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Question 1
Correct
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A 41-year-old woman has been complaining of tiredness over the past few weeks. She has angular stomatitis but no koilonychia. What is the most probable cell type to be seen in her blood film?
Your Answer: Macrocytes
Explanation:This is a case of Vit. B12 or folic acid deficiency. The anaemia with angular stomatitis is highly suggestive of Vit. B12 or folate deficiency. The absence of koilonychia excludes Iron deficiency anaemia.
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This question is part of the following fields:
- Haematology & Oncology
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Question 2
Incorrect
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Around 30 patients have been admitted to the hospital following a suspected chemical attack in the city. The patients are extremely unwell, with symptoms of excessive salivation, lacrimation, diarrhoea, and emesis. Sarin gas was suspected as the most likely agent used in the attack. What is the mechanism of action of this chemical agent?
Your Answer: Anti-cholinergic
Correct Answer: Inhibition of acetylcholinesterase
Explanation:Sarin acts by inhibiting acetylcholinesterase.
Sarin gas is a highly toxic synthetic organophosphorus compound which causes inhibition of the enzyme acetylcholinesterase
Sarin gas is a highly toxic synthetic organophosphorus compound which causes inhibition of the enzyme acetylcholinesterase. This results in high levels of acetylcholine (ACh).The effects of excessive ACh can be remembered by the mnemonic DUMBELLS:
Diarrhoea
Urination
Miosis/muscle weakness
Bronchorrhea/Bradycardia
Emesis
Lacrimation
Salivation/sweatingOrganophosphate insecticide poisoning:
One of the effects of organophosphate poisoning is inhibition of acetylcholinesterase
Features can be predicted by the accumulation of acetylcholine (mnemonic = SLUD)
Salivation
Lacrimation
Urination
Defecation/diarrhoea
cardiovascular: hypotension, bradycardia
miosis, muscle fasciculation.Organophosphate poisoning is treated with the anti-muscarinic atropine.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 3
Incorrect
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A 75-year-old woman experienced right sided weakness shortly after she woke up. However, the weakness resolved in 30 minutes and left no disability. Her CT and ECG appear normal. What extra actions should be taken if she is already on Aspirin, Simvastatin, Amlodipine and Bendroflumethiazide?
Your Answer: Add Clopidogrel
Correct Answer: Start Aspirin 300 mg for 2 weeks
Explanation:The patient has most probably experienced a transient ischemic attack which should be initially managed with aspirin 300 mg for two weeks.
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This question is part of the following fields:
- Nervous System
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Question 4
Correct
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A 23-year-old patient was involved in a MVA. Clinical examination reveals a fixed dilated pupil and reduced consciousness. Which of the following nerves is most likely damaged?
Your Answer: Oculomotor nerve
Explanation:The oculomotor nerve is the 3rd cranial nerve. When damaged it affects the ocular motility causing mainly ptosis or diplopia. Damage to it can also affect the pupillary functions causing pupil dilation and light reflex impairment.
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This question is part of the following fields:
- Nervous System
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Question 5
Correct
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A 54-year-old heavy smoker presented with acute chest pain for 3 hrs which associated with excessive sweating and vomiting. His past medical history was unremarkable but his father has passed away due to a heart attack at the age of 50. Examination findings were normal and ECG was also normal. He was pain free after 12 hours from admission. What is the most appropriate investigation that can be done at this moment?
Your Answer: Troponin T
Explanation:The positive family history and the smoking make him an ideal candidate for a myocardial infarction. The chest pain is also a suggestive symptom. So troponin is needed to rule out MI.
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This question is part of the following fields:
- Cardiovascular System
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Question 6
Incorrect
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From the following options, choose the one which is not a cause of liver cirrhosis.
Your Answer: Galactosaemia
Correct Answer: Schistosomiasis
Explanation:Schistosomiasis is a cause of portal hypertension and periportal fibrosis – it is, however, not a cause of cirrhosis. The main causes of cirrhosis include: alcohol and hepatitis B, C, and D. Autoimmune causes include: both primary and secondary biliary cirrhosis and autoimmune hepatitis. There are a number of inherited conditions which cause cirrhosis, such as hereditary hemochromatosis, Wilson’s disease, Alpha-1 anti-trypsin deficiency, galactosaemia glycogen storage disease, and cystic fibrosis. Additionally, there are also vascular causes, such as hepatic venous congestion, Budd-Chiari syndrome, and veno-occlusive disease. Intestinal bypass surgery has also been implicated as a causative factor for cirrhosis.
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This question is part of the following fields:
- Gastrointestinal System
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Question 7
Correct
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A 62-year-old female with a history of COPD and hypertension presents with pain on swallowing. Current medication includes a salbutamol and becotide inhaler, bendrofluazide and amlodipine. What is the most likely cause of the presentation?
Your Answer: Oesophageal candidiasis
Explanation:The history gives you a woman who is on inhaled steroid therapy. It is always a good idea for patients to rinse their mouths well after using inhaled steroids. Odynophagia (pain on swallowing) is a symptom of oesophageal candidiasis, which is the most likely answer given the steroids. Typically, you might see this in someone who is immunocompromised (classically, in HIV+ patients).
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This question is part of the following fields:
- Gastrointestinal System
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Question 8
Correct
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A 23-year-old man is being investigated for excessive bleeding following a tooth extraction.
His coagulation profile shows:
Plts: 173 x 10^9/L
PT: 12.9 secs
APTT: 84 secs
Which clotting factor is he most likely deficient in?Your Answer: Factor VIII
Explanation:The patient is most likely a case of haemophilia A which is the genetic deficiency of clotting factor VIII in blood.
Haemophilia is an X-linked recessive disorder of coagulation. Up to 30% of patients have no family history of the condition. Haemophilia A is more common than haemophilia B and accounts for 90% of the cases. In haemophilia B (Christmas disease), there is a deficiency of clotting factor IX.
Characteristic features of haemophilia include hemarthrosis, haematomas, and prolonged bleeding following trauma or surgery. Coagulation profile of a haemophiliac person shows prolonged bleeding time, activated partial thromboplastin time (APTT), thrombin time (TT), but a normal prothrombin time (PT).
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This question is part of the following fields:
- Haematology & Oncology
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Question 9
Correct
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A 22 year-old university graduate presented with progressive unsteadiness during walking over the last year. She had been otherwise healthy apart from recent difficulty hearing her lecturer in classes. She took no prescription medication but had occasionally taken cocaine during her first year of college. She also admits to drinking up to 30 units of alcohol per week and smoked 10 cigarettes per day. Her parents were both well, but her father's sister had problems with walking before she died. Examination reveals normal tone and power throughout all four limbs. Reflexes were normal in the upper limbs but decreased at the knees and absent at the ankles. Coordination was normal in all four limbs but her gait was ataxic. Sensation in the upper limbs was normal but decreased vibratory sensation and proprioception was noted to the ankles bilaterally. What is the most likely diagnosis?
Your Answer: Friedreich's ataxia
Explanation:Friedreich’s ataxia is an autosomal recessive disorder that usually begins before the end of the teens. It has an estimated prevalence in Europe of 1 in 50,000 and life expectancy is around 40-50 years. Neurological features include a progressive ataxia, cerebellar dysarthria, lower limb areflexia, decreased vibratory sensation and proprioception, and pyramidal weakness. Pes cavus and scoliosis are also both seen. Cardiomyopathy occurs in over 70% of cases. Less common features include optic atrophic, diabetes mellitus, and deafness.
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This question is part of the following fields:
- Nervous System
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Question 10
Incorrect
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The ECG of a 29-year-old female shows an irregular rhythm with a HR of 154 bpm. She presented complaining of heart palpitations and hot flashes for the past 4 days. What is the most likely treatment?
Your Answer: Flecainide
Correct Answer: Beta blockers
Explanation:At 29 years old, the most probable cause of this arrhythmia is thyrotoxicosis. β blockers relieve symptoms such as tachycardia, tremor, and anxiety in thyrotoxic patients. β blockade should be used as the primary treatment only in patients with thyrotoxicosis due to thyroiditis.
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This question is part of the following fields:
- Cardiovascular System
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Question 11
Correct
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A 34-year-old male has been brought to accident and emergency after being involved in a road collision. After his initial evaluation, his score on the Glasgow Coma Scale is 6. What is the most appropriate next step in his treatment?
Your Answer: Secure airway
Explanation:The appropriate next step in this patient’s treatment is to secure his airway.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 12
Incorrect
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A 9-year-old boy with central cyanosis underwent cardiac catheterization. His study results were given below
Right atrium 7 mmHg  Saturation 60 %
Right ventricle 110/6 mmHg  Saturation 55 %
Pulmonary artery 20/5 mmHg Saturation 55 %
Left atrium (mean)Â 9 mmHg Saturation 98 %
Left ventricle 110/80 mmHg Saturation 87 %
Aorta 110/80 mmHg Saturation 76 %
Â
Which the following abnormalities are present in this patient?Your Answer: Ventricular septal defect
Correct Answer: Pulmonary stenosis
Explanation:The overall diagnosis is Fallot’s tetralogy. Ventricular septal defect with left to right shunt is indicated by drop of oxygen saturation from left atrium to left ventricle. Pulmonary stenosis is indicated by the pressure difference between the pulmonary artery and the right atrium. There is oxygen saturation drop from the left ventricle to the aorta which can be due to the overriding aorta.
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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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Which of the following is true concerning baclofen?
Your Answer: Reduces Ca2+ release from sarcoplasmic reticulum
Correct Answer: Causes hallucinations when withdrawn
Explanation:Baclofen is used to treat spastic movement symptoms such as those seen in cerebral palsy and multiple sclerosis. It is known to be associated with a withdrawal syndrome similar to alcohol withdrawal; thus, gradual withdrawal is necessary to avoid this.
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This question is part of the following fields:
- Nervous System
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Question 14
Incorrect
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A 72-year-old woman presents with 18 month history of gait ataxia, dysarthria, and dysphagia.
On examination there is down beating nystagmus and slurred speech. There is past pointing in both upper limbs and a wide-based ataxic gait. Reflexes and sensation are normal. There is no wasting or fasciculations. Plantar response is flexor bilaterally.
What is the most likely diagnosis?Your Answer: Motor neuron disease
Correct Answer: Arnold-Chiari malformation
Explanation:Downbeat nystagmus (DBN) suggests a lesion in the lower part of the medulla. Arnold-Chiari malformation usually presents with symptoms due to brainstem and lower cranial nerve dysfunction such as DBN.
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This question is part of the following fields:
- Nervous System
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Question 15
Incorrect
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A 55-year-old woman admitted to the hospital with her third urinary tract infection in as many months. She has type-2 diabetes and started Empagliflozin (a sodium glucose co-transporter 2 inhibitor) 4 months ago. You suspect recurrent urinary tract infections secondary to her empagliflozin.
Where is the main site of action of the drug?Your Answer: Late distal convoluted tubule
Correct Answer: Early proximal convoluted tubule
Explanation:Selective sodium-glucose transporter-2 (SGLT2) is expressed in the proximal renal tubules and is responsible for the majority of the reabsorption of filtered glucose from the tubular lumen.
Empagliflozin; SGLT2 inhibitors reduce glucose reabsorption and lower the renal threshold for glucose, thereby increasing urinary glucose excretion, thus increasing the risk of urinary tract infections. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 16
Incorrect
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A 25-year-old woman was admitted to hospital with a 3 day history of feeling generally unwell, with fatigue, arthralgia and pruritus. She had recently finished a 5 day course of antibiotics for a urinary tract infection but there was no other significant past medical history. She had no significant findings on clinical examination except for a widespread erythematous rash.
Investigation results are below:
Haemoglobin (Hb) 12.6 g/dl
White cell count (WCC) 13.0 × 109/l (eosinophilia)
Platelets 390 × 109/l
Creatinine 720 μmol/l
Na+ 135 mmol/l
K+ 5.2 mmol/l
Urea 22.0 mmol/l
Urinalysis Protein ++ blood +
What is the most important investigation to establish the diagnosis?Your Answer: Antistreptolysin-O titre
Correct Answer: Renal biopsy
Explanation:There is a strong suspicion of drug-induced acute tubulo-interstitial nephritis with the classic triad of symptoms of rash, joint pain and eosinophils in the blood, associated with non-specific symptoms of fever and fatigue. This can be confirmed with renal biopsy showing interstitial oedema with a heavy infiltrate of inflammatory cells and variable tubular necrosis.
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This question is part of the following fields:
- Renal System
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Question 17
Incorrect
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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: True hermaphroditism
Correct 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 18
Incorrect
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A middle-aged female presented in the emergency department with breathlessness for the last few hours. Lung function tests were performed and the results showed her TLCO to be very low but the KCO was 190%. Which of the following is the most probable cause of such findings?
Your Answer: Hereditary haemorrhagic telangiectasia
Correct Answer: Neuromuscular chest wall disorder
Explanation:A patient suffering from extrapulmonary restriction like a neuromuscular chest wall disorder would show similar signs and symptoms. Due to the restriction the lungs cannot fully inflate for gaseous exchange and hence TLCO drops. On the other hand, no change in cardiac output takes place and this leads to higher density of blood per unit volume resulting in raised KCO. No such findings are observed in diseases like scleroderma, PPH, hereditary haemorrhagic telangiectasia and alpha-1 antitrypsin deficiency.
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This question is part of the following fields:
- Respiratory System
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Question 19
Correct
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A 27-year-old lady presents with severe morning headaches associated with nausea. Head MRI reveals a large compressive tumour arising from the falx cerebri. The tumour is well delineated. What is the most probable diagnosis?
Your Answer: Meningioma
Explanation:Meningiomas are the most common benign tumours of the brain. Their name is derived from the fact that they arise from the dura mater which together with the pia matter and arachnoid mater form the meninges. The chances that a meningioma is benign are almost 98%. They are non-invasive and well delineated, causing sign and symptoms of brain compression.
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This question is part of the following fields:
- Nervous System
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Question 20
Incorrect
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A 28-year-old woman presents with lethargy, arthralgia and cough. Over the past three weeks she has also developed painful erythematous nodules on both shins. Respiratory examination is normal.
A chest x-ray is performed which is reported as follows:
Bilateral mediastinal nodal enlargement. No evidence of lung parenchymal disease. Normal cardiac size.
Given the likely diagnosis, what would be the most appropriate course of action?Your Answer: Oral cyclophosphamide
Correct Answer: Observation
Explanation:Sarcoidosis is an inflammatory disease that affects one or more organs but most commonly affects the lungs and lymph glands. The inflammation may change the normal structure and possibly the function of the affected organ(s).
The presentation in sarcoidosis varies with the extent and severity of organ involvement, as follows:
Asymptomatic (incidentally detected on chest imaging): Approximately 5% of cases.
Systemic complaints (fever, anorexia): 45% of cases
Pulmonary complaints (dyspnoea on exertion, cough, chest pain, and haemoptysis [rare]): 50% of casesLöfgren syndrome (fever, bilateral hilar lymphadenopathy, and polyarthralgias): Common in Scandinavian patients, but uncommon in African-American and Japanese patients.
Dermatologic manifestations may include the following:
– Erythema nodosum
РA lower-extremity panniculitis with painful, erythematous nodules (often with L̦fgren syndrome)
– Lupus pernio (the most specific associated cutaneous lesion)
– Violaceous rash on the cheeks or nose (common)
– Maculopapular plaques (uncommon)Staging of sarcoidosis is as follows:
Stage 0: Normal chest radiographic findings
Stage I: Bilateral hilar lymphadenopathy
Stage II: Bilateral hilar lymphadenopathy and infiltrates
Stage III: Infiltrates alone
Stage IV: FibrosisNonsteroidal anti-inflammatory drugs (NSAIDs) are indicated for the treatment of arthralgias and other rheumatic complaints. Patients with stage I sarcoidosis often require only occasional treatment with NSAIDs.
Treatment in patients with pulmonary involvement is as follows:
Asymptomatic patients may not require treatment
In patients with minimal symptoms, serial re-evaluation is prudent
Treatment is indicated for patients with significant respiratory symptoms
Corticosteroids can produce small improvements in the functional vital capacity and in the radiographic appearance in patients with more severe stage II and III disease.This patient has Stage 1 Sarcoidosis so observation is the most appropriate action.
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This question is part of the following fields:
- Respiratory System
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Question 21
Incorrect
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A 50-year-old diabetic and hypertensive patient who is on medication, presented in the OPD with complaints of constipation, polyuria, polydipsia and confusion. On investigation: Serum calcium was 3.07, serum electrophoresis is negative and the X-ray is normal. Which is the most probable cause of these symptoms?
Your Answer: Urinary Tract Infection (UTI)
Correct Answer: Drug induced-Bendroflumethiazide
Explanation:Bendroflumethiazide is a drug used for treating hypertension and is a diuretic. It produces side effects such as constipation, frequent urination, fatigue, polydipsia etc.
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This question is part of the following fields:
- Pharmacology
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Question 22
Incorrect
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Briefly state the mechanism of action of salbutamol.
Your Answer: Beta2 receptor agonist which increases cGMP levels and leads to muscle relaxation and bronchodilation
Correct Answer: Beta2 receptor agonist which increases cAMP levels and leads to muscle relaxation and bronchodilation
Explanation:Salbutamol stimulates beta-2 adrenergic receptors, which are the predominant receptors in bronchial smooth muscle (beta-2 receptors are also present in the heart in a concentration between 10% and 50%).
Stimulation of beta-2 receptors leads to the activation of enzyme adenyl cyclase that forms cyclic AMP (adenosine-mono-phosphate) from ATP (adenosine-tri-phosphate). This increase of cyclic AMP relaxes bronchial smooth muscle and decrease airway resistance by lowering intracellular ionic calcium concentrations. Salbutamol relaxes the smooth muscles of airways, from trachea to terminal bronchioles.
Increased cyclic AMP concentrations also inhibits the release of bronchoconstrictor mediators such as histamine and leukotriene from the mast cells in the airway.
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This question is part of the following fields:
- Respiratory System
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Question 23
Incorrect
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A 48-year-old male presented with exertional angina for 2 weeks. He has no significant past medical history or cardiac risk factors except a total cholesterol of 5.8 mmol/L. He has been already started on aspirin. Which of the following is the most suitable drug combination for him?
Your Answer: Calcium-channel blocker and nitrate
Correct Answer: B-blocker and statin
Explanation:Beta blockers and calcium channel blockers have proven prognostic benefits. Nitrates don’t have any proven prognostic benefits. A statin is indicated for a patient with angina and cholesterol level of 5.5 to 8.5 to prevent risk of myocardial infarction. So the preferred combination from the given answers is beta blocker + statin.
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This question is part of the following fields:
- Cardiovascular System
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Question 24
Correct
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Which one of the following is the most common type of Hodgkin lymphoma?
Your Answer: Nodular sclerosing
Explanation:The most common type of Hodgkin’s lymphoma (HL) is nodular sclerosing.
HL is a malignant proliferation of lymphocytes characterised by the presence of distinctive giant cells known as Reed-Sternberg cells. It has a bimodal age distribution being most common in the third and seventh decades of life.
According to the histological classification, there are four types of HL:
1. Nodular sclerosing: most common (around 70%), more common in women, associated with lacunar cells, good prognosis
2. Mixed cellularity: Around 20%, associated with a large number of Reed-Sternberg cells, good prognosis
3. Lymphocyte-predominant: Around 5%, Reed-Sternberg cells with nuclei surrounded by a clear space found, best prognosis
4. Lymphocyte-depleted: rare, worst prognosis
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This question is part of the following fields:
- Haematology & Oncology
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Question 25
Correct
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From the following responses, what is the commonest cardiovascular abnormality associated with Marfan's syndrome of an adult?
Your Answer: Aortic root dilatation
Explanation:The main cardiovascular manifestations associated with Marfan’s syndrome are aortic dilatation and mitral valve prolapse.
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This question is part of the following fields:
- Cardiovascular System
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Question 26
Correct
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A 30-year-old man presents with hypertension and decreased serum potassium levels. Which hormone should be tested in addition in order to establish the diagnosis?
Your Answer: Aldosterone
Explanation:High blood pressure and a low level of potassium in the blood indicates hyperaldosteronism. Therefore, aldosterone should be tested immediately to establish the diagnosis. Hyperaldosteronism, is a medical condition wherein too much aldosterone is produced by the adrenal glands, which can lead to lowered levels of potassium in the blood (hypokalaemia) and increased hydrogen ion excretion (alkalosis).
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This question is part of the following fields:
- Cardiovascular System
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Question 27
Incorrect
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A 41-year-old male patient presents with dysphagia, haemoptysis and vocal hoarseness. He's been smoking for 25 years and has a past history of regular cannabis use. What is the most probable diagnosis?
Your Answer: Pharyngeal carcinoma
Correct Answer: Squamous cell laryngeal cancer
Explanation:Progressive hoarseness of the voice is a very typical and early finding in people suspected to have squamous cell laryngeal cancer. Due to mechanical compression, patients might experience dysphagia as well as pain. The ‘lump in the throat sensation is not uncommon too. Haemoptysis might be present, together with respiratory symptoms such as dyspnoea. Other symptoms consist of constitutional complaints, such as weight loss or fatigue.
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This question is part of the following fields:
- Haematology & Oncology
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Question 28
Correct
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A 25-year-old athlete presented with a 7-month history of difficulty gripping things. He complained of finding it particularly difficult in cold weather. He remembered his father having similar problems. Upon examination, he had a bilateral ptosis with weakness of the facial muscles. He also had difficulty opening his eyes quickly. Limb examination revealed distal weakness in both hands with difficulty opening and closing both hands quickly. Which of the following is the most likely diagnosis?
Your Answer: Myotonic dystrophy
Explanation:Myotonic dystrophy is the most likely diagnosis here.
It is a multisystem disorder causing cognitive impairment, cataracts, cardiac problems and testicular atrophy, as well as affecting the muscles. Patients have muscle weakness, normally worse distally, and/or myotonia (which is worse in cold weather).
On examination, patients may also have frontal balding, a myopathic facies, bilateral ptosis, an ophthalmoplegia and wasting of facial muscles and other limb muscles. Myotonic dystrophy is associated with diabetes mellitus and pituitary dysfunction.
Diagnosis is normally based on clinical features with a characteristic electromyogram (EMG) of myotonic discharges. Creatine kinase is generally normal and muscle biopsy is non-specific. -
This question is part of the following fields:
- Nervous System
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Question 29
Incorrect
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A 28-year-old patient presents with inflammatory bowel disease. 5-ASA would be most appropriate in treating which condition?
Your Answer:
Correct Answer: Maintenance therapy for ulcerative colitis
Explanation:5-ASA is not an acute treatment; it is for maintenance therapy for ulcerative colitis and/or Crohn’s. The most benefit is seen in patients with ulcerative colitis.
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This question is part of the following fields:
- Gastrointestinal System
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Question 30
Incorrect
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Which complication of chronic renal failure is most likely associated with the accumulation of aluminium?
Your Answer:
Correct Answer: Dialysis dementia
Explanation:Dialysis dementia is a unique neurological syndrome associated with chronic dialysis. Aluminium toxicity is probably the major factor in the pathogenesis of the dementia, which is due to aluminium-containing compounds in the dialysis fluid. Patients with dialysis dementia present with progressive dementia, dysarthria and seizures.
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This question is part of the following fields:
- Renal System
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SESSION STATS - PERFORMANCE PER SPECIALTY
