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Question 1
Incorrect
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A patient complaining of nocturnal cough and wheeze is investigated for asthma. Which of the following tests would be most useful in aiding the diagnosis?
Your Answer: FEV1 and FVC measurements
Correct Answer: ANCA
Explanation:Churg-Strauss disease (CSD) is one of three important fibrinoid, necrotizing, inflammatory leukocytoclastic systemic small-vessel vasculitides that are associated with antineutrophil cytoplasm antibodies (ANCAs).
The first (prodromal) phase of Churg-Strauss disease (CSD) consists of asthma usually in association with other typical allergic features, which may include eosinophilia. During the second phase, the eosinophilia is characteristic (see below) and ANCAs with perinuclear staining pattern (pANCAs) are detected. The treatment would therefore be different from asthma. For most patients, especially those patients with evidence of active vasculitis, treatment with corticosteroids and immunosuppressive agents (cyclophosphamide) is considered first-line therapy -
This question is part of the following fields:
- Respiratory System
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Question 2
Incorrect
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A clinical trial is conducted to study the benefits of a new oral medication to improve the symptoms of patients with asthma. In the trial 400 patients with asthma, half were given the new medication and half a placebo. Three months later they are asked to rate their symptoms using the following scale: much improved, slight improvement, no change, slight worsening, significantly worse. What is the most appropriate statistical test to see whether the new medication is beneficial?
Your Answer: Wilcoxon signed-rank test
Correct Answer: Mann-Whitney U test
Explanation:The type of significance test used depends on whether the data is parametric (can be measured, usually normally distributed) or non-parametric.
Parametric tests:
Student’s t-test – paired or unpaired*
Pearson’s product-moment coefficient – correlationNon-parametric tests:
Mann-Whitney U test – unpaired data
Wilcoxon signed-rank test – compares two sets of observations on a single sample
chi-squared test – used to compare proportions or percentages
Spearman, Kendall rank – correlation.The outcome measured is not normally distributed, i.e. it is non-parametric. This excludes the Student’s t-tests. We are not comparing percentages/proportions so the chi-squared test is excluded. The Mann-Whitney U test is a nonparametric test of the null hypothesis that it is equally likely that a randomly selected value from one sample will be less than or greater than a randomly selected value from a second sample.
This test can be used to investigate whether two independent samples were selected from populations having the same distribution. -
This question is part of the following fields:
- Evidence Based Medicine
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Question 3
Incorrect
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A 60-year-old female with a recent history of MI, complained of exertional dyspnoea. On examination there was a third heart sound. ECG showed ST elevations in leads V1 to V4. Which of the following is the most probable reason for this presentation?
Your Answer: Dressler's syndrome
Correct Answer: Left ventricular aneurysm
Explanation:Electrocardiography is characterized by ST elevation that persists several weeks after an acute MI. The features of heart failure (exertional dyspnoea and third or fourth heart sound) favours the diagnosis.
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This question is part of the following fields:
- Cardiovascular System
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Question 4
Correct
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A newly married female presented with fever, dysuria, frequency and lower abdominal pain for 2 days duration. On examination, she was febrile with lower abdominal tenderness. Urine microscopy reveals 20-30 pus cells/hpf and 10-20 red cells/hpf. Which of the following would be the most probable cause for this presentation?
Your Answer: Cystitis
Explanation:The patient has what is known as ‘honeymoon cystitis’.
Most common presentation of schistosomiasis is haematuria.
Patients with kidney trauma also present with haematuria following a positive history for such injury.
Pain due to calculi are colicky in nature and severe. -
This question is part of the following fields:
- Women's Health
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Question 5
Correct
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A 32-year-old man, originally from Pakistan, was admitted with ascites and weight loss. The protein level on ascitic tap was 9 g/l.
Which of the following is the most likely cause of this presentation?Your Answer: Hepatic cirrhosis
Explanation:This is a low protein level, indicating the fluid is transudative. The only answer choice that is a transudative fluid is in hepatic cirrhosis. Exudative fluid would be seen in tuberculous peritonitis, peritoneal lymphoma, with liver mets, and with intra-abdominal malignancy.
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This question is part of the following fields:
- Hepatobiliary System
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Question 6
Incorrect
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A 54-year-old male, with a smoking history of 15 pack years presents with worsening dyspnoea, fever and cough. He works at a foundry. Vitals are as follows:
Respiratory rate: 28/min
Heart rate: 80 bpm
Temp: 37.6C
Chest auscultation reveals bilateral crepitations throughout the lung fields.
Calcified hilar nodules are visible on the chest X-ray. Further evaluation shows an eggshell calcification on HRCT.
Which of the following is the most likely diagnosis?Your Answer: Histoplasmosis
Correct Answer: Silicosis
Explanation:Silicosis is a common occupational lung disease that is caused by the inhalation of crystalline silica dust. Silica is the most abundant mineral on earth. Workers that are involved for example in construction, mining, or glass production are among the individuals with the highest risk of developing the condition. Acute silicosis causes severe symptoms (e.g., exertional dyspnoea, cough with sputum) and has a very poor prognosis.
Chronic silicosis has a very variable prognosis and affected individuals may remain asymptomatic for several decades. However, radiographic signs are usually seen early on. Typical radiographic findings are calcifications of perihilar lymph nodes, diffuse ground glass opacities, large numbers of rounded, solitary nodules or bigger, confluent opacities. Avoiding further exposure to silica is crucial, especially since the only treatment available is symptomatic (e.g., bronchodilators). Silicosis is associated with an increased risk of tuberculosis and lung cancer. Berylliosis typically affects individuals who are exposed to aerospace industry. Histoplasmosis and tuberculosis do not form eggshell calcifications. -
This question is part of the following fields:
- Respiratory System
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Question 7
Incorrect
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Causes of dilated pupils include which of the following?
Your Answer: Pontine haemorrhage
Correct Answer: Ethylene glycol poisoning
Explanation:Ethylene glycol poisoning is the only poison listed that will cause dilation of the pupils whereas all the other listed conditions and poisons will present with small pupils other than in the case of Myotonic dystrophy wherein the patient will present with a cortical cataract.
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This question is part of the following fields:
- Nervous System
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Question 8
Incorrect
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A 28-year-old male has presented to his doctor with hypertension. Upon examination, he is found to have palpable kidneys. An abdominal ultrasound shows enlarged cystic kidneys on both sides. From the list of options, choose the most likely condition present in this patient.
Your Answer: Mitral stenosis
Correct Answer: Polycythaemia
Explanation:The most likely diagnosis for this patient is adult polycystic kidneys. This disease is associated with the following: valvular heart abnormalities, incompetence, and aneurysms of the cerebral circulation. It can also be associated with excessive erythropoietin production and polycythaemia. There is an increased incidence of aortic incompetence, and mitral valve prolapse occurs in 25 per cent of patients. Hepatic cysts can also occur, and present in 70 per cent of patients – these can also involve the pancreas in 10 per cent of patients and the spleen. Cerebral berry aneurysms are present in around 5-8 per cent of patients, but familial clustering is also observed. That is if there is a family history, over 20 per cent of patients will also have an aneurysm. Diverticular disease is also thought to be increased in patients with polycystic kidney disease.
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This question is part of the following fields:
- Renal System
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Question 9
Incorrect
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A baby is born with complications including microcephaly, hepatosplenomegaly and elevated total bilirubin. Which of the following is the most likely diagnosis in this case?
Your Answer: Syphilis
Correct Answer: Cytomegalovirus (CMV)
Explanation:CMV infection is usually asymptomatic in adults. However, if the mother is infected for the first time during pregnancy then there is high chances of this infection passing on to the foetus. CMV infection can cause blindness, deafness, learning difficulties, restricted growth etc. Hepatitis B, herpes simplex, syphilis and HIV do not present with these classical signs of CMV infection in new-borns. It is estimated that 10 stillbirths occur in England and Wales every year due to CMV infection. The foetus is most at risk in early pregnancy. There is no effective prevention.
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This question is part of the following fields:
- Infectious Diseases
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Question 10
Incorrect
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Which of the following is an appetite stimulant?
Your Answer: Insulin
Correct Answer: Neuropeptide Y
Explanation:Neuropeptide Y induces appetite during trials in rats. Other agents mentioned here are either appetite suppressants or have no effect on appetite.
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This question is part of the following fields:
- Gastrointestinal System
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Question 11
Correct
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A 28-year-old male was admitted with palpitations and chest discomfort for the past 1 hour. On examination his pulse rate was 200 bpm and blood pressure was 80/50 mmHg. His ECG revealed narrow complex tachycardia with a heart rate of 200 bpm. Which of the following is the most appropriate management of this patient?
Your Answer: Synchronised DC synchronised cardioversion
Explanation:Narrow complex tachycardia with hypotension is a medical emergency. Immediate synchronized cardioversion is the ideal management.
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This question is part of the following fields:
- Cardiovascular System
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Question 12
Correct
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A 23-year-old male patient presents with urethritis for the last 2 weeks that has not responded to antibiotics. Lately he has developed an onset of new range of symptoms that are linked to his HLA B27 positivity. Which of the following signs is not related to Reiter's syndrome?
Your Answer: A mild fever with a generalised macular rash
Explanation: -
This question is part of the following fields:
- Musculoskeletal System
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Question 13
Correct
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A 42-year-old female presents with morning stiffness that usually takes an hour to settle and a one year history of intermittent pain and swelling of the small joints of her hands. Examination reveals symmetric soft tissue swelling over the PIP and MCP joints and rheumatoid nodules on the elbows. There is also an effusion of both wrists. Lab results are positive for rheumatoid factor. X-ray of the wrists and hands shows erosions and bony decalcification. NSAIDs are started and the patient is referred to a rheumatologist for consideration of DMARD. Previous history is significant for TB. Which of the following should be avoided?
Your Answer: Infliximab
Explanation:Anti-TNF-? therapy is effective for patients with arthritis but it can oftentimes lead to the reactivation of latent TB. Hence it should be used with great caution in patients with a past history of TB or current infection.
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This question is part of the following fields:
- Musculoskeletal System
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Question 14
Incorrect
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Choose the correct statement regarding hyponatremia:
Your Answer: In a dehydrated patient with urinary sodium < 20mmol/L it may be due to the diuretic stage of renal failure
Correct Answer: Hyperlipidaemia may cause pseudohyponatraemia
Explanation:The Hyperlipidaemia Effect: Pseudohyponatremia in Pancreatic Cancer; Patients who have disorders of cholestasis commonly present with volume depletion due to vomiting and poor oral intake, which, in turn, often leads to hypovolemic hyponatremia. It is less well known that disorders of cholestasis, including tumours of the hepatobiliary system, can be accompanied by hyperlipidaemia.
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This question is part of the following fields:
- Fluids & Electrolytes
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Question 15
Incorrect
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A 40-year-old male was diagnosed with HIV. He had had multiple sexual partners. He was not willing to change his lifestyle, nor was he willing to inform any of his former partners. What is the most suitable next step for the doctor?
Your Answer: Implement Public Health Act
Correct Answer: Give general advice
Explanation:General advice should be given to the patient as HIV is not a notifiable disease. Informing someone about the disease without the patient’s consent will breach the confidentiality.
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This question is part of the following fields:
- Ethical & Legal
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Question 16
Correct
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The increased risk of oesophageal malignancy in patients with Barrett's oesophagus is approximately:
Your Answer: 50 - 100 times risk
Explanation:Barrett’s oesophagus is the transformation of the normal squamous epithelium of the oesophagus to columnar, intestinal type epithelium. It is often seen in patients with reflux and there is a 50-100 fold increased risk of oesophageal adenocarcinoma in patients with Barrett’s oesophagus.
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This question is part of the following fields:
- Gastrointestinal System
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Question 17
Incorrect
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A 24-year-old woman presents as an emergency to her GP with acute vomiting which began some 3-4 hours after attending an afternoon meeting. Cream cakes were served during the coffee break.
Which of the following organisms is the most likely cause of this acute attack of vomiting?Your Answer: Bacillus cereus
Correct Answer: Staphylococcus aureus
Explanation:Staph. aureus is the most likely cause. It is found in foods like dairy products, cold meats, or mayonnaise. It produces a heat-stable ENDOTOXIN (remember this) that causes nausea, vomiting, and diarrhoea 1-6 hours after ingestion of contaminated food. B. cereus is classically associated with fried rice being reheated. Salmonella is typical with raw eggs and undercooked poultry. Campylobacter which is most commonly associated with food poisoning, is seen with poultry 50% of the time. Yersinia enterocolitica is seen with raw or undercooked pork, and may be a case presenting with mesenteric adenitis.
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This question is part of the following fields:
- Gastrointestinal System
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Question 18
Incorrect
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A 65-year-old woman presents at clinic complaining of worsening hoarseness of voice and dyspnoea over the past month. She has a history of toxic multinodular goitre successfully treated with radioiodine. On examination, she has a firm asymmetrical swelling of the thyroid gland. Laryngoscopy demonstrates a right vocal cord paralysis and apparent external compression of the trachea.
What is the most likely diagnosis?Your Answer: Medullary thyroid cancer
Correct Answer: Anaplastic thyroid cancer
Explanation:Thyroid malignancies are divided into papillary carcinomas (80%), follicular carcinomas (10%), medullary thyroid carcinomas (5-10%), anaplastic carcinomas (1-2%), primary thyroid lymphomas (rare), and primary thyroid sarcomas (rare).
Hürthle cell carcinoma is a rare thyroid malignancy that is often considered a variant of follicular carcinoma.
– Papillary and Follicular carcinoma are slow-growing tumours
– Sporadic cases of Medullary thyroid carcinoma also typically manifest with painless solitary thyroid nodules in the early stages.
– Anaplastic thyroid carcinoma has the most aggressive biologic behaviour of all thyroid malignancies and has one of the worst survival rates of all malignancies in general. It manifests as a rapidly growing thyroid mass in contrast to a well-differentiated carcinoma, which are comparatively slow-growing. Patients commonly present with associated symptoms due to local invasion. Hoarseness and dyspnoea resulting from the involvement of the recurrent laryngeal nerve and airway occur in as many as 50% of patients.
– Almost all patients with primary thyroid lymphoma have either a clinical history or histological evidence of chronic lymphocytic thyroiditis. The risk of primary thyroid lymphoma increases 70-fold in patients with chronic lymphocytic thyroiditis compared with the general population. Regional and distant lymphadenopathy is common. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 19
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: Valvular aortic stenosis
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 20
Incorrect
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A 63-year-old man, known to have small cell lung cancer and ischaemic heart disease (IHD), presents with increasing shortness of breath for the past 7 days. It becomes worse at night and is associated with an occasional non-productive cough. He has also noticed that his wedding ring feels tight. His cancer was diagnosed five months ago and he has recently completed a course of chemotherapy. From a cardiac point of view, he had a myocardial infarction (MI) two years ago following which he had primary angioplasty with stent placement. He has had no episode of angina since then.
Clinical examination of his chest is unremarkable. He does, however, have distended neck veins and periorbital oedema.
What is the most likely diagnosis?Your Answer:
Correct Answer: Superior vena cava obstruction
Explanation:Superior vena cava (SVC) obstruction is an oncological emergency caused by compression of the SVC and is most commonly associated with lung cancer.
Some causes of the condition include:
1. Common malignancies: non small cell lung cancer, lymphoma
2. Other malignancies: metastatic seminoma, Kaposi’s sarcoma, breast cancer
3. Aortic aneurysm
4. Mediastinal fibrosisClinical features of SVC obstruction include:
1. Dyspnoea: most common
2. Swelling of the face, neck, and arms: conjunctival and periorbital oedema may be seen
3. Headache: often worse in the morning
4. Visual disturbances
5. Pulseless jugular venous distensionManagement options are:
1. General: dexamethasone, balloon venoplasty, stenting
2. Small cell lung cancer: chemotherapy and radiotherapy
3. Non small cell lung cancer: radiotherapy -
This question is part of the following fields:
- Haematology & Oncology
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Question 21
Incorrect
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A 29-year-old woman presents to clinic complaining of intermittent diarrhoea and constipation. Full blood count and viscosity were normal. Flexible sigmoidoscopy was unremarkable.
What is the next most appropriate management step?Your Answer:
Correct Answer: High-fibre diet
Explanation:This is most likely describing irritable bowel syndrome (IBS). Symptoms are either diarrhoea, constipation, or both, abdominal pain, bloating, with various durations. It is a functional, not organic, problem, as far as research shows at this point. It is essentially a diagnosis of exclusion. Treatment is a high fibre diet with fluids. Caffeine should be avoided as this can worsen symptoms. Full colonoscopy is not warranted at this time, neither is a barium enema. A wheat-free diet is not likely to help as there is no evidence they have an allergy to this.
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This question is part of the following fields:
- Gastrointestinal System
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Question 22
Incorrect
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A 7-year-old child presented to the paediatric clinic with a swollen face, hands and feet. She gained 2 kilograms over the last month despite poor feeding. What is the investigation of choice in this case?
Your Answer:
Correct Answer: Urinary albumin
Explanation:This is a case of nephrotic syndrome that can be confirmed by the presence of urinary albumin. It should be further investigated by a tissue sample to confirm the diagnosis.
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This question is part of the following fields:
- Renal System
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Question 23
Incorrect
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A 60-year-old female underwent a surgery involving the posterior triangle of the neck. After the surgery, she had difficulty when moving her right shoulder joint. Which of the following nerves is most probably involved?
Your Answer:
Correct Answer: Accessory nerve
Explanation:The accessory nerve innervates the trapezius muscle which is involved in shoulder movements. Any injury to this nerve will result in the difficulty of movements around the shoulder.
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This question is part of the following fields:
- Musculoskeletal System
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Question 24
Incorrect
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A 51-year-old man was admitted with right-sided hemiparesis and right upper motor neuron facial nerve palsy. He was known to be on warfarin for a mitral valve replacement and had been adequately anticoagulated. He was also taking furosemide and had recently been started on St John's wort for low mood.
On examination, his pulse was 90 bpm and regular, and his blood pressure was 150/80 mmHg. Cardiac examination demonstrated normal prosthetic valve sounds with an ejection systolic murmur at the left sternal edge. CT scan showed evidence of a left middle cerebral artery infarction.
What is the possible explanation for the presentation?Your Answer:
Correct Answer: St John's wort reduces the activity of warfarin
Explanation:St John’s wort interferes with warfarin by increasing its breakdown and decreasing its effectiveness. This leads to the need for adjustment in the dose of warfarin and careful attention to monitoring if the patient decides to continue with the drug. Ideally, an alternative antidepressant should also be considered.
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This question is part of the following fields:
- Haematology & Oncology
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Question 25
Incorrect
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A 17-year-old boy presents with a 2 day history of colicky abdominal pain, vomiting and diarrhoea. He has been passing blood mixed with diarrhoea. He has no significant past medical history and takes no regular medication.
On examination he is pyrexial and clinically dehydrated. Cardiorespiratory and abdominal examinations are normal.
What is the most likely diagnosis?Your Answer:
Correct Answer: Campylobacter infection
Explanation:The patient has bloody diarrhoea that sounds like a food poisoning in the clinical scenario. Campylobacter is the most common cause of this in the United Kingdom. This is then followed by Salmonella and Shigella. The symptoms are usually self limiting. This is more likely to be bacterial from the food than a viral gastroenteritis.
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This question is part of the following fields:
- Gastrointestinal System
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Question 26
Incorrect
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A 39-year-old accountant with long-standing gastro-oesophageal reflux disease is reviewed in clinic. He has recently switched from ranitidine to omeprazole.
What is the main benefit of omeprazole compared to ranitidine?Your Answer:
Correct Answer: Irreversible blockade of H+/K+ ATPase
Explanation:Proton pump inhibitors can reduce gastric acid secretion by up to 99%. Acid production resumes following the normal renewal of gastric parietal cells.
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This question is part of the following fields:
- Pharmacology
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Question 27
Incorrect
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A 40-year-old male was admitted following 30%, burns sustained from an apartment fire. What is the most appropriate initial treatment of this patient?
Your Answer:
Correct Answer: Intravenous fluids
Explanation:As this patient has more than a 15% burn area, he needs IV fluids. These patients are more prone to infection and dehydration. Burn area is calculated using the rule of nines and requires fluid replacement over the first 24 hrs, calculated using Parkland’s burn formula.
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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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A 62-year-old male presented with worsening breathlessness and fatigability. On examination there was bilateral ankle swelling and pulsatile liver. Auscultation revealed a pansystolic murmur best heard at the lower left sternal border. Which of the following is the most probable diagnosis?
Your Answer:
Correct Answer: Tricuspid regurgitation
Explanation:All the clinical features are suggestive of tricuspid regurgitation. The pansystolic murmur of mitral regurgitation is best heard at the apex.
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This question is part of the following fields:
- Cardiovascular System
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Question 29
Incorrect
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A 23-year-old man is referred to the pneumologist with a suspicion of bronchiectasis. History reveals he's been having recurrent pulmonary infections his whole life together with difficulties gaining weight. He's a non-smoker with a clear family history and he admits inhalers haven't helped him in the past. He is finally suspected of having cystic fibrosis. What is the normal function of the cystic fibrosis transmembrane regulator?
Your Answer:
Correct Answer: Chloride channel
Explanation: -
This question is part of the following fields:
- Respiratory System
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Question 30
Incorrect
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A 5-month-old baby presents with symptoms of irritability, blood in the stools and vomiting. Examination reveals a rigid abdomen and drawing of knees upon palpation. Which is the most appropriate action you should take for this baby?
Your Answer:
Correct Answer: Refer to paediatric surgeons
Explanation:Intussusception is the most suggested case here based on the child’s symptoms. The urgent course of treatment is to bring the child to a paediatric surgical unit. If air reduction attempts fail, surgery will have to be done. Risk factors for intussusception include viral infection and intestinal lymphadenopathy.
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This question is part of the following fields:
- Emergency & Critical Care
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SESSION STATS - PERFORMANCE PER SPECIALTY
