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Question 1
Correct
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A 58-year-old lady was admitted to hospital with increasing thirst and generalised abdominal pain. She was diagnosed with breast carcinoma three years previously and treated with a radical mastectomy.
Investigations showed:
Serum corrected calcium 3.5 mmol/L (NR 2.2-2.6)
Serum alkaline phosphatase 1100 IU/L
Her serum calcium was still elevated following 4 litres of 0.9% saline intravenous infusion.
Which of the following is the most appropriate next step?Your Answer: Pamidronate 60 mg intravenously
Explanation:This case has hypercalcaemia most likely associated with the bony metastases from her pre-existing breast carcinoma. The most appropriate next step is to give Pamidronate 60mg intravenously, a bisphosphonate, to immediately inhibit bone resorption and formation.
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This question is part of the following fields:
- Renal System
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Question 2
Incorrect
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A 70-year-old male with advanced COPD currently on treatment with salbutamol (as required) presents for review. After a complete history and examination, you conclude that he requires to be stepped up in his inhalational therapy. The decision to add tiotropium bromide to his regime was taken. Which of the following best describe the mechanism of action of tiotropium?
Your Answer: It is a short-acting anticholinergic agent
Correct Answer: It is a long-acting anticholinergic agent
Explanation:Tiotropium is a specific long-acting antimuscarinic agent indicated as maintenance therapy for patients with COPD (chronic obstructive pulmonary disease).
It should be used cautiously in patients with narrow-angle glaucoma, prostatic hyperplasia or bladder neck obstruction.
The most frequently encountered adverse effects of tiotropium include pharyngitis, bronchitis, sinusitis, dry mouth, cough, and headaches. Paradoxical bronchospasm may also occur as a rare side-effect.
Dry mouth occurs in up to 14% of patients taking tiotropium, in keeping with its anticholinergic profile.
Rarer side-effects include tachycardia, blurred vision, urinary retention, and constipation. -
This question is part of the following fields:
- Respiratory System
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Question 3
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: Amiodarone
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 4
Incorrect
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In chemotherapy, what is the rationale behind using combinations of chemotherapeutic agents rather than single agents?
Your Answer: Fewer side-effects occur in combination therapy
Correct Answer: Combination therapy decreases the chances of drug resistance developing
Explanation:There are two main reasons for using combinations of chemotherapeutic agents rather than single agents. First, different drugs exert their effects through different mechanisms, therefore, carefully combining them will increase the number of tumour cells killed in each cycle as well as decrease their chances of developing drug resistance. Second, there may be an even greater effect with drugs that are synergistic.
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This question is part of the following fields:
- Haematology & Oncology
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Question 5
Incorrect
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A woman with severe renal failure undergoes a kidney transplant. However, after a few hours, she develops fever and anuria. The doctors are suspecting hyperacute organ rejection. Which are the cells primarily responsible for hyperacute organ rejection?
Your Answer: Eosinophils
Correct Answer: B Cells
Explanation:Hyperacute rejection appears in the first minutes following transplantation and occurs only in vascularized grafts. This very fast rejection is characterized by vessel thrombosis leading to graft necrosis. Hyperacute rejection is caused by the presence of antidonor antibodies existing in the recipient before transplantation. These antibodies induce both complement activation and stimulation of endothelial cells to secrete Von Willebrand procoagulant factor, resulting in platelet adhesion and aggregation. The result of these series of reactions is the generation of intravascular thrombosis leading to lesion formation and ultimately to graft loss. Today, this type of rejection is avoided in most cases by checking for ABO compatibility and by excluding the presence of antidonor human leukocyte antigen (HLA) antibodies by cross-match techniques between donor graft cells and recipient sera. This type of rejection is also observed in models of xenotransplantation of vascularized organs between phylogenetically distant species when no immunosuppressive treatment is given to the recipients.
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This question is part of the following fields:
- Renal System
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Question 6
Incorrect
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A 40-year-old man presents with periorbital and pedal oedema. 24h urine shows 9g of protein/d and serum cholesterol of 7 mmol/L. What would be the most likely diagnosis?
Your Answer: Glomerulonephropathy
Correct Answer: Membranous glomerulonephropathy
Explanation:Membranous glomerulonephritis . However some authors believe FSGS a more commoner cause of nephrotic syndrome.
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This question is part of the following fields:
- Renal System
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Question 7
Incorrect
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A 23-year-old man is referred to the pneumologist with a suspicion of bronchiectasis. History reveals he's been having recurrent pulmonary infections his whole life together with difficulties gaining weight. He's a non-smoker with a clear family history and he admits inhalers haven't helped him in the past. He is finally suspected of having cystic fibrosis. What is the normal function of the cystic fibrosis transmembrane regulator?
Your Answer: Potassium channel
Correct Answer: Chloride channel
Explanation: -
This question is part of the following fields:
- Respiratory System
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Question 8
Correct
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Cocaine abuse has many serious side effects. Which of the following is not a notable side effect of chronic cocaine abuse?
Your Answer: Hyponatraemia
Explanation:Chronic cocaine abuse can produce many serious side effects such as erectile dysfunction, ejaculatory dysfunction, hypersomnia, anxiety, hallucinations etc.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 9
Incorrect
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A keratitis with dendritic ulceration of the cornea is diagnosed in a 32-year-old patient. What is the most likely cause?
Your Answer: Chlamydia
Correct Answer: Herpes simplex virus
Explanation:The dendritic ulceration seen on fluorescein staining of the eye is pathopneumonic for keratitis caused by HSV (herpes simplex virus). Presentation is that of blepharoconjunctivitis. Treatment is required, the treatment is typically topical acyclovir. Topical steroids can make the infection worse. The other answer choices would not have this dendritic pattern seen on fluorescein staining.
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This question is part of the following fields:
- Infectious Diseases
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Question 10
Incorrect
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A young woman presents to the emergency after being involved in a fight where she was stabbed in the neck. On examination, her tongue deviates to the right side on protrusion. Which of the following nerves is involved?
Your Answer: Glossopharyngeal nerve
Correct Answer: Hypoglossal nerve injury
Explanation:The motor functions of the intrinsic tongue muscles, as well as the genioglossus, hyoglossus, and styloglossus muscles, are all innervated by the hypoglossal nerve. These muscles are essential for swallowing and speech. To test nerve function, the physical examiner has a patient protrude his or her tongue. In intranuclear, or lower motor neuron lesions, the tongue deviates toward the injured side, as the contralateral genioglossus is acting unopposed. In contrast, supranuclear (upper motor neuron) lesions result in deviation away from the lesion. In addition to causing deviation toward the lesion, an injury involving a hypoglossal nucleus may result in tongue atrophy and fasciculation
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This question is part of the following fields:
- Nervous System
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Question 11
Correct
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Which of the following is not a tumour suppressor gene?
Your 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 12
Incorrect
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An 82-year-old patient presents to the clinic complaining of palpitations. ECG reveals waves with saw-tooth pattern, QRS complex of 80ms duration, a ventricular rate of 150/min and a regular R-R interval. Which of the following is most likely responsible for these findings?
Your Answer: Atrial fib
Correct Answer: Atrial flutter
Explanation:Atrial flutter is a common supraventricular tachyarrhythmia that is usually caused by a single macroreentrant rhythm within the atria, associated with a sawtooth appearance on the ECG. In stable patients the treatment includes rate control and rhythm control, however in unstable patients, a synchronized cardioversion is required.
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This question is part of the following fields:
- Cardiovascular System
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Question 13
Incorrect
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A 30-year-old painter presents with a burning pain in both feet, which has deteriorated over the last six months. He drinks 60 units of alcohol weekly and has a family history of pernicious anaemia.
On examination he has impairment of all modalities of sensation in both feet but particularly pain, temperature and absent ankle jerks.
What is the most likely diagnosis?Your Answer: Chronic inflammatory demyelinating polyradiculopathy
Correct Answer: Alcoholic peripheral neuropathy
Explanation:Because of the patient’s history of excessive alcohol consumption, there is a strong suspicion of alcoholic peripheral neuropathy. In the UK, alcohol abuse and diabetes are the most common causes of peripheral neuropathy.
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This question is part of the following fields:
- Nervous System
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Question 14
Incorrect
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A 52-year-old shopkeeper presents with pain in her hands. Examination reveals plaques on the extensor surfaces of her upper limbs and a telescoping deformity of both index fingers. Nails show pitting and horizontal ridging. The patient is most likely suffering from which of the following?
Your Answer: Reactive arthritis
Correct Answer: Arthritis mutilans
Explanation:Arthritis mutilans is a rare (occurs in only 5% of the patients) and extremely severe form psoriatic arthritis characterized by resorption of bones and the consequent collapse of soft tissue. When this affects the hands, it can cause a phenomenon sometimes referred to as ‘telescoping fingers.’ The associated nail changes are also characteristic of arthritis.
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This question is part of the following fields:
- Musculoskeletal System
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Question 15
Incorrect
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A 22-year-old patient was diagnosed with glioblastoma multiforme, after he was investigated for seizures. The cell of origin of this tumour is?
Your Answer: Myelocyte precursors
Correct Answer: Astrocytes
Explanation:Glioblastoma multiforme is the most common anaplastic malignant tumour of the glial cells. It is a mixture of poorly differentiated anaplastic astrocytes.
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This question is part of the following fields:
- Nervous System
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Question 16
Incorrect
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A 72-year-old woman presents with 18 month history of gait ataxia, dysarthria, and dysphagia.
On examination there is down beating nystagmus and slurred speech. There is past pointing in both upper limbs and a wide-based ataxic gait. Reflexes and sensation are normal. There is no wasting or fasciculations. Plantar response is flexor bilaterally.
What is the most likely diagnosis?Your Answer: Botulism
Correct Answer: Arnold-Chiari malformation
Explanation:Downbeat nystagmus (DBN) suggests a lesion in the lower part of the medulla. Arnold-Chiari malformation usually presents with symptoms due to brainstem and lower cranial nerve dysfunction such as DBN.
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This question is part of the following fields:
- Nervous System
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Question 17
Incorrect
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A 54-year-old plumber presents with general deterioration. He drinks approximately 25 units of alcohol each week and is a smoker of five cigarettes daily. Examination reveals that he is jaundiced, has numerous spider naevi on his chest and he has a temperature of 37.2°C. Abdominal examination reveals hepatosplenomegaly.
Investigations reveal:
Bilirubin 100 micromol/L (1-22)
Alkaline phosphatase 310 iu/l (45 - 105)
ALT 198 iu/l (5 - 35)
AST 158 iu/l (1 - 31)
Albumin 25 g/L (37 - 49)
Hepatitis B virus surface antigen positive
Hepatitis B virus e antigen negative
Hepatitis B virus DNA awaited
What is the most likely diagnosis?Your Answer: Carcinoma of the pancreas
Correct Answer: Chronic hepatitis B infection
Explanation:The clinical scenario describes a man in liver failure. Given the serological results, he is most likely to have a chronic hepatitis B infection. In chronic hepatitis B infection, you have +HBsAg, +anti-HBc, (-)IgM antiHBc, and (-) anti-HBs. In acute hepatitis B infection, you have +HBsAg, +anti-HBc, +IgM anti-HBc, and negative anti-HBs. in immunity due to natural infection, you have negative HBsAg, +anti-HBc, and + anti-HBs. In immunity due to vaccination, you have negative HBsAg, negative anti-HBc, and positive anti-HBs. While he could have a superimposed hepatitis D infection on top of hepatitis B, there is no mention of hepatitis D serology, make this an incorrect answer. The other choices do not involve hepatitis serologies.
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This question is part of the following fields:
- Hepatobiliary System
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Question 18
Incorrect
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Which of the following peripheral neuropathy inducing clinical diagnoses is predominantly associated with sensory loss?
Your Answer: Porphyria
Correct Answer: Uraemia
Explanation:Diseases that cause predominantly sensory loss include diabetes, uraemia, leprosy, alcoholism, vitamin B12 deficiency, and amyloidosis.
Those that cause predominantly motor loss include Guillain-Barre syndrome, porphyria, lead poisoning, hereditary sensorimotor neuropathies, chronic inflammatory demyelinating polyneuropathy, and diphtheria. -
This question is part of the following fields:
- Nervous System
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Question 19
Incorrect
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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: Tetralogy of Fallot
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 20
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 tibial nerve
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 21
Incorrect
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A 62-year-old obese female presented with dilated veins over the lateral aspect of her right ankle. Which of the following is most responsible for her presentation?
Your Answer: Long saphenous vein
Correct Answer: Short saphenous vein
Explanation:Varicose veins (venous insufficiency syndrome) are dilated, tortuous veins due to reverse venous flow. All the given veins can be affected from this condition. As the patient has varicose veins over lateral aspect of ankle, the short saphenous vein is affected. The great or long saphenous vein travels along the medial aspect of the ankle
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This question is part of the following fields:
- Cardiovascular System
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Question 22
Incorrect
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Which of the following characteristics does the jugular venous waveform have in tricuspid regurgitation?
Your Answer: Prominent y descent
Correct Answer: Large V waves
Explanation:The jugular venous pulsation has a biphasic waveform.
– The a wave corresponds to right atrial contraction and ends synchronously with the carotid artery pulse. The peak of the ‘a’ wave demarcates the end of atrial systole.
– The c wave corresponds to right ventricular contraction causing the tricuspid valve to bulge towards the right atrium during RV isovolumetric contraction.
– The x’ descent follows the ‘c’ wave and occurs as a result of the right ventricle pulling the tricuspid valve downward during ventricular systole (ventricular ejection/atrial relaxation). (As stroke volume is ejected, the ventricle takes up less space in the pericardium, allowing relaxed atrium to enlarge). The x’ (x prime) descent can be used as a measure of right ventricle contractility.
– The x descent follows the ‘a’ wave and corresponds to atrial relaxation and rapid atrial filling due to low pressure.
– The v wave corresponds to venous filling when the tricuspid valve is closed and venous pressure increases from venous return – this occurs during and following the carotid pulse.
– The y descent corresponds to the rapid emptying of the atrium into the ventricle following the opening of the tricuspid valve. -
This question is part of the following fields:
- Cardiovascular System
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Question 23
Incorrect
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A 22-year-old woman presents with anxiety and weight loss with increased appetite.
Thyrotoxicosis is suspected and various investigations are performed.
Which of the following findings is most consistent with Graves' disease?Your Answer: Low thyroid uptake of technecium-99m
Correct Answer: High titre of thyroid peroxidase autoantibodies
Explanation:Free T4 levels or the free T4 index is usually elevated, as is the free T3 level or free T3 index
– Assays for thyrotropin-receptor antibodies (particularly TSIs) almost always are positive.
– Detection of TSIs is diagnostic for Graves disease.
– Other markers of thyroid autoimmunity, such as antithyroglobulin antibodies or antithyroid peroxidase antibodies, are usually present.
– Other autoantibodies that may be present include thyrotropin receptor-blocking antibodies and anti-sodium-iodide symporter antibody.
The presence of these antibodies supports the diagnosis of autoimmune thyroid disease.
– The radioactive iodine uptake is increased and the uptake is diffusely distributed over the entire gland. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 24
Incorrect
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A 38-year-old male complained of painless, right sided testicular enlargement for 4 months. The size has been gradually increasing. On examination, there was no tenderness or redness. It was firm in consistency and not transilluminating. The most likely diagnosis is?
Your Answer: Hydrocele
Correct Answer: Testicular tumour
Explanation:History is suggestive of testicular tumour due to the gradual onset, non tender, firm mass. Hydroceles transiluminate and a varicocele has a bag of worms texture. Epididymo-orchitis is tender and often red or inflamed. An ependymal cyst is confined to the epididymis.
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This question is part of the following fields:
- Men's Health
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Question 25
Incorrect
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A 55-year-old alcoholic is admitted with portal hypertension. The wedged hepatic venous pressure is recorded. This pressure is reflective of which part of the hepatic vascular system?
Your Answer: Hepatic vein
Correct Answer: Sinusoids
Explanation:The wedged hepatic venous pressure is a reflection of the portal venous pressure in the hepatic sinusoids. This is a fact to remember. Here is a great but concise explanation as to why: https://www.ncbi.nlm.nih.gov/pubmed/18695309
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This question is part of the following fields:
- Hepatobiliary System
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Question 26
Correct
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A 45-year-old male suffers multiple injuries in a road traffic accident. He complains of inability to urinate for the past 4 hours. Radiological examination reveals a fractured pelvis. Which of the following will be the most appropriate step in the management of this patient?
Your Answer: Suprapubic catheter
Explanation:When faced with urethral trauma, initial management decisions must be made in the context of other injuries and patient stability. These patients often have multiple injuries, and management must be coordinated with other specialists, usually trauma, critical care, and orthopaedic specialists. Life-threatening injuries must be corrected first in any trauma algorithm. Initial emergent treatment remains controversial, but mainstays of therapy include drainage of the urinary bladder, often with placement of a suprapubic catheter (SPT) and primary endoscopic realignment of the urethra if possible.
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This question is part of the following fields:
- Renal System
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Question 27
Incorrect
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A 45-year-old woman who is being treated for Hodgkin's lymphoma with ABVD chemotherapy is reviewed on the haematology ward.
Six days ago, she was admitted with a fever of 38.9°C and was immediately started on piperacillin + tazobactam (Tazocin). Her blood picture on arrival was as follows:
Haemoglobin: 10.1 g/dL
Platelets: 311 x 10^9/L
White cell count: 0.8 x 10^9/L
Neutrophils: 0.35 x 10^9/L
Lymphocytes: 0.35 x 10^9/L
After 48 hours, she remained febrile and tachycardic. Tazocin was stopped and meropenem in combination with vancomycin was prescribed.
She still remains unwell today with a temperature of 38.4°C, heart rate of 96 bpm, and blood pressure of 102/66 mmHg. Respiratory examination is consistently unremarkable and blood and urine cultures have failed to show any cause for the fever.
Which of the following is the most appropriate next step of management?Your Answer: Refer for a stem cell transplant
Correct Answer: Add amphotericin B
Explanation:This patient meets the diagnostic criteria for neutropenic sepsis, which is a relatively common complication of cancer therapy – usually chemotherapy occurring 7-14 days after. It is defined as a neutrophil count of <0.5 x 10^9/L in a patient undergoing anticancer treatment and who has either a temperature higher than 38°C or has other features consistent with clinically significant sepsis. Management approach is the same as mentioned in this case. However, if the patient still remains unwell, then an antifungal such as amphotericin B is started after risk-stratifying the patient and carrying out investigations (e.g. HRCT and Aspergillus PCR) to determine the likelihood of systemic fungal infection.
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This question is part of the following fields:
- Haematology & Oncology
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Question 28
Incorrect
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A 55-year-old male with a history of myocardial infarction 4 years ago, was admitted with a history of fever for the past 2 weeks. On investigation, his echocardiography revealed a small vegetation around the mitral valve. His blood culture was positive for Streptococcus viridans. Which of the following is the most appropriate antibiotic therapy?
Your Answer: IV vancomycin + benzylpenicillin
Correct Answer: IV benzylpenicillin
Explanation:According to the American Heart Association (AHA) penicillin-susceptible S viridans, S bovis, and other streptococci (MIC of penicillin of ≤0.1 mcg/mL) should be treated with penicillin G or ceftriaxone or penicillin G + a gentamicin combination or vancomycin (if allergy to penicillin).
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This question is part of the following fields:
- Cardiovascular System
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Question 29
Incorrect
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Which of the following is not associated with atrial myxoma?
Your Answer: Mid-diastolic murmur
Correct Answer: J wave on ECG
Explanation:J waves in an ECG is associated with hypothermia, hypercalcemia, the Brugada syndrome, and idiopathic ventricular fibrillation. The other responses are all associated with atrial myxoma
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This question is part of the following fields:
- Cardiovascular System
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Question 30
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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SESSION STATS - PERFORMANCE PER SPECIALTY
