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Question 1
Correct
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A 56-year-old man injected his usual insulin dose and went to the washroom to wash his hands before going to dinner. His wife found him unconscious in the washroom a few minutes later. Which of the following investigations needs to be done?
Your Answer: Random capillary glucose
Explanation:The state of this patient is most likely a diabetic coma caused by hypoglycaemic shock. A random capillary glucose check can confirm the glucose level and whether prompt IM glucagon should be given.
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This question is part of the following fields:
- Cardiovascular System
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Question 2
Incorrect
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A 74-year-old man presents to the physician with complaints of hoarseness of voice and cough for the past 3 weeks. The patient has been a smoker and quit 3 years ago. Radiological examination reveals a mass in the mediastinum. Which investigation should be employed to establish a diagnosis?
Your Answer: Thoracoscopy
Correct Answer: LN biopsy
Explanation:Masses in the middle mediastinum most commonly represent lymph nodes that are enlarged by a malignant, infectious, or inflammatory process. Masses in the posterior mediastinum are usually benign tumours or cysts originating from either the nerves that are present in this area (neurogenic tumours) or from the oesophagus (foregut duplication cysts). Lymph node biopsy would be the ideal choice of investigation in this case.
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This question is part of the following fields:
- Respiratory System
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Question 3
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: Precipitation of thyroid eye disease
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 4
Incorrect
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A 32-year-old female patient has the following signs and symptoms: smooth goitre, lid lag and bilateral exophthalmos with puffy eyelids and conjunctival injections. She has a history of thyrotoxicosis but wants to fall pregnant. What would be the most appropriate treatment for her?
Your Answer: Thyroidectomy
Correct Answer: 18m of Propylthiouracil (PTU) alone
Explanation:Propylthiouracil (PTU) is a safe choice for a woman that is planning a pregnancy because it does not have the teratogenic effects as carbimazole does. Methimazole (MMI) and propylthiouracil (PTU) are the standard anti-thyroid drugs used in the treatment of hyperthyroidism in pregnancy. Carbimazole can cause spina bifida, CV malformations as well as hypospadia.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 5
Incorrect
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A 30-year-old male came in with chills and dilated pupils, which were withdrawal signs and symptoms of a certain drug. Which of the following can cause above presentation?
Your Answer: Cocaine
Correct Answer: Heroine
Explanation:Both cocaine and heroine withdrawal cause dilated pupils. Heroine withdrawal causes chills.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 6
Correct
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A 72-year-old man presents with sudden and severe pain on the medial aspect of his right calf while walking uphill. Foot extension is normal and there is no associated ankle swelling. Which of the following is the most likely diagnosis?
Your Answer: Popliteal cyst
Explanation:A popliteal cyst, also known as a Baker’s cyst, is a fluid-filled swelling that causes a lump at the back of the knee, leading to tightness and restricted movement. The cyst can be painful when you bend or extend your knee.
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This question is part of the following fields:
- Musculoskeletal System
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Question 7
Correct
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A 45-year-old woman has been diagnosed with T1N1M1 malignancy in the left breast, with metastases detectable in the lower thoracic vertebrae and the left lung. Before the initiation of treatment of this patient with trastuzumab, which is the most important investigation to perform?
Your Answer: Echo
Explanation:Before the initiation of trastuzumab, an echocardiography is a must to rule out any pre-existing cardiac abnormalities as trastuzumab is cardiotoxic.
Trastuzumab (Herceptin) is a monoclonal antibody directed against the HER2/neu receptor. It is used mainly in metastatic breast cancer although some patients with early disease are now also given trastuzumab.
Adverse effects include:
Flu-like symptoms and diarrhoea are common.
Cardiotoxicity:
– Risk increases when anthracyclines are used concomitantly.
– Trastuzumab-induced cardiac dysfunctions are regarded as less severe and largely reversible because primary cardiomyocyte do not show ultrastructure changes unlike those associated with anthracycline-induced cardiotoxicity.
– Primary myocyte injury does not occur in patients who were treated with trastuzumab. -
This question is part of the following fields:
- Women's Health
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Question 8
Incorrect
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A patient has been diagnosed with multi-drug resistant tuberculosis and is currently being treated with rifampicin, isoniazid, and pyrazinamide. He is commenced on streptomycin.
Which among the following is the most likely neurological side-effect of streptomycin?Your Answer: Cochlear damage
Correct Answer: Vestibular damage
Explanation:Vestibular damage is a neurological side effect of streptomycin.
Streptomycin is an aminoglycoside bactericidal antibiotic. It is used in the treatment of tularaemia and resistant mycobacterial infections.
The most common neurological side-effect is vestibular damage leading to vertigo and vomiting.
Cochlear damage is less frequent and results in deafness.
Other side-effects include rashes, angioneurotic oedema, and nephrotoxicity. -
This question is part of the following fields:
- Infectious Diseases
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Question 9
Correct
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Which of the following physical findings is least typical on a patient with multiple sclerosis?
Your Answer: Decreased tone
Explanation:Attacks or exacerbations of multiple sclerosis (MS) are characterized by symptoms that reflect central nervous system (CNS) involvement, hence upper motor neuron symptoms are seen.
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This question is part of the following fields:
- Nervous System
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Question 10
Correct
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Choose the standard method for comparing distributions in data sets (such as between the expected frequency of an event and the observed frequency of an event) from the list of options.
Your Answer: Chi squared (X²) test
Explanation:The Chi-squared test evaluates if two variables are related. The other statistical tests mentioned do not perform this function.
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This question is part of the following fields:
- Evidence Based Medicine
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Question 11
Incorrect
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A 48-year-old hairdresser presented to her GP complaining of tingling in the right palm and right wrist pain. She had intermittently experienced these symptoms; however, recently they had been keeping her awake all night. She had noticed a reduction in grip and was struggling to work at the salon. Otherwise, she felt well in herself and had not noticed any weakness in the other hand or lower limb. Her weight was stable, and she denied any neck problems or swallowing difficulties. She had a past medical history of hypothyroidism and hypertension and took regular thyroxine, Bendroflumethiazide and ibuprofen. She was a non-smoker and rarely drank alcohol. On examination, she appeared alert and oriented. Fundoscopy and cranial nerve examination were all normal and neck movements were full.
On examination of the upper limb, there was wasting over the right thenar eminence and fasciculations with a small burn over the right index finger. There was weakness of thumb abduction and opposition, with loss of pinprick and light touch sensation over the thumb, index and middle finger in the right hand. Nerve conduction studies showed absent sensory action potential in right median palmar branches and denervation of the right abductor pollicis brevis.
What is the most likely diagnosis?Your Answer: Motor neurone disease
Correct Answer: Median nerve palsy
Explanation:The history is consistent with carpal tunnel syndrome (CTS) arising as a result of pressure on the median nerve in the carpal tunnel. The median nerve supplies the muscles of the thenar eminence: the abductor pollicis (C7, C8), flexor pollicis brevis and opponens pollicis, and the lateral two lumbricals. The nerve conduction studies confirm marked denervation and absent sensory potentials within the median nerve territory.
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This question is part of the following fields:
- Nervous System
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Question 12
Incorrect
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A 67-year-old male presented with a history of chronic backache and altered sensation over the lateral side of his right calf and foot. Which of the following nerve roots will most likely be involved in this patient?
Your Answer: S1-S2
Correct Answer: L5-S1
Explanation:Lesions in L5-S1 region leads to altered sensation on the lateral side of calf and foot, along with back pain. There might be difficulty in extension of the leg, foot inversion, plantar flexion and toe flexion, as muscles controlling these functions are supplied by S1.
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This question is part of the following fields:
- Nervous System
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Question 13
Correct
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A 55-year-old man known with Addison's disease presented with complaints of recurrent attacks of postural hypotension. What kind of electrolyte imbalance would be seen in his biochemical profile investigations?
Your Answer: Low Na+, High K+
Explanation:Patients suffering from Addison’s disease have low aldosterone. Aldosterone increases Na+ absorption and excretion of K+. So in these patients there would be decreased Na+ and increased K+ levels.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 14
Correct
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A 45-year-old obese patient arrives at the clinic for a regular health check up. His labs are as follows: Fasting blood sugar: 6 mmol/l, Oral glucose tolerance test (OGTT): 10 mmol/L. What is the most likely diagnosis?
Your Answer: Impaired glucose tolerance
Explanation:Impaired glucose tolerance means that blood glucose is raised beyond normal levels, but not high enough to warrant a diabetes diagnosis. With impaired glucose tolerance you face a much greater risk of developing diabetes and cardiovascular disease. Impaired glucose tolerance is defined as 2-hour glucose levels of 140 to 199 mg per dL (7.8 to 11.0 mmol) on the 75-g oral glucose tolerance test, and impaired fasting glucose is defined as glucose levels of 100 to 125 mg per dL (5.6 to 6.9 mmol per L) in fasting patients.
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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 75-year-old man was admitted to the hospital with worsening dyspnoea. He was given a five day course of Amoxicillin.
On examination, his blood pressure was 89/59 mmHg with a respiratory rate of 35/min. A chest x-ray revealed left lower lobe consolidation.
Past medical history: Type 2 diabetes mellitus
Arterial blood gas on air:
pH 7.34
pCO2 5.4 kPa
pO2 9.0 kPa
Which antibiotic therapy is the most suitable?Your Answer: Intravenous co-amoxiclav + clarithromycin
Explanation:CURB Pneumonia Severity Score:
– Confusion (abbreviated Mental Test Score <=8) (1 point)
– Urea (BUN > 19 mg/dL or 7 mmol/L) (1 point)
– Respiratory Rate > 30 per minute (1 point)
– Blood Pressure: diastolic < 60 or systolic < 90 mmHg (1 point) Based on the CURB Pneumonia Severity Score, the patient has severe pneumonia. According to the 2009 Centres for Medicare and Medicaid Services (CMS) and Joint Commission consensus guidelines, inpatient treatment of pneumonia should be given within four hours of hospital admission (or in the emergency department if this is where the patient initially presented) and should consist of the following antibiotic regimens, which are also in accordance with IDSA/ATS guidelines. For non-intensive care unit (ICU) patients:
Beta-lactam (intravenous [IV] or intramuscular [IM] administration) plus macrolide (IV or oral [PO])
Beta-lactam (IV or IM) plus doxycycline (IV or PO)
Antipneumococcal quinolone monotherapy (IV or IM)If the patient is younger than 65 years with no risk factors for drug-resistant organisms, administer macrolide monotherapy (IV or PO)
For ICU patients:
IV beta-lactam plus IV macrolide
IV beta-lactam plus IV antipneumococcal quinoloneIf the patient has a documented beta-lactam allergy, administer IV antipneumococcal quinolone plus IV aztreonam.
The most suitable antibiotic therapy for this patient is therefore Intravenous co-amoxiclav + clarithromycin.
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This question is part of the following fields:
- Respiratory System
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Question 16
Correct
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A 30-year-old woman is admitted for drainage of an abscess in her left forearm. She has revealed that she was regular heroin user and has stopped for the past few days. Clinical signs are pointing towards opioid withdrawal. What is the next step in managing this patient?
Your Answer: Give her 10 mg of methadone syrup and wait 60 min to determine its effect
Explanation:The next step in managing this patient is to give 10 mg and continue administering in 10 mg increments each hour until symptoms are under control.
Methadone alleviates opioid withdrawal symptoms and reduces cravings. Methadone is useful for detoxification from longer-acting opioids such as morphine or methadone itself.
Methadone should be used with caution if the patient has:
Respiratory deficiency
Acute alcohol dependence
Head injury
Treatment with monoamine oxidase inhibitors (MAOIs)
Ulcerating colitis or Crohn’s disease
Severe hepatic impairment
The dose must be reviewed on a daily basis and adjusted based upon how well the symptoms are controlled and the presence of side effects. The greater the dose of opioids used by the patient, the greater the dose of methadone required to control withdrawal symptoms.To avoid the risk of overdose in the first days of treatment The recommended dosing of methadone is 30mg in two doses of 15mg morning and evening.
It is important to note that a methadone dose equivalent to what the patient reports they are taking should never be given.
It is rare to need more than 40 mg per 24 hours: beware of overdosing which can lead to respiratory arrest. -
This question is part of the following fields:
- Pharmacology
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Question 17
Correct
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A 39-year-old female had surgery for the removal of thyroid carcinoma. One week later, she presented in the OPD with complaints of numbness, tingling, involuntary spasm of the upper extremities, paraesthesia and respiratory stridor. Which of the following is the most likely cause?
Your Answer: Hypocalcaemia
Explanation:Hypocalcaemia presents with such symptoms. It probably happened due to accidental removal of a parathyroid gland during the thyroid surgery. Hypocalcaemia causes laryngospasm which produces stridor.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 18
Incorrect
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A 50-year-old male presented with acute severe central chest pain and acute ST elevation myocardial infarction was diagnosed. He was treated with streptokinase. 2 days later he was sweating excessively and he was found to be hypotensive. Which of the following cannot be considered as a reason for this presentation?
Your Answer: Ventricular septal defect
Correct Answer: Hypotensive effect of streptokinase
Explanation:Hypotensive effect of streptokinase occurs during the streptokinase infusion which is usually transient. Acute mitral regurgitation due to rupture of papillary muscles, ventricular septal defects and reinfarctions (left or right) are known to cause hypotension after 24 hrs. Pulmonary embolism is less likely but cannot be excluded.
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This question is part of the following fields:
- Cardiovascular System
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Question 19
Incorrect
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A 36-year-old lady with back pain is found to have loss of sensation of the kneecaps. Choose the dermatome most likely compromised:
Your Answer: L3
Correct Answer: L4
Explanation:L4 dermatome distribution includes the kneecaps.
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This question is part of the following fields:
- Nervous System
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Question 20
Incorrect
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A 39-year-old man was admitted with an exacerbation of asthma. He responded to treatment but the medical intern was concerned that Aspergillus fumigatus was cultured from his sputum.
Subsequently arranged serum total, IgE level was elevated at 437 ng/ml (normal 40-180 ng/ml), RAST to Aspergillus fumigatus was class III, Aspergillus fumigatus precipitins were negative.
What would be the most appropriate management step in this patient?Your Answer: Itraconazole
Correct Answer: No change in medication
Explanation:Allergic bronchopulmonary aspergillosis (ABPA) is a form of lung disease that occurs in some people who are allergic to Aspergillus. With ABPA, this allergic reaction causes the immune system to overreact to Aspergillus leading to lung inflammation. ABPA causes bronchospasm (tightening of airway muscles) and mucus build-up resulting in coughing, breathing difficulty and airway obstruction.
Blood tests are used to look for signs of an allergic reaction. This includes evaluating your immunoglobulin E (IgE) level. This level is increased with any type of allergy. Many people with asthma have higher than normal IgE levels. In ABPA however, the IgE level is extremely high (more than 1000 ng/ml or 417 IU/ml). In addition to total IgE, all patients with ABPA have high levels of IgE that is specific to Aspergillus. A blood test can be done to measure specific IgE to Aspergillus. A blood or skin test for IgE antibodies to Aspergillus can be done to see if a person is sensitized (allergic) to this fungus. If these skin tests are negative (i.e. does not show a skin reaction) to Aspergillus fumigatus, the person usually does not have ABPA.
Therefore, there should be no change in medication since this patient does not have ABPA. -
This question is part of the following fields:
- Respiratory System
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Question 21
Correct
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A 40-year-old male returning from an African country, presented with lower abdominal pain and haematuria. Bladder calcifications were detected on abdominal x-ray. Which of the following is the most probable cause?
Your Answer: Schistosoma haematobium
Explanation:Schistosoma haematobium characteristically causes urinary tract disease. S.mansoni, S. mekongi, S. intercalatum, and S. japonicum cause intestinal tract and liver disease.
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This question is part of the following fields:
- Infectious Diseases
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Question 22
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: Pulmonary angiography
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 23
Incorrect
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A 19-year-old football player was hit in his chest by an opponent. He became breathless and turned blue. What will be the initial management?
Your Answer:
Correct Answer: Give oxygen
Explanation:As the patient is turning blue, giving oxygen will be the first priority in his management.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 24
Incorrect
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A 17-year-old boy was brought to clinic, as his parents were concerned regarding possible delayed puberty. He was otherwise well, played sports regularly and his academic performance was good. His height was 1.7m and weight was 70 kg. On examination, he had a small penis and testes, absent pubic hair, but no other abnormalities. Investigations revealed: Serum testosterone 4 nmol/L (9-35) Plasma follicle stimulating hormone (FSH) 1 U/L (1-7) Plasma luteinising hormone (LH) 1 U/L (1-10) Plasma prolactin 300 mU/L (<450) Plasma TSH 2 mU/L (0.5-5) Which one of the following is the most likely cause?
Your Answer:
Correct Answer: Kallman's syndrome
Explanation:Klinefelter’s syndrome: The low follicle-stimulating hormone (FSH) and luteinising hormone (LH), together with the low testosterone, suggests a hypogonadotropic hypogonadism. We know that there is no mental retardation, and we are told that physical examination is normal and sense of smell would usually not be tested. Consequently a diagnosis of Kallman’s is suggested. We are not told of a family history of growth delay, thus this is unlikely to be constitutional delay. The thyroid-stimulating hormone (TSH) is normal, making hypothyroidism unlikely and this together with the normal prolactin make hypopituitarism most unlikely.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 25
Incorrect
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A 54-year-old female patient presents with a one week history of bloody diarrhoea, fever and abdominal pain. She has a history of rheumatoid arthritis which she controls with methotrexate. Her stool sample shows Campylobacter jejuni. What is the single most appropriate management?
Your Answer:
Correct Answer: Fluids + clarithromycin
Explanation:This woman is receiving methotrexate, an immunosuppressant, to control her rheumatoid arthritis. In such immunocompromised patients, BNF suggests clarithromycin as first-line management.
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This question is part of the following fields:
- Fluids & Electrolytes
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Question 26
Incorrect
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An old man presented with headache and weakness of the left half of the body. His CT scan showed an intracranial bleed (ICB). All of the following factors can lead to ICB except?
Your Answer:
Correct Answer: Moderate alcohol use
Explanation:Moderate alcohol intake has no association with intracranial bleeding (ICB), rather some authors suggested that it is protective. Patients with a previous history of DVT, mitral valve prolapse or those using cocaine are at an increased risk of developing an ICB.
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This question is part of the following fields:
- Cardiovascular System
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Question 27
Incorrect
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A 50-year-old lung cancer patient presents with diminished reflexes, retention of urine, postural hypotension and sluggish pupillary reaction. What is the most likely explanation for her symptoms?
Your Answer:
Correct Answer: Paraneoplastic syndrome
Explanation:Paraneoplastic syndromes are more common in patients with lung cancer. Signs and symptoms include inappropriate antidiuretic hormone secretion, finger clubbing, hypercoagulability and Eaton-Lambert syndrome.
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This question is part of the following fields:
- Respiratory System
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Question 28
Incorrect
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In last 5 days, an old man has complained of severe left sided headache, which was aggravated by bright lights. He has not vomited but feels nauseated. What is the most likely diagnosis?
Your Answer:
Correct Answer: Migraine
Explanation:Migraine without aura have the following characteristics: Nausea and vomiting accompanied by >5 headaches that last for 4-72 hours, plus any unilateral, pulsating headache or are aggravated by routine daily activities.
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This question is part of the following fields:
- Nervous System
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Question 29
Incorrect
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A 50-year-old female was examined after complaining of weak limbs. It was discovered she had burn marks on her fingers, diminished reflexes, and wasted and weak hands. Additionally, she has dissociated sensory loss and weak spastic legs. What is the diagnosis for this patient?
Your Answer:
Correct Answer: Syringomyelia
Explanation:All of the symptoms experienced by this patient are consistent with Syringomyelia. The sensory features are as follows: loss of temperature and pain sensation; sensory loss in the arms, shoulders, and upper body; touch, vibration, and position senses are affected in the feet as the syrinx enlarges into the dorsal column. Motor features are as follows: muscle wasting and weakness which begins in the hand, and moves onto the forearms and shoulders; loss of tendon reflexes. Autonomic involvement, such as the bladder and bowel, can occur.
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This question is part of the following fields:
- Nervous System
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Question 30
Incorrect
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A 45-year-old male, chronic smoker presented with a 6 month history of a productive cough with blood stained sputum and shortness of breath. The most likely diagnosis would be?
Your Answer:
Correct Answer: Bronchiectasis
Explanation:Bronchiectasis is characterised by a blood stained productive cough with copious amount of sputum production, along with dyspnoea.
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This question is part of the following fields:
- Respiratory System
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Question 31
Incorrect
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A 23-year-old student commences chemotherapy for B-type acute lymphoblastic leukaemia. She suffers from vomiting, but 36 hours later her condition worsens and her bloods reveal a corrected calcium of 2.0 mmol/l and serum potassium of 6.7 mmol/l.
Which of the following options is the best way to avoid this problem from occurring?Your Answer:
Correct Answer: Hydration and allopurinol pre-chemotherapy
Explanation:This case is most likely tumour lysis syndrome, often occurring immediately after starting chemotherapy because the tumour cells are killed and their contents are released into the bloodstream. After treating lymphomas or leukaemia, there is a sudden hypocalcaemia, hyperphosphatemia, and hyperkalaemia
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This question is part of the following fields:
- Renal System
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Question 32
Incorrect
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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:
Correct 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 33
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:
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 34
Incorrect
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A non-cyanosed 1-year-old female patient has a continuous murmur which is loudest at the left sternal edge. What pulse abnormality is most associated with patent ductus arteriosus if that's her suspected diagnosis?
Your Answer:
Correct Answer: Collapsing pulse
Explanation:DIAGNOSIS:
A consensus definition for hemodynamically significant PDA is lacking. The diagnosis is often suspected clinically, when an infant demonstrates signs of excessive shunting from the arterial to pulmonary circulation. Continuous or a systolic murmur; note, a silent PDA may also occur when the ductus shunt is large enough that nonturbulent flow fails to generate a detectible murmur.
A low diastolic blood pressure (due to runoff into the ductus during diastole, more frequent in the most premature infants).
A wide pulse pressure (due to ductus runoff or steal)Hypotension (especially in the most premature infants)
Bounding pulses
Increased serum creatinine concentration or oliguria
Hepatomegaly -
This question is part of the following fields:
- Cardiovascular System
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Question 35
Incorrect
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A 27-year-old woman is admitted on the medical intake. She is 10 weeks postpartum and has been generally unwell for two weeks with malaise, sweating and anxiety.
On examination, she is hemodynamically stable and clinically euthyroid.
TFTs show the following:
Free T4 33 pmol/L (9-23)
Free T3 8 nmol/L (3.5-6)
TSH <0.02 mU/L (0.5-5)
What is the appropriate management?Your Answer:
Correct Answer: Propranolol 20 mg tds
Explanation:The patient is most likely to have Postpartum thyroiditis which goes through 2 phases; hypothyroid and a hyperthyroid phase.
The hyperthyroid phase of postpartum thyroiditis occurs between 2 and 10 months postpartum. Most commonly, it presents at 3 months. Symptoms more common in women with hyperthyroid postpartum thyroiditis include palpitations, fatigue, heat intolerance, and irritability/nervousness. The frequency of asymptomatic hyperthyroidism is 33%.
Untreated, the hyperthyroidism resolves spontaneously within 2-3 months. This phase is diagnosed by the combination of a low serum TSH concentration in the presence of thyroid peroxidase antibodies, in women who are TSH receptor antibody-negative. Free T4 levels are typically elevated but may be normal.
Treatment of hyperthyroidism, when necessary, is based on symptom severity and should be a joint decision of patient and physician. Beta-blockers such as propranolol are given to alleviate palpitations, irritability, and nervousness. The morbidity associated with treatment is the side effects of beta-blockade. The downside of withholding treatment is allowing the woman to remain symptomatic. Antithyroid medicines (thioureas) are not a potential treatment alternative, because the hyperthyroidism is caused by destructive thyroiditis resulting in the release of preformed thyroid hormone. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 36
Incorrect
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A 59-year-old surgeon presents with a progressive paraesthesia and numbness in both feet, which have deteriorated over the last six months. He has a 10 year history of type 2 diabetes mellitus and had cervical spondylosis, for which he underwent surgery eight years ago. He also confessed to drinking approximately 40 units of alcohol weekly.
On examination he had mild bilateral weakness of foot dorsiflexion and both ankle reflexes were absent. There was absent sensation to light touch to mid-shin level with loss of joint position sensation in the toes and absent vibration sensation below the hips. He had a marked sensory ataxia and pseudoathetosis of the upper limbs. He had no evidence of a retinopathy and urinalysis was normal.
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Vitamin B 12 deficiency
Explanation:Diabetic peripheral neuropathy usually goes in parallel with retinopathy and nephropathy. It is also slowly progressive and affects mainly the spinothalamic pathway.
Alcohol induced peripheral neuropathy is also slowly progressive and affects mainly the spinothalamic pathway.
Vitamin B 12 deficiency usually causes a more rapidly progressive neuropathy with dorsal column involvement (joint position and vibration involvement with sensory ataxia and pseudoathetosis of upper limbs). -
This question is part of the following fields:
- Nervous System
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Question 37
Incorrect
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A 64-year-old woman presents with malaise, ankle swelling and shortness of breath. Her blood pressure is 215/140 mmHg, she has +2 peripheral oedema and the skin over her fingers appears very tight. Fundoscopy discloses bilateral papilledema.
Plasma creatinine concentration is 370 μmol/l, potassium is 4.9 mmol/l, haemoglobin is 8.9 g/dl and her platelet count is 90 x 109 /ml.
What is the pathological hallmark of this condition?Your Answer:
Correct Answer: Mucoid intimal thickening of vascular endothelium
Explanation:The history is suggestive of scleroderma renal crisis, where we would expect thrombotic microangiopathy process with vascular endothelium involvement manifesting as mucoid intimal thickening or onion skin effect.
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This question is part of the following fields:
- Renal System
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Question 38
Incorrect
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A 57-year-old, alcoholic male was admitted to the medical ward for an ascitic tap. The ascitic fluid was found to be yellow in colour. Which of the following had most likely lead to this observation?
Your Answer:
Correct Answer: Decompensated cirrhosis
Explanation:Uncomplicated cirrhotic ascites is usually translucent. If the patient is deeply jaundiced, the fluid might appear yellow/brown.
Turbidity or cloudiness of the ascites fluid suggests that infection is present and further diagnostic testing should be performed.
Pink or bloody fluid is most often caused by mild trauma, with subcutaneous blood contaminating the sample.
Bloody ascites is also associated with hepatocellular carcinoma or any malignancy-associated ascites.
Milky-appearing fluid usually has an elevated triglyceride concentration. Such fluid, commonly referred to as chylous ascites, can be related to thoracic duct injury or obstruction or lymphoma, but it is often related primarily to cirrhosis. -
This question is part of the following fields:
- Hepatobiliary System
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Question 39
Incorrect
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A 32-year-old woman presents to the GP with tiredness and anxiety during the third trimester of her second pregnancy.
The Examination is unremarkable, with a BP of 110/70 mmHg and a pulse of 80. Her BMI is 24 and she has an abdomen consistent with a 31-week pregnancy. The GP decides to check some thyroid function tests.
Which of the following is considered to be normal?Your Answer:
Correct Answer: Elevated total T4
Explanation:During pregnancy, profound changes in thyroid physiology occur to provide sufficient thyroid hormone (TH) to both the mother and foetus. This is particularly important during early pregnancy because the fetal thyroid starts to produce considerable amounts of TH only from approximately 20 weeks of gestation, until which time the foetus heavily depends on the maternal supply of TH. This supply of TH to the foetus, as well as increased concentrations of TH binding proteins (thyroxine-binding globulin) and degradation of TH by placental type 3 iodothyronine deiodinase, necessitate an increased production of maternal TH. This requires an intact thyroid gland and adequate availability of dietary iodine and is in part mediated by the pregnancy hormone human chorionic gonadotropin, which is a weak agonist of the thyroid-stimulating hormone (TSH) receptor. As a consequence, serum-free thyroxine (FT4) concentrations increase and TSH concentrations decrease from approximately the eighth week throughout the first half of pregnancy, resulting in different reference intervals for TSH and FT4 compared to the non-pregnant state.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 40
Incorrect
-
All of the following drugs reduce the tone of the lower oesophageal sphincter except?
Your Answer:
Correct Answer: Domperidone
Explanation:Domperidone is a D2 dopaminergic receptor antagonist which works as an anti emetic by increasing the tone of the lower oesophageal sphincter and increasing the gut motility.
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This question is part of the following fields:
- Pharmacology
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Question 41
Incorrect
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A 74-year-old retired judge who is known to have Alzheimer's disease is examined in clinic. His latest Mini Mental State Examination (MMSE) score is 18 out of 30. Which of the following is the most appropriate treatment option?
Your Answer:
Correct Answer: Supportive care + donepezil
Explanation:NICE now recommends the three acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) as options for managing mild to moderate Alzheimer’s disease. Memantine is reserved for patients with moderate to severe Alzheimer’s.
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This question is part of the following fields:
- Nervous System
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Question 42
Incorrect
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A female patient presents with pain upon inspiration and dyspnoea. She had a myocardial infarction four days ago. What is the most probable diagnosis?
Your Answer:
Correct Answer: Pericarditis
Explanation:Although viral infection is the most common identifiable cause of acute pericarditis, the condition may be associated with many diseases. Non-viral causes of pericarditis include bacterial infection, MI, chest trauma, and neoplasm. Post-MI pericarditis may develop two to four days after an acute infarction and results from a reaction between the pericardium and the damaged adjacent myocardium. Dressler’s syndrome is a post-MI phenomenon in which pericarditis develops weeks to months after an acute infarction; this syndrome is thought to reflect a late autoimmune reaction mediated by antibodies to circulating myocardial antigens.
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This question is part of the following fields:
- Cardiovascular System
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Question 43
Incorrect
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Three days after being admitted for a myocardial infarction, a male patient complains of sudden change in vision. The medical registrar examines the patient and finds that the patient's vision in both eyes is significantly reduced although the patient still claims that he can see. The pupils are equal in size, and the pupil responses are normal with normal fundoscopy. Significantly, the patient has now developed atrial fibrillation.
A referral is made to the ophthalmologist who confirms bilateral blindness. Despite this, however, the patient fervently believes that he can see and has taken to describing objects that he has never seen previously, in discriminating detail.
What is the most likely diagnosis?Your Answer:
Correct Answer: Bilateral occipital cortex infarction
Explanation:Bilateral occipital cortex infarction will produce varying degrees of cortical blindness, wherein the patient has no vision but fundoscopy findings are normal. When there are extensive lesions, patients my present with denial of their condition, known as Anton’s Syndrome, and begin to describe objects that they have never seen before.
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This question is part of the following fields:
- Nervous System
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Question 44
Incorrect
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A 28-year-old primigravida in her 24th week of pregnancy presented with a history of fast and regular palpitations. There is no history of collapse. On examination she was well, pulse rate was 102 bpm, which was regular and her blood pressure was 110/70 mmHg. Her JVP was not elevated. Heart sounds were normal. ECG showed sinus tachycardia. Which of the following can be expected due to the physiological changes which occur during pregnancy?
Your Answer:
Correct Answer: Tachycardia
Explanation:The cardiovascular alterations which occur during pregnancy are for the optimal growth and development of the foetus and help to protect the mother from the risks of delivery, such as haemorrhage. The changes are characterized by an increased vascular volume, cardiac output, and heart rate, with a marked fall in vascular resistance and reduction in blood pressure.
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This question is part of the following fields:
- Cardiovascular System
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Question 45
Incorrect
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Which one of the following is true regarding Escherichia coli infection?
Your Answer:
Correct Answer: E coli is an important cause of neonatal meningitis
Explanation:Escherichia coli (also known as E. coli) is a gram-negative, facultatively anaerobic, rod-shaped bacterium commonly found in the lower intestine of warm-blooded organisms. Most E. coli strains are harmless, but some serotypes can cause serious food poisoning in their hosts, and are occasionally responsible for product recalls due to food contamination. The harmless strains are part of the normal flora of the gut, and can benefit their hosts by producing vitamin K2, and preventing colonization of the intestine with pathogenic bacteria. Virulent strains can cause gastroenteritis, urinary tract infections, and neonatal meningitis.
The most common causes of neonatal meningitis is bacterial infection of the blood, known as bacteremia (specifically Group B Streptococci (GBS; Streptococcus agalactiae), Escherichia coli, and Listeria monocytogenes). Although there is a low mortality rate in developed countries, there is a 50% prevalence rate of neurodevelopmental disabilities in E. coli and GBS meningitis -
This question is part of the following fields:
- Infectious Diseases
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Question 46
Incorrect
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A 67-year-old butcher presents with a six month history of a gradually increasing burning sensation in his feet. Examination reveals normal cranial nerves and higher mental function. He has normal bulk, tone, power, light touch, pinprick sensation, coordination and reflexes in upper and lower limbs.
These clinical findings are consistent with which of the following?Your Answer:
Correct Answer: Small fibre sensory neuropathy
Explanation:The burning sensation described is typical of a neuropathy affecting the small unmyelinated and thinly myelinated nerve fibres. General neurological examination and reflexes are usually normal in this type of neuropathy unless there is coexisting large (myelinated) fibre involvement. Neuropathy affecting the large myelinated sensory fibres generally causes glove and stocking sensory loss and loss of reflexes.
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This question is part of the following fields:
- Nervous System
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Question 47
Incorrect
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A 55-year-old man presented with retrosternal chest pain associated with excessive sweating and vomiting. On examination his BP was 100/60 mmHg and pulse rate was 72 bpm. Bibasal crepitations were auscultated. His ECG showed ST elevation in V1 to V4 and ST depression in leads II, III and aVF. Which of the following would be the finding during angioplasty?
Your Answer:
Correct Answer: Complete occlusion of the left anterior descending artery
Explanation:The ECG findings are suggestive of anterior myocardial infarction and the most likely artery affected is the left anterior descending artery. Occlusion of the right coronary artery will be shown by ST elevation in lead II, III, aVF and occlusion of the circumflex artery will show changes in leads I, aVL, V5 and V6. To have ST elevation, there should be complete occlusion of the artery.
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This question is part of the following fields:
- Cardiovascular System
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Question 48
Incorrect
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A 74-year-old man who has been diagnosed with atrial fibrillation and heart failure is being started on digoxin. What is the mechanism of action of digoxin?
Your Answer:
Correct Answer: Inhibits the Na+/K+ ATPase pump
Explanation:Digoxin acts by inhibiting the Na+/K+ ATPase pump.
Digoxin is a cardiac glycoside now mainly used for rate control in the management of atrial fibrillation. As it has positive inotropic properties it is sometimes used for improving symptoms (but not mortality) in patients with heart failure.Mechanism of action:
It decreases the conduction through the atrioventricular node which slows the ventricular rate in atrial fibrillation and atrial flutter.
It increases the force of cardiac muscle contraction due to inhibition of the Na+/K+ ATPase pump. It also stimulates the vagus nerve.Digoxin toxicity:
Plasma concentration alone does not determine whether a patient has developed digoxin toxicity. The likelihood of toxicity increases progressively from 1.5 to 3 mcg/l.
Clinical feature of digoxin toxicity include a general feeling of unwell, lethargy, nausea & vomiting, anorexia, confusion, xanthopsia, arrhythmias (e.g. AV block, bradycardia), and gynaecomastiaPrecipitating factors:
Hypokalaemia
Increasing age
Renal failure
Myocardial ischemia
Hypomagnesaemia, hypercalcemia, hypernatremia, acidosis
Hypoalbuminemia
Hypothermia
Hypothyroidism
Drugs: amiodarone, quinidine, verapamil, diltiazem, spironolactone (competes for secretion in the distal convoluted tubule, therefore, reduce excretion), ciclosporin. Also, drugs that cause hypokalaemia e.g. thiazides and loop diuretics.Management of digoxin toxicity:
Digibind
Correct arrhythmias
Monitor and maintain potassium levels within the normal limits. -
This question is part of the following fields:
- Pharmacology
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Question 49
Incorrect
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Which of the following is not a tumour suppressor gene?
Your Answer:
Correct Answer: myc
Explanation:Myc is a family of regulator genes and proto-oncogenes that code for transcription factors.
A tumor suppressor gene, or antioncogene, is a gene that protects a cell from one step on the path to cancer. When this gene mutates to cause a loss or reduction in its function, the cell can progress to cancer, usually in combination with other genetic changes. Tumor suppressor genes can be grouped into categories including caretaker genes, gatekeeper genes, and landscaper genes; the classification schemes are continually evolving.
Examples include:
Gene Associated cancers
p53 Common to many cancers, Li-Fraumeni syndrome
APC Colorectal cancer
BRCA1 Breast and ovarian cancer
BRCA2 Breast and ovarian cancer
NF1 Neurofibromatosis
Rb Retinoblastoma
WT1 Wilm’s tumour -
This question is part of the following fields:
- Haematology & Oncology
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Question 50
Incorrect
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A 60-year-old male had an MI one week ago, but has now presented with a pericardial rub and dyspnoea. An ECG was performed and shows ST elevation. A chest x-ray shows loss of margin at the costovertebral angle. Choose the single most likely cause.
Your Answer:
Correct Answer: Dressler's syndrome
Explanation:The pericardial rub indicates pericarditis, which then causes widespread ST elevation. Therefore, the condition is not a new MI but is Dressler’s syndrome.
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This question is part of the following fields:
- Cardiovascular System
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Question 51
Incorrect
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A 42-year-old male with long history of diabetes is complaining of a red-hot tender lump near his anus. What is the most possible diagnosis?
Your Answer:
Correct Answer: Abscess
Explanation:A diabetic patient is a patient with depressed immunity. It is not uncommon to develop abscesses. Diabetic patients have a defected cellular innate immunity. On the other hand, bacteria become much more virulent in a high glucose environment in the interstitium.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 52
Incorrect
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A 70-year-old male tells doctors he has been exposed to asbestos 20 years ago and has attempted to quit smoking. He has lost a lot of weight and his voice is very hoarse. Choose the most likely cancer diagnosis in this patient.
Your Answer:
Correct Answer: Bronchial Carcinoma
Explanation:A hoarse voice, exposure to asbestos, and smoking are all consistent with bronchial carcinoma in this patient.
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This question is part of the following fields:
- Respiratory System
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Question 53
Incorrect
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A 60-year old male presented to the OPD with a complaint of a rusty-coloured sputum along with a cough for 3 days. His has a history of smoking for 40 years, and a history of significant weight loss. His chest X-ray revealed solid nodules in both lungs and bilateral hilar lymphadenopathy. Out of the following, which one is the most appropriate investigation?
Your Answer:
Correct Answer: LN biopsy
Explanation:The patient’s age, a history of long-term smoking, and bilateral hilar lymphadenopathy are strong indications of malignancy. Lymph node biopsy would be essential in order to check the degree of metastasis in the mediastinal lymph nodes.
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This question is part of the following fields:
- Respiratory System
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Question 54
Incorrect
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In which part of the body is conjugated bilirubin metabolised to urobilinogen?
Your Answer:
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 55
Incorrect
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A 71-year-old woman presents with dyspnoea and unsteadiness. She's known to suffer from epilepsy and is managed on carbamazepine. Blood exams are as follows: MCV=70, Hb=8.5, WBC=2, Neutrophils=1, Platelets=50. What is the most likely diagnosis?
Your Answer:
Correct Answer: Aplastic anaemia
Explanation:The results of the blood exam are suggestive of aplastic anaemia which might be secondary to carbamazepine use. The use of antiepileptic’s, in particular carbamazepine and valproate, is associated with a nine fold increased risk of aplastic anaemia.
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This question is part of the following fields:
- Haematology & Oncology
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Question 56
Incorrect
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A 55-year-old diabetic male presents with a feeling of generally being unwell. He also has a history of atrial fibrillation and epilepsy. His main complaint is a blue tinge to his vision. Which one of his medications is most likely to be responsible?
Your Answer:
Correct Answer: Sildenafil
Explanation:Blue tinge of vision/cyanopsia is caused due to the intake of sildenafil citrate.
Sildenafil citrate (Viagra) is the first oral drug to be widely approved for the treatment of erectile dysfunction.
It is a potent and selective inhibitor of type-V phosphodiesterase, the primary form of the enzyme found in human penile erectile tissue, thereby preventing the breakdown of cyclic guanosine monophosphate (cGMP), the intracellular second messenger of nitric oxide.Uses:
It is used for the treatment of erectile dysfunction, idiopathic pulmonary hypertension, premature ejaculation, high altitude illness, penile rehabilitation after radical prostatectomy, angina pectoris, and lower urinary tract symptoms.Adverse effects:
Mild headache, flushing, dyspepsia, cyanopsia, back pain, and myalgias – due to a high concentration of PDE11 enzyme in skeletal muscle, which shows significant cross-reactivity with the use of tadalafil.
It can also cause hypotension, dizziness, and rhinitis.Note: Xanthopsia (yellow-green vision) may occur secondary to treatment with digoxin.
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This question is part of the following fields:
- Pharmacology
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Question 57
Incorrect
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A 44-year-old alcoholic man was operated on for a strangulated abdominal hernia, however a few days after the operation he became agitated. According to the patient, he used to see snakes curling over his body. O/E he was agitated, tachycardiac and confused. The most likely diagnosis would be?
Your Answer:
Correct Answer: Delirium tremens
Explanation:Delirium tremens occurs due to alcohol withdrawal and presents clinically with hallucinations, agitations, confusion and hyperthermia. Wernicke’s encephalopathy is characterised by encephalopathy, oculomotor dysfunction and ataxic gait. In Korsakoff’s syndrome, there is marked short term memory loss, however the long term memory is preserved & the sensorium is also intact.
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This question is part of the following fields:
- Nervous System
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Question 58
Incorrect
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A 39-year-old woman with a history of rheumatoid arthritis has recently been switched from methotrexate to leflunomide. Monitoring of full blood count and LFTs has been carried out. Which of the following parameters should also be monitored in this case?
Your Answer:
Correct Answer: Blood pressure
Explanation:Blood pressure should be routinely measured as leflunomide may cause hypertension and thus an increase in BP. It doesn’t cause changes in blood sugar levels, peak expiratory flow rate or haematuria.
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This question is part of the following fields:
- Musculoskeletal System
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Question 59
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:
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 60
Incorrect
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A 34-year-old woman is admitted to the oncologist clinic for further investigations. She has experienced fever, sometimes glandular and night sweats. Clinical examination reveals lymphadenopathy and a biopsy is performed. The biopsy reveals the presence of Reed-Sternberg cells, confirming what was suspected to be a Hodgkin's lymphoma. Which cell surface marker is associated with this condition?
Your Answer:
Correct Answer: CD15
Explanation:The CD15 antigen, also known as Lewis (hapten)X, serves as an immuno-phenotypic marker for Reed-Sternberg cells and its expression has diagnostic, but also prognostic significance in Hodgkin Lymphoma.
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This question is part of the following fields:
- Haematology & Oncology
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Question 61
Incorrect
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A 40-year-old female is receiving a course of chemotherapy for breast cancer. She is, however, experiencing troublesome vomiting which is not responding to domperidone.
Which of the following is the most appropriate next step of management?Your Answer:
Correct Answer: Add a 5-HT3 antagonist
Explanation:Nausea and vomiting are the common side effects of chemotherapy. Risk factors for the development of these symptoms include age<50 years, anxiety, concurrent use of opioids, and the type of chemotherapy administered. For patients at low risk of these symptoms, drugs such as metoclopramide may be used. For high-risk patients, however, 5-HT3 receptor antagonists such as ondansetron are often effective, especially if combined with dexamethasone.
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This question is part of the following fields:
- Haematology & Oncology
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Question 62
Incorrect
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A 37-year old female nurse presents with severe generalized itching, claiming that she had previously applied cream to the body of a patient with similar symptoms. What is the mechanism that produces her itch?
Your Answer:
Correct Answer: Allergic reaction
Explanation:Contact dermatitis is a red, itchy rash caused by direct contact with a substance or an allergic reaction to it. The entry of allergen into the epidermis or dermis causes a localized allergic reaction. Local mast-cell activation in the skin leads immediately to a local increase in vascular permeability, which causes extravasation of fluid and swelling. Histamine released by mast cells activated by allergen in the skin causes large, itchy, red swellings of the skin.
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This question is part of the following fields:
- The Skin
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Question 63
Incorrect
-
A 28-year-old woman presents with easy bruising. She has no history of mucosal bleeding and is generally well apart from occasional diarrhoea. She has previously attended a psychiatric unit for self-harming behaviour and is now brought in by her mother having consumed a number of pills. Her mother has had recurrent venous thromboses, but there is no family history of a bleeding disorder.
Her full blood count (FBC) is normal, but her coagulation profile shows:
Activated partial thromboplastin time (APTT): 60 secs (28-38 secs)
Prothrombin time (PT): no clot after 120 secs (10-14 secs)
Fibrinogen: 3.6 g/L (2-4 g/L)
What is the most likely explanation?Your Answer:
Correct Answer: Warfarin overdose
Explanation:Warfarin inhibits the vitamin K-dependent procoagulants II, VII, IX, and X as well as anticoagulant protein C and S. It is highly protein-bound and can be displaced by a wide variety of drugs. It has a half-life of 36-48 hours.
Bleeding is the major side effect. Easy bruising, as seen in this case, is commonly seen in patients of warfarin overdose. Grossly prolonged PT and lesser increase in APTT may be seen in such cases.
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This question is part of the following fields:
- Haematology & Oncology
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Question 64
Incorrect
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A 72-year-old male with a history of type II diabetes mellitus and hypertension for 15 years, presented with gradual onset difficulty in breathing on exertion and bilateral ankle swelling for the past 3 months. On examination he had mild ankle oedema. His JVP was not elevated. His heart sounds were normal but he had bibasal crepitations on auscultation. Which of the following clinical signs has the greatest sensitivity in detecting heart failure in this patient?
Your Answer:
Correct Answer: Third heart sound
Explanation:The presence of a third heart sound is the most sensitive indicator of heart failure. All of the other signs can be found in heart failure with varying degrees.
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This question is part of the following fields:
- Cardiovascular System
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Question 65
Incorrect
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A 60-year-old man with a history of recent thyrotoxicosis underwent major surgery a week ago. He now presents with altered mental status, tachycardia, high-grade fever, vomiting and cardiac failure. A diagnosis of thyroid storm (crisis) is made.
What is the most important next step in management?Your Answer:
Correct Answer: Transfer the patient to ITU
Explanation:Thyroid storm, also referred to as thyrotoxic crisis, is an acute, life-threatening, hypermetabolic state induced by excessive release of thyroid hormones (THs) in individuals with thyrotoxicosis.
Patients with thyroid storm should be treated in an ICU setting for close monitoring of vital signs and for access to invasive monitoring and inotropic support, if necessary.
– Supportive measures
If needed, immediately provide supplemental oxygen, ventilatory support, and intravenous fluids. Dextrose solutions are the preferred intravenous fluids to cope with continuously high metabolic demand.
– Correct electrolyte abnormalities.
– Treat cardiac arrhythmia, if necessary.
– Aggressively control hyperthermia by applying ice packs and cooling blankets and by administering acetaminophen (15 mg/kg orally or rectally every 4 hours).
– Antiadrenergic drugs.
– Thionamides: Correct the hyperthyroid state. Administer antithyroid medications to block further synthesis of thyroid hormones (THs).
High-dose propylthiouracil (PTU) or methimazole may be used for treatment of thyroid storm.
– Administer glucocorticoids to decrease peripheral conversion of T4 to T3. This may also be useful in preventing relative adrenal insufficiency due to hyperthyroidism and improving vasomotor symptoms.
– Bile acid sequestrants prevent reabsorption of free THs in the gut (released from conjugated TH metabolites secreted into bile through the enterohepatic circulation).
– Treat the underlying condition. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 66
Incorrect
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Which type of cell is responsible for the production of surfactant?
Your Answer:
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 67
Incorrect
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A 35-year-old female admitted with heat intolerance, neck pain, palpitations and recent onset weight loss despite increased appetite. Which of the following is most likely to be associated with diagnosis of thyroiditis associated with viral infection?
Your Answer:
Correct Answer: Reduced uptake on thyroid isotope scan
Explanation:Subacute thyroiditis (De Quervain’s thyroiditis) is a self-limiting thyroid condition presenting with three clinical courses of hyperthyroidism, hypothyroidism, and return to normal thyroid function. In subacute thyroiditis serum thyroglobulin (TG) levels are elevated. ESR is usually greater than 50 mm/h, often exceeding 100 mm/h. Radio-iodine uptake is low or nil. Antithyroperoxidase antibodies are associated with autoimmune thyroiditis
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 68
Incorrect
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A prolonged QT interval is linked to which of the following?
Your Answer:
Correct Answer: Hypocalcaemia
Explanation:Prolonged QT interval can be seen in the following conditions: Hypocalcaemia, hypothermia, severe bradycardia, Class 1 and 3 antiarrhythmic drugs, non-sedating antihistamines, tricyclic antidepressants etc.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 69
Incorrect
-
A middle aged male arrives at the clinic due to chest pain and productive cough. The temperature is recorded to be 38C֯. Radiological examination reveals lobar consolidation and pleurisy. Which of the following would be the best management plan for this patient?
Your Answer:
Correct Answer: Amoxicillin
Explanation:The mainstay of drug therapy for bacterial pneumonia is antibiotic treatment. The choice of agent is based on the severity of the patient’s illness, host factors (e.g., comorbidity, age), and the presumed causative agent. Lobar pneumonia is frequently associated with pneumococcus and Hemophilus infection. Amoxicillin can be effectively used in such cases.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 70
Incorrect
-
A 15-year-old girl presents with vomiting and her investigations show:
Sodium 115 mmol/L (137-144)
Potassium 3.0 mmol/L (3.5-4.9)
Urea 2.1 mmol/L (2.5-7.5)
Urine sodium 2 mmol/L
Urine osmolality 750 mosmol/kg (350-1000)
What is the most likely diagnosis?Your Answer:
Correct Answer: Bulimia nervosa
Explanation:The patient is most likely to have Bulimia nervosa. A young girl with a low body mass contributes to the low urea. Hypokalaemia and hyponatraemia are due to vomiting. Her urine sodium is also low.
– In Addison’s diseases, there are low levels of sodium and high levels of potassium in the blood. In acute adrenal crisis: The most consistent finding is elevated blood urea nitrogen (BUN) and creatinine. Urinary and sweat sodium also may be elevated.
– In Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) there is hyponatremia with corresponding hypo-osmolality, continued renal excretion of sodium, urine less than maximally dilute and absence of clinical evidence of volume depletion. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 71
Incorrect
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A 30-year-old lawyer presents with non-specific symptoms of tiredness.
Blood tests reveal normal thyroid function, cortisol, growth hormone and gonadotropins. Pituitary MRI reveals a 0.8cm microadenoma.
Which of the following represents the most appropriate course of action?Your Answer:
Correct Answer: Observation and reassurance
Explanation:The patient has a non-functioning pituitary tumour as her hormone profile is normal.
Non-functioning pituitary tumours are relatively common. A large number of these tumours are incidentally found pituitary microadenomas (<1 cm) and are usually of no clinical importance. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 72
Incorrect
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A 72-year-old man is referred to the haematology department with raised haemoglobin and platelet levels. A diagnosis of polycythaemia vera is suspected.
Which other abnormality of the blood would be most consistent with this diagnosis?Your Answer:
Correct Answer: Neutrophilia
Explanation:Neutrophilia is also commonly associated with polycythaemia vera.
Polycythaemia vera (PV), also known as polycythaemia rubra vera, is a myeloproliferative disorder caused by clonal proliferation of marrow stem cells leading to an increase in red cell volume, often accompanied by overproduction of neutrophils and platelets. It has peak incidence in the sixth decade of life, with typical features including hyperviscosity, pruritus, splenomegaly, haemorrhage (secondary to abnormal platelet function), and plethoric appearance.
Some management options of PV include lose-dose aspirin, venesection (first-line treatment), hydroxyurea (slightly increased risk of secondary leukaemia), and radioactive phosphorus (P-32) therapy.
In PV, thrombotic events are a significant cause of morbidity and mortality. 5-15% of the cases progress to myelofibrosis or AML. The risk of having AML is increased with chemotherapy treatment.
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This question is part of the following fields:
- Haematology & Oncology
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Question 73
Incorrect
-
Tranexamic acid is used to treat heavy menstrual bleeding in women. It inhibits menorrhagia by which of the following mechanisms?
Your Answer:
Correct Answer: Inhibits fibrinolysis
Explanation:Tranexamic acid prevents menorrhagia by inhibiting fibrinolysis thus promoting coagulation.
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This question is part of the following fields:
- Pharmacology
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Question 74
Incorrect
-
A 41-year-old gentleman undergoes a temporal lobectomy after the discovery of a brain tumour. Which one of the following consequences would be least likely to develop?
Your Answer:
Correct Answer: Astereognosis
Explanation:Astereognosis is associated with lesions to the parietal lobe, not the temporal lobe, so this symptom would not arise in this patient.
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This question is part of the following fields:
- Nervous System
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Question 75
Incorrect
-
Which of the following statements is false regarding the bioavailability of a drug?
Your Answer:
Correct Answer: The bioavailability of a drug given orally is often affected by the degree of renal elimination
Explanation:Renal elimination of a drug has no role in altering the bioavailability of a drug.
The bioavailability of a drug is the proportion of the drug which reaches systemic circulation.
Mathematically, bioavailability is the AUCoral/AUCiv x 100%, where AUC = area under the concentration-time curve following a single (oral or iv) dose.Other options are true:
By definition, the bioavailability of a drug given intravenously is 100%.
Drugs given orally that undergo high pre-systemic (first-pass) metabolism in the liver or gut wall have a low bioavailability e.g. lidocaine.
Bioavailability is also affected by the degree of absorption from the gut and this can change depending on gut motility and administration of other drugs. -
This question is part of the following fields:
- Pharmacology
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Question 76
Incorrect
-
A 44-year-old call centre worker with asthma is prescribed a leukotriene inhibitor. He presents with severe abdominal pain and a pleural effusion. Which of the following is the most likely cause of the effusion?
Your Answer:
Correct Answer: Churg-Strauss syndrome
Explanation:Churg-Strauss syndrome is characterised by reactions in the serosal membranes. Hence, pericardial effusions and pleural effusions are common. Cytological analysis of the transudate shows high levels of eosinophils. Leukotriene inhibitors are known to increase the incidence of this syndrome.
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This question is part of the following fields:
- Respiratory System
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Question 77
Incorrect
-
A 50-year-old woman with lung cancer develops deep vein thrombosis (DVT). She is reviewed in the hospital clinic and started on low-molecular-weight heparin (LMWH).
Which of the following should be the most appropriate treatment plan?Your Answer:
Correct Answer: Continue on LMWH for 6 months
Explanation:Patients with active cancer are at a continuous risk of having venous thromboembolism (VTE), such as DVT. Therefore, a six-month course of an anticoagulant such as LMWH is recommended. LMWH is the drug of choice since its side effects can be reversed and it can be stopped easily in case of a cancer-related bleed, for example, massive haemoptysis in a patient with lung cancer.
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This question is part of the following fields:
- Haematology & Oncology
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Question 78
Incorrect
-
A 40-year-old lady who underwent a recent subtotal gastrectomy for peptic ulcer disease has now developed anaemia with a haemoglobin of 6.4, tiredness, fatigue and loss of vibration sensation in both legs. What is the underlying cause of her symptoms?
Your Answer:
Correct Answer: B12 deficiency
Explanation:Vit B12 needs intrinsic factor to be absorbed, which is secreted in the stomach. Its deficiency is characterised by macrocytic anaemia with peripheral neuropathy.
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This question is part of the following fields:
- Gastrointestinal System
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Question 79
Incorrect
-
From the following responses, what is the commonest cardiovascular abnormality associated with Marfan's syndrome of an adult?
Your Answer:
Correct Answer: Aortic root dilatation
Explanation:The main cardiovascular manifestations associated with Marfan’s syndrome are aortic dilatation and mitral valve prolapse.
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This question is part of the following fields:
- Cardiovascular System
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Question 80
Incorrect
-
A 8-year-old girl with suspected patent foramen ovale, presented with her parents for the confirmation of the diagnosis. Which of the following is the best investigation to confirm the diagnosis?
Your Answer:
Correct Answer: Transoesophageal Echocardiography
Explanation:A 3-dimensional transoesophageal echocardiography (3D TEE) provides direct visualization of the entire PFO anatomy and surrounding structures. It allows more accurate diagnosis.
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This question is part of the following fields:
- Cardiovascular System
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Question 81
Incorrect
-
A west Indian man complains of limb and abdominal pain. He is also anaemic and has frequent infections, which precipitate these symptoms. On examination, his spleen is not palpable and he has a mild jaundice. What is your most probable diagnosis?
Your Answer:
Correct Answer: Sickle cell disease
Explanation:Sickle cell disease (SCD) and its variants are genetic disorders resulting from the presence of a mutated form of haemoglobin, haemoglobin S (HbS). This leads to a rigid, sickle-like shape of red blood cells under certain circumstances which can result in attacks of pain (sickle cell crisis), anaemia, swelling in the hands and feet, bacterial infections and stroke. Anaemia and jaundice happen due to insufficient healthy red blood cell capacity and increased breakdown of haem groups by the liver.
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This question is part of the following fields:
- Gastrointestinal System
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Question 82
Incorrect
-
A 20-year-old football player has fallen and hit his head on the ground. He did not lose consciousness but has a left side subconjunctival haemorrhage, swelling, and tenderness over his left cheek. Which of the following is the most appropriate initial investigation?
Your Answer:
Correct Answer: Facial XR
Explanation:History and examination findings are suggestive of facial injury and intracranial haemorrhage is unlikely. To exclude any facial fracture, an X-ray is suggested.
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This question is part of the following fields:
- Nervous System
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Question 83
Incorrect
-
A 18-year-old male was screened for hypertrophic cardiomyopathy (HOCM) as his brother had the same condition. What is the echocardiographic finding that is related to the highest risk of sudden cardiac death?
Your Answer:
Correct Answer: Significant thickening of the interventricular septum
Explanation:There are five prognostic factors which indicate poor prognosis in HOCM:
-family history of HOCM-related sudden cardiac death
-unexplained recent syncope
-large left ventricular wall thickness (MLVWT > 30 mm)
-multiple bursts of nsVT on ambulatory electrocardiography
-hypotensive or attenuated blood pressure response to exercise -
This question is part of the following fields:
- Cardiovascular System
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Question 84
Incorrect
-
Which of the following statements is the most characteristic of primary Raynaud's phenomenon?
Your Answer:
Correct Answer: Fingers are symmetrically involved during an attack
Explanation:A typical attack may last less than an hour but can also persist for longer. In primary Raynaud’s, attacks are more likely symmetric, episodic, and without evidence of peripheral vascular disease. Patients more commonly have a negative ANA and normal inflammatory markers. There should be no evidence of tissue gangrene, digital pitting, or tissue injury in primary Raynaud’s. In contrast, patients with secondary Raynaud’s will describe attacks that are more frequent, painful, often asymmetric and may lead to digital ulcerations.
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This question is part of the following fields:
- Musculoskeletal System
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Question 85
Incorrect
-
A 52-year-old woman with polycystic kidney disease and a slowly rising creatinine, which was 320 μmol/L at her last clinic visit 3 weeks ago, is brought into the Emergency Department having been found collapsed at home by her partner. She is now fully conscious but complains of a headache.
What is the most likely diagnosis?Your Answer:
Correct Answer: Subarachnoid haemorrhage
Explanation:One of the most important complications in patients with PKD is being affected by berry aneurysms that may burst, causing a subarachnoid haemorrhage, which seems to be the case in this patient.
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This question is part of the following fields:
- Renal System
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Question 86
Incorrect
-
A 45-year-old appears at the OPD with symptoms of persistent cough and purulent sputum. He is a chronic smoker and had measles in the past. Upon auscultation, inspiratory crepitation and finger clubbing are noted. What is the single most likely diagnosis?
Your Answer:
Correct Answer: Bronchiectasis
Explanation:A history of measles, whooping cough, or other severe lung infections like tuberculosis (TB) and pneumonia can lead to airway damage and possibly bronchiectasis.
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This question is part of the following fields:
- Respiratory System
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Question 87
Incorrect
-
A 69-year-old male with a history of Hepatitis C liver cirrhosis presented with spontaneous bacterial peritonitis. He had no symptoms of hypovolaemia. Choose the best treatment option to prevent the patient from developing hepatorenal syndrome.
Your Answer:
Correct Answer: Intravenous albumin administration
Explanation:In randomised controlled trials, the administration of albumin has been shown to lower the risk of the hepatorenal syndrome – this is thought to be due to its positive effect on circulatory systems. Diuretics can aid in the prevention of renal failure, but this patient is not showing signs of hypovolaemia. Synthetic disaccharide lactulose is primarily used for the prevention of hepatic encephalopathy, which has no function in preventing hepatorenal syndrome. Limited evidence is available for the use of Neomycin as a treatment for hepatic encephalopathy, but is associated with nephrotoxicity and ototoxicity.
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This question is part of the following fields:
- Renal System
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Question 88
Incorrect
-
A 70-year-old male underwent surgery for rectal carcinoma. 10 days after the operation, he presents with a mass in his pelvis and a high-grade fever. Choose the most likely diagnosis from the list of options below.
Your Answer:
Correct Answer: Pelvic Abscess
Explanation:Developing a pelvis abscess is one of the most common postoperative surgical complications after rectal operations. The symptoms of a pelvic mass and fever are also consistent with a pelvic abscess.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 89
Incorrect
-
A 31-year-old female complains of bilateral proximal muscle weakness. There is marked blanching of fingers especially in response to cold weather. Lab results are as follows:
Anti Jo-1: positive
ANA: positive
CK: 2000 U/L
ESR: 60mm/hr
EMG: myopathic changes
Presence of which of the following signifies the worst prognosis?Your Answer:
Correct Answer: Interstitial lung disease
Explanation:Polymyositis is an inflammatory disorder causing symmetrical, proximal muscle weakness. It is thought to be a T-cell mediated cytotoxic process directed against muscle fibres. It may be idiopathic or associated with connective tissue disorders. It may also be associated with malignancy for example small cell lung carcinoma.
Dermatomyositis is a variant of the disease where skin manifestations are prominent, for example a purple (heliotrope) rash on the cheeks and eyelids.
It typically affects middle-aged, female: male 3:1. Features include proximal muscle weakness +/- tenderness, Raynaud’s phenomenon, respiratory muscle weakness, interstitial lung disease: e.g. fibrosing alveolitis or organising pneumonia, dysphagia, dysphonia. Investigations: elevated creatine kinase, other muscle enzymes (lactate dehydrogenase (LD), aldolase, AST and ALT) are also elevated in 85-95% of patients, EMG, muscle biopsy. Anti-Jo-1 antibodies are seen in pattern of disease associated with lung involvement, Raynaud’s and fever. Interstitial lung disease plays a major role in morbidity and mortality in patients with polymyositis and is considered a major risk factor for premature death in patients with myositis. -
This question is part of the following fields:
- Musculoskeletal System
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Question 90
Incorrect
-
The ECG of a 29-year-old female shows an irregular rhythm with a HR of 154 bpm. She presented complaining of heart palpitations and hot flashes for the past 4 days. What is the most likely treatment?
Your Answer:
Correct Answer: Beta blockers
Explanation:At 29 years old, the most probable cause of this arrhythmia is thyrotoxicosis. β blockers relieve symptoms such as tachycardia, tremor, and anxiety in thyrotoxic patients. β blockade should be used as the primary treatment only in patients with thyrotoxicosis due to thyroiditis.
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This question is part of the following fields:
- Cardiovascular System
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Question 91
Incorrect
-
Which of the following immune responses occurs in Coeliac disease?
Your Answer:
Correct Answer: Type IV hypersensitivity
Explanation:Celiac disease is classified as a Type IV hypersensitivity mediated by T-cell response. Negatively charged gliadin has been shown to induce interleukin 15 in the enteric epithelial cells, stimulating the proliferation of the natural killer cells and intraepithelial lymphocytes to express NK-G2D, a marker for natural killer T lymphocytes.
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This question is part of the following fields:
- Immune System
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Question 92
Incorrect
-
A 51-year-old smoker was recently diagnosed with non small cell lung carcinoma. Investigations show presence of a 3 x 3 x 2 cm tumour on the left side of the lower lung lobe. the mass has invaded the parietal pleura. Ipsilateral hilar node is also involved but there is no metastatic spread.
What is the stage of this cancer?Your Answer:
Correct Answer: T2 N1 M0
Explanation:The tumour has only invaded the visceral pleura and measures 3cm in the greatest dimension. Hence it is designated at T2. Ipsilateral peribronchial and/or hilar lymph node involvement would make it N1. There is no distal metastasis so M would be 0.
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This question is part of the following fields:
- Respiratory System
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Question 93
Incorrect
-
A 25-year-old previously well male presented with chest discomfort and difficulty in breathing while running to the bus. Symptoms disappeared after resting. But the symptoms reappeared whilst he was climbing the stairs. On examination he was not dyspnoeic at rest. BP was 110/70 mmHg and pulse rate was 72 bpm. His heart sounds were normal. There was an additional clicking noise in the fourth left intercostal space which is heard with each heartbeat. Which of the following is the most probable cause for his presentation?
Your Answer:
Correct Answer: Spontaneous pneumothorax
Explanation:The given history is more compatible with spontaneous pneumothorax. Left-sided pneumothoraxes may be associated with a clicking noise, which is heard with each heart-beat and can sometimes be heard by the patient.
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This question is part of the following fields:
- Cardiovascular System
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Question 94
Incorrect
-
A 25-year-old athlete presented with a 7-month history of difficulty gripping things. He complained of finding it particularly difficult in cold weather. He remembered his father having similar problems. Upon examination, he had a bilateral ptosis with weakness of the facial muscles. He also had difficulty opening his eyes quickly. Limb examination revealed distal weakness in both hands with difficulty opening and closing both hands quickly. Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Myotonic dystrophy
Explanation:Myotonic dystrophy is the most likely diagnosis here.
It is a multisystem disorder causing cognitive impairment, cataracts, cardiac problems and testicular atrophy, as well as affecting the muscles. Patients have muscle weakness, normally worse distally, and/or myotonia (which is worse in cold weather).
On examination, patients may also have frontal balding, a myopathic facies, bilateral ptosis, an ophthalmoplegia and wasting of facial muscles and other limb muscles. Myotonic dystrophy is associated with diabetes mellitus and pituitary dysfunction.
Diagnosis is normally based on clinical features with a characteristic electromyogram (EMG) of myotonic discharges. Creatine kinase is generally normal and muscle biopsy is non-specific. -
This question is part of the following fields:
- Nervous System
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Question 95
Incorrect
-
A urine culture of a 50-year-old patient with urosepsis has isolated a multi-drug resistant Escherichia coli. What is the most likely reason for the multidrug resistance?
Your Answer:
Correct Answer: Extended spectrum beta-lactamase (ESBL) production
Explanation:Extended-spectrum beta-lactamases (ESBL) are enzymes that confer resistance to most beta-lactam antibiotics, including penicillins, cephalosporins, and the monobactam aztreonam. Extended spectrum beta-lactamase (ESBL) production is the main reason for multi-drug resistance among E.coli. Commonly used medications to treat ESBL-involved infections include carbapenems (imipenem, meropenem, and doripenem), cephamycins (cefoxitin and cefotetan), Fosfomycin, nitrofurantoin, beta-lactamase inhibitors (clavulanic acid, tazobactam, or sulbactam), non-beta-lactamases and colistin (if all other medications have failed.)
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This question is part of the following fields:
- Infectious Diseases
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Question 96
Incorrect
-
A 23-year-old female presents to the hospital with worsening shortness of breath, increased volume of purulent sputum and left-sided chest pain. She has a history of cystic fibrosis. Medical notes state that she is under consideration for the transplant list and for some years has been colonised with pseudomonas.
On examination she has a temperature of 38.4°C and FEV1 falling below 75% of the previous value that was recorded. She looks unwell and is tachycardic and hypotensive with a respiratory rate of 21/min. Burkholderia cepacia is confirmed as the pathogen in this case.
What would be the most appropriate antibiotic regime?Your Answer:
Correct Answer: Ceftazidime and aminoglycoside
Explanation:Burkholderia cepacia is an aerobic gram-negative bacillus found in various aquatic environments. B cepacia is an organism of low virulence and is a frequent colonizer of fluids used in the hospital (e.g., irrigation solutions, intravenous fluids).
B cepacia, as a non-aeruginosa pseudomonad, is usually resistant to aminoglycosides, antipseudomonal penicillin, and antipseudomonal third-generation cephalosporins and polymyxin B.
B cepacia is often susceptible to trimethoprim plus sulfamethoxazole (TMP-SMX), cefepime, meropenem, minocycline, and tigecycline and has varying susceptibility to fluoroquinolones.
Based on the options available, ceftazidime and aminoglycoside would be the best option. -
This question is part of the following fields:
- Respiratory System
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Question 97
Incorrect
-
A 45-year-old male presents to the clinic complaining of vomiting and early morning headaches. CT scan of the brain shows multiple ring enhancing lesions. Which of the following is the cause of this finding?
Your Answer:
Correct Answer: Toxoplasmosis
Explanation:Toxoplasmosis is a disease caused by the obligate intracellular parasite Toxoplasma gondii. Transmission occurs either through ingestion of cysts found, for example, in raw meat or cat faeces, or from mother to foetus through the placenta.
The clinical presentation depends on the patient’s immune status: In immunocompetent individuals, 90% of cases are harmless and asymptomatic, with the remaining 10% displaying mild mononucleosis-like symptoms. In immunosuppressed patients (e.g., those who are HIV-positive), infection may result in cerebral toxoplasmosis (headache, confusion, focal neurologic deficits) or toxoplasma chorioretinitis (eye pain, reduced vision).
Treatment is indicated for immunosuppressed patients, infected mothers, congenital toxoplasmosis, and immunocompetent patients with more severe symptoms. The treatment of choice is usually a combination of pyrimethamine, sulfadiazine, and leucovorin (folinic acid), with the exception of new infections during pregnancy, which are treated with spiramycin. -
This question is part of the following fields:
- Infectious Diseases
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Question 98
Incorrect
-
A 19-year-old male presents with a 1-year history of diarrhoea as well as abdominal discomfort. He has 10 episodes of loose stools per day and 3 episodes of loose stools per night. He reports weight loss in the past few months. On examination of the abdomen, tenderness was present in the right lower quadrant. Endoscopy revealed cobblestone mucosa in the ileum. Which of the following conditions is he most likely suffering from?
Your Answer:
Correct Answer: Crohn's Disease
Explanation:Cobblestone mucosa is characteristic of Crohn’s Disease. It is not a feature of any of the other options mentioned. Crohn’s disease is a condition of IBD (Inflammatory Bowel Disease).
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This question is part of the following fields:
- Gastrointestinal System
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Question 99
Incorrect
-
A 3-year old boy presents with an abdominal mass. Which of the following is associated with Wilms tumour (nephroblastoma)?
Your Answer:
Correct Answer: Beckwith-Wiedemann syndrome
Explanation:Beckwith-Wiedemann syndrome is a inherited condition associated with organomegaly, macroglossia, abdominal wall defects, Wilm’s tumour and neonatal hypoglycaemia. Wilm’s tumour is a kidney cancer that usually occurs in children. The causes are unknown, however, risk factors include race and family history. Of note, Wilm’s tumour can occur as part of the following syndromes: WAGR syndrome, Denys-Drash syndrome, and Beckwith-Wiedmann syndrome and not the other listed options in this question.
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This question is part of the following fields:
- Renal System
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Question 100
Incorrect
-
Which of the following types of renal stones are said to have a semi-opaque appearance on x-ray?
Your Answer:
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 101
Incorrect
-
A 23-year-old woman complains of numbness in her right hand that improves by shaking it. The surgeon has suggested a surgical option. Ligation of which of the following structures will improve the condition?
Your Answer:
Correct Answer: Flexor retinaculum
Explanation:The most likely cause is median nerve inflammation due to carpal tunnel syndrome. It is treated surgically with ablation of the flexor retinaculum.
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This question is part of the following fields:
- Nervous System
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Question 102
Incorrect
-
A 24-year-old male with a history of a cardiac murmur which was not properly followed up, presented with right sided hemiparesis. His blood pressure was 120/70 mmHg. His ECG revealed right bundle branch block with right axis deviation. Which of the following is the most likely cause for this presentation?
Your Answer:
Correct Answer: Ostium secundum atrial septal defect
Explanation:Ostium secundum atrial septal defects are known to cause stroke due to the passage of emboli from the right sided circulation to the left sided circulation. ECG shows tall, peaked P waves (usually best seen in leads II and V2) and prolongation of the PR interval, rSR pattern in leads V3 R and V1 as well as right axis deviation.
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This question is part of the following fields:
- Cardiovascular System
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Question 103
Incorrect
-
A 60-year-old male was diagnosed with advanced intestinal carcinoma with metastasis. His doctor prescribed him NSAIDs and tramadol initially but his pain was not responding to it. Which of the following drugs is the most suitable alternative option?
Your Answer:
Correct Answer: Oramorph
Explanation:According to WHO, initial pain management for patients with malignancy involves NSAIDs and weak opioids. After their pain stops responding to them, stronger opioids such as oxycodone and morphine are prescribed.
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This question is part of the following fields:
- Pharmacology
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Question 104
Incorrect
-
A 72-year-old woman presents with left side groin pain. She says she suddenly collapsed and was not able to lift her leg anymore. She is on calcium supplements and alendronate. What is the best diagnosis?
Your Answer:
Correct Answer: Fracture of neck of femur
Explanation:Fracture of the neck of femur is characterised by inability to lift the affected limb. This is relatively common in osteoporotic patients.
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This question is part of the following fields:
- Musculoskeletal System
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Question 105
Incorrect
-
Of the following options, which is an absolute contraindication to β blockers?
Your Answer:
Correct Answer: Heart block
Explanation:The Joint British Societies’ 2005 guidelines list asthma and heart block as ‘compelling contraindications’ to β blockers – this is because complications can occur which can prove to be fatal. All of the other options listed may be exacerbated by β blockers, and so are only considered to be ‘relative’ contraindications.
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This question is part of the following fields:
- Cardiovascular System
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Question 106
Incorrect
-
A 63-year-old man with known allergic bronchopulmonary aspergillosis presents to the A&E Department with an exacerbation. Which therapy represents the most appropriate management?
Your Answer:
Correct Answer: Oral glucocorticoids
Explanation:Allergic bronchopulmonary aspergillosis (ABPA) is a form of lung disease that occurs in some people who are allergic to Aspergillus. With ABPA, this allergic reaction causes the immune system to overreact to Aspergillus leading to lung inflammation. ABPA causes bronchospasm (tightening of airway muscles) and mucus build-up resulting in coughing, breathing difficulty and airway obstruction.
Treatment of ABPA aims to control inflammation and prevent further injury to your lungs. ABPA is a hypersensitivity reaction that requires treatment with oral corticosteroids. Inhaled steroids are not effective. ABPA is usually treated with a combination of oral corticosteroids and anti-fungal medications. The corticosteroid is used to treat inflammation and blocks the allergic reaction. Examples
of corticosteroids include: prednisone, prednisolone or methylprednisolone. Inhaled corticosteroids alone – such as used for asthma treatment – are not effective in treating ABPA. Usually treatment with an oral corticosteroid is needed for months.The second type of therapy used is an anti-fungal medication, like itraconazole and voriconazole. These medicines help kill Aspergillus so that it no longer colonizes the airway. Usually one of these drugs is given for at least 3 to 6 months. However, even this treatment is not curative and can have side effects.
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This question is part of the following fields:
- Respiratory System
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Question 107
Incorrect
-
Which of the following features occurs very less frequently with drug induced lupus?
Your Answer:
Correct Answer: Glomerulonephritis
Explanation:Drug induced lupus typically presents with pulmonary involvement and no renal or neurological involvement. Hence glomerulonephritis would be highly unlikely in this case. Rash and arthralgias are classic presentations. Pleurisy can be present as pulmonary involvement may occur with DILE.
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This question is part of the following fields:
- Musculoskeletal System
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Question 108
Incorrect
-
A patient presents with occasionally severe retrosternal chest pain and dysphagia for both solids and liquids. What would be the best management option if the barium swallow showed a dilated oesophagus which tapers to a fine distal end?
Your Answer:
Correct Answer: Dilatation of the LES
Explanation:Dysphagia for both solids and liquids indicates either obstruction or impaired oesophageal peristalsis which is usually due to neuromuscular causes such as achalasia. Achalasia is the failure of smooth muscle fibres to relax, which can cause the lower oesophageal sphincter to remain closed. The lower part of the oesophagus is more narrow than normal and presents as a birds beak appearance on barium swallow. If dysphagia was present only on solid food consumption, a benign or malignant tumour must be suspected.
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This question is part of the following fields:
- Gastrointestinal System
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Question 109
Incorrect
-
A 36-year-old man with diabetes is referred with abnormal liver biochemistry. Which of the following is in keeping with a diagnosis of haemochromatosis?
Your Answer:
Correct Answer: Transferrin saturation 78% (20-50)
Explanation:A high transferrin saturation is seen in hemochromatosis, as well as a high iron level (>30), a high ferritin level, and a LOW TIBC (<20). Think of it like the opposite findings of iron deficiency anaemia which is a low iron, low ferritin, high TIBC.
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This question is part of the following fields:
- Gastrointestinal System
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Question 110
Incorrect
-
A 24-year-old waiter applies for a job at a cafeteria. He gives a history of having had enteric fever 2 years ago. Which of the following investigations is most likely to indicate a chronic carrier status?
Your Answer:
Correct Answer: Culture of intestinal secretions
Explanation:The chronic asymptomatic carrier state is thought to be why there is continued appearance of the bacterium in human populations. As shedding of the organism is intermittent and sometimes at low levels, methods to detect it have been limited. The Salmonella typhi may be cultured from intestinal secretions, faeces or urine in chronic carriers and is recommended to confirm the diagnosis. Vi agglutination test can also be high in normal people in areas with typhoid endemic. Full blood count or blood culture would not be helpful to determine carrier status. Widal antigen test is unable to differentiate carriers from people with a hx of prior infection.
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This question is part of the following fields:
- Gastrointestinal System
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Question 111
Incorrect
-
A 70-year-old male patient was started on gentamicin after developing a pseudomonas aeruginosa infection. Which of the following is associated with aminoglycoside nephrotoxicity?
Your Answer:
Correct Answer: Frequency of aminoglycoside dosing
Explanation:Aminoglycosides can induce acute kidney injury by damaging the cells of the proximal tubule which is its site of reabsorption after glomerular filtration. When the aminoglycoside is administered less frequently, the kidney has more time to recover by eliminating the drug and preventing its accumulation and possible toxic effects.
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This question is part of the following fields:
- Renal System
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Question 112
Incorrect
-
A 55-year-old male presented with a mass in his right groin. On examination there was a pulsatile mass just below the midpoint of the inguinal ligament. Which of the following is the most probable diagnosis?
Your Answer:
Correct Answer: Femoral hernia
Explanation:Midpoint of the inguinal ligament is halfway between the pubic tubercle and the anterior superior iliac spine (the two attachments of the inguinal ligament). The opening to the inguinal canal is located just above this point. The femoral artery is at the mid-inguinal point which is halfway between the pubic symphysis and the anterior superior iliac spine. As the mass is at the midpoint of the inguinal ligament, the most probable answer is a femoral hernia. A femoral aneurysm is also a possibility.
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This question is part of the following fields:
- Musculoskeletal System
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Question 113
Incorrect
-
A 35-year-old chronic smoker complains of pain in the calf while walking. This symptom has been increasing in severity for 4 months. There is a painful ulcer at the base of left first toe, which despite treatment has not improved. Dorsalis pedis and posterior tibial pulses were absent on the same side. What is the most compatible diagnosis of this presentation?
Your Answer:
Correct Answer: Thromboangitis Obliterans
Explanation:Thromboangitis obliterans or Buerger’s disease is an inflammatory vasculopathy which is characterized by an inflammatory endarteritis and mainly affects small and medium-sized arteries as well as veins of the upper and lower extremities. It is caused by a prothrombotic state and subsequent obstruction of blood vessels. Ischemic pain, features of inflammation along the vein affected, Raynaud’s phenomenon and painful non-healing ulcers are common presentations.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 114
Incorrect
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A 40-year old male presented to the OPD with a history of difficulty swallowing and blood-stained vomit. History of weight loss is also present. The abdominal X-ray was normal. Which of the following should be done next?
Your Answer:
Correct Answer: Oesophagogastroduodenoscopy
Explanation:An esophagogastroduodenoscopy (OGD) should be ordered to visualize and identify the source of bleeding. This procedure can harvest tissue samples for histological analysis and can also treat varices that may be causing the bleeding.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 115
Incorrect
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A 30-year-old female presents with an infected skin ulcer. She is prescribed flucloxacillin and later develops jaundice, pale stools, and dark-coloured urine. What is the single most likely diagnosis?
Your Answer:
Correct Answer: Cholestatic jaundice
Explanation:Due to its cholestatic properties, Flucloxacillin can block bile flow through the liver, leading to the accumulation of bilirubin in the blood, giving rise to jaundice. Dark urine is the result of excessive bilirubin in the blood being filtered by the kidney. Pale stools is an effect of the blocked bile flow through the liver.
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This question is part of the following fields:
- Hepatobiliary System
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Question 116
Incorrect
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A 68-year-old man is admitted with an infective exacerbation of chronic obstructive pulmonary disease (COPD).
Investigations: blood gas taken whilst breathing 28% oxygen on admission:
pH 7.30
p(O2) 7.8 kPa
p(CO2) 7.4 kPa
Which condition best describes the blood gas picture?Your Answer:
Correct Answer: Decompensated type-2 respiratory failure
Explanation:The normal partial pressure reference values are:
– PaO2 more than 80 mmHg (11 kPa)
– PaCO2 less than 45 mmHg (6.0 kPa).
This patient has an elevated PaCO2 (7.4kPa)
Hypoxemia (PaO2 <8kPa) with hypercapnia (PaCO2 >6.0kPa).
The pH is also lower than 7.35 at 7.3Type 2 respiratory failure is caused by inadequate alveolar ventilation; both oxygen and carbon dioxide are affected. Defined as the build-up of carbon dioxide levels (PaCO2) that has been generated by the body but cannot be eliminated. The underlying causes include:
– Increased airways resistance (chronic obstructive pulmonary disease, asthma, suffocation)
– Reduced breathing effort (drug effects, brain stem lesion, extreme obesity)
– A decrease in the area of the lung available for gas exchange (such as in chronic bronchitis)
– Neuromuscular problems (Guillain-Barre syndrome, motor neuron disease)
– Deformed (kyphoscoliosis), rigid (ankylosing spondylitis), or flail chest. -
This question is part of the following fields:
- Respiratory System
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Question 117
Incorrect
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A 30-year-old female presents with polyuria and is passing 4 litres of urine per day. She was recently started on a new medication.
Results show:
Serum sodium 144 mmol/L (137-144)
Plasma osmolality 299 mosmol/L (275-290)
Urine osmolality 210 mosmol/L (350-1000)
Which of the following drugs was prescribed?Your Answer:
Correct Answer: Lithium
Explanation:The patient’s presentation is consistent with diabetes insipidus: eunatreaemia, high serum osmolality, and inappropriately dilute urine, which leads to the suspicion of lithium-induced diabetes insipidus.
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This question is part of the following fields:
- Renal System
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Question 118
Incorrect
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A 68-year-old female is on long term prednisolone therapy for polymyalgia rheumatica. Which of the following would be the most suitable protection against osteoporosis?
Your Answer:
Correct Answer: Oral bisphosphonate
Explanation:Prevention of osteoporosis associated with chronic glucocorticoid therapy is done by administrating bisphosphonates. Oral bisphosphonates are indicated for patients aged above 65 who have been on steroid therapy for over 3 months, so as to reduce the risk of steroid induced osteoporosis. HRT is usually done in post menopausal women who have oestrogen related bone resorption.
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This question is part of the following fields:
- Musculoskeletal System
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Question 119
Incorrect
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A 65-year-old man with hypertension presented with sudden onset right arm weakness which resolved after 10 hrs. He has had 2 similar episodes during the last 6 weeks. On examination his blood pressure was 140/80 mmHg and pulse rate was 88 bpm. His ECG showed atrial fibrillation and the CT scan of his brain was normal. Which of the following is the most appropriate management for this patient?
Your Answer:
Correct Answer: Warfarin
Explanation:CHA₂DS₂-VASc score is used for atrial fibrillation stroke risk calculation.
Congestive heart failure – 1 point
Hypertension – 1 point
Age >75 years – 2 points
Diabetes mellitus – 1 point
Stroke/Transient Ischemic Attack/Thromboembolic event – 2 points
Vascular disease (prior MI, PAD, or aortic plaque) – 1 point
Age 65 to 74 years – 1 point
Sex category (i.e., female sex) – 1 point
Score of 2 or more is considered as high risk and anticoagulation is indicated. This patient’s score is 4, so he needs life-long warfarin to prevent a stroke. -
This question is part of the following fields:
- Cardiovascular System
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Question 120
Incorrect
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There is a measure of dispersion of a set of data from its mean. Which of following is the best term which can describe the above?
Your Answer:
Correct Answer: Standard deviation (root mean square deviation)
Explanation:Standard deviation is defined as the measure of dispersion of a set of data from its mean. It measures the absolute variability of a distribution; the higher the dispersion or variability, the greater is the standard deviation and greater will be the magnitude of the deviation of the value from their mean.
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This question is part of the following fields:
- Evidence Based Medicine
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Question 121
Incorrect
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A 70-year-old male came to the OPD with complaints of nocturia, difficulty in initiating urination and continuous dribbling of urine afterwards. A transrectal US guided biopsy was performed and the diagnosis of BPH was made. His TURP was planned. Which of the following electrolyte imbalance is most likely to occur?
Your Answer:
Correct Answer: Hyponatremia
Explanation:In a TURP procedure, fluid is used to irrigate the bladder and to remove blood clots. IV fluids are also given to the patient post-operatively. These factors will lead to dilutional hyponatremia.
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This question is part of the following fields:
- Fluids & Electrolytes
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Question 122
Incorrect
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A 11-year-old is referred to neurology due to episodes her GP feels are epileptiform. Her mother reports that she appears to just 'stop', sometimes even in mid conversation, for several seconds at random times during the day. During these episodes, she can be unresponsive to questioning and has no recollection of them.
Which of these drugs is contraindicated in this condition?Your Answer:
Correct Answer: Carbamazepine
Explanation:The patient’s history points to absence seizures. Carbamazepine has been shown to aggravate generalized seizure types, especially absence seizures, because it acts directly on the ventrobasal complex of the thalamus which is critical to the neurophysiology of absence seizures.
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This question is part of the following fields:
- Nervous System
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Question 123
Incorrect
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A 45-year-old known asthmatic was admitted with acute severe asthma and was treated with nebulised salbutamol, ipratropium and bromide, along with 100% oxygen therapy. He was also given IV hydrocortisone, however there was no significant improvement. What would be the next step in management of this patient?
Your Answer:
Correct Answer: IV Aminophylline
Explanation:Aminophylline is a very effective bronchodilator. It is short acting and therefore very effective in acute scenarios.
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This question is part of the following fields:
- Respiratory System
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Question 124
Incorrect
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A 27-year-old woman was admitted with vaginal bleeding and left sided pelvic pain for 2 days. There was no history of fever. She gave a history of absent periods for past 8 weeks. Abdominal examination revealed guarding and rebound tenderness in left iliac region. There was left sided cervical excitation on vaginal examination. What is the most probable diagnosis?
Your Answer:
Correct Answer: Ectopic pregnancy
Explanation:The history of amenorrhoea, pelvic pain and vaginal bleeding with peritonism and cervical excitation is more suggestive of an ectopic pregnancy. Endometriosis usually has a chronic presentation and dysmenorrhoea. Salpingitis usually presents with a fever. Ovarian torsion and ovarian tumours have different clinical presentations including increased abdominal size and persistent bloating.
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This question is part of the following fields:
- Women's Health
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