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Question 1
Incorrect
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A 75-year-old man was admitted with urinary dribbling and incontinence. Upon examination, there is a palpable mass up to the umbilicus. His clothes smell of ammonia and he is known to be a chronic alcoholic. What is the next most appropriate step?
Your Answer: Suprapubic catheter
Correct Answer: Urethral catheter
Explanation:It is obvious in this case that chronic alcohol use has contributed to the patient’s urinary incontinence which requires a urethral catheter. Suprapubic catheters are usually preferred in cases of acute urinary retention while condom catheters are indicated in less severe cases of urinary incontinence. We would administer antibiotics if we suspected a urinary infection causing the urinary incontinence, but in this case the cause is obvious.
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This question is part of the following fields:
- Renal System
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Question 2
Correct
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A 42-year-old man presented with palpitations and shortness of breath on exertion. On examination his lungs were clear and heart sounds were normal. There was a left sided parasternal heave. His electrocardiogram (ECG) revealed atrial fibrillation with right axis deviation. Echocardiography showed dilated right heart chambers. Left and right heart catheterisation study revealed the following
Inferior vena cava Oxygen saturations 63 %
Superior vena cava Oxygen saturations 59 %
Right atrium Oxygen saturations 77 %
Right ventricle Oxygen saturations 78 %
Pulmonary artery Oxygen saturations 82 %
Arterial saturation Oxygen saturations 98 %
What is the most likely diagnosis from the following answers?Your Answer: Atrial septal defect
Explanation:Right ventricular volume overload is indicated by a parasternal heave and right axis deviation. Oxygen saturation in right atrium is higher than oxygen saturation of the inferior and superior vena cavae. So the most probable diagnosis is atrial septal defect.
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This question is part of the following fields:
- Cardiovascular System
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Question 3
Incorrect
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Which one of the following statements regarding interleukin 1 (IL-1) is true?
Your Answer: It reduces expression of selectin molecules on the endothelium
Correct Answer: It is released mainly by macrophages/monocytes
Explanation:Interleukin 1 alpha and interleukin 1 beta (IL1 alpha and IL1 beta) are cytokines that participate in the regulation of immune responses, inflammatory reactions, and hematopoiesis. It is secreted mainly by macrophages and monocytes and acts as a costimulator of T cell and B cell proliferation.
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This question is part of the following fields:
- Immune System
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Question 4
Incorrect
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A 38-year-old musician presented with a two-day history of sudden-onset occipital headache associated with nausea and vomiting. The next day, his right hand became weak for a few hours. On the same day he had an episode of sensory disturbance in his right upper limb consisting of tingling in his hand that spread up the arm, to his shoulder lasting less than two minutes in total. On the day of admission he had a similar episode of sensory disturbance lasting 30 seconds in total. On examination he had bilateral papilledema, no neck stiffness and an otherwise normal neurological examination. Which of the following is the most likely diagnosis?
Your Answer: Carotid dissection
Correct Answer: Venous sinus thrombosis
Explanation:Cerebral venous sinus thrombosis (CVST) is associated with headache (>90% of cases), seizures, focal weakness (40%) and papilledema (40%), all seen in this patient.
Risk factors for CVST include genetic or acquired prothrombotic disorders, pregnancy, the oral contraceptive pill, vasculitis, malignancy, dehydration and infection. However, there are multiple other associated factors.
Diagnosis is normally confirmed with magnetic resonance venography (MRV). Treatment is with anticoagulation, initially with heparin and subsequently with warfarin. -
This question is part of the following fields:
- Nervous System
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Question 5
Correct
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A 33-year-old Afro-Caribbean gentleman with a 5 year history of HIV infection presents with swollen ankles. He has been treated with highly active antiretroviral therapy (HAART) for 2 years, with partial response.
His plasma creatinine concentration is 358 μmol/l, albumin is 12 g/dl, CD4 count is 35/μl and 24 hour urine protein excretion rate is 6.8 g. Renal ultrasound shows echogenic kidneys 13.5 cm in length.
What would a renal biopsy show?Your Answer: Microcystic tubular dilatation and collapsing FSGS
Explanation:HIV-associated nephropathy (HIVAN) show typical findings of scarring called focal segmental glomerulosclerosis (FSGS) and microcystic tubular dilatation, prominent podocytes, and collapsing capillary loops.
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This question is part of the following fields:
- Renal System
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Question 6
Correct
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A 32-year-old male presents to the emergency after being involved in a horrific fire incident at home with 55% burns over is trunk, back and arms. He has an episode of 300ml of hematemesis which prompts endoscopy. Endoscopy reveals several ulcers in the stomach. How would you manage this patient?
Your Answer: IV PPI
Explanation:Curling’s ulcer is an acute gastric erosion resulting as a complication from severe burns when reduced plasma volume leads to ischemia and cell necrosis (sloughing) of the gastric mucosa. The medical management of patients with stress ulcers is more or less similar to the management of peptic ulcer disease in general. The medication targeting acid peptic disease includes proton pump inhibitors, antihistamines, and ulcer-healing drugs like sucralfate. Patients with overt GI bleeding from ulceration will require endoscopic evaluation and management of the stress ulcers. Endoscopic therapies may include epinephrine injection, electro-cauterization, or clipping of the bleeding vessels. Bleeding ulcers refractory to localized endoscopic treatment may need embolization of the culprit vessel or rarely surgical intervention as a last resort. Surgical interventions are commonly indicated for patients with refractory bleeding despite endoscopic or angiographic treatment or patients with unstable hemodynamics to undergo endoscopic or angiographic procedures. Surgeries are performed as an ultimate life-saving approach.
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This question is part of the following fields:
- Fluids & Electrolytes
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Question 7
Correct
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A baby born a few days earlier is brought into the emergency with complaints of vomiting, constipation and decreased serum potassium. Which of the following is the most probable cause?
Your Answer: Pyloric stenosis: hypokalaemic hypochloraemic metabolic alkalosis
Explanation:In pyloric stenosis a new-born baby presents with a history of vomiting, constipation and deranged electrolytes. Excessive vomiting leads to hypokalaemia. Difficulty in food passing from the stomach to the small intestine causes constipation. Hypokalaemia also causes constipation. None of the other disorders mentioned present with the hypokalaemia, vomiting and constipation triad in a new-born.
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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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A 28-year-old primigravida in her 24th week of pregnancy presented with a history of fast and regular palpitations. There is no history of collapse. On examination she was well, pulse rate was 102 bpm, which was regular and her blood pressure was 110/70 mmHg. Her JVP was not elevated. Heart sounds were normal. ECG showed sinus tachycardia. Which of the following can be expected due to the physiological changes which occur during pregnancy?
Your Answer: Tachycardia
Explanation:The cardiovascular alterations which occur during pregnancy are for the optimal growth and development of the foetus and help to protect the mother from the risks of delivery, such as haemorrhage. The changes are characterized by an increased vascular volume, cardiac output, and heart rate, with a marked fall in vascular resistance and reduction in blood pressure.
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This question is part of the following fields:
- Cardiovascular System
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Question 9
Incorrect
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A 16-year-old boy suffers recurrent episodes of haematuria following a flu-like illness. He is otherwise well. Physical examination is normal. Urinalysis reveals no proteinuria, blood ++, and 2-3 white blood cells/mm3.
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What is the most probable diagnosis?Your Answer: Acute pyelonephritis
Correct Answer: IgA nephropathy
Explanation:IgA nephropathy’s characteristic presentation is haematuria following a non-specific upper respiratory infection as was evident in this case. IgA nephropathy also usually occurs in children and young males, like this patient.
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This question is part of the following fields:
- Renal System
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Question 10
Incorrect
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You are asked to fill the first part of a cremation form. Which of the following would need to be removed prior to cremation?
Your Answer: Hip replacement
Correct Answer: Pacemaker
Explanation:Pacemakers have small electrical parts installed in them that can explode when exposed to extreme heat and pressure.
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This question is part of the following fields:
- Ethical & Legal
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Question 11
Correct
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Which of the following parameters is increased as a result of asthma?
Your Answer: Residual volume
Explanation:In asthma, a reversible increase in residual volume (RV), functional residual capacity (FRC), and total lung capacity (TLC) may occur. There is a fall in FEV1, FVC and gas transfer.
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This question is part of the following fields:
- Respiratory System
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Question 12
Correct
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A 30-year-old male, who is the brother of a patient with hypertrophic cardiomyopathy has come for the screening. Which of the following is the most appropriate method of screening?
Your Answer: Echocardiography
Explanation:12-lead electrocardiography and transthoracic echocardiography are recommended as a screening method for family members of patients with HCM.
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This question is part of the following fields:
- Cardiovascular System
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Question 13
Correct
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A 25-year-old male presented with acute severe central chest pain which radiated backwards between his scapulae. He didn't have difficulty in breathing and the pain wasn't exacerbated by deep inspiration or a change in position. His father had died due to a heart disease when he was small. He also has a cardiac murmur which was never properly investigated. On examination he was tachycardic with a BP of 165/60 mmHg. There was a diastolic murmur at lower left sternal border which is best heard with the patient sitting forward. Which of the following is the most probable cause for his chest pain?
Your Answer: Aortic dissection
Explanation:The most probable diagnosis is Marfan’s syndrome because of a family history of cardiac death and heart murmurs. A characteristic feature is pain which radiates to the back. A wide pulse pressure and a diastolic heart murmur is suggestive of aortic dissection.
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This question is part of the following fields:
- Cardiovascular System
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Question 14
Correct
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An 18-year-old woman in her 30th week of pregnancy is brought to the hospital in altered sensorium. She is taking slow, shallow breaths and her breath has a fruity smell. An arterial blood gas (ABG) shows the presence of ketones. What is the most probable diagnosis?
Your Answer: Diabetic Ketoacidosis (DKA)
Explanation:This a case of gestational diabetes presenting with DKA. It is a serious case that requires immediate intervention. Pregnant diabetics tend to develop DKA on a lower serum glucose level than non-pregnant diabetics. The shortness of breath is a trial to wash the excess CO2 to compensate for the metabolic acidosis seen in the ABG. The fruity smell is acetone excreted through the lungs. The main treatment of this case is proper fluid management and insulin infusion.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 15
Incorrect
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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(9;22)
Correct Answer: t(8;14)
Explanation: -
This question is part of the following fields:
- Haematology & Oncology
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Question 16
Correct
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A 65-year-old man, after suffering from a pathological rib fracture, complains of recurrent infection. Bone marrow aspiration revealed a calcium level of 3.9 mmol/l and alkaline phosphatase level of 160u/l. What type of cell would be found in abundance in the marrow spear?
Your Answer: Plasma cells
Explanation:Multiple myeloma or plasma cell myeloma, is a cancer of plasma cells, responsible for producing antibodies. It often, presents early with no symptoms followed by bone pain and pathological fractures (metastases), raised calcium levels, bleeding, frequent infections, and anaemia. It usually occurs around the age of 61 and is more common in men than women.
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This question is part of the following fields:
- Geriatric Medicine
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Question 17
Correct
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A 40-year-old female presented with pain and whitening of the hands on exposure to cold. She has difficulty in swallowing solid foods so she has started swallowing only liquids. She developed shortness of breath on exertion and, subsequently, at rest. Which of the following is the most likely cause for dysphagia in this patient?
Your Answer: Systemic sclerosis
Explanation:Difficulty in swallowing which improves with liquids is mainly due to an obstructive lesion in oesophagus. But pulmonary involvement (breathlessness on exertion and later on rest) and Raynaud’s phenomena can only be described by systemic sclerosis.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 18
Correct
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A 54-year-old man is found collapsed in the street and is brought to the A&E. The results from the blood tests reveal Calcium = 1.62mmol/l and Albumin = 33 g/l. The man is known to have a history of alcoholic liver disease. Which of the following is the best management regarding his calcium levels?
Your Answer: 10ml of 10% calcium gluconate over 10 minutes
Explanation:Acute, symptomatic hypocalcaemia is treated with 10ml of 10% calcium gluconate over 10 minutes.
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This question is part of the following fields:
- Fluids & Electrolytes
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Question 19
Incorrect
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A 60-year-old female presented with difficulty in breathing. What is the clinical sign that will indicate the presence of established pulmonary hypertension?
Your Answer: Single loud second heart sound
Correct Answer: Raised jugular venous pressure
Explanation:A prominent A wave is observed in the jugular venous pulse and this indicates the presence of established pulmonary hypertension. In addition the pulmonic component of the second heart sound (P2) may be increased and the P2 may demonstrate fixed or paradoxical splitting. The signs of right ventricular failure include a high-pitched systolic murmur of tricuspid regurgitation, hepatomegaly, a pulsatile liver, ascites, and peripheral oedema.
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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 41-year-old gentleman required high doses of intravenous diuretics after his renal transplant for the purposes of fluid management. Soon after administration he developed hearing loss, tinnitus, and vertigo.
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Which diuretic is most likely to have caused this?Your Answer: Furosemide
Explanation:Furosemide is a loop diuretic that is known to have significant ototoxicity side-effects although the mechanism is not fully known.
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This question is part of the following fields:
- Renal System
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Question 21
Incorrect
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Which of the following features is characteristic of immune thrombocytopenic purpura?
Your Answer: Pancytopenia is a recognised complication
Correct Answer: Autoimmune haemolytic anaemia is a recognised association
Explanation:Immune thrombocytopenic purpura (ITP) refers to thrombocytopaenia occurring in the absence of toxic exposure or other diseases associated with low platelets and involves IgG-type antibodies. It is characterised by normal or increased marrow megakaryocytes, shortened platelet survival, and the absence of splenomegaly. Autoimmune haemolytic anaemia (AIHA) occurs commonly in association with ITP. Leukemic transformation, however, does not occur in ITP.
In neonatal ITP, IgG antibodies are passively transferred across the placenta. The infant platelet count may be normal at birth but decreases within 12-24 hours. It is rarely severe enough to induce bleeding diathesis in the infant.
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This question is part of the following fields:
- Haematology & Oncology
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Question 22
Correct
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A 31-year-old female complains of bilateral proximal muscle weakness. There is marked blanching of fingers especially in response to cold weather. Lab results are as follows:
Anti Jo-1: positive
ANA: positive
CK: 2000 U/L
ESR: 60mm/hr
EMG: myopathic changes
Presence of which of the following signifies the worst prognosis?Your Answer: Interstitial lung disease
Explanation:Polymyositis is an inflammatory disorder causing symmetrical, proximal muscle weakness. It is thought to be a T-cell mediated cytotoxic process directed against muscle fibres. It may be idiopathic or associated with connective tissue disorders. It may also be associated with malignancy for example small cell lung carcinoma.
Dermatomyositis is a variant of the disease where skin manifestations are prominent, for example a purple (heliotrope) rash on the cheeks and eyelids.
It typically affects middle-aged, female: male 3:1. Features include proximal muscle weakness +/- tenderness, Raynaud’s phenomenon, respiratory muscle weakness, interstitial lung disease: e.g. fibrosing alveolitis or organising pneumonia, dysphagia, dysphonia. Investigations: elevated creatine kinase, other muscle enzymes (lactate dehydrogenase (LD), aldolase, AST and ALT) are also elevated in 85-95% of patients, EMG, muscle biopsy. Anti-Jo-1 antibodies are seen in pattern of disease associated with lung involvement, Raynaud’s and fever. Interstitial lung disease plays a major role in morbidity and mortality in patients with polymyositis and is considered a major risk factor for premature death in patients with myositis. -
This question is part of the following fields:
- Musculoskeletal System
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Question 23
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 24
Incorrect
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A 62-year-old patient with shortness of breath has a chest x ray, which shows right lower lobe consolidation. Dyspnoea started one week ago. Which of the following would support admission of the patient?
Your Answer: A PaO2 of 9.8 kPa (11-13)
Correct Answer: A respiratory rate of 32/min
Explanation:CURB-65 is a clinical prediction score that has been validated for predicting mortality in community-acquired pneumonia. It is comprised of five features which are given a point if present on the patient.
C=confusion
U=urea >7mmol/L
R=respiratory rate >30/min or more
B=blood pressure (SBP)<90mmHg or (DBP)<60mmHg.
Lastly, the patient gets a point if he/she is 65-year-old or older. The score provides guidance for management:
0-1: Treat as an outpatient
2: Consider a short stay in hospital or watch very closely as an outpatient
3-5: Requires hospitalization with consideration as to whether they need to be in the intensive care unit. -
This question is part of the following fields:
- Respiratory System
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Question 25
Correct
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A 54-year-old female presents with fatigue and xerostomia. Bloods tests reveal the following:
Hb 13.9 g/dl
WBC 6.1 *109/l
Platelets 246 *109/l
Bilirubin 33 µmol/l
ALP 292 u/l
ALT 47 u/l
What is the most likely diagnosis?Your Answer: Primary biliary cirrhosis
Explanation:With a bilirubin of 33, automatically the diagnosis from the choices listed is primary biliary cirrhosis or autoimmune hepatitis, not SLE, mono, or Primary Sjogren’s Syndrome. With autoimmune hepatitis, however, you would not expect such a high bilirubin and would expect very high AST/ALT, which here is just mildly elevated. This makes primary biliary cirrhosis the most likely answer. The classic presentation is itching in a middle-aged woman. The dry mouth is likely due to Sicca Syndrome, which occurs in 70% of cases of PBC, but with these liver function tests, PBC is most the likely answer.
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This question is part of the following fields:
- Hepatobiliary System
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Question 26
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: Disulfiram
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 27
Correct
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A 20-year-old girl is presented to the OPD with her mother. Her mother reports that she eats very large portions of food most of the time, but takes diet pills and remains depressed because she thinks she is overweight. However, on general physical examination, she appears to be very thin and her blood pressure is lower than normal. Investigations reveal that she has hypokalaemia. What is this girl most likely suffering from?
Your Answer: Bulimia nervosa
Explanation:Bulimia nervosa is a condition in which a person is involved in binge eating and then purging in an attempt to stay thin despite eating a lot of food. Frequent vomiting can cause electrolyte imbalance that manifests as hyperkalaemia and may lead to hypotension.
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This question is part of the following fields:
- Gastrointestinal System
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Question 28
Correct
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A 45-year-old female presented with weight loss, night sweats and abdominal pain for 6 months. Abdominal ultrasound scan showed a tubo-ovarian mass. What is the most likely organism, which is responsible for this presentation?
Your Answer: Mycobacterium tuberculosis
Explanation:Constitutional symptoms such as weight loss, evening pyrexia and night sweats are associated with Mycobacterium Tuberculosis (TB). TB can affect any system of the body and should be top in the list of differentials particularly if the patient has a history of contact with a known TB patient.
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This question is part of the following fields:
- Infectious Diseases
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Question 29
Correct
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A 62-year-old software developer with lung cancer is currently taking MST 30 mg bd for pain relief.
What dose of oral morphine solution should he be prescribed for breakthrough pain?Your Answer: 10 mg
Explanation:The total daily morphine dose is 30 x 2 = 60 mg. Therefore, the breakthrough dose should be one-sixth of this, 10 mg.
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This question is part of the following fields:
- Haematology & Oncology
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Question 30
Correct
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A 60-year-old man with type 1 diabetes is brought to the clinic with his wife. He is limping and his wife noticed that his ankle was abnormally-shaped after he stepped out of the shower.
Examination of his right ankle reveals a painless warm swollen joint.
There is crepitus and what appears to be palpable bone debris. X-ray reveals gross joint destruction and apparent dislocation. Joint aspiration fluid shows no microbes.
Investigations:
His CRP and white count are of normal values.
Historical review of HB A1c reveals that it has rarely been below 9%.
What is the most likely diagnosis?Your Answer: Charcot's ankle
Explanation:Charcot arthropathy is a progressive condition of the musculoskeletal system that is characterized by joint dislocations, pathologic fractures, and debilitating deformities. It results in progressive destruction of bone and soft tissues at weight-bearing joints. In its most severe form, it may cause significant disruption of the bony architecture.
Charcot arthropathy can occur at any joint; however, it occurs most commonly in the lower extremity, at the foot and ankle. Diabetes is now considered to be the most common aetiology of Charcot arthropathy. -
This question is part of the following fields:
- Endocrine System & Metabolism
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SESSION STATS - PERFORMANCE PER SPECIALTY
