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Question 1
Correct
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A thin 18-year-old girl has bilateral parotid swelling with thickened calluses on the dorsum of her hand. What is the single most likely diagnosis?
Your Answer: Bulimia nervosa
Explanation:Bulimia nervosa is a condition in which a person is involved in binge eating and then purging. This patient has swollen parotid glands. The glands swell in order to increase saliva production so that the saliva lost in the vomiting is compensated. This patient also has thickened calluses on the back of her hand. This is known as Russell’s sign. This occurs because of putting fingers in the mouth again and again to induce the gag reflex and vomit. The knuckles get inflamed in the process after coming in contact with the teeth multiple times.
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This question is part of the following fields:
- Gastrointestinal System
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Question 2
Correct
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A 41-year-old female is referred to medical assessment unit by her physician for querying thrombotic thrombocytopenic purpura (TTP) after she presented with a temperature of 38.9C. Her subsequent urea and electrolytes showed deteriorating renal function with a creatinine 3 times greater than her baseline.
What is the underlying pathophysiology of TTP?Your Answer: Failure to cleave von Willebrand factor normally
Explanation:Thrombotic thrombocytopenic purpura (TTP) is characterised by the von Willebrand factor (vWF) microthrombi within the vessels of multiple organs. In this condition, the ADAMTS13 metalloprotease enzyme which is responsible for the breakdown of vWF multimer, is deficient, causing its build-up and leading to platelet clots that then decreases the circulating platelets, leading to bleeding in the patient.
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This question is part of the following fields:
- Renal System
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Question 3
Correct
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A 25-year-old male had an emergency appendicectomy. His doctor prescribed him prophylactic antibiotics to avoid infection after the surgery. Which of the following antibiotics is the best choice for post abdominal surgery?
Your Answer: Cefuroxime
Explanation:Cefuroxime is the best choice in the case of gut surgery as it is very effective in preventing infections against gut anaerobes, enterococci and coliforms.
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This question is part of the following fields:
- Gastrointestinal System
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Question 4
Incorrect
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A 25-year-old woman is reviewed in clinic. She was previously treated with omeprazole, amoxicillin and clarithromycin for Helicobacter pylori (H. pylori). She remains on PPI therapy but continues to have epigastric discomfort. You suspect she has ongoing H. pylori infection and request a urea breath test to investigate this.
How long would the patient need to stop her PPI therapy before the urea breath test?Your Answer: Not at all
Correct Answer: 14 days
Explanation:PPI will affect the accuracy of the test. In general, most recommend discontinuing PPI therapy for 2 weeks prior to a urea breath test. PPI’s have an anti-H. pylori effect.
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This question is part of the following fields:
- Gastrointestinal System
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Question 5
Correct
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A 57-year-old male presented to the OPD with a complaint of fever, cough and chest pain for 3 days. The right lung base was dull on percussion and the breath sounds were reduced in intensity. Which of the following investigations is most appropriate?
Your Answer: CXR
Explanation:Because of the patient’s acute presentation of symptoms accompanied by lung abnormalities observed on physical examination, the next step is to visualize the suspected acute inflammatory process by ordering a CXR. Bronchoscopy, CT and MRI are done in cases in which there is suspicion of any tumour formation. V/Q scan is done in cases where pulmonary embolism is suspected.
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This question is part of the following fields:
- Respiratory System
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Question 6
Incorrect
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A 38-year-old woman has a melanocytic naevi on her left forearm.
Which of the following features do not suggest malignant change?Your Answer: Itch
Correct Answer: Decrease in size
Explanation:Melanocytic nevi are benign neoplasms or hamartomas composed of melanocytes. Melanocytes are derived from the neural crest and migrate during embryogenesis to selected ectodermal sites (primarily the skin and the CNS), but also to the eyes and the ears.
They tend to appear during early childhood and during the first 30 years of life. They may change slowly, becoming raised, changing color or gradually fading.. Pregnancy can increase the number of naevi as well as the degree of hyperpigmentation.
They may become malignant and this should be suspected if the naevus increases in size, develops an irregular surface or becomes darker, itches or bleeds. -
This question is part of the following fields:
- The Skin
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Question 7
Incorrect
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A 60-year-old male presented in OPD with a complaint of inability to walk properly because of his left foot. History reveals he has undergone left knee surgery to for severe arthritis. On examination, dorsiflexion of his left foot was found to be compromised, and sensation over the dorsum of his left foot was impaired. Which of the following conditions is this man most likely suffering from?
Your Answer: Compression of the S1 nerve root
Correct Answer: Compression of common peroneal nerve
Explanation:The branches of the common peroneal nerve innervate the skin of the dorsum of the foot as well as the muscles which help to carry out dorsiflexion of the foot. Compression of the common peroneal nerve cause foot drop as well as the loss in sensation of the skin on the dorsum of the foot.
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This question is part of the following fields:
- Nervous System
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Question 8
Correct
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While investigating a patient with hepatocellular carcinoma (HCC), blood tests reveal a raised level of serum ferritin. What would be the most probable cause for HCC in this patient?
Your Answer: Haemochromatosis
Explanation:Haemochromatosis is the excessive accumulation of iron in the body mainly involving the liver, pancreas, testes, skin etc. Serum ferritin is high indicating iron overload. Haemochromatosis is a known cause for chronic liver cell disease, cirrhosis and HCC.
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This question is part of the following fields:
- Gastrointestinal System
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Question 9
Incorrect
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A 70-year-old female was brought in by the paramedics after she collapsed whilst shopping. She has a tachycardia of 150 bpm and her BP is 100/60 mmHg. Her ECG showed a broad complex tachycardia. Which of the following is more suggestive of a ventricular tachycardia (VT) over a supraventricular tachycardia (SVT) with aberrant conduction?
Your Answer: QRS < 160 ms
Correct Answer: Atrioventricular dissociation
Explanation:To differentiate VT from SVT with aberrant conduction the following electrocardiographic features should be looked for:
Evidence of preceding atrial activity for SVT. Oesophageal leads are helpful if P waves are hidden in the QRS complex.
QRS duration more than 140 ms for VT.
QRS morphology: Features of QRS morphology that favour SVT are RBBB or triphasic patterns like rSR in V1 and qRS in V6. Monophasic pattern like R or qR in V1 and rS or QS in V6 or multiple morphology QRS complexes favour VT.
AV dissociation for VT. -
This question is part of the following fields:
- Cardiovascular System
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Question 10
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: Raised ferritin level
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 11
Correct
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A 63-year-old gentleman is admitted to the Emergency Department, with a past history of chronic renal failure, who complains of increasing shortness of breath. Bloods reveal a creatinine of 570 μmol/l, urea of 48 mmol/l. He is also anaemic with a haemoglobin (Hb) of 8.9 g/dl.
On examination he has a pericardial rub and there are bibasal crackles consistent with heart failure.
Which of the following represents the best treatment option for this patient?Your Answer: Urgent haemodialysis
Explanation:This case presents with symptoms and lab results suggestive of uremic pericarditis, which is an indication for immediate haemodialysis. Uremic pericarditis is caused by inflammation of the membranes of the pericardial sac, which usually resolves after a period of intensive dialysis.
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This question is part of the following fields:
- Renal System
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Question 12
Incorrect
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Which is the most common type of inherited colorectal cancer:
Your Answer: Familial adenomatous polyposis
Correct Answer: Hereditary non-polyposis colorectal carcinoma
Explanation:Hereditary non-polyposis syndrome (HNPCC) is the most common type of inherited colorectal cancer. It often presents in younger and younger generations down a family. FAP presents with 100’s-1000’s of polyps and is less common. Li-Fraumeni syndrome and Fanconi syndrome are rare. For Peutz-Jeghers syndrome, the thing you will look for in the question stem is discoloured spots on the lips, this is classic.
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This question is part of the following fields:
- Gastrointestinal System
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Question 13
Correct
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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: 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 14
Incorrect
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A 15-year-old boy presented to a urologist with a complaint of blood in the urine and pain in his abdomen. On examination, abdominal swelling is present and blood pressure is elevated. Which of the following is the most appropriate investigation in this case?
Your Answer: CT
Correct Answer: Ultrasound
Explanation:Haematuria and abdominal swelling may indicate either polycystic kidney disease or a tumour. Because of the patient’s age, the likelihood of a tumorous growth is small, thus an ultrasound is the best choice for this case.
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This question is part of the following fields:
- Renal System
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Question 15
Incorrect
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Which of the following conditions is not linked to hyperuricemia?
Your Answer: Thiazide diuretic therapy
Correct Answer: Osteoarthritis
Explanation:Hyperuricemia is an elevated uric acid level in the blood. The normal upper limit is 6.8mg/dL, and anything over 7 mg/dL is considered saturated, and symptoms can occur. Causes of hyperuricemia can be classified into three functional types:
1. Increased production of uric acid – Purine rich diet, Tumour lysis syndrome, HGPRT deficiency (Lesch-Nyhan and Kelley-Seegmiller syndromes), Increased PRPP synthetase activity and Polycythaemia
2. Decreased excretion of uric acid – Renal impairment, Metabolic syndrome, Drugs (diuretics, low-dose aspirin, cyclosporin, tacrolimus, pyrazinamide, ethambutol, levodopa, nicotinic acid), Acidosis, Pre-eclampsia and eclampsia, Hypothyroidism and hyperparathyroidism, Sarcoidosis, Familial juvenile gouty nephropathy, Chronic lead intoxication, Trisomy 21
3. Idiopathic and mixed type – Alcohol, Exercise, Glucose-6-phosphatase deficiency, Aldolase B deficiency -
This question is part of the following fields:
- Musculoskeletal System
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Question 16
Correct
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A 67-year-old man presents with anaemia and weight loss. Upon endoscopy, a gastric tumour is revealed, later established as an adenocarcinoma. The patient refuses any treatment and claims that his condition is not influencing the quality of his life. Clinical examination has nothing particularly interesting to show and the patient seems to be conscious of his decision, regardless of the likely curative nature of surgery. What is the single most appropriate management?
Your Answer: Respect his wishes and book a follow-up appointment for four weeks
Explanation:The patient seems to be conscious about his decision, which should be respected. According to Mental Capacity Act 2005, a person who makes an unwise decision should not be treated as unable to make a decision.
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This question is part of the following fields:
- Haematology & Oncology
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Question 17
Correct
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A 71-year-old female presents with a pansystolic murmur. History reveals a myocardial infarction which manifested three days ago. What is the most likely cause of the murmur?
Your Answer: Rupture of papillary muscle
Explanation:A pan-systolic murmur is the result of mitral regurgitation. Mitral regurgitation in this case is most probably due to post-MI rupture of the papillary muscle of the mitral valve.
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This question is part of the following fields:
- Cardiovascular System
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Question 18
Correct
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Which of the following allows for a diagnosis of diabetes mellitus?
Your Answer: Symptomatic patient with random glucose 12.0 mmol/L on one occasion
Explanation:Criteria for the diagnosis of diabetes
1. A1C >6.5%. The test should be performed in a laboratory using a method that is certified and standardized.*
OR
2. Fasting glucose >126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.*
OR
3. 2-h plasma glucose >200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.*
OR
4. In a patient with classic symptoms of hyperglycaemia or hyperglycaemic crisis, a random plasma glucose >200 mg/dl (11.1 mmol/l).
*In the absence of unequivocal hyperglycaemia, criteria 1-3 should be confirmed by repeat testing. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 19
Correct
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A 50-year-old woman under treatment for manic-depressive psychosis presents in an unconscious state after an episode of seizure on the street. Her husband who accompanied her into the ER reported that they argued about 6-7 hours ago. On examination, she is found to be hypertonic with a GCS of 8, BP: 90/60 mmHg and a pulse of 105 bpm. Blood investigations revealed a lithium level of 3.2 mmol/L. She was intubated and ventilated. Which of the following interventions is most appropriate in this case?
Your Answer: Gastric lavage and normal saline infusion
Explanation:Among the above statements, gastric lavage and normal saline IV infusion are the most appropriate interventions for a patient of acute lithium toxicity.
Activated charcoal is not effective after lithium overdose, although gastric lavage should be considered if patients present within 6-8 h.
Where levels are above 3 mmol/l, the use of normal saline to induce diuresis should be considered, although careful monitoring of fluid balance is necessary.
Where levels of lithium are above 4 mmol/l, dialysis is often required. Haemodialysis is preferred, but in a facility where haemodialysis is not possible, peritoneal dialysis may be considered.
Patients should not be discharged until they are asymptomatic and have a serum lithium level less than 1.5 mEq/L. -
This question is part of the following fields:
- Pharmacology
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Question 20
Incorrect
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A drunken man has fallen asleep in a position with his arm hanging down. After waking up he complained of wrist drop and sensory loss at the web of the thumb. Which of the following structures is most likely to be affected?
Your Answer: Median nerve
Correct Answer: Radial nerve
Explanation:This presentation is known as ‘Saturday night palsy’. When someone falls asleep with a arm hanging over the arm rest of a chair, the radial nerve compresses and causes wrist drop and loss of sensation at the web of the thumb.
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This question is part of the following fields:
- Nervous System
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Question 21
Incorrect
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A 19-year-old patient in casualty only opens her eyes upon painful stimuli, extends her limbs, and occasionally says inappropriate words. What is her Glasgow coma score?
Your Answer: 10
Correct Answer: 7
Explanation:The Glasgow Coma Scale provides a score for assessment of impaired consciousness in response to specific stimuli considering the eye opening, verbal response and motor response. The score runs from 3 to 15, a coma being defined as a GCS of 8 or less. According to this patient’s responses and the respective points for each response, the score is 7 and the patient is in a coma.
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This question is part of the following fields:
- Nervous System
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Question 22
Incorrect
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A 10-year-old boy presents with generalized swelling. This includes puffiness in the face and swollen ankles - these symptoms have been present for 4 days. The swelling began just a few days after he suffered from a mild cold with a runny nose. His only past medical history is that of eczema. His urine analysis showed the following: haematuria; proteinuria (10g/24h); creat 60 umol/l; and albumin of 15g/l. From the list of options, what is the single most likely diagnosis for this patient?
Your Answer: Minimal change nephropathy
Correct Answer: IgA nephropathy
Explanation:A 10 year old child, with a history of URTI and haematuria, presents a picture consistent with a diagnosis of IgA nephropathy. This condition can present with proteinuria and generalized swelling. However, an important differentiating point from rapidly progressive GN is the duration. IgA nephropathy is usually <10 days (commonly 4-5 day history of infection).
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This question is part of the following fields:
- Renal System
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Question 23
Correct
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Around 30 patients have been admitted to the hospital following a suspected chemical attack in the city. The patients are extremely unwell, with symptoms of excessive salivation, lacrimation, diarrhoea, and emesis. Sarin gas was suspected as the most likely agent used in the attack. What is the mechanism of action of this chemical agent?
Your Answer: Inhibition of acetylcholinesterase
Explanation:Sarin acts by inhibiting acetylcholinesterase.
Sarin gas is a highly toxic synthetic organophosphorus compound which causes inhibition of the enzyme acetylcholinesterase
Sarin gas is a highly toxic synthetic organophosphorus compound which causes inhibition of the enzyme acetylcholinesterase. This results in high levels of acetylcholine (ACh).The effects of excessive ACh can be remembered by the mnemonic DUMBELLS:
Diarrhoea
Urination
Miosis/muscle weakness
Bronchorrhea/Bradycardia
Emesis
Lacrimation
Salivation/sweatingOrganophosphate insecticide poisoning:
One of the effects of organophosphate poisoning is inhibition of acetylcholinesterase
Features can be predicted by the accumulation of acetylcholine (mnemonic = SLUD)
Salivation
Lacrimation
Urination
Defecation/diarrhoea
cardiovascular: hypotension, bradycardia
miosis, muscle fasciculation.Organophosphate poisoning is treated with the anti-muscarinic atropine.
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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 57-year-old diabetic, smoker complains of non-healing ulcers and cramp-like pain in the calves relieved by rest. Examination results are as follows: absent distal pulses, and cold extremities with hair loss around the ankles. What is the most probable diagnosis?
Your Answer: Buerger's disease
Correct Answer: Chronic ischemia of the limbs
Explanation:Chronic Limb Ischaemia presents with calf pain that is relieved by rest.
Intermittent claudication is not a diagnosis but a symptom and is not necessarily associated with diabetes.
Buerger’s disease occurs in younger heavy smokers (usually before age of 50).
DVT causes pain that is consistent, not intermittent as in claudication. -
This question is part of the following fields:
- Musculoskeletal System
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Question 25
Incorrect
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A 40-year-old non-smoker is diagnosed as having emphysema. Further tests reveal that he has alpha-1 antitrypsin deficiency. What is the main role of alpha-1 antitrypsin in the body?
Your Answer: Trypsin activator
Correct Answer: Protease inhibitor
Explanation:Alpha-1-antitrypsin (AAT) is a member of the serine proteinase inhibitor (serpin) family of proteins with a broad spectrum of biological functions including inhibition of proteases, immune modulatory functions, and the transport of hormones.
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This question is part of the following fields:
- Respiratory System
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Question 26
Correct
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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: 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 27
Incorrect
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A 3-year-old girl presents to A&E following a few days of being lethargic, having runny nose, sore throat, and fever. She has unceasing stridor and drooling of saliva while her body is inclined forward. What is the most important next step in her management?
Your Answer: Immediate bronchoscopy
Correct Answer: Call ENT specialist
Explanation:A consultation with an ENT is required to establish the reason for the child’s drooling and stridor indicating and obstructive process. Enlarged tonsils and adenoids should be checked.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 28
Incorrect
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A 27-year-old woman presents with diarrhoea. She has had a previous ileal resection for Crohn's Disease. Her inflammatory markers are normal. What is the most likely cause of her diarrhoea?
Your Answer: Bacterial overgrowth
Correct Answer: Bile Acid Malabsorption
Explanation:The question describes a patient who has had an ileal resection. Bile acids are reabsorbed in the distal ileum. Since this has been resected in this patient, one would expect her to have malabsorption of bile acids, causing her diarrhoea. This is a more likely correct answer than a Crohn’s flare, bacterial overgrowth, gastroenteritis, or tropical sprue, given the details included in the question prompt.
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This question is part of the following fields:
- Gastrointestinal System
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Question 29
Incorrect
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Which of the following cancers is responsible in producing osteoblastic bone metastases instead of osteolytic?
Your Answer: Choriocarcinoma in either gender
Correct Answer: Prostate adenocarcinoma
Explanation:Osteoblastic (or sclerotic) bone metastases, characterized by deposition of new bone, present in prostate cancer, carcinoid, small cell lung cancer, Hodgkin lymphoma or medulloblastoma.
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This question is part of the following fields:
- Musculoskeletal System
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Question 30
Correct
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A 40-year-old male was admitted following 30%, burns sustained from an apartment fire. What is the most appropriate initial treatment of this patient?
Your Answer: Intravenous fluids
Explanation:As this patient has more than a 15% burn area, he needs IV fluids. These patients are more prone to infection and dehydration. Burn area is calculated using the rule of nines and requires fluid replacement over the first 24 hrs, calculated using Parkland’s burn formula.
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This question is part of the following fields:
- Emergency & Critical Care
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SESSION STATS - PERFORMANCE PER SPECIALTY
