FOCP Quiz (50 Questions)

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  Thời Gian Còn Lại


0 [{"id":420505,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:30:25","updated_at":"2018-03-31 12:01:47","questionName":"A 65 year old man presents to his GP with a three month history of gradually worsening shortness of breath. He reports a decline in exercise tolerance, from being able to walk indefinitely to about 500m before stopping to get his breath. He has also developed a cough productive of white sputum. There is no history of wheeze, haemoptysis, night sweats or weight loss. He has recently cut down to 5 cigarettes a day, having had a total pack-year history of 40 years. He drinks 20 units of alcohol weekly, and previously worked in a shipyard for most of his life. On examination, clubbing is noted on both hands, and a slight wheeze is present in the right lung base. Chest expansion and percussion are normal in both sides, and cardiovascular examination shows no abnormalities. What is the most likely diagnosis?","questionTimeSeconds":"0","questionTimeMinutes":"3","questionImagePath":null,"position":16,"explanation":"This question stem shows the importance of carefully reading all of the information available to you \u2013 on first glance this looks like a classic history of COPD, but the presence of clubbing means that there is most likely another cause of the symptoms. Bronchiectasis can cause clubbing, but is less common than lung cancer and typically produces recurrent episodes of pneumonia. Heart failure could cause these symptoms but is not a cause of clubbing. TB can cause clubbing, but is again less common than lung cancer and would be more likely to produce constitutional symptoms such as night sweats. Learning outcome: breathlessness (core presentation), lung cancer any manifestation (core condition), describe common signs of disease including clubbing (respiratory system outcomes)","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420555,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:41:42","updated_at":"2018-03-31 12:01:47","questionName":"A 35 year old man presents to his GP for his annual asthma review. His asthma is well- controlled with daily inhaled fluticasone and salmeterol. The GP notes that the patient has gained a significant amount of weight since his last review, with prominent central adiposity producing pigmented striae and wasting of the arm and leg muscles. A blood glucose measurement performed by the GP comes back as 14mmol\/L. On further questioning, the patient notes that he appears to have gained weight since his regular HIV medications were changed by his specialist. What is the most likely diagnosis?","questionTimeSeconds":"0","questionTimeMinutes":"3","questionImagePath":null,"position":25,"explanation":"This is a tricky question that relies on you both being able to recognise clinical signs of Cushing\u2019s syndrome and being able to differentiate it from Cushing\u2019s disease (which is specifically an ACTH-secreting pituitary tumour). The most likely cause of this patient\u2019s Cushing\u2019s syndrome is an interaction between his inhaled steroid and new HIV medication \u2013 the examiners would not expect you to know that this is possible, and so would give you a stereotypical description of the condition to help you. Pigmented striae in particular are suggestive of Cushing\u2019s syndrome in this question stem. Conn\u2019s syndrome is an aldosterone-secreting tumour which causes hypertension with hypokalaemia and metabolic alkalosis \u2013 it is not a core condition for third year. The presence of an alternative explanation for the Cushingoid signs makes Cushing\u2019s disease less likely, and the question does not mention a bitemporal hemianopia which is the classic visual field defect occurring with pituitary tumours. Hypothyroidism could cause weight gain, but does not explain the pigmented striae. Metabolic syndrome equally would not explain the striae or the wasted arm and leg muscles, and does not explain the rapid onset of obesity (instead being a complication). This is a difficult question! Learning outcome: Cushing\u2019s syndrome (core condition), describe clinical features of Cushing\u2019s syndrome particularly iatrogenic (endocrine system outcomes)","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420531,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:38:26","updated_at":"2018-03-31 12:01:47","questionName":"A 49 year old woman presents to the Emergency Department with a two day history of abdominal pain and fevers with chills. The pain is localised to the right upper quadrant and is constant and severe. She had an admission one week previously with abdominal pain which resulted in a laparoscopic cholecystectomy. On examination, the patient is jaundiced with temperature 38.7\u00b0C, HR 110bpm and BP 98\/60. She is markedly tender in her right upper quadrant. There is no guarding or rebound tenderness, and no masses or hepatosplenomegaly are palpated. Bowel sounds are present and normal, and the remainder of the clinical examination is unremarkable. What is the most likely diagnosis?","questionTimeSeconds":"0","questionTimeMinutes":"3","questionImagePath":null,"position":22,"explanation":"This patient is presenting with Charcot\u2019s triad \u2013 fever with jaundice and RUQ pain. This is the classic set of symptoms\/signs associated with acute cholangitis, an infection of the common bile duct. Acute cholecystitis, inflammation of the gallbladder often secondary to gallstones, is an unlikely cause as the patient had her gallbladder removed the previous week. Biliary colic would not produce the inflammatory signs such as fever and chills. Hepatitis A is an important differential and serology for this would likely be sent, but the history of recent biliary surgery and likely history of problematic gallstones makes cholangitis more likely. Pancreatitis is more likely to cause epigastric pain that radiates through to the back. Learning outcome: jaundice (core presentation), abdominal pain (core presentation)","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420504,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:29:45","updated_at":"2018-03-31 12:01:47","questionName":"A 76 year old woman with Alzheimer\u2019s Disease has been admitted to hospital after being found on the floor at home by her carer. She is found to have a fractured left neck of femur, and receives a left total hip replacement. One day post-operatively she is noted on the morning obs round to have developed a tachycardia of 120bpm, and is reviewed urgently by the surgical F2. The patient has difficulty communicating due to her dementia, and repeatedly tells the doctor that she is out of breath, but is unable to answer further questions. The F2 documents her examination findings and preliminary investigations ( shown below), What is the most likely diagnosis?","questionTimeSeconds":"0","questionTimeMinutes":"4","questionImagePath":"uploads\/focp-quiz-50-questions\/investigations2.jpg","position":15,"explanation":"This is similar to a question that we received in our exam, with which the main difficulty was differentiating DVT from cellulitis. Risk factors for venous thromboembolism (VTE) in this patient include recent surgery and hip fracture, while clues in the question stem towards the diagnosis include the tender left calf and reduced oxygen saturation\/dyspnoea. The three infective options are very sensible differentials, particularly urosepsis and surgical site infection, but the temperature of 37.9 and lack of localising symptoms\/signs are evidence against them. Learning outcome: pulmonary embolus (core condition)","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420529,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:35:48","updated_at":"2018-03-31 12:01:47","questionName":"A 55 year old publican presents to the Emergency Department with an episode of haematemesis. His wife informs the team that he has consumed approximately four cans of lager daily along with variable quantities of spirits for many years. He recognises that his drinking is excessive, and he has tried to stop in the past but relapsed after one month. On examination, he is oriented in place, person and time, but is significantly distressed. His heart rate is 130bpm and BP 108\/72mmHg. He has ten spider naevi distributed across his chest, and there is evidence of gynaecomastia. Abdominal examination reveals a distended non-tender abdomen with significant ascites. What is the most important next step in this patient?","questionTimeSeconds":"0","questionTimeMinutes":"3","questionImagePath":null,"position":20,"explanation":"This question stem is describing a patient with a likely variceal bleed, given the significant alcohol history and signs of cirrhosis on examination (several spider naevi, gynaecomastia and ascites). Endoscopy allows both confirmation of the diagnosis and source of bleeding and treatment of the bleed with band ligation. Abdominal ultrasound may be useful in looking for radiological evidence of cirrhosis as well as screening for hepatocellular carcinoma, but is not indicated acutely. GGT would be expected to be elevated in this patient given his history of alcohol excess, but is not useful diagnostically. Laparotomy is overly invasive given that the bleeding can be treated endoscopically. Serum AFP is a screening test for hepatocellular carcinoma, but imaging with ultrasound or other modalities (e.g. CT) is preferred. Learning outcome: alcohol misuse any manifestation (core condition), liver disease any (core condition), describe common signs of disease including peripheral signs of chronic liver disease (gastrointestinal system outcomes), upper GI endoscope (core investigation)","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420528,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:35:07","updated_at":"2018-03-31 12:01:47","questionName":"A 25 year old man presents to his GP with a two week history of episodic central chest pain. The pain occurs suddenly independent of exercise, and lasts approximately 20 minutes, and is accompanied by shortness of breath and nausea. He has no significant past medical history. His grandfather had a myocardial infarction aged 75. He has never smoked, and drinks 20 units of alcohol weekly. Cardiovascular and respiratory examination are unremarkable. What is the most likely diagnosis?","questionTimeSeconds":"0","questionTimeMinutes":"3","questionImagePath":null,"position":19,"explanation":"Asthma is unlikely in this case as it does not typically cause chest pain. Pneumothoraces would produce abnormal findings (e.g. hyperresonance and reduced breath sounds) on respiratory examination. The onset independent of exercise and duration of the pain, combined with the patient\u2019s young age and negative smoking history, make stable angina unlikely. The question does not give you sufficient information to diagnose unstable angina. By exclusion, panic disorder is therefore the most likely diagnosis in this case. Learning outcome: non-cardiac chest pain and anxiety (core condition)","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420557,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:42:59","updated_at":"2018-03-31 12:01:47","questionName":"A 45 year old man is brought to the Emergency Department having been found unresponsive by his partner. His partner tells you that they had been drinking throughout the afternoon to celebrate a new job, and found the patient unconscious in a chair three hours after returning home. The patient has a history of ischaemic heart disease, type 1 diabetes and coeliac disease. His airway is patent, lung fields are clear with respiratory rate of 14 cycles\/min and O2 sats 95% on room air. His heart rate is 80bpm with BP 118\/82, and his capillary refill time is less than 2 seconds peripherally and centrally. His pupils are equal and reactive to light and accommodation, GCS 10\/15 and blood glucose 1.7mmol\/L. He does not have any rashes, and his temperature is 36.9\u00b0C. What is the most appropriate initial management?","questionTimeSeconds":"0","questionTimeMinutes":"3","questionImagePath":null,"position":27,"explanation":"This question is testing you on your knowledge of acute management of hypoglycaemia. The likely trigger in this case is alcohol consumption on the background of type 1 diabetes. If the patient is conscious and able to swallow, 10-20g glucose is given orally as liquid, granulated sugar or sugar lumps. After 10-15 minutes the blood glucose measurement would be taken, and if the hypoglycaemia has not resolved another dose can be given. In cases where the patient is unconscious, glucose should be given intravenously. In community settings, or if IV access is difficult, intramuscular glucagon is the alternative. Options D and E are treatments for DKA, which is inappropriate in this situation. Learning outcome: diabetes (core condition), describe clinical features of hypoglycaemia (endocrine system outcomes)","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420553,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:39:16","updated_at":"2018-03-31 12:01:47","questionName":"A 16 year old girl is brought into the Emergency Department by her mother after a prolonged episode of vomiting at home. She reports feeling very nauseated with generalised abdominal pains and increased urinary frequency but normal bowel habit. Her mother reports that the daughter has appeared irritable and confused since waking up that morning. On examination, the patient has a generally tender abdomen with no palpable masses. Her mucosal membranes are dry, and she has an increased respiratory rate with deep sighing breathing. Her heart rate is 100bpm and her BP is 105\/85. Her ABG shows a high anion gap metabolic acidosis with partial respiratory compensation, and her blood glucose is found to be 20mmol\/L. A urine dip shows glucose +++ and ketones +++. What is the most appropriate initial management?","questionTimeSeconds":"0","questionTimeMinutes":"3","questionImagePath":null,"position":23,"explanation":"This question stem is describing a patient with diabetic ketoacidosis (DKA), which can often be a first presentation of type 1 diabetes. Diagnosis of DKA is very simple \u2013 the patient simply needs to have the D, the K and the A! D (diabetes) \u2013 glucose >11 mmol\/L or known history of diabetes K (ketones) \u2013 blood ketones >3 mmol\/L or >2+ ketones on dipstick A (acidosis) \u2013 bicarbonate <15 mmol\/L and\/or venous pH <7.3 Questions on DKA management do appear on the exam. The initial management of DKA is fluids \u2013 don\u2019t be tricked into giving insulin first. If the patient is hypotensive with systolic BP <90mmHg then give a 500ml bolus of saline over 10-15 minutes (as in option B). However, in this case the systolic BP is above 90 so 1L of fluids should be given over the first hour. Potassium chloride is not added to the first bag, but is added to subsequent bags given insulin\u2019s effect of drawing potassium into cells (thus potentially causing a hypokalaemia). Insulin should be started after fluids, and is given as a fixed-rate insulin infusion at 0.1 unit\/kg\/hr. Acidosis typically corrects itself with fluids and insulin, so bicarbonate infusions are not routinely indicated. Bolus insulin should only be given if there is a delay in setting up an infusion, and should be given intramuscularly. Learning outcome: diabetes (core condition), describe clinical features of diabetic ketoacidosis (endocrine system outcomes)","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420530,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:36:42","updated_at":"2018-07-03 13:18:52","questionName":"A 35 year old man presents to his GP for evaluation of persistently abnormal LFTs following a series of hospital admissions for community acquired pneumonia. The patient has had multiple admissions in the past two years for respiratory tract infections, and is now dyspnoeic between episodes with reduced exercise tolerance and a chronic cough productive of white sputum. He does not report any abdominal pain or change in the colour of his stools or urine. He drinks 10 units of alcohol weekly, and has never smoked. On examination, the patient has mild scleral jaundice. There is reduced air entry in all areas of the chest, and the heart sounds are both present but quiet. On abdominal palpation, there is mild right upper quadrant tenderness and the liver edge is palpable 2cm below the costal margin. What investigation is most likely to confirm the diagnosis? His recent investigation results are below:","questionTimeSeconds":"0","questionTimeMinutes":"4","questionImagePath":"uploads\/focp-quiz-50-questions\/investigations3.jpg","position":21,"explanation":"This question stem is describing a patient with likely alpha-1-antitrypsin deficiency. Although a very rare condition, it can appear in SBAs given its characteristic presentation of early- onset COPD (including in cases where the patient has never smoked) alongside liver disease (often progressing to cirrhosis) \u2013 essentially in any case with concomitant COPD and liver disease, think of alpha-1-antitrypsin deficiency. A CT chest is not unreasonable to determine the cause of the patient\u2019s chronic respiratory symptoms, but is unlikely to provide any explanation for the liver disease. Legionella urinary antigen would be useful if a young patient presented with a pneumonia with mildly deranged LFTs, but is unlikely to explain the chronic respiratory illness. Serum caeruloplasmin is a test for Wilson\u2019s disease (in which the caeruloplasmin is low), which would produce either fulminant hepatic failure or cirrhosis with neurological symptoms (e.g. movement disorders) and Kayser-Fleischer rings. Serum ferritin is elevated in haemochromatosis, but is unlikely to be useful in this scenario given that it is also raised in inflammation and the patient has a resolving pneumonia. This is a very difficult question for third year! Learning outcome: liver disease any (core condition)","question_score_id":null,"lang":"","questionAudioPath":null},{"id":420556,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:42:20","updated_at":"2018-03-31 12:01:47","questionName":"A 48 year old man presents to the Emergency Department complaining of chest pain and breathlessness of 24 hours duration. The chest pain is central and exacerbated by inspiration and lying flat. He had a self-limiting episode of vomiting and fever last week. On examination, the patient is sitting forward on the bed with oxygen saturation of 99% and heart rate of 108bpm in regular rhythm. A friction rub is present on cardiac auscultation. The remainder of the cardiovascular and respiratory examination is unremarkable. What is the most likely diagnosis?","questionTimeSeconds":"0","questionTimeMinutes":"3","questionImagePath":null,"position":26,"explanation":"Clues that this patient has acute pericarditis include that the pain is relieved by sitting forward (and exacerbated by lying flat), the history of a likely recent viral infection and the presence of a friction rub (a very characteristic finding, along with saddle-shaped ST elevation on an ECG). Although pericarditis is not a core condition, the examiners will occasionally give you questions geared towards a core presentation \u2013 they would not expect you to know much about it apart from classic history and examination findings in the context of chest pain. Aortic dissection is classically described as an intense tearing pain felt between the shoulder blades. CAP is possible given the patient\u2019s symptoms, but would not produce a friction rub and would be more likely to produce abnormal respiratory signs. PE should be considered given the pleuritic pain with dyspnoea and tachycardia, but again does not explain the friction rub. Thyrotoxicosis is unlikely to cause dyspnoea unless it causes acute atrial fibrillation, and the patient in this question has a regular pulse. Learning outcome: chest pain (core presentation)","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420507,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:31:52","updated_at":"2018-03-31 12:01:47","questionName":"A 75 year old woman presents to the Emergency Department with severe abdominal pain and distension. The abdominal pain was gradual in onset over 48 hours and is now constant with occasional exacerbations peaking at 9\/10 severity. She feels nauseated but has not experienced vomiting. She has not opened her bowels today, and yesterday had some mild diarrhoea with no blood or mucus. On examination, the patient\u2019s abdomen is distended and voluntary guarding is present on palpation. There is no evidence of hepatosplenomegaly. High-pitched tinkling bowel sounds are heard on auscultation. The remainder of the clinical examination is normal. An abdominal X-ray is performed, which is reported as showing multiple central dilated bowel loops with visible valvulae conniventes. What is the most likely diagnosis?","questionTimeSeconds":"0","questionTimeMinutes":"3","questionImagePath":null,"position":18,"explanation":"This question stem is describing small bowel obstruction \u2013 \u201chigh-pitched tinkling bowel sounds\u201d are a useful buzzword used in exams to describe obstruction, while the AXR appearance of small bowel obstruction confirms the diagnosis (valvulae conniventes are markings extending across the width of the bowel, while haustrations in the large bowel only extend partly across the bowel). The commonest cause of small bowel obstruction is intra- abdominal adhesions from previous surgery or inflammatory disease. Caecal volvulus produces a pattern of large bowel obstruction, and has a single distended loop of large bowel extending from the right lower quadrant on AXR. Diverticulitis would not produce the signs and radiographic evidence of obstruction. Sigmoid volvulus classically produces a \u201ccoffee bean sign\u201d on AXR. Learning outcome: acute abdomen or peritonitis (core condition), AXR (core investigation), interpret an AXR and describe features of bowel obstruction (gastrointestinal system outcomes)","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420579,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:45:35","updated_at":"2018-03-31 12:01:47","questionName":"A 38 year old nurse presents to her GP with a two week history of feeling anxious. On further questioning, she states that she feels generally anxious with no specific triggers or panic attacks, and experiences feelings of palpitations and sweating intermittently throughout the day. She describes, as a contributing factor to her anxiety, self-esteem issues around her appearance as she has recently lost a stone in weight and feels that her face now looks \u201ctoo intense\u201d, particularly as patients have been complaining that she is \u201cstaring\u201d at them. The GP notices that the patient has a fine tremor of her hands while giving the history, and the patient\u2019s eyes appear red and irritated. Her pulse is found to be irregularly irregular. What is the most likely diagnosis?","questionTimeSeconds":"0","questionTimeMinutes":"3","questionImagePath":null,"position":29,"explanation":"Although a relatively vague history, this question stem describes several clinical features of thyrotoxicosis, in particular Graves\u2019 disease. The presence of anxiety, palpitations, sweating, weight loss, tremor and likely atrial fibrillation are all features of thyrotoxicosis, while the history of \u201cstaring eyes\u201d with signs of inflammation describe thyroid eye disease which is a feature specifically of Graves\u2019 disease. Other symptoms the question may describe include amenorrhoea, diarrhoea, increased appetite, and mania. Other signs that may have been described include palmar erythema, brisk reflexes, goitre, proximal myopathy, or lid lag. Other features of Graves\u2019 disease include thyroid dermopathy (also known as pretibial myxoedema) over the shins, and thyroid acropachy (clubbing in association with Graves\u2019 disease). Hashimoto\u2019s thyroiditis is an autoimmune cause of hypothyroidism, so would not fit with these symptoms. Phaeochromocytoma is a catecholamine-secreting tumour, and could produce all of the symptoms here except for the eye disease; it is also much rarer than Graves\u2019 disease. Generalised anxiety disorder could equally produce many of these features, but would not explain the atrial fibrillation or eye disease. Anorexia nervosa also does not explain atrial fibrillation or eye disease, and would typically present in a younger patient (e.g. adolescence). Learning outcome: thyroid disorders (core condition), describe clinical features of hypo\/hyperthyroidism (endocrine system outcomes)","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420554,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:41:02","updated_at":"2018-03-31 12:01:47","questionName":"A 42 year old man is referred to the Infectious Diseases clinic for follow-up of a positive HIV test as part of an occupational health screen. As well as a confirmatory HIV test, the consultant orders a set of serological tests for associated infections ( shown below). What is the most appropriate next step in managing this patient?","questionTimeSeconds":"0","questionTimeMinutes":"5","questionImagePath":"uploads\/focp-quiz-50-questions\/investigations4.jpg","position":24,"explanation":"Hepatitis B serology is a common exam question in third year as well as later years. As long as you are systematic in their interpretation, then you will be fine! The key tests to understand for most SBAs are surface antigen, surface antibody and core antibody. Surface antigen \u2013 is the virus present in the patient? Surface antibody \u2013 is the patient immune to HBV (either from vaccination or past infection)? Core antibody \u2013 has the patient been exposed to HBV? E antigen \u2013 is the patient highly infectious? A mnemonic for the difference between surface and core antibody is that vaccines only scratch the surface, while infection gets to the core \u2013 so if you have been immunised against HBV you will only be positive for surface antibody, whereas if you have been infected you will be positive for core antibody (+\/- surface antibody if you have managed to clear the infection and become naturally immune). This patient\u2019s serology results are consistent with chronic carriage \u2013 he has been exposed given his core antibody, he is not immune as he has negative surface antibody, and the virus is present in his blood given the positive surface antigen. Learning outcome: liver disease any (core condition), ICP core condition","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420506,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:31:08","updated_at":"2018-03-31 12:01:47","questionName":"An 18 year old man presents to the Emergency Department complaining of abdominal pain. It began spontaneously the previous night as a generalised central ache, but it is now felt as an intense pain over his right groin. He has vomited twice since this morning, once while getting out of bed and again on reaching the department. He reports no haematemesis or coffee ground vomiting. He experienced some mild diarrhoea last night, and has not opened his bowels since. He reports no urinary symptoms. On examination, the patient has generalised involuntary guarding over the entire abdomen, with rebound tenderness present. On palpation of the left iliac fossa, the patient reports intense pain, pointing to the right iliac fossa. Bowel sounds are present but quiet. What is the most likely diagnosis?","questionTimeSeconds":"0","questionTimeMinutes":"3","questionImagePath":null,"position":17,"explanation":"The history of a pain migrating from the umbilical region to the right iliac fossa is classical of acute appendicitis \u2013 this is because the condition begins triggering the pain receptors in the enteric nervous system producing poorly-localised midgut pain, but as the inflamed appendix grows and begins irritating the parietal peritoneum the pain becomes more localised. The stem also describes presence of Rovsing\u2019s sign (LIF palpation producing pain in the RIF) which is a sign of appendicitis. Testicular torsion is an important differential to exclude in young men with abdominal pain causing vomiting \u2013 however this would not produce the features of peritonitis on examination (involuntary guarding and rebound tenderness). Diverticulitis is unlikely in a young patient. Perforated duodenal ulcers would cause peritonism but the pain would be worse in the epigastric\/RUQ\/umbilical regions. Acute cholecystitis would produce RUQ pain classically in a patient with risk factors for gallstones (fair fat fertile female in her 40s), and the stem may describe Murphy\u2019s sign rather than Rovsing\u2019s. Learning outcome: acute abdomen or peritonitis (core condition)","question_score_id":null,"lang":null,"questionAudioPath":null},{"id":420578,"quiz_id":"21312","answer_id":null,"answerType_id":"0","created_at":"2018-03-31 11:44:20","updated_at":"2018-03-31 12:01:47","questionName":"A 64 year old woman presents to her GP with a two week history of increasing shortness of breath. She reports a gradual onset of breathlessness, with no cough, wheeze or chest pain. On further questioning, she reports 8kg of weight loss in the last six months, although she does state that she has been trying to lose weight. She is an ex-smoker of 20 years with a 20 pack-year history, and consumes only occasional alcohol on weekends. She has had no recent travel. Her past medical history is significant for invasive ductal carcinoma of the right breast 15 years previously, which was successfully treated with wide local excision and radiotherapy. On examination, there is reduced chest expansion on the right, with a stony dull percussion inferior to the right sixth intercostal space and reduced air entry in the right base. Suspecting a malignant pleural effusion, the GP refers the patient for a pleurocentesis. What pattern is most likely in this patient\u2019s pleural fluid?","questionTimeSeconds":"0","questionTimeMinutes":"3","questionImagePath":null,"position":28,"explanation":"This question stem is describing a patient with a likely malignant pleural effusion \u2013 the history of breast cancer on the same side as the effusion, as well as the recent significant weight loss, should raise concern of a return of her cancer with metastases to the lung\/pleura. To answer this question, you need to be aware of two aspects of malignant pleural effusions; firstly that they produce an exudate, and secondly what the characteristics of an exudate are on analysis. The protein content of pleural fluid helps you to differentiate between transudates and exudates, with the former having protein of <30 g\/L and the latter having protein of >30 g\/L. However, if the fluid protein is between 25-35 (i.e. is borderline between the two) then Light\u2019s criteria can be used to differentiate them \u2013 a fairly common exam question, although perhaps not in Stage 3: Three of the answers have a high protein \u2013 the purulent sample can be excluded as that would be more consistent with infection i.e. empyema. To differentiate between the two remaining options, malignant effusions usually have a low pH and glucose owing to the metabolic activity of the metastases. This is a difficult question for the Stage 3 exam! Learning outcome: pleural tap (core investigation)","question_score_id":null,"lang":null,"questionAudioPath":null}]
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A 65 year old man presents to his GP with a three month history of gradually worsening shortness of breath. He reports a decline in exercise tolerance, from being able to walk indefinitely to about 500m before stopping to get his breath. He has also developed a cough productive of white sputum. There is no history of wheeze, haemoptysis, night sweats or weight loss. He has recently cut down to 5 cigarettes a day, having had a total pack-year history of 40 years. He drinks 20 units of alcohol weekly, and previously worked in a shipyard for most of his life. On examination, clubbing is noted on both hands, and a slight wheeze is present in the right lung base. Chest expansion and percussion are normal in both sides, and cardiovascular examination shows no abnormalities. What is the most likely diagnosis?

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