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Question 1
Correct
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A 42-year-old female with a history of SLE presents with an exacerbation of wrist pain. Which of the following markers would be the most suitable for monitoring disease activity?
Your Answer: Anti-dsDNA titres
Explanation:A high level of anti-dsDNA in the blood is strongly associated with lupus and is often significantly increased during or just prior to a flare-up. When the anti-dsDNA is positive and the person tested has other clinical signs and symptoms associated with lupus, it means that the person tested likely has lupus. This is especially true if an anti-Sm test is also positive.
In the evaluation of someone with lupus nephritis, a high level (titre) of anti-dsDNA is generally associated with ongoing inflammation and damage to the kidneys.
A very low level of anti-dsDNA is considered negative but does not exclude a diagnosis of lupus. Only about 65-85% of those with lupus will have anti-dsDNA.
Low to moderate levels of the autoantibody may be seen with other autoimmune disorders, such as Sjögren syndrome and mixed connective tissue disease (MCTD).
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This question is part of the following fields:
- Musculoskeletal System
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Question 2
Correct
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A young woman is complaining of a sensation of spinning and loss of balance every time she moves sideways on the bed while lying supine. What would you do next?
Your Answer: Head roll test
Explanation:The most probable diagnosis is benign paroxysmal positional vertigo (BPPV). It is a peripheral vestibular disorder characterized by short episodes of mild to intense dizziness and influenced by specific changes in head position. BPPV is the most common cause of vertigo accounting for nearly one-half of patients with peripheral vestibular dysfunction. In order to establish the diagnosis, the head roll test is performed where the head is turned about 90° to each side while supine.
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This question is part of the following fields:
- Nervous System
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Question 3
Incorrect
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A 68-year-old male presented with swelling in the lower pole of his parotid gland. It is revealed that this has been ongoing for the past 10 years. Upon examination, the swelling is firm in consistency. From the list of options, choose the most probable diagnosis for this patient.
Your Answer: Parotitis
Correct Answer: Pleomorphic adenoma
Explanation:A pleomorphic adenoma is also called a benign mixed tumour – this is the most common tumour of the parotid gland. It also causes over a third of all submandibular tumours. This type of a tumour is slow-growing and has no symptoms, which means it has great malignant potentiality.
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This question is part of the following fields:
- Geriatric Medicine
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Question 4
Incorrect
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A 28-year-old woman is investigated for bloody diarrhoea which started around six weeks ago. She is currently passing 3-4 loose stools a day which normally contain a small amount of blood. Other than feeling lethargic she remains systemically well with no fever or significant abdominal pain. A colonoscopy is performed which shows inflammatory changes in the ascending colon consistent with ulcerative colitis. Bloods show the following:
Hb: 14.2 g/dl
Platelets: 323 * 109/l
WBC: 8.1 * 109/l
CRP: 22 mg/l
What is the most appropriate first-line medication to induce remission?Your Answer: Oral prednisolone
Correct Answer: Oral aminosalicylate
Explanation:Given she is not showing signs of systemic illness, you do not need to treat for an acute flair (which would be steroids), but you need to put her on maintenance medication. Oral ASA would be the best option for this, it is first line. You cannot give rectal ASA because the location of her disease is in the ascending colon and the enema will not reach.
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This question is part of the following fields:
- Gastrointestinal System
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Question 5
Incorrect
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A 48-year-old chronic smoker who smokes 20 cigarettes per day, presented with a persistent cough, wheezing and difficulty in breathing. He was treated with oxygen but the symptoms did not improve. Which of the following is the next step?
Your Answer:
Correct Answer: Check ABG
Explanation:The history is suggestive of a COPD exacerbation. As he is not responding to oxygen, an ABG should be performed to assess the level of hypoxaemia and then a decision about further management can be made. A CXR and salbutamol are also important in the acute management.
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This question is part of the following fields:
- Respiratory System
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Question 6
Incorrect
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A 57-year-old man, who suffers from biventricular cardiac failure, comes to his doctor for a review. His symptoms are currently well controlled; he is taking Ramipril 10mg, Spironolactone 25mg, Bisoprolol 10mg, and Furosemide 40mg. His main complaint is of painful gynaecomastia that he says has developed over the past 6 months. Physical exam reveals a blood pressure of 125/80 mmHg and no residual signs of cardiac failure. Renal function is unchanged from 6 months earlier, with stable creatinine at 125 µmol/l.
Which of the following is the most appropriate next step?Your Answer:
Correct Answer: Change the spironolactone to eplerenone
Explanation:Spironolactone is an aldosterone antagonist diuretic that is well-known to cause gynaecomastia because it increases testosterone clearance and oestradiol production. The patient’s primary complaint of gynaecomastia should immediately prompt discontinuation of spironolactone and replacement with Eplerenone, which lacks the antiandrogenic effects, and thus there is less risk of gynaecomastia.
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This question is part of the following fields:
- Renal System
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Question 7
Incorrect
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A 34-year-old woman is admitted to the hospital with a one-week history of dark urine and fatigue. One day before admission, she developed severe abdominal pain and abdominal distension.
On examination, she has pallor, jaundice, an enlarged tender liver, and ascites. Her investigations show:
Hb: 7.9 g/dL
WCC: 3.2 x 10^9/L
Plts: 89 x 10^9/L
MCV: 101 fL
Peripheral smear: Mild polychromasia
AST: 144 U/L
ALT: 130 U/L
Bilirubin: 54 μmol/L
Urine hemosiderin: ++
Urine urobilinogen +
Abdominal ultrasound reveals an enlarged liver, ascites, and absent flow in the hepatic veins.
Which single test would you request to confirm the underlying diagnosis?Your Answer:
Correct Answer: Flow cytometry for CD55 and CD59 expression
Explanation:The patient has paroxysmal nocturnal haemoglobinuria (PNH) complicated by acute hepatic vein thrombosis (Budd-Chiari syndrome).
PNH is an acquired clonal disorder of haematopoietic stem cells, characterised by variable combination of intravascular haemolysis, thrombosis, and bone marrow failure. Diagnosis is made by flow cytometric evaluation of blood, which confirms the CD55 and CD59 deficiencies and deficiency of expression of other GPI-linked proteins. This test is replacing older complement-based assays such as the Ham test and sucrose lysis test.
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This question is part of the following fields:
- Haematology & Oncology
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Question 8
Incorrect
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A study is performed to assess a new proton pump inhibitor (PPI) in 120 elderly patients who are receiving aspirin. A control group of 240 elderly patients is given the standard PPI. The final evaluation after five years revealed that 24 individuals receiving the new PPI experienced an upper GI bleed. What is the absolute risk reduction if 60 individuals receiving the standard PPI experienced the same condition?
Your Answer:
Correct Answer: 0.05
Explanation:Absolute risk reduction (ARR) – also called risk difference (RD) – is the most useful way of presenting research results to help your decision-making. Absolute risk reduction = (Control event rate) – (Experimental event rate) = 0.05 = 5% reduction
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This question is part of the following fields:
- Evidence Based Medicine
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Question 9
Incorrect
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A 26-year-old male has been taken to the emergency department with chest pain and increasing shortness of breath. He revealed that he has been a heavy smoker for the last 4 years, but doesn't have any past medical history. Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Pneumothorax
Explanation:Increasing shortness of breath, chest pain, and no previous medical history are consistent with a pneumothorax diagnosis. Heavy tobacco use is also a risk factor for developing this condition spontaneously.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 10
Incorrect
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A 11-year-old girl with a history of recurrent chest infections, was admitted with a fever, productive cough, anorexia and weight loss. On examination she was febrile and tachycardic. Her mother said that the girl was not thriving well. Which of the following organisms is responsible for this presentation?
Your Answer:
Correct Answer: Pseudomonas
Explanation:History of recurrent infections and failure to thrive (probably due to pancreatic enzyme insufficiency) is highly suggestive of cystic fibrosis. Pseudomonas has been identified as an important respiratory pathogen in patients with cystic fibrosis.
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This question is part of the following fields:
- Infectious Diseases
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Question 11
Incorrect
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A 30-year-old male is brought to the emergency department following his collapse in a nightclub. His friends who accompanied him admit that, of recent, he has been using increasing amounts of cocaine. Which among the following is commonly associated with cocaine overdose?
Your Answer:
Correct Answer: Metabolic acidosis
Explanation:Metabolic acidosis is associated with cocaine overdose.
In overdose, cocaine leads to agitation, tachycardia, hypertension, sweating, hallucinations, and finally convulsions.
Metabolic acidosis, hyperthermia, rhabdomyolysis, and ventricular arrhythmias also occur.
Chronic use may be associated with premature coronary artery disease, dilated cardiomyopathy, and increased risk of cerebral haemorrhage.
There are 3 stages for acute cocaine toxicity:
Stage I: CNS symptoms of headache, vertigo, pseudo hallucinations, hyperthermia, hypertension.
Stage II: increased deep tendon reflexes, tachypnoea, irregular breathing, hypertension.
Stage III: Areflexia, coma, fixed and dilated pupils, hypotension, ventricular fibrillation, apnoea, and respiratory failure.Treatment:
– Airway, breathing, and circulation to be secured. The patient’s fever should be managed, and one should rule out hypoglycaemia as a cause of the neuropsychiatric symptoms.
– Cardiovascular toxicity and agitation are best-treated first-line with benzodiazepines to decrease CNS sympathetic outflow.
– The mixed beta/alpha blocker labetalol is safe and effective for treating concomitant cocaine-induced hypertension and tachycardia.
– Non-dihydropyridine calcium channels blockers such as diltiazem and verapamil have been shown to reduce hypertension reliably, but not tachycardia.
– Dihydropyridine agents such as nifedipine should be avoided, as reflex tachycardia may occur.
– The alpha-blocker phentolamine has been recommended but only treats alpha-mediated hypertension and not tachycardia. -
This question is part of the following fields:
- Emergency & Critical Care
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Question 12
Incorrect
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Which of the following allows for a diagnosis of diabetes mellitus?
Your Answer:
Correct Answer: Symptomatic patient with random glucose 12.0 mmol/L on one occasion
Explanation:Criteria for the diagnosis of diabetes
1. A1C >6.5%. The test should be performed in a laboratory using a method that is certified and standardized.*
OR
2. Fasting glucose >126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.*
OR
3. 2-h plasma glucose >200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.*
OR
4. In a patient with classic symptoms of hyperglycaemia or hyperglycaemic crisis, a random plasma glucose >200 mg/dl (11.1 mmol/l).
*In the absence of unequivocal hyperglycaemia, criteria 1-3 should be confirmed by repeat testing. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 13
Incorrect
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A 34-year-old known alcoholic male has been found unconscious near a pub. The paramedics that attended to him said he was sweating and surrounded by empty cans of cider. Choose the most appropriate initial investigation from the list of options.
Your Answer:
Correct Answer: Capillary blood sugar
Explanation:Capillary blood sugar should be tested as alcohol-induced hypoglycaemia can present itself in cases such as these.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 14
Incorrect
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A 56-year-old woman has a family history of haemochromatosis and is homozygous for the C282Y mutation. Her ferritin is 927 mg/L (normal range 15-150), haemoglobin 12.5 g/dL (normal range 11.5-16) and aspartate aminotransferase 87 U/L (normal range <40).
Which is the best course of action?Your Answer:
Correct Answer: Weekly venesection to drop her ferritin into the low-normal range
Explanation:Venesection should be done (essentially blood-letting) to decrease the too-high ferratin level. IV Desterrioxamine would have the opposite effect. ASA does not have to do with ferritin. You do not just watch this and recheck. And you do not want to make the patient anaemic.
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This question is part of the following fields:
- Hepatobiliary System
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Question 15
Incorrect
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A 45-year-old known asthmatic was admitted with acute severe asthma and was treated with nebulised salbutamol, ipratropium and bromide, along with 100% oxygen therapy. He was also given IV hydrocortisone, however there was no significant improvement. What would be the next step in management of this patient?
Your Answer:
Correct Answer: IV Aminophylline
Explanation:Aminophylline is a very effective bronchodilator. It is short acting and therefore very effective in acute scenarios.
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This question is part of the following fields:
- Respiratory System
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Question 16
Incorrect
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A 28-year-old 9 week pregnant woman is newly diagnosed with asthma. She is not on any medication at the moment. Her PEFR diary shows wide diurnal variations and she also gives a past history of eczema.
Which of the following is correct?Your Answer:
Correct Answer: Low dose inhaled corticosteroids would be considered acceptable
Explanation:The following drugs should be used as normal during pregnancy:
short acting β2 -agonists
long acting β2- agonists
inhaled corticosteroids
oral and intravenous theophyllinesUse steroid tablets as normal when indicated during pregnancy for severe asthma. Steroid tablets should never be withheld because of pregnancy.
If leukotriene receptor antagonists are required to achieve adequate control of asthma then they should not be withheld during pregnancy. -
This question is part of the following fields:
- Respiratory System
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Question 17
Incorrect
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A 67-year-old male presented with a history of chronic backache and altered sensation over the lateral side of his right calf and foot. Which of the following nerve roots will most likely be involved in this patient?
Your Answer:
Correct Answer: L5-S1
Explanation:Lesions in L5-S1 region leads to altered sensation on the lateral side of calf and foot, along with back pain. There might be difficulty in extension of the leg, foot inversion, plantar flexion and toe flexion, as muscles controlling these functions are supplied by S1.
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This question is part of the following fields:
- Nervous System
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Question 18
Incorrect
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A 56-year-old woman presents with persistent cough, pyrexia, crackles and left sided chest pain which worsens upon deep inspiration. She has a history of smoking. What is the most likely diagnosis?
Your Answer:
Correct Answer: Pneumonia
Explanation:The clinical picture is very suggestive of pneumonia. Pneumonia presents with chest pain exacerbated by deep breathing, fever and localized crackles or consolidation.
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This question is part of the following fields:
- Respiratory System
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Question 19
Incorrect
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A 45-year-old male is brought to the emergency department after being found collapsed, outside a nightclub. The ER team found an empty bottle of amyl nitrate in his pocket. The patient is hypoxic with an O2 saturation of 84% and is confused. Which of the following is the best treatment for this patient?
Your Answer:
Correct Answer: Methylene blue
Explanation:The best treatment for the patient in question would be methylene blue.
The most probable diagnosis in this patient is methemoglobinemia due to the ingestion of amyl nitrate.Amyl nitrate promotes the formation of methaemoglobin, which avidly conserves oxygen and leads to decreased tissue oxygen saturations.
Treatment of choice includes methylene blue and vitamin C.
Adverse effects:
Benign side effects include green or blue discoloration of urine and patients should be forewarned.
Significant side effects are based on methylene blue, itself, being an oxidizing agent and an inhibitor of monoamine oxidase A (MAO-A).
As an oxidizing agent, methylene blue can actually precipitate methemoglobinemia or haemolysis in high doses or when ineffectively reduced.
Methylene blue administration in a patient taking a serotonergic agents may predispose to serotonin syndrome.Note: Although methylene blue administration is controversial in the setting of G6PD-deficiency due to reduced levels of NADPH, it is not contraindicated and should be administered cautiously and judiciously.
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This question is part of the following fields:
- Pharmacology
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Question 20
Incorrect
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Which one of the following is true of gamma delta T cells?
Your Answer:
Correct Answer: They play a role in the skin and gut
Explanation:Gamma delta T cells are of low abundance in the body, are found in the gut mucosa, skin, lungs and uterus, and are involved in the initiation and propagation of immune responses. Their ligands are not known in detail, but the gamma delta T cell receptors recognise intact proteins rather than MHC-presented peptides. Like alpha beta T cells, they develop in the thymus.
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This question is part of the following fields:
- Haematology & Oncology
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Question 21
Incorrect
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A 76-year-old man has been admitted with a respiratory tract infection.
On examination, he was found to be confused and dyspnoeic with O2 saturation of 88%. He has a 60 pack-year smoking history. An arterial blood gas analysis reveals CO2 retention. He has been deemed unfit for admission into the intensive care unit. The physician elects to begin a doxapram infusion.
Among the following statements which best fits with the characteristics of doxapram?Your Answer:
Correct Answer: Epilepsy is a contraindication for doxapram use
Explanation:The statement that fits the characteristics of doxapram is, epilepsy is a contraindication for doxapram use. Concurrent use with theophylline may increase agitation not relaxation.
Doxapram is a central respiratory stimulant. In clinical practice, doxapram is usually used for patients who have an acute exacerbation of chronic obstructive pulmonary disease (COPD) who are unsuitable for admission to the intensive therapy unit for ventilatory support. Doxapram infusion may buy an extra 24 h to allow for recovery.
Contraindications include: ischaemic heart disease, epilepsy, cerebral oedema, acute stroke, asthma, hypertension, hyperthyroidism, and pheochromocytoma.
The infusion may worsen agitation and dyspnoea and lead to hypertension, nausea, vomiting and urinary retention.Drug interactions:
Concomitant administration of doxapram and aminophylline (theophylline) can cause increased skeletal muscle activity, agitation, and hyperactivity. -
This question is part of the following fields:
- Pharmacology
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Question 22
Incorrect
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From the options provided below, which intervention plays the greatest role in increasing survival in patients with COPD?
Your Answer:
Correct Answer: Smoking cessation
Explanation:Smoking cessation is the most effective intervention in stopping the progression of COPD, as well as increasing survival and reducing morbidity. This is why smoking cessation should be the top priority in the treatment of COPD. Long term oxygen therapy (LTOT) may increase survival in hypoxic patients. The rest of the options dilate airways, reduce inflammation and thereby improve symptoms but do not necessarily increase survival.
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This question is part of the following fields:
- Respiratory System
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Question 23
Incorrect
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Which one of the following features is least recognised in long-term lithium use?
Your Answer:
Correct Answer: Alopecia
Explanation:All the above side-effects, with the exception of alopecia, may be seen in patients taking lithium.
Common lithium side effects may include:
– dizziness, drowsiness;
– tremors in your hands;
– trouble walking;
– dry mouth, increased thirst or urination;
– nausea, vomiting, loss of appetite, stomach pain;
– cold feeling or discoloration in your fingers or toes;
– rash; or.
– blurred vision. -
This question is part of the following fields:
- Pharmacology
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Question 24
Incorrect
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A 71-year-old woman residing in a nursing home for a couple of years complains of drooling of saliva and sudden difficulty in swallowing while eating. She is a known hypertensive on treatment. What would be your next step?
Your Answer:
Correct Answer: Endoscopy
Explanation:Dysphagia or difficulty in swallowing. Endoscopy allows for visual examination of the oesophagus and is indicated in patients with dysphagia to determine the underlying aetiology, exclude malignant and premalignant conditions, assess the need for therapy, and perform therapy including dilation.
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This question is part of the following fields:
- Geriatric Medicine
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Question 25
Incorrect
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A 32-year-old woman was referred for endoscopy and found to have a duodenal ulcer and a positive urease test. She was given lansoprazole, amoxicillin and clarithromycin for 7 days.
Which of the following is the most appropriate way of determining the successful eradication of H. pylori?Your Answer:
Correct Answer: Urea breath test
Explanation:Urea breath test is the most sensitive test to determine if there has been RESOLUTION/ERADICATION of the infection with H. pylori. The best test for initial diagnosis would be EGD with biopsy.
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This question is part of the following fields:
- Gastrointestinal System
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Question 26
Incorrect
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A 51-year-old woman recently put on antihypertensives showed the following results on 2 occasions: Na+ = 132, K+ = 7.6, Urea = 11.3, and Creatinine = 112. Which of the following drugs is responsible for this result?
Your Answer:
Correct Answer: Ramipril
Explanation:Ramipril is an ACE Inhibitor. Treatment with angiotensin-converting-enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) has consistently been shown to reduce the risk of renal and cardiovascular morbidity and mortality in a range of patients. However, ACEI and ARB therapy increase serum potassium which increases the risk of hyperkalaemia.
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This question is part of the following fields:
- Pharmacology
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Question 27
Incorrect
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A 46-year-old male, known with Rheumatoid Arthritis presents with a swollen and painful right ankle. No drug allergies are reported. On examination, the vitals are as follows:
Temp: 38.8
BP: 90/60 mmHg
Pulse: 110/min.
Right ankle examination reveals tenderness, warmth, erythema and tense joint effusion. Blood samples including blood cultures are collected and fluid resuscitation is initiated. Which of the following interventions would be most appropriate for this man?Your Answer:
Correct Answer: Administer i.v. flucloxacillin, and arrange joint aspiration urgently
Explanation:Although microscopic analysis of joint fluid aspirate and culture is the basis of septic arthritis diagnosis and should usually be collected before the administration of antibiotics, the patient is showing signs of septic shock. A delay in antibiotics might lead to worsening of symptoms so they are administered first.
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This question is part of the following fields:
- Musculoskeletal System
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Question 28
Incorrect
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A 85-year-old male with a history of Alzheimer's dementia was brought into Casualty by family members, who stated that he had episodes of aggression. Which of the following drugs is most suitable as the pharmacological management for this presentation?
Your Answer:
Correct Answer: Risperidone
Explanation:Regarding the pharmacological management, Risperidone is the most suitable drug from the given answers as it is recommended for the treatment of aggression associated with moderate to severe Alzheimer’s disease. Quetiapine and Benzodiazepine are not recommended.
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This question is part of the following fields:
- Geriatric Medicine
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Question 29
Incorrect
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A 14-year-old known asthmatic presents to the A&E department with difficulty breathing. She was seen by her regular doctor the day before with a sore throat which he diagnosed as tonsillitis and was prescribed oral Amoxicillin for 5 days.
Past medical history:
Ulcerative colitis diagnosed four years ago.
Current medications:
Inhaled salbutamol and beclomethasone
Mesalazine 400 mg TDS
She was observed to be alert and oriented but she had laboured breathing. Inspiratory wheeze was noted. She was pale, sweaty and cyanosed. Her temperature was 36.7ºC, pulse 121/minute and blood pressure 91/40 mmHg. The lungs were clear and the remainder of the examination was normal. She was given high-flow oxygen through a face mask but despite this her breathing became increasingly difficult.
What is the most likely causative agent?
Your Answer:
Correct Answer: Haemophilus influenzae
Explanation:Acute epiglottitis is a life-threatening disorder with serious implications to the anaesthesiologist because of the potential for laryngospasm and irrevocable loss of the airway. There is inflammatory oedema of the arytenoids, aryepiglottic folds and the epiglottis; therefore, supraglottitis may be used instead or preferred to the term acute epiglottitis.
Acute epiglottitis can occur at any age. The responsible organism used to be Hemophilus influenzae type B (Hib), but infection with group A b-haemolytic Streptococci has become more frequent after the widespread use of Hemophilus influenzae vaccination.
The typical presentation in epiglottitis includes acute occurrence of high fever, severe sore throat and difficulty in swallowing with the sitting up and leaning forward position in order to enhance airflow. There is usually drooling because of difficulty and pain on swallowing. Acute epiglottitis usually leads to generalized toxaemia. The most common differential diagnosis is croup and a foreign body in the airway. A late referral to an acute care setting with its serious consequences may result from difficulty in differentiation between acute epiglottitis and less urgent causes of a sore throat, shortness of breath and dysphagia.
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This question is part of the following fields:
- Respiratory System
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Question 30
Incorrect
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A 32-year-old man notices a pruritic scaly annular rash on his thigh. He claims that the rash appeared after a walk in the park. Which drug would you suggest he starts?
Your Answer:
Correct Answer: Doxycycline
Explanation:The clinical picture of an itchy, scaly annular rash after a walk in the park suggests erythema migrans. The pathogen responsible is a spirochete, Borrelia Burgdorferi transmitted by ticks leading to Lyme disease. Doxycycline is the antibiotic of choice if no contraindications.
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This question is part of the following fields:
- Infectious Diseases
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SESSION STATS - PERFORMANCE PER SPECIALTY
