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Question 1
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A literature review of a number of studies was conducted to assess the potential efficacy of a new drug, which may reduce the chance of patients with chronic kidney disease (CKD) developing gout. In one study 120 out of 1200 patients receiving the new drug developed gout. The total number of the patients were 2000 and the remaining 800 individuals received a placebo. From the patients that had received the placebo, 200 developed gout. What is the absolute risk reduction of developing gout?
Your Answer: 0.15
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) = 0.15 = 15%
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This question is part of the following fields:
- Evidence Based Medicine
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Question 2
Correct
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Which of the following is a good prognostic factor in chronic lymphocytic leukaemia?
Your Answer: Female sex
Explanation:Good prognosis of chronic lymphocytic leukaemia (CLL) is associated with deletion of the long arm of chromosome 13 (del 13q). This is the most common abnormality, seen in around 50% of all CLL patients. Poor prognosis of the disease is related to deletion of part of the short arm of chromosome 17 (del 17p). This is seen in around 5-10% of the patients suffering from CLL.
Poor prognostic factors of CLL include:
1. Male sex
2. Age >70 years
3. Lymphocyte count >50
4. Prolymphocytes comprising more than 10% of blood lymphocytes
5. Lymphocyte doubling time <12 months
6. Raised LDH
7. CD38 expression positive -
This question is part of the following fields:
- Haematology & Oncology
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Question 3
Correct
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Which treatment of chronic obstructive pulmonary disease (COPD) increases the long-term prognosis in patients?
Your Answer: Long-term domiciliary oxygen therapy
Explanation:COPD is commonly associated with progressive hypoxemia. Oxygen administration reduces mortality rates in patients with advanced COPD because of the favourable effects on pulmonary hemodynamics.
Long-term oxygen therapy improves survival 2-fold or more in hypoxemic patients with COPD, according to 2 landmark trials, the British Medical Research Council (MRC) study and the US National Heart, Lung and Blood Institute’s Nocturnal Oxygen Therapy Trial (NOTT). Hypoxemia is defined as PaO2 (partial pressure of oxygen in arterial blood) of less than 55 mm Hg or oxygen saturation of less than 90%. Oxygen was used for 15-19 hours per day.
Therefore, specialists recommend long-term oxygen therapy for patients with a PaO2 of less than 55 mm Hg, a PaO2 of less than 59 mm Hg with evidence of polycythaemia, or cor pulmonale. Patients should be evaluated after 1-3 months after initiating therapy, because some patients may not require long-term oxygen.
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This question is part of the following fields:
- Respiratory System
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Question 4
Correct
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An 85-year-old elderly male presents with complaint of worsening breathlessness over the last 2 years. He has a longstanding history of COPD and currently takes salbutamol, ipratropium, salmeterol, beclomethasone and theophylline. FEV1 comes out to be less than 30%. What will be the most suitable next step in the management of this patient?
Your Answer: Assessment for long term O2 therapy
Explanation:Long-term oxygen therapy (LTOT) is the cornerstone mode of treatment in patients with severe chronic obstructive pulmonary disease (COPD) associated with resting hypoxaemia. When appropriately prescribed and correctly used, LTOT has clearly been shown to improve survival in hypoxemic COPD patients. Requirements to proceed to LTOT is the patient should be stable and on appropriate optimum therapy (as in given case) and having stopped smoking tobacco. The patient should be shown to have a PaO2 of less than 7.3 kPa and/or a PaCO2 of greater than 6 kPa on two occasions at least 3 weeks apart. FEV1 should be less than 1.5 litres, and there should be a less than 15% improvement in FEV1 after bronchodilators. Patients with a PaO2 between 7.3 and 8 kPa who have polycythaemia, right heart failure or pulmonary hypertension may benefit from LTOT.
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This question is part of the following fields:
- Respiratory System
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Question 5
Correct
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A 50-year-old smoker with a history of hypertension presented with acute severe chest pain and acute myocardial infarction was diagnosed. Which of the following is a contraindication for thrombolysis?
Your Answer: History of likely ischaemic stroke within the past month
Explanation:Absolute contraindications for fibrinolytic use in STEMI
Prior intracranial haemorrhage (ICH)
Known structural cerebral vascular lesion
Known malignant intracranial neoplasm
Ischemic stroke within 3 months
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed head trauma or facial trauma within 3 months
Intracranial or intraspinal surgery within 2 months
Severe uncontrolled hypertension (unresponsive to emergency therapy)
For streptokinase, prior treatment within the previous 6 months -
This question is part of the following fields:
- Cardiovascular System
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Question 6
Correct
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A 52-year-old gentleman known with rheumatoid arthritis presented with a 5 day history of red, painful swollen knee joint. He was afebrile and the joint was warm on touch. Hamstring muscles were spastic. Which of the following tests should be done next?
Your Answer: Joint aspiration for cytology and culture and sensitivity
Explanation:Rheumatoid arthritis can affect any joint of the body. Aspirate will reveal increased TLC, and it will be sterile.
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This question is part of the following fields:
- Immune System
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Question 7
Correct
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A 30-year-old male, who is the brother of a patient with hypertrophic cardiomyopathy has come for the screening. Which of the following is the most appropriate method of screening?
Your Answer: Echocardiography
Explanation:12-lead electrocardiography and transthoracic echocardiography are recommended as a screening method for family members of patients with HCM.
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This question is part of the following fields:
- Cardiovascular System
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Question 8
Correct
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A 45-year-old female presented with weight loss, night sweats and abdominal pain for 6 months. Abdominal ultrasound scan showed a tubo-ovarian mass. What is the most likely organism, which is responsible for this presentation?
Your Answer: Mycobacterium tuberculosis
Explanation:Constitutional symptoms such as weight loss, evening pyrexia and night sweats are associated with Mycobacterium Tuberculosis (TB). TB can affect any system of the body and should be top in the list of differentials particularly if the patient has a history of contact with a known TB patient.
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This question is part of the following fields:
- Infectious Diseases
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Question 9
Correct
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A 21-year-old male was brought in unconscious state with high fever, swollen nasal mucosa and constricted pupils. Which of the following substances can cause this presentation?
Your Answer: Cocaine
Explanation:This presentation is suggestive of cocaine toxicity. The major effects of cocaine poisoning include CNS effects such as agitation, seizures and psychosis, and cardiovascular effects such as dysrhythmias, myocardial infarction and cardiovascular collapse. The common route for cocaine ingestion is through the nose, hence the irritated swollen septum.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 10
Correct
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An 83-year-old gentleman presents to his GP with increasing oedema and ascites. He is hypertensive, for which he takes amlodipine. There is shortness of breath on exercise. His alcohol history is two cans of stout per day.
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ECG is normal, and CXR reveals normal heart size and no signs of cardiac failure. Serum albumin is 23 g/dl; urinary albumin excretion is 7 g/24 h, with no haematuria. He has mild anaemia with a normal MCV. Total cholesterol is elevated.
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What diagnosis fits best with this clinical picture?Your Answer: Nephrotic syndrome
Explanation:Nephrotic syndrome usually presents with the symptoms in this patient: low albumin, abnormal cholesterol, increased urinary albumin excretion, oedema, and as a consequence, hypertension as well.
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This question is part of the following fields:
- Renal System
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Question 11
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You are reviewing a 70-year-old gentleman who has been suffering from multiple myeloma for the past 3 years. He presents with lethargy, muscle aches and pain in his lower back.
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Arterial blood sampling reveals a metabolic acidosis. Serum potassium is 3.1 mmol/l (3.5-4.9), and urine pH is 5.1 (> 5.3).
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What is the most likely diagnosis?Your Answer: Renal tubular acidosis-type II
Explanation:This case is most likely RTA type II, due to decreased proximal bicarbonate reabsorption, which leads to metabolic acidosis, hypokalaemia, hyperchloremia, and <6 urine pH .
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This question is part of the following fields:
- Renal System
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Question 12
Correct
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A 65-year-old male patient presents with a non-explosive cough, muscle twitching on the level of the tongue and aspiration pneumonia. He also claims that occasionally the food he swallows comes back through his nose. What is the most likely cause of dysphagia in this case?
Your Answer: Bulbar palsy
Explanation:Bulbar palsy and pseudobulbar palsy are rare types of a motor neuron disease that affect the cranial motor nerves. Bulbar palsy is a lower motor neuron palsy that affects the nuclei of the 9th to 12th cranial nerves. Pseudobulbar palsy is an upper motor neuron palsy that affects the corticobulbar tracts of the 5th, 7th and 9th to 12th cranial nerves. Any condition which disrupts or damages the cranial nerve nuclei or corticobulbar tracts can cause bulbar or pseudobulbar palsy (e.g., stroke, multiple sclerosis, infections, brain stem tumours). Both bulbar and pseudobulbar palsy are seen mainly in men over 75 years old and present with progressive dysarthria and dysphagia. In addition, patients with pseudobulbar palsy present with a lack of facial expression, difficulty chewing, and emotional lability. Lower motor neuron signs (atrophy and fasciculations of the tongue, absent gag reflex) differentiate bulbar palsy from pseudobulbar palsy, which presents with upper motor neuron signs (spastic tongue, exaggerated gag, and jaw jerk reflexes). Diagnosis is mainly clinical and treatment mostly supportive with a poor prognosis. Life expectancy is around 1-3 years following diagnosis.
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This question is part of the following fields:
- Haematology & Oncology
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Question 13
Correct
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A 75-year-old man was admitted with urinary dribbling and incontinence. Upon examination, there is a palpable mass up to the umbilicus. His clothes smell of ammonia and he is known to be a chronic alcoholic. What is the next most appropriate step?
Your Answer: Urethral catheter
Explanation:It is obvious in this case that chronic alcohol use has contributed to the patient’s urinary incontinence which requires a urethral catheter. Suprapubic catheters are usually preferred in cases of acute urinary retention while condom catheters are indicated in less severe cases of urinary incontinence. We would administer antibiotics if we suspected a urinary infection causing the urinary incontinence, but in this case the cause is obvious.
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This question is part of the following fields:
- Renal System
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Question 14
Correct
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A 38-year-old alcoholic presented with an ataxic gait, nystagmus and confusion. What is the most likely clinical diagnosis?
Your Answer: Wernicke's encephalopathy
Explanation:Wernicke’s encephalopathy is a clinical triad of encephalopathy, gait ataxia and nystagmus.
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This question is part of the following fields:
- Nervous System
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Question 15
Correct
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A 25-year-old previously well male presented with chest discomfort and difficulty in breathing while running to the bus. Symptoms disappeared after resting. But the symptoms reappeared whilst he was climbing the stairs. On examination he was not dyspnoeic at rest. BP was 110/70 mmHg and pulse rate was 72 bpm. His heart sounds were normal. There was an additional clicking noise in the fourth left intercostal space which is heard with each heartbeat. Which of the following is the most probable cause for his presentation?
Your Answer: Spontaneous pneumothorax
Explanation:The given history is more compatible with spontaneous pneumothorax. Left-sided pneumothoraxes may be associated with a clicking noise, which is heard with each heart-beat and can sometimes be heard by the patient.
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This question is part of the following fields:
- Cardiovascular System
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Question 16
Correct
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A 85-year-old previously well man was found to have a BP of 155/90 mmHg. His average reading from the monitoring of his ambulatory BP was 147/92 mmHg. His calculated 10 year cardiovascular risk was 15%. Which of the following is the most appropriate management of this patient?
Your Answer: Give lifestyle advice and repeat blood pressure in 6 months
Explanation:According to different guidelines for patients above 80 years, the targeted systolic blood pressure varies from 140-150 mmHg. As this patient’s BP is within that range, he can be kept under observation.
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This question is part of the following fields:
- Cardiovascular System
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Question 17
Correct
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A 20-year-old football player has fallen and hit his head on the ground. He did not lose consciousness but has a left side subconjunctival haemorrhage, swelling, and tenderness over his left cheek. Which of the following is the most appropriate initial investigation?
Your Answer: Facial XR
Explanation:History and examination findings are suggestive of facial injury and intracranial haemorrhage is unlikely. To exclude any facial fracture, an X-ray is suggested.
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This question is part of the following fields:
- Nervous System
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Question 18
Correct
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Which one of the following types of thyroid cancer is associated with the RET oncogene?
Your Answer: Medullary
Explanation:RET (rearranged during transfection) is a receptor tyrosine kinase involved in the development of neural crest derived cell lineages, kidney, and male germ cells. Different human cancers, including papillary and medullary thyroid carcinomas, lung adenocarcinomas, and myeloproliferative disorders display gain-of-function mutations in RET.
In over 90% of cases, MEN2 syndromes are due to germline missense mutations of the RET gene.
Multiple endocrine neoplasias type 2 (MEN2) is an inherited disorder characterized by the development of medullary thyroid cancer (MTC), parathyroid tumours, and pheochromocytoma. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 19
Incorrect
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A 35-year-old male has presented with a wrist drop of his right hand. After a medical examination, an area of sensory loss on the dorsum is revealed. Choose the nerve most likely to be affected from the list of options.
Your Answer: Median nerve
Correct Answer: Radial nerve
Explanation:The radial nerve supplies the following: brachioradialis, extensor carpi radialis longus, and the extensor muscles of the forearm (which is via the posterior interosseous nerve). The sensory branches supply the following: dorsum of the thumb, dorsum of the fingers up to the PIPJ (proximal interphalangeal joint), and the middle of the ring finger. The loss of muscle power depends on the extent of the nerve damage – the usual posture is a wrist drop, coupled with thumb adduction and hand pronation. Sensation in this male patient is impaired in this area. The thoracic nerve supplies the serratus anterior muscle, and thus, damage causes winging of the scapula. A median nerve palsy causes the following: the inability to abduct and oppose the thumb; weakness in the forearm, pronation and finger flexion; and sensory loss of the thumb. A T1 nerve root lesion causes Klimke’s palsy – this is a loss of finger flexion, abduction and adduction, and reduced sensation in the medial upper limb. The ulnar nerve is usually compromised at the elbow which causes numbness in the 5th finger, the medial aspect of the ring finger, and the dorsum of the hand (over the 5th finger). A clawed hand can develop (the little and ring fingers curl in towards the palm) if the weakness of the small muscles of the hand is allowed to progress.
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This question is part of the following fields:
- Nervous System
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Question 20
Correct
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Which of the following is the most useful marker of prognosis in multiple myeloma?
Your Answer: B2-microglobulin
Explanation:B2-microglobulin is a useful marker of prognosis in multiple myeloma (MM). Raised levels imply a poorer prognosis. Low levels of albumin are also associated with a poor prognosis.
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This question is part of the following fields:
- Haematology & Oncology
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Question 21
Correct
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A 64-year-old male patient was admitted for dysphagia, emesis and weight loss. He has a firm lump in his left supraclavicular fossa. What is the most probable diagnosis?
Your Answer: Gastric carcinoma
Explanation:The history is suggestive of gastric carcinoma with dysphagia, vomiting, weight loss and lymphatic metastasis to the supraclavicular node, known as Virchow’s node.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 22
Correct
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A 34-year-old's chest x-ray showed diffuse bilateral alveolar shadows. He also suffers from shortness of breath, weight loss and dry cough due to Kaposi's sarcoma but no fever was noted. Which is the most likely causative organism?
Your Answer: Pneumocystis jiroveci
Explanation:Pneumocystis Jiroveci. This causative organism is responsible for pneumonia in individuals that have a compromised immune system. Symptoms include cyanosis, dry cough and in some cases, diffuse bilateral alveolar shadows on CXR. Co-trimoxazole is normally the treatment for this.
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This question is part of the following fields:
- Infectious Diseases
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Question 23
Correct
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A 56-year-old male has presented with visual loss on his left side and a history of right sided weakness. Where is the occlusion in this patient?
Your Answer: Carotid artery
Explanation:The carotid artery divides itself into two parts: the internal carotid and the external carotid. The internal carotid continues down as the middle cerebral and gives rise to the ophthalmic branch. For this reason, middle cerebral occlusion may give rise to partial visual loss but not complete mono-ocular blindness. Middle cerebral artery occlusion causes paralysis or weakness of contralateral face and arm (faciobracheal). It also causes sensory loss of the contralateral face and arm. Anterior cerebral artery occlusion causes paralysis or weakness of the contralateral foot and leg. Again, sensory loss is experienced at the contralateral foot and leg.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 24
Correct
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A 54-year-old plumber presents with general deterioration. He drinks approximately 25 units of alcohol each week and is a smoker of five cigarettes daily. Examination reveals that he is jaundiced, has numerous spider naevi on his chest and he has a temperature of 37.2°C. Abdominal examination reveals hepatosplenomegaly.
Investigations reveal:
Bilirubin 100 micromol/L (1-22)
Alkaline phosphatase 310 iu/l (45 - 105)
ALT 198 iu/l (5 - 35)
AST 158 iu/l (1 - 31)
Albumin 25 g/L (37 - 49)
Hepatitis B virus surface antigen positive
Hepatitis B virus e antigen negative
Hepatitis B virus DNA awaited
What is the most likely diagnosis?Your Answer: Chronic hepatitis B infection
Explanation:The clinical scenario describes a man in liver failure. Given the serological results, he is most likely to have a chronic hepatitis B infection. In chronic hepatitis B infection, you have +HBsAg, +anti-HBc, (-)IgM antiHBc, and (-) anti-HBs. In acute hepatitis B infection, you have +HBsAg, +anti-HBc, +IgM anti-HBc, and negative anti-HBs. in immunity due to natural infection, you have negative HBsAg, +anti-HBc, and + anti-HBs. In immunity due to vaccination, you have negative HBsAg, negative anti-HBc, and positive anti-HBs. While he could have a superimposed hepatitis D infection on top of hepatitis B, there is no mention of hepatitis D serology, make this an incorrect answer. The other choices do not involve hepatitis serologies.
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This question is part of the following fields:
- Hepatobiliary System
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Question 25
Correct
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A 23-year-old woman comes for the advice regarding contraceptives. Her mother passed away due to cervical cancer and she worries about cervical cancer. Which of the following is the most suitable contraceptive method for her?
Your Answer: Barrier method
Explanation:Cervical cancer results from genital infection with HPV. PV infections can be transmitted via nonsexual routes, but the result from sexual contact. So the best contraceptive method in relation to prevention of cervical cancer is the barrier method. But it will not prevent cervical cancer a 100%.
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This question is part of the following fields:
- Women's Health
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Question 26
Correct
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You are asked to fill the first part of a cremation form. Which of the following would need to be removed prior to cremation?
Your Answer: Pacemaker
Explanation:Pacemakers have small electrical parts installed in them that can explode when exposed to extreme heat and pressure.
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This question is part of the following fields:
- Ethical & Legal
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Question 27
Correct
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A 41-year-old male experiences hand tremors that are absent at rest, but aggravated on extension and continuous with movement. What is the most probable diagnosis?
Your Answer: Benign essential tremor
Explanation:Tremors that linger on movement, seen on an outstretched hand, and absent on rest are called benign essential tremors.
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This question is part of the following fields:
- Nervous System
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Question 28
Correct
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A 60-year-old patient diagnosed with Type-2 diabetes mellitus is not responding to dietary modifications and weight reduction. He needs to be started on an oral hypoglycemic agent. Which among the following statements regarding oral hypoglycaemic agents is true?
Your Answer: Acarbose inhibits ?-glucosidase
Explanation: -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 29
Correct
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Which is the most appropriate agent for the prophylaxis of cluster headaches?
Your Answer: Verapamil
Explanation:Verapamil, can effectively reduce the number of attacks during a cluster headache period of exacerbation. Oral sumatriptan has not been shown to be effective prophylactically. Verapamil in dosages of 360 to 480 mg daily is one of the few treatments for episodic cluster headache tested in a randomized controlled trial (RCT) and found effective in reducing attack frequency.
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This question is part of the following fields:
- Nervous System
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Question 30
Correct
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A 20-year-old female has been referred for investigation of an iron deficiency anaemia. Her mother passed away at age 28, due to colonic carcinoma complicating Peutz-Jegher syndrome. Choose the mode of inheritance of Peutz-Jegher syndrome which is most likely.
Your Answer: Autosomal dominant
Explanation:Peutz-Jegher syndrome is an autosomal dominant condition which is characterised by perioral pigmentation and hamartomas of the bowel. It was initially assumed that these did not predispose to malignancy, but due to recent studies, the opposite is now believed to be true.
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This question is part of the following fields:
- Gastrointestinal System
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SESSION STATS - PERFORMANCE PER SPECIALTY
