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Question 1
Correct
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In adults in the United Kingdom, which of the following pathogens is the most likely cause of viral infectious gastroenteritis:
Your Answer: Norovirus
Explanation:Norovirus is the most common viral cause of epidemic gastroenteritis worldwide; it is also a common cause of endemic diarrhoea in community settings. In the United Kingdom, norovirus has become the most common cause of gastroenteritis in adults and children since the introduction of rotavirus vaccination.
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This question is part of the following fields:
- Microbiology
- Pathogens
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Question 2
Incorrect
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Which of the following pathogens is most likely to cause an infection in a chemo patient with significant neutropenia?
Your Answer: Haemophilus influenzae
Correct Answer: Candida
Explanation:Chemotherapy that is too aggressive weakens your immune system, putting you at risk for a fungal and many other infection.
Neutropenia is a condition in which a person’s neutrophil count is abnormally low. Neutrophils are an infection-fighting type of white blood cell. Neutrophils fight infection by killing bacteria and fungi (yeast) that infiltrate the body.
Fungal organisms are significant pathogens in the setting of neutropenia.
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This question is part of the following fields:
- Immune Responses
- Pathology
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Question 3
Correct
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Achlorhydria is diagnosed in a 37-year-old individual who has had recurring episodes of gastroenteritis. This is an autoimmune illness of the gastric parietal cells that causes insufficient stomach acid production.
Damage to stomach parietal cells will alter the secretion of which other substance?Your Answer: Intrinsic factor
Explanation:Achlorhydria is an autoimmune illness of the gastric parietal cells that causes insufficient stomach acid production. The parietal cells that have been injured are unable to create the necessary amount of stomach acid. As a result, the pH of the stomach rises, food digestion suffers, and the risk of gastroenteritis rises.
The secretion of hydrochloric acid and intrinsic factor is controlled by the gastric parietal cells, which are epithelial cells in the stomach. These cells can be found in the gastric glands, the fundus lining, and the stomach body.
In response to the following three stimuli, the stomach parietal cells release hydrochloric acid:
H2 Histamine receptors are stimulated by histamine (most significant contribution)
Acetylcholine stimulates M3 Receptors via parasympathetic action.
CCK2 receptors are stimulated by Gastrin.Intrinsic factor, which is essential for vitamin B12 absorption, is also produced by stomach parietal cells.
Omeprazole is a proton pump inhibitor that is both selective and irreversible. It inhibits the H+/K+-ATPase system present on the secretory membrane of gastric parietal cells, which lowers stomach acid secretion.
Ranitidine inhibits histamine H2-receptors in a competitive manner. The reversible inhibition of H2-receptors in gastric parietal cells reduces both the volume and concentration of gastric acid. -
This question is part of the following fields:
- Gastrointestinal Physiology
- Physiology
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Question 4
Incorrect
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A 31-year-old man with sickle-cell disease receives a blood transfusion for symptomatic anaemia. He presents to the Emergency Department three weeks later with a rash, fever, and diarrhoea. He has pancytopenia and abnormal liver function results on blood tests.
Which of the transfusion reactions is most likely to have happened?Your Answer: Delayed haemolytic reaction
Correct Answer: Graft-vs-host disease
Explanation:Blood transfusion can be a life-saving treatment with significant clinical benefits, but it also comes with a number of risks and potential complications, including:
Immunological side effects
Errors in administration (episodes of ‘wrong blood’)
Viruses and Infections (bacterial, viral, possibly prion)
ImmunodilutionA culture of better safety procedures as well as steps to reduce the use of transfusion has emerged as a result of growing awareness of avoidable risk and improved reporting systems. Transfusion errors, on the other hand, continue to occur, and some serious adverse reactions go unreported.
Transfusion-associated graft-vs-host disease (TA-GVHD) is a rare blood transfusion complication that causes fever, rash, and diarrhoea 1-4 weeks after the transfusion. Pancytopenia and liver function abnormalities are common laboratory findings.
TA-GVHD, unlike GVHD following allogeneic marrow transplantation, causes profound marrow aplasia with a mortality rate of >90%. Survival is uncommon, with death occurring within 1-3 weeks of the onset of symptoms.
Because of immunodeficiency, severe immunosuppression, or shared HLA antigens, viable T lymphocytes in blood components are transfused, engraft, and react against the recipient’s tissues, and the recipient is unable to reject the donor lymphocytes.
The following is a list of the most common transfusion reactions and complications:1) Reaction to a febrile transfusion
The temperature rises by one degree from the baseline. Chills and malaise are also possible symptoms.
The most common response (1 in 8 transfusions).
Cytokines from leukocytes in transfused red cell or platelet components are usually to blame.
Only supportive. The use of paracetamol is beneficial.2) Acute haemolytic reaction is a type of haemolytic reaction that occurs when the
Fever, chills, pain at the transfusion site, nausea, vomiting, and dark urine are all symptoms of a transfusion reaction.
Early on, many people report a sense of ‘impending doom.’
The most serious reaction. ABO incompatibility is frequently caused by a clerical error.
STOP THE TRANSFUSION OF INFORMATION. IV fluids should be given. It’s possible that diuretics will be required.3) Haemolytic reaction that is delayed
It usually happens 4 to 8 days after a blood transfusion.
Fever, anaemia, jaundice, and haemoglobinuria are all symptoms that the patient has.
Positive Coombs test for direct antiglobulin.
Because of the low titre antibody, it is difficult to detect in a cross-match, and it is unable to cause lysis at the time of transfusion.
The majority of delayed haemolytic reactions are harmless and do not require treatment.
Anaemia and renal function should be monitored and treated as needed.4) Reaction to allergens
Foreign plasma proteins are usually to blame, but anti-IgA could also be to blame.
Urticaria, pruritus, and hives are typical allergic reactions. It’s possible that it’s linked to laryngeal oedema or bronchospasm.
Anaphylaxis is a rare occurrence.
Antihistamines can be used to treat allergic reactions symptomatically. It is not necessary to stop transfusions.
If the patient develops anaphylaxis, the transfusion should be stopped and the patient should be given adrenaline and treated according to the ALS protocol.5) TRALI (Transfusion Related Acute Lung Injury)
Within 6 hours of transfusion, there was a sudden onset of non-cardiogenic pulmonary oedema.
It’s linked to the presence of antibodies to recipient leukocyte antigens in the donor blood.
The most common cause of death from transfusion reactions is this.
STOP THE TRANSFUSION OF INFORMATION. Oxygen should be given to the patient. Around 75% of patients will require aggressive respiratory support.
The use of diuretics should be avoided.6) TACO (Transfusion Associated Circulatory Overload)
Acute or worsening respiratory distress within 6 hours of a large blood transfusion. Fluid overload and pulmonary and peripheral oedema can be seen. Rapid blood pressure rises are common. BNP is usually 1.5 times higher than it was before the transfusion. It is most common in the elderly and those who have chronic anaemia.Blood transfusions should be given slowly, over the course of 3-4 hours.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 5
Correct
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A 20-year-old female presents with painful wrist following a fall while skating. X-rays shows fracture of the ulna.
The initial phase of bone healing is?
Your Answer: Haematoma at the fracture site
Explanation:Haemorrhage occurs into the fracture site from the ruptured vessels in the bone marrow and those supplying the periosteum immediately after fracture. This hematoma formation is the first phase of bone healing.
The 4 stages of bone healing are:
Haematoma at the fracture site (provides a framework for healing)
Callus formation
Lamellar bone formation
Remodelling -
This question is part of the following fields:
- General Pathology
- Pathology
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Question 6
Incorrect
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Regarding the partial pressure of gases, which of the following statements is INCORRECT:
Your Answer: The total pressure exerted by the atmosphere at sea level is 760 mmHg (101 kPa).
Correct Answer: At high altitude, the oxygen fraction is reduced.
Explanation:At altitude, the oxygen fraction is unaltered but the barometric pressure and thus partial pressure of oxygen is reduced.
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This question is part of the following fields:
- Physiology
- Respiratory
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Question 7
Correct
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Despite taking the oral contraceptive pill, a 29-year-old woman becomes pregnant. During a medication review, you discover that she is epileptic and that her antiepileptic therapy has recently been changed.
Which of the following antiepileptics is most likely to impair the oral contraceptive pill's effectiveness?Your Answer: Carbamazepine
Explanation:The metabolism of ethinyl oestradiol and progestogens has been shown to be increased by enzyme-inducing antiepileptics. The oral contraceptive pill (OCP) is less effective in preventing pregnancy as a result of this increased breakdown.
Antiepileptic drugs that induce enzymes include:
Carbamazepine
Phenytoin
Phenobarbital
TopiramateAntiepileptics that do not induce enzymes are unlikely to affect contraception. Non-enzyme-inducing anticonvulsants include the following:
Clonazepam
Gabapentin
Levetiracetam
Piracetam
Sodium valproate is a type of valproate that is used toLamotrigine is an antiepileptic drug that does not cause the production of enzymes. It does, however, require special consideration, unlike other non-enzyme-inducing antiepileptics. The OCP does not appear to affect epilepsy directly, but it does appear to lower lamotrigine levels in the blood. This could result in a loss of seizure control and the occurrence of seizures.
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This question is part of the following fields:
- CNS Pharmacology
- Pharmacology
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Question 8
Incorrect
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The Auerbach's plexus is a set of ganglia that controls peristalsis and is located in the gut wall.
Auerbach's plexus is located in which layer of the gut wall?Your Answer: Serosa
Correct Answer: Muscular layer
Explanation:The Auerbach’s plexus, also known as the myenteric plexus, is a collection of ganglia that controls peristalsis and is located in the gut wall.
In the muscular layer of the wall, it is located between the circular and longitudinal muscle layers. It is a linear network of linked neurons that runs the length of the gastrointestinal system. The myenteric plexus generates an increase in gut wall tone and the strength of rhythmical contractions when stimulated.
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This question is part of the following fields:
- Gastrointestinal Physiology
- Physiology
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Question 9
Incorrect
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Renal potassium excretion is promoted by all but which one of the following:
Your Answer: Metabolic alkalosis
Correct Answer: Increased intracellular magnesium
Explanation:Aldosterone: A rise in [K+] in the extracellular fluid of the adrenal cortex directly stimulates aldosterone release. Aldosterone promotes the synthesis of Na+/K+ATPases and the insertion of more Na+/K+ATPases into the basolateral membrane, and also stimulates apical sodium and potassium channel activity, overall acting to increase sodium reabsorption and potassium secretion.
pH changes: Potassium secretion is reduced in acute acidosis and increased in acute alkalosis. A higher pH increases the apical K+channel activity and the basolateral Na+/K+ATPase activity – both changes that promote K+secretion.
Flow rates: Increased flow rates in the collecting duct reduce K+concentration in the lumen and therefore enhance K+secretion. Increased flow also activates BK potassium channels, and ENaC channels which promote potassium secretion and sodium reabsorption respectively.
Sodium delivery: Decreased Na+delivery to the collecting ducts results in less Na+reabsorption and hence a reduced gradient for K+secretion.
Magnesium: Intracellular magnesium can bind and block K+channels inhibiting K+secretion into the tubules. Therefore magnesium deficiency reduces this inhibitory effect and so allows more potassium to be secreted into tubules and can cause hypokalaemia. -
This question is part of the following fields:
- Physiology
- Renal
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Question 10
Incorrect
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Question 11
Correct
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A 54-year-old woman presents with polyuria and polydipsia. She is known to suffer from bipolar disorder, which has been well controlled by the use of lithium for many years.
What is the SINGLE most likely diagnosis?Your Answer: Nephrogenic diabetes insipidus
Explanation:Diabetes insipidus is the inability to produce concentrated urine. It is characterised by the presence of excessive thirst, polyuria and polydipsia. There are two distinct types of diabetes insipidus:
Cranial (central) diabetes insipidus and;
Nephrogenic diabetes insipidus
Cranial diabetes insipidus is caused by a deficiency of vasopressin (anti-diuretic hormone). Patients with cranial diabetes insipidus can have a urine output as high as 10-15 litres per 24 hours, but adequate fluid intake allows most patients to maintain normonatraemia. 30% of cases are idiopathic, and a further 30% are secondary to head injuries. Other causes include neurosurgery, brain tumours, meningitis, granulomatous disease (e.g. sarcoidosis) and drugs, such as naloxone and phenytoin. A very rare inherited form also exists that is associated with diabetes mellitus, optic atrophy, nerve deafness and bladder atonia.
Nephrogenic diabetes insipidus is caused by renal resistance to the action of vasopressin. As with cranial diabetes insipidus, urine output is markedly elevated. Serum sodium levels can be maintained by secondary polydipsia or can be elevated. Causes of nephrogenic diabetes insipidus include chronic renal disease, metabolic disorders (e.g. hypercalcaemia and hypokalaemia) and drugs, including long-term lithium usage and demeclocycline.
In view of the history of long-term lithium use, in this case, nephrogenic diabetes insipidus is the most likely diagnosis. -
This question is part of the following fields:
- Physiology
- Renal Physiology
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Question 12
Incorrect
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A 75-year-old man with rheumatoid arthritis had gained weight, developed resistant hypertension, muscle weakness, and ankle oedema. This patient is most likely suffering from what condition?
Your Answer: Cushing's disease
Correct Answer: Cushing's syndrome
Explanation:Overuse of cortisol medication, as seen in the treatment of patients with chronic asthma or rheumatoid arthritis, can cause Cushing’s syndrome.
Weight gain, thin arms and legs, a round face, increased fat around the base of the neck, a fatty hump between the shoulders, easy bruising, wide purple stretch marks primarily on the abdomen, breasts, hips, and under the arms, weak muscles, hirsutism, hypertension, erectile dysfunction, osteoporosis, frontal alopecia, acne, depression, poor wound healing, and polycythaemia are all clinical features of Cushing’s syndrome.
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This question is part of the following fields:
- Endocrine
- Physiology
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Question 13
Incorrect
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A 70-year-old patient is diagnosed with Cushing's disease. She has a history of weight gain, hypertension, and easy bruising.
In this patient, which of the following is the MOST LIKELY UNDERLYING CAUSE?Your Answer: Iatrogenic administration of corticosteroids
Correct Answer: Pituitary adenoma
Explanation:Cushing’s syndrome is a collection of symptoms and signs caused by prolonged exposure to elevated levels of either endogenous or exogenous glucocorticoids.
The most common cause of Cushing’s syndrome is the iatrogenic administration of corticosteroids. The second most common cause of Cushing’s syndrome is Cushing’s disease.
Cushing’s disease should be distinguished from Cushing’s syndrome and refers to one specific cause of the syndrome, an adenoma of the pituitary gland that secretes large amounts of ACTH and, in turn, elevates cortisol levels. This patient has a diagnosis of Cushing’s disease, and this is, therefore, the underlying cause in this case.
The endogenous causes of Cushing’s syndrome include:
Pituitary adenoma (Cushing’s disease)
Ectopic corticotropin syndrome, e.g. small cell carcinoma of the lung
Adrenal hyperplasia
Adrenal adenoma
Adrenal carcinoma -
This question is part of the following fields:
- Endocrine Physiology
- Physiology
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Question 14
Incorrect
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A 6-year-old girl is brought into the paediatric emergency room by her mother in a state of high-grade fever and extreme irritability. She is also reluctant to urinate as it is associated with lower abdominal pain and stinging. She has no history of any UTIs requiring antibiotics in the past 12 months.
The urine sensitivity test report is still unavailable. A clean catch urine sample is taken for urine dipstick, which reveals the presence of blood, protein, leukocytes and nitrites. Fresh blood tests were sent, and her estimated GFR is calculated to be 40 ml/minute.
Out of the following, which antibiotic is most appropriate to be prescribed to this patient?Your Answer: Co-amoxiclav
Correct Answer: Trimethoprim
Explanation:The NICE guidelines for children and young people under 16 years lower UTIs are:
1. Get a urine sample before antibiotics are taken, and do a dipstick test OR send for culture and susceptibility
2. Assess and manage children under 5 with lower UTI with fever as recommended in the NICE guideline on fever in under 5s.
3. Prescribe an immediate antibiotic prescription and take into account the previous urine culture and susceptibility results, previous antibiotic use, which may have led to resistant bacteria
4. If urine culture and susceptibility report is sent
– Review the choice of antibiotic when the results are available AND
– change the antibiotic according to susceptibility results if the bacteria are resistant and symptoms are not improving, using a narrow-spectrum antibiotic wherever possibleThe choice of antibiotics for non-pregnant young people under 16 years with lower UTI is summarised below:
1. Children under 3 months:
– Refer to paediatric specialist and treat with intravenous antibiotic in line with NICE guideline on fever in under 5s
2. Children over 3 months:
– First-choice
Nitrofurantoin – if eGFR >45 ml/minute
Trimethoprim – (if low risk of resistance*)
– Second-choice (no improvement in lower UTI symptoms on first-choice for at least 48 hours, or when first-choice not suitable)
Nitrofurantoin – if eGFR >45 ml/minute and not used as first-choice
Amoxicillin (only if culture results available and susceptible)
Cefalexin -
This question is part of the following fields:
- Infections
- Pharmacology
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Question 15
Incorrect
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Regarding local anaesthetics, which of the following statements is INCORRECT:
Your Answer: Lidocaine has class Ib anti-arrhythmic properties.
Correct Answer: Adrenaline should be used in digital nerve blocks to create a bloodless field.
Explanation:It is not advisable to give adrenaline/epinephrine with a local anaesthetic injection in digits or appendages because of the risk of ischaemic necrosis.
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This question is part of the following fields:
- Anaesthesia
- Pharmacology
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Question 16
Correct
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A well recognised adverse effect of metoclopramide is which of the following?
Your Answer: Acute dystonic reaction
Explanation:Side effects of metoclopramide are commonly associated with extrapyramidal effects and hyperprolactinemia. Therefore its use must be limited to short-term use. Metoclopramide can induce acute dystonic reactions which involve facial and skeletal muscle spasms and oculogyric crises. These dystonic effects are more common in the young girls and young women, and in the very old. These symptoms usually occur shortly after starting treatment with this drug and subside within 24 hours of stopping it. Abortion of dystonic attacks can be carried out by injection of an antiparkinsonian drug like procyclidine.
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This question is part of the following fields:
- Central Nervous System
- Pharmacology
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Question 17
Incorrect
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Which of the following muscles laterally rotates the hip?
Your Answer: Gluteus medius
Correct Answer: Gluteus maximus
Explanation:External (lateral) rotation at the hip joint is produced by the gluteus maximus together with a group of 6 small muscles (lateral rotators): piriformis, obturator internus, superior and inferior gemelli, quadratus femoris and obturator externus.
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This question is part of the following fields:
- Anatomy
- Lower Limb
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Question 18
Correct
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A 23-year-old has a known diagnosis of HIV. Blood is sent to the laboratory for tests.
AIDS be diagnosed at a CD4 counts below?Your Answer: 200 cells/mm 3
Explanation:A normal CD4 count ranges from 500-1000 cells/mm3.
At CD4 count of less than 350 cells/mm3 treatment with anti-retroviral therapy should be considered.
At a CD4 count of >200 cells/mm3 AIDS is diagnosed.
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This question is part of the following fields:
- Microbiology
- Specific Pathogen Groups
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Question 19
Incorrect
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Question 20
Correct
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The most common source of healthcare-associated bacteraemia is:
Your Answer: Intravenous cannula
Explanation:Healthcare-associated bacteraemia is most commonly caused by intravenous access. Any intravenous device that is left in place for a long time increases the risk of infection. It allows bacteria like Staphylococcus aureus and Staphylococcus epidermidis to enter the body.
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This question is part of the following fields:
- Microbiology
- Principles
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Question 21
Incorrect
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Which of the following statements is correct regarding the lymphatic system?
Your Answer: About 2 L is filtered by the microcirculation per day.
Correct Answer: Lymphatic vessels contain both smooth muscle and unidirectional valves.
Explanation:Fluid filtration out of the capillaries is usually slightly greater than fluid absorption into the capillaries. About 8 L of fluid per day is filtered by the microcirculation and returns to the circulation by the lymphatic system. Lymphatic capillaries drain into collecting lymphatics, then into larger lymphatic vessels. Both of these containing smooth muscle and unidirectional valves. From this point, lymph is propelled by smooth muscle constriction and vessel compression by body movements into afferent lymphatics. It then goes to the lymph nodes where phagocytes remove bacteria and foreign materials. It is here that most fluid is reabsorbed by capillaries, and the remainder returns to the subclavian veins via efferent lymphatics and the thoracic duct. The lymphatic system has a major role to play in the body’s immune defence and also has a very important role in the absorption and transportation of fats.
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This question is part of the following fields:
- Cardiovascular
- Physiology
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Question 22
Incorrect
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Funnel plots are typically used to display:
Your Answer: The strength of evidence of constituent trials in a meta-analysis
Correct Answer: The existence of publication bias in meta-analysis
Explanation:Funnel plots are used to demonstrate the existence of publication bias in meta-analysis. Funnel plots are scatter plots of treatment effects estimated from individual studies on the x axis and some measure of study size on the y axis. Each point on the graph represents one of the studies. A symmetrical inverted funnel shape indicates an absence of publication bias. If there is publication bias, there will be asymmetry of the open wide end due to the absence of small negative results.
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This question is part of the following fields:
- Evidence Based Medicine
- Study Methodology
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Question 23
Incorrect
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Regarding transport across a membrane, which of the following statements is CORRECT:
Your Answer: Facilitated diffusion is an active process requiring metabolic energy.
Correct Answer: Ion channels may be voltage-gated or ligand-gated.
Explanation:Diffusion is the passive movement of ions across a cell membrane down their electrochemical or concentration gradient through ion channels. Ion channels can be voltage-gated (regulated according to the potential difference across the cell membrane) or ligand-gated (regulated by the presence of a specific signal molecule). Facilitated diffusion is the process of spontaneous passive transport of molecules or ions down their concentration gradient across a cell membrane via specific transmembrane transporter (carrier) proteins. The energy required for conformational changes in the transporter protein is provided by the concentration gradient rather than by metabolic activity. In secondary active transport there is no direct coupling of ATP but the initial Na+ electrochemical gradient that drives the secondary active transport is set up by a process that requires metabolic energy. Examples include the sodium/calcium exchanger, or the sodium/glucose symporter.
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This question is part of the following fields:
- Basic Cellular
- Physiology
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Question 24
Correct
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A patient is sent in by her GP with suspected ectopic pregnancy. Tubal ectopic pregnancies occur most commonly in which part of the uterine tube:
Your Answer: Ampulla
Explanation:Ectopic pregnancy most commonly occurs in the ampulla (70% of cases).
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This question is part of the following fields:
- Abdomen
- Anatomy
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Question 25
Correct
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When the pulmonary artery is completely blocked, what is the ventilation over perfusion ratio for the area that it supplies?
Your Answer: Infinity
Explanation:The ventilation/perfusion ratio (V/Q ratio) is a ratio used to assess the efficiency and adequacy of the matching ventilation and perfusion.
A pulmonary artery carries deoxygenated blood from the right side of the heart to the lungs. When a large pulmonary embolus completed blocked a pulmonary artery the alveoli were ventilated but not perfused at all, then the V/Q ratio would be infinity.
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This question is part of the following fields:
- Physiology
- Respiratory Physiology
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Question 26
Correct
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Question 27
Correct
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Which of the following is the most abundant peripheral blood leucocyte:
Your Answer: Neutrophils
Explanation:Neutrophils are the most abundant peripheral blood leucocyte, comprising about 50 – 70% of circulating white cells. Neutrophils have a characteristic dense nucleus consisting of between two and five lobes, and a pale cytoplasm with an irregular outline containing many fine pink-blue or grey-blue granules. The granules are divided into primary, which appear at the promyelocyte stage, and secondary, which appear at the myelocyte stage and predominate in the mature nucleus. Both types of granule are lysosomal in origin; the primary contains myeloperoxidase and other acid hydrolases; the secondary contains lactoferrin, lysozyme and other enzymes. The lifespan of neutrophils in the blood is only 6 – 10 hours. In response to tissue damage, cytokines and complement proteins, neutrophils migrate from the bloodstream to the site of insult within minutes, where they destroy pathogens by phagocytosis.
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This question is part of the following fields:
- Immune Responses
- Pathology
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Question 28
Correct
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A critically ill 48-year-old individual appears with symptoms and signs of an anaphylactic reaction.
In an allergic reaction, which of the following is an absolute contraindication to the injection of adrenaline?Your Answer: None of the other options
Explanation:Even if the following relevant contraindications exist, adrenaline can be given in life-threatening anaphylactic reactions:
Coronary artery disease (CAD)
Coronary artery disease (CAD) Second stage of labour
Hypertension that is uncontrolled
Severe Ventricular arrhythmias -
This question is part of the following fields:
- Pharmacology
- Respiratory Pharmacology
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Question 29
Correct
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Regarding flucloxacillin, which of the following statements is CORRECT:
Your Answer: It is resistant to bacterial beta-lactamases.
Explanation:Flucloxacillin is unique in that it is beta-lactamase stable and it can be used in infections caused by beta-lactamase producing staphylococci e.g. S. aureus. It is acid-stable and can therefore be given by mouth as well as by injection. It is used first line for treatment of widespread impetigo infection, cellulitis, mastitis, osteomyelitis, septic arthritis, severe erysipelas, severe/spreading otitis externa and infective endocarditis caused by staphylococci. The most common adverse effects of flucloxacillin include nausea, vomiting, skin rash, and diarrhoea. Cholestatic jaundice and hepatitis may occur very rarely, up to two months after treatment with flucloxacillin has been stopped. Administration for more than 2 weeks and increasing age are risk factors. First line treatment of animal and human bites is co-amoxiclav.
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This question is part of the following fields:
- Infections
- Pharmacology
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Question 30
Correct
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Which coronary artery is mostly likely affected if an ECG shows a tombstone pattern in leads V2, V3 and V4?
Your Answer: Left anterior descending artery
Explanation:Tombstoning ST elevation myocardial infarction can be described as a STEMI characterized by tombstoning ST-segment elevation. This myocardial infarction is associated with extensive myocardial damage, reduced left ventricle function, serious hospital complications and poor prognosis. Tombstoning ECG pattern is a notion beyond morphological difference and is associated with more serious clinical results.
Studies have shown that tombstoning is more commonly found in anterior than non-anterior STEMI, thus, higher rates of left anterior descending artery disease are observed in patients with tombstoning pattern.
The following ECG leads determine the location and vessels involved in myocardial infarction:
ECG Leads Location Vessel involved
V1-V2 Septal wall Left anterior descending
V3-V4 Anterior wall Left anterior descending
V5-V6 Lateral wall Left circumflex artery
II, III, aVF Inferior wall Right coronary artery (80%) or Left circumflex artery (20%)
I, aVL High lateral wall Left circumflex artery
V1, V4R Right ventricle Right coronary artery
V7-V9 Posterior wall Right coronary artery -
This question is part of the following fields:
- Anatomy
- Thorax
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Question 31
Correct
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A patent has weakness of humeral flexion and extension. A CT scan reveals that he has suffered damage to the nerve that innervates pectoralis major.
Pectoralis major receives its innervation from which of the following nerves? Select ONE answer only.Your Answer: Lateral and medial pectoral nerves
Explanation:Pectoralis major is a thick, fan-shaped muscle situated in the chest. It makes up the bulk of the chest musculature in the male and lies underneath the breast in the female. It overlies the thinner pectoralis minor muscle.
Superficial muscles of the chest and arm showing pectoralis major (from Gray’s Anatomy)
Pectoralis major has two heads; the clavicular head and the sternocostal head. The clavicular head originates from the anterior border and medial half of the clavicle. The sternocostal head originates from the anterior surface of the sternum, the superior six costal cartilages and the aponeurosis of the external oblique muscle. It inserts into the lateral lip of the bicipital groove of the humerus.
Pectoralis major receives dual innervation from the medial pectoral nerve and the lateral pectoral nerve.
Its main actions are as follows:
Flexes humerus (clavicular head)
Extends humerus (sternocostal head)
Adducts and medially rotates the humerus
Draws scapula anteriorly and inferiorly -
This question is part of the following fields:
- Anatomy
- Upper Limb
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Question 32
Incorrect
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A 27-year-old man was sent to the emergency department by ambulance with suspected anaphylaxis. What is the best first-line treatment for this patient?
Your Answer: 0.5 mL of 1:10000 adrenaline solution intramuscularly
Correct Answer: 500 micrograms of adrenaline intramuscularly
Explanation:Anaphylaxis is the sudden onset of systemic hypersensitivity due to IgE-mediated chemical release from mast cells and basophils.
If anaphylaxis is suspected, 500 micrograms of adrenaline should be administered promptly (0.5 ml of 1:1000 solution).
In anaphylaxis, the intramuscular route is the most immediate approach; the optimal site is the anterolateral aspect of the middle part of the thigh.
Intravenous adrenaline should only be given by people who are well-versed in the use and titration of vasopressors in their routine clinical practice.
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This question is part of the following fields:
- Pharmacology
- Respiratory
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Question 33
Incorrect
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Carbon dioxide is transported in the blood approximately:
Your Answer: 80% as bicarbonate ions and 20% dissolved in plasma
Correct Answer: 60% as bicarbonate ions, 30% as carbamino compounds and 10% dissolved in plasma.
Explanation:Carbon dioxide is transported in the blood from tissues to the lungs in three ways as bicarbonate ions (60%), as carbamino compounds with proteins (30%) or simply dissolved in plasma (10%).
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This question is part of the following fields:
- Physiology
- Respiratory
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Question 34
Correct
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EMLA cream is a topical local anaesthetic containing which of the following:
Your Answer: 50/50 mixture 2.5% lidocaine and 2.5% prilocaine
Explanation:EMLA cream, an effective topical local anaesthetic, is a 50/50 mixture of 2.5% prilocaine and 2.5% lidocaine.
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This question is part of the following fields:
- Anaesthesia
- Pharmacology
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Question 35
Incorrect
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Regarding fat digestion, which of the following statements is CORRECT:
Your Answer: Gastric lipase is the most important enzyme in lipid digestion.
Correct Answer: Chylomicrons are exocytosed from enterocytes to enter lacteals and thus the lymphatic system.
Explanation:Dietary fat is chiefly composed of triglycerides (esters of free fatty acids and glycerol which may be saturated or unsaturated). The essential fatty acids are linoleic acid and alpha-linoleic acid, which cannot be manufactured in the body. Dietary fat provides 37 kJ (9 kcal) of energy per gram. Fats are digested almost entirely in the small intestine and are only released from the stomach into the duodenum at the rate at which they can be digested.
Pancreatic lipase is the most significant enzyme for fat digestion. In the duodenum fat is emulsified by bile acids, a process where larger lipid droplets are broken down into much smaller droplets providing a greater surface area for enzymatic digestion. Micelles are arranged so that hydrophobic lipid molecules lie in the centre, surrounded by bile acids arranged such the outer region is hydrophilic. Dietary and synthesised lipids are incorporated into chylomicrons in the Golgi body, which are exocytosed from the basolateral membrane to enter lacteals and thus the lymphatic system. -
This question is part of the following fields:
- Gastrointestinal
- Physiology
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Question 36
Correct
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Osteoclasts are a type of bone cell that are critical in the maintenance, repair and remodelling of bones.
Which of the following inhibits osteoclast activity? Select ONE answer only.Your Answer: Calcitonin
Explanation:Osteoclasts are a type of bone cell that breaks down bone tissue. This is a critical function in the maintenance, repair and remodelling of bones. The osteoclast disassembles and digests the composite of hydrated protein and minerals at a molecular level by secreting acid and collagenase. This process is known as bone resorption and also helps to regulate the plasma calcium concentration.
Osteoclastic activity is controlled by a number of hormones:
1,25-dihydroxycholecalciferol increases osteoclastic activity
Parathyroid hormone increases osteoclastic activity
Calcitonin inhibits osteoclastic activity
Bisphosphonates are a class of drug that slow down and prevent bone damage. They are osteoclast inhibitors. -
This question is part of the following fields:
- Endocrine Physiology
- Physiology
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Question 37
Correct
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Which of the following is considered an example of an observational study?
Your Answer: Cohort study
Explanation:The two most common types of observational studies are cohort studies and case-control studies; a third type is cross-sectional studies.
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This question is part of the following fields:
- Evidence Based Medicine
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Question 38
Incorrect
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A 77 year old lady presents to ED with her left leg shortened and externally rotated following slipping and falling on a wet bathroom floor. There is an intracapsular fracture of the neck of femur seen on imaging studies. She is at risk of avascular necrosis of the head of femur.
This is caused by lack of blood supply from which of these arteries?
Your Answer: Lateral circumflex artery
Correct Answer: Medial circumflex artery
Explanation:The primary blood supply to the head of the femur is from branches of the medial femoral circumflex artery.
The superior and inferior gluteal arteries supply the hip joint but not the head of femur.
The lateral circumflex artery anastomoses with the medial femoral circumflex artery and assists in supplying the head of femur.
The obturator artery is an important source of blood supply in children up to about 8 years. It gives rise to the artery of the head of femur which runs in the ligamentum teres and is insufficient to supply the head of femur in adults.
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This question is part of the following fields:
- Anatomy
- Lower Limb
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Question 39
Incorrect
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Due to severe palpitations, a 28-year-old woman is transported to the Emergency Department by ambulance. Her heart rate is 180 beats per minute, and the rhythm strip shows supraventricular tachycardia. You intend to give adenosine.
Which of the following is NOT a contraindication for adenosine use?Your Answer: Long QT syndrome
Correct Answer: History of heart transplant
Explanation:The purine nucleoside adenosine is used to diagnose and treat paroxysmal supraventricular tachycardia. Adenosine works by stimulating A1-adenosine receptors and opening potassium channels that are sensitive to acetylcholine. This causes the atrioventricular (AV) node’s cell membrane to become hyperpolarized, slowing conduction by inhibiting calcium channels.
Patients who have had a heart transplant are extremely sensitive to the effects of adenosine and should start with a lower dose of 3 mg, then 6 mg, and finally 12 mg. Dipyridamole potentiates the effects of adenosine, so it should be used with caution in patients who are taking it.
The use of adenosine is contraindicated in the following situations:
Asthma
COPD (chronic obstructive pulmonary disease)
Decompensated heart failure
Long QT syndrome
AV block in the second or third degree
Sinusitis is a condition in which the sinuses become (unless pacemaker fitted)
Hypotension that is severeIt has a half-life of less than 10 seconds and acts quickly within that time frame. The actions last between 10 and 20 seconds.
Because of the short half-life of the drug, any side effects are usually only temporary. These are some of them:
a feeling of impending doom
Flushing of the face
Dyspnoea
Uncomfortable chest
Tastes metallic -
This question is part of the following fields:
- Cardiovascular Pharmacology
- Pharmacology
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Question 40
Correct
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Typically, granulomatous inflammation is associated with one of the following infections:
Your Answer: Tuberculosis
Explanation:Granulomatous inflammation is typically seen when an infective agent with a digestion-resistance capsule (e.g. Mycobacterium tuberculosis) or a piece of inert foreign material (such as suture or glass) is introduced into the tissue. A transient acute inflammatory response occurs and when this is ineffective in eradicating the stimulus, chronic inflammation occurs.
Tuberculosis is the prototype of the granulomatous diseases, but sarcoidosis, cat-scratch disease, lymphogranuloma inguinale, leprosy, brucellosis, syphilis, some mycotic infections, berylliosis, reactions of irritant lipids, and some autoimmune diseases are also included
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This question is part of the following fields:
- Inflammatory Responses
- Pathology
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Question 41
Correct
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Regarding cellular respiration, which of the following statements is CORRECT:
Your Answer: When fats are used as the primary energy source, an excess of acetyl-CoA is produced.
Explanation:Cellular respiration is the process by which cells obtain energy in the form of adenosine triphosphate (ATP). ATP transfers chemical energy from the energy rich substances in the cell to the cell’s energy requiring reactions e.g. active transport, DNA replication and muscle contraction.Cellular respiration is essentially a three step process: 1) Glycolysis, 2)The Krebs cycle, 3)The electron transfer system.The main respiratory substrate used by cells is 6-carbon glucose. Fats and proteins can also be used as respiratory substrates. When fats are being used as the primary energy source, in the absence of glucose, an excess amount of acetyl-CoA is produced, and is converted into acetone and ketone bodies. This can occur in starvation, fasting or in diabetic ketoacidosis. Proteins are used as an energy source only if protein intake is very high, or if glucose and fat sources are depleted.
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This question is part of the following fields:
- Basic Cellular
- Physiology
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Question 42
Correct
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Which of the following is NOT a pharmacological effect of beta-blockers:
Your Answer: Reduced AV conduction time
Explanation:Effects of beta-blockers:
Cardiovascular system:
Reduce blood pressure
Reduce heart rate, contractility and cardiac output
Increase AV conduction time, refractoriness and suppress automaticityEye:
Reduce intraocular pressureRespiratory system:
Cause bronchoconstriction -
This question is part of the following fields:
- Cardiovascular
- Pharmacology
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Question 43
Correct
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A patient presents to ED with heartburn for which they already take regular antacids. Which of the following drugs can be affected if taken with antacids:
Your Answer: Digoxin
Explanation:Antacids should preferably not be taken at the same time as other drugs since they may affect absorption. When antacids are taken with acidic drugs (e.g. digoxin, phenytoin, chlorpromazine, isoniazid) they cause the absorption of the acidic drugs to be decreased, which causes low blood concentrations of the drugs, which ultimately results in reduced effects of the drugs. Antacids taken with drugs such as pseudoephedrine and levodopa increase absorption of the drugs and can cause toxicity/adverse events due to increased blood levels of the drugs. Antacids that contain magnesium trisilicate and magnesium hydroxide when taken with some other medications (such as tetracycline) will bind to the drugs, and reduce their absorption and effects.
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This question is part of the following fields:
- Gastrointestinal
- Pharmacology
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Question 44
Correct
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A 49-year-old woman with haemoglobin of 6 g/dL following persistent vaginal bleeding receives blood transfusion. She developed pain and burning at her cannula site and complains of a feeling of “impending doom”, nausea, and severe back pain shortly after transfusion was started. Her temperature is 38.9ºC.
What is the most appropriate treatment?Your Answer: Stop the transfusion and administer IV fluids
Explanation:Acute haemolytic transfusion reactions present with: Feeling of ‘impending doom’ as the earliest symptom, fever and chills, pain and warmth at transfusion site, nausea and vomiting, back, joint, and chest pain. Transfusion should be stopped immediately and IV fluid (usually normal saline) administered.
Supportive measures and paracetamol can be given since patient has fever but it is not the immediate first step.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 45
Correct
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A 20-year-old patient had sustained a supracondylar fracture due to falling from a skateboard. The frequency of acute nerve injuries accompanying supracondylar humeral fractures ranges from 10 to 20%. The most common complication is injury to which nerve?
Your Answer: Median nerve
Explanation:According to various studies, the frequency of acute nerve damage associated with supracondylar humeral fractures in children ranges from 10% to 20%.
Median nerve injury and anterior interosseous nerve injury are the most common consequences.
Damage to this nerve indicated weakening or abnormal extension of the index finger’s distal interphalangeal joint and the thumb’s interphalangeal joint. The absence of sensibility is a distinguishing attribute.
A surgical neck humerus fracture may cause injury to the axillary nerve. A midshaft humerus fracture might cause injury to the radial nerve. A medial epicondylar fracture might cause injury to the ulnar nerve.
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This question is part of the following fields:
- Anatomy
- Upper Limb
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Question 46
Correct
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A tumour compresses the jugular foramen of a 50-year-old patient. Compression of several nerves in the jugular foramen will result in which of the following complications?
Your Answer: Loss of gag reflex
Explanation:The glossopharyngeal nerve, which is responsible for the afferent pathway of the gag reflex, the vagus nerve, which is responsible for the efferent pathway of the gag reflex, and the spinal accessory nerve all exit the skull through the jugular foramen. These nerves are most frequently affected if the jugular foramen is compressed. As a result, the patient’s gag reflex is impaired.
The vestibulocochlear nerve is primarily responsible for hearing. The trigeminal nerve provides sensation in the face. The facial nerve innervates the muscles of face expression (including those responsible for closing the eye). Tongue motions are controlled mostly by the hypoglossal nerve.
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This question is part of the following fields:
- Anatomy
- Cranial Nerve Lesions
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Question 47
Incorrect
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Which of the following is most likely to cause a homonymous hemianopia:
Your Answer: Pituitary adenoma
Correct Answer: Posterior cerebral artery stroke
Explanation:A posterior cerebral stroke will most likely result in a contralateral homonymous hemianopia with macular sparing.
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This question is part of the following fields:
- Anatomy
- Central Nervous System
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Question 48
Incorrect
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Regarding hepatitis C, which of the following statements is INCORRECT:
Your Answer: Treatment often involves combination therapy with ribavirin and pegylated interferon.
Correct Answer: Anti-HCV IgG antibodies are diagnostic of acute infection.
Explanation:Anti-HCV IgG antibodies indicate exposure to hepatitis C but this could be acute, chronic or resolved infection. If the antibody test is positive, HCV RNA should be tested for, which if positive indicates that a person has current infection with active hepatitis C.
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This question is part of the following fields:
- Microbiology
- Pathogens
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Question 49
Correct
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A 64-year-old woman with a history of chronic breathlessness is referred for lung function testing.
Which of the following statements regarding lung function testing is FALSE? Select ONE answer only.Your Answer: In restrictive lung disease, the FVC is increased
Explanation:In restrictive lung disorders there is a reduction in the forced vital capacity (FVC) and the forced expiratory volume in one second (FEV1). The decline in the FVC is greater than that of the FEV1, resulting in preservation of the FEV1/FVC ratio (>0.7%).
In obstructive lung disease, FEV1is reduced to <80% of normal and FVC is usually reduced but to a lesser extent than FEV1. The FEV1/FVC ratio is reduced to <0.7.
According to the latestNICE guidelines(link is external), airflow obstruction is defined as follows:
Mild airflow obstruction = an FEV1 of >80% in the presence of symptoms
Moderate airflow obstruction = FEV1 of 50-79%
Severe airflow obstruction = FEV1 of 30-49%
Very severe airflow obstruction = FEV1<30%.
Spirometry is a poor predictor of durability and quality of life in COPD but can be used as part of the assessment of severity.
COPD can only be diagnosed on spirometry if the FEV1 is <80% and FEV1/FVC ratio is < 0.7. -
This question is part of the following fields:
- Physiology
- Respiratory Physiology
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Question 50
Incorrect
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Which of these statements about the monospot test is true?
Your Answer: It is positive in infectious mononucleosis before the onset of symptoms
Correct Answer: It can be positive in rubella
Explanation:Infectious mononucleosis can be diagnosed using specific EBV antibodies and a variety of unrelated non-EBV heterophile antibodies.
Heterophile antibodies:
About 70-90% of patients with EBV infectious mononucleosis produce antibodies against an antigen produced in one species that react against antigens from other species called heterophile antibodies. False positives can be seen with rubella, hepatitis, SLE, malaria, toxoplasmosis, lymphoma and leukaemia.These antibodies can be detected by two main screening tests:
The monospot test uses horse red blood cells. It agglutinates in the presence of heterophile antibodies.
Paul-Bunnell test uses sheep red blood cells. The blood agglutinates in the presence of heterophile antibodies.EBV-specific antibodies:
Patients can remain heterophile-negative after six weeks and are then considered to be heterophile-negative and should be tested for EBV-specific antibodies. EBV-specific antibodies test are helpful if a false positive heterophile antibody test is suspected.
The indirect Coombs test is used to detect in-vitro antibody-antigen reactions. It is typically used in antenatal antibody screening and in preparation for blood transfusion.
Heterophile antibody tests are generally not positive in the incubation period of infectious mononucleosis (4-6 weeks) before the onset of symptoms. -
This question is part of the following fields:
- Microbiology
- Specific Pathogen Groups
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SESSION STATS - PERFORMANCE PER SPECIALTY
