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Question 1
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A 56-year-old obese female presents due to moderate pain in her finger joints which occurs mostly at the end of the day which gets better with rest. There is also some associated swelling. On examination, there is enlargement of her distal interphalangeal joints and tenderness to palpation. Which of the following is the most likely diagnosis?
Your Answer: Osteoarthritis
Explanation: -
This question is part of the following fields:
- Musculoskeletal System
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Question 2
Correct
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A 35-year-old chronic smoker complains of pain in the calf while walking. This symptom has been increasing in severity for 4 months. There is a painful ulcer at the base of left first toe, which despite treatment has not improved. Dorsalis pedis and posterior tibial pulses were absent on the same side. What is the most compatible diagnosis of this presentation?
Your Answer: Thromboangitis Obliterans
Explanation:Thromboangitis obliterans or Buerger’s disease is an inflammatory vasculopathy which is characterized by an inflammatory endarteritis and mainly affects small and medium-sized arteries as well as veins of the upper and lower extremities. It is caused by a prothrombotic state and subsequent obstruction of blood vessels. Ischemic pain, features of inflammation along the vein affected, Raynaud’s phenomenon and painful non-healing ulcers are common presentations.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 3
Correct
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Which type of lung cancer is most commonly linked to cavitating lesions?
Your Answer: Squamous cell
Explanation:Squamous-cell carcinoma is the most common histological type of lung cancer to cavitate (82% of cavitary primary lung cancer), followed by adenocarcinoma and large cell carcinoma. Multiple cavitary lesions in primary lung cancer are rare, however, multifocal bronchoalveolar cell carcinoma can occasionally have multiple cavitary lesions. Small cell carcinoma is not known to cavitate.
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This question is part of the following fields:
- Respiratory System
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Question 4
Incorrect
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A 59-year-old scientist is referred to you with a 2-year history of ascending lower limb numbness and, more recently, foot drop. In the last 6 months he has also developed numbness in his fingers. He has a distal reduction to pinprick and relatively preserved muscle power, except for ankle dorsiflexion and hyporeflexia in his legs. The GP has already organised nerve conduction studies and the report is sent along with the patient. Which of the following would be suggestive of an axonal neuropathy?
Your Answer: Reduced conduction velocity
Correct Answer: Reduced compound muscle action potential amplitude
Explanation:Reduced conduction velocity is associated with demyelinating neuropathies. An abnormally slow response is associated with very proximal disease, i.e. radiculopathies. Delayed P100 latency is a feature of performing visual evoked potentials in those with optic nerve disease. Conduction block is usually associated with certain types of demyelinating neuropathy.
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This question is part of the following fields:
- Nervous System
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Question 5
Correct
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Which of the following statements is false regarding the bioavailability of a drug?
Your Answer: The bioavailability of a drug given orally is often affected by the degree of renal elimination
Explanation:Renal elimination of a drug has no role in altering the bioavailability of a drug.
The bioavailability of a drug is the proportion of the drug which reaches systemic circulation.
Mathematically, bioavailability is the AUCoral/AUCiv x 100%, where AUC = area under the concentration-time curve following a single (oral or iv) dose.Other options are true:
By definition, the bioavailability of a drug given intravenously is 100%.
Drugs given orally that undergo high pre-systemic (first-pass) metabolism in the liver or gut wall have a low bioavailability e.g. lidocaine.
Bioavailability is also affected by the degree of absorption from the gut and this can change depending on gut motility and administration of other drugs. -
This question is part of the following fields:
- Pharmacology
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Question 6
Correct
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A west Indian man complains of limb and abdominal pain. He is also anaemic and has frequent infections, which precipitate these symptoms. On examination, his spleen is not palpable and he has a mild jaundice. What is your most probable diagnosis?
Your Answer: Sickle cell disease
Explanation:Sickle cell disease (SCD) and its variants are genetic disorders resulting from the presence of a mutated form of haemoglobin, haemoglobin S (HbS). This leads to a rigid, sickle-like shape of red blood cells under certain circumstances which can result in attacks of pain (sickle cell crisis), anaemia, swelling in the hands and feet, bacterial infections and stroke. Anaemia and jaundice happen due to insufficient healthy red blood cell capacity and increased breakdown of haem groups by the liver.
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This question is part of the following fields:
- Gastrointestinal System
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Question 7
Correct
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A 35-year-old man is referred to the clinic by his GP. He complains of lethargy and tiredness. He has recently been discharged from the hospital after being admitted to the intensive care unit following a motorbike accident.
His thyroid function testing is :
TSH 0.3 IU/l (0.5-4.5)
Free T4 8 pmol/l (9-25)
Free T3 3.1 pmol/l (3.4-7.2)
Which of the following is most likely to be the diagnosis?Your Answer: Sick euthyroid syndrome
Explanation:Euthyroid sick syndrome (also known as nonthyroidal illness syndrome) can be described as abnormal findings on thyroid function tests that occurs in the setting of a nonthyroidal illness (NTI), without pre-existing hypothalamic-pituitary and thyroid gland dysfunction. After recovery from an NTI, these thyroid function test result abnormalities should be completely reversible.
Multiple alterations in serum thyroid function test findings have been recognized in patients with a wide variety of NTIs without evidence of pre-existing thyroid or hypothalamic-pituitary disease. The most prominent alterations are low serum triiodothyronine (T3) and elevated reverse T3 (rT3), leading to the general term low T3 syndrome. Thyroid-stimulating hormone (TSH), thyroxine (T4), free T4 (FT4), and free T4 index (FTI) also are affected in variable degrees based on the severity and duration of the NTI. As the severity of the NTI increases, both serum T3 and T4 levels drop, but they gradually normalize as the patient recovers.
Reverse T3 is used to differentiate between this condition and secondary thyroid failure. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 8
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 9
Incorrect
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A 35-year-old woman is referred to the oncology clinic by a general surgeon. She has undergone mastectomy for carcinoma of the right breast.
Out of the following, which factor is associated with a poor prognosis in patients with breast cancer?Your Answer: Oestrogen receptor-positive tumour
Correct Answer: Young age
Explanation:Poor prognostic factors for breast cancer include:
1. Young age (<40 years)
2. Premenopausal at the time of diagnosis
3. Increased tumour size
4. High-grade tumour
5. Oestrogen and progesterone receptor-negative tumour
6. Positive lymph node status -
This question is part of the following fields:
- Haematology & Oncology
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Question 10
Incorrect
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A 24-year-old male is admitted with worsening shortness of breath with signs of left ventricular failure. He has a known genetic condition.
On examination, there is an ejection systolic murmur loudest over the aortic area radiating to the carotids, bibasal crepitations and pitting oedema to the knees bilaterally. On closer inspection of the patient, you note a wide vermillion border, small spaced teeth and a flat nasal bridge. The patient also has a disinhibited friendly demeanour.
What is the likely precipitating valvular issue?Your Answer: Subvalvular aortic stenosis
Correct Answer: Supravalvular aortic stenosis
Explanation:Supravalvular aortic stenosis, is associated with a condition called William’s syndrome.
William’s syndrome is an inherited neurodevelopmental disorder caused by a microdeletion on chromosome 7. The most common symptoms of Williams syndrome are heart defects and unusual facial features. Other symptoms include failure to gain weight appropriately in infancy (failure to thrive) and low muscle tone. Individuals with Williams syndrome tend to have widely spaced teeth, a long philtrum, and a flattened nasal bridge.
Most individuals with Williams syndrome are highly verbal relative to their IQ, and are overly sociable, having what has been described as a cocktail party type personality. -
This question is part of the following fields:
- Emergency & Critical Care
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Question 11
Correct
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There is a measure of dispersion of a set of data from its mean. Which of following is the best term which can describe the above?
Your Answer: Standard deviation (root mean square deviation)
Explanation:Standard deviation is defined as the measure of dispersion of a set of data from its mean. It measures the absolute variability of a distribution; the higher the dispersion or variability, the greater is the standard deviation and greater will be the magnitude of the deviation of the value from their mean.
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This question is part of the following fields:
- Evidence Based Medicine
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Question 12
Correct
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A 45-year-old female presented in the OPD with complaints of tiredness and lethargy. On examination, her BP was 160/100 mmHg. On lab examination her Na+=142 mmol/L, K+=3.0mmol/L. Which is the most likely diagnosis?
Your Answer: Conn's syndrome
Explanation:In Conn’s syndrome hypokalaemia and hypertension are present due to high levels of aldosterone with normal to high sodium levels. In this disease, the patient presents with hypertension and feelings of tiredness or fatigue.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 13
Incorrect
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A 4-year-old boy admitted with fever for 2 days had a left sided focal fits, which persisted for 4 minutes. There was no history of head injury. On examination, he was drowsy but there were no focal neurological signs. Urine dipstick was negative. What is the investigation of choice that can be done at this stage to arrive at a diagnosis?
Your Answer: CXR
Correct Answer: CSF analysis
Explanation:This presentation could be due to either a meningitis or encephalitis, which are clinically not distinguishable from the given history. Encephalitis is mostly viral and in UK herpes simplex virus is the main cause. Advanced neuro imaging and EEG will help to differentiate them however from the given answers CSF analysis is the most appropriate, provided that intracranial pressure is not raised. CSF analysis will help to differentiate a pyogenic meningitis from other forms of meningitis and encephalitis.
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This question is part of the following fields:
- Infectious Diseases
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Question 14
Correct
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A 57-year-old female arrives at the emergency due to chest pain, shortness of breath and palpitations. ECG is done which shows a supraventricular tachycardia with a heart rate of 220/min. carotid massage fails to bring the heart rate down. How would you manage this patient?
Your Answer: DC shock
Explanation:Synchronized electrical cardioversion may also be used to treat stable ventricular tachycardia (VT) that does not respond to a trial of intravenous medications. Unstable patients with SVT and a pulse are always treated with synchronized cardioversion. The appropriate voltage for cardioverting SVT is 50-100 J. This is what AHA recommends and also SVT converts quite readily with 50-100 J.
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This question is part of the following fields:
- Cardiovascular System
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Question 15
Incorrect
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Regarding the 3rd heart sound, which one of the following statements is correct?
Your Answer: It is lost in constrictive pericarditis
Correct Answer: It may be a normal finding in women up to the age of 50
Explanation:The 3rd heart sound corresponds to early diastolic filling in ventricular relaxation after the closure of the aortic valve. Associated conditions include cardiac failure, constrictive pericarditis and atrial myxomas. It is low pitched and accentuated by inspiration. The 3rd heart sound may arise from ventricular relaxation and it can be seen as a normal finding among children, young adults and women till 50 years of age.
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This question is part of the following fields:
- Cardiovascular System
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Question 16
Incorrect
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Which of the following is not a tumour suppressor gene?
Your Answer: Rb
Correct Answer: myc
Explanation:Myc is a family of regulator genes and proto-oncogenes that code for transcription factors.
A tumor suppressor gene, or antioncogene, is a gene that protects a cell from one step on the path to cancer. When this gene mutates to cause a loss or reduction in its function, the cell can progress to cancer, usually in combination with other genetic changes. Tumor suppressor genes can be grouped into categories including caretaker genes, gatekeeper genes, and landscaper genes; the classification schemes are continually evolving.
Examples include:
Gene Associated cancers
p53 Common to many cancers, Li-Fraumeni syndrome
APC Colorectal cancer
BRCA1 Breast and ovarian cancer
BRCA2 Breast and ovarian cancer
NF1 Neurofibromatosis
Rb Retinoblastoma
WT1 Wilm’s tumour -
This question is part of the following fields:
- Haematology & Oncology
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Question 17
Incorrect
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A 20-year-old boy presented with left hemiscrotal pain and fever for 2 days. He denied any history of trauma. On examination he was febrile. There was redness and tenderness of the left hemiscrotum. Which of the following is the most appropriate management for this patient?
Your Answer: USG of scrotum
Correct Answer: Give antibiotics
Explanation:The history is suggestive of acute Epididymo-orchitis. The treatment option is antibiotics.
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This question is part of the following fields:
- Men's Health
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Question 18
Correct
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A 60-year-old male with no past medical history presented to Casualty with acute chest pain. ST elevation myocardial infarction (STEMI) is diagnosed following an ECG on arrival. He was subsequently successfully thrombolysed. Which of the following combinations of drugs is the most suitable combination for him to be taking 4 weeks after his STEMI?
Your Answer: ACE inhibitor + beta-blocker + statin + aspirin + clopidogrel
Explanation:According to NICE guidelines (2013) all people who have had an acute MI, treatment should be offered with ACE inhibitor, dual antiplatelet therapy (aspirin plus a second antiplatelet agent), beta-blocker and a statin.
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This question is part of the following fields:
- Cardiovascular System
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Question 19
Incorrect
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A 60-year-old man with a history of chronic lymphocytic leukaemia is admitted to the acute medical unit for pneumonia. This is his fourth admission for pneumonia in the past six months.
Which of the following factors is most likely to be responsible?Your Answer: Immature lymphocytes
Correct Answer: Hypogammaglobulinaemia
Explanation:Hypogammaglobulinemia is a complication of chronic lymphocytic leukaemia (CLL) that leads to recurrent infections.
CLL is a type of cancer caused by monoclonal proliferation of well-differentiated lymphocytes, typically B cells (99%). Onset of the disease is usually asymptomatic and later constitutes anorexia, weight loss, bleeding, and recurrent infections. Lymphadenopathy is more marked in CLL than in chronic myelogenous leukaemia (CML).
Investigations to diagnose CLL include blood film and immunophenotyping. Smudge cells (also known as smear cells) seen on the blood film point towards CLL. Complications of the disease include hypogammaglobulinemia leading to recurrent infections, autoimmune haemolytic anaemia in 10-15% of the patients, and transformation to high-grade lymphoma (Richter’s transformation).
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This question is part of the following fields:
- Haematology & Oncology
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Question 20
Correct
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Where is the site of action of spironolactone?
Your Answer: Distal convoluted tubule
Explanation:Spironolactone is an aldosterone antagonist which acts in the distal convoluted tubule. It is a potassium-sparing diuretic that prevents the body from absorbing too much salt and keeps the potassium levels from getting too low. Spironolactone is used to treat heart failure, high blood pressure (hypertension), or hypokalaemia (low potassium levels in the blood).
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This question is part of the following fields:
- Pharmacology
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Question 21
Correct
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A patient with a history of asthma presents with worsening of her symptoms and dyspnoea. She recently started taking a new medicine and she feels it might have aggravated her symptoms.
Which of the following is likely responsible for her symptoms?Your Answer: Timolol eye drops
Explanation:β-blockers are the class of drug most often chosen to treat glaucoma, although other medical therapies are available. Systemic absorption of timolol eye drops can cause unsuspected respiratory impairment and exacerbation of asthma. Physicians should be alert to the possibility of respiratory side-effects of topical therapy with β-blockers. Leukotriene antagonists and salbutamol are used in asthma treatment. HRT and ferrous sulphate do not lead to the exacerbation of asthma.
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This question is part of the following fields:
- Respiratory System
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Question 22
Correct
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Which of the following statements describe the mechanism of fibrates most accurately?
Your Answer: Increased lipoprotein lipase activity via PPAR-alpha
Explanation:The main mechanism of fibrate drugs is activation of gene transcription factors known as PPARs, particularly PPAR-?, which regulate the expression of genes that control lipoprotein metabolism. There are several consequences of PPAR-? activation, which reduce circulating LDL cholesterol and triglycerides and increase HDL cholesterol.
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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 70-year-old male presents with chest pain. His past medical history includes hypertension and angina. He continues to smoke about 20 cigarettes per day despite being advised about lifestyle modifications.
Blood investigations obtained in the emergency department show:
Na+: 133 mmol/l
K+: 3.3 mmol/l
Urea: 4.5 mmol/l
Creatinine: 90 μmol/l
Which among the following is the most likely explanation for the abnormalities seen in the above investigations?Your Answer: Bendroflumethiazide therapy
Explanation:The blood investigations in this patient reveal hyponatremia as well as hypokalaemia. Among the options provided, Bendroflumethiazide therapy can cause the above presentation with the electrolyte disturbances.
Note:
– Spironolactone is a potassium-sparing diuretic that is associated with hyperkalaemia.
– Enalapril therapy can cause side effects of dizziness, hypotension, cough, and rarely a rash.
– Felodipine therapy can cause side effects of dizziness, headache, cough, and palpitations. -
This question is part of the following fields:
- Emergency & Critical Care
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Question 24
Incorrect
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A 70-year-old male patient presented with chronic congestive heart failure. Which of the following is the most important factor to consider when prescribing drugs for this patient?
Your Answer: Loop diuretic administration would result in a decrease in mortality
Correct Answer: Administration of a B-blocker reduces the time spent in hospital
Explanation:It is proven that spironolactone has survival benefits and loop diuretics only give symptomatic relief. Beta blockers are however, known to improve exercise tolerance, left ventricular function and reduce symptoms. They also reduce the mortality associated with heart failure. So administration of beta blockers will reduce the time spent in hospital by improving symptoms.
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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 30-year-old male was brought in with a history of a stab injury to left chest. He was complaining of chest pain. On examination he was tachycardic, hypotensive and had an elevated JVP, pulsus paradoxus and muffled heart sounds. Respiratory examination was unremarkable. Which of the following is most probable diagnosis?
Your Answer: Cardiac tamponade
Explanation:Becks triad (hypotension, elevated systemic venous pressure, often with jugular venous distention and muffled heart sounds) is a characteristic collection of clinical findings found in cardiac tamponade. Pulsus paradoxus is also associated with it. The history and clinical findings in this scenario are compatible with the diagnosis of cardica tamponade. The normal respiratory examination excludes tension pneumothorax.
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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 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: 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 27
Correct
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A 21 year-old software developer undergoes a planned lumbar puncture (LP) as part of a neurological investigation for possible multiple sclerosis. During the consent process, she expresses concern about a post-LP headache. What is the mechanism of post-LP headaches?
Your Answer: Leaking cerebrospinal fluid from the dura
Explanation:Leaking of cerebrospinal fluid from the dura is the most likely explanation for post-lumbar puncture headaches. It is thought that ongoing leak of cerebrospinal fluid (CSF) through the puncture site causes ongoing CSF loss, leading to low pressure. A post-LP headache is typically frontal or occipital and occurs within three days. It is normally associated with worsening on standing and improvement when lying down. Treatment in severe cases includes an epidural blood patch, but most resolve on their own.
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This question is part of the following fields:
- Nervous System
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Question 28
Incorrect
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A 16-year-old girl comes to clinic complaining of primary amenorrhoea, despite having developed secondary sexual characteristics at 11 years of age.
On examination, she has well-developed breasts and small bilateral groin swellings.
What is the most likely diagnosis?Your Answer: Congenital adrenal hyperplasia
Correct Answer: Complete androgen insensitivity syndrome
Explanation:Androgen insensitivity syndrome (AIS), previously referred to as testicular feminization, is an X-linked disorder in which the patients are genotypically male (possessing and X and Y chromosome) and phenotypically female. This disorder is rare, with reported incidences from 1 in 20,000 to 1 in 60,000 live male births, and is the result of a missing gene on the X chromosome that is responsible for the cytoplasmic or nuclear testosterone receptor. In its absence, the gonad, which is a testis, produces normal amounts of testosterone; however, the end tissues are unable to respond due to the deficient receptors leading to the external genitalia developing in a female fashion. Anti-mullerian hormone, which is produced by the testis, is normal in these patients, leading to regression of the Mullerian duct. Wolffian duct development, which depends on testosterone, does not occur as the ducts lack the receptors.
The cumulative effect is a genotypic male with normal external female genitalia (without pubic or axillary hair), no menses, normal breast development, short or absent vagina, no internal sex organs, and the presence of testis. Frequently, these patients have bilateral inguinal hernias in childhood, and their presence should arouse suspicion of the diagnosis. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 29
Incorrect
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A 20-year-old man presents with an acute exacerbation of asthma associated with a chest infection. He is unable to complete a sentence and his peak flow rate was 34% of his normal level. He is treated with high-flow oxygen, nebulised bronchodilators, and oral corticosteroids for three days, but his condition has not improved.
Which of the following intravenous treatments would be the best option for this patient?Your Answer: Aminophylline
Correct Answer: Magnesium
Explanation:A single dose of intravenous magnesium sulphate is safe and may improve lung function and reduce intubation rates in patients with acute severe asthma. Intravenous magnesium sulphate may also reduce hospital admissions in adults with acute asthma who have had little or no response to standard treatment.
Consider giving a single dose of intravenous magnesium sulphate to patients with acute severe asthma (PEF <50% best or predicted) who have not had a good initial response to inhaled bronchodilator therapy. Magnesium sulphate (1.2-2 g IV infusion over 20 minutes) should only be used following consultation with senior medical staff.
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This question is part of the following fields:
- Respiratory System
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Question 30
Incorrect
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A 28-year-old man is investigated for cervical lymphadenopathy. Lymph node biopsy reveals nodular sclerosing Hodgkin lymphoma.
Which one of the following factors is associated with a poor prognosis?Your Answer: Mediastinal involvement
Correct Answer: Night sweats
Explanation: -
This question is part of the following fields:
- Haematology & Oncology
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SESSION STATS - PERFORMANCE PER SPECIALTY
