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Question 1
Incorrect
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A 35-year-old female, known case of antiphospholipid syndrome, arrives at the clinic due to a swollen and painful left leg. Doppler ultrasonography confirms the diagnosis of a deep vein thrombosis. She was previously diagnosed with DVT 4 months back and was on warfarin therapy (target INR 2-3) when it occurred. How should her anticoagulation be managed?
Your Answer: Life-long warfarin, target INR 2 - 3
Correct Answer: Life-long warfarin, increase target INR to 3 - 4
Explanation:If the INR in the range of 2-3 has still resulted in thrombosis, the target INR is increased to 3-4. However, because the risk of bleeding increases as the INR rises, the INR is closely monitored and adjustments are made as needed to maintain the INR within the target range.
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This question is part of the following fields:
- Musculoskeletal System
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Question 2
Incorrect
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In which part of the body is conjugated bilirubin metabolised to urobilinogen?
Your Answer: Common bile duct
Correct Answer: Large intestine
Explanation:Urobiligen is produced by the action of bacteria on bilirubin in the intestine. As a reminder, unconjugated bilirubin becomes conjugated in the hepatocyte. Conjugated bilirubin goes through enterohepatic circulation. About half of the urobiligen is reabsorbed and excreted by the kidneys in the urine. The rest is converted to stercobilinogen –> stercobilin, which is excreted in stool, giving it its brown colour.
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This question is part of the following fields:
- Gastrointestinal System
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Question 3
Incorrect
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Regarding neonatal meningitis, which of the following statements is true?
Your Answer: Is most commonly caused by Haemophilus influenzae
Correct Answer: Has an above average incidence in babies with a meningomyelocele
Explanation:The commonest time for bacterial meningitis is in the 1st month of life and group B Streptococcus is the commonest organism. The anterior fontanelle is full, but does not bulge with normal flexion. Neurological manifestations include seizures, irritability, poor tone, lethargy and tremors, however no findings of sensorineural deafness have been noted. One of the risk factors for introduction of meningeal infection is Meningomyelocele.
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This question is part of the following fields:
- Infectious Diseases
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Question 4
Incorrect
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A young girl presents to the clinic complaining of episodic headaches that usually last for 2-3 days. These headaches are preceded by fortification spectra. During these episodes, the patient prefers to stay in a quiet and dark room. How will you manage the acute stage?
Your Answer: Sumatriptan
Correct Answer: Aspirin
Explanation:Migraine is characterized by recurrent episodes of typically unilateral, localized headaches that are frequently accompanied by nausea, vomiting, and sensitivity to light and sound. In approximately 25% of cases, patients experience an aura preceding the headache, which involves reversible focal neurologic abnormalities, for example, visual field defects (scotomas) or paresis lasting less than an hour. Migraine is a clinical diagnosis. Treatment of attacks consists of general measures (e.g., bedrest and protection from outer stimuli) together with administration of nonsteroidal anti-inflammatory drugs (e.g., aspirin) and antiemetics (e.g., prochlorperazine) if nausea is present. In severe cases, triptans may be added. Prophylactic treatment (e.g., beta blockers) may be indicated if migraines are especially frequent or long lasting, or if abortive therapy fails or is contraindicated.
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This question is part of the following fields:
- Pharmacology
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Question 5
Incorrect
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A 35-year-old alcoholic presented with epigastric pain radiating backward. His pain was relieved with opioid analgesics and anti PUD medications, however after 1 week he developed a fever with a similar kind of abdominal pain to that of his initial presentation. US abdomen shows a fluid collection. The most likely site for the fluid collection would be?
Your Answer: Left paracolic gutter
Correct Answer: Lesser sac
Explanation:The most likely diagnosis in this case is acute pancreatitis, which typically presents with severe abdominal pain and vomiting, along with deranged LFTs and raised serum amylase. It makes a boundary wall for the lesser sac and therefore the most likely site of fluid collection would be in the lesser sac.
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This question is part of the following fields:
- Gastrointestinal System
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Question 6
Incorrect
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A 33-year-old male was brought in with complaints of an unsteady gait. According to the patient, he suffered a severe headache in the morning, with associated vomiting. Slowly his condition deteriorated until he was unable to walk. On exam, he had nystagmus and there was past pointing of the right arm. He speech was slurred, his uvula was deviated towards the right and there was decreased pinprick sensation on the right half of the body. The most likely site of the lesion in this patient would be?
Your Answer: Right lateral medulla
Correct Answer: Left lateral medulla
Explanation:Loss of sensations in left (ipsilateral) side of the face and contralateral (right) side of the body indicates a defect in left lateral medulla. Further cerebellar signs lead to the diagnosis of Lateral Medullary Syndrome.
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This question is part of the following fields:
- Nervous System
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Question 7
Incorrect
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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: Tibia
Correct 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 42-year-old previously well woman presented with acute severe central chest pain for the past 2 hours. She has a family history of premature coronary artery disease. Her husband passed away recently due to prostate cancer. On examination her blood pressure was 130/80 mmHg and pulse rate was 80 bpm. Her ECG showed ST segment elevation and her troponin was slightly elevated. Emergency angiogram revealed slight wall irregularities with no luminal obstruction. Cardiovascular MR showed an apical ballooning of the myocardium resembling an octopus pot. Which of the following is the most likely cause for the ST segment elevation?
Your Answer: Takotsubo cardiomyopathy
Explanation:Causes for ST segment elevation other than myocardial infarction
Natural variants
-Early repolarization
-Left ventricular hypertrophy and hypertrophic cardiomyopathy
-Left bundle branch block
Artefacts
-Leads mispositioning
-Electrical cardioversion
Cardiovascular diseases
-Pericarditis/ Myocarditis
-Aortic dissection
-Prinzmetal’s angina
-Takotsubo Cardiomyopathy
-Brugada Syndrome and arrhythmogenic right ventricular cardiomyopathy/dysplasia
Pulmonary diseases
-Pulmonary thromboembolism
-Pneumothorax
-Atelectasis and pulmonary metastases
Gastrointestinal diseases
-Acute pancreatitis
-Acute cholecystitis
Other conditions
-Hyperkalaemia
-Drug induced ST segment elevation (e.g. – clozapine)
-Haemorrhagic cerebrovascular diseaseCoronary artery disease and myocardial infarction can be excluded with a negative angiogram and a slightly elevated troponin. Hypertrophic cardiomyopathy can be excluded with cardiovascular MR findings. Left ventricular aneurysm usually occurs following a myocardial infarction, but there is no positive history for that. The characteristic findings on cardiovascular MR confirms the diagnosis of Takotsubo cardiomyopathy.
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This question is part of the following fields:
- Cardiovascular System
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Question 9
Correct
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A 70-year-old male with advanced COPD currently on treatment with salbutamol (as required) presents for review. After a complete history and examination, you conclude that he requires to be stepped up in his inhalational therapy. The decision to add tiotropium bromide to his regime was taken. Which of the following best describe the mechanism of action of tiotropium?
Your Answer: It is a long-acting anticholinergic agent
Explanation:Tiotropium is a specific long-acting antimuscarinic agent indicated as maintenance therapy for patients with COPD (chronic obstructive pulmonary disease).
It should be used cautiously in patients with narrow-angle glaucoma, prostatic hyperplasia or bladder neck obstruction.
The most frequently encountered adverse effects of tiotropium include pharyngitis, bronchitis, sinusitis, dry mouth, cough, and headaches. Paradoxical bronchospasm may also occur as a rare side-effect.
Dry mouth occurs in up to 14% of patients taking tiotropium, in keeping with its anticholinergic profile.
Rarer side-effects include tachycardia, blurred vision, urinary retention, and constipation. -
This question is part of the following fields:
- Respiratory System
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Question 10
Correct
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A 42-year-old male has suffered a stroke - he is unable to walk in a straight line and has slurred speech. From the list of options, choose the most appropriate investigation to proceed with.
Your Answer: CT scan brain
Explanation:CT scans are used to produce images of the brain. It can be used to detect a stroke from a blood clot or bleeding within the brain.
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This question is part of the following fields:
- Nervous System
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Question 11
Correct
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A 28-year-old male was admitted with severe central abdominal pain managed as an acute pancreatitis due to his serum amylase being markedly elevated. He is a known epileptic patient and has been on anti-epileptics. What would be the antiepileptic drug responsible for this clinical presentation?
Your Answer: Sodium valproate/Carbamazepine
Explanation:Both Sodium valproate and Carbamazepine are correct. These drugs can cause drug induced pancreatitis however more cases have been reported with Sodium valproate.
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This question is part of the following fields:
- Gastrointestinal System
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Question 12
Correct
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A 28-year-old male has presented to his doctor with hypertension. Upon examination, he is found to have palpable kidneys. An abdominal ultrasound shows enlarged cystic kidneys on both sides. From the list of options, choose the most likely condition present in this patient.
Your Answer: Polycythaemia
Explanation:The most likely diagnosis for this patient is adult polycystic kidneys. This disease is associated with the following: valvular heart abnormalities, incompetence, and aneurysms of the cerebral circulation. It can also be associated with excessive erythropoietin production and polycythaemia. There is an increased incidence of aortic incompetence, and mitral valve prolapse occurs in 25 per cent of patients. Hepatic cysts can also occur, and present in 70 per cent of patients – these can also involve the pancreas in 10 per cent of patients and the spleen. Cerebral berry aneurysms are present in around 5-8 per cent of patients, but familial clustering is also observed. That is if there is a family history, over 20 per cent of patients will also have an aneurysm. Diverticular disease is also thought to be increased in patients with polycystic kidney disease.
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This question is part of the following fields:
- Renal System
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Question 13
Correct
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A 60-year-old female with a recent history of MI, complained of exertional dyspnoea. On examination there was a third heart sound. ECG showed ST elevations in leads V1 to V4. Which of the following is the most probable reason for this presentation?
Your Answer: Left ventricular aneurysm
Explanation:Electrocardiography is characterized by ST elevation that persists several weeks after an acute MI. The features of heart failure (exertional dyspnoea and third or fourth heart sound) favours the diagnosis.
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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 30-year-old woman is referred to endocrinology with thyrotoxicosis. Following a discussion of management options, she chooses to have radioiodine therapy. Which one of the following is the most likely adverse effect?
Your Answer: Oesophagitis
Correct Answer: Hypothyroidism
Explanation:Approximately one third of patients treated with radioiodine therapy develop transient hypothyroidism. Unless a patient is highly symptomatic, thyroxine replacement may be withheld if hypothyroidism occurs within the first 2 months of therapy. If it persists for longer than 2 months, permanent hypothyroidism is likely and replacement with T4 should be initiated.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 15
Correct
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A 45-year-old smoker presented with sudden onset of chest pain radiating to his left arm, with associated sweating. ECG showed ST elevation in leads I, aVL and V1-V4. The most likely diagnosis would be?
Your Answer: Anterior MI
Explanation:An anterior wall myocardial infarction is characterised by ST elevation in leads I, aVL and V1-V5.
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This question is part of the following fields:
- Cardiovascular System
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Question 16
Incorrect
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A 61-year-old gentleman presents with heart failure and pedal oedema. The oedema occurs due to:
Your Answer: Decreased filtration fraction
Correct Answer: Increased release of renin
Explanation:The oedema is an effect of the a decreased cardiac output that increases renin release which leads to vasoconstriction and sodium and water retention.
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This question is part of the following fields:
- Renal System
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Question 17
Incorrect
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A 58-year-old gentleman with a long history of gout presents with loin pain. Other past history of note includes an ileostomy after bowel surgery. There is no history of weight loss from malabsorption syndrome after his bowel surgery. Excretion urography reveals evidence of bilateral renal stones.
What is the most likely composition of his renal stones?Your Answer: Cysteine stones
Correct Answer: Uric acid stones
Explanation:Uric acid stones will most likely be found in this case because of the patient’s long history of gout. Additionally, studies have shown that ileostomy patients have an increased risk for the development of uric acid stones.
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This question is part of the following fields:
- Renal System
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Question 18
Incorrect
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All of the following are associated with yellow nail syndrome except:
Your Answer: Pleural effusions
Correct Answer: Cardiomegaly
Explanation:Yellow nail syndrome is a very rare medical syndrome that includes pleural effusions, lymphedema (due to under development of the lymphatic vessels) and yellow dystrophic nails. Approximately 40% will also have bronchiectasis. It is also associated with chronic sinusitis and persistent coughing and it usually affects adults.
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This question is part of the following fields:
- The Skin
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Question 19
Incorrect
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A 32-year-old female who is 37 weeks pregnant presents with a swollen, painful right calf. A deep vein thrombosis (DVT) is confirmed on Doppler scan.
What should be the preferred anticoagulant?Your Answer: Clopidogrel
Correct Answer: Subcutaneous low molecular weight heparin (LMWH)
Explanation:Subcutaneous (S/C) low-molecular-weight heparin (LMWH) is a preferred anticoagulant in pregnancy. Warfarin is contraindicated due to its teratogenic effects, especially in the first trimester and at term.
Pregnancy is a hypercoagulable state with the majority of VTE incidents occurring in the last trimester.
Hypercoagulability in pregnancy is caused by:
1. Increase in factors VII, VIII, X, and fibrinogen
2. Decrease in protein S
3. Uterus pressing on IVC causing venous stasis in legsManagement options include:
1. S/C LMWH preferred to IV heparin (less bleeding and thrombocytopaenia)
2. Warfarin contraindicated -
This question is part of the following fields:
- Haematology & Oncology
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Question 20
Incorrect
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Which one of the following features is least associated with Waldenström's macroglobulinemia?
Your Answer: Monoclonal IgM paraproteinaemia
Correct Answer: Bone pain
Explanation:Waldenström’s macroglobulinemia (also called lymphoplasmacytic lymphoma) is an uncommon type of non-Hodgkin lymphoma seen in older people. It is a lymphoplasmacytoid malignancy characterised by the secretion of a monoclonal IgM paraprotein. Its features include weight loss and lethargy; monoclonal IgM paraproteinemia; hyperviscosity syndrome leading to bilateral central retinal vein occlusion (CRVO) and hence, visual disturbances; hepatosplenomegaly and lymphadenopathy; and cryoglobulinemia. It is not, however, associated with bone pain.
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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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What is the site of action of antidiuretic hormone?
Your Answer: Distal convoluted tubule
Correct Answer: Collecting ducts
Explanation:Vasopressin, also called antidiuretic hormone (ADH), regulates the tonicity of body fluids. It is released from the posterior pituitary in response to hypertonicity and promotes water reabsorption in the collecting ducts of the kidneys by the insertion of aquaporin-2 channels.. An incidental consequence of this renal reabsorption of water is concentrated urine and reduced urine volume. In high concentrations may also raise blood pressure by inducing moderate vasoconstriction.
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This question is part of the following fields:
- Renal System
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Question 22
Incorrect
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A 75-year-old man presented to hospital after suffering a stroke. The doctor admitted him and advised of the Barthel score index. During rehabilitation, which one of the following limitations are best described by Barthel score index?
Your Answer: It correlates poorly with other prognostic scales
Correct Answer: Floor and ceiling effects
Explanation:Barthel scoring has floor and ceiling effects which is the most widely recognised limitation. Floor effect means that the patient who is bed bound can score initially low, whereas the ceiling effect shows that despite being bed bound, a patient can achieve a maximum score i.e. 100. The test is easy to perform and correlates well with other prognostic scales.
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This question is part of the following fields:
- Geriatric Medicine
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Question 23
Incorrect
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An elderly man presents with complaints of a chronic cough with haemoptysis and night sweats on a few nights per week for the past four months. He is known to smoke 12 cigarettes per day and he had previously undergone treatment for Tuberculosis seven years ago.
His blood pressure was found to be 143/96 mmHg and he is mildly pyrexial 37.5°C. Evidence of consolidation affecting the right upper lobe was also found.
Investigations;
Hb 11.9 g/dl
WCC 11.1 x109/l
PLT 190 x109/l
Na+ 138 mmol/l
K+ 4.8 mmol/l
Creatinine 105 μmol/l
CXR Right upper lobe cavitating lesion
Aspergillus precipitins positive
Which of the following is most likely the diagnosis?Your Answer: Reactivated tuberculosis
Correct Answer: Aspergilloma
Explanation:An aspergilloma is a fungus ball (mycetoma) that develops in a pre-existing cavity in the lung parenchyma. Underlying causes of the cavitary disease may include treated tuberculosis or other necrotizing infection, sarcoidosis, cystic fibrosis, and emphysematous bullae. The ball of fungus may move within the cavity but does not invade the cavity wall. Aspergilloma may manifest as an asymptomatic radiographic abnormality in a patient with pre-existing cavitary lung disease due to sarcoidosis, tuberculosis, or other necrotizing pulmonary processes. In patients with HIV disease, aspergilloma may occur in cystic areas resulting from prior Pneumocystis jiroveci pneumonia. Of patients with aspergilloma, 40-60% experience haemoptysis, which may be massive and life threatening. Less commonly, aspergilloma may cause cough and fever.
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This question is part of the following fields:
- Respiratory System
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Question 24
Incorrect
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A 31-year-old homosexual male is complaining of recent weight loss and blurred vision. A fundoscope was performed showing retinal haemorrhage. What is the single most appropriate option?
Your Answer: Haemophilus influenza
Correct Answer: Cytomegalovirus (CMV)
Explanation:CMV is the best answer . Weight loss is mostly caused by HIV, which commonly presents with retinal haemorrhage and retinopathy when associated with CMV.
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This question is part of the following fields:
- Infectious Diseases
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Question 25
Incorrect
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Regarding haemochromatosis, which of the following is true?
Your Answer: Haemochromatosis invariably progresses to cirrhosis
Correct Answer: Haemochromatosis may be treated with therapeutic phlebotomy
Explanation:Haemochromatosis is an abnormally high rate of the production of haemoglobin. It is an autosomal recessive disease copied on chromosome 6. It is associated with hepatic disorders, cardiac diseases and skin pigmentation. It is treated by regular venesection.
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This question is part of the following fields:
- Haematology & Oncology
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Question 26
Incorrect
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Which of the following types of renal stones are said to have a semi-opaque appearance on x-ray?
Your Answer: Urate stones
Correct Answer: Cystine stones
Explanation:Only cystine stones are semi-opaque because they contain sulphur. All the other stones will appear either radio-lucent or radio-opaque.
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This question is part of the following fields:
- Renal System
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Question 27
Incorrect
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An 80-year-old woman with advanced COPD has been admitted to the medicine ward in an unconscious state. She appears to have an acute lower respiratory tract infection. After consulting with an anaesthesiologist it was concluded that she was not a candidate for intensive care unit admission and thus, a decision was made to start the patient on doxapram therapy. Which of the following best fits the characteristics of doxapram?
Your Answer: It is compatible in infusion with aminophylline
Correct Answer: It is contraindicated in hyperthyroidism
Explanation:The two statements that fit the characteristics of doxapram are, epilepsy is a contraindication for doxapram use and concurrent use with theophylline may increase agitation.
Doxapram is a central respiratory stimulant. In clinical practice, doxapram is usually used for patients who have an acute exacerbation of chronic obstructive pulmonary disease (COPD) who are unsuitable for admission to the intensive therapy unit for ventilatory support. Doxapram infusion may buy an extra 24 h to allow for recovery.
Contraindications include: ischaemic heart disease, epilepsy, cerebral oedema, acute stroke, asthma, hypertension, hyperthyroidism, and pheochromocytoma.
The infusion may worsen agitation and dyspnoea and lead to hypertension, nausea, vomiting and urinary retention.Drug interactions:
Concomitant administration of doxapram and aminophylline (theophylline) can cause increased skeletal muscle activity, agitation, and hyperactivity. -
This question is part of the following fields:
- Geriatric Medicine
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Question 28
Incorrect
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A 22-year-old nulliparous female presents with shortness of breath. She has a history of recurrent deep vein thrombosis. Complete blood count and clotting screen reveals the following results:
Hb: 12.4 g/dl
Plt: 137
WBC: 7.5*109/l
PT: 14 secs
APTT: 46 secs
Which of the following would be the most likely diagnosis?Your Answer: Protein C deficiency
Correct Answer: Antiphospholipid syndrome
Explanation:The combination of APTT and low platelets with recurrent DVTs make antiphospholipid syndrome the most likely diagnosis.
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This question is part of the following fields:
- Musculoskeletal System
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Question 29
Incorrect
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A 19-year-old woman comes to the endocrine clinic with excessive hairiness and acne. She tells you that she has a period only every few months and when she has one it tends to be very heavy.
On examination, she has obvious facial acne. Her BP is 142/78 mmHg, her pulse is 72 bpm and regular and her BMI is 30. There is facial hair and hair around her upper chest and breasts.
Investigations show:
Haemoglobin 11.9 g/dl (11.5-16.0)
White cell count 6.0 x 10(9)/l (4-11)
Platelets 202 x 10(9)/l (150-400)
Sodium 137 mmol/l (135-146)
Potassium 3.9 mmol/l (3.5-5)
Creatinine 90 µmol/l (79-118)
Total testosterone normal
Free androgen index elevated
LH / FSH ratio 2.2
Which of the following is the most likely diagnosis?Your Answer: Germ cell tumour
Correct Answer: Polycystic ovarian syndrome
Explanation:Rotterdam criteria for the diagnosis of polycystic ovary syndrome:
Two of the following three criteria are required:
1. Oligo/anovulation
2. Hyperandrogenism
– Clinical (hirsutism or less commonly male pattern alopecia) or
– Biochemical (raised FAI or free testosterone)
3. Polycystic ovaries on ultrasound
Other aetiologies must be excluded such as congenital adrenal hyperplasia, androgen-secreting tumours, Cushing syndrome, thyroid dysfunction and hyperprolactinaemia.
Cushing’s is excluded because there would have been marked obesity, hypertension and other related features. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 30
Incorrect
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A 32-year-old man notices a pruritic scaly annular rash on his thigh. He claims that the rash appeared after a walk in the park. Which drug would you suggest he starts?
Your Answer: Penicillin
Correct Answer: Doxycycline
Explanation:The clinical picture of an itchy, scaly annular rash after a walk in the park suggests erythema migrans. The pathogen responsible is a spirochete, Borrelia Burgdorferi transmitted by ticks leading to Lyme disease. Doxycycline is the antibiotic of choice if no contraindications.
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This question is part of the following fields:
- Infectious Diseases
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SESSION STATS - PERFORMANCE PER SPECIALTY
