyperplasia\n - Endometrial or cervical cancer\n - Fibroids\n - Pregnancy\n \n \n# Signs and Symptoms\n \n \nThe primary sign of irregular menstrual bleeding is an abnormal bleeding pattern, which may include heavy, prolonged, or frequent periods, or bleeding between periods.\n\nWomen aged over 40 with persistent intermenstrual bleeding, new onset menorrhagia and/or severe anaemia (secondary to vaginal bleeding) should be referred to gynaecology and seen within 30 days for suspicion of possible endometrial malignancy.\n \nWomen with post-menopausal bleeding should be referred to gynaecology under a 2-week wait referral to investigate possible endometrial malignancy. \n \n# Differential Diagnosis\n \nThe differential diagnoses for irregular menstrual bleeding include:\n \n - **Polycystic ovarian syndrome:** May also have signs of hyperandrogenism (e.g. hirsutism) and insulin resistance. \n - **Genitourinary infection:** May present with symptoms like lower abdominal pain, dysuria, or unusual vaginal discharge.\n - **Endometrial hyperplasia/cancer:** May show symptoms like pelvic pain, weight loss, or postmenopausal bleeding.\n - **Cervical cancer:** Possible symptoms include abnormal vaginal bleeding, pelvic pain, or pain during intercourse.\n - **Fibroids:** Symptoms may include heavy menstrual bleeding, prolonged menstrual periods, pelvic pressure or pain, frequent urination, difficulty emptying the bladder, constipation, and backache or leg pains.\n - **Pregnancy:** Symptoms may include missed periods, nausea or vomiting, increased urination, and breast tenderness.\n \n \n# Investigations\n \n \nInvestigations to confirm the cause of irregular menstrual bleeding may include:\n \n**Bedside:**\n\n - Pelvic examination, including speculum examination +/- cervical smear if overdue. \n - Pregnancy test \n\n**Bloods:**\n\n- FSH levels, especially if suspecting menopause. \n- LH/FSH ratio, if suspecting PCOS. \n- Oestrogen, progesterone levels \n- Testosterone levels \n\n**Imaging:**\n \n - Pelvic ultrasound, particularly if examination findings suggest conditions like fibroids. \n\n**Invasive tests:**\n\n - Cervical biopsy, if cervical smear is abnormal +/- abnormal findings on examination\n - Endometrial biopsy, if endometrial pathology is suspected\n \n \n# Management\n \n \nThe primary management strategies for irregular menstrual bleeding, provided that investigations rule out any underlying pathology, include:\n \n \n - The combined oral contraceptive pill: This can regulate the menstrual cycle.\n - Mirena® intrauterine system: This can reduce overall bleeding.\n - Norethisterone: This is taken on cycle days 5-26 to prevent bleeding.\n - Progestogens, e.g., medroxyprogesterone acetate: This can induce amenorrhoea but cannot be used long term.\n\nIf an underlying cause is found, the focus of management should be treating that condition. \n\n\n# References\n\n[RCOG Guidelines for abnormal uterine bleeding](https://www.rcog.org.uk/media/oxyfyvy0/2020-05-21-joint-rcog-bsge-bgcs-guidance-for-management-of-abnormal-ute.pdf)\n\n[NHS UK - Irregular periods](https://www.nhs.uk/conditions/irregular-periods/)\n\n[GP Notebook](https://gpnotebook.com/en-GB/pages/gynaecology/referral-criteria-from-primary-care-abnormal-uterine-bleeding)",
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"question": "A 17-year-old female attends the drop-in clinic at her local sexual health clinic with irregular menstrual bleeding.\n\nShe has a progestogen-only subdermal implant in situ for contraception, inserted when she was 16. She was initially entirely amenorrhoeic with the implant, however in the past six months has had irregular bleeding, occurring every 4-7 weeks and lasting for 2-9 days.\n\nWhat is the most appropriate management plan?",
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"explanation": "Whilst an abdominal or transvaginal ultrasound scan is likely to form part of the investigation of this woman, it is usually requested following urgent gynaecology referral.",
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"explanation": "This woman is over the age of 50 and has several symptoms which may suggest an ovarian malignancy - early satiety, bloating, weight loss and a pelvic mass.",
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"explanation": "Whilst a CA-125 blood test may help in the diagnosis of ovarian malignancy, the most appropriate management is to refer to gynaecology urgently. A reassuring CA-125 level would not change this.",
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"explanation": "This woman does not have any symptoms of upper gastrointestinal malignancy. Whilst having gastrointestinal reflux disease may place her at a higher risk of Barratt's oesophagus and malignant transformation, her symptoms point toward a pelvic malignancy.",
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"explanation": "Whilst this woman is obese, she complains of unintentional weight loss, which is a red flag for malignancy. Suggesting she lose more weight is not appropriate at this stage.",
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"comment": "I think the explanation should say somewhere that we're referring under 2ww Because there is a pelvic mass on examination. if it were just the other symptoms and no pelvic mass (and/or ascites/abdominal mass), ca125 first would be the right answer. ",
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"comment": "thanks for clarifying",
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"comment": "That's right, I see this in my clinic quite often, I'm glad budding medical students like you are taking an interest in my lifes work - Abhishek \"the consultant\" Abidhar",
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"explanation": "# Summary\n \n \nOvarian cancer is a major cause of gynaecological cancer-related mortality in the UK, due primarily to the non-specific nature of symptoms in early stages. The most common type is epithelial ovarian tumours, though germ cell tumours and sex cord stromal tumours also occur. Risk factors include older age, smoking, numerous ovulations, obesity, HRT, and BRCA genes. Parity, breastfeeding, early menopause, and COCP use can be protective. Symptoms typically include abdominal discomfort, bloating, early satiety, and urinary changes, with ascites signifying advanced disease. Differentials include IBS, fibroids, ovarian cysts, and other cancers. Initial investigations include CA-125 and pelvic and abdominal ultrasound. Management depends on disease stage and patient fitness, but can include surgery and chemotherapy.\n \n \n# Definition\n \n \nOvarian cancer is a malignancy originating from various cell types found within the ovary. \n \n \n# Aetiology\n \n \nThe causes of ovarian cancer can be divided into risk factors and protective factors. \n \n \nRisk factors include:\n \n \n - Advanced age\n - Smoking\n - Increased number of ovulations (early menarche, late menopause)\n - Obesity\n - Hormone replacement therapy (HRT)\n - Genetic predisposition (BRCA 1 and 2 genes)\n\nProtective factors include:\n\n - Childbearing (parity)\n - Breastfeeding\n - Early menopause\n - Use of combined oral contraceptive pill (COCP)\n\n\n# Classification\n \n \nThe types of ovarian cancers can be classified according to the cell type from which the cancer originates. The types include:\n \n \n**Epithelial ovarian tumours**\n \n \n - Originate from the epithelium which lines the fimbria of the fallopian tubes or the ovaries\n - Epithelial tumours are partially cystic, and the cysts can contain fluid. \n - The initial metastatic spread typically involves the peritoneal cavity, with seeding particularly affecting the bladder, paracolic gutters and the diaphragm. \n - Around 90% of ovarian cancers are epithelial ovarian tumours.\n \n \n**Germ cell tumours features**\n \n \n - Originate from the germ cells in the embryonic gonad. \n - These tumours typically grow rapidly and spread predominantly via the lymphatic route\n - Germ cell tumours most commonly arise in young women, which is atypical for most cases of ovarian cancer. \n - Tumour markers include alpha-fetoprotein and sometimes beta human chorionic gonadotrophin (B-HCG).\n \n \n**Sex cord stromal tumours**\n \n \n - Originate from connective tissue. \n - They are rare, making up less than 5% of all ovarian tumours. They are malignant tumours, but are much less aggressive than epithelial tumours. \n - Additionally, ovarian cancer can be secondary to another cancer elsewhere, which has metastasised to the ovary. A Krukenberg tumour refers to a \"signet ring\" sub-type of stromal tumour, typically gastrointestinal in origin, which has metastasised to the ovary. \n \n \n \n# Signs and Symptoms\n \n \nThe clinical features of ovarian cancer typically present late in the disease progression and include:\n \n \n - Abdominal discomfort\n - Bloating\n - Early satiety\n - Urinary frequency or change in bowel habits\n \n \nIn later stages, the disease may cause:\n \n \n - Ascites (due to vascular growth factors increasing vessel permeability)\n - Pelvic, back and abdominal pain\n - Palpable abdominal or pelvic mass\n \n \n# Differential diagnosis\n \n \nDifferential diagnoses for ovarian cancer include:\n \n \n- Gastrointestinal conditions (e.g., irritable bowel syndrome): characterised by abdominal pain, bloating, and changes in bowel habits. \n2. Fibroids: may cause heavy menstrual bleeding, pelvic pressure or pain, frequent urination, and constipation. \n3. Ovarian cysts: can cause pelvic pain, fullness or heaviness in the abdomen, and bloating.\n4. Other cancers (e.g., bladder, endometrial): may present with symptoms such as abnormal bleeding, pelvic pain, and urinary symptoms.\n \n \n# Investigations\n \n \nInvestigations for suspected ovarian cancer include:\n \n**Bedside:**\n \n * Abdominal examination: tenderness, abdominal mass\n * Bimanual examination: adnexal mass\n\n \n**Bloods:**\n \n* CA-125 levels\n * Measure CA125 in women (especially those aged over 50) with frequent or persistent symptoms of ovarian cancer (i.e. 12 or more times per month)\n * Consider this measurement in women with non-specific symptoms of malignancy, such as unexplained weight loss, fatigue or changes in bowel habit \n* AFP and beta-hCG levels (for younger women who may have germ cell cancers)\n\n \n**Imaging:**\n\n* Pelvic and abdominal ultrasound scan\n * May be helpful to rule out or identify malignancy where CA125 is 35 IU/ml or higher \n* CT chest/abdomen/pelvis (for staging)\n\n**Invasive:**\n \nFurther investigations may include:\n \n* Tissue biopsy \n \n \n**Risk of Malignancy Index** \n\nThese results can be used to calculate the Risk of Malignancy Index (RMI), which stratifies the likelihood of cancer: \n \n\n**RMI = U x M x CA125**\n\n\n* U = ultrasound result (between 0-3)\n* M = menopausal status (1 = premenopausal, 3 = postmenopausal) \n* Serum CA-125 is measured in IU/ml\n\n- NICE advise referring all women with an RMI I score of 250 or greater to a specialist multidisciplinary team\n\n\n**2 Week Wait (2WW) Referral Criteria:**\n\n* Physical examination showing ascites and/or a pelvic abdominal mass (that is not due to uterine fibroids) \n* Ultrasound findings suggestive of ovarian malignancy\n\n\n\n# Staging\n \n \nStage I (limited to the ovaries):\n \n - Stage IA: limited to one ovary, the capsule is intact\n - Stage IB: limited to both ovaries, capsules intact.\n - Stage IC: tumour limited to one or both ovaries with any of the following: capsule ruptured, tumour on ovarian surface, malignant cells in ascites or peritoneal washings.\n \n \nStage II (involving one or both ovaries with pelvic extension and/or implants):\n \n - Stage IIA: extension and/or implants on the uterus and/or Fallopian tubes. No malignant cells in ascites or peritoneal washings\n - Stage IIB: extension to and/or implants on other pelvic tissues. No malignant cells in ascites or peritoneal washings\n - Stage IIC: pelvic extension and/or implants (Stage IIA or Stage IIB) with malignant cells in ascites or peritoneal washings.\n \n \nStage III (involving one or both ovaries with microscopically confirmed peritoneal implants outside the pelvis):\n \n - Stage IIIA: microscopic peritoneal metastasis beyond pelvis (no macroscopic tumour)\n - Stage IIIB: macroscopic peritoneal metastasis beyond pelvis <2 cm\n - Stage IIIC: peritoneal metastasis beyond pelvis >2 cm and/or regional lymph node metastasis.\n \n \nStage IV: tumour involving one or both ovaries with distant metastasis.\n \n \n\n# Management\n \n \nManagement depends on the stage of the cancer and the patient's fitness for treatment.\n\nSurgery: \n\n* If early disease surgery can include removal of the uterus, ovaries, fallopian tubes and omentectomy\n* In advanced disease further debulking surgery can be performed.\n\n \nChemotherapy:\n\n* Adjuvant chemotherapy in combination with surgery\n* Intraperitoneal chemotherapy may be performed at the time of operation\n\nBiological therapies are being trialled \n \n \n# Complications\n\n* Bowel obstruction/constipation\n* Ascites\n* Chemotherapy complications: alopecia, intraperitoneal toxicity, neutropenia, peripheral neuropathy\n* Immunotherapy complications: bowel perforation or fistula, hypertension, poor wound healing \n* Surgical complications: thromboembolism, infection, haemorrhage, death\n* Death\n\n# Prognosis \n\n5-year survival:\n\n* 75% for women younger than 50\n* > 35% for women over 65\n* > 90% for women with localised disease on diagnosis\n* 30% for women with distant disease on diagnosis \n\n# NICE Guidelines\n \n \n [Click here to read NICE CKS on Ovarian cancer](https://cks.nice.org.uk/topics/ovarian-cancer/)\n \n \n# References \n\n[Patient Info](https://patient.info/doctor/ovarian-cancer-pro)",
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"question": "A 56-year-old woman attends her general practitioner complaining of weight loss. She states she has lost around 7kg in the past six months and attributes this to just not being able to eat proper meals the way she used to. She feels she becomes full quickly and always feels bloated. Her last menstrual period was age 54, and she has no menopausal symptoms.\n\nShe has a past medical history of gastroesophageal reflux disease, obesity and type 2 diabetes. She takes omeprazole and metformin.\n\nOn examination, the woman is obese with a BMI of approximately 40. The abdomen is soft and non-tender; however, there is a fullness felt in the left iliac fossa. Bimanual examination also reveals a potential mass in the left adnexa.\n\nWhat is the most appropriate management?",
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"explanation": "Whilst chromosomal abnormalities are a common cause of spontaneous miscarriage, this mother has other features that point toward an infective cause.",
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"explanation": "Despite the maternal vomiting, gastroenteritis is a less likely cause of foetal demise. Gastroenteritis rarely causes sepsis or uterine activity.",
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"explanation": "Chorioamnionitis is a common cause of second trimester miscarriage and typically occurs due to ascending infection from the vagina. Chorioamnionitis typically presents with maternal fever, tachycardia and abdominal pain. There may be an offensive vaginal discharge or preterm prelabour rupture of membranes. In some cases, it leads to foetal demise.",
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"explanation": "Whilst urinary tract infection is the most common type of infection in pregnancy, there are no signs or symptoms of urinary tract infection.",
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"comment": "i dont understand there is no evidence of premature rupture of membranes",
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"comment": "Dont need it bro just makes it more likely ",
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"explanation": "# Summary\n\nChorioamnionitis is an infection of the membranes in the uterus and is typically characterized by fever, abdominal pain, offensive vaginal discharge, and signs of preterm rupture of membranes. Key signs include maternal and foetal tachycardia, pyrexia and uterine tenderness. Investigation typically involves blood tests and cultures. Management includes hospital admission, delivery, and intravenous broad spectrum antibiotic therapy.\n\n\n# Definition\n\n\n\nChorioamnionitis, also referred to as intra-amniotic infection (IAI), is a bacterial infection that affects the membranes surrounding the fetus (the amniotic sac) and the amniotic fluid within the uterus. \n\n\n# Epidemiology\n\n\n\nChorioamnionitis affects approximately 1-4% of all births and is commonly associated with premature delivery. \n\n\n# Aetiology\n\n\n\nThe infection is often caused by bacteria ascending from the vagina into the uterus, with the most common organisms being Group B streptococcus, E. coli, and anaerobic bacteria.\n\n\n# Signs and Symptoms\n\n\n\nPatients with chorioamnionitis typically present with the following symptoms and signs:\n\n- Fever\n- Abdominal pain\n- Offensive vaginal discharge\n- Evidence of preterm rupture of membranes\n- Maternal and foetal tachycardia\n- Pyrexia\n- Uterine tenderness\n\n\n# Differential Diagnosis\n\n\n\nThe main differentials for chorioamnionitis include:\n\n- Urinary tract infection: presents with dysuria, frequency, urgency, suprapubic pain, and possibly pyrexia.\n- Appendicitis: presents with right lower quadrant pain, nausea, vomiting, and possibly fever.\n- Placental abruption: presents with vaginal bleeding, abdominal pain, and rigid uterus.\n\n# Investigations\n\n\nThe diagnosis of chorioamnionitis is commonly established by clinical signs and symptoms. However, laboratory investigations including blood tests and cultures, can be used to confirm the diagnosis and identify the causative organism. \n\n# Management\n\n\nChorioamnionitis is an indication for hospital admission and delivery. Management includes:\n\n- Intravenous broad spectrum antibiotic therapy as part of the sepsis six protocol.\n- Monitoring of both mother and foetus for complications.\n- In some cases, early delivery may be necessary to prevent further complications.\n\n# References\n\n\n\n[RCOG guidelines on bacterial infection in pregnancy ](https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_64a.pdf)\n",
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"question": "A 23-year-old woman presents to accident and emergency at 19 weeks gestation with severe abdominal pain and vomiting.\n\n\nHer observations are as follows:\n\n\n - Heart rate: 140 beats per minute\n - Blood pressure: 108/72mmHg\n - Respiratory rate: 20 breaths per minute\n - SpO2: 99% on room air\n - Temperature 38.1°C\n\n\nHer full blood count tests are as follows:\n\n\n||||\n|--------------|:-------:|---------------|\n|Haemoglobin|126 g/L|(M) 130 - 170, (F) 115 - 155|\n|White Cell Count|16.7x10<sup>9</sup>/L|3.0 - 10.0|\n|Platelets|450x10<sup>9</sup>/L|150 - 400|\n\n\n\nAn abdominal examination reveals a gravid uterus with diffuse abdominal tenderness. There is sporadic uterine activity.\n\n\nA midwife attends who is unable to auscultate the foetal heart.\n\n\nA transabdominal ultrasound scan confirms a non-viable pregnancy with no foetal heart.\n\n\nWhat is the most likely cause for this foetal demise?",
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"explanation": "Sulfasalazine is unlikely to be contributing to her vaginal bleeding and should not be suddenly stopped in a patient with inflammatory arthritis.",
"id": "49891",
"label": "e",
"name": "Stop sulfasalazine for a period of four weeks",
"picture": null,
"votes": 6
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"explanation": "If her bleeding appeared to be due to vulvovaginal atrophy, increasing her estradiol may be beneficial, but this is not the case here.",
"id": "49888",
"label": "b",
"name": "Increase estradiol pessaries to one 10 microgram pessary daily for two weeks",
"picture": null,
"votes": 3
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst Mirena coils are licenced for managing heavy menstrual bleeding, this does not appear to be menstrual bleeding here, so this would be inappropriate.",
"id": "49890",
"label": "d",
"name": "Swap her copper coil for a Mirena coil",
"picture": null,
"votes": 54
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst this woman no longer requires contraception and could have her copper coil removed, this would be unlikely to address the issue of her new postmenopausal bleeding, which requires investigation.",
"id": "49889",
"label": "c",
"name": "Remove her copper coil",
"picture": null,
"votes": 145
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "This woman has postmenopausal bleeding, which requires urgent referral to gynaecology for investigation of endometrial cancer.",
"id": "49887",
"label": "a",
"name": "Urgent referral to gynaecology",
"picture": null,
"votes": 1808
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"explanation": "# Summary\n \n \nPostmenopausal bleeding is an important symptom that requires thorough investigation due to the potential for serious underlying pathology, such as endometrial cancer. The primary investigations include referral to gynaecology, transvaginal ultrasound, and biopsy of the endometrium. Management strategies will be determined based on the underlying cause of the bleeding. \n \n \n# Definition\n \nPostmenopausal bleeding is any vaginal bleeding that occurs after a patient has not experienced periods for 12 months or more, and who are not receiving hormone therapy. If a woman is receiving hormone replacement therapy (HRT), bleeding is considered postmenopausal if it occurs more than 6 months after menstruation has stopped.\n \n \n# Aetiology\n \nThe most common causes of postmenopausal bleeding include:\n\n* Endometrial atrophy\n* Vaginal atrophy\n* Endometrial polyps\n* Uterine fibroids\n* Endometrial cancer. \n\nOther less common causes include cervical cancer, ovarian tumours and certain medications, such as hormone replacement therapy (HRT) and anticoagulants.\n \n \n# Signs and symptoms\n \n \nFurther symptoms to postmenopausal bleeding will depend on the underlying cause, but may include pelvic pain, weight loss, and systemic symptoms of malignancy.\n \n \n# Differential Diagnosis\n \n \n - **Endometrial cancer:** Often the only symptom is postmenopausal bleeding.\n - **Vaginal atrophy:** Can also cause pruritus, dyspareunia, and vaginal discharge.\n - **Cyclical combined HRT:** Causes regular vaginal bleeding. With continuous HRT, it is common to experience breakthrough bleeding in the first 6 months.\n - **Bleeding disorders:** May be suggested if there is frequent bleeding elsewhere (e.g. recurrent epistaxis) or a family history of a bleeding disorder.\n \n \n# Investigations\n \nAll cases of postmenopausal bleeding should be referral to gynaecology under the 2-week wait pathway. \n\nThe gynaecologist will likely consider the following investigations: \n\n**Bedside:**\n\n- Bimanual and speculum examination\n\n**No blood tests** are required for diagnosis in the first instance, though if underlying bleeding/clotting disorders are suspected a clotting screen would be indicated. \n\n**Imaging:**\n\n - Transvaginal ultrasound to look for abnormal thickening of the endometrium\n - CT CAP: performed following diagnosis of endometrial cancer, for FIGO staging \n\n**Special tests:**\n\n - Biopsy of the endometrium, obtained via hysteroscopy or pipelle\n\n**2 Week Wait Criteria**\n\n- All cases of postmenopausal bleeding in women aged 55 or older should be referred to gynaecology under a 2-week wait. \n\n- In women aged under 55, a 2-week wait referral should also be considered.\n\n- For those not referred in the immediate instance who have a TV USS performed, refer under 2-week wait if endometrial thickness is >4mm, or if otherwise high clinical suspicion of endometrial cancer remains. \n\n \n# Management\n \n \nThe management of postmenopausal bleeding is guided by the underlying cause. This may include hormonal therapy for conditions such as endometrial atrophy, surgical interventions for polyps or cancers, or supportive care for symptoms related to vaginal atrophy. In all cases, ongoing monitoring is essential to ensure that treatment is effective and to detect any changes in the patient's condition.\n\n\n# NICE Guidelines\n\n[Click here for NICE guidelines on Gynaecological Cancers](https://cks.nice.org.uk/topics/gynaecological-cancers-recognition-referral/)\n\n# References\n\n[Patient Info: Postmenopausal bleeding](https://patient.info/doctor/postmenopausal-bleeding)",
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"question": "A 54-year-old woman presents to her general practitioner with intermittent vaginal bleeding. She describes bleeding almost every day, of varying severity. There is no associated pain. She had her last menstrual period at age 51 and does not complain of any menopausal symptoms. She has a copper coil in situ, which was inserted when she was 48.\n\nShe has a past medical history of type 2 diabetes and rheumatoid arthritis.\n\nShe takes the following medications:\n\n- Metformin 1g twice daily\n- Sulfazalazine 500mg four times a day\n- Co-codamol 30/500mg as required\n- Estradiol intravaginal pessary 10 micrograms twice weekly\n\nWhat is the most appropriate management?",
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"explanation": "An artificial rupture of membranes (ARM) can only be performed where the cervix is favourable, the foetus is well engaged, and there is space to access the cervical os.",
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"explanation": "Intravenous oxytocin is not used alone for induction of labour, however may be required later in the process to facilitate effective contractions.",
"id": "49893",
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"explanation": "Intravaginal prostaglandin E2 analogues such as Propess and Prostin are the first-line treatment in the induction of labour where there are no contraindications. These aim to soften and ripen the cervix in preparation for labour.",
"id": "49892",
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"explanation": "Misoprostol, oral or vaginal, can be used to induce labour however is associated with an increased risk of uterine hyperstimulation",
"id": "49895",
"label": "d",
"name": "An oral prostaglandin E1 analogue, e.g. misoprostol every 4 hours",
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"explanation": "This woman's cervix is described as very unfavourable, therefore insertion of a balloon catheter may be impossible. She has no contraindications to induction of labour using intravaginal prostaglandin E2 analogues such as Propress and Prostin.",
"id": "49894",
"label": "c",
"name": "Foley intracervical balloon catheter",
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"comment": "I don't think that misoprostol is incorrect as of the most recent guidelines:\n\n\"For women with a Bishop score of 6 or less, offer induction of labour with dinoprostone as vaginal tablet, vaginal gel or controlled-release vaginal delivery system or with low dose (25 microgram) oral misoprostol tablets. [2021]\"\n\nThis is different to the 2008 guidelines which state \"1.3.2.3 Misoprostol10 should only be offered as a method of induction of\nlabour to women who have intrauterine fetal death (see\nsection 1.2.9) or in the context of a clinical trial.\"\n\nPlease update this?",
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"explanation": "# Summary\n\nInduction of labour is an artificially initiated process to start labour, usually applied for post-dates (>41 weeks gestation), preterm prelabour rupture of membranes, intrauterine foetal death, abnormal CTG, and certain maternal conditions. Contraindications include previous classical/vertical incision during caesarean section, multiple lower uterine segment caesarean sections, transmissible infections, and others. Methods include membrane sweep, vaginal prostaglandins, amniotomy, and balloon catheter. Management revolves around these methods, with careful monitoring and preparation for possible surgical intervention if necessary.\n\n\n# Definition\n\n\n\nInduction of labour is the medically initiated process of starting labour artificially. It is performed under specific circumstances to ensure the safety of the mother and the child.\n\n# Indications\n\n\n\nInduction of labour is typically indicated under certain conditions:\n\n- Post-dates i.e. >41 weeks gestation\n- Preterm prelabour rupture of membranes\n- Intrauterine foetal death\n- Abnormal CTG\n- Maternal conditions such as pre-eclampsia, diabetes, cholestasis\n\n# Contraindications \n\nCertain conditions pose a risk for labour induction:\n\n- Previous classical/vertical incision during caesarean section\n- Multiple lower uterine segment caesarean sections\n- Transmissible infections e.g. herpes simplex\n- Placenta praevia\n- Malpresentations\n- Severe foetal compromise\n- Cord prolapse\n- Vasa previa\n\n\n# Investigations\n\n\nInvestigations for the need for labour induction can involve:\n\n- Ultrasound scans: To confirm gestational age, foetal position, and placental location.\n- Blood tests: To check the mother’s health status, particularly in cases of maternal conditions such as pre-eclampsia or diabetes.\n\n# Management\n\n\nThe management of labour induction involves various methods:\n\n- Membrane sweep: Inserting a gloved finger into the external os and separating the membranes from the cervix.\n- Vaginal prostaglandins (PGE2): These are used to ripen the cervix and induce contractions.\n- Amniotomy: Artificial rupture of membranes.\n- Balloon catheter: This is inserted into the cervix to mechanically dilate it.\n\n# References\n\n\n\n[Click here for more information from NICE on Induction of Labour](https://www.nice.org.uk/guidance/CG70)",
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"question": "A 24-year-old woman is attending for labour induction for a large-for-dates baby at 38+2 weeks gestation.\n\nHer observations are as follows:\n\n- Heart rate: 66 beats per minute\n- Blood pressure: 124/76 mmHg\n- Respiratory rate: 18 breaths per minute\n- Oxygen saturations: 100% on room air\n- Temperature: 36.7°C\n\nA cardiotocograph is performed, which is reassuring.\n\nA midwife performs a vaginal examination and describes her cervix as long, closed, firm, and posterior. Her Bishops score is 0.\n\nWhat is the most appropriate management?",
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"__typename": "QuestionChoice",
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"explanation": "Implantation bleeding occurs in the two weeks following conception, as the embryo implants into the endometrium. This woman is approximately 11 weeks gestation, which is after any implantation bleeding should have settled.",
"id": "49901",
"label": "e",
"name": "Implantation bleeding",
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"__typename": "QuestionChoice",
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"explanation": "There was an intrauterine pregnancy which has now fully miscarried, with all products of conception expelled, and the uterus is now empty. The os is usually closed. The patient may have been alerted to the miscarriage by pain and bleeding.",
"id": "49899",
"label": "c",
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"explanation": "This is where there are some mild symptoms of bleeding with the foetus retained within the uterus as the cervical os is closed. Hence there is the 'threat' of a miscarriage, but it is not certain. There may be little or no pain. Ultrasound reveals that the foetus is present intrauterine.",
"id": "49897",
"label": "a",
"name": "Threatened miscarriage",
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"explanation": "The uterus still contains foetal tissue, but the foetus is no longer alive. The miscarriage is 'missed' as often the woman is asymptomatic so does not realise something is wrong. The cervical os is closed.",
"id": "49900",
"label": "d",
"name": "Missed miscarriage",
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"explanation": "There is often heavy bleeding and pain, where the foetus is currently intrauterine but the cervical os is open. Hence it is inevitable that the foetus will be lost. Ultrasound reveals that the foetus is present intrauterine.",
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"explanation": "# Summary\n \nMiscarriage is the loss of a pregnancy before 24 weeks gestation, with over 10% of recognised pregnancies ending in miscarriage. The main clinical features are vaginal bleeding, pain and tissue loss. Differential diagnoses include ectopic pregnancy. Key investigations involve transvaginal ultrasound and potentially serial hCG measurements. Management typically involves ensuring complete removal of foetal material, either expectantly or through medical or surgical intervention. Anti-D prophylaxis may be required in rhesus negative women.\n \n \n# Definition\n \n \nMiscarriage is defined as the loss of a pregnancy prior to 24 weeks gestation. Just over 10% of recognised pregnancies end in miscarriage, although the total number of miscarriages is higher as some occur without the woman realising she is pregnant.\n \n \n# Aetiology\n \n \nThe cause is often idiopathic. Known causes can be split into:\n \n \n**Foetal pathology:**\n \n - Genetic disorder\n - Abnormal development\n - Placental failure\n \n \n**Maternal pathology:**\n\n - Uterine abnormality\n - Cervical incompetence\n - Polycystic ovary syndrome\n - Poorly controlled diabetes\n - Poorly controlled thyroid disease\n - Anti-phospholipid syndrome\n \n\n# Classification \n \n \nThere are several types of miscarriage, these are:\n \n \n**Threatened miscarriage**\n \n \nThis is where there are some mild symptoms of bleeding with the foetus retained within the uterus as the cervical os is closed. Hence there is the \"threat\" of a miscarriage, but it is not certain. There may be little or no pain. Ultrasound reveals that there is an intrauterine foetus present.\n \n \n**Inevitable miscarriage**\n \n \nThere is often heavy bleeding and pain, where the foetus is currently intrauterine but the cervical os is open. Hence it is inevitable that the foetus will be lost. Ultrasound reveals that the foetus is present intrauterine.\n \n \n**Complete miscarriage**\n \n \nThere was an intrauterine pregnancy which has now fully miscarried, with all products of conception expelled, and the uterus is now empty. The os is usually closed. The patient may have been alerted to the miscarriage by pain and bleeding.\n \n \n**Missed miscarriage**\n \n \nThe uterus still contains foetal tissue, but the foetus is no longer alive. The miscarriage is 'missed' as often the woman is asymptomatic so does not realise something is wrong. The cervical os is closed.\n\n\n# Signs and Symptoms \n \n \n - Vaginal bleeding\n - Vaginal tissue loss\n - Abdominal/pelvic pain \n \n \n# Differential Diagnosis\n \n\n- **Ectopic pregnancy:** Presents primarily with lower abdominal pain (may include shoulder tip pain) and also some vaginal bleeding, although classically not as much bleeding as in a miscarriage. Beta-hCG levels can help distinguish the two conditions. \n- **Hydatidiform mole:** Presents with severe nausea and vomiting, and uterus that is much larger than expected. \n- **Cystitis:** Presents with lower abdominal pain and fever, but some patients may also experience haematuria. \n\n \n \n# Investigations\n \n**Bedside:**\n\n* Speculum examination: Check for opening of cervix and any passage of contents. \n\n**Bloods:**\n\n* Beta hCG: Serial serum hCG measurements 48 hours apart can help give an indication of the location and prognosis of the pregnancy.\n * If the levels fall then it is suggested that the foetus will not develop or there has been a miscarriage.\n * If there is only a slight increase or a plateau in hCG levels then this may indicate an ectopic pregnancy.\n * A normal increase in hCG suggests the foetus is growing normally, but does not exclude ectopic pregnancy\n\n\n**Imaging:**\n\n - Transvaginal ultrasound: Used to establish whether there are any foetal components within the uterine cavity and whether a foetal heartbeat can be detected.\n\n \n \n# Management\n \n \nMiscarriage often cannot be prevented or stopped. Management therefore revolves around ensuring complete removal of foetal material.\n\n**Conservative:**\n\n- Expectant management, i.e. allowing the products of conception to naturally expel. \n\t- This is offered first-line for 7-14 days, unless: \n\t - There is an increased risk of haemorrhage (e.g. late first trimester)\n\t - There are increased risks of effects of haemorrhage (e.g. coagulopathy) \n\t - Previous traumatic pregnancy experiences (e.g. miscarriage, stillbirth)\n\t - There is evidence of infection. \n- Offer all women written and verbal information about expectant management of miscarriage. \n- Provide analgesia\n- If there is resolution of bleeding and pain (suggesting completed miscarriage), provide the patient with a urine pregnancy test to complete 3 weeks later. If positive, to please return. \n- Offer repeat TV USS following period of expectant management if the process of bleeding and pain have not started, or if they are persisting or worsening (suggesting incomplete miscarriage). \n\n\n**Medical:**\n\n- If this is a missed miscarriage, offer: 200 mg oral mifepristone and, 48 hours later, 800 micrograms misoprostol (vaginal, oral or sublingual)\n- If incomplete miscarriage, offer: 600-800 micrograms misoprostol (vaginal, oral or sublingual) only. \n- Offer all patients anti-emetics and analgesia, as required. \n- Advise follow-up if bleeding has not started within 48h following misoprostol. \n- Offer all women written and verbal information about medical management of miscarriage. \n- Provide the patient with a urine pregnancy test to complete 3 weeks later. If positive, to please return. If negative but patient still symptomatic (e.g. bleeding, pain, fever), then advise to return for consideration of further management. \n\n\n**Surgical:**\n \n- Offer women the choice of:\n - Manual vacuum aspiration under local anaesthetic (in outpatient or clinic setting)\n - Surgical management under general anaesthetic (in theatre)\n\n- Usually used when medical management has failed, or if this is patient preference (e.g. due to past traumatic experiences). \n \n- If the patient is rhesus negative they may require anti-D prophylaxis.\n \n\n# Complications \n\nComplications of surgical management of miscarriage: \n\n- Incomplete evacuation of the uterus: Caused by retained pregnancy tissue despite intervention, leading to continued vaginal bleeding and lower abdominal pain. \n- Post-uterine evacuation bleeding: This may occur following the procedure as tissue in this area is highly vascularised. \n- Asherman's Syndrome: Secondary to trauma to the endometrial lining, leading to adhesions that obstruct the uterine cavity and lead to infertility, recurrent miscarriages or high-risk pregnancy in future. \n\n\nOther complications: \n\n- Sepsis: May occur before or following miscarriage, especially in cases of retained products of conception. \n- Psychological impact: Very variable between patients, but offering mental health support is crucial to all patients. \n- Recurrent miscarriage: If occurs, important to investigate an underlying cause; 1-2% risk. \n\n \n# Recurrent miscarriage\n \n \nRecurrent miscarriage is defined as the loss of 3 or more consecutive pregnancies.\n \n \n**Investigations in recurrent miscarriage**\n \n \nInvestigations include blood tests (antiphospholipid antibodies, thrombophilia screen), cytogenetic analysis of products of conception (if abnormal then the parents should be karyotyped), and pelvic ultrasound to identify uterine abnormalities.\n \n \n**Management of recurrent miscarriage**\n \n \nThe management is tailored to the contributing pathology:\n \n \n- Genetic disorder: Refer to a clinical geneticist for genetic counselling. Options include continuing pregnancy attempts with prenatal diagnosis or use of a donor egg/sperm. \n \n- Uterine structural abnormality: May be treated surgically. For some congenital uterine malformations there is insufficient evidence to recommend surgical treatment. \n \n- Cervical incompetence: Regular ultrasound monitoring of the cervix. May use cervical cerclage. \n \n- Polycystic ovary syndrome: Difficult to manage as pathophysiology is not fully understood. There is no consensus on the most appropriate management, especially in women who wish to conceive. Suppression of the high LH has not been found to be effective. \n \n- Antiphospholipid syndrome: Heparin or low-dose aspirin. \n \n- Thrombophilia: Heparin may increase the live birth rate. \n \n- Diabetes: Improve glycaemic control. \n \n \n# NICE Guidelines\n \n[Click here for NICE CKS page on miscarriage](https://cks.nice.org.uk/topics/miscarriage/)",
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"question": "A 17-year-old woman presents to accident and emergency with a 4-hour history vaginal bleeding. She is approximately 11 weeks gestation. She describes the bleeding as bright red, and associated with lower abdominal cramps.\n\nShe does not complain of any unusual vaginal discharge, or any other symptoms.\n\nOn examination, her observations are normal. Her abdomen is soft and non-tender. On speculum examination, the cervical os is closed, however there is some red blood evident at the cervix.\n\nAn abdominal ultrasound scan reveals a foetus of approximately 11 weeks. A foetal heartbeat is present.\n\nWhat is the diagnosis?",
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"explanation": "Polymorphic eruption of pregnancy is also known as PUPPP (Pruritic Urticarial Papules and Plaques of Pregnancy). This usually starts on the abdomen, spares the umbilicus, and may spread to the thighs or buttocks. Symptomatic treatment includes emollients, topical corticosteroids, and antihistamines.",
"id": "49902",
"label": "a",
"name": "Polymorphic eruption of pregnancy",
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"explanation": "Atopic eruption of pregnancy presents similarly to eczema and is most common in women with a history of eczema. Typical sites include the face, neck, chest and flexor surfaces of the upper limbs. Treatment is with emollients and topical corticosteroids.",
"id": "49904",
"label": "c",
"name": "Atopic eruption of pregnancy",
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"__typename": "QuestionChoice",
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"explanation": "Pemphigoid gestationis is rare, and causes itchy rash which typically forms around the umbilicus and progresses to form blisters. The condition is likely to flare up again throughout the pregnancy. Management is with emollients and topical corticosteroids.",
"id": "49905",
"label": "d",
"name": "Pemphigoid gestationis",
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Contact dermatitis is a type of eczema occurring following exposure to a causative agent. It presents with a dry, painful and pruritic skin rash where the skin has been in contact with a certain irritant.",
"id": "49906",
"label": "e",
"name": "Contact dermatitis",
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"explanation": "Obstetric cholestasis is caused by elevated bile acids, and does not cause a rash in itself but does cause intense pruritus, which can then develop into a rash. Cholestasis is treated with ursodeoxycholic acid, with emollients and antihistamines being useful for the itchy rash.",
"id": "49903",
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"name": "Obstetric cholestasis",
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"comment": "Why is this not pemphoid gestationitis? ",
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"comment": "it could be, but its much more rare",
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"comment": "It says fluid-filled vesicles- isn't that more likely to be blisters than papules or plaques?",
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"comment": "vesicles is definitely pointing towards pemphigoid >>> Polymorphic eruption has papule and plaques?? ",
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"explanation": "# Overview\n\nRash is common in pregnancy and can occur due to any of the reasons a rash may occur in a non-pregnant individual. However there are conditions specifically related to pregnancy.\n\n# Polymorphic eruption of pregnancy (PEP) features\n\nPEP occurs most frequently in the third trimester and presents with itchy papules, typically first appearing on striae gravidarum, but may spread to the entire abdomen, thighs and buttocks. It may progress to a widespread eczematous rash with fluid-filled vesicles. PEP can be treated with emollients and and topical corticosteroids.\n\n# Obstetric Cholestasis\n\nObstetric cholestasis is caused by elevated bile acids, and does not cause a rash in itself but does cause intense pruritus which can then develop into a rash. Cholestasis is treated with Ursodeoxycholic Acid, with emollients and antihistamines being useful for the itchy rash.\n\n# Atopic eruption of pregnancy\n\nPresents similarly to eczema and is most common in women with a history of eczema. Typical sites include the face, neck, chest and flexor surfaces of the upper limbs. Treatment is with emollients and topical corticosteroids.\n\n# Pemphigoid gestationis\n\nA rare, itchy rash which typically forms around the umbilicus and progresses to form blisters, thought to be auto-immune in aetiology. Management is with emollients and topical corticosteroids. The condition is likely to flare up again throughout the pregnancy.\n\n# External links\n\n[- Royal College of Obstetricians and Gynaecologist: Obstetric Cholestasis](https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg43/)\n[- British Association of Dermatologists: Polymorphic Eruption of Pregnancy](https://www.bad.org.uk/shared/get-file.ashx?id=227&itemtype=document)\n[- British Association of Dermatologists: Pemphigoid Gestationis](https://www.bad.org.uk/shared/get-file.ashx?id=224&itemtype=document)",
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"question": "A 24-year-old woman attends her general practitioner worried about a rash. She is 35 weeks pregnant, and has noticed an itchy rash on her abdomen and thighs in the last few days. She says is started on her stomach, and initially wasn't itchy, however it has become itchy over the last day.\n\nOn examination, she has a widespread eczematous rash consisting of papules and plaques over her abdomen, thighs and buttocks. There is umbilical sparing. There is evidence of excoriation across her abdomen.",
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"__typename": "QuestionChoice",
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"explanation": "Oestradiol is not tested for as part of combined screening.",
"id": "49911",
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"name": "Oestradiol",
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"__typename": "QuestionChoice",
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"explanation": "Alpha-fetoprotein (AFP) is performed as part of the triple screening test, which is performed later in pregnancy, after 13 weeks. AFP is reduced in pregnancies with Down syndrome.",
"id": "49908",
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"name": "Alpha-fetoprotein (AFP)",
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"explanation": "Beta-hCG is tested as part of the combined screening test, alongside nuchal translucency and pregnancy-associated plasma protein-A (PAPP-A). The combined test gives an overall risk of Down syndrome.",
"id": "49907",
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"explanation": "Amniotic fluid level is not tested for as part of combined screening.",
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"name": "Amniotic fluid level",
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"__typename": "QuestionChoice",
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"explanation": "Pregnancy-associated plasma protein-A (PAPP-A) is tested as part of the combined screening test, alongside beta-hCG and nuchal translucency. Pregnancy-associated plasma protein-A (PAPP-A) is reduced in pregnancies with Down syndrome.",
"id": "49909",
"label": "c",
"name": "Pregnancy-associated plasma protein-A (PAPP-A)",
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"explanation": "# Summary\n\n\nScreening for Down Syndrome in pregnancy typically involves the use of the Combined Test, Triple Test, or Quadruple Test. These tests measure various hormones and proteins in the blood and use ultrasound scanning to provide a risk score. A high-risk result may warrant further diagnostic tests, such as chorionic villus sampling or amniocentesis, for a definitive answer. \n\n# Combined test\n\nThe recommended screening test for Down Syndrome is the combined test, which measures:\n\n- Nuchal translucency using ultrasound scan\n- PAPP-A hormone (level reduced in pregnancy affected with Down's syndrome)\n- Beta-hCG hormone (raised in pregnancy affected by Down's syndrome)\n\nThe combined test is carried out between 11 and 13 weeks of pregnancy in the first trimester and combination of these components is used to provide a risk score.\n\nWhere the combined test is unavailable or the woman attends presents for the first time after 13 weeks gestation, the triple test or quadruple test is offered which involve a blood test to measure hormone levels.\n\n# Triple test\n\nThe triple test:\n\n- Beta-hCG\n- AFP (reduced in pregnancies affected by Down syndrome)\n- uE3 (reduced in pregnancies affected by Down syndrome)\n\n# Quadruple test\n\nThe quadruple test is the triple test but with the addition of Inhibin-A levels (raised in pregnancies affected by Down syndrome).\n\n# Further tests\n\nNote that these screening tests will only give a result of increased or decreased risk of having a baby with Down syndrome compared to the normal population. Women with a high risk result may be offered a diagnostic test such as chorionic villus sampling or amniocentesis to provide a definitive answer.",
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"question": "A 42-year-old woman attends her general practitioner after finding out she is pregnant. Her last menstrual period was six weeks ago. She is aware that having a pregnancy in her 40's is higher risk for Down syndrome and is keen to \"get tested\" as soon as possible.\n\nShe is offered the combined test at 11 weeks. Which of the following is a component of combined screening that, if raised, may indicate a higher risk of Down syndrome?",
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"explanation": "Imperforate hymen would not affect the development of secondary sexual characteristics and usually manifests with cyclical pain.",
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"__typename": "QuestionChoice",
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"explanation": "Androgen insensitivity syndrome occurs in people with an XY genotype; however, their body does not respond to androgens, so they fail to develop male secondary sexual characteristics.",
"id": "49916",
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"name": "Androgen insensitivity syndrome",
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"__typename": "QuestionChoice",
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"explanation": "Primary amenorrhoea is diagnosed where there is absent menstruation and absent secondary sexual characteristics at age 13. Turner syndrome results from the chromosomal abnormality X0, where one X chromosome is missing. Affected individuals are phenotypically female, with short stature, webbed neck, widely spaced nipple and a wide carrying angle. They are also likely to have congenital heart defects, ovarian dysgenesis and delayed puberty.",
"id": "49912",
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"name": "Turner syndrome",
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"__typename": "QuestionChoice",
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"explanation": "Whilst excessive exercise can cause amenorrhoea, including primary amenorrhoea, there is no indication this is the case in this scenario. In addition, this girl has features of Turner syndrome.",
"id": "49915",
"label": "d",
"name": "Excessive exercise",
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"votes": 3
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"__typename": "QuestionChoice",
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"explanation": "Constitutional delay is the most common cause of delayed puberty; however, this girl has several features of Turner syndrome, making this diagnosis more likely.",
"id": "49913",
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"name": "Constitutional delay",
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"comment": "how do you differentiate between androgen insensitivity syndrome & Turner's syndrome?",
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"comment": "I think in androgen insensitivity syndrome, there will be normal breast tissue development due to conversion of androgen to oestrogen.",
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"explanation": "# Summary\n \n \nPrimary amenorrhoea is a condition where menstrual periods do not start by the age of 15 in females with normal growth and secondary sexual characteristics, or at age 13 with absent pubertal maturation. The key signs and symptoms are the absence of menstruation and possibly the absence of secondary sexual characteristics. The main causes include delayed puberty, genetic abnormalities, disruptions in the hypothalamic or pituitary glands, structural abnormalities of the genital tract, and pregnancy. Investigations include hormonal and genetic tests, and imaging. Management involves treating the underlying cause, which may include hormone replacement therapy, surgery, or psychological support.\n \n \n# Definition\n \nPrimary amenorrhoea is the failure of menstrual periods to start by 15 years of age in a female with normal growth and secondary sexual characteristics. This condition may also be diagnosed at age 13 in the presence of absent pubertal maturation as well as absent menses.\n \n \n# Aetiology\n \n \nPrimary amenorrhoea can result from:\n \n \n- Constitutional delay in puberty\n- Chromosomal or genetic abnormalities, including: \n - Turner syndrome (45 XO)\n - Kallmann syndrome\n - Androgen insensitivity syndrome\n- Dysregulation of the hypothalamic or pituitary glands, which could be due to:\n - Anorexia or other eating disorders\n - Excessive exercise\n - Other forms of extreme physical or psychological stress\n- Structural abnormalities of the genital tract, for example:\n - An imperforate hymen that obstructs menstrual flow (leading to haematocolpos)\n - Uterine agenesis\n \n \n# Signs and Symptoms\n \nThe primary symptom is the absence of menstrual periods. In some cases, secondary sexual characteristics may also be absent.\n \n \n# Differential Diagnosis\n \n \nPossible conditions that could cause similar symptoms include those which cause secondary amenorrhoea. The key in distinguishing primary and secondary amenorrhoea is understanding if the woman has ever experienced menstruation, or periods, before. If yes, then it is secondary. Please see the chapter on secondary amenorrhoea for full details. \n\n \n# Investigations\n \n**Bedside:**\n\n- Speculum examination: To identify any structural abnormalities (e.g. imperforate hymen). \n\n**Bloods:**\n \n - Hormonal tests: Including levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol. \n\n**Imaging:**\n \n - Transvaginal ultrasound scan: To identify structural abnormalities. \n\n**Special tests:**\n\n - Genetic tests: To identify chromosomal or genetic abnormalities. \n\n \n \n# Management\n \n \nManagement depends on the underlying cause and may involve:\n\n**Conservative:**\n\n - Psychological support: Especially important for conditions related to stress or eating disorders, or genetic syndromes. \n - Lifestyle modifications: For issues related to excessive exercise or low body weight. \n \n**Medical:**\n\n - Hormone replacement therapy: For hormonal imbalances\n\n**Surgical:** \n\n - Applicable to structural abnormalities\n\n\n# NICE Guidelines\n\n[Click here for NICE guidelines on management of primary amenorrhoea](https://cks.nice.org.uk/topics/amenorrhoea/management/primary-amenorrhoea/)\n\n[Click here for NICE CKS: Amenorrhoea](https://cks.nice.org.uk/topics/amenorrhoea/)\n\n# References \n\n[BMJ Best Practice: Assessment of primary amenorrhoea](https://bestpractice.bmj.com/topics/en-gb/1101)",
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"question": "A 14-year-old girl is brought into the general practice by her mother, who is concerned that she doesn't seem to be physically maturing like her peers.\n\nOn examination, the girl appears short, approximately 145cm in height. She reports that she has not started her periods. She has a broad flat chest with no evidence of breast budding. She reports that she has no pubic or axillary hair.\n\nWhat is the most likely cause of this girl's primary amenorrhoea?",
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"answer": false,
"explanation": "Gram-negative rods",
"id": "49921",
"label": "e",
"name": "Gram-positive cocci on a vaginal specimen may indicate bacterial vaginosis.",
"picture": null,
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Gram-positive budding yeast cells",
"id": "49920",
"label": "d",
"name": "these are likely to be lactobacilli.",
"picture": null,
"votes": 62
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"__typename": "QuestionChoice",
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"explanation": "Gram-positive cocci on a vaginal specimen may indicate bacterial vaginosis.",
"id": "49918",
"label": "b",
"name": "Gram-positive cocci",
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"__typename": "QuestionChoice",
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"explanation": "Gram-positive bacilli are a normal finding on a vaginal sample",
"id": "49919",
"label": "c",
"name": "Gram positive bacilli",
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has signs and symptoms of pelvic inflammatory disease. Gram-negative diplococci inside cells on a vaginal specimen indicate gonorrhoea infection, one of the most common causes of pelvic inflammatory disease.",
"id": "49917",
"label": "a",
"name": "Intracellular gram-negative diplococci",
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"explanation": "# Summary\n\n\nPelvic Inflammatory Disease (PID) is a sexually transmitted infection that spreads from the vagina into the cervix and upper genital tract. The primary pathogens are Chlamydia trachomatis and Neisseria gonorrhoeae, though often, no pathogen can be isolated. Patients typically present with generalised abdominal pain, discharge, postcoital bleeding, adnexal tenderness, cervical motion tenderness, and sometimes right upper quadrant pain due to Fitz-Hugh-Curtis syndrome. The diagnostic approach includes pelvic examination, pregnancy test, swabs for gonorrhoea and chlamydia, blood tests, and transvaginal ultrasound. Management typically consists of a combination of antibiotics, usually administered in an outpatient setting, and analgesia as required.\n\n\n# Definition\n\n\nPelvic inflammatory disease (PID) is a condition that arises when an infection spreads from the vagina to the cervix, and subsequently to the upper genital tract.\n\n\n# Aetiology\n\n\nWhile Gonorrhoea and Chlamydia contribute to approximately 20% of PID cases, various anaerobic bacteria are also implicated. In certain instances, no pathogen can be isolated. PID is predominantly spread via sexual contact.\n\n\n# Signs and Symptoms\n\n\nPID is typically diagnosed based on clinical symptoms and signs. These include:\n\n\n- Bilateral abdominal pain\n- Vaginal discharge\n- Post-coital bleeding\n- Adnexal tenderness\n- Cervical motion tenderness upon bi-manual examination\n- Fever\n\n\nApproximately 10% of patients present with right upper quadrant pain, secondary to inflammation of the liver capsule. This condition is referred to as Fitz-Hugh-Curtis syndrome (see below).\n\n\n# Differential Diagnosis\n\n\nSeveral conditions may present similarly to PID and should be considered in the differential diagnosis:\n\n\n- **Appendicitis:** Presents with right lower quadrant abdominal pain, fever, nausea, and vomiting.\n- **Ectopic Pregnancy:** Symptoms may include unilateral lower abdominal pain and vaginal bleeding. A positive pregnancy test is a key distinguishing factor.\n- **Endometriosis:** Chronic pelvic pain, dysmenorrhea, and dyspareunia are common. Pain typically worsens during menstruation.\n- **Ovarian Cyst:** Symptoms can include unilateral lower abdominal pain, bloating, and a palpable mass on examination.\n- **Urinary Tract Infection:** Symptoms usually include dysuria, frequency, urgency, suprapubic pain, and possible fever.\n\n\n# Investigations\n\n\nThe following investigations are usually carried out to diagnose PID:\n\n\n**Bedside:**\n\n\n- Bimanual examination, which may show cervical motion tenderness\n- Pregnancy test\n- Swabs for gonorrhoea and chlamydia, or urinary NAAT testing \n\n\n**Bloods:**\n\n\n- FBC, including WCC \n- CRP \n\n\n**Imaging:** \n\n- Transvaginal ultrasound\n\n\n# Management\n\n\nTreatment of PID is **medical** involves a combination of antibiotics, the first-line being:\n\n- Ceftriaxone (given intramuscularly) + doxycycline + metronidazole\n\n\nIf the infection is mild/moderate, these antibiotics are given orally (except ceftriaxone which is intramuscularly) and in an outpatient setting. \nIf the infection is severe, all three antibiotics are given intravenously (and may later be converted to oral) in an inpatient setting.\n\n\n\n\nIn addition, it is important to avoid unprotected intercourse whilst PID is untreated to prevent spread of infection to sexual partners.\n\n\n# Complications\n\n\nThe potential complications associated with PID are:\n\n\n- Chronic pelvic pain: This is likely a result of tubal damage, secondary to inflammation. \n- Infertility: Occurs as a result of tubal damage, impairing passage of an ovum and/or sperm for fertilisation to occur. \n- Ectopic pregnancy: Occurs as a result of tubal damage and scarring causing impaired passage of a fertilised ovum through to the endometrium. \n- Fitz-Hugh-Curtis Syndrome (see below). \n\n# Fitz-Hugh-Curtis Syndrome\n\n\nFitz-Hugh-Curtis syndrome occurs when adhesions form between the anterior liver capsule and the anterior abdominal wall or diaphragm in the context of PID. Despite this, liver function tests are usually normal. An abdominal ultrasound should be performed to rule out the presence of stones. A definitive diagnosis and treatment typically require laparoscopy and administration of antibiotics.\n\n\n# NICE Guidelines\n\n[Click here to see information on NICE about PID](https://cks.nice.org.uk/topics/pelvic-inflammatory-disease/)\n\n# References\n\n\n[Patient Info](https://patient.info/womens-health/pelvic-pain-in-women/pelvic-inflammatory-disease)",
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"explanation": "Intracellular gram-negative diplococci",
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"question": "A 22-year-old female presents to her local sexual health clinic with a 4 day history of abdominal cramps, similar to menstrual cramps.She has also noticed new thick thick, yellow vaginal discharge. She denies any vulval itching\n\nShe has had unprotected intercourse with multiple casual male partners in the last three months.\n\nShe has a Mirena coil in situ for contraception.\n\nA bimanual examination reveals cervical tenderness, and on speculum examination, the cervix appears inflamed. Her coil threads are visible. There is a thick yellow-green discharge present in the vaginal vault. A sample is obtained from the upper vagina and cervix for near-patient microscopy.\n\n\nWhat is the most likely finding on microscopy which would account for her symptoms?",
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173,458,726 | false | 26 | null | 6,494,970 | null | false | [] | null | 10,021 | {
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"explanation": "Whilst ovarian torsion is a sensible differential, a ruptured ovarian cyst is more common. Combined with the fact she is mid-cycle and that the pain seems to have alleviated slightly, ovarian cyst rupture is the more likely diagnosis. Ovarian torsion often presents with worsening pain, sometimes associated with nausea and vomiting.",
"id": "49925",
"label": "d",
"name": "Ovarian torsion",
"picture": null,
"votes": 856
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst ectopic pregnancy is a possibility, this would be rare with a copper intrauterine device in situ.",
"id": "49923",
"label": "b",
"name": "Ectopic pregnancy",
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"votes": 109
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"explanation": "Appendicitis typically presents with central periumbilical pain which localises to the right lower quadrant. This doesn't fit with her pain being on the left and sudden-onset.",
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"label": "e",
"name": "Appendicitis",
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"votes": 13
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"__typename": "QuestionChoice",
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"explanation": "Ovarian cyst rupture presents with a sudden-onset sharp unilateral pain.",
"id": "49922",
"label": "a",
"name": "Ovarian cyst rupture",
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"votes": 902
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"__typename": "QuestionChoice",
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"explanation": "Whilst perforation of an intrauterine device can cause unilateral pain; this is usually within the first few days following insertion.",
"id": "49924",
"label": "c",
"name": "Intrauterine device perforation",
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"comment": "quite hard to distinguish cyst rupture from torsion ",
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"explanation": "# Summary\n \n \nAn ovarian cyst is a fluid-filled sac that can develop in the ovaries. They are often asymptomatic, but can cause acute unilateral pain and even intra-peritoneal haemorrhage in severe cases. The key differentials to consider are ovarian torsion, ectopic pregnancy and gastrointestinal conditions such as appendicitis. A pregnancy test is often the first investigation to exclude an ectopic pregnancy, and a diagnostic laparoscopy may be required if the patient is unstable. The management of ovarian cysts is mainly conservative, but surgery may be required in some cases.\n \n \n# Definition\n \n \nAn ovarian cyst is a fluid-filled sac that develops within or on the surface of an ovary. They can vary in size and can occur as a normal part of the menstrual cycle or as a result of an underlying condition.\n \n \n# Epidemiology\n \n \nOvarian cysts are a common condition, with most women experiencing at least one in their lifetime, although many are asymptomatic. They are most likely to occur during a woman's reproductive years, but can occur at any age.\n \n \n# Aetiology\n \n \nOvarian cysts can be caused by a variety of factors, including hormonal imbalances, endometriosis, pregnancy and pelvic infections.\n \n \n# Signs and Symptoms\n \n \nSigns and symptoms of an ovarian cyst can include:\n \n \n - Asymptomatic presentation\n - Acute unilateral pain\n - Bloating and early satiety\n - Palpable adnexal mass\n \n \n# Differential Diagnosis\n \n \nThe primary differentials to consider when diagnosing an ovarian cyst include:\n \n \n - **Ovarian torsion:** Characterised by sudden, severe pain, often accompanied by nausea and vomiting.\n - **Ectopic pregnancy:**Symptoms include abdominal pain, amenorrhea, and vaginal bleeding.\n - **Appendicitis:** Presents with abdominal pain that begins near the navel and then moves lower and to the right, loss of appetite, nausea, and vomiting.\n \n \n# Investigations\n \n \nInvestigations into a suspected ovarian cyst should include:\n \n**Bedside:**\n\n- Bimanual examination: To feel for any masses. \n- Pregnancy test: To exclude an ectopic pregnancy\n\n**Bloods:**\n\nIn cases of diagnostic uncertainty consider performing:\n\n- CA125: Especially in post-menopausal women, if suspecting cancer. However, specificity (and sensitivity) are below 80%. \n\n**Imaging:**\n\n- Transvaginal Ultrasound Scan: First line and best test to visualise the cyst. \n\n**Invasive tests:** \n\n- Diagnostic laparoscopy, particularly in cases where the patient is unstable\n \n \n# Management\n \n**Conservative:**\n \nMost ovarian cysts are managed conservatively, through monitoring and pain management, if they are simple or unilocular cysts. Exact management depends on their size: \n\n- If cyst is <5cm: no follow-up is required\n- If 5-7cm: repeat TV USS yearly\n- If >7cm: MRI with/without surgical intervention. \n\n\n**Medical:**\n\nFor recurrent or unresolved simple cysts.\n\n- Combined oral contraceptive pill, as prevention of ovulation will also help prevent formation of new cysts. \n\n\n\n**Surgical:**\n\nUsed in cases of recurrent cysts, sustained cysts >5cm, and cysts that look suspicious or multiloculated.\n\n- Laparoscopic cystectomy \n \n \n# Complications\n\n- Cyst rupture: Most often seen in corpus luteum and dermoid cysts that are large, symptomatic and untreated. Rupture can lead to intra-peritoneal haemorrhage with haemodynamic compromise, or peritonitis in the case of dermoid cyst rupture leading to an inflammatory reaction. \n- Ovarian torsion: Most often seen with large cysts that are untreated, where the cyst twists around itself. Most commonly occurs with dermoid cysts and requires urgent surgical intervention to prevent ovary necrosis. \n- Dyspareunia: Can occur as a result of large cysts. \n\n\n \n# References\n[Click here for RCOG Guidelines on Ovarian masses](https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/ovarian-masses-in-premenopausal-women-management-of-suspected-green-top-guideline-no-62/)\n\n \n[RCOG Guidance: Ovarian masses in premenopausal women](https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/ovarian-masses-in-premenopausal-women-management-of-suspected-green-top-guideline-no-62/)\n\n[RCOG Guidance: Ovarian cysts in postmenopausal women](https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/ovarian-cysts-in-postmenopausal-women-green-top-guideline-no-34/)\n\n[BMJ Best Practice](https://bestpractice.bmj.com/topics/en-gb/660)\n\n[NHS Website](https://www.nhs.uk/conditions/ovarian-cyst/)\n\n[Patient Info](https://patient.info/womens-health/pelvic-pain-in-women/ovarian-cyst)",
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"question": "A 24-year-old female presents to accident and emergency with acute onset left iliac fossa pain.\n\nShe describes the pain as \"stabbing\" and of intensity 9/10. It came on suddenly while she was out for her daily jog approximately 1 hour ago. She thinks the pain has alleviated a little since then.\n\nHer last menstrual period was 13 days ago. Her last sexual contact was 21 days ago. She has a copper intrauterine device in situ, which was inserted three months ago.\n\nWhat is the most likely diagnosis?",
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"__typename": "QuestionChoice",
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"explanation": "Previous history of uterine rupture is a contraindication to vaginal birth after caesarean section. Other contraindications include a classical (vertical) caesarean section scar, and any other condition that would normally contraindicate a vaginal delivery (e.g. major placenta praevia).",
"id": "49927",
"label": "a",
"name": "Previous history of uterine rupture",
"picture": null,
"votes": 2019
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "BMI over 30 is not a contraindication to vaginal birth after caesarean section",
"id": "49930",
"label": "d",
"name": "BMI over 30",
"picture": null,
"votes": 32
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "There are no specific contraindications regarding previous gestational age at birth.",
"id": "49929",
"label": "c",
"name": "Previous preterm delivery",
"picture": null,
"votes": 20
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Previous postpartum haemorrhage is not a contraindication to vaginal birth after caesarean section.",
"id": "49931",
"label": "e",
"name": "Previous postpartum haemorrhage",
"picture": null,
"votes": 118
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "There is no specific age limit for vaginal birth after caesarean section in the absence of any other contraindications.",
"id": "49928",
"label": "b",
"name": "Age over 35",
"picture": null,
"votes": 12
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"explanation": "\n# Summary\n\nVaginal Birth After Caesarean section (VBAC) refers to the delivery method for pregnant women at 37 weeks or more of gestation who have previously had a single caesarean delivery. The success rate for VBAC typically ranges from 60-80%. Noteworthy risks include an increased chance of uterine rupture or requirement of caesarean section. Key contraindications include a classical caesarean scar, previous history of uterine rupture, or the typical contraindications to vaginal delivery like major placenta praevia.\n\n\n# Risks\n\n- Increased risk of uterine rupture (scar rupture)\n- Increased risk of requiring caesarean section (failed VBAC)\n\n# Contraindications\n\n- Classical (vertical) caesarean scar\n- Previous history of uterine rupture\n- the usual contraindications to a vaginal delivery (such as major placenta praevia)",
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"question": "A 38-year-old woman attends the antenatal clinic for a routine appointment at 36 weeks gestation. She is para 1, having had an emergency caesarean section 6 years prior for foetal distress.\n\nWhich of the following would contraindicate a vaginal birth?",
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"explanation": "Whilst a urinary pregnancy test may form part of this woman's investigations, she does not disclose any unprotected intercourse. Pregnancy is not a likely cause of a 6-month history of intermenstrual bleeding.",
"id": "49934",
"label": "c",
"name": "Urinary pregnancy test",
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"explanation": "This woman has symptoms of cervical cancer, i.e. intermenstrual and post-coital bleeding. Therefore it is essential to perform a speculum examination. Alongside a speculum examination, she should have testing for sexually transmitted infection and if her cervix appears normal, a routine cervical smear can be obtained.",
"id": "49932",
"label": "a",
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"explanation": "Whilst endometrial pathology can cause intermenstrual and post-coital bleeding, and this may be seen on an ultrasound scan, the first-line investigation in primary care is a speculum examination to visualise the cervix.",
"id": "49936",
"label": "e",
"name": "Transvaginal ultrasound scan",
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"explanation": "A digital rectal examination is not necessary in the absence of any rectal symptoms.",
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"__typename": "QuestionChoice",
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"explanation": "Vaccination for human papillomavirus should be given to unvaccinated individuals in certain groups e.g. men who have sex with men.",
"id": "49933",
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"name": "Vaccination for human papillomavirus",
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"explanation": "# Summary\n \n \nCervical cancer is the 3rd most common cancer worldwide and the 4th largest cause of cancer death. It is primarily caused by persistent human papillomavirus (HPV) infection and is commonly squamous cell carcinoma. The key clinical features include vaginal discharge, bleeding, discomfort, and changes in urinary or bowel habits. Investigations involve an urgent colposcopy and CT scans for staging. Management strategies depend on the stage of cancer and the patient's fertility desires, ranging from conisation and radical trachelectomy for early-stage cancers to radiotherapy and chemotherapy for more advanced cases.\n \n \n# Definition\n \n \nCervical cancer is a type of cancer that occurs in the cells of the cervix (the lower part of the uterus that connects to the vagina). The majority of cervical cancers are squamous cell carcinomas. \n \n \n# Epidemiology\n \n \nCervical cancer is the 4th most common cancer in women worldwide. In the UK, it is the 14th most common cancer amongst women.\nOver 90% of cervical cancer deaths and similarly higher prevalence is seen in low- and middle-income countries (LMICs), highlighting inequity in access to HPV-prevention (vaccination), cervical cancer screening and treatment options between LMICs and high-income countries. \n \n \n# Aetiology\n \nCervical cancer is strongly associated with persistent human papilloma virus (HPV) infection. The majority of cases are squamous cell carcinoma.\n \nRisk factors for cervical cancer include: \n \n - HPV 16 and 18 infection (accounts for 70% of cases)\n - Multiple sexual partners\n - Smoking\n - Immunosuppression (e.g. HIV or organ transplants)\n \n \n# Signs and symptoms\n \n \nMost cases of cervical cancer are picked up asymptomatically at cervical screening. Other clinical features include:\n \n - Vaginal discharge\n - Bleeding (e.g. postcoital or with micturition or defaecation)\n - Vaginal discomfort\n - Urinary or bowel habit change\n - Suprapubic pain\n - Abnormal white/red patches on the cervix.\n - Pelvic bulkiness on PV examination\n - Mass felt on PR examination\n \n \n# Differential diagnosis\n \n \nThe differential diagnosis for cervical cancer includes other causes of abnormal vaginal bleeding or discharge such as vaginitis, cervicitis, endometrial cancer, and cervical polyps. Key signs and symptoms of these differentials include:\n \n \n1. **Vaginitis:** itching, burning, pain, and abnormal discharge\n2. **Cervicitis:** abnormal discharge, pelvic pain, and postcoital bleeding\n3. **Endometrial cancer:** abnormal vaginal bleeding, pelvic pain, and unintentional weight loss\n4. **Cervical polyps:** abnormal vaginal bleeding, discharge, and pain during intercourse\n \n \n# Investigations\n\n**Bedside:**\n\n* Speculum examination (with sample for cytology and HPV testing) \n\n**Bloods:**\n\n* FBC (anaemia)\n* LFTs (liver involvement)\n* U&Es (renal involvement) \n\n**Imaging:**\n\n* CT chest/abdomen/pelvis (for staging)\n\n**Invasive:** \n\n* Colposcopy (urgent) and cervical biopsy \n \n\n# Management\n \n \nThe treatment for cervical cancer depends on the stage of the cancer, and also whether the woman wants to retain fertility.\n \n \n - For very small cancers in stage IA treatment options include conisation with free margins if aiming to spare fertility. Conisation is done using a scalpel (cold-knife conisation), laser, or electrosurgical loop, and is usually performed as an outpatient.\n - Radical trachelectomy can be done for slightly more advanced, yet still early-stage cancers when the aim is to spare fertility. This involves removal of the cervix, the upper vagina and pelvic lymph nodes.\n - Where maintaining fertility is not an aim a laparoscopic hysterectomy and lymphadenectomy is offered for women for early-stage cancer.\n - For invasive, infiltrating and early metastatic cancer a radical (Wertheim's) hysterectomy can be performed which involves removal of the uterus, primary tumour, pelvic lymph nodes, and sometimes the upper third of the vagina and uterovesical and uterosacral ligaments.\n - If the cancer has spread outside the cervix and uterus, then surgical management is often unlikely to be curative. These cancers are treated with radiotherapy and/or chemotherapy.\n \n# Complications \n\n* Surgical complications: bladder dysfunction, leg oedema (due to lymphadenectomy), preterm birth \n* Radiation complications: vaginal stenosis, vaginal atrophy, bladder dysfunction, urethral strictures\n\n# Prognosis \n\nCervical cancer is preventable through screening. Mortality has decreased significantly as a result of improved treatment and screening programmes. Overall 5-year survival is 67%. However, this varies based on stage of disease at diagnosis:\n\n* Stage I: >90%\n* Stage II-III: 50-70%\n* Stage IV: <20%\n\n# Cervical Screening\n \n \n - For all women and people with a cervix between the age of 25-64 years. \n - Cervical sample is taken and tested for high-risk HPV viruses. \n - From 24 to 49 women are called every three years, and afterwards every five years.\n- The idea behind the screening process is to identify dyskaryotic cells which are pre-cancerous allowing management before invasive cancer can develop.\n \n \n## Outcomes in screening\n \n \nOutcomes from screening can be as follows:\n \n \n - Anybody with a negative HPV test is returned to routine recall.\n - Anybody with a positive HPV test has cytological testing. \n - Patients who are HPV positive but have negative cytology results should have a repeat HPV test in 12 months and again at 24 months if still positive. If they remain positive at 24 months they should be referred to colposcopy.\n - In some cases the sample may be inadequate, in which case the smear should be repeated. If it still not adequate for the next two samples, then the woman should be referred for colposcopy.\n \n \n# HPV Vaccination\n \n \n - Girls and boys aged 12 to 13 years are offered the HPV vaccine as part of the NHS vaccination programme\n - The vaccine helps protect against cancers caused by HPV, including cervical cancer, some mouth and throat cancers and some cancers of the anal and genital areas. It also helps protect against genital warts\n - Gardasil is the vaccination used and protects against HPV types 6, 11, 16, 18, 31, 33, 45, 52 and 58\n \n# NICE Guidelines\n \n [Click here for NICE CKS on Cervical cancer](https://cks.nice.org.uk/topics/cervical-cancer-hpv/)\n \n \n [Click here for NICE CKS on Cervical cancer screening](https://cks.nice.org.uk/topics/cervical-screening/)\n \n \n# References\n \n[Cancer UK](https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/cervical-cancer) \n[NHS Page](https://www.nhs.uk/conditions/cervical-cancer/)",
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"question": "A 43-year-old female presents to her general practitioner with a 6-month history of bleeding between periods and post-coital bleeding. She is very nervous and has never attended her general practice for anything before. She is aware she should have been attending cervical smears, but was too scared. She has a regular male partner and always uses condoms for intercourse.\n\nWhich of the following is essential to perform in this patient?",
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"explanation": "Signet ring cells seen within the ovary are most commonly metastasis from gastrointestinal cancer.",
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"explanation": "Signet ring cells seen within the ovary are most commonly metastasis from gastrointestinal cancer.",
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"explanation": "# Summary\n \n \nOvarian cancer is a major cause of gynaecological cancer-related mortality in the UK, due primarily to the non-specific nature of symptoms in early stages. The most common type is epithelial ovarian tumours, though germ cell tumours and sex cord stromal tumours also occur. Risk factors include older age, smoking, numerous ovulations, obesity, HRT, and BRCA genes. Parity, breastfeeding, early menopause, and COCP use can be protective. Symptoms typically include abdominal discomfort, bloating, early satiety, and urinary changes, with ascites signifying advanced disease. Differentials include IBS, fibroids, ovarian cysts, and other cancers. Initial investigations include CA-125 and pelvic and abdominal ultrasound. Management depends on disease stage and patient fitness, but can include surgery and chemotherapy.\n \n \n# Definition\n \n \nOvarian cancer is a malignancy originating from various cell types found within the ovary. \n \n \n# Aetiology\n \n \nThe causes of ovarian cancer can be divided into risk factors and protective factors. \n \n \nRisk factors include:\n \n \n - Advanced age\n - Smoking\n - Increased number of ovulations (early menarche, late menopause)\n - Obesity\n - Hormone replacement therapy (HRT)\n - Genetic predisposition (BRCA 1 and 2 genes)\n\nProtective factors include:\n\n - Childbearing (parity)\n - Breastfeeding\n - Early menopause\n - Use of combined oral contraceptive pill (COCP)\n\n\n# Classification\n \n \nThe types of ovarian cancers can be classified according to the cell type from which the cancer originates. The types include:\n \n \n**Epithelial ovarian tumours**\n \n \n - Originate from the epithelium which lines the fimbria of the fallopian tubes or the ovaries\n - Epithelial tumours are partially cystic, and the cysts can contain fluid. \n - The initial metastatic spread typically involves the peritoneal cavity, with seeding particularly affecting the bladder, paracolic gutters and the diaphragm. \n - Around 90% of ovarian cancers are epithelial ovarian tumours.\n \n \n**Germ cell tumours features**\n \n \n - Originate from the germ cells in the embryonic gonad. \n - These tumours typically grow rapidly and spread predominantly via the lymphatic route\n - Germ cell tumours most commonly arise in young women, which is atypical for most cases of ovarian cancer. \n - Tumour markers include alpha-fetoprotein and sometimes beta human chorionic gonadotrophin (B-HCG).\n \n \n**Sex cord stromal tumours**\n \n \n - Originate from connective tissue. \n - They are rare, making up less than 5% of all ovarian tumours. They are malignant tumours, but are much less aggressive than epithelial tumours. \n - Additionally, ovarian cancer can be secondary to another cancer elsewhere, which has metastasised to the ovary. A Krukenberg tumour refers to a \"signet ring\" sub-type of stromal tumour, typically gastrointestinal in origin, which has metastasised to the ovary. \n \n \n \n# Signs and Symptoms\n \n \nThe clinical features of ovarian cancer typically present late in the disease progression and include:\n \n \n - Abdominal discomfort\n - Bloating\n - Early satiety\n - Urinary frequency or change in bowel habits\n \n \nIn later stages, the disease may cause:\n \n \n - Ascites (due to vascular growth factors increasing vessel permeability)\n - Pelvic, back and abdominal pain\n - Palpable abdominal or pelvic mass\n \n \n# Differential diagnosis\n \n \nDifferential diagnoses for ovarian cancer include:\n \n \n- Gastrointestinal conditions (e.g., irritable bowel syndrome): characterised by abdominal pain, bloating, and changes in bowel habits. \n2. Fibroids: may cause heavy menstrual bleeding, pelvic pressure or pain, frequent urination, and constipation. \n3. Ovarian cysts: can cause pelvic pain, fullness or heaviness in the abdomen, and bloating.\n4. Other cancers (e.g., bladder, endometrial): may present with symptoms such as abnormal bleeding, pelvic pain, and urinary symptoms.\n \n \n# Investigations\n \n \nInvestigations for suspected ovarian cancer include:\n \n**Bedside:**\n \n * Abdominal examination: tenderness, abdominal mass\n * Bimanual examination: adnexal mass\n\n \n**Bloods:**\n \n* CA-125 levels\n * Measure CA125 in women (especially those aged over 50) with frequent or persistent symptoms of ovarian cancer (i.e. 12 or more times per month)\n * Consider this measurement in women with non-specific symptoms of malignancy, such as unexplained weight loss, fatigue or changes in bowel habit \n* AFP and beta-hCG levels (for younger women who may have germ cell cancers)\n\n \n**Imaging:**\n\n* Pelvic and abdominal ultrasound scan\n * May be helpful to rule out or identify malignancy where CA125 is 35 IU/ml or higher \n* CT chest/abdomen/pelvis (for staging)\n\n**Invasive:**\n \nFurther investigations may include:\n \n* Tissue biopsy \n \n \n**Risk of Malignancy Index** \n\nThese results can be used to calculate the Risk of Malignancy Index (RMI), which stratifies the likelihood of cancer: \n \n\n**RMI = U x M x CA125**\n\n\n* U = ultrasound result (between 0-3)\n* M = menopausal status (1 = premenopausal, 3 = postmenopausal) \n* Serum CA-125 is measured in IU/ml\n\n- NICE advise referring all women with an RMI I score of 250 or greater to a specialist multidisciplinary team\n\n\n**2 Week Wait (2WW) Referral Criteria:**\n\n* Physical examination showing ascites and/or a pelvic abdominal mass (that is not due to uterine fibroids) \n* Ultrasound findings suggestive of ovarian malignancy\n\n\n\n# Staging\n \n \nStage I (limited to the ovaries):\n \n - Stage IA: limited to one ovary, the capsule is intact\n - Stage IB: limited to both ovaries, capsules intact.\n - Stage IC: tumour limited to one or both ovaries with any of the following: capsule ruptured, tumour on ovarian surface, malignant cells in ascites or peritoneal washings.\n \n \nStage II (involving one or both ovaries with pelvic extension and/or implants):\n \n - Stage IIA: extension and/or implants on the uterus and/or Fallopian tubes. No malignant cells in ascites or peritoneal washings\n - Stage IIB: extension to and/or implants on other pelvic tissues. No malignant cells in ascites or peritoneal washings\n - Stage IIC: pelvic extension and/or implants (Stage IIA or Stage IIB) with malignant cells in ascites or peritoneal washings.\n \n \nStage III (involving one or both ovaries with microscopically confirmed peritoneal implants outside the pelvis):\n \n - Stage IIIA: microscopic peritoneal metastasis beyond pelvis (no macroscopic tumour)\n - Stage IIIB: macroscopic peritoneal metastasis beyond pelvis <2 cm\n - Stage IIIC: peritoneal metastasis beyond pelvis >2 cm and/or regional lymph node metastasis.\n \n \nStage IV: tumour involving one or both ovaries with distant metastasis.\n \n \n\n# Management\n \n \nManagement depends on the stage of the cancer and the patient's fitness for treatment.\n\nSurgery: \n\n* If early disease surgery can include removal of the uterus, ovaries, fallopian tubes and omentectomy\n* In advanced disease further debulking surgery can be performed.\n\n \nChemotherapy:\n\n* Adjuvant chemotherapy in combination with surgery\n* Intraperitoneal chemotherapy may be performed at the time of operation\n\nBiological therapies are being trialled \n \n \n# Complications\n\n* Bowel obstruction/constipation\n* Ascites\n* Chemotherapy complications: alopecia, intraperitoneal toxicity, neutropenia, peripheral neuropathy\n* Immunotherapy complications: bowel perforation or fistula, hypertension, poor wound healing \n* Surgical complications: thromboembolism, infection, haemorrhage, death\n* Death\n\n# Prognosis \n\n5-year survival:\n\n* 75% for women younger than 50\n* > 35% for women over 65\n* > 90% for women with localised disease on diagnosis\n* 30% for women with distant disease on diagnosis \n\n# NICE Guidelines\n \n \n [Click here to read NICE CKS on Ovarian cancer](https://cks.nice.org.uk/topics/ovarian-cancer/)\n \n \n# References \n\n[Patient Info](https://patient.info/doctor/ovarian-cancer-pro)",
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"question": "A 53-year-old woman presents to accident and emergency with acute onset right iliac fossa pain. She is taken for an emergency laparoscopy which reveals acute ovarian torsion and a right ovarian mass. She undergoes a right oophorectomy and makes a good recovery postoperatively. Pathology of the ovary reveals a mass containing an invasive proliferation of mucin-producing signet-ring cells.\n\nWhich of the following cancers should now be screened for?",
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"explanation": "Women with stress urinary incontinence should be referred for a trial of at least three months of supervised pelvic floor muscle training (PFMT).",
"id": "49942",
"label": "a",
"name": "Refer the woman for pelvic floor muscle training (PFMT)",
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"explanation": "Duloxetine can be used as a second-line option for women with stress urinary incontinence where conservative management options have failed.",
"id": "49945",
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"name": "Trial of duloxetine",
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"explanation": "Where a woman does not have symptoms of urinary tract infection (UTI) and urinalysis is negative for either leucocytes or nitrites, a urine samples should not be sent for culture as she is unlikely to have a UTI.",
"id": "49944",
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"explanation": "Antibiotics should not be prescribed for leukocytes on urinalysis in the absence of symptoms of urinary tract infection (e.g. dysuria, frequency or urgency).",
"id": "49943",
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"name": "Prescribe a three-day course of oral trimethoprim",
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"explanation": "Referral for surgical management may be considered where conservative options have failed.",
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"comment": "but the urinalysis came back positive for leucocytes?",
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"comment": "Leukocytes in the absence of nitrates do not usually indicate UTI\n",
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"comment": "Got the q right but is a pessary not more appropriate, pelvic training isn't going to necessarily reverse a prolapse is it even if there is an element of stress incontinence?",
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"comment": "you start with conservative measures first for prolapse so would try pelvic floor exercises, then can go medical (with pessaries), then surgical ",
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"explanation": "# Summary\n \n \nVaginal prolapse refers to the displacement of pelvic structures from their normal position towards or through the vaginal opening. Key signs and symptoms include pelvic discomfort, a sensation of pressure or 'heaviness', and visible protrusion of tissue from the vagina. Investigations primarily involve pelvic examination and potentially imaging studies. Management strategies range from conservative measures such as pelvic floor exercises, to pessary use, and surgical intervention.\n \n \n# Definition\n \n \nVaginal prolapse is characterised by the descent of one or more pelvic structures from their normal anatomical position, moving towards or through the vaginal opening. \n \n \n# Epidemiology\n \n \nVaginal prolapse is a common condition, particularly in postmenopausal women and those who have undergone childbirth. The prevalence increases with age and parity, with an estimated 50% of women having some degree of prolapse, though only a fraction of these will experience symptoms.\n \n \n# Aetiology\n \n \nRisk factors for developing vaginal prolapse include:\n \n \n - Vaginal childbirth, particularly with traumatic or complicated deliveries\n - Increasing age\n - Menopause\n - Hysterectomy\n - Obesity\n - Chronic cough\n - Heavy lifting\n - Connective tissue disorders\n \n\n# Classification\n \n \nPelvic organ prolapse can involve different structures, defined according to the organ which has prolapsed into the vagina and their position:\n \n \n**Anterior vaginal wall:**\n \n - Cystocele: bladder (may lead to stress incontinence)\n - Urethrocele: urethra\n - Cystourethrocele: both bladder and urethra\n \n \n**Posterior vaginal wall:**\n\n - Enterocele: small intestine\n - Rectocele: rectum\n \n \n**Apical vaginal wall:**\n\n - Uterine prolapse: uterus\n - Vaginal vault prolapse: roof of the vagina (common after hysterectomy)\n\n\n\n# Signs and Symptoms\n \nSymptoms of genital prolapse can vary depending on the type and severity but may include:\n \n - Pelvic discomfort or a sensation of 'heaviness'\n - Visible protrusion of tissue from the vagina\n - Urinary symptoms such as incontinence, recurrent urinary tract infections or difficulties voiding\n - Defecatory symptoms, including constipation or incomplete bowel emptying\n - Sexual dysfunction, including dyspareunia \n \n\n# Differential Diagnosis\n \n \nDifferential diagnoses for genital prolapse may include:\n \n \n - **Gynaecological malignancy:** associated with abnormal vaginal bleeding, weight loss, and pelvic pain\n - **Cervicitis:** characterised by vaginal discharge, bleeding, and pelvic pain\n - **Urethral diverticulum:** presents with dysuria, recurrent UTIs, and a palpable anterior vaginal mass\n \n \n# Investigations\n \n \n**Bedside:**\n\n- Detailed pelvic examination, including speculum and bimanual exam. A Sim's speculum is preferred for examination of vaginal prolapse. \n\nNo **blood tests** are indicated for vaginal prolapse. \n\n**Imaging:**\n\n- MRI may be helpful for surgical planning.\n\n**Invasive tests:**\n\n- Urodynamic studies may be indicated if there are co-existing urinary symptoms.\n\n\n \n# Management\n \n \nManagement strategies for genital prolapse include:\n\n**Conservative:** \n \n - Lifestyle modifications, including weight loss, smoking cessation, avoiding heavy lifting\n - Pelvic floor exercises \n - Pessary use, which can provide symptomatic relief and may be particularly suitable for women who are not surgical candidates\n\n**Surgical:** \n\n - Surgical repair, which may involve native tissue repairs or the use of mesh. Surgical approach can be vaginal, abdominal, or laparoscopic/robotic.\n \n \nSurgeries for **uterine prolapse** include: \n \n - Vaginal sacrospinous hysteropexy (with sutures)\n - Manchester repair\n - Vaginal hysterectomy \n\nSurgeries for **vault prolapse** include: \n \n - Sacrocolpopexy with mesh\n - Vaginal sacrospinous fixation with sutures \n\nSurgeries for **anterior prolapse** include: \n \n - Anterior colporrhaphy\n\nSurgeries for **posterior prolapse** include: \n \n - Posterior colporrhaphy\n\n\n# Complications\n\n- Complications of surgery: Urinary incontinence (after anterior repair), faecal incontinence, dyspareunia (after posterior repair), recurrence of prolapse. \n- Vaginal erosion: Untreated prolapsed uterus may lead to ulceration and subsequent erosion of the vaginal wall. \n\n\n# NICE Guidelines\n\n[Click here for NICE guidance on pelvic organ prolapse](https://www.nice.org.uk/guidance/ng123)\n\n# References\n\n[BMJ Best Practice](https://bestpractice.bmj.com/topics/en-gb/659/)\n\n[RCOG Guidance](https://www.rcog.org.uk/for-the-public/browse-our-patient-information/pelvic-organ-prolapse/)",
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"question": "A 55-year-old woman attends her general practitioner with a 1-year history of a lump in her vagina. She also complains of leaking urine when she coughs or sneezes, which has been ongoing for the past eight months. On examination, her abdomen is soft and non-tender. On digital vaginal examination, a small cystocele is felt at the anterior vaginal wall. She can contract her pelvic floor muscles voluntarily. She has no dysuria or increased urinary frequency. Urinalysis is positive for leucocytes but otherwise negative.\n\nWhat is the most appropriate next step?",
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"explanation": "Foetal MRI is indicated in very specific cases where ultrasound findings are equivocal e.g. spina bifida, suspicious masses. In this case the ultrasound findings are common to congenital CMV infection, so testing for this is the next step.",
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"explanation": "These are ultrasound findings common to congenital cytomegalovirus (CMV) infection, which can be tested for using amniocentesis.",
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"explanation": "The combined test is performed between weeks 11 and 13 of pregnancy and aims to give a risk of Down syndrome. The pregnancy is already 20 weeks, and there is no a suspicion of Down syndrome here.",
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"explanation": "Summary\n\nCytomegalovirus (CMV) is a member of the herpesvirus family, with a majority of the population having been infected at some point. Pregnant women infected for the first time with CMV risk transmission to the foetus, potentially causing congenital cytomegalovirus disease. Key signs and symptoms at birth include low birth weight, jaundice, microcephaly, seizures, pneumonia, and a petechial rash, though some infants may show no symptoms. Long-term consequences can include hearing loss, visual impairment, and learning disability. Antenatal diagnosis can be achieved through ultrasound detection of foetal abnormalities and amniocentesis confirmation of CMV infection, while postnatal diagnosis generally involves testing an infant's saliva, urine, or blood.\n\n\n# Definition\n\n\n\nCytomegalovirus (CMV) is a common virus that belongs to the herpesvirus family. The majority of the population will have been infected by CMV at some point in their lives, often without showing any symptoms. Pregnant women who contract the virus for the first time during pregnancy pose a risk of transmission to the fetus, potentially leading to the development of congenital cytomegalovirus disease.\n\n\n# Epidemiology\n\n\n\nCMV is widespread, with the majority of adults having been infected by the virus at some point in their lives. Primary infection during pregnancy, however, can result in congenital infection of the foetus and potential development of congenital cytomegalovirus disease.\n\n\n# Aetiology\n\n\n\nCMV is transmitted through close contact with a person excreting the virus in their saliva, urine, or other bodily fluids. Primary infection during pregnancy can result in transmission of the virus to the foetus, potentially leading to congenital cytomegalovirus disease.\n\n\n# Signs and Symptoms\n\n\n\nInfants born with congenital cytomegalovirus disease may exhibit the following features:\n\n- Low birth weight\n- Jaundice\n- Microcephaly\n- Seizures\n- Pneumonia\n- Petechial rash\n\nSome infants may show no symptoms at birth, while others may develop long-term neurological consequences such as hearing loss, visual impairment, and learning disability.\n\n\n# Differential Diagnosis\n\n\n\nThe differential diagnosis for CMV should consider other infectious diseases that can lead to similar symptoms in infants, such as:\n\n- Toxoplasmosis: Can also cause low birth weight, microcephaly, and jaundice, as well as eye infections and brain damage.\n- Rubella: Can lead to low birth weight, microcephaly, and jaundice, as well as heart defects, cataracts, and hearing loss.\n- Herpes simplex virus: Can cause seizures, jaundice, and pneumonia, as well as skin lesions and eye infections.\n\n# Investigations\n\n\nAntenatally, foetal abnormalities associated with CMV can be detected on ultrasound, and infection can be confirmed by amniocentesis. Routine screening for CMV antibodies in the mother is not currently recommended.\n\nPostnatally, CMV infection is typically diagnosed by testing an affected infant's saliva, urine, or blood for the presence of the virus.\n\n# Management\n\n\nManagement of congenital CMV infection primarily involves supportive care and monitoring for long-term neurological consequences. Antiviral therapy may be used in certain cases to prevent or treat severe disease. Further research is needed to establish the most effective treatment strategies.\n\n# References\n\n\n\n[Click here for RCOG guidelines on Congenital Cytomegalovirus Infection ](https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.14836)",
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"question": "A 30-year-old woman attends for her 20-week foetal anomaly scan. The scan notes microcephaly with periventricular calcification, hyperechogenic bowel, splenomegaly and hepatomegaly.\n\nWhich of the following is the most appropriate next step in management?",
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"explanation": "Whilst uterine rupture is a cause of foetal distress, this usually presents with sudden onset and continuous abdominal pain. There is often a history of previous caesarean section.",
"id": "49955",
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"explanation": "Whilst umbilical cord prolapse is a cause of foetal distress, this occurs after the membranes have ruptured. This woman reports no history of vaginal loss on admission.",
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"explanation": "Whilst placental abruption is a cause of foetal distress, this condition usually presents with sudden and severe abdominal pain, accompanied by a \"woody\" hard uterus and foetal distress.",
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"explanation": "Placenta praevia occurs where part of the placenta overlies the cervical os. This can lead to brisk antepartum haemorrhage before or during labour. This is less likely in this case as there was no visible antepartum haemorrhage, and the description of the placenta fits a type 1 vasa praevia.",
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"comment": "how can it be vasa praevia if there was no bleeding?\n",
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"comment": "vasa praevia is when the foetal blood vessels cross the cervical os. This will lead to APH when they burst but they don't always, Bursting of the blood vessels usually occurs with rupture of the membranes.\n If the delivery was attempted vaginally, there 100% would have been bleeding. But the baby was born by caesarian which probably did not give the blood vessels the chance to rupture",
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"explanation": "# Summary\n\n\nVasa praevia is a potentially fatal obstetric condition where foetal vessels run near or across the internal cervical os, placing them at risk of rupture during membrane rupture. The classic triad of symptoms includes painless vaginal bleeding, rupture of membranes, and foetal bradycardia or death. Diagnosis is typically made antenatally via transabdominal or transvaginal ultrasonography. Management involves an elective caesarean section before the rupture of membranes, usually around 35-36 weeks of gestation. Emergency caesarean section is required if the mother goes into labour or her membranes rupture.\n\n\n# Definition\n\n\nVasa praevia is a condition seen in obstetrics where the foetal vessels, unprotected by the umbilical cord or placental tissue, run dangerously close to or across the internal cervical os. These vessels are prone to rupture during the rupture of membranes, which can result in foetal haemorrhage and potentially foetal death.\n\n\n# Aetiology\n\n\nThe aetiology of vasa praevia remains unclear, but it has been associated with multiple gestations, in vitro fertilization, and velamentous cord insertion.\n\n\n# Signs and Symptoms\n\n\nThe classic triad of symptoms in vasa praevia includes:\n\n- Painless vaginal bleeding\n- Rupture of membranes\n- Foetal bradycardia (or resulting foetal death)\n\n\n# Differential Diagnosis\n\n\nThe differential diagnosis for vasa praevia includes placenta praevia and abruptio placentae. \n\n- Placenta praevia: Characterized by painless vaginal bleeding, but without the accompanying foetal bradycardia or death seen in vasa praevia. \n- Abruptio placentae: Typically presents with painful vaginal bleeding, abdominal pain, and uterine tenderness and rigidity. Foetal distress is common.\n\n# Investigations\n\nDiagnosis of vasa praevia is usually made with transabdominal or transvaginal ultrasonography. Most cases can now be diagnosed antenatally, a significant improvement from prior times when the condition was usually only diagnosed post-delivery following a foetal death due to haemorrhage.\n\n# Management\n\nThe primary management strategy for vasa praevia is an elective caesarean section prior to the rupture of membranes, typically arranged for 35-36 weeks gestation. However, if the mother goes into labour or her membranes rupture, an emergency caesarean section should be carried out immediately to prevent foetal death.\n\n# References\n\n\n[Click here for the Green Top Guidelines on vasa praevia](https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg27b/)",
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"question": "A 25-year-old parous woman attends her local maternity unit in established labour at 39+7 weeks. She had a spontaneous vaginal delivery 2 years prior and has had no problems during either pregnancy. She is experiencing regular, painful contractions. She has not experienced any vaginal loss.\n\nA cardiotocograph is performed upon admission, which reveals a foetal heart rate of 110 beats per minute, with deep decelerations with contractions that are slow to recover.\n\nThe woman is transferred to theatre for an emergency caesarean section, and a live male infant is delivered.\n\nAs the midwife examines the placenta to check the membranes are complete, she describes the umbilical cord as \"velamentous\".\n\nWhat is the most likely cause of the intrapartum foetal distress?",
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