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Question 1
Incorrect
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A 60-year-old man with atrial fibrillation (AF) who is on warfarin and is awaiting tooth extraction. Recent INR was 2.7 and his target INR was 2.0-3.0. Which of the following is the most appropriate management?
Your Answer: Admit to hospital + switch to subcutaneous low-molecular weight heparin prior to extraction
Correct Answer:
Explanation:The latest reserches say that simple tooth extraction in patients on warfarin treatment can be performed safely without high risk of bleeding, providing that the INR is equal to or less than 3.5 on the day of extraction. A close follow-up and monitoring of patients taking warfarin is mandatory after dental extraction.
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This question is part of the following fields:
- Cardiovascular System
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Question 2
Correct
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A 45-year-old male presents with lower backache and pain in his hips. Blood tests are normal except for elevated serum alkaline phosphatase which is 1200 IU/l (45-105). Radiological examination shows combined osteolytic and osteosclerotic lesions. What is the most common site of occurrence of this disease?
Your Answer: Pelvis
Explanation:The patient most likely suffers from Paget’s disease of the bone as his radiological examination shows both osteolytic and osteosclerotic lesions. Any bone or bones can be affected, but Paget’s disease occurs most frequently in the pelvis > lumbar spine > femur > thoracic spine > sacrum > skull > tibia.
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This question is part of the following fields:
- Musculoskeletal System
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Question 3
Incorrect
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A 45-year-old woman has complained of right hypochondrial pain and severe epigastric pain for the past few hours. Upon examination, her CBC is normal, her serum ALP is raided, but she has normal transaminase. She had a cholecystectomy done three months prior. Choose the most appropriate avenue of investigation for this patient.
Your Answer: US abdomen
Correct Answer: MRCP
Explanation:MRCP is the most appropriate procedure in this instance. The post-operative US of the abdomen does not give good results for the hepatobiliary system. ERCP is invasive and is linked to complications such as pancreatitis, cholangitis, etc.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 4
Correct
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A 61-year-old woman with a history of hypothyroidism and inflammatory arthritis is admitted after slipping on ice and falling over. Some routine blood tests are performed:
Na+ 141 mmol/l
K+ 2.9 mmol/l
Chloride 114 mmol/l
Bicarbonate 16 mmol/l
Urea 5.2 mmol/l
Creatinine 75 µmol/l
Which one of the following is most likely to explain these results?Your Answer: Renal tubular acidosis (type 1)
Explanation:The patient’s underlying arthritis has most likely led to Renal tubular acidosis RTA type 1, which presents with the following symptoms consistent with the presentation of the patient: Normal anion gap metabolic acidosis/acidaemia, hypokalaemia and hyperchloremia. Comparatively, the other conditions are ruled out because Aspirin and diabetic ketoacidosis is associated with a raised anion gap, Conn’s syndrome explains hypokalaemia but not the metabolic acidosis, and RTA type 4 is associated with hyperkalaemia.
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This question is part of the following fields:
- Renal System
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Question 5
Correct
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Concerning myosin, which of the following statements is true?
Your Answer: Myosin heavy chain mutations are associated with development of familial hypertrophic cardiomyopathy
Explanation:Myosin is a protein found in contractile tissues. It is described in two groups: conventional myosin, which is arranged in pairs of light chains against pairs of heavy chain myosin. Unconventional myosin that is not arranged in filaments, preforms many functions in a wide range of cells, such as in organelle transport and in endocytosis. Myosin contains Adenosine triphosphate (ATP) and contains actin binding sites to preform its function. Other types of mutations in myosin can be seen besides the heavy chain mutation cardiomyopathy and they include: Carney’s complex , Usher syndrome and non-syndromic deafness
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This question is part of the following fields:
- Cardiovascular System
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Question 6
Correct
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A 26-year-old woman is 24 weeks pregnant had a recent ultrasound that shows the foetus large for dates.
She has an oral glucose tolerance test (OGTT) which was requested due to a combination of her Asian ethnicity and background of obesity.
The following results are obtained:
Time (hours) Blood glucose (mmol/l)
0 9.2
2 14.2
What is the most appropriate management?Your Answer: Start insulin
Explanation:Insulin remains the standard of care for the treatment of uncontrolled gestational diabetes. Tight control maintained in the first trimester and throughout pregnancy plays a vital role in decreasing poor fetal outcomes, including structural anomalies, macrosomia, hypoglycaemia of the new-born, adolescent and adult obesity, and diabetes.
The baby is already large for dates so nutritional therapy can not be used alone. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 7
Correct
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A 60-year-old male smoker presented in the emergency room with a history of chest pain and a cough for the last few days. He is now complaining of increasing dyspnoea and sharp pains around the 4th and 5th ribs. On CXR, there is right sided hilar enlargement. Which of the following is the most likely diagnosis?
Your Answer: Bronchogenic carcinoma
Explanation:The history of smoking with a cough and bone pain is suggestive of bronchogenic carcinoma. CXR findings are also supportive of this diagnosis. In COPD, a cough with dyspnoea and wheezing is prominent.
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This question is part of the following fields:
- Respiratory System
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Question 8
Incorrect
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A 58-year-old woman has multiple non-healing leg ulcers. She reports feeling unwell for several months. Examination findings include a normal blood pressure, pulse 90 bpm, pale conjunctivae and poor dentition associated with bleeding gums. What is the most likely underlying diagnosis?
Your Answer: Vitamin B12 deficiency
Correct Answer: Vitamin C deficiency
Explanation:Severe vitamin C deficiency results in scurvy, a disorder characterized by hemorrhagic manifestations and abnormal osteoid and dentin formation.
Vitamin C plays a role in collagen, carnitine, hormone, and amino acid formation. It is essential for bone and blood vessel health and wound healing and facilitates recovery from burns. Vitamin C is also an antioxidant, supports immune function, and facilitates the absorption of iron (see table Sources, Functions, and Effects of Vitamins).
Dietary sources of vitamin C include citrus fruits, tomatoes, potatoes, broccoli, strawberries, and sweet peppers. (See also Overview of Vitamins.) -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 9
Incorrect
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A 50-year-old male with a history of type II diabetes mellitus and hypertension presented with exertional dyspnoea and chest pain for 2 weeks. On examination his blood pressure was 145/80 mmHg. On auscultation reversed splitting of the second heart sound and bibasal crepitations were detected. What would be the most likely finding on his ECG?
Your Answer: P pulmonale
Correct Answer: Left bundle branch block
Explanation:When closure of the pulmonary valve occurs before the aortic valve, reversed splitting occurs. The causes of reversed splitting are aortic stenosis, hypertrophic cardiomyopathy, left bundle branch block (LBBB), and a ventricular pacemaker.
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This question is part of the following fields:
- Cardiovascular System
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Question 10
Incorrect
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A 75-year-old gentleman sustained an injury to his arm after falling on outstretched hands. An X-ray confirms the fracture of the distal radius with backward shift of the distal fragment. The name given to this kind of deformity is?
Your Answer: Mallet finger
Correct Answer: Dinner fork deformity
Explanation:Dinner fork deformity is the name given to the fracture of distal radius, in which the distal fragment is dorsally angulated, displaced and sometimes impacted. Coxa vara is the hip deformity when angle between the head and shaft of the femur is reduced to more than 120 degree. A garden fork deformity is a reversed Colles fracture.
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This question is part of the following fields:
- Musculoskeletal System
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Question 11
Incorrect
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A 58-year-old psychologist with small cell lung cancer complains of muscle weakness. Each one of the following are features of Lambert-Eaton syndrome, except:
Your Answer: Dry mouth
Correct Answer: Repeated muscle contractions lead to decreased muscle strength
Explanation:In myasthenia gravis, repeated muscle contractions lead to reduced muscle strength. The opposite is however classically seen in the related disorder Lambert-Eaton syndrome. Lambert-Eaton myasthenic syndrome is seen in association with small cell lung cancer, and to a lesser extent breast and ovarian cancer. It may also occur independently as an autoimmune disorder. Lambert-Eaton myasthenic syndrome is caused by an antibody directed against pre-synaptic voltage gated calcium channel in the peripheral nervous system.
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This question is part of the following fields:
- Nervous System
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Question 12
Incorrect
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A 33-year-old lady who is known hepatitis C positive comes to your clinic. She is 28 weeks pregnant and her obstetrician wants you to assess her and provide medical advice for the mother and child.
Which of the following statements concerning hepatitis C are most accurate in her case?Your Answer: A high viral load at delivery increases the risk of transmission
Correct Answer: Breast-feeding does not increase the risk of transmission
Explanation:Breast feeding has not been shown to increase the risk of transmission of HCV from mother to baby. This is simply a fact to memorize. The other answer choices are not the most accurate as there is no evidence-proven way to decrease the chance that baby will get HCV from the mother during the birth. About 5 out of every 100 infants born to HCV infected mothers become infected.
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This question is part of the following fields:
- Infectious Diseases
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Question 13
Incorrect
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A 35-year-old male was brought to you in a confused state. Although not your patient, you can make out that the man has a history of schizophrenia, and has recently had his medications altered. Clinically, you find evidence of a lower respiratory tract infection, and blood investigations indicate a neutropenic picture.
What is the most likely drug causing the neutropenia?Your Answer: Olanzapine
Correct Answer: Clozapine
Explanation:Clozapine can cause neutropenia or agranulocytosis.
Clozapine is an atypical antipsychotic used in the treatment of schizophrenia, and in patients who are intolerant to, or unresponsive to other antipsychotics.
It is a weak D2-receptor and D1-receptor blocking activity, with noradrenolytic, anticholinergic, and antihistaminic properties.
Many antipsychotic drugs can occasionally cause bone marrow depression, but agranulocytosis is particularly associated with clozapine.
Other side effects include:
Hypotension, tachycardia
Fever, sedation, seizures (with high doses)
Appetite increase
Constipation
Heartburn
Weight gain
Extrapyramidal symptoms
Agranulocytosis
Neuroleptic malignant syndrome -
This question is part of the following fields:
- Pharmacology
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Question 14
Correct
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A 39-year-old female presented in the OPD with amenorrhea. On investigations, it was revealed that she had high levels of FSH and LSH, normal levels of prolactin and low levels of oestradiol hormone. Which of the following conditions is most likely?
Your Answer: Premature ovarian failure
Explanation:Premature ovarian failure presents before the age of 40 in females with a triad of symptoms: amenorrhea, hypergonadism and low oestradiol. This triad is present in the patient.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 15
Incorrect
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A patient was admitted due to vomiting for further investigations. He noticed blood in his vomit and the physicians decided to perform an esophagogastroduodenoscopy which revealed haemorrhage in the lesser curvature of the stomach. Which artery is responsible for the bleeding?
Your Answer: Pancreaticoduodenal artery
Correct Answer: Right gastric artery
Explanation:The right gastric artery arises from the hepatic artery or the left hepatic artery and supplies the pylorus, traveling along the lesser curvature of the stomach anastomosing with the left gastric artery.
The pancreaticoduodenal artery supplies mainly the upper and lower duodenum and the head of the pancreas.
The gastro-omental arteries supply the greater curvature of the stomach. -
This question is part of the following fields:
- Gastrointestinal System
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Question 16
Correct
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A 25-year-old youth was brought to the A&E following a stab injury to the right back of the chest. On examination he was dyspnoeic, his trachea was deviated to the left side and there were engorged veins and absent breath sounds on the right side. Which of the following is the most probable diagnosis?
Your Answer: Tension pneumothorax
Explanation:History is suggestive of right sided tension pneumothorax. It can’t be a simple pneumothorax because of tracheal deviation and engorged veins.
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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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Which among the following antihypertensives is centrally acting?
Your Answer: Minoxidil
Correct Answer: Moxonidine
Explanation:Moxonidine and alpha-methyl dopa are centrally acting antihypertensives and modify blood pressure through modifying sympathetic activity.
Other options:
Verapamil is a calcium antagonist.
Minoxidil and hydralazine are both vasodilators.
Phenoxybenzamine is an alpha-blocker.Adverse effects:
Dry mouth and somnolence were the most frequently reported adverse events, followed by headache, dizziness, nausea and allergic skin reactions. -
This question is part of the following fields:
- Pharmacology
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Question 18
Incorrect
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A 26-year-old technician with no past medical history presents to the neurology clinic complaining of muscle pain. He describes severe bilateral cramping calf pain on minimal exercise. This has been present since his late teens and as such he has avoided exercise. Recently, he has attended the local gym to try and lose weight, but attempts at exercise have been dampened by the pain. He does note that if he perseveres with exercise, the pain settles. He has noticed passing dark urine in the evenings following a prolonged bout of exercise. Which of the following clinical tests would be most useful in aiding the diagnosis in this patient?
Your Answer: Creatine kinase
Correct Answer: Muscle biopsy
Explanation:The differential diagnosis of bilateral exercise-induced pain would include metabolic muscle disease, lumbar canal stenosis and intermittent claudication. The patient’s age, history and lack of other risk factors make the latter two options unlikely.
The syndrome described is in fact McArdle’s disease (myophosphorylase deficiency). This is a disorder of carbohydrate metabolism. Clinical features of pain and fatigue are precipitated in early exercise, as carbohydrates cannot be mobilized to provide an energy substrate to the muscle. With prolonged exercise, fatty acid metabolism provides energy, and symptoms lessen. The dark urine described is likely to represent myoglobinuria following rhabdomyolysis. Definitive diagnosis of most metabolic muscle diseases relies on muscle biopsy and enzyme analysis.
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This question is part of the following fields:
- Nervous System
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Question 19
Incorrect
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Cancer of the prostate is associated with which of the following:
Your Answer: Caucasian race
Correct Answer: Exposure to cadmium
Explanation:Risk factors for prostate cancer include:
Black ethnicity
A family history of breast or prostate cancer
High intake of animal fats and low selenium intake
Exposure to radiation or heavy metals including cadmium -
This question is part of the following fields:
- Men's Health
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Question 20
Incorrect
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A 20-year-old student nurse was admitted after her third collapse in recent months. She was noted to have a blood sugar of 0.9 mmol/l on finger-prick testing and responded well to intravenous glucose therapy.
Venous blood taken at the same showed a markedly raised insulin level, but her C-peptide levels were normal.
What diagnosis fits best with this clinical picture?Your Answer: Insulinoma
Correct Answer: Self-administration of a short-acting insulin
Explanation:The patient has hyperinsulinemia and hypoglycaemia, but her C-peptide levels are normal. This is strongly suggestive of the fact that she is self-administering insulin.
In Insulinoma, common diagnostic criteria include:
– blood glucose level < 50 mg/dl with hypoglycaemic symptoms,
– relief of symptoms after eating
– absence of sulfonylurea on plasma assays.
The classic diagnostic criteria include the demonstration of the following during a supervised fast:
Increased plasma insulin level
Increased C peptide level
Increased proinsulin level
However, the patient has normal C-peptide levels.
In type-1 diabetes mellitus, insulin and C-peptide levels are low. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 21
Correct
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A 40-year old male presented to the OPD with a history of difficulty swallowing and blood-stained vomit. History of weight loss is also present. The abdominal X-ray was normal. Which of the following should be done next?
Your Answer: Oesophagogastroduodenoscopy
Explanation:An esophagogastroduodenoscopy (OGD) should be ordered to visualize and identify the source of bleeding. This procedure can harvest tissue samples for histological analysis and can also treat varices that may be causing the bleeding.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 22
Correct
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A 70-year-old male patient with hypertension complains of acute urinary retention. He provides a history of urinary frequency for the past 18 months and has been taking Nifedipine and Propranolol for blood pressure control. Which of the following is the most probable cause for his acute presentation?
Your Answer: Drug induced
Explanation:Calcium channel blockers decrease smooth-muscle contractility in the bladder and this can cause urinary retention.
An enlarged prostate gland could be the reason if he gave a history of obstructive symptoms.
Diabetes presents with polyuria.
Bladder cancer commonly presents with painless haematuria. -
This question is part of the following fields:
- Renal System
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Question 23
Correct
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A 46-year-old woman complains of ulceration with bloody discharge around her right nipple accompanied by redness, excoriations, and severe itchiness. What is the most likely diagnosis?
Your Answer: Paget's disease of the breast
Explanation:Paget’s disease of the breast is a type of cancer that outwardly may have the appearance of eczema, with skin changes involving the nipple of the breast. Symptoms may include redness of the nipple skin and crusting may occur around the area. In more advance cases, symptoms may include itching or a burning pain in the nipple.
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This question is part of the following fields:
- Women's Health
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Question 24
Correct
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A 25-year-old man wants to start a relationship but is concerned about his small phallus. He also has difficulty becoming aroused. On examination, he is slim and has gynecomastia. There is a general paucity of body hair, his penis and testes are small.
Which diagnosis fits best with this history and examination?Your Answer: Klinefelter's syndrome
Explanation:The patient most likely has Klinefelter’s syndrome.
Klinefelter syndrome (KS) refers to a group of chromosomal disorders in which the normal male karyotype, 46,XY, has at least one extra X chromosome. XXY aneuploidy, the most common human sex chromosome disorder. It is also the most common chromosomal disorder associated with male hypogonadism and infertility.
Klinefelter syndrome is characterized by hypogonadism (micro-orchidism, oligospermia/azoospermia), gynecomastia in late puberty, hyalinization and fibrosis of the seminiferous tubules, elevated urinary gonadotropin levels, and behavioural concerns. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 25
Correct
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A 74-year-old patient presents with back pain, pallor and palpitations. Blood exams reveal multiple plasma cells in the peripheral smear. What is the most likely diagnosis?
Your Answer: Multiple myeloma
Explanation:Multiple myeloma presents with bone pain usually in the back or at the level of the ribs. Pathological fractures are common. The patient usually experiences fatigue, paleness, weakness, dyspnoea and gastro-intestinal complaints such as nausea and constipation. Characteristic for this case is the presence of many plasma cells in the peripheral blood smear.
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This question is part of the following fields:
- Haematology & Oncology
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Question 26
Correct
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A number of tests have been ordered for a 49-year-old male who has systemic lupus erythematosus (SLE). He was referred to the clinic because he has increased shortness of breath. One test in particular is transfer factor of the lung for carbon monoxide (TLCO), which is elevated. Which respiratory complication of SLE is associated with this finding?
Your Answer: Alveolar haemorrhage
Explanation:Alveolar haemorrhage (AH) is a rare, but serious manifestation of SLE. It may occur early or late in disease evolution. Extrapulmonary disease may be minimal and may be masked in patients who are already receiving immunosuppressants for other symptoms of SLE.
DLCO or TLCO (diffusing capacity or transfer factor of the lung for carbon monoxide (CO)) is the extent to which oxygen passes from the air sacs of the lungs into the blood.
Factors that can increase the DLCO include polycythaemia, asthma (can also have normal DLCO) and increased pulmonary blood volume as occurs in exercise. Other factors are left to right intracardiac shunting, mild left heart failure (increased blood volume) and alveolar haemorrhage (increased blood available for which CO does not have to cross a barrier to enter). -
This question is part of the following fields:
- Respiratory System
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Question 27
Incorrect
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A kidney, ureter, and bladder (KUB) ultrasound for a hypertensive man with a BP of 160/90 mmHg and proteinuria++ revealed a decrease in size of the kidneys with smooth borders and normal pelvicalyceal system. What is the cause of hypertension in the patient?
Your Answer: Essential HTN
Correct Answer: Chronic glomerulonephritis
Explanation:Causes of hypertension in bilateral renal artery stenosis are as follows: 90% probable cause is atherosclerosis with manifestations of CAD, TIA or stroke. The other less common cause is fibromuscular dysplasia that includes carotid and vertebral artery with manifestations of headache, TIA, and stroke.
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This question is part of the following fields:
- Gastrointestinal System
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Question 28
Incorrect
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A 43-year-old female presents with an array of symptoms including weakness, lethargy, dysphagia, dry mouth, gritty sensation in her eyes and increased photosensitivity. In order to confirm the suspected diagnosis, which of the following tests should be performed?
Your Answer: Antineutrophil antibodies
Correct Answer: Labial gland biopsy
Explanation:To confirm the diagnosis, especially in patients with negative anti-Ro or anti-La antibodies, labial gland biopsy is done. In performing a labial biopsy, the surgeon typically makes a shallow 1/2 inch wide incision on either side of the inner lip after numbing the area with a local anaesthetic. Schirmer’s test determines whether the eye produces enough tears to keep it moist. This test can be done for ocular symptoms of Sjogren syndrome but is of no diagnostic importance as it can be positive with many other diseases.
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This question is part of the following fields:
- Musculoskeletal System
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Question 29
Incorrect
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A 65-year-old female presented with episodes of unilateral blindness, which spontaneously resolved. Her cardiovascular examination was normal. What is the single most appropriate investigation that can be performed to arrive at a diagnosis?
Your Answer: MRI brain scan
Correct Answer: Carotid duplex ultrasonography
Explanation:Amaurosis fugax (transient ipsilateral visual loss) and transient ischemic attacks (TIAs) are presentations of atherosclerotic disease of the carotid artery which can be identified by carotid duplex ultrasonography (US), with or without colour, which is the screening test of choice to evaluate for carotid stenosis.
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This question is part of the following fields:
- Nervous System
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Question 30
Correct
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A 72-year-old woman who presented with headache and neck stiffness was started on IV ceftriaxone after undergoing a lumbar puncture. The CSF culture shows listeria monocytogenes. What is the treatment of choice?
Your Answer: Change to IV amoxicillin + gentamicin
Explanation:The best option would be the combination of ampicillin and gentamycin. Changing to IV amoxicillin+gentamycin is however the best among the given choices here.
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This question is part of the following fields:
- Infectious Diseases
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SESSION STATS - PERFORMANCE PER SPECIALTY
