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Question 1
Correct
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A 23-year-old man is being investigated for excessive bleeding following a tooth extraction.
His coagulation profile shows:
Plts: 173 x 10^9/L
PT: 12.9 secs
APTT: 84 secs
Which clotting factor is he most likely deficient in?Your Answer: Factor VIII
Explanation:The patient is most likely a case of haemophilia A which is the genetic deficiency of clotting factor VIII in blood.
Haemophilia is an X-linked recessive disorder of coagulation. Up to 30% of patients have no family history of the condition. Haemophilia A is more common than haemophilia B and accounts for 90% of the cases. In haemophilia B (Christmas disease), there is a deficiency of clotting factor IX.
Characteristic features of haemophilia include hemarthrosis, haematomas, and prolonged bleeding following trauma or surgery. Coagulation profile of a haemophiliac person shows prolonged bleeding time, activated partial thromboplastin time (APTT), thrombin time (TT), but a normal prothrombin time (PT).
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This question is part of the following fields:
- Haematology & Oncology
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Question 2
Correct
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A 60-year-old man presents to his GP complaining of a cough and breathlessness for 2 weeks. He reports that before the onset of these symptoms, he was fit and well and was not on any medication. He is a known smoker of 10 cigarettes per day and has been smoking for over 25 years.
On examination, the GP diagnosed a mild viral chest infection and reassured the patient that the symptoms would settle of their own accord.
Two weeks later, the patient presented again to the GP, this time complaining of thirst, polyuria and generalised muscle weakness. The GP noticed the presence of ankle oedema.
A prick test confirmed the presence of hyperglycaemia and the patient was referred to the hospital for investigations where the medical registrar ordered a variety of blood tests.
Some of these results are shown below:
Na 144 mmol/l
K 2.2 mmol/l
Bicarbonate 34 mmol/l
Glucose 16 mmol/l
What is the most likely diagnosis?Your Answer: Ectopic ACTH production
Explanation:The patient has small cell lung cancer presented by paraneoplastic syndrome; Ectopic ACTH secretion.
Small cell lung cancer (SCLC), previously known as oat cell carcinoma is a neuroendocrine carcinoma that exhibits aggressive behaviour, rapid growth, early spread to distant sites, exquisite sensitivity to chemotherapy and radiation, and a frequent association with distinct paraneoplastic syndromes.
Common presenting signs and symptoms of the disease, which very often occur in advanced-stage disease, include the following:
– Shortness of breath
– Cough
– Bone pain
– Weight loss
– Fatigue
– Neurologic dysfunction
Most patients with this disease present with a short duration of symptoms, usually only 8-12 weeks before presentation. The clinical manifestations of SCLC can result from local tumour growth, intrathoracic spread, distant spread, and/or paraneoplastic syndromes.
SIADH is present in 15% of the patients and Ectopic secretion of ACTH is present in 2-5% of the patients leading to ectopic Cushing’s syndrome. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 3
Correct
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A 9-year-old girl complains of perioral blisters and a burning sensation of her face. Some of the blisters are crusted and some are weeping. What is the most likely diagnosis?
Your Answer: Impetigo
Explanation:Impetigo appears more commonly on the face than other exposed areas like the limbs. Its blisters are clustered and may have a fluid discharge.
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This question is part of the following fields:
- The Skin
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Question 4
Incorrect
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Regarding Giardia Lamblia which one of the following statements is true?
Your Answer: May be excluded by stool microscopy
Correct Answer: May cause intestinal malabsorption
Explanation:Giardiasis also known as travellers diarrhoea is caused by Giardia lamblia, which is an anaerobic parasite affecting the small intestine. It can lead to diarrhoea, flatulence, abdominal cramps, malodourous greasy stools and intestinal malabsorption. It can also cause bloody diarrhoea. The investigation of choice is stool examination for trophozoites and cysts. It is treated by metronidazole and tinidazole as first line therapies.
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This question is part of the following fields:
- Infectious Diseases
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Question 5
Correct
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A 62 year male presented with epistaxis, nasal blockage, double vision, ear fullness and left sided conductive deafness for 1 week. He was a heavy smoker and alcoholic. Which of the following is the most probable diagnosis?
Your Answer: Nasopharyngeal ca
Explanation:Because of the involvement of nose, ear and vision, the most probable diagnosis is nasopharyngeal carcinoma. Both smoking and alcohol are risk factors.
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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 young woman is complaining of a sensation of spinning and loss of balance every time she moves sideways on the bed while lying supine. What would you do next?
Your Answer: Advice on posture
Correct Answer: Head roll test
Explanation:The most probable diagnosis is benign paroxysmal positional vertigo (BPPV). It is a peripheral vestibular disorder characterized by short episodes of mild to intense dizziness and influenced by specific changes in head position. BPPV is the most common cause of vertigo accounting for nearly one-half of patients with peripheral vestibular dysfunction. In order to establish the diagnosis, the head roll test is performed where the head is turned about 90° to each side while supine.
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This question is part of the following fields:
- Nervous System
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Question 7
Correct
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A 47-year-old man with a history of alcohol induced liver disease is admitted to the gastroenterology ward. He has developed tense ascites again and a plan is made to site an ascitic drain. His renal function after 2 days is as follows:
Na+ 131 mmol/l
K+ 3.8 mmol/l
Urea 12.2 mmol/l
Creatinine 205 µmol/l
Which of the following pathophysiological changes is most likely to be responsible for the declining renal function?Your Answer: Splanchnic vasodilation
Explanation:Hepatorenal syndrome is renal vasoconstriction that cannot overcome the effects of splanchnic vasodilation. Vasoactive mediators cause this splanchnic vasodilation, reducing SVR, which is sensed by the juxtaglomerular apparatus, activating the RAAS system, leading to renal vasoconstriction. However, the overall splanchnic vasodilation effect is greater than this renal vasoconstriction effect.
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This question is part of the following fields:
- Gastrointestinal System
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Question 8
Correct
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Which of the following findings would point towards a diagnosis of neonatal hypothyroidism?
Your Answer: Mother has hyperthyroidism
Explanation:Transient congenital hypothyroidism can be due to: iodine deficiency or excess, maternal consumption of goitrogens or antithyroid medications during pregnancy, transplacental passage of TSH receptor-blocking antibodies, and neonatal very low birth weight and prematurity
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 9
Incorrect
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Which one of the following is not associated with non-alcoholic steatohepatitis?
Your Answer: Jejunoileal bypass
Correct Answer: Type 1 diabetes mellitus
Explanation:There are two types of Non-alcoholic fatty liver disease (NAFLD); simple fatty liver and non-alcoholic steatohepatitis (NASH). Simple fatty liver and NASH are two separate conditions.
Simple fatty liver, also called non-alcoholic fatty liver (NAFL), is a form of NAFLD in which you have fat in your liver but little or no inflammation or liver cell damage. Simple fatty liver typically does not progress to cause liver damage or complications.
Non-alcoholic steatohepatitis (NASH)
NASH is a form of NAFLD in which you have hepatitis and liver cell damage, in addition to fat in your liver. Inflammation and liver cell damage can cause fibrosis, or scarring, of the liver. NASH may lead to cirrhosis or liver cancer. Type I diabetes is not associated with NASH (non-alcoholic steatohepatitis), but type II diabetes is. Hyperlipidaemia, obesity, sudden weight loss/starvation and jejunoileal bypass are all associated with NASH. This is the most common cause of liver disease in the developed world. -
This question is part of the following fields:
- Hepatobiliary System
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Question 10
Correct
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A 73-year-old gentleman with type 2 diabetes mellitus, complains of difficulty walking and trouble with his hands. It began with a tingling sensation in his soles, which later extended up to his ankles. He now feels unsteady when walking, and more recently, has noticed numbness and tingling in the fingers of both hands.
On examination, he has absent ankle reflexes, a high steppage gait, and altered sensation to his mid-calves.
What is the underlying pathological process?Your Answer: Axonal degeneration
Explanation:This case presents with sensorimotor neuropathy secondary to his DM. The progression of the neuropathy, known dying-back neuropathy, is a distal axonopathy or axonal degeneration as where the sensorimotor loss begins distally and travels proximally.
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This question is part of the following fields:
- Nervous System
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Question 11
Correct
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A 70-year-old man underwent temporary transvenous pacing. While in the coronary care unit he developed presyncope. His pulse rate was 30 bpm. His ECG showed pacing spikes which were not related to QRS complexes. What is the most appropriate action that can be taken?
Your Answer: Increase the pacing voltage to a maximum
Explanation:Pacemaker spikes on the ECG indicate that pacemaker is functioning. The most probable cause for this presentation is the change of the position of the tip of the pacing wire. Increasing the voltage will solve the problem. If it works, repositioning of the pacing wire should be done.
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This question is part of the following fields:
- Cardiovascular System
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Question 12
Correct
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A 35-year-old lady was brought to the emergency department in an unconscious state. She is a known drug addict and has a 1 day history of anuria. CXR revealed pulmonary oedema. Serum electrolytes showed hyperkalaemia. The next management step would be?
Your Answer: IV calcium gluconate
Explanation:IV calcium gluconate is the drug of choice in hyperkalaemia, as it is a life threatening condition and prompt management is required.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 13
Correct
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Which of the following is an appetite stimulant?
Your Answer: Neuropeptide Y
Explanation:Neuropeptide Y induces appetite during trials in rats. Other agents mentioned here are either appetite suppressants or have no effect on appetite.
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This question is part of the following fields:
- Gastrointestinal System
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Question 14
Correct
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A 47-year-old man is seen in clinic with a 3 month history of chronic epigastric discomfort. The pain comes and goes and radiates to his back and his right shoulder tip at times. It is worse after meals but there is no relieving factor. He feels nauseous most of the time and has foul-smelling stools. He has lost 2 stones in weight. He also complains of intermittent light-headedness. He drinks a bottle of wine on most nights and smokes 20 cigarettes /day.
On examination, he is thin and looks neglected. His abdomen is soft, but tender on deep palpation in the epigastric area. He has a 2 cm non-tender liver edge. He also has decreased sensation to light touch on both feet.
Bloods:
sodium 131 mmol/l
potassium 4.2 mmol/l
creatine 64 μmol/l
amylase 35 U/l
alanine aminotransferase (ALT) 104 U/l
alkaline phosphatase (ALP) 121 U/l
bilirubin 24 μmol/l
calcium 2.01 mmol/l
whole cell count (WCC) 12.1 × 109/l
haemoglobin (Hb) 10.2 g/dl
platelets 462 × 109/l
abdominal X-ray (AXR) normal
oesophago-gastro duodenoscopy (OGD) mild gastritis
Campylobacter-like organism (CLO) test negative
ultrasound abdomen mildly enlarged liver with fatty change
spleen and kidneys normal
pancreas partially obscured by overlying bowel gas
72-h stool fat 22 g in 72 h
He is referred for a secretin test:
volume collected 110 ml
bicarbonate 52 mEq/l
What is the most likely diagnosis?Your Answer: Chronic pancreatitis
Explanation:The question describes an alcohol abusing man with chronic epigastric discomfort, radiating into his back, worse with meals, and foul-smelling stools, weight loss, as well as chronic nausea. This is likely, thus chronic pancreatitis due to alcohol abuse. Hepatomegaly and peripheral neuropathy secondary to anaemia support the diagnosis of long term alcohol abuse. Bacterial overgrowth may present with diarrhoea and is a less likely diagnosis than pancreatitis. Celiac disease is a less likely diagnosis than pancreatitis, and you would also expect mention of diarrhoea. VIPoma would also likely present with diarrhoea. Cecal carcinoma would more than likely present with blood in the stool.
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This question is part of the following fields:
- Gastrointestinal System
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Question 15
Correct
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All of the following statements regarding iron metabolism are correct EXCEPT?
Your Answer: In iron deficiency anaemia total iron binding capacity and transferrin saturation will both be decreased
Explanation:Iron deficiency anaemia is characterised by decreased iron stores, however there is increased iron binding capacity. Transferrin is the iron transporting protein. Because of the decreased presence of iron in blood, the transferrin saturation is decreased. Ferritin is an iron storage protein that is affected according to the iron stores but its also an acute phase reactant and levels can be effected by other conditions. Each unit of packed RBCs transfused to an adult contains 200 ml of RBCs and 200mg of iron. Only 5-10% of dietary iron is absorbed in the portal circulation which can be increased by the intake of vitamin C, animal foods and amino acids.
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This question is part of the following fields:
- Gastrointestinal System
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Question 16
Correct
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A 55-year-old patient was diagnosed with hepatocellular carcinoma. Tramadol was prescribed to treat the pain. However, the patient is still experiencing intense pain. Which of the following would be the most appropriate treatment for this patient?
Your Answer: Escalate opioid therapy
Explanation:Because the patient’s pain is not responding to Tramadol treatment (already an opioid analgesic), opioid therapy should be escalated until there is pain relief without intolerable side effect.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 17
Correct
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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: 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 18
Incorrect
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A 52-year-old chef presents to the ED with acute visual changes. He has a past medical history of hypertension and type 2 diabetes mellitus. On neurological examination, his upper and lower limbs are normal however he has a homonymous hemianopia with central preservation. Where is the most likely cause of his problems within the central nervous system?
Your Answer: Optic chiasm
Correct Answer: Optic radiation
Explanation:Lesions in the optic radiation can cause a homonymous hemianopia with macular sparing, as a result of collateral circulation offered to macular tracts by the middle cerebral artery.
Lesions in the optic tract also cause a homonymous hemianopia, but without macular sparing.
Lesions in the optic chiasm, optic nerve, and temporal lobe cause bitemporal hemianopia, ipsilateral complete blindness, and superior homonymous quadrantanopia respectively. -
This question is part of the following fields:
- Nervous System
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Question 19
Correct
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A 75-year-old female smoker who is diabetic and hypertensive, presents to the emergency which acute chest pain and worsening condition. She is obese and has recently been immobile due to a hip pain. The doctor fails to resuscitate her and she is pronounced dead. What do you think caused her death?
Your Answer: Pulmonary embolism
Explanation:Pulmonary embolism (PE) is the obstruction of one or more pulmonary arteries by solid, liquid, or gaseous masses. In most cases, the embolism is caused by blood thrombi, which arise from the deep vein system in the legs or pelvis (deep vein thrombosis) and embolize to the lungs via the inferior vena cava.
Risk factors include: immobility, inherited hypercoagulability disorders, being overweight or obese, smoking cigarettes, taking birth control pills (oral contraceptives) or hormone replacement therapy, having diseases such as stroke, paralysis, chronic heart disease, or high blood pressure, pregnancy, and recent surgery.
The clinical presentation is variable and, depending on the extent of vessel obstruction, can range from asymptomatic to cardiogenic shock. Symptoms are often nonspecific, including chest pain, coughing, dyspnoea, and tachycardia.
The diagnosis of PE is based primarily on the clinical findings and is confirmed by detection of an embolism in contrast CT pulmonary angiography (CTA). Arterial blood gas analysis typically shows evidence of respiratory alkalosis with low partial oxygen pressure, low partial carbon dioxide pressure, and elevated pH. Another commonly performed test is the measurement of D-dimer levels, which can rule out PE if negative.
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This question is part of the following fields:
- Cardiovascular System
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Question 20
Correct
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A patient with chronic renal failure, treated with regular haemodialysis, attends the renal clinic. He has been treated for six months with oral ferrous sulphate, 200 mg three times a day. His haemoglobin at this clinic attendance is 7.6. His previous result was 10.6 six months ago.
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Which of the following is the most appropriate treatment?Your Answer: IV iron and subcutaneous erythropoietin
Explanation:The patient should be prescribed IV iron and subcutaneous erythropoietin to enhance erythropoiesis to address the dropped haemoglobin.
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This question is part of the following fields:
- Renal System
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Question 21
Correct
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A 8-year-old boy who recently migrated from Nigeria was seen in A&E department with a six-week history of progressive swelling of his jaw, fever, night sweats, and weight loss. His mother reported an episode of sore throat in the past which was treated with antibiotics, but he developed a rash subsequently. Other than that, there was no other significant past medical history. On examination, a painless, nontender 4x3cm mass was found that was fixed and hard. The only other examination finding of note was rubbery symmetrical cervical lymphadenopathy.
Which of the following translocation would most likely be found on biopsy karyotyping?Your Answer: t(8;14)
Explanation: -
This question is part of the following fields:
- Haematology & Oncology
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Question 22
Incorrect
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A 32 year-old man presents with his first generalized tonic-clonic seizure (GTCS). He has been complaining of headaches for the past 2 weeks, although he has been able to continue working at his job. Upon examination, he has mild left hemiparesis and bilateral extensor plantar responses. General examination is otherwise unremarkable. An urgent CT scan of the brain shows a 5cm multicentric mass lesion in the right frontal lobe with surrounding vasogenic oedema and some hemisphere shift. Which of the following is the most likely underlying pathology?
Your Answer: Oligodendroglioma
Correct Answer: Glioblastoma
Explanation:Glioblastoma multiforme, also considered as grade IV astrocytoma, is the most malignant form of the tumour and accounts for about 20% of all cerebral tumours. These often remain clinically silent until they have reached a large enough size. In adults, glioblastoma multiforme usually occurs in the cerebral hemispheres, especially the frontal and temporal lobes of the brain. About half occupy more than one hemisphere at presentation, and some are multicentric. Biopsy shows high cellularity with mitoses, pleomorphism, and vascular hyperplasia. Prognosis is extremely poor, with only 20% surviving beyond 1 year and 10% beyond 2 years.
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This question is part of the following fields:
- Nervous System
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Question 23
Correct
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A 47-year-old male with type II diabetes mellitus presents to your clinic with a history suggestive of erectile dysfunction. You decide to start him on sildenafil citrate. What is the mechanism of action of this drug?
Your Answer: Phosphodiesterase type V inhibitor
Explanation:Sildenafil (Viagra) is a phosphodiesterase type V inhibitor used in the treatment of impotence.
Contraindications:
– Patients taking nitrates and related drugs such as nicorandil
– Hypotension
– Recent stroke or myocardial infarction (NICE recommend waiting 6 months)Side-effects:
Visual disturbances e.g. cyanopsia, non-arthritic anterior ischaemic Neuropathy
Nasal congestion
Flushing
Gastrointestinal side-effects
Headache -
This question is part of the following fields:
- Pharmacology
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Question 24
Correct
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Which of the following is not associated with atrial myxoma?
Your 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 25
Correct
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A defect in DNA gyrase can lead to which of the following cancerous conditions?
Your Answer: Xeroderma pigmentosum
Explanation:Xeroderma pigmentosum is an X-linked recessive condition, which is caused by mutations in DNA gyrase which further encodes the XP gene. The defect may lead to skin cancer at an early stage of life, especially at photo exposed sites.
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This question is part of the following fields:
- The Skin
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Question 26
Incorrect
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A 2-day-old girl is admitted by her mother because she gets cyanotic upon feeding and she wouldn't stop crying. The doctors suspect a congenital heart disease. What is the most probable aetiology?
Your Answer: Tetralogy of Fallot
Correct Answer: Transposition of the great arteries
Explanation:Transposition of the great arteries results in a significant hypoxemic status that is observed clinically by central cyanosis. The bluish discoloration of the skin and mucous membranes is therefore the basic pattern of clinical presentation in transposition. Its onset and severity depend on anatomical and functional variants that influence the degree of mixing between the two circulations. Limited intercirculatory mixing, usually present if the ventricular septum is intact or the atrial septal defect is restrictive, is related to progressive and profound central cyanosis evident within the first hours of life. Tachypnoea, tachycardia, diaphoresis, poor weight gain, a gallop rhythm, and eventually hepatomegaly can be then detected later on during infancy. Heart murmurs associated with left outflow tract obstruction, due to a persistent arterial duct or a septal defect may be heard, but they are not a constant finding.
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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 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: Sodium channel
Correct Answer: Chloride channel
Explanation: -
This question is part of the following fields:
- Respiratory System
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Question 28
Correct
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A 33-year-old male presents with a rash and low grade fever (37.6°C). Twenty-one days ago, he underwent allogeneic bone marrow transplant for high-risk acute myeloid leukaemia. The rash was initially maculopapular affecting his palms and soles but 24 hours later, general erythroderma is noted involving the trunk and limbs. Other than that, he remains asymptomatic. His total bilirubin was previously normal but is now noted to be 40 μmol/L (1-22).
How would you manage the patient at this stage?Your Answer: High-dose methylprednisolone
Explanation:This is a classical picture of graft versus host disease (GVHD) following bone marrow transplant. Acute GVHD occurs in the first 100 days post transplant with chronic GVHD occurring 100-300 days after transplant. GVHD is graded according to the Seattle system, and each organ involved is scored (skin, liver, and gut).
The standard initial treatment in the acute setting is high-dose methylprednisolone started immediately. If there is no response, a more intensive immunosuppressive agent such as alemtuzumab or antilymphocyte globulin is needed.
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This question is part of the following fields:
- Haematology & Oncology
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Question 29
Correct
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A 18-year-old gentleman is referred to dermatology. He has around 10 hyperpigmented macules on his torso which vary in size from 1.5-5 cm in size. His GP also noted some freckles in the groin region. He is also currently under orthopaedic review due to a worsening scoliosis of the spine. His father suffered from similar problems before having a fatal myocardial infarction two years ago. Which chromosome is most likely to have a gene defect?
Your Answer: Chromosome 17
Explanation:The patient’s history and presentation and familial history, meets the diagnostic criteria for Neurofibromatosis type I, presenting with neurofibromas noted in this patient as hyperpigmented macules and freckles, musculoskeletal disorders like the scoliosis in this case, and a familial history. Neurofibromatosis type I is caused by a mutation on Chromosome 17.
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This question is part of the following fields:
- Nervous System
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Question 30
Correct
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A 40-year-old woman presents with weight loss, palpitations, diarrhoea and cessation of periods. She has been treated by her GP for anxiety. Examination reveals a single nodule on the left of her thyroid, about 1.5 cm in diameter.
Thyroid scan shows increased uptake within the nodule with reduced activity throughout the rest of the gland.
Thyroid function tests showed a free thyroxine of 30 pmol/l (9-25 pmol/l), TSH < 0.05 mU/l (0.5-5).
Based on these findings, what would be the definitive treatment?Your Answer: Radioactive iodine therapy
Explanation:Patients who have autonomously functioning nodules should be treated definitely with radioactive iodine or surgery.
Na131 I treatment – In the United States and Europe, radioactive iodine is considered the treatment of choice for Toxic Nodular Goitre. Except for pregnancy, there are no absolute contraindications to radioiodine therapy. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 31
Correct
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A 23-year-old man visited the OPD with a complaint of pain in the abdomen and dark urine. His blood pressure was found to be elevated. Which of the following should be done next to reach a diagnosis?
Your Answer: US
Explanation:Hypertension along with haematuria give an indication of cystic kidneys which can be diagnosed with an ultrasound.
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This question is part of the following fields:
- Renal System
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Question 32
Correct
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A 60-year-old man presented with difficulty in breathing. On examination he was severely dyspnoeic and tachycardic. What is the clinical sign that would favour the diagnosis of cardiac tamponade over constrictive pericarditis?
Your Answer: Pulsus paradoxus
Explanation:Pulsus paradoxus is defined as the exaggerated fall in systolic blood pressure during inspiration by greater than 10 mmHg. Cardiac tamponade is the classic cause of pulsus paradoxus. Kussmaul’s sign (a rise in the jugular venous pressure on inspiration) is mostly seen in constrictive pericarditis. Hypotension, muffled heart sounds and raised JVP can be seen in both conditions.
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This question is part of the following fields:
- Cardiovascular System
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Question 33
Correct
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A 33-year-old male presented with complaints of arthritis involving the knee joint. O/E the overlying joint was red, swollen and tender. The patient also gave a history of constipation and noting a change in his shoe size. The most likely diagnosis in this patient would be?
Your Answer: Pseudogout
Explanation:Pseudogout is caused by the deposition of calcium pyrophosphate crystals and effects the large joints, as compared to gout where the small joints are usually involved. The joint tends to be tender, swollen and warm, giving a picture of cellulitis. Pseudogout has an association with hypothyroidism, therefore symptoms of dry skin and constipation can also be present.
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This question is part of the following fields:
- Musculoskeletal System
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Question 34
Correct
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A 51-year-old obese female, with a history of smoking, presents to the clinic with worsening dyspnoea. She is currently on oestrogen therapy for menopausal symptoms.
Clinical examination, ECG and radiological findings correspond to right sided heart failure. There are no signs of left ventricular dysfunction.
Which of the following is the most likely cause of cor pulmonale?Your Answer: Recurrent small pulmonary embolisms
Explanation:Postmenopausal oestrogen therapy and hormone therapy are associated with an increased risk of thromboembolism. The relative risk seems to be even greater if the treated population has pre-existing risk factors for thromboembolism, such as obesity, immobilization, and fracture. Cor pulmonale can occur secondary to small recurrent pulmonary embolisms. Pneumonias and bronchiectasis usually present with purulent sputum, and in case of carcinoma there may be other associated symptoms like weight loss, etc.
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This question is part of the following fields:
- Respiratory System
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Question 35
Incorrect
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A 16-year-old boy is being treated with ADH for diabetes insipidus. His blood results show:
fasting plasma glucose level: 6 mmol/l (3- 6)
sodium 148 mmol/l (137-144)
potassium 4.5 mmol/l (3.5-4.9)
calcium 2.8 mmol/l (2.2-2.6).
However, he still complains of polyuria, polydipsia and nocturia.
What could be the most probable cause?Your Answer: Hypercalcaemia
Correct Answer: Nephrogenic diabetes insipidus
Explanation:Diabetes insipidus (DI) is defined as the passage of large volumes (>3 L/24 hr) of dilute urine (< 300 mOsm/kg). It has the following 2 major forms:
Central (neurogenic, pituitary, or neurohypophyseal) DI, characterized by decreased secretion of antidiuretic hormone (ADH; also referred to as arginine vasopressin [AVP])
Nephrogenic DI, characterized by decreased ability to concentrate urine because of resistance to ADH action in the kidney.
The boy most probably has nephrogenic diabetes insidious (DI) not central DI so he is not responding to the ADH treatment. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 36
Correct
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Cancer of the prostate is associated with which of the following:
Your Answer: Exposure to cadmium
Explanation:Risk factors for prostate cancer include:
Black ethnicity
A family history of breast or prostate cancer
High intake of animal fats and low selenium intake
Exposure to radiation or heavy metals including cadmium -
This question is part of the following fields:
- Men's Health
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Question 37
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 38
Correct
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A 45-year-old male patient who was initially investigated for having an abdominal mass is diagnosed as having Burkitt lymphoma. He is due to start chemotherapy today.
Which one of the following should be given prior to his chemotherapy in order to reduce the risk of tumour lysis syndrome?Your Answer: Rasburicase
Explanation:Rasburicase should be given prior to chemotherapy in order to reduce the risk of tumour lysis syndrome (TLS). Rasburicase is a recombinant version of urate oxidase which is an enzyme that metabolizes uric acid to allantoin. Allantoin is 5-10 times more soluble than uric acid, hence, renal excretion is more effective.
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.
Burkitt lymphoma is a high-grade B-cell neoplasm. There are two major forms:
1. Endemic (African) form: typically involves maxilla or mandible.
2. Sporadic form: abdominal (e.g. ileocaecal) tumours are the most common form. More common in patients with HIV.Burkitt lymphoma is associated with the c-myc gene translocation, usually t(8;14). The Epstein-Barr virus (EBV) is strongly implicated in development of the African form of Burkitt lymphoma and to a lesser extent, the sporadic form.
Management of the lymphoma is with chemotherapy. This tends to produce a rapid response which may cause TLS.
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This question is part of the following fields:
- Haematology & Oncology
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Question 39
Incorrect
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Question 40
Correct
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A 55-year-old male underwent a pneumonectomy. Post operatively he was drowsy and found to have a hyponatremia. What would be the most likely reason for his condition?
Your Answer: Removal of hormonally active tumour
Explanation:The syndrome of inappropriate antidiuretic hormone (SIADH) is often associated with small-cell lung carcinoma which manifests as a paraneoplastic disorder. SIADH due to non-small-cell cancer has been shown to be triggered following open surgical procedures, however this is an extremely rare phenomenon.
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This question is part of the following fields:
- Respiratory System
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Question 41
Correct
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A 69-year-old diabetic female presents for a regular outpatient visit. Her BMI is calculated to be 33. Lab results: GFR=29, Urea=13, Creatinine=390 mmol/L. Which of the following drugs should ideally be used by this patient?
Your Answer: Insulin
Explanation:The management of patients with diabetes and nephropathy necessitates attention to several aspects of care. Importantly, glycaemic control should be optimized for the patient, attaining the necessary control to reduce complications but done in a safe, monitored manner. Screening for development of nephropathy should be performed on a regular basis to identify microalbuminuria or reductions in GFR and if identified, the diabetes regimen should be tailored accordingly. Prevention and treatment of diabetic nephropathy and other complications necessitates a multifactorial approach. From the options provided insulin is the most suitable as sulfonylureas and biguanides are contraindicated in renal failure. Glitazones are known to cause many side effects including fluid retention and oedema. Hence, insulin will be the best option in this scenario.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 42
Incorrect
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A 52-year-old female who was a smoker, with a history of asymptomatic atrial septal defect (ASD) presented with difficulty in breathing on exertion and ankle oedema for the past 2 weeks. She has defaulted on her follow up for ASD. On examination she was cyanosed and clubbing was noted. Her pulse rate was 92 and blood pressure was 100/60 mmHg. Echocardiography revealed a dilated right ventricle of the heart. The right ventricular pressure was 90 mmHg. Significant tricuspid and pulmonary regurgitation were also noted. Which of the following is the most probable diagnosis?
Your Answer: Pulmonary emboli disease
Correct Answer: Eisenmenger's syndrome
Explanation:According to echocardiography findings pulmonary pressure is closer to systemic blood pressure and it is evidence of pulmonary hypertension. Because of the reversal of shunt due to pulmonary hypertension, cyanosis and clubbing have developed. So the most probable diagnosis is Eisenmenger’s syndrome.
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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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A 56-year-old woman presents to the clinic complaining of shoulder pain that she has been experiencing for the last 4 weeks. She does not remember getting injured previously. The pain worsens on movement especially when she is moving the arm quickly. At night, lying on the affected side is painful. Examination reveals no erythema or swelling. However, pain is felt on passive abduction between 60 to 120 degrees and she is unable to abduct the arm past 70-80 degrees. Flexion and extension are intact. What is the most likely diagnosis?
Your Answer: Acromioclavicular joint injury
Correct Answer: Supraspinatus tendonitis
Explanation:Supraspinatus tendinopathy is a common and disabling condition that becomes more prevalent after middle age and is a common cause of pain in the shoulder. A predisposing factor is resistive overuse. This patient has the classic painful arc that is a sign of shoulder impingement characteristic of supraspinatus tendonitis.
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This question is part of the following fields:
- Musculoskeletal System
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Question 44
Incorrect
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A 60-year-old male is under treatment with azathioprine after a renal transplant. During his review, he complains of pain and swelling over his left great toe. Investigations reveal hyperuricemia. Suspecting gout, he was started on allopurinol. Subsequently, he develops aplastic anaemia. Which of the following is the most appropriate reason for his bone marrow failure?
Your Answer: Acute viral infection
Correct Answer: Mercaptopurine toxicity
Explanation:The cause for bone marrow suppression in this patient is most probably mercaptopurine toxicity.
Azathioprine is metabolized to 6-mercaptopurine (6-MP), which itself is metabolized by xanthine oxidase.
Xanthine oxidase inhibition by allopurinol leads to the accumulation of 6-MP which then precipitates bone marrow failure.
This may be potentially fatal if unrecognized.
Clinical presentation:
Toxicity symptoms include gastrointestinal symptoms, bradycardia, hepatotoxicity, myelosuppression. -
This question is part of the following fields:
- Pharmacology
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Question 45
Correct
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A 68-year-old man who has chronic obstructive pulmonary disease (COPD) is reviewed. On examination, there is evidence of cor pulmonale with a significant degree of pedal oedema. His FEV1 is 44%. During a recent hospital stay his pO2 on room air was 7.4 kPa.
Which one of the following interventions is most likely to increase survival in this patient?Your Answer: Long-term oxygen therapy
Explanation:Assess the need for oxygen therapy in people with:
– very severe airflow obstruction (FEV1 below 30% predicted)
– cyanosis (blue tint to skin)
– polycythaemia
– peripheral oedema (swelling)
– a raised jugular venous pressure
– oxygen saturations of 92% or less breathing air.Also consider assessment for people with severe airflow obstruction (FEV1 30-49% predicted).
Consider long-term oxygen therapy for people with COPD who do not smoke and who:
have a partial pressure of oxygen in arterial blood (PaO2) below 7.3 kPa when stable or have a PaO2 above 7.3 and below 8 kPa when stable, if they also have 1 or more of the following:
– secondary polycythaemia
– peripheral oedema
– pulmonary hypertension. -
This question is part of the following fields:
- Respiratory System
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Question 46
Incorrect
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A 20-year-old female is suffering from amenorrhea. She has a BMI of 14 but still thinks that she needs to lose weight. She watches her food intake obsessively. Choose the most likely diagnosis.
Your Answer: Depression
Correct Answer: Anorexia nervosa
Explanation:Anorexia is consistent with the symptoms described.
Anorexia is an eating disorder characterised by an abnormally low body weight, an intense fear of gaining weight and a distorted perception of weight. People with anorexia place a high value on controlling their weight and shape, using extreme efforts that tend to significantly interfere with their lives.
Some people who have anorexia binge and purge, similar to individuals who have bulimia. But people with anorexia generally struggle with an abnormally low body weight, while individuals with bulimia typically are normal to above normal weight.
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This question is part of the following fields:
- Women's Health
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Question 47
Incorrect
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A 55-year-old male presents to the emergency with acute onset breathlessness. He underwent a total hip replacement 7 days back. On examination, the JVP is raised. Which other investigation would be most helpful in leading to an accurate diagnosis?
Your Answer: V/Q Scan
Correct Answer: CTPA
Explanation:The most pertinent diagnosis suspected in this case would be a pulmonary embolism considering the recent surgical history and acute onset of breathlessness. A CT pulmonary angiogram (CTPA) is a medical diagnostic test that employs computed tomography (CT) angiography to obtain an image of the pulmonary arteries. Its main use is to diagnose pulmonary embolism (PE).
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This question is part of the following fields:
- Emergency & Critical Care
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Question 48
Correct
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A 27-year-old male is admitted after drinking engine coolant in an apparent suicide attempt.
Lab investigations reveal:
pH 7.1 (7.36-7.44)
pO2 15.3 kPa (11.3-12.6)
pCO2 3.2 kPa (4.7-6.0)
Standard bicarbonate 2.2 mmol/L (20-28)
Serum calcium 1.82 mmol/L (2.2-2.6)
After replacing calcium, which of the following is the most urgent treatment for this man?Your Answer: 8.4% bicarbonate infusion
Explanation:Carbon monoxide has high affinity for haemoglobin and myoglobin resulting in a left-shift of the oxygen dissociation curve and tissue hypoxia. There are approximately 50 deaths per year from accidental carbon monoxide poisoning in the UK. In these circumstances, antidotal therapy to block alcohol dehydrogenase with ethanol or 4-MP alone is insufficient to treat the poisoning. Data suggest that a severe lactic acidosis needs initial correction and in this patient the most appropriate treatment would be IV fluids with bicarbonate to correct the metabolic acidosis. Haemodialysis may be required thereafter.
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This question is part of the following fields:
- Fluids & Electrolytes
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Question 49
Correct
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A 48-year-old male presents to the clinic complaining of a swelling in his left groin that disappears on lying down. He also reports occasional haematuria and a mass in his left loin. On examination, the swelling is bluish in colour and has an appearance and consistency like that of a 'bag of worms'. What is the most likely diagnosis?
Your Answer: Left sided renal cell carcinoma
Explanation:Renal cell carcinoma (RCC) may remain clinically occult for most of its course. The classic triad of flank pain, haematuria, and flank mass is uncommon (10%) and is indicative of advanced disease. A varicocele, usually left sided, is due to obstruction of the testicular vein.
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This question is part of the following fields:
- Men's Health
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Question 50
Incorrect
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A 20-year-old woman presents with weakness and is found to have a serum potassium of 2.2 mmol/l and pH 7.1.
Â
Which of the following would be LEAST useful in differentiating between renal tubular acidosis Types 1 and 2?Your Answer: Renal calculi
Correct Answer: Osteomalacia
Explanation:Osteomalacia is a marked softening of the bones that can present in both type I and type II Renal Tubular Acidosis (RTA) and will thus not differentiate the two types in any case. The other measures will allow differentiation of the two types.
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This question is part of the following fields:
- Renal System
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Question 51
Incorrect
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A 53-year-old male underwent a partial gastrectomy 15 years ago for a complicated peptic ulcer. Which of the following elements may be deficient in this man?
Your Answer: Glucose
Correct Answer: Iron
Explanation:The proper gastric acidity is required to transform iron from ferric to ferrous state in order to be absorbable. Even partial gastrectomy may cause dumping syndrome. Malabsorption is rare.
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This question is part of the following fields:
- Gastrointestinal System
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Question 52
Incorrect
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Which one of the following congenital infections is most characteristically associated with chorioretinitis?
Your Answer: Cytomegalovirus
Correct Answer: Toxoplasma gondii
Explanation:The common congenital infections encountered are rubella, toxoplasmosis and cytomegalovirus. Cytomegalovirus is the most common congenital infection in the UK. Maternal infection is usually asymptomatic.
Congenital toxoplasmosis is associated with fetal death and abortion, and in infants, it is associated with neurologic deficits, neurocognitive deficits, and chorioretinitis. -
This question is part of the following fields:
- Infectious Diseases
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Question 53
Incorrect
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A 59-year-old woman has an 11mm skin lesion on her right forearm, which bleeds easily on contact and has changed in appearance over the last 11 months.
Your Answer: Benign mole
Correct Answer: Malignant melanoma
Explanation:Melanoma is more common in men than women. Reasons for the disease includes: UV light and genetic predisposition or mutations. Diagnosis is by biopsy and analysis of any skin lesion that has signs of being potentially cancerous.
Early warning signs of melanoma ABCDE:
Asymmetry
Borders (irregular with edges and corners)
Colour (variegated)
Diameter (greater than 6 mm)
Evolving over time -
This question is part of the following fields:
- The Skin
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Question 54
Incorrect
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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: CT
Correct 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 55
Correct
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A 72-year-old female presents with tiredness and weakness. On examination, she is pale and has a haemoglobin of 72 g/L with an MCV of 68 fL. Which nail changes may be seen in association with this patient's condition?
Your Answer: Koilonychia
Explanation:Koilonychia, known as spoon nails, is a condition of the nails bending inwards, taking the shape of a spoon. This is a strong indication of iron-deficiency anaemia (IDA). The rest of the patient’s symptoms further indicate IDA.
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This question is part of the following fields:
- The Skin
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Question 56
Incorrect
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A 1-day-old baby started having pallor and jaundice. The mother's first child did not have jaundice at birth. On clinical investigations, direct Coombs test is positive. Mother's blood group is A negative. Baby's blood group is O positive. What is the most probable cause of the condition of this new-born?
Your Answer: Formula feed
Correct Answer: Rhesus incompatibility
Explanation:Jaundice in a new-born on the day of delivery is most likely due to Rh incompatibility. This occurs when the mother is Rh-negative and the baby is Rh-positive. Antibodies in the mother against the Rh factor in the baby will destroy the red blood cells in the baby, increasing the bilirubin in the blood. Breast milk jaundice and Galactosemia do not occur immediately after birth, and congenital rubella syndrome and formula feeding does not cause jaundice in babies.
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This question is part of the following fields:
- Immune System
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Question 57
Incorrect
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A 32-year-old Indian male presents to the clinic with fever, cough and an enlarged cervical lymph node. Examination reveals a caseating granuloma in the lymph node. Which of the following is the most likely diagnosis?
Your Answer: Goitre
Correct Answer: TB adenitis
Explanation:Tuberculous lymphadenitis is a chronic, specific granulomatous inflammation of the lymph node with caseation necrosis, caused by infection with Mycobacterium tuberculosis or a related bacteria. The characteristic morphological element is the tuberculous granuloma (caseating tubercle).
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This question is part of the following fields:
- Infectious Diseases
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Question 58
Incorrect
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A 25-year-old man is complaining of respiratory distress and chest pain. Examination reveals distention of neck veins, hypotension, and tachycardia. His breathing sounds on the left side are diminished and absent on the right side. The trachea is also deviated to the left side. What is the next appropriate immediate management?
Your Answer: Left side chest drainage
Correct Answer: Right needle thoracostomy
Explanation:The patient history suggests a tension pneumothorax which is a life-threatening situation in which excess air is introduced into the pleural space surrounding the lung. When there is a significant amount of air trapped in the pleural cavity, the increasing pressure from this abnormal air causes the lung to shrink and collapse, leading to respiratory distress. This pressure also pushes the mediastinum (including the heart and great vessels) away from its central position, e.g. deviated trachea, and diminishing the cardiac output. Tension pneumothoraxes cause chest pain, extreme shortness of breath, respiratory failure, hypoxia, tachycardia, and hypotension. These are definitively managed by insertion of a chest tube. However, in the emergency setting temporizing measures are needed while chest tube materials are being gathered. In these situations, urgent needle thoracostomy (also called needle decompression) is performed.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 59
Correct
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Which of the following bronchodilators is an anticholinergic commonly used in addition to adrenoceptor stimulants?
Your Answer: Oxitropium bromide
Explanation:All of these drugs are anti-asthmatic drugs that work through different pathways. Oxitropium bromide is an anticholinergic drug that is often used with beta agonists to improve their action.
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This question is part of the following fields:
- Pharmacology
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Question 60
Incorrect
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A 48-year-old man is diagnosed with acute myeloid leukaemia. Cytogenetic testing is carried out.
Which one of the following is mostly associated with a poor prognosis?Your Answer: Deletions of chromosome 8
Correct Answer: Deletions of chromosome 5
Explanation:Deletion of part of chromosome 5 or 7 is a poor prognostic feature for acute myeloid leukaemia (AML).
AML is the acute expansion of the myeloid stem line, which may occur as a primary disease or follow the secondary transformation of a myeloproliferative disorder. It is more common over the age of 45 and is characterized by signs and symptoms largely related to bone marrow failure such as anaemia (pallor, lethargy), frequent infections due to neutropenia (although the total leucocyte count may be very high), thrombocytopaenia (bleeding), ostealgia, and splenomegaly.
The disease has poor prognosis if:
1. Age of the patient >60 years
2. >20% blasts seen after the first course of chemotherapy
3. Chromosomal aberration with deletion of part of chromosome 5 or 7.Acute promyelocytic leukaemia (APL) is an aggressive form of AML.
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This question is part of the following fields:
- Haematology & Oncology
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Question 61
Correct
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A 19-year-old previously well male presented with abdominal pain and a reduced level of consciousness. On examination he was drowsy, tachypnoeic and dehydrated with dry mucous membranes. His random blood sugar was 17 mmol/l. Which of the following is the most appropriate next step?
Your Answer: ABG
Explanation:The most probable diagnosis is diabetic ketoacidosis. ABG is mandatory to look for acidosis and correct pH accordingly.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 62
Incorrect
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A 70-year-old man underwent emergency surgery for an acute abdomen. Following surgery, he was noted to be oliguric. Investigations revealed the following: Sodium 121 mmol/L (137-144) Potassium 6.6 mmol/L (3.5-4.9) Chloride 92 mmol/L (95-107) Urea 17.2 mmol/L (2.5-7.5) Creatinine 250 µmol/L (60-110) pH 7.16 (7.36-7.44) Standard bicarbonate 15.6 mmol/L (20-28). What is the calculated anion gap for this patient?
Your Answer: 10 mmol/L
Correct Answer: 20 mmol/L
Explanation:Anion gap is calculated as (Na + K) − (Cl + HCO3). Therefore in this patient, the calculated value is 20 mmol/L. The normal anion gap is between 8-16 mmol/l. The excessive value here reflects the presence of other acidic anions, and in this case with the metabolic acidosis, the constituents may be lactate, etc.
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This question is part of the following fields:
- Renal System
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Question 63
Incorrect
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The following are commonly recognized disease syndromes associated with Clostridium species, except:
Your Answer: gas gangrene
Correct Answer: exfoliative skin rash
Explanation:Clostridium species do not present with an exfoliative skin rash. C. perfringens is a common aetiology in necrotizing infections (gas gangrene) as well as food poisoning, which often also includes diarrhoea. C. difficle causes diarrhoea. C. tetany and C. botulinum have neurotoxins that can lead to paralysis.
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This question is part of the following fields:
- Infectious Diseases
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Question 64
Incorrect
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Which one of the following is least associated with photosensitivity?
Your Answer: Dermatomyositis
Correct Answer: Acute intermittent porphyria
Explanation:Sunlight, especially its ultraviolet radiation component, can cause increased or additional types of damage in predisposed individuals, such as those taking certain phototoxic drugs, or those with certain conditions associated with photosensitivity, including:
– Psoriasis
– Atopic eczema
– Erythema multiforme
– Seborrheic dermatitis
– Autoimmune bullous diseases (immunobullous diseases)
– Mycosis fungoides
– Smith-Lemli-Opitz syndrome
– Porphyria cutanea tarda
Also, many conditions are aggravated by strong light, including:
– Systemic lupus erythematosus
– Sjögren’s syndrome
– Sinear Usher syndrome
– Rosacea
– Dermatomyositis
– Darier’s disease
– Kindler-Weary syndrome
Acute intermittent porphyria (AIP) belongs to the group inborn errors of metabolism and most patients with AIP are not light sensitive. -
This question is part of the following fields:
- The Skin
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Question 65
Incorrect
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A 65-year-old man was seen at autopsy. He had swollen legs and signs of a transudate fluid at his liver. Before passing away, he was treated for bronchitis and TB. What is the most probable cause of the transudate?
Your Answer: Liver cirrhosis
Correct Answer: Cardiac failure
Explanation:The patient most probably experienced congestive hepatopathy and leg oedema due to right sided cardiac failure.
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This question is part of the following fields:
- Cardiovascular System
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Question 66
Incorrect
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A 51-year-old woman admitted to the hospital for 3 days due to haemoptysis developed an ataxic gait, visual problems, and altered state of consciousness. What is the most appropriate management of this patient?
Your Answer: Diazepam
Correct Answer: High potent vitamins
Explanation:Wernicke’s encephalopathy presents with neurological symptoms as a result of biochemical deficits in the central nervous system due to depleted B-vitamin reserves, particularly thiamine (vitamin B1). Classically, Wernicke encephalopathy is characterised by the triad – ophthalmoplegia, ataxia, and confusion. Thiamine treatment should be started immediately and usually continued until clinical improvement ceases.
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This question is part of the following fields:
- Nervous System
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Question 67
Correct
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An 81-year-old male presented to the emergency department following a fall at home. He was diagnosed with osteoporosis about five years ago. He presently complains of significant low back pain.
A lumbar spine X-ray was suggestive of a fractured lumbar vertebra.
A subsequent MRI scan of the lumbosacral spine revealed a new L3 burst fracture with no evidence of cord compression.
A neurosurgical consult was sought and conservative management was planned accordingly in the form of pain control, physiotherapy, and mobilization (as allowed by the pain).
He also has been diagnosed with chronic renal disease (stage IV) with a creatinine clearance of 21 ml/min, he was started on a Buprenorphine patch.
Which of the following opioids would be safest to use for his breakthrough pain?Your Answer: Oxycodone
Explanation:Oxycodone is a safer opioid to use in patients with moderate to end-stage renal failure.
Active metabolites of morphine accumulate in renal failure which means that long-term use is contraindicated in patients with moderate/severe renal failure.
These toxic metabolites can accumulate causing toxicity and risk overdose.
Oxycodone is mainly metabolised in the liver and thus safer to use in patients with moderate to end-stage renal failure with dose reductions.
Adverse effects:
Constipation is the most common overall side effect. Others include: asthenia, dizziness, dry mouth, headache, nausea, pruritus, etc.Medications in renal failure:
Drugs to be avoided in patients with renal failure
Antibiotics: tetracycline, nitrofurantoin
NSAIDs
Lithium
Metformin
Drugs that require dose adjustment:
Most antibiotics including penicillin, cephalosporins, vancomycin, gentamicin, streptomycin
Digoxin, atenolol
Methotrexate
Sulphonylureas
Furosemide
Opioids
Relatively safe drugs:
Antibiotics: erythromycin, rifampicin
Diazepam
Warfarin -
This question is part of the following fields:
- Geriatric Medicine
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Question 68
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: Pretibial myxoedema
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 69
Incorrect
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A 51 year-old teacher presents complaining of numerous falls. He states he has difficulty walking up stairs, and he thinks it is because of his weak legs rather than blackouts. He is hypertensive and has suffered chronic back pain for many years. He has smoked for many years as well and has a chronic smokers cough. Upon examination, he has weakness of hip flexion and particularly knee extension. He is unable to keep his fingers flexed against force, with the right being weaker than the left. There are no sensory abnormalities and reflexes are preserved bilaterally. Which of the following is the most likely diagnosis?
Your Answer: Polymyositis
Correct Answer: Inclusion body myositis
Explanation:The pattern of muscle involvement seen with quadriceps and long-finger flexors is characteristic of inclusion body myositis, an inflammatory myopathy. Polymyositis is likely to cause a predominantly proximal weakness, associated with muscle pain. The signs and symptoms are not consistent with upper cord compression, as there would likely be sensory signs, reflex changes, and possible urinary symptoms. Motor neuron disease cannot be ruled out, but there are no findings of upper motor neuron or bulbar features.
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This question is part of the following fields:
- Nervous System
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Question 70
Incorrect
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A young man presents to the clinic with recurrent episodes of breathlessness. Past medical history reveals recurrent episodes of colicky abdominal pain for the past three years.
On examination, he has a productive cough with foul smelling sputum.
Investigations show: Sputum culture with Heavy growth of Pseudomonas aeruginosa and Haemophilus influenzae.
Chest x-ray: Tramline and ring shadows.
What is his diagnosis?Your Answer:
Correct Answer: Cystic fibrosis
Explanation:Cystic fibrosis (CF) is a multisystemic, autosomal recessive disorder that predominantly affects infants, children, and young adults. CF is the most common life-limiting genetic disorder in whites, with an incidence of 1 case per 3200-3300 new-borns in the United States.
People with CF can have a variety of symptoms, including:
Very salty-tasting skin
Persistent coughing, at times with phlegm
Frequent lung infections including pneumonia or bronchitis
Wheezing or shortness of breath
Poor growth or weight gain in spite of a good appetite
Frequent greasy, bulky stools or difficulty with bowel movements
Male infertilitySigns of bronchiectasis include the tubular shadows; tram tracks, or horizontally oriented bronchi; and the signet-ring sign, which is a vertically oriented bronchus with a luminal airway diameter that is 1.5 times the diameter of the adjacent pulmonary arterial branch.
Bronchiectasis is characterized by parallel, thick, line markings radiating from hila (line tracks) in cylindrical bronchiectasis. Ring shadows represent dilated thick-wall bronchi seen in longitudinal section or on-end or dilated bronchi in varicose bronchiectasis.
Pseudomonas aeruginosa is the key bacterial agent of cystic fibrosis (CF) lung infections, and the most important pathogen in progressive and severe CF lung disease. This opportunistic pathogen can grow and proliferate in patients, and exposure can occur in hospitals and other healthcare settings.
Haemophilus influenzae is regularly involved in chronic lung infections and acute exacerbations of CF patients
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This question is part of the following fields:
- Respiratory System
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SESSION STATS - PERFORMANCE PER SPECIALTY
