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Question 1
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A 33-year-old male presented with complaints of arthritis involving the knee joint. O/E the overlying joint was red, swollen and tender. The patient also gave a history of constipation and noting a change in his shoe size. The most likely diagnosis in this patient would be?
Your Answer: Pseudogout
Explanation:Pseudogout is caused by the deposition of calcium pyrophosphate crystals and effects the large joints, as compared to gout where the small joints are usually involved. The joint tends to be tender, swollen and warm, giving a picture of cellulitis. Pseudogout has an association with hypothyroidism, therefore symptoms of dry skin and constipation can also be present.
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This question is part of the following fields:
- Musculoskeletal System
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Question 2
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Question 3
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A 53-year-old diabetic man presents to the emergency with pain in left loin and haematuria that was sudden in onset. Investigations revealed an 8mm stone in the left lower ureter. Supportive therapy was initiated with nifedipine and steroids. The patients returned to the emergency with vomiting and worsening pain and passage of two stones. Renal function tests are significant for an impending ARF. Which of the following steps would be employed in the management of this patient?
Your Answer: Percutaneous nephrostomy
Explanation:Nephrolithiasis encompasses the formation of all types of urinary calculi in the kidney, which may deposit along the entire urogenital tract from the renal pelvis to the urethra. Nephrolithiasis manifests as sudden onset colicky flank pain that may radiate to the groin, testes, or labia (renal/ureteric colic) and is usually associated with haematuria.
Risk factors include low fluid intake, high-sodium, high-purine, and low-potassium diets, which can raise the calcium, uric acid, and oxalate levels in the urine and thereby promote stone formation.
Diagnostics include noncontrast spiral CT of the abdomen and pelvis or ultrasound to detect the stone, as well as urinalysis to assess for concomitant urinary tract infection and serum BUN/creatinine to evaluate kidney function. Urinary stones are most commonly composed of calcium oxalate. Less common stones are made up of uric acid, struvite (due to infection with urease-producing bacteria), calcium phosphate, or cystine.
Small uncomplicated stones without concurrent infection or severe dilation of the urinary tract may be managed conservatively with hydration and analgesics to promote spontaneous stone passage. When the spontaneous passage appears unlikely or fails due to the stone’s size or location, first-line urological interventions include shock wave lithotripsy, ureterorenoscopy, and, in case of large kidney stones, percutaneous nephrolithotomy. The most important preventive measure is adequate hydration.
Collected stones should be sent for chemical analysis because in many cases specific lifestyle guidance, diet changes, and/or initiation of medical treatment (e.g., thiazide diuretics, urine alkalinisation) can prevent future stone formation. -
This question is part of the following fields:
- Renal System
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Question 4
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A 45-year-old male presents to A&E, after hitting his car multiple times when reversing. He complains of double vision when he looked back during reversing. He also complains of double vision when looking with an outward gaze. Which is the nerve involved in this patient?
Your Answer: Abducent nerve
Explanation:This nerve is responsible for the side to side movement of the eye, hence why damage can cause double vision.
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This question is part of the following fields:
- Nervous System
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Question 5
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A 60-year-old male presents with thickened patches of skin over his knuckles and extensor surfaces that are consistent with Gottron's papules. Results reveal an elevated creatine kinase. Diagnosis of dermatomyositis is suspected. Which of the following autoantibody is most specific for this condition?
Your Answer: Anti-Mi-2 antibodies
Explanation:Anti-Mi-2 antibodies are highly specific for dermatomyositis, but sensitivity is low; only 25% of patients with dermatomyositis demonstrate these antibodies. A positive antinuclear antibody (ANA) finding is common in patients with dermatomyositis, but is not necessary for diagnosis. Anti-Jo-1 antibodies are mostly associated with polymyositis. Anti Scl-70 antibodies and anti centromere antibodies are most commonly found in systemic scleroderma.
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This question is part of the following fields:
- Musculoskeletal System
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Question 6
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A 14 year-old is brought to the ED after being hit on the head with a cricket ball during a match. His teacher describes that he initially collapsed on the ground and complained of a sore head. Two minutes later, he got up and said he felt OK and continued playing. However, 30 minutes later he suddenly collapsed and lost consciousness. What injury is he most likely to have sustained?
Your Answer: Extradural haematoma
Explanation:A lucid interval, in which the patient portrays a temporary improvement in condition after a traumatic brain injury, is especially indicative of an epidural haematoma.
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This question is part of the following fields:
- Nervous System
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Question 7
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While investigating a patient with hepatocellular carcinoma (HCC), blood tests reveal a raised level of serum ferritin. What would be the most probable cause for HCC in this patient?
Your Answer: Haemochromatosis
Explanation:Haemochromatosis is the excessive accumulation of iron in the body mainly involving the liver, pancreas, testes, skin etc. Serum ferritin is high indicating iron overload. Haemochromatosis is a known cause for chronic liver cell disease, cirrhosis and HCC.
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This question is part of the following fields:
- Gastrointestinal System
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Question 8
Incorrect
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Which one of the following is true regarding Escherichia coli infection?
Your Answer: The O157:H7 strain is typically spread via shellfish
Correct Answer: E coli is an important cause of neonatal meningitis
Explanation:Escherichia coli (also known as E. coli) is a gram-negative, facultatively anaerobic, rod-shaped bacterium commonly found in the lower intestine of warm-blooded organisms. Most E. coli strains are harmless, but some serotypes can cause serious food poisoning in their hosts, and are occasionally responsible for product recalls due to food contamination. The harmless strains are part of the normal flora of the gut, and can benefit their hosts by producing vitamin K2, and preventing colonization of the intestine with pathogenic bacteria. Virulent strains can cause gastroenteritis, urinary tract infections, and neonatal meningitis.
The most common causes of neonatal meningitis is bacterial infection of the blood, known as bacteremia (specifically Group B Streptococci (GBS; Streptococcus agalactiae), Escherichia coli, and Listeria monocytogenes). Although there is a low mortality rate in developed countries, there is a 50% prevalence rate of neurodevelopmental disabilities in E. coli and GBS meningitis -
This question is part of the following fields:
- Infectious Diseases
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Question 9
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An 18-year-old girl presents with short history of marked, right hip pain and an associated limp. She has a history of acute lymphoblastic leukaemia for which she completed treatment for last six months.
Your Answer: Avascular necrosis of the femoral head
Explanation:Avascular necrosis (AVN) of the femoral head is a pathological process that results from disruption of the blood supply to the bone and occurs most commonly in the femoral epiphysis. Patients usually present with pain and limited joint motion. The mechanism involves impaired circulation to a specific area that ultimately becomes necrotic. AVN is most frequently associated with high doses of oral and intravenous corticosteroids and prolonged duration of therapy. Cancer patients receiving chemotherapy are usually also treated with corticosteroids.
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This question is part of the following fields:
- Musculoskeletal System
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Question 10
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Which of the following is the most common clinical feature of carbon monoxide poisoning?
Your Answer: Headache
Explanation:The symptoms and signs of carbon monoxide poisoning are variable and nonspecific. The most common symptoms of CO poisoning are headache, dizziness, weakness, nausea, vomiting, chest pain, and altered mental status.
The clinical presentation of CO poisoning is the result of its underlying systemic toxicity. Its effects are caused not only by impaired oxygen delivery but also by disrupting oxygen utilization and respiration at the cellular level, particularly in high-oxygen demand organs (i.e., heart and brain).
Symptoms of severe CO poisoning include malaise, shortness of breath, headache, nausea, chest pain, irritability, ataxia, altered mental status, other neurologic symptoms, loss of consciousness, coma, and death; signs include tachycardia, tachypnea, hypotension, various neurologic findings including impaired memory, cognitive and sensory disturbances; metabolic acidosis, arrhythmias, myocardial ischemia or infarction, and noncardiogenic pulmonary edema, although any organ system might be involved.
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This question is part of the following fields:
- Pharmacology
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Question 11
Incorrect
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A 27-year-old realtor presented with progressive weakness of both legs over the last 3 years. He complained of being unable to see well at night and having an impaired sense of smell. On examination he had a shortened fourth toe bilaterally with pes cavus. Neurological examination revealed a loss of pinprick sensation to bilateral knees, and weakness of both legs that was more prominent distally. Which of the following would be the best blood test to order to make a diagnosis?
Your Answer: ANCA
Correct Answer: Phytanic acid
Explanation:The diagnosis is Refsum’s disease. This is an autosomal recessive disorder that causes a sensorimotor peripheral neuropathy. It is caused by defective alpha oxidation of phytanic acid leading to its accumulation in tissues. Cardiac conduction abnormalities and cardiomyopathies may also occur.
Epiphyseal dysplasia causes a characteristic shortening of the fourth toe. Serum phytanic acid levels are elevated. Treatment is by dietary restriction of foods containing phytanic acid (dairy products, fish, beef and lamb). -
This question is part of the following fields:
- Nervous System
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Question 12
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A 60-year-old female presented after an acute overdose of amiodarone. Her blood pressure was 110/70 mmHg and pulse rate was 35 bpm. She was given 500 mcg of atropine but there was no response. Which of the following is the most appropriate next step?
Your Answer: Isoprenaline
Explanation:Permanent pacing is not indicated as the bradycardia is reversible. Temporary pacing is the definite treatment. Isoprenaline can be used until temporary pacing is available.
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This question is part of the following fields:
- Cardiovascular System
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Question 13
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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: 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.
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This question is part of the following fields:
- The Skin
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Question 14
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Which of the following is not a recognised feature of methemoglobinemia?
Your Answer: Decreased pO2 but normal oxygen saturation
Explanation:Normal pO2 but decreased oxygen saturation is characteristic of methemoglobinemia.
Methemoglobinemia is a rare condition in which the haemoglobin iron is in oxidized or ferric state (Fe3+) and cannot reversibly bind oxygen. Normally, the conversion of ferrous form of iron (Fe2+) to its ferric form (Fe3+) is regulated by NADH methaemoglobin reductase, which results in the reduction of methaemoglobin to haemoglobin. Disruption in the enzyme leads to increased methaemoglobin in the blood. There is tissue hypoxia as Fe3+ cannot bind oxygen, and hence the oxygen-haemoglobin dissociation curve is shifted to the left.
Methemoglobinemia can occur due to congenital or acquired causes. Congenital causes include haemoglobin variants such as HbM and HbH, and deficiency of NADH methaemoglobin reductase. Acquired causes are drugs (e.g. sulphonamides, nitrates, dapsone, sodium nitroprusside, and primaquine) and chemicals (such as aniline dyes).
The features of methemoglobinemia are cyanosis, dyspnoea, anxiety, headache, severe acidosis, arrhythmias, seizures, and loss of consciousness. Patients have normal pO2 but oxygen saturation is decreased. Moreover, presence of chocolate-brown coloured arterial blood (colour does not change with addition of O2) and brown urine also point towards the diagnosis of methemoglobinemia.
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This question is part of the following fields:
- Haematology & Oncology
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Question 15
Incorrect
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A young girl presents to the clinic complaining of episodic headaches that usually last for 2-3 days. These headaches are preceded by fortification spectra. During these episodes, the patient prefers to stay in a quiet and dark room. How will you manage the acute stage?
Your Answer: Cafergot
Correct Answer: Aspirin
Explanation:Migraine is characterized by recurrent episodes of typically unilateral, localized headaches that are frequently accompanied by nausea, vomiting, and sensitivity to light and sound. In approximately 25% of cases, patients experience an aura preceding the headache, which involves reversible focal neurologic abnormalities, for example, visual field defects (scotomas) or paresis lasting less than an hour. Migraine is a clinical diagnosis. Treatment of attacks consists of general measures (e.g., bedrest and protection from outer stimuli) together with administration of nonsteroidal anti-inflammatory drugs (e.g., aspirin) and antiemetics (e.g., prochlorperazine) if nausea is present. In severe cases, triptans may be added. Prophylactic treatment (e.g., beta blockers) may be indicated if migraines are especially frequent or long lasting, or if abortive therapy fails or is contraindicated.
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This question is part of the following fields:
- Pharmacology
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Question 16
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A 70-year-old female from a nursing home presented in the emergency department with complaints of headache, blurred vision and confused state for the last 4 to 5 days. On examination, she has several bruises on her head. Which of the following is the most likely cause behind the confused state of this patient?
Your Answer: Subdural hematoma
Explanation:Bruises on her head are suggestive of a head injury. Confused state with a headache and blurred vision are due to a subdural hematoma.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 17
Incorrect
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A 21-year-old patient is referred to the tertiary neurology clinic because of a possible diagnosis of Juvenile Parkinson's disease. His symptoms began predominantly with dystonia affecting the lower limbs, but he now has more classical signs of older onset Parkinson's including tremor, bradykinesia, and rigidity.
You map out his family tree and understand that his sister developed Parkinson's at the age of 16 but that his parents do not have signs of Parkinson's.
Which of the following is the most likely mode of inheritance?Your Answer: Autosomal dominant
Correct Answer: Autosomal recessive
Explanation:Juvenile Onset Parkinson’s is an autosomal recessive condition that usually presents in late childhood to early adulthood, initially with gait disorders caused by lower limb dystonia that later develops to the more classical signs Parkinson’s.
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This question is part of the following fields:
- Nervous System
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Question 18
Incorrect
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A 56-year-old female patient is complaining of a swollen upper limb after an insect bite. Although the bite site looks better, the gross oedema is still present. What is the most likely aetiology? Keep in mind that she has a history of breast cancer and radical mastectomy with axillary lymphadenectomy 10 years ago.
Your Answer: Filariasis
Correct Answer: Lymphedema
Explanation:Lymphedema is most commonly the result of removal or damage to lymph nodes.
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This question is part of the following fields:
- The Skin
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Question 19
Incorrect
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During the examination of an elderly confused and non-coherent gentleman who was brought to casualty by a concerned neighbour, you notice that he has bilaterally small pupils, which do not appear to react to light. Under the circumstances, it is difficult to judge their response to accommodation.
Which of the following conditions may not account for the pupillary appearance in this patient?Your Answer: Pilocarpine eye drops for glaucoma
Correct Answer: Acute alcohol intoxication
Explanation:Acute alcohol intoxication presents with pupillary dilation, thus, this is ruled out in this patient. All the other listed causes present with small pupils bilaterally.
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This question is part of the following fields:
- Nervous System
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Question 20
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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.
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This question is part of the following fields:
- Ethical & Legal
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SESSION STATS - PERFORMANCE PER SPECIALTY
