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Question 1
Incorrect
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A 13-year-old boy presented with difficulty in breathing on exertion. According to his mother who was also present, his exercise tolerance has been gradually worsening for the past weeks. It has reached the point where he is unable to participate in his weekly soccer match. Cardiac catheterization was performed and the results are given below.
Anatomical site
Oxygen saturation (%)
Pressure (mmHg)
Superior vena cava
73
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Right atrium
71
6
Right ventricle
72
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Pulmonary artery
86
53/13
PCWP
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15
Left ventricle
97
111/10
Aorta
96
128/61
Which of the following is the diagnosis?Your Answer: Primary pulmonary hypertension
Correct Answer: Patent ductus arteriosus
Explanation:The oxygen saturation in the pulmonary artery is higher than that of the right ventricle. The pressure of the pulmonary artery and of the PCWP are also high. So patent ductus arteriosus is highly suggestive.
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This question is part of the following fields:
- Cardiovascular System
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Question 2
Incorrect
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Which of the following drugs would be the safest to prescribe in a 22-year-old man with seropositive rheumatoid arthritis who is planning to start a family?
Your Answer: Sulfasalazine
Correct Answer: Prednisolone
Explanation:Prednisolone although has many undesirable side effects it may be considered relatively safe compared to the drugs that are provided here. Prolonged treatment with sulphasalazine may depress semen quality and cause irreversible infertility. Methotrexate and leflunomide both inhibit purine/pyrimidine synthesis (the former by inhibiting folate metabolism) and are contraindicated in pregnancy or while trying to conceive. In males, a temporary or permanent decrease in sperm count may occur with cyclophosphamide. Because the recovery of fertility after cyclophosphamide therapy is variable, sperm banking should be considered before treatment is begun.
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This question is part of the following fields:
- Musculoskeletal System
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Question 3
Incorrect
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A 23-year-old male patient presents with urethritis for the last 2 weeks that has not responded to antibiotics. Lately he has developed an onset of new range of symptoms that are linked to his HLA B27 positivity. Which of the following signs is not related to Reiter's syndrome?
Your Answer: Tenderness over the planter surface of the ankle
Correct Answer: A mild fever with a generalised macular rash
Explanation: -
This question is part of the following fields:
- Musculoskeletal System
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Question 4
Incorrect
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Question 5
Correct
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An 82-year-old male woke up experiencing incoherent speech - he is also finding it difficult to find the right words to explain his thoughts. Doctors have examined him, and everything else appears to be normal. They have also found that his comprehension is good. From the list of options, choose the anatomical site which in this instance, is most likely affected.
Your Answer: Broca's Area
Explanation:The combination of good comprehension but poor speech quality in this patient is consistent with damage to the Broca’s area. The Wernicke’s area is responsible for the understanding of speech, and so is not consistent with this patient.
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This question is part of the following fields:
- Geriatric Medicine
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Question 6
Incorrect
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A 2-day-old girl is admitted by her mother because she gets cyanotic upon feeding and she wouldn't stop crying. The doctors suspect a congenital heart disease. What is the most probable aetiology?
Your Answer: Ventricular septal defect
Correct Answer: Transposition of the great arteries
Explanation:Transposition of the great arteries results in a significant hypoxemic status that is observed clinically by central cyanosis. The bluish discoloration of the skin and mucous membranes is therefore the basic pattern of clinical presentation in transposition. Its onset and severity depend on anatomical and functional variants that influence the degree of mixing between the two circulations. Limited intercirculatory mixing, usually present if the ventricular septum is intact or the atrial septal defect is restrictive, is related to progressive and profound central cyanosis evident within the first hours of life. Tachypnoea, tachycardia, diaphoresis, poor weight gain, a gallop rhythm, and eventually hepatomegaly can be then detected later on during infancy. Heart murmurs associated with left outflow tract obstruction, due to a persistent arterial duct or a septal defect may be heard, but they are not a constant finding.
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This question is part of the following fields:
- Cardiovascular System
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Question 7
Correct
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A 33-year-old Afro-Caribbean gentleman with a 5 year history of HIV infection presents with swollen ankles. He has been treated with highly active antiretroviral therapy (HAART) for 2 years, with partial response.
His plasma creatinine concentration is 358 μmol/l, albumin is 12 g/dl, CD4 count is 35/μl and 24 hour urine protein excretion rate is 6.8 g. Renal ultrasound shows echogenic kidneys 13.5 cm in length.
What would a renal biopsy show?Your Answer: Microcystic tubular dilatation and collapsing FSGS
Explanation:HIV-associated nephropathy (HIVAN) show typical findings of scarring called focal segmental glomerulosclerosis (FSGS) and microcystic tubular dilatation, prominent podocytes, and collapsing capillary loops.
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This question is part of the following fields:
- Renal System
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Question 8
Incorrect
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A 21-year-old male presented in the OPD with a testicular mass. During examination, the mass was found to be painless and 2.5cm in diameter. The surface is irregular and non-transilluminating. What is the most likely diagnosis?
Your Answer: Seminoma
Correct Answer: Teratoma
Explanation:The age group of the patient (20 to 30 years) is indicative of teratoma. It is also painless and non-transilluminating.
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This question is part of the following fields:
- Men's Health
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Question 9
Incorrect
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Which one of the following statements regarding interleukin 1 (IL-1) is true?
Your Answer: It inhibits the release of nitric oxide by the endothelium
Correct Answer: It is released mainly by macrophages/monocytes
Explanation:Interleukin 1 alpha and interleukin 1 beta (IL1 alpha and IL1 beta) are cytokines that participate in the regulation of immune responses, inflammatory reactions, and hematopoiesis. It is secreted mainly by macrophages and monocytes and acts as a costimulator of T cell and B cell proliferation.
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This question is part of the following fields:
- Immune System
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Question 10
Correct
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A 32-year-old male with a history of smoking half a pack of cigarettes per day complains of worsening breathlessness on exertion. He was working as a salesman until a few months ago. His father passed away due to severe respiratory disease at a relatively young age. Routine blood examination reveals mild jaundice with bilirubin level of 90 µmol/l. AST and ALT are also raised. Chest X-ray reveals basal emphysema. Which of the following explanation is most likely the cause of these symptoms?
Your Answer: ?-1-Antitrypsin deficiency
Explanation:Alpha-1 antitrypsin deficiency is an inherited disorder that may cause lung and liver disease. The signs and symptoms of the condition and the age at which they appear vary among individuals. This would be the most likely option as it is the only disease that can affect both liver and lung functions.
People with alpha-1 antitrypsin deficiency usually develop the first signs and symptoms of lung disease between ages 20 and 50. The earliest symptoms are shortness of breath following mild activity, reduced ability to exercise, and wheezing. Other signs and symptoms can include unintentional weight loss, recurring respiratory infections, fatigue, and rapid heartbeat upon standing. Affected individuals often develop emphysema. Characteristic features of emphysema include difficulty breathing, a hacking cough, and a barrel-shaped chest. Smoking or exposure to tobacco smoke accelerates the appearance of emphysema symptoms and damage to the lungs.
About 10 percent of infants with alpha-1 antitrypsin deficiency develop liver disease, which often causes yellowing of the skin and sclera (jaundice). Approximately 15 percent of adults with alpha-1 antitrypsin deficiency develop liver damage (cirrhosis) due to the formation of scar tissue in the liver. Signs of cirrhosis include a swollen abdomen, swollen feet or legs, and jaundice. Individuals with alpha-1 antitrypsin deficiency are also at risk of developing hepatocellular carcinoma. -
This question is part of the following fields:
- Respiratory System
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Question 11
Correct
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Which of the following types of reactions are a part of the phase II metabolism of a drug?
Your Answer: Conjugation
Explanation:Drug metabolism can be broadly classified into:
Phase I (functionalization) reactions: also termed non-synthetic reactions, they include oxidation, reduction, hydrolysis, cyclization and de-cyclization. The most common and vital reactions are oxidation reactions. (Of the given enzymes only Alcohol dehydrogenase is involved in phase I drug metabolism. Succinate dehydrogenase, is a vital enzyme involved in the Kreb’s cycle and the mitochondrial electron transport chain). They are mainly catalysed by Cytochrome P-450 enzyme.Phase II (conjugation) reactions: occur following phase I reactions, they include reactions: glucuronidation and sulphate conjugation, etc. They are mostly catalysed by UDP-glucuronosyltransferase enzyme. Other phase II enzymes include: sulfotransferases, N-acetyltransferases, glutathione S-transferases and methyltransferases.
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This question is part of the following fields:
- Pharmacology
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Question 12
Correct
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A 32-year-old woman was referred for endoscopy and found to have a duodenal ulcer and a positive urease test. She was given lansoprazole, amoxicillin and clarithromycin for 7 days.
Which of the following is the most appropriate way of determining the successful eradication of H. pylori?Your Answer: Urea breath test
Explanation:Urea breath test is the most sensitive test to determine if there has been RESOLUTION/ERADICATION of the infection with H. pylori. The best test for initial diagnosis would be EGD with biopsy.
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This question is part of the following fields:
- Gastrointestinal System
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Question 13
Incorrect
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A 74-year-old man with longstanding Waldenström's macroglobulinemia presents to the rheumatology clinic with joint pain and generalised weakness. Which of the following would be most indicative of type I cryoglobulinemia?
Your Answer: Livedo reticularis
Correct Answer: Raynaud's phenomenon
Explanation:Cryoglobulins are proteins that precipitate from an individual’s serum or plasma at temperatures lower than 37°C. They can be a mixture of immunoglobulin (Ig) and complement components or immunoglobulins alone. These cryoglobulins deposit in medium and large-sized blood vessels throughout the body, causing endothelial injury and end-organ damage known as cryoglobulinemia.
Cryoglobulinemia can be divided into three main types, depending on which kind of antibody your body produces.
Type I cryoglobulinemia is frequently associated with an underlying health condition, such as cancer of your blood or immune system.
Type II cryoglobulinemia and type III cryoglobulinemia are often seen in people with long-term (chronic) inflammatory conditions, such as autoimmune diseases. Type II cryoglobulinemia is very common in people with hepatitis C virus (HCV). Another name for types II and III cryoglobulinemia is mixed cryoglobulinemia.
People with cryoglobulinemia may or may not experience symptoms. When symptoms are present, they most commonly include a particular rash, usually over the lower legs as well as fatigue and joint pain.
Other cryoglobulinemia symptoms may include:
- Change in the color of your hands and/or feet with cold temperatures, called Raynaud’s phenomenon.
- Weight loss.
- High blood pressure
- Swelling (edema) of ankles and legs.
- Skin ulcers and gangrene.
- Enlarged liver (hepatomegaly) or enlarged spleen (splenomegaly).
Raynaud’s syndrome causes spasms in small blood vessels in your fingers and toes. This limits blood flow and leads to symptoms like skin color changes, cold skin and a pins and needles sensation. Common triggers of Raynaud’s attacks include cold weather and stress. Many people have mild symptoms that they can manage through lifestyle changes.
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This question is part of the following fields:
- Haematology & Oncology
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Question 14
Incorrect
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A young man is reviewed for difficulty breathing. Lung function tests showed that his peak expiratory flow rate is 54% below the normal range for his age and height. What is a possible diagnosis?
Your Answer: Kyphoscoliosis
Correct Answer: Asthma
Explanation:Peak Expiratory Flow (PEF), also called Peak Expiratory Flow Rate (PEFR) is a person’s maximum speed of expiration, as measured with a peak flow meter. Measurement of PEFR requires some practise to correctly use a meter and the normal expected value depends on a patient’s gender, age and height.
It is classically reduced in obstructive lung disorders, such as Asthma, COPD or Cystic Fibrosis. -
This question is part of the following fields:
- Respiratory System
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Question 15
Incorrect
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A 63-year-old man with known allergic bronchopulmonary aspergillosis presents to the A&E Department with an exacerbation. Which therapy represents the most appropriate management?
Your Answer: Intravenous voriconazole
Correct Answer: Oral glucocorticoids
Explanation:Allergic bronchopulmonary aspergillosis (ABPA) is a form of lung disease that occurs in some people who are allergic to Aspergillus. With ABPA, this allergic reaction causes the immune system to overreact to Aspergillus leading to lung inflammation. ABPA causes bronchospasm (tightening of airway muscles) and mucus build-up resulting in coughing, breathing difficulty and airway obstruction.
Treatment of ABPA aims to control inflammation and prevent further injury to your lungs. ABPA is a hypersensitivity reaction that requires treatment with oral corticosteroids. Inhaled steroids are not effective. ABPA is usually treated with a combination of oral corticosteroids and anti-fungal medications. The corticosteroid is used to treat inflammation and blocks the allergic reaction. Examples
of corticosteroids include: prednisone, prednisolone or methylprednisolone. Inhaled corticosteroids alone – such as used for asthma treatment – are not effective in treating ABPA. Usually treatment with an oral corticosteroid is needed for months.The second type of therapy used is an anti-fungal medication, like itraconazole and voriconazole. These medicines help kill Aspergillus so that it no longer colonizes the airway. Usually one of these drugs is given for at least 3 to 6 months. However, even this treatment is not curative and can have side effects.
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This question is part of the following fields:
- Respiratory System
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Question 16
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 17
Incorrect
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A homeless woman presented with a cough and fever for the last 3 months. She also complained of night sweats and weight loss. Her CXR showed lung opacities. What is the next appropriate step for this patient?
Your Answer: Mantoux test
Correct Answer: Acid fast bacilli
Explanation:History and CXR are suggestive of tuberculosis. Acid fast bacilli should be seen on microscopy to confirm the diagnosis.
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This question is part of the following fields:
- Infectious Diseases
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Question 18
Correct
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A 50-year-old heavy drinker is brought to the A&E in a drowsy state. He is responding to questions however on examination he has nystagmus and hyper-reflexia. His MCV is 103fL.What is the most likely cause for his cognitive impairment?
Your Answer: B1 Deficiency
Explanation:Thiamine deficiency is very common with alcoholism. It manifests by Wernicke-Korsakoff encephalopathy. The patient is usually agitated, with an abnormal gait and amnesia.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 19
Incorrect
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A 15-year-old girl is referred to the paediatric unit with reduced urine output and lethargy. She has been passing bloody diarrhoea for the past four days. On admission she appears dehydrated. Bloods show the following:
Na+ 142 mmol/l
K+ 4.8 mmol/l
Bicarbonate 22 mmol/l
Urea 10.1 mmol/l
Creatinine 176 µmol/l
Hb 10.4 g/dl
MCV 90 fl
Plt 91 * 109/l
WBC 14.4 * 109/l
Given the likely diagnosis, which one of the following organisms is the most likely cause?Your Answer: Shigella
Correct Answer: E. coli
Explanation:The likely diagnosis in this case is Haemolytic Uremic Syndrome (HUS), which is generally seen in young children presenting with a triad of symptoms, namely: acute renal failure, microangiopathic haemolytic anaemia, and thrombocytopenia. The typical cause of HUS is ingestion of a strain of Escherichia coli.
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This question is part of the following fields:
- Infectious Diseases
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Question 20
Incorrect
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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: Spironolactone therapy
Correct 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 21
Correct
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Which of the following skin conditions is not associated with diabetes mellitus?
Your Answer: Sweet's syndrome
Explanation:Diabetic dermadromes constitute a group of cutaneous conditions commonly seen in people with diabetes with longstanding disease. Conditions included in this group are:
– Acral dry gangrene
– Carotenosis
– Diabetic dermopathy
– Diabetic bulla
– Diabetic cheiroarthropathy
– Malum perforans
– Necrobiosis lipoidica
– Limited joint mobility
– Scleroderma
– Waxy skin is observed in roughly 50%. Sweet’s syndrome is also known as acute febrile neutrophilic dermatosis has a strong association with acute myeloid leukaemia. It is not associated with diabetes mellitus. -
This question is part of the following fields:
- The Skin
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Question 22
Incorrect
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The family of a 10-year-old boy was advised to take the boy to see an oncologist, for suspected lymphoma. The boy had lymphadenopathy on presentation. His mother says that he's had a fever, night sweats and has experienced weight loss. The boy underwent a lymph node biopsy at the oncologist which suggests Burkitt's lymphoma. Which oncogene are you expecting to see after molecular testing?
Your Answer: p53
Correct Answer: c-MYC
Explanation:Burkitt lymphoma is a germinal centre B-cell-derived cancer that was instrumental in the identification of MYC as an important human oncogene more than three decades ago. Recently, new genomics technologies have uncovered several additional oncogenic mechanisms that cooperate with MYC to create this highly aggressive cancer.
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This question is part of the following fields:
- Haematology & Oncology
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Question 23
Incorrect
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A 26-year-old patient, previously fit and well, is admitted with fluctuating confusion and frank haematuria. He has recently been complaining of generalised malaise and joint pains. Examination reveals jaundice, splenomegaly, and petechiae. His blood pressure is 155/84 mmHg, temperature 37.9oC.
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Initial investigations reveal:
Haemoglobin 9.5 g/dl
White cell count 12 × 109/l
Platelets 40 × 109/l
Creatinine 142 μmol/l
Sodium 139 mmol/l
Potassium 4.5 mmol/l
Urea 9.2 mmol/l
Lactate dehydrogenase 495 U/l (10-250)
Urinalysis Protein ++, blood +++
Blood film shows schistocytes
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What treatment should NOT be given to this patient?Your Answer: Plasma exchange with fresh frozen plasma
Correct Answer: Platelet transfusion
Explanation:There is a strong suspicion of Thrombotic Thrombocytopenic Purpura (TTP) in this patient as he presents with neurological changes (from confusion to convulsions and coma), fever, haemolysis, thrombocytopenia, and renal failure. Additionally, TTP cases may present with jaundice, splenomegaly, and hypertension as seen in this patient. With a diagnosis of TTP, recent studies have shown that platelet transfusion is not recommended in this case because it has been shown to increase the risk for arterial thrombosis and mortality possibly due to increased aggregations.
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This question is part of the following fields:
- Renal System
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Question 24
Incorrect
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A 30-year-old man has been unwell for the last 3 weeks and now developed a rash. Chickenpox is diagnosed.
What is the appropriate treatment?Your Answer: No medication
Correct Answer: Acyclovir
Explanation:You may treat chickenpox with acyclovir if it is commenced within the first 24 hours of the rash’s appearance. Erythromycin, doxycycline, and ampicillin would not help because it’s a viral infection (Varicella) not a bacterial infection.
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This question is part of the following fields:
- Infectious Diseases
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Question 25
Correct
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A 40-year-old male is awaiting a liver biopsy. Which of the following is the most important investigation that has to be performed prior to the procedure?
Your Answer: Coagulation profile
Explanation:As the liver is highly vascular, there is a high risk of bleeding during and after the procedure. Patients may have existing liver diseases, which affect the production of clotting factors. So a coagulation profile is necessary to detect any abnormality and correct them prior to the liver biopsy.
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This question is part of the following fields:
- Hepatobiliary System
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Question 26
Correct
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A 25-year-old female presented with blisters on the tongue. Some of them secreted pinkish fluid while some were crusted. Which of the following is the most probable diagnosis?
Your Answer: HSV1
Explanation:The history is suggestive of acute gingivostomatitis, which is a manifestation of primary HSV-1 infection. Patients present with gingivitis and vesicular lesions which develop on the oral mucosa, tongue, and lips and later rupture and coalesce, leaving ulcerated plaques.
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This question is part of the following fields:
- Infectious Diseases
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Question 27
Correct
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A 21 year-old male, who is a known alcoholic, presents with a fever, haemoptysis, green sputum and an effusion clinically. There is concern that it may be an empyema.
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Which test would be most useful to resolve the suspicion?Your Answer: Pleural fluid pH
Explanation:If a pleural effusion is present, a diagnostic thoracentesis may be performed and analysed for pH, lactate dehydrogenase, glucose levels, specific gravity, and cell count with differential. Pleural fluid may also be sent for Gram stain, culture, and sensitivity. Acid-fast bacillus testing may also be considered and the fluid may be sent for cytology if cancer is suspected.
The following findings are suggestive of an empyema or parapneumonic effusion that will likely need a chest tube or pigtail catheter for complete resolution:
-Grossly purulent pleural fluid
-pH level less than 7.2
-WBC count greater than 50,000 cells/µL (or polymorphonuclear leukocyte count of 1,000 IU/dL)
-Glucose level less than 60 mg/dL
-Lactate dehydrogenase level greater than 1,000 IU/mL
-Positive pleural fluid cultureThe most often used golden criteria for empyema are pleural effusion with macroscopic presence of pus, a positive Gram stain or culture of pleural fluid, or a pleural fluid pH under 7.2 with normal peripheral blood ph.
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This question is part of the following fields:
- Respiratory System
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Question 28
Correct
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A 57-year-old, alcoholic male was admitted to the medical ward for an ascitic tap. The ascitic fluid was found to be yellow in colour. Which of the following had most likely lead to this observation?
Your Answer: Decompensated cirrhosis
Explanation:Uncomplicated cirrhotic ascites is usually translucent. If the patient is deeply jaundiced, the fluid might appear yellow/brown.
Turbidity or cloudiness of the ascites fluid suggests that infection is present and further diagnostic testing should be performed.
Pink or bloody fluid is most often caused by mild trauma, with subcutaneous blood contaminating the sample.
Bloody ascites is also associated with hepatocellular carcinoma or any malignancy-associated ascites.
Milky-appearing fluid usually has an elevated triglyceride concentration. Such fluid, commonly referred to as chylous ascites, can be related to thoracic duct injury or obstruction or lymphoma, but it is often related primarily to cirrhosis. -
This question is part of the following fields:
- Hepatobiliary System
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Question 29
Correct
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A 59-year-old patient presents with altered bowel habits and bleeding per rectum. Exam and sigmoidoscopy showed an ulcer. What is the single most likely diagnosis?
Your Answer: Colorectal carcinoma
Explanation:The patient’s symptoms along with his age indicates a diagnosis of colorectal cancer. Blood test marker CA-19-9 is a prognostic index for colorectal cancer which confirms the suspicion. Celiac disease is not usually associated with bleeding per rectum and it is associated with a reaction to products containing gliadin. Crohn’s disease and UC are inflammatory bowel diseases and on endoscopy, show many other features of inflammation and not just a single ulcer. A patient with IBS will also have bloating and intermittent diarrhoea with constipation.
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This question is part of the following fields:
- Gastrointestinal System
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Question 30
Incorrect
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A 24-year-old gentleman presents with visual loss in his right eye, and this is diagnosed as optic neuritis.
Which one of the following statements would be seen in an afferent pupillary defect?Your Answer: Pupil of affected eye larger than the unaffected eye
Correct Answer: Accommodation response is unaffected
Explanation:Afferent pupillary defect is simply a delayed pupillary response to light. Accommodation is otherwise unaffected.
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This question is part of the following fields:
- Nervous System
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SESSION STATS - PERFORMANCE PER SPECIALTY
