-
Question 1
Correct
-
From the given responses what is the most characteristic clinical feature of a patient with vitamin C deficiency?
Your Answer: Perifollicular haemorrhages and hyperkeratosis
Explanation:Scurvy is a state of dietary deficiency of vitamin C (ascorbic acid). Although scurvy is uncommon, it still occurs and can affect adults and children who have chronic dietary vitamin C deficiency. The most common cutaneous findings are follicular hyperkeratosis, perifollicular haemorrhages, ecchymosis, xerosis, leg oedema, poor wound healing, and bent or coiled body hairs.
Cheilosis and beefy red tongue are associated with vitamin B12 deficiency and iron deficiency.
Diarrhoea and delusions are associated with pellagra which is caused by vitamin B3 (Niacin) deficiency.
Ocular muscle paralysis and dementia are associated with vitamin B1 (Thiamine) deficiency. -
This question is part of the following fields:
- Gastrointestinal System
-
-
Question 2
Incorrect
-
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
-
-
Question 3
Correct
-
A 20-year-old male student presents to the clinic with swelling of his face, hands and feet along with diffuse abdominal pain. He has a history of similar recurrent episodes since he was 10 years old, with each episode lasting 2-3 days. Examination reveals swelling on face, hands, feet but no sign of urticaria. Family history is significant for similar episodes in the mother who experienced these since childhood, and a brother who passed away following respiratory distress at age of 8 during one such episode. Which of the following tests would be the most helpful in reaching the diagnosis?
Your Answer: C1 esterase inhibitor
Explanation:Hereditary C1 inhibitor deficiency leads to recurrent angioedema without urticaria or pruritus. Physical triggers include dental work, surgery or intubation. Medical triggers include angiotensin-converting enzyme (ACE) inhibitor, tamoxifen, oestrogen-containing medications (e.g., hormone replacement therapy and oral contraceptives). It is diagnosed on the basis of low levels of C1 esterase inhibitor or elevated levels of dysfunctional C1 esterase inhibitor. C4 levels are low between attacks. IgE levels, eosinophils, skin prick tests and RASTs are helpful in other allergic conditions and asthma but not of use in this case.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 4
Incorrect
-
A 60-year-old male patient with hypertension presented with acute onset retrosternal chest pain for 3 hours. On examination his pulse rate was 68 bpm, BP was 100/60 mmHg and JVP was seen 3mm from the sternal notch. Respiratory examination was normal. His ECG showed narrow QRS complexes, ST segment elevation of 2mm in leads II, III and aVF and a complete heart block. What is the most immediate treatment from the following answers?
Your Answer: Temporary transcutaneous pacemaker
Correct Answer: Chewable aspirin 300 mg
Explanation:The diagnosis is inferior ST elevation myocardial infarction. As the right coronary artery supplies the SA and AV nodes and bundle of His, conduction abnormalities are more common with inferior MIs. The most immediate drug management is high dose Aspirin. Definite treatment is urgent cardiac revascularization.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 5
Correct
-
A 51-year-old woman recently put on antihypertensives showed the following results on 2 occasions: Na+ = 132, K+ = 7.6, Urea = 11.3, and Creatinine = 112. Which of the following drugs is responsible for this result?
Your Answer: Ramipril
Explanation:Ramipril is an ACE Inhibitor. Treatment with angiotensin-converting-enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) has consistently been shown to reduce the risk of renal and cardiovascular morbidity and mortality in a range of patients. However, ACEI and ARB therapy increase serum potassium which increases the risk of hyperkalaemia.
-
This question is part of the following fields:
- Pharmacology
-
-
Question 6
Correct
-
In a study, 50 out of 100 smokers develop lung cancers and 50 out of 200 non-smokers develop lung cancers. Which of the following is accurate?
Your Answer: Relative risk=2
Explanation:Relative risk = (Incidence in exposed group)/incidence in unexposed group). So in this case RR = (50/100)/(50/200) = 2.
-
This question is part of the following fields:
- Evidence Based Medicine
-
-
Question 7
Correct
-
A 32-year-old man complains of fever, rash and photophobia. The physician suspects this to be a case of meningitis. Which of the following medication would be ideally used in this patient?
Your Answer: Cefotaxime
Explanation:Broad-spectrum cephalosporins, especially cefotaxime and ceftriaxone, are widely used in the treatment of suspected pneumococcal meningitis and are considered the treatment of choice for meningitis caused by partially penicillin-resistant pneumococcal strains.
-
This question is part of the following fields:
- Pharmacology
-
-
Question 8
Correct
-
A 20-year-old student nurse was admitted after her third collapse in recent months. She was noted to have a blood sugar of 0.9 mmol/l on finger-prick testing and responded well to intravenous glucose therapy.
Venous blood taken at the same showed a markedly raised insulin level, but her C-peptide levels were normal.
What diagnosis fits best with this clinical picture?Your Answer: Self-administration of a short-acting insulin
Explanation:The patient has hyperinsulinemia and hypoglycaemia, but her C-peptide levels are normal. This is strongly suggestive of the fact that she is self-administering insulin.
In Insulinoma, common diagnostic criteria include:
– blood glucose level < 50 mg/dl with hypoglycaemic symptoms,
– relief of symptoms after eating
– absence of sulfonylurea on plasma assays.
The classic diagnostic criteria include the demonstration of the following during a supervised fast:
Increased plasma insulin level
Increased C peptide level
Increased proinsulin level
However, the patient has normal C-peptide levels.
In type-1 diabetes mellitus, insulin and C-peptide levels are low. -
This question is part of the following fields:
- Endocrine System & Metabolism
-
-
Question 9
Incorrect
-
A 52-year-old chef presents to the ED with acute visual changes. He has a past medical history of hypertension and type 2 diabetes mellitus. On neurological examination, his upper and lower limbs are normal however he has a homonymous hemianopia with central preservation. Where is the most likely cause of his problems within the central nervous system?
Your Answer: Optic tract
Correct Answer: Optic radiation
Explanation:Lesions in the optic radiation can cause a homonymous hemianopia with macular sparing, as a result of collateral circulation offered to macular tracts by the middle cerebral artery.
Lesions in the optic tract also cause a homonymous hemianopia, but without macular sparing.
Lesions in the optic chiasm, optic nerve, and temporal lobe cause bitemporal hemianopia, ipsilateral complete blindness, and superior homonymous quadrantanopia respectively. -
This question is part of the following fields:
- Nervous System
-
-
Question 10
Correct
-
Psoriatic arthropathy most commonly presents with which of the following types of arthritis?
Your Answer: Peripheral asymmetric oligoarthropathy
Explanation:Most patients with psoriatic arthritis present with monoarthritis or asymmetric oligoarthritis. The most common form of the disease is the one involving a few joints of the peripheral skeleton with a distinct asymmetry of symptoms. Involvement of the smaller joints of the hands and feet, especially distal interphalangeal joints, seems to be a characteristic feature. Arthritis mutilans is a rare and severe complication of psoriatic arthritis.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 11
Correct
-
Which of the following stimulates the secretion of gastrin?
Your Answer: Amino acids
Explanation:Gastrin is released from G cells in the antrum of the stomach after a meal. It stimulates parietal cells to release HCl. Gastrin is stimulated by a number of things: antrum distention, vagal stimulation, peptides (especially amino acids) in the stomach, hypercalcemia. Gastrin release is inhibited by acid, SST, GIP, VIP, secretin, glucagon, and calcitonin.
-
This question is part of the following fields:
- Gastrointestinal System
-
-
Question 12
Correct
-
A 71-year-old woman with a medical history of a blood transfusion in the early 1980s presents with a 10 month history of malaise and is noted to have impaired renal function. Her urine sediment reveals red cell casts.
The results of immunological investigations are as follows: serum IgG 6.5 g/L (normal range 6-13), IgA 1.5 g/L (normal range 0.8-4.0), IgM 5.7 g/L (normal range 0.4-2.0), serum electrophoresis shows a faint band in the gamma region, complement C3 1.02 g/L (normal range 0.75-1.65), complement C4 <0.02 g/L (normal range 0.20-0.65), and rheumatoid factor 894 IU/L (normal range <40).
Which of the following investigations is likely to be most important in making a definitive diagnosis?Your Answer: Cryoglobulins
Explanation:The patient’s history of a blood transfusion and lab results showing a markedly low C4 (with normal C3), elevated rheumatoid factor, and elevated serum IgM is highly suggestive of hepatitis C-associated cryoglobulinaemic vasculitis. Testing for Cryoglobulins will confirm this suspicion.
-
This question is part of the following fields:
- Renal System
-
-
Question 13
Incorrect
-
An 81-year-old male presented to the emergency department following a fall at home. He was diagnosed with osteoporosis about five years ago. He presently complains of significant low back pain.
A lumbar spine X-ray was suggestive of a fractured lumbar vertebra.
A subsequent MRI scan of the lumbosacral spine revealed a new L3 burst fracture with no evidence of cord compression.
A neurosurgical consult was sought and conservative management was planned accordingly in the form of pain control, physiotherapy, and mobilization (as allowed by the pain).
He also has been diagnosed with chronic renal disease (stage IV) with a creatinine clearance of 21 ml/min, he was started on a Buprenorphine patch.
Which of the following opioids would be safest to use for his breakthrough pain?Your Answer: Morphine
Correct Answer: Oxycodone
Explanation:Oxycodone is a safer opioid to use in patients with moderate to end-stage renal failure.
Active metabolites of morphine accumulate in renal failure which means that long-term use is contraindicated in patients with moderate/severe renal failure.
These toxic metabolites can accumulate causing toxicity and risk overdose.
Oxycodone is mainly metabolised in the liver and thus safer to use in patients with moderate to end-stage renal failure with dose reductions.
Adverse effects:
Constipation is the most common overall side effect. Others include: asthenia, dizziness, dry mouth, headache, nausea, pruritus, etc.Medications in renal failure:
Drugs to be avoided in patients with renal failure
Antibiotics: tetracycline, nitrofurantoin
NSAIDs
Lithium
Metformin
Drugs that require dose adjustment:
Most antibiotics including penicillin, cephalosporins, vancomycin, gentamicin, streptomycin
Digoxin, atenolol
Methotrexate
Sulphonylureas
Furosemide
Opioids
Relatively safe drugs:
Antibiotics: erythromycin, rifampicin
Diazepam
Warfarin -
This question is part of the following fields:
- Geriatric Medicine
-
-
Question 14
Correct
-
A cohort study is being designed to look at the relationship between smoking and prostate cancer. What is the usual outcome measure in a cohort study?
Your Answer: Relative risk
Explanation:A cohort study is a particular form of longitudinal study that samples a cohort (a group of people who share a defining characteristic, typically those who experienced a common event in a selected period, such as birth or graduation), performing a cross-section at intervals through time.
The relative risk (RR) or risk ratio is the ratio of the probability of an outcome in an exposed group to the probability of an outcome in an unexposed group. Relative risk is used in the statistical analysis of the data of experimental, cohort and cross-sectional studies, to estimate the strength of the association between treatments or risk factors, and outcomes. -
This question is part of the following fields:
- Evidence Based Medicine
-
-
Question 15
Incorrect
-
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: Increased serum urate
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
-
-
Question 16
Incorrect
-
A 41-year-old gentleman undergoes a temporal lobectomy after the discovery of a brain tumour. Which one of the following consequences would be least likely to develop?
Your Answer: Wernicke's aphasia
Correct Answer: Astereognosis
Explanation:Astereognosis is associated with lesions to the parietal lobe, not the temporal lobe, so this symptom would not arise in this patient.
-
This question is part of the following fields:
- Nervous System
-
-
Question 17
Incorrect
-
A new-born male is admitted to NICU with convulsions, limb hypoplasia and rudimentary digits. Which of the following is the most likely cause?
Your Answer: Cytomegalovirus (CMV)
Correct Answer: Varicella
Explanation:Infection of chickenpox in the first half of pregnancy can result in congenital varicella syndrome. It presents as cerebral, cortical and cerebellar hypoplasia with convulsions and rudimentary digits. Prevention is by administering varicella vaccine, even before pregnancy. Varicella immunoglobulin is administered to pregnant women who are exposed to infection. Infection during pregnancy is treated with acyclovir.
-
This question is part of the following fields:
- Infectious Diseases
-
-
Question 18
Correct
-
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.
-
This question is part of the following fields:
- Gastrointestinal System
-
-
Question 19
Correct
-
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.
-
This question is part of the following fields:
- Evidence Based Medicine
-
-
Question 20
Correct
-
A 45-year-old male complained of deteriorating vision after starting a new drug. Which of following could NOT be responsible for this presentation?
Your Answer: Irinotecan
Explanation:Chloroquine causes Bull’s eye maculopathy which consists of a number of different conditions in which there is a ring of pale-looking damage around a darker area of the macula.
Ethambutol causes optic neuritis.
Quinine causes blurred vision and changes in colour vision.
Vincristine causes optic nerve atrophy as a result of chronic optic nerve oedema or optic neuritis.
Irinotecan does not have any ocular side effects. -
This question is part of the following fields:
- Pharmacology
-
-
Question 21
Correct
-
A 34-year-old female presents to the clinic with skin tightness. On examination she has sclerodactyly, thickened skin of the shoulders and bi-basal crepitations. Her HRCT chest shows ground glass changes. Raynaud phenomenon is suspected and she is started on a monthly dose of IV cyclophosphamide (1 gm/month) for 6 months and a daily dose of 10 mg of oral prednisolone. However, she returned over a period of few weeks after developing exertional dyspnoea, pedal oedema and feeling unwell. On examination, JVP is raised, there is marked pedal oedema and bi basal crepitations on chest auscultation. Urine dipstick shows haematuria (++) and proteinuria (++). What in your opinion is the most likely cause of her deteriorating renal function?
Your Answer: Scleroderma renal crisis
Explanation:Scleroderma renal crisis (SRC) is a rare but severe complication in patients with systemic sclerosis (SSc). It is characterized by malignant hypertension, microangiopathic haemolytic anaemia with schistocytes and oligo/anuric acute renal failure. SRC occurs in 5% of patients with systemic scleroderma, particularly in the first years of disease evolution and in the diffuse form. Patients may develop symptoms of fluid overload.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 22
Correct
-
A gentleman arrives at the renal clinic for review. He has long standing chronic renal failure and is unfortunately suffering from metabolic bone disease. His GP has asked for an explanation of the causes and features of metabolic bone disease.
Which of the following best describes the biochemical changes involved?Your Answer: Phosphate excretion is decreased, parathyroid hormone levels are increased and 1,25-OH vitamin D levels are decreased
Explanation:The patient’s chronic renal failure causes decreased renal hydroxylation of vitamin D which leads to decreased calcium absorption in the gut. Simultaneously, there is also decreased renal excretion of phosphate, and this combination of factors results in increased PTH levels.
-
This question is part of the following fields:
- Renal System
-
-
Question 23
Correct
-
An 8-week-old baby was found to have bilateral cataracts. Further investigation revealed thrombocytopenia, a patent ductus arteriosus and hepatosplenomegaly. Which of the following is the most probable diagnosis?
Your Answer: Rubella
Explanation:The clinical presentation is suggestive of congenital rubella syndrome. The classic triad of presenting symptoms includes sensorineural hearing loss, ocular abnormalities (cataract, infantile glaucoma, and pigmentary retinopathy) and congenital heart disease (patent ductus arteriosus and pulmonary artery stenosis). Other findings in congenital rubella syndrome include CNS abnormalities (mental retardation, behavioural disorders, encephalographic abnormalities, hypotonia, meningoencephalitis, and microcephaly), hepatosplenomegaly, and jaundice.
-
This question is part of the following fields:
- Infectious Diseases
-
-
Question 24
Correct
-
A 65-year-old woman presents at clinic complaining of worsening hoarseness of voice and dyspnoea over the past month. She has a history of toxic multinodular goitre successfully treated with radioiodine. On examination, she has a firm asymmetrical swelling of the thyroid gland. Laryngoscopy demonstrates a right vocal cord paralysis and apparent external compression of the trachea.
What is the most likely diagnosis?Your Answer: Anaplastic thyroid cancer
Explanation:Thyroid malignancies are divided into papillary carcinomas (80%), follicular carcinomas (10%), medullary thyroid carcinomas (5-10%), anaplastic carcinomas (1-2%), primary thyroid lymphomas (rare), and primary thyroid sarcomas (rare).
Hürthle cell carcinoma is a rare thyroid malignancy that is often considered a variant of follicular carcinoma.
– Papillary and Follicular carcinoma are slow-growing tumours
– Sporadic cases of Medullary thyroid carcinoma also typically manifest with painless solitary thyroid nodules in the early stages.
– Anaplastic thyroid carcinoma has the most aggressive biologic behaviour of all thyroid malignancies and has one of the worst survival rates of all malignancies in general. It manifests as a rapidly growing thyroid mass in contrast to a well-differentiated carcinoma, which are comparatively slow-growing. Patients commonly present with associated symptoms due to local invasion. Hoarseness and dyspnoea resulting from the involvement of the recurrent laryngeal nerve and airway occur in as many as 50% of patients.
– Almost all patients with primary thyroid lymphoma have either a clinical history or histological evidence of chronic lymphocytic thyroiditis. The risk of primary thyroid lymphoma increases 70-fold in patients with chronic lymphocytic thyroiditis compared with the general population. Regional and distant lymphadenopathy is common. -
This question is part of the following fields:
- Endocrine System & Metabolism
-
-
Question 25
Correct
-
The increased risk of oesophageal malignancy in patients with Barrett's oesophagus is approximately:
Your Answer: 50 - 100 times risk
Explanation:Barrett’s oesophagus is the transformation of the normal squamous epithelium of the oesophagus to columnar, intestinal type epithelium. It is often seen in patients with reflux and there is a 50-100 fold increased risk of oesophageal adenocarcinoma in patients with Barrett’s oesophagus.
-
This question is part of the following fields:
- Gastrointestinal System
-
-
Question 26
Correct
-
A 35-year-old woman under treatment for long-term epilepsy with valproate presented with complaints of excessive weight gain. She is consuming oral contraceptive pills.
Which among the following is the best alternative to valproate for treating long-term epilepsy?Your Answer: Lamotrigine
Explanation:Among the given anti-epileptics the best drug that can be given in this patient is lamotrigine.
Topiramate, carbamazepine, phenytoin, and phenobarbital are all hepatic enzyme inducers and are associated with decreased effectiveness of the oral contraceptive (OCP) due to acceleration of the metabolism of oestrogens and progestogens.
If she is planning on pregnancy then registry studies suggest that lamotrigine would also be the best choice.
Other hepatic enzyme inducers include rifampicin, spironolactone, griseofulvin, etc. -
This question is part of the following fields:
- Pharmacology
-
-
Question 27
Correct
-
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).
-
This question is part of the following fields:
- Pharmacology
-
-
Question 28
Correct
-
A 46-year-old woman was referred to the endocrinology department with hypercalcemia and raised parathyroid hormone levels. Her blood tests are highly suggestive of primary hyperparathyroidism.
She has type 2 diabetes controlled by metformin alone. Her albumin-adjusted serum calcium level is 3.5 mmol/litre.
Which of the following is the most important reason for her referral?Your Answer: Albumin-adjusted serum calcium level of 3.5 mmol/litre
Explanation:Indications for surgery for the treatment of primary hyperparathyroidism:
1. Symptoms of hypercalcaemia such as thirst, frequent or excessive urination, or constipation
2. End-organ disease (renal stones, fragility fractures or osteoporosis)
3. An albumin-adjusted serum calcium level of 2.85 mmol/litre or above. -
This question is part of the following fields:
- Endocrine System & Metabolism
-
-
Question 29
Correct
-
A 19-year-old male presents with a 1-year history of diarrhoea as well as abdominal discomfort. He has 10 episodes of loose stools per day and 3 episodes of loose stools per night. He reports weight loss in the past few months. On examination of the abdomen, tenderness was present in the right lower quadrant. Endoscopy revealed cobblestone mucosa in the ileum. Which of the following conditions is he most likely suffering from?
Your Answer: Crohn's Disease
Explanation:Cobblestone mucosa is characteristic of Crohn’s Disease. It is not a feature of any of the other options mentioned. Crohn’s disease is a condition of IBD (Inflammatory Bowel Disease).
-
This question is part of the following fields:
- Gastrointestinal System
-
-
Question 30
Correct
-
A 3-year-old child choked on a foreign object, which was removed at the hospital. The parents are now asking for advice on how to manage future occurrences at home. What do you advise?
Your Answer: Turn the child on his back and give thumps
Explanation:Give up to five back blows: hit them firmly on their back between the shoulder blades. Back blows create a strong vibration and pressure in the airway, which is often enough to dislodge the blockage.
-
This question is part of the following fields:
- Emergency & Critical Care
-
-
Question 31
Correct
-
A 32-year-old primigravida, with a history of pulmonary hypertension, presents to the clinic at 36 weeks gestation with worsening shortness of breath.
Which of the following is the most accurate statements regarding her condition?Your Answer: Risk of maternal mortality in patients with pulmonary hypertension is 30%
Explanation:Historically, high rates of maternal and fetal death have been reported for pregnant women with pulmonary hypertension (30-56% and 11-28%, respectively). The causes of poor maternal outcomes are varied and include risk of death from right heart failure and stroke from intracardiac shunting. Furthermore, there is a high peri-/post-partum risk due to haemodynamic stress, bleeding complications and the use of general anaesthesia, which can all lead to right heart failure.
The most common risk to the foetus is death, with premature birth and growth retardation being reported in successfully delivered children.
CXR is not contraindicated in pregnancy. D-dimers are not used as a diagnostic aid as they are almost always elevated in pregnancy. Nifedipine, although contraindicated in pregnant women may be used judiciously if the need arises. -
This question is part of the following fields:
- Respiratory System
-
-
Question 32
Correct
-
A 30-year-old man with type-1 diabetes mellitus on insulin presents in the A&E with fever, cough, vomiting and abdominal pain.
Examination reveals a dry mucosa, decreased skin turgor and a temperature of 37.8 °C.
Chest examination reveals bronchial breathing in the right lower lobe, and a chest X-ray shows it to be due to a right lower zone consolidation.
Other investigations show:
Blood glucose: 35 mmol/l
Na+: 132 mmol/l
K+: 5.5 mmol/l
urea: 8.0 mmol/l
creatinine: 120 μmol/l
pH: 7.15
HCO3: 12 mmol/l
p(CO2): 4.6 kPa
chloride: 106 mmol/l.
Urinary ketones are positive (+++).
The patient is admitted to the hospital and treated. Which of the following should not be used while treating him?Your Answer: Bicarbonate
Explanation:Bicarbonate therapy is not indicated in mild and moderate forms of DKA because metabolic acidosis will correct with insulin therapy. The use of bicarbonate in severe DKA is controversial due to a lack of prospective randomized studies. It is thought that the administration of bicarbonate may actually result in peripheral hypoxemia, worsening of hypokalaemia, paradoxical central nervous system acidosis, cerebral oedema in children and young adults, and an increase in intracellular acidosis. Because severe acidosis is associated with worse clinical outcomes and can lead to impairment in sensorium and deterioration of myocardial contractility, bicarbonate therapy may be indicated if the pH is 6.9 or less.
-
This question is part of the following fields:
- Endocrine System & Metabolism
-
-
Question 33
Incorrect
-
A 34-year-old male presented with exertional dyspnoea and chest pain for the past 2 weeks. On examination there was a mid-systolic murmur which is best heard at the apex and double apical impulse. His ECG showed left ventricular hypertrophy (LVH). What is the risk factor which would be most indicative of the potential for sudden death in this patient?
Your Answer: Family history of sudden death
Correct Answer: Degree of left ventricular hypertrophy
Explanation:The history is suggestive of hypertrophic obstructive cardiac myopathy. The degree of left ventricular hypertrophy is strongly associated with sudden cardiac death.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 34
Correct
-
A team of physicians presented their audit of fluid management for dengue haemorrhagic fever one year ago. A number of recommendations were made at that time and changes were implemented. Which of the following is the most appropriate next step that this team should take?
Your Answer: Re-audit
Explanation:Clinical audit is defined as a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. To see whether the recommendations have been implemented, a re-audit has to be performed.
-
This question is part of the following fields:
- Ethical & Legal
-
-
Question 35
Correct
-
A 30-year-old previously well female presented with yellowish discolouration of her sclera. Investigations revealed low haemoglobin, a retic count of 8% and the occasional spherocyte on blood film. Which of the following is the most appropriate single investigation?
Your Answer: Direct coombs test
Explanation:A low haemoglobin and a high retic count is suggestive of a haemolytic anaemia. Occasional spherocytes can be seen on blood film during haemolysis and it is not a specific finding. Direct Coombs test will help to identify autoimmune haemolytic anaemia, where there are antibodies attached to RBCs.
-
This question is part of the following fields:
- Endocrine System & Metabolism
-
-
Question 36
Correct
-
Which of the following is NOT a cause of onycholysis?
Your Answer: Mycoplasma pneumonia
Explanation:Onycholysis is the separation of the distal edge of the nail from the vascular nailbed causing whiteness of the free edge. Causes include:
– Idiopathic
– Trauma, excessive manicuring
– Infection: especially fungal
– Skin disease: psoriasis, dermatitis
– Impaired peripheral circulation e.g. Raynaud’s
– Systemic disease: hyper/hypothyroidism, reactive arthritis, porphyria cutanea tarda
– Sometimes a reaction to detergents (e.g. washing dishes with bare hands, using detergent-based shampoos or soaps).
– Patients with hepatocellular dysfunction may develop hair-thinning or hair loss and nail changes such as clubbing, leukonychia (whitening), or onycholysis. -
This question is part of the following fields:
- The Skin
-
-
Question 37
Correct
-
A 60-year-old previously well male patient was admitted with acute severe central chest pain associated with excessive sweating and nausea for the past 45 minutes. On examination he was found to have xanthelasma. His blood pressure was 170/100 mmHg and pulse rate was 104 bpm. His ECG showed ST elevation more than 2mm in leads II, III and aVF. His troponin T was 120 ng/ml. His FBC and renal functions were normal. He was given aspirin, clopidogrel, morphine and IV 5 mg of atenolol. Which of the following is the most appropriate next step?
Your Answer: Immediate referral to cardiologist for primary angioplasty
Explanation:The diagnosis is acute inferior ST elevation myocardial infarction so the most appropriate management is primary angioplasty.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 38
Correct
-
Out of the following, which is not associated with polycythaemia vera?
Your Answer: Raised ESR
Explanation:Polycythaemia vera (PV) is associated with a low ESR.
PV, also known as polycythaemia rubra vera, is a myeloproliferative disorder caused by clonal proliferation of marrow stem cells leading to an increase in red cell volume, often accompanied by overproduction of neutrophils and platelets. It has peak incidence in the sixth decade of life, with typical features including hyperviscosity, pruritus, splenomegaly, haemorrhage (secondary to abnormal platelet function), and plethoric appearance. PV is associated with a low ESR.
Some management options of PV include lose-dose aspirin, venesection (first-line treatment), hydroxyurea (slightly increased risk of secondary leukaemia), and radioactive phosphorus (P-32) therapy.
In PV, thrombotic events are a significant cause of morbidity and mortality. 5-15% of the cases progress to myelofibrosis or acute myeloid leukaemia (AML). The risk of having AML is increased with chemotherapy treatment.
-
This question is part of the following fields:
- Haematology & Oncology
-
-
Question 39
Correct
-
A 59-year-old woman has an 11mm skin lesion on her right forearm, which bleeds easily on contact and has changed in appearance over the last 11 months.
Your Answer: Malignant melanoma
Explanation:Melanoma is more common in men than women. Reasons for the disease includes: UV light and genetic predisposition or mutations. Diagnosis is by biopsy and analysis of any skin lesion that has signs of being potentially cancerous.
Early warning signs of melanoma ABCDE:
Asymmetry
Borders (irregular with edges and corners)
Colour (variegated)
Diameter (greater than 6 mm)
Evolving over time -
This question is part of the following fields:
- The Skin
-
-
Question 40
Correct
-
A 43-year-old man with hemochromatosis presents with a painful and swollen right knee. X-ray shows extensive chondrocalcinosis but no fracture. Given the most likely diagnosis, which of the following would be present in the joint fluid aspirate?
Your Answer: Positively birefringent rhomboid-shaped crystals
Explanation:Pseudogout is a paroxysmal joint inflammation due to calcium pyrophosphate crystal deposition (calcium pyrophosphate dihydrate). Arthrocentesis should be performed, especially in acute cases.
Polarized light microscopy: detection of rhomboid-shaped, positively birefringent CPPD crystals.
Synovial fluid findings: 10,000-50,000 WBCs/μL with > 90% neutrophils.
X-ray findings: cartilage calcification of the affected joint (chondrocalcinosis).
Fibrocartilage (meniscus, annulus fibrosus of intervertebral disc) and hyaline cartilage (joint cartilage) may be affected. -
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 41
Incorrect
-
A 42-year-old man with alcoholic liver disease is admitted with pyrexia. He has been unwell for the past three days and has multiple previous admissions before with variceal bleeding. Examination shows multiple stigmata of chronic liver disease, ascites and jaundice.
Paracentesis is performed with the following results: Neutrophils 487 cells/ul
What is the most appropriate treatment?Your Answer: Intravenous ciprofloxacin
Correct Answer: Intravenous cefotaxime
Explanation:This describes a clinical scenario of spontaneous bacterial peritonitis. The diagnosis is made when fluid removed (ascites) is found to have > 250/mm cubed of PMNs (polymorphonuclear leukocytes). Cefotaxime or another third generation cephalosporin is the treatment of choice.
-
This question is part of the following fields:
- Hepatobiliary System
-
-
Question 42
Incorrect
-
A 44-year-old call centre worker with asthma is prescribed a leukotriene inhibitor. He presents with severe abdominal pain and a pleural effusion. Which of the following is the most likely cause of the effusion?
Your Answer: Pancreatitis
Correct Answer: Churg-Strauss syndrome
Explanation:Churg-Strauss syndrome is characterised by reactions in the serosal membranes. Hence, pericardial effusions and pleural effusions are common. Cytological analysis of the transudate shows high levels of eosinophils. Leukotriene inhibitors are known to increase the incidence of this syndrome.
-
This question is part of the following fields:
- Respiratory System
-
-
Question 43
Incorrect
-
A 9-year-old girl complains of perioral blisters and a burning sensation of her face. Some of the blisters are crusted and some are weeping. What is the most likely diagnosis?
Your Answer: Chicken pox
Correct Answer: Impetigo
Explanation:Impetigo appears more commonly on the face than other exposed areas like the limbs. Its blisters are clustered and may have a fluid discharge.
-
This question is part of the following fields:
- The Skin
-
-
Question 44
Correct
-
A 28-year-old woman is evaluated in the endocrinology clinic for increased urine output. She weighs 60 kg and has a 24-hour urine output of 3500 ml. Her basal urine osmolality is 210 mOsm/kg.
She undergoes a fluid deprivation test and her urine osmolality after fluid deprivation (loss of weight 3 kg) is 350 mOsm/kg. Subsequent injection of subcutaneous DDAVP (desmopressin acetate) did not result in a further significant rise of urine osmolality after 2 hours (355 mOsm/kg).
Which of the following is the most likely diagnosis?Your Answer: Primary polydipsia
Explanation:In central and nephrogenic diabetes insipidus (DI), urinary osmolality will be less than 300 mOsm/kg after water deprivation. After the administration of ADH, the osmolality will rise to more than 750 mOsm/kg in central DI but will not rise at all in nephrogenic DI. In primary polydipsia, urinary osmolality be above 750 mOsm/kg after water deprivation. A urinary osmolality that is 300-750 mOsm/kg after water deprivation and remains below 750 mOsm/kg after administration of ADH may be seen in partial central DI, partial nephrogenic DI, and primary polydipsia.
-
This question is part of the following fields:
- Endocrine System & Metabolism
-
-
Question 45
Correct
-
A 50-year-old woman was investigated following an osteoporotic hip fracture. The following results are obtained:
TSH < 0.05 mu/l
Free T4 29 pmol/l
Which of the following autoantibodies is most likely to be present?Your Answer: TSH receptor stimulating autoantibodies
Explanation:The patient has hyperthyroidism and its most common cause is Grave’s Disease.
Grave’s Disease is an autoimmune disease due to circulating autoantibodies known as TSH receptor stimulating autoantibodies or Thyroid-stimulating immunoglobulins (TSIs) that bind to and activate thyrotropin receptors, causing the thyroid gland to grow and the thyroid follicles to increase the synthesis of thyroid hormone. -
This question is part of the following fields:
- Endocrine System & Metabolism
-
-
Question 46
Correct
-
A 42-year-old woman who has been a smoker since she was a teenager has the following blood result: Hgb=19. What hormone should you check?
Your Answer: Erythropoietin
Explanation:An increase in the patient’s haemoglobin tells us that the patient might be having an increased number of red blood cells. Smoking causes raised carboxyhaemoglobin levels and thus hypoxemia. Hypoxemia will increase the erythropoietin levels in the blood.
-
This question is part of the following fields:
- Haematology & Oncology
-
-
Question 47
Correct
-
A 32-year-old lady, known with a history of Type 1 diabetes presents to the clinic with increasing tiredness, mild upper abdominal discomfort and itching. The GP has arranged some investigations prior to her clinic visit.
Investigations;
Hb 13.2 g/dl
WCC 5.0 x109/l
PLT 240 x109/l
Na+ 140 mmol/l
K+ 4.9 mmol/l
Creatinine 90 μmol/l
HbA1c 8.3%
Anti-Smooth muscle antibody positive
Immunoglobulins increased
Which of the following would be the next appropriate investigation?Your Answer: Liver function testing
Explanation:The key to this question is anti-smooth muscle antibodies. This is a finding of autoimmune hepatitis, which can be seen in type I diabetics. This also fits with her clinical picture. If you know these two facts, you should get every question correct regarding autoimmune hepatitis. Liver function testing is the best answer, then and should be elevated to indicate inflammation of the liver. Hepatic US, CK, thyroid function testing, short synacthen test are not helpful in the diagnosis of autoimmune hepatitis.
-
This question is part of the following fields:
- Gastrointestinal System
-
-
Question 48
Incorrect
-
A 39 year-old engineer presents with progressive weakness of his hands. Upon examination, you notice wasting of the small muscles of the hand. A diagnosis of syringomyelia is suspected. Which one of the following features would most support this diagnosis?
Your Answer: Hyper-reflexia in the upper limbs
Correct Answer: Loss of temperature sensation in the hands
Explanation:Syringomyelia is a development of a cavity (syrinx) within the spinal cord. Signs and symptoms include loss of feeling, paralysis, weakness, and stiffness in the back, shoulders, and extremities. Syringomyelia may also cause a loss of the ability to feel extremes of hot or cold, especially in the hands. Symptoms typically vary depending on the extent and, often more critically, on the location of the syrinx within the spinal cord.
-
This question is part of the following fields:
- Nervous System
-
-
Question 49
Incorrect
-
A 32-year-old lady is found to be hepatitis B surface antigen positive. This positive result has persisted for more than six months. Hepatitis B envelope antigen (HBeAg) is negative. HBV DNA is negative. Her liver function tests are all entirely normal.
Which of the following options would be the best for further management?Your Answer: Liver biopsy but no antiviral therapy
Correct Answer: No antiviral therapy but monitor serology
Explanation:Again, remember the Hepatitis B serologies: In chronic hepatitis B infection, you have +HBsAg, +anti-HBc, (-)IgM antiHBc, and (-) anti-HBs. In acute hepatitis B infection, you have +HBsAg, + anti-HBc, + IgM anti-HBc, and negative anti-HBs. In immunity due to natural infection, you have negative HBsAg, + anti-HBc, and + anti-HBs. In immunity due to vaccination, you have negative HBsAg, negative anti-HBc, and positive anti-HBs. IN THIS CASE, the person is HBsAg+ for 6 months and everything else is negative, normal transaminase. They do not need antiviral therapy, but their serology should be monitored serially. There would be no reason to do a liver biopsy.
-
This question is part of the following fields:
- Gastrointestinal System
-
-
Question 50
Correct
-
A 19-year-old girl suffers from a hereditary disease and presents at her GP with a renal colic. She claims that her mother had this problem too. What type of renal calculus is most likely responsible for the renal colic?
Your Answer: Cystine
Explanation:The patient seems to have inherited cystinuria which is an autosomal recessive disease. Typical for the disease is the abnormally high concentration of cysteine in the urine, finally causing cystinuria. In a person with cystinuria, the high concentrations of cysteine in the kidney results in the formation of stones with frequent colic pains and complications. If the genotype is partially expressed, then the phenotype might be even asymptomatic, thus the disease has a high variability.
-
This question is part of the following fields:
- Renal System
-
SESSION STATS - PERFORMANCE PER SPECIALTY
