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Question 1
Incorrect
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A 68-year-old woman with contralateral hemisensory loss presents with severe burning pain in this area. In which of the following areas has arterial occlusion most probably occurred?
Your Answer: Posterior inferior cerebellar artery
Correct Answer: Thalamogeniculate artery
Explanation:The woman’s clinical evolution suggests that there was a thalamic stroke in the contralateral hemisphere. The artery most likely affected is the thalamogeniculate artery. Sensory loss is usually unilateral and presents at the opposite side of the brain lesion. This kind of stroke can result in severe burning pain which is responsive to tricyclics.
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This question is part of the following fields:
- Nervous System
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Question 2
Correct
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An 85-year-old elderly male presents with complaint of worsening breathlessness over the last 2 years. He has a longstanding history of COPD and currently takes salbutamol, ipratropium, salmeterol, beclomethasone and theophylline. FEV1 comes out to be less than 30%. What will be the most suitable next step in the management of this patient?
Your Answer: Assessment for long term O2 therapy
Explanation:Long-term oxygen therapy (LTOT) is the cornerstone mode of treatment in patients with severe chronic obstructive pulmonary disease (COPD) associated with resting hypoxaemia. When appropriately prescribed and correctly used, LTOT has clearly been shown to improve survival in hypoxemic COPD patients. Requirements to proceed to LTOT is the patient should be stable and on appropriate optimum therapy (as in given case) and having stopped smoking tobacco. The patient should be shown to have a PaO2 of less than 7.3 kPa and/or a PaCO2 of greater than 6 kPa on two occasions at least 3 weeks apart. FEV1 should be less than 1.5 litres, and there should be a less than 15% improvement in FEV1 after bronchodilators. Patients with a PaO2 between 7.3 and 8 kPa who have polycythaemia, right heart failure or pulmonary hypertension may benefit from LTOT.
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This question is part of the following fields:
- Respiratory System
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Question 3
Incorrect
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A 32-year-old man presents with progressive central abdominal pain and vomiting associated with significant weight loss (five stone in 3 months).He gives a history of binge drinking and depression, and smokes twenty cigarettes per day. Because eating provokes abdominal pain and vomiting, he has eaten virtually nothing for a month. CT scanning of his abdomen showed a normal pancreas but dilated loops of small bowel with a possible terminal ileal stricture. His albumin level was 20 and C-reactive protein level was 50. Which statement is NOT true?
Your Answer: Chronic pancreatitis is very unlikely in view of the normal CT
Correct Answer: Infliximab should be prescribed as soon as possible
Explanation:Stricturing is associated with Crohn’s disease, and elevated CRP supports this diagnosis in this patient, as well. Infliximab should not yet be started. Acute treatment is steroids (of a flare) however this man needs surgery. Although surgery should be avoided if at all possible in Crohn’s disease, and minimal surgery should occur (resecting as little as possible, given possible need for future resections), including possible stricturoplasty instead of resection. Chronic pancreatitis is unlikely given it would not cause stricture. Patients undergoing surgery should always have informed consent, which always includes risk of a stoma for any bowel surgery. Given the amount of weight he has lost he is at significant risk for refeeding syndrome, which can cause hypokalaemia, hypophosphatemia and hypomagnesemia.
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This question is part of the following fields:
- Gastrointestinal System
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Question 4
Correct
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All of the following are true regarding the management of thyroid diseases during pregnancy, except?
Your Answer: Block-and-replace is preferable in pregnancy compared to antithyroid drug titration
Explanation: -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 5
Incorrect
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A 71-year-old female presents for investigation of fatigue and weight loss.
Investigations reveal:
Haemoglobin 9.0 g/dL (11.5-16.5)
White cell count 2.0 x109/L (4-11 x109)
Platelet count 250 x109/L (150-400 x109)
Total protein 74 g/L (61-76)
Albumin 28 g/L (37-49)
Urea 16 mmol/L (2.5-7.5)
Creatinine 250 mol/L (60-110)
Plasma glucose 6.5 mmol/L (3.0-6.0)
Urine dipstick analysis: Protein+ & blood+
Renal ultrasound: Normal
Which one of the following investigations would be most appropriate for this patient?Your Answer: 24 hour urinary protein estimation
Correct Answer: Plasma protein electrophoresis
Explanation:This patient’s symptoms of anaemia, leukopenia, and elevated non-albumin protein concentration with fatigue and weight loss, point to myeloma. Thus plasma protein electrophoresis or Serum Protein Electrophoresis (SPE) is indicated when there is suspicion of myeloma.
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This question is part of the following fields:
- Renal System
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Question 6
Incorrect
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A 57-year-old homeless man presents with fever and a productive cough which has green sputum with streaks of blood. A chest x-ray reveals consolidation in the right upper lobe with evidence of cavitation. He is a known alcoholic.
What is the most likely causative agent?Your Answer: Streptococcus Pneumoniae
Correct Answer: Klebsiella Pneumoniae
Explanation:Infection with Klebsiella organisms occurs in the lungs, where they cause destructive changes. Necrosis, inflammation, and haemorrhage occur within lung tissue, sometimes producing a thick, bloody, mucoid sputum described as currant jelly sputum.
The illness typically affects middle-aged and older men with debilitating diseases such as alcoholism, diabetes, or chronic bronchopulmonary disease. An increased tendency exists toward abscess formation, cavitation, empyema, and pleural adhesions. -
This question is part of the following fields:
- Respiratory System
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Question 7
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 8
Correct
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A 30-year-old man presented with polydipsia and polyuria for the last two years.
Investigations reveal:
Serum urea 9.5 mmol/L (2.5-7.5)
Serum creatinine 108 mol/L (60-110)
Serum corrected calcium 2.9 mmol/L (2.2-2.6)
Serum phosphate 0.7 mmol/L (0.8-1.4)
Plasma parathyroid hormone 6.5 pmol/L (0.9-5.4)
Which of the following is directly responsible for the increase in intestinal calcium absorption?Your Answer: 1,25 Dihydroxy vitamin D
Explanation:This patient has hypercalcaemia due to hyperparathyroidism. However, the intestinal absorption of calcium is mainly controlled by 1,25 dihydroxy-vitamin D. Under the influence of calcitriol (active form of vitamin D), intestinal epithelial cells increase their synthesis of calbindin (calcium-binding carrier protein) necessary for active calcium ion absorption.
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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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A 28-year-old female presents to her GP with joint pain , fever, a butterfly rash and fatigue. She has marked peripheral oedema. She is found to be hypertensive, in acute renal failure, low albumin levels and proteinuria.
A renal biopsy is performed and reveals focal glomerulonephritis with subendothelial and mesangial immune deposits.
What is the most likely diagnosis?Your Answer: Lupus nephritis class I
Correct Answer: Lupus nephritis Class III
Explanation:This case presents with characteristic symptoms of SLE and with her renal biopsy results of focal glomerulonephritis, this is clearly Class III SLE.
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This question is part of the following fields:
- Renal System
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Question 10
Correct
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A girl suffered full thickness circumferential burn to her right arm. What is best step in management?
Your Answer: Escharotomy
Explanation:An escharotomy is a surgical procedure used to treat full-thickness (third-degree) circumferential burns. In full-thickness burns, both the epidermis and the dermis are destroyed along with sensory nerves in the dermis. The tough leathery tissue remaining after a full-thickness burn has been termed eschar.
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This question is part of the following fields:
- The Skin
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Question 11
Correct
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Which of the following measurements is a poor prognostic factor in patients suffering from pneumonia?
Your Answer: Respiratory rate 35/min
Explanation:CURB Pneumonia Severity Score estimates the mortality of community-acquired pneumonia to help determine inpatient vs. outpatient treatment.
Select Criteria:
Confusion (abbreviated Mental Test Score <=8) (1 point)
Urea (BUN > 19 mg/dL or 7 mmol/L) (1 point)
Respiratory Rate > 30 per minute (1 point)
Blood Pressure: diastolic < 60 or systolic < 90 mmHg (1 point) The CURB-65 scores range from 0 to 5. Clinical management decisions can be made based on the score:
Score Risk Disposition
0 or 1 – 1.5% mortality – Outpatient care
2 – 9.2% mortality – Inpatient vs. observation admission
> 3 – 22% mortality – Inpatient admission with consideration for ICU admission with score of 4 or 5 -
This question is part of the following fields:
- Respiratory System
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Question 12
Correct
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Which one of the following is the most common cause of hypothyroidism in the UK?
Your Answer: Hashimoto's thyroiditis
Explanation:Hashimoto thyroiditis is the most common cause of hypothyroidism in developed countries. In contrast, worldwide, the most common cause of hypothyroidism is an inadequate dietary intake of iodine. This disease is also known as chronic autoimmune thyroiditis and chronic lymphocytic thyroiditis.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 13
Correct
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A 48-year-old man is diagnosed with diffuse large B-cell lymphoma and is started on chemotherapy. Two days following his first treatment session, he presents to the A&E with nausea, vomiting, and myalgia. On examination, he appears clinically dehydrated. A diagnosis of tumour lysis syndrome (TLS) is suspected.
Which of the following would be consistent with the diagnosis of TLS?Your Answer: Low corrected calcium
Explanation:Out of the aforementioned markers, low corrected calcium is the only biochemistry result consistent with the diagnosis. All of the other markers are elevated in TLS.
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. As phosphate precipitates calcium, the serum concentration of calcium becomes low. 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.
Patients at high risk of TLS should be given IV rasburicase or IV allopurinol immediately prior to and during the first few days of chemotherapy. Rasburicase is a recombinant version of urate oxidase which is an enzyme that metabolizes uric acid to allantoin. Allantoin is much more water soluble than uric acid and is therefore more easily excreted by the kidneys. Patients in lower-risk groups
should be given oral allopurinol during cycles of chemotherapy in an attempt to avoid the condition.TLS is graded according to the Cairo-Bishop scoring system as:
1. Laboratory tumour lysis syndrome
2. Clinical tumour lysis syndrome -
This question is part of the following fields:
- Haematology & Oncology
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Question 14
Correct
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A woman presents having overdosed on Imipramine. Which investigation should be done immediately?
Your Answer: ECG
Explanation:Imipramine is a NSRI tricyclic antidepressant. It has a narrow therapeutic index . It might cause tachyarrhythmia and ECG changes.
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This question is part of the following fields:
- Pharmacology
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Question 15
Correct
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A 35-year-old female with chronic pelvic pain, was recently diagnosed with PID. She was prescribed doxycycline. After 2 days she returned with complaints of abdominal bloating, nausea and regurgitation. Which of the following advice should be given to her?
Your Answer: Take Doxycycline after meals
Explanation:Doxycycline is known to cause dyspeptic symptoms. So advising to take Doxycycline after meals is important. Taking with meals or adding an antacid is not advised, as both will cause reduction in drug absorption.
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This question is part of the following fields:
- Pharmacology
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Question 16
Incorrect
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A 33-year-old female presents with dyspnoea, myalgia, arthralgia and a skin rash. The presence of which of the following antibodies would be the most specific for SLE?
Your Answer: ANA
Correct Answer: Anti-Sm
Explanation:Anti-Sm antibodies are essential for diagnosis of SLE, especially in anti-dsDNA-negative patients. ANA are also found in 95% of the patients with SLE but they may also occur with other conditions like Juvenile inflammatory arthritis, chronic activity hepatitis, and Sjogren’s syndrome. Anti-Ro, although also found with SLE are more characteristic of Sjogren Syndrome. RF is usually associated with rheumatoid arthritis and cANCA with Wegener’s granulomatosis, Churg Strauss, and microscopic polyangiitis.
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This question is part of the following fields:
- Musculoskeletal System
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Question 17
Incorrect
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A 51-year-old real estate agent takes hydrocortisone 20mg in the mornings and 5mg at night for Addison's disease. The endocrinology consultant would like her to take prednisolone instead.
What dose of prednisolone should be started?Your Answer: 10 mg
Correct Answer: 7 mg
Explanation:1mg Prednisolone = 4mg hydrocortisone, so the actual equivalent daily dose is 7mg.
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This question is part of the following fields:
- Pharmacology
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Question 18
Incorrect
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A 45-year-old appears at the OPD with symptoms of persistent cough and purulent sputum. He is a chronic smoker and had measles in the past. Upon auscultation, inspiratory crepitation and finger clubbing are noted. What is the single most likely diagnosis?
Your Answer: COPD
Correct Answer: Bronchiectasis
Explanation:A history of measles, whooping cough, or other severe lung infections like tuberculosis (TB) and pneumonia can lead to airway damage and possibly bronchiectasis.
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This question is part of the following fields:
- Respiratory System
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Question 19
Correct
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A 74-year-old retired judge who is known to have Alzheimer's disease is examined in clinic. His latest Mini Mental State Examination (MMSE) score is 18 out of 30. Which of the following is the most appropriate treatment option?
Your Answer: Supportive care + donepezil
Explanation:NICE now recommends the three acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) as options for managing mild to moderate Alzheimer’s disease. Memantine is reserved for patients with moderate to severe Alzheimer’s.
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This question is part of the following fields:
- Nervous System
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Question 20
Incorrect
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A 20-year-old pregnant female in her first trimester met a child with chickenpox. She was investigated for the varicella antibody, which came back negative. She visited her GP. Which of the following measures is the most appropriate one?
Your Answer: Reassurance
Correct Answer: Ig
Explanation:After the exposure to chickenpox while pregnant, even if the patient is negative for antibodies she requires immunoglobulin to prevent further issues.
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This question is part of the following fields:
- Infectious Diseases
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Question 21
Incorrect
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A 65-year-old man with a history of type 2 diabetes comes to the clinic for review. His HbA1c is elevated at 64 mmol/mol despite taking 1g of metformin BD. On examination, his blood pressure is 142/88 mmHg, his pulse is 82 beats per minute and regular. His BMI is 33 kg/m². A decision is made to start him on dapagliflozin. Which of the following would you expect on starting therapy?
Your Answer: Hypoglycaemia
Correct Answer: Increased total cholesterol
Explanation:Dapagliflozin works by inhibiting sodium glucose cotransporter 2 (SGLT2) and blocking resorption of glucose in the kidney, leading to an increase in urinary glucose excretion and lowering of both plasma glucose levels and body weight.
All studies with SGLT2 inhibitors have found significant reductions in BP, with greater reductions seen in systolic (1.66 to 6.9mmHg) than diastolic (0.88 to 3.5mmHg) BP.
While some trials have shown no change in lipid parameters, others have shown a modest but statistically significant increase in both HDL and LDL cholesterol with no effect on triglycerides or the LDL/HDL ratio. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 22
Correct
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A 74-year-old woman referred by her GP because of increasing weight loss, early satiety and increasing anorexia. She admits to 2 or 3 episodes of vomiting blood. The GP feels an epigastric mass.
There is both a microcytic anaemia and abnormal liver enzymes. Her past history, which may be of importance, includes excess consumption of sherry and spirits, and a 30 pack-year smoking history.
Which diagnosis fits best with this clinical picture?Your Answer: Gastric carcinoma
Explanation:With a clinical history of weight loss, smoking, drinking alcohol, and hematemesis, the most likely answer is gastric carcinoma (also a mass). Based on symptomatology alone this is more likely than gastric lymphoma, as she has many risk factors for adenocarcinoma and/or squamous cell carcinoma. Helicobacter gastritis would not likely present with the severity of symptoms, neither would benign gastric ulcers.
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This question is part of the following fields:
- Gastrointestinal System
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Question 23
Correct
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A 56-year-old woman taking procainamide develops drug induced erythematosus. Which of the following features is the most characteristic of this condition?
Your Answer: It may occur with chlorpromazine
Explanation:Drug induced lupus is usually positive for antinuclear and antihistone antibodies, typically without renal or neurologic involvement. However, pulmonary involvement is common. Drugs that can induce lupus include isoniazid, hydralazine, procainamide, chlorpromazine, and other anticonvulsants.
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This question is part of the following fields:
- Musculoskeletal System
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Question 24
Incorrect
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A diabetic 50-year-old male presented in the emergency room with ischaemic gangrene of the lower leg, ulceration over the medial malleolus and infection spreading proximally. Which of the following types of amputation is most suitable in this patient?
Your Answer: Above knee amputation
Correct Answer: Below knee amputation
Explanation:The type of amputation depends on the degree of gangrene, ischaemia and the extent of involvement of the foot, leg, knee etc. In this case, below-knee amputation is the most appropriate choice.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 25
Correct
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A 75-year-old man was brought to the clinic by his wife because lately he has lost interest in activities he previously enjoyed. His wife is worried and claims he's generally withdrawn. What would exclude depression in favour of dementia?
Your Answer: Urinary incontinence
Explanation:Urinary incontinence is not a usual symptom of depression. A depressed patient is usually capable of maintaining control of his body sphincters. In dementia, however, urinary incontinence is an important and late symptom of the disease, non-related to any urinary tract pathology. It is rather related to the cognitive impairment caused by dementia.
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This question is part of the following fields:
- Geriatric Medicine
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Question 26
Incorrect
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Which of the following features occurs very less frequently with drug induced lupus?
Your Answer: Pleurisy
Correct Answer: Glomerulonephritis
Explanation:Drug induced lupus typically presents with pulmonary involvement and no renal or neurological involvement. Hence glomerulonephritis would be highly unlikely in this case. Rash and arthralgias are classic presentations. Pleurisy can be present as pulmonary involvement may occur with DILE.
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This question is part of the following fields:
- Musculoskeletal System
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Question 27
Correct
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A 57-year-old female presented to the cardiology centre with a history of chest tightness for a few hours, accompanied by pain radiating to the left side of the shoulder and neck. ECG was normal. What is the next best investigation for this patient?
Your Answer: Cardiac enzymes
Explanation:This patient’s symptoms of angina radiating to the neck and shoulders gives a strong suspicion of MI. Cardiac enzymes such as troponins are highly specific and sensitive for a heart attack.
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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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A 23-year-old woman presents with hirsutism and oligomenorrhea for the last five years. She is very anxious about her irregular menses and worried as her mother was diagnosed with uterine cancer recently. She is a lawyer and does not want to conceive, at least for the next couple of years.
The examination is essentially normal except for coarse dark hair being noticed under her chin and over her lower back.
Investigations done during the follicular phase:
Serum androstenedione 10.1 nmol/l (0.6-8.8)
Serum dehydroepiandrosterone sulphate 11.6 ىmol/l (2-10)
Serum 17-hydroxyprogesterone 5.6 nmol/l (1-10)
Serum oestradiol 220 pmol/l (200-400)
Serum testosterone 3.6 nmol/l (0.5-3)
Serum sex hormone binding protein 32 nmol/l (40-137)
Plasma luteinising hormone 3.3 U/l (2.5-10)
Plasma follicle-stimulating hormone 3.6 U/l (2.5-10)
What is the most appropriate treatment?Your Answer: Combined OCP
Explanation:This patient has polycystic ovarian syndrome (PCOS). Medical management of PCOS is aimed at the treatment of metabolic derangements, anovulation, hirsutism, and menstrual irregularity.
First-line medical therapy usually consists of an oral contraceptive to induce regular menses. The contraceptive not only inhibits ovarian androgen production but also increases sex hormone-binding globulin (SHBG) production. The American College of Obstetricians and Gynaecologists (ACOG) recommends the use of combination low-dose hormonal contraceptive agents for long-term management of menstrual dysfunction.
If symptoms such as hirsutism are not sufficiently alleviated, an androgen-blocking agent may be added. Pregnancy should be excluded before therapy with oral contraceptives or androgen-blocking agents are started.
First-line treatment for ovulation induction when fertility is desired is clomiphene citrate. Second-line strategies may be equally effective in infertile women with clomiphene citrate-resistant PCOS. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 29
Incorrect
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An elderly man presents with fever of 38°C and a very severe headache. His BP is 85/50 mm Hg. He has neck stiffness and photophobia. What is the most appropriate management?
Your Answer: CT head and Lumbar puncture
Correct Answer: CT head
Explanation:In elderly patients, symptoms suggestive of meningitis could be due to an intracranial mass lesion (such as abscess, tumour or an intracerebral haematoma). Therefore elderly patients are increased risk of cerebral herniation from an LP. A CT head should be done before an LP to exclude a mass lesion.
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This question is part of the following fields:
- Geriatric Medicine
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Question 30
Incorrect
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A 43-year-old police officer is admitted with a history of unsteadiness and slurring of speech. This has worsened over a period of three months. He complains of a tremor affecting his right hand and diplopia on right lateral gaze. He smokes 30 cigarettes a day and takes regular diclofenac for his arthritis. On examination, he is dysarthric and feels nauseated. Fundoscopy is normal, however there is marked horizontal nystagmus and evidence of a right VI nerve palsy. There also appears to be some mild facial weakness on the right side. Upon conducting Weber's test, a louder tone is heard in the left ear. On conducting the Rinne test, both ears are normal. On examination of the upper limb, there is a right intention tremor and dysdiadochokinesis. Tone, power and reflexes are normal. On examination of the lower limb, tone, power and reflexes are normal, however he appears to walk with a broad-based gait and is leaning to the right.
Lumbar puncture:
Opening pressure 13 cm H20 (5-18)
Protein 0.67 g/l (0.15-0.45)
WCC 3 cells/ml (<5)
Red cell count (RCC) 2 cells/ml (<5)
Glucose 3.2 mmol/l (3.3-4.4)
Blood glucose 5.8 mmol/l (3.0-6.0)
Oligoclonal bands Present
Serum oligoclonal bands Present
Magnetic resonance scan shows a calcified lesion broadly attached to the petrous part of the temporal bone. In view of the above history and findings, what is the likely cause of this patient's symptoms?Your Answer: Primary progressive multiple sclerosis
Correct Answer: Meningioma of the cerebellar pontine angle
Explanation:This patient has a combination of right cerebellar dysfunction with right-sided cranial nerve palsies (VI, VII, and VIII). The magnetic resonance imaging (MRI) shows a calcified meningioma within the right cerebellar pontine area, which would account for these findings. The cerebrospinal fluid (CSF) analysis shows oligoclonal bands, however, these are matched in the serum, which reflects a systemic inflammatory response from his rheumatoid arthritis.
The MRI scan and CSF analysis would not be consistent with progressive multiple sclerosis. The progressive nature of her symptoms would be against a diagnosis of brainstem infarct, and one would expect more pyramidal signs in the peripheral nervous system.
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This question is part of the following fields:
- Nervous System
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SESSION STATS - PERFORMANCE PER SPECIALTY
