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Question 1
Correct
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The digital rectal examination and flexible sigmoidoscopy of a 30-year-old woman are normal. However, she still complains of recurrent and brief episodes of severe rectal pain. What is the most likely diagnosis?
Your Answer: Proctalgia fugax
Explanation:The digital rectal examination and sigmoidoscopy are normal, a fact that excludes all the other possible diagnoses. Proctalgia fugax is a functional anorectal disorder characterized by severe, intermittent episodes of rectal pain that are self-limiting. The diagnosis of proctalgia fugax requires exclusion of other causes of rectal or anal pain.
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This question is part of the following fields:
- Gastrointestinal System
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Question 2
Correct
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A 65-year-old man is referred to the oncology clinic with progressively worsening lower back pain for the last three months and history of weight loss for the past eight months. MRI lumbar spine confirms the suspicion of bone metastasis.
What is the most likely primary tumour?Your Answer: Prostate carcinoma
Explanation:Prostate cancer is the most common primary tumour that metastasises to the bone.
Most common tumours causing bone metastasis (in descending order):
1. Prostate (32%)
2. Breast (22%)
3. Kidneys (16%)
4. Lungs
5. ThyroidMost common sites of bone metastasis (in descending order):
1. Spine
2. Pelvis
3. Ribs
4. Skull
5. Long bones -
This question is part of the following fields:
- Haematology & Oncology
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Question 3
Incorrect
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A 48-year-old chronic smoker who smokes 20 cigarettes per day, presented with a persistent cough, wheezing and difficulty in breathing. He was treated with oxygen but the symptoms did not improve. Which of the following is the next step?
Your Answer: Salbutamol
Correct Answer: Check ABG
Explanation:The history is suggestive of a COPD exacerbation. As he is not responding to oxygen, an ABG should be performed to assess the level of hypoxaemia and then a decision about further management can be made. A CXR and salbutamol are also important in the acute management.
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This question is part of the following fields:
- Respiratory System
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Question 4
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 5
Correct
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A 64-year-old woman with metastatic breast cancer has developed progressive back pain over the last 2 days. She also reports of weakness of her lower limbs and difficulty in walking. On examination, she has reduced power in both legs and increased tone associated with brisk knee and ankle reflexes. There is some sensory loss in the lower limbs and feet but perianal sensation is normal.
What is the most likely diagnosis?Your Answer: Spinal cord compression at T10
Explanation:The upper motor neurone signs in this patient point towards a diagnosis of spinal cord compression above the level of L1 and rules out cauda equina syndrome.
Spinal cord compression is an oncological emergency and affects up to 5% of cancer patients. Extradural compression accounts for the majority of cases, usually due to vertebral body metastases. One of the most common causes of spinal cord compression is osteoarthritis. It is also more commonly seen in patients with lung, breast, or prostate cancer.
Clinical features include:
1. Back pain: the earliest and most common symptom, may worsen on lying down or coughing
2. Lower limb weakness
3. Sensory changes: sensory loss and numbness
4. Neurological signs: depending on the level of the lesion.
Lesions above L1 usually result in upper motor neurone signs in the legs. Lesions below L1 usually cause lower motor neurone signs in the legs and perianal numbness. Tendon reflexes are increased below the level of the lesion and absent at the level of the lesion.Management options are:
1. High-dose oral dexamethasone
2. Urgent MRI for consideration of radiotherapy or surgery -
This question is part of the following fields:
- Haematology & Oncology
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Question 6
Correct
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Which one of the following is the most common cause of hypothyroidism in the UK?
Your Answer: Hashimoto's thyroiditis
Explanation:Hashimoto thyroiditis is the most common cause of hypothyroidism in developed countries. In contrast, worldwide, the most common cause of hypothyroidism is an inadequate dietary intake of iodine. This disease is also known as chronic autoimmune thyroiditis and chronic lymphocytic thyroiditis.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 7
Correct
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A 61-year-old gentleman presents with heart failure and pedal oedema. The oedema occurs due to:
Your Answer: Increased release of renin
Explanation:The oedema is an effect of the a decreased cardiac output that increases renin release which leads to vasoconstriction and sodium and water retention.
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This question is part of the following fields:
- Renal System
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Question 8
Correct
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A 45-year-old male is suffering from bronchial carcinoma. This is causing obstruction of the superior vena cava. Which of the following is the most suitable palliative treatment option in this case?
Your Answer: Radiotherapy
Explanation:Bronchial carcinoma causes obstruction of the superior vena cava through its mass effect. From the options listed in this case, radiotherapy is the most suitable treatment option.
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This question is part of the following fields:
- Cardiovascular System
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Question 9
Incorrect
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A 35-year-old male presented to the ER after being rescued from a house fire. He complained of feeling dizzy and having a worsening headache. On examination, he was dyspnoeic, drowsy and confused. There was no evidence of facial burns and no stridor. He was normotensive, tachycardic (pulse rate: 102 bpm), tachypnoeic (respiratory rate: 35/min) and had O2 saturation of 100% in room air. His venous blood gas results are given below:
pH - 7.28
pCO2 - 3.5 kPa
pO2 - 15.9 kPa
Na+ - 139 mmol/L
K+ - 4.5 mmol/L
Bicarbonate - 11 mmol/L
Chloride - 113 mmol/L
Lactate - 13.6 mmol/L
Keeping in mind the likely diagnosis, which among the following is the most appropriate intervention for this patient?Your Answer: 15 litres of high-flow oxygen via face mask
Correct Answer: Intravenous hydroxocobalamin
Explanation:The most appropriate intervention in this patient is intravenous hydroxocobalamin.
The clinical scenario provided is suggestive of acute cyanide toxicity secondary to burning plastics in the house fire.
Cyanide ions inhibit mitochondrial cytochrome oxidase, preventing aerobic respiration. This manifests in normal oxygen saturations, a high pO2 and flushing (or ‘brick red’ skin) brought on by the excess oxygenation of venous blood. In the question above it is important to note that the blood gas sample given is venous rather than arterial. His blood gas also demonstrates an increased anion gap, consistent with his high lactate (generated by anaerobic respiration due to the inability to use available oxygen).The recommended treatment for moderate cyanide toxicity in the UK is one of three options: sodium thiosulfate, hydroxocobalamin or dicobalt edetate.
Among the options given is hydroxocobalamin and this is, therefore, the correct answer. Hydroxocobalamin additionally has the best side-effect profile and speed of onset compared with other treatments for cyanide poisoning.
Other options:
– Intubation would be appropriate treatment in the context of airway burns but this patient has no evidence of these, although close monitoring would be advised.
– High-flow oxygen is the treatment for carbon monoxide poisoning – a sensible differential, but this man’s very high lactate and high venous pO2 fit better with cyanide toxicity. Intravenous dexamethasone would be another treatment for airway oedema once an endotracheal tube had been placed.
– Intravenous sodium nitroprusside is a treatment for high blood pressure that can cause cyanide poisoning, and would, therefore, be inappropriate.Note:
Cyanide may be used in insecticides, photograph development and the production of certain metals. Toxicity results from reversible inhibition of cellular oxidizing enzymes
Clinical presentation:
Classical features: brick-red skin, the smell of bitter almonds
Acute: hypoxia, hypotension, headache, confusion
Chronic: ataxia, peripheral neuropathy, dermatitisManagement:
Supportive measures: 100% oxygen
Definitive: hydroxocobalamin (intravenously), also a combination of amyl nitrite (inhaled), sodium nitrite (intravenously), and sodium thiosulfate (intravenously). -
This question is part of the following fields:
- Pharmacology
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Question 10
Incorrect
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Which complication of chronic renal failure is most likely associated with the accumulation of aluminium?
Your Answer: Constipation
Correct Answer: Dialysis dementia
Explanation:Dialysis dementia is a unique neurological syndrome associated with chronic dialysis. Aluminium toxicity is probably the major factor in the pathogenesis of the dementia, which is due to aluminium-containing compounds in the dialysis fluid. Patients with dialysis dementia present with progressive dementia, dysarthria and seizures.
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This question is part of the following fields:
- Renal System
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Question 11
Incorrect
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A 37-year-old woman presents with sudden blindness. She claims she had a similar episode last year which resolved in three months. Fundoscopy is normal. Upon examination, mild weakness of the right upper limb is found. Reflexes on the same limb are exaggerated. What is the best treatment?
Your Answer: Pilocarpine eye drops
Correct Answer: Corticosteroids
Explanation:The age of the patients together with sudden loss of vision, remission and relapse of optic neuritis, focal neurological symptoms and exaggerated reflexes all suggest multiple sclerosis. This is treated with corticosteroids.
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This question is part of the following fields:
- Nervous System
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Question 12
Correct
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A 63-year-old gentleman presents with left-sided eye pain and diplopia for the past 2 days. Examination of his eyes shows his pupils equal and reactive to light with no proptosis. There is however an apparent palsy of the 6th cranial nerve associated with a partial 3rd nerve palsy on the left side. Examining the remaining cranial demonstrates hyperaesthesia of the upper face on the left side. Where is the likely lesion?
Your Answer: Cavernous sinus
Explanation:A lesion on the cavernous sinus would explain the palsy observed on the III and VI cranial nerves because the cranial nerves III, IV, V, and VI pass through the cavernous sinus. Pain in the eye is due to the nearby ophthalmic veins that feeds the cavernous sinus. Additionally, the lesions in the other structures would have presented with pupil abnormalities and less localized pain and symptoms.
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This question is part of the following fields:
- Nervous System
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Question 13
Correct
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A 50-year-old woman came to the diabetes clinic for her regular follow up.
The following results are obtained:
Urine analysis: Protein+
HBA1c 86 mmol/mol (10.0%)
What is her average blood glucose level during the past 2 months?Your Answer: 15
Explanation:The level of haemoglobin A1c (HbA1c), also known as glycated haemoglobin, determines how well a patient’s blood glucose level has been controlled over the previous 8-12 weeks. Recent studies have been made to correlate between HbA1c and average glucose level.
Using the following formula: Average blood glucose (mmol/l) = (1.98 x 1 HbA1c) – 4.29 -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 14
Correct
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A 17-year-old Jewish girl presents with primary amenorrhoea. On examination, she looks a little hirsute and has evidence of facial acne. She is within her predicted adult height and has normal breast and external genitalia development, however, there is excess hair over her lower abdomen and around her nipple area.
Investigations were as follows:
Hb 13.1 g/dl
WCC 8.6 x109/l
PLT 201 x109/l
Na+ 139 mmol/l
K+ 4.5 mmol/l
Creatinine 110 µmol/l
17-OH progesterone 1.4 times the upper limit of normal
Pelvic ultrasound: bilateral ovaries and uterus visualised.
Which of the following is the most likely diagnosis?Your Answer: Non-classical congenital adrenal hyperplasia
Explanation:Mild deficiencies of 21-hydroxylase or 3-beta-hydroxysteroid dehydrogenase activity may present in adolescence or adulthood with oligomenorrhea, hirsutism, and/or infertility. This is termed nonclassical adrenal hyperplasia.
Late-onset or nonclassical congenital adrenal hyperplasia (NCAH) due to 21-hydroxylase deficiency is one of the most common autosomal recessive disorders. Reported prevalence ranges from 1 in 30 to 1 in 1000. Affected individuals typically present due to signs and symptoms of androgen excess.
Treatment needs to be directed toward the symptoms. Goals of treatment include normal linear growth velocity, a normal rate of skeletal maturation, ‘on-time’ puberty, regular menstrual cycles, prevention of or limited progression of hirsutism and acne, and fertility. Treatment needs to be individualized and should not be initiated merely to decrease abnormally elevated hormone concentrations.
Normal Ultrasound rules out Turner’s syndrome. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 15
Correct
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A 48-year-old female presented in the emergency department with complaints of increased thirst, confusion and drowsiness. When taking her history it was found that she was treated successfully for breast malignancy 2 years ago. Which of the following abnormalities is most likely responsible for these symptoms?
Your Answer: Hypercalcemia
Explanation:Treated breast malignancy is pointing towards hypercalcemia as it is very common in patients of CA. The symptoms of hypercalcemia are increased thirst, drowsiness and confusion.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 16
Correct
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A 48-year-old man presents with severe retrosternal pain, which was present for the past 40 minutes. ECG shows ST elevation and blood tests reveal high troponin levels. He has already been given oxygen, GTN and morphine. What is the next most appropriate step?
Your Answer: Percutaneous angiography
Explanation:The patient is experiencing an acute myocardial infarction and percutaneous angiography is the next most appropriate step in management. Percutaneous coronary intervention (PCI), also known as coronary angioplasty, is a nonsurgical technique for treating obstructive coronary artery disease, including unstable angina, acute myocardial infarction (MI), and multivessel coronary artery disease (CAD).
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This question is part of the following fields:
- Cardiovascular System
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Question 17
Incorrect
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A 57-year-old female presented to the cardiology centre with a history of chest tightness accompanied by pain radiating to the left side of the neck and left shoulder. The pain started 3 hours ago. ECG was normal. What is the next best investigation for this patient?
Your Answer: CT
Correct Answer: Cardiac enzymes
Explanation:This patient’s symptoms of angina radiating to the neck and shoulders gives a strong suspicion of MI. Cardiac enzymes such as troponins are highly specific and sensitive for a heart attack.
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This question is part of the following fields:
- Cardiovascular System
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Question 18
Correct
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A 44-year-old female is admitted to the emergency with dyspnoea, syncope, fever and arthropathy. She was recently diagnosed with pulmonary emboli. Cardiovascular examination reveals an early diastolic sound with a mid diastolic rumble. The JVP is found to be elevated and there are prominent a waves. Which of the following would be the most likely cause of her symptoms?
Your Answer: Atrial myxoma
Explanation:Cardiac myxomas are the most common type of primary tumour of the heart. They are usually benign and arise from primary connective tissue. Most cardiac myxomas arise sporadically; however, 10% are hereditary (following an autosomal dominant pattern). Even though they may develop in any chamber of the heart, most (+-75 %) cardiac myxomas arise in the left atrium, usually from the interatrial septum, while the rest occur in the right atrium (ventricular myxomas are rare). Clinical features are primarily caused by obstruction of the blood flow through the heart and include dyspnoea on exertion, palpitations, syncope, weight loss, or even sudden death. Rarely, life-threatening conditions (e.g., stroke) may result from an embolization from the myxoma. Typical examination findings include abnormal heart sounds, such as a rumbling diastolic murmur over the apex or a characteristic tumour plop.
The diagnosis is not easily established clinically because of the nonspecific nature of symptoms. Echocardiography is the diagnostic procedure of choice. Surgical resection of the tumour is the curative treatment of choice. The prognosis is usually favourable, but tumours can recur after inadequate resection. -
This question is part of the following fields:
- Cardiovascular System
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Question 19
Correct
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A patient has been taking morphine 60 mg twice a day and sevredol (quick release morphine) 20 mg three times a day, per os. You are asked to prescribe morphine subcutaneously for this palliative care patient via a syringe driver. Which of the following dosing regimen would you choose?
Your Answer: 90 mg over 24 hours. 15 mg as required, for breakthrough pain.
Explanation:Morphine is almost twice as effective when given intravenously or subcutaneously as when given orally. This means that the first step is to calculate the total amount of morphine that the patient used to take orally, which is 180 mg. Since the patient needed 180 mg of morphine tablets in 24 hours to control his pain, he now would need approximately 90 mg given in the same time span. In order to calculate the breakthrough dose, one sixth of the total dose of morphine required per 24 hours should be calculated. The patient now requires 90 mg of morphine subcutaneously, meaning that he would need 15 mg for breakthrough pain.
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This question is part of the following fields:
- Pharmacology
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Question 20
Incorrect
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A 30-year-old male with a scaphoid fracture came to the clinic after 2 weeks of applying the scaphoid cast. After removing the cast he had difficulty moving his thumb, index and middle fingers. Which of the following is the most appropriate management for this presentation?
Your Answer: Release of common flexor sheath
Correct Answer: Release of flexor retinaculum
Explanation:This patient has carpal tunnel syndrome which involves the median nerve. The treatment is releasing of the flexor retinaculum.
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This question is part of the following fields:
- Nervous System
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Question 21
Incorrect
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A 39-year-old man was admitted with an exacerbation of asthma. He responded to treatment but the medical intern was concerned that Aspergillus fumigatus was cultured from his sputum.
Â
Subsequently arranged serum total, IgE level was elevated at 437 ng/ml (normal 40-180 ng/ml), RAST to Aspergillus fumigatus was class III, Aspergillus fumigatus precipitins were negative.
Â
What would be the most appropriate management step in this patient?Your Answer: High dose oral corticosteroids and Itraconazole
Correct Answer: No change in medication
Explanation:Allergic bronchopulmonary aspergillosis (ABPA) is a form of lung disease that occurs in some people who are allergic to Aspergillus. With ABPA, this allergic reaction causes the immune system to overreact to Aspergillus leading to lung inflammation. ABPA causes bronchospasm (tightening of airway muscles) and mucus build-up resulting in coughing, breathing difficulty and airway obstruction.
Blood tests are used to look for signs of an allergic reaction. This includes evaluating your immunoglobulin E (IgE) level. This level is increased with any type of allergy. Many people with asthma have higher than normal IgE levels. In ABPA however, the IgE level is extremely high (more than 1000 ng/ml or 417 IU/ml). In addition to total IgE, all patients with ABPA have high levels of IgE that is specific to Aspergillus. A blood test can be done to measure specific IgE to Aspergillus. A blood or skin test for IgE antibodies to Aspergillus can be done to see if a person is sensitized (allergic) to this fungus. If these skin tests are negative (i.e. does not show a skin reaction) to Aspergillus fumigatus, the person usually does not have ABPA.
Therefore, there should be no change in medication since this patient does not have ABPA. -
This question is part of the following fields:
- Respiratory System
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Question 22
Incorrect
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A 48-year-old hairdresser presented to her GP complaining of tingling in the right palm and right wrist pain. She had intermittently experienced these symptoms; however, recently they had been keeping her awake all night. She had noticed a reduction in grip and was struggling to work at the salon. Otherwise, she felt well in herself and had not noticed any weakness in the other hand or lower limb. Her weight was stable, and she denied any neck problems or swallowing difficulties. She had a past medical history of hypothyroidism and hypertension and took regular thyroxine, Bendroflumethiazide and ibuprofen. She was a non-smoker and rarely drank alcohol. On examination, she appeared alert and oriented. Fundoscopy and cranial nerve examination were all normal and neck movements were full.
On examination of the upper limb, there was wasting over the right thenar eminence and fasciculations with a small burn over the right index finger. There was weakness of thumb abduction and opposition, with loss of pinprick and light touch sensation over the thumb, index and middle finger in the right hand. Nerve conduction studies showed absent sensory action potential in right median palmar branches and denervation of the right abductor pollicis brevis.
What is the most likely diagnosis?Your Answer: Motor neurone disease
Correct Answer: Median nerve palsy
Explanation:The history is consistent with carpal tunnel syndrome (CTS) arising as a result of pressure on the median nerve in the carpal tunnel. The median nerve supplies the muscles of the thenar eminence: the abductor pollicis (C7, C8), flexor pollicis brevis and opponens pollicis, and the lateral two lumbricals. The nerve conduction studies confirm marked denervation and absent sensory potentials within the median nerve territory.
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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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Treatment of an acute attack of gout with allopurinol may result in which of the following?
Your Answer: Complete remission of symptoms within a few days of treatment
Correct Answer: Exacerbation and prolongation of the attack
Explanation:Initiation of allopurinol treatment during an attack can exacerbate and prolong the episode. Thus treatment should be delayed until the attack resolves.
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This question is part of the following fields:
- Pharmacology
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Question 24
Correct
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An 87-year-old woman had to double up her dosage of morphine 60mg into 120mg twice a day, in addition to another 10mg oral Morphine 6 times a day. What is the best method of management?
Your Answer: Subcutaneous morphine infusion
Explanation:Stable dose of Morphine is essential for chronic cases of pain that are non-malignant in origin. Using the SC route avoids having to intravenously cannulate a patient and allows for a continuous infusion of drugs over a calculated period of time providing constant dosing A significant advantage is that plasma levels of a drug are much more stable, and appropriate symptom control can be achieved without the toxic effects of the peaks and troughs resulting from episodic drug administration.
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This question is part of the following fields:
- Geriatric Medicine
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Question 25
Incorrect
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A homeless woman presented with a cough and fever for the last 3 months. She also complained of night sweats and weight loss. Her CXR showed lung opacities. What is the next appropriate step for this patient?
Your Answer: CT scan.
Correct Answer: Acid fast bacilli
Explanation:History and CXR are suggestive of tuberculosis. Acid fast bacilli should be seen on microscopy to confirm the diagnosis.
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This question is part of the following fields:
- Infectious Diseases
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Question 26
Incorrect
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A 31-year-old female with systemic lupus erythematosus wants to know if she has any predisposing factors for the disease. Which of the following carries the greatest risk of developing SLE?
Your Answer: Positive HLA-DR2
Correct Answer: Monozygotic twin
Explanation:An overall concordance rate in monozygotic twins was documented to be 25% as compared to dizygotic twins with 3%. First degree relatives have a chance of around 3% of developing the disease. Caucasians show an increase frequency of HLA-B8. The Japanese lupus patients had a stronger association with HLA-DR2.
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This question is part of the following fields:
- Musculoskeletal System
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Question 27
Incorrect
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A 17-year-old boy presents with tremors. Upon inquiry, the mother reports that the boy has a history of very aggressive episodes. She also reports that he has been hallucinating for some time. On examination, there were needle marks on his arm. What drug has been used?
Your Answer: Heroine
Correct Answer: Lysergic acid diethylamide (LSD)
Explanation:Psychedelic drugs, like LSD, bring on a state of altered consciousness, causing thought, audio, or visual changes. Low body temperature and tremors are associated with many drugs but closed-eye hallucinations are strongly associated with LSD and other psychedelic drugs.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 28
Incorrect
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Which of the following enzymes are involved in Phase I drug metabolism?
Your Answer:
Correct Answer: Alcohol dehydrogenase
Explanation:Drug metabolism can be broadly classified into:
Phase I (functionalization) reactions: also termed non-synthetic reactions, they include oxidation, reduction, hydrolysis, cyclization and de-cyclization. The most common and vital reactions are oxidation reactions. (Of the given enzymes only Alcohol dehydrogenase is involved in phase I drug metabolism. Succinate dehydrogenase, is a vital enzyme involved in the Kreb’s cycle and the mitochondrial electron transport chain). They are mainly catalysed by Cytochrome P-450 enzyme.Phase II (conjugation) reactions: occur following phase I reactions, they include reactions: glucuronidation and sulphate conjugation, etc. They are mostly catalysed by UDP-glucuronosyltransferase enzyme. Other phase II enzymes include: sulfotransferases, N-acetyltransferases, glutathione S-transferases and methyltransferases.
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This question is part of the following fields:
- Pharmacology
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Question 29
Incorrect
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An soccer player suddenly collapsed on the field and started coughing along with shortness of breath. The investigation of choice in this case would be?
Your Answer:
Correct Answer: Chest x-ray
Explanation:Exercise induced asthma is characterised by sudden onset wheezing, cough and shortness of breath while performing hectic physical activity. The best investigation to perform is a chest X-ray.
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This question is part of the following fields:
- Respiratory System
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Question 30
Incorrect
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A new-born male is admitted to NICU with convulsions, limb hypoplasia and rudimentary digits. Which of the following is the most likely cause?
Your Answer:
Correct Answer: Varicella
Explanation:Infection of chickenpox in the first half of pregnancy can result in congenital varicella syndrome. It presents as cerebral, cortical and cerebellar hypoplasia with convulsions and rudimentary digits. Prevention is by administering varicella vaccine, even before pregnancy. Varicella immunoglobulin is administered to pregnant women who are exposed to infection. Infection during pregnancy is treated with acyclovir.
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This question is part of the following fields:
- Infectious Diseases
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Question 31
Incorrect
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A 53-year-old male underwent a partial gastrectomy 15 years ago for a complicated peptic ulcer. Which of the following elements may be deficient in this man?
Your Answer:
Correct Answer: Iron
Explanation:The proper gastric acidity is required to transform iron from ferric to ferrous state in order to be absorbable. Even partial gastrectomy may cause dumping syndrome. Malabsorption is rare.
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This question is part of the following fields:
- Gastrointestinal System
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Question 32
Incorrect
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A 25-year-old man presents with bloody diarrhoea associated with systemic upset. Blood tests show the following:
Hb 13.4 g/dl
Platelets 467 * 109/l
WBC 8.2 * 109/l
CRP 89 mg/l
A diagnosis of ulcerative colitis is suspected. Which part of the bowel is most likely to be affected?Your Answer:
Correct Answer: Rectum
Explanation:The most COMMON site of inflammation from ulcerative colitis is the rectum, making this the correct answer. This is simply a fact you need to memorize. In general, ulcerative colitis only occurs in colorectal regions– nothing in the small bowel (unless there is backwash into the terminal ileum) and nothing further up the GI tract. In Crohn’s it can affect the entire GI tract from mouth to anus.
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This question is part of the following fields:
- Gastrointestinal System
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Question 33
Incorrect
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Impaired glucose tolerance is indicated by what glucose venous plasma level 2 hours after taking the OGTT test?
Your Answer:
Correct Answer: Between 7.8-11.0mmol/l
Explanation:According to the criteria of the World Health Organization and the American Diabetes Association, impaired glucose tolerance is defined as:
two-hour glucose levels of 140 to 199 mg per dL (7.8 to 11.0 mmol/l) on the 75-g oral glucose tolerance test. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 34
Incorrect
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A 40-year-old woman presents with weight loss, palpitations, diarrhoea and cessation of periods. She has been treated by her GP for anxiety. Examination reveals a single nodule on the left of her thyroid, about 1.5 cm in diameter.
Thyroid scan shows increased uptake within the nodule with reduced activity throughout the rest of the gland.
Thyroid function tests showed a free thyroxine of 30 pmol/l (9-25 pmol/l), TSH < 0.05 mU/l (0.5-5).
Based on these findings, what would be the definitive treatment?Your Answer:
Correct Answer: Radioactive iodine therapy
Explanation:Patients who have autonomously functioning nodules should be treated definitely with radioactive iodine or surgery.
Na131 I treatment – In the United States and Europe, radioactive iodine is considered the treatment of choice for Toxic Nodular Goitre. Except for pregnancy, there are no absolute contraindications to radioiodine therapy. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 35
Incorrect
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A 73-year-old woman attends COPD clinic for review. Her blood gases were checked on her last visit two months back. The test was repeated again today.
The paO2 on both occasions was 6.8 kPa. There is no CO2 retention on 28% O2. She stopped smoking around 6 months ago and is maintained on combination inhaled steroids and long acting b2-agonist therapy.
What is the next best step in management?Your Answer:
Correct Answer: Suggest she uses an oxygen concentrator for at least 19 h per day
Explanation:Long-term oxygen therapy (LTOT) > 15 h/day improves survival in hypoxemic chronic obstructive pulmonary disease (COPD). It significantly helps in reducing pulmonary hypertension associated with COPD and treating underlying pathology of future heart failure. There is little to no benefit of oxygen therapy for less than 15 hours.
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This question is part of the following fields:
- Respiratory System
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Question 36
Incorrect
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A 3-year old boy presents with an abdominal mass. Which of the following is associated with Wilms tumour (nephroblastoma)?
Your Answer:
Correct Answer: Beckwith-Wiedemann syndrome
Explanation:Beckwith-Wiedemann syndrome is a inherited condition associated with organomegaly, macroglossia, abdominal wall defects, Wilm’s tumour and neonatal hypoglycaemia. Wilm’s tumour is a kidney cancer that usually occurs in children. The causes are unknown, however, risk factors include race and family history. Of note, Wilm’s tumour can occur as part of the following syndromes: WAGR syndrome, Denys-Drash syndrome, and Beckwith-Wiedmann syndrome and not the other listed options in this question.
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This question is part of the following fields:
- Renal System
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Question 37
Incorrect
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A 38-year-old musician presented with a two-day history of sudden-onset occipital headache associated with nausea and vomiting. The next day, his right hand became weak for a few hours. On the same day he had an episode of sensory disturbance in his right upper limb consisting of tingling in his hand that spread up the arm, to his shoulder lasting less than two minutes in total. On the day of admission he had a similar episode of sensory disturbance lasting 30 seconds in total. On examination he had bilateral papilledema, no neck stiffness and an otherwise normal neurological examination. Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Venous sinus thrombosis
Explanation:Cerebral venous sinus thrombosis (CVST) is associated with headache (>90% of cases), seizures, focal weakness (40%) and papilledema (40%), all seen in this patient.
Risk factors for CVST include genetic or acquired prothrombotic disorders, pregnancy, the oral contraceptive pill, vasculitis, malignancy, dehydration and infection. However, there are multiple other associated factors.
Diagnosis is normally confirmed with magnetic resonance venography (MRV). Treatment is with anticoagulation, initially with heparin and subsequently with warfarin. -
This question is part of the following fields:
- Nervous System
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Question 38
Incorrect
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An 80-year-old patient known to have diabetes mellitus presented in the emergency room with the complaint of involuntary movements of his right arm and leg which disappeared during sleep. Which of the following is the most suitable explanation for this complaint?
Your Answer:
Correct Answer: Contralateral subthalamic nucleus infarction
Explanation:These symptoms represent hemiballismus which is common in diabetic patients after the infarction of contralateral subthalmic nucleus. These symptoms are usually present during activity phase and resolve while resting.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 39
Incorrect
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Which of the following treatments would you advise for a young, 21-year-old student who has ankylosing spondylitis and complains of worsening back pain and morning stiffness?
Your Answer:
Correct Answer: Oral NSAIDs
Explanation:NSAIDs are considered as the first line of treatment for managing pain and stiffness associated with ankylosing spondylitis. Other useful medications include TNF-alpha inhibitors. Other drugs like paracetamol, colchicine, and steroids are not routinely used. Bilateral total hip replacement might be indicated in advanced disease contrary to complicated spinal surgery.
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This question is part of the following fields:
- Musculoskeletal System
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Question 40
Incorrect
-
A 32-year-old male who is a known case of sickle cell disease presents to the Accident and Emergency (A&E) department with fever, tachypnoea, and rib pain. On examination, he has a low-grade fever of 37.9°C, oxygen saturation of 95% on air, and bilateral vesicular breath sounds on chest auscultation. CXR shows opacification in the right middle zone.
Which of these statements most accurately describes the initial management of this patient?Your Answer:
Correct Answer: Incentive spirometry is indicated
Explanation:This is a typical picture of acute chest syndrome (ACS). According to the British Committee for Standards in Haematology (BCSH), ACS is defined as ‘an acute illness characterised by fever and/or respiratory symptoms, accompanied by a new pulmonary infiltrate on chest X-ray’. ACS occurs in sequestration crisis, which is one of the four main types of crises occurring in sickle cell disease.
The fundamentals of initial management are as follows:
1. Oxygen therapy to maintain saturation >95%
2. Intravenous fluids to ensure euvolemia
3. Adequate pain relief
4. Incentive spirometry in all patients presenting with rib or chest pain
5. Antibiotics with cover for atypical organisms
6. Bronchodilators if asthma co-exists with acute chest syndrome, or if there is an evidence of acute bronchospasm on auscultation
7. Early consultation with the critical care team and haematology departmentA senior haematologist then makes a decision as to whether a simple or exchange transfusion is necessary in order to achieve a target Hb of 10.0-11.0g/dL in either instance.
Sickle Cell Crises:
Sickle cell anaemia is characterised by periods of good health with intervening crises:
1. Sequestration crisis: acute chest syndrome (i.e. fever, dyspnoea, chest/rib pain, low pO2, and pulmonary infiltrates)2. Thrombotic (painful or vaso-occlusive) crisis: precipitated by infection, dehydration, and deoxygenation
3. Aplastic crisis: sudden fall in haemoglobin without marked reticulocytosis, usually occurring secondary to parvovirus infection
4. Haemolytic crisis: fall in haemoglobin secondary to haemolysis, rare type of sickle cell crises
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This question is part of the following fields:
- Haematology & Oncology
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Question 41
Incorrect
-
A son has brought his 72-year-old mother to clinic. He is concerned about her short-term memory problems for the past 10 months. He has to remind her to take her medications and she has had two incidents of falling over in the last 10 months. Which of the following assists in the diagnosis of above condition?
Your Answer:
Correct Answer: Progressive loss of function
Explanation:The clinical presentation is dementia. To differentiate Alzheimer disease and vascular dementia, the progressive loss of function is important. Progressive loss of function is usually associated with vascular dementia and rest of the responses are associated with Alzheimer disease.
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This question is part of the following fields:
- Geriatric Medicine
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Question 42
Incorrect
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A 40-year-old female presented with pain and whitening of the hands on exposure to cold. She has difficulty in swallowing solid foods so she has started swallowing only liquids. She developed shortness of breath on exertion and, subsequently, at rest. Which of the following is the most likely cause for dysphagia in this patient?
Your Answer:
Correct Answer: Systemic sclerosis
Explanation:Difficulty in swallowing which improves with liquids is mainly due to an obstructive lesion in oesophagus. But pulmonary involvement (breathlessness on exertion and later on rest) and Raynaud’s phenomena can only be described by systemic sclerosis.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 43
Incorrect
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Around 30 patients have been admitted to the hospital following a suspected chemical attack in the city. The patients are extremely unwell, with symptoms of excessive salivation, lacrimation, diarrhoea, and emesis. Sarin gas was suspected as the most likely agent used in the attack. What is the mechanism of action of this chemical agent?
Your Answer:
Correct Answer: Inhibition of acetylcholinesterase
Explanation:Sarin acts by inhibiting acetylcholinesterase.
Sarin gas is a highly toxic synthetic organophosphorus compound which causes inhibition of the enzyme acetylcholinesterase
Sarin gas is a highly toxic synthetic organophosphorus compound which causes inhibition of the enzyme acetylcholinesterase. This results in high levels of acetylcholine (ACh).The effects of excessive ACh can be remembered by the mnemonic DUMBELLS:
Diarrhoea
Urination
Miosis/muscle weakness
Bronchorrhea/Bradycardia
Emesis
Lacrimation
Salivation/sweatingOrganophosphate insecticide poisoning:
One of the effects of organophosphate poisoning is inhibition of acetylcholinesterase
Features can be predicted by the accumulation of acetylcholine (mnemonic = SLUD)
Salivation
Lacrimation
Urination
Defecation/diarrhoea
cardiovascular: hypotension, bradycardia
miosis, muscle fasciculation.Organophosphate poisoning is treated with the anti-muscarinic atropine.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 44
Incorrect
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A 58-year-old woman has multiple non-healing leg ulcers. She reports feeling unwell for several months. Examination findings include a normal blood pressure, pulse 90 bpm, pale conjunctivae and poor dentition associated with bleeding gums. What is the most likely underlying diagnosis?
Your Answer:
Correct Answer: Vitamin C deficiency
Explanation:Severe vitamin C deficiency results in scurvy, a disorder characterized by hemorrhagic manifestations and abnormal osteoid and dentin formation.
Vitamin C plays a role in collagen, carnitine, hormone, and amino acid formation. It is essential for bone and blood vessel health and wound healing and facilitates recovery from burns. Vitamin C is also an antioxidant, supports immune function, and facilitates the absorption of iron (see table Sources, Functions, and Effects of Vitamins).
Dietary sources of vitamin C include citrus fruits, tomatoes, potatoes, broccoli, strawberries, and sweet peppers. (See also Overview of Vitamins.) -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 45
Incorrect
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A 55-year-old diabetic male presents with a feeling of generally being unwell. He also has a history of atrial fibrillation and epilepsy. His main complaint is a blue tinge to his vision. Which one of his medications is most likely to be responsible?
Your Answer:
Correct Answer: Sildenafil
Explanation:Blue tinge of vision/cyanopsia is caused due to the intake of sildenafil citrate.
Sildenafil citrate (Viagra) is the first oral drug to be widely approved for the treatment of erectile dysfunction.
It is a potent and selective inhibitor of type-V phosphodiesterase, the primary form of the enzyme found in human penile erectile tissue, thereby preventing the breakdown of cyclic guanosine monophosphate (cGMP), the intracellular second messenger of nitric oxide.Uses:
It is used for the treatment of erectile dysfunction, idiopathic pulmonary hypertension, premature ejaculation, high altitude illness, penile rehabilitation after radical prostatectomy, angina pectoris, and lower urinary tract symptoms.Adverse effects:
Mild headache, flushing, dyspepsia, cyanopsia, back pain, and myalgias – due to a high concentration of PDE11 enzyme in skeletal muscle, which shows significant cross-reactivity with the use of tadalafil.
It can also cause hypotension, dizziness, and rhinitis.Note: Xanthopsia (yellow-green vision) may occur secondary to treatment with digoxin.
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This question is part of the following fields:
- Pharmacology
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Question 46
Incorrect
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A 42-year-old female with a history of hypertension presented with increased thirst, polyuria and nocturia for 2 weeks duration. Her random blood sugar was 12 mmol/l. Which of the following antihypertensives can cause the above clinical presentation?
Your Answer:
Correct Answer: Bendroflumethiazide
Explanation:Thiazides and beta-blockers have been most commonly linked to the development of diabetes mellitus.
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This question is part of the following fields:
- Pharmacology
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Question 47
Incorrect
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All of the following statements regarding glucagon-like peptide-1 (GLP-1) are true, except?
Your Answer:
Correct Answer: Increased levels are seen in type 2 diabetes mellitus
Explanation:Glucagon-like peptide 1 (GLP-1) is a 30-amino acid peptide hormone produced in the intestinal epithelial endocrine L-cells by differential processing of proglucagon. GLP-1 is released in response to meal intake.
The main actions of GLP-1 are to stimulate insulin secretion (i.e., to act as an incretin hormone) and to inhibit glucagon secretion, thereby contributing to limit postprandial glucose excursions. It also inhibits gastrointestinal motility and secretion and thus acts as an enterogastrone and part of the ileal brake mechanism. GLP-1 also appears to be a physiological regulator of appetite and food intake.
Decreased secretion of GLP-1 may contribute to the development of obesity, and exaggerated secretion may be responsible for postprandial reactive hypoglycaemia. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 48
Incorrect
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A 35-year-old female, known case of antiphospholipid syndrome, arrives at the clinic due to a swollen and painful left leg. Doppler ultrasonography confirms the diagnosis of a deep vein thrombosis. She was previously diagnosed with DVT 4 months back and was on warfarin therapy (target INR 2-3) when it occurred. How should her anticoagulation be managed?
Your Answer:
Correct Answer: Life-long warfarin, increase target INR to 3 - 4
Explanation:If the INR in the range of 2-3 has still resulted in thrombosis, the target INR is increased to 3-4. However, because the risk of bleeding increases as the INR rises, the INR is closely monitored and adjustments are made as needed to maintain the INR within the target range.
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This question is part of the following fields:
- Musculoskeletal System
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Question 49
Incorrect
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A 40-year-old male is awaiting a liver biopsy. Which of the following is the most important investigation that has to be performed prior to the procedure?
Your Answer:
Correct Answer: Coagulation profile
Explanation:As the liver is highly vascular, there is a high risk of bleeding during and after the procedure. Patients may have existing liver diseases, which affect the production of clotting factors. So a coagulation profile is necessary to detect any abnormality and correct them prior to the liver biopsy.
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This question is part of the following fields:
- Hepatobiliary System
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Question 50
Incorrect
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A 65-year-old male was admitted for surgery 4 days ago. He suddenly became confused and aggressive. His attention span was reduced, and he became very restless. Which single option from the history best explains his condition?
Your Answer:
Correct Answer: Alcohol consumption
Explanation:Patient was dependent on alcohol. After 4 days of admission he developed signs of alcohol withdrawal.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 51
Incorrect
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A 19-year-old patient in casualty only opens her eyes upon painful stimuli, extends her limbs, and occasionally says inappropriate words. What is her Glasgow coma score?
Your Answer:
Correct Answer: 7
Explanation:The Glasgow Coma Scale provides a score for assessment of impaired consciousness in response to specific stimuli considering the eye opening, verbal response and motor response. The score runs from 3 to 15, a coma being defined as a GCS of 8 or less. According to this patient’s responses and the respective points for each response, the score is 7 and the patient is in a coma.
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This question is part of the following fields:
- Nervous System
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Question 52
Incorrect
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A 57-year-old diabetic, smoker complains of non-healing ulcers and cramp-like pain in the calves relieved by rest. Examination results are as follows: absent distal pulses, and cold extremities with hair loss around the ankles. What is the most probable diagnosis?
Your Answer:
Correct Answer: Chronic ischemia of the limbs
Explanation:Chronic Limb Ischaemia presents with calf pain that is relieved by rest.
Intermittent claudication is not a diagnosis but a symptom and is not necessarily associated with diabetes.
Buerger’s disease occurs in younger heavy smokers (usually before age of 50).
DVT causes pain that is consistent, not intermittent as in claudication. -
This question is part of the following fields:
- Musculoskeletal System
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Question 53
Incorrect
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Which of the following is most consistent with congenital adrenal hyperplasia (CAH)?
Your Answer:
Correct Answer: Premature epiphyseal closure
Explanation:Exposure to excessive androgens is usually accompanied by premature epiphyseal maturation and closure, resulting in a final adult height that is typically significantly below that expected from parental heights.
congenital adrenal hyperplasia (CAH) is associated with precocious puberty caused by long term exposure to androgens, which activate the hypothalamic-pituitary-gonadal axis. Similarly, CAH is associated with hyperpigmentation and hyperreninemia due to sodium loss and hypovolaemia.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 54
Incorrect
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A 21-year-old male presented in the OPD with a testicular mass. During examination, the mass was found to be painless and 2.5cm in diameter. The surface is irregular and non-transilluminating. What is the most likely diagnosis?
Your Answer:
Correct Answer: Teratoma
Explanation:The age group of the patient (20 to 30 years) is indicative of teratoma. It is also painless and non-transilluminating.
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This question is part of the following fields:
- Men's Health
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Question 55
Incorrect
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Which of the following abnormal facial movements is not a well-recognised association?
Your Answer:
Correct Answer: Facial synkinesis - Wilson's disease
Explanation:Wilson’s disease may have an asymmetric tremor which is variable in character and may be predominantly resting, postural, or kinetic.
Progressive supra-nuclear palsy – blepharospasm, apraxia of lid opening and/or apraxia of lid closing.
Tourette’s syndrome – one or more motor or vocal tics.
Multiple Sclerosis – continuous facial myokymia.
Tardive dyskinesia is a side-effect of conventional antipsychotics, neuroleptics, anticholinergics, and toxins resulting in stiff, jerky movements of your face and body -
This question is part of the following fields:
- Nervous System
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Question 56
Incorrect
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A 37-year-old male fell whilst walking home and landed on his outstretched hand. He is now complaining of pain in his right arm. X-rays were conducted and indicate a fracture of the radial head. Choose the most commonly associated nerve injury from the list of options.
Your Answer:
Correct Answer: Radial nerve
Explanation:There will be a radial nerve injury due to finger drop with both sensation intact and a normal wrist.
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This question is part of the following fields:
- Nervous System
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Question 57
Incorrect
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A 41-year-old man who has had two episodes of pneumonia in succession and an episode of haemoptysis is observed to have paroxysms of coughing and increasing wheezing. A single lesion which is well-defined is seen in the lower right lower lobe on a chest x-ray. There is no necrosis but biopsy shows numerous abnormal cells, occasional nuclear pleomorphism and absent mitoses.
Which diagnosis fits the clinical presentation?Your Answer:
Correct Answer: Bronchial carcinoid
Explanation:Bronchial carcinoids are uncommon, slow growing, low-grade, malignant neoplasms, comprising 1-2% of all primary lung cancers.
It is believed to be derived from surface of bronchial glandular epithelium. Mostly located centrally, they produce symptoms and signs of bronchial obstruction such as localized wheeze, non resolving recurrent pneumonitis, cough, chest pain, and fever. Haemoptysis is present in approximately 50% of the cases due to their central origin and hypervascularity.
Central bronchial carcinoids are more common than the peripheral type and are seen as endobronchial nodules or hilar/perihilar mass closely related to the adjacent bronchus. Chest X-ray may not show the central lesion depending on how small it is. -
This question is part of the following fields:
- Respiratory System
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Question 58
Incorrect
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A 35-year-old factory worker presents with a history of episodic dyspnoea. The complaint worsens when he is working. He starts to feel wheezy, with a tendency to cough. Which diagnostic investigation would be the most useful in this case?
Your Answer:
Correct Answer: Serial peak flow measurements at work and at home
Explanation:Serial Peak Expiratory Flow measurement at work and home is a feasible, sensitive, and specific test for the diagnosis of occupational asthma. For a diagnosis of occupational asthma, it is important to establish a relationship objectively between the workplace exposure and asthma symptoms and signs. Physiologically, this can be achieved by monitoring airflow limitation in relation to occupational exposure(s). If there is an effect of a specific workplace exposure, airflow limitation should be more prominent on work days compared with days away from work (or days away from the causative agent). Airflow limitation can be measured by spirometry, with peak expiratory flow (PEF) and/or forced expiratory volume in 1 s(FEV1) being the most useful for observing changes in airway calibre. Other tests mentioned are less reliable and would not help in establishing a satisfactory diagnosis of occupational asthma.
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This question is part of the following fields:
- Respiratory System
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Question 59
Incorrect
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A 55-year-old alcoholic is admitted with portal hypertension. The wedged hepatic venous pressure is recorded. This pressure is reflective of which part of the hepatic vascular system?
Your Answer:
Correct Answer: Sinusoids
Explanation:The wedged hepatic venous pressure is a reflection of the portal venous pressure in the hepatic sinusoids. This is a fact to remember. Here is a great but concise explanation as to why: https://www.ncbi.nlm.nih.gov/pubmed/18695309
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This question is part of the following fields:
- Hepatobiliary System
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Question 60
Incorrect
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A 23-year-old student commences chemotherapy for B-type acute lymphoblastic leukaemia. She suffers from vomiting, but 36 hours later her condition worsens and her bloods reveal a corrected calcium of 2.0 mmol/l and serum potassium of 6.7 mmol/l.
Which of the following options is the best way to avoid this problem from occurring?Your Answer:
Correct Answer: Hydration and allopurinol pre-chemotherapy
Explanation:This case is most likely tumour lysis syndrome, often occurring immediately after starting chemotherapy because the tumour cells are killed and their contents are released into the bloodstream. After treating lymphomas or leukaemia, there is a sudden hypocalcaemia, hyperphosphatemia, and hyperkalaemia
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This question is part of the following fields:
- Renal System
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Question 61
Incorrect
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A 33-year-old woman presents to the clinic with chronic fatigue. She has 3 children and a full-time job and is finding it very difficult to hold everything together. There is no significant past medical history.
On examination, her BP is 145/80 mmHg and her BMI is 28.
Investigations show:
Hb 12.5 g/dl
WCC 6.7 x109/l
PLT 204 x109/l
Na+ 141 mmol/l
K+ 4.9 mmol/l
Creatinine 120 μmol/l
Total cholesterol 5.0 mmol/l
TSH 7.8 U/l
Free T4 10.0 pmol/l (10-22)
Free T3 4.9 pmol/l (5-10)
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Subclinical hypothyroidism
Explanation:Elevated TSH (usually 4.5-10.0 mIU/L) with normal free T4 is considered mild or subclinical hypothyroidism.
Hypothyroidism commonly manifests as a slowing in physical and mental activity but may be asymptomatic. Symptoms and signs are often subtle and neither sensitive nor specific.
The following are symptoms of hypothyroidism:
– Fatigue, loss of energy, lethargy
– Weight gain
– Decreased appetite
– Cold intolerance
– Dry skin
– Hair loss
– Sleepiness
– Muscle pain, joint pain, weakness in the extremities
– Depression
– Emotional lability, mental impairment
– Forgetfulness, impaired memory, inability to concentrate
– Constipation
– Menstrual disturbances, impaired fertility
– Decreased perspiration
– Paraesthesia and nerve entrapment syndromes
– Blurred vision
– Decreased hearing
– Fullness in the throat, hoarseness
Physical signs of hypothyroidism include the following:
– Weight gain
– Slowed speech and movements
– Dry skin
– Jaundice
– Pallor
– Coarse, brittle, straw-like hair
– Loss of scalp hair, axillary hair, pubic hair, or a combination
– Dull facial expression
– Coarse facial features
– Periorbital puffiness
– Macroglossia
– Goitre (simple or nodular)
– Hoarseness
– Decreased systolic blood pressure and increased diastolic blood pressure
– Bradycardia
– Pericardial effusion
– Abdominal distention, ascites (uncommon)
– Hypothermia (only in severe hypothyroid states)
– Nonpitting oedema (myxoedema)
– Pitting oedema of lower extremities
– Hyporeflexia with delayed relaxation, ataxia, or both. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 62
Incorrect
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A 50-year-old Afro-Caribbean male is noted to have a blood pressure of 186/99 mmHg. He also suffers from asthma. Which of the following anti-hypertensive drugs will be ineffective in this specific patient?
Your Answer:
Correct Answer: ACE inhibitor
Explanation:The Afro-Caribbean population is found to have an increased sensitivity of blood pressure to salt intake as well as a reduced tendency to excrete the ingested salt, associated with low renin levels. ACE inhibitors will then be an ineffective group of anti-hypertensive drugs for this specific population.
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This question is part of the following fields:
- Pharmacology
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Question 63
Incorrect
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A study is developed to assess a new anti-hypertensive drug and two groups of patients are randomly chosen. The first group takes an established anti-hypertensive drug for 3 months and the second group receives the new drug, again for 3 months. To assess the efficacy of the new drug, blood pressure is measured before and after taking the drug in both groups of patients. After a period of 1 month off medication, the groups swap medication and blood pressure is measured again, finally the difference in blood pressure after receiving each drug is calculated. Which of the following significance tests would you apply to assess the results of the study?
Your Answer:
Correct Answer: Student's paired t-test
Explanation:A t test is a type of statistical test that is used to compare the means of two groups. It is one of the most widely used statistical hypothesis tests in pain studies. There are two types of statistical inferences: parametric and nonparametric methods. Parametric methods refer to a statistical technique in which one defines the probability distribution of probability variables and makes inferences about the parameters of the distribution. In cases in which the probability distribution cannot be defined, nonparametric methods are employed. T tests are a type of parametric method; they can be used when the samples satisfy the conditions of normality, equal variance, and independence. In this case the data is parametric, and they belong to the same patients, so a paired t test should be used.
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This question is part of the following fields:
- Evidence Based Medicine
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Question 64
Incorrect
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Which of the following options is true of patients with oesophageal varices?
Your Answer:
Correct Answer: In spontaneous bacterial peritonitis cefotaxime appears to be a useful antibiotic
Explanation:Spironolactone has been shown to have no effect on the mechanisms of portal hypertension. Also, chronic use of propranolol can reduce the risk of variceal bleeding. The banding of large varices has been shown to be effective, too. Octreotide and terlipressin are also both used to prevent secondary haemorrhage. Cefotaxime is the most commonly used cephalosporin when treating spontaneous bacterial peritonitis. Spironolactone helps to combat secondary hyperaldosteronism which is related to liver failure. It also helps to treat salt and water retention, which both contribute to portal hypertension.
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This question is part of the following fields:
- Gastrointestinal System
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Question 65
Incorrect
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A 46-year-old man presents with a swollen, red, and painful left calf. He does not have a history of any recent surgery or a long-haul flight. He is generally fit and well and takes no regular medication other than propranolol for migraine prophylaxis. There is also no history of venous thromboembolism (VTE) in his family.
The patient is referred to the deep vein thrombosis (DVT) clinic where he is diagnosed with a proximal DVT in his left calf. Following the diagnosis, he is started on low-molecular-weight heparin (LMWH) whilst awaiting review by the warfarin clinic.
Other than commencing warfarin, what further action, if any, is required?Your Answer:
Correct Answer: Investigate for underlying malignancy + check antiphospholipid antibodies
Explanation: -
This question is part of the following fields:
- Haematology & Oncology
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Question 66
Incorrect
-
A 34-year-old male has been brought to accident and emergency after being involved in a road collision. After his initial evaluation, his score on the Glasgow Coma Scale is 6. What is the most appropriate next step in his treatment?
Your Answer:
Correct Answer: Secure airway
Explanation:The appropriate next step in this patient’s treatment is to secure his airway.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 67
Incorrect
-
A 38-year-old woman has a melanocytic naevi on her left forearm.
Which of the following features do not suggest malignant change?Your Answer:
Correct Answer: Decrease in size
Explanation:Melanocytic nevi are benign neoplasms or hamartomas composed of melanocytes. Melanocytes are derived from the neural crest and migrate during embryogenesis to selected ectodermal sites (primarily the skin and the CNS), but also to the eyes and the ears.
They tend to appear during early childhood and during the first 30 years of life. They may change slowly, becoming raised, changing color or gradually fading.. Pregnancy can increase the number of naevi as well as the degree of hyperpigmentation.
They may become malignant and this should be suspected if the naevus increases in size, develops an irregular surface or becomes darker, itches or bleeds. -
This question is part of the following fields:
- The Skin
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Question 68
Incorrect
-
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:
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 69
Incorrect
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A 7-month-old baby girl is admitted with poor feeding and irritability for 2 days. She is lethargic and persistently crying. Urine dipstick showed leukocytes. What is the single most important investigation to arrive at a diagnosis?
Your Answer:
Correct Answer: Urine for C&S
Explanation:The clinical presentation and leucocytes on the urine dipstick is suggestive of a urinary tract infection. To confirm the diagnosis, urine should be sent for culture and sensitivity.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 70
Incorrect
-
A 32-year-old female who is 37 weeks pregnant presents with a swollen, painful right calf. A deep vein thrombosis (DVT) is confirmed on Doppler scan.
What should be the preferred anticoagulant?Your Answer:
Correct Answer: Subcutaneous low molecular weight heparin (LMWH)
Explanation:Subcutaneous (S/C) low-molecular-weight heparin (LMWH) is a preferred anticoagulant in pregnancy. Warfarin is contraindicated due to its teratogenic effects, especially in the first trimester and at term.
Pregnancy is a hypercoagulable state with the majority of VTE incidents occurring in the last trimester.
Hypercoagulability in pregnancy is caused by:
1. Increase in factors VII, VIII, X, and fibrinogen
2. Decrease in protein S
3. Uterus pressing on IVC causing venous stasis in legsManagement options include:
1. S/C LMWH preferred to IV heparin (less bleeding and thrombocytopaenia)
2. Warfarin contraindicated -
This question is part of the following fields:
- Haematology & Oncology
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Question 71
Incorrect
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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:
Correct 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 72
Incorrect
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A 30-year-old male with Down's Syndrome was found to have a systolic murmur during routine clinical examination. Which of the following is the most common cardiac defect associated with Down's Syndrome which will explain this finding?
Your Answer:
Correct Answer: Endocardial cushion defect
Explanation:Atrioventricular septal defect (AVSD) also known as endocardial cushion defect is the most common cardiac abnormality in Down’s Syndrome.
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This question is part of the following fields:
- Cardiovascular System
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Question 73
Incorrect
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A 48-year-old man with a two year history of ulcerative colitis, has been receiving parenteral nutrition for 4 months. He has developed a dermatitis and has noticed some loss of hair. Serum biochemistry shows a marginally raised glucose concentration and a lower alkaline phosphatase activity.
Which of the following is the most likely?Your Answer:
Correct Answer: Zinc deficiency
Explanation:Zinc deficiency can present with alopecia, dermatitis, poor growth, increased susceptibility to infection, and cognitive deficiency. Magnesium deficiency can cause fatigue, cramping and an irregular EKG. Copper deficiency can present with fatigue and weakness. Chromium deficiency can present with hyperglycaemia.
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This question is part of the following fields:
- Gastrointestinal System
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Question 74
Incorrect
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A 66-year-old woman comes to you with a tender lump near the anal opening and a fever. She has history of T1DM for the last 20 years. What treatment should she get?
Your Answer:
Correct Answer: I&D + antibiotics
Explanation:Surgical incision and drainage is the most common treatment for anal abscesses. About 50% of patients with an anal abscess will develop a complication called a fistula. Diabetes is a risk factor for an anal abscess.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 75
Incorrect
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A 64-year-old woman presents with malaise, ankle swelling and shortness of breath. Her blood pressure is 215/140 mmHg, she has +2 peripheral oedema and the skin over her fingers appears very tight. Fundoscopy discloses bilateral papilledema.
Â
Plasma creatinine concentration is 370 μmol/l, potassium is 4.9 mmol/l, haemoglobin is 8.9 g/dl and her platelet count is 90 x 109 /ml.
Â
What is the pathological hallmark of this condition?Your Answer:
Correct Answer: Mucoid intimal thickening of vascular endothelium
Explanation:The history is suggestive of scleroderma renal crisis, where we would expect thrombotic microangiopathy process with vascular endothelium involvement manifesting as mucoid intimal thickening or onion skin effect.
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This question is part of the following fields:
- Renal System
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Question 76
Incorrect
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A 13-year-old girl is brought by her mother to the A&E with breathlessness, fatigue and palpitations. Anamnesis does not reveal any syncope or chest pain in the past. on the other hand, these symptoms were present intermittently for a year. Clinical examination reveals a pan-systolic murmur associated with giant V waves in the jugular venous pulse. Chest auscultation and resting ECG are normal. 24 hour ECG tape shows a short burst of supraventricular tachycardia. What is the most probable diagnosis?
Your Answer:
Correct Answer: Ebstein's anomaly
Explanation:Ebstein’s anomaly is characterised by apical displacement and adherence of the septal and posterior leaflets of the tricuspid valve to the underlying myocardium, thereby displacing the functional tricuspid orifice apically and dividing the right ventricle into two portions. The main haemodynamic abnormality leading to symptoms is tricuspid valve incompetence. The clinical spectrum is broad; patients may be asymptomatic or experience right-sided heart failure, cyanosis, arrhythmias and sudden cardiac death (SCD). Many Ebstein’s anomaly patients have an interatrial communication (secundum atrial septal defect (ASD II) or patent foramen ovale). Other structural anomalies may also be present, including a bicuspid aortic valve (BAV), ventricular septal defect (VSD), and pulmonary stenosis. The morphology of the tricuspid valve in Ebstein anomaly, and consequently the clinical presentation, is highly variable. The tricuspid valve leaflets demonstrate variable degrees of failed delamination (separation of the valve tissue from the myocardium) with fibrous attachments to the right ventricular endocardium.
The displacement of annular attachments of septal and posterior (inferior) leaflets into the right ventricle toward the apex and right ventricular outflow tract is the hallmark finding of Ebstein anomaly. -
This question is part of the following fields:
- Cardiovascular System
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Question 77
Incorrect
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What is the mechanism of action of carbimazole?
Your Answer:
Correct Answer: Inhibition of the iodination of tyrosine
Explanation:Carbimazole is used to treat hyperthyroidism. Carbimazole is a pro-drug as after absorption it is converted to the active form, methimazole. Methimazole prevents thyroid peroxidase enzyme from coupling and iodinating the tyrosine residues on thyroglobulin, hence reducing the production of the thyroid hormones T3 and T4 (thyroxine).
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This question is part of the following fields:
- Pharmacology
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Question 78
Incorrect
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A 72-year-old retired fisherman presents with weakness of shoulders and hips over the last four months. Finger flexion is also weak but the extension is normal. There has been some difficulty swallowing liquids. Past medical history is not significant except for sexually transmitted disease that he caught some 40 years ago in South Pacific and got treated with antibiotics. He smokes and drinks one or two tots of rum at the weekend. Creatine kinase level is 125. Which of the following investigations is most significant in establishing a diagnosis?
Your Answer:
Correct Answer: Muscle biopsy with electron microscopy
Explanation:Inclusion body myositis (IBM) is a progressive muscle disorder characterized by muscle inflammation, weakness, and atrophy (wasting). It is a type of inflammatory myopathy. IBM develops in adulthood, usually after age 50. The symptoms and rate of progression vary from person to person. The most common symptoms include progressive weakness of the legs, arms, fingers, and wrists. Some people also have weakness of the facial muscles (especially muscles controlling eye closure), or difficulty swallowing (dysphagia). Muscle cramping and pain are uncommon, but have been reported in some people. The underlying cause of IBM is poorly understood and likely involves the interaction of genetic, immune-related, and environmental factors. Some people may have a genetic predisposition to developing IBM, but the condition itself typically is not inherited. Elevated creatine kinase (CK) levels in the blood (at most ,10 times normal) are typical in IBM. Muscle biopsy may display several common findings including; inflammatory cells invading muscle cells, vacuolar degeneration, inclusions or plaques of abnormal proteins.
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This question is part of the following fields:
- Musculoskeletal System
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Question 79
Incorrect
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A 32-year-old gentleman presents to his GP with a 2 month history of constant abdominal pain and early satiety. He has hypertension for which he takes enalapril.
On examination, he has mild tenderness on both flanks. Well-circumscribed masses are palpable in both the left and right flanks. A soft systolic murmur is heard loudest at the apex.
His observations are heart rate 67/min, blood pressure 152/94 mmHg, temperature 37.2C, respiratory rate 14/min, saturations 97%.
Which additional feature is most likely to be found in this patient?Your Answer:
Correct Answer: Hepatomegaly
Explanation:This patient shows classic symptoms of autosomal-dominant polycystic kidney disease (ADPKD). The abdominal pain and early satiety is caused by the enlarged kidneys that were apparent from the physical examination. Additionally, hypertension is a common symptom along with the systolic murmur that was heard, suggesting mitral valve involvement. In ADPKD cases, the most common extra-renal manifestation is the development of liver cysts which are associated with hepatomegaly.
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This question is part of the following fields:
- Renal System
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Question 80
Incorrect
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A 48-year-old artist presented with tremors. Which of the following is more suggestive of parkinsonism than an essential tremor?
Your Answer:
Correct Answer: Unilaterality
Explanation:Essential tremors are usually symmetrical and generalized. It often affects the head and the voice of the patient. Usually it is first noticed by first degree relatives. It is improved by benzodiazepines and beta blockers. On the other hand, Parkinsonism tends to develop in older patients. It is characterised by bradykinesia and rigidity. It improves by L-dopa and dopamine agonists. A simple test is to ask the patient to write a short sentence. Parkinsonism shows micrographiam whilst essential tremors will have tremulous writing.
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This question is part of the following fields:
- Nervous System
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Question 81
Incorrect
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A 35-year-old female with chronic pelvic pain, was recently diagnosed with PID. She was prescribed doxycycline. After 2 days she returned with complaints of abdominal bloating, nausea and regurgitation. Which of the following advice should be given to her?
Your Answer:
Correct Answer: Take Doxycycline after meals
Explanation:Doxycycline is known to cause dyspeptic symptoms. So advising to take Doxycycline after meals is important. Taking with meals or adding an antacid is not advised, as both will cause reduction in drug absorption.
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This question is part of the following fields:
- Pharmacology
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Question 82
Incorrect
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A 62-year-old software developer with lung cancer is currently taking MST 30 mg bd for pain relief.
What dose of oral morphine solution should he be prescribed for breakthrough pain?Your Answer:
Correct Answer: 10 mg
Explanation:The total daily morphine dose is 30 x 2 = 60 mg. Therefore, the breakthrough dose should be one-sixth of this, 10 mg.
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This question is part of the following fields:
- Haematology & Oncology
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Question 83
Incorrect
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A 71-year-old woman presents with dyspnoea and unsteadiness. She's known to suffer from epilepsy and is managed on carbamazepine. Blood exams are as follows: MCV=70, Hb=8.5, WBC=2, Neutrophils=1, Platelets=50. What is the most likely diagnosis?
Your Answer:
Correct Answer: Aplastic anaemia
Explanation:The results of the blood exam are suggestive of aplastic anaemia which might be secondary to carbamazepine use. The use of antiepileptic’s, in particular carbamazepine and valproate, is associated with a nine fold increased risk of aplastic anaemia.
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This question is part of the following fields:
- Haematology & Oncology
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Question 84
Incorrect
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A 68-year-old male patient presents with central chest pain and associated flushing. He claims the pain is crushing in character. ECG reveals T wave inversion in II, III and AVF. Blood exams are as follows: Troponin T = 0.9 ng/ml. Which substance does troponin bind to?
Your Answer:
Correct Answer: Tropomyosin
Explanation:Troponin T is a 37 ku protein that binds to tropomyosin, thereby attaching the troponin complex to the thin filament.
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This question is part of the following fields:
- Musculoskeletal System
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Question 85
Incorrect
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A 3 month old infant born to HIV positive mother presented with jaundice, epileptic seizures and microcephaly. The most likely cause will be?
Your Answer:
Correct Answer: Cytomegalovirus
Explanation:Congenital cytomegalovirus infection causes; jaundice, hepatosplenomegaly, petechia, microcephaly, hearing loss and seizures.
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This question is part of the following fields:
- Infectious Diseases
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Question 86
Incorrect
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A 19-year-old football player was hit in his chest by an opponent. He became breathless and turned blue. What will be the initial management?
Your Answer:
Correct Answer: Give oxygen
Explanation:As the patient is turning blue, giving oxygen will be the first priority in his management.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 87
Incorrect
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A 30-year-old man has been unwell for the last 3 weeks and now developed a rash. Chickenpox is diagnosed.
What is the appropriate treatment?Your Answer:
Correct Answer: Acyclovir
Explanation:You may treat chickenpox with acyclovir if it is commenced within the first 24 hours of the rash’s appearance. Erythromycin, doxycycline, and ampicillin would not help because it’s a viral infection (Varicella) not a bacterial infection.
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This question is part of the following fields:
- Infectious Diseases
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Question 88
Incorrect
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A study is developed to compare two chemotherapy schemas for individuals with small cell lung cancer. Which of the following would you choose to compare survival time with in this particular study?
Your Answer:
Correct Answer: Hazard ratio
Explanation:The hazard ratio describes the relative risk of the complication based on comparison of event rates.
Hazard ratios have also been used to describe the outcome of therapeutic trials where the question is to what extent treatment can shorten the duration of the illness. However, the hazard ratio, a type of relative risk, does not always accurately portray the degree of abbreviation of the illness that occurred. In these circumstances, time-based parameters available from the time-to-event curve, such as the ratio of the median times of the placebo and drug groups, should be used to describe the magnitude of the benefit to the patient. The difference between hazard-based and time-based measures is analogous to the odds of winning a race and the margin of victory. The hazard ratio is the odds of a patient’s healing faster under treatment but does not convey any information about how much faster this event may occur.
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This question is part of the following fields:
- Evidence Based Medicine
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Question 89
Incorrect
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A 25-year-old youth was brought to the A&E following a stab injury to the right back of the chest. On examination he was dyspnoeic, his trachea was deviated to the left side and there were engorged veins and absent breath sounds on the right side. Which of the following is the most probable diagnosis?
Your Answer:
Correct Answer: Tension pneumothorax
Explanation:History is suggestive of right sided tension pneumothorax. It can’t be a simple pneumothorax because of tracheal deviation and engorged veins.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 90
Incorrect
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A 24-year-old male is admitted with worsening shortness of breath with signs of left ventricular failure. He has a known genetic condition.
On examination, there is an ejection systolic murmur loudest over the aortic area radiating to the carotids, bibasal crepitations and pitting oedema to the knees bilaterally. On closer inspection of the patient, you note a wide vermillion border, small spaced teeth and a flat nasal bridge. The patient also has a disinhibited friendly demeanour.
What is the likely precipitating valvular issue?Your Answer:
Correct Answer: Supravalvular aortic stenosis
Explanation:Supravalvular aortic stenosis, is associated with a condition called William’s syndrome.
William’s syndrome is an inherited neurodevelopmental disorder caused by a microdeletion on chromosome 7. The most common symptoms of Williams syndrome are heart defects and unusual facial features. Other symptoms include failure to gain weight appropriately in infancy (failure to thrive) and low muscle tone. Individuals with Williams syndrome tend to have widely spaced teeth, a long philtrum, and a flattened nasal bridge.
Most individuals with Williams syndrome are highly verbal relative to their IQ, and are overly sociable, having what has been described as a cocktail party type personality. -
This question is part of the following fields:
- Emergency & Critical Care
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Question 91
Incorrect
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Choose the correct definition regarding the standard error of the mean:
Your Answer:
Correct Answer: Standard deviation / square root (number of patients)
Explanation:The SEM is an indicator of how close the sample mean is to the population mean. In reality, however, only one sample is extracted from the population. Therefore, the SEM is estimated using the standard deviation (SD) and a sample size (Estimated SEM). The SEM computed by a statistical program is an estimated value calculated via this process.
Estimated Standard Error of the Mean (SEM)=SDn?
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This question is part of the following fields:
- Evidence Based Medicine
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Question 92
Incorrect
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A 70-year-old complains of lower urinary tract symptoms. Which one of the following statements regarding benign prostatic hyperplasia is incorrect?
Your Answer:
Correct Answer: Goserelin is licensed for refractory cases
Explanation:Goserelin (Zoladex) is usually prescribed to treat hormone-sensitive cancers of the breast and prostate not for BPH. All other statements are correct.
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This question is part of the following fields:
- Renal System
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Question 93
Incorrect
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A 20-year-old male, who was otherwise completely healthy, has developed severe and sudden pain in his lower back. It started after getting up from his bed. What is the most probable diagnosis in this case?
Your Answer:
Correct Answer: PID
Explanation:Sudden onset of severe lower back pain whilst is felt more when bending (such as getting up from a bed) is consistent with a diagnosis of a prolapsed intervertebral disc.
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This question is part of the following fields:
- Musculoskeletal System
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Question 94
Incorrect
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A 13-year-old boy complains of several episodes of collapse. He describes the majority of these episodes occurring when he is laughing. He states that he loses power in his legs and falls to the ground. He is alert throughout and recovers quickly. He also describes excessive daytime sleepiness with episodes in the morning of being awake but being unable to move his body. Examination is unremarkable. A diagnosis of narcolepsy is made. Which of the following is the first line treatment for excessive daytime sleepiness?
Your Answer:
Correct Answer: Modafinil
Explanation:Narcolepsy is a rare condition characterised by excessive daytime sleepiness, sleep paralysis, hypnagogic hallucinations, and cataplexy (sudden collapse triggered by emotion such as laughing or crying). There is no cure for narcolepsy. Treatment options include stimulants, such as methylphenidate (Ritalin) or modafinil (Provigil), antidepressants, such as fluoxetine (Prozac), citalopram (Celexa), paroxetine (Paxil), sertraline (Zoloft) and sodium oxybate (Xyrem). Modafinil has replaced methylphenidate and amphetamine as the first-line treatment of excessive daytime sleepiness (EDS).
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This question is part of the following fields:
- Nervous System
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Question 95
Incorrect
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A 40-year-old man is referred by his general practitioner. He has a family history of premature cardiovascular disease.
Cholesterol testing reveals triglyceride levels of 4.2 mmol/l and a high-density lipoprotein (HDL) level of 0.8 mmol/l.
You advise him to start fibrate therapy.
Which of the following best describes the mode of action for fibrates?Your Answer:
Correct Answer: They are inhibitors of lipoprotein lipase activity and increase HDL synthesis
Explanation:Treatment with fibrates, a widely used class of lipid-modifying agents, results in a substantial decrease in plasma triglycerides and is usually associated with a moderate decrease in LDL cholesterol and an increase in HDL cholesterol concentrations.
Evidence from studies is available to implicate 5 major mechanisms underlying the above-mentioned modulation of lipoprotein phenotypes by fibrates:
1. Induction of lipoprotein lipolysis.
2. Induction of hepatic fatty acid (FA) uptake and reduction of hepatic triglyceride production.
3. Increased removal of LDL particles. Fibrate treatment results in the formation of LDL with a higher affinity for the LDL receptor, which is thus catabolized more rapidly.
4. Reduction in neutral lipid (cholesteryl ester and triglyceride) exchange between VLDL and HDL may result from decreased plasma levels of TRL.
5. Increase in HDL production and stimulation of reverse cholesterol transport. Fibrates increase the production of apoA-I and apoA-II in the liver, which may contribute to the increase of plasma HDL concentrations and a more efficient reverse cholesterol transport. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 96
Incorrect
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Which of the following is not a recognised feature of methemoglobinemia?
Your Answer:
Correct Answer: Decreased pO2 but normal oxygen saturation
Explanation:Normal pO2 but decreased oxygen saturation is characteristic of methemoglobinemia.
Methemoglobinemia is a rare condition in which the haemoglobin iron is in oxidized or ferric state (Fe3+) and cannot reversibly bind oxygen. Normally, the conversion of ferrous form of iron (Fe2+) to its ferric form (Fe3+) is regulated by NADH methaemoglobin reductase, which results in the reduction of methaemoglobin to haemoglobin. Disruption in the enzyme leads to increased methaemoglobin in the blood. There is tissue hypoxia as Fe3+ cannot bind oxygen, and hence the oxygen-haemoglobin dissociation curve is shifted to the left.
Methemoglobinemia can occur due to congenital or acquired causes. Congenital causes include haemoglobin variants such as HbM and HbH, and deficiency of NADH methaemoglobin reductase. Acquired causes are drugs (e.g. sulphonamides, nitrates, dapsone, sodium nitroprusside, and primaquine) and chemicals (such as aniline dyes).
The features of methemoglobinemia are cyanosis, dyspnoea, anxiety, headache, severe acidosis, arrhythmias, seizures, and loss of consciousness. Patients have normal pO2 but oxygen saturation is decreased. Moreover, presence of chocolate-brown coloured arterial blood (colour does not change with addition of O2) and brown urine also point towards the diagnosis of methemoglobinemia.
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This question is part of the following fields:
- Haematology & Oncology
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Question 97
Incorrect
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A 61-year-old male presented to the emergency with renal colicky pain and a subsequent passage of stone the next day. Radiological examination, however, revealed no signs of calculi. The renal calculus was most likely composed of which of the following?
Your Answer:
Correct Answer: Uric acid
Explanation:Calcium-containing stones are relatively radio dense, and they can often be detected by a traditional radiograph of the abdomen that includes the kidneys, ureters, and bladder (KUB film). Some 60% of all renal stones are radiopaque. In general, calcium phosphate stones have the greatest density, followed by calcium oxalate and magnesium ammonium phosphate stones. Cystine calculi are only faintly radio dense, while uric acid stones are usually entirely radiolucent.
Uric acid is the relatively water-insoluble end product of purine nucleotide metabolism. It poses a special problem because of its limited solubility, particularly in the acidic environment of the distal nephron of the kidney. It is problematic because humans do not possess the enzyme uricase, which converts uric acid into the more soluble compound allantoin. Three forms of kidney disease have been attributed to excess uric acid: acute uric acid nephropathy, chronic urate nephropathy, and uric acid nephrolithiasis. These disorders share the common element of excess uric acid or urate deposition, although the clinical features vary.
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This question is part of the following fields:
- Renal System
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Question 98
Incorrect
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Which of the following allows for a diagnosis of diabetes mellitus?
Your Answer:
Correct Answer: Symptomatic patient with random glucose 12.0 mmol/L on one occasion
Explanation:Criteria for the diagnosis of diabetes
1. A1C >6.5%. The test should be performed in a laboratory using a method that is certified and standardized.*
OR
2. Fasting glucose >126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.*
OR
3. 2-h plasma glucose >200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.*
OR
4. In a patient with classic symptoms of hyperglycaemia or hyperglycaemic crisis, a random plasma glucose >200 mg/dl (11.1 mmol/l).
*In the absence of unequivocal hyperglycaemia, criteria 1-3 should be confirmed by repeat testing. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 99
Incorrect
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In which part of the body is conjugated bilirubin metabolised to urobilinogen?
Your Answer:
Correct Answer: Large intestine
Explanation:Urobiligen is produced by the action of bacteria on bilirubin in the intestine. As a reminder, unconjugated bilirubin becomes conjugated in the hepatocyte. Conjugated bilirubin goes through enterohepatic circulation. About half of the urobiligen is reabsorbed and excreted by the kidneys in the urine. The rest is converted to stercobilinogen –> stercobilin, which is excreted in stool, giving it its brown colour.
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This question is part of the following fields:
- Gastrointestinal System
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Question 100
Incorrect
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Which of the following procedures does not require antibiotic prophylaxis?
Your Answer:
Correct Answer: Dental procedure for a patient with an atrial septal defect
Explanation:According to latest NICE guidelines, patients with isolated atrial septal defects do not require prophylactic antibiotics originally used in prevention of infective endocarditis in dental procedures.
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This question is part of the following fields:
- Infectious Diseases
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SESSION STATS - PERFORMANCE PER SPECIALTY
