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Question 1
Correct
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Which of the following is most helpful in differentiating chronic from acute renal failure?
Your Answer: Kidney size at ultrasound scan
Explanation:The size of the kidneys on ultrasound would differentiate chronic from acute renal failures. Chronic renal failure is more associated with small-sized kidneys.
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This question is part of the following fields:
- Renal System
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Question 2
Correct
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A 28-year-old woman presents with painful genital ulceration. She reports that these attacks have been recurrent over the past 4 years. She has been treated previously with oral acyclovir but this has had little effect on the duration of her symptoms. Over the past year, she has noticed almost weekly attacks of mouth ulcers that heal slowly. Past medical history is significant for treatment of thrombophlebitis two years ago. Which of the following is the most likely diagnosis?
Your Answer: Behcet's syndrome
Explanation:Behçet disease is a rare vasculitic disorder that is characterized by a triple-symptom complex of recurrent oral aphthous ulcers, genital ulcers, and uveitis. The systemic manifestations can be variable. Ocular disease has the greatest morbidity, followed by vascular disease generally from active vasculitis. Cutaneous manifestations can occur in up 75% of patients with Behcet disease and can range from acneiform lesions, to nodules and erythema nodosum. GI manifestations can be severe. Differentiating Behçet disease from active inflammatory bowel disease can be clinically difficult. Herpes would have ideally responded to acyclovir. Sarcoidosis does not have genital and oral ulcerations.
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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 55-year-old male visited his diabetic clinic with a complaint of inability to walk properly due to weakness of his lower limbs. On examination, dorsiflexion was found to be weak bilaterally and there was diminished sensation on the dorsum of his feet as well as on the lower lateral portions of his legs. Which of the following could have led to this condition?
Your Answer: Compression of the S1 nerve root
Correct Answer: Compression of the common peroneal nerve
Explanation:The branches of the common peroneal nerve innervate the skin of the dorsum of the foot as well as the muscles which help to carry out dorsiflexion of the foot. Compression of the common peroneal nerve cause foot drop as well as the loss in sensation of the skin on the dorsum of the foot.
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This question is part of the following fields:
- Nervous System
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Question 4
Correct
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A 24-year-old male with a history of a cardiac murmur which was not properly followed up, presented with right sided hemiparesis. His blood pressure was 120/70 mmHg. His ECG revealed right bundle branch block with right axis deviation. Which of the following is the most likely cause for this presentation?
Your Answer: Ostium secundum atrial septal defect
Explanation:Ostium secundum atrial septal defects are known to cause stroke due to the passage of emboli from the right sided circulation to the left sided circulation. ECG shows tall, peaked P waves (usually best seen in leads II and V2) and prolongation of the PR interval, rSR pattern in leads V3 R and V1 as well as right axis deviation.
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This question is part of the following fields:
- Cardiovascular System
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Question 5
Incorrect
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A 44-year-old man presents suffering from retrosternal chest pain that started 2 hours ago and radiates to the throat. Which investigation would you immediately perform?
Your Answer: Electrocardiogram
Correct Answer: Troponin levels
Explanation:The patient’s age and symptoms are indicating a myocardial infarction. Although, the cause of the pain could also be related to the digestive system, a possible myocardial infarction should be excluded or, if present, managed immediately. Troponins are used to establish the diagnosis. Levels of troponin can become elevated in the blood within 3 or 4 hours after heart injury and may remain elevated for 10 to 14 days.
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This question is part of the following fields:
- Cardiovascular System
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Question 6
Correct
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A young woman complains of constipation and pain on defecation. The pain is anorectal and a digital rectal examination was impossible due to pain and spasm. What is most likely the diagnosis?
Your Answer: Anal fissure
Explanation:Symptoms of anal fissure include sharp pain in the anal area upon defecation or anal stimulation. It may also cause burning or itching as well as visible fresh blood on the stools or on the toilet paper. It is usually visible upon inspection.
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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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An 80 year-old Zimbabwean woman with known rheumatoid arthritis was admitted to hospital with a four week history of weight loss, night sweats and cough. She was given a course of Amoxicillin for the past week but her condition deteriorated and she was referred to the hospital when she developed haemoptysis.
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She was on maintenance prednisolone 10 mg once per day and four weeks earlier, she had received infliximab for a flare up of rheumatoid arthritis. She lived with her husband but had been admitted to hospital himself with influenza four days earlier. She was a lifelong non-smoker and worked most of her life as a missionary in Zimbabwe and South Africa.
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On examination she looked cachexic and was pyrexial with a temperature of 38.5°C. Her blood pressure was 181/101 mmHg, pulse 121 beats per minute and oxygen saturations of 89% on room air. Her heart sounds were normal and there were no audible murmurs. Auscultation of her lung fields revealed bronchial breath sounds in the left upper zone. Examination of her abdomen was normal.
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Mantoux test < 5mm (after 48 hours)
A chest radiograph revealed cavitating left upper lobe consolidation.
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What is the most likely diagnosis?Your Answer: Post-primary tuberculosis
Explanation:Post-primary pulmonary tuberculosis is a chronic disease commonly caused by either endogenous reactivation of a latent infection or exogenous re-infection by Mycobacterium tuberculosis.
Post-primary pulmonary tuberculosis (also called reactivation tuberculosis) develops in 5%-20% of patients infected with M. tuberculosis.Found mainly in adults, this form of tuberculosis arises from the reactivation of bacilli that lay dormant within a fibrotic area of the lung. In adults, reinfection with a strain of mycobacterium that differs from that which caused the primary infection is also possible. Predisposing factors include immunosuppression, diabetes, malnutrition and alcoholism.
Infliximab is a monoclonal antibody against tumour necrosis factor ? (TNF-?). It is FDA approved for many autoimmune conditions, including rheumatoid arthritis and Crohn’s disease. One of the many known side effects of infliximab therapy is reactivation of latent tuberculosis (TB). Because of the resemblances in clinical and radiological features, tubercular lesions in the lung may mimic malignancy. TB accounts for 27% of all infections initially presumed to be lung cancer on imaging studies.
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This question is part of the following fields:
- Respiratory System
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Question 8
Incorrect
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A 28-year-old woman is involved in a cycling accident. She has severe pain and swelling of her right upper leg. An x-ray confirms a fracture of neck of fibula. What is the most common associated nerve injury?
Your Answer: Sciatic nerve
Correct Answer: Lateral peroneal nerve
Explanation:Lateral peroneal nerve, also known as the superficial peroneal nerve.
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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 68-year-old man is admitted with an infective exacerbation of chronic obstructive pulmonary disease (COPD).
Investigations: blood gas taken whilst breathing 28% oxygen on admission:
pH 7.30
p(O2) 7.8 kPa
p(CO2) 7.4 kPa
Which condition best describes the blood gas picture?Your Answer: Decompensated type-2 respiratory failure
Explanation:The normal partial pressure reference values are:
– PaO2 more than 80 mmHg (11 kPa)
– PaCO2 less than 45 mmHg (6.0 kPa).
This patient has an elevated PaCO2 (7.4kPa)
Hypoxemia (PaO2 <8kPa) with hypercapnia (PaCO2 >6.0kPa).
The pH is also lower than 7.35 at 7.3Type 2 respiratory failure is caused by inadequate alveolar ventilation; both oxygen and carbon dioxide are affected. Defined as the build-up of carbon dioxide levels (PaCO2) that has been generated by the body but cannot be eliminated. The underlying causes include:
– Increased airways resistance (chronic obstructive pulmonary disease, asthma, suffocation)
– Reduced breathing effort (drug effects, brain stem lesion, extreme obesity)
– A decrease in the area of the lung available for gas exchange (such as in chronic bronchitis)
– Neuromuscular problems (Guillain-Barre syndrome, motor neuron disease)
– Deformed (kyphoscoliosis), rigid (ankylosing spondylitis), or flail chest. -
This question is part of the following fields:
- Respiratory System
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Question 10
Correct
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A 28-year-old woman is referred to the endocrinology clinic. She has been trying to conceive for the last 3 years without any success. Her prolactin level is 2600 mU/l (normal <360). The Endocrinologist arranges pituitary magnetic resonance imaging (MRI) that demonstrates a microprolactinoma.
Which two of the following pharmacological agents may be appropriate treatment choices?Your Answer: Carbergoline
Explanation:Cabergoline, an ergot derivative, is a long-acting dopamine agonist. It is usually better tolerated than Bromocriptine (BEC), and its efficacy profiles are somewhat superior to those of BEC. It offers the convenience of twice-a-week administration, with a usual starting dose of 0.25 mg biweekly to a maximum dose of 1 mg biweekly. Some studies have shown efficacy even with once-a-week dosing. Cabergoline appears to be more effective in lowering prolactin levels and restoring ovulation. Up to 70% of patients who do not respond to BEC respond to cabergoline.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 11
Correct
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A female patient presents with pain upon inspiration and dyspnoea. She had a myocardial infarction four days ago. What is the most probable diagnosis?
Your Answer: Pericarditis
Explanation:Although viral infection is the most common identifiable cause of acute pericarditis, the condition may be associated with many diseases. Non-viral causes of pericarditis include bacterial infection, MI, chest trauma, and neoplasm. Post-MI pericarditis may develop two to four days after an acute infarction and results from a reaction between the pericardium and the damaged adjacent myocardium. Dressler’s syndrome is a post-MI phenomenon in which pericarditis develops weeks to months after an acute infarction; this syndrome is thought to reflect a late autoimmune reaction mediated by antibodies to circulating myocardial antigens.
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This question is part of the following fields:
- Cardiovascular System
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Question 12
Correct
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A 35-year-old sales representative presents with severe pain going down her neck and right arm. She admits that this pain is worse on sitting and driving for long periods. Past history is significant for two previous road traffic accidents. Examination reveals weakness and sensory loss over C5/C6 nerve distribution. There is pain with neck movement and particularly extension. Which of the following investigations would be the most helpful in this case?
Your Answer: MRI scan of the cervical spinal cord
Explanation:Cervical radiculopathy is usually due to compression or injury to a nerve root by a herniated disc or degenerative changes. Levels C5 to T1 are the most commonly affected. It is usually, but not always, accompanied by cervical radicular pain, a sharp and shooting pain that travels from the neck and down the upper limb and may be severe. This needs to be differentiated from pain referred from the musculoskeletal (somatic) structures in the neck, which may be aching rather than sharp, and is more severe in the neck than in the upper limb. The neurological signs of cervical radiculopathy depend on the site of the lesion. The patient may have motor dysfunction, sensory deficits or alteration in tendon reflexes. While pain is a common presenting symptom, not all radiculopathies are painful (i.e. only motor deficits may be obvious). CT scanning cannot accurately demonstrate the commonest cause for cervical radiculopathy (disc herniation) without myelography, which requires hospital admission, lumbar puncture and the use of contrast. In patients with cervical radiculopathy, MRI is the imaging technique of choice for the detection of root compression by disc herniation and osteophytes. MRI allows the nerve roots to be directly visualised. Nerve conduction studies are also useful in determining the nerve roots that are involved.
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This question is part of the following fields:
- Musculoskeletal System
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Question 13
Correct
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A 28-year-old female presented with complaints of weight gain, thinning of scalp hair, dryness and coldness of the skin, constipation and fatigue. Which of the following is the most likely diagnosis?
Your Answer: Hypothyroidism
Explanation:The symptoms this female presented with in the OPD are major symptoms of hypothyroidism due to insufficient thyroid hormone.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 14
Correct
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A 55-year-old female with a history of hypertension presented with severe central chest pain for the past one hour, associated with sweating and vomiting. Her ECG showed ST elevation myocardial infarction, evident in leads V2-V4. Which of the following is an absolute contraindication for thrombolysis?
Your Answer: Intracranial neoplasm
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 15
Correct
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A 35-year-old gentleman with a history of alcohol excess presents to hospital with progressive abdominal distension. He now complains of early satiety and abdominal discomfort as a result of the distension. Examination reveals a significantly distended abdomen with shifting dullness. A diagnostic ascitic tap is performed and the fluid sent for analysis.
What is the most appropriate first line treatment for his ascites?Your Answer: Paracentesis
Explanation:The first line treatment for ascites that is symptomatic is paracentesis. If it is not symptomatic, treatment could be with salt and fluid restriction as well as spironolactone. If spironolactone maximum dosage is reached, you can use furosemide additionally. Amiloride is not a diuretic that is recommended in this case.
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This question is part of the following fields:
- Gastrointestinal System
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Question 16
Correct
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A 26-year-old patient, previously fit and well, is admitted with fluctuating confusion and frank haematuria. He has recently been complaining of generalised malaise and joint pains. Examination reveals jaundice, splenomegaly, and petechiae. His blood pressure is 155/84 mmHg, temperature 37.9oC.
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Initial investigations reveal:
Haemoglobin 9.5 g/dl
White cell count 12 × 109/l
Platelets 40 × 109/l
Creatinine 142 μmol/l
Sodium 139 mmol/l
Potassium 4.5 mmol/l
Urea 9.2 mmol/l
Lactate dehydrogenase 495 U/l (10-250)
Urinalysis Protein ++, blood +++
Blood film shows schistocytes
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What treatment should NOT be given to this patient?Your Answer: Platelet transfusion
Explanation:There is a strong suspicion of Thrombotic Thrombocytopenic Purpura (TTP) in this patient as he presents with neurological changes (from confusion to convulsions and coma), fever, haemolysis, thrombocytopenia, and renal failure. Additionally, TTP cases may present with jaundice, splenomegaly, and hypertension as seen in this patient. With a diagnosis of TTP, recent studies have shown that platelet transfusion is not recommended in this case because it has been shown to increase the risk for arterial thrombosis and mortality possibly due to increased aggregations.
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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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A 44 year-old electrician is referred to you complaining of increasing problems with concentration. He also complains of irregular jerky movements of his extremities and fingers. He consumes approximately 25 units of alcohol per week. His father was diagnosed with dementia at the age of 40. Apart from generalized choreiform movements, his neurological and systemic examinations were normal. Which of the following is the most likely diagnosis?
Your Answer: Huntington's disease
Explanation:Huntington’s disease is an autosomal inherited condition characterized by progressive dementia and worsening choreiform movements. Symptoms typically appear between ages 30 and 50. Ultimately the weakened individual succumbs to pneumonia, heart failure, or other complications.
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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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A 60-year-old man who has been complaining of increasing shortness of breath had a post-bronchodilator spirometry done.
FEV1/FVC 0. 63
FEV1% predicted 63%
What is the best interpretation of these results?Your Answer: COPD (stage 2 - moderate)
Explanation: -
This question is part of the following fields:
- Respiratory System
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Question 19
Incorrect
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A 51-year-old smoker was recently diagnosed with non small cell lung carcinoma. Investigations show presence of a 3 x 3 x 2 cm tumour on the left side of the lower lung lobe. the mass has invaded the parietal pleura. Ipsilateral hilar node is also involved but there is no metastatic spread.
What is the stage of this cancer?Your Answer: T4 N1 M0
Correct Answer: T2 N1 M0
Explanation:The tumour has only invaded the visceral pleura and measures 3cm in the greatest dimension. Hence it is designated at T2. Ipsilateral peribronchial and/or hilar lymph node involvement would make it N1. There is no distal metastasis so M would be 0.
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This question is part of the following fields:
- Respiratory System
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Question 20
Correct
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A 62-year-old male presented with worsening breathlessness and fatigability. On examination there was bilateral ankle swelling and pulsatile liver. Auscultation revealed a pansystolic murmur best heard at the lower left sternal border. Which of the following is the most probable diagnosis?
Your Answer: Tricuspid regurgitation
Explanation:All the clinical features are suggestive of tricuspid regurgitation. The pansystolic murmur of mitral regurgitation is best heard at the apex.
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This question is part of the following fields:
- Cardiovascular System
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Question 21
Correct
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A 40-year-old man complains of impotence and reduced libido for 4 months. He has been married for 15 years and has two children. He smokes five cigarettes per day and drinks approximately 12 units of alcohol weekly.
Examination reveals an obese man who is phenotypically normal with normal secondary sexual characteristics.
Investigations are as follows:
Hb 13.4 g/dl (13.0-18.0)
WCC 6 x 109/l (4-11)
Platelets 210 x 109/l (150-400)
Electrolytes Normal
Fasting glucose 5.6 mmol/l (3.0-6.0)
LFTs Normal
T4 12.7 pmol/l (10-22)
TSH 2.1 mU/l (0.4-5)
Prolactin 259 mU/l (<450)
Testosterone 6.6 nmol/l (9-30)
LH 23.7 mU/l (4-8)
FSH 18.1 mU/l (4-10)
What is the next investigation needed for this patient?Your Answer: Ultrasound examination of the testes
Explanation:The patient has primary Hypogonadism.
Since he already had two children, Klinefelter syndrome is excluded and the patient does not need karyotyping.
His lab results are normal indicating normal pituitary gland functions.
So the next step is testicular ultrasound as testicular tumour, infiltration or idiopathic failure is suspected. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 22
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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Question 23
Correct
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A 45-year-old man with diabetes comes to the clinic for his annual review.
He has had diabetes for eight years and he is also being treated for hypertension. He is on the following medications: metformin 500 mg tds, gliclazide 80 mg daily, atorvastatin 10 mg/d, Ramipril 10 mg/d and Bendroflumethiazide 2.5 mg/d.
He is noted to be obese (130kg). Physical examination is otherwise unremarkable.
Investigations reveal:
HbA1c 8.1% (3.8-6.4)
Fasting glucose 9 mmol/L (3.0-6.0)
24 hr Urine free cortisol 354 mmol/d (<250)
9am Plasma ACTH 4 ng/dL (10-50)
CT abdomen 3 cm right adrenal mass
Which of the following is most likely to be the adrenal mass?Your Answer: Cortisol secreting adenoma
Explanation:The patient has Cushing syndrome suggested by the elevated 24hr urine free cortisol. Hence, the mass is most probably a cortisol secreting adenoma.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 24
Correct
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A 23-year-old female visited the OPD with a complaint of postcoital bleeding as well as excessive vaginal discharge. Her past medical history is positive for oral contraceptive pills. Which of the following investigations would you recommend in this case?
Your Answer: Speculum with or without cervical smear
Explanation:A speculum test is necessary in order to visualize the cervix to rule out cervical ectropion that may be responsible for the post-coital bleeding. A smear is not necessary if the cervix is adequately visualized, however, it can rule out infection as well.
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This question is part of the following fields:
- Women's Health
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Question 25
Correct
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A 40-year-old woman presents to the ED with palpitations and shortness of breath.
Recent thyroid function tests on the hospital computer reveal thyroid-stimulating hormone (TSH) of <0.05 mU/l and a markedly elevated T4. You arrange blood gas testing.
Which of the following findings would be most consistent with Grave's disease?Your Answer: Decreased pa(CO2)
Explanation:Hyperthyroid patients show significantly lower resting arterial CO2 tension, tidal volume and significantly higher mean inspiratory flow and pa(O2) than healthy patients. This may of course lead to misdiagnosis of patients with hyperthyroidism as having hyperventilation syndrome.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 26
Correct
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Which of the following describes the reason for the decline of the use of beta blockers as antihypertensives in last few years?
Your Answer: Less likely to prevent stroke + potential impairment of glucose tolerance
Explanation:According to the latest research, beta blockers are associated with higher incidence of fatal and non-fatal strokes, all cardiovascular events, and cardiovascular mortality. New-onset diabetes also associates with beta blockers.
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This question is part of the following fields:
- Cardiovascular System
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Question 27
Correct
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A 35-year-old gentleman presents to the Emergency Department with abdominal pain. This started earlier on in the day and is getting progressively worse. The pain is located on his left flank and radiates down into his groin. He has no history of this pain or any other condition. Examination reveals a gentleman who is flushed and sweaty but is otherwise unremarkable. What is the most suitable initial management?
Your Answer: IM diclofenac 75 mg
Explanation:Because of the patient’s presentation with flank pain that radiates to the groin, we are suspecting renal colic. We should follow guidelines for acute renal management and prescribe IM diclofenac for immediate relief of pain.
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This question is part of the following fields:
- Renal System
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Question 28
Correct
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A 60-year-old male smoker presented in the emergency room with a history of chest pain and a cough for the last few days. He is now complaining of increasing dyspnoea and sharp pains around the 4th and 5th ribs. On CXR, there is right sided hilar enlargement. Which of the following is the most likely diagnosis?
Your Answer: Bronchogenic carcinoma
Explanation:The history of smoking with a cough and bone pain is suggestive of bronchogenic carcinoma. CXR findings are also supportive of this diagnosis. In COPD, a cough with dyspnoea and wheezing is prominent.
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This question is part of the following fields:
- Respiratory System
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Question 29
Correct
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A 56-year-old man injected his usual insulin dose and went to the washroom to wash his hands before going to dinner. His wife found him unconscious in the washroom a few minutes later. Which of the following investigations needs to be done?
Your Answer: Random capillary glucose
Explanation:The state of this patient is most likely a diabetic coma caused by hypoglycaemic shock. A random capillary glucose check can confirm the glucose level and whether prompt IM glucagon should be given.
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This question is part of the following fields:
- Cardiovascular System
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Question 30
Correct
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A 52-year-old man has squamous-cell carcinoma of his lower lip. Which of the following is most likely to be a feature of this type of carcinoma?
Your Answer: It is capable of metastasising via the lymphatics
Explanation:Squamous-cell skin cancer usually presents as a hard lump with a scaly top but can also form an ulcer. Onset is often over months and it is more likely to spread to distant areas than basal cell cancer vie the lymphatics. The greatest risk factor is high total exposure to ultraviolet radiation from the Sun. Other risks include prior scars, chronic wounds, actinic keratosis, lighter skin, Bowen’s disease, arsenic exposure, radiation therapy, poor immune system function, previous basal cell carcinoma, and HPV infection. While prognosis is usually good, if distant spread occurs five-year survival is ,34%
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This question is part of the following fields:
- The Skin
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Question 31
Incorrect
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Which of the following is not a known cause of occupational asthma?
Your Answer: Flour
Correct Answer: Cadmium
Explanation:Occupational asthma (OA) could be divided into a nonimmunological, irritant-induced asthma and an immunological, allergy-induced asthma. In addition, allergy-induced asthma can be caused by two different groups of agents: high molecular weight proteins (>5,000 Da) or low molecular weight agents (<5,000 Da), generally chemicals like the isocyanates.
Isocyanates are very reactive chemicals characterized by one or more isocyanate groups (-N=C=O). The main reactions of this chemical group are addition reactions with ethanol, resulting in urethanes, with amines (resulting in urea derivates) and with water. Here, the product is carbamic acid which is not stable and reacts further to amines, releasing free carbon dioxide.Diisocyanates and polyisocyanates are, together with the largely nontoxic polyol group, the basic building blocks of the polyurethane (PU) chemical industry, where they are used solely or in combination with solvents or additives in the production of adhesives, foams, elastomers, paintings, coatings and other materials.
The complex salts of platinum are one of the most potent respiratory sensitising agents having caused occupational asthma in more than 50% of exposed workers. Substitution of ammonium hexachlor platinate with platinum tetra amine dichloride in the manufacture of catalyst has controlled the problem in the catalyst industry. Ammonium hexachlorplatinate exposure still occurs in the refining process.
Rosin based solder flux fume is produced when soldering. This fume is a top cause of occupational asthma.
Bakeries, flour mills and kitchens where flour dust and additives in the flour are a common cause of occupational asthma.
Cadmium was not found to cause occupational asthma.
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This question is part of the following fields:
- Respiratory System
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Question 32
Correct
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A 25-year-old female presented with multiple small genital ulcers, which are painful following a sexual intercourse with an unknown man. Which of the following can be used topically for this presentation?
Your Answer: Acyclovir
Explanation:The most probable diagnosis is Herpes Simplex infection. Topical Acyclovir can be used in early stages.
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This question is part of the following fields:
- Infectious Diseases
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Question 33
Correct
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Which one of the following is most suggestive of Wilson's disease?
Your Answer: Reduced serum caeruloplasmin
Explanation:In Wilson’s disease, serum caeruloplasmin is decreased. Skin pigmentation is not increased, but may become jaundiced. 24 hour urine copper excretion is increased. Hepatic copper concentration is increased. Serum copper level is also increased. Key point: high copper. Remember Kayser-Fleisher rings for the eyes in Wilson’s disease.
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This question is part of the following fields:
- Gastrointestinal System
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Question 34
Correct
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A 65-year-old man known to have renal cell carcinoma, is currently undergoing treatment. He presents to the acute medical ward with one month history of worsening central lower back pain, which becomes worse at night and cannot be managed with an analgesia at home. He has no other new symptoms.
Out of the following, which investigation should be performed next?Your Answer: MRI whole spine
Explanation:An MRI whole spine should be performed in a patient suspected of spinal metastasis which can occur before developing metastatic spinal cord compression. This patient has renal cell carcinoma, which readily metastasises to the bones and also has progressive back pain. He, therefore, needs urgent imaging of his spine before any neurological compromise develops. MRI whole spine is preferable because patients with spinal metastasis often have metastases at multiple levels within the spine. Plain radiographs and CT scans should not be performed as they have a lower sensitivity for revealing lesions and cannot exclude cord compression.
In general, imaging should be performed within one week if symptoms suspicious of spinal metastasis without neurological symptoms are present. If there are symptoms suggestive of malignant spinal cord compression, then imaging should be done within 24 hours.
The signs and symptoms of spinal metastases include:
1. Unrelenting lumbar back pain
2. Thoracic or cervical back pain
3. Pain associated with tenderness and worsens with sneezing, coughing, or straining
4. Nocturnal pain -
This question is part of the following fields:
- Haematology & Oncology
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Question 35
Correct
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A 30-year-old primigravida in her 23rd week of pregnancy presented with palpitations. Her ECG showed supraventricular tachycardia (SVT). 15 minutes after admission the SVT spontaneously reverted to sinus rhythm. She had two episodes of SVT later which were associated with palpitations. Which of the following is the most appropriate treatment for this presentation?
Your Answer: Verapamil
Explanation:Both long-acting calcium channel blockers and beta blockers improve symptoms of patients with SVT. Verapamil does not have adverse maternal or fetal side effects which would suggest that the use of verapamil in the treatment of supraventricular arrhythmias in pregnancy is safe and effective. Beta blockers are associated with intrauterine fetal growth restriction.
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This question is part of the following fields:
- Cardiovascular System
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Question 36
Correct
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A 25-year-old male presented with an episode of syncope. His examination findings were normal. He gave a history of sudden cardiac death of a close relative. His ECG showed incomplete right bundle-branch block and ST-segment elevations in the anterior precordial leads. What is the most probable diagnosis?
Your Answer: Brugada syndrome
Explanation:Brugada syndrome is an autosomal dominant disorder characterized by sudden cardiac death. The positive family history and characteristic ECG findings are in favour of Brugada syndrome. Usually the physical findings are normal.
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This question is part of the following fields:
- Cardiovascular System
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Question 37
Correct
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A 30-year-old male is brought to the emergency department following his collapse in a nightclub. His friends who accompanied him admit that, of recent, he has been using increasing amounts of cocaine. Which among the following is commonly associated with cocaine overdose?
Your Answer: Metabolic acidosis
Explanation:Metabolic acidosis is associated with cocaine overdose.
In overdose, cocaine leads to agitation, tachycardia, hypertension, sweating, hallucinations, and finally convulsions.
Metabolic acidosis, hyperthermia, rhabdomyolysis, and ventricular arrhythmias also occur.
Chronic use may be associated with premature coronary artery disease, dilated cardiomyopathy, and increased risk of cerebral haemorrhage.
There are 3 stages for acute cocaine toxicity:
Stage I: CNS symptoms of headache, vertigo, pseudo hallucinations, hyperthermia, hypertension.
Stage II: increased deep tendon reflexes, tachypnoea, irregular breathing, hypertension.
Stage III: Areflexia, coma, fixed and dilated pupils, hypotension, ventricular fibrillation, apnoea, and respiratory failure.Treatment:
– Airway, breathing, and circulation to be secured. The patient’s fever should be managed, and one should rule out hypoglycaemia as a cause of the neuropsychiatric symptoms.
– Cardiovascular toxicity and agitation are best-treated first-line with benzodiazepines to decrease CNS sympathetic outflow.
– The mixed beta/alpha blocker labetalol is safe and effective for treating concomitant cocaine-induced hypertension and tachycardia.
– Non-dihydropyridine calcium channels blockers such as diltiazem and verapamil have been shown to reduce hypertension reliably, but not tachycardia.
– Dihydropyridine agents such as nifedipine should be avoided, as reflex tachycardia may occur.
– The alpha-blocker phentolamine has been recommended but only treats alpha-mediated hypertension and not tachycardia. -
This question is part of the following fields:
- Emergency & Critical Care
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Question 38
Correct
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A 35-year-old gentleman is investigated for recurrent renal stones. He has been hospitalised on multiple occasions and has required lithotripsy three times. Investigations show the following:
Calcium 2.08 mmol/l
Phosphate 0.85 mmol/l
Parathyroid hormone 4.1 pmol/L (normal range = 0.8 - 8.5)
24 hour urinary calcium 521 mg/24 hours (normal range < 300)
Which one of the following treatments will most likely reduce the incidence of renal stones?Your Answer: Indapamide
Explanation:Indapamide is a mild thiazide-like diuretic with hypotensive effect, and compared to other thiazides, it is reported to also have less metabolic derangements. However, it may have beneficial hypo-calciuric effects that are often associated with thiazides, thus, in this case, we would recommend prescribing this to the patient.
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This question is part of the following fields:
- Renal System
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Question 39
Correct
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A 50-year-old diabetic and hypertensive patient who is on medication, presented in the OPD with complaints of constipation, polyuria, polydipsia and confusion. On investigation: Serum calcium was 3.07, serum electrophoresis is negative and the X-ray is normal. Which is the most probable cause of these symptoms?
Your Answer: Drug induced-Bendroflumethiazide
Explanation:Bendroflumethiazide is a drug used for treating hypertension and is a diuretic. It produces side effects such as constipation, frequent urination, fatigue, polydipsia etc.
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This question is part of the following fields:
- Pharmacology
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Question 40
Correct
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A 62-year-old male has woken up to find his speech is altered. He recently suffered from a flu-like illness. The movement of his eyelids and lips are weak on the right-hand side. Which anatomical site is most likely to be affected in this patient?
Your Answer: Facial nerve
Explanation:Viral infection is a very common cause of facial nerve palsy, which is consistent with the symptoms described.
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This question is part of the following fields:
- Nervous System
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Question 41
Correct
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A 19-year-old male who is a first year student at university presented in the emergency room with acute disorientation. He was previously relaxed and well. Which of the following is the most likely cause behind his condition?
Your Answer: Drug toxicity
Explanation:History of being well and sudden appearance of agitation and confused state at this age is suggestive of drug intake and toxicity.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 42
Correct
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A 26-year-old man with type-1 diabetes presents for review. His HbA1c is 6.8% yet he is concerned that his morning blood sugar levels are occasionally as high as 24 mmol/l. He is currently managed on a bd mixed insulin regimen.
He was sent for continuous glucose monitoring and his glucose profile reveals dangerous dipping in blood glucose levels during the early hours of the morning.
Which of the following changes to his insulin regime is most appropriate?Your Answer: Move him to a basal bolus regime
Explanation:The patients high morning blood sugar levels are suggestive to Somogyi Phenomenon which suggests that hypoglycaemia during the late evening induced by insulin could cause a counter regulatory hormone response that produces hyperglycaemia in the early morning.
Substitution of regular insulin with an immediate-acting insulin analogue, such as Humulin lispro, may be of some help. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 43
Correct
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A 63-year-old man, known to have small cell lung cancer and ischaemic heart disease (IHD), presents with increasing shortness of breath for the past 7 days. It becomes worse at night and is associated with an occasional non-productive cough. He has also noticed that his wedding ring feels tight. His cancer was diagnosed five months ago and he has recently completed a course of chemotherapy. From a cardiac point of view, he had a myocardial infarction (MI) two years ago following which he had primary angioplasty with stent placement. He has had no episode of angina since then.
Clinical examination of his chest is unremarkable. He does, however, have distended neck veins and periorbital oedema.
What is the most likely diagnosis?Your Answer: Superior vena cava obstruction
Explanation:Superior vena cava (SVC) obstruction is an oncological emergency caused by compression of the SVC and is most commonly associated with lung cancer.
Some causes of the condition include:
1. Common malignancies: non small cell lung cancer, lymphoma
2. Other malignancies: metastatic seminoma, Kaposi’s sarcoma, breast cancer
3. Aortic aneurysm
4. Mediastinal fibrosisClinical features of SVC obstruction include:
1. Dyspnoea: most common
2. Swelling of the face, neck, and arms: conjunctival and periorbital oedema may be seen
3. Headache: often worse in the morning
4. Visual disturbances
5. Pulseless jugular venous distensionManagement options are:
1. General: dexamethasone, balloon venoplasty, stenting
2. Small cell lung cancer: chemotherapy and radiotherapy
3. Non small cell lung cancer: radiotherapy -
This question is part of the following fields:
- Haematology & Oncology
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Question 44
Correct
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A new study was developed to assess the benefit of omega-3 fish oils in patients with established ischaemic heart disease. The power of the study is equal to:
Your Answer: 1 - probability of making a type II error
Explanation:The power of a test is defined as 1 − the probability of Type II error. The Type II error is concluding at no difference (the null is not rejected) when in fact there is a difference, and its probability is named β. Therefore, the power of a study reflects the probability of detecting a difference when this difference exists. It is also very important to medical research that studies are planned with an adequate power so that meaningful conclusions can be issued if no statistical difference has been shown between the treatments compared. More power means less risk for Type II errors and more chances to detect a difference when it exists.
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This question is part of the following fields:
- Evidence Based Medicine
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Question 45
Incorrect
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A 30-year-old female who was on chemotherapy developed a high-grade fever and productive cough over 2 days. On examination, there was evidence of a chest infection. Her WBC was 2100/ml. What is the most suitable treatment for this condition?
Your Answer: Piperacillin+Co-amoxiclav
Correct Answer: Piperacillin+tazobactam
Explanation:This patient has leukopenia following chemotherapy and she is more prone to severe bacterial infections. Neutropenic sepsis is common among cancer patients and it is one of the main reasons for death amongst these patients. As the first line monotherapy for high-risk patients, Piperacillin-tazobactam, Cefepime, Meropenem and Imipenem-cilastatin can be started as they all have antipseudomonal activity.
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This question is part of the following fields:
- Haematology & Oncology
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Question 46
Correct
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A 64-year-old woman with ankylosing spondylitis presents with cough, weight loss and tiredness. Her chest x-ray shows longstanding upper lobe fibrosis. Three sputum tests stain positive for acid fast bacilli (AFB) but are consistently negative for Mycobacterium tuberculosis on culture.
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Which of the following is the most likely causative agent?Your Answer: Mycobacterium avium intracellular complex
Explanation:Pulmonary mycobacterium avium complex (MAC) infection in immunocompetent hosts generally manifests as cough, sputum production, weight loss, fever, lethargy, and night sweats. The onset of symptoms is insidious.
In patients who may have pulmonary infection with MAC, diagnostic testing includes acid-fast bacillus (AFB) staining and culture of sputum specimens.The ATS/IDSA guidelines include clinical, radiographic, and bacteriologic criteria to establish a diagnosis of nontuberculous mycobacterial lung disease.
Clinical criteria are as follows:
Pulmonary signs and symptoms such as cough, fatigue, weight loss; less commonly, fever and weight loss; dyspnoea
Appropriate exclusion of other diseases (e.g., carcinoma, tuberculosis).
At least 3 sputum specimens, preferably early-morning samples taken on different days, should be collected for AFB staining and culture. Sputum AFB stains are positive for MAC in most patients with pulmonary MAC infection. Mycobacterial cultures grow MAC in about 1-2 weeks, depending on the culture technique and bacterial burden.
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This question is part of the following fields:
- Respiratory System
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Question 47
Correct
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Which of the following statements regarding the proton pump inhibitors is true?
Your Answer: They cause hair loss, diarrhoea, and headache
Explanation:Common side effects of omeprazole include: headache, abdominal pain, diarrhoea, nausea, vomiting, gas (flatulence), dizziness, upper respiratory infection, acid reflux, constipation, rash, cough.
Less common side effects of Omeprazole include: bone fracture (osteoporosis related), deficiency of granulocytes in the blood, loss of appetite, gastric polyps, hip fracture, hair loss, chronic inflammation of the stomach, destruction of skeletal muscle, taste changes, abnormal dreams.
Rare side effects of Omeprazole include: liver damage, inflammation within the kidneys, pancreatitis, dermatologic disorder, potentially life threatening (toxic epidermal necrolysis). -
This question is part of the following fields:
- Pharmacology
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Question 48
Correct
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A 70-year-old smoker was recently diagnosed with small cell lung cancer. Which of the following electrolyte combinations confirms the diagnosis of SIADH?
Your Answer: Low serum Na, low serum osmolarity, high urine osmolarity
Explanation:Due to the high amount of ADH in their blood, patient is voiding a low volume of urine with high osmolarity and as a result low levels of electrolytes will be present in the serum.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 49
Incorrect
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A 53-year-old female teacher asks about hormone replacement therapy (HRT).
What is the most compelling indication for starting HRT?Your Answer: Prevention of osteoporosis
Correct Answer: Control of vasomotor symptoms such as flushing
Explanation:Hormone replacement therapy (HRT) involves the use of a small dose of oestrogen, combined with a progestogen (in women with a uterus), to help alleviate menopausal symptoms. The main indication is the control of vasomotor symptoms. The other indications, such as reversal of vaginal atrophy and prevention of osteoporosis, should be treated with other agents as first-line therapies.
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This question is part of the following fields:
- Pharmacology
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Question 50
Correct
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An echocardiogram of a 50-year-old male patient showed an infarct in the anterolateral aspect of the left side of the heart and apex. An angiogram was then done. Obstruction of which of the following arteries is the cause of this myocardial infarction?
Your Answer: Left anterior descending artery
Explanation:The left coronary artery is responsible for supplying the entire left side of the heart, however, it divides into the left anterior descending artery which supplies the apex of the heart and the interventricular septum, and the left circumflex artery which supplies the posterolateral part of the left ventricle and a portion of the papillary muscle. The infarction is noted at the apex of the heart and the interventricular septum, therefore, the obstruction has occurred in the left anterior descending artery.
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This question is part of the following fields:
- Cardiovascular System
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Question 51
Incorrect
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Which is the mechanism of action of trimethoprim?
Your Answer: Cell wall inhibition
Correct Answer: Inhibition of folic acid metabolism
Explanation:Trimethoprim interferes with the action of dihydrofolate reductase and thus inhibits folic acid metabolism and restricts DNA synthesis.
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This question is part of the following fields:
- Pharmacology
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Question 52
Correct
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A 33-year-old Afro-Caribbean gentleman with a 5 year history of HIV infection presents with swollen ankles. He has been treated with highly active antiretroviral therapy (HAART) for 2 years, with partial response.
His plasma creatinine concentration is 358 μmol/l, albumin is 12 g/dl, CD4 count is 35/μl and 24 hour urine protein excretion rate is 6.8 g. Renal ultrasound shows echogenic kidneys 13.5 cm in length.
What would a renal biopsy show?Your Answer: Microcystic tubular dilatation and collapsing FSGS
Explanation:HIV-associated nephropathy (HIVAN) show typical findings of scarring called focal segmental glomerulosclerosis (FSGS) and microcystic tubular dilatation, prominent podocytes, and collapsing capillary loops.
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This question is part of the following fields:
- Renal System
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Question 53
Incorrect
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Regarding neonatal meningitis, which of the following statements is true?
Your Answer: Is most commonly caused by Haemophilus influenzae
Correct Answer: Has an above average incidence in babies with a meningomyelocele
Explanation:The commonest time for bacterial meningitis is in the 1st month of life and group B Streptococcus is the commonest organism. The anterior fontanelle is full, but does not bulge with normal flexion. Neurological manifestations include seizures, irritability, poor tone, lethargy and tremors, however no findings of sensorineural deafness have been noted. One of the risk factors for introduction of meningeal infection is Meningomyelocele.
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This question is part of the following fields:
- Infectious Diseases
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Question 54
Incorrect
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A 25-year-old male presents to the emergency department with fever, sweating, hyperventilation and breathing difficulty. He also complains of a continuous ringing sensation in both his ears for the past couple of days. He admits to consuming a lot of over the counter painkillers for the past few days. Which of the following drugs is the most likely cause of these symptoms?
Your Answer: Co-proxamol
Correct Answer: Aspirin
Explanation: -
This question is part of the following fields:
- Emergency & Critical Care
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Question 55
Correct
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A 62-year-old woman with scleroderma and Raynaud's phenomenon complains of weight loss and has been referred for an opinion. Gastrointestinal associations of progressive systemic sclerosis include which of the following?
Your Answer: Oesophageal stricture
Explanation:Oesophageal stricture is a complication of systemic sclerosis, think of the oesophagus as sclerosing (fibrosing) leading to stricture and you never forget. Based on the clinical presentation of systemic sclerosis this is more likely than pancreatic dysfunction, PSC, lymphoma, or diverticulitis. Additionally, CREST syndrome stands for: calcinosis cutis, Raynaud’s phenomenon (which the patient has), oesophageal dysmotility, sclerodactyly, and telangiectasias), this is a form of systemic sclerosis you should be familiar with.
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This question is part of the following fields:
- Gastrointestinal System
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Question 56
Correct
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A team of physicians presented their audit of fluid management for dengue haemorrhagic fever one year ago. A number of recommendations were made at that time and changes were implemented. Which of the following is the most appropriate next step that this team should take?
Your Answer: Re-audit
Explanation:Clinical audit is defined as a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. To see whether the recommendations have been implemented, a re-audit has to be performed.
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This question is part of the following fields:
- Ethical & Legal
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Question 57
Correct
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A 62-year-old obese female presented with dilated veins over the lateral aspect of her right ankle. Which of the following is most responsible for her presentation?
Your Answer: Short saphenous vein
Explanation:Varicose veins (venous insufficiency syndrome) are dilated, tortuous veins due to reverse venous flow. All the given veins can be affected from this condition. As the patient has varicose veins over lateral aspect of ankle, the short saphenous vein is affected. The great or long saphenous vein travels along the medial aspect of the ankle
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This question is part of the following fields:
- Cardiovascular System
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Question 58
Incorrect
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A 60-year-old man with previous history of myocardial infarction and hypertension presented with severe retrosternal chest pain for the past 2 hours. During initial management he collapsed and pulseless ventricular tachycardia was detected. The external defibrillator arrived in 3 minutes. From the following answers, what is the most appropriate immediate management of this patient whilst waiting for the defibrillator?
Your Answer: Continuous chest compressions should be started
Correct Answer:
Explanation:Immediate Management of Pulseless Ventricular Tachycardia:
- Continuous Chest Compressions:
- Continuous chest compressions should be started immediately to maintain circulation while the defibrillator is being prepared. High-quality chest compressions are crucial and should not be delayed.
- Defibrillation:
- Once the defibrillator arrives, defibrillation should be performed as soon as possible. For pulseless ventricular tachycardia, delivering a shock is critical to attempt to restore a normal heart rhythm.
Other options:
He should be given a precordial thump: This is not recommended as a primary action when a defibrillator is available or arriving imminently.
A ventilation to compression ratio of 30:2 should be commenced: While ventilation is important, continuous chest compressions take precedence in the initial phase. The ratio of 30:2 is used during CPR when ventilations are also being provided, typically when two rescuers are present.
Await arrival of defibrillator, then deliver shock: Waiting passively without performing chest compressions is not appropriate.
Intravenous adrenaline should be given: Adrenaline is part of the advanced life support protocol, but the first immediate action should be chest compressions followed by defibrillation.
- Continuous Chest Compressions:
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This question is part of the following fields:
- Cardiovascular System
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Question 59
Incorrect
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A 8-year-old girl with suspected patent foramen ovale, presented with her parents for the confirmation of the diagnosis. Which of the following is the best investigation to confirm the diagnosis?
Your Answer: Bubble Echocardiography
Correct Answer: Transoesophageal Echocardiography
Explanation:A 3-dimensional transoesophageal echocardiography (3D TEE) provides direct visualization of the entire PFO anatomy and surrounding structures. It allows more accurate diagnosis.
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This question is part of the following fields:
- Cardiovascular System
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Question 60
Incorrect
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A 50-year-old woman under treatment for manic-depressive psychosis presents in an unconscious state after an episode of seizure on the street. Her husband who accompanied her into the ER reported that they argued about 6-7 hours ago. On examination, she is found to be hypertonic with a GCS of 8, BP: 90/60 mmHg and a pulse of 105 bpm. Blood investigations revealed a lithium level of 3.2 mmol/L. She was intubated and ventilated. Which of the following interventions is most appropriate in this case?
Your Answer: Normal saline infusion
Correct Answer: Gastric lavage and normal saline infusion
Explanation:Among the above statements, gastric lavage and normal saline IV infusion are the most appropriate interventions for a patient of acute lithium toxicity.
Activated charcoal is not effective after lithium overdose, although gastric lavage should be considered if patients present within 6-8 h.
Where levels are above 3 mmol/l, the use of normal saline to induce diuresis should be considered, although careful monitoring of fluid balance is necessary.
Where levels of lithium are above 4 mmol/l, dialysis is often required. Haemodialysis is preferred, but in a facility where haemodialysis is not possible, peritoneal dialysis may be considered.
Patients should not be discharged until they are asymptomatic and have a serum lithium level less than 1.5 mEq/L. -
This question is part of the following fields:
- Pharmacology
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SESSION STATS - PERFORMANCE PER SPECIALTY
