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Question 1
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A 28-year-old male was admitted with severe central abdominal pain managed as an acute pancreatitis due to his serum amylase being markedly elevated. He is a known epileptic patient and has been on anti-epileptics. What would be the antiepileptic drug responsible for this clinical presentation?
Your Answer: Sodium valproate/Carbamazepine
Explanation:Both Sodium valproate and Carbamazepine are correct. These drugs can cause drug induced pancreatitis however more cases have been reported with Sodium valproate.
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This question is part of the following fields:
- Gastrointestinal System
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Question 2
Correct
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A 68-year-old man presents with acute symptoms of gout on his first metatarsophalangeal joint. Which option best explains the underlying mechanism of gout?
Your Answer: Decreased renal excretion of uric acid
Explanation:Primary gout is related more often to underexcretion of uric acid or overproduction.
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This question is part of the following fields:
- Musculoskeletal System
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Question 3
Incorrect
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A 16-year-old female has been admitted to hospital after overdosing on paracetamol 4 hours ago. She has also consumed a large amount of alcohol. Her plasma paracetamol concentration is only just below a level which requires treatment. From the list of options, choose the most appropriate treatment option for this patient.
Your Answer: N-acetylcysteine
Correct Answer: Refer to psychiatry ward
Explanation:As her paracetamol level is under the required treatment threshold, she requires no medical treatment. However, she has taken a simultaneous drug overdose and excessive alcohol consumption. These two factors together require psychiatric evaluation and so she should be referred to the psychiatry ward.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 4
Incorrect
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A 44-year-old man complains of unceasing chest pain which is aggravated by inspiration four weeks after his MI. His temperature is 37.5C and ESR is 45mm/h. What is the single most likely explanation for the abnormal investigations
Your Answer: Acute pericarditis
Correct Answer: Dressler syndrome
Explanation:Dressler syndrome signs and symptoms include pericarditis, low-grade fever, and pleuritic chest pain. It commonly occurs two to five weeks following the initial event or for as long as three months.
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This question is part of the following fields:
- Cardiovascular System
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Question 5
Correct
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A 76-year-old lady with known carcinoma of the caecum, was admitted to the hospital for right hemicolectomy. She had a history of osteoarthritis for which she was taking nonsteroidal anti-inflammatory agents (NSAIDs), intermittently. Two years ago, she had a fibroma removed from her right breast as well. The patient was a non-smoker and drank approximately 8 units of alcohol per week.
Investigations carried out pre-operatively showed:
Hb: 10.8 g/dL
MCV: 75 fL
WCC: 8.4 x10^9/L
Plts: 402 x10^9/L
The surgery remained uncomplicated, and she was given two units of packed red blood cells postoperatively. Three days later, she has now become jaundiced and complains of fatigue.
Her blood count now shows:
Hb: 7.2 g/dL
MCV: 110 fL
WCC: 9.5 x10^9/L
Plts: 395 x10^9/L
Which of the following is the best investigation to confirm the diagnosis?Your Answer: Direct Coombs test
Explanation:The direct Coombs test will specifically confirm immune-mediated haemolysis occurring post-transfusion in the aforementioned case.
There are two types of Coombs test used in immunohematology and immunology:
1. Direct Coombs test – It confirms autoimmune haemolytic anaemia by detecting antibodies or complement proteins attached to the surface of red blood cells.
2. Indirect Coombs test – It is used in prenatal testing of pregnant women and in testing prior to a blood transfusion. It detects antibodies floating freely in the blood, against foreign red blood cells.
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This question is part of the following fields:
- Haematology & Oncology
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Question 6
Incorrect
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Which of the following stimulates the secretion of gastrin?
Your Answer: Somatostatin
Correct Answer: Amino acids
Explanation:Gastrin is released from G cells in the antrum of the stomach after a meal. It stimulates parietal cells to release HCl. Gastrin is stimulated by a number of things: antrum distention, vagal stimulation, peptides (especially amino acids) in the stomach, hypercalcemia. Gastrin release is inhibited by acid, SST, GIP, VIP, secretin, glucagon, and calcitonin.
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This question is part of the following fields:
- Gastrointestinal System
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Question 7
Correct
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A 56-year-old obese female presents due to moderate pain in her finger joints which occurs mostly at the end of the day which gets better with rest. There is also some associated swelling. On examination, there is enlargement of her distal interphalangeal joints and tenderness to palpation. Which of the following is the most likely diagnosis?
Your Answer: Osteoarthritis
Explanation: -
This question is part of the following fields:
- Musculoskeletal System
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Question 8
Correct
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A 68-year-old male patient presents with central chest pain and associated flushing. He claims the pain is crushing in character. ECG reveals T wave inversion in II, III and AVF. Blood exams are as follows: Troponin T = 0.9 ng/ml. Which substance does troponin bind to?
Your Answer: Tropomyosin
Explanation:Troponin T is a 37 ku protein that binds to tropomyosin, thereby attaching the troponin complex to the thin filament.
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This question is part of the following fields:
- Musculoskeletal System
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Question 9
Correct
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A 25-year-old girl's ECG revealed a normal PR interval and QRS while the QT is prolonged. History reveals she has been having frequent fainting attacks since childhood. What is the cause of these syncopal attacks?
Your Answer: Torsade de pointes
Explanation:Patients with a long QT wave syndrome are prone to recurrent syncope if they have Torsade’s de pointes since it degenerates into fibrillation of the ventricles.
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This question is part of the following fields:
- Cardiovascular System
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Question 10
Incorrect
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Which of the given adverse effects should be anticipated following the administration of an anticholinesterase?
Your Answer: Bradycardia and mydriasis
Correct Answer: Bradycardia and miosis
Explanation:Bradycardia and miosis should be anticipated following the administration of anticholinesterases.
Anticholinesterase agents include the following medications:
– Pyridostigmine, neostigmine, and edrophonium which play a significant role in the diagnosis and the management of myasthenia gravis.
– Rivastigmine, galantamine and donepezil are cholinesterase inhibitors found to be significantly useful in the management of Alzheimer’s disease.Mechanism of action and pharmacological effects:
Inhibition of cholinesterase increases the level and the duration of action of acetylcholine within the synaptic cleft.Thus, cholinergic effects such as a reduction in heart rate (bradycardia), miosis (pupillary constriction), increased secretions, increased gastrointestinal motility and reduction in BP may occur with anticholinesterases.
Toxins such as organophosphates and carbamates also are primarily anticholinergic and cause the following typical SLUDGE symptoms:
– Salivation
– Lacrimation
– Urination
– Diaphoresis
– Gastrointestinal upset
– Emesis -
This question is part of the following fields:
- Pharmacology
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Question 11
Correct
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A 25-year-old woman is presenting with diarrhoea and abdominal bloating over the last 4 months. On examination, she has a blistering rash over her elbows. Biochemical investigation showed that she has low serum albumin, calcium and folate concentrations. On jejunal biopsy there is shortening of the villi and lymphocytosis. What is the most likely cause?
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’.
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This question is part of the following fields:
- Gastrointestinal System
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Question 12
Incorrect
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Which one of the following conditions is least likely to be associated with pyoderma gangrenosum?
Your Answer: IgA monoclonal gammopathy
Correct Answer: Syphilis
Explanation:The following are conditions commonly associated with pyoderma gangrenosum:
Inflammatory bowel disease:
– Ulcerative colitis
– Crohn’s disease
Arthritides:
– Rheumatoid arthritis
– Seronegative arthritis
Haematological disease:
– Myelocytic leukaemia[8]
– Hairy cell leukaemia
– Myelofibrosis
– Myeloid metaplasia
– Monoclonal gammopathy
Autoinflammatory disease:
– Pyogenic sterile arthritis, pyoderma gangrenosum, and acne syndrome (PAPA syndrome)
– Granulomatosis with polyangiitis -
This question is part of the following fields:
- The Skin
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Question 13
Incorrect
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A 74-year-old man presents to the physician with complaints of hoarseness of voice and cough for the past 3 weeks. The patient has been a smoker and quit 3 years ago. Radiological examination reveals a mass in the mediastinum. Which investigation should be employed to establish a diagnosis?
Your Answer: CT thorax
Correct Answer: LN biopsy
Explanation:Masses in the middle mediastinum most commonly represent lymph nodes that are enlarged by a malignant, infectious, or inflammatory process. Masses in the posterior mediastinum are usually benign tumours or cysts originating from either the nerves that are present in this area (neurogenic tumours) or from the oesophagus (foregut duplication cysts). Lymph node biopsy would be the ideal choice of investigation in this case.
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This question is part of the following fields:
- Respiratory System
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Question 14
Correct
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A 42-year-old male patient who was on enalapril for hypertension presented with generalized body weakness. Investigations revealed hyperkalaemia. Which of the following can be expected in his ECG?
Your Answer: Tall, tented T waves
Explanation:In hyperkalaemia the ECG will show tall, tented T waves as well as small P waves and widened QRS complexes.Â
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This question is part of the following fields:
- Cardiovascular System
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Question 15
Correct
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Question 16
Correct
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A 21-year-old woman presents with lethargy and confusion. On examination, you note a purpuric rash covering the abdominal wall and thighs, and a fever of 38C. Investigations reveal haemolytic anaemia, thrombocytopenia, and acute kidney injury.
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Which feature of the presentation makes the diagnosis of thrombotic thrombocytopenic purpura more likely than haemolytic uremic syndrome?Your Answer: Confusion
Explanation:Confusion in the patient refers to neurological symptoms that are more associated with thrombotic thrombocytopenic purpura than with haemolytic uremic syndrome. All the other symptoms present in both conditions similarly.
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This question is part of the following fields:
- Renal System
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Question 17
Correct
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Which one of the following immunological changes is seen in progressive HIV infection?
Your Answer: Increase in B2-microglobulin levels
Explanation:The immunological changes in HIV include depletion in CD4+ T cell, cytokine dysregulation and immune dysfunction. The dominant immunologic feature of HIV infection is progressive depletion of the helper T cell (CD4+ T cell), which reverses the normal CD4:CD8 ratio and subsequently lead to immunodeficiency. Other imuunological changes include:
increased B2-microglobulin
decreased IL-2 production
polyclonal B-cell activation
decreased NK cell function
reduced delayed hypersensitivity responses -
This question is part of the following fields:
- Infectious Diseases
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Question 18
Correct
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A 23-year-old man is being investigated for excessive bleeding following a tooth extraction.
His coagulation profile shows:
Plts: 173 x 10^9/L
PT: 12.9 secs
APTT: 84 secs
Which clotting factor is he most likely deficient in?Your Answer: Factor VIII
Explanation:The patient is most likely a case of haemophilia A which is the genetic deficiency of clotting factor VIII in blood.
Haemophilia is an X-linked recessive disorder of coagulation. Up to 30% of patients have no family history of the condition. Haemophilia A is more common than haemophilia B and accounts for 90% of the cases. In haemophilia B (Christmas disease), there is a deficiency of clotting factor IX.
Characteristic features of haemophilia include hemarthrosis, haematomas, and prolonged bleeding following trauma or surgery. Coagulation profile of a haemophiliac person shows prolonged bleeding time, activated partial thromboplastin time (APTT), thrombin time (TT), but a normal prothrombin time (PT).
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This question is part of the following fields:
- Haematology & Oncology
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Question 19
Correct
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A 69-year-old diabetic female presents for a regular outpatient visit. Her BMI is calculated to be 33. Lab results: GFR=29, Urea=13, Creatinine=390 mmol/L. Which of the following drugs should ideally be used by this patient?
Your Answer: Insulin
Explanation:The management of patients with diabetes and nephropathy necessitates attention to several aspects of care. Importantly, glycaemic control should be optimized for the patient, attaining the necessary control to reduce complications but done in a safe, monitored manner. Screening for development of nephropathy should be performed on a regular basis to identify microalbuminuria or reductions in GFR and if identified, the diabetes regimen should be tailored accordingly. Prevention and treatment of diabetic nephropathy and other complications necessitates a multifactorial approach. From the options provided insulin is the most suitable as sulfonylureas and biguanides are contraindicated in renal failure. Glitazones are known to cause many side effects including fluid retention and oedema. Hence, insulin will be the best option in this scenario.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 20
Correct
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A 32-year-old woman presents with a painful elbow which she has been feeling for the past two weeks. Which of the following will be consistent with a diagnosis of tennis elbow?
Your Answer: Pain on wrist extension against resistance
Explanation:Lateral epicondylitis (tennis elbow) is an overuse injury of the hand and finger extensor tendons that originate in the lateral humeral epicondyle that occurs following repeated or excessive pronation/supination and extension of the wrist (e.g., in racquet sports). Clinical features include pain and tenderness over the lateral epicondyle and along extensor muscles and thickening of the tendons. The examiner holds the patient’s hand with the thumb placed over the lateral epicondyle – The patient makes a fist, supinates the forearm, deviates radially, and extends the fist against the examiner’s resistance which will result in pain over the lateral epicondyle. Conservative treatment includes rest, physiotherapy and orthotic braces. If this fails corticosteroids and lidocaine injections are employed. Surgery is indicated in patients with persistent symptoms despite 6 months of conservative treatment. Excision of abnormal tendon tissue; longitudinal incisions (tenotomies) in scarred and fibrotic areas to promote healing.
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This question is part of the following fields:
- Musculoskeletal System
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Question 21
Correct
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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
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This question is part of the following fields:
- Nervous System
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Question 22
Correct
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A 43-year-old right-handed migraineur is admitted to hospital having developed paraesthesia affecting her left arm. This came on suddenly during a migrainous attack while out shopping. The paraesthesia appeared to affect the entire left arm and in the last few hours, has spread to involve the left side of the face. She had had a similar episode several months ago whereby she developed some right-sided leg and arm weakness while at work. The weakness lasted several minutes and subsequently abated. At the time, she was also having one of her migraines. She has a long-standing history of migraines, which typically start with a prolonged aura and fortification spectra. Other than migraines, for which she has been taking pizotifen, she has no other past medical history. Her sister also suffers from migraines, and her mother has a history of dementia in her 50s. She is a non-smoker and drinks minimal alcohol.
On examination she was orientated but apathetic. Her blood pressure was 130/65 mmHg, pulse 62/min, and temperature 36.2ºC. There were no carotid bruits and heart sounds were entirely normal. There was reduced sensation to all modalities over the left side of the face extending to the vertex and the entire left arm. Tone and reflexes appeared intact; however, handgrip was reduced on the left due to numbness. The lower limb appeared entirely normal.
Magnetic resonance (MR) scan showed bilateral, multifocal, T2/FLAIR (fluid attenuated inversion recovery ) hyperintensities in the deep white matter. MR Spinal cord was normal.
What is the diagnosis?Your Answer: CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy)
Explanation:CADASIL is the most common form of hereditary stroke disorder. This case has a strong history of migraine with aura with stroke-like episodes, characteristic of CADASIL. Additionally, there is positive family history of migraine and early dementia but no other vascular risk factors like hypertension, diabetes, or hypercholesterolaemia, which all confirm the suspicion of CADASIL, an arteriopathy where there is thickening of the smooth muscle cells in the blood vessels.
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This question is part of the following fields:
- Nervous System
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Question 23
Correct
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A 75-year-old male patient with a three weeks history of recurrent epistaxis and haemoptysis presents with acute kidney injury. Which antibody would you expect positive?
Your Answer: C ANCA
Explanation:Pulmonary renal syndrome is most commonly due to an ANCA positive vasculitis. The history of recurrent epistaxis makes Wegener’s granulomatosis the most probable diagnosis. It presents with pulmonary haemorrhage producing haemoptysis, rapidly progressive glomerulonephritis and anti-glomerular basement membrane antibodies. Recurrent epistaxis favours the diagnosis. In this patient we suspect C ANCA to be positive.
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This question is part of the following fields:
- Musculoskeletal System
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Question 24
Correct
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A 24-year-old presents with diarrhoea. She has had a previous ileal resection for Crohn's Disease. She has also had two recent episodes of loin to groin pain. Her bloods are normal including her inflammatory markers
What is the most likely diagnosis?Your Answer: Short bowel syndrome
Explanation:Given her history of bowel resections, the most likely answer in this case is short bowel syndrome. IBS is a diagnosis of exclusion and less likely. Bacterial overgrowth does not relate to resection history, so unlikely. Celiac disease or a flare of IBD are also less likely than short bowel syndrome in this case, simply given the history. Also her labs are normal making these unlikely. History, history, history!
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This question is part of the following fields:
- Gastrointestinal System
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Question 25
Correct
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Cancer of the prostate is associated with which of the following:
Your Answer: Exposure to cadmium
Explanation:Risk factors for prostate cancer include:
Black ethnicity
A family history of breast or prostate cancer
High intake of animal fats and low selenium intake
Exposure to radiation or heavy metals including cadmium -
This question is part of the following fields:
- Men's Health
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Question 26
Correct
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A 60-year-old man has been admitted with dehydration following an attack of gastritis. His initial blood results revealed raised calcium and erythrocyte sedimentation rate (ESR). He has a history of hypertension, angina, chronic obstructive pulmonary disease (COPD), and diabetes.
His most recent results have arrived on the ward, showing:
Hb: 13.8 g/dL
WCC: 7.7 x 10^9/L
Plts: 212 x 10^9/L
Na+: 138 mmol/L
K+: 4.7 mmol/L
Ca+2: 2.4 mmol/L
Urea: 7.2 mmol/L
Creatinine: 104 mmol/L
Albumin: 38 g/L
IgG: 24 g/L (6.0-13.0)
IgA: 2.1 g/L (0.8-3.0)
IgM: 1.3 g/L (0.4-2.5)
Trace amounts of Bence Jones protein have also been detected in the urine. CXR shows normal heart and mediastinal contours, clear lungs bilaterally, osteopenia of the bony skeleton with no lytic lesions.
What is the most likely diagnosis?Your Answer: Monoclonal gammopathy of undetermined significance
Explanation: -
This question is part of the following fields:
- Haematology & Oncology
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Question 27
Incorrect
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A 65-year-old gentleman presented with 2 weeks history of exertional dyspnoea, orthopnoea and chest pain. Past history revealed that a few years ago, he had been treated with antibiotics for complaints of fever, joint pains and chest pain. The most likely diagnosis will be?
Your Answer: Mitral valve prolapse
Correct Answer: Mitral valve stenosis
Explanation:The commonest symptom of mitral valve stenosis is dyspnoea, and it is one of the most common clinical findings which can be seen in rheumatic fever.
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This question is part of the following fields:
- Cardiovascular System
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Question 28
Incorrect
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A 35-year-old female presented with purple stretch marks on her abdomen, easy bruising and weight gain. A low dose Dexamethasone suppression test did not show any but a high dose Dexamethasone suppression test showed suppression of cortisol levels. Which of the following is the most likely cause for this presentation?
Your Answer: Pseudo-cushing's
Correct Answer: Pituitary Adenoma
Explanation:Clinical features are due to excess cortisol. High-dose dexamethasone suppression test shows suppression in patients with Cushing’s disease. Cushing syndrome includes all causes of glucocorticoid excess, whereas Cushing’s disease is reserved only for pituitary-dependent Cushing’s syndrome.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 29
Correct
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A 30-year-old man presented with polydipsia and polyuria for the last two years.
Investigations reveal:
Serum urea 9.5 mmol/L (2.5-7.5)
Serum creatinine 108 mol/L (60-110)
Serum corrected calcium 2.9 mmol/L (2.2-2.6)
Serum phosphate 0.7 mmol/L (0.8-1.4)
Plasma parathyroid hormone 6.5 pmol/L (0.9-5.4)
Which of the following is directly responsible for the increase in intestinal calcium absorption?Your Answer: 1,25 Dihydroxy vitamin D
Explanation:This patient has hypercalcaemia due to hyperparathyroidism. However, the intestinal absorption of calcium is mainly controlled by 1,25 dihydroxy-vitamin D. Under the influence of calcitriol (active form of vitamin D), intestinal epithelial cells increase their synthesis of calbindin (calcium-binding carrier protein) necessary for active calcium ion absorption.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 30
Correct
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In a study, 50 out of 100 smokers develop lung cancers and 50 out of 200 non-smokers develop lung cancers. Which of the following is accurate?
Your Answer: Relative risk=2
Explanation:Relative risk = (Incidence in exposed group)/incidence in unexposed group). So in this case RR = (50/100)/(50/200) = 2.
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This question is part of the following fields:
- Evidence Based Medicine
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SESSION STATS - PERFORMANCE PER SPECIALTY
