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Question 1
Correct
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Question 2
Incorrect
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A 70-year-old complains of lower urinary tract symptoms. Which one of the following statements regarding benign prostatic hyperplasia is incorrect?
Your Answer: Side-effects of 5 alpha-reductase inhibitors include ejaculation disorders and gynaecomastia
Correct Answer: Goserelin is licensed for refractory cases
Explanation:Goserelin (Zoladex) is usually prescribed to treat hormone-sensitive cancers of the breast and prostate not for BPH. All other statements are correct.
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This question is part of the following fields:
- Renal System
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Question 3
Incorrect
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A 50-year-old patient was admitted to the hospital for elective herniorrhaphy. Which of the following options will lead to a postponement of his operation?
Your Answer: Systolic BP less than 90mmHg
Correct Answer: Myocardial infarction two months ago
Explanation:Patients with a recent cerebrovascular incident (less than 60 days) are at very high risk of cardiac complications when under general anaesthesia. Complications like MI, heart failure and even death. Elective surgery should be postponed till stabilization of the cardiac condition is achieved.
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This question is part of the following fields:
- Cardiovascular System
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Question 4
Correct
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Which one of the following is the most common type of Hodgkin lymphoma?
Your Answer: Nodular sclerosing
Explanation:The most common type of Hodgkin’s lymphoma (HL) is nodular sclerosing.
HL is a malignant proliferation of lymphocytes characterised by the presence of distinctive giant cells known as Reed-Sternberg cells. It has a bimodal age distribution being most common in the third and seventh decades of life.
According to the histological classification, there are four types of HL:
1. Nodular sclerosing: most common (around 70%), more common in women, associated with lacunar cells, good prognosis
2. Mixed cellularity: Around 20%, associated with a large number of Reed-Sternberg cells, good prognosis
3. Lymphocyte-predominant: Around 5%, Reed-Sternberg cells with nuclei surrounded by a clear space found, best prognosis
4. Lymphocyte-depleted: rare, worst prognosis
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This question is part of the following fields:
- Haematology & Oncology
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Question 5
Correct
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A 30-year-old male presented with palpitations for 1 week. The palpitations were intermittent and lasted a few hours per day. Which of the following is the most appropriate management?
Your Answer: 24 hr ECG
Explanation:Palpitations can be due to many reasons. As palpitations are not constant in this case, a 24 hr ECG is important to isolate these episodes and find any cardiac cause. Drugs depend on the cause for the palpitations.
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This question is part of the following fields:
- Cardiovascular System
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Question 6
Correct
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A 37-year-old woman known with ulcerative colitis is referred with a microcytic anaemia. Blood tests reveal the following results:
Hb 88 g/L (120-160)
WCC 3.6 ×109/L (4-11)
Platelets 222 ×109/L (150-400)
MCV 70 fL (80-96)
Haptoglobins <0.04 g/L (0.13-1.63)
Lactate dehydrogenase 850 U/L (100-250)
Bilirubin 68 µmol/L (1-22)
Alkaline phosphatase 100 U/L (45-105)
ALT 23 U/L (5-40)
Which investigation would confirm the underlying diagnosis?Your Answer: Direct Coombs' test
Explanation:This a case of autoimmune haemolytic anaemia which is a rare complication of the less used treatment, salazopyrine, used for inflammatory bowel disease (IBD). A direct Coombs’ test looks for erythrocytes already coated with antibody, whereas the indirect test is used to detect potential red cell antibody interactions floating around in the blood.
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This question is part of the following fields:
- Gastrointestinal System
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Question 7
Incorrect
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A new blood test developed to screen individuals for cardiac failure was performed on 500 patients. The results were positive for 40 out of 50 patients with echocardiography-established heart failure. However, the test was also positive for 20 patients with no signs of heart failure. What is the positive predictive value of the test?
Your Answer: 0.8
Correct Answer: 0.66
Explanation:Positive predictive value = TP (true positives) / [TP + FP (false positives)] = 40 / (40 + 20) = 0.66
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This question is part of the following fields:
- Evidence Based Medicine
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Question 8
Correct
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A 32-year-old female has had an episode of a severe occipital headache. This is accompanied by vomiting and unconsciousness. She has been taken to the emergency department, where she is conscious and completely alert. Her pulse is normal and no abnormal neurological signs are found. From the list of options, choose the next step in her treatment.
Your Answer: CT brain
Explanation:Severe headaches and LOC can be caused by basilar migraines (but here the patient has no neurological deficit and becomes completely alert when recovering from unconscious periods). In order to diagnose basilar migraines, there needs to be a history of at least two other migraine attacks with an aura. The diagnostic criteria of a basilar migraine are not fulfilled and so the patient must not be discharged without a CT scan (or MRI).
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This question is part of the following fields:
- Nervous System
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Question 9
Incorrect
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A 32-year-old female is diagnosed with SLE based on her complaints of polyarthralgia, mouth ulcers and ANA positivity. Labs reveal normal urinalysis, urea and electrolytes. ESR is 90mm in the first hour. How will you manage this patient?
Your Answer: Prednisolone 30 mg/day
Correct Answer: Hydroxychloroquine 200 mg/day
Explanation:Hydroxychloroquine is used in the management of SLE as it prevents disease progression and has relatively mild side effects, for instance headache, nausea etc. Its use reduces the usage of corticosteroids. It is particularly effective when the disease is less severe and there is no organ involvement. Cyclophosphamide and prednisolone are indicated in cases of renal, neurological and lung involvement.
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This question is part of the following fields:
- Musculoskeletal System
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Question 10
Incorrect
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Regarding Giardia Lamblia which one of the following statements is true?
Your Answer: May be treated with co-trimoxazole (Septrin)
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 11
Incorrect
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A 40-year-old truck operator who smokes one and a half packs of cigarette per day complains of a cough and fever for the last three days. He also has right-sided chest pain when he inhales. On examination he is slightly cyanosed, has a temperature of 38.1°C, a respiratory rate of 39/min, a BP of 104/71 mm/Hg and a pulse rate of 132/min. He has basal crepitations and dullness to percussion at the right lung base.
What could be a probable diagnosis?Your Answer: Mesothelioma
Correct Answer: Bronchopneumonia
Explanation:Bronchopneumonia presents as a patchy consolidation involving one or more lobes, usually the dependent lung zones, a pattern attributable to aspiration of oropharyngeal contents.
Symptoms of bronchopneumonia may be like other types of pneumonia. This condition often begins with flu-like symptoms that can become more severe over a few days. The symptoms include:
– fever
– a cough that brings up mucus
– shortness of breath
– chest pain
– rapid breathing
– sweating
– chills
– headaches
– muscle aches
– pleurisy, or chest pain that results from inflammation due to excessive coughing
– fatigue
– confusion or delirium, especially in older peopleThere are several factors that can increase your risk of developing bronchopneumonia. These include:
– Age: People who are 65 years of age or older, and children who are 2 years or younger, have a higher risk for developing bronchopneumonia and complications from the condition.
– Environmental: People who work in, or often visit, hospital or nursing home facilities have a higher risk for developing bronchopneumonia.
– Lifestyle: Smoking, poor nutrition, and a history of heavy alcohol use can increase your risk for bronchopneumonia.
– Medical conditions: Having certain medical conditions can increase your risk for developing this type of pneumonia. These include: chronic lung disease, such as asthma or chronic obstructive pulmonary disease (COPD), HIV/AIDS, having a weakened immune system due to chemotherapy or the use of immunosuppressive drugs. -
This question is part of the following fields:
- Respiratory System
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Question 12
Correct
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An 80-year-old woman is admitted with a right lower lobe pneumonia. There is consolidation and a moderate sized pleural effusion on the same side. An ultrasound guided pleural fluid aspiration is performed. The appearance of the fluid is clear and is sent off for culture. Whilst awaiting the culture results, which one of the following is the most important factor when determining whether a chest tube should be placed?
Your Answer: pH of the pleural fluid
Explanation:In adult practice, biochemical analysis of pleural fluid plays an important part in the management of pleural effusions. Protein levels or Light’s criteria differentiate exudates from transudates, while infection is indicated by pleural acidosis associated with raised LDH and low glucose levels. In terms of treatment, the pH may even guide the need for tube drainage, suggested by pH <7.2 in an infected effusion, although the absolute protein values are of no value in determining the likelihood of spontaneous resolution or chest drain requirements. pH is therefore the most important factor.
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This question is part of the following fields:
- Respiratory System
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Question 13
Incorrect
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A 28-year-old male was admitted with severe central abdominal pain managed as an acute pancreatitis due to his serum amylase being markedly elevated. He is a known epileptic patient and has been on anti-epileptics. What would be the antiepileptic drug responsible for this clinical presentation?
Your Answer: Lamotrigine
Correct Answer: Sodium valproate/Carbamazepine
Explanation:Both Sodium valproate and Carbamazepine are correct. These drugs can cause drug induced pancreatitis however more cases have been reported with Sodium valproate.
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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 65-year-old male patient is found to have an elevated serum paraprotein level of 35 g/L. Bone marrow aspirate reveals 32% monoclonal plasma cell infiltrate. He has no evidence of anaemia, renal impairment, hypercalcaemia, or lytic lesions.
What should be the next step in management?Your Answer: Observe and monitor
Explanation:The patient is asymptomatic but matches the diagnostic criteria for multiple myeloma (MM). Therefore, the underlying diagnosis of this condition is smouldering multiple myeloma (SMM). SMM is an early precursor to MM. Its treatment is typically to watch and wait.
MM is a neoplasm of the bone marrow plasma cells. Peak incidence is in patients aged 60-70 years.
Clinical features of MM include:
1. Ostealgia, osteoporosis, pathological fractures (typically vertebral), and osteolytic lesions
2. Lethargy
3. Infections
4. Hypercalcaemia
5. Renal failure
6. Other features: amyloidosis e.g. macroglossia, carpal tunnel syndrome; neuropathy; hyperviscosityDiagnosis of MM is based on the confirmation of (a) one major criterion and one minor criterion or (b) three minor criteria in an individual who has signs or symptoms of multiple myeloma.
Major criteria:
1. >30% plasma cells on bone marrow biopsy
2. Monoclonal band of paraprotein on electrophoresis: >35g/L for IgG, 20g/L for IgA, or >1g of light chains excreted in the urine per dayMinor criteria:
1. 10-30% plasma cells on bone marrow biopsy
2. Abnormal monoclonal band but levels less than listed above
3. Lytic bone lesions observed radiographically
4. Immunosuppression -
This question is part of the following fields:
- Haematology & Oncology
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Question 15
Correct
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What is the mechanism of action of sildenafil citrate?
Your Answer: Inhibition of phosphodiesterase V
Explanation:Sildenafil citrate (Viagra) is the first oral drug to be widely approved for the treatment of erectile dysfunction.
It is a potent and selective inhibitor of type-V phosphodiesterase, the primary form of the enzyme found in human penile erectile tissue, thereby preventing the breakdown of cyclic guanosine monophosphate (cGMP), the intracellular second messenger of nitric oxide.Uses:
It is used for the treatment of erectile dysfunction, idiopathic pulmonary hypertension, premature ejaculation, high altitude illness, penile rehabilitation after radical prostatectomy, angina pectoris, and lower urinary tract symptoms.Adverse effects:
Mild headache, flushing, dyspepsia, cyanopsia, back pain, and myalgias – due to a high concentration of PDE11 enzyme in skeletal muscle, which shows significant cross-reactivity with the use of tadalafil.
It can also cause hypotension, dizziness, and rhinitis. -
This question is part of the following fields:
- Pharmacology
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Question 16
Incorrect
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A 42-year-old male arrives at the clinic due to cough and haemoptysis. Examination shows nasal mucosal ulceration. The doctor suspects Wegener's granulomatosis. Which anatomical area would be most commonly involved in this condition?
Your Answer: Kidneys
Correct Answer: Lungs
Explanation:Granulomatosis with polyangiitis (GPA, previously known as Wegener’s granulomatosis) is a systemic vasculitis that affects both small and medium-sized vessels. Patients typically initially suffer from a limited form that may consist of constitutional symptoms and localized manifestations such as chronic sinusitis, rhinitis, otitis media, ocular conditions. In later stages, more serious manifestations may arise, including pulmonary complications and glomerulonephritis, although the skin, eyes, and heart may also be involved but these lesions are less common.
Diagnosis is based on laboratory testing (positive for PR3-ANCA/c-ANCA), imaging, and biopsy of affected organs, which demonstrate necrotizing granulomatous inflammation. GPA is treated with immunosuppressive drugs, typically consisting of glucocorticoids combined with methotrexate, cyclophosphamide, or rituximab. Relapses are common and the following systems are affected: Lower respiratory tract (95% of cases), renal involvement (80% of cases), skin lesions (45% of cases), ocular involvement (45% of cases) and cardiac involvement (33% of cases). -
This question is part of the following fields:
- Musculoskeletal System
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Question 17
Correct
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A 27-year-old woman presents with a history of weight loss and palpitations. Examination reveals unilateral proptosis. She also admits that despite having a healthy appetite she has difficulty putting on weight. What is the most probable diagnosis?
Your Answer: Thyroid-associated ophthalmopathy
Explanation:The patient’s age and symptoms suggest Grave’s disease with thyroid-associated ophthalmopathy. In Grave’s disease, weight loss is noticed regardless of normal eating habits of the patient. Palpitations are also typical and may be confused with a panic attack. Proptosis is usually bilateral, but unilateral is also possible.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 18
Correct
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A 4-year-old child was brought in by his mother with complaints of vesicular eruption over his palms, soles and oral mucosa for the last 5 days. He was slightly febrile. There were no other signs. The most likely causative organism in this case would be?
Your Answer: Coxsackie
Explanation:This patient is most likely suffering from hand, foot mouth disease which is caused by coxsackie virus A16. Its incubation period ranges from 5-7 days and only symptomatic treatment is required.
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This question is part of the following fields:
- The Skin
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Question 19
Incorrect
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During the examination of an elderly confused and non-coherent gentleman who was brought to casualty by a concerned neighbour, you notice that he has bilaterally small pupils, which do not appear to react to light. Under the circumstances, it is difficult to judge their response to accommodation.
Which of the following conditions may not account for the pupillary appearance in this patient?Your Answer: Diabetes mellitus
Correct Answer: Acute alcohol intoxication
Explanation:Acute alcohol intoxication presents with pupillary dilation, thus, this is ruled out in this patient. All the other listed causes present with small pupils bilaterally.
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This question is part of the following fields:
- Nervous System
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Question 20
Correct
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A 28-year-old male was screened for hypertrophic cardiomyopathy (HOCM). His father has passed away recently at the age of 48 and found to have HOCM during post mortem examination. On examination of this patient his BP was 142/84 mmHg and pulse rate was 68 bpm which was regular. There was a mid systolic murmur and a double apex beat. Echocardiography showed a septal wall thickness of 3.3 cm. What is the factor most closely linked to his 20 year risk of sudden cardiac death?
Your Answer: Septal wall thickness of 3.3 cm
Explanation:There are five prognostic factors which indicate poor prognosis in HOCM:
-family history of HOCM-related sudden cardiac death
-unexplained recent syncope
-large left ventricular wall thickness (MLVWT > 30 mm)
-multiple bursts of nsVT on ambulatory electrocardiography
-hypotensive or attenuated blood pressure response to exercise -
This question is part of the following fields:
- Cardiovascular System
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Question 21
Correct
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A 55-year-old man presents to the ED complaining of extreme fatigue. He has a history of Graves disease. On examination, his blood pressure is 103/58 mmHg, pulse 64/min and temperature 36.3ºC.
The following results are obtained:
Na+ 135 mmol/l
K+ 5.4 mmol/l
Urea 5.2 mmol/l
Creatinine 42 umol/l
TSH 3.5 mu/l
Free thyroxine (T4) 12 pmol/l
You arrange for a random cortisol test, however, whilst awaiting the result he becomes unresponsive. In addition to giving intravenous steroids and fluid, what test is urgent to check first given the likely diagnosis?Your Answer: Glucose
Explanation:The patient is most likely to have Addison’s disease as he has a history of autoimmune disease, hyperkalaemia and hypotension.
It is important to keep an Addisonian crisis on the differential in cases of shock, especially since adrenal crisis can be the patient’s first presentation of adrenal insufficiency.
Patients with Addison’s disease are prone to developing hypoglycaemia due to loss of the glucogenic effect of glucocorticoids. Given the sudden deterioration, a glucose level must be checked. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 22
Incorrect
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A 45-year-old male was discharged recently after treatment of bleeding peptic ulcers. 3 days after discharge he was readmitted complaining of acute severe chest pain for the past 1 hour. His ECG showed an acute ST elevation myocardial infarction. His FBC, blood urea, serum electrolytes and serum creatinine were within normal ranges. Faecal occult blood was negative. Which of the following is the most appropriate management for this patient?
Your Answer: Thombolyse with tissue plasminogen activator
Correct Answer: Primary angioplasty
Explanation:The patient has a recent history of bleeding peptic ulcer disease, which is an absolute contraindication for thrombolysis. So he should be offered primary angioplasty.
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This question is part of the following fields:
- Cardiovascular System
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Question 23
Correct
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A 23-year-old patient was involved in a MVA. Clinical examination reveals a fixed dilated pupil and reduced consciousness. Which of the following nerves is most likely damaged?
Your Answer: Oculomotor nerve
Explanation:The oculomotor nerve is the 3rd cranial nerve. When damaged it affects the ocular motility causing mainly ptosis or diplopia. Damage to it can also affect the pupillary functions causing pupil dilation and light reflex impairment.
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This question is part of the following fields:
- Nervous System
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Question 24
Incorrect
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Which one of the following statements is true regarding autosomal recessive polycystic kidney disease?
Your Answer: Is due to a defect on chromosome 16
Correct Answer: May be diagnosed on prenatal ultrasound
Explanation:Autosomal recessive polycystic kidney disease (ARPKD) is less common than ADPKD (dominant form) but can already present with symptoms and be diagnosed on prenatal ultrasound.
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This question is part of the following fields:
- Renal System
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Question 25
Correct
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A 60-year-old patient with hypertension attended his regular clinic. His compliance was poor. His blood pressure was 180/100 mmHg. His pulse rate was 85 bpm which was irregularly irregular. On examination there was bibasal crepitation. No murmurs were heard. What is the most likely cause for these findings?
Your Answer: Left ventricular hypertrophy
Explanation:Left ventricular hypertrophy due to long standing hypertension is the most probable cause. The irregularly irregular pulse was suggestive of atrial fibrillation, which is due to diastolic dysfunction. Poor ventricular filling causes pulmonary congestion which manifests as bibasal crepitations.
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This question is part of the following fields:
- Cardiovascular System
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Question 26
Correct
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A 4-year-old boy is admitted to the hospital after developing hemarthrosis in his right knee whilst playing in the garden.
Following blood results are obtained:
Plts: 220 x 10^9/L
PT: 11 secs
APTT: 76 secs
Factor VIIIc activity: Normal
What is the most likely diagnosis?Your Answer: Haemophilia B
Explanation:A grossly elevated APTT may be caused by heparin therapy, haemophilia, or antiphospholipid syndrome. A normal factor VIIIc activity, however, points towards the diagnosis of haemophilia B, which is the deficiency of factor IX in the 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 due to the deficiency of clotting factor VIII and is more common than haemophilia B, accounting 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 27
Correct
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A 42-year-old female presented with pain in her calves during walking which settled after resting. On examination there were orange colour deposits in the her palmar creases. Her fasting lipid profile showed a total cholesterol of 9.2 mmol/l (<5) and triglycerides of 7.0 mmol/l (<2). Which of the following is the most likely diagnosis?
Your Answer: Type III hyperlipidaemia
Explanation:Palmar xanthomas are found in type III hyperlipoproteinemia. Her total cholesterol level and triglyceride level support the diagnosis.
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This question is part of the following fields:
- Cardiovascular System
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Question 28
Correct
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In an emergency bowel procedure, which among these antibiotics are indicated during anaesthetic induction?
Your Answer: Metronidazole
Explanation:Antibiotic prophylaxis is utilized to avert infection and is based on the degree of contamination involved in the surgical procedure. Operations where the wound is contained with minimal risk of contamination, antibiotic prophylaxis is questionable. In this case there is a high risk of contamination.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 29
Incorrect
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Which one of the following statements regarding epidemiological measures is correct?
Your Answer: Pre-test probability = 1 / incidence
Correct Answer: Cross-sectional surveys can be used to estimate the prevalence of a condition in the population
Explanation:The incidence rate is the number of new cases per population at risk in a given time period. For example, if a population initially contains 1,000 non-diseased persons and 28 develop a condition over two years of observation, the incidence proportion is 28 cases per 1,000 persons per two years, i.e. 2.8% per two years.
Prevalence is the proportion of a particular population found to be affected by a medical condition (typically a disease or a risk factor such as smoking or seat-belt use). It is derived by comparing the number of people found to have the condition with the total number of people studied, and is usually expressed as a fraction, as a percentage, or as the number of cases per 10,000 or 100,000 people.
Incidence should not be confused with prevalence, which is the proportion of cases in the population at a given time rather than rate of occurrence of new cases. Thus, incidence conveys information about the risk of contracting the disease, whereas prevalence indicates how widespread the disease is. -
This question is part of the following fields:
- Evidence Based Medicine
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Question 30
Incorrect
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A 6-year-old boy presented in the emergency department with a cough and knee swelling after falling on the road. He had a non-blanching rash on his buttocks and investigations revealed: PT=13, APTT=71, Hgb=11, WBC=8, Plt=200. Which is the most likely diagnosis?
Your Answer: Von-Willebrand disease
Correct Answer: Haemophilia
Explanation:From the options mentioned here, the closest diagnosis is haemophilia. This is a mixed picture, as a purpuric rash on the buttocks does not correlate with this diagnosis. However, the most appropriate diagnosis is haemophilia.
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This question is part of the following fields:
- Emergency & Critical Care
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SESSION STATS - PERFORMANCE PER SPECIALTY
