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Question 1
Correct
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You are attending to a patient that has presented with a severe headache in the Emergency Department. The patient has signs of cerebral oedema and raised intracranial pressure.
You discuss the case with the on-call neurology registrar and decide to prescribe Mannitol. The nurse assisting you asks you to reconsider this management plan as she suspects the patient has a contraindication to Mannitol.
Out of the following, what is a contraindication to mannitol?Your Answer: Severe cardiac failure
Explanation:Mannitol is the most widely used osmotic diuretic that is most commonly used to reduce cerebral oedema and intracranial pressure.
It is recommended to use mannitol for the reduction of CSF pressure/cerebral oedema in a dose of 0.25-2 g/kg as an intravenous infusion over 30-60 minutes. This can be repeated 1-2 times after 4-8 hours if needed.Mannitol has several contraindications and some of them are listed below:
1. Anuria due to renal disease
2. Acute intracranial bleeding (except during craniotomy)
3. Severe cardiac failure
4. Severe dehydration
5. Severe pulmonary oedema or congestion
6. Known hypersensitivity to mannitol -
This question is part of the following fields:
- Cardiovascular Pharmacology
- Pharmacology
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Question 2
Correct
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Which of the following is NOT a typical clinical feature of diabetic ketoacidosis:
Your Answer: Cheyne–Stokes respiration
Explanation:Clinical features of DKA:
Symptoms: Polyuria, polydipsia, thirst, lethargy, weight loss, nausea, vomiting, anorexia, abdominal pain, dehydration, headache, altered mental state
Signs: Dry mucous membranes, ketotic breath, tachycardia, hypotension, Kussmaul breathing, focal signs of precipitant e.g. infection -
This question is part of the following fields:
- Endocrine
- Physiology
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Question 3
Incorrect
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Among the following infectious diseases, which is typically considered to have an incubation period of less than 3 weeks?
Your Answer: Infectious mononucleosis
Correct Answer: Diphtheria
Explanation:C. diphtheriae, which is the causative agent of diphtheria, is carried in the upper respiratory tract and spread by droplet infection or hand-to-mouth contact. The incubation period averages 2 to 5 days.
Infectious mononucleosis is caused by Epstein-Barr virus (EBV). The incubation period for EBV varies from 2 weeks to 2 months.
The incubation for Hepatitis A virus is approximately 1 month.
The incubation period for Hepatitis C ranges from 2 weeks to 6 months.
The period from infection to development of anti-HIV antibodies is usually less than 1 month but may be up to 3 months.
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This question is part of the following fields:
- Microbiology
- Specific Pathogen Groups
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Question 4
Correct
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Compliance is greater in all but which one of the following:
Your Answer: Pulmonary oedema
Explanation:Compliance changes at different lung volumes. Initially at lower lung volumes the compliance of the lung is poor and greater pressure change is required to cause a change in volume. This occurs if the lungs become collapsed for a period of time. At functional residual capacity (FRC) compliance is optimal since the elastic recoil of the lung tending towards collapse is balanced by the tendency of the chest wall to spring outwards. At higher lung volumes the compliance of the lung again becomes less as the lung becomes stiffer. At all volumes, the base of the lung has a greater compliance than the apex. Patients with emphysema have increased compliance. Compliance is affected by a person’s age, sex and height.
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This question is part of the following fields:
- Physiology
- Respiratory
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Question 5
Correct
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A 32-year old male patient has been diagnosed with meningococcal meningitis and was given appropriate treatments. Because he is a family man, he fears that he might transmit the infection to the rest of his family members.
The causative agent of meningococcal meningitis is spread via what mode of transmission?Your Answer: Respiratory droplet route
Explanation:N. meningitidis, the causative agent of meningococcal meningitis, is considered both a commensal and a pathogen. It can be found in the surfaces of mucous membranes such as the nasopharynx and oropharynx. With this, it can be transmitted from a carrier to a new host via respiratory droplet secretions.
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This question is part of the following fields:
- Microbiology
- Pathogens
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Question 6
Correct
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Which of the following acts to inhibit antidiuretic hormone (ADH) release from the posterior pituitary:
Your Answer: Atrial natriuretic peptide
Explanation:ADH release is inhibited by low plasma osmolality, alcohol, caffeine, glucocorticoids and atrial natriuretic peptide (ANP).
ADH release is stimulated primarily by raised plasma osmolality detected by osmoreceptors in the anterior hypothalamus. Other factors that increase ADH release include: extracellular fluid volume depletion, angiotensin II, nausea, pain, stress, exercise, emotion, hypoglycaemia.
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This question is part of the following fields:
- Endocrine
- Physiology
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Question 7
Correct
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A 66-year-old female with a history of stroke one year ago presents to the Family Medicine clinic complaining of fatigue, weight loss, and tongue discolouration. On examination, she seems malnourished, her tongue is beefy red, and an ataxic gait pattern is noticed.
Which ONE of the following conditions does this patient most likely have?Your Answer: Vitamin B12 deficiency
Explanation:A history of stroke and poor nutritional status points towards a nutritional deficiency as the most likely cause of her symptoms. The examination would differentiate between Vitamin B12 and Folic acid deficiency as in the former. The patient has a beefy red tongue and symptoms indicating peripheral nervous system involvement or subacute combined spinal cord degeneration. The patient may also have a lemon-yellow skin colour, loss of proprioception and vibratory sense and oral ulceration.
Investigations in B12 deficiency can reveal the following:
1. Macrocytic anaemia
2. Neutropoenia
3. Thrombocytopaenia
4. Blood film: anisocytosis, poikilocytosis
5. Low serum B12
6. Raised serum bilirubin (haemolysis)
7. Intrinsic factor antibodies
8. Positive Schilling test -
This question is part of the following fields:
- Haematology
- Pathology
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Question 8
Correct
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Which of the following is NOT a common side effect of antihistamines:
Your Answer: Tremor
Explanation:Common side effects of antihistamines may include:
Anticholinergic effects (blurred vision, dry mouth, urinary retention)
Headache
Gastrointestinal disturbances
Psychomotor impairment (sedation, dizziness and loss of appetite)
These side effects are significantly reduced with second-generation agents. -
This question is part of the following fields:
- Pharmacology
- Respiratory
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Question 9
Incorrect
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Polyuria and polydipsia develop in a patient with a history of affective disorder, who has been on long-term lithium treatment. She has a fluid deprivation test done because she is suspected of having nephrogenic diabetic insipidus. Which of the following urine osmolality findings would be the most reliable in confirming the diagnosis?
Your Answer: After fluid deprivation >300 mosmol/kg, after IM desmopressin <300 mosmol/kg
Correct Answer: After fluid deprivation <300 mosmol/kg, after IM desmopressin >800 mosmol/kg
Explanation:The inability to produce concentrated urine is a symptom of diabetes insipidus. Excessive thirst, polyuria, and polydipsia are all symptoms of this condition. There are two forms of diabetes insipidus: Nephrogenic diabetes insipidus and cranial (central) diabetes insipidus.
A lack of ADH causes cranial diabetic insipidus. Patients with cranial diabetes insipidus can have a urine output of up to 10-15 litres per 24 hours, however most patients can maintain normonatraemia with proper fluid consumption. Thirty percent of cases are idiopathic, while another thirty percent are caused by head injuries. Neurosurgery, brain tumours, meningitis, granulomatous disease (e.g. sarcoidosis), and medicines like naloxone and phenytoin are among the other reasons. There is also a very rare hereditary type that is linked to diabetes, optic atrophy, nerve deafness, and bladder atonia.
Renal resistance to the action of ADH causes nephrogenic diabetes insipidus. Urine output is significantly increased, as it is in cranial diabetes insipidus. Secondary polydipsia can keep serum sodium levels stable or raise them. Chronic renal dysfunction, metabolic diseases (e.g., hypercalcaemia and hypokalaemia), and medications, such as long-term lithium use and demeclocycline, are all causes of nephrogenic diabetes insipidus.
The best test to establish if a patient has diabetes insipidus vs another cause of polydipsia is the water deprivation test, commonly known as the fluid deprivation test. It also aids in the distinction between cranial and nephrogenic diabetes insipidus. Weight, urine volume, urine osmolality, and serum osmolality are all measured after patients are denied water for up to 8 hours. At the end of the 8-hour period, 2 micrograms of IM desmopressin is given, and measures are taken again at 16 hours.
The following are the way results are interpreted:
Urine osmolality after fluid deprivation : Urine osmolality after IM desmopressin
Cranial diabetes insipidus: <300 mosmol/kg : >800 mosmol/kg
Nephrogenic diabetes insipidus: <300 mosmol/kg : <300 mosmol/kg
Primary polydipsia: >800 mosmol/kg : >800 mosmol/kg -
This question is part of the following fields:
- Physiology
- Renal Physiology
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Question 10
Incorrect
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Identify the type of graph described below:
A graph that is a useful summary of a set of bivariate data (two variables), usually drawn before working out a linear correlation coefficient or fitting a regression line.Your Answer: Histogram
Correct Answer: Scatterplot
Explanation:A scatterplot is a useful summary of a set of bivariate data (two variables), usually drawn before working out a linear correlation coefficient or fitting a regression line. It gives a good visual picture of the relationship between the two variables, and aids the interpretation of the correlation coefficient or regression model. Each unit contributes one point to the scatterplot, on which points are plotted but not joined. The resulting pattern indicates the type and strength of the relationship between the two variables.
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This question is part of the following fields:
- Evidence Based Medicine
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Question 11
Incorrect
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Where does angiotensin II directly act on the renal nephron:
Your Answer: Collecting ducts
Correct Answer: Proximal tubule
Explanation:Angiotensin II acts to directly increase Na+reabsorption from the proximal tubule (by activating Na+/H+antiporters).
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This question is part of the following fields:
- Physiology
- Renal
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Question 12
Incorrect
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A thyroid function test is done for a 55-year-old woman with non-specific symptoms, the results are shown below:
TSH = 5.2
Free T4 is normal
Free T3 is normal
The most likely diagnosis in this patient is?
Your Answer: Primary hypothyroidism
Correct Answer: Subclinical hypothyroidism
Explanation:Hypothyroidism is diagnosed using the results of thyroid function tests (TFTs).
In the early stages of the disease, the earliest biochemical change noticed is a rise in thyroid-stimulating hormone (TSH) levels. Free triiodothyronine (T3) and thyroxine (T4) levels are usually normal.
In primary hypothyroidism, the serum TSH level is usually greater than 10 mU/L, and free T4 levels are below the reference range.
Subclinical hypothyroidism is diagnosed when the serum TSH level is above the reference range, and the free T4 levels are within the reference range. The test should, however, be repeated after 3-6 months to exclude transient causes of raised TSH.
In summary, how to interpret TFTs in cases of suspected hypothyroidism is shown below:
Subclinical hypothyroidism
TSH is raised
Free T4 is normal
Free T3 is normalPrimary hypothyroidism
TSH is raised
Free T4 is lowered
Free T3 is lowered or normalSecondary hypothyroidism
TSH is lowered or normal
Free T4 is lowered
Free T3 is lowered or normal -
This question is part of the following fields:
- Endocrine Physiology
- Physiology
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Question 13
Incorrect
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Identify the type of graph described below:
A graph wherein the frequency distribution is represented by adjoining vertical bars and cases are stacked in adjoining columns. It can be used for continuous quantitative data, such as to analyse outbreak data to show an epidemic curve.Your Answer: Forest plot
Correct Answer: Histogram
Explanation:A histogram is used to demonstrate the distribution of continuous quantitative data. It is a very familiar graphical display device for representing the distribution of a single batch of data. The range of the data is divided into class intervals or bins, and the number of values falling into each interval is counted. The histogram then consists of a series of rectangles whose widths are defined by the class limits implied by the binwidths, and whose heights depend on the number of values in each bin. Histograms quickly reveal such attributes of the data distribution as location, spread, and symmetry. If the data are multimodal (i.e., more than one “hump” in the distribution of the data), this is quickly evident as well.
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This question is part of the following fields:
- Evidence Based Medicine
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Question 14
Incorrect
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A 60-year-old patient had a sudden onset of palpitations and shortness of breath. He had a history of poorly controlled hypertension and ischemic heart disease. His ECG also shows atrial fibrillation. Based on the patient’s condition, which pharmacologic cardioversion would be best to use?
Your Answer: Adenosine
Correct Answer: Amiodarone
Explanation:Chemical cardioversion, or pharmacologic cardioversion, is the treatment of abnormal heart rhythms using drugs.
Flecainide and propafenone are examples of drugs used as chemical cardioverters.
However, given the situation of the patient, these drugs are contraindicated for his ischaemic heart disease. Amiodarone is also an antiarrhythmic drug and is the best choice for this situation.
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This question is part of the following fields:
- Cardiovascular
- Pharmacology
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Question 15
Incorrect
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Compliance is decreased by all but which one of the following:
Your Answer: Pulmonary fibrosis
Correct Answer: Aging
Explanation:Factors increasing compliance:
Old age
EmphysemaFactors decreasing compliance:
Pulmonary fibrosis
Pulmonary oedema
Atelectasis
Extremes of lung volumes (at higher lung volumes the compliance of the lung becomes less as the lung becomes stiffer) -
This question is part of the following fields:
- Physiology
- Respiratory
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Question 16
Incorrect
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Which of the following is considered an example of an observational study?
Your Answer: Double-blind trial
Correct Answer: Cohort study
Explanation:The two most common types of observational studies are cohort studies and case-control studies; a third type is cross-sectional studies.
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This question is part of the following fields:
- Evidence Based Medicine
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Question 17
Incorrect
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Which of the following does NOT affect the rate of flow of a liquid through a tube:
Your Answer: Pressure differences across the ends of the tube
Correct Answer: Surface tension
Explanation:Flow through a tube is dependent upon:
The pressure difference across the ends of the tube (P1– P2)
The resistance to flow provided by the tube (R)
This is Darcy’s law, which is analogous to Ohm’s law in electronics:
Flow = (P1– P2) / R
Resistance in the tube is defined by Poiseuille’s law, which is determined by the diameter of the tube and the viscosity of the fluid. Poiseuille’s law is as follows:
Resistance = (8VL) / (πR4)
Where:
V = The viscosity of the fluid
L = The length of the tube
R = The radius of the tube
Therefore, in simple terms, resistance is directly proportional to the viscosity of the fluid and the length of the tube and inversely proportional to the radius of the tube. Of these three factors, the most important quantitatively and physiologically is vessel radius.
It can be seen that small changes in the radius can have a dramatic effect on the flow of the fluid. For example, the constriction of an artery by 20% will decrease the flow by approximately 60%.
Another important and frequently quoted example of this inverse relationship is that of the radius of an intravenous cannula. Doubling the diameter of a cannula increases the flow rate by 16-fold (r4). This is the reason the diameter of an intravenous cannula in resuscitation scenarios is so important.
*Please note that knowledge of the detail of Poiseuille’s law is not a requirement of the RCEM Basic Sciences Curriculum. -
This question is part of the following fields:
- Basic Cellular
- Physiology
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Question 18
Incorrect
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You examine a child who has been admitted to the paediatric emergency department with a flu-like illness. His parents tell you that he was born with an inborn defect of steroid metabolism and that he was treated for it with hormone replacement therapy.
Which of the following is classified as a steroid hormone?
Your Answer: Noradrenaline
Correct Answer: Aldosterone
Explanation:Hormones can be classified into three categories depending on their chemical composition: amines, peptides (and proteins), and steroids. Amines are made up of single amino acids (for example, tyrosine), peptide hormones are made up of peptides (or proteins), and steroid hormones are made up of cholesterol.
The table below lists some prominent instances of each of these three hormone classes:1. Peptide hormone:
Adrenocorticotropic hormone (ACTH)
Prolactin
Vasopressin
Oxytocin
Glucagon
Insulin
Somatostatin
Cholecystokinin2. Amine hormone:
Adrenaline (epinephrine)
Noradrenaline (norepinephrine)
Dopamine3. Steroid hormone:
Mineralocorticoids (e.g. aldosterone)
Glucocorticoids (e.g. cortisol)
Progestogens
Androgens
Oestrogens -
This question is part of the following fields:
- Endocrine Physiology
- Physiology
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Question 19
Incorrect
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If the null hypothesis is wrongly rejected when it is actually true, this is an example of:
Your Answer: A test with a type II error
Correct Answer: A test with a type I error
Explanation:A type I error occurs when the null hypothesis is wrongly rejected when it is actually true and we conclude that there is a difference of effect when in reality there is none (a false positive result).
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This question is part of the following fields:
- Evidence Based Medicine
- Statistics
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Question 20
Incorrect
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A 34-year-old man presented to the emergency room after being involved in a road traffic accident. Upon observation and examination, it was noted that he was hypotensive and has muffled heart sounds. It was suspected that he has pericardial effusion, so an emergency pericardiocentesis was to be performed.
In performing pericardiocentesis for suspected pericardial effusion, which of the following anatomical sites are at risk of being punctured?Your Answer:
Correct Answer: 1 cm below the left xiphocostal angle
Explanation:Pericardiocentesis is a procedure done to remove fluid build-up in the sac around the heart known as the pericardium. The pericardium can be tapped from almost any reasonable location on the chest wall. However, for the usual blind pericardiocentesis, the subxiphoid approach is preferred. Ideally, 2-D echocardiography is used to guide needle insertion and the subsequent path of the needle/catheter.
In the subxiphoid approach, the needle is inserted 1 cm inferior to the left xiphocostal angle with an angle of 30 degrees from the patient’s chest with a direction towards the left mid-clavicle.
The fingers may sense a distinct give when the needle penetrates the parietal pericardium. Successful removal of fluid confirms the needle’s position.
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This question is part of the following fields:
- Abdomen And Pelvis
- Anatomy
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Question 21
Incorrect
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A 23-year-old male is referred to your haematology clinic after an acute attack of haemolytic anaemia. He was diagnosed with glucose-6-phosphate dehydrogenase deficiency ten years ago.
Which ONE of the following options is FALSE with regards to this disorder?Your Answer:
Correct Answer: Acute haemolysis can be triggered by cephalosporin antibiotics
Explanation:Glucose-6-phosphate dehydrogenase deficiency is an X-linked recessive disorder in which there is a deficiency of the enzyme G6PD. This causes instability of red blood cell membranes under oxidative stress leading to haemolysis.
Triggers include:
1) Fava beans
2) Sulphonamides
3) Primaquine
4) Anti-TB drugs
5) InfectionsMost individuals will be asymptomatic until exposed to one of the triggers listed above. It is the commonest human enzyme defect and affects males more than females because of the X-linked inheritance pattern. The use of penicillins and cephalosporins is generally safe.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 22
Incorrect
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A 70-year-old patient presents with a chronic digoxin overdose. She has vomited several times, is extremely tired, and her vision 'appears yellow,' according to her.
Which of the following is a reason for this patient's use of Digifab?Your Answer:
Correct Answer: Coexistent renal failure
Explanation:An antidote for digoxin overdose is digoxin-specific antibody (Digifab). It’s a lyophilized preparation of digoxin-immune ovine Fab immunoglobulin fragments that’s sterile, purified, and lyophilized. These fragments were extracted from the blood of healthy sheep that had been immunised with a digoxin derivative called digoxin-dicarboxymethoxylamine (DDMA), a digoxin analogue that contains the functionally important cyclopentaperhydrophenanthrene:lactone ring moiety coupled to keyhole limpet hemocyanin (KLH).
Digifab has a higher affinity for digoxin than digoxin does for its sodium pump receptor, which is thought to be the site of its therapeutic and toxic effects. When given to a patient who is intoxicated, Digifab binds to digoxin molecules, lowering free digoxin levels and shifting the equilibrium away from binding to receptors, reducing cardio-toxic effects. The kidney and reticuloendothelial system then clear the Fab-digoxin complexes.
The following summarises the indications for Digifab in acute and chronic digoxin toxicity:
Acute digoxin toxicity
Chronic digoxin toxicity
Cardiac arrest
Life-threatening arrhythmia
Potassium level > 5 mmol/l
>10 mg digoxin ingested (adult)
>4 mg digoxin ingested (child)
Digoxin level > 12 ng/ml
Cardiac arrest
Life-threatening arrhythmia
Significant gastrointestinal symptoms
Symptoms of digoxin toxicity -
This question is part of the following fields:
- Cardiovascular Pharmacology
- Pharmacology
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Question 23
Incorrect
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Regarding inflammatory bowel disease, acute mild to moderate disease of the rectum or rectosigmoid should be treated initially with:
Your Answer:
Correct Answer: Local aminosalicylate
Explanation:Acute mild to moderate disease affecting the rectum (proctitis) or the rectosigmoid is treated initially with local application of an aminosalicylate; alternatively, a local corticosteroid can be used but it is less effective. A combination of a local aminosalicylate and a local corticosteroid can be used for proctitis that does not respond to a local aminosalicylate alone.
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This question is part of the following fields:
- Gastrointestinal
- Pharmacology
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Question 24
Incorrect
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A pheochromocytoma is diagnosed in a 38-year-old female who has had episodes of acute sweating, palpitations, and paroxysmal hypertension.
Which of the following is the MOST SUITABLE INITIAL TREATMENT?Your Answer:
Correct Answer: Alpha-blocker
Explanation:A phaeochromocytoma is a rare functional tumour that develops in the adrenal medulla from chromaffin cells. Extra-adrenal paragangliomas (extra-adrenal pheochromocytomas) are tumours that arise in the sympathetic nervous system’s ganglia and are closely connected to extra-adrenal paragangliomas (extra-adrenal pheochromocytomas). Catecholamines are secreted by these tumours, which generate a variety of symptoms and indications associated with sympathetic nervous system hyperactivity.
Hypertension is the most prevalent presenting symptom, which can be continuous or intermittent.Symptoms are usually intermittent, occurring anywhere from many times a day to occasionally. The symptoms of the condition tend to grow more severe and frequent as the disease progresses.
The ultimate therapy of choice is surgical resection, and if full resection is done without metastases, hypertension is typically cured.Preoperative medical treatment is critical because it lowers the risk of hypertensive crises during surgery. This is commonly accomplished by combining non-competitive alpha-blockers (such as phenoxybenzamine) with beta-blockers. To allow for blood volume expansion, alpha-blockade should be started at least 7-10 days before surgery. Beta-blockade, which helps to regulate tachycardia and some arrhythmias, can be started after this is accomplished. Hypertensive crises can be triggered if beta-blockade is started too soon.
There should also be genetic counselling, as well as a search for and management of any linked illnesses. -
This question is part of the following fields:
- Endocrine Physiology
- Physiology
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Question 25
Incorrect
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Superficial fibular nerve palsy results in which of the following clinical features:
Your Answer:
Correct Answer: Loss of eversion of the foot
Explanation:Damage to the superficial fibular nerve results in loss of eversion of the foot and loss of sensation over the lower anterolateral leg and the dorsum of the foot.
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This question is part of the following fields:
- Anatomy
- Lower Limb
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Question 26
Incorrect
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A range of one standard deviation above and below the mean includes what approximate percentage of the sample values:
Your Answer:
Correct Answer: 0.68
Explanation:A range of one SD above and below the mean (+/- 1 SD) includes 68.2% of the sample values.
A range of two SD above and below the mean (+/- 2 SD) includes 95.4% of the sample values.
A range of three SD above and below the mean (+/- 3 SD) includes 99.7% of the sample values. -
This question is part of the following fields:
- Evidence Based Medicine
- Statistics
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Question 27
Incorrect
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A 32-year-old woman with a history of bipolar disorder exhibits lithium toxicity symptoms.
Which of the following is the MOST LIKELY feature to be present?Your Answer:
Correct Answer: Clonus
Explanation:Lithium toxicity manifests itself in the following ways:
Ataxia
Clonus
Coma
Confusion
Convulsions
Diarrhoea
Increased muscle tone
Nausea and vomiting
Nephrogenic diabetes insipidus
Renal failure
Tremor -
This question is part of the following fields:
- CNS Pharmacology
- Pharmacology
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Question 28
Incorrect
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When a child has chickenpox, how long should he or she be off from school?
Your Answer:
Correct Answer: Until all vesicles have crusted over
Explanation:To avoid the spread of infection, infected patients should be isolated. All lesions should be crusted over before children return to nursery or school, even if the standard exclusion time is 5 days.
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This question is part of the following fields:
- Microbiology
- Pathogens
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Question 29
Incorrect
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Which segment of the colon is most likely to be affected in diverticulitis?
Your Answer:
Correct Answer: Sigmoid colon
Explanation:Diverticulitis refers to inflammation and infection associated with a diverticulum and is estimated to occur in 10% to 25% of people with diverticulosis. Peridiverticular and pericolic infection results from a perforation (either macroscopic or microscopic) of a diverticulum, which leads to contamination, inflammation, and infection. The spectrum of disease ranges from mild, uncomplicated diverticulitis that can be treated in the outpatient setting, to free perforation and diffuse peritonitis that requires emergency laparotomy. Most patients present with left sided abdominal pain, with or without fever, and leucocytosis. The most common location for diverticulitis is the sigmoid colon.
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This question is part of the following fields:
- Abdomen And Pelvis
- Anatomy
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Question 30
Incorrect
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Fusidic acid is primarily indicated for infections caused by which of the following microorganisms:
Your Answer:
Correct Answer: Staphylococcal infections
Explanation:Fusidic acid is a narrow spectrum antibiotic used for staphylococcal infections, primarily topically for minor staphylococcal skin (impetigo) or eye infection. It is sometimes used orally for penicillin-resistant staphylococcal infection, including osteomyelitis or endocarditis, in combination with other antibacterials.
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This question is part of the following fields:
- Infections
- Pharmacology
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Question 31
Incorrect
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Regarding bile acids, which of the following statements is INCORRECT:
Your Answer:
Correct Answer: The main primary bile acids are deoxycholic acid and lithocholic acid.
Explanation:Bile acids have a hydrophobic and a hydrophilic end and in aqueous solution, bile salts orient themselves around droplets of lipid forming micelles to keep the lipid droplets dispersed. The principal primary bile acids are cholic acid and chenodeoxycholic acid. They are made more soluble by conjugation with taurine or glycine in the liver. Of the bile acids excreted into the intestine, about 95% are reabsorbed into the portal circulation by active transport mechanisms in the distal ileum and recycled by the liver.
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This question is part of the following fields:
- Gastrointestinal
- Physiology
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Question 32
Incorrect
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A 71-year-old man treated with antibiotics for a chest infection returns with a profuse, offensive smelling diarrhoea. A diagnosis of Clostridium difficile diarrhoea is made after investigations.
Which antibiotic is associated with the greatest risk of causing Clostridium Difficile diarrhoea?
Your Answer:
Correct Answer: Ciprofloxacin
Explanation:Clostridium difficile, a Gram-positive, anaerobic, spore forming bacteria is present in the gut of approximately 3% of healthy adults (2012 UK HPA estimates). Following use of broad spectrum antibiotics, which alter normal gut flora, Clostridium difficile infection (CDI) occurs. About 80% of Clostridium Difficile infections are seen in people over the age of 65 and its main clinical features are:
Abdominal cramps, severe bloody and/or watery diarrhoea, offensive smelling diarrhoea, and fever.CDI is the most severe consequence of antibiotic treatment and is a major cause of morbidity and mortality.
Risk for CDI has been found to be greatest with clindamycin followed by fluoroquinolones Tetracyclines are not associated with risk for CDI. -
This question is part of the following fields:
- Microbiology
- Specific Pathogen Groups
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Question 33
Incorrect
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You are treating a patient with a Clostridium difficile infection. His condition was found to be antibiotic-associated. Which of the following pieces of advice on preventing the spread of this disease should you give this patient?
Your Answer:
Correct Answer: Washing hands with soap and water
Explanation:Clostridium difficile (C. diff) can cause colitis, or inflammation of the colon.
To prevent its spread, one should practice good hand hygiene, regularly clean areas of the home that may become contaminated with C. difficile, practice good hand hygiene, and clean surfaces, spills, and accidents.
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This question is part of the following fields:
- Microbiology
- Principles
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Question 34
Incorrect
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The following are all important buffers of H+EXCEPT for:
Your Answer:
Correct Answer: Calcium
Explanation:Buffers are weak acids or bases that can donate or accept H+ions respectively and therefore resist changes in pH. Buffering does not alter the body’s overall H+load, ultimately the body must get rid of H+by renal excretion if the buffering capacity of the body is not to be exceeded and a dangerous pH reached. Bicarbonate and carbonic acid (formed by the combination of CO2 with water, potentiated by carbonic anhydrase) are the most important buffer pair in the body, although haemoglobin provides about 20% of buffering in the blood, and phosphate and proteins provide intracellular buffering. Buffers in urine, largely phosphate, allow the excretion of large quantities of H+.
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This question is part of the following fields:
- Physiology
- Renal
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Question 35
Incorrect
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During her pregnancy, a 28-year-old lady was given an antibiotic. The neonate is born with bilateral deafness as a result of this.
From the following antibiotics, which one is most likely to cause this side effect?Your Answer:
Correct Answer: Gentamicin
Explanation:Aminoglycosides cross the placenta and are linked to poisoning of the 8th cranial nerve in the foetus, as well as permanent bilateral deafness.
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This question is part of the following fields:
- Infections
- Pharmacology
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Question 36
Incorrect
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Which of the following side effects has limited the use of etomidate as an intravenous induction agent:
Your Answer:
Correct Answer: Adrenocortical suppression
Explanation:Etomidate causes the least cardiovascular depression of the intravenous induction agents, with only a small reduction in the cardiac output and blood pressure. In the past, etomidate was widely used to induce anaesthesia in the shocked, elderly or cardiovascularly unstable patient. However, more recently it has become less popular as a single induction dose blocks the normal stress-induced increase in adrenal cortisol production for 4 – 8 hours, and up to 24 hours in elderly and debilitated patients. Although no increase in mortality has been identified following a single dose during induction of anaesthesia, the use of etomidate has declined due to a perceived potential morbidity.
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This question is part of the following fields:
- Anaesthesia
- Pharmacology
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Question 37
Incorrect
-
A 26-year-old athlete presents with buttock pain after tearing his gluteus maximus muscle.
Which of the following is NOT an action of the gluteus maximus muscle? Select ONE answer only.Your Answer:
Correct Answer: Hip abduction
Explanation:Gluteus maximus is the main extensor muscle of the hip and assists with lateral rotation of the thigh at the hip joint. It also acts as a hip adductor, steadies the thigh, and assists in raising the trunk from a flexed position.
Gluteus maximus is innervated by the inferior gluteal nerve. -
This question is part of the following fields:
- Anatomy
- Lower Limb
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Question 38
Incorrect
-
Which coronary artery is mostly likely affected if an ECG shows a tombstone pattern in leads V2, V3 and V4?
Your Answer:
Correct Answer: Left anterior descending artery
Explanation:Tombstoning ST elevation myocardial infarction can be described as a STEMI characterized by tombstoning ST-segment elevation. This myocardial infarction is associated with extensive myocardial damage, reduced left ventricle function, serious hospital complications and poor prognosis. Tombstoning ECG pattern is a notion beyond morphological difference and is associated with more serious clinical results.
Studies have shown that tombstoning is more commonly found in anterior than non-anterior STEMI, thus, higher rates of left anterior descending artery disease are observed in patients with tombstoning pattern.
The following ECG leads determine the location and vessels involved in myocardial infarction:
ECG Leads Location Vessel involved
V1-V2 Septal wall Left anterior descending
V3-V4 Anterior wall Left anterior descending
V5-V6 Lateral wall Left circumflex artery
II, III, aVF Inferior wall Right coronary artery (80%) or Left circumflex artery (20%)
I, aVL High lateral wall Left circumflex artery
V1, V4R Right ventricle Right coronary artery
V7-V9 Posterior wall Right coronary artery -
This question is part of the following fields:
- Anatomy
- Thorax
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Question 39
Incorrect
-
A 27 year old woman presents to ED having sustained a deep laceration to the dorsum of her ring finger whilst cooking. Her proximal interphalangeal joint is fixed in flexion and the distal interphalangeal joint is hyperextended. Which of the following structures in the digit has most likely been injured:
Your Answer:
Correct Answer: Insertion of the central slip of the extensor tendon
Explanation:Damage to the central slip of the extensor digitorum tendon would result in loss of extension at the proximal interphalangeal joint resulting in a fixed flexion deformity of this joint, and hyperextension of the distal interphalangeal joint due to a loss of balancing forces. This is called the Boutonniere deformity.
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This question is part of the following fields:
- Anatomy
- Upper Limb
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Question 40
Incorrect
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A 29 year old man presents to ED followed an alleged assault whilst out drinking. He received blunt trauma to his right axilla. He is complaining of difficulty abducting his right arm above the level of his shoulder, and on inspection, the inferior angle of his right scapula protrudes more than that of his left scapula. Which of the following nerves has most likely been affected:
Your Answer:
Correct Answer: Long thoracic nerve
Explanation:Damage to the long thoracic nerve results in weakness/paralysis of the serratus anterior muscle causing difficulty abducting the upper limb above 90 degrees and giving a ‘winged ‘ scapula appearance where the medial border, particularly the inferior angle, of the scapula moves laterally and posteriorly away from the thoracic wall (this becomes more pronounced if the patient presses the upper limb against a wall).
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This question is part of the following fields:
- Anatomy
- Upper Limb
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Question 41
Incorrect
-
Which of the following pathogens is the common cause of diarrhoea in a patient who has had a prolonged course of a broad spectrum of antibiotics?
Your Answer:
Correct Answer: Clostridium difficile
Explanation:Clostridium difficile is the most likely cause of diarrhoea after a long course of broad-spectrum antibiotic treatment.
Clostridium difficile-associated diarrhoea appeared to be linked to an increase in the usage of third-generation cephalosporins.
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This question is part of the following fields:
- Microbiology
- Pathogens
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Question 42
Incorrect
-
Streptococcus pneumoniae is commonly implicated in all of the following infectious diseases EXCEPT for:
Your Answer:
Correct Answer: Impetigo
Explanation:Impetigo is a highly contagious infection of the superficial epidermis that most commonly affects young children but can occur in any age group. In children it is the most common bacterial skin infection and it is the third most common skin disease overall, behind dermatitis and viral warts.
The commonest causative organism is Staphylococcus aureus. Streptococcus pyogenesis the second commonest and causes fewer cases, either alone or in combination withS. aureus.The streptococcal form tends to be commoner in warmer, more humid climates. (Hirschmann JV. Impetigo: etiology and therapy. Curr Clin Top Infect Dis. 2002;22:42–51.)
Impetigo is most commonly spread by direct person-to-person contact, and can spread rapidly through families and school classes. It can also, less commonly, be spread by indirect contact.
There are two main forms of impetigo:
Non-bullous impetigo – lesions usually start as tiny pustules or vesicles that evolve rapidly into honey-crusted plaques that tend to be under 2 cm in diameter. These can be itchy but are rarely painful.
Bullous impetigo – lesions have a thin roof and tend to rupture spontaneously. This type is more likely to be painful and may be associated with systemic upset. -
This question is part of the following fields:
- Microbiology
- Pathogens
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Question 43
Incorrect
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A 60-year-old female with a past history of rheumatic fever and a prosthetic mitral valve presents to you with fever and an episode of expressive dysphasia that lasted around 30 minutes. There is no history of known drug allergies On examination you note a systolic murmur and you suspect it is infective endocarditis.
Which antibacterial agents would be the most appropriate to prescribe in this case?
Your Answer:
Correct Answer: Vancomycin, rifampicin and gentamicin
Explanation:Endocarditis is infective or non infective inflammation (marantic endocarditis) of the inner layer of the heart and it often involves the heart valves.
Risk factors include:
Prosthetic heart valves
Congenital heart defects
Prior history of endocarditis
Rheumatic fever
Illicit intravenous drug useIn the presentation of endocarditis, the following triad is often quoted:
Persistent fever
Embolic phenomena
New or changing murmurA combination of vancomycin, rifampicin and gentamicin is advised if the patient has a cardiac prostheses, is penicillin allergic, or if methicillin-resistant Staphylococcus aureus (MRSA) is suspected. In this case the patient has a prosthetic valve making this the most appropriate initial treatment regimen.
Flucloxacillin and gentamicin are current recommended by NICE and the BNF for the initial ‘blind’ therapy in endocarditis. This patient has prostheses and this is not the most appropriate initial treatment regimen.
Other features that may be present include heart failure, splenomegaly, finger clubbing, renal features (haematuria, proteinuria, nephritis), and vasculitic features (splinter haemorrhages, Osler’s nodes, Janeway lesions, Roth’s spots).
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This question is part of the following fields:
- Microbiology
- Specific Pathogen Groups
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Question 44
Incorrect
-
Which of the following nerves is most likely associated with an anterior shoulder dislocation?
Your Answer:
Correct Answer: Axillary nerve
Explanation:In an anterior dislocation, the arm is an abducted and externally rotated position. In the externally rotated position, the posterosuperior aspect of the humeral head abuts and drives through the anteroinferior aspect of the glenoid rim. This can damage the humeral head, glenoid labrum, or both. An associated humeral head compression fracture is described as a Hill Sach’s lesion. If large enough, it can lead to locked dislocations that may require open reduction. The glenoid labrum is a fibrocartilaginous structure that rings the circumference of the glenoid fossa. Bankart lesions are injuries to the anteroinferior glenoid labrum complex and the most common capsulolabral injury. A bony Bankart lesion refers to an associated fracture of the glenoid rim. These capsulolabral lesions are risk factors for recurrent dislocation.
Axillary nerve injury is identified in about 42% of acute anterior shoulder dislocations. Nerve transection is rare, and traction injuries are more common. Arterial injury has also been described. The subclavian artery becomes the axillary artery after passing the first rib. The distal portion of the axillary artery is anatomically fixed and, therefore, susceptible to injury in anterior dislocations. Ischemic injury, including pseudoaneurysm and arterial laceration, is rare but carries marked morbidity if not quickly identified.
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This question is part of the following fields:
- Anatomy
- Upper Limb
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Question 45
Incorrect
-
Following an injury sustained during a rugby match, a 16-year-old boy is brought to the Emergency Department by his mother. His forearm appears to be deformed, and you believe he has a distal radius fracture. A numerical rating scale is used to assess his pain, and the triage nurse informs you that he is in moderate pain.'
The RCEM guidance recommends which of the following analgesics for the treatment of moderate pain in a child of this age?Your Answer:
Correct Answer: Oral codeine phosphate 1 mg/kg
Explanation:According to a 2018 audit conducted by the Royal College of Emergency Medicine (RCEM), the standard of care for children presenting to EDs with fractured limbs has deteriorated, with most patients waiting longer than ever before for pain relief. More than one-tenth of the children who came in with significant pain from a limb fracture received no pain relief at all.
For all patients, including children, the Agency for Health Care Policy and Research (AHCPR) in the United States recommends using the ABCs of pain management:
A – Ask about pain regularly. Assess pain systematically.
B – Believe the patient and family in their reports of pain and what relieves it.
C – Choose pain control options appropriate for the patient, family, and setting.
D – Deliver interventions in a timely, logical, coordinated fashion.
E – Empower patients and their families. Enable patients to control their course to the greatest extent possible.The RCEM guidelines recommend assessing a child’s pain within 15 minutes of arrival. This is a fundamental requirement. For the assessment of pain in children, a variety of rating scales are available; which one is used depends on the child’s age and ability to use the scale. These are some of them:
Faces of Wong-Baker Scale for assessing pain
Scale of numerical evaluation
The behavioural scale is a scale that measures how people behave.The RCEM has provided the following visual guide:
The RCEM has established the following guidelines for when patients in severe pain should receive appropriate analgesia:
100% within 60 minutes of arrival or triage, whichever is earliest
75% within 30 minutes of arrival or triage, whichever is earliest
50% within 20 minutes of arrival or triage, whichever is earliest -
This question is part of the following fields:
- CNS Pharmacology
- Pharmacology
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Question 46
Incorrect
-
During swallowing, which of the following structures primarily closes the tracheal opening:
Your Answer:
Correct Answer: Epiglottis
Explanation:The vocal cords of the larynx are strongly
approximated, and the larynx is pulled upward
and anteriorly by the neck muscles. These actions,
combined with the presence of ligaments that
prevent upward movement of the epiglottis, cause
the epiglottis to swing back over the opening
of the larynx. All these effects acting together
prevent the passage of food into the nose and
trachea. Most essential is the tight approximation
of the vocal cords, but the epiglottis helps to
prevent food from ever getting as far as the vocal
cords. Destruction of the vocal cords or of the
muscles that approximate them can cause
strangulation. -
This question is part of the following fields:
- Gastrointestinal
- Physiology
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Question 47
Incorrect
-
Which of the following statements is correct with regards to Horner's syndrome?
Your Answer:
Correct Answer: Miosis occurs due to paralysis of the dilator pupillae muscle.
Explanation:The characteristics of Horner’s syndrome are pupil constriction, partial ptosis and anhidrosis.
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This question is part of the following fields:
- Anatomy
- Head And Neck
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Question 48
Incorrect
-
Regarding Cryptococcus neoformans, which of the following statements is INCORRECT:
Your Answer:
Correct Answer: Patients with complement deficiency are at particular risk of infection.
Explanation:Cryptococcus neoformans typically causes infection in patients with lymphoma, those taking steroid or cytotoxic therapy, those with T-cell deficiency e.g. AIDS and those with intense exposure, such as pigeon fanciers.
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This question is part of the following fields:
- Microbiology
- Pathogens
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Question 49
Incorrect
-
A 71-year-old woman presents with complaints of fatigue and worsening muscle weakness, and blood tests done shows a potassium level of 2.4 mmol/L.
Which is NOT a recognised cause of hypokalaemia?
Your Answer:
Correct Answer: Type 4 renal tubular acidosis
Explanation:A plasma potassium less than 3.5 mmol/L defines hypokalaemia.
Excessive liquorice ingestion causes hypermineralocorticoidism and leads to hypokalaemia.
Gitelman’s syndrome causes metabolic alkalosis with hypokalaemia and hypomagnesaemia. It is an inherited defect of the distal convoluted tubules.
Bartter’s syndrome causes hypokalaemic alkalosis. It is a rare inherited defect in the ascending limb of the loop of Henle.
Type 1 and 2 renal tubular acidosis both cause hypokalaemia
Type 4 renal tubular acidosis causes hyperkalaemia.
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This question is part of the following fields:
- Physiology
- Renal Physiology
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Question 50
Incorrect
-
An analytical cohort study is done to compare the relationship between omega 3 intake and occurrence of myocardial infarction (MI) among males aged over 65 years. The following are the data from the study:
No. of subjects taking placebo: 100 men
No. of subjects taking placebo who suffered an MI: 15 men
No. of subjects taking omega 3: 100 men
No. of subjects taking omega 3 who suffered an MI: 5 men
Compute for the absolute risk in the treatment (omega 3) group.Your Answer:
Correct Answer: 0.05
Explanation:The absolute risk (AR) is the probability or chance of an event. It is computed as the number of events in treated or control groups, divided by the number of people in that group.
AR = 5/100 = 0.05
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This question is part of the following fields:
- Evidence Based Medicine
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SESSION STATS - PERFORMANCE PER SPECIALTY
