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Question 1
Correct
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Of the following medications, which is available over the counter (OTC) to treat heavy blood loss during menstruation?
Your Answer: Tranexamic acid
Explanation:Since March 2011, tranexamic acid has been available to buy from pharmacies to help treat heavy blood loss during menstruation. NSAIDs (such as ibuprofen and naproxen) are available to purchase over the counter, but these aid in the treatment of dysmenorrhea rather than menorrhagia. MIRENA, norethisterone, and COCP are not available to purchase over the counter to treat heavy blood loss (however COCP is available for contraceptive use).
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This question is part of the following fields:
- Pharmacology
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Question 2
Incorrect
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A 30-year-old male came in with chills and dilated pupils, which were withdrawal signs and symptoms of a certain drug. Which of the following can cause above presentation?
Your Answer: Cocaine
Correct Answer: Heroine
Explanation:Both cocaine and heroine withdrawal cause dilated pupils. Heroine withdrawal causes chills.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 3
Incorrect
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Which one of the following has no role in increased gastric acid secretion in patients with peptic ulcer disease?
Your Answer: Histamine
Correct Answer: Secretin
Explanation:Secretin is produced in the duodenum in response to a low pH and the presence of carbohydrate and fat. It turns off antral G cell gastrin synthesis. While others that are mentioned such as gastrin, histamine etc. are involved in increased acid secretion.
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This question is part of the following fields:
- Gastrointestinal System
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Question 4
Correct
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You are asked to fill the first part of a cremation form. Which of the following would need to be removed prior to cremation?
Your Answer: Pacemaker
Explanation:Pacemakers have small electrical parts installed in them that can explode when exposed to extreme heat and pressure.
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This question is part of the following fields:
- Ethical & Legal
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Question 5
Incorrect
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A 66-year-old COPD patient visits the clinic for a review. He has no increase in his sputum volume or change in its colour. He has been a smoker for 39 years and previously worked at the shipping docks.
On examination, he is pursed lip breathing but managing complete sentences.
Investigations:
BP is 141/72 mmHg
Pulse 82 bpm and regular
Sp(O2) 92% on room air
RR 19 breaths/min
Temperature 37.1°C.
Examination of his chest revealed a widespread wheeze with coarse crepitations heard in the L mid-zone. FEV1 :FVC ratio in the clinic today was 68%.
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Which of the following would be the most useful investigation that should be performed to establish the diagnosis?Your Answer: Chest X-ray
Correct Answer: High-resolution CT thorax
Explanation:High-resolution CT (HRCT) scanning is more sensitive than standard chest radiography and is highly specific for diagnosing emphysema (outlined bullae are not always visible on a radiograph).
HRCT scanning may provide an adjunct means of diagnosing various forms of COPD (i.e., lower lobe disease may suggest AAT deficiency) and may help the clinician to determine whether surgical intervention would benefit the patient.
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This question is part of the following fields:
- Respiratory System
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Question 6
Incorrect
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A 69 year-old librarian with motor neuron disease is seen in clinic. Which of the following interventions will have the greatest effect on survival?
Your Answer: Riluzole
Correct Answer: Non-invasive ventilation
Explanation:Motor neuron disease is a neurological condition of unknown cause which can present with both upper and lower motor neuron signs. It rarely presents before age 40 and various patterns of disease are recognised, including amyotrophic lateral sclerosis, progressive muscular atrophy and bulbar palsy.
Non-invasive ventilation (usually BIPAP) is used at night, with studies having shown a survival benefit of around 7 months. Riluzole prevents stimulation of glutamate receptors, used mainly in amyotrophic lateral sclerosis and has been shown to prolong life by about 3 months. -
This question is part of the following fields:
- Nervous System
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Question 7
Incorrect
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Where is the site of action of spironolactone?
Your Answer: Ascending loop of Henle
Correct Answer: Distal convoluted tubule
Explanation:Spironolactone is an aldosterone antagonist which acts in the distal convoluted tubule. It is a potassium-sparing diuretic that prevents the body from absorbing too much salt and keeps the potassium levels from getting too low. Spironolactone is used to treat heart failure, high blood pressure (hypertension), or hypokalaemia (low potassium levels in the blood).
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This question is part of the following fields:
- Pharmacology
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Question 8
Incorrect
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A 28-year-old female with a history of psoriatic arthritis would most likely have which of the following hand conditions?
Your Answer: Arthritis mutilans
Correct Answer: Nail dystrophy
Explanation:Nail dystrophy (pitting of nails, onycholysis, subungual hyperkeratosis), dactylitis, sausage shaped fingers are most commonly seen with psoriatic arthropathy. There is asymmetric joint involvement most commonly distal interphalangeal joints. Uveitis and sacroiliitis may also occur. Arthritis mutilans may occur but is very rare. Cutaneous lesions may or may not develop. When they do, its usually much after the symptoms of arthritis.
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This question is part of the following fields:
- Musculoskeletal System
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Question 9
Correct
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A 60-year-old man who has been complaining of increasing shortness of breath had a post-bronchodilator spirometry done.
FEV1/FVC 0. 63
FEV1% predicted 63%
What is the best interpretation of these results?Your Answer: COPD (stage 2 - moderate)
Explanation: -
This question is part of the following fields:
- Respiratory System
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Question 10
Correct
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A 60-year-old male presents with thickened patches of skin over his knuckles and extensor surfaces that are consistent with Gottron's papules. Results reveal an elevated creatine kinase. Diagnosis of dermatomyositis is suspected. Which of the following autoantibody is most specific for this condition?
Your Answer: Anti-Mi-2 antibodies
Explanation:Anti-Mi-2 antibodies are highly specific for dermatomyositis, but sensitivity is low; only 25% of patients with dermatomyositis demonstrate these antibodies. A positive antinuclear antibody (ANA) finding is common in patients with dermatomyositis, but is not necessary for diagnosis. Anti-Jo-1 antibodies are mostly associated with polymyositis. Anti Scl-70 antibodies and anti centromere antibodies are most commonly found in systemic scleroderma.
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This question is part of the following fields:
- Musculoskeletal System
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Question 11
Incorrect
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Which of the following forms of acute viral hepatitis has a much higher mortality in pregnant than non-pregnant females?
Your Answer: Hepatitis C
Correct Answer: Hepatitis E
Explanation:Pregnant patient in a third world country with hepatitis: The answer is most likely Hepatitis E. The mortality for Hepatitis E in pregnant women is very high. It is transmitted faecal-orally. There is no hepatitis G. Hepatitis C, B, A are less likely to be the correct answer than E given it’s classic association with pregnancy and poor living conditions.
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This question is part of the following fields:
- Infectious Diseases
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Question 12
Incorrect
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A 25-year-old female presents to the emergency department with severe breathlessness and tinnitus. She is under treatment for asthma and depression with albuterol and amitriptyline respectively.
On examination, she seems agitated with a BP of 100/44, a pulse rate of 112 bpm, a respiratory rate of 30 cycles/min, and a temperature of 37.8'C.
An arterial blood gas performed reveals:
pH: 7.48 (7.36 - 7.44)
pO2: 11.2 kPa (11.3 - 12.6 kPa)
pCO2: 1.9 kPa (4.7 - 6.0 kPa)
Bicarbonate: 13 mmol/l (20 - 28 mmol/L)
What is the most probable diagnosis?Your Answer: Tricyclic antidepressant overdose
Correct Answer: Salicylate poisoning
Explanation:The blood gas analysis provided above is suggestive of a mixed respiratory alkalosis and metabolic acidosis characteristic of salicylate overdose.
Pathophysiology:
The direct stimulation of the cerebral medulla causes hyperventilation and respiratory alkalosis.
As it is metabolized, it causes an uncoupling of oxidative phosphorylation in the mitochondria.
Lactate levels then increase due to the increase in anaerobic metabolism. This, along with a slight contribution from the salicylate metabolites result in metabolic acidosis.Tinnitus is characteristic and salicylate ototoxicity may produce deafness. Other neurological sequelae include encephalopathy and agitation, seizures and CNS depression and coma. Cardiovascular complications include tachycardia, hypotension, and dysrhythmias (VT, VF, and asystole).
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This question is part of the following fields:
- Emergency & Critical Care
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Question 13
Correct
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A 75-year-old male with rheumatoid arthritis underwent a colectomy 2 days ago for colon cancer. He was put on a prophylactic dose of low molecular weight heparin postoperatively as well as prednisolone. Now he complains of central chest pain and his ECG revealed an acute ST elevation myocardial infarction. He was given aspirin and oxygen as the initial treatment. Which of the following is the most appropriate management for this patient?
Your Answer: IV diamorphine + arrange percutaneous coronary intervention
Explanation:There is a high risk of bleeding due to recent surgery and heparin. So thrombolysis is not an option. The most appropriate management is percutaneous coronary intervention.
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This question is part of the following fields:
- Cardiovascular System
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Question 14
Correct
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A 5-year-old girl was admitted for fever, anaemia, thrombocytopenia and signs of pulmonary infection. She now presents a few days later with signs of meningism. What is the most probable diagnosis?
Your Answer: Acute lymphoblastic leukaemia (ALL)
Explanation:Acute lymphoblastic leukaemia (ALL) is a cancer of the lymphoid line of blood cells characterized by the development of large numbers of immature lymphocytes. Symptoms may include feeling tired, frequent infections with fever as well as anaemia with thrombocytopenia. As an acute leukaemia, ALL progresses rapidly and is typically fatal within weeks or months if left untreated. The patient’s age also favours the diagnosis of ALL as it occurs most commonly in children, particularly those between the ages of two and five.
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This question is part of the following fields:
- Haematology & Oncology
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Question 15
Correct
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A 43-year-old female presented with a 5 day history of a productive cough with rusty coloured sputum. Chest X-ray showed lobar consolidation on her left side. The most likely causative organism would be?
Your Answer: Streptococcus pneumoniae
Explanation:Streptococcus pneumonia is the chief causative organism for lobar pneumonia in this age group patients. Typically patients present with rusty coloured sputum and a cough. Pneumocystis jiroveci is responsible for causing pneumocystis pneumonia among immunocompromised patients.
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This question is part of the following fields:
- Infectious Diseases
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Question 16
Incorrect
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A 30-year-old female presents with a 4-day history of diarrhoea and vomiting. She has been unable to keep fluids down for 4 days and has been treated with metoclopramide. She develops a dystonic reaction.
What is the most appropriate treatment for the woman?Your Answer: Domperidone
Correct Answer: Benztropine
Explanation:Acute dystonic reactions (extrapyramidal symptoms) such as spasmodic torticollis, trismus, and oculogyric crises can occur following the administration of metoclopramide or stemetil and thus, neither is recommended for the treatment of nausea in young women.
Such reactions respond well to treatment with benztropine or procyclidine.
– Benztropine: It is an anticholinergic medication with significant CNS penetration.
A single dose of benztropine 1 to 2 mg IV followed by 1 to 2 mg p.o twice a day for up to 7 days to prevent a recurrence. Subsequently, both the offending agent and those from the same group should be avoided.
– Alternatively, diphenhydramine can be used intravenously (up to a dose of 50mg) or intramuscularly followed by p.o therapy every 6 hours for 1 to 2 to prevent a recurrence.
– Second-line therapy with IV benzodiazepines is reserved for those patients who do not respond to anticholinergics. -
This question is part of the following fields:
- Emergency & Critical Care
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Question 17
Correct
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A 32-year-old male has recently had a splenectomy following a motorcycle accident. He is up to date with all vaccinations which were offered as part of his childhood vaccination scheme. It is July. Which of the following vaccinations does he require in the first instance?
Your Answer: Pneumococcus, meningococcus type B and C, Haemophilus type B
Explanation:Acquired asplenia or hyposlenia can occur following splenectomy. Hyposplenism is used to describe reduced (‘hypo-‘) splenic functioning and is associated with increased risk of sepsis from polysaccharide encapsulated bacteria. In particular, patients are at risk from Streptococcus pneumoniae, Haemophilus influenzae, and meningococcus. The risk is elevated as much as 350-fold.
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This question is part of the following fields:
- Infectious Diseases
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Question 18
Correct
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Which one of the following paraneoplastic features is less likely to be seen in patients with squamous cell lung cancer?
Your Answer: Lambert-Eaton syndrome
Explanation:Lambert-Eaton myasthenic syndrome (LEMS) is a rare presynaptic disorder of neuromuscular transmission in which release of acetylcholine (ACh) is impaired, causing a unique set of clinical characteristics, which include proximal muscle weakness, depressed tendon reflexes, post-tetanic potentiation, and autonomic changes.
In 40% of patients with LEMS, cancer is present when the weakness begins or is found later. This is usually a small cell lung cancer (SCLC). However, LEMS has also been associated with non-SCLC, lymphosarcoma, malignant thymoma, or carcinoma of the breast, stomach, colon, prostate, bladder, kidney, or gallbladder.
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This question is part of the following fields:
- Respiratory System
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Question 19
Correct
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A 50-year-old woman presents with coughing up copious sputum with blood streaks, increased breathlessness, and finger clubbing. She has a history of chronic cough. What is the initial investigation?
Your Answer: Chest x-ray
Explanation:Finger clubbing and past history suggest a chronic pulmonary process going on. A CXR will allow the pathology to be visualised including any infective or cancerous causes.
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This question is part of the following fields:
- Respiratory System
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Question 20
Incorrect
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A 45-year-old male who is a heavy alcoholic was admitted with loss of memory, hallucinations and difficulty walking. On examination, he had an ataxic gait. He was given Acamprosate. Which one of the following can be given with the above drug?
Your Answer: Diazepam
Correct Answer: Thiamine
Explanation:Wernicke’s encephalopathy is characterised by the triad of ophthalmoplegia, ataxia, and confusion. It must be viewed as a medical emergency with rapid correction of thiamine deficiency as the goal of therapy. Acamprosate is a medication used to treat alcohol dependence by stabilizing chemical signalling in the brain that would otherwise be disrupted by alcohol withdrawal
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This question is part of the following fields:
- Nervous System
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Question 21
Correct
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A woman complains of diarrhoea, experiencing watery stools 10 daily. She also complains of abdominal bloating, cramps, flatulence, and recent weight loss. She has now developed signs of iron deficiency anaemia. What is the most likely cause of her condition?
Your Answer: Malabsorption
Explanation:Diarrhoea, iron deficiency anaemia and folic acid deficiency are suggestive of malabsorption. Malabsorption leads to a decrease in the solid content of the stools resulting in diarrhoea. Decrease in the absorption of folic acid causes folic acid deficiency, and iron deficiency in the body leads to iron deficiency anaemia.
Jejunal villous atrophy is characterized with pain and weight loss as well, which this patient does not have.
A patient with increased catabolism has sudden weight loss along with deficiencies of nutrients. -
This question is part of the following fields:
- Gastrointestinal System
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Question 22
Correct
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A 58-year-old male patient complains of emesis, fatigue, palpitations and weight loss. His blood group is type A. Clinical examination revealed an enlarged liver, ascites and a left supraclavicular lump which is palpable. What is the most probable diagnosis?
Your Answer: Gastric carcinoma
Explanation:Gastric carcinoma may present as atypical general symptoms including emesis, fatigue and weight loss. It may also result in anaemia which might be responsible for the palpitations. The left supraclavicular swelling is referring to Virchow’s node, strongly associated with gastric cancer. Ascites and hepatomegaly generally appear late in the course of the disease and Blood group A has been shown to be associated with gastric cancer.
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This question is part of the following fields:
- Gastrointestinal System
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Question 23
Correct
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A 33-year-old male was brought in with complaints of an unsteady gait. According to the patient, he suffered a severe headache in the morning, with associated vomiting. Slowly his condition deteriorated until he was unable to walk. On exam, he had nystagmus and there was past pointing of the right arm. He speech was slurred, his uvula was deviated towards the right and there was decreased pinprick sensation on the right half of the body. The most likely site of the lesion in this patient would be?
Your Answer: Left lateral medulla
Explanation:Loss of sensations in left (ipsilateral) side of the face and contralateral (right) side of the body indicates a defect in left lateral medulla. Further cerebellar signs lead to the diagnosis of Lateral Medullary Syndrome.
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This question is part of the following fields:
- Nervous System
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Question 24
Incorrect
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A 65-year-old male patient admitted with myocardial infarction received thrombolysis, which lead to full resolution of the ST elevations on his ECG. He was on aspirin, clopidogrel, atorvastatin and enalapril. The next day he complained of pain in his legs and there was a diffuse petechial rash over his lower legs, especially in the feet. All his peripheral pulses were palpable. His FBC revealed neutrophilia with eosinophilia. His IgE antibodies were 3 kU/L (<2). What is the most likely reason for this presentation?
Your Answer: Allergic reaction to thrombolysis
Correct Answer: Cholesterol emboli
Explanation:He has a consequence of atherosclerotic disease (MI). The most probable diagnosis is cutaneous cholesterol emboli as it is more common after anticoagulation or thrombolytics, the skin involvement, eosinophilia and raised IgE. It is more common above 60 yrs. of age.
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This question is part of the following fields:
- Cardiovascular System
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Question 25
Correct
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A 68-year-old gentleman has been receiving dialysis for 6 years. His PTH is elevated at 345 pg/ml (NR 25-65), phosphate 2.13 mmol/l and corrected calcium 2.01 mmol/l.
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Of the following, which is most likely responsible for renal osteodystrophy?Your Answer: Diminished activity of renal 1-?-hydroxylase
Explanation:Renal osteodystrophy is a metabolic bone disease often affecting long-term dialysis patients. The kidneys are no longer able to maintain the calcium levels in the blood, thus the PTH increases as the body attempts to raise blood calcium levels. Osteomalacia in these cases is most likely caused by the diminished activity of renal 1-a-hydroxylase that is important for hydroxylation of Calciferol to calcitriol (Vitamin D). This bioactive form of Vitamin D is responsible for increasing intestinal absorption of calcium.
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This question is part of the following fields:
- Renal System
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Question 26
Correct
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A 32 year-old man presents with his first generalized tonic-clonic seizure (GTCS). He has been complaining of headaches for the past 2 weeks, although he has been able to continue working at his job. Upon examination, he has mild left hemiparesis and bilateral extensor plantar responses. General examination is otherwise unremarkable. An urgent CT scan of the brain shows a 5cm multicentric mass lesion in the right frontal lobe with surrounding vasogenic oedema and some hemisphere shift. Which of the following is the most likely underlying pathology?
Your Answer: Glioblastoma
Explanation:Glioblastoma multiforme, also considered as grade IV astrocytoma, is the most malignant form of the tumour and accounts for about 20% of all cerebral tumours. These often remain clinically silent until they have reached a large enough size. In adults, glioblastoma multiforme usually occurs in the cerebral hemispheres, especially the frontal and temporal lobes of the brain. About half occupy more than one hemisphere at presentation, and some are multicentric. Biopsy shows high cellularity with mitoses, pleomorphism, and vascular hyperplasia. Prognosis is extremely poor, with only 20% surviving beyond 1 year and 10% beyond 2 years.
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This question is part of the following fields:
- Nervous System
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Question 27
Correct
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Which among these medications does NOT cause gastric ulceration?
Your Answer: Misoprostol
Explanation:Misoprostol is effective in preventing gastric ulceration since it is a prostaglandin analogue. Celecoxib, being a selective COX-2 inhibitor only elevates risk of ulceration as well as NSAIDs. Renal failure on the other hand results in elevated gastric acid after reducing the breakdown of gastrin.
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This question is part of the following fields:
- Gastrointestinal System
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Question 28
Correct
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A patient has an autosomal recessive disorder, which causes lysine, arginine, ornithine and cystine to appear in his urine. The treatment proposed is the combination of urinary alkalinisation with penicillamine. Choose the most likely type of renal calculus present.
Your Answer: Cystine
Explanation:The presence in the urine of cystine, orthinine, arginine and lysine indicate a tubular reabsorption defect. This condition is a hereditary one, and stone formation is more common in homozygotes. The patient has no other abnormalities that could indicate stone formation.
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This question is part of the following fields:
- Renal System
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Question 29
Correct
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A 70-year-old male patient presented with increased difficulty in breathing during the last 4 months. He was diagnosed with mitral stenosis. On examination his BP was 120/80 mmHg and pulse rate was 68 bpm. There were bibasal crepitations on auscultation. He was on bisoprolol, furosemide and ISDN. From the given answers, what is the most likely indication of worsening of his mitral stenosis?
Your Answer: Haemoptysis
Explanation:Haemoptysis is a symptom which indicates the worsening of mitral stenosis. It occurs due to the rupture of pulmonary veins or the capillary system due to pulmonary venous hypertension. Elevated serum creatinine is seen in worsening aortic stenosis. Worsening of tricuspid regurgitation causes ascites and a pulsatile liver.
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This question is part of the following fields:
- Cardiovascular System
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Question 30
Correct
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A 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: 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 31
Correct
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A 54-year-old man is found collapsed in the street and is brought to the A&E. The results from the blood tests reveal Calcium = 1.62mmol/l and Albumin = 33 g/l. The man is known to have a history of alcoholic liver disease. Which of the following is the best management regarding his calcium levels?
Your Answer: 10ml of 10% calcium gluconate over 10 minutes
Explanation:Acute, symptomatic hypocalcaemia is treated with 10ml of 10% calcium gluconate over 10 minutes.
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This question is part of the following fields:
- Fluids & Electrolytes
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Question 32
Correct
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A 49-year-old female presents to the clinic complaining of pain in her left elbow that is localized to the left lateral epicondyle. She has spent the weekend painting her house. A diagnosis of lateral epicondylitis is suspected. The pain would characteristically worsen on which of the following movements?
Your Answer: Resisted wrist extension with the elbow extended
Explanation:Lateral epicondylitis (tennis elbow) is an overuse injury of the hand and finger extensor tendons that originate in the lateral humeral epicondyle that occurs following repeated or excessive pronation/supination and extension of the wrist (e.g., in racquet sports). Clinical features include pain and tenderness over the lateral epicondyle and along extensor muscles, thickening of the tendons. The examiner holds the patient’s hand with the thumb placed over the lateral epicondyle – The patient makes a fist, supinates the forearm, deviates radially, and extends the fist against the examiner’s resistance which results in pain over the lateral epicondyle. Conservative treatment includes rest, physiotherapy and orthotic braces. If this fails corticosteroids and lidocaine injections are employed. Surgery is indicated in patients with persistent symptoms despite 6 months of conservative treatment. Excision of abnormal tendon tissue; longitudinal incisions (tenotomies) in scarred and fibrotic areas to promote healing.
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This question is part of the following fields:
- Musculoskeletal System
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Question 33
Incorrect
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A 45-year-old woman has complained of right hypochondrial pain and severe epigastric pain for the past few hours. Upon examination, her CBC is normal, her serum ALP is raided, but she has normal transaminase. She had a cholecystectomy done three months prior. Choose the most appropriate avenue of investigation for this patient.
Your Answer: ERCP
Correct Answer: MRCP
Explanation:MRCP is the most appropriate procedure in this instance. The post-operative US of the abdomen does not give good results for the hepatobiliary system. ERCP is invasive and is linked to complications such as pancreatitis, cholangitis, etc.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 34
Correct
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A 25-year-old woman with type-1 diabetes mellitus attends for her routine review and says she is keen on becoming pregnant.
Which of the following is most likely to make you ask her to defer pregnancy at this stage?Your Answer: Hb A1C 9.4%
Explanation:Pregnancies affected by T1DM are at increased risk for preterm delivery, preeclampsia, macrosomia, shoulder dystocia, intrauterine fetal demise, fetal growth restriction, cardiac and renal malformations, in addition to rare neural conditions such as sacral agenesis.
Successful management of pregnancy in a T1DM patient begins before conception. Research indicates that the implementation of preconception counselling, emphasizing strict glycaemic control before and throughout pregnancy, reduces the rate of perinatal mortality and malformations.
The 2008 bulletin from the National Institute for Health and Clinical Excellence recommends that preconception counselling be offered to all patients with diabetes. Physicians are advised to guide patients on achieving personalized glycaemic control goals, increasing the frequency of glucose monitoring, reducing their HbA1C levels, and recommend avoiding pregnancy if the said level is > 10%.
Other sources suggest deferring pregnancy until HbA1C levels are > 8%, as this margin is associated with better outcomes. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 35
Correct
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A 70-year-old male with advanced COPD currently on treatment with salbutamol (as required) presents for review. After a complete history and examination, you conclude that he requires to be stepped up in his inhalational therapy. The decision to add tiotropium bromide to his regime was taken. Which of the following best describe the mechanism of action of tiotropium?
Your Answer: It is a long-acting anticholinergic agent
Explanation:Tiotropium is a specific long-acting antimuscarinic agent indicated as maintenance therapy for patients with COPD (chronic obstructive pulmonary disease).
It should be used cautiously in patients with narrow-angle glaucoma, prostatic hyperplasia or bladder neck obstruction.
The most frequently encountered adverse effects of tiotropium include pharyngitis, bronchitis, sinusitis, dry mouth, cough, and headaches. Paradoxical bronchospasm may also occur as a rare side-effect.
Dry mouth occurs in up to 14% of patients taking tiotropium, in keeping with its anticholinergic profile.
Rarer side-effects include tachycardia, blurred vision, urinary retention, and constipation. -
This question is part of the following fields:
- Respiratory System
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Question 36
Correct
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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: 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 37
Incorrect
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Cholecystokinin is secreted from:
Your Answer: G cells in stomach
Correct Answer: I cells in upper small intestine
Explanation:Cholecystokinin (CCK) was discovered in 1928 in jejunal extracts as a gallbladder contraction factor. It was later shown to be member of a peptide family, which are all ligands for the CCK1 and CCK2 receptors. CCK peptides are known to be synthetized in the small intestinal endocrine I-cells and cerebral neurons.
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This question is part of the following fields:
- Gastrointestinal System
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Question 38
Incorrect
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A 60-year-old man with previous history of myocardial infarction and hypertension presented with severe retrosternal chest pain for the past 2 hours. During initial management he collapsed and pulseless ventricular tachycardia was detected. The external defibrillator arrived in 3 minutes. From the following answers, what is the most appropriate immediate management of this patient whilst waiting for the defibrillator?
Your Answer: Continuous chest compressions should be started
Correct Answer:
Explanation:Immediate Management of Pulseless Ventricular Tachycardia:
- Continuous Chest Compressions:
- Continuous chest compressions should be started immediately to maintain circulation while the defibrillator is being prepared. High-quality chest compressions are crucial and should not be delayed.
- Defibrillation:
- Once the defibrillator arrives, defibrillation should be performed as soon as possible. For pulseless ventricular tachycardia, delivering a shock is critical to attempt to restore a normal heart rhythm.
Other options:
He should be given a precordial thump: This is not recommended as a primary action when a defibrillator is available or arriving imminently.
A ventilation to compression ratio of 30:2 should be commenced: While ventilation is important, continuous chest compressions take precedence in the initial phase. The ratio of 30:2 is used during CPR when ventilations are also being provided, typically when two rescuers are present.
Await arrival of defibrillator, then deliver shock: Waiting passively without performing chest compressions is not appropriate.
Intravenous adrenaline should be given: Adrenaline is part of the advanced life support protocol, but the first immediate action should be chest compressions followed by defibrillation.
- Continuous Chest Compressions:
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This question is part of the following fields:
- Cardiovascular System
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Question 39
Correct
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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: 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 40
Correct
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How should DVT during pregnancy be managed?
Your Answer: Dalteparin
Explanation:Deep vein thrombosis (DVT) is a serious condition in which a blood clot forms in a deep vein, usually in the leg.
Subcutaneous low molecular weight heparin (LMWH) is the preferred treatment for most patients with acute DVT, including in pregnancy. A large meta-analyses comparing LMWH to unfractionated heparin (UFH) showed that LMWH decreased the risk of mortality, recurrent veno-thrombo embolism (VTE), and haemorrhage compared with heparin. Other advantages of LMWH may include more predictable therapeutic response, ease of administration and monitoring, and less heparin-induced thrombocytopenia. Disadvantages of LMWH include cost and longer half-life compared with heparin.
Warfarin, which is administered orally, is used if long-term anticoagulation is needed. The international normalized ratio (INR) is followed, with a target range of 2-3. Warfarin crosses the placenta and is teratogenic, causing a constellation of anomalies known as warfarin embryopathy, with greatest risk between the sixth and twelfth week of gestation.
Other options are not indicated for use. -
This question is part of the following fields:
- Respiratory System
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Question 41
Correct
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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: 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 42
Correct
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A 64-year-old woman with ankylosing spondylitis presents with cough, weight loss and tiredness. Her chest x-ray shows longstanding upper lobe fibrosis. Three sputum tests stain positive for acid fast bacilli (AFB) but are consistently negative for Mycobacterium tuberculosis on culture.
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Which of the following is the most likely causative agent?Your Answer: Mycobacterium avium intracellular complex
Explanation:Pulmonary mycobacterium avium complex (MAC) infection in immunocompetent hosts generally manifests as cough, sputum production, weight loss, fever, lethargy, and night sweats. The onset of symptoms is insidious.
In patients who may have pulmonary infection with MAC, diagnostic testing includes acid-fast bacillus (AFB) staining and culture of sputum specimens.The ATS/IDSA guidelines include clinical, radiographic, and bacteriologic criteria to establish a diagnosis of nontuberculous mycobacterial lung disease.
Clinical criteria are as follows:
Pulmonary signs and symptoms such as cough, fatigue, weight loss; less commonly, fever and weight loss; dyspnoea
Appropriate exclusion of other diseases (e.g., carcinoma, tuberculosis).
At least 3 sputum specimens, preferably early-morning samples taken on different days, should be collected for AFB staining and culture. Sputum AFB stains are positive for MAC in most patients with pulmonary MAC infection. Mycobacterial cultures grow MAC in about 1-2 weeks, depending on the culture technique and bacterial burden.
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This question is part of the following fields:
- Respiratory System
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Question 43
Incorrect
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Which of the following is not associated with atrial myxoma?
Your Answer: Clubbing
Correct Answer: J wave on ECG
Explanation:J waves in an ECG is associated with hypothermia, hypercalcemia, the Brugada syndrome, and idiopathic ventricular fibrillation. The other responses are all associated with atrial myxoma
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This question is part of the following fields:
- Cardiovascular System
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Question 44
Correct
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A 75 year male who has been on treatment for joint pain for a long period, presented with vomiting and sudden-onset severe epigastric pain for the past 1 hour. He also complained of shoulder tip pain. On examination his abdomen was rigid. Which of the following is the most appropriate investigation to arrive at a diagnosis at this stage?
Your Answer: Erect CXR
Explanation:The most probable diagnosis is perforated peptic ulcer. History of possible NSAID/steroid use for joint pain, sudden-onset severe epigastric pain, vomiting and shoulder tip pain, support the diagnosis. Erect CXR will show the air under the diaphragm which is diagnostic.
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This question is part of the following fields:
- Gastrointestinal System
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Question 45
Correct
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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: 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 46
Correct
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A 60-year-old man with type 1 diabetes is brought to the clinic with his wife. He is limping and his wife noticed that his ankle was abnormally-shaped after he stepped out of the shower.
Examination of his right ankle reveals a painless warm swollen joint.
There is crepitus and what appears to be palpable bone debris. X-ray reveals gross joint destruction and apparent dislocation. Joint aspiration fluid shows no microbes.
Investigations:
His CRP and white count are of normal values.
Historical review of HB A1c reveals that it has rarely been below 9%.
What is the most likely diagnosis?Your Answer: Charcot's ankle
Explanation:Charcot arthropathy is a progressive condition of the musculoskeletal system that is characterized by joint dislocations, pathologic fractures, and debilitating deformities. It results in progressive destruction of bone and soft tissues at weight-bearing joints. In its most severe form, it may cause significant disruption of the bony architecture.
Charcot arthropathy can occur at any joint; however, it occurs most commonly in the lower extremity, at the foot and ankle. Diabetes is now considered to be the most common aetiology of Charcot arthropathy. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 47
Correct
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A 20-year-old woman who is sexually active is having deep dyspareunia and vaginal discharge. She has a negative smear for Gonococcus. Which of the following is the most likely diagnosis?
Your Answer: Chlamydial trachomatis
Explanation:This case is highly suggested of PID or Pelvic Inflammatory disease with chlamydia as the more common infective agent. Tetracyclines are used for treatment.
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This question is part of the following fields:
- Infectious Diseases
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Question 48
Incorrect
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A 4-year-old child was brought in by his mother with complaints of vesicular eruption over his palms, soles and oral mucosa for the last 5 days. He was slightly febrile. There were no other signs. The most likely causative organism in this case would be?
Your Answer: Measles
Correct Answer: Coxsackie
Explanation:This patient is most likely suffering from hand, foot mouth disease which is caused by coxsackie virus A16. Its incubation period ranges from 5-7 days and only symptomatic treatment is required.
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This question is part of the following fields:
- The Skin
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Question 49
Correct
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A 59-year-old woman has an 11mm skin lesion on her right forearm, which bleeds easily on contact and has changed in appearance over the last 11 months.
Your Answer: Malignant melanoma
Explanation:Melanoma is more common in men than women. Reasons for the disease includes: UV light and genetic predisposition or mutations. Diagnosis is by biopsy and analysis of any skin lesion that has signs of being potentially cancerous.
Early warning signs of melanoma ABCDE:
Asymmetry
Borders (irregular with edges and corners)
Colour (variegated)
Diameter (greater than 6 mm)
Evolving over time -
This question is part of the following fields:
- The Skin
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Question 50
Correct
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A 28-year-old male complained of an annular rash following an insect bite he received during a hiking trip. Which of the following is the drug of choice?
Your Answer: Doxycycline PO
Explanation:The described rash is the typical rash of erythema migrans of Lyme disease, which is treated by doxycycline PO
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This question is part of the following fields:
- Infectious Diseases
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Question 51
Correct
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A 25-year-old male presented with acute severe central chest pain which radiated backwards between his scapulae. He didn't have difficulty in breathing and the pain wasn't exacerbated by deep inspiration or a change in position. His father had died due to a heart disease when he was small. He also has a cardiac murmur which was never properly investigated. On examination he was tachycardic with a BP of 165/60 mmHg. There was a diastolic murmur at lower left sternal border which is best heard with the patient sitting forward. Which of the following is the most probable cause for his chest pain?
Your Answer: Aortic dissection
Explanation:The most probable diagnosis is Marfan’s syndrome because of a family history of cardiac death and heart murmurs. A characteristic feature is pain which radiates to the back. A wide pulse pressure and a diastolic heart murmur is suggestive of aortic dissection.
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This question is part of the following fields:
- Cardiovascular System
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Question 52
Incorrect
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A 33-year-old artist who recently arrived in the UK from New York presents in ED. He has a past history of insulin-dependant diabetes mellitus. He describes a few days of fever, headache and myalgia. Admission was prompted by worsening headache and back pain. While waiting in the medical receiving unit, he becomes progressively drowsier. Examination revealed flaccid paralysis and depressed tendon reflexes. He was reviewed by the intensive care team and arrangements were made for ventilation. A computerised tomography (CT) brain is performed that is normal.
Cerebrospinal fluid examination reveals:
Protein 0.9 g/l (<0.45 g/l)
Glucose 4 mmol/l
White cell count (WCC) 28/mm3 (mostly lymphocytes)
Blood testing reveals:
Haemoglobin (Hb) 14 g/dl (13-18)
Platelets 620 x 109/l (150-400 x 109)
WCC 12 x 109/l (4-11 x 109)
Sodium 135 mmol/l (137-144)
Potassium 4.6 mmol/l (3.5-4.9)
Urea 8 mmol/l (2.5-7.5)
Creatinine 120 mmol/l (60-110)
Glucose 6 mmol/l
Which of the following is the most likely infective process?Your Answer: Lyme disease
Correct Answer: West Nile disease
Explanation: -
This question is part of the following fields:
- Nervous System
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Question 53
Correct
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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: 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 54
Incorrect
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A 47-year-old woman is being treated with steroids for her diagnosis of giant cell arteritis (GCA). What is the other drug that can be added to this?
Your Answer: Beta blockers
Correct Answer: Aspirin
Explanation:Low dose aspirin is proven efficient in aversion of complications connected with giant cell arteritis such as stroke.
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This question is part of the following fields:
- Pharmacology
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Question 55
Incorrect
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An 85-year-old elderly male presents with complaint of worsening breathlessness over the last 2 years. He has a longstanding history of COPD and currently takes salbutamol, ipratropium, salmeterol, beclomethasone and theophylline. FEV1 comes out to be less than 30%. What will be the most suitable next step in the management of this patient?
Your Answer: Trial of non-invasive ventilation
Correct Answer: Assessment for long term O2 therapy
Explanation:Long-term oxygen therapy (LTOT) is the cornerstone mode of treatment in patients with severe chronic obstructive pulmonary disease (COPD) associated with resting hypoxaemia. When appropriately prescribed and correctly used, LTOT has clearly been shown to improve survival in hypoxemic COPD patients. Requirements to proceed to LTOT is the patient should be stable and on appropriate optimum therapy (as in given case) and having stopped smoking tobacco. The patient should be shown to have a PaO2 of less than 7.3 kPa and/or a PaCO2 of greater than 6 kPa on two occasions at least 3 weeks apart. FEV1 should be less than 1.5 litres, and there should be a less than 15% improvement in FEV1 after bronchodilators. Patients with a PaO2 between 7.3 and 8 kPa who have polycythaemia, right heart failure or pulmonary hypertension may benefit from LTOT.
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This question is part of the following fields:
- Respiratory System
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Question 56
Correct
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A 45-year-old female presented in the OPD with complaints of tiredness and lethargy. On examination, her BP was 160/100 mmHg. On lab examination her Na+=142 mmol/L, K+=3.0mmol/L. Which is the most likely diagnosis?
Your Answer: Conn's syndrome
Explanation:In Conn’s syndrome hypokalaemia and hypertension are present due to high levels of aldosterone with normal to high sodium levels. In this disease, the patient presents with hypertension and feelings of tiredness or fatigue.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 57
Incorrect
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Of the following disorders, which one causes acute tubular damage?
Your Answer: Berger's disease
Correct Answer: Myoglobinuria
Explanation:Myoglobinuria is the condition when there is degeneration of necrosed muscle that it is excreted in the urine. This condition would then cause acute tubular damage leading to renal failure.
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This question is part of the following fields:
- Renal System
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Question 58
Correct
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A 26-year-old woman presents to a reproductive endocrinology clinic with a history of not being able to conceive after 2 years of using no contraception. Polycystic ovarian syndrome maybe her diagnosis.
Which of the following is most likely to be associated with this condition?Your Answer: Elevated LH/FSH ratio
Explanation:In patients with polycystic ovarian syndrome (PCOS), FSH levels are within the reference range or low. Luteinizing hormone (LH) levels are elevated for Tanner stage, sex, and age. The LH-to-FSH ratio is usually greater than 3.
Women with PCOS have abnormalities in the metabolism of androgens and oestrogen and in the control of androgen production. PCOS can result from abnormal function of the hypothalamic-pituitary-ovarian (HPO) axis.
The major features of PCOS include menstrual dysfunction, anovulation, and signs of hyperandrogenism. Other signs and symptoms of PCOS may include the following:
– Hirsutism
– Infertility
– Obesity and metabolic syndrome
– Diabetes
– Obstructive sleep apnoeaAndrogen excess can be tested by measuring total and free testosterone levels or a free androgen index. An elevated free testosterone level is a sensitive indicator of androgen excess. Other androgens, such as dehydroepiandrosterone sulphate (DHEA-S), may be normal or slightly above the normal range in patients with polycystic ovarian syndrome (PCOS). Levels of sex hormone-binding globulin (SHBG) are usually low in patients with PCOS.
Some women with PCOS have insulin resistance and an abnormal lipid profile (cholesterol >200 mg/dL; LDL >160 mg/dL). Approximately one-third of women with PCOS who are overweight have impaired glucose tolerance or type 2 diabetes mellitus by 30 years of age.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 59
Correct
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Which one of the following is a contraindication to the use of a triptan in the management of migraine?
Your Answer: A history of ischaemic heart disease
Explanation:A history of ischaemic heart disease in a contraindication for prescribing triptans because they act by constricting cerebral and also coronary vessels, increasing the risk of stroke.
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This question is part of the following fields:
- Nervous System
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Question 60
Correct
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When considering the anatomical location of intracranial meningiomas, which of the following relations is well recognised?
Your Answer: Parasagittal - spastic paraparesis
Explanation:The localisation of intracranial lesions (based on both history and examination) is crucial. Meningiomas are slow in growth, and its subtle effects are very different from the more aggressive, intrinsic lesions. Olfactory groove lesions affect the sense of smell and may produce ipsilateral optic atrophy. Sphenoid ridge lesions will produce exophthalmos. Chiasmal lesions usually produce bitemporal hemianopia.
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This question is part of the following fields:
- Nervous System
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SESSION STATS - PERFORMANCE PER SPECIALTY
