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Question 1
Correct
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Question 2
Incorrect
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A clinical trial is conducted to study the benefits of a new oral medication to improve the symptoms of patients with asthma. In the trial 400 patients with asthma, half were given the new medication and half a placebo. Three months later they are asked to rate their symptoms using the following scale: much improved, slight improvement, no change, slight worsening, significantly worse. What is the most appropriate statistical test to see whether the new medication is beneficial?
Your Answer: Student's t-test (unpaired)
Correct Answer: Mann-Whitney U test
Explanation:The type of significance test used depends on whether the data is parametric (can be measured, usually normally distributed) or non-parametric.
Parametric tests:
Student’s t-test – paired or unpaired*
Pearson’s product-moment coefficient – correlationNon-parametric tests:
Mann-Whitney U test – unpaired data
Wilcoxon signed-rank test – compares two sets of observations on a single sample
chi-squared test – used to compare proportions or percentages
Spearman, Kendall rank – correlation.The outcome measured is not normally distributed, i.e. it is non-parametric. This excludes the Student’s t-tests. We are not comparing percentages/proportions so the chi-squared test is excluded. The Mann-Whitney U test is a nonparametric test of the null hypothesis that it is equally likely that a randomly selected value from one sample will be less than or greater than a randomly selected value from a second sample.
This test can be used to investigate whether two independent samples were selected from populations having the same distribution. -
This question is part of the following fields:
- Evidence Based Medicine
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Question 3
Incorrect
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A 30-year-old woman presents with amenorrhoea and galactorrhoea. She has normal visual fields. You are concerned that she may have a prolactinoma.
Investigations were done and the results are as shown below:
Hb 12.5 g/dl
WCC 4.9 x109/l
PLT 199 x109/l
Na+ 140 mmol/l
K+ 4.9 mmol/l
Creatinine 90 ىmol/l
Prolactin 1150 mU/l
MRI shows a 7 mm pituitary microadenoma.
Which of the following hormones would you expect to be lower than normal?Your Answer: GH
Correct Answer: LH
Explanation:Prolactinomas, benign lesions that produce the hormone prolactin, are the most common hormone-secreting pituitary tumours.
Based on its size, a prolactinoma can be classified as a microprolactinoma (< 10 mm diameter) or a macroprolactinoma (>10 mm diameter). If the prolactinoma is large enough to compress the surrounding normal hormone-secreting pituitary cells, it may result in deficiencies of one or more hormones (e.g., thyroid-stimulating hormone [TSH], growth hormone [GH], adrenocorticotropic hormone). However, the patient has microadenoma so it is unlikely to cause compression manifestations.
Hyperprolactinemia inhibits GnRH secretion from the medial basal hypothalamus and LH release from the pituitary. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 4
Correct
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Where is the site of action of spironolactone?
Your Answer: Distal convoluted tubule
Explanation:Spironolactone is an aldosterone antagonist which acts in the distal convoluted tubule. It is a potassium-sparing diuretic that prevents the body from absorbing too much salt and keeps the potassium levels from getting too low. Spironolactone is used to treat heart failure, high blood pressure (hypertension), or hypokalaemia (low potassium levels in the blood).
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This question is part of the following fields:
- Pharmacology
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Question 5
Incorrect
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An 82-year-old woman is brought in by her carer with fluctuating consciousness. On examination she is deeply jaundiced, hypotensive with a tachycardia and has a hepatic flap. Initial blood tests reveal an ALT of 1000 U/l, INR 3.4, ALP 600 U/l and a bilirubin of 250 mmol/l.
Repeat blood tests 6 hours later show an ALT of 550 U/l, INR 4.6, ALP 702 U/l and bilirubin of 245 m mol/l. The toxicology screen for paracetamol and aspirin is negative; she is positive for hepatitis B surface antibody and negative for hepatitis B surface antigen.
Which of the following would best explain her clinical condition?Your Answer: Acute liver failure secondary to alcohol
Correct Answer: Acute liver failure secondary to paracetamol
Explanation:Liver flap is pathognomonic for liver failure. Paracetamol (also known as acetaminophen) overdose usually presents with symptoms including liver failure, resulting in confusion, jaundice, and coagulopathy a few days after overdose. The first 24 hours, people usually have minimal symptoms. Diagnosis is based on blood levels of acetaminophen at specific times after it was taken (see reference). If she took it a few days ago, levels may indeed be undetectable. The hepatitis B serology suggests prior vaccination. Wilson’s disease is not the most likely diagnosis given her presentation. The AST:ALT ratio would be expected to be reversed in alcohol induced liver failure.
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This question is part of the following fields:
- Hepatobiliary System
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Question 6
Correct
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A 15-year-old boy was admitted to the ED with a history of sudden onset chest pain and difficulty in breathing after strenuous exercise. On examination, there was reduced breath sounds on the right side but he was not cyanosed. He maintained oxygen sats of 93% on air. What is the single most appropriate investigation?
Your Answer: CXR
Explanation:The history and examination is suggestive of a spontaneous pneumothorax. The best investigation that can be performed at this stage is a CXR. Spontaneous primary pneumothorax occurs in the absence of a known lung pathology. Proposed risk factors shown to predispose patients to primary spontaneous pneumothorax (PSP) include smoking, family history, Marfan syndrome, homocystinuria, and thoracic endometriosis.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 7
Incorrect
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A 50-year-old man undergoes a colonoscopy due to the finding of blood in his stools. The colonoscopy revealed four polyps which were variable in size from one at 0.5cm, 2 at approximately 1.5cm and one at 2 cm.
When should this patient have a follow up colonoscopy?Your Answer: 6 months
Correct Answer: 3 years
Explanation:According to the British Society of Gastroenterology guidelines – this patient has 3-4 adenomas with 3 of them > 1 cm in size. This places him at medium risk and the recommendation is for a 3-year follow up period.
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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 is the most severe form among the following?
Your Answer: Class VI: sclerosing glomerulonephritis
Correct Answer: Class IV: diffuse proliferative glomerulonephritis
Explanation:The classes refer to the WHO classification of glomerulonephritis in SLE patients.
class I: normal kidney
class II: mesangial glomerulonephritis
class III: focal (and segmental) proliferative glomerulonephritis
class IV: diffuse proliferative glomerulonephritis
class V: diffuse membranous glomerulonephritis
class VI: sclerosing glomerulonephritisClass IV: diffuse proliferative glomerulonephritis is the most common and the most severe form, where more than 50% of the glomeruli are involved.
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This question is part of the following fields:
- Renal System
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Question 9
Incorrect
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Which of the following drugs is the strongest opioid?
Your Answer: Immediate-release morphine 10 mgs QDS orally
Correct Answer: Modified-release morphine 30 mg BD orally
Explanation:Modified release morphine in BD dose is the strongest opioid of the selection.
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This question is part of the following fields:
- Pharmacology
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Question 10
Correct
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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 11
Correct
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A 20-year-old man presents with an acute exacerbation of asthma associated with a chest infection. He is unable to complete a sentence and his peak flow rate was 34% of his normal level. He is treated with high-flow oxygen, nebulised bronchodilators, and oral corticosteroids for three days, but his condition has not improved.
Which of the following intravenous treatments would be the best option for this patient?Your Answer: Magnesium
Explanation:A single dose of intravenous magnesium sulphate is safe and may improve lung function and reduce intubation rates in patients with acute severe asthma. Intravenous magnesium sulphate may also reduce hospital admissions in adults with acute asthma who have had little or no response to standard treatment.
Consider giving a single dose of intravenous magnesium sulphate to patients with acute severe asthma (PEF <50% best or predicted) who have not had a good initial response to inhaled bronchodilator therapy. Magnesium sulphate (1.2-2 g IV infusion over 20 minutes) should only be used following consultation with senior medical staff.
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This question is part of the following fields:
- Respiratory System
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Question 12
Correct
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A 57-year-old female presented to the cardiology centre with a history of chest tightness for a few hours, accompanied by pain radiating to the left side of the shoulder and neck. ECG was normal. What is the next best investigation for this patient?
Your Answer: Cardiac enzymes
Explanation:This patient’s symptoms of angina radiating to the neck and shoulders gives a strong suspicion of MI. Cardiac enzymes such as troponins are highly specific and sensitive for a heart attack.
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This question is part of the following fields:
- Cardiovascular System
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Question 13
Incorrect
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A 36 year-old accountant presents with a sudden onset of headache which progressed to him collapsing. Upon arrival in A&E, he has a heart rate of 76 bpm, blood pressure 220/140, and Glasgow Coma Score of 9 (E2, M5, V2). Which of the following should be done immediately?
Your Answer: Give nimodipine 60 mg 4-hourly via a nasogastric tube
Correct Answer: Give high flow oxygen via a non-rebreather mask
Explanation:This man is likely suffering from a subarachnoid haemorrhage or intracerebral bleed. The priority is to prevent a secondary brain injury. Important first steps include ensuring a secure airway, normalizing cardiovascular function, and treating seizures. His airway is likely to be protected with a GCS of 9, although he may benefit from a nasal or oral airway, and close attention should be paid to his airway if going for a CT scan. He should receive high flow oxygen and his blood pressure should not be treated acutely, as i is often appropriate to compensate for a rise in intracranial pressure. Nimodipine should be given if a subarachnoid haemorrhage is proven. Attention should also be given to maintaining a normal blood sugar, as hyperglycaemia worsens outcomes.
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This question is part of the following fields:
- Nervous System
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Question 14
Correct
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A 54-year-old female presents with fatigue and xerostomia. Bloods tests reveal the following:
Hb 13.9 g/dl
WBC 6.1 *109/l
Platelets 246 *109/l
Bilirubin 33 µmol/l
ALP 292 u/l
ALT 47 u/l
What is the most likely diagnosis?Your Answer: Primary biliary cirrhosis
Explanation:With a bilirubin of 33, automatically the diagnosis from the choices listed is primary biliary cirrhosis or autoimmune hepatitis, not SLE, mono, or Primary Sjogren’s Syndrome. With autoimmune hepatitis, however, you would not expect such a high bilirubin and would expect very high AST/ALT, which here is just mildly elevated. This makes primary biliary cirrhosis the most likely answer. The classic presentation is itching in a middle-aged woman. The dry mouth is likely due to Sicca Syndrome, which occurs in 70% of cases of PBC, but with these liver function tests, PBC is most the likely answer.
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This question is part of the following fields:
- Hepatobiliary System
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Question 15
Correct
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A 20-year-old female is suffering from amenorrhea. She has a BMI of 14 but still thinks that she needs to lose weight. She watches her food intake obsessively. Choose the most likely diagnosis.
Your Answer: Anorexia nervosa
Explanation:Anorexia is consistent with the symptoms described.
Anorexia is an eating disorder characterised by an abnormally low body weight, an intense fear of gaining weight and a distorted perception of weight. People with anorexia place a high value on controlling their weight and shape, using extreme efforts that tend to significantly interfere with their lives.
Some people who have anorexia binge and purge, similar to individuals who have bulimia. But people with anorexia generally struggle with an abnormally low body weight, while individuals with bulimia typically are normal to above normal weight.
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This question is part of the following fields:
- Women's Health
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Question 16
Correct
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Raloxifene is used in the treatment of osteoporosis, which of the following best describes it?
Your Answer: A selective oestrogen receptor modulator
Explanation:Raloxifene is a selective oestrogen-receptor modulator (SERM) that has been approved for use in the prevention and treatment of osteoporosis in postmenopausal women.
A SERM interacts with oestrogen receptors, functioning as an agonist in some tissues and an antagonist in other tissues. Because of their unique pharmacologic properties, these agents can achieve the desired effects of oestrogen without the possible stimulatory effects on the breasts or uterus. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 17
Incorrect
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Which of the following is not a tumour suppressor gene?
Your Answer: APC
Correct Answer: myc
Explanation:Myc is a family of regulator genes and proto-oncogenes that code for transcription factors.
A tumor suppressor gene, or antioncogene, is a gene that protects a cell from one step on the path to cancer. When this gene mutates to cause a loss or reduction in its function, the cell can progress to cancer, usually in combination with other genetic changes. Tumor suppressor genes can be grouped into categories including caretaker genes, gatekeeper genes, and landscaper genes; the classification schemes are continually evolving.
Examples include:
Gene Associated cancers
p53 Common to many cancers, Li-Fraumeni syndrome
APC Colorectal cancer
BRCA1 Breast and ovarian cancer
BRCA2 Breast and ovarian cancer
NF1 Neurofibromatosis
Rb Retinoblastoma
WT1 Wilm’s tumour -
This question is part of the following fields:
- Haematology & Oncology
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Question 18
Correct
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The conductive system of the heart anatomically includes the:
Your Answer: Atrioventricular node
Explanation:The cardiac conduction system is a collection of nodes and specialised cells including the:
Sinoatrial node
Atrioventricular node
Atrioventricular bundle (bundle of His)
Purkinje fibres -
This question is part of the following fields:
- Cardiovascular System
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Question 19
Correct
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A 66-year-old gentleman is seen in the Emergency Department complaining of muscle weakness and lethargy. Admission bloods show the following:
Na+ 138 mmol/l
K+ 6.6 mmol/l
Bicarbonate 15 mmol/l
Urea 9.2 mmol/l
Creatinine 110 µmol/l
An ECG is done which shows no acute changes.
What is the most appropriate initial treatment to lower the serum potassium level?Your Answer: Insulin/dextrose infusion
Explanation:Insulin/dextrose infusion will increase the activity of the sodium-potassium pump in the cells, which will in turn decrease serum potassium levels.
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This question is part of the following fields:
- Renal System
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Question 20
Correct
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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.
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This question is part of the following fields:
- Endocrine System & Metabolism
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SESSION STATS - PERFORMANCE PER SPECIALTY
