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  • Question 1 - A 55-year-old female school teacher complains of double vision when she writes on...

    Incorrect

    • A 55-year-old female school teacher complains of double vision when she writes on the school blackboard. She has no history of trauma. Her most recent visit to her GP was to seek attention for a rash which developed after she was bitten when walking through the forest on a school trip. Choose the cranial nerve most likely to be affected here.

      Your Answer: Oculomotor

      Correct Answer: Abducens

      Explanation:

      This nerve is responsible for the side to side movement of the eye, hence why damage can cause double vision.

    • This question is part of the following fields:

      • Nervous System
      38.8
      Seconds

  • Question 2 - A 73-year-old woman presents with severe emphysema. She is on maximal therapy including...

    Incorrect

    • A 73-year-old woman presents with severe emphysema. She is on maximal therapy including high dose Seretide and tiotropium. She tells you that she is so unwell that she can barely manage the walk the 160 metres to the bus stop.
       
      On examination she looks short of breath at rest. Her BP is 158/74 mmHg, pulse is 76 and regular. There are quiet breath sounds, occasional coarse crackles and wheeze on auscultation of the chest.
       
      Investigations show:
       
      Haemoglobin 14.2 g/dl (13.5-17.7)
      White cell count 8.4 x 109/l (4-11)
      Platelets 300 x 109/l (150-400)
      Sodium 137 mmol/l (135-146)
      Potassium 4.1 mmol/l (3.5-5)
      Creatinine 127 micromol/l (79-118)
      pH 7.4 (7.35-7.45)
      pCO2 7.5 kPa (4.8-6.1)
      pO2 9.7 kPa (10-13.3)
      Chest x-ray - Prominent upper lobe emphysema.
      FEV1 - 30% of predicted.
       
      Which of the features of her history, examination or investigations would preclude referral for lung reduction surgery?

      Your Answer: FEV1 30% predicted

      Correct Answer: pCO2 7.4

      Explanation:

      Nice guidelines for lung reduction surgery:

      FEV1 > 20% predicted
      PaCO2 < 7.3 kPa
      TLco > 20% predicted
      Upper lobe predominant emphysema

      This patient has pCO2 of 7.4 so she is unsuitable for referral for lung reduction surgery.

    • This question is part of the following fields:

      • Respiratory System
      108
      Seconds

  • Question 3 - A 32-year-old patient that has just returned from India, complains of dyspnoea. On...

    Correct

    • A 32-year-old patient that has just returned from India, complains of dyspnoea. On examination, you notice grey membranes on the uvula and tonsils and a low-grade fever. What is the most likely diagnosis?

      Your Answer: Diphtheria

      Explanation:

      Characteristic findings on patients suffering from diphtheria are the grey membrane on the uvula and tonsils together with the low grade fever and dyspnoea. It’s of great importance that the patient has recently been to India where there is a know prevalence.

    • This question is part of the following fields:

      • Infectious Diseases
      18.7
      Seconds

  • Question 4 - A 28-year-old 9 week pregnant woman is newly diagnosed with asthma. She is...

    Correct

    • 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: 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 theophyllines

      Use 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
      37
      Seconds

  • Question 5 - A 15-year-old boy presented to a urologist with a complaint of blood in...

    Incorrect

    • A 15-year-old boy presented to a urologist with a complaint of blood in the urine and pain in his abdomen. On examination, abdominal swelling is present and blood pressure is elevated. Which of the following is the most appropriate investigation in this case?

      Your Answer: CT

      Correct Answer: Ultrasound

      Explanation:

      Haematuria and abdominal swelling may indicate either polycystic kidney disease or a tumour. Because of the patient’s age, the likelihood of a tumorous growth is small, thus an ultrasound is the best choice for this case.

    • This question is part of the following fields:

      • Renal System
      63.4
      Seconds

  • Question 6 - A 60-year-old patient was admitted to the surgery department for elective herniorrhaphy. Due...

    Correct

    • A 60-year-old patient was admitted to the surgery department for elective herniorrhaphy. Due to a problem in his history, his operation was postponed. Which of the following is the most likely cause for this postponement?

      Your Answer: MI 2 months ago

      Explanation:

      After an MI, elective surgeries are recommended to be delayed for at least 6 months. This will help the patient become physically fit for the stress of surgery. Any surgery before this can carry a significant increased risk of mortality.

    • This question is part of the following fields:

      • Cardiovascular System
      36.1
      Seconds

  • Question 7 - A 60-year-old previously well male was admitted with a suspected pulmonary embolism. On...

    Correct

    • A 60-year-old previously well male was admitted with a suspected pulmonary embolism. On examination his BP was 130/80 mmHg and pulse rate was 88 bpm. His CXR was normal. He was treated with low molecular weight heparin. Which of the following is the most appropriate initial lung investigation for this patient?

      Your Answer: Computed tomographic pulmonary angiography

      Explanation:

      Computed tomographic pulmonary angiography (CTPA) is the standard investigative tool, used for diagnosing a pulmonary embolism. Pulmonary angiography is indicated if CTPA is not available.

    • This question is part of the following fields:

      • Cardiovascular System
      178
      Seconds

  • Question 8 - A 60-year-old Muslim man with type 2 diabetes comes to the clinic for...

    Incorrect

    • A 60-year-old Muslim man with type 2 diabetes comes to the clinic for advice. He is about to start fasting for Ramadan and he is not sure how to modify the administration of his diabetes medications. He is currently on metformin 500mg tds.

      What is the most appropriate advice?

      Your Answer: No change to the metformin dose

      Correct Answer: 500 mg at the predawn meal + 1000 mg at the sunset meal

      Explanation:

      Biguanides (Metformin):
      People who take metformin alone should be able to fast safely given that the possibility of hypoglycaemia is minimal. However, patients should modify its dose and administration timing to provide two-thirds of the total daily dose, which should be taken immediately with the sunset meal, while the other third is taken before the predawn meal.

      Thiazolidinediones: No change needed.

      Sulfonylurea:
      Once-daily sulfonylurea (such as glimepiride or gliclazide MR): the total daily dose should be taken with the sunset meal.
      Shorter-acting sulfonylurea (such as gliclazide twice daily): the same daily dose remains unchanged, and one dose should be taken at the sunset meal and the other at the predawn meal.
      Long-acting sulfonylurea (such as glibenclamide): these agents should be avoided.

      It is important that diabetic patients to eat a healthy balanced diet and choose foods with a low glycaemic index (such as complex carbohydrates), which can help to maintain blood glucose levels during fasting. Moreover, it is crucial to consume adequate fluids to prevent dehydration. Physical activity is encouraged, especially during non-fasting periods.

    • This question is part of the following fields:

      • Endocrine System & Metabolism
      22.1
      Seconds

  • Question 9 - A 50-year-old male presented with pain in the left lumbar region. His abdominal...

    Correct

    • A 50-year-old male presented with pain in the left lumbar region. His abdominal X-ray revealed stones in his left kidney. Analysis of one of the stones that he passed in the urine showed that it was composed of uric acid. Which of the following is the most likely cause of this type of renal stone?

      Your Answer: Thiazide diuretics

      Explanation:

      Like all diuretics, thiazide diuretics decrease the amount of body fluid. This leads to an increase in the concentration of uric acid in the body; hence the chances of forming uric acid stones.
      Allopurinol is actually a drug used to treat gout, reducing uric acid levels in the body. Therefore, allopurinol would rather decrease the chances of having uric acid stones.
      Primary hyperparathyroidism is not concerned with uric acid stones. It is related to calcium metabolism and hence, calcium stones.

    • This question is part of the following fields:

      • Renal System
      31.3
      Seconds

  • Question 10 - A 51-year-old man was admitted with right-sided hemiparesis and right upper motor neuron...

    Correct

    • A 51-year-old man was admitted with right-sided hemiparesis and right upper motor neuron facial nerve palsy. He was known to be on warfarin for a mitral valve replacement and had been adequately anticoagulated. He was also taking furosemide and had recently been started on St John's wort for low mood.

      On examination, his pulse was 90 bpm and regular, and his blood pressure was 150/80 mmHg. Cardiac examination demonstrated normal prosthetic valve sounds with an ejection systolic murmur at the left sternal edge. CT scan showed evidence of a left middle cerebral artery infarction.

      What is the possible explanation for the presentation?

      Your Answer: St John's wort reduces the activity of warfarin

      Explanation:

      St John’s wort interferes with warfarin by increasing its breakdown and decreasing its effectiveness. This leads to the need for adjustment in the dose of warfarin and careful attention to monitoring if the patient decides to continue with the drug. Ideally, an alternative antidepressant should also be considered.

    • This question is part of the following fields:

      • Haematology & Oncology
      93.2
      Seconds

  • Question 11 - A 74-year-old man who has been diagnosed with atrial fibrillation and heart failure...

    Correct

    • A 74-year-old man who has been diagnosed with atrial fibrillation and heart failure is being started on digoxin. What is the mechanism of action of digoxin?

      Your Answer: Inhibits the Na+/K+ ATPase pump

      Explanation:

      Digoxin acts by inhibiting the Na+/K+ ATPase pump.
      Digoxin is a cardiac glycoside now mainly used for rate control in the management of atrial fibrillation. As it has positive inotropic properties it is sometimes used for improving symptoms (but not mortality) in patients with heart failure.

      Mechanism of action:
      It decreases the conduction through the atrioventricular node which slows the ventricular rate in atrial fibrillation and atrial flutter.
      It increases the force of cardiac muscle contraction due to inhibition of the Na+/K+ ATPase pump. It also stimulates the vagus nerve.

      Digoxin toxicity:
      Plasma concentration alone does not determine whether a patient has developed digoxin toxicity. The likelihood of toxicity increases progressively from 1.5 to 3 mcg/l.
      Clinical feature of digoxin toxicity include a general feeling of unwell, lethargy, nausea & vomiting, anorexia, confusion, xanthopsia, arrhythmias (e.g. AV block, bradycardia), and gynaecomastia

      Precipitating factors:
      Hypokalaemia
      Increasing age
      Renal failure
      Myocardial ischemia
      Hypomagnesaemia, hypercalcemia, hypernatremia, acidosis
      Hypoalbuminemia
      Hypothermia
      Hypothyroidism
      Drugs: amiodarone, quinidine, verapamil, diltiazem, spironolactone (competes for secretion in the distal convoluted tubule, therefore, reduce excretion), ciclosporin. Also, drugs that cause hypokalaemia e.g. thiazides and loop diuretics.

      Management of digoxin toxicity:
      Digibind
      Correct arrhythmias
      Monitor and maintain potassium levels within the normal limits.

    • This question is part of the following fields:

      • Pharmacology
      13.2
      Seconds

  • Question 12 - Which of the following is the most common clinical feature of carbon monoxide...

    Correct

    • Which of the following is the most common clinical feature of carbon monoxide poisoning?

      Your Answer: Headache

      Explanation:

      The symptoms and signs of carbon monoxide poisoning are variable and nonspecific. The most common symptoms of CO poisoning are headache, dizziness, weakness, nausea, vomiting, chest pain, and altered mental status.

      The clinical presentation of CO poisoning is the result of its underlying systemic toxicity. Its effects are caused not only by impaired oxygen delivery but also by disrupting oxygen utilization and respiration at the cellular level, particularly in high-oxygen demand organs (i.e., heart and brain).

      Symptoms of severe CO poisoning include malaise, shortness of breath, headache, nausea, chest pain, irritability, ataxia, altered mental status, other neurologic symptoms, loss of consciousness, coma, and death; signs include tachycardia, tachypnea, hypotension, various neurologic findings including impaired memory, cognitive and sensory disturbances; metabolic acidosis, arrhythmias, myocardial ischemia or infarction, and noncardiogenic pulmonary edema, although any organ system might be involved.

    • This question is part of the following fields:

      • Pharmacology
      16.2
      Seconds

  • Question 13 - A 51-year-old woman recently put on antihypertensives showed the following results on 2...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Pharmacology
      39.5
      Seconds

  • Question 14 - Fabry's disease is a rare genetic disorder that leads to excessive deposition of...

    Incorrect

    • Fabry's disease is a rare genetic disorder that leads to excessive deposition of neutral glycosphingolipids in the vascular endothelium of several organs and in epithelial and smooth muscle cells. Which of the following is least likely to be associated with Fabry's disease?

      Your Answer: Pain is the most debilitating symptom in childhood

      Correct Answer: Inherited in an autosomal dominant fashion

      Explanation:

      Fabry disease (Angiokeratoma corporis diffusum) is an X-linked lysosomal disorder which occurs due to deficiency or absence of alpha-galactosidase A (?-GAL A) activity as a result of a genetic mutation in the GLA gene. As Fabry’s disease follows X-linked genetics it manifestis predominantly in men. Ongoing burning, tingling pain and discomfort, known as acroparesthesia, mainly affecting the hands and feet is the most debilitating symptom in childhood.

    • This question is part of the following fields:

      • Musculoskeletal System
      52.4
      Seconds

  • Question 15 - An 18-year-old male presented to the OPD with complaints of abdominal pain and...

    Correct

    • An 18-year-old male presented to the OPD with complaints of abdominal pain and diarrhoea. There is a history of pubertal delay. On examination, he has pallor and looks short for his age. Tissue biopsy of the small intestines reveals damaged villi. Which of the following is the most likely cause of this condition?

      Your Answer: Coeliac disease

      Explanation:

      Celiac disease has characteristic shortened intestinal villi. When patients with celiac disease eat products containing gluten, they are unable to absorb the nutrients due to flattened or shortened intestinal villi. The blistering rash present on the patient’s elbows strongly suggests celiac disease. This rash is a sign of the condition Dermatitis Herpetiformis which is associate with celiac disease. Therefore, it is also often called ‘gluten rash’.

    • This question is part of the following fields:

      • Gastrointestinal System
      21.9
      Seconds

  • Question 16 - A 61-year-old gentleman presents with pain in his right flank and haematuria. A...

    Incorrect

    • A 61-year-old gentleman presents with pain in his right flank and haematuria. A CT scan of the abdomen reveals a large 8 × 8 cm solid mass in the right kidney and a 3 × 3 cm solid mass occupying the upper pole of the left kidney.

      What is the most appropriate treatment for this patient?

      Your Answer: Right radical nephrectomy and biopsy of the mass on the left side

      Correct Answer: Right radical nephrectomy and left partial nephrectomy

      Explanation:

      This patient presents with the classic triad of renal carcinoma: haematuria, loin pain and a mass in the kidneys. Management will entail right radical nephrectomy because of the 8x8cm solid mass and a left partial nephrectomy of the 3x3cm solid mass.

    • This question is part of the following fields:

      • Renal System
      58.7
      Seconds

  • Question 17 - A 70-year-old male came to the OPD with complaints of nocturia, difficulty in...

    Correct

    • A 70-year-old male came to the OPD with complaints of nocturia, difficulty in initiating urination and continuous dribbling of urine afterwards. A transrectal US guided biopsy was performed and the diagnosis of BPH was made. His TURP was planned. Which of the following electrolyte imbalance is most likely to occur?

      Your Answer: Hyponatremia

      Explanation:

      In a TURP procedure, fluid is used to irrigate the bladder and to remove blood clots. IV fluids are also given to the patient post-operatively. These factors will lead to dilutional hyponatremia.

    • This question is part of the following fields:

      • Fluids & Electrolytes
      56
      Seconds

  • Question 18 - Which of the following allows for a diagnosis of diabetes mellitus? ...

    Correct

    • Which of the following allows for a diagnosis of diabetes mellitus?

      Your 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
      39.3
      Seconds

  • Question 19 - A woman is being seen at the clinic. Her clinic notes are missing...

    Incorrect

    • A woman is being seen at the clinic. Her clinic notes are missing and the only results available are lung function tests. Her date of birth is also missing from the report. 
      FEV1 0.4 (1.2-2.9 predicted)
      Total lung capacity 7.3 (4.4-6.8 predicted)
      Corrected transfer factor 3.3 (4.2-8.8 predicted)
       
      Which disease can be suspected From these results?

      Your Answer: Severe chronic obstructive pulmonary disease

      Correct Answer: Moderate COPD

      Explanation:

    • This question is part of the following fields:

      • Respiratory System
      109
      Seconds

  • Question 20 - A 46-year-old man presents with a swollen, red, and painful left calf. He...

    Incorrect

    • A 46-year-old man presents with a swollen, red, and painful left calf. He does not have a history of any recent surgery or a long-haul flight. He is generally fit and well and takes no regular medication other than propranolol for migraine prophylaxis. There is also no history of venous thromboembolism (VTE) in his family.

      The patient is referred to the deep vein thrombosis (DVT) clinic where he is diagnosed with a proximal DVT in his left calf. Following the diagnosis, he is started on low-molecular-weight heparin (LMWH) whilst awaiting review by the warfarin clinic.

      Other than commencing warfarin, what further action, if any, is required?

      Your Answer: Check anti-phospholipid antibodies + hereditary thrombophilia screening

      Correct Answer: Investigate for underlying malignancy + check antiphospholipid antibodies

      Explanation:

    • This question is part of the following fields:

      • Haematology & Oncology
      68.6
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Nervous System (0/1) 0%
Respiratory System (1/3) 33%
Infectious Diseases (1/1) 100%
Renal System (1/3) 33%
Cardiovascular System (2/2) 100%
Endocrine System & Metabolism (1/2) 50%
Haematology & Oncology (1/2) 50%
Pharmacology (3/3) 100%
Musculoskeletal System (0/1) 0%
Gastrointestinal System (1/1) 100%
Fluids & Electrolytes (1/1) 100%
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