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Question 1
Correct
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Which is NOT true of vitiligo?
Your Answer: A positive family history is not a risk factor
Explanation:The cause of Vitiligo is typically unknown. It is believed to be due to genetic susceptibility that is triggered by an environmental factor such that an autoimmune disease occurs. This results in the destruction of skin pigment cells. Risk factors include a family history of the condition or other autoimmune diseases, such as hyperthyroidism, alopecia areata, and pernicious anaemia. Vitiligo is classified into two main types: segmental and non-segmental. Most cases are non-segmental meaning they affect both sides and typically get worse with time. The prevalence of vitiligo is 0.5-1% of populations worldwide. Typical sites include backs of hands, wrists, knees, neck and around body orifices. The Koebner phenomenon refers to skin lesions appearing on lines of trauma. This occurs in vitiligo secondary to scratching.
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This question is part of the following fields:
- The Skin
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Question 2
Correct
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A patient was admitted due to vomiting for further investigations. He noticed blood in his vomit and the physicians decided to perform an esophagogastroduodenoscopy which revealed haemorrhage in the lesser curvature of the stomach. Which artery is responsible for the bleeding?
Your Answer: Right gastric artery
Explanation:The right gastric artery arises from the hepatic artery or the left hepatic artery and supplies the pylorus, traveling along the lesser curvature of the stomach anastomosing with the left gastric artery.
The pancreaticoduodenal artery supplies mainly the upper and lower duodenum and the head of the pancreas.
The gastro-omental arteries supply the greater curvature of the stomach. -
This question is part of the following fields:
- Gastrointestinal System
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Question 3
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 4
Correct
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A 19-year-old lady with established anorexia nervosa is admitted with a BMI of 16. However, she gives the consent to be fed by a nasogastric tube. Which of the following electrolyte disturbances are you most likely to find?
Your Answer: Hypophosphataemia
Explanation:Refeeding syndrome can be defined as the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding (whether enterally or parenterally). These shifts result from hormonal and metabolic changes and may cause serious clinical complications. The hallmark biochemical feature of refeeding syndrome is hypophosphatemia. However, the syndrome is complex and may also feature abnormal sodium and fluid balance; changes in glucose, protein, and fat metabolism; thiamine deficiency; hypokalaemia; and hypomagnesaemia.
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This question is part of the following fields:
- Fluids & Electrolytes
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Question 5
Correct
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A 42-year-old man presented with palpitations and shortness of breath on exertion. On examination his lungs were clear and heart sounds were normal. There was a left sided parasternal heave. His electrocardiogram (ECG) revealed atrial fibrillation with right axis deviation. Echocardiography showed dilated right heart chambers. Left and right heart catheterisation study revealed the following
Inferior vena cava Oxygen saturations 63 %
Superior vena cava Oxygen saturations 59 %
Right atrium Oxygen saturations 77 %
Right ventricle Oxygen saturations 78 %
Pulmonary artery Oxygen saturations 82 %
Arterial saturation Oxygen saturations 98 %
What is the most likely diagnosis from the following answers?Your Answer: Atrial septal defect
Explanation:Right ventricular volume overload is indicated by a parasternal heave and right axis deviation. Oxygen saturation in right atrium is higher than oxygen saturation of the inferior and superior vena cavae. So the most probable diagnosis is atrial septal defect.
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This question is part of the following fields:
- Cardiovascular System
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Question 6
Correct
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A 17-year-old man presents with fever and extensive preauricular swelling on the right side of his face. However, tenderness is present bilaterally. He also complains of acute pain and otalgia on the right aspect of the face. What is the most likely diagnosis?
Your Answer: Mumps
Explanation:Mumps presents with a prodromal phase of general malaise and fever. On examination there is usually painful parotid swelling which has high chances of becoming bilateral. In OM with effusion there are no signs of infection and the only symptom is usually hearing loss. Acute otitis externa produces otalgia as well as ear discharge and itching. Acute OM produces otalgia and specific findings upon otoscopy. In acute mastoiditis the patient experiences ear discharge, otalgia, headache, hearing loss and other general signs of inflammation.
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This question is part of the following fields:
- Infectious Diseases
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Question 7
Correct
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A 25-year-old patient has presented with symptoms which all point to the cerebellopontine angle (CPA) a tumour. These are numbness in the face, vertigo, and tinnitus. Choose the most appropriate investigation from the list of options.
Your Answer: MRI Brain
Explanation:MRI scans are used to diagnose tumours in the cerebellopontine angle.
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This question is part of the following fields:
- Nervous System
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Question 8
Incorrect
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A 44-year-old man presents suffering from retrosternal chest pain that started 2 hours ago and radiates to the throat. Which investigation would you immediately perform?
Your Answer: Electrocardiogram
Correct Answer: Troponin levels
Explanation:The patient’s age and symptoms are indicating a myocardial infarction. Although, the cause of the pain could also be related to the digestive system, a possible myocardial infarction should be excluded or, if present, managed immediately. Troponins are used to establish the diagnosis. Levels of troponin can become elevated in the blood within 3 or 4 hours after heart injury and may remain elevated for 10 to 14 days.
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This question is part of the following fields:
- Cardiovascular System
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Question 9
Incorrect
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A 55-year-old female presents with complaints of retrosternal chest pain and dysphagia (which is intermittent and unpredictable in nature). When she swallows, food very suddenly 'sticks' in her chest. She is able to clear it when she drinks water, and then can finish the meal without any further incidence. A barium meal shows she has a corkscrew oesophagus. What is the most likely type of dysphagia here?
Your Answer: Oesophageal carcinoma
Correct Answer: Oesophageal spasm
Explanation:All of the symptoms observed in this patient are typical of uncoordinated irregular oesophageal peristalsis – this is characteristic of oesophageal spasm. The cork-screw oesophagus is also diagnostic of the condition.
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This question is part of the following fields:
- Gastrointestinal System
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Question 10
Correct
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A 8-year-old boy who recently migrated from Nigeria was seen in A&E department with a six-week history of progressive swelling of his jaw, fever, night sweats, and weight loss. His mother reported an episode of sore throat in the past which was treated with antibiotics, but he developed a rash subsequently. Other than that, there was no other significant past medical history. On examination, a painless, nontender 4x3cm mass was found that was fixed and hard. The only other examination finding of note was rubbery symmetrical cervical lymphadenopathy.
Which of the following translocation would most likely be found on biopsy karyotyping?Your Answer: t(8;14)
Explanation: -
This question is part of the following fields:
- Haematology & Oncology
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Question 11
Correct
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A 65-year-old heavy smoker presented with acute central chest pain for 2 hours. Which of the following ECG findings is an indication for thrombolysis in this patient?
Your Answer: 1 mm ST elevation in 2 limb leads
Explanation:Thrombolytic therapy is indicated in patients with evidence of ST-segment elevation MI (STEMI) or presumably new left bundle-branch block (LBBB) presenting within 12 hours of the onset of symptoms if there are no contraindications to fibrinolysis. STEMI is defined as new ST elevation at the J point in at least two contiguous leads of 2 mm (0.2 mV) or more in men or 1.5 mm (0.15 mV) in women in leads V2-V3 and/or 1 mm (0.1 mV) or more in other contiguous limb leads.
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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 13-year-old boy complains of several episodes of collapse. He describes the majority of these episodes occurring when he is laughing. He states that he loses power in his legs and falls to the ground. He is alert throughout and recovers quickly. He also describes excessive daytime sleepiness with episodes in the morning of being awake but being unable to move his body. Examination is unremarkable. A diagnosis of narcolepsy is made. Which of the following is the first line treatment for excessive daytime sleepiness?
Your Answer: Modafinil
Explanation:Narcolepsy is a rare condition characterised by excessive daytime sleepiness, sleep paralysis, hypnagogic hallucinations, and cataplexy (sudden collapse triggered by emotion such as laughing or crying). There is no cure for narcolepsy. Treatment options include stimulants, such as methylphenidate (Ritalin) or modafinil (Provigil), antidepressants, such as fluoxetine (Prozac), citalopram (Celexa), paroxetine (Paxil), sertraline (Zoloft) and sodium oxybate (Xyrem). Modafinil has replaced methylphenidate and amphetamine as the first-line treatment of excessive daytime sleepiness (EDS).
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This question is part of the following fields:
- Nervous System
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Question 13
Correct
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A 52-year-old gentleman known with rheumatoid arthritis presented with a 5 day history of red, painful swollen knee joint. He was afebrile and the joint was warm on touch. Hamstring muscles were spastic. Which of the following tests should be done next?
Your Answer: Joint aspiration for cytology and culture and sensitivity
Explanation:Rheumatoid arthritis can affect any joint of the body. Aspirate will reveal increased TLC, and it will be sterile.
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This question is part of the following fields:
- Immune System
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Question 14
Correct
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Which of the following is not a recognised feature of methemoglobinemia?
Your Answer: Decreased pO2 but normal oxygen saturation
Explanation:Normal pO2 but decreased oxygen saturation is characteristic of methemoglobinemia.
Methemoglobinemia is a rare condition in which the haemoglobin iron is in oxidized or ferric state (Fe3+) and cannot reversibly bind oxygen. Normally, the conversion of ferrous form of iron (Fe2+) to its ferric form (Fe3+) is regulated by NADH methaemoglobin reductase, which results in the reduction of methaemoglobin to haemoglobin. Disruption in the enzyme leads to increased methaemoglobin in the blood. There is tissue hypoxia as Fe3+ cannot bind oxygen, and hence the oxygen-haemoglobin dissociation curve is shifted to the left.
Methemoglobinemia can occur due to congenital or acquired causes. Congenital causes include haemoglobin variants such as HbM and HbH, and deficiency of NADH methaemoglobin reductase. Acquired causes are drugs (e.g. sulphonamides, nitrates, dapsone, sodium nitroprusside, and primaquine) and chemicals (such as aniline dyes).
The features of methemoglobinemia are cyanosis, dyspnoea, anxiety, headache, severe acidosis, arrhythmias, seizures, and loss of consciousness. Patients have normal pO2 but oxygen saturation is decreased. Moreover, presence of chocolate-brown coloured arterial blood (colour does not change with addition of O2) and brown urine also point towards the diagnosis of methemoglobinemia.
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This question is part of the following fields:
- Haematology & Oncology
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Question 15
Incorrect
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A 32-year-old asthmatic woman presents with an acute attack. Her arterial blood gases breathing air are as follows:
pH 7.31
pO2 9.6 kPa
pCO2 5.1 kPa
What do these results signify?Your Answer: Cardiorespiratory arrest could be imminent
Correct Answer: Her respiratory effort may be failing because she is getting tired
Explanation:In any patient with asthma, a decreasing PaO2 and an increasing PaCO2, even into the normal range, indicates severe airway obstruction that is leading to respiratory muscle fatigue and patient exhaustion.
Chest tightness and cough, which are the most common symptoms of asthma, are probably the result of inflammation, mucus plugs, oedema, or smooth muscle constriction in the small peripheral airways. Because major obstruction of the peripheral airways can occur without recognizable increases of airway resistance or FEV1, the physiologic alterations in acute exacerbations are generally subtle in the early stages. Poorly ventilated alveoli subtending obstructed bronchioles continue to be perfused, and as a consequence, the P(A-a)O2 increases and the PaO2 decreases. At this stage, ventilation is generally increased, with excessive elimination of carbon dioxide and respiratory alkalemia.
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This question is part of the following fields:
- Respiratory System
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Question 16
Correct
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A 25-year-old male presents at the OPD complaining of excessive tiredness and frequent headaches. On examination, his blood pressure was 205/100 mmHg. Blood tests reveal a decreased serum potassium and renin level and elevated aldosterone level. Which condition is this patient most likely suffering from?
Your Answer: Primary hyperaldosteronism (Conn's disease)
Explanation:Conn’s disease is a condition in which excessive amounts of aldosterone are secreted from the adrenal glands. Because aldosterone increases the reabsorption of sodium, it leads to a very high blood pressure.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 17
Incorrect
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A 17-year-old boy was brought to clinic, as his parents were concerned regarding possible delayed puberty. He was otherwise well, played sports regularly and his academic performance was good. His height was 1.7m and weight was 70 kg. On examination, he had a small penis and testes, absent pubic hair, but no other abnormalities. Investigations revealed: Serum testosterone 4 nmol/L (9-35) Plasma follicle stimulating hormone (FSH) 1 U/L (1-7) Plasma luteinising hormone (LH) 1 U/L (1-10) Plasma prolactin 300 mU/L (<450) Plasma TSH 2 mU/L (0.5-5) Which one of the following is the most likely cause?
Your Answer: Constitutional delay
Correct Answer: Kallman's syndrome
Explanation:Klinefelter’s syndrome: The low follicle-stimulating hormone (FSH) and luteinising hormone (LH), together with the low testosterone, suggests a hypogonadotropic hypogonadism. We know that there is no mental retardation, and we are told that physical examination is normal and sense of smell would usually not be tested. Consequently a diagnosis of Kallman’s is suggested. We are not told of a family history of growth delay, thus this is unlikely to be constitutional delay. The thyroid-stimulating hormone (TSH) is normal, making hypothyroidism unlikely and this together with the normal prolactin make hypopituitarism most unlikely.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 18
Correct
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A 46-year-old woman complains of ulceration with bloody discharge around her right nipple accompanied by redness, excoriations, and severe itchiness. What is the most likely diagnosis?
Your Answer: Paget's disease of the breast
Explanation:Paget’s disease of the breast is a type of cancer that outwardly may have the appearance of eczema, with skin changes involving the nipple of the breast. Symptoms may include redness of the nipple skin and crusting may occur around the area. In more advance cases, symptoms may include itching or a burning pain in the nipple.
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This question is part of the following fields:
- Women's Health
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Question 19
Correct
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A 55-year-old diabetic male presents with a feeling of generally being unwell. He also has a history of atrial fibrillation and epilepsy. His main complaint is a blue tinge to his vision. Which one of his medications is most likely to be responsible?
Your Answer: Sildenafil
Explanation:Blue tinge of vision/cyanopsia is caused due to the intake of sildenafil citrate.
Sildenafil citrate (Viagra) is the first oral drug to be widely approved for the treatment of erectile dysfunction.
It is a potent and selective inhibitor of type-V phosphodiesterase, the primary form of the enzyme found in human penile erectile tissue, thereby preventing the breakdown of cyclic guanosine monophosphate (cGMP), the intracellular second messenger of nitric oxide.Uses:
It is used for the treatment of erectile dysfunction, idiopathic pulmonary hypertension, premature ejaculation, high altitude illness, penile rehabilitation after radical prostatectomy, angina pectoris, and lower urinary tract symptoms.Adverse effects:
Mild headache, flushing, dyspepsia, cyanopsia, back pain, and myalgias – due to a high concentration of PDE11 enzyme in skeletal muscle, which shows significant cross-reactivity with the use of tadalafil.
It can also cause hypotension, dizziness, and rhinitis.Note: Xanthopsia (yellow-green vision) may occur secondary to treatment with digoxin.
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This question is part of the following fields:
- Pharmacology
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Question 20
Correct
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A 21 year-old male, who is a known alcoholic, presents with a fever, haemoptysis, green sputum and an effusion clinically. There is concern that it may be an empyema.
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Which test would be most useful to resolve the suspicion?Your Answer: Pleural fluid pH
Explanation:If a pleural effusion is present, a diagnostic thoracentesis may be performed and analysed for pH, lactate dehydrogenase, glucose levels, specific gravity, and cell count with differential. Pleural fluid may also be sent for Gram stain, culture, and sensitivity. Acid-fast bacillus testing may also be considered and the fluid may be sent for cytology if cancer is suspected.
The following findings are suggestive of an empyema or parapneumonic effusion that will likely need a chest tube or pigtail catheter for complete resolution:
-Grossly purulent pleural fluid
-pH level less than 7.2
-WBC count greater than 50,000 cells/µL (or polymorphonuclear leukocyte count of 1,000 IU/dL)
-Glucose level less than 60 mg/dL
-Lactate dehydrogenase level greater than 1,000 IU/mL
-Positive pleural fluid cultureThe most often used golden criteria for empyema are pleural effusion with macroscopic presence of pus, a positive Gram stain or culture of pleural fluid, or a pleural fluid pH under 7.2 with normal peripheral blood ph.
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This question is part of the following fields:
- Respiratory System
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Question 21
Correct
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A 50-year-old male patient was started on amiodarone. Prior to commencement, his blood urea and electrolytes were checked. What is the reason for doing this investigation before starting amiodarone?
Your Answer: To detect hypokalaemia
Explanation:Any antiarrhythmic drugs can potentially cause arrhythmias. Before starting amiodarone, any electrolyte imbalance including hypokalaemia, hypomagnesemia, or hypocalcaemia should be corrected to prevent any arrhythmias.
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This question is part of the following fields:
- Cardiovascular System
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Question 22
Incorrect
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A 67-year-old man who has terminal lung cancer and is taking morphine slow release tablet (MST) 60mg bd as an analgesic, is reviewed. Recently, he has been unable to take medications orally and, thus, a decision has been made to set up a syringe driver.
Out of the following, what dose of diamorphine should be prescribed for the syringe driver?Your Answer: 30mg
Correct Answer: 40mg
Explanation:The dose is calculated, using the conversion factor, as follows:
(Conversion factor used to convert oral morphine to subcutaneous diamorphine = Divide the total daily dose of oral morphine by 3)
Hence,
60mg*2 = 120mg
120mg/3 = 40mgThe side effects of opioids can be transient or persistent, and these include constipation, nausea, and drowsiness. Therefore, all patients taking opioids should also be prescribed a laxative and an anti-emetic (if the nausea is persistent). Dose-adjustment may be necessary in cases of persistent drowsiness. Moreover, strong opioids can also provide quick relief from metastatic bone pain, as compared to NSAIDs, bisphosphonates, and radiotherapy.
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This question is part of the following fields:
- Haematology & Oncology
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Question 23
Correct
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A 60-year-old male presents with intermittent haemoptysis and chronic, productive cough. He has a strong history of smoking and has recently lost weight. What is the patient most likely suffering from?
Your Answer: Bronchogenic carcinoma
Explanation:The combination of haemoptysis, chronic productive cough, and recent weight loss in a smoker is a strong indication of bronchogenic carcinoma.
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This question is part of the following fields:
- Respiratory System
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Question 24
Correct
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Which of the following is correct regarding lead poisoning?
Your Answer: Causes a peripheral neuropathy due to demyelination
Explanation:Lead can be absorbed through the skin and by inhalation. It is associated with iron deficiency and a microcytic anaemia. The most common gastrointestinal symptoms are abdominal colic and constipation.
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This question is part of the following fields:
- Pharmacology
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Question 25
Incorrect
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During the examination of an elderly confused and non-coherent gentleman who was brought to casualty by a concerned neighbour, you notice that he has bilaterally small pupils, which do not appear to react to light. Under the circumstances, it is difficult to judge their response to accommodation.
Which of the following conditions may not account for the pupillary appearance in this patient?Your Answer: Opiate analgesia
Correct Answer: Acute alcohol intoxication
Explanation:Acute alcohol intoxication presents with pupillary dilation, thus, this is ruled out in this patient. All the other listed causes present with small pupils bilaterally.
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This question is part of the following fields:
- Nervous System
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Question 26
Correct
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A 60-year-old patient diagnosed with Type-2 diabetes mellitus is not responding to dietary modifications and weight reduction. He needs to be started on an oral hypoglycemic agent. Which among the following statements regarding oral hypoglycaemic agents is true?
Your Answer: Acarbose inhibits ?-glucosidase
Explanation: -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 27
Incorrect
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A 60-year-old male with a history of diabetes and hypertension presented with left sided arm and leg weakness and loss of vision in the left eye for a brief period. His symptoms improved within a few hours. Which of the following is the most appropriate investigation that can be done at this stage?
Your Answer: CT brain
Correct Answer: Doppler USG
Explanation:Amaurosis fugax (transient ipsilateral visual loss) and transient ischemic attacks (TIAs) are presentations of atherosclerotic disease of the carotid artery which can be identified by carotid duplex ultrasonography (US), with or without colour. This is the screening test of choice to evaluate for carotid stenosis.
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This question is part of the following fields:
- Nervous System
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Question 28
Correct
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A 60-year-old lady has been admitted to the stroke ward following a sudden onset of dizziness and visual disturbances, which started yesterday morning. She initially thought she was just dehydrated, however, later realised she was unable to read her own shopping list. On the ward rounds, the consultant examines her and finds she is indeed unable to read. She is, however, able to write. When she writes a sentence it makes perfect sense, although she is again unable to read it out. She has no problems with her speech and is able to converse normally. She has no motor focal neurological deficit. The consultant asks you where the lesion is likely to be?
Your Answer: Corpus callosum
Explanation:The patient presents with sudden onset of alexia (the inability to read) WITHOUT agraphia (inability to write) which is consistent with lesions of the corpus callosum where there is a disconnect syndrome and the patient’s language and visual centres are actually in tact, but are unable to communicate between hemispheres. In this case, the damage due to the stroke is most likely in the left visual cortex, leaving visual processing to the intact right hemisphere which unfortunately cannot communicate the information to the language centres (Broca and Wernicke’s) in the left hemisphere, hence the alexia. Alternatively, the speech and writing are unaffected as the language centres can still communicate with the primary motor cortex.
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This question is part of the following fields:
- Nervous System
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Question 29
Correct
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Barrett's oesophagus is well recognized as a complication of gastroesophageal reflux disease. What is the pathological change that occurs in the above condition?
Your Answer: Squamous to columnar epithelium
Explanation:Barrett’s oesophagus is characterised by the metaplastic replacement of the normal squamous epithelium of the lower oesophagus by columnar epithelium.
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This question is part of the following fields:
- Gastrointestinal System
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Question 30
Correct
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A 57-year-old male arrives at the clinic due to intermittent vertigo, tinnitus and hearing loss. Which of the following will be the best treatment option for this patient?
Your Answer: Buccal prochlorperazine
Explanation:This patient’s history of intermittent attacks suggests Meniere’s disease. Meniere’s disease is a disorder of the inner ear that can lead to dizzy spells (vertigo) and hearing loss. In most cases, Meniere’s disease affects only one ear. Prochlorperazine can be used for complaints of nausea, vomiting and vertigo associated with Meniere’s disease. It is available as a tablet, injection and buccal preparation.
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This question is part of the following fields:
- Pharmacology
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Question 31
Correct
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A 50-year-old male is awaiting an anterior resection of rectum. Which of the following is the most common postoperative complication of the above surgery?
Your Answer: Infection
Explanation:The most frequent postoperative surgical complications after colorectal resections are surgical site infection, anastomotic leakage, intra-abdominal abscess, ileus and bleeding. Among them surgical site infection is the most common post-operative complication. Being a clean-contaminated procedure, there is contamination of both the peritoneal cavity and the surfaces of the surgical wound which leads to infections.
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This question is part of the following fields:
- Gastrointestinal System
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Question 32
Correct
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Regarding bupropion (Zyban), all of the following statements are true except?
Your Answer: It is associated with an idiosyncratic risk of seizure
Explanation:Bupropion (Zyban) is an amphetamine derivative which is used primarily as an anti depressant and for smoking cessation. It acts by increasing dopamine levels in the CNS. It has fewer withdrawal symptoms compared to other drugs. It is associated with dose associated risk of epileptic seizures in 1: 1000 patients and is contraindicated in a patient already suffering from epilepsy. Chief side effects include tremors, anxiety, insomnia, depression and a hypersensitivity urticarial rash. It inhibits the cytochrome p450 enzyme system in the liver and greater precaution is required when it is to be administered with other drugs like paroxetine, risperidone, beta blockers, propafenone and flecainide.
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This question is part of the following fields:
- Pharmacology
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Question 33
Incorrect
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A 33-year-old lady who is known hepatitis C positive comes to your clinic. She is 28 weeks pregnant and her obstetrician wants you to assess her and provide medical advice for the mother and child.
Which of the following statements concerning hepatitis C are most accurate in her case?Your Answer: A high viral load at delivery increases the risk of transmission
Correct Answer: Breast-feeding does not increase the risk of transmission
Explanation:Breast feeding has not been shown to increase the risk of transmission of HCV from mother to baby. This is simply a fact to memorize. The other answer choices are not the most accurate as there is no evidence-proven way to decrease the chance that baby will get HCV from the mother during the birth. About 5 out of every 100 infants born to HCV infected mothers become infected.
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This question is part of the following fields:
- Infectious Diseases
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Question 34
Incorrect
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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 cerebellar hemisphere
Correct 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 35
Incorrect
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Which of the following is most consistent with congenital adrenal hyperplasia (CAH)?
Your Answer: Hypopigmentation
Correct Answer: Premature epiphyseal closure
Explanation:Exposure to excessive androgens is usually accompanied by premature epiphyseal maturation and closure, resulting in a final adult height that is typically significantly below that expected from parental heights.
congenital adrenal hyperplasia (CAH) is associated with precocious puberty caused by long term exposure to androgens, which activate the hypothalamic-pituitary-gonadal axis. Similarly, CAH is associated with hyperpigmentation and hyperreninemia due to sodium loss and hypovolaemia.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 36
Incorrect
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A 56-year-old woman presents to the clinic complaining of shoulder pain that she has been experiencing for the last 4 weeks. She does not remember getting injured previously. The pain worsens on movement especially when she is moving the arm quickly. At night, lying on the affected side is painful. Examination reveals no erythema or swelling. However, pain is felt on passive abduction between 60 to 120 degrees and she is unable to abduct the arm past 70-80 degrees. Flexion and extension are intact. What is the most likely diagnosis?
Your Answer: Adhesive capsulitis (frozen shoulder)
Correct Answer: Supraspinatus tendonitis
Explanation:Supraspinatus tendinopathy is a common and disabling condition that becomes more prevalent after middle age and is a common cause of pain in the shoulder. A predisposing factor is resistive overuse. This patient has the classic painful arc that is a sign of shoulder impingement characteristic of supraspinatus tendonitis.
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This question is part of the following fields:
- Musculoskeletal System
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Question 37
Correct
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A 55-year-old male visited his diabetic clinic with a complaint of inability to walk properly due to weakness of his lower limbs. On examination, dorsiflexion was found to be weak bilaterally and there was diminished sensation on the dorsum of his feet as well as on the lower lateral portions of his legs. Which of the following could have led to this condition?
Your Answer: Compression of the common peroneal nerve
Explanation:The branches of the common peroneal nerve innervate the skin of the dorsum of the foot as well as the muscles which help to carry out dorsiflexion of the foot. Compression of the common peroneal nerve cause foot drop as well as the loss in sensation of the skin on the dorsum of the foot.
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This question is part of the following fields:
- Nervous System
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Question 38
Correct
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A 63-year-old man with known allergic bronchopulmonary aspergillosis presents to the A&E Department with an exacerbation. Which therapy represents the most appropriate management?
Your Answer: Oral glucocorticoids
Explanation:Allergic bronchopulmonary aspergillosis (ABPA) is a form of lung disease that occurs in some people who are allergic to Aspergillus. With ABPA, this allergic reaction causes the immune system to overreact to Aspergillus leading to lung inflammation. ABPA causes bronchospasm (tightening of airway muscles) and mucus build-up resulting in coughing, breathing difficulty and airway obstruction.
Treatment of ABPA aims to control inflammation and prevent further injury to your lungs. ABPA is a hypersensitivity reaction that requires treatment with oral corticosteroids. Inhaled steroids are not effective. ABPA is usually treated with a combination of oral corticosteroids and anti-fungal medications. The corticosteroid is used to treat inflammation and blocks the allergic reaction. Examples
of corticosteroids include: prednisone, prednisolone or methylprednisolone. Inhaled corticosteroids alone – such as used for asthma treatment – are not effective in treating ABPA. Usually treatment with an oral corticosteroid is needed for months.The second type of therapy used is an anti-fungal medication, like itraconazole and voriconazole. These medicines help kill Aspergillus so that it no longer colonizes the airway. Usually one of these drugs is given for at least 3 to 6 months. However, even this treatment is not curative and can have side effects.
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This question is part of the following fields:
- Respiratory System
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Question 39
Correct
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Which of the following statements is false regarding the bioavailability of a drug?
Your Answer: The bioavailability of a drug given orally is often affected by the degree of renal elimination
Explanation:Renal elimination of a drug has no role in altering the bioavailability of a drug.
The bioavailability of a drug is the proportion of the drug which reaches systemic circulation.
Mathematically, bioavailability is the AUCoral/AUCiv x 100%, where AUC = area under the concentration-time curve following a single (oral or iv) dose.Other options are true:
By definition, the bioavailability of a drug given intravenously is 100%.
Drugs given orally that undergo high pre-systemic (first-pass) metabolism in the liver or gut wall have a low bioavailability e.g. lidocaine.
Bioavailability is also affected by the degree of absorption from the gut and this can change depending on gut motility and administration of other drugs. -
This question is part of the following fields:
- Pharmacology
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Question 40
Correct
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A 26-year-old male was being investigated further following several hypertensive episodes. There was a marked difference in his systolic blood pressures between the right brachial and the right femoral arteries. Which of the following is most probable diagnosis?
Your Answer: Coarctation of the aorta
Explanation:From the given physical findings (the difference in BP between the radial and femoral arteries), the most probable diagnosis is coarctation of the aorta.
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This question is part of the following fields:
- Cardiovascular System
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Question 41
Incorrect
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A 52-year-old chef presents to the ED with acute visual changes. He has a past medical history of hypertension and type 2 diabetes mellitus. On neurological examination, his upper and lower limbs are normal however he has a homonymous hemianopia with central preservation. Where is the most likely cause of his problems within the central nervous system?
Your Answer: Optic chiasm
Correct Answer: Optic radiation
Explanation:Lesions in the optic radiation can cause a homonymous hemianopia with macular sparing, as a result of collateral circulation offered to macular tracts by the middle cerebral artery.
Lesions in the optic tract also cause a homonymous hemianopia, but without macular sparing.
Lesions in the optic chiasm, optic nerve, and temporal lobe cause bitemporal hemianopia, ipsilateral complete blindness, and superior homonymous quadrantanopia respectively. -
This question is part of the following fields:
- Nervous System
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Question 42
Incorrect
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A 28-year-old male complained of the following: nausea, vertigo, vomiting for longer than 30 minutes, tinnitus, and hearing loss in his left ear. Which of the following treatment options is most appropriate for this patient?
Your Answer: Buccal prochlorperazine (2nd line)
Correct Answer: Cyclazine (1st line)
Explanation:Cyclizine and prochlorperazine are both used for the treatment of Meniere’s disease.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 43
Incorrect
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A 6-year-old boy presented in the emergency department with a cough and knee swelling after falling on the road. He had a non-blanching rash on his buttocks and investigations revealed: PT=13, APTT=71, Hgb=11, WBC=8, Plt=200. Which is the most likely diagnosis?
Your Answer: Von-Willebrand disease
Correct Answer: Haemophilia
Explanation:From the options mentioned here, the closest diagnosis is haemophilia. This is a mixed picture, as a purpuric rash on the buttocks does not correlate with this diagnosis. However, the most appropriate diagnosis is haemophilia.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 44
Correct
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A 59-year-old surgeon presents with a progressive paraesthesia and numbness in both feet, which have deteriorated over the last six months. He has a 10 year history of type 2 diabetes mellitus and had cervical spondylosis, for which he underwent surgery eight years ago. He also confessed to drinking approximately 40 units of alcohol weekly.
On examination he had mild bilateral weakness of foot dorsiflexion and both ankle reflexes were absent. There was absent sensation to light touch to mid-shin level with loss of joint position sensation in the toes and absent vibration sensation below the hips. He had a marked sensory ataxia and pseudoathetosis of the upper limbs. He had no evidence of a retinopathy and urinalysis was normal.
Which of the following is the most likely diagnosis?Your Answer: Vitamin B 12 deficiency
Explanation:Diabetic peripheral neuropathy usually goes in parallel with retinopathy and nephropathy. It is also slowly progressive and affects mainly the spinothalamic pathway.
Alcohol induced peripheral neuropathy is also slowly progressive and affects mainly the spinothalamic pathway.
Vitamin B 12 deficiency usually causes a more rapidly progressive neuropathy with dorsal column involvement (joint position and vibration involvement with sensory ataxia and pseudoathetosis of upper limbs). -
This question is part of the following fields:
- Nervous System
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Question 45
Incorrect
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A 32-year-old male who is a known case of sickle cell disease presents to the Accident and Emergency (A&E) department with fever, tachypnoea, and rib pain. On examination, he has a low-grade fever of 37.9°C, oxygen saturation of 95% on air, and bilateral vesicular breath sounds on chest auscultation. CXR shows opacification in the right middle zone.
Which of these statements most accurately describes the initial management of this patient?Your Answer: Empirical antibiotic therapy is not indicated
Correct Answer: Incentive spirometry is indicated
Explanation:This is a typical picture of acute chest syndrome (ACS). According to the British Committee for Standards in Haematology (BCSH), ACS is defined as ‘an acute illness characterised by fever and/or respiratory symptoms, accompanied by a new pulmonary infiltrate on chest X-ray’. ACS occurs in sequestration crisis, which is one of the four main types of crises occurring in sickle cell disease.
The fundamentals of initial management are as follows:
1. Oxygen therapy to maintain saturation >95%
2. Intravenous fluids to ensure euvolemia
3. Adequate pain relief
4. Incentive spirometry in all patients presenting with rib or chest pain
5. Antibiotics with cover for atypical organisms
6. Bronchodilators if asthma co-exists with acute chest syndrome, or if there is an evidence of acute bronchospasm on auscultation
7. Early consultation with the critical care team and haematology departmentA senior haematologist then makes a decision as to whether a simple or exchange transfusion is necessary in order to achieve a target Hb of 10.0-11.0g/dL in either instance.
Sickle Cell Crises:
Sickle cell anaemia is characterised by periods of good health with intervening crises:
1. Sequestration crisis: acute chest syndrome (i.e. fever, dyspnoea, chest/rib pain, low pO2, and pulmonary infiltrates)2. Thrombotic (painful or vaso-occlusive) crisis: precipitated by infection, dehydration, and deoxygenation
3. Aplastic crisis: sudden fall in haemoglobin without marked reticulocytosis, usually occurring secondary to parvovirus infection
4. Haemolytic crisis: fall in haemoglobin secondary to haemolysis, rare type of sickle cell crises
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This question is part of the following fields:
- Haematology & Oncology
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Question 46
Correct
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A female palliative cancer patient has painful bone metastases. Which breakthrough dose of morphine would you prescribe, if she has been taking long acting morphine tablets (120mg) every 12 hours?
Your Answer: 40 mg
Explanation:To calculate the breakthrough dose for oral morphine solution, you need to find the dose she should receive every 4 hours, according to the total amount of morphine she receives. If she is receiving 120 mg every 12 hours, then she should receive 40 mg every 4 hours as a breakthrough dose.
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This question is part of the following fields:
- Pharmacology
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Question 47
Incorrect
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A 77-year-old female who is a known to have COPD and metastatic lung cancer is admitted with increasing shortness of breath. Following discussion with her family, it is decided to withdraw active treatment including fluids and antibiotics as the admission likely represents a terminal event. Two days after admission, she becomes agitated and restless.
What is the most appropriate management for her agitation and confusion?Your Answer: Intramuscular haloperidol
Correct Answer: Subcutaneous midazolam
Explanation:Generally, underlying causes of confusion need to be looked for and treated as appropriate, for example, hypercalcaemia, infection, urinary retention, and medication. If specific treatments fail, the following may be tried:
1. First choice: haloperidol
2. Other options: chlorpromazine, levomepromazineIn the terminal phase of the illness, agitation or restlessness is best treated with midazolam.
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This question is part of the following fields:
- Haematology & Oncology
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Question 48
Incorrect
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Which one of the following statements regarding hepatocellular carcinoma is correct?
Your Answer: Alcohol excess is the most common underlying cause worldwide
Correct Answer: Diabetes mellitus is a risk factor
Explanation:Diabetes is a risk factor for hepatocellular carcinoma. Screening has been shown to be effective. Bevacizumab is not used for advanced cases. The incidence is higher in men. Alcohol is not the most common underlying cause worldwide; this is from cirrhosis from diseases like hepatitis B and C.
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This question is part of the following fields:
- Hepatobiliary System
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Question 49
Correct
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A 45-year-old man presents with tiredness and central weight gain.
He underwent pituitary surgery for a non-functional pituitary tumour two years ago. Although he recovered from his pituitary surgery well, he has been found to have complete anterior hypopituitarism. Accordingly he is receiving stable replacement therapy with testosterone monthly injections, thyroxine and hydrocortisone.
On examination, there are no specific abnormalities, his vision is 6/9 in both eyes and he has no visual field defects.
From his notes, you see that he has gained 8 kg in weight over the last six months and his BMI is 31. His blood pressure is 122/72 mmHg.
Thyroid function tests and testosterone concentrations have been normal. A postoperative MRI scan report shows that the pituitary tumour has been adequately cleared with no residual tissue.
Which of the following is the most likely cause of his current symptoms?Your Answer: Growth hormone deficiency
Explanation:The somatotroph cells of the anterior pituitary gland produce growth hormone (GH).
GH deficiency in adults usually manifests as reduced physical performance and impaired psychological well-being. It results in alterations in the physiology of different systems of the body, manifesting as altered lipid metabolism, increased subcutaneous and visceral fat, decreased muscle mass, decreased bone density, low exercise performance, and reduced quality of life. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 50
Correct
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A previously well 33-year-old female was admitted with a history of recurrent episodes of palpitations. She didn't have chest pain. She frequently drank plenty of coffee and alcohol. Her blood pressure was 120/80 mmHg and pulse rate was 200 bpm which was regular. There was no sign of heart failure. Her ECG revealed narrow complex tachycardia. She was given 3mg of IV adenosine but there was no response. Which of the following is the most appropriate management if she doesn't respond to 6mg of IV adenosine?
Your Answer: IV 12mg adenosine
Explanation:Vagal manoeuvres can be tried first. If not responding to these then adenosine can be trialled. If 3mg of adenosine has no effect, then give adenosine 6 mg rapid IV push. If patient does not convert, give adenosine 12 mg rapid IV push. Can repeat 12 mg dose of adenosine once if there is no response. If no response, diltiazem or beta-blockers can be given as alternatives.
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This question is part of the following fields:
- Cardiovascular System
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SESSION STATS - PERFORMANCE PER SPECIALTY
