-
Question 1
Incorrect
-
A 72-year-old woman presents with a 3 month history of colicky abdominal pain after eating, and diarrhoea. She has lost 7 kg in weight over the last few months. A recent gastroscopy and colonoscopy were normal. Her past medical history includes angina and a right carotid endarterectomy at the age of 62 years. Her current medication includes aspirin, atenolol, simvastatin and losartan.
right carotid endarterectomy at the age of 62 years. Her current medication includes aspirin, atenolol, simvastatin and losartan.
Blood tests revealed:
Haemoglobin (Hb) 118 g/l
Mean corpuscular volume (MCV) 80 fl
White cell count (WCC) 12.3 x 109/l
Platelets 210 x 109/l
Na+ 133 mmol/l
K+ 5.2 mmol/l
Urea 8.1 mmol/l
Creatinine 134 mmol/l
Select the most appropriate further investigations.Your Answer: Gastroscopy
Correct Answer: Contrast-enhanced computed tomography (CT) of the abdomen
Explanation:The patient is 74 years old. She has had a recent gastroscopy and colonoscopy. She has a history of angina and a right CEA. She is having colicky abdominal pain after meals and weight loss, which points to a possible diagnosis of chronic mesenteric ischemia. Thus, you would want to do a contrast-enhanced CT scan of the abdomen to look for this. A 24 hour cardiac monitor would also be helpful to look for any abnormal rhythm that could be a potential aetiology of her disease.
-
This question is part of the following fields:
- Gastrointestinal System
-
-
Question 2
Correct
-
A 28-year-old female with a history of psoriatic arthritis would most likely have which of the following hand conditions?
Your Answer: Nail dystrophy
Explanation:Nail dystrophy (pitting of nails, onycholysis, subungual hyperkeratosis), dactylitis, sausage shaped fingers are most commonly seen with psoriatic arthropathy. There is asymmetric joint involvement most commonly distal interphalangeal joints. Uveitis and sacroiliitis may also occur. Arthritis mutilans may occur but is very rare. Cutaneous lesions may or may not develop. When they do, its usually much after the symptoms of arthritis.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 3
Incorrect
-
A 28-year-old female presented with complaints of joint pains, myalgia, haematuria and a facial rash which exacerbates on exposure to sunlight. RFTs show raised urea and creatinine, and there were red cell casts on urine microscopy. The investigation of choice in this case would be?
Your Answer: Renal biopsy
Correct Answer: Auto antibodies
Explanation:Considering the history and presenting complaints, this patient is most likely suffering from systemic lupus erythematosus, which will be confirmed by testing for auto antibodies like ANA, anti ds DNA, anti histone antibodies etc.
-
This question is part of the following fields:
- Immune System
-
-
Question 4
Correct
-
A 28-year-old manual worker had stepped on a rusty nail. He says he received tetanus toxoid 8 years ago. What should be done for him now?
Your Answer: Human immunoglobulin only
Explanation:Only immunoglobulins are required, as he is already immunized.
-
This question is part of the following fields:
- Endocrine System & Metabolism
-
-
Question 5
Correct
-
Which of the following is most likely linked to male infertility in cystic fibrosis?
Your Answer: Failure of development of the vas deferens
Explanation:The vas deferens is a long tube that connects the epididymis to the ejaculatory ducts. It acts as a canal through which mature sperm may pass through the penis during ejaculation.
Most men with CF (97-98 percent) are infertile because of a blockage or absence of the vas deferens, known as congenital bilateral absence of the vas deferens (CBAVD). The sperm never makes it into the semen, making it impossible for them to reach and fertilize an egg through intercourse. The absence of sperm in the semen can also contribute to men with CF having thinner ejaculate and lower semen volume.
-
This question is part of the following fields:
- Respiratory System
-
-
Question 6
Incorrect
-
Which of the following procedures does not require antibiotic prophylaxis?
Your Answer: Emergency sigmoid colectomy
Correct Answer: Dental procedure for a patient with an atrial septal defect
Explanation:According to latest NICE guidelines, patients with isolated atrial septal defects do not require prophylactic antibiotics originally used in prevention of infective endocarditis in dental procedures.
-
This question is part of the following fields:
- Infectious Diseases
-
-
Question 7
Incorrect
-
A 60-year-old female presented after an acute overdose of amiodarone. Her blood pressure was 110/70 mmHg and pulse rate was 35 bpm. She was given 500 mcg of atropine but there was no response. Which of the following is the most appropriate next step?
Your Answer: Glucagon
Correct Answer: Isoprenaline
Explanation:Permanent pacing is not indicated as the bradycardia is reversible. Temporary pacing is the definite treatment. Isoprenaline can be used until temporary pacing is available.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 8
Correct
-
From the following responses, what is the commonest cardiovascular abnormality associated with Marfan's syndrome of an adult?
Your Answer: Aortic root dilatation
Explanation:The main cardiovascular manifestations associated with Marfan’s syndrome are aortic dilatation and mitral valve prolapse.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 9
Incorrect
-
Which one of the following features is least recognised in long-term lithium use?
Your Answer: Weight gain
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
-
-
Question 10
Incorrect
-
A 25-year-old woman comes to the endocrine clinic for her regular follow up. She has hypertension, controlled by a combination of Ramipril and indapamide and was diagnosed with 11-beta hydroxylase deficiency since birth when she was found to have clitoromegaly.
Which of the following is most likely to be elevated?Your Answer: 17-OH progesterone
Correct Answer: 11-Deoxycortisol
Explanation:11-beta hydroxylase is stimulated by ACTH and responsible for conversion of 11-deoxycortisol to cortisol and deoxycorticosterone to corticosterone.
In 11-beta hydroxylase deficiency, the previously mentioned conversions are partially blocked, leading to:
– Increased levels of ACTH
– Accumulation of 11-deoxycortisol (which has limited biological activity) and deoxycorticosterone (which has mineralocorticoid activity)
– Overproduction of adrenal androgens (DHEA, androstenedione, and testosterone) -
This question is part of the following fields:
- Endocrine System & Metabolism
-
-
Question 11
Incorrect
-
A 32-year-old man presents with progressive central abdominal pain and vomiting associated with significant weight loss (five stone in 3 months).He gives a history of binge drinking and depression, and smokes twenty cigarettes per day. Because eating provokes abdominal pain and vomiting, he has eaten virtually nothing for a month. CT scanning of his abdomen showed a normal pancreas but dilated loops of small bowel with a possible terminal ileal stricture. His albumin level was 20 and C-reactive protein level was 50. Which statement is NOT true?
Your Answer: Chronic pancreatitis is very unlikely in view of the normal CT
Correct Answer: Infliximab should be prescribed as soon as possible
Explanation:Stricturing is associated with Crohn’s disease, and elevated CRP supports this diagnosis in this patient, as well. Infliximab should not yet be started. Acute treatment is steroids (of a flare) however this man needs surgery. Although surgery should be avoided if at all possible in Crohn’s disease, and minimal surgery should occur (resecting as little as possible, given possible need for future resections), including possible stricturoplasty instead of resection. Chronic pancreatitis is unlikely given it would not cause stricture. Patients undergoing surgery should always have informed consent, which always includes risk of a stoma for any bowel surgery. Given the amount of weight he has lost he is at significant risk for refeeding syndrome, which can cause hypokalaemia, hypophosphatemia and hypomagnesemia.
-
This question is part of the following fields:
- Gastrointestinal System
-
-
Question 12
Correct
-
A young woman presents to the emergency after being involved in a fight where she was stabbed in the neck. On examination, her tongue deviates to the right side on protrusion. Which of the following nerves is involved?
Your Answer: Hypoglossal nerve injury
Explanation:The motor functions of the intrinsic tongue muscles, as well as the genioglossus, hyoglossus, and styloglossus muscles, are all innervated by the hypoglossal nerve. These muscles are essential for swallowing and speech. To test nerve function, the physical examiner has a patient protrude his or her tongue. In intranuclear, or lower motor neuron lesions, the tongue deviates toward the injured side, as the contralateral genioglossus is acting unopposed. In contrast, supranuclear (upper motor neuron) lesions result in deviation away from the lesion. In addition to causing deviation toward the lesion, an injury involving a hypoglossal nucleus may result in tongue atrophy and fasciculation
-
This question is part of the following fields:
- Nervous System
-
-
Question 13
Correct
-
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 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
-
-
Question 14
Correct
-
A 50-year-old male was under treatment for bipolar disease. He was brought to the emergency department as he had become increasingly confused over the past two days. He had vomiting and diarrhoea. He was also consuming and passing a lot of water.
On examination, he was disoriented. He had vertical nystagmus and was ataxic.
What two investigations are likely to lead to the correct diagnosis?Your Answer: Desmopressin test and serum lithium level
Explanation:Desmopressin test (done to differentiate nephrogenic diabetes insipidus from central diabetes insipidus), and serum lithium levels can together confirm a diagnosis of lithium-induced nephrogenic diabetes insipidus.
Bipolar disease is most often managed with mood stabilizers like lithium. This patient develops gastrointestinal symptoms followed by an acute confusional state associated with polyuria and polydipsia. These symptoms are suggestive of diabetes insipidus.
In a case where these symptoms occur in a bipolar patient under treatment, lithium-induced nephrogenic diabetes insipidus should be considered as the most probable cause.
Lithium intoxication can present with symptoms of nausea, vomiting, mental dullness, action tremor, weakness, ataxia, slurred speech, blurred vision, dizziness, especially vertical nystagmus and stupor or coma. Diffuse myoclonic twitching and nephrogenic diabetes insipidus can also occur. Such a clinical syndrome occurs above the serum level of lithium of 1.5-2.0 mEq/L.
Management:
– Correcting electrolyte abnormalities in patients with acute disease is critical and often life-saving.
– Treatment should be initiated with parenteral fluids to replete hypovolemia (normal saline at 200-250 mL/h), followed by administration of hypotonic fluid (0.5% normal saline).
– On the restoration of the volume status of the patient forced diuresis should be initiated by the administration of parenteral furosemide or bumetanide accompanied by continued intravenous hypotonic fluid administration to maintain volume status.
– Polyuria is managed with hydrochlorothiazide combined with amiloride, acetazolamide. -
This question is part of the following fields:
- Emergency & Critical Care
-
-
Question 15
Incorrect
-
A 67 year-old attorney presents with a 2 month history of tremors affecting his left arm. He suffers from depressive psychosis for the last 10 years, for which he has been receiving intermittent chlorpromazine and amitriptyline but has not been on any therapy for the last 4 months. He describes that his two brothers also had tremors. Upon examination, he has a resting tremor of his left hand with cogwheel rigidity of that arm and mild generalized bradykinesia. Which of the following is the most likely diagnosis?
Your Answer: Drug-induced parkinsonism
Correct Answer: Idiopathic Parkinson's disease
Explanation:The most likely diagnosis is idiopathic Parkinson’s disease because of the unilateral presentation. In addition, cogwheel rigidity is a classic presenting symptom. Neuroleptic-induced parkinsonism is usually bilateral and symmetrical. Essential tremors do not cause rest tremors.
-
This question is part of the following fields:
- Nervous System
-
-
Question 16
Correct
-
Which of the following findings would point towards a diagnosis of neonatal hypothyroidism?
Your Answer: Mother has hyperthyroidism
Explanation:Transient congenital hypothyroidism can be due to: iodine deficiency or excess, maternal consumption of goitrogens or antithyroid medications during pregnancy, transplacental passage of TSH receptor-blocking antibodies, and neonatal very low birth weight and prematurity
-
This question is part of the following fields:
- Endocrine System & Metabolism
-
-
Question 17
Correct
-
A 3-year-old boy presents with recurrent urinary tract infections. What is the most common cause for this problem in a child of this age?
Your Answer: Vesicoureteric reflux
Explanation:Vesicoureteral reflux is the condition when the urine flows backwards from the bladder into the kidneys, which is the most common cause of UTI in patients this age.
-
This question is part of the following fields:
- Renal System
-
-
Question 18
Incorrect
-
A 51-year-old real estate agent takes hydrocortisone 20mg in the mornings and 5mg at night for Addison's disease. The endocrinology consultant would like her to take prednisolone instead.
What dose of prednisolone should be started?Your Answer: 10 mg
Correct Answer: 7 mg
Explanation:1mg Prednisolone = 4mg hydrocortisone, so the actual equivalent daily dose is 7mg.
-
This question is part of the following fields:
- Pharmacology
-
-
Question 19
Correct
-
An 82-year-old woman is brought in by her carer with fluctuating consciousness. On examination she is deeply jaundiced, hypotensive with a tachycardia and has a hepatic flap. Initial blood tests reveal an ALT of 1000 U/l, INR 3.4, ALP 600 U/l and a bilirubin of 250 mmol/l.
Repeat blood tests 6 hours later show an ALT of 550 U/l, INR 4.6, ALP 702 U/l and bilirubin of 245 m mol/l. The toxicology screen for paracetamol and aspirin is negative; she is positive for hepatitis B surface antibody and negative for hepatitis B surface antigen.
Which of the following would best explain her clinical condition?Your Answer: Acute liver failure secondary to paracetamol
Explanation:Liver flap is pathognomonic for liver failure. Paracetamol (also known as acetaminophen) overdose usually presents with symptoms including liver failure, resulting in confusion, jaundice, and coagulopathy a few days after overdose. The first 24 hours, people usually have minimal symptoms. Diagnosis is based on blood levels of acetaminophen at specific times after it was taken (see reference). If she took it a few days ago, levels may indeed be undetectable. The hepatitis B serology suggests prior vaccination. Wilson’s disease is not the most likely diagnosis given her presentation. The AST:ALT ratio would be expected to be reversed in alcohol induced liver failure.
-
This question is part of the following fields:
- Hepatobiliary System
-
-
Question 20
Incorrect
-
A 35-year-old chronic smoker complains of pain in the calf while walking. This symptom has been increasing in severity for 4 months. There is a painful ulcer at the base of left first toe, which despite treatment has not improved. Dorsalis pedis and posterior tibial pulses were absent on the same side. What is the most compatible diagnosis of this presentation?
Your Answer: Deep Vein Thrombosis
Correct Answer: Thromboangitis Obliterans
Explanation:Thromboangitis obliterans or Buerger’s disease is an inflammatory vasculopathy which is characterized by an inflammatory endarteritis and mainly affects small and medium-sized arteries as well as veins of the upper and lower extremities. It is caused by a prothrombotic state and subsequent obstruction of blood vessels. Ischemic pain, features of inflammation along the vein affected, Raynaud’s phenomenon and painful non-healing ulcers are common presentations.
-
This question is part of the following fields:
- Emergency & Critical Care
-
SESSION STATS - PERFORMANCE PER SPECIALTY
