QBANK Flashcards
(30 cards)
which of the following is an indication for immediate empirical treatment with n acetylcysteine in paracetamol poisoning ?
A. patient presenting six hours or more after ingestion
B. you are working in rural australia where serum paracetamol level would be available within 24 hours
C. you are certain about timing of the dose
D. patient is fully conscious and can give you detailed history
E. age less than 16 years
Answer b
N-Acetylcysteine Should be started Immediately or empirically In the following situation
-patient presents 8 hours or more after ingestion
-when serum paracetamol level is not available within an 8 hour time window
-when there is uncertainty as to the timing of the overdose
-When the patient is unconscious or has a suspected overdose
So while working in remote areas in australia some blood tests are reported within 24 hours so any patient with suspected or proven paracetamol poisoning should be treated with n-acetylcysteine empirically. period age less than 16 does not change the management. Age less than six years does follow different protocol in paracetamol poisoning .
A 57 year old male presents with nausea and vomiting for the last 12 hours . he is found to have sub acute small bowel obstruction and would require surgery is conservative measures fail . he has a background history of percutaneous coronary intervention eight weeks ago when drug-eluting stents were inserted period he is currently on aspirin clopidogrel simvastatin, ramipril and metoprolol what will you do next?
A. Withhold clopidogrel and continue aspirin B. continue both aspirin and clopidogrel C. withhold simvastatin D. give therapeutic heparin E. defer surgery for six months
answer a
any elective surgery requiring cessation of antiplatelet therapy should be postponed for 6 weeks after insertion of bare-metal stents and twelve months after insertion of the drug-eluting stent. in patients requiring urgent surgery associated with high risk of bleeding within recommended time frames, aspirin should be continued and clopidogrel should be discontinued for 5 to 7 days before surgery. as this patient may require surgery so it is recommended to withhold clopidogrel and continue aspirin. You should be coupled with bridging anticoagulation like heparin ( prophylaxis dose , not the therapeutic dose) if the patient is high risk for coronary artery disease .
A 38 year old female with history of smoking comes for contraception advice which of the following is an appropriate option for her? A. Progesterone only pills B. combined oral contraceptive pills C. male condoms D. Diaphragm E. cervical cap
Answer a
Smoking in women aged more than 35 is absolute contraindication to combined oral contraceptive pills. Best option in this patient is progesterone only pills. POP is also an acceptable alternative method of contraception during breastfeeding. Failure rate per year is 3 to 10% compared with 2 to 6% for the combined pill. All the options are associated with high pregnancy rates
What is the most appropriate test To diagnose hemochromatosis?
Liver biopsy
serum ferritin level and transferrin saturation
Hfe genotype
ultrasound of liver and testes
full blood count
Answer b
The most appropriate test to investigate symptomatic or asymptomatic cases of hemochromatosis is to carry on iron studies. Fasting transferrin saturation more than 60% for men or more than 50% for women has been accurate in detecting over 90% of patients with homozygous hereditary hemochromatosis who have clinical symptoms. If iron studies are abnormal, then hfe mutation analysis should be performed. Since the advent of hfe mutation Analysis, liver biopsy has become less important as a clinical tool in the diagnosis Of hemochromatosis. Liver biopsy should be considered only for the purpose of determining the presence or absence of advanced fibrosis or cirrhosis , which does not have prognostic value . ultrasound of liver and testes is not an appropriate test to diagnose hemochromatosis . the full blood count may show raised hematocrit and platelet count, However it is not diagnostic for hemochromatosis.
- A 38 year old woman presented to your clinic for contraception advice . she has a history of epilepsy and has been prescribed carbamazepine by her neurologist period she does not smoke period she is on progesterone only pills for her contraception . what is the best advice for her ?
Stop progesterone only pill
Cease progesterone only pill and start taking combined oral contraceptive pills
Stop carbamazepine
continue with carbamazepine and progesterone only pills as there is no interaction
advise her to get mri done in 12 months
answer b
anti epileptic drugs such as carbon has been or hepatic enzyme inducers
concomitant use of enzyme inducing drugs is an absolute contraindication 2 using the progesterone only pill and it must be discontinued while the patient is on carbamazepine the patient is a non smoker so she would benefit from being on high estrogen containing combined oral contraceptive pills .
6. A young woman presented for your advice on her choice of oral contraceptive pills . she does not want to use any other method past medical history includes hypertension and diet managed type 2 diabetes mellitus. what will you prescribe her ? Biphasic oral contraceptive pills progesterone only pills triphasic oral contraceptive pills estrogen only pills no contraception possible
Answer B
The following are the conditions in which progesterone only methods are suitable: Hypertension superficial thrombophlebitis history of thromboembolism Biliary tract disease Thyroid disease Epilepsy Diabetes without vascular disease
progesterone only methods are contraindicated In suspected pregnancy, breast cancer, and Undiagnosed bleeding. Relative contraindications are active viral hepatitis and severe chronic liver disease.
A 60 year old man presented with left homonymous hemianopia. His family is concerned as he only saves on the right side of his face and thinks he belongs to only the right side of his body which of the following artery is involved in this stroke ?
A. posterior cerebral artery right middle cerebral artery C. left posterior inferior cerebellar artery D. Left middle cerebral artery E. Basilar artery
Answer B
middle cerebral artery lesions presents with contralateral hemiparesis which is worse in the arm and face then in the legs . other symptoms include dysarthria, contralateral homonymous Hemianopia, aphasia and sensory neglect if non dominant hemisphere is affected. this patient has right mca lesion which is causing left sided neglect and left sided contralateral homonymous hemianopia.
Posterior cerebral artery lesion with contralateral homonymous hemianopia . However other symptoms include unilateral cortical blindness , memory loss and unilateral third cranial nerve palsy . hemiballismus is also a feature of pca lesion .
Posterior inferior cerebellar artery syndrome Pica presents with lateral medullary syndrome . Symptoms include Dysphagia ataxia vertigo, diplopia and truncal ataxia. Basilar artery stroke can cause Vertibrobasilar insufficiency
A 48 year old lady was found to have low serum sodium on day 3 after cranial surgery. Her laboratory investigations are given below.
serum sodium 117 mmol/l
plasma osmolality 25 mosm/kg
urine osmolarity 525 mosm/kg
what is the most likely diagnosis?
A. Diabetes insipidus Siadh C. water intoxication D. Dehydration E. renal failure
Answer B
Siadh is defined as less than maximally dilute urine in the presence of plasma hypo-osmolality (hyponatremia) without volume depletion or overload.
findings in siadh
a low serum osmolality
an inappropriately elevated urine osmolality (above 100mosmol/kg and usually above 300)
urine sodium concentration usually above 40meq/L
diabetes insipidus is characterized by polydipsia due to decreased formation of adh. central diabetes insipidus or resistance to adh nephrogenic by urine osmolality is usually below 250
a low plasma sodium concentration less than 137 with a low urine osmolality less than the plasma osmolality is usually indicative of water overload due to primary polydipsia
a normal a high normal plasma sodium concentration greater than 14222 water loss points towards the i particularly if the urine osmolality is less than the plasma osmolality\
dehydration increases put serum as well as urine osmolality
Which of the following antibiotics can produce a clinical disturbance similar to botulism ?
answer a
gentamicin prevents the release of ach from nerve endings like botulism toxin and can cause muscle paralysis in high-risk patients . symptoms subside rapidly as the responsible drug is eliminated. it is contraindicated in patients with pre-existing disturbance of neuromuscular transmission . is it is best avoided in myasthenia gravis
A 30 year old male comes to your clinic after a knee injury while playing football. He reports severe pain, swelling and clicking of the knee. He is unable to bend the knee and it locks in partial flexion. On examination there is a joint effusion, medial joint line tenderness , the joint is held in a flexed position. What is the most likely diagnosis?
A. Anterior cruciate ligament injury Medial meniscus tear C. collateral ligaments injury D. medial collateral ligament and medial meniscus injury E. none of the above
answer b
this patient has developed clinical features of acute meniscal tear. the acute meniscal tear happens from compression with rotational force through the knee. the medial meniscal is more commonly injured than lateral meniscus due to its attached with deep fibers medial collateral ligament injury.
Which one of the following medications can significantly increase the HDL cholesterol?
a. Gemfibrozil
b. Simvastatin
c. Cholestyramine
d. Colestipol
e. Pravastatin
The correct answer is a.
Drugs causing a significant increase in HDL cholesterol include gemfibrozil and nicotinic acid.
Drugs causing a minor increase in HDL cholesterol include simvastatin, pravastatin, cholestyramine and colestipol
A 57-year-old male presents with ongoing vomiting for last 2 days associated with absolute constipation.On examination, there is no abdominal distension. Gastrografin studies confirmed the presence of small bowel obstruction,
Which of the following is the most common cause of small bowel obstruction
a. Postoperative adhesions
b. Bowel cancer
c. Crohn’s disease
d. Hernias
e. Hypokalemia
The correct answer is a.
Postoperative adhesions remain the most common cause of small bowel obstruction.
The risk of developing an obstruction after surgery from postoperative adhesions is 9% within the first year after abdominal surgery, 19% by 4 years and 35% by 10 years.
Malignant tumours, (bowel cancer,ovarian cancer) are the second most common cause of small bowel obstruction involving about 20% of the cases.us
Hernias are the third leading cause of intestinal obstruction and account for approximately 10% of all cases,
Intraluminal strictures can be caused in Crohn’s disease and radiation therapy.
Hypokalemia can cause temporary paralysis of ileum in children however it can rarely cause small bowel obstruction in adults as well.
A 35-year-old morbidly obese woman with BMI 42 has not been able to conceive after 12 months of marriage.Her husband has normal sperm analysis and has no other abnormality.Her fallopian tube appears to be obstructed. What is the most appropriate next step in her management?
a. Suggest her to lose weight
b. Start her on combined oral contraceptive pills
c. Start estrogen
d. Start clomiphene
e. In-vitro fertilization
The correct answer is a.
This patient has presented with inability to conceive over 12 months, and her fallopian tubes are obstructed. She has BMI of 42.
In-vitro fertilisation (IVF) is an alternate option to get pregnant for this patient as she has obstructed Fallopian tubes.
However it takes a woman with a BMI over 35, twice as many IVF cycles to get pregnant as a woman with a healthy weight.So best advice would be to lose weight for successful IVF as the first step in management.IVF success rates are reduced by 25% in obese (BMI less than 40) patients and 50%.
Which of the following is the most common organism seen in spontaneous bacterial peritonitis?
a. Escherichia coli
b. Streptococcus viridans a
c. Staphylococcus aureus
d. Enterococcus species
e. Clostridium difficile
The correct answer is a.
in spontaneous bacterial peritonitis, the most common organism is Escherichia coli.
Gram-positive bacteria, including Streptococcus viridian, Staphylococcus aureus, and Enterococcus species can also be found in the ascitic culture.
- An-overseas economics student is referred to you for further assessment of positive tuberculin skin test. He does not have any signs and symptoms of tuberculosis.An apical opacity is found on chest X-ray. Sputum examination is positive for acid-fast bacilli.
Which of the following is the most appropriate management?
a. Isoniazid
b. Rifampicin, isoniazid, pyrazinamide,ethambutol
C. Isolation
d. Repeat Mantoux test
e. Repeat chest X-ray in 6 weeks
Correct Answer: b. Rifampicin isoniazid, pyrazinamide,ethambutol
Answer Detail:
The correct answer is b.
Investigations for active tuberculosis include chest x-ray, three sputum samples obtained for acid-fast bacilli (AFB), nucleic acid amplification testing (NAAT), FBC, and electrolytes. Stained smears should be made from sputum specimens to identify AFB, as this is the first bacteriological evidence of infection and gives an estimate of how infectious the patient is. If acid-fast bacilli are seen on sputum smear, anti-tuberculous therapy should be started and the patient maintained in isolation. Initial intensive phase treatment involves the first-line drugs isoniazid, rifampicin, pyrazinamide, and ethambutol for 8 weeks. Then the number of drugs is reduced according to response.
An elderly male with a history of alcoholic cirrhosis and oesophageal varices presents with upper gastrointestinal bleed. Which one of the following is true regarding spontaneous bacterial peritonitis and this condition?
a. Start on prophylactic antibiotics
b. No antibiotics needed
c. Do urgent ascitic tap and wait for the neutrophil count
d. Do an ascitic culture and wait for the result
e. Start blood transfusion
The correct answer is a.
The risk of spontaneous bacterial peritonitis is increased in patients with a history of hepatic cirrhosis and variceal bleeding.Prophylaxis against spontaneous bacterial peritonitis is recommended when a patient presents with upper gastrointestinal bleeding.
Blood transfusion is only needed if there is a significant drop in haemoglobin after blood loss in such cases. However, this is not mentioned in this instance, and it is the incorrect choice.
Doing a therapeutic or diagnostic ascitic tap is only needed if the patient has ascites.
A 25-year-old male, unemployed, presents to your office for a follow-up. History revealed that he enjoyed going out to nightclubs and having casual sex with multiple partners. He had his first hepatitis B serology last week with the following results: HBsAg-positive; HBsAb-negative, HBcAb(IgM)-positive, HBeAg-positive.
What is the most likely interpretation of his result?
a. An early hepatic cirrhosis
b. History of hepatitis B infection which resolved, resulting in life-long immunity
c. Past hepatitis B vaccination and is now immune
d. Hepatitis B carrier
e. Acute hepatitis B infection
The correct answer is e.
A positive HBsAg is indicative of an acute infection which occurs about 1-6 months after exposure to the hepatitis B virus. This diagnosis of acute infection is supported by the positive HBcAb (IgM) which is only present in an acute infection.
If HBsAg persists after six months, it defines a carrier status as chronic.
HBeAg is positive which implies high infectivity in recent infection. Following a Hep B vaccination would give a positive HBsAb serology.In this case, patient needs education about hepatitis B, safe sex and drugs
A 67-year old presented with ear pain initially for last 4 days and then developed left sided facial weakness, inability to close left eye and drooling from the comer of the mouth. He is found to have an erythematous vesicular rash along the auditory canal.
What will you do for him?
a. Acyclovir oral
b. Prednisolone
c. Methotrexate
d. Clindamycin
e. Gabapentin
The correct answer is b.
This patient has a clinical diagnosis of Ramsay-Hunt syndrome. It is lower motor neuron facial palsy which results in the abrupt onset of unilateral facial weakness, impaired blinking and drooling from the comer of the mouth.
Typical triad of symptoms for Ramsay Hunt syndrome ipsilateral facial paralysis, ear pain, and vesicles in the auditory canal and auricle. It is due to reactivation of varicella zoster infection.
There may be a loss of taste at anterior two-thirds of the tongue and hyperacusis.
There is no evidence that antiviral drugs like acyclovir are useful in Ramsay Hunt Syndrome if a patient presents after 72 hours of the symptoms onset.
If the patient presents within 72 hours of the symptoms onset, both antiviral and steroids should be used.
This patient should be treated with prednisolone 70mg daily for three days and then tapering doses of prednisolone for next 14 days.As this patient has presented more than 72 hours after the symptoms onset. so there is no benefit of prescribing antiviral treatment.
All of the following are associated with increased risk of carcinoma cervix except?
a. All women who had been sexually active in past
b. All women who are sexually active now
C. Age more than 25 years at first sexual intercourse
d. Multiple sexual partners
e. Genital wart virus infection
The correct answer is C.
Risk factors for development carcinoma of cervix include:
-All women who are or ever have been sexually active.
-Early age at first sexual intercourse.
-Multiple sexual partners.
-Genital warts virus infection.
-Cigarette smoking.
Age over 25 at first sexual intercourse decreases the risk of getting carcinoma cervix. So option c is the correct response.
A mother brings her 2-year old child with an episode of tonic-clonic seizure lasting for one minute.The child also has a history of fever with coryza for past three days.
How will you treat?
a. Oral paracetamol
b. Reassurance
C. EEG
d. Sodium valproate
e. Rectal diazepam
The correct response is b.
This child had a simple febrile seizure which lasted for one minute.No treatment of seizure is required if it has stopped itself. Reassurance is necessary for simple febrile convulsions. The onset of the seizure. The convulsion may be a terrifying experience for the parents to observe.
Paracetamol has not been shown to reduce the risk of further febrile convulsions. An electroencephalogram (EEG) is not indicated for simple febrile seizure.
The rate of postictal EEG abnormalities in children with complex febrile seizure is low, and studies that have shown an EEG abnormality have been unable to translate this into a long term predictor for future febrile seizure and afebrile seizures.
Rectal diazepam is useful in the acute management of seizures and is indicated in following situations:
1-A child with a pattern of prolonged seizures (usually longer than ten mins.) which have previously responded to intravenous or rectal diazepam. 2-A child with clusters of repeated seizures in whom oral treatment is inappropriate. 3-A child with severe epilepsy who is remote from emergency services.
Rectal diazepam is not necessary for children with mild or well-controlled forms of epilepsy. The seizure, in this case, has resolved in less than one minute, so rectal diazepam is not required.
All of the following features favour the diagnosis of achalasia, except?
a. Dysphagia of liquids
b. Regurgitation of food
c. Painful swallowing
d. Nocturnal regurgitation
e. Dysphagia of solids
Answer Detail: The correct answer is c.
Achalasia is a neurogenic esophageal motility disorder characterized by impaired esophageal peristalsis, a lack of lower esophageal sphincter relaxation during swallowing, and an elevation of lower esophageal
sphincter resting pressure, Achalasia occurs at any age but usually begins between ages 20 and 60. Onset is insidious, and progression is gradual over months or years. Dysphagia for both solids and liquids is the major symptom. Nocturnal regurgitation of undigested food occurs in about 35 percent of patients and may cause cough and pulmonary aspiration. When the diagnosis of achalasia is suspected, a barium esophagram with fluoroscopy is the single best diagnostic study. This test will reveal loss of primary peristalsis in the distal two-thirds of the oesophagus with to-and-fro movement in the supine position, Odynophagia is a condition in which an individual experiences pain each time he or she swallows.It is not a feature of achalasia.
A 94-year-old woman comes to your clinic for follow up. She had a Faecal Occult Blood test which is positive. You have recommended her to have a colonoscopy as the most appropriate next step in her management. However, she refuses to go ahead with that and informs you that she would rather not worry about that.It seems she understands the risks. Her daughter who is also present in the consultation requests you to organise colonoscopy for her mother. Her past medical history includes type 2 diabetes mellitus and chronic obstructive airway disease.
What will you do next?
a. Listen to the patient and respect her wishes
b. Listen to the patients daughter and organise colonoscopy
c. Refer the matter to Supreme Court of Australia
d. Refer the case to a senior colleague
e. Refer the matter to local council
The correct answer is a.
This patient is a 94-year-old lady with Type 2 diabetes mellitus and COPD. She has positive FOBT and should be ideally referred to have a colonoscopy to rule out bowel cancer. However as the patient has got the capacity to make a decision and she understands the risks of not having the colonoscopy, she can make an informed choice not to go ahead with colonoscopy. Her decision should be respected.
There is no need to apply to the court as the patient is a competent adult and can make decisions about her health. As long as the patient is capable of making decisions about her health, her daughter cannot take over any decisions for her.
Referring the matter to the senior colleague or the local council is not required.
A Faecal Occult Blood Test (FOBT) can detect minimal amounts of blood in your bowel motions. The test involves taking samples from two or three bowel movements using a test kit. These are analysed at a pathology laboratory, and if blood is detected, further tests may be required. A positive FOBT may indicate: 1. a polyp or adenoma; 2. colorectal cancer; 3.non-neoplastic lesion: haemorrhoids, proctitis.
The standard care in Australia is to have a colonoscopy after each positive FOBT.
A 25 year old male has been admitted to mental health ward under involuntary treatment order for psychosis. On physical examination, he is found to have a 5cmx5cm ulcer on the plantar surface of the left foot.Debridement and wound wash are required along with intravenous antibiotics as the initial step to treat this wound.
How will you proceed regarding consent?
a. No consent required as patient is already involuntary
b. Take consent from the treating psychiatrist
c. Take consent from the patient
d. Contact the family of the patient for informed consent
e. Apply to the mental health tribunal for consent to debride the wound
The correct answer is c.
Patients who are subject to an involuntary treatment under mental health act (Australia),may still have capacity to give consent or decline consent for a specific healthcare matter not related to their mental illness (for example the use of antibiotics for chest infection, or a surgical procedure on the limb).
An assessment of the patient’s capacity to make decisions about health care for a specific matter is undertaken in the usual way and documented appropriately.
if patient lacks capacity to give consent for health care for a condition unrelated to mental illness, the consent of the substitute decision maker is required enabling them to be treated for that condition outside the mental health act.
Involuntary treatment order only applies to mental health treatment,
For any other medical condition.consent should be sought from the patient. Most mental health patients can give consent for any medical treatment if they have capacity.
Which of the following is the most common mode of transmission of hepatitis B in Australia?
a. Sexual transmission
b. Breast feeding
c. Intravenous drug abuse
d. Vertical transmission
e. Blood transfusion
The correct answer is d.
Hepatitis B is found in blood and body fluids including saliva, semen, vaginal secretions and breast milk. The most common ways hepatitis B is spread include:
1-sexual contact 2-sharing of injecting equipment 3-needle-stick injuries in the health care setting 4-reuse of unsterilised or inadequately sterilised needles 5-child-to-child transmission through household contact such as biting 6-sharing personal items such as razors, toothbrushes or nail clippers.
In Australia, around 187,000 people are chronically infected with hepatitis B.
Most people in Australia get infected with the hepatitis B virus through mother-to-child (vertical transmission) during childbirth. Also, most people with hepatitis B in Australia are from East Asia where vertical transmission is the most common mode of hepatitis B transmission.
