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Question 1
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A 80-year-old male with hypertension presented with his second episode of atrial fibrillation. He was warfarinised and discharged. Later he was reviewed and found to be in sinus rhythm. Which of the following is the most appropriate next step?
Your Answer: Continue lifelong warfarin
Explanation:CHA₂DS₂-VASc score is used for atrial fibrillation stroke risk calculation.
Congestive heart failure – 1 point
Hypertension – 1 point
Age >75 years – 2 points
Diabetes mellitus – 1 point
Stroke/Transient Ischemic Attack/Thromboembolic event – 2 points
Vascular disease (prior MI, PAD, or aortic plaque) – 1 point
Age 65 to 74 years – 1 point
Sex category (i.e., female sex) – 1 point
A score of 2 or more is considered as high risk and anticoagulation is indicated. This patient’s score is 3, so he needs life long warfarin to prevent stroke. -
This question is part of the following fields:
- Cardiovascular System
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Question 2
Correct
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A 85-year-old male with a history of hypertension presented with a couple of pre-syncopal episodes. He describes these episodes as him having felt as if he was going to faint and he has had to sit down. There were no precipitating factors, associated chest pain or palpitations. He doesn't have chest pain, shortness of breath on exertion, orthopnoea or paroxysmal nocturnal dyspnoea. On examination he looked well. Blood pressure was 140/80 mmHg and pulse rate was 78 bpm which was irregular. His lungs were clear and heart sounds were normal. ECG showed sinus rhythm with occasional ventricular ectopic beats. Which of the following is an indication for permanent pacemaker implantation?
Your Answer: Second-degree block associated with symptoms
Explanation:Indications for permanent pacemaker implantation
-Sinus node dysfunction
-Acquired Atrioventricular(AV) block (Complete third-degree AV block with or without symptoms, Symptomatic second degree AV block, Mobitz type I and II, Exercise-induced second or third degree AV block in the absence of myocardial infarction, Mobitz II with widened QRS complex)
-Chronic bifascicular block
-After acute phase of myocardial infarction
-Neurocardiogenic syncope and hypersensitive carotid sinus syndrome
-Post cardiac transplantation
-Hypertrophic cardiomyopathy
-Pacing to detect and terminate tachycardia
-Cardiac resynchronization therapy in patients with severe systolic heart failure
-Patients with congenital heart disease -
This question is part of the following fields:
- Cardiovascular System
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Question 3
Correct
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Which of the following is suggestive of co-existence of mitral regurgitation and mitral stenosis?
Your Answer: Displaced apex beat
Explanation:Apex beat displacement is caused by mitral regurgitation and because it is not found in mitral stenosis, it is suggestive of mixed mitral disease. The other given responses occur in mitral stenosis.
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This question is part of the following fields:
- Cardiovascular System
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Question 4
Correct
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A 32-year-old primigravida, with a history of pulmonary hypertension, presents to the clinic at 36 weeks gestation with worsening shortness of breath.
Which of the following is the most accurate statements regarding her condition?Your Answer: Risk of maternal mortality in patients with pulmonary hypertension is 30%
Explanation:Historically, high rates of maternal and fetal death have been reported for pregnant women with pulmonary hypertension (30-56% and 11-28%, respectively). The causes of poor maternal outcomes are varied and include risk of death from right heart failure and stroke from intracardiac shunting. Furthermore, there is a high peri-/post-partum risk due to haemodynamic stress, bleeding complications and the use of general anaesthesia, which can all lead to right heart failure.
The most common risk to the foetus is death, with premature birth and growth retardation being reported in successfully delivered children.
CXR is not contraindicated in pregnancy. D-dimers are not used as a diagnostic aid as they are almost always elevated in pregnancy. Nifedipine, although contraindicated in pregnant women may be used judiciously if the need arises. -
This question is part of the following fields:
- Respiratory System
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Question 5
Incorrect
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In last 5 days, an old man has complained of severe left sided headache, which was aggravated by bright lights. He has not vomited but feels nauseated. What is the most likely diagnosis?
Your Answer: SAH
Correct Answer: Migraine
Explanation:Migraine without aura have the following characteristics: Nausea and vomiting accompanied by >5 headaches that last for 4-72 hours, plus any unilateral, pulsating headache or are aggravated by routine daily activities.
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This question is part of the following fields:
- Nervous System
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Question 6
Incorrect
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A 30-year-old male underwent an urgent appendectomy. 3 hours after the procedure he developed tachycardia and fever. He was also having pain in his abdomen and shoulder area. What is the first step in the management?
Your Answer: Emergency exploratory laparotomy
Correct Answer: Maintain IV access and give IV fluids
Explanation:The features mentioned in this case indicate an internal haemorrhage. This should be managed initially by passing an IV line and IV fluids.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 7
Incorrect
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During the examination of an elderly confused and non-coherent gentleman who was brought to casualty by a concerned neighbour, you notice that he has bilaterally small pupils, which do not appear to react to light. Under the circumstances, it is difficult to judge their response to accommodation.
Which of the following conditions may not account for the pupillary appearance in this patient?Your Answer: Old age
Correct Answer: Acute alcohol intoxication
Explanation:Acute alcohol intoxication presents with pupillary dilation, thus, this is ruled out in this patient. All the other listed causes present with small pupils bilaterally.
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This question is part of the following fields:
- Nervous System
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Question 8
Correct
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A 37-year-old woman known with ulcerative colitis is referred with a microcytic anaemia. Blood tests reveal the following results:
Hb 88 g/L (120-160)
WCC 3.6 ×109/L (4-11)
Platelets 222 ×109/L (150-400)
MCV 70 fL (80-96)
Haptoglobins <0.04 g/L (0.13-1.63)
Lactate dehydrogenase 850 U/L (100-250)
Bilirubin 68 µmol/L (1-22)
Alkaline phosphatase 100 U/L (45-105)
ALT 23 U/L (5-40)
Which investigation would confirm the underlying diagnosis?Your Answer: Direct Coombs' test
Explanation:This a case of autoimmune haemolytic anaemia which is a rare complication of the less used treatment, salazopyrine, used for inflammatory bowel disease (IBD). A direct Coombs’ test looks for erythrocytes already coated with antibody, whereas the indirect test is used to detect potential red cell antibody interactions floating around in the blood.
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This question is part of the following fields:
- Gastrointestinal System
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Question 9
Correct
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An 18-year-old male presented to the OPD with complaints of abdominal pain and diarrhoea. There is a history of pubertal delay. On examination, he has pallor and looks short for his age. Tissue biopsy of the small intestines reveals damaged villi. Which of the following is the most likely cause of this condition?
Your Answer: Coeliac disease
Explanation:Celiac disease has characteristic shortened intestinal villi. When patients with celiac disease eat products containing gluten, they are unable to absorb the nutrients due to flattened or shortened intestinal villi. The blistering rash present on the patient’s elbows strongly suggests celiac disease. This rash is a sign of the condition Dermatitis Herpetiformis which is associate with celiac disease. Therefore, it is also often called ‘gluten rash’.
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This question is part of the following fields:
- Gastrointestinal System
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Question 10
Correct
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An 80-year-old woman is brought to the ER with altered sensorium. She is accompanied by her daughter who noticed the acute change. The patient has had a nagging cough with purulent sputum and haemoptysis for the last few days. Previous history includes a visit to her GP two weeks back because of influenza.
On examination, the patient appears markedly agitated with a respiratory rate of 35/min. Blood gases reveal that she is hypoxic. White blood cell count is 20 x 109/l, and creatinine is 250 mmol/l. Chest X-ray is notable for patchy areas of consolidation, necrosis and empyema formation.
Which of the following lead to the patient's condition?Your Answer: Staphylococcus aureus pneumonia
Explanation:Though a common community pathogen, Staphylococcus Aureas is found twice as frequently in pneumonias in hospitalized patients. It often attacks the elderly and patients with CF and arises as a co-infection with influenza viral pneumonia. The clinical course is characterized by high fevers, chills, a cough with purulent bloody sputum, and rapidly progressing dyspnoea. The gross pathology commonly reveals an acute bronchopneumonia pattern that may evolve into a necrotizing cavity with congested lungs and airways that contain a bloody fluid and thick mucoid secretions.
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This question is part of the following fields:
- Geriatric Medicine
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SESSION STATS - PERFORMANCE PER SPECIALTY
