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Question 1
Incorrect
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A 44 year-old electrician is referred to you complaining of increasing problems with concentration. He also complains of irregular jerky movements of his extremities and fingers. He consumes approximately 25 units of alcohol per week. His father was diagnosed with dementia at the age of 40. Apart from generalized choreiform movements, his neurological and systemic examinations were normal. Which of the following is the most likely diagnosis?
Your Answer: Alcoholic cerebral degeneration
Correct Answer: Huntington's disease
Explanation:Huntington’s disease is an autosomal inherited condition characterized by progressive dementia and worsening choreiform movements. Symptoms typically appear between ages 30 and 50. Ultimately the weakened individual succumbs to pneumonia, heart failure, or other complications.
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This question is part of the following fields:
- Nervous System
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Question 2
Correct
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A 22-year-old woman presents with anxiety and weight loss with increased appetite.
Thyrotoxicosis is suspected and various investigations are performed.
Which of the following findings is most consistent with Graves' disease?Your Answer: High titre of thyroid peroxidase autoantibodies
Explanation:Free T4 levels or the free T4 index is usually elevated, as is the free T3 level or free T3 index
– Assays for thyrotropin-receptor antibodies (particularly TSIs) almost always are positive.
– Detection of TSIs is diagnostic for Graves disease.
– Other markers of thyroid autoimmunity, such as antithyroglobulin antibodies or antithyroid peroxidase antibodies, are usually present.
– Other autoantibodies that may be present include thyrotropin receptor-blocking antibodies and anti-sodium-iodide symporter antibody.
The presence of these antibodies supports the diagnosis of autoimmune thyroid disease.
– The radioactive iodine uptake is increased and the uptake is diffusely distributed over the entire gland. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 3
Correct
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A 67-year-old man presents with anaemia and weight loss. Upon endoscopy, a gastric tumour is revealed, later established as an adenocarcinoma. The patient refuses any treatment and claims that his condition is not influencing the quality of his life. Clinical examination has nothing particularly interesting to show and the patient seems to be conscious of his decision, regardless of the likely curative nature of surgery. What is the single most appropriate management?
Your Answer: Respect his wishes and book a follow-up appointment for four weeks
Explanation:The patient seems to be conscious about his decision, which should be respected. According to Mental Capacity Act 2005, a person who makes an unwise decision should not be treated as unable to make a decision.
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This question is part of the following fields:
- Haematology & Oncology
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Question 4
Incorrect
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A 28-year-old man is investigated for lethargy. His full blood count (FBC) report shows:
Hb: 8.6 g/dL
Plts: 42 x 10^9/L
WCC: 36.4 x 10^9/L
His blood film report reveals 30% myeloblasts with Auer rods. Given the likely diagnosis, which one of the following is associated with a good prognosis?Your Answer: Translocation between chromosome 9 and 14
Correct Answer: Translocation between chromosome 15 and 17
Explanation:A translocation between chromosome 15 and 17 is seen in acute promyelocytic leukaemia (APL), which is known to carry a good prognosis.
Acute myeloid leukaemia (AML) is the acute expansion of the myeloid stem line, which may occur as a primary disease or follow the secondary transformation of a myeloproliferative disorder. It is more common over the age of 45 and is characterized by signs and symptoms largely related to bone marrow failure such as anaemia (pallor, lethargy), frequent infections due to neutropenia (although the total leucocyte count may be very high), thrombocytopaenia (bleeding), ostealgia, and splenomegaly. The disease has poor prognosis if:
The disease has poor prognosis if:
1. Age of the patient >60 years
2. >20% blasts seen after the first course of chemotherapy
3. Chromosomal aberration with deletion of part of chromosome 5 or 7.APL is an aggressive form of AML. It is associated with t(15;17) and has a good prognosis. The general age of presentation is less than that in other types of AML (average age is 25 years old). On blood film, abundant Auer rods are seen with myeloperoxidase staining. Thrombocytopaenia or DIC is seen in patients presenting with this disease.
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This question is part of the following fields:
- Haematology & Oncology
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Question 5
Incorrect
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A 25-year-old female was admitted following the ingestion of 36 paracetamol tablets. On examination she was confused and disoriented. Investigations after 24 hrs showed a normal FBC, pH - 7.2, serum creatinine - 3.7mg/dl and INR 6.5. Which of the following is the most appropriate management for her?
Your Answer: Give N-Acetylcysteine
Correct Answer: Liver transplantation
Explanation: -
This question is part of the following fields:
- Emergency & Critical Care
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Question 6
Incorrect
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Which the following features is most suggestive of megaloblastic anaemia?
Your Answer: Atrophic gastritis
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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Question 7
Correct
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A 45-year-old male presents with lower backache and pain in his hips. Blood tests are normal except for elevated serum alkaline phosphatase which is 1200 IU/l (45-105). Radiological examination shows combined osteolytic and osteosclerotic lesions. What is the most common site of occurrence of this disease?
Your Answer: Pelvis
Explanation:The patient most likely suffers from Paget’s disease of the bone as his radiological examination shows both osteolytic and osteosclerotic lesions. Any bone or bones can be affected, but Paget’s disease occurs most frequently in the pelvis > lumbar spine > femur > thoracic spine > sacrum > skull > tibia.
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This question is part of the following fields:
- Musculoskeletal System
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Question 8
Correct
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A 12-year-old boy hit his head on a pole on the school playground. His friends noted that he lost consciousness for a few seconds. The school nurse sent him to the Emergency Department as he had a small nasal bleed that stopped spontaneously. In the intervening two hours, he has noticed a watery discharge from his nose. On examination, there is considerable bruising on his nose and forehead, he was complaining of a headache. Which is the most appropriate diagnosis?
Your Answer: Basilar skull fracture
Explanation:Orbital bone fracture: The child has sustained a head injury and subsequently describes a CSF rhinorrhoea (indicating a cerebro-spinal fluid leak). CSF rhinorrhoea can occur in skull or nasal bone fractures. Given the symptoms of loss of consciousness and headache, this child is more at risk of having suffered a skull fracture requiring emergency CT head investigation and specialist neurosurgical management. An ethmoid bone fracture may also present this way. A skull x ray would help to determine an air fluid level and indeed allow some visualisation of the nasal bones, though in children the nasal bones do not visualise well due to lack of fusion. Either way this child would need assessment in the nearest Emergency Department and the school would be expected to follow a ‘head injury’ protocol.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 9
Correct
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A patient develops methemoglobinemia after being prescribed isosorbide mononitrate. Which enzyme is most likely to be deficient?
Your Answer: NADH methaemoglobin reductase
Explanation:Methemoglobinemia is a rare condition in which the haemoglobin iron is in oxidized or ferric state (Fe3+) and cannot reversibly bind oxygen. Normally, the conversion of ferrous form of iron (Fe2+) to its ferric form (Fe3+) is regulated by NADH methaemoglobin reductase, which results in the reduction of methaemoglobin to haemoglobin. Disruption in the enzyme leads to increased methaemoglobin in the blood. There is tissue hypoxia as Fe3+ cannot bind oxygen, and hence the oxygen-haemoglobin dissociation curve is shifted to the left.
Methemoglobinemia can occur due to congenital or acquired causes. Congenital causes include haemoglobin variants such as HbM and HbH, and deficiency of NADH methaemoglobin reductase. Acquired causes are drugs (e.g. sulphonamides, nitrates, dapsone, sodium nitroprusside, and primaquine) and chemicals (such as aniline dyes).
The features of methemoglobinemia are cyanosis, dyspnoea, anxiety, headache, severe acidosis, arrhythmias, seizures, and loss of consciousness. Patients have normal pO2 but oxygen saturation is decreased. Moreover, presence of chocolate-brown coloured arterial blood (colour does not change with addition of O2) and brown urine also point towards the diagnosis of methemoglobinemia.
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This question is part of the following fields:
- Haematology & Oncology
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Question 10
Correct
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A 62-year-old male patient with long standing COPD presented with reduced vision of his right eye. He had been on multiple medications. Which of the following drugs is responsible for his visual deterioration?
Your Answer: Corticosteroid
Explanation:Prolonged use of corticosteroids causes cataracts and this would be the reason for his presentation. B2 agonists, diuretics and Theophylline can cause blurred vision.
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This question is part of the following fields:
- Pharmacology
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Question 11
Incorrect
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In which of the following options does reversed splitting of the second heart sound occur?
Your Answer: Mild aortic stenosis (AS)
Correct Answer: Left bundle branch block (LBBB)
Explanation:Reversed splitting of the second heart sound occurs with reversal of the normal A2, P2 pattern – A2 may, therefore, be delayed, as with severe AS and LBBB. P2 may be early, as in Wolff-Parkinson-White Type B and persistent ductus arteriosus. Atrial septal defects show wide fixed splitting. Also, RBBB has wide (not fixed) splitting.
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This question is part of the following fields:
- Cardiovascular System
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Question 12
Correct
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A baby born a few days earlier is brought into the emergency with complaints of vomiting, constipation and decreased serum potassium. Which of the following is the most probable cause?
Your Answer: Pyloric stenosis: hypokalaemic hypochloraemic metabolic alkalosis
Explanation:In pyloric stenosis a new-born baby presents with a history of vomiting, constipation and deranged electrolytes. Excessive vomiting leads to hypokalaemia. Difficulty in food passing from the stomach to the small intestine causes constipation. Hypokalaemia also causes constipation. None of the other disorders mentioned present with the hypokalaemia, vomiting and constipation triad in a new-born.
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This question is part of the following fields:
- Gastrointestinal System
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Question 13
Correct
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Which of the following describes the reason for the decline of the use of beta blockers as antihypertensives in last few years?
Your Answer: Less likely to prevent stroke + potential impairment of glucose tolerance
Explanation:According to the latest research, beta blockers are associated with higher incidence of fatal and non-fatal strokes, all cardiovascular events, and cardiovascular mortality. New-onset diabetes also associates with beta blockers.
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This question is part of the following fields:
- Cardiovascular System
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Question 14
Incorrect
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A 74-year-old woman referred by her GP because of increasing weight loss, early satiety and increasing anorexia. She admits to 2 or 3 episodes of vomiting blood. The GP feels an epigastric mass.
There is both a microcytic anaemia and abnormal liver enzymes. Her past history, which may be of importance, includes excess consumption of sherry and spirits, and a 30 pack-year smoking history.
Which diagnosis fits best with this clinical picture?Your Answer: Pancreatic carcinoma
Correct Answer: Gastric carcinoma
Explanation:With a clinical history of weight loss, smoking, drinking alcohol, and hematemesis, the most likely answer is gastric carcinoma (also a mass). Based on symptomatology alone this is more likely than gastric lymphoma, as she has many risk factors for adenocarcinoma and/or squamous cell carcinoma. Helicobacter gastritis would not likely present with the severity of symptoms, neither would benign gastric ulcers.
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This question is part of the following fields:
- Gastrointestinal System
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Question 15
Correct
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A 73-year-old gentleman with type 2 diabetes mellitus, complains of difficulty walking and trouble with his hands. It began with a tingling sensation in his soles, which later extended up to his ankles. He now feels unsteady when walking, and more recently, has noticed numbness and tingling in the fingers of both hands.
On examination, he has absent ankle reflexes, a high steppage gait, and altered sensation to his mid-calves.
What is the underlying pathological process?Your Answer: Axonal degeneration
Explanation:This case presents with sensorimotor neuropathy secondary to his DM. The progression of the neuropathy, known dying-back neuropathy, is a distal axonopathy or axonal degeneration as where the sensorimotor loss begins distally and travels proximally.
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This question is part of the following fields:
- Nervous System
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Question 16
Incorrect
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A 20-year-old pregnant female in her first trimester met a child with chickenpox. She was investigated for the varicella antibody, which came back negative. She visited her GP. Which of the following measures is the most appropriate one?
Your Answer: Acyclovir
Correct Answer: Ig
Explanation:After the exposure to chickenpox while pregnant, even if the patient is negative for antibodies she requires immunoglobulin to prevent further issues.
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This question is part of the following fields:
- Infectious Diseases
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Question 17
Incorrect
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A 70-year-old male presents with an ulcer between his toes - it has a punched-out appearance. He is known to both smoke and drinks heavily. Upon examination, the ulcer is yellow in colour. His foot also turns red when it hangs from the bed. From the list given, choose the single most likely diagnosis for this patient.
Your Answer: Neuropathic ulcer
Correct Answer: Arterial ischemia ulcer
Explanation:Arterial ischemia ulcers present with many of the symptoms observed in this patient: ulcer on the lower extremities, pain, swelling, yellow sores, a punched-out appearance, the foot turning red when dangling from a bed. Smoking a lot is also known to be a causative factor here. This type of ulcer develops due to damage to the arteries caused by a lack of blood flow to the tissue – they are also deep wounds. Venous ischemic ulcers usually form in the knee or inner ankle area as opposed to the foot.
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This question is part of the following fields:
- The Skin
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Question 18
Correct
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Presence of which of the following indicates a worse prognosis in rheumatoid arthritis?
Your Answer: Anti-CCP antibodies
Explanation:Rheumatoid arthritis is both common and chronic, with significant consequences for multiple organ systems. Anti-cyclic citrullinated peptide (anti-CCP) antibody testing is particularly useful in the diagnosis of rheumatoid arthritis, with high specificity, presence early in the disease process, and ability to identify patients who are likely to have severe disease and irreversible damage. However, its sensitivity is low, and a negative result does not exclude disease. Anti-CCP antibodies have not been found at a significant frequency in other diseases to date, and are more specific than rheumatoid factor for detecting rheumatoid arthritis. The other factors that are mentioned do not play a key prognostic role.
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This question is part of the following fields:
- Musculoskeletal System
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Question 19
Correct
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A 19-year-old girl suffers from a hereditary disease and presents at her GP with a renal colic. She claims that her mother had this problem too. What type of renal calculus is most likely responsible for the renal colic?
Your Answer: Cystine
Explanation:The patient seems to have inherited cystinuria which is an autosomal recessive disease. Typical for the disease is the abnormally high concentration of cysteine in the urine, finally causing cystinuria. In a person with cystinuria, the high concentrations of cysteine in the kidney results in the formation of stones with frequent colic pains and complications. If the genotype is partially expressed, then the phenotype might be even asymptomatic, thus the disease has a high variability.
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This question is part of the following fields:
- Renal System
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Question 20
Incorrect
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A 5-year-old child was found to have orchidomegaly and splenomegaly. Blood tests show a WBC = 1.7 X 104/L, Hb = 7.1 g/dl and platelets = 44 X 104g/dl. His parents mention that he suffers from fatigue while at presentation he looks pale and has a fever. What is the most likely diagnosis?
Your Answer: Acute myeloid leukaemia
Correct Answer: Acute lymphoblastic leukaemia
Explanation:Acute lymphoblastic leukaemia (ALL) is an aggressive type of blood and bone marrow cancer which can appear in childhood. Signs of childhood ALL include: Fever, Easy bruising, Petechiae, Bone or joint pain, Painless lumps in multiple areas of the body, Weakness, fatigue or paleness, and Loss of appetite. Blood tests may show elevated white blood cells, decreased values of red blood cells and low platelet count.
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This question is part of the following fields:
- Haematology & Oncology
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Question 21
Incorrect
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An ECG taken on a patient shows dominant R wave in V1. Which of the following cannot be the reason for above ECG change?
Your Answer: Duchenne muscular dystrophy
Correct Answer: Primary pulmonary hypertension
Explanation:Dominant R wave in V1 can be a normal variant in children and young adults. Other causes are right ventricular hypertrophy, pulmonary embolus, persistence of left to right shunt, Right Bundle Branch Block (RBBB), posterior myocardial infarction (ST elevation in Leads V7, V8, V9), Wolff-Parkinson-White (WPW) Type A, Incorrect lead placement (e.g. V1 and V3 reversed), dextrocardia, hypertrophic cardiomyopathy and dystrophy (myotonic dystrophy and Duchenne Muscular dystrophy).
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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 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: 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 23
Incorrect
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A 41-year-old gentleman required high doses of intravenous diuretics after his renal transplant for the purposes of fluid management. Soon after administration he developed hearing loss, tinnitus, and vertigo.
Â
Which diuretic is most likely to have caused this?Your Answer: Acetazolamide
Correct Answer: Furosemide
Explanation:Furosemide is a loop diuretic that is known to have significant ototoxicity side-effects although the mechanism is not fully known.
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This question is part of the following fields:
- Renal System
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Question 24
Correct
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A 20-year-old female has been referred for investigation of an iron deficiency anaemia. Her mother passed away at age 28, due to colonic carcinoma complicating Peutz-Jegher syndrome. Choose the mode of inheritance of Peutz-Jegher syndrome which is most likely.
Your Answer: Autosomal dominant
Explanation:Peutz-Jegher syndrome is an autosomal dominant condition which is characterised by perioral pigmentation and hamartomas of the bowel. It was initially assumed that these did not predispose to malignancy, but due to recent studies, the opposite is now believed to be true.
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This question is part of the following fields:
- Gastrointestinal System
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Question 25
Incorrect
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A 60-year-old previously well male was admitted with a suspected pulmonary embolism. On examination his BP was 130/80 mmHg and pulse rate was 88 bpm. His CXR was normal. He was treated with low molecular weight heparin. Which of the following is the most appropriate initial lung investigation for this patient?
Your Answer: Ventilation-perfusion scan
Correct Answer: Computed tomographic pulmonary angiography
Explanation:Computed tomographic pulmonary angiography (CTPA) is the standard investigative tool, used for diagnosing a pulmonary embolism. Pulmonary angiography is indicated if CTPA is not available.
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This question is part of the following fields:
- Cardiovascular System
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Question 26
Correct
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While investigating a patient with hepatocellular carcinoma (HCC), blood tests reveal a raised level of serum ferritin. What would be the most probable cause for HCC in this patient?
Your Answer: Haemochromatosis
Explanation:Haemochromatosis is the excessive accumulation of iron in the body mainly involving the liver, pancreas, testes, skin etc. Serum ferritin is high indicating iron overload. Haemochromatosis is a known cause for chronic liver cell disease, cirrhosis and HCC.
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This question is part of the following fields:
- Gastrointestinal System
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Question 27
Incorrect
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Using DEXA, which of the following bone mineral density values indicates osteopenia in the measured site?
Your Answer: A T score of -0.9
Correct Answer: A T score of -2.6
Explanation:Osteopenia is an early sign of bone weakening that is less severe than osteoporosis.
The numerical result of the bone density test is quantified as a T score. The lower the T score, the lower the bone density. T scores greater than -1.0 are considered normal and indicate healthy bone. T scores between -1.0 and -2.5 indicate osteopenia. T scores lower than -2.5 indicate osteoporosis.
DEXA also provides the patient’s Z-score, which reflects a value compared with that of person matched for age and sex.
Z-score values of -2.0 SD or lower are defined as below the expected range for age and those above -2.0 SD as within the expected range for age. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 28
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: Median 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 29
Correct
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A 65-year-old man with a history of type 2 diabetes comes to the clinic for review. His HbA1c is elevated at 64 mmol/mol despite taking 1g of metformin BD. On examination, his blood pressure is 142/88 mmHg, his pulse is 82 beats per minute and regular. His BMI is 33 kg/m². A decision is made to start him on dapagliflozin. Which of the following would you expect on starting therapy?
Your Answer: Increased total cholesterol
Explanation:Dapagliflozin works by inhibiting sodium glucose cotransporter 2 (SGLT2) and blocking resorption of glucose in the kidney, leading to an increase in urinary glucose excretion and lowering of both plasma glucose levels and body weight.
All studies with SGLT2 inhibitors have found significant reductions in BP, with greater reductions seen in systolic (1.66 to 6.9mmHg) than diastolic (0.88 to 3.5mmHg) BP.
While some trials have shown no change in lipid parameters, others have shown a modest but statistically significant increase in both HDL and LDL cholesterol with no effect on triglycerides or the LDL/HDL ratio. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 30
Incorrect
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Psoriatic arthropathy most commonly presents with which of the following types of arthritis?
Your Answer: Psoriatic spondylitis
Correct Answer: Peripheral asymmetric oligoarthropathy
Explanation:Most patients with psoriatic arthritis present with monoarthritis or asymmetric oligoarthritis. The most common form of the disease is the one involving a few joints of the peripheral skeleton with a distinct asymmetry of symptoms. Involvement of the smaller joints of the hands and feet, especially distal interphalangeal joints, seems to be a characteristic feature. Arthritis mutilans is a rare and severe complication of psoriatic arthritis.
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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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An 82-year-old male woke up experiencing incoherent speech - he is also finding it difficult to find the right words to explain his thoughts. Doctors have examined him, and everything else appears to be normal. They have also found that his comprehension is good. From the list of options, choose the anatomical site which in this instance, is most likely affected.
Your Answer: Wernicke's Area
Correct Answer: Broca's Area
Explanation:The combination of good comprehension but poor speech quality in this patient is consistent with damage to the Broca’s area. The Wernicke’s area is responsible for the understanding of speech, and so is not consistent with this patient.
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This question is part of the following fields:
- Geriatric Medicine
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Question 32
Incorrect
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A 43-year-old man is about to be started on chemotherapy for a high-grade lymphoma. He is given intravenous rasburicase to help lower the risk of tumour lysis syndrome (TLS).
What is the mechanism of action of this drug?Your Answer: Converts uric acid to hypoxanthine
Correct Answer: Converts uric acid to allantoin
Explanation:Rasburicase is a recombinant version of urate oxidase which is an enzyme that metabolizes uric acid to allantoin.
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.
Patients at high risk of TLS should be given IV rasburicase or IV allopurinol immediately prior to and during the first few days of chemotherapy. Allantoin is much more water soluble than uric acid and is therefore more easily excreted by the kidneys. Patients in lower-risk groups should be given oral allopurinol during cycles of chemotherapy in an attempt to avoid the condition.
TLS is graded according to the Cairo-Bishop scoring system as:
1. Laboratory tumour lysis syndrome
2. Clinical tumour lysis syndrome -
This question is part of the following fields:
- Haematology & Oncology
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Question 33
Incorrect
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A 28-year-old man presents to the clinic with fatigue, exertional dyspnoea, abdominal discomfort, xerophthalmia and xerostomia. Examination reveals enlargement of the parotid glands bilaterally, hepatomegaly and peripheral motor neuropathy. Lab results are negative for RF, ANA, SS-A and SS-B antibodies. What is the most likely diagnosis?
Your Answer: Sjogren's syndrome
Correct Answer: Diffuse infiltrative lymphocytic syndrome (DILS)
Explanation:The Diffuse Infiltrative Lymphocytosis Syndrome (DILS) is a rare multisystemic syndrome described in HIV-infected patients. It is characterised by CD8(+) T-cell lymphocytosis associated with a CD8(+) T-cell infiltration of multiple organs. DILS is usually seen in uncontrolled or untreated HIV infection but can also manifest itself independently of CD4(+) T-cell counts. The syndrome may present as a Sjögren-like disease that generally associates sicca signs with bilateral parotiditis, lymphadenopathy, and extra glandular organ involvement. The latter may affect the lungs, nervous system, liver, kidneys, and digestive tract. Anomalies of the respiratory system are often identified as lymphocytic interstitial pneumonia. Facial nerve palsy, aseptic meningitis or polyneuropathy are among the more frequent neurological features. Hepatic lymphocytic infiltration, lymphocytic interstitial nephropathy and digestive tract lymphocytic infiltration account for more rarely noted complications. Sicca syndrome, organomegaly and/or organ dysfunction associated with polyclonal CD8(+) T-cell organ-infiltration are greatly suggestive of DILS in people living with HIV.
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This question is part of the following fields:
- Musculoskeletal System
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Question 34
Incorrect
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A 16-year-old female has been admitted to hospital after overdosing on paracetamol 4 hours ago. She has also consumed a large amount of alcohol. Her plasma paracetamol concentration is only just below a level which requires treatment. From the list of options, choose the most appropriate treatment option for this patient.
Your Answer: N-acetylcysteine
Correct Answer: Refer to psychiatry ward
Explanation:As her paracetamol level is under the required treatment threshold, she requires no medical treatment. However, she has taken a simultaneous drug overdose and excessive alcohol consumption. These two factors together require psychiatric evaluation and so she should be referred to the psychiatry ward.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 35
Incorrect
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A 60-year-old gentleman is found dead in his apartment. He was known to be suffering from primary systemic amyloidosis. What is the most probable cause for his death?
Your Answer: Respiratory failure
Correct Answer: Cardiac involvement
Explanation:Primary amyloidosis is characterised by abnormal protein build-up in the tissues and organ such as the heart, liver, spleen, kidneys, skin, ligaments, and nerves. However, the most common cause of death in patients with primary amyloidosis is heart failure.
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This question is part of the following fields:
- Renal System
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Question 36
Incorrect
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A 55-year-old obese woman presents to casualty. She has rigors and reports a fever. On examination there is jaundice and tenderness over the right upper quadrant of her abdomen.
She has an elevated white blood cell count and a markedly raised alkaline phosphatase level; transaminases and bilirubin are also abnormal.
Which of these diagnoses best fits the clinical picture?Your Answer: Right kidney stone
Correct Answer: Ascending cholangitis
Explanation:This question describes Charcot’s triad– fever, RUQ pain, and jaundice, which is seen in ascending cholangitis. Reynold’s pentad is a worsened version of this, where you have RUQ pain, fever, jaundice, hypotension, and altered mental status. Risk factors for gallstones are the 4F’s- female, fat, forty, and fertile. You would not have the elevated bilirubin, ALP, transaminases with a kidney stone or in peptic ulcer disease. Hepatitis would not cause elevation of bilirubin.
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This question is part of the following fields:
- Hepatobiliary System
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Question 37
Incorrect
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Which type of cell is responsible for the production of surfactant?
Your Answer: Type I pneumocyte
Correct Answer: Type II pneumocyte
Explanation:Type I pneumocyte: The cell responsible for the gas (oxygen and carbon dioxide) exchange that takes place in the alveoli. It is a very thin cell stretched over a very large area. This type of cell is susceptible to a large number of toxic insults and cannot replicate itself.
Type II pneumocyte: The cell responsible for the production and secretion of surfactant (the molecule that reduces the surface tension of pulmonary fluids and contributes to the elastic properties of the lungs). The type 2 pneumocyte is a smaller cell that can replicate in the alveoli and will replicate to replace damaged type 1 pneumocytes. Alveolar macrophages are the primary phagocytes of the innate immune system, clearing the air spaces of infectious, toxic, or allergic particles that have evaded the mechanical defences of the respiratory tract, such as the nasal passages, the glottis, and the mucociliary transport system. The main role of goblet cells is to secrete mucus in order to protect the mucous membranes where they are found. Goblet cells accomplish this by secreting mucins, large glycoproteins formed mostly by carbohydrates. -
This question is part of the following fields:
- Respiratory System
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Question 38
Correct
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A 40-year-old woman presents to the ED with palpitations and shortness of breath.
Recent thyroid function tests on the hospital computer reveal thyroid-stimulating hormone (TSH) of <0.05 mU/l and a markedly elevated T4. You arrange blood gas testing.
Which of the following findings would be most consistent with Grave's disease?Your Answer: Decreased pa(CO2)
Explanation:Hyperthyroid patients show significantly lower resting arterial CO2 tension, tidal volume and significantly higher mean inspiratory flow and pa(O2) than healthy patients. This may of course lead to misdiagnosis of patients with hyperthyroidism as having hyperventilation syndrome.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 39
Incorrect
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In a patient with prostate cancer, what is the mechanism by which goserelin acts?
Your Answer: Androgen receptor antagonist
Correct Answer: GnRH agonist
Explanation:Androgen deprivation therapy (ADT) for prostate cancer:
Goserelin (Zoladex) is a synthetic gonadotropin-releasing hormone (GnRH) analogue; chronic stimulation of goserelin results in suppression of LH, FSH serum levels thereby preventing a rise in testosterone.
Dosage form: 3.6 mg/10.8mg implants.
Adverse effects include flushing, sweating, diarrhoea, erectile dysfunction, less commonly, rash, depression, hypersensitivity, etc.
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This question is part of the following fields:
- Pharmacology
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Question 40
Incorrect
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Which of the following features is not associated with an oculomotor nerve palsy?
Your Answer: Eye is deviated 'down and out'
Correct Answer: Miosis
Explanation:Oculomotor nerve palsy is an eye condition resulting from damage to the third cranial nerve or a branch thereof. A complete oculomotor nerve palsy will result in a characteristic down and out position in the affected eye. This is because the lateral rectus (innervated by the sixth cranial nerve) and superior oblique (innervated by the fourth cranial or trochlear nerve), is unantagonized by the paralyzed superior rectus, inferior rectus and inferior oblique. The affected individual will also have a ptosis, or drooping of the eyelid, and mydriasis (pupil dilation), not miosis.
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This question is part of the following fields:
- Nervous System
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Question 41
Incorrect
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A 34-year-old HIV positive man is referred to gastroenterology due to jaundiced sclera. Liver function tests are as follows:
Albumin 34 g/l
ALP 540 iu/l
Bilirubin 67 µmol/l
ALT 45 iu/l
What is the most likely diagnosis?Your Answer: Hepatic abscess
Correct Answer: Sclerosing cholangitis
Explanation:HIV can cause strictures in the biliary tract (see source for details of the disease). This makes the diagnosis of primary sclerosing cholangitis most likely given the clinical presentation and lab values. Due to its association with HIV this is more likely than all of the other answer choices. Know this association.
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This question is part of the following fields:
- Hepatobiliary System
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Question 42
Correct
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A 42-year-old male patient who was on enalapril for hypertension presented with generalized body weakness. Investigations revealed hyperkalaemia. Which of the following can be expected in his ECG?
Your Answer: Tall, tented T waves
Explanation:In hyperkalaemia the ECG will show tall, tented T waves as well as small P waves and widened QRS complexes.Â
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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 16-year-old woman presents with a 7 month history of secondary amenorrhoea and three months history of galactorrhoea. She has been otherwise well. She had menarche at the age of 12 and has otherwise had regular periods. She has been sexually active for approximately one year and has occasionally used condoms for contraception. She smokes five cigarettes daily and occasionally smokes cannabis.
On examination, she appears well, and clinically euthyroid, has a pulse of 70 bpm and blood pressure of 112/70 mmHg.
Investigations show:
Serum oestradiol 130 nmol/L (130-600)
Serum LH 4.5 mU/L (2-20)
Serum FSH 2.2 mU/L (2-20)
Serum prolactin 6340 mU/L (50-450)
Free T4 7.2 pmol/L (10-22)
TSH 2.2 mU/L (0.4-5.0)
What is the most likely diagnosis?Your Answer: Prolactinoma
Explanation:The patient has hyperprolactinaemia with otherwise normal oestradiol, FSH and LH. This is highly suggestive of Prolactinoma rather than a non functioning tumour.
In polycystic ovaries, there is increase in the level of LH while FSH is normal or low. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 44
Correct
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In end stage renal disease, deficiency of erythropoietin can lead to which of the following conditions?
Your 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 45
Correct
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Which feature is NOT characteristic of carcinoid syndrome?
Your Answer: Persistent hypotension
Explanation:Carcinoid syndrome is a paraneoplastic syndrome comprising of signs and symptoms that occur secondary to carcinoid tumours. Diarrhoea, dermatitis, bronchospasm and right sided cardiac valve lesions (tricuspid insufficiency and pulmonary stenosis) are characteristic of carcinoid syndrome.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 46
Incorrect
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A 27-year-old male is admitted after drinking engine coolant in an apparent suicide attempt.
Lab investigations reveal:
pH 7.1 (7.36-7.44)
pO2 15.3 kPa (11.3-12.6)
pCO2 3.2 kPa (4.7-6.0)
Standard bicarbonate 2.2 mmol/L (20-28)
Serum calcium 1.82 mmol/L (2.2-2.6)
After replacing calcium, which of the following is the most urgent treatment for this man?Your Answer: Alcohol infusion
Correct Answer: 8.4% bicarbonate infusion
Explanation:Carbon monoxide has high affinity for haemoglobin and myoglobin resulting in a left-shift of the oxygen dissociation curve and tissue hypoxia. There are approximately 50 deaths per year from accidental carbon monoxide poisoning in the UK. In these circumstances, antidotal therapy to block alcohol dehydrogenase with ethanol or 4-MP alone is insufficient to treat the poisoning. Data suggest that a severe lactic acidosis needs initial correction and in this patient the most appropriate treatment would be IV fluids with bicarbonate to correct the metabolic acidosis. Haemodialysis may be required thereafter.
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This question is part of the following fields:
- Fluids & Electrolytes
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Question 47
Correct
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A 30-year-old female went to her local doctor's surgery for a follow-up to a cervical smear test. The smear was sent to histology and was identified as CIN2. Choose the most appropriate management for this patient.
Your Answer: Refer for colposcopy
Explanation:Screening for cervical carcinoma helps to prevent the development of the disease. According to NICE, the screening interval using liquid-based cytology (as opposed to PAP) is 3 years for women less than 50 years old and 5 years for women over 50 years old. If a smear test is conducted and it shows no endocervical cells then it should be conducted again. This is because there was either inadequate preparation or sampling, or the sampling was done at the wrong point in the menstrual cycle. For severe dyskaryosis or carcinoma in situ, the patient needs treatment and should, therefore, be referred for a colposcopy. Clue cells are vaginal epithelial cells that are fuzzy (i.e.. without distinct edges) when looking at through a microscope. When bacterial vaginosis is present, over 20 per cent of the sample cells are clue cells. Bacterial vaginosis is treated with metronidazole therapy. Although trichomoniasis is treated with metronidazole too, the patient should be tested for other sexually transmitted diseases.
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This question is part of the following fields:
- Women's Health
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Question 48
Incorrect
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A 32-year-old woman presents with a painful elbow which she has been feeling for the past two weeks. Which of the following will be consistent with a diagnosis of tennis elbow?
Your Answer: Pain on pronation of the forearm
Correct Answer: Pain on wrist extension against resistance
Explanation:Lateral epicondylitis (tennis elbow) is an overuse injury of the hand and finger extensor tendons that originate in the lateral humeral epicondyle that occurs following repeated or excessive pronation/supination and extension of the wrist (e.g., in racquet sports). Clinical features include pain and tenderness over the lateral epicondyle and along extensor muscles and thickening of the tendons. The examiner holds the patient’s hand with the thumb placed over the lateral epicondyle – The patient makes a fist, supinates the forearm, deviates radially, and extends the fist against the examiner’s resistance which will result in pain over the lateral epicondyle. Conservative treatment includes rest, physiotherapy and orthotic braces. If this fails corticosteroids and lidocaine injections are employed. Surgery is indicated in patients with persistent symptoms despite 6 months of conservative treatment. Excision of abnormal tendon tissue; longitudinal incisions (tenotomies) in scarred and fibrotic areas to promote healing.
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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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Which one of the following statements regarding minimal change glomerulonephritis is incorrect?
Your Answer: Is a common cause of nephrotic syndrome
Correct Answer: Hypertension is found in approximately 25% of patients
Explanation:Hypertension and haematuria are not common presentations in minimal change glomerulonephritis, all other statements are correct.
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This question is part of the following fields:
- Renal System
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Question 50
Correct
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A 35-year-old female presented with complaints of earache and a high-grade fever. During examination, numerous small vesicles were found within the ear canal and her ear is very tender. Which one of the following organisms is most likely to be responsible for such a condition?
Your Answer: Herpes zoster
Explanation:Herpes zoster is a viral disorder in which painful vesicular lesions are present in a specific dermatome area. High-grade fever may present as well due to infection. Varicella zoster, measles, herpes simplex and HIV do not present with tender lesions of a limited area.
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This question is part of the following fields:
- Infectious Diseases
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SESSION STATS - PERFORMANCE PER SPECIALTY
