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Question 1
Correct
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A 53-year-old woman presents with a painless lump in the left breast associated with nipple discharge. The skin over the lump has an orange peel skin appearance. According to the patient, the lump has increased in size, with time.
Diagnosis of breast cancer is strongly suspected. Which of the following would be most useful in monitoring the prognosis of breast cancer, in this case?Your Answer: Lymph node metastases
Explanation:The prognosis of breast cancer depends chiefly on the extent of nodal metastases.
The breast cancer TNM staging system is the most common way that doctors use to stage breast cancer. TNM stands for Tumour, Node, Metastasis. The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero), which is non-invasive ductal carcinoma in situ (DCIS), and stages I through IV (1 through 4), which are used for invasive breast cancer.
Staging can be clinical or pathological. Clinical staging is based on the results of tests done before surgery, which may include physical examinations, mammogram, ultrasound, and MRI scans. Pathologic staging is based on what is found during surgery to remove breast tissue and lymph nodes. In general, pathological staging provides the most information to determine a patient’s prognosis.
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This question is part of the following fields:
- Haematology & Oncology
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Question 2
Incorrect
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A 34-year-old woman is admitted to the oncologist clinic for further investigations. She has experienced fever, sometimes glandular and night sweats. Clinical examination reveals lymphadenopathy and a biopsy is performed. The biopsy reveals the presence of Reed-Sternberg cells, confirming what was suspected to be a Hodgkin's lymphoma. Which cell surface marker is associated with this condition?
Your Answer: CD16
Correct Answer: CD15
Explanation:The CD15 antigen, also known as Lewis (hapten)X, serves as an immuno-phenotypic marker for Reed-Sternberg cells and its expression has diagnostic, but also prognostic significance in Hodgkin Lymphoma.
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This question is part of the following fields:
- Haematology & Oncology
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Question 3
Incorrect
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A 20-year-old boy presented with left hemiscrotal pain and fever for 2 days. He denied any history of trauma. On examination he was febrile. There was redness and tenderness of the left hemiscrotum. Which of the following is the most appropriate management for this patient?
Your Answer: Exploratory surgery
Correct Answer: Give antibiotics
Explanation:The history is suggestive of acute Epididymo-orchitis. The treatment option is antibiotics.
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This question is part of the following fields:
- Men's Health
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Question 4
Incorrect
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A 45-year-old male, chronic smoker presented with a 6 month history of a productive cough with blood stained sputum and shortness of breath. The most likely diagnosis would be?
Your Answer: Lung Cancer
Correct Answer: Bronchiectasis
Explanation:Bronchiectasis is characterised by a blood stained productive cough with copious amount of sputum production, along with dyspnoea.
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This question is part of the following fields:
- Respiratory System
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Question 5
Correct
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A 45-year-old woman with a history of hypothyroidism, presents with ptosis and muscle weakness. She's noticed that her muscle weakness becomes worse towards the end of the day. Clinical examination reveals fatigable ptosis and proximal limb weakness. Myasthenia gravis is suspected. Which receptor is implicated in the pathophysiology of this condition?
Your Answer: Nicotinic acetylcholine receptors
Explanation:Myasthenia gravis (MG) is an organ-specific autoimmune disease caused by an antibody-mediated assault on the muscle nicotinic acetylcholine receptor (AChR) at the neuromuscular junction. Binding of antibodies to the AChR leads to loss of functional AChRs and impairs the neuromuscular signal transmission, resulting in muscular weakness.
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This question is part of the following fields:
- Immune System
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Question 6
Correct
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A 30-year-old painter presents with a burning pain in both feet, which has deteriorated over the last six months. He drinks 60 units of alcohol weekly and has a family history of pernicious anaemia.
On examination he has impairment of all modalities of sensation in both feet but particularly pain, temperature and absent ankle jerks.
What is the most likely diagnosis?Your Answer: Alcoholic peripheral neuropathy
Explanation:Because of the patient’s history of excessive alcohol consumption, there is a strong suspicion of alcoholic peripheral neuropathy. In the UK, alcohol abuse and diabetes are the most common causes of peripheral neuropathy.
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This question is part of the following fields:
- Nervous System
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Question 7
Correct
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A 25-year-old male presents to the emergency department with fever, sweating, hyperventilation and breathing difficulty. He also complains of a continuous ringing sensation in both his ears for the past couple of days. He admits to consuming a lot of over the counter painkillers for the past few days. Which of the following drugs is the most likely cause of these symptoms?
Your Answer: Aspirin
Explanation: -
This question is part of the following fields:
- Emergency & Critical Care
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Question 8
Correct
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Which one of the following types of thyroid cancer is associated with the RET oncogene?
Your Answer: Medullary
Explanation:RET (rearranged during transfection) is a receptor tyrosine kinase involved in the development of neural crest derived cell lineages, kidney, and male germ cells. Different human cancers, including papillary and medullary thyroid carcinomas, lung adenocarcinomas, and myeloproliferative disorders display gain-of-function mutations in RET.
In over 90% of cases, MEN2 syndromes are due to germline missense mutations of the RET gene.
Multiple endocrine neoplasias type 2 (MEN2) is an inherited disorder characterized by the development of medullary thyroid cancer (MTC), parathyroid tumours, and pheochromocytoma. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 9
Correct
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A 32-year-old woman presents to the GP with tiredness and anxiety during the third trimester of her second pregnancy.
The Examination is unremarkable, with a BP of 110/70 mmHg and a pulse of 80. Her BMI is 24 and she has an abdomen consistent with a 31-week pregnancy. The GP decides to check some thyroid function tests.
Which of the following is considered to be normal?Your Answer: Elevated total T4
Explanation:During pregnancy, profound changes in thyroid physiology occur to provide sufficient thyroid hormone (TH) to both the mother and foetus. This is particularly important during early pregnancy because the fetal thyroid starts to produce considerable amounts of TH only from approximately 20 weeks of gestation, until which time the foetus heavily depends on the maternal supply of TH. This supply of TH to the foetus, as well as increased concentrations of TH binding proteins (thyroxine-binding globulin) and degradation of TH by placental type 3 iodothyronine deiodinase, necessitate an increased production of maternal TH. This requires an intact thyroid gland and adequate availability of dietary iodine and is in part mediated by the pregnancy hormone human chorionic gonadotropin, which is a weak agonist of the thyroid-stimulating hormone (TSH) receptor. As a consequence, serum-free thyroxine (FT4) concentrations increase and TSH concentrations decrease from approximately the eighth week throughout the first half of pregnancy, resulting in different reference intervals for TSH and FT4 compared to the non-pregnant state.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 10
Incorrect
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A 27-year-old woman was admitted with vaginal bleeding and left sided pelvic pain for 2 days. There was no history of fever. She gave a history of absent periods for past 8 weeks. Abdominal examination revealed guarding and rebound tenderness in left iliac region. There was left sided cervical excitation on vaginal examination. What is the most probable diagnosis?
Your Answer: Ovarian torsion
Correct Answer: Ectopic pregnancy
Explanation:The history of amenorrhoea, pelvic pain and vaginal bleeding with peritonism and cervical excitation is more suggestive of an ectopic pregnancy. Endometriosis usually has a chronic presentation and dysmenorrhoea. Salpingitis usually presents with a fever. Ovarian torsion and ovarian tumours have different clinical presentations including increased abdominal size and persistent bloating.
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This question is part of the following fields:
- Women's Health
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Question 11
Incorrect
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A 33-year-old man with a known history of alcoholic liver disease is reviewed following a suspected oesophageal variceal haemorrhage. He has been resuscitated and intravenous terlipressin has been given. His blood pressure is now 104/60 mmHg and his pulse is 84/min. What is the most appropriate intervention?
Your Answer: Sengstaken-Blakemore tube
Correct Answer: Endoscopic variceal band ligation
Explanation:The correct course of action after giving terlipressin and resuscitating with IV fluids is to perform an EGD with endoscopic variceal band ligation. According to NICE: ‘Offer endoscopic variceal band ligation for the primary prevention of bleeding for people with cirrhosis who have medium to large oesophageal varices. There are serious complications of a TIPS procedure and it is not the first line treatment.
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This question is part of the following fields:
- Gastrointestinal System
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Question 12
Correct
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Which area in the body controls the hypoxic drive to breathe?
Your Answer: Carotid body
Explanation:The carotid body consists of chemosensitive cells at the bifurcation of the common carotid artery that respond to changes in oxygen tension and, to a lesser extent, pH. In contrast to central chemoreceptors (which primarily respond to PaCO2) and the aortic bodies (which primarily have circulatory effects: bradycardia, hypertension, adrenal stimulation, and also bronchoconstriction), carotid bodies are most sensitive to PaO2. At a PaO2 of approximately 55-60 mmHg, they send their impulses via CN IX to the medulla, increasing ventilatory drive (increased respiratory rate, tidal volume, and minute ventilation). Thus, patients who rely on hypoxic respiratory drive will typically have a resting PaO2 around 60 mm Hg.
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This question is part of the following fields:
- Respiratory System
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Question 13
Correct
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An 18-year-old boy was admitted with severe pain and swelling of his scrotum following a kick to the groin. What is the most appropriate management that can be done at this stage?
Your Answer: Exploratory surgery
Explanation:The most worrying condition is testicular torsion and to exclude it exploratory surgery is required.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 14
Correct
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How would you advise your patient to apply an emollient and a steroid cream, in order to treat her eczema?
Your Answer: First use emollient then steroids.
Explanation:If steroid is applied first, applying an emollient after could spread it from where it had been applied. If steroid is applied immediately after the emollient then it cannot be absorbed, this is why there should be a time interval of around thirty minutes between these two treatments in order for them to be effective.
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This question is part of the following fields:
- The Skin
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Question 15
Incorrect
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A 70-year-old man underwent emergency surgery for an acute abdomen. Following surgery, he was noted to be oliguric. Investigations revealed the following: Sodium 121 mmol/L (137-144) Potassium 6.6 mmol/L (3.5-4.9) Chloride 92 mmol/L (95-107) Urea 17.2 mmol/L (2.5-7.5) Creatinine 250 µmol/L (60-110) pH 7.16 (7.36-7.44) Standard bicarbonate 15.6 mmol/L (20-28). What is the calculated anion gap for this patient?
Your Answer: 10 mmol/L
Correct Answer: 20 mmol/L
Explanation:Anion gap is calculated as (Na + K) − (Cl + HCO3). Therefore in this patient, the calculated value is 20 mmol/L. The normal anion gap is between 8-16 mmol/l. The excessive value here reflects the presence of other acidic anions, and in this case with the metabolic acidosis, the constituents may be lactate, etc.
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This question is part of the following fields:
- Renal System
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Question 16
Correct
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A 42-year-old male patient is admitted with recurrent pancreatitis. He also has a history of parotitis. CT scan is carried out revealing no pancreatic mass, but evidence of widespread lymphadenopathy is seen. Dedicated liver imaging reveals a stricture in the common bile duct but no stones.
What is the most likely diagnosis?Your Answer: IgG4 disease
Explanation:IgG4-related disease (IgG4-RD) is a fibro-inflammatory condition that can affect nearly any organ system: the pancreas, biliary tree, salivary glands, periorbital tissues, kidneys, lungs, lymph nodes, meninges, aorta, breast, prostate, thyroid, pericardium, and skin. The histopathological features are similar across organs, regardless of the site. IgG4-RD is analogous to sarcoidosis, in which diverse organ manifestations are linked by similar histopathological characteristics. Raised concentrations of IgG4 in tissue and serum can be helpful in diagnosing IgG4 disease, but neither is a specific diagnostic marker.
Some IgG4-RDs are:
1. Autoimmune pancreatitis
2. Riedel’s Thyroiditis
3. Mediastinal and Retroperitoneal Fibrosis
4. Periaortitis/periarteritis/Inflammatory aortic aneurysm
5. Kuttner Tumour (submandibular glands)
6. IgG4-related Mikulicz disease (lacrimal, parotid, and submandibular glands) -
This question is part of the following fields:
- Haematology & Oncology
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Question 17
Incorrect
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A 22-year-old male presents with loose stools and abdominal pain that is vague in nature. He previously had an episode of lower abdominal pain that was associated with pyrexia which settled on its own. He has also experienced mild weight loss recently. On examination, he is pale and has an ill defined mass in the right iliac fossa. What is the most likely diagnosis?
Your Answer: Appendicular mass
Correct Answer: Crohn's disease
Explanation:Crohn’s Disease (CD) is an inflammatory bowel disease, the pathogenesis of which is not fully understood. The clinical presentation of CD may be similar to ulcerative colitis (UC), the other most common inflammatory bowel disease. CD mostly affects young adults and adolescents between the ages of 15 and 35. It is typically located in the terminal ileum, but can discontinuously affect the entire gastrointestinal tract and commonly leads to complications such as fistulas, abscesses, and stenosis. Clinical features include diarrhoea, weight loss, and abdominal pain in the right lower quadrant (RLQ), as well as extraintestinal manifestations in the eyes, joints, or skin. It is often difficult to diagnose because there is no confirmatory test. Diagnosis is therefore based on the patient’s medical history, physical examination, lab tests, imaging (e.g., MRI), endoscopy, and serological testing. Acute episodes are treated with corticosteroids, and in severe cases, immunosuppressants may be indicated. Antibiotics and surgical intervention may be needed to help treat complications. Because the entire gastrointestinal tract may be affected, Crohn disease cannot be cured (in contrast to ulcerative colitis). The goal of treatment is thus to avoid the progression and recurrence of inflammatory episodes.
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This question is part of the following fields:
- Gastrointestinal System
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Question 18
Correct
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A 38-year-old male complained of painless, right sided testicular enlargement for 4 months. The size has been gradually increasing. On examination, there was no tenderness or redness. It was firm in consistency and not transilluminating. The most likely diagnosis is?
Your Answer: Testicular tumour
Explanation:History is suggestive of testicular tumour due to the gradual onset, non tender, firm mass. Hydroceles transiluminate and a varicocele has a bag of worms texture. Epididymo-orchitis is tender and often red or inflamed. An ependymal cyst is confined to the epididymis.
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This question is part of the following fields:
- Men's Health
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Question 19
Correct
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A 21-year-old girl looking unkempt, agitated, malnourished, and nervous, came to the hospital asking for painkillers for her abdominal pain. She is sweating, shivering, and complains of joint pain. What could be the substance misuse here?
Your Answer: Heroin
Explanation:The appearance and complaints of this patient are strongly indicative of heroin abuse. The other substances listed usually present differently; cocaine and ecstasy users usually have a boost of confidence, someone under the effect of LSD is usually very sociable and relaxed, alcohol abusers might have symptoms like restlessness, hallucinations, shakiness, and insomnia.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 20
Incorrect
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A 54-year-old female presents with fatigue and xerostomia. Bloods tests reveal the following:
Hb 13.9 g/dl
WBC 6.1 *109/l
Platelets 246 *109/l
Bilirubin 33 µmol/l
ALP 292 u/l
ALT 47 u/l
What is the most likely diagnosis?Your Answer: Infectious mononucleosis
Correct Answer: Primary biliary cirrhosis
Explanation:With a bilirubin of 33, automatically the diagnosis from the choices listed is primary biliary cirrhosis or autoimmune hepatitis, not SLE, mono, or Primary Sjogren’s Syndrome. With autoimmune hepatitis, however, you would not expect such a high bilirubin and would expect very high AST/ALT, which here is just mildly elevated. This makes primary biliary cirrhosis the most likely answer. The classic presentation is itching in a middle-aged woman. The dry mouth is likely due to Sicca Syndrome, which occurs in 70% of cases of PBC, but with these liver function tests, PBC is most the likely answer.
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This question is part of the following fields:
- Hepatobiliary System
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Question 21
Correct
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An echocardiogram of a 50-year-old male patient showed an infarct in the anterolateral aspect of the left side of the heart and apex. An angiogram was then done. Obstruction of which of the following arteries is the cause of this myocardial infarction?
Your Answer: Left anterior descending artery
Explanation:The left coronary artery is responsible for supplying the entire left side of the heart, however, it divides into the left anterior descending artery which supplies the apex of the heart and the interventricular septum, and the left circumflex artery which supplies the posterolateral part of the left ventricle and a portion of the papillary muscle. The infarction is noted at the apex of the heart and the interventricular septum, therefore, the obstruction has occurred in the left anterior descending artery.
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This question is part of the following fields:
- Cardiovascular System
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Question 22
Correct
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A 60-year-old male is under treatment with azathioprine after a renal transplant. During his review, he complains of pain and swelling over his left great toe. Investigations reveal hyperuricemia. Suspecting gout, he was started on allopurinol. Subsequently, he develops aplastic anaemia. Which of the following is the most appropriate reason for his bone marrow failure?
Your Answer: Mercaptopurine toxicity
Explanation:The cause for bone marrow suppression in this patient is most probably mercaptopurine toxicity.
Azathioprine is metabolized to 6-mercaptopurine (6-MP), which itself is metabolized by xanthine oxidase.
Xanthine oxidase inhibition by allopurinol leads to the accumulation of 6-MP which then precipitates bone marrow failure.
This may be potentially fatal if unrecognized.
Clinical presentation:
Toxicity symptoms include gastrointestinal symptoms, bradycardia, hepatotoxicity, myelosuppression. -
This question is part of the following fields:
- Pharmacology
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Question 23
Incorrect
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Arrange the following opioid analgesics in order of increasing potency.
Your Answer: Morphine, codeine, oxycodone, diamorphine
Correct Answer: Codeine, morphine, oxycodone, diamorphine
Explanation:Opioid analgesics produce pain relief by attaching to the opioid receptors in the brain. Out of these, codeine is the least potent and diamorphine the most potent. Codeine is used to relieve mild to moderate pain. Morphine is a stronger analgesic used to treat pain like that experienced after surgery or injury. Oxycodone acts like the endorphins in the brain and reduces pain sensation. It is more potent than codeine and morphine and is used for relieving moderate to severe forms of pain. Among the listed, diamorphine is the most potent opioid analgesic. It is administered intravenously, subcutaneously, or intramuscularly to treat severe pain after surgery or in terminally-ill patients.
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This question is part of the following fields:
- Pharmacology
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Question 24
Incorrect
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A 35-year-old male presented to the ER after being rescued from a house fire. He complained of feeling dizzy and having a worsening headache. On examination, he was dyspnoeic, drowsy and confused. There was no evidence of facial burns and no stridor. He was normotensive, tachycardic (pulse rate: 102 bpm), tachypnoeic (respiratory rate: 35/min) and had O2 saturation of 100% in room air. His venous blood gas results are given below:
pH - 7.28
pCO2 - 3.5 kPa
pO2 - 15.9 kPa
Na+ - 139 mmol/L
K+ - 4.5 mmol/L
Bicarbonate - 11 mmol/L
Chloride - 113 mmol/L
Lactate - 13.6 mmol/L
Keeping in mind the likely diagnosis, which among the following is the most appropriate intervention for this patient?Your Answer: Intubate and ventilate
Correct Answer: Intravenous hydroxocobalamin
Explanation:The most appropriate intervention in this patient is intravenous hydroxocobalamin.
The clinical scenario provided is suggestive of acute cyanide toxicity secondary to burning plastics in the house fire.
Cyanide ions inhibit mitochondrial cytochrome oxidase, preventing aerobic respiration. This manifests in normal oxygen saturations, a high pO2 and flushing (or ‘brick red’ skin) brought on by the excess oxygenation of venous blood. In the question above it is important to note that the blood gas sample given is venous rather than arterial. His blood gas also demonstrates an increased anion gap, consistent with his high lactate (generated by anaerobic respiration due to the inability to use available oxygen).The recommended treatment for moderate cyanide toxicity in the UK is one of three options: sodium thiosulfate, hydroxocobalamin or dicobalt edetate.
Among the options given is hydroxocobalamin and this is, therefore, the correct answer. Hydroxocobalamin additionally has the best side-effect profile and speed of onset compared with other treatments for cyanide poisoning.
Other options:
– Intubation would be appropriate treatment in the context of airway burns but this patient has no evidence of these, although close monitoring would be advised.
– High-flow oxygen is the treatment for carbon monoxide poisoning – a sensible differential, but this man’s very high lactate and high venous pO2 fit better with cyanide toxicity. Intravenous dexamethasone would be another treatment for airway oedema once an endotracheal tube had been placed.
– Intravenous sodium nitroprusside is a treatment for high blood pressure that can cause cyanide poisoning, and would, therefore, be inappropriate.Note:
Cyanide may be used in insecticides, photograph development and the production of certain metals. Toxicity results from reversible inhibition of cellular oxidizing enzymes
Clinical presentation:
Classical features: brick-red skin, the smell of bitter almonds
Acute: hypoxia, hypotension, headache, confusion
Chronic: ataxia, peripheral neuropathy, dermatitisManagement:
Supportive measures: 100% oxygen
Definitive: hydroxocobalamin (intravenously), also a combination of amyl nitrite (inhaled), sodium nitrite (intravenously), and sodium thiosulfate (intravenously). -
This question is part of the following fields:
- Pharmacology
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Question 25
Incorrect
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Regarding cranial nerves, which of the following statements is true?
Your Answer: The abducens nerve supplies the lacrimal gland
Correct Answer: The vagus nerve supplies the palatal muscles
Explanation:In addition to the pharynx and larynx, the vagus nerve also innervates the palatoglossus of the tongue, and the majority of the muscles of the soft palate.
The lacrimal gland is supplied by the facial nerve.
The glossopharyngeal nerve supplies the parotid salivary gland controlling salivary secretions.
The oculomotor nerve carries parasympathetic efferents to the sphincter pupillae muscle and innervates the superior rectus.
The optic nerve carries sympathetic postganglionic fibres to the dilator pupillae muscle.
The trochlear nerve supplies the superior oblique muscle. -
This question is part of the following fields:
- Nervous System
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Question 26
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: She should be given supplemental oxygen, but is unlikely to need a high FiO2 to achieve normoxia
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 27
Incorrect
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Choose the molecule that acts as the co-receptor for cells expressing antigens linked with MHC class I molecules:
Your Answer: CD2b
Correct Answer: CD8
Explanation:CD8+ T cells recognize antigens in the form of short peptide fragments bound to major histocompatibility complex class I (MHCI) molecules on the target cell surface.1 Specific engagement of peptide-MHCI (pMHCI) complexes via the clonotypically expressed ?β T-cell receptor (TCR) triggers a range of effector functions that play a critical role in protective immunity against intracellular infections and various malignancies.
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This question is part of the following fields:
- Immune System
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Question 28
Incorrect
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Which of the following stimulates bicarbonate secretion from the pancreas and liver?
Your Answer: Motilin
Correct Answer: Secretin
Explanation:Secretin stimulates bicarbonate secretion from the pancreas and liver. VIP induces relaxation of the stomach and gallbladder, secretion of water into pancreatic juice/ bile, and inhibits gastric acid secretion/absorption. CCK classically stimulates gallbladder contraction and relaxation of the sphincter of Oddi. Gastrin stimulates the secretion of HCl by parietal cells in the stomach. Motilin, as the name suggests, increases motility.
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This question is part of the following fields:
- Gastrointestinal System
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Question 29
Incorrect
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In end stage renal disease, deficiency of erythropoietin can lead to which of the following conditions?
Your Answer: Hyperlipidaemia
Correct Answer: Anaemia
Explanation:Erythropoietin is necessary for normal Hb levels. Reduced levels of erythropoietin in renal failure leads to anaemia in these patients.
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This question is part of the following fields:
- Renal System
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Question 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
Incorrect
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Regarding the 3rd heart sound, which one of the following statements is correct?
Your Answer: Is lost in AF
Correct Answer: It may be a normal finding in women up to the age of 50
Explanation:The 3rd heart sound corresponds to early diastolic filling in ventricular relaxation after the closure of the aortic valve. Associated conditions include cardiac failure, constrictive pericarditis and atrial myxomas. It is low pitched and accentuated by inspiration. The 3rd heart sound may arise from ventricular relaxation and it can be seen as a normal finding among children, young adults and women till 50 years of age.
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This question is part of the following fields:
- Cardiovascular System
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Question 32
Correct
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What is the mode of spread of chickenpox?
Your Answer: Airborne
Explanation:Chickenpox is a highly communicable viral disease caused by human (alpha) herpesvirus 3 (varicella-zoster virus, VZV). It is transmitted from person to person by direct contact (touching the rash), droplet or air born spread (coughing and sneezing).
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This question is part of the following fields:
- Infectious Diseases
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Question 33
Incorrect
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A patient with a history of asthma presents with worsening of her symptoms and dyspnoea. She recently started taking a new medicine and she feels it might have aggravated her symptoms.
Which of the following is likely responsible for her symptoms?Your Answer: Ferrous sulphate
Correct Answer: Timolol eye drops
Explanation:β-blockers are the class of drug most often chosen to treat glaucoma, although other medical therapies are available. Systemic absorption of timolol eye drops can cause unsuspected respiratory impairment and exacerbation of asthma. Physicians should be alert to the possibility of respiratory side-effects of topical therapy with β-blockers. Leukotriene antagonists and salbutamol are used in asthma treatment. HRT and ferrous sulphate do not lead to the exacerbation of asthma.
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This question is part of the following fields:
- Respiratory System
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Question 34
Incorrect
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A 51-year-old smoker was recently diagnosed with non small cell lung carcinoma. Investigations show presence of a 3 x 3 x 2 cm tumour on the left side of the lower lung lobe. the mass has invaded the parietal pleura. Ipsilateral hilar node is also involved but there is no metastatic spread.
What is the stage of this cancer?Your Answer: T2 N0 M0
Correct Answer: T2 N1 M0
Explanation:The tumour has only invaded the visceral pleura and measures 3cm in the greatest dimension. Hence it is designated at T2. Ipsilateral peribronchial and/or hilar lymph node involvement would make it N1. There is no distal metastasis so M would be 0.
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This question is part of the following fields:
- Respiratory System
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Question 35
Incorrect
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A 47-year-old hypertensive man presents with difficulty using his right arm, slow walking and occasional loss of balance. He has a broad-based gait with cogwheel rigidity and intention tremor of his right arm. His blood pressure is 140/80 mmHg sitting and 100/60 mmHg standing. Which of the following is the most likely diagnosis?
Your Answer: Corticobasal degeneration
Correct Answer: Multiple system atrophy
Explanation:This patient presents with a combination of akinetic rigid syndrome, cerebellar signs and the suggestion of autonomic features. This is most indicative of a diagnosis of multiple system atrophy.
Multiple system atrophy (MSA) is a rare neurodegenerative disorder characterized by autonomic dysfunction, tremors, slow movement, muscle rigidity, and postural instability (collectively known as parkinsonism) and ataxia.
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This question is part of the following fields:
- Nervous System
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Question 36
Incorrect
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A 55-year-old lady who a known case of normal pressure hydrocephalus (NPH) presented with complaints of weakness in her lower limbs, urinary incontinence and progressively worsening confusion. Which of the following statements is true regarding NPH?
Your Answer: Is not improved by ventriculoperitoneal shunting
Correct Answer: Is associated with gait disturbance
Explanation:Normal pressure hydrocephalus is a form of communicating hydrocephalus characterised by enlarged ventricles with normal opening pressure on lumbar puncture. For diagnostic purposes, a triad of urinary incontinence, gait abnormality and dementia is necessary. It is necessary to diagnose the condition early because it is reversible by placing a ventriculoperitoneal shunt. It is most common in patients aged more than 60 years.
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This question is part of the following fields:
- Infectious Diseases
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Question 37
Incorrect
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From the following options, choose the one which is not a cause of liver cirrhosis.
Your Answer: Wilson's disease
Correct Answer: Schistosomiasis
Explanation:Schistosomiasis is a cause of portal hypertension and periportal fibrosis – it is, however, not a cause of cirrhosis. The main causes of cirrhosis include: alcohol and hepatitis B, C, and D. Autoimmune causes include: both primary and secondary biliary cirrhosis and autoimmune hepatitis. There are a number of inherited conditions which cause cirrhosis, such as hereditary hemochromatosis, Wilson’s disease, Alpha-1 anti-trypsin deficiency, galactosaemia glycogen storage disease, and cystic fibrosis. Additionally, there are also vascular causes, such as hepatic venous congestion, Budd-Chiari syndrome, and veno-occlusive disease. Intestinal bypass surgery has also been implicated as a causative factor for cirrhosis.
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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 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: Barium meal
Correct 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 39
Correct
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A number of tests have been ordered for a 49-year-old male who has systemic lupus erythematosus (SLE). He was referred to the clinic because he has increased shortness of breath. One test in particular is transfer factor of the lung for carbon monoxide (TLCO), which is elevated. Which respiratory complication of SLE is associated with this finding?
Your Answer: Alveolar haemorrhage
Explanation:Alveolar haemorrhage (AH) is a rare, but serious manifestation of SLE. It may occur early or late in disease evolution. Extrapulmonary disease may be minimal and may be masked in patients who are already receiving immunosuppressants for other symptoms of SLE.
DLCO or TLCO (diffusing capacity or transfer factor of the lung for carbon monoxide (CO)) is the extent to which oxygen passes from the air sacs of the lungs into the blood.
Factors that can increase the DLCO include polycythaemia, asthma (can also have normal DLCO) and increased pulmonary blood volume as occurs in exercise. Other factors are left to right intracardiac shunting, mild left heart failure (increased blood volume) and alveolar haemorrhage (increased blood available for which CO does not have to cross a barrier to enter). -
This question is part of the following fields:
- Respiratory System
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Question 40
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 G
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 41
Incorrect
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A 48-year-old chronic smoker who smokes 20 cigarettes per day, presented with a persistent cough, wheezing and difficulty in breathing. He was treated with oxygen but the symptoms did not improve. Which of the following is the next step?
Your Answer: Salbutamol
Correct Answer: Check ABG
Explanation:The history is suggestive of a COPD exacerbation. As he is not responding to oxygen, an ABG should be performed to assess the level of hypoxaemia and then a decision about further management can be made. A CXR and salbutamol are also important in the acute management.
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This question is part of the following fields:
- Respiratory System
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Question 42
Incorrect
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A 40-year-old female presented with palmar xanthomas and tuberoeruptive xanthomas on her elbows and knees. Which of the following is the most probable diagnosis?
Your Answer: Type IV hyperlipoproteinaemia
Correct Answer: Type III hyperlipoproteinaemia
Explanation:Palmar xanthomas and tuberoeruptive xanthomas are found in type III hyperlipoproteinemia (dysbetalipoproteinemia,broad-beta disease, remnant removal disease)
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This question is part of the following fields:
- Cardiovascular System
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Question 43
Correct
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A 48-year-old hairdresser presents to the GP with loss of sensation over the lateral three and a half fingers of her right hand, tenderness over her right forearm, and inability to make a tight fist. She complains of pain in her right arm when twisting door handles anticlockwise. Phalen's and Tinel's tests are negative. She is otherwise neurologically intact. Which of the following is the most likely diagnosis?
Your Answer: Pronator teres syndrome
Explanation:Entrapment of the median nerve by pronator teres causes a median nerve neuropathy, which is worse during pronation of the forearm. Examination should involve excluding carpal tunnel syndrome and pronation of the affected forearm against resistance, which brings on the pain. Unlike carpal tunnel syndrome, the median nerve proximal to the wrist may be tender to palpation.
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This question is part of the following fields:
- Nervous System
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Question 44
Incorrect
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Which of the following is not a known cause of occupational asthma?
Your Answer: Soldering flux resin
Correct Answer: Cadmium
Explanation:Occupational asthma (OA) could be divided into a nonimmunological, irritant-induced asthma and an immunological, allergy-induced asthma. In addition, allergy-induced asthma can be caused by two different groups of agents: high molecular weight proteins (>5,000 Da) or low molecular weight agents (<5,000 Da), generally chemicals like the isocyanates.
Isocyanates are very reactive chemicals characterized by one or more isocyanate groups (-N=C=O). The main reactions of this chemical group are addition reactions with ethanol, resulting in urethanes, with amines (resulting in urea derivates) and with water. Here, the product is carbamic acid which is not stable and reacts further to amines, releasing free carbon dioxide.Diisocyanates and polyisocyanates are, together with the largely nontoxic polyol group, the basic building blocks of the polyurethane (PU) chemical industry, where they are used solely or in combination with solvents or additives in the production of adhesives, foams, elastomers, paintings, coatings and other materials.
The complex salts of platinum are one of the most potent respiratory sensitising agents having caused occupational asthma in more than 50% of exposed workers. Substitution of ammonium hexachlor platinate with platinum tetra amine dichloride in the manufacture of catalyst has controlled the problem in the catalyst industry. Ammonium hexachlorplatinate exposure still occurs in the refining process.
Rosin based solder flux fume is produced when soldering. This fume is a top cause of occupational asthma.
Bakeries, flour mills and kitchens where flour dust and additives in the flour are a common cause of occupational asthma.
Cadmium was not found to cause occupational asthma.
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This question is part of the following fields:
- Respiratory System
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Question 45
Incorrect
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Which of the following signs is least suggestive of cervical myelopathy?
Your Answer: Extensor plantar responses
Correct Answer: Bladder disturbance
Explanation:Cervical myelopathy is mostly caused by spondylosis of C5-C7. Sphincters are usually not involved. The lower limbs usually are hypertonic with weakness and up going planter reflex. Vibration and proprioception tend to be lost. Biceps jerk is inverted or even absent. Although cervical spondylosis is the most common cause, an intrinsic lesion might give a similar picture.
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This question is part of the following fields:
- Nervous System
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Question 46
Incorrect
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A 32-year-old Indian male presents to the clinic with fever, cough and an enlarged cervical lymph node. Examination reveals a caseating granuloma in the lymph node. Which of the following is the most likely diagnosis?
Your Answer: Goitre
Correct Answer: TB adenitis
Explanation:Tuberculous lymphadenitis is a chronic, specific granulomatous inflammation of the lymph node with caseation necrosis, caused by infection with Mycobacterium tuberculosis or a related bacteria. The characteristic morphological element is the tuberculous granuloma (caseating tubercle).
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This question is part of the following fields:
- Infectious Diseases
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Question 47
Correct
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A 42-year-old patient has been admitted with a very swollen and painful right knee. He was unable to walk on it so came into hospital. It is currently being treated as gout with non steroidal anti-inflammatory drugs. You notice he is of short stature, has shortened arms and legs and a flat nasal bridge. A mutation in which gene is responsible for this condition?
Your Answer: Fibroblast growth factor receptor
Explanation:Achondroplasia is a common cause of dwarfism. It is caused by a mutation in fibroblast growth factor receptor 3 (FGFR3). In normal development FGFR3 has a negative regulatory effect on bone growth. In achondroplasia, the mutated form of the receptor is constitutively active and this leads to severely shortened bones. The effect is genetically dominant, with one mutant copy of the FGFR3 gene being sufficient to cause achondroplasia, while two copies of the mutant gene are invariably fatal. A person with achondroplasia thus has a 50% chance of passing dwarfism to each of their offspring. People with achondroplasia can be born to parents that do not have the condition due to spontaneous mutation. It occurs as a sporadic mutation in approximately 80% of cases (associated with advanced paternal age) or it may be inherited as an autosomal dominant genetic disorder.
People with achondroplasia have short stature, with an average adult height of 131 centimeters (52 inches) for males and 123 centimeters (48 inches) for females. -
This question is part of the following fields:
- Musculoskeletal System
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Question 48
Correct
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A 28-year-old male is complaining about sore feet and lower back pain. He says it feels like walking on gravel. He also mentioned have some urethral discharge that he had not received any treatment for. He had a holiday in Morocco recently. What is the most likely diagnosis?
Your Answer: Sjogren's Syndrome
Explanation:This is a case of Sjogren Syndrome (aka Reiter’s disease). It is characterised by a triad of: seronegative arthritis mostly sacroiliitis (walking on gravel reflects planter fasciitis), urethritis and conjunctivitis. Sjogren Syndrome usually follows gastroenteritis or non specific urethritis. On the other hand gonococcal arthritis usually occurs in patients who are systemically unwell.
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This question is part of the following fields:
- Musculoskeletal System
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Question 49
Incorrect
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A 60-year-old male was diagnosed with advanced intestinal carcinoma with metastasis. His doctor prescribed him NSAIDs and tramadol initially but his pain was not responding to it. Which of the following drugs is the most suitable alternative option?
Your Answer: Intravenous morphine
Correct Answer: Oramorph
Explanation:According to WHO, initial pain management for patients with malignancy involves NSAIDs and weak opioids. After their pain stops responding to them, stronger opioids such as oxycodone and morphine are prescribed.
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This question is part of the following fields:
- Pharmacology
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Question 50
Incorrect
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A 75-year-old gentleman sustained an injury to his arm after falling on outstretched hands. An X-ray confirms the fracture of the distal radius with backward shift of the distal fragment. The name given to this kind of deformity is?
Your Answer: Mallet finger
Correct Answer: Dinner fork deformity
Explanation:Dinner fork deformity is the name given to the fracture of distal radius, in which the distal fragment is dorsally angulated, displaced and sometimes impacted. Coxa vara is the hip deformity when angle between the head and shaft of the femur is reduced to more than 120 degree. A garden fork deformity is a reversed Colles fracture.
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This question is part of the following fields:
- Musculoskeletal System
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Question 51
Incorrect
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A 27-year-old lady presents with severe morning headaches associated with nausea. Head MRI reveals a large compressive tumour arising from the falx cerebri. The tumour is well delineated. What is the most probable diagnosis?
Your Answer: Low-grade glioma
Correct Answer: Meningioma
Explanation:Meningiomas are the most common benign tumours of the brain. Their name is derived from the fact that they arise from the dura mater which together with the pia matter and arachnoid mater form the meninges. The chances that a meningioma is benign are almost 98%. They are non-invasive and well delineated, causing sign and symptoms of brain compression.
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This question is part of the following fields:
- Nervous System
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Question 52
Incorrect
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A 72-year-old man presents with chronic back and right hip pain which has been increasingly affecting him over the past few months. He finds it very difficult to mobilise in the mornings. Clinical examination is unremarkable, apart from a limitation of right hip flexion due to pain. Investigations show: Haemoglobin:    12.1 g/dl (13.5-17.7) White cell count:  8.2 x 109/l (4-11) Platelets:         200 x 109/l (150-400) C reactive protein: 9 nmol/l (<10) ESR:             15 mm/hr (<20) Sodium:          140 mmol/l (135-146) Potassium:       3.9 mmol/l (3.5-5) Creatinine:       92 µmol/l (79-118) ALT:             12 U/l (5-40) Alkaline phos:    724 U/l (39-117) Calcium:         2.55 mmol/l (2.20-2.67) Which of the following is the most likely diagnosis?
Your Answer: Malignant melanoma
Correct Answer: Paget's disease
Explanation:Paget’s disease of bone is a chronic disease of the skeleton. In healthy bone, a process called remodeling removes old pieces of bone and replaces them with new, fresh bone. Paget’s disease causes this process to shift out of balance, resulting in new bone that is abnormally shaped, weak, and brittle. Paget’s disease most often affects older people, occurring in approximately 2 to 3% of the population over the age of 55.
Many patients with Paget’s disease have no symptoms at all and are unaware they have the disease until X-rays are taken for some other reason. When bone pain and other symptoms are present, they can be related to the disease itself or to complications that arise from the disease — such as arthritis, bone deformity, and fractures. In patients with Paget’s disease, alkaline phosphatase levels are usually quite elevated — a reflection of the high bone turnover rate.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 53
Incorrect
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A 34-year-old woman presents to the emergency department due to right sided weakness. Past history reveals a DVT following the birth of her daughter, and two miscarriages. Head CT confirms an ischaemic stroke in the territory of left middle cerebral artery. What would be the most likely finding on echocardiography?
Your Answer: Dilated cardiomyopathy
Correct Answer: Normal
Explanation:The patient most likely suffers from antiphospholipid syndrome. The clinical criteria consist of vascular thrombosis and pregnancy morbidity. Vascular thrombosis is defined as one or more clinical episodes of arterial, venous, or small-vessel thrombosis in any tissue or organ confirmed by findings from imaging studies, Doppler studies, or histopathology. ASD, VSDs would cause paradoxical emboli and stroke, however the recurrent pregnancy loss in this case is strongly suggestive of antiphospholipid syndrome. The ECG would be normal in most cases associated with anti phospholipid syndrome.
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This question is part of the following fields:
- Musculoskeletal System
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Question 54
Incorrect
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Which one of the following is most associated with the development of acute pancreatitis?
Your Answer: Amyloidosis
Correct Answer: Hyperchylomicronaemia
Explanation:Hyperchylomicronaemia is an increase (markedly) in chylomicrons, and this can cause acute pancreatitis, as well as xanthomas. It can be seen in familial lipoprotein lipase (LPL) deficiency, primary type V hyperlipoproteinemia, idiopathic hyperchylomicronaemia, and familial apolipoprotein CII deficiency. Treatment is dietary fat restriction in order to avoid pancreatitis attacks.
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This question is part of the following fields:
- Gastrointestinal System
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Question 55
Incorrect
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A 65-year-old gentleman with a history of chronic renal failure due to diabetes comes to the clinic for review. He has reported increasing bone and muscle aches over the past few weeks.
Â
Medications include ramipril, amlodipine and indapamide for blood pressure control, atorvastatin for lipid management, and insulin for control of his blood sugar. On examination his BP is 148/80 mmHg, his pulse is 79 and regular. His BMI is 28.
Â
Investigations show:
Haemoglobin 10.7 g/dl (13.5-17.7)
White cell count 8.2 x 10(9)/l (4-11)
Platelets 202 x 10(9)/l (150-400)
Serum sodium 140 mmol/l (135-146)
Serum potassium 5.0 mmol/l (3.5-5)
Creatinine 192 μmol/l (79-118)
Calcium 2.18 mmol/l (2.2-2.67)
Phosphate 1.9 mmol/l (0.7-1.5)
Â
He has tried following a low phosphate diet.
Â
Which of the following would be the next most appropriate step in controlling his phosphate levels?Your Answer: Vitamin D supplementation
Correct Answer: Sevelamer
Explanation:Sevelamer is a phosphate-binding drug that can lower raised serum phosphate levels in chronic kidney disease. Because of its aluminium-related side-effects, aluminium hydroxide is no longer the drug of choice.
The other options are calcium-containing salts that may increase risks of tissue calcification. -
This question is part of the following fields:
- Renal System
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Question 56
Correct
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A 43 year-old female artist with no past medical history presents to the emergency department with a 2-day history of pins and needles in the lower limbs, and progressive walking difficulties. She states she had diarrhoea 1 week ago. On examination, there is a loss of pinprick sensation noted to the lower limbs from mid-thigh distally and in the upper limbs from MCP joints distally. There is bilateral weakness of ankle dorsiflexion, noted at 3/5, and knee flexion and extension weakness, noted at 4/5 bilaterally. Power in upper and lower limbs is otherwise normal. Knee and ankle deep tendon reflexes are absent. Which of the following is the most likely diagnosis?
Your Answer: Guillain-Barre syndrome
Explanation:Guillain-Barre syndrome is an immune mediated demyelination of the peripheral nervous system often triggered by an infection (classically Campylobacter jejuni). Characteristic features include progressive weakness of all four limbs, and it is classically ascending, affecting the lower extremities first. Sensory symptoms tend to be mild.
Functional neurological syndrome can be discounted due to presence of hard neurological signs. Multiple sclerosis can be excluded because of the presence of lower motor neuron signs and absence of upper motor neuron signs. Chronic inflammatory demyelinating polyneuropathy is the chronic form of Guillain-Barre syndrome.
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This question is part of the following fields:
- Nervous System
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Question 57
Incorrect
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A 57-year-old male presented to the OPD with a complaint of fever, cough and chest pain for 3 days. The right lung base was dull on percussion and the breath sounds were reduced in intensity. Which of the following investigations is most appropriate?
Your Answer: MRI
Correct Answer: CXR
Explanation:Because of the patient’s acute presentation of symptoms accompanied by lung abnormalities observed on physical examination, the next step is to visualize the suspected acute inflammatory process by ordering a CXR. Bronchoscopy, CT and MRI are done in cases in which there is suspicion of any tumour formation. V/Q scan is done in cases where pulmonary embolism is suspected.
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This question is part of the following fields:
- Respiratory System
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Question 58
Incorrect
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Gentamicin is used along with benzylpenicillin in the treatment of infective endocarditis caused by streptococcus viridans. Which of the following mechanisms is present in this case?
Your Answer: Inhibition of protein synthesis (transcription)
Correct Answer: Inhibition of protein synthesis (translation)
Explanation:Gentamicin acts along with benzylpenicillin to inhibit protein synthesis at the level of ribosomes. Indirectly it inhibits the translation process.
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This question is part of the following fields:
- Pharmacology
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Question 59
Correct
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Question 60
Incorrect
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A 40-year-old truck operator who smokes one and a half packs of cigarette per day complains of a cough and fever for the last three days. He also has right-sided chest pain when he inhales. On examination he is slightly cyanosed, has a temperature of 38.1°C, a respiratory rate of 39/min, a BP of 104/71 mm/Hg and a pulse rate of 132/min. He has basal crepitations and dullness to percussion at the right lung base.
What could be a probable diagnosis?Your Answer: Atelectasis due to carcinoma of the lung
Correct Answer: Bronchopneumonia
Explanation:Bronchopneumonia presents as a patchy consolidation involving one or more lobes, usually the dependent lung zones, a pattern attributable to aspiration of oropharyngeal contents.
Symptoms of bronchopneumonia may be like other types of pneumonia. This condition often begins with flu-like symptoms that can become more severe over a few days. The symptoms include:
– fever
– a cough that brings up mucus
– shortness of breath
– chest pain
– rapid breathing
– sweating
– chills
– headaches
– muscle aches
– pleurisy, or chest pain that results from inflammation due to excessive coughing
– fatigue
– confusion or delirium, especially in older peopleThere are several factors that can increase your risk of developing bronchopneumonia. These include:
– Age: People who are 65 years of age or older, and children who are 2 years or younger, have a higher risk for developing bronchopneumonia and complications from the condition.
– Environmental: People who work in, or often visit, hospital or nursing home facilities have a higher risk for developing bronchopneumonia.
– Lifestyle: Smoking, poor nutrition, and a history of heavy alcohol use can increase your risk for bronchopneumonia.
– Medical conditions: Having certain medical conditions can increase your risk for developing this type of pneumonia. These include: chronic lung disease, such as asthma or chronic obstructive pulmonary disease (COPD), HIV/AIDS, having a weakened immune system due to chemotherapy or the use of immunosuppressive drugs. -
This question is part of the following fields:
- Respiratory System
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Question 61
Incorrect
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A 23-year-old female visited the OPD with a complaint of postcoital bleeding as well as excessive vaginal discharge. Her past medical history is positive for oral contraceptive pills. Which of the following investigations would you recommend in this case?
Your Answer: Culdotomy
Correct Answer: Speculum with or without cervical smear
Explanation:A speculum test is necessary in order to visualize the cervix to rule out cervical ectropion that may be responsible for the post-coital bleeding. A smear is not necessary if the cervix is adequately visualized, however, it can rule out infection as well.
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This question is part of the following fields:
- Women's Health
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Question 62
Incorrect
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A 45-year-old man with diabetes comes to the clinic for his annual review.
He has had diabetes for eight years and he is also being treated for hypertension. He is on the following medications: metformin 500 mg tds, gliclazide 80 mg daily, atorvastatin 10 mg/d, Ramipril 10 mg/d and Bendroflumethiazide 2.5 mg/d.
He is noted to be obese (130kg). Physical examination is otherwise unremarkable.
Investigations reveal:
HbA1c 8.1% (3.8-6.4)
Fasting glucose 9 mmol/L (3.0-6.0)
24 hr Urine free cortisol 354 mmol/d (<250)
9am Plasma ACTH 4 ng/dL (10-50)
CT abdomen 3 cm right adrenal mass
Which of the following is most likely to be the adrenal mass?Your Answer: Incidentaloma
Correct Answer: Cortisol secreting adenoma
Explanation:The patient has Cushing syndrome suggested by the elevated 24hr urine free cortisol. Hence, the mass is most probably a cortisol secreting adenoma.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 63
Incorrect
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A 30-year-old female who was on chemotherapy developed a high-grade fever and productive cough over 2 days. On examination, there was evidence of a chest infection. Her WBC was 2100/ml. What is the most suitable treatment for this condition?
Your Answer: Penicillin+tazobactam
Correct Answer: Piperacillin+tazobactam
Explanation:This patient has leukopenia following chemotherapy and she is more prone to severe bacterial infections. Neutropenic sepsis is common among cancer patients and it is one of the main reasons for death amongst these patients. As the first line monotherapy for high-risk patients, Piperacillin-tazobactam, Cefepime, Meropenem and Imipenem-cilastatin can be started as they all have antipseudomonal activity.
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This question is part of the following fields:
- Haematology & Oncology
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Question 64
Correct
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A 57-year-old school teacher is found to have abnormal liver function tests at a health screening. Other than tiredness and occasional gritty eyes that she attributes to age, she is well. She is postmenopausal and takes hormone replacement therapy (HRT) but no other medication. She smokes 12 cigarettes per day but takes no alcohol. There is nothing to find on examination.
Some of her blood results are shown below:
Albumin 40 g/l (37-49)
Alanine aminotransferase(ALT) 14 U/l (5-35)
Alkaline Phosphatase 300 U/l (45-105)
AMA positive >1:40
Anti-dsDNA weakly positive
Bilirubin 12 μmol/l (1-22)
High-density lipoprotein (HDL) cholesterol 4.0 mmol/l (>1.55)
Liver-kidney microsomal antibody (anti-LKM) negative
Liver transaminase (AST) 10 U/l (1-31)
Low-density lipoprotein (LDL) cholesterol 4.0 mmol/l (<3.36)
Plasma thromboplastin (PT) 12 s (11.5-15.5)
Smooth muscle antibody (SMA) negative
Which of the following would be an appropriate next step?Your Answer: Ursodeoxycholic acid
Explanation:The patient is AMA+ and weakly + for anti-dsDNA, suggesting an autoimmune process. She also has gritty eyes, which makes you think Sjogren’s syndrome. She has an elevated ALP and normal AST/ ALT. All of these factors, in addition to her middle age and the fact that she is a woman, make the diagnosis of primary biliary cirrhosis (PBC) most likely. It is associated with conditions (autoimmune) such as Sjogren’s syndrome. The treatment for this disease initially is ursodeoxycholic acid. Liver transplantation is the definitive treatment for end-stage disease.
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This question is part of the following fields:
- Hepatobiliary System
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Question 65
Incorrect
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A 53-year-old female, longstanding case of rheumatoid arthritis comes for a review. Which of the following features are commonly associated with her condition?
Your Answer: Proteinuria from renal deposition of amyloid
Correct Answer: Proximal interphalangeal joint involvement in the hands
Explanation:Rheumatoid arthritis is a polyarthritis that results in symmetrical pain and swelling of the affected joints (also at rest). It particularly affects the metacarpophalangeal joints (MCPJs) and proximal interphalangeal joints (PIPJs), not the distal interphalangeal joints (DIPs).
Ulcerative colitis and IBD are associated with seronegative arthritides, not RA. The condition can also cause various extra-articular manifestations such as ocular symptoms, rheumatoid nodules and pulmonary fibrosis. Scleritis, episcleritis and keratoconjunctivitis sicca are more common than uveitis. Early intervention with disease-modifying antirheumatic drugs (DMARDs) plays a decisive role in successful treatment. -
This question is part of the following fields:
- Musculoskeletal System
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Question 66
Correct
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A 62 year-old male presents with exertional chest pain and is found to have extensive coronary artery disease on angiogram. Which of the following cell types is most implicated in the development of coronary artery plaques?
Your Answer: Macrophages
Explanation:An atheroma is an accumulation of degenerative material in the tunica intima (inner layer) of artery walls. The material consists of (mostly) macrophage cells, or debris, containing lipids (cholesterol and fatty acids), calcium and a variable amount of fibrous connective tissue.
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This question is part of the following fields:
- Immune System
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Question 67
Incorrect
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A 60-year-old man, newly diagnosed with acromegaly, may have all of the following, except?
Your Answer: Carpal tunnel syndrome
Correct Answer: Hypohydrosis
Explanation:Acromegaly occurs due to excessive action of insulin-like growth factor I (IGF-I) after the growth plate cartilage fuses in adulthood.
It can be an insidious disease. Symptoms, which may precede diagnosis by several years, can be divided into the following groups:
1. Symptoms due to local mass effects of an intracranial tumour
Tumour damage to the pituitary stalk may cause hyperprolactinemia (Increased blood prolactin levels associated with galactorrhoea) due to loss of inhibitory regulation of prolactin secretion by the hypothalamus
2. Symptoms due to excess of GH/IGF-I including:
– Hyperhidrosis (Not hypohidrosis)
– Arthritis
– Peripheral Neuropathies e.g. Carpal Tunnel Syndrome -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 68
Incorrect
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A 31-year-old homosexual male is complaining of recent weight loss and blurred vision. A fundoscope was performed showing retinal haemorrhage. What is the single most appropriate option?
Your Answer: Mycobacterium avium
Correct Answer: Cytomegalovirus (CMV)
Explanation:CMV is the best answer . Weight loss is mostly caused by HIV, which commonly presents with retinal haemorrhage and retinopathy when associated with CMV.
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This question is part of the following fields:
- Infectious Diseases
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Question 69
Incorrect
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A 70-year-old male patient presented with chronic congestive heart failure. Which of the following is the most important factor to consider when prescribing drugs for this patient?
Your Answer: Administration of spironolactone has no effect on the incidence of sudden cardiac death
Correct Answer: Administration of a B-blocker reduces the time spent in hospital
Explanation:It is proven that spironolactone has survival benefits and loop diuretics only give symptomatic relief. Beta blockers are however, known to improve exercise tolerance, left ventricular function and reduce symptoms. They also reduce the mortality associated with heart failure. So administration of beta blockers will reduce the time spent in hospital by improving symptoms.
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This question is part of the following fields:
- Cardiovascular System
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Question 70
Incorrect
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A 26-year-old graduate student with a history of migraines presents for examination. His headaches are now occurring about once a week. He describes unilateral, throbbing headaches that may last over 24 hours. Neurological examination is unremarkable. Other than a history of asthma, he is fit and well. What is the most suitable therapy to reduce the frequency of migraine attacks?
Your Answer: Pizotifen
Correct Answer: Topiramate
Explanation:It should be noted that as a general rule 5-HT receptor agonists are used in the acute treatment of migraine whilst 5-HT receptor antagonists are used in prophylaxis. NICE produced guidelines in 2012 on the management of headache, including migraines. Prophylaxis should be given if patients are experiencing 2 or more attacks per month. Modern treatment is effective in about 60% of patients. NICE advises either topiramate or propranolol ‘according to the person’s preference, comorbidities and risk of adverse events’. Propranolol should be used in preference to topiramate in women of child bearing age as it may be teratogenic and it can reduce the effectiveness of hormonal contraceptives.
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This question is part of the following fields:
- Nervous System
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Question 71
Correct
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A 50-year-old male presented with acute severe central chest pain and acute ST elevation myocardial infarction was diagnosed. He was treated with streptokinase. 2 days later he was sweating excessively and he was found to be hypotensive. Which of the following cannot be considered as a reason for this presentation?
Your Answer: Hypotensive effect of streptokinase
Explanation:Hypotensive effect of streptokinase occurs during the streptokinase infusion which is usually transient. Acute mitral regurgitation due to rupture of papillary muscles, ventricular septal defects and reinfarctions (left or right) are known to cause hypotension after 24 hrs. Pulmonary embolism is less likely but cannot be excluded.
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This question is part of the following fields:
- Cardiovascular System
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Question 72
Correct
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A 30-year-old male with a history of premature cardiovascular disease in the family has come for review of his lab investigations.
His fasting cholesterol is 8.4 mmol/l with high-density lipoprotein (HDL) of 1.6 mmol/l.
You elect to commence him on atorvastatin 20 mg PO daily.
Which of the following best describes the mechanism of action of the statins?Your Answer: They inhibit HMG CoA reductase
Explanation:Statins are a selective, competitive inhibitor of hydroxymethylglutaryl-CoA (HMG-CoA) reductase, which is the enzyme responsible for the conversion of HMG-CoA to mevalonate in the cholesterol synthesis pathway.
Statins are usually well tolerated with myopathy, rhabdomyolysis, hepatotoxicity, and diabetes mellitus being the most common adverse reactions.
This is the rate-limiting step in cholesterol synthesis, that leads to increased hepatic low-density lipoprotein (LDL) receptors and reduced hepatic VLDL synthesis coupled with increased very-low-density lipoprotein (VLDL) clearance. -
This question is part of the following fields:
- Pharmacology
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Question 73
Incorrect
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An 18-year-old boy, thin with a tall stature, and a high arched palate arrives at the hospital with a spontaneous pneumothorax. He is accompanied by his brother who has a similar appearance. You suspect Marfan's Syndrome.
The gene encoding which of the following proteins is defective in this condition?Your Answer: Tropoelastin
Correct Answer: Fibrillin-1
Explanation:A variety of proteins compose the structure of microfibrils, the most prominent of which are the two fibrillins. Fibrillin-1 a scaffolding protein is encoded by FBN1 on human chromosome 15q21 and fibrillin-2 is encoded by FBN2 on 5q23. Mutations in FBN1 produce Marfan syndrome, a pleiotropic autosomal dominant connective tissue disorder with prominent manifestations in the skeleton, eye and cardiovascular system. A number of conditions related to Marfan syndrome are also due to FBN1 mutations.
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This question is part of the following fields:
- Musculoskeletal System
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Question 74
Correct
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A 30-year-old previously well female presented with yellowish discolouration of her sclera. Investigations revealed low haemoglobin, a retic count of 8% and the occasional spherocyte on blood film. Which of the following is the most appropriate single investigation?
Your Answer: Direct coombs test
Explanation:A low haemoglobin and a high retic count is suggestive of a haemolytic anaemia. Occasional spherocytes can be seen on blood film during haemolysis and it is not a specific finding. Direct Coombs test will help to identify autoimmune haemolytic anaemia, where there are antibodies attached to RBCs.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 75
Correct
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A 40-year-old man complains of impotence and reduced libido for 4 months. He has been married for 15 years and has two children. He smokes five cigarettes per day and drinks approximately 12 units of alcohol weekly.
Examination reveals an obese man who is phenotypically normal with normal secondary sexual characteristics.
Investigations are as follows:
Hb 13.4 g/dl (13.0-18.0)
WCC 6 x 109/l (4-11)
Platelets 210 x 109/l (150-400)
Electrolytes Normal
Fasting glucose 5.6 mmol/l (3.0-6.0)
LFTs Normal
T4 12.7 pmol/l (10-22)
TSH 2.1 mU/l (0.4-5)
Prolactin 259 mU/l (<450)
Testosterone 6.6 nmol/l (9-30)
LH 23.7 mU/l (4-8)
FSH 18.1 mU/l (4-10)
What is the next investigation needed for this patient?Your Answer: Ultrasound examination of the testes
Explanation:The patient has primary Hypogonadism.
Since he already had two children, Klinefelter syndrome is excluded and the patient does not need karyotyping.
His lab results are normal indicating normal pituitary gland functions.
So the next step is testicular ultrasound as testicular tumour, infiltration or idiopathic failure is suspected. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 76
Incorrect
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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: Liver metastases
Correct 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 77
Incorrect
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A 45-year-old male patient who was initially investigated for having an abdominal mass is diagnosed as having Burkitt lymphoma. He is due to start chemotherapy today.
Which one of the following should be given prior to his chemotherapy in order to reduce the risk of tumour lysis syndrome?Your Answer: Sodium bicarbonate
Correct Answer: Rasburicase
Explanation:Rasburicase should be given prior to chemotherapy in order to reduce the risk of tumour lysis syndrome (TLS). Rasburicase is a recombinant version of urate oxidase which is an enzyme that metabolizes uric acid to allantoin. Allantoin is 5-10 times more soluble than uric acid, hence, renal excretion is more effective.
TLS is a potentially fatal condition occurring as a complication during the treatment of high-grade lymphomas and leukaemias. It occurs from the simultaneous breakdown (lysis) of the tumour cells and subsequent release of chemicals into the bloodstream. This leads to hyperkalaemia and hyperphosphatemia in the presence of hyponatraemia. TLS can occur in the absence of chemotherapy, but it is usually triggered by the introduction of combination chemotherapy. Awareness of the condition is critical for its prophylactic management.
Burkitt lymphoma is a high-grade B-cell neoplasm. There are two major forms:
1. Endemic (African) form: typically involves maxilla or mandible.
2. Sporadic form: abdominal (e.g. ileocaecal) tumours are the most common form. More common in patients with HIV.Burkitt lymphoma is associated with the c-myc gene translocation, usually t(8;14). The Epstein-Barr virus (EBV) is strongly implicated in development of the African form of Burkitt lymphoma and to a lesser extent, the sporadic form.
Management of the lymphoma is with chemotherapy. This tends to produce a rapid response which may cause TLS.
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This question is part of the following fields:
- Haematology & Oncology
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Question 78
Incorrect
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Type 2 hypersensitivity is mediated by:
Your Answer: IgE and mast cells
Correct Answer: IgG, IgM & complement
Explanation:In type II hypersensitivity the antibodies, IgG and IgM bind to antigens to form complexes that activate the classical pathway of complement to eliminate cells presenting foreign antigens.
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This question is part of the following fields:
- Immune System
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Question 79
Correct
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A 54-year-old gentleman presented with a 3 month history of a nodular growth over the dorsum of the his nose, about 0.6 cm in size. The base of nodule is slightly ulcerated and its margins are raised. The most likely diagnosis would be?
Your Answer: Basal cell carcinoma
Explanation:Basal cell carcinoma is usually located on sun exposed sites. It has got many variants and clinically it presents as a slow growing mass/nodule with rolled margins and an ulcerated base.
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This question is part of the following fields:
- The Skin
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Question 80
Incorrect
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A 58-year-old male attends a doctor's surgery to get help with quitting drinking alcohol. He expressed that he wishes to avoid the unpleasant alcohol craving experiences. From the following options, what should be prescribed to the patient?
Your Answer: Methadone
Correct Answer: Acamprosate
Explanation:Acamprosate (calcium acetyl-homotaurine) helps to restore the normal activity of glutaminergic neurons, which usually become hyperexcited following chronic alcohol exposure.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 81
Incorrect
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A 50-year-old woman under treatment for manic-depressive psychosis presents in an unconscious state after an episode of seizure on the street. Her husband who accompanied her into the ER reported that they argued about 6-7 hours ago. On examination, she is found to be hypertonic with a GCS of 8, BP: 90/60 mmHg and a pulse of 105 bpm. Blood investigations revealed a lithium level of 3.2 mmol/L. She was intubated and ventilated. Which of the following interventions is most appropriate in this case?
Your Answer: Normal saline infusion
Correct Answer: Gastric lavage and normal saline infusion
Explanation:Among the above statements, gastric lavage and normal saline IV infusion are the most appropriate interventions for a patient of acute lithium toxicity.
Activated charcoal is not effective after lithium overdose, although gastric lavage should be considered if patients present within 6-8 h.
Where levels are above 3 mmol/l, the use of normal saline to induce diuresis should be considered, although careful monitoring of fluid balance is necessary.
Where levels of lithium are above 4 mmol/l, dialysis is often required. Haemodialysis is preferred, but in a facility where haemodialysis is not possible, peritoneal dialysis may be considered.
Patients should not be discharged until they are asymptomatic and have a serum lithium level less than 1.5 mEq/L. -
This question is part of the following fields:
- Pharmacology
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Question 82
Incorrect
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A 60-year-old female underwent pelvic surgery. She was given low molecular weight heparin (LMWH) after the procedure. After a week, she complained of sudden chest pain and difficulty in breathing. Her ECG and CXR were normal. What is the most suitable option for her?
Your Answer: Change to unfractionated heparin and do CT. pulmonary angiography.
Correct Answer: Keep on low molecular weight heparin and do CT. pulmonary angiography.
Explanation:CT pulmonary angiography will decide the proper cause of her symptoms. Until that has happened LMWP should be continued.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 83
Incorrect
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A 20-year-old male student presents to the clinic with swelling of his face, hands and feet along with diffuse abdominal pain. He has a history of similar recurrent episodes since he was 10 years old, with each episode lasting 2-3 days. Examination reveals swelling on face, hands, feet but no sign of urticaria. Family history is significant for similar episodes in the mother who experienced these since childhood, and a brother who passed away following respiratory distress at age of 8 during one such episode. Which of the following tests would be the most helpful in reaching the diagnosis?
Your Answer: IgE levels
Correct Answer: C1 esterase inhibitor
Explanation:Hereditary C1 inhibitor deficiency leads to recurrent angioedema without urticaria or pruritus. Physical triggers include dental work, surgery or intubation. Medical triggers include angiotensin-converting enzyme (ACE) inhibitor, tamoxifen, oestrogen-containing medications (e.g., hormone replacement therapy and oral contraceptives). It is diagnosed on the basis of low levels of C1 esterase inhibitor or elevated levels of dysfunctional C1 esterase inhibitor. C4 levels are low between attacks. IgE levels, eosinophils, skin prick tests and RASTs are helpful in other allergic conditions and asthma but not of use in this case.
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This question is part of the following fields:
- Musculoskeletal System
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Question 84
Incorrect
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A 23-year-old woman comes for the advice regarding contraceptives. Her mother passed away due to cervical cancer and she worries about cervical cancer. Which of the following is the most suitable contraceptive method for her?
Your Answer: IUCD
Correct Answer: Barrier method
Explanation:Cervical cancer results from genital infection with HPV. PV infections can be transmitted via nonsexual routes, but the result from sexual contact. So the best contraceptive method in relation to prevention of cervical cancer is the barrier method. But it will not prevent cervical cancer a 100%.
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This question is part of the following fields:
- Women's Health
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Question 85
Incorrect
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A 30-year-old previously well male was found to have a blood pressure of 140/90 mmHg. Investigations revealed microalbuminuria. FBS and HbA1c were normal. Which of the following is the most appropriate management for this patient?
Your Answer: Renal biopsy
Correct Answer: Renal scan
Explanation:A renal scan is important in the diagnosis of early renal damage, acute or chronic nephropathies and nephrovascular disease. Renal resistive index (RRI) which is measured by Doppler sonography, is proved to be a marker of renal disease onset and progression. Young hypertension with microalbuminuria is an indication for a renal scan to identify the possible aetiology.
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This question is part of the following fields:
- Renal System
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Question 86
Incorrect
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Which of the following is the most common route of hepatitis B transmission worldwide?
Your Answer: Blood inoculation through needles
Correct Answer: Perinatal transmission
Explanation:Perinatal transmission is the most common cause of Hepatitis B infection worldwide. Post-exposure prophylaxis should be provided, which consists of hepatitis B immune globulin and hepatitis B vaccine within 12 hours of birth. Without this, about 40% will develop chronic infection.
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This question is part of the following fields:
- Infectious Diseases
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Question 87
Incorrect
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A 58-year-old woman with a longstanding history of hypertension arrives at the hospital complaining of recurrent falls when trying to get out of bed or get up from sitting. She is currently on an antihypertensive regimen? What do you think is most likely responsible for her falls?
Your Answer: Infection
Correct Answer: Thiazide
Explanation:The causes of orthostatic hypotension include the following: Hypovolemia (a drop in the volume of blood) and dehydration (low fluid volume in the body). Common causes of these are bleeding, elevated sugar, diarrhoea, vomiting, and medications like thiazide diuretics (HCTZ) and loop diuretics (furosemide, bumetanide)
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This question is part of the following fields:
- Emergency & Critical Care
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Question 88
Incorrect
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In idiopathic hypercalciuria, what management should be initiated if there is renal stone disease or bone demineralization?
Your Answer: Dietary modification
Correct Answer: Dietary modification and thiazide diuretics
Explanation:Idiopathic hypercalciuria presents with excess calcium in the urine without an apparent cause. Dietary modification is the first step in addressing this condition, however, because hypercalciuria increases the risk of developing renal stones and bone demineralisation, thiazide diuretics should be prescribed to increase calcium reabsorption when these symptoms are also present.
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This question is part of the following fields:
- Renal System
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Question 89
Incorrect
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Which of the following involving the scalp may produce alopecia (hair loss)?
Your Answer: Bullous pemphigoid
Correct Answer: Discoid lupus erythematosus
Explanation:Infective causes of hair loss include:
Dissecting cellulitis
Fungal infections (such as tinea capitis)
Folliculitis
Secondary syphilis
Demodex folliculorum
Lupus erythematosus (hair loss may be permanent due to scarring of the hair follicles).
Psoriasis and seborrheic dermatitis commonly involve the scalp but do not produce hair loss. -
This question is part of the following fields:
- The Skin
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Question 90
Incorrect
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A 28-year-old female hiker begins complaining of headache and nausea after reaching a height of 5010 metres. Despite having the headache and feeling nauseous, she continues to hike but becomes progressively worse. She is seen staggering, complains of feeling dizzy and has an ataxic gait.
Which of the following is the appropriate treatment of this patient?Your Answer: Descent + acetazolamide
Correct Answer: Descent + dexamethasone
Explanation:High Altitude Cerebral Oedema (HACE) is a severe and potentially fatal manifestation of high altitude illness and is often characterized by ataxia, fatigue, and altered mental status. HACE is often thought of as an extreme form/end-stage of Acute Mountain Sickness (AMS). Although HACE represents the least common form of altitude illness, it may progress rapidly to coma and death as a result of brain herniation within 24 hours, if not promptly diagnosed and treated.
HACE generally occurs after 2 days above 4000m but can occur at lower elevations (2500m) and with faster onset. Some, but not all, individuals will suffer from symptoms of AMS such as headache, insomnia, anorexia, nausea prior to transitioning to HACE. Some may also have concomitant High Altitude Pulmonary Oedema (HAPE). HACE in isolation is rare, but the absence of concomitant HAPE or symptoms of AMS prior to deterioration does not rule-out the presence of HACE.
Most cases develop as a progression of AMS and will include a history of recent ascent to altitude and prior complaints/findings of AMS including a headache, fatigue, nausea, insomnia, and/or light-headedness. Some may also have signs/symptoms of HAPE. Transition to HACE is heralded by signs of encephalopathy including ataxia (usually the earliest clinical finding) and altered mentation which may range from mild to severe. Other symptoms may include a more severe headache, difficulty speaking, lassitude, a decline in the level of consciousness, and/or focal neurological deficits or seizures.
The mainstay of treatment is the immediate descent of at least 1000m or until symptoms improve. If descent is not an option, one may use a portable hyperbaric chamber and/or supplemental oxygen to temporize illness, but this should never replace or delay evaluation/descent when possible. If available, dexamethasone 8mg for one dose, followed by 4mg every 6 hours should be given to adults via PO, IM, or IV routes.
Acetazolamide has proven to be beneficial in only a single clinical study. The suggested dosing regimen for Acetazolamide is 250 mg PO, given twice daily. Though effective in alleviating or temporizing symptoms, none of the adjunct treatment modalities are definitive or a replacement for an immediate descent. -
This question is part of the following fields:
- Respiratory System
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Question 91
Incorrect
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The conductive system of the heart anatomically includes the:
Your Answer: Phrenic nerve
Correct Answer: Atrioventricular node
Explanation:The cardiac conduction system is a collection of nodes and specialised cells including the:
Sinoatrial node
Atrioventricular node
Atrioventricular bundle (bundle of His)
Purkinje fibres -
This question is part of the following fields:
- Cardiovascular System
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Question 92
Incorrect
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Which of the following drugs will most likely trigger an exacerbation of acute intermittent porphyria (AIP)?
Your Answer: Barbiturates
Correct Answer: Oral contraceptive pill
Explanation:Hormonal contraceptives all contain man-made oestrogen and progestin hormones in a limited amount. These hormones prevent pregnancy by inhibiting the body’s natural cyclical hormones to prevent pregnancy. Even though all of these drugs except Ibuprofen can cause AIP in a vulnerable woman. The most likely cause is the OCP.
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This question is part of the following fields:
- Pharmacology
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Question 93
Incorrect
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A 27-year-old realtor presented with progressive weakness of both legs over the last 3 years. He complained of being unable to see well at night and having an impaired sense of smell. On examination he had a shortened fourth toe bilaterally with pes cavus. Neurological examination revealed a loss of pinprick sensation to bilateral knees, and weakness of both legs that was more prominent distally. Which of the following would be the best blood test to order to make a diagnosis?
Your Answer: ANCA
Correct Answer: Phytanic acid
Explanation:The diagnosis is Refsum’s disease. This is an autosomal recessive disorder that causes a sensorimotor peripheral neuropathy. It is caused by defective alpha oxidation of phytanic acid leading to its accumulation in tissues. Cardiac conduction abnormalities and cardiomyopathies may also occur.
Epiphyseal dysplasia causes a characteristic shortening of the fourth toe. Serum phytanic acid levels are elevated. Treatment is by dietary restriction of foods containing phytanic acid (dairy products, fish, beef and lamb). -
This question is part of the following fields:
- Nervous System
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Question 94
Incorrect
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A 25-year-old female presented with multiple small genital ulcers, which are painful following a sexual intercourse with an unknown man. Which of the following can be used topically for this presentation?
Your Answer: Foscarnet
Correct Answer: Acyclovir
Explanation:The most probable diagnosis is Herpes Simplex infection. Topical Acyclovir can be used in early stages.
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This question is part of the following fields:
- Infectious Diseases
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Question 95
Incorrect
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A 55-year-old male, known hypertensive on antihypertensive medications, presented with complaints of dizziness and lethargy, especially when rising from the chair. The most appropriate test would be?
Your Answer: CT scan
Correct Answer: Ambulatory blood pressure
Explanation:Ambulatory blood pressure recording is used to monitor BP for 24 hours whilst continuing the daily routine activities.
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This question is part of the following fields:
- Nervous System
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Question 96
Incorrect
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An 18-year-old, previously well boy was admitted following a generalized tonic-clonic convulsion for 5 minutes with urinary incontinence and eye rolling. On examination, he was drowsy and had bilateral upgoing plantar reflexes. A short while ago he had been playing rugby and had taken a hit to the head. He was apparently normal for a few minutes before fitting. His blood sugar level was normal. Which of the following is the most probable reason for this presentation?
Your Answer: Idiopathic epilepsy
Correct Answer: Post-traumatic seizure
Explanation:The history is suggestive of a post-traumatic seizure which frequently occurs after moderate or severe traumatic brain injury. Although upgoing plantars can be identified in a post-ictal status, an intracranial bleed has to be excluded. A single seizure cannot be considered epilepsy
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This question is part of the following fields:
- Nervous System
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Question 97
Correct
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A 69-year-old male, who is a hypertensive and a smoker presented with sudden onset central chest pain radiating to his back. Examination revealed a pulsatile mass in the abdomen. Which of the following is the most appropriate next step?
Your Answer: USG
Explanation:The history is suggestive of ruptured Abdominal Aortic Aneurysm (AAA). Characteristic pain, pulsatile abdominal mass and risk factors such as age>60, hypertension and smoking support the diagnosis. Ultrasonography is the standard imaging tool for AAA. It can also detect free peritoneal blood.
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This question is part of the following fields:
- Cardiovascular System
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Question 98
Incorrect
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A 74-year-old man presents to the physician with complaints of hoarseness of voice and cough for the past 3 weeks. The patient has been a smoker and quit 3 years ago. Radiological examination reveals a mass in the mediastinum. Which investigation should be employed to establish a diagnosis?
Your Answer:
Correct Answer: LN biopsy
Explanation:Masses in the middle mediastinum most commonly represent lymph nodes that are enlarged by a malignant, infectious, or inflammatory process. Masses in the posterior mediastinum are usually benign tumours or cysts originating from either the nerves that are present in this area (neurogenic tumours) or from the oesophagus (foregut duplication cysts). Lymph node biopsy would be the ideal choice of investigation in this case.
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This question is part of the following fields:
- Respiratory System
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Question 99
Incorrect
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A 60-year-old male patient with NSTEMI was started on low dose aspirin as secondary prevention. Which of the following, describe the action of aspirin as an antiplatelet agent?
Your Answer:
Correct Answer: Inhibits the production of thromboxane A2
Explanation:The antithrombotic action of aspirin is due to inhibition of platelet function by acetylation of the platelet cyclooxygenase (COX) at the functionally important amino acid serine529. This prevents the access of the substrate (arachidonic aid) to the catalytic site of the enzyme at tyrosine385 and results in an irreversible inhibition of platelet-dependent thromboxane formation.
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This question is part of the following fields:
- Cardiovascular System
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Question 100
Incorrect
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Which the following features is most suggestive of megaloblastic anaemia?
Your Answer:
Correct Answer: Hypersegmented neutrophils in peripheral blood film
Explanation:Hypersegmented neutrophils in the peripheral blood film is suggestive of megaloblastic changes in bone marrow.
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This question is part of the following fields:
- Haematology & Oncology
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SESSION STATS - PERFORMANCE PER SPECIALTY
