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Question 1
Correct
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A 60-year-old man complains of weight loss, fatigue, fever and abdominal discomfort. Abdominal ultrasound reveals massive splenomegaly and the lab results return the following: WBC=127, Hgb=8.7, Plt=138. Basophils were also found on the peripheral blood film. What is the most likely diagnosis?
Your Answer: CML
Explanation:CML is a myeloproliferative disorder involving neoplastic proliferation of mature myeloid cells, especially granulocytes and their precursors. The non-acute symptoms of marked splenomegaly and anaemia accompanied by of fever and abdominal discomfort rules out the other conditions.
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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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Which of the following statements regarding psoriasis is incorrect?
Your Answer: Abnormal T cell activity stimulates keratinocyte proliferation
Correct Answer: Mediated by type 2 helper T cells
Explanation:Psoriasis is a long-lasting autoimmune disease characterized by patches of skin typically red, dry, itchy, and scaly. Psoriasis can affect the nails and produces a variety of changes in the appearance of finger and toe nails including pitting and onycholysis. Nail psoriasis occurs in 40-45% of people with psoriasis affecting the skin and has a lifetime incidence of 80-90% in those with psoriatic arthritis. Psoriasis is mediated by type 1 helper T cells which are involved in the cell mediated response.
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This question is part of the following fields:
- The Skin
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Question 3
Correct
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A 36-year-old man presents with severe pain in his right big toe which is erythematous and swollen. He recently had an appendicectomy. Personal history reveals that he consumes 30 units of alcohol per week. Choose the most likely diagnosis.
Your Answer: Gout
Explanation:Chronic alcoholism leads to increased levels of uric acid in the blood. Gout is caused by high levels of uric acid.
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This question is part of the following fields:
- Musculoskeletal System
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Question 4
Correct
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A 24-year-old male with a history of a cardiac murmur which was not properly followed up, presented with right sided hemiparesis. His blood pressure was 120/70 mmHg. His ECG revealed right bundle branch block with right axis deviation. Which of the following is the most likely cause for this presentation?
Your Answer: Ostium secundum atrial septal defect
Explanation:Ostium secundum atrial septal defects are known to cause stroke due to the passage of emboli from the right sided circulation to the left sided circulation. ECG shows tall, peaked P waves (usually best seen in leads II and V2) and prolongation of the PR interval, rSR pattern in leads V3 R and V1 as well as right axis deviation.
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This question is part of the following fields:
- Cardiovascular System
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Question 5
Incorrect
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The drug of choice for delirium tremens will be?
Your Answer: IV Midazolam
Correct Answer: IV Chlordiazepoxide
Explanation:The drugs of choice for delirium tremens are benzodiazepines such as chlordiazepoxide, diazepam or lorazepam. Chlordiazepoxide is a long acting drug and is the preferred drug, before the other benzodiazepines. Barbiturates are the 2nd drugs of choice.
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This question is part of the following fields:
- Nervous System
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Question 6
Correct
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A 63-year-old heavy smoker complains of pain on exertion in both calves and his buttocks. He has also recently developed erectile dysfunction. On examination, peripheral pulses in both lower limbs including distal and femoral are absent. Where is the single most probable site of obstruction?
Your Answer: Aorto iliac
Explanation:The penis receives its blood supply by the internal pudendal artery, a branch of the internal iliac artery. Erectile dysfunction indicates obstruction at the level of the common iliac arteries or higher.
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This question is part of the following fields:
- Cardiovascular System
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Question 7
Correct
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A 22-year-old female presents to the ER with a respiratory infection for which the physician prescribes her azithromycin. She, however, is currently on combined oral contraceptive pills. Regarding her contraception, what should be advised to this patient?
Your Answer: No extra precaution
Explanation:Rifampicin is the only antibiotic that has been reported to reduce plasma oestrogen concentrations. When taking Rifampicin, oral contraceptives cannot be relied upon and a second method of contraception is mandatory. Amoxicillin, ampicillin, griseofulvin, metronidazole and tetracycline have been rarely associated with contraceptive failure. When these agents are used, the clinician should discuss the available data with the patient and suggest a second form of birth control. Other antibiotics are most likely safe to use concomitantly with oral contraceptives.
The danger with COCP is enzyme inducers which can lower the levels of the hormone in he blood, azithromycin is not an enzyme inducer. No additional precautions are required to maintain contraceptive efficacy when using antibiotics that are not enzyme inducers with combined hormonal methods for durations of 3 weeks or less. The only proviso would be that if the antibiotics (and/or the illness) caused vomiting or diarrhoea, then the usual additional precautions relating to these conditions should be observed.Inducers: RASAG
– Rifampicin
– Anticonvulsants, particularly phenytoin, carbamazepine, phenobarbitone and primidone
– Spironolactone, St Johns wort
– Alcohol, long term
– Griseofulvin -
This question is part of the following fields:
- Women's Health
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Question 8
Correct
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A 70-year-old woman had a major surgery for removal of cancer of the ovary and lymph node dissection 6 days ago. She had not passed any flatus or stool since then. She recently developed recurrent vomiting and severe abdominal distention. What is the next step of management?
Your Answer: NG tube suction and IV fluids
Explanation:This patient developed paralytic ileus. It should be treated conservatively using IV fluids and NG tube.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 9
Incorrect
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A 23-year-old woman presents with hirsutism and oligomenorrhea for the last five years. She is very anxious about her irregular menses and worried as her mother was diagnosed with uterine cancer recently. She is a lawyer and does not want to conceive, at least for the next couple of years.
The examination is essentially normal except for coarse dark hair being noticed under her chin and over her lower back.
Investigations done during the follicular phase:
Serum androstenedione 10.1 nmol/l (0.6-8.8)
Serum dehydroepiandrosterone sulphate 11.6 ىmol/l (2-10)
Serum 17-hydroxyprogesterone 5.6 nmol/l (1-10)
Serum oestradiol 220 pmol/l (200-400)
Serum testosterone 3.6 nmol/l (0.5-3)
Serum sex hormone binding protein 32 nmol/l (40-137)
Plasma luteinising hormone 3.3 U/l (2.5-10)
Plasma follicle-stimulating hormone 3.6 U/l (2.5-10)
What is the most appropriate treatment?Your Answer: Finasteride
Correct Answer: Combined OCP
Explanation:This patient has polycystic ovarian syndrome (PCOS). Medical management of PCOS is aimed at the treatment of metabolic derangements, anovulation, hirsutism, and menstrual irregularity.
First-line medical therapy usually consists of an oral contraceptive to induce regular menses. The contraceptive not only inhibits ovarian androgen production but also increases sex hormone-binding globulin (SHBG) production. The American College of Obstetricians and Gynaecologists (ACOG) recommends the use of combination low-dose hormonal contraceptive agents for long-term management of menstrual dysfunction.
If symptoms such as hirsutism are not sufficiently alleviated, an androgen-blocking agent may be added. Pregnancy should be excluded before therapy with oral contraceptives or androgen-blocking agents are started.
First-line treatment for ovulation induction when fertility is desired is clomiphene citrate. Second-line strategies may be equally effective in infertile women with clomiphene citrate-resistant PCOS. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 10
Incorrect
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A 55-year-old female presents with complaints of retrosternal chest pain and dysphagia (which is intermittent and unpredictable in nature). When she swallows, food very suddenly 'sticks' in her chest. She is able to clear it when she drinks water, and then can finish the meal without any further incidence. A barium meal shows she has a corkscrew oesophagus. What is the most likely type of dysphagia here?
Your Answer: Plummer-Vinson syndrome
Correct Answer: Oesophageal spasm
Explanation:All of the symptoms observed in this patient are typical of uncoordinated irregular oesophageal peristalsis – this is characteristic of oesophageal spasm. The cork-screw oesophagus is also diagnostic of the condition.
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This question is part of the following fields:
- Gastrointestinal System
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Question 11
Correct
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A 65-year-old male patient is found to have an elevated serum paraprotein level of 35 g/L. Bone marrow aspirate reveals 32% monoclonal plasma cell infiltrate. He has no evidence of anaemia, renal impairment, hypercalcaemia, or lytic lesions.
What should be the next step in management?Your Answer: Observe and monitor
Explanation:The patient is asymptomatic but matches the diagnostic criteria for multiple myeloma (MM). Therefore, the underlying diagnosis of this condition is smouldering multiple myeloma (SMM). SMM is an early precursor to MM. Its treatment is typically to watch and wait.
MM is a neoplasm of the bone marrow plasma cells. Peak incidence is in patients aged 60-70 years.
Clinical features of MM include:
1. Ostealgia, osteoporosis, pathological fractures (typically vertebral), and osteolytic lesions
2. Lethargy
3. Infections
4. Hypercalcaemia
5. Renal failure
6. Other features: amyloidosis e.g. macroglossia, carpal tunnel syndrome; neuropathy; hyperviscosityDiagnosis of MM is based on the confirmation of (a) one major criterion and one minor criterion or (b) three minor criteria in an individual who has signs or symptoms of multiple myeloma.
Major criteria:
1. >30% plasma cells on bone marrow biopsy
2. Monoclonal band of paraprotein on electrophoresis: >35g/L for IgG, 20g/L for IgA, or >1g of light chains excreted in the urine per dayMinor criteria:
1. 10-30% plasma cells on bone marrow biopsy
2. Abnormal monoclonal band but levels less than listed above
3. Lytic bone lesions observed radiographically
4. Immunosuppression -
This question is part of the following fields:
- Haematology & Oncology
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Question 12
Incorrect
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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: Ecstasy
Correct 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 13
Incorrect
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A 30-year-old lawyer presents with non-specific symptoms of tiredness.
Blood tests reveal normal thyroid function, cortisol, growth hormone and gonadotropins. Pituitary MRI reveals a 0.8cm microadenoma.
Which of the following represents the most appropriate course of action?Your Answer: Bilateral sterotactic pituitary irradiation
Correct Answer: Observation and reassurance
Explanation:The patient has a non-functioning pituitary tumour as her hormone profile is normal.
Non-functioning pituitary tumours are relatively common. A large number of these tumours are incidentally found pituitary microadenomas (<1 cm) and are usually of no clinical importance. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 14
Incorrect
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An 81-year-old male patient was admitted after an ischaemic stroke. Physical examination reveals left hemiparesis. How would you classify this hemiparesis based on the WHO International Classification of Functioning, Disability and Health?
Your Answer: Right total anterior circulation infarct
Correct Answer: Impairment of body function
Explanation:Symptoms and signs are classified as ‘impairment of body function’.
The types of impairment classified as ‘activity limitation’ include difficulties that a patient may have in executing certain activities.
The type of impairment classified as ‘participation restriction’ are problems a patient may have in social roles.
The type of impairment classified as ‘pathology’ would be the diagnosis/disease.
Right total anterior circulation infarct relates to the Oxford Bamford classification for stroke. -
This question is part of the following fields:
- Geriatric Medicine
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Question 15
Correct
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A 21-year-old woman presents with painful vesicles in her right ear and a fever for some time. What is the most probable diagnosis?
Your Answer: Herpes zoster
Explanation:Herpes zoster oticus is a viral infection of the inner, middle, and external ear. It manifests as severe otalgia with associated cutaneous vesicular eruption, usually of the external canal and pinna. When associated with facial paralysis, the infection is called Ramsay Hunt syndrome.
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This question is part of the following fields:
- The Skin
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Question 16
Incorrect
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A 60-year-old man with previous history of myocardial infarction and hypertension presented with severe retrosternal chest pain for the past 2 hours. During initial management he collapsed and pulseless ventricular tachycardia was detected. The external defibrillator arrived in 3 minutes. From the following answers, what is the most appropriate immediate management of this patient whilst waiting for the defibrillator?
Your Answer: Intravenous adrenaline should be given
Correct Answer:
Explanation:Immediate Management of Pulseless Ventricular Tachycardia:
- Continuous Chest Compressions:
- Continuous chest compressions should be started immediately to maintain circulation while the defibrillator is being prepared. High-quality chest compressions are crucial and should not be delayed.
- Defibrillation:
- Once the defibrillator arrives, defibrillation should be performed as soon as possible. For pulseless ventricular tachycardia, delivering a shock is critical to attempt to restore a normal heart rhythm.
Other options:
He should be given a precordial thump: This is not recommended as a primary action when a defibrillator is available or arriving imminently.
A ventilation to compression ratio of 30:2 should be commenced: While ventilation is important, continuous chest compressions take precedence in the initial phase. The ratio of 30:2 is used during CPR when ventilations are also being provided, typically when two rescuers are present.
Await arrival of defibrillator, then deliver shock: Waiting passively without performing chest compressions is not appropriate.
Intravenous adrenaline should be given: Adrenaline is part of the advanced life support protocol, but the first immediate action should be chest compressions followed by defibrillation.
- Continuous Chest Compressions:
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This question is part of the following fields:
- Cardiovascular System
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Question 17
Correct
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A 25-year-old pregnant mother who is known to have hepatitis B gave birth to a male infant. She is now concerned about her child contracting hep B. Which of the following is the most suitable option for the baby in this case?
Your Answer: HepB full vaccine and Ig
Explanation:Hepatitis B full vaccine and Ig should be given to babies born to hepatitis B positive mothers. Hepatitis B vaccine alone or Ig alone is not sufficient to prevent the infection in the new-born baby.
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This question is part of the following fields:
- Infectious Diseases
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Question 18
Incorrect
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A 70-year-old man presents with nocturia, hesitancy and terminal dribbling of urine.
Prostate examination reveals a moderately enlarged prostate with no irregular features and a well-defined median sulcus. Blood investigations show a PSA level of 1.3 ng/mL. Among the options provided below what is the most appropriate management for this patient?Your Answer: 5 alpha-reductase inhibitor
Correct Answer: Alpha-1 antagonist
Explanation: -
This question is part of the following fields:
- Pharmacology
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Question 19
Incorrect
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A 24-year-old male was involved in a traffic collision. X-rays indicated that the neck of the humerus had suffered a fracture. Choose the single most associated nerve injury from the list of options.
Your Answer: Musculocutaneous nerve
Correct Answer: Axillary nerve
Explanation:Fractures in the neck of the humerus are well documented to cause damage to the auxiliary nerve.
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This question is part of the following fields:
- Nervous System
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Question 20
Incorrect
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A 44-year-old obese woman presented with severe abdominal pain in her right hypochondrium. An US abdomen was done which showed the presence of gallstones. The next step in management would be?
Your Answer: Low fat diet
Correct Answer: Laparoscopic Cholecystectomy
Explanation:With patients who are obese and have gallstones, the best procedure to be done is a laparoscopic cholecystectomy. Reassurance and low fat diets would not have much affect because these symptoms would recur if a cholecystectomy is not done.
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This question is part of the following fields:
- Hepatobiliary System
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Question 21
Incorrect
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A 45-year-old male presents to A&E, after hitting his car multiple times when reversing. He complains of double vision when he looked back during reversing. He also complains of double vision when looking with an outward gaze. Which is the nerve involved in this patient?
Your Answer: Oculomotor nerve
Correct Answer: Abducent nerve
Explanation:This nerve is responsible for the side to side movement of the eye, hence why damage can cause double vision.
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This question is part of the following fields:
- Nervous System
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Question 22
Incorrect
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A 65-year-old male was admitted for surgery 4 days ago. He suddenly became confused and aggressive. His attention span was reduced, and he became very restless. Which single option from the history best explains his condition?
Your Answer: Obvious cognitive impairment
Correct Answer: Alcohol consumption
Explanation:Patient was dependent on alcohol. After 4 days of admission he developed signs of alcohol withdrawal.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 23
Incorrect
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A 60-year-old male patient with hypertension presented with acute onset retrosternal chest pain for 3 hours. On examination his pulse rate was 68 bpm, BP was 100/60 mmHg and JVP was seen 3mm from the sternal notch. Respiratory examination was normal. His ECG showed narrow QRS complexes, ST segment elevation of 2mm in leads II, III and aVF and a complete heart block. What is the most immediate treatment from the following answers?
Your Answer: iv Reteplase
Correct Answer: Chewable aspirin 300 mg
Explanation:The diagnosis is inferior ST elevation myocardial infarction. As the right coronary artery supplies the SA and AV nodes and bundle of His, conduction abnormalities are more common with inferior MIs. The most immediate drug management is high dose Aspirin. Definite treatment is urgent cardiac revascularization.
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This question is part of the following fields:
- Cardiovascular System
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Question 24
Incorrect
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Which is NOT true of vitiligo?
Your Answer: There is no known cure
Correct Answer: A positive family history is not a risk factor
Explanation:The cause of Vitiligo is typically unknown. It is believed to be due to genetic susceptibility that is triggered by an environmental factor such that an autoimmune disease occurs. This results in the destruction of skin pigment cells. Risk factors include a family history of the condition or other autoimmune diseases, such as hyperthyroidism, alopecia areata, and pernicious anaemia. Vitiligo is classified into two main types: segmental and non-segmental. Most cases are non-segmental meaning they affect both sides and typically get worse with time. The prevalence of vitiligo is 0.5-1% of populations worldwide. Typical sites include backs of hands, wrists, knees, neck and around body orifices. The Koebner phenomenon refers to skin lesions appearing on lines of trauma. This occurs in vitiligo secondary to scratching.
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This question is part of the following fields:
- The Skin
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Question 25
Incorrect
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A diabetic 50-year-old male presented in the emergency room with ischaemic gangrene of the lower leg, ulceration over the medial malleolus and infection spreading proximally. Which of the following types of amputation is most suitable in this patient?
Your Answer: Supracondylar amputation
Correct Answer: Below knee amputation
Explanation:The type of amputation depends on the degree of gangrene, ischaemia and the extent of involvement of the foot, leg, knee etc. In this case, below-knee amputation is the most appropriate choice.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 26
Incorrect
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Which of the following features is characteristic of acute intermittent porphyria?
Your Answer: Photosensitivity
Correct Answer: Increased urinary porphobilinogen between acute attacks
Explanation:Urinary porphobilinogen is increased between attacks of acute intermittent porphyria (AIP) and even more so, between acute attacks.
AIP is a rare autosomal dominant condition caused by a defect in porphobilinogen deaminase, an enzyme involved in the biosynthesis of haem. This results in the toxic accumulation of delta-aminolaevulinic acid and porphobilinogen.
Abdominal and neuropsychiatric symptoms are characteristic of AIP especially in people between the ages of 20-40 years. The disease is more common in females than in males (5:1). Major signs and symptoms of AIP include abdominal pain, vomiting, motor neuropathy, hypertension, tachycardia, and depression.
Diagnosis:
1. Urine turns deep red on standing (classical picture of AIP)
2. Raised urinary porphobilinogen (elevated between attacks and to a greater extent, between acute attacks)
3. Raised serum levels of delta-aminolaevulinic acid and porphobilinogen
4. Assay of red blood cells for porphobilinogen deaminase -
This question is part of the following fields:
- Haematology & Oncology
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Question 27
Incorrect
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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: Pulmonary embolus
Correct 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 28
Incorrect
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A 23-year-old male patient presents with urethritis for the last 2 weeks that has not responded to antibiotics. Lately he has developed an onset of new range of symptoms that are linked to his HLA B27 positivity. Which of the following signs is not related to Reiter's syndrome?
Your Answer: Conjunctivitis
Correct Answer: A mild fever with a generalised macular rash
Explanation: -
This question is part of the following fields:
- Musculoskeletal System
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Question 29
Incorrect
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Which of the following is not associated with right axis deviation?
Your Answer: Right ventricular hypertrophy
Correct Answer: Wolf-Parkinson-White syndrome with right-sided accessory pathway
Explanation:Causes for right axis deviation:
-Right ventricular hypertrophy and Left posterior fascicular block
-Lateral myocardial infarction.
-Acute or chronic lung diseases: Pulmonary embolism, pulmonary hypertension, chronic obstructive pulmonary disease (COPD), cor pulmonale.
-Congenital heart disease (e.g., dextrocardia, secundum atrial septal defect).
-Wolff-Parkinson-White syndrome.
-Ventricular ectopic rhythms (e.g., ventricular tachycardia). -
This question is part of the following fields:
- Cardiovascular System
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Question 30
Correct
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A 56-year-old man who is a known alcoholic presents to the clinic with a fever and cough. Past medical history states that he has a long history of smoking and is found to have a cavitating lesion on his chest x-ray.
Which organism is least likely to be the cause of his pneumonia?Your Answer: Enterococcus faecalis
Explanation:Cavitating pneumonia is a complication that can occur with a severe necrotizing pneumonia and in some publications it is used synonymously with the latter term. It is a rare complication in both children and adults. Albeit rare, cavitation is most commonly caused by Streptococcus pneumoniae, and less frequently Aspergillus spp., Legionella spp. and Staphylococcus aureus.
In children, cavitation is associated with severe illness, although cases usually resolve without surgical intervention, and long-term follow-up radiography shows clear lungs without pulmonary sequelae
Although the absolute cavitary rate may not be known, according to one series, necrotizing changes were seen in up to 6.6% of adults with pneumococcal pneumonia. Klebsiella pneumoniae is another organism that is known to cause cavitation.Causative agents:
Mycobacterium tuberculosis
Klebsiella pneumoniae
Streptococcus pneumoniae
Staphylococcus aureusEnterococcus faecalis was not found to be a causative agent.
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This question is part of the following fields:
- Respiratory System
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SESSION STATS - PERFORMANCE PER SPECIALTY
