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Question 1
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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 2
Correct
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A 23-year-old man visited the OPD with a complaint of pain in the abdomen and dark urine. His blood pressure was found to be elevated. Which of the following should be done next to reach a diagnosis?
Your Answer: US
Explanation:Hypertension along with haematuria give an indication of cystic kidneys which can be diagnosed with an ultrasound.
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This question is part of the following fields:
- Renal System
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Question 3
Correct
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Question 4
Incorrect
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A 25-year-old female presents with diarrhoea and 8 kg weight loss over the last 3 months. She has also experienced amenorrhea for the past 12 weeks. Which of the following is the next best step in the management of this patient?
Your Answer: 24 hours urinary VMA (Vanillyl mandelic Acid)
Correct Answer: Thyroid Function Test
Explanation:Weight loss is most commonly linked to hyperthyroidism. An overactive thyroid gland (hyperthyroidism) or underactive thyroid gland (hypothyroidism) can cause menstrual irregularities, including amenorrhea. In this scenario, we would carry out thyroid function tests.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 5
Correct
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A 45-year-old male complains of numbness in the little and ring fingers of his left hand. Which of the following nerves is responsible for this presentation?
Your Answer: Ulnar Nerve
Explanation:There are three branches of the ulnar nerve that are responsible for its sensory innervation. The palmar cutaneous branch innervates the medial half of the palm. The dorsal cutaneous branch innervates the dorsal surface of the medial one and a half fingers, and the associated dorsal hand area. The superficial branch innervates the palmar surface of the medial one and a half fingers. According to the given history, the superficial branch of ulnar nerve has been affected.
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This question is part of the following fields:
- Nervous System
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Question 6
Correct
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A 23-year-old male presents with a history of lower back pain for the last one year. Presence of which of the following features most likely points towards ankylosing spondylitis?
Your Answer: Bilateral erosion of sacroiliac joints on X-ray
Explanation:Bilateral erosions of the sacroiliac joints on pelvic radiographs of patients with ankylosing spondylitis are an important feature of the modified New York classification criteria. Although HLA-B27 is commonly associated with AS, it can also be found in normal individuals. Back stiffness is worse in the morning and gets better as the day progresses. Tenderness and limited lumbar motion can be associated with other spine problems as well and is not characteristic of rheumatoid arthritis.
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This question is part of the following fields:
- Musculoskeletal System
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Question 7
Correct
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A 45-year-old male patient who was initially investigated for having an abdominal mass is diagnosed as having Burkitt lymphoma. He is due to start chemotherapy today.
Which one of the following should be given prior to his chemotherapy in order to reduce the risk of tumour lysis syndrome?Your Answer: Rasburicase
Explanation:Rasburicase should be given prior to chemotherapy in order to reduce the risk of tumour lysis syndrome (TLS). Rasburicase is a recombinant version of urate oxidase which is an enzyme that metabolizes uric acid to allantoin. Allantoin is 5-10 times more soluble than uric acid, hence, renal excretion is more effective.
TLS is a potentially fatal condition occurring as a complication during the treatment of high-grade lymphomas and leukaemias. It occurs from the simultaneous breakdown (lysis) of the tumour cells and subsequent release of chemicals into the bloodstream. This leads to hyperkalaemia and hyperphosphatemia in the presence of hyponatraemia. TLS can occur in the absence of chemotherapy, but it is usually triggered by the introduction of combination chemotherapy. Awareness of the condition is critical for its prophylactic management.
Burkitt lymphoma is a high-grade B-cell neoplasm. There are two major forms:
1. Endemic (African) form: typically involves maxilla or mandible.
2. Sporadic form: abdominal (e.g. ileocaecal) tumours are the most common form. More common in patients with HIV.Burkitt lymphoma is associated with the c-myc gene translocation, usually t(8;14). The Epstein-Barr virus (EBV) is strongly implicated in development of the African form of Burkitt lymphoma and to a lesser extent, the sporadic form.
Management of the lymphoma is with chemotherapy. This tends to produce a rapid response which may cause TLS.
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This question is part of the following fields:
- Haematology & Oncology
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Question 8
Incorrect
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Which of the following drugs would be the safest to prescribe in a 22-year-old man with seropositive rheumatoid arthritis who is planning to start a family?
Your Answer: Sulfasalazine
Correct Answer: Prednisolone
Explanation:Prednisolone although has many undesirable side effects it may be considered relatively safe compared to the drugs that are provided here. Prolonged treatment with sulphasalazine may depress semen quality and cause irreversible infertility. Methotrexate and leflunomide both inhibit purine/pyrimidine synthesis (the former by inhibiting folate metabolism) and are contraindicated in pregnancy or while trying to conceive. In males, a temporary or permanent decrease in sperm count may occur with cyclophosphamide. Because the recovery of fertility after cyclophosphamide therapy is variable, sperm banking should be considered before treatment is begun.
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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 hypertensive man presents to the emergency in a state of restlessness and shock. He has a history of a pulsatile abdominal mass. Pulse is calculated to be 120/min and the BP: 70/40 mmHg. How should he be managed?
Your Answer: IV fluids 0.9% NS crystalloids to bring SBP to 90mmHg
Explanation:Pre-operative hemodynamic stability is directly associated with the patient’s mortality, and pre-operative shock is the most serious risk factor affecting survival after a ruptured abdominal aortic aneurysm (AAA). For this reason, it is important to stabilize the patient’s blood pressure. However, aggressive fluid resuscitation before achieving control of the proximal aorta can lead to further haemorrhaging, which may result in an increased risk of mortality. Thus, the primary goal in the initial management of patients with AAA is achieving hemodynamic stability to allow perfusion of the vital organs. This is the concept underlying permissive hypotension. This usually involves maintaining a systolic blood pressure of 70 to 90 mmHg, and avoiding aggressive resuscitation to pressures higher than 100 mmHg.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 10
Correct
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A 42-year-old previously well woman presented with acute severe central chest pain for the past 2 hours. She has a family history of premature coronary artery disease. Her husband passed away recently due to prostate cancer. On examination her blood pressure was 130/80 mmHg and pulse rate was 80 bpm. Her ECG showed ST segment elevation and her troponin was slightly elevated. Emergency angiogram revealed slight wall irregularities with no luminal obstruction. Cardiovascular MR showed an apical ballooning of the myocardium resembling an octopus pot. Which of the following is the most likely cause for the ST segment elevation?
Your Answer: Takotsubo cardiomyopathy
Explanation:Causes for ST segment elevation other than myocardial infarction
Natural variants
-Early repolarization
-Left ventricular hypertrophy and hypertrophic cardiomyopathy
-Left bundle branch block
Artefacts
-Leads mispositioning
-Electrical cardioversion
Cardiovascular diseases
-Pericarditis/ Myocarditis
-Aortic dissection
-Prinzmetal’s angina
-Takotsubo Cardiomyopathy
-Brugada Syndrome and arrhythmogenic right ventricular cardiomyopathy/dysplasia
Pulmonary diseases
-Pulmonary thromboembolism
-Pneumothorax
-Atelectasis and pulmonary metastases
Gastrointestinal diseases
-Acute pancreatitis
-Acute cholecystitis
Other conditions
-Hyperkalaemia
-Drug induced ST segment elevation (e.g. – clozapine)
-Haemorrhagic cerebrovascular diseaseCoronary artery disease and myocardial infarction can be excluded with a negative angiogram and a slightly elevated troponin. Hypertrophic cardiomyopathy can be excluded with cardiovascular MR findings. Left ventricular aneurysm usually occurs following a myocardial infarction, but there is no positive history for that. The characteristic findings on cardiovascular MR confirms the diagnosis of Takotsubo cardiomyopathy.
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This question is part of the following fields:
- Cardiovascular System
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Question 11
Incorrect
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You are reviewing a 70-year-old gentleman who has been suffering from multiple myeloma for the past 3 years. He presents with lethargy, muscle aches and pain in his lower back.
Â
Arterial blood sampling reveals a metabolic acidosis. Serum potassium is 3.1 mmol/l (3.5-4.9), and urine pH is 5.1 (> 5.3).
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What is the most likely diagnosis?Your Answer: Renal tubular acidosis-type I
Correct Answer: Renal tubular acidosis-type II
Explanation:This case is most likely RTA type II, due to decreased proximal bicarbonate reabsorption, which leads to metabolic acidosis, hypokalaemia, hyperchloremia, and <6 urine pH .
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This question is part of the following fields:
- Renal System
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Question 12
Correct
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A 17-year-old man presents with fever and extensive preauricular swelling on the right side of his face. However, tenderness is present bilaterally. He also complains of acute pain and otalgia on the right aspect of the face. What is the most likely diagnosis?
Your Answer: Mumps
Explanation:Mumps presents with a prodromal phase of general malaise and fever. On examination there is usually painful parotid swelling which has high chances of becoming bilateral. In OM with effusion there are no signs of infection and the only symptom is usually hearing loss. Acute otitis externa produces otalgia as well as ear discharge and itching. Acute OM produces otalgia and specific findings upon otoscopy. In acute mastoiditis the patient experiences ear discharge, otalgia, headache, hearing loss and other general signs of inflammation.
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This question is part of the following fields:
- Infectious Diseases
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Question 13
Correct
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A 69-year-old male with a history of Hepatitis C liver cirrhosis presented with spontaneous bacterial peritonitis. He had no symptoms of hypovolaemia. Choose the best treatment option to prevent the patient from developing hepatorenal syndrome.
Your Answer: Intravenous albumin administration
Explanation:In randomised controlled trials, the administration of albumin has been shown to lower the risk of the hepatorenal syndrome – this is thought to be due to its positive effect on circulatory systems. Diuretics can aid in the prevention of renal failure, but this patient is not showing signs of hypovolaemia. Synthetic disaccharide lactulose is primarily used for the prevention of hepatic encephalopathy, which has no function in preventing hepatorenal syndrome. Limited evidence is available for the use of Neomycin as a treatment for hepatic encephalopathy, but is associated with nephrotoxicity and ototoxicity.
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This question is part of the following fields:
- Renal System
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Question 14
Incorrect
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A 42-year-old female presented with pain in her calves during walking which settled after resting. On examination there were orange colour deposits in the her palmar creases. Her fasting lipid profile showed a total cholesterol of 9.2 mmol/l (<5) and triglycerides of 7.0 mmol/l (<2). Which of the following is the most likely diagnosis?
Your Answer: Familial hypercholesterolaemia
Correct Answer: Type III hyperlipidaemia
Explanation:Palmar xanthomas are found in type III hyperlipoproteinemia. Her total cholesterol level and triglyceride level support the diagnosis.
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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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Organophosphates, such as Sarin, have been used as chemical-warfare agents by terrorists.
Which of the following statements is true concerning organophosphate poisoning?Your Answer: Atropine is useful in the management of organophosphate poisoning
Explanation:The principal action of organophosphates is the inhibition of acetylcholinesterase’s, therefore leading to the accumulation of acetylcholine at muscarinic receptors (miosis, hypersalivation, sweating, diarrhoea, excessive bronchial secretions), nicotinic receptors (muscle fasciculations and tremor) and in the central nervous system (anxiety, loss of memory, headache, coma).
Removal from the source of the organophosphate, adequate decontamination, supplemental oxygen and atropine are the initial treatment measures. Pralidoxime, an activator of cholinesterase, should be given to all symptomatic patients.
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This question is part of the following fields:
- Pharmacology
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Question 16
Correct
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An 81-year-old male presented to the emergency department following a fall at home. He was diagnosed with osteoporosis about five years ago. He presently complains of significant low back pain.
A lumbar spine X-ray was suggestive of a fractured lumbar vertebra.
A subsequent MRI scan of the lumbosacral spine revealed a new L3 burst fracture with no evidence of cord compression.
A neurosurgical consult was sought and conservative management was planned accordingly in the form of pain control, physiotherapy, and mobilization (as allowed by the pain).
He also has been diagnosed with chronic renal disease (stage IV) with a creatinine clearance of 21 ml/min, he was started on a Buprenorphine patch.
Which of the following opioids would be safest to use for his breakthrough pain?Your Answer: Oxycodone
Explanation:Oxycodone is a safer opioid to use in patients with moderate to end-stage renal failure.
Active metabolites of morphine accumulate in renal failure which means that long-term use is contraindicated in patients with moderate/severe renal failure.
These toxic metabolites can accumulate causing toxicity and risk overdose.
Oxycodone is mainly metabolised in the liver and thus safer to use in patients with moderate to end-stage renal failure with dose reductions.
Adverse effects:
Constipation is the most common overall side effect. Others include: asthenia, dizziness, dry mouth, headache, nausea, pruritus, etc.Medications in renal failure:
Drugs to be avoided in patients with renal failure
Antibiotics: tetracycline, nitrofurantoin
NSAIDs
Lithium
Metformin
Drugs that require dose adjustment:
Most antibiotics including penicillin, cephalosporins, vancomycin, gentamicin, streptomycin
Digoxin, atenolol
Methotrexate
Sulphonylureas
Furosemide
Opioids
Relatively safe drugs:
Antibiotics: erythromycin, rifampicin
Diazepam
Warfarin -
This question is part of the following fields:
- Geriatric Medicine
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Question 17
Incorrect
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Which among the following antihypertensives is centrally acting?
Your Answer: Minoxidil
Correct Answer: Moxonidine
Explanation:Moxonidine and alpha-methyl dopa are centrally acting antihypertensives and modify blood pressure through modifying sympathetic activity.
Other options:
Verapamil is a calcium antagonist.
Minoxidil and hydralazine are both vasodilators.
Phenoxybenzamine is an alpha-blocker.Adverse effects:
Dry mouth and somnolence were the most frequently reported adverse events, followed by headache, dizziness, nausea and allergic skin reactions. -
This question is part of the following fields:
- Pharmacology
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Question 18
Incorrect
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A 28-year-old woman is investigated for bloody diarrhoea which started around six weeks ago. She is currently passing 3-4 loose stools a day which normally contain a small amount of blood. Other than feeling lethargic she remains systemically well with no fever or significant abdominal pain. A colonoscopy is performed which shows inflammatory changes in the ascending colon consistent with ulcerative colitis. Bloods show the following:
Hb: 14.2 g/dl
Platelets: 323 * 109/l
WBC: 8.1 * 109/l
CRP: 22 mg/l
What is the most appropriate first-line medication to induce remission?Your Answer: Rectal aminosalicylate
Correct Answer: Oral aminosalicylate
Explanation:Given she is not showing signs of systemic illness, you do not need to treat for an acute flair (which would be steroids), but you need to put her on maintenance medication. Oral ASA would be the best option for this, it is first line. You cannot give rectal ASA because the location of her disease is in the ascending colon and the enema will not reach.
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This question is part of the following fields:
- Gastrointestinal System
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Question 19
Correct
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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: 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 20
Incorrect
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Using DEXA, which of the following bone mineral density values indicates osteopenia in the measured site?
Your Answer: A T score of -1.8
Correct Answer: A T score of -2.6
Explanation:Osteopenia is an early sign of bone weakening that is less severe than osteoporosis.
The numerical result of the bone density test is quantified as a T score. The lower the T score, the lower the bone density. T scores greater than -1.0 are considered normal and indicate healthy bone. T scores between -1.0 and -2.5 indicate osteopenia. T scores lower than -2.5 indicate osteoporosis.
DEXA also provides the patient’s Z-score, which reflects a value compared with that of person matched for age and sex.
Z-score values of -2.0 SD or lower are defined as below the expected range for age and those above -2.0 SD as within the expected range for age. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 21
Correct
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A 40-year-old male returning from an African country, presented with lower abdominal pain and haematuria. Bladder calcifications were detected on abdominal x-ray. Which of the following is the most probable cause?
Your Answer: Schistosoma haematobium
Explanation:Schistosoma haematobium characteristically causes urinary tract disease. S.mansoni, S. mekongi, S. intercalatum, and S. japonicum cause intestinal tract and liver disease.
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This question is part of the following fields:
- Infectious Diseases
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Question 22
Incorrect
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A 25-year-old patient has presented with symptoms which all point to the cerebellopontine angle (CPA) a tumour. These are numbness in the face, vertigo, and tinnitus. Choose the most appropriate investigation from the list of options.
Your Answer: MRI Head
Correct Answer: MRI Brain
Explanation:MRI scans are used to diagnose tumours in the cerebellopontine angle.
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This question is part of the following fields:
- Nervous System
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Question 23
Incorrect
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Which area in the body controls the hypoxic drive to breathe?
Your Answer: Areas on ventrolateral surface of the medulla
Correct Answer: Carotid body
Explanation:The carotid body consists of chemosensitive cells at the bifurcation of the common carotid artery that respond to changes in oxygen tension and, to a lesser extent, pH. In contrast to central chemoreceptors (which primarily respond to PaCO2) and the aortic bodies (which primarily have circulatory effects: bradycardia, hypertension, adrenal stimulation, and also bronchoconstriction), carotid bodies are most sensitive to PaO2. At a PaO2 of approximately 55-60 mmHg, they send their impulses via CN IX to the medulla, increasing ventilatory drive (increased respiratory rate, tidal volume, and minute ventilation). Thus, patients who rely on hypoxic respiratory drive will typically have a resting PaO2 around 60 mm Hg.
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This question is part of the following fields:
- Respiratory System
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Question 24
Correct
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A 30-year-old male with a history of premature cardiovascular disease in the family has come for review of his lab investigations.
His fasting cholesterol is 8.4 mmol/l with high-density lipoprotein (HDL) of 1.6 mmol/l.
You elect to commence him on atorvastatin 20 mg PO daily.
Which of the following best describes the mechanism of action of the statins?Your Answer: They inhibit HMG CoA reductase
Explanation:Statins are a selective, competitive inhibitor of hydroxymethylglutaryl-CoA (HMG-CoA) reductase, which is the enzyme responsible for the conversion of HMG-CoA to mevalonate in the cholesterol synthesis pathway.
Statins are usually well tolerated with myopathy, rhabdomyolysis, hepatotoxicity, and diabetes mellitus being the most common adverse reactions.
This is the rate-limiting step in cholesterol synthesis, that leads to increased hepatic low-density lipoprotein (LDL) receptors and reduced hepatic VLDL synthesis coupled with increased very-low-density lipoprotein (VLDL) clearance. -
This question is part of the following fields:
- Pharmacology
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Question 25
Correct
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A 74-year-old woman referred by her GP because of increasing weight loss, early satiety and increasing anorexia. She admits to 2 or 3 episodes of vomiting blood. The GP feels an epigastric mass.
There is both a microcytic anaemia and abnormal liver enzymes. Her past history, which may be of importance, includes excess consumption of sherry and spirits, and a 30 pack-year smoking history.
Which diagnosis fits best with this clinical picture?Your Answer: Gastric carcinoma
Explanation:With a clinical history of weight loss, smoking, drinking alcohol, and hematemesis, the most likely answer is gastric carcinoma (also a mass). Based on symptomatology alone this is more likely than gastric lymphoma, as she has many risk factors for adenocarcinoma and/or squamous cell carcinoma. Helicobacter gastritis would not likely present with the severity of symptoms, neither would benign gastric ulcers.
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This question is part of the following fields:
- Gastrointestinal System
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Question 26
Incorrect
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A 3-year-old girl presents to A&E following a few days of being lethargic, having runny nose, sore throat, and fever. She has unceasing stridor and drooling of saliva while her body is inclined forward. What is the most important next step in her management?
Your Answer: High flow O2
Correct Answer: Call ENT specialist
Explanation:A consultation with an ENT is required to establish the reason for the child’s drooling and stridor indicating and obstructive process. Enlarged tonsils and adenoids should be checked.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 27
Correct
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A 55-year-old man attends follow-up for liver cirrhosis, which reveals a large dominant nodule in the right lobe of liver on CT Scan. Which tumour marker would most likely be elevated?
Your Answer: Alpha feto-protein (AFP)
Explanation:A considerably increased serum AFP is characteristic of hepatocellular cancer. A distinct nodule for cirrhotic patients should be investigated to rule out hepatocellular cancer.
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This question is part of the following fields:
- Gastrointestinal System
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Question 28
Correct
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A 50-year-old female patient is started on cyclophosphamide for vasculitis associated with Wegener's granulomatosis. Which of the following adverse effects is most characteristically associated with cyclophosphamide use?
Your Answer: Haemorrhagic cystitis
Explanation:Cyclophosphamide is a cytotoxic alkylating agent that acts by causing cross-linking of DNA strands. Its major adverse effects include haemorrhagic cystitis, myelosuppression, and transitional cell carcinoma.
Cardiomyopathy is caused by doxorubicin and ototoxicity is caused by cisplatin. Alopecia and weight gain are associated with a variety of chemotherapeutic agents especially those that treat breast cancers (e.g. paclitaxel).
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This question is part of the following fields:
- Haematology & Oncology
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Question 29
Correct
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A diagnosed case of scabies presented in OPD for some medical advice. Which of the following statements best suits scabies?
Your Answer: It causes itchiness in the skin even where there is no obvious lesion to be seen
Explanation:Scabies is an infection caused by a microscopic mite known as Sarcoptes scabies. The chief presenting complaint is itching especially in skin folds and mostly during night. It spreads from one person to another through skin contact, and therefore it is more prevalent in crowded areas like hospitals, hostels and even at homes where people live in close contact with each other. Treatment options include benzyl benzoate, ivermectin, sulphur and permethrin.
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This question is part of the following fields:
- The Skin
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Question 30
Correct
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A 35-year-old male who has smoked 20 cigarettes per day was referred to the National Chest Hospital because he has had a nine month history of shortness of breath which is getting worse. Tests revealed that he had moderate emphysema. His family history showed that his father died from COPD at the age of 52. Genetic testing found the PiSZ genotype following the diagnosis of alpha-1 antitrypsin (A1AT) deficiency. What levels of alpha-1 antitrypsin would be expected if they were to be measured?
Your Answer: 40% of normal
Explanation: -
This question is part of the following fields:
- Respiratory System
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Question 31
Correct
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A 60-year-old male patient with hypertension presented with acute onset retrosternal chest pain for 3 hours. On examination his pulse rate was 68 bpm, BP was 100/60 mmHg and JVP was seen 3mm from the sternal notch. Respiratory examination was normal. His ECG showed narrow QRS complexes, ST segment elevation of 2mm in leads II, III and aVF and a complete heart block. What is the most immediate treatment from the following answers?
Your Answer: Chewable aspirin 300 mg
Explanation:The diagnosis is inferior ST elevation myocardial infarction. As the right coronary artery supplies the SA and AV nodes and bundle of His, conduction abnormalities are more common with inferior MIs. The most immediate drug management is high dose Aspirin. Definite treatment is urgent cardiac revascularization.
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This question is part of the following fields:
- Cardiovascular System
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Question 32
Correct
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A 30-year-old patient has ataxia, nystagmus and vertigo with a history of headaches. Where is the most likely site of the lesion?
Your Answer: Cerebellum
Explanation:Damage to the cerebellum can cause asynergia, dysmetria, adiadochokinesia, intention tremor, staggering, ataxic gait, tendency toward falling, hypotonia, ataxic dysarthria and nystagmus.
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This question is part of the following fields:
- Nervous System
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Question 33
Incorrect
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A 24-year-old female, 28 weeks pregnant presents to the clinic complaining of shortness of breath and right sided pleuritic chest pain. The doctor suspects pulmonary embolism.
Which of the following statement is incorrect regarding the management of this case?Your Answer: Chest x-ray should be performed
Correct Answer: Ventilation-perfusion scanning exposes the foetus to less radiation than computed tomographic pulmonary angiography
Explanation:V/Q scanning carries a slightly increased risk of childhood cancer compared with CTPA – 1/280,000 versus less than 1/1,000,000 – but carries a lower risk of maternal breast cancer. The rest of the options are true.
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This question is part of the following fields:
- Respiratory System
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Question 34
Correct
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A 48-year-old male presented with exertional angina for 2 weeks. He has no significant past medical history or cardiac risk factors except a total cholesterol of 5.8 mmol/L. He has been already started on aspirin. Which of the following is the most suitable drug combination for him?
Your Answer: B-blocker and statin
Explanation:Beta blockers and calcium channel blockers have proven prognostic benefits. Nitrates don’t have any proven prognostic benefits. A statin is indicated for a patient with angina and cholesterol level of 5.5 to 8.5 to prevent risk of myocardial infarction. So the preferred combination from the given answers is beta blocker + statin.
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This question is part of the following fields:
- Cardiovascular System
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Question 35
Correct
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An 18-year-old woman in her 30th week of pregnancy is brought to the hospital in altered sensorium. She is taking slow, shallow breaths and her breath has a fruity smell. An arterial blood gas (ABG) shows the presence of ketones. What is the most probable diagnosis?
Your Answer: Diabetic Ketoacidosis (DKA)
Explanation:This a case of gestational diabetes presenting with DKA. It is a serious case that requires immediate intervention. Pregnant diabetics tend to develop DKA on a lower serum glucose level than non-pregnant diabetics. The shortness of breath is a trial to wash the excess CO2 to compensate for the metabolic acidosis seen in the ABG. The fruity smell is acetone excreted through the lungs. The main treatment of this case is proper fluid management and insulin infusion.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 36
Correct
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A 69-year-old man on the cardiology ward who is hypotensive, and tachycardic is having profuse melaena. He was commenced on dabigatran 150mg bd by the cardiologists 48 hours earlier for non-valvular atrial fibrillation. Following appropriate resuscitation which of the following treatments is most likely to improve his bleeding?
Your Answer: Idarucizumab (Praxbind)
Explanation:Idarucizumab (Praxbind) is a newer antidote for dabigatran, the first of its kind. It is a monoclonal antibody fragment that binds dabigatrin with a higher affinity than thrombin. It is very expensive.
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This question is part of the following fields:
- Gastrointestinal System
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Question 37
Correct
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A 45-year-old male has presented at the hospital with an inoperable carcinoma and pain in his back. His pain has since been controlled well with morphine, but he soon starts vomiting. Morphine administration was ceased, and he was started on both fentanyl patches and metoclopramide. He soon develops stiffness in his neck and a fever. From the list of options, choose the cause of his symptoms.
Your Answer: Metoclopramide
Explanation:Metoclopramide side-effects are consistent with the patient’s symptoms: fever and stiffness of the neck. The other medications are not consistent with this symptom.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 38
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 39
Incorrect
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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 recessive
Correct 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 40
Correct
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A 32-year-old female is diagnosed with SLE based on her complaints of polyarthralgia, mouth ulcers and ANA positivity. Labs reveal normal urinalysis, urea and electrolytes. ESR is 90mm in the first hour. How will you manage this patient?
Your Answer: Hydroxychloroquine 200 mg/day
Explanation:Hydroxychloroquine is used in the management of SLE as it prevents disease progression and has relatively mild side effects, for instance headache, nausea etc. Its use reduces the usage of corticosteroids. It is particularly effective when the disease is less severe and there is no organ involvement. Cyclophosphamide and prednisolone are indicated in cases of renal, neurological and lung involvement.
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This question is part of the following fields:
- Musculoskeletal System
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Question 41
Incorrect
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A 57-year-old, alcoholic male was admitted to the medical ward for an ascitic tap. The ascitic fluid was found to be yellow in colour. Which of the following had most likely lead to this observation?
Your Answer: Pyogenic peritonitis
Correct Answer: Decompensated cirrhosis
Explanation:Uncomplicated cirrhotic ascites is usually translucent. If the patient is deeply jaundiced, the fluid might appear yellow/brown.
Turbidity or cloudiness of the ascites fluid suggests that infection is present and further diagnostic testing should be performed.
Pink or bloody fluid is most often caused by mild trauma, with subcutaneous blood contaminating the sample.
Bloody ascites is also associated with hepatocellular carcinoma or any malignancy-associated ascites.
Milky-appearing fluid usually has an elevated triglyceride concentration. Such fluid, commonly referred to as chylous ascites, can be related to thoracic duct injury or obstruction or lymphoma, but it is often related primarily to cirrhosis. -
This question is part of the following fields:
- Hepatobiliary System
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Question 42
Correct
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A 40-year-old female presented in the OPD with a 4-day history of severe episodes of dizziness. She reports that her room starts spinning and then she tends to fall. She also complains of deafness, tinnitus, and a sensation of clogging in the ear. What condition do you think this patient is suffering from?
Your Answer: Meniere's disease
Explanation:The patient presents with the classic symptoms of Meniere’s disease. This is a condition in which the amount of endolymph in the internal ear increases because of an increase in endolymph production, a reduction of endolymph drainage, or as a result of an infection. Hearing and balance tests should be done for the proper analysis of the patient’s condition and to rule out other conditions.
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This question is part of the following fields:
- Nervous System
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Question 43
Correct
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A 51-year-old man was admitted with right-sided hemiparesis and right upper motor neuron facial nerve palsy. He was known to be on warfarin for a mitral valve replacement and had been adequately anticoagulated. He was also taking furosemide and had recently been started on St John's wort for low mood.
On examination, his pulse was 90 bpm and regular, and his blood pressure was 150/80 mmHg. Cardiac examination demonstrated normal prosthetic valve sounds with an ejection systolic murmur at the left sternal edge. CT scan showed evidence of a left middle cerebral artery infarction.
What is the possible explanation for the presentation?Your Answer: St John's wort reduces the activity of warfarin
Explanation:St John’s wort interferes with warfarin by increasing its breakdown and decreasing its effectiveness. This leads to the need for adjustment in the dose of warfarin and careful attention to monitoring if the patient decides to continue with the drug. Ideally, an alternative antidepressant should also be considered.
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This question is part of the following fields:
- Haematology & Oncology
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Question 44
Incorrect
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A 72-year-old male presents complaining of having intermittent trouble with swallowing. He has also been regurgitating stale food material. He sometimes wakes up in the middle of the night feeling like he is suffocating. Choose the most likely diagnosis.
Your Answer: Benign structure
Correct Answer: Pharyngeal pouch
Explanation:In benign stricture, oesophageal carcinoma, and systemic sclerosis, there is persistent dysphagia (rather than intermittent). In oesophageal spasm, there is no regurgitation of stale food material. The symptoms described are consistent with pharyngeal pouch.
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This question is part of the following fields:
- Gastrointestinal System
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Question 45
Correct
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After examination, a 50-year-old woman was found to have fissuring of the skin of her hands. She has been complaining of fatigue and difficulty in climbing stairs for a couple of months. CXR shows pulmonary fibrosis. Which antibody would you expect to be positive?
Your Answer: Anti Scl 70
Explanation:Anti-Scl-70 antibodies are associated with pulmonary fibrosis and indicate a poor prognosis when positive. Also, they are a specific marker for the diffuse type of systemic sclerosis. Systemic scleroderma, also called diffuse scleroderma or systemic sclerosis, is an autoimmune disease of the connective tissue. It is characterized by thickening of the skin caused by accumulation of collagen, and by injuries to small arteries.
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This question is part of the following fields:
- Musculoskeletal System
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Question 46
Correct
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A patient is told to consult a pathologist regarding the stone that was found in his urine. The pathologist describes the stone as laminated, with areas of black staining. Urinalysis indicates hypercalciuria. Which is the most likely type of renal calculus?
Your Answer: Calcium oxylate
Explanation:Hypercalciuria is the most common cause of kidney stone disease. It is an identifiable cause and can be primary (or idiopathic) or secondary. Secondary hypercalciuria might be due to hyperparathyroidism (2-3%), high levels of vitamin D, Cushing’s syndrome, sarcoidosis or milk-alkali syndrome. Hypercalciuria can also be idiopathic and is considered the commonest metabolic abnormality in people with stone disease. Factors favouring stone formation are: abnormal urine constituents, infection and stasis. In these cases, investigations fail to reveal any calcium metabolism disorders.
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This question is part of the following fields:
- Renal System
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Question 47
Correct
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In end stage renal disease, deficiency of erythropoietin can lead to which of the following conditions?
Your Answer: Anaemia
Explanation:Erythropoietin is necessary for normal Hb levels. Reduced levels of erythropoietin in renal failure leads to anaemia in these patients.
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This question is part of the following fields:
- Renal System
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Question 48
Incorrect
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A 45-year-old male complained of deteriorating vision after starting a new drug. Which of following could NOT be responsible for this presentation?
Your Answer: Vincristine
Correct Answer: Irinotecan
Explanation:Chloroquine causes Bull’s eye maculopathy which consists of a number of different conditions in which there is a ring of pale-looking damage around a darker area of the macula.
Ethambutol causes optic neuritis.
Quinine causes blurred vision and changes in colour vision.
Vincristine causes optic nerve atrophy as a result of chronic optic nerve oedema or optic neuritis.
Irinotecan does not have any ocular side effects. -
This question is part of the following fields:
- Pharmacology
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Question 49
Incorrect
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In which condition is the sniff test useful in diagnosis?
Your Answer: Pharyngeal pouch
Correct Answer: Phrenic nerve palsy
Explanation:The phrenic nerve provides the primary motor supply to the diaphragm, the major respiratory muscle.
Phrenic nerve paralysis is a rare cause of exertional dyspnoea that should be included in the differential diagnosis. Fluoroscopy is considered the most reliable way to document diaphragmatic paralysis. During fluoroscopy a patient is asked to sniff and there is a paradoxical rise of the paralysed hemidiaphragm. This is to confirm that the cause is due to paralysis rather than unilateral weakness. -
This question is part of the following fields:
- Respiratory System
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Question 50
Incorrect
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A 25-year-old pregnant female suddenly developed a rash on her torso. It started as macules and then became vesicles. After 3 days she died. During her post-mortem, positive findings suggestive of pneumonitis were found. Which one of the following is the most common cause?
Your Answer: Rubella
Correct Answer: Varicella zoster virus (VZV)
Explanation:Varicella zoster virus (VZV) presents in this way and the rash transforms from macules to vesicles. Pneumonitis is a common complication of VZV infection.
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This question is part of the following fields:
- Infectious Diseases
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SESSION STATS - PERFORMANCE PER SPECIALTY
