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Question 1
Incorrect
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A 60-year-old male with a history of diabetes and hypertension presented with left sided arm and leg weakness and loss of vision in the left eye for a brief period. His symptoms improved within a few hours. Which of the following is the most appropriate investigation that can be done at this stage?
Your Answer: 24h ECG
Correct Answer: Doppler USG
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. This 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 2
Incorrect
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A 72-year-old female, known with rheumatoid arthritis for last 17 years, presents with recurrent attacks of red eyes with a sensation of grittiness. Which of the following is most likely cause of the red eyes?
Your Answer: scleritis
Correct Answer: keratoconjunctivitis sicca
Explanation:Rheumatoid arthritis is an inflammatory systemic disease associated with some extraarticular manifestations. Keratoconjunctivitis sicca, episcleritis, scleritis, corneal changes, and retinal vasculitis are the most common ocular complications among extraarticular manifestations of RA. The overall prevalence of keratoconjunctivitis sicca also known as dry eye syndrome among patients of RA is 21.2% and is the most common with sense of grittiness in the eyes.
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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 37-year-old male patient presented with bilateral kidney stones. He gave a history of sarcoidosis. What is the most probable cause for renal stones?
Your Answer:
Correct Answer: Hyper calcaemic
Explanation:Sarcoidosis is a multisystem granulomatous disorder which may involve the kidneys to a variable degree. Renal calculi have been reported to occur in about 10% of patients with chronic sarcoidosis. Hypercalcaemia due to marked hyperabsorption of dietary calcium, bone resorption and renal tubular calcium reabsorption causes hypercalciuria. Both hypercalcemia and hypercalciuria contribute to nephrolithiasis.
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This question is part of the following fields:
- Renal System
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Question 4
Incorrect
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A 39-year-old female had surgery for the removal of thyroid carcinoma. One week later, she presented in the OPD with complaints of numbness, tingling, involuntary spasm of the upper extremities, paraesthesia and respiratory stridor. Which of the following is the most likely cause?
Your Answer:
Correct Answer: Hypocalcaemia
Explanation:Hypocalcaemia presents with such symptoms. It probably happened due to accidental removal of a parathyroid gland during the thyroid surgery. Hypocalcaemia causes laryngospasm which produces stridor.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 5
Incorrect
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A 65-year-male patient was started on warfarin for chronic atrial fibrillation (AF). Which of the following clotting factors is not affected by warfarin?
Your Answer:
Correct Answer: Factor XII
Explanation:Carboxylation of factor II, VII, IX, X and protein C is affected by warfarin. Factor XII is not affected.
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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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In a patient with prostate cancer, what is the mechanism by which goserelin acts?
Your Answer:
Correct Answer: GnRH agonist
Explanation:Androgen deprivation therapy (ADT) for prostate cancer:
Goserelin (Zoladex) is a synthetic gonadotropin-releasing hormone (GnRH) analogue; chronic stimulation of goserelin results in suppression of LH, FSH serum levels thereby preventing a rise in testosterone.
Dosage form: 3.6 mg/10.8mg implants.
Adverse effects include flushing, sweating, diarrhoea, erectile dysfunction, less commonly, rash, depression, hypersensitivity, etc.
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This question is part of the following fields:
- Pharmacology
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Question 7
Incorrect
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A 25-year-old male presented with an episode of syncope. His examination findings were normal. He gave a history of sudden cardiac death of a close relative. His ECG showed incomplete right bundle-branch block and ST-segment elevations in the anterior precordial leads. What is the most probable diagnosis?
Your Answer:
Correct Answer: Brugada syndrome
Explanation:Brugada syndrome is an autosomal dominant disorder characterized by sudden cardiac death. The positive family history and characteristic ECG findings are in favour of Brugada syndrome. Usually the physical findings are normal.
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This question is part of the following fields:
- Cardiovascular System
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Question 8
Incorrect
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Which of the following statements is false regarding the bioavailability of a drug?
Your Answer:
Correct Answer: The bioavailability of a drug given orally is often affected by the degree of renal elimination
Explanation:Renal elimination of a drug has no role in altering the bioavailability of a drug.
The bioavailability of a drug is the proportion of the drug which reaches systemic circulation.
Mathematically, bioavailability is the AUCoral/AUCiv x 100%, where AUC = area under the concentration-time curve following a single (oral or iv) dose.Other options are true:
By definition, the bioavailability of a drug given intravenously is 100%.
Drugs given orally that undergo high pre-systemic (first-pass) metabolism in the liver or gut wall have a low bioavailability e.g. lidocaine.
Bioavailability is also affected by the degree of absorption from the gut and this can change depending on gut motility and administration of other drugs. -
This question is part of the following fields:
- Pharmacology
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Question 9
Incorrect
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Which of the following drugs will most likely trigger an exacerbation of acute intermittent porphyria (AIP)?
Your Answer:
Correct Answer: Oral contraceptive pill
Explanation:Hormonal contraceptives all contain man-made oestrogen and progestin hormones in a limited amount. These hormones prevent pregnancy by inhibiting the body’s natural cyclical hormones to prevent pregnancy. Even though all of these drugs except Ibuprofen can cause AIP in a vulnerable woman. The most likely cause is the OCP.
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This question is part of the following fields:
- Pharmacology
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Question 10
Incorrect
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A 68-year-old male presented with right sided hip pain and was found to have a fracture of right hip. On examination he had bilateral pedal oedema and was also found to be deaf. Which of the following is the most probable diagnosis?
Your Answer:
Correct Answer: Paget's disease
Explanation:Paget disease is a localized disorder of bone remodelling . Hip pain is most common when the acetabulum and proximal femur are involved. The most common neurologic complication is deafness as a result of involvement of the petrous temporal bone. Bilateral pedal oedema is due to associated heart failure.
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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 64-year-old female presents with sudden onset pain, swelling and stiffness in her right knee. Her medical history is significant for osteoarthritis affecting her hand joints and diet controlled diabetes mellitus. On examination, the right knee is swollen, erythematous and tender. Which of the following tests would be most useful in the diagnosis of this case?
Your Answer:
Correct Answer: Aspiration and examination of the synovial fluid
Explanation:Arthrocentesis should usually be done when there is a suspicion of pseudogout or septic arthritis as in this case which leads to an early diagnosis and prompt treatment. Polarized microscopy demonstrates weakly positively birefringent rhomboid crystals which are blue when parallel to light and yellow when perpendicular to light. Elevated serum uric acid levels that cause gout are usually found after large consumption of alcohol or meat, or post surgery. Autoimmune diseases like SLE, RA etc require an autoimmune screen.
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This question is part of the following fields:
- Musculoskeletal System
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Question 12
Incorrect
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A 32-year-old lady is found to be hepatitis B surface antigen positive. This positive result has persisted for more than six months. Hepatitis B envelope antigen (HBeAg) is negative. HBV DNA is negative. Her liver function tests are all entirely normal.
Which of the following options would be the best for further management?Your Answer:
Correct Answer: No antiviral therapy but monitor serology
Explanation:Again, remember the Hepatitis B serologies: In chronic hepatitis B infection, you have +HBsAg, +anti-HBc, (-)IgM antiHBc, and (-) anti-HBs. In acute hepatitis B infection, you have +HBsAg, + anti-HBc, + IgM anti-HBc, and negative anti-HBs. In immunity due to natural infection, you have negative HBsAg, + anti-HBc, and + anti-HBs. In immunity due to vaccination, you have negative HBsAg, negative anti-HBc, and positive anti-HBs. IN THIS CASE, the person is HBsAg+ for 6 months and everything else is negative, normal transaminase. They do not need antiviral therapy, but their serology should be monitored serially. There would be no reason to do a liver biopsy.
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This question is part of the following fields:
- Gastrointestinal System
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Question 13
Incorrect
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A 29-year-old male patient with a history of three previous chest infections in the past seven months presents with fever, pleuritic pain and productive cough. Chest x-ray shows lobar consolidation and the diagnosis of a fourth chest infection is established, after sputum culture reveals Haemophilus influenzae. The previous chest infections were due to Streptococcus pneumoniae. After a period of six weeks, a full blood count, urea, CRP, electrolytes and chest x-ray turn out as normal. What is the investigation you would choose next?
Your Answer:
Correct Answer: Serum immunoglobulins
Explanation:Hypogammaglobulinemia occurs due to a variety of underlying primary or secondary immunodeficient states, including HIV which is suspected in this case. The most commonly recognised clinical feature is recurrent infection.
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This question is part of the following fields:
- Respiratory System
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Question 14
Incorrect
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A 20-year-old female is suffering from amenorrhea. She has a BMI of 14 but still thinks that she needs to lose weight. She watches her food intake obsessively. Choose the most likely diagnosis.
Your Answer:
Correct Answer: Anorexia nervosa
Explanation:Anorexia is consistent with the symptoms described.
Anorexia is an eating disorder characterised by an abnormally low body weight, an intense fear of gaining weight and a distorted perception of weight. People with anorexia place a high value on controlling their weight and shape, using extreme efforts that tend to significantly interfere with their lives.
Some people who have anorexia binge and purge, similar to individuals who have bulimia. But people with anorexia generally struggle with an abnormally low body weight, while individuals with bulimia typically are normal to above normal weight.
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This question is part of the following fields:
- Women's Health
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Question 15
Incorrect
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A 48-year-old man is diagnosed with acute myeloid leukaemia. Cytogenetic testing is carried out.
Which one of the following is mostly associated with a poor prognosis?Your Answer:
Correct Answer: Deletions of chromosome 5
Explanation:Deletion of part of chromosome 5 or 7 is a poor prognostic feature for acute myeloid leukaemia (AML).
AML is the acute expansion of the myeloid stem line, which may occur as a primary disease or follow the secondary transformation of a myeloproliferative disorder. It is more common over the age of 45 and is characterized by signs and symptoms largely related to bone marrow failure such as anaemia (pallor, lethargy), frequent infections due to neutropenia (although the total leucocyte count may be very high), thrombocytopaenia (bleeding), ostealgia, and splenomegaly.
The disease has poor prognosis if:
1. Age of the patient >60 years
2. >20% blasts seen after the first course of chemotherapy
3. Chromosomal aberration with deletion of part of chromosome 5 or 7.Acute promyelocytic leukaemia (APL) is an aggressive form of AML.
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This question is part of the following fields:
- Haematology & Oncology
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Question 16
Incorrect
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An 18-year-old male has been taken to the emergency department and is in a semi-unconscious state. Upon examination, he has the following stats: pulse = 60 bpm; RR = 8/min; and BP = 120/70 mmHg. The doctors also notice needle track marks on both of his arms, and his pupils are very small. From the list of options, choose the most suitable treatment.
Your Answer:
Correct Answer: Naloxone
Explanation:A reduced state of consciousness, RR 8/min, hypotension, miosis, and needle track marks on the arm are all symptoms of an opiate drug overdose, and so Naloxone is the most appropriate course of treatment.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 17
Incorrect
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A 45-year-old male was discharged recently after treatment of bleeding peptic ulcers. 3 days after discharge he was readmitted complaining of acute severe chest pain for the past 1 hour. His ECG showed an acute ST elevation myocardial infarction. His FBC, blood urea, serum electrolytes and serum creatinine were within normal ranges. Faecal occult blood was negative. Which of the following is the most appropriate management for this patient?
Your Answer:
Correct Answer: Primary angioplasty
Explanation:The patient has a recent history of bleeding peptic ulcer disease, which is an absolute contraindication for thrombolysis. So he should be offered primary angioplasty.
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This question is part of the following fields:
- Cardiovascular System
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Question 18
Incorrect
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A 37-year-old woman known with ulcerative colitis is referred with a microcytic anaemia. Blood tests reveal the following results:
Hb 88 g/L (120-160)
WCC 3.6 ×109/L (4-11)
Platelets 222 ×109/L (150-400)
MCV 70 fL (80-96)
Haptoglobins <0.04 g/L (0.13-1.63)
Lactate dehydrogenase 850 U/L (100-250)
Bilirubin 68 µmol/L (1-22)
Alkaline phosphatase 100 U/L (45-105)
ALT 23 U/L (5-40)
Which investigation would confirm the underlying diagnosis?Your Answer:
Correct Answer: Direct Coombs' test
Explanation:This a case of autoimmune haemolytic anaemia which is a rare complication of the less used treatment, salazopyrine, used for inflammatory bowel disease (IBD). A direct Coombs’ test looks for erythrocytes already coated with antibody, whereas the indirect test is used to detect potential red cell antibody interactions floating around in the blood.
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This question is part of the following fields:
- Gastrointestinal System
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Question 19
Incorrect
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A 11-year-old is referred to neurology due to episodes her GP feels are epileptiform. Her mother reports that she appears to just 'stop', sometimes even in mid conversation, for several seconds at random times during the day. During these episodes, she can be unresponsive to questioning and has no recollection of them.
Which of these drugs is contraindicated in this condition?Your Answer:
Correct Answer: Carbamazepine
Explanation:The patient’s history points to absence seizures. Carbamazepine has been shown to aggravate generalized seizure types, especially absence seizures, because it acts directly on the ventrobasal complex of the thalamus which is critical to the neurophysiology of absence seizures.
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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 45-year-old male patient presents with severe pharyngitis and dysphagia. He's found to be HIV positive and with oesophageal candidiasis. Which of the following regarding HIV virus is correct?
Your Answer:
Correct Answer: HIV is an RNA virus
Explanation:The human immunodeficiency virus (HIV) is grouped to the genus Lentivirus within the family of Retroviridae, subfamily Orthoretrovirinae. The HIV genome consists of two identical single-stranded RNA molecules that are enclosed within the core of the virus particle. The genome of the HIV provirus, also known as proviral DNA, is generated by the reverse transcription of the viral RNA genome into DNA, degradation of the RNA and integration of the double-stranded HIV DNA into the human genome.
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This question is part of the following fields:
- Infectious Diseases
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Question 21
Incorrect
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A 60-year-old male with no past medical history presented to Casualty with acute chest pain. ST elevation myocardial infarction (STEMI) is diagnosed following an ECG on arrival. He was subsequently successfully thrombolysed. Which of the following combinations of drugs is the most suitable combination for him to be taking 4 weeks after his STEMI?
Your Answer:
Correct Answer: ACE inhibitor + beta-blocker + statin + aspirin + clopidogrel
Explanation:According to NICE guidelines (2013) all people who have had an acute MI, treatment should be offered with ACE inhibitor, dual antiplatelet therapy (aspirin plus a second antiplatelet agent), beta-blocker and a statin.
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This question is part of the following fields:
- Cardiovascular System
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Question 22
Incorrect
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Which of the following is suggestive of co-existence of mitral regurgitation and mitral stenosis?
Your Answer:
Correct Answer: Displaced apex beat
Explanation:Apex beat displacement is caused by mitral regurgitation and because it is not found in mitral stenosis, it is suggestive of mixed mitral disease. The other given responses occur in mitral stenosis.
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This question is part of the following fields:
- Cardiovascular System
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Question 23
Incorrect
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A 50-year-old male presented with episodes of collapse during the last month. Each episode persisted for about 2-3 minutes. They were self-limiting and associated with twitching of the limbs. There was no associated tonic-clonic movements, tongue biting, urinary or faecal incontinence. On examination he had reversed splitting of S2 and an ejection systolic murmur at the right sternal border. His electrocardiogram (ECG) showed left ventricular hypertrophy with strain pattern. CXR showed an area of calcification over the cardiac silhouette. Which of the following is the most probable diagnosis of this patient?
Your Answer:
Correct Answer: Aortic stenosis
Explanation:The classic triad of symptoms in patients with aortic stenosis is chest pain, heart failure and syncope. Pulsus parvus et tardus, pulsus alternans, hyperdynamic left ventricle, reversed splitting of the S2, prominent S4 and systolic murmur are some of the common findings of aortic stenosis. A calcified aortic valve is found in almost all adults with hemodynamically significant aortic stenosis.
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This question is part of the following fields:
- Cardiovascular System
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Question 24
Incorrect
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A girl suffered full thickness circumferential burn to her right arm. What is best step in management?
Your Answer:
Correct Answer: Escharotomy
Explanation:An escharotomy is a surgical procedure used to treat full-thickness (third-degree) circumferential burns. In full-thickness burns, both the epidermis and the dermis are destroyed along with sensory nerves in the dermis. The tough leathery tissue remaining after a full-thickness burn has been termed eschar.
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This question is part of the following fields:
- The Skin
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Question 25
Incorrect
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A 55-year-old male, known hypertensive on antihypertensive medications, presented with complaints of dizziness and lethargy, especially when rising from the chair. The most appropriate test would be?
Your Answer:
Correct Answer: Ambulatory blood pressure
Explanation:Ambulatory blood pressure recording is used to monitor BP for 24 hours whilst continuing the daily routine activities.
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This question is part of the following fields:
- Nervous System
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Question 26
Incorrect
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A 72-year-old man is referred to the haematology department with raised haemoglobin and platelet levels. A diagnosis of polycythaemia vera is suspected.
Which other abnormality of the blood would be most consistent with this diagnosis?Your Answer:
Correct Answer: Neutrophilia
Explanation:Neutrophilia is also commonly associated with polycythaemia vera.
Polycythaemia vera (PV), also known as polycythaemia rubra vera, is a myeloproliferative disorder caused by clonal proliferation of marrow stem cells leading to an increase in red cell volume, often accompanied by overproduction of neutrophils and platelets. It has peak incidence in the sixth decade of life, with typical features including hyperviscosity, pruritus, splenomegaly, haemorrhage (secondary to abnormal platelet function), and plethoric appearance.
Some management options of PV include lose-dose aspirin, venesection (first-line treatment), hydroxyurea (slightly increased risk of secondary leukaemia), and radioactive phosphorus (P-32) therapy.
In PV, thrombotic events are a significant cause of morbidity and mortality. 5-15% of the cases progress to myelofibrosis or AML. The risk of having AML is increased with chemotherapy treatment.
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This question is part of the following fields:
- Haematology & Oncology
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Question 27
Incorrect
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A woman is prescribed docetaxel as part of her chemotherapy for breast cancer. What is the mechanism of action of docetaxel?
Your Answer:
Correct Answer: Prevents microtubule disassembly
Explanation:The principal mechanism of action of taxanes (e.g. docetaxel) is the prevention of microtubule disassembly.
Other aforementioned options are ruled out because:
1. Doxorubicin: stabilizes DNA topoisomerase II complex and inhibits DNA and RNA synthesis.
2. Vincristine, vinblastine: inhibits formation of microtubules.
3. Cisplatin: causes cross-linking in DNA.
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This question is part of the following fields:
- Haematology & Oncology
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Question 28
Incorrect
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A 74-year-old widow is undergoing haemodialysis for chronic renal failure. What is the most common problem that can arise in this case?
Your Answer:
Correct Answer: Protein-calorie malnutrition
Explanation:Protein-calorie malnutrition is observed in almost 50% of dialysis patients, contributing to increased morbidity and mortality. All the other complications listed can usually be prevented thanks to modern-day dialysis techniques.
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This question is part of the following fields:
- Renal System
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Question 29
Incorrect
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In the event of an overdose, haemodialysis is ineffective as a treatment modality for which of the following drugs?
Your Answer:
Correct Answer: Tricyclics
Explanation:Tricyclic compounds can’t be cleared by haemodialysis.
Drugs that can be cleared with haemodialysis include: (BLAST)
– Barbiturate
– Lithium
– Alcohol (inc methanol, ethylene glycol)
– Salicylates
– Theophyllines (charcoal hemoperfusion is preferable)Drugs which cannot be cleared with haemodialysis include:
– Tricyclics
– Benzodiazepines
– Dextropropoxyphene (Co-proxamol)
– Digoxin
– Beta-blockers -
This question is part of the following fields:
- Emergency & Critical Care
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Question 30
Incorrect
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A 22-year-old man presents with red and flaky patches at the corners of his mouth. Upon examination, angular cheilitis is diagnosed. Anamnesis reveals a history of excessive drinking and malnutrition. What is the most probable deficiency responsible for his condition?
Your Answer:
Correct Answer: Vitamin B2 deficiency
Explanation:Riboflavin, vitamin B2, is a water-soluble and heat-stable vitamin that the body uses to metabolize fats, protein, and carbohydrates into glucose for energy. Riboflavin deficiency can cause fatigue, swollen throat, blurred vision, and depression. It can affect the skin by causing skin cracks, itching, and dermatitis around the mouth. Hyperaemia and oedema around throat, liver degeneration, and hair loss can also occur along with reproductive issues. Usually, people with riboflavin deficiency also have deficiencies of other nutrients. In most cases, riboflavin deficiency can be reversed unless it has caused anatomical changes such as cataracts.
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This question is part of the following fields:
- The Skin
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Question 31
Incorrect
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A 32-year-old man, originally from Pakistan, was admitted with ascites and weight loss. The protein level on ascitic tap was 9 g/l.
Which of the following is the most likely cause of this presentation?Your Answer:
Correct Answer: Hepatic cirrhosis
Explanation:This is a low protein level, indicating the fluid is transudative. The only answer choice that is a transudative fluid is in hepatic cirrhosis. Exudative fluid would be seen in tuberculous peritonitis, peritoneal lymphoma, with liver mets, and with intra-abdominal malignancy.
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This question is part of the following fields:
- Hepatobiliary System
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Question 32
Incorrect
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A 13-year-old male, who is otherwise healthy, has presented with recurrent episodes of swelling in his face and tongue. He also complains of abdominal pain. His father has had similar episodes. Choose the most likely diagnosis for this patient.
Your Answer:
Correct Answer: C1 esterase deficiency
Explanation:C1 esterase deficiency is most often associated with swelling of the peripheries and laryngeal oedema. Severe pain in the abdomen is also consistent with this diagnosis. It is also an autosomal dominant condition.
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This question is part of the following fields:
- Immune System
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Question 33
Incorrect
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A 79-year-old nursing home resident presents to the clinic with an intensely itchy rash. Examination reveals white linear lesions on the wrists and elbows, and red papules on the penile surface. Which of the following will be the most suitable management plan for this patient?
Your Answer:
Correct Answer: Topical permethrin
Explanation:Scabies is a parasitic skin infestation caused by Sarcoptes scabiei mite, which is primarily transmitted via direct human-to-human contact. The female scabies mite burrows into the superficial skin layer, causing severe pruritus, particularly at night. Primary lesions commonly include erythematous papules, vesicles, or burrows. Treatment involves topical medical therapy (e.g. permethrin) and decontamination of all clothing and textiles.
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This question is part of the following fields:
- Infectious Diseases
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Question 34
Incorrect
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A 25-year-old woman is presenting with diarrhoea and abdominal bloating over the last 4 months. On examination, she has a blistering rash over her elbows. Biochemical investigation showed that she has low serum albumin, calcium and folate concentrations. On jejunal biopsy there is shortening of the villi and lymphocytosis. What is the most likely cause?
Your Answer:
Correct Answer: Coeliac disease
Explanation:Celiac disease has characteristic shortened intestinal villi. When patients with celiac disease eat products containing gluten, they are unable to absorb the nutrients due to flattened or shortened intestinal villi. The blistering rash present on the patient’s elbows strongly suggests celiac disease. This rash is a sign of the condition Dermatitis Herpetiformis which is associate with celiac disease. Therefore, it is also often called ‘gluten rash’.
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This question is part of the following fields:
- Gastrointestinal System
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Question 35
Incorrect
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A 17-year-old boy presents with a 2 day history of colicky abdominal pain, vomiting and diarrhoea. He has been passing blood mixed with diarrhoea. He has no significant past medical history and takes no regular medication.
On examination he is pyrexial and clinically dehydrated. Cardiorespiratory and abdominal examinations are normal.
What is the most likely diagnosis?Your Answer:
Correct Answer: Campylobacter infection
Explanation:The patient has bloody diarrhoea that sounds like a food poisoning in the clinical scenario. Campylobacter is the most common cause of this in the United Kingdom. This is then followed by Salmonella and Shigella. The symptoms are usually self limiting. This is more likely to be bacterial from the food than a viral gastroenteritis.
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This question is part of the following fields:
- Gastrointestinal System
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Question 36
Incorrect
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A 70-year-old complains of lower urinary tract symptoms. Which one of the following statements regarding benign prostatic hyperplasia is incorrect?
Your Answer:
Correct Answer: Goserelin is licensed for refractory cases
Explanation:Goserelin (Zoladex) is usually prescribed to treat hormone-sensitive cancers of the breast and prostate not for BPH. All other statements are correct.
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This question is part of the following fields:
- Renal System
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Question 37
Incorrect
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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:
Correct 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 38
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:
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 39
Incorrect
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A 65-year-old real estate broker presents with a tremor. Which one of the following features would suggest a diagnosis of essential tremor rather than Parkinson's disease?
Your Answer:
Correct Answer: Tremor is worse when the arms are outstretched
Explanation:Difficulty in initiating movement (bradykinesia), postural instability and unilateral symptoms (initially) are typical of Parkinson’s. Essential tremor symptoms are usually worse if arms are outstretched and eased by rest and alcohol.
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This question is part of the following fields:
- Nervous System
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Question 40
Incorrect
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A 16-year-old female has been admitted to hospital after overdosing on paracetamol 4 hours ago. She has also consumed a large amount of alcohol. Her plasma paracetamol concentration is only just below a level which requires treatment. From the list of options, choose the most appropriate treatment option for this patient.
Your Answer:
Correct Answer: Refer to psychiatry ward
Explanation:As her paracetamol level is under the required treatment threshold, she requires no medical treatment. However, she has taken a simultaneous drug overdose and excessive alcohol consumption. These two factors together require psychiatric evaluation and so she should be referred to the psychiatry ward.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 41
Incorrect
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A 41-year-old man who has had two episodes of pneumonia in succession and an episode of haemoptysis is observed to have paroxysms of coughing and increasing wheezing. A single lesion which is well-defined is seen in the lower right lower lobe on a chest x-ray. There is no necrosis but biopsy shows numerous abnormal cells, occasional nuclear pleomorphism and absent mitoses.
Which diagnosis fits the clinical presentation?Your Answer:
Correct Answer: Bronchial carcinoid
Explanation:Bronchial carcinoids are uncommon, slow growing, low-grade, malignant neoplasms, comprising 1-2% of all primary lung cancers.
It is believed to be derived from surface of bronchial glandular epithelium. Mostly located centrally, they produce symptoms and signs of bronchial obstruction such as localized wheeze, non resolving recurrent pneumonitis, cough, chest pain, and fever. Haemoptysis is present in approximately 50% of the cases due to their central origin and hypervascularity.
Central bronchial carcinoids are more common than the peripheral type and are seen as endobronchial nodules or hilar/perihilar mass closely related to the adjacent bronchus. Chest X-ray may not show the central lesion depending on how small it is. -
This question is part of the following fields:
- Respiratory System
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Question 42
Incorrect
-
Hepatitis C is what kind of virus?
Your Answer:
Correct Answer: A variable RNA virus
Explanation:Hepatitis C is a single-stranded positive sense RNA virus. It is variable because of the high rate of error of RNA-dependent RNA polymerase and the pressure from the host immune system has caused HCV to evolve and develop seven genetic lineages.
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This question is part of the following fields:
- Infectious Diseases
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Question 43
Incorrect
-
A female in her early 20's who has been diagnosed with asthma for the past four years visits the office for a review. She has been using Beclomethasone dipropionate inhaler 200mcg bd along with Salbutamol inhaler 100mcg prn and her asthma is still uncontrolled. Her chest examination is clear and she has good inhaler technique. What would be the most appropriate next step in the management of her asthma?
Your Answer:
Correct Answer: Add a leukotriene receptor antagonist
Explanation:The NICE 2017 guidelines state that in patients who are uncontrolled with a SABA (Salbutamol) and ICS (Inhaled corticosteroid e.g. Beclomethasone), a leukotriene receptor antagonist (LTRA) should be added.
If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS as maintenance therapy, offer a leukotriene receptor antagonist (LTRA) in addition to the ICS and review the response to treatment in 4 to 8 weeks.This recommendation is also stated in NICE 2019 guidelines.
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This question is part of the following fields:
- Respiratory System
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Question 44
Incorrect
-
A 67-year-old man who has terminal lung cancer and is taking morphine slow release tablet (MST) 60mg bd as an analgesic, is reviewed. Recently, he has been unable to take medications orally and, thus, a decision has been made to set up a syringe driver.
Out of the following, what dose of diamorphine should be prescribed for the syringe driver?Your Answer:
Correct Answer: 40mg
Explanation:The dose is calculated, using the conversion factor, as follows:
(Conversion factor used to convert oral morphine to subcutaneous diamorphine = Divide the total daily dose of oral morphine by 3)
Hence,
60mg*2 = 120mg
120mg/3 = 40mgThe side effects of opioids can be transient or persistent, and these include constipation, nausea, and drowsiness. Therefore, all patients taking opioids should also be prescribed a laxative and an anti-emetic (if the nausea is persistent). Dose-adjustment may be necessary in cases of persistent drowsiness. Moreover, strong opioids can also provide quick relief from metastatic bone pain, as compared to NSAIDs, bisphosphonates, and radiotherapy.
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This question is part of the following fields:
- Haematology & Oncology
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Question 45
Incorrect
-
A diagnosed case of scabies presented in OPD for some medical advice. Which of the following statements best suits scabies?
Your Answer:
Correct Answer: It causes itchiness in the skin even where there is no obvious lesion to be seen
Explanation:Scabies is an infection caused by a microscopic mite known as Sarcoptes scabies. The chief presenting complaint is itching especially in skin folds and mostly during night. It spreads from one person to another through skin contact, and therefore it is more prevalent in crowded areas like hospitals, hostels and even at homes where people live in close contact with each other. Treatment options include benzyl benzoate, ivermectin, sulphur and permethrin.
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This question is part of the following fields:
- The Skin
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Question 46
Incorrect
-
Which of the following serum tumour markers is the most essential for monitoring the clinical progression of a man with teratoma of the testis following chemotherapy?
Your Answer:
Correct Answer: Alpha-fetoprotein
Explanation:Testicular teratomas are best monitored with the following tumour markers: Alpha-fetoprotein (AFP), beta-hCG, and PLAP (placental like isoenzyme of alkaline phosphatase). For ovarian tumours, we use CA125, pancreatic tumours we use CA19-9, CA15-3 for breast carcinoma and carcinoembryonic antigen (CEA) for colonic tumours.
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This question is part of the following fields:
- Men's Health
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Question 47
Incorrect
-
A 60-year-old male patient with a history of heavy smoking was admitted complaining of acute severe central chest pain for the past one hour. His blood pressure was 150/90 mmHg and pulse rate was 88 bpm. His peripheral oxygen saturation was 93%. ECG showed ST elevation > 2 mm in lead II, III and aVF. He was given loading doses of aspirin, clopidogrel and atorvastatin and face mask oxygen was given. Which one of the following investigations should be done and then depending on result, definitive treatment can be initiated?
Your Answer:
Correct Answer: None
Explanation:The history and ECG findings are adequate to begin cardiac revascularization of this patient. There is no need for cardiac markers to confirm the diagnosis. Further delay in starting definite treatment is not recommended.
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This question is part of the following fields:
- Cardiovascular System
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Question 48
Incorrect
-
A 32-year-old man complains of fever, rash and photophobia. The physician suspects this to be a case of meningitis. Which of the following medication would be ideally used in this patient?
Your Answer:
Correct Answer: Cefotaxime
Explanation:Broad-spectrum cephalosporins, especially cefotaxime and ceftriaxone, are widely used in the treatment of suspected pneumococcal meningitis and are considered the treatment of choice for meningitis caused by partially penicillin-resistant pneumococcal strains.
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This question is part of the following fields:
- Pharmacology
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Question 49
Incorrect
-
A 35-year-old man is referred to the clinic by his GP. He complains of lethargy and tiredness. He has recently been discharged from the hospital after being admitted to the intensive care unit following a motorbike accident.
His thyroid function testing is :
TSH 0.3 IU/l (0.5-4.5)
Free T4 8 pmol/l (9-25)
Free T3 3.1 pmol/l (3.4-7.2)
Which of the following is most likely to be the diagnosis?Your Answer:
Correct Answer: Sick euthyroid syndrome
Explanation:Euthyroid sick syndrome (also known as nonthyroidal illness syndrome) can be described as abnormal findings on thyroid function tests that occurs in the setting of a nonthyroidal illness (NTI), without pre-existing hypothalamic-pituitary and thyroid gland dysfunction. After recovery from an NTI, these thyroid function test result abnormalities should be completely reversible.
Multiple alterations in serum thyroid function test findings have been recognized in patients with a wide variety of NTIs without evidence of pre-existing thyroid or hypothalamic-pituitary disease. The most prominent alterations are low serum triiodothyronine (T3) and elevated reverse T3 (rT3), leading to the general term low T3 syndrome. Thyroid-stimulating hormone (TSH), thyroxine (T4), free T4 (FT4), and free T4 index (FTI) also are affected in variable degrees based on the severity and duration of the NTI. As the severity of the NTI increases, both serum T3 and T4 levels drop, but they gradually normalize as the patient recovers.
Reverse T3 is used to differentiate between this condition and secondary thyroid failure. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 50
Incorrect
-
Which one of the following is true of gamma delta T cells?
Your Answer:
Correct Answer: They play a role in the skin and gut
Explanation:Gamma delta T cells are of low abundance in the body, are found in the gut mucosa, skin, lungs and uterus, and are involved in the initiation and propagation of immune responses. Their ligands are not known in detail, but the gamma delta T cell receptors recognise intact proteins rather than MHC-presented peptides. Like alpha beta T cells, they develop in the thymus.
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This question is part of the following fields:
- Haematology & Oncology
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Question 51
Incorrect
-
A 57-year-old male presented to the OPD with a complaint of yellow discoloration of his skin. On examination, he was found to have digital clubbing, jaundice, an enlarged and nodular liver, as well as caput medusa. Clinical investigations revealed normal electrolyte levels but low albumin levels. Which of the following is the appropriate management of this patient's fluid intake?
Your Answer:
Correct Answer: Albumin infusion
Explanation:This patient has an accumulation of fluid inside his body which, along with the lowered albumin level, tells us that the oncotic pressure of the blood is very low in this patient. Therefore, albumin infusion is the best option for him because albumin is the key human protein that contributes the most to the oncotic pressure.
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This question is part of the following fields:
- Fluids & Electrolytes
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Question 52
Incorrect
-
A 74-year-old man with longstanding Waldenström's macroglobulinemia presents to the rheumatology clinic with joint pain and generalised weakness. Which of the following would be most indicative of type I cryoglobulinemia?
Your Answer:
Correct Answer: Raynaud's phenomenon
Explanation:Cryoglobulins are proteins that precipitate from an individual’s serum or plasma at temperatures lower than 37°C. They can be a mixture of immunoglobulin (Ig) and complement components or immunoglobulins alone. These cryoglobulins deposit in medium and large-sized blood vessels throughout the body, causing endothelial injury and end-organ damage known as cryoglobulinemia.
Cryoglobulinemia can be divided into three main types, depending on which kind of antibody your body produces.
Type I cryoglobulinemia is frequently associated with an underlying health condition, such as cancer of your blood or immune system.
Type II cryoglobulinemia and type III cryoglobulinemia are often seen in people with long-term (chronic) inflammatory conditions, such as autoimmune diseases. Type II cryoglobulinemia is very common in people with hepatitis C virus (HCV). Another name for types II and III cryoglobulinemia is mixed cryoglobulinemia.
People with cryoglobulinemia may or may not experience symptoms. When symptoms are present, they most commonly include a particular rash, usually over the lower legs as well as fatigue and joint pain.
Other cryoglobulinemia symptoms may include:
- Change in the color of your hands and/or feet with cold temperatures, called Raynaud’s phenomenon.
- Weight loss.
- High blood pressure
- Swelling (edema) of ankles and legs.
- Skin ulcers and gangrene.
- Enlarged liver (hepatomegaly) or enlarged spleen (splenomegaly).
Raynaud’s syndrome causes spasms in small blood vessels in your fingers and toes. This limits blood flow and leads to symptoms like skin color changes, cold skin and a pins and needles sensation. Common triggers of Raynaud’s attacks include cold weather and stress. Many people have mild symptoms that they can manage through lifestyle changes.
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This question is part of the following fields:
- Haematology & Oncology
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Question 53
Incorrect
-
A 58-year-old lady was admitted to hospital with increasing thirst and generalised abdominal pain. She was diagnosed with breast carcinoma three years previously and treated with a radical mastectomy.
Â
Investigations showed:
Serum corrected calcium 3.5 mmol/L (NR 2.2-2.6)
Serum alkaline phosphatase 1100 IU/L
Â
Her serum calcium was still elevated following 4 litres of 0.9% saline intravenous infusion.
Â
Which of the following is the most appropriate next step?Your Answer:
Correct Answer: Pamidronate 60 mg intravenously
Explanation:This case has hypercalcaemia most likely associated with the bony metastases from her pre-existing breast carcinoma. The most appropriate next step is to give Pamidronate 60mg intravenously, a bisphosphonate, to immediately inhibit bone resorption and formation.
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This question is part of the following fields:
- Renal System
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Question 54
Incorrect
-
Which of the following medications is a long acting adrenergic beta-receptor agonist?
Your Answer:
Correct Answer: Formoterol
Explanation:Terbutaline is a long acting beta receptor agonist. It is used as an add on drug for step 3 in treatment of bronchial asthma. It causes relaxation of bronchial smooth muscles and thus, bronchodilatation.
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This question is part of the following fields:
- Pharmacology
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Question 55
Incorrect
-
A 28-year-old primigravida in her 24th week of pregnancy presented with a history of fast and regular palpitations. There is no history of collapse. On examination she was well, pulse rate was 102 bpm, which was regular and her blood pressure was 110/70 mmHg. Her JVP was not elevated. Heart sounds were normal. ECG showed sinus tachycardia. Which of the following can be expected due to the physiological changes which occur during pregnancy?
Your Answer:
Correct Answer: Tachycardia
Explanation:The cardiovascular alterations which occur during pregnancy are for the optimal growth and development of the foetus and help to protect the mother from the risks of delivery, such as haemorrhage. The changes are characterized by an increased vascular volume, cardiac output, and heart rate, with a marked fall in vascular resistance and reduction in blood pressure.
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This question is part of the following fields:
- Cardiovascular System
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Question 56
Incorrect
-
A 50-year-old farmer, under treatment for depression, presents to the emergency department following an intentional overdose of an unidentified substance. On examination, he was found to be bradycardic, hypotensive, hyper-salivating, and disoriented. On ocular examination, his pupils were found to be miotic. What is the most likely substance he ingested?
Your Answer:
Correct Answer: An organophosphate insecticide
Explanation: -
This question is part of the following fields:
- Emergency & Critical Care
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Question 57
Incorrect
-
A 74-year-old man presents with 12 kg weight loss and persistent back pain that is unrelated to activity for the past several months. Laboratory findings show :
WCC: 6.7 x 109/l (5.4 neutrophils, 1.2 lymphocytes and 0.2 monocytes)
Haemoglobin: 11.2 g/dl
haematocrit: 33.3%
MCV: 88 fl
Platelet count: 89 x 109/l.
The biochemistry shows:
sodium 144 mmol/l
potassium 4.5 mmol/l
chloride 100 mmol/l
bicarbonate 26 mmol/l
urea 14 mmol/l
creatinine 90 μmol/l
a glucose of 5.4 mmol/l.
A CT scan of the spine reveals scattered 0.4 to 1.2 cm bright lesions in the vertebral bodies.
Which of the following additional laboratory test findings is he most likely to have?Your Answer:
Correct Answer: Serum prostate specific antigen of 35 microgram/l
Explanation:Old age, persistent backache, weight loss, and osteosclerotic lesions make prostatic adenocarcinoma the most likely diagnosis. The sequelae include severe pain, pathological fractures, hypercalcemia and cord compression. Prostatic adenocarcinoma is detected by elevated levels of prostate specific antigen. Positive serology for borrelia burgdorferi would hint at Lyme disease which does not cause osteosclerotic bone lesions, neither would Neisseria gonorrhoeae have such a presentation.
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This question is part of the following fields:
- Musculoskeletal System
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Question 58
Incorrect
-
A 20-year-old woman presents to the hospital with sharp, left-sided chest pain and shortness of breath.
On examination her pulse is 101 beats per minute and blood pressure is 124/61 mmHg. She is seen to be mildly breathless at rest but her oxygen saturation on air was 98%.
CXR reveals a left pneumothorax with a 4 cm rim of air visible.
Which management strategy is appropriate in this patient?Your Answer:
Correct Answer: Needle aspiration
Explanation:Pneumothorax is defined as air in the pleural space and may be classified as spontaneous, traumatic or iatrogenic. Primary spontaneous pneumothorax occurs in patients without clinically apparent lung disease.
Primary pneumothorax has an incidence of 18-28 per 100,000 per year for men and 1.2-6 per 100,000 per year for women. Most patients present with ipsilateral pleuritic chest pain and acute shortness of breath. Shortness of breath is largely dependent on the size of the pneumothorax and whether there is underlying chronic lung disease.Young patients may have chest pain only. Most episodes of pneumothorax occur at rest. Symptoms may resolve within 24 hours in patients with primary spontaneous pneumothorax. The diagnosis of a pneumothorax is confirmed by finding a visceral pleural line displaced from the chest wall, without distal lung markings, on a posterior-anterior chest radiograph.
Breathless patients should not be left without intervention regardless of the size of pneumothorax. If there is a rim of air >2cm on the chest X-ray, this should be aspirated.
Aspiration is successful in approximately 70 per cent of patients; the patient may be discharged subsequently. A further attempt at aspiration is recommended if the patient remains symptomatic and a volume of less than 2.5 litres has been aspirated on the first attempt.If unsuccessful, an intercostal drain is inserted. This may be removed after 24 hours after full re-expansion or cessation of air leak without clamping and discharge may be considered.
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This question is part of the following fields:
- Respiratory System
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Question 59
Incorrect
-
A 11-year-old girl with a history of recurrent chest infections, was admitted with a fever, productive cough, anorexia and weight loss. On examination she was febrile and tachycardic. Her mother said that the girl was not thriving well. Which of the following organisms is responsible for this presentation?
Your Answer:
Correct Answer: Pseudomonas
Explanation:History of recurrent infections and failure to thrive (probably due to pancreatic enzyme insufficiency) is highly suggestive of cystic fibrosis. Pseudomonas has been identified as an important respiratory pathogen in patients with cystic fibrosis.
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This question is part of the following fields:
- Infectious Diseases
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Question 60
Incorrect
-
An 80-year-old male has been receiving treatment for prostate cancer. He has complained of pain in his pelvis and, following radiological investigations, is shown to have pelvic metastases. Choose the most appropriate course of investigation for this patient.
Your Answer:
Correct Answer: Palliative radiotherapy
Explanation:The patient could respond well to palliative radiotherapy. This course of action is likely to shrink the cancer and will, therefore, reduce the pain felt. Analgesics should then be used to control the symptoms.
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This question is part of the following fields:
- Haematology & Oncology
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Question 61
Incorrect
-
A 65-year-old heavy smoker presented with acute central chest pain for 2 hours. Which of the following ECG findings is an indication for thrombolysis in this patient?
Your Answer:
Correct Answer: 1 mm ST elevation in 2 limb leads
Explanation:Thrombolytic therapy is indicated in patients with evidence of ST-segment elevation MI (STEMI) or presumably new left bundle-branch block (LBBB) presenting within 12 hours of the onset of symptoms if there are no contraindications to fibrinolysis. STEMI is defined as new ST elevation at the J point in at least two contiguous leads of 2 mm (0.2 mV) or more in men or 1.5 mm (0.15 mV) in women in leads V2-V3 and/or 1 mm (0.1 mV) or more in other contiguous limb leads.
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This question is part of the following fields:
- Cardiovascular System
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Question 62
Incorrect
-
A 40-year-old male returning from an African country, presented with lower abdominal pain and haematuria. Bladder calcifications were detected on abdominal x-ray. Which of the following is the most probable cause?
Your Answer:
Correct Answer: Schistosoma haematobium
Explanation:Schistosoma haematobium characteristically causes urinary tract disease. S.mansoni, S. mekongi, S. intercalatum, and S. japonicum cause intestinal tract and liver disease.
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This question is part of the following fields:
- Infectious Diseases
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Question 63
Incorrect
-
Among the following which is the beneficial effect of nitroglycerin?
Your Answer:
Correct Answer: Dilation of systemic veins
Explanation:Dilation of systemic veins is a beneficial effect of nitro-glycerine.
Administration of nitro-glycerine results in the dilation of systemic veins and decrease of myocardial wall tension and oxygen demand. Dilatation of systemic veins can cause reduced systemic vascular resistance leading to reduced cardiac workload thus reducing anginal symptoms secondary to demand ischemia.
This is accompanied by vasodilation of large and medium-sized coronary arteries with increased coronary blood flow to the sub endocardium.
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This question is part of the following fields:
- Pharmacology
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Question 64
Incorrect
-
A female patient presents with pain upon inspiration and dyspnoea. She had a myocardial infarction four days ago. What is the most probable diagnosis?
Your Answer:
Correct Answer: Pericarditis
Explanation:Although viral infection is the most common identifiable cause of acute pericarditis, the condition may be associated with many diseases. Non-viral causes of pericarditis include bacterial infection, MI, chest trauma, and neoplasm. Post-MI pericarditis may develop two to four days after an acute infarction and results from a reaction between the pericardium and the damaged adjacent myocardium. Dressler’s syndrome is a post-MI phenomenon in which pericarditis develops weeks to months after an acute infarction; this syndrome is thought to reflect a late autoimmune reaction mediated by antibodies to circulating myocardial antigens.
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This question is part of the following fields:
- Cardiovascular System
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Question 65
Incorrect
-
A 39-year-old woman with a history of rheumatoid arthritis has recently been switched from methotrexate to leflunomide. Monitoring of full blood count and LFTs has been carried out. Which of the following parameters should also be monitored in this case?
Your Answer:
Correct Answer: Blood pressure
Explanation:Blood pressure should be routinely measured as leflunomide may cause hypertension and thus an increase in BP. It doesn’t cause changes in blood sugar levels, peak expiratory flow rate or haematuria.
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This question is part of the following fields:
- Musculoskeletal System
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Question 66
Incorrect
-
A 30-year-old woman is admitted for drainage of an abscess in her left forearm. She has revealed that she was regular heroin user and has stopped for the past few days. Clinical signs are pointing towards opioid withdrawal. What is the next step in managing this patient?
Your Answer:
Correct Answer: Give her 10 mg of methadone syrup and wait 60 min to determine its effect
Explanation:The next step in managing this patient is to give 10 mg and continue administering in 10 mg increments each hour until symptoms are under control.
Methadone alleviates opioid withdrawal symptoms and reduces cravings. Methadone is useful for detoxification from longer-acting opioids such as morphine or methadone itself.
Methadone should be used with caution if the patient has:
Respiratory deficiency
Acute alcohol dependence
Head injury
Treatment with monoamine oxidase inhibitors (MAOIs)
Ulcerating colitis or Crohn’s disease
Severe hepatic impairment
The dose must be reviewed on a daily basis and adjusted based upon how well the symptoms are controlled and the presence of side effects. The greater the dose of opioids used by the patient, the greater the dose of methadone required to control withdrawal symptoms.To avoid the risk of overdose in the first days of treatment The recommended dosing of methadone is 30mg in two doses of 15mg morning and evening.
It is important to note that a methadone dose equivalent to what the patient reports they are taking should never be given.
It is rare to need more than 40 mg per 24 hours: beware of overdosing which can lead to respiratory arrest. -
This question is part of the following fields:
- Pharmacology
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Question 67
Incorrect
-
A 3-year old boy presents with an abdominal mass. Which of the following is associated with Wilms tumour (nephroblastoma)?
Your Answer:
Correct Answer: Beckwith-Wiedemann syndrome
Explanation:Beckwith-Wiedemann syndrome is a inherited condition associated with organomegaly, macroglossia, abdominal wall defects, Wilm’s tumour and neonatal hypoglycaemia. Wilm’s tumour is a kidney cancer that usually occurs in children. The causes are unknown, however, risk factors include race and family history. Of note, Wilm’s tumour can occur as part of the following syndromes: WAGR syndrome, Denys-Drash syndrome, and Beckwith-Wiedmann syndrome and not the other listed options in this question.
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This question is part of the following fields:
- Renal System
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Question 68
Incorrect
-
A young man has ingested 25 tablets of paracetamol 500 mg. What is the suggested minimum time interval between ingestion and measuring the blood plasma paracetamol levels?
Your Answer:
Correct Answer: 4 hours
Explanation:The post-ingestion plasma level, which is required in order to guide the treatment, reaches a peak at 4 hours. Levels requiring antidote (N-acetyl cysteine) include: 100 mcg per ml at 4 hours, 35 mcg per ml at 10 hours and 25 mcg per ml at 12 hours. These levels are in conjunction with the levels recorded and they should all be put down on a treatment nomogram.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 69
Incorrect
-
A 50-year-old patient was started on ezetimibe, for his cholesterol a few days back. Which among the following statements is true regarding ezetimibe?
Your Answer:
Correct Answer: Its principal action is to reduce intestinal cholesterol absorption
Explanation:Ezetimibe is a cholesterol-lowering agent that acts to prevent cholesterol absorption by directly inhibiting cholesterol receptors on enterocytes.
It does not affect the absorption of drugs (e.g. digoxin, thyroxine) or fat-soluble vitamins (A, D and K) as the anion-exchange resins do. It does not affect the cytochrome P450 enzyme system.
The increased risk of myositis associated with the statins is not seen with ezetimibe.
The most common adverse effects include headache, runny nose, and sore throat.
Less common reactions include body aches, back pain, chest pain, diarrhoea, joint pain, fatigue, and weakness. -
This question is part of the following fields:
- Pharmacology
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Question 70
Incorrect
-
A 35-year-old sales representative presents with severe pain going down her neck and right arm. She admits that this pain is worse on sitting and driving for long periods. Past history is significant for two previous road traffic accidents. Examination reveals weakness and sensory loss over C5/C6 nerve distribution. There is pain with neck movement and particularly extension. Which of the following investigations would be the most helpful in this case?
Your Answer:
Correct Answer: MRI scan of the cervical spinal cord
Explanation:Cervical radiculopathy is usually due to compression or injury to a nerve root by a herniated disc or degenerative changes. Levels C5 to T1 are the most commonly affected. It is usually, but not always, accompanied by cervical radicular pain, a sharp and shooting pain that travels from the neck and down the upper limb and may be severe. This needs to be differentiated from pain referred from the musculoskeletal (somatic) structures in the neck, which may be aching rather than sharp, and is more severe in the neck than in the upper limb. The neurological signs of cervical radiculopathy depend on the site of the lesion. The patient may have motor dysfunction, sensory deficits or alteration in tendon reflexes. While pain is a common presenting symptom, not all radiculopathies are painful (i.e. only motor deficits may be obvious). CT scanning cannot accurately demonstrate the commonest cause for cervical radiculopathy (disc herniation) without myelography, which requires hospital admission, lumbar puncture and the use of contrast. In patients with cervical radiculopathy, MRI is the imaging technique of choice for the detection of root compression by disc herniation and osteophytes. MRI allows the nerve roots to be directly visualised. Nerve conduction studies are also useful in determining the nerve roots that are involved.
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This question is part of the following fields:
- Musculoskeletal System
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Question 71
Incorrect
-
A 50-year-old man with a history of hyperlipidaemia, currently under treatment with simvastatin 10mg was found to have persistently high cholesterol levels. Previous attempts to increase the dose of simvastatin have resulted in myalgia. Given this history, which one of the following lipid-regulating drugs should definitely be avoided?
Your Answer:
Correct Answer: Bezafibrate
Explanation:Both fibrates and nicotinic acid have been associated with myositis, especially when combined with a statin. However, the Committee on Safety of Medicines has produced guidance which specifically warns about the concomitant prescription of fibrates with statins concerning muscle toxicity.
Bezafibrate: It is a fibric acid derivative (fibrate) that has been used as a class of agents known to decrease triglyceride levels while substantially increasing HDL-C levels.
Pharmacological effects:
– Increases VLDL catabolism by increasing lipoprotein and hepatic triglyceride lipase.
– Decreases triglyceride synthesis by inhibiting acetyl-CoA reductase.
– Decreases cholesterol synthesis by inhibiting HMG-CoA reductase.Side effects:
– Hypersensitivity
– Primary biliary cirrhosis
– Pre-existing gallbladder disease
– Concurrent use with HMG-CoA inhibitors (statins) can produce myopathy
– Hepatic/renal impairment in a patient warrants dose adjustment as this drug is primarily excreted via the renal mechanism.Contraindications: Concurrent use of MAO inhibitors, hypersensitivity, pre-existing cholestasis, and pregnancy.
Use: It can be used to treat Barth syndrome (characterized by dilated cardiomyopathy, neutropenia (presenting with recurrent infections), skeletal myopathy and short stature)
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This question is part of the following fields:
- Pharmacology
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Question 72
Incorrect
-
A 68-year-old female is on long term prednisolone therapy for polymyalgia rheumatica. Which of the following would be the most suitable protection against osteoporosis?
Your Answer:
Correct Answer: Oral bisphosphonate
Explanation:Prevention of osteoporosis associated with chronic glucocorticoid therapy is done by administrating bisphosphonates. Oral bisphosphonates are indicated for patients aged above 65 who have been on steroid therapy for over 3 months, so as to reduce the risk of steroid induced osteoporosis. HRT is usually done in post menopausal women who have oestrogen related bone resorption.
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This question is part of the following fields:
- Musculoskeletal System
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Question 73
Incorrect
-
A 75-year-old woman experiences weakness of her left hand. Clinical examination reveals wasting of the hypothenar eminence and weakness of finger abduction and thumb adduction. The lesion is most probably located at:
Your Answer:
Correct Answer: Ulnar nerve
Explanation:Patients with compressive neuropathy of the ulnar nerve typically describe numbness and tingling of the ulnar-sided digits of the hand, classically in the small finger and ulnar aspect of the ring finger. Among the general population, symptoms usually begin intermittently and are often worse at night, particularly if the elbow is flexed while sleeping. As the disease progresses, paraesthesia may occur more frequently and during the daytime.
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This question is part of the following fields:
- Nervous System
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Question 74
Incorrect
-
A teenage girl presented in the OPD with a history of amenorrhea. She said she was exercising daily and needs to lose weight. On examination, she is 162 cm in height and 45 kgs in weight. Which of the following is the most probable cause in this case?
Your Answer:
Correct Answer: Hypomagnesaemia and hypocalcaemia are possibly present
Explanation:This scenario represents anorexia nervosa disorder, a psychological disorder. Extreme weight loss with a strict diet can lead to deficiency of many nutrients like magnesium and calcium. This can also cause amenorrhea.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 75
Incorrect
-
A 23-year-old male medical student presents to the A&E department with pleuritic chest pain. He does not have productive cough nor is he experiencing shortness of breath. He has no past medical history. A chest x-ray which was done shows a right-sided pneumothorax with a 1 cm rim of air and no mediastinal shift.
What is the most appropriate treatment option?Your Answer:
Correct Answer: Discharge with outpatient chest x-ray
Explanation:Primary spontaneous pneumothorax is an abnormal accumulation of air in the space between the lungs and the chest cavity (called the pleural space) that can result in the partial or complete collapse of a lung. This type of pneumothorax is described as primary because it occurs in the absence of lung disease such as emphysema. Spontaneous means the pneumothorax was not caused by an injury such as a rib fracture. Primary spontaneous pneumothorax is likely due to the formation of small sacs of air (blebs) in lung tissue that rupture, causing air to leak into the pleural space. Air in the pleural space creates pressure on the lung and can lead to its collapse. A person with this condition may feel chest pain on the side of the collapsed lung and shortness of breath. Patients are typically aged 18-40 years, tall, thin, and, often, are smokers.
In small pneumothoraxes with minimal symptoms, no active treatment is required. These patients can be safely discharged with early outpatient review and should be given written advice to return if breathlessness worsens. Patients who have been discharged without intervention should be advised that air travel should be avoided until a radiograph has confirmed resolution of the pneumothorax.
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This question is part of the following fields:
- Respiratory System
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Question 76
Incorrect
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A 23-year-old male patient presents with urethritis for the last 2 weeks that has not responded to antibiotics. Lately he has developed an onset of new range of symptoms that are linked to his HLA B27 positivity. Which of the following signs is not related to Reiter's syndrome?
Your Answer:
Correct Answer: A mild fever with a generalised macular rash
Explanation: -
This question is part of the following fields:
- Musculoskeletal System
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Question 77
Incorrect
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Which of the following does the inferior mesenteric artery supply?
Your Answer:
Correct Answer: From the splenic flexure to the first third of the rectum
Explanation:The coeliac axis supplies the liver and stomach and from the oesophagus to the first half of the duodenum.
The second half of the duodenum to the first two thirds of the transverse colon is supplied by the superior mesenteric artery.
The inferior mesenteric supplies the last third of the transverse colon (approximately from the splenic flexure) to the first third of the rectum.
The last two thirds of the rectum are supplied by the middle rectal artery.
The greater curvature of the stomach is supplied by branches of the splenic artery, which itself comes from the coeliac axis. -
This question is part of the following fields:
- Gastrointestinal System
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Question 78
Incorrect
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A 26-year-old man with a history of 'brittle' asthma is admitted with an asthma attack. High-flow oxygen and nebulised salbutamol have already been administered by the Paramedics. The patient is unable to complete sentences and he has a bilateral expiratory wheeze. He is also unable to perform a peak flow reading. His respiratory rate is 31/minute, sats 93% (on high-flow oxygen) and pulse 119/minute. Intravenous hydrocortisone is immediately administered and nebulised salbutamol given continuously. Intravenous magnesium sulphate is administered after six minutes of no improvement. These are the results from the blood gas sample that was taken after another six minutes:
pH 7.32
pCO2 6.8 kPa
pO2 8.9 kPa
What is the most appropriate therapy in this patient?Your Answer:
Correct Answer: Intubation
Explanation: -
This question is part of the following fields:
- Emergency & Critical Care
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Question 79
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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Question 80
Incorrect
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Which one of the following conditions is least likely to be associated with pyoderma gangrenosum?
Your Answer:
Correct Answer: Syphilis
Explanation:The following are conditions commonly associated with pyoderma gangrenosum:
Inflammatory bowel disease:
– Ulcerative colitis
– Crohn’s disease
Arthritides:
– Rheumatoid arthritis
– Seronegative arthritis
Haematological disease:
– Myelocytic leukaemia[8]
– Hairy cell leukaemia
– Myelofibrosis
– Myeloid metaplasia
– Monoclonal gammopathy
Autoinflammatory disease:
– Pyogenic sterile arthritis, pyoderma gangrenosum, and acne syndrome (PAPA syndrome)
– Granulomatosis with polyangiitis -
This question is part of the following fields:
- The Skin
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Question 81
Incorrect
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A 48-year-old woman presented to you with a breast mass. On examination, it is hard, irregular and ill defined. The surface of the breast is slightly bruised however, there is no discharge. The most probable diagnosis is?
Your Answer:
Correct Answer: Fat necrosis
Explanation:Fat necrosis is often a result of a trauma or surgery. In fat necrosis the enzyme lipase releases fatty acids from triglycerides. The fatty acids combine with calcium to form soaps. These soaps appear as white chalky deposits which are firm lumps with no associated discharge. The given case has a bruise which indicates prior trauma.
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This question is part of the following fields:
- Women's Health
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Question 82
Incorrect
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Question 83
Incorrect
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A 42-year-old female presented with pain in her calves during walking which settled after resting. On examination there were orange colour deposits in the her palmar creases. Her fasting lipid profile showed a total cholesterol of 9.2 mmol/l (<5) and triglycerides of 7.0 mmol/l (<2). Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Type III hyperlipidaemia
Explanation:Palmar xanthomas are found in type III hyperlipoproteinemia. Her total cholesterol level and triglyceride level support the diagnosis.
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This question is part of the following fields:
- Cardiovascular System
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Question 84
Incorrect
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A 30-year-old male with Down's Syndrome was found to have a systolic murmur during routine clinical examination. Which of the following is the most common cardiac defect associated with Down's Syndrome which will explain this finding?
Your Answer:
Correct Answer: Endocardial cushion defect
Explanation:Atrioventricular septal defect (AVSD) also known as endocardial cushion defect is the most common cardiac abnormality in Down’s Syndrome.
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This question is part of the following fields:
- Cardiovascular System
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Question 85
Incorrect
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A 37-year-old woman presents with signs of decreased air entry at the right base after an emergency laparotomy cholecystectomy 18h ago but with no obvious abnormality showed on her CXR. What is the most appropriate management strategy?
Your Answer:
Correct Answer: Chest physiotherapy
Explanation:Non-invasive action via chest physiotherapy is helpful in the reduction or clearance of excessive secretions from airways.
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This question is part of the following fields:
- Respiratory System
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Question 86
Incorrect
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A 41-year-old gentleman undergoes a temporal lobectomy after the discovery of a brain tumour. Which one of the following consequences would be least likely to develop?
Your Answer:
Correct Answer: Astereognosis
Explanation:Astereognosis is associated with lesions to the parietal lobe, not the temporal lobe, so this symptom would not arise in this patient.
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This question is part of the following fields:
- Nervous System
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Question 87
Incorrect
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A 63-year-old man with known allergic bronchopulmonary aspergillosis presents to the A&E Department with an exacerbation. Which therapy represents the most appropriate management?
Your Answer:
Correct Answer: Oral glucocorticoids
Explanation:Allergic bronchopulmonary aspergillosis (ABPA) is a form of lung disease that occurs in some people who are allergic to Aspergillus. With ABPA, this allergic reaction causes the immune system to overreact to Aspergillus leading to lung inflammation. ABPA causes bronchospasm (tightening of airway muscles) and mucus build-up resulting in coughing, breathing difficulty and airway obstruction.
Treatment of ABPA aims to control inflammation and prevent further injury to your lungs. ABPA is a hypersensitivity reaction that requires treatment with oral corticosteroids. Inhaled steroids are not effective. ABPA is usually treated with a combination of oral corticosteroids and anti-fungal medications. The corticosteroid is used to treat inflammation and blocks the allergic reaction. Examples
of corticosteroids include: prednisone, prednisolone or methylprednisolone. Inhaled corticosteroids alone – such as used for asthma treatment – are not effective in treating ABPA. Usually treatment with an oral corticosteroid is needed for months.The second type of therapy used is an anti-fungal medication, like itraconazole and voriconazole. These medicines help kill Aspergillus so that it no longer colonizes the airway. Usually one of these drugs is given for at least 3 to 6 months. However, even this treatment is not curative and can have side effects.
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This question is part of the following fields:
- Respiratory System
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Question 88
Incorrect
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A 76-year-old man has been admitted with a respiratory tract infection.
On examination, he was found to be confused and dyspnoeic with O2 saturation of 88%. He has a 60 pack-year smoking history. An arterial blood gas analysis reveals CO2 retention. He has been deemed unfit for admission into the intensive care unit. The physician elects to begin a doxapram infusion.
Among the following statements which best fits with the characteristics of doxapram?Your Answer:
Correct Answer: Epilepsy is a contraindication for doxapram use
Explanation:The statement that fits the characteristics of doxapram is, epilepsy is a contraindication for doxapram use. Concurrent use with theophylline may increase agitation not relaxation.
Doxapram is a central respiratory stimulant. In clinical practice, doxapram is usually used for patients who have an acute exacerbation of chronic obstructive pulmonary disease (COPD) who are unsuitable for admission to the intensive therapy unit for ventilatory support. Doxapram infusion may buy an extra 24 h to allow for recovery.
Contraindications include: ischaemic heart disease, epilepsy, cerebral oedema, acute stroke, asthma, hypertension, hyperthyroidism, and pheochromocytoma.
The infusion may worsen agitation and dyspnoea and lead to hypertension, nausea, vomiting and urinary retention.Drug interactions:
Concomitant administration of doxapram and aminophylline (theophylline) can cause increased skeletal muscle activity, agitation, and hyperactivity. -
This question is part of the following fields:
- Pharmacology
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Question 89
Incorrect
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A 32-year-old man notices a pruritic scaly annular rash on his thigh. He claims that the rash appeared after a walk in the park. Which drug would you suggest he starts?
Your Answer:
Correct Answer: Doxycycline
Explanation:The clinical picture of an itchy, scaly annular rash after a walk in the park suggests erythema migrans. The pathogen responsible is a spirochete, Borrelia Burgdorferi transmitted by ticks leading to Lyme disease. Doxycycline is the antibiotic of choice if no contraindications.
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This question is part of the following fields:
- Infectious Diseases
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Question 90
Incorrect
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What are the most common types of transformation seen in patients with polycythaemia vera?
Your Answer:
Correct Answer: Myelofibrosis + acute myeloid leukaemia
Explanation:5-15% of the cases of polycythaemia vera progress to myelofibrosis or acute myeloid leukaemia (AML).
Polycythaemia vera (PV), also known as polycythaemia rubra vera, is a myeloproliferative disorder caused by clonal proliferation of marrow stem cells leading to an increase in red cell volume, often accompanied by overproduction of neutrophils and platelets. It has peak incidence in the sixth decade of life, with typical features including hyperviscosity, pruritus, splenomegaly, haemorrhage (secondary to abnormal platelet function), and plethoric appearance.
Some management options of PV include lose-dose aspirin, venesection (first-line treatment), hydroxyurea (slightly increased risk of secondary leukaemia), and radioactive phosphorus (P-32) therapy.
In PV, thrombotic events are a significant cause of morbidity and mortality. 5-15% of the cases progress to myelofibrosis or AML. The risk of having AML is increased with chemotherapy treatment.
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This question is part of the following fields:
- Haematology & Oncology
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Question 91
Incorrect
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A 46-year-old woman was referred to the endocrinology department with hypercalcemia and raised parathyroid hormone levels. Her blood tests are highly suggestive of primary hyperparathyroidism.
She has type 2 diabetes controlled by metformin alone. Her albumin-adjusted serum calcium level is 3.5 mmol/litre.
Which of the following is the most important reason for her referral?Your Answer:
Correct Answer: Albumin-adjusted serum calcium level of 3.5 mmol/litre
Explanation:Indications for surgery for the treatment of primary hyperparathyroidism:
1. Symptoms of hypercalcaemia such as thirst, frequent or excessive urination, or constipation
2. End-organ disease (renal stones, fragility fractures or osteoporosis)
3. An albumin-adjusted serum calcium level of 2.85 mmol/litre or above. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 92
Incorrect
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A 30-year-old lawyer presents with non-specific symptoms of tiredness.
Blood tests reveal normal thyroid function, cortisol, growth hormone and gonadotropins. Pituitary MRI reveals a 0.8cm microadenoma.
Which of the following represents the most appropriate course of action?Your Answer:
Correct Answer: Observation and reassurance
Explanation:The patient has a non-functioning pituitary tumour as her hormone profile is normal.
Non-functioning pituitary tumours are relatively common. A large number of these tumours are incidentally found pituitary microadenomas (<1 cm) and are usually of no clinical importance. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 93
Incorrect
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A 54-year-old man presents to the physician complaining of chest pain and fever. He underwent hemicolectomy a few days back. Echocardiography is done which shows a systolic murmur. Which other investigation would be required?
Your Answer:
Correct Answer: Blood culture
Explanation:Infective endocarditis (IE) is an infectious inflammation of the endocardium that affects the heart valves. The condition is a result of bacteraemia, which is most commonly caused by dental procedures, surgery, distant primary infections, and nonsterile injections. IE clinically presents with either an acute or subacute course. Acute disease is usually caused by Staphylococcus aureus and causes rapid endocardium destruction. Subacute progression is most commonly caused by viridans streptococci species and generally affects individuals with pre-existing damage to the heart valves, structural heart defects, or the presence of prosthetic valves. Clinical features include constitutional symptoms (fatigue, fever/chills, malaise) in combination with signs of pathological cardiac changes (e.g., new or changed heart murmur, heart failure signs) and possibly manifestations of subsequent damage to other organs (e.g., glomerulonephritis, septic embolic stroke). Diagnosis is made based on the Duke criteria, whose main features include positive blood cultures and evidence of endocardial involvement in echocardiography. Initial treatment of IE consists of empiric IV antibiotic therapy, which is then adapted to blood culture results and continued for four to six weeks. Prophylaxis is only administered in specific circumstances, e.g., in patients with pre-existing heart conditions undergoing dental or surgical procedures. If left untreated, infective endocarditis can be fatal within a few weeks.
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This question is part of the following fields:
- Cardiovascular System
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Question 94
Incorrect
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A 56-year-old woman presents to the clinic complaining of shoulder pain that she has been experiencing for the last 4 weeks. She does not remember getting injured previously. The pain worsens on movement especially when she is moving the arm quickly. At night, lying on the affected side is painful. Examination reveals no erythema or swelling. However, pain is felt on passive abduction between 60 to 120 degrees and she is unable to abduct the arm past 70-80 degrees. Flexion and extension are intact. What is the most likely diagnosis?
Your Answer:
Correct Answer: Supraspinatus tendonitis
Explanation:Supraspinatus tendinopathy is a common and disabling condition that becomes more prevalent after middle age and is a common cause of pain in the shoulder. A predisposing factor is resistive overuse. This patient has the classic painful arc that is a sign of shoulder impingement characteristic of supraspinatus tendonitis.
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This question is part of the following fields:
- Musculoskeletal System
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Question 95
Incorrect
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A 57-year-old man, who suffers from biventricular cardiac failure, comes to his doctor for a review. His symptoms are currently well controlled; he is taking Ramipril 10mg, Spironolactone 25mg, Bisoprolol 10mg, and Furosemide 40mg. His main complaint is of painful gynaecomastia that he says has developed over the past 6 months. Physical exam reveals a blood pressure of 125/80 mmHg and no residual signs of cardiac failure. Renal function is unchanged from 6 months earlier, with stable creatinine at 125 µmol/l.
Which of the following is the most appropriate next step?Your Answer:
Correct Answer: Change the spironolactone to eplerenone
Explanation:Spironolactone is an aldosterone antagonist diuretic that is well-known to cause gynaecomastia because it increases testosterone clearance and oestradiol production. The patient’s primary complaint of gynaecomastia should immediately prompt discontinuation of spironolactone and replacement with Eplerenone, which lacks the antiandrogenic effects, and thus there is less risk of gynaecomastia.
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This question is part of the following fields:
- Renal System
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Question 96
Incorrect
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A 12-year-old boy has a history of fever for one week (39C), with no other symptoms leading up to the fever. He recently had a surgical extraction of one of his incisors two weeks before consultation. On examination of CVS, a mid-systolic click followed by a late systolic murmur is heard. Which of the following is the most probable diagnosis?
Your Answer:
Correct Answer: Infection
Explanation:Tooth extraction or any surgical procedure may introduce bacteria into the blood stream. The most commonly involved organisms include Staphylococcus aureus and Streptococcus viridans. Once in the blood, these organisms have a very high tendency of attaching to the walls of the heart and causing inflammation known as endocarditis.
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This question is part of the following fields:
- Cardiovascular System
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Question 97
Incorrect
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A 70-year-old man underwent emergency surgery for an acute abdomen. Following surgery, he was noted to be oliguric. Investigations revealed the following: Sodium 121 mmol/L (137-144) Potassium 6.6 mmol/L (3.5-4.9) Chloride 92 mmol/L (95-107) Urea 17.2 mmol/L (2.5-7.5) Creatinine 250 µmol/L (60-110) pH 7.16 (7.36-7.44) Standard bicarbonate 15.6 mmol/L (20-28). What is the calculated anion gap for this patient?
Your Answer:
Correct Answer: 20 mmol/L
Explanation:Anion gap is calculated as (Na + K) − (Cl + HCO3). Therefore in this patient, the calculated value is 20 mmol/L. The normal anion gap is between 8-16 mmol/l. The excessive value here reflects the presence of other acidic anions, and in this case with the metabolic acidosis, the constituents may be lactate, etc.
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This question is part of the following fields:
- Renal System
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Question 98
Incorrect
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Which virus is severe acute respiratory syndrome (SARS) caused by?
Your Answer:
Correct Answer: A coronavirus
Explanation:Severe acute respiratory syndrome (SARS) is a viral respiratory illness caused by a coronavirus called SARS-associated coronavirus (SARS-CoV). SARS was first reported in Asia in February 2003.
In general, SARS begins with a high fever (temperature greater than 38.0°C). Other symptoms may include headache, an overall feeling of discomfort, and body aches. Some people also have mild respiratory symptoms at the outset. About 10 to 20 percent of patients have diarrhoea. After 2 to 7 days, SARS patients may develop a dry cough. Most patients develop pneumonia. -
This question is part of the following fields:
- Respiratory System
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Question 99
Incorrect
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A 36-year-old man with diabetes is referred with abnormal liver biochemistry. Which of the following is in keeping with a diagnosis of haemochromatosis?
Your Answer:
Correct Answer: Transferrin saturation 78% (20-50)
Explanation:A high transferrin saturation is seen in hemochromatosis, as well as a high iron level (>30), a high ferritin level, and a LOW TIBC (<20). Think of it like the opposite findings of iron deficiency anaemia which is a low iron, low ferritin, high TIBC.
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This question is part of the following fields:
- Gastrointestinal System
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Question 100
Incorrect
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A 60-year-old male patient with NSTEMI was started on low dose aspirin as secondary prevention. Which of the following, describe the action of aspirin as an antiplatelet agent?
Your Answer:
Correct Answer: Inhibits the production of thromboxane A2
Explanation:The antithrombotic action of aspirin is due to inhibition of platelet function by acetylation of the platelet cyclooxygenase (COX) at the functionally important amino acid serine529. This prevents the access of the substrate (arachidonic aid) to the catalytic site of the enzyme at tyrosine385 and results in an irreversible inhibition of platelet-dependent thromboxane formation.
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This question is part of the following fields:
- Cardiovascular System
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Question 101
Incorrect
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A 21-year-old patient is referred to the tertiary neurology clinic because of a possible diagnosis of Juvenile Parkinson's disease. His symptoms began predominantly with dystonia affecting the lower limbs, but he now has more classical signs of older onset Parkinson's including tremor, bradykinesia, and rigidity.
You map out his family tree and understand that his sister developed Parkinson's at the age of 16 but that his parents do not have signs of Parkinson's.
Which of the following is the most likely mode of inheritance?Your Answer:
Correct Answer: Autosomal recessive
Explanation:Juvenile Onset Parkinson’s is an autosomal recessive condition that usually presents in late childhood to early adulthood, initially with gait disorders caused by lower limb dystonia that later develops to the more classical signs Parkinson’s.
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This question is part of the following fields:
- Nervous System
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Question 102
Incorrect
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A 70-year old man presents with difficulty speaking and has a history of weakness in his facial muscles, as well as in his right arm and leg. What is the most appropriate prophylactic regimen in this case?
Your Answer:
Correct Answer: Aspirin 300mg for 2 weeks followed by aspirin 75mg and dipyridamole 200mg
Explanation:Left-sided hemiparesis along with slurred speech are strong indications of stroke in the right cerebral hemisphere. This occurs due to poor blood flow to the brain from the heart. Aspirin 300mg has analgesic, antipyretic, and anti-inflammatory properties that can address the acute symptoms of stroke like migraine and neuralgic pain. With a reduced dose of 75mg of Aspirin, its anti-platelet effect can inhibit further thrombus formation and prevent another stroke. Dipyridamole 200mg is an anti-coagulant preventing clot formation in the blood.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 103
Incorrect
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A 85-year-old male with a history of hypertension presented with a couple of pre-syncopal episodes. He describes these episodes as him having felt as if he was going to faint and he has had to sit down. There were no precipitating factors, associated chest pain or palpitations. He doesn't have chest pain, shortness of breath on exertion, orthopnoea or paroxysmal nocturnal dyspnoea. On examination he looked well. Blood pressure was 140/80 mmHg and pulse rate was 78 bpm which was irregular. His lungs were clear and heart sounds were normal. ECG showed sinus rhythm with occasional ventricular ectopic beats. Which of the following is an indication for permanent pacemaker implantation?
Your Answer:
Correct Answer: Second-degree block associated with symptoms
Explanation:Indications for permanent pacemaker implantation
-Sinus node dysfunction
-Acquired Atrioventricular(AV) block (Complete third-degree AV block with or without symptoms, Symptomatic second degree AV block, Mobitz type I and II, Exercise-induced second or third degree AV block in the absence of myocardial infarction, Mobitz II with widened QRS complex)
-Chronic bifascicular block
-After acute phase of myocardial infarction
-Neurocardiogenic syncope and hypersensitive carotid sinus syndrome
-Post cardiac transplantation
-Hypertrophic cardiomyopathy
-Pacing to detect and terminate tachycardia
-Cardiac resynchronization therapy in patients with severe systolic heart failure
-Patients with congenital heart disease -
This question is part of the following fields:
- Cardiovascular System
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Question 104
Incorrect
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A 40-year-old lady who underwent a recent subtotal gastrectomy for peptic ulcer disease has now developed anaemia with a haemoglobin of 6.4, tiredness, fatigue and loss of vibration sensation in both legs. What is the underlying cause of her symptoms?
Your Answer:
Correct Answer: B12 deficiency
Explanation:Vit B12 needs intrinsic factor to be absorbed, which is secreted in the stomach. Its deficiency is characterised by macrocytic anaemia with peripheral neuropathy.
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This question is part of the following fields:
- Gastrointestinal System
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Question 105
Incorrect
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A 37-year old female nurse presents with severe generalized itching, claiming that she had previously applied cream to the body of a patient with similar symptoms. What is the mechanism that produces her itch?
Your Answer:
Correct Answer: Allergic reaction
Explanation:Contact dermatitis is a red, itchy rash caused by direct contact with a substance or an allergic reaction to it. The entry of allergen into the epidermis or dermis causes a localized allergic reaction. Local mast-cell activation in the skin leads immediately to a local increase in vascular permeability, which causes extravasation of fluid and swelling. Histamine released by mast cells activated by allergen in the skin causes large, itchy, red swellings of the skin.
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This question is part of the following fields:
- The Skin
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Question 106
Incorrect
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Which among the following antihypertensives is centrally acting?
Your Answer:
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 107
Incorrect
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A 55-year-old man develops central abdominal pain a few hours after having an Endoscopic Retrograde Cholangiopancreatography (ERCP) performed. Investigations reveal the following:
Amylase 545 u/dl
Erect chest x-ray Normal heart and lungs. No free air noted
What is the most appropriate management?Your Answer:
Correct Answer: Intravenous fluids + analgesia
Explanation:A very common complication after ERCP is post-ERCP pancreatitis, which based on the clinical scenario , this man has. The treatment for this is pain control, lots of intravenous fluids, and traditionally bowel rest, although more recent evidence suggests early feeding is better.
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This question is part of the following fields:
- Hepatobiliary System
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Question 108
Incorrect
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A 42-year-old female with a history of hypertension presented with increased thirst, polyuria and nocturia for 2 weeks duration. Her random blood sugar was 12 mmol/l. Which of the following antihypertensives can cause the above clinical presentation?
Your Answer:
Correct Answer: Bendroflumethiazide
Explanation:Thiazides and beta-blockers have been most commonly linked to the development of diabetes mellitus.
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This question is part of the following fields:
- Pharmacology
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Question 109
Incorrect
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Which of the following is the most common route of hepatitis B transmission worldwide?
Your Answer:
Correct Answer: Perinatal transmission
Explanation:Perinatal transmission is the most common cause of Hepatitis B infection worldwide. Post-exposure prophylaxis should be provided, which consists of hepatitis B immune globulin and hepatitis B vaccine within 12 hours of birth. Without this, about 40% will develop chronic infection.
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This question is part of the following fields:
- Infectious Diseases
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Question 110
Incorrect
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A 30 year male admitted following a stab injury to his left upper chest. He complained of difficulty in breathing. On examination his chest movements were unequal on the left side. Which of the following nerves is most likely to be damaged?
Your Answer:
Correct Answer: Left phrenic nerve
Explanation:Difficulty in breathing and unequal chest movements are due to paralysis of the diaphragm. So the nerve affected is the left phrenic nerve.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 111
Incorrect
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A 60-year-old man with type 1 diabetes is brought to the clinic with his wife. He is limping and his wife noticed that his ankle was abnormally-shaped after he stepped out of the shower.
Examination of his right ankle reveals a painless warm swollen joint.
There is crepitus and what appears to be palpable bone debris. X-ray reveals gross joint destruction and apparent dislocation. Joint aspiration fluid shows no microbes.
Investigations:
His CRP and white count are of normal values.
Historical review of HB A1c reveals that it has rarely been below 9%.
What is the most likely diagnosis?Your Answer:
Correct Answer: Charcot's ankle
Explanation:Charcot arthropathy is a progressive condition of the musculoskeletal system that is characterized by joint dislocations, pathologic fractures, and debilitating deformities. It results in progressive destruction of bone and soft tissues at weight-bearing joints. In its most severe form, it may cause significant disruption of the bony architecture.
Charcot arthropathy can occur at any joint; however, it occurs most commonly in the lower extremity, at the foot and ankle. Diabetes is now considered to be the most common aetiology of Charcot arthropathy. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 112
Incorrect
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A 35-year-old female has been recently diagnosed with hypertension. She's sexually active and is not using any birth control other than barrier method. Which among the following antihypertensives is contraindicated in this patient?
Your Answer:
Correct Answer: Lisinopril
Explanation:Among the following hypertensives, lisinopril (an ACE inhibitor) is contraindicated in patients who are planning for pregnancy.
Per the NICE guidelines, when treating the woman in question, she should be treated as if she were pregnant given the absence of effective contraception.
ACE inhibitors such as lisinopril are known teratogens and most be avoided.Drugs contraindicated in pregnancy:
Antibiotics
Tetracyclines
Aminoglycosides
Sulphonamides and trimethoprim
QuinolonesOther drugs:
ACE inhibitors, angiotensin II receptor antagonists
Statins
Warfarin
Sulfonylureas
Retinoids (including topical)
Cytotoxic agents
The majority of antiepileptics including valproate, carbamazepine, and phenytoin are known to be potentially harmful. -
This question is part of the following fields:
- Pharmacology
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Question 113
Incorrect
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An 18-year-old female patient presents with a history of headache and photophobia. You believe that the diagnosis is subarachnoid haemorrhage but your colleague insists on bacterial meningitis. Which of the following would you use to support your diagnosis?
Your Answer:
Correct Answer: A family history of polycystic renal disease
Explanation:Hypertension could be the result of polycystic renal disease and is a risk factor for subarachnoid haemorrhage (SAH). What are common in polycystic renal disease are cerebral aneurysms which could rupture if hypertension is present. Both meningitis and SAH can lead to a fluctuating level of consciousness and opiate abuse is not a risk factor for either SAH nor meningitis. Finally, diabetes is not linked with none of the possible diagnoses because hypertension is not a risk factor of diabetes.
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This question is part of the following fields:
- Nervous System
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Question 114
Incorrect
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The increased risk of oesophageal malignancy in patients with Barrett's oesophagus is approximately:
Your Answer:
Correct Answer: 50 - 100 times risk
Explanation:Barrett’s oesophagus is the transformation of the normal squamous epithelium of the oesophagus to columnar, intestinal type epithelium. It is often seen in patients with reflux and there is a 50-100 fold increased risk of oesophageal adenocarcinoma in patients with Barrett’s oesophagus.
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This question is part of the following fields:
- Gastrointestinal System
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Question 115
Incorrect
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A 33-year-old artist who recently arrived in the UK from New York presents in ED. He has a past history of insulin-dependant diabetes mellitus. He describes a few days of fever, headache and myalgia. Admission was prompted by worsening headache and back pain. While waiting in the medical receiving unit, he becomes progressively drowsier. Examination revealed flaccid paralysis and depressed tendon reflexes. He was reviewed by the intensive care team and arrangements were made for ventilation. A computerised tomography (CT) brain is performed that is normal.
Cerebrospinal fluid examination reveals:
Protein 0.9 g/l (<0.45 g/l)
Glucose 4 mmol/l
White cell count (WCC) 28/mm3 (mostly lymphocytes)
Blood testing reveals:
Haemoglobin (Hb) 14 g/dl (13-18)
Platelets 620 x 109/l (150-400 x 109)
WCC 12 x 109/l (4-11 x 109)
Sodium 135 mmol/l (137-144)
Potassium 4.6 mmol/l (3.5-4.9)
Urea 8 mmol/l (2.5-7.5)
Creatinine 120 mmol/l (60-110)
Glucose 6 mmol/l
Which of the following is the most likely infective process?Your Answer:
Correct Answer: West Nile disease
Explanation: -
This question is part of the following fields:
- Nervous System
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Question 116
Incorrect
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Which of the following is least likely to cause warm autoimmune haemolytic anaemia?
Your Answer:
Correct Answer: Mycoplasma infection
Explanation:Mycoplasma infection causes cold autoimmune haemolytic anaemia (AIHA). The rest of the aforementioned options cause warm AIHA.
AIHA may be divided into ‘warm’ and ‘cold’ types, according to the temperature at which the antibodies best cause haemolysis. It is most commonly idiopathic but may be secondary to a lymphoproliferative disorder, infection, or drugs.
1. Warm AIHA:
In warm AIHA, the antibody (usually IgG) causes haemolysis best at body temperature and tends to occur in extravascular sites, for example, spleen. Management options include steroids, immunosuppression, and splenectomy. It is caused by autoimmune diseases such as SLE (rarely causes mixed-type AIHA), cancers such as lymphomas and CLL, and drugs such as methyldopa.2. Cold AIHA:
The antibody in cold AIHA is usually IgM and causes haemolysis best at 4°C and occurs more commonly intravascularly. Features may include symptoms of Raynaud’s disease and acrocyanosis. Patients do not respond well to steroids. Cold AIHA is caused by cancers such as lymphomas, and infections such as mycoplasma and EBV. -
This question is part of the following fields:
- Haematology & Oncology
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Question 117
Incorrect
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A 55-year-old obese woman presents to casualty. She has rigors and reports a fever. On examination there is jaundice and tenderness over the right upper quadrant of her abdomen.
She has an elevated white blood cell count and a markedly raised alkaline phosphatase level; transaminases and bilirubin are also abnormal.
Which of these diagnoses best fits the clinical picture?Your Answer:
Correct Answer: Ascending cholangitis
Explanation:This question describes Charcot’s triad– fever, RUQ pain, and jaundice, which is seen in ascending cholangitis. Reynold’s pentad is a worsened version of this, where you have RUQ pain, fever, jaundice, hypotension, and altered mental status. Risk factors for gallstones are the 4F’s- female, fat, forty, and fertile. You would not have the elevated bilirubin, ALP, transaminases with a kidney stone or in peptic ulcer disease. Hepatitis would not cause elevation of bilirubin.
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This question is part of the following fields:
- Hepatobiliary System
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Question 118
Incorrect
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A 32-year-old primigravida in her 37th week of pregnancy was admitted for the management of pre-eclampsia. Her blood pressure was 180/110 mmHg and urine protein was +++. Magnesium sulphate was started. Which of the following are important parameters that should be monitored during the administration of magnesium sulphate?
Your Answer:
Correct Answer: Reflexes + respiratory rate
Explanation:The clinical effect and toxicity of MgSO4 can be linked to its concentration in plasma. A concentration of 1.8 to 3.0 mmol/L has been suggested for treatment of eclamptic convulsions. Maternal toxicity is rare when MgSO4 is carefully administered and monitored. The first warning of impending toxicity in the mother is loss of the patellar reflex at plasma concentrations between 3.5 and 5 mmol/L. Respiratory paralysis occurs at 5 to 6.5 mmol/L. Cardiac conduction is altered at greater than 7.5 mmol/L, and cardiac arrest can be expected when concentrations of magnesium exceed 12.5 mmol/L. Careful attention to the monitoring guidelines can prevent toxicity. Deep tendon reflexes, respiratory rate, urine output and serum concentrations are the most commonly monitored parameters.
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This question is part of the following fields:
- Cardiovascular System
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Question 119
Incorrect
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A 30-year-old woman presents with amenorrhoea and galactorrhoea. She has normal visual fields. You are concerned that she may have a prolactinoma.
Investigations were done and the results are as shown below:
Hb 12.5 g/dl
WCC 4.9 x109/l
PLT 199 x109/l
Na+ 140 mmol/l
K+ 4.9 mmol/l
Creatinine 90 Ù‰mol/l
Prolactin 1150 mU/l
MRI shows a 7 mm pituitary microadenoma.
Which of the following hormones would you expect to be lower than normal?Your Answer:
Correct Answer: LH
Explanation:Prolactinomas, benign lesions that produce the hormone prolactin, are the most common hormone-secreting pituitary tumours.
Based on its size, a prolactinoma can be classified as a microprolactinoma (< 10 mm diameter) or a macroprolactinoma (>10 mm diameter). If the prolactinoma is large enough to compress the surrounding normal hormone-secreting pituitary cells, it may result in deficiencies of one or more hormones (e.g., thyroid-stimulating hormone [TSH], growth hormone [GH], adrenocorticotropic hormone). However, the patient has microadenoma so it is unlikely to cause compression manifestations.
Hyperprolactinemia inhibits GnRH secretion from the medial basal hypothalamus and LH release from the pituitary. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 120
Incorrect
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A 34-year-old man presents with haemoptysis and weight loss. History reveals he suffers from night sweats and upon auscultation you notice reduced breath sounds over the apex of his right lung and significant nail clubbing. You refer him to a pneumologist who administers the following antibiotics: rifampicin, ethambutol, pyrazinamide and isoniazid. What is the mechanism of action of the first drug?
Your Answer:
Correct Answer: Inhibit RNA synthesis
Explanation:Rifampicin specifically inhibits bacterial RNA polymerase, the enzyme responsible for DNA transcription, by forming a stable drug-enzyme complex with a binding constant of 10(-9) M at 37 C.
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This question is part of the following fields:
- Infectious Diseases
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Question 121
Incorrect
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A 21-year-old male presented in the OPD with a testicular mass. During examination, the mass was found to be painless and 2.5cm in diameter. The surface is irregular and non-transilluminating. What is the most likely diagnosis?
Your Answer:
Correct Answer: Teratoma
Explanation:The age group of the patient (20 to 30 years) is indicative of teratoma. It is also painless and non-transilluminating.
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This question is part of the following fields:
- Men's Health
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Question 122
Incorrect
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A 23-year-old woman experiences visual disturbances and anxiety associated with sudden change in posture. She also has nausea, vomiting, and dizziness occasionally. What is the most likely diagnosis?
Your Answer:
Correct Answer: BPPV
Explanation:The most probable diagnosis is benign paroxysmal positional vertigo (BPPV). It is a peripheral vestibular disorder characterized by short episodes of mild to intense dizziness and influenced by specific changes in head position. BPPV is the most common cause of vertigo accounting for nearly one-half of patients with peripheral vestibular dysfunction. In order to establish the diagnosis, the head roll test is performed where the head is turned about 90° to each side while supine.
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This question is part of the following fields:
- Nervous System
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Question 123
Incorrect
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Which of the following is the mechanism of action of bivalirudin in acute coronary syndrome?
Your Answer:
Correct Answer: Reversible direct thrombin inhibitor
Explanation:Bivalirudin is a competitive, direct thrombin inhibitor. It inhibits both free and clot-bound thrombin and thrombin-induced platelet aggregation. Thrombin enables fibrinogen conversion to fibrin during the coagulation cascade. So inhibition of fibrinogen conversion to fibrin inhibits thrombus development.
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This question is part of the following fields:
- Cardiovascular System
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Question 124
Incorrect
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A clinical trial is conducted to study the benefits of a new oral medication to improve the symptoms of patients with asthma. In the trial 400 patients with asthma, half were given the new medication and half a placebo. Three months later they are asked to rate their symptoms using the following scale: much improved, slight improvement, no change, slight worsening, significantly worse. What is the most appropriate statistical test to see whether the new medication is beneficial?
Your Answer:
Correct Answer: Mann-Whitney U test
Explanation:The type of significance test used depends on whether the data is parametric (can be measured, usually normally distributed) or non-parametric.
Parametric tests:
Student’s t-test – paired or unpaired*
Pearson’s product-moment coefficient – correlationNon-parametric tests:
Mann-Whitney U test – unpaired data
Wilcoxon signed-rank test – compares two sets of observations on a single sample
chi-squared test – used to compare proportions or percentages
Spearman, Kendall rank – correlation.The outcome measured is not normally distributed, i.e. it is non-parametric. This excludes the Student’s t-tests. We are not comparing percentages/proportions so the chi-squared test is excluded. The Mann-Whitney U test is a nonparametric test of the null hypothesis that it is equally likely that a randomly selected value from one sample will be less than or greater than a randomly selected value from a second sample.
This test can be used to investigate whether two independent samples were selected from populations having the same distribution. -
This question is part of the following fields:
- Evidence Based Medicine
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Question 125
Incorrect
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A 50-year-old male was taken to hospital after he experienced tightness in his chest and a chronic cough. Upon examination, he revealed that he has been smoking 20 cigarettes a day for the past 35 years, and was subsequently diagnosed with COPD. From the list of options, choose the most appropriate ABG picture.
Your Answer:
Correct Answer: Respiratory Acidosis
Explanation:COPD impairs the lung’s ability to remove CO2 from the blood, and this removes acid from the body. Excess CO2 causes the pH of the blood to increase, making it far too acidic, and causing respiratory acidosis.
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This question is part of the following fields:
- Respiratory System
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Question 126
Incorrect
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A 22-year-old male has had complex tics since childhood. He repeatedly bends his knees and rubs his nose. He is prone to loud vocalisations, sometimes including swear-words. A diagnosis of Gilles de la Tourette syndrome has been made. Which of the following is the best treatment option?
Your Answer:
Correct Answer: Risperidone
Explanation:Gilles de la Tourette syndrome is the most severe and rare of the tic syndromes, consisting of multiple tics involving both motor actions and vocalisation. Onset is usually in childhood. Symptoms include utterance of obscenities (coprolalia); echolalia (repetition of another person’s spoken words) and palilalia (involuntary repetition of words, phrases, or sentences).
The underlying cause is unknown, with no particular imaging or standard histopathological abnormalities having been identified. The EEG shows non-specific abnormalities in about half of patients. However, more recent immunocytochemical studies have suggested altered dopamine uptake in the striatal system.
Risperidone is an effective therapeutic option without the effects associated with chlorpromazine and haloperidol. -
This question is part of the following fields:
- Nervous System
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Question 127
Incorrect
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In idiopathic hypercalciuria, what management should be initiated if there is renal stone disease or bone demineralization?
Your Answer:
Correct Answer: Dietary modification and thiazide diuretics
Explanation:Idiopathic hypercalciuria presents with excess calcium in the urine without an apparent cause. Dietary modification is the first step in addressing this condition, however, because hypercalciuria increases the risk of developing renal stones and bone demineralisation, thiazide diuretics should be prescribed to increase calcium reabsorption when these symptoms are also present.
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This question is part of the following fields:
- Renal System
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Question 128
Incorrect
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A 20-year-old male was admitted with a right sided pneumothorax. A chest drain was inserted just below the 4th rib in the midclavicular line. What is the structure at risk of damage during the above procedure?
Your Answer:
Correct Answer: Intercostal artery
Explanation:From the given answers, the most suitable answer is the intercostal artery. However the most vulnerable structure is the intercostal nerve, then intercostal artery and finally intercostal vein.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 129
Incorrect
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A 50-year-old woman came to the diabetes clinic for her regular follow up.
The following results are obtained:
Urine analysis: Protein+
HBA1c 86 mmol/mol (10.0%)
What is her average blood glucose level during the past 2 months?Your Answer:
Correct Answer: 15
Explanation:The level of haemoglobin A1c (HbA1c), also known as glycated haemoglobin, determines how well a patient’s blood glucose level has been controlled over the previous 8-12 weeks. Recent studies have been made to correlate between HbA1c and average glucose level.
Using the following formula: Average blood glucose (mmol/l) = (1.98 x 1 HbA1c) – 4.29 -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 130
Incorrect
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A 34-year-old female presents to the clinic with skin tightness. On examination she has sclerodactyly, thickened skin of the shoulders and bi-basal crepitations. Her HRCT chest shows ground glass changes. Raynaud phenomenon is suspected and she is started on a monthly dose of IV cyclophosphamide (1 gm/month) for 6 months and a daily dose of 10 mg of oral prednisolone. However, she returned over a period of few weeks after developing exertional dyspnoea, pedal oedema and feeling unwell. On examination, JVP is raised, there is marked pedal oedema and bi basal crepitations on chest auscultation. Urine dipstick shows haematuria (++) and proteinuria (++). What in your opinion is the most likely cause of her deteriorating renal function?
Your Answer:
Correct Answer: Scleroderma renal crisis
Explanation:Scleroderma renal crisis (SRC) is a rare but severe complication in patients with systemic sclerosis (SSc). It is characterized by malignant hypertension, microangiopathic haemolytic anaemia with schistocytes and oligo/anuric acute renal failure. SRC occurs in 5% of patients with systemic scleroderma, particularly in the first years of disease evolution and in the diffuse form. Patients may develop symptoms of fluid overload.
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This question is part of the following fields:
- Musculoskeletal System
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Question 131
Incorrect
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A 50-year-old retired coal miner with simple silicosis presented with shortness of breath. He had been short of breath for 3 months. Around 3 months ago he began keeping turtle doves as pets.
On auscultation he had basal crepitations and chest x-ray showed fine nodular shadowing in the apices.
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What is the most likely diagnosis?Your Answer:
Correct Answer: Extrinsic allergic alveolitis
Explanation:Extrinsic allergic alveolitis (EAA) refers to a group of lung diseases that can develop after exposure to certain substances. The name describes the origin and the nature of these diseases:
‘extrinsic’ – caused by something originating outside the body
‘allergic’ – an abnormally increased (hypersensitive) body reaction to a common substance
‘alveolitis’ – inflammation in the small air sacs of the lungs (alveoli)Symptoms can include: fever, cough, worsening breathlessness and weight loss. The diagnosis of the disease is based on a history of symptoms after exposure to the allergen and a range of clinical tests which usually includes: X-rays or CT scans, lung function and blood tests.
EAA is not a ‘new’ occupational respiratory disease and occupational causes include bacteria, fungi, animal proteins, plants and chemicals.
Examples of EAA include:
Bird fancier’s lung (BFL) is a type of hypersensitivity pneumonitis (HP). It is triggered by exposure to avian proteins present in the dry dust of the droppings and sometimes in the feathers of a variety of birds. The lungs become inflamed, with granuloma formation. Birds such as pigeons, parakeets, cockatiels, shell parakeets (budgerigars), parrots, turtle doves, turkeys and chickens have been implicated.
People who work with birds or own many birds are at risk. Bird hobbyists and pet store workers may also be at risk. This disease is an inflammation of the alveoli in the lungs caused by an immune response to inhaled allergens from birds. Initial symptoms include shortness of breath (dyspnoea), especially after sudden exertion or when exposed to temperature change, which can resemble asthma, hyperventilation syndrome or pulmonary embolism. Chills, fever, non-productive cough and chest discomfort may also occur.
A definitive diagnosis can be difficult without invasive testing, but extensive exposure to birds combined with reduced diffusing capacity are strongly suggestive of this disease. X-ray or CT scans will show physical changes to the lung structure (a ground glass appearance) as the disease progresses. Precise distribution and types of tissue damage differ among similar diseases, as does response to treatment with Prednisone.
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This question is part of the following fields:
- Respiratory System
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Question 132
Incorrect
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A 75-year-old male patient with type 2 diabetes mellitus, was admitted with confusion. On examination he was drowsy and had tremors. Which of the following is the best investigation, which is important for the further management?
Your Answer:
Correct Answer: Blood sugar
Explanation:The presentation is highly suggestive of a hypoglycaemic episode, which is more common amongst older patient with diabetes mellitus. The chance of hypoglycaemia is higher with insulin users. Blood sugar measurement is crucial in the management.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 133
Incorrect
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A 42-year-old man presented with palpitations and shortness of breath on exertion. On examination his lungs were clear and heart sounds were normal. There was a left sided parasternal heave. His electrocardiogram (ECG) revealed atrial fibrillation with right axis deviation. Echocardiography showed dilated right heart chambers. Left and right heart catheterisation study revealed the following
Inferior vena cava Oxygen saturations 63 %
Superior vena cava Oxygen saturations 59 %
Right atrium Oxygen saturations 77 %
Right ventricle Oxygen saturations 78 %
Pulmonary artery Oxygen saturations 82 %
Arterial saturation Oxygen saturations 98 %
What is the most likely diagnosis from the following answers?Your Answer:
Correct Answer: Atrial septal defect
Explanation:Right ventricular volume overload is indicated by a parasternal heave and right axis deviation. Oxygen saturation in right atrium is higher than oxygen saturation of the inferior and superior vena cavae. So the most probable diagnosis is atrial septal defect.
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This question is part of the following fields:
- Cardiovascular System
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Question 134
Incorrect
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A 33-year-old man with a known history of alcoholic liver disease is reviewed following a suspected oesophageal variceal haemorrhage. He has been resuscitated and intravenous terlipressin has been given. His blood pressure is now 104/60 mmHg and his pulse is 84/min. What is the most appropriate intervention?
Your Answer:
Correct Answer: Endoscopic variceal band ligation
Explanation:The correct course of action after giving terlipressin and resuscitating with IV fluids is to perform an EGD with endoscopic variceal band ligation. According to NICE: ‘Offer endoscopic variceal band ligation for the primary prevention of bleeding for people with cirrhosis who have medium to large oesophageal varices. There are serious complications of a TIPS procedure and it is not the first line treatment.
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This question is part of the following fields:
- Gastrointestinal System
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Question 135
Incorrect
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A 60-year-old man presented with severe central chest pain for the last 2 hours. He was on insulin for diabetes mellitus and he was dependent on haemodialysis because of end stage renal failure. He had undergone haemodialysis 48 hours prior to this presentation. His ECG showed an acute inferior myocardial infarction. Despite thrombolysis and other appropriate treatment, he continued to have chest pain after 6 hours from the initial presentation. His blood pressure was 88/54 mmHg and he had bibasal crepitations. His investigation results are given below.
Serum sodium 140 mmol/l (137-144)
Serum potassium 6.6 mmol/l (3.5-4.9)
Serum urea 50 mmol/l (2.5-7.5)
Serum creatinine 940 μmol/l (60-110)
Haemoglobin 10.2g/dl (13.0-18.0)
Troponin T >24 g/l (<0.04)
Left ventricular ejection fraction was 20%
What is the most appropriate management for this patient?Your Answer:
Correct Answer: Coronary angiography and rescue PCI
Explanation:According to the history the patient has cardiogenic shock and pulmonary oedema. On-going ischaemia is indicated by persisting symptoms. So the most appropriate management is coronary angiography and rescue PCI. There are no indications for blood transfusion at this moment and it will aggravate the pulmonary oedema. Haemodialysis, beta blockers and furosemide cannot be given due to low blood pressure.
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This question is part of the following fields:
- Cardiovascular System
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Question 136
Incorrect
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A 42-year-old woman who has been a smoker since she was a teenager has the following blood result: Hgb=19. What hormone should you check?
Your Answer:
Correct Answer: Erythropoietin
Explanation:An increase in the patient’s haemoglobin tells us that the patient might be having an increased number of red blood cells. Smoking causes raised carboxyhaemoglobin levels and thus hypoxemia. Hypoxemia will increase the erythropoietin levels in the blood.
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This question is part of the following fields:
- Haematology & Oncology
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Question 137
Incorrect
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A 27-year-old patient presents to the OPD with a history of longstanding constipation, blood on the side of stool and extremely painful defecation. Digital rectal examination also results in pain. What is the most likely diagnosis?
Your Answer:
Correct Answer: Anal fissure
Explanation:An anal fissure is a longitudinal tear of the perianal skin distal to the dentate line, often due to increased anal sphincter tone. Anal fissures are classified according to aetiology (e.g., trauma or underlying disease) or duration of disease (e.g., acute or chronic). They are typically very painful and may present with bright red blood per rectum (haematochezia). Anal fissures are a clinical diagnosis based on history and examination findings. Management is primarily conservative, and includes stool softeners, analgesia, and possible local muscle relaxation; because of the risk of incontinence, surgical intervention is a last resort.
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This question is part of the following fields:
- Gastrointestinal System
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Question 138
Incorrect
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A 21 year-old male, who is a known alcoholic, presents with a fever, haemoptysis, green sputum and an effusion clinically. There is concern that it may be an empyema.
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Which test would be most useful to resolve the suspicion?Your Answer:
Correct Answer: Pleural fluid pH
Explanation:If a pleural effusion is present, a diagnostic thoracentesis may be performed and analysed for pH, lactate dehydrogenase, glucose levels, specific gravity, and cell count with differential. Pleural fluid may also be sent for Gram stain, culture, and sensitivity. Acid-fast bacillus testing may also be considered and the fluid may be sent for cytology if cancer is suspected.
The following findings are suggestive of an empyema or parapneumonic effusion that will likely need a chest tube or pigtail catheter for complete resolution:
-Grossly purulent pleural fluid
-pH level less than 7.2
-WBC count greater than 50,000 cells/µL (or polymorphonuclear leukocyte count of 1,000 IU/dL)
-Glucose level less than 60 mg/dL
-Lactate dehydrogenase level greater than 1,000 IU/mL
-Positive pleural fluid cultureThe most often used golden criteria for empyema are pleural effusion with macroscopic presence of pus, a positive Gram stain or culture of pleural fluid, or a pleural fluid pH under 7.2 with normal peripheral blood ph.
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This question is part of the following fields:
- Respiratory System
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Question 139
Incorrect
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A 35-year-old woman is referred to the acute medical unit with a 5 day history of polyarthritis and a low-grade fever.
Examination reveals shin lesions which the patient states are painful. Chest x-ray shows a bulky mediastinum.
What is the most appropriate diagnosis?Your Answer:
Correct Answer: Lofgren's syndrome
Explanation:Lofgren’s syndrome is an acute form of sarcoidosis characterized by erythema nodosum, bilateral hilar lymphadenopathy (BHL), and polyarthralgia or polyarthritis. Other symptoms include anterior uveitis, fever, ankle periarthritis, and pulmonary involvement.
Löfgren syndrome is usually an acute disease with an excellent prognosis, typically resolving spontaneously from 6-8 weeks to up to 2 years after onset. Pulmonologists, ophthalmologists, and rheumatologists often define this syndrome differently, describing varying combinations of arthritis, arthralgia, uveitis, erythema nodosum, hilar adenopathy, and/or other clinical findings.
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This question is part of the following fields:
- Respiratory System
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Question 140
Incorrect
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A case-control study is being designed to look at the relationship between eczema and a new vaccine for yellow fever. What is the usual outcome measure in a case-control study?
Your Answer:
Correct Answer: Odds ratio
Explanation:A case-control study (also known as case-referent study) is a type of observational study in which two existing groups differing in outcome are identified and compared on the basis of some supposed causal attribute. Case-control studies are often used to identify factors that may contribute to a medical condition by comparing subjects who have that condition/disease (the cases) with patients who do not have the condition/disease but are otherwise similar (the controls).
An odds ratio (OR) is a statistic that quantifies the strength of the association between two events, A and B. The odds ratio is defined as the ratio of the odds of A in the presence of B and the odds of A in the absence of B or vice versa. -
This question is part of the following fields:
- Evidence Based Medicine
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Question 141
Incorrect
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A 28-year-old 9 week pregnant woman is newly diagnosed with asthma. She is not on any medication at the moment. Her PEFR diary shows wide diurnal variations and she also gives a past history of eczema.
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Which of the following is correct?Your Answer:
Correct Answer: Low dose inhaled corticosteroids would be considered acceptable
Explanation:The following drugs should be used as normal during pregnancy:
short acting β2 -agonists
long acting β2- agonists
inhaled corticosteroids
oral and intravenous theophyllinesUse steroid tablets as normal when indicated during pregnancy for severe asthma. Steroid tablets should never be withheld because of pregnancy.
If leukotriene receptor antagonists are required to achieve adequate control of asthma then they should not be withheld during pregnancy. -
This question is part of the following fields:
- Respiratory System
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Question 142
Incorrect
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A 26-year-old student has been brought to the emergency department in a confused state. His friends report that he has been complaining of headaches for the past few weeks. He has a low-grade fever and on examination is noted to have abnormally pink mucosa. What is the most likely diagnosis?
Your Answer:
Correct Answer: Carbon monoxide poisoning
Explanation: -
This question is part of the following fields:
- Emergency & Critical Care
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Question 143
Incorrect
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Regarding bupropion (Zyban), which one of the following statements is true?
Your Answer:
Correct Answer: It has an antidepressant effect
Explanation:The chief role of bupropion is that it acts as an antidepressant agent, which was used extensively to treat war veterans with post traumatic stress disorders. It is also very effective nicotine replacement therapy. Contraindications include epileptic seizures as it decreases the threshold of epilepsy in these patients to 1:1000.
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This question is part of the following fields:
- Pharmacology
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Question 144
Incorrect
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From the list of options, choose the least useful therapy in preventing oesophageal variceal bleeding in portal hypertension.
Your Answer:
Correct Answer: Variceal sclerotherapy
Explanation:Selective beta blockade and nitrates help to reduce portal pressure and therefore reduce the risk of bleeding (as does banding). Moreover, sclerotherapy, despite its use, has not actually been shown to reduce the risk of bleedings as primary prevention – however, it may reduce the risk of rebleeding after an index bleed. The mortality of variceal bleedings is known to be 50% at each episode.
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This question is part of the following fields:
- Gastrointestinal System
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Question 145
Incorrect
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Which one of the following congenital infections is most characteristically associated with chorioretinitis?
Your Answer:
Correct Answer: Toxoplasma gondii
Explanation:The common congenital infections encountered are rubella, toxoplasmosis and cytomegalovirus. Cytomegalovirus is the most common congenital infection in the UK. Maternal infection is usually asymptomatic.
Congenital toxoplasmosis is associated with fetal death and abortion, and in infants, it is associated with neurologic deficits, neurocognitive deficits, and chorioretinitis. -
This question is part of the following fields:
- Infectious Diseases
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Question 146
Incorrect
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An 8-year-old boy is presented with arthritis, cough and non-blanching purpura. His coagulation profile is normal. His CBC: Hb 11.8 TLC 7.2*10^9 Plt 286*10^9. What is the most likely diagnosis?
Your Answer:
Correct Answer: Henoch-Schönlein Purpura (HSP)
Explanation:The best answer is Henoch-Schönlein Purpura (HSP). This patient has a characteristic rash and the labs are consistent with this diagnosis.
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This question is part of the following fields:
- Cardiovascular System
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Question 147
Incorrect
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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:
Correct 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 148
Incorrect
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Which one of the following features is least associated with Waldenström's macroglobulinemia?
Your Answer:
Correct Answer: Bone pain
Explanation:Waldenström’s macroglobulinemia (also called lymphoplasmacytic lymphoma) is an uncommon type of non-Hodgkin lymphoma seen in older people. It is a lymphoplasmacytoid malignancy characterised by the secretion of a monoclonal IgM paraprotein. Its features include weight loss and lethargy; monoclonal IgM paraproteinemia; hyperviscosity syndrome leading to bilateral central retinal vein occlusion (CRVO) and hence, visual disturbances; hepatosplenomegaly and lymphadenopathy; and cryoglobulinemia. It is not, however, associated with bone pain.
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This question is part of the following fields:
- Haematology & Oncology
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Question 149
Incorrect
-
A woman complains of diarrhoea, experiencing watery stools 10 daily. She also complains of abdominal bloating, cramps, flatulence, and recent weight loss. She has now developed signs of iron deficiency anaemia. What is the most likely cause of her condition?
Your Answer:
Correct Answer: Malabsorption
Explanation:Diarrhoea, iron deficiency anaemia and folic acid deficiency are suggestive of malabsorption. Malabsorption leads to a decrease in the solid content of the stools resulting in diarrhoea. Decrease in the absorption of folic acid causes folic acid deficiency, and iron deficiency in the body leads to iron deficiency anaemia.
Jejunal villous atrophy is characterized with pain and weight loss as well, which this patient does not have.
A patient with increased catabolism has sudden weight loss along with deficiencies of nutrients. -
This question is part of the following fields:
- Gastrointestinal System
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Question 150
Incorrect
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A 32-year-old male presents following a car accident. He has a swollen foot, with loss of sensation in the space between the 3rd metatarsal and big toe and foot tenderness. In addition, his dorsalis pedis is not palpable. Which is the most probable diagnosis?
Your Answer:
Correct Answer: Compartment syndrome
Explanation:Acute compartment syndrome results from severe high pressure in the compartment with concomitant insufficient blood supply to the tissue involved. Acute compartment syndrome is a surgical emergency that can lead to severe impairment of the function of the affected limb, if left untreated.
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This question is part of the following fields:
- Musculoskeletal System
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Question 151
Incorrect
-
A 20-year-old student presents to the university health service complaining of flu-like symptoms, lethargy and jaundiced sclerae and an inability to eat due to a sore throat. He remembered that his father may have suffered from a liver condition. On further questioning a history of intravenous drug use on two occasions is identified.
Investigations reveal:
Alanine transaminase (ALT) 23 U/l
Aspartate transaminase (AST) 28 U/l
Bilirubin 78 μmol/l
Albumin 41g/l
Which of the following diagnoses fits best with this clinical picture?Your Answer:
Correct Answer: Gilbert's syndrome
Explanation:When a patient presents with an illness (unrelated to the liver) or a stressful event on the body, and develops asymptomatic jaundice, think Gilbert’s syndrome. It is autosomal dominant. It is an unconjugated hyperbilirubinemia from impaired glucuronyl transferase. Classically, Crigler-Najjar would be in infants, and it would be symptomatic. It is also an unconjugated hyperbilirubinemia.
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This question is part of the following fields:
- Gastrointestinal System
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Question 152
Incorrect
-
Barrett's oesophagus is well recognized as a complication of gastroesophageal reflux disease. What is the pathological change that occurs in the above condition?
Your Answer:
Correct Answer: Squamous to columnar epithelium
Explanation:Barrett’s oesophagus is characterised by the metaplastic replacement of the normal squamous epithelium of the lower oesophagus by columnar epithelium.
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This question is part of the following fields:
- Gastrointestinal System
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Question 153
Incorrect
-
A 52-year-old man is referred to the oncology clinic by his GP. He recently suffered a fracture of his right humerus with minimal trauma.
The results of the blood tests, taken on his arrival, prompted the referral:
Hb: 8.9 g/dL
WCC: 9.5 x 10^9/L
Plts: 140 x 10^9/L
MCV: 86 fL
ESR: 60mm/1st hour
Na+: 149 mmol/L
K+: 3.6 mmol/L
Urea: 15 mmol/L
Creatinine: 160 mmol/L
Calcium (corrected): 2.89 mmol/l
Albumin: 28g/L
Total protein: 89 g/L
X-ray of right humerus reported a possible pathological fracture. Which of the following investigations would help best in confirming the most likely diagnosis?Your Answer:
Correct Answer: Protein electrophoresis
Explanation:The most likely diagnosis with anaemia, raised erythrocyte sedimentation rate (ESR), hypercalcaemia, renal impairment, and raised total protein with low albumin is multiple myeloma (MM). Protein electrophoresis will confirm the presence of monoclonal band of paraprotein. Of note, a radioisotope bone scan is not a good test for picking up the lytic lesions of MM.
Diagnosis of MM is based on the confirmation of (a) one major criterion and one minor criterion or (b) three minor criteria in an individual who has signs or symptoms of multiple myeloma.
Major criteria:
1. >30% plasma cells on bone marrow biopsy
2. Monoclonal band of paraprotein on electrophoresis: >35g/L for IgG, 20g/L for IgA, or >1g of light chains excreted in the urine per dayMinor criteria:
1. 10-30% plasma cells on bone marrow biopsy
2. Abnormal monoclonal band but levels less than listed above
3. Lytic bone lesions observed radiographically
4. Immunosuppression -
This question is part of the following fields:
- Haematology & Oncology
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Question 154
Incorrect
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A 53 year-old dancer presents to the ED with increasing weakness. She has no pertinent past medical history aside from a recent diarrhoeal illness, which she attributes to an undercooked chicken meal. Her husband says that she has been unable to get up out of a chair for the past day. Upon examination, there is bilateral limb weakness and areflexia noted, but it is more severe in the lower limbs. You notice that if she lies flat in the bed, her oxygen saturations fall by around 2% on the pulse oximeter and she is unable to perform spirometry. Which of the following represents the most appropriate immediate management of choice in this patient?
Your Answer:
Correct Answer: ITU review for consideration of ventilation
Explanation:This woman has a history that is suggestive of Guillain- Barre syndrome. This may be precipitated by Campylobacter, and her history of recent diarrhoeal illness is pointing towards that. Certain features point to a poor prognosis, including rapidity of onset, reduced vital capacity or respiratory failure, age >40 and reduced amplitude of compound muscle action potential. Her inability to perform spirometry and desaturating whilst lying flat are suggestive of impending respiratory muscle weakness. Review for consideration of ventilation is recommended. Further management of choice for Guillain-Barre syndrome is IV immunoglobulins. Steroids have no value in the treatment of the condition.
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This question is part of the following fields:
- Nervous System
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Question 155
Incorrect
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A 50-year-old farmer presented with fever, malaise, cough, and shortness of breath. He also reports a history of severe weight loss. Examination revealed tachypnoea, coarse end-inspiratory crackles and wheeze. His chest X-ray showed fluffy nodular shadowing and lab results showed polymorphonuclear leukocytosis. Which of the following is the most appropriate diagnosis?
Your Answer:
Correct Answer: Extrinsic allergic alveolitis
Explanation:Extrinsic allergic alveolitis, also known as hypersensitivity pneumonitis, is an allergic response of the lungs to an environmental allergen. Nodular shadowing in the chest X-ray is characteristic of extrinsic allergic alveolitis.
Churg-Strauss syndrome is an auto-immune disorder that is known to cause vasculitis mostly in patients having a pre-existing airway disease.
Cryptogenic organizing pneumonia is an inflammatory condition of the alveoli. The CXR of which shows ground-glass opacifications.
The CXR of progressive massive fibrosis also shows opacifications normally in the upper lung lobes. -
This question is part of the following fields:
- Respiratory System
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Question 156
Incorrect
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Wolff-Parkinson-White syndrome is not linked with which of the following?
Your Answer:
Correct Answer: Ventricular tachycardia in the absence of drug therapy
Explanation:Ventricular tachycardia is not linked with Wolff-Parkinson-White syndrome. The other options are linked to WPW syndrome.
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This question is part of the following fields:
- Cardiovascular System
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Question 157
Incorrect
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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:
Correct 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 158
Incorrect
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A 60-year-old male had an MI one week ago, but has now presented with a pericardial rub and dyspnoea. An ECG was performed and shows ST elevation. A chest x-ray shows loss of margin at the costovertebral angle. Choose the single most likely cause.
Your Answer:
Correct Answer: Dressler's syndrome
Explanation:The pericardial rub indicates pericarditis, which then causes widespread ST elevation. Therefore, the condition is not a new MI but is Dressler’s syndrome.
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This question is part of the following fields:
- Cardiovascular System
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Question 159
Incorrect
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The phonocardiogram of a 40-year-old male patient showed a normal S1 but an abnormal S2. S2 was fixed and widely split. Out of the following, which condition do you think this patient most likely suffering from?
Your Answer:
Correct Answer: Secundum atrial septal defect
Explanation:The second heart sound (S2) corresponds to the closing of the semilunar valves, first the aortic and then the pulmonary valve. The gap between the closure of these two valves is normally insignificant and is heard as a single heart sound. In certain pathological conditions, this gap increases when there is a delay in right ventricular emptying, but in cases other than an atrial septal defect, the sound is not fixed. In an atrial septal defect, the right ventricle continuously receives blood, causing a delay and a fixed and split S2.
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This question is part of the following fields:
- Cardiovascular System
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Question 160
Incorrect
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A 32 year-old man presents with his first generalized tonic-clonic seizure (GTCS). He has been complaining of headaches for the past 2 weeks, although he has been able to continue working at his job. Upon examination, he has mild left hemiparesis and bilateral extensor plantar responses. General examination is otherwise unremarkable. An urgent CT scan of the brain shows a 5cm multicentric mass lesion in the right frontal lobe with surrounding vasogenic oedema and some hemisphere shift. Which of the following is the most likely underlying pathology?
Your Answer:
Correct Answer: Glioblastoma
Explanation:Glioblastoma multiforme, also considered as grade IV astrocytoma, is the most malignant form of the tumour and accounts for about 20% of all cerebral tumours. These often remain clinically silent until they have reached a large enough size. In adults, glioblastoma multiforme usually occurs in the cerebral hemispheres, especially the frontal and temporal lobes of the brain. About half occupy more than one hemisphere at presentation, and some are multicentric. Biopsy shows high cellularity with mitoses, pleomorphism, and vascular hyperplasia. Prognosis is extremely poor, with only 20% surviving beyond 1 year and 10% beyond 2 years.
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This question is part of the following fields:
- Nervous System
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Question 161
Incorrect
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Which of the following parameters is increased as a result of asthma?
Your Answer:
Correct Answer: Residual volume
Explanation:In asthma, a reversible increase in residual volume (RV), functional residual capacity (FRC), and total lung capacity (TLC) may occur. There is a fall in FEV1, FVC and gas transfer.
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This question is part of the following fields:
- Respiratory System
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Question 162
Incorrect
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A 65-year-old previously well man was referred due to an abnormal heart sound which was detected during a medical check up. On examination he looked well. His blood pressure was 120/70 mmHg and pulse rate was 68 bpm which was regular. His jugular venous pressure was not elevated and he didn't have ankle oedema. He had an early diastolic murmur, best heard at the left sternal edge, which was more clear in expiration when the patient leant forward. His lungs were clear. His FBC, Urea and electrolytes, LFTs and lipid profile were normal. His ECG showed sinus rhythm. His chest X-ray was normal. Echocardiography showed mild to moderate aortic regurgitation with normal left ventricular size and normal function.
Which of the following is the most appropriate way of managing this patient?Your Answer:
Correct Answer: Start him on an angiotensin-converting enzyme (ACE) inhibitor
Explanation:Although this patient’s left ventricular function is normal at the time of examination, there is chance of deterioration of it due to aortic regurgitation. It is found that ACE inhibitors slow the development of left ventricular dysfunction. So this patient should be started on an ACE inhibitor.
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This question is part of the following fields:
- Cardiovascular System
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Question 163
Incorrect
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Which of the following statements regarding the clinical effects of long-term oxygen therapy (LTOT) is the most accurate?
Your Answer:
Correct Answer: Reduced sympathetic outflow
Explanation:Studies have shown that benefits of Long-tern oxygen therapy (LTOT) include improved exercise tolerance, with improved walking distance, and ability to perform daily activities, reduction of secondary polycythaemia, improved sleep quality and reduced sympathetic outflow, with increased sodium and water excretion, leading to improvement in renal function.
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This question is part of the following fields:
- Respiratory System
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Question 164
Incorrect
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An 81-year-old woman had fallen down in her house. She is now unable to walk. An x-ray was done on her left hip joint, which showed a fracture in the neck of the femur. Which nerve is most likely to be injured?
Your Answer:
Correct Answer: Sciatic nerve
Explanation:Femoral neck fractures are common injuries that most often result from low-energy falls in the elderly; however, they also can occur in young patients as a result of high-energy mechanisms
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This question is part of the following fields:
- Musculoskeletal System
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Question 165
Incorrect
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A 45-year-old appears at the OPD with symptoms of persistent cough and purulent sputum. He is a chronic smoker and had measles in the past. Upon auscultation, inspiratory crepitation and finger clubbing are noted. What is the single most likely diagnosis?
Your Answer:
Correct Answer: Bronchiectasis
Explanation:A history of measles, whooping cough, or other severe lung infections like tuberculosis (TB) and pneumonia can lead to airway damage and possibly bronchiectasis.
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This question is part of the following fields:
- Respiratory System
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Question 166
Incorrect
-
A 52-year-old gentleman known with rheumatoid arthritis presented with a 5 day history of red, painful swollen knee joint. He was afebrile and the joint was warm on touch. Hamstring muscles were spastic. Which of the following tests should be done next?
Your Answer:
Correct Answer: Joint aspiration for cytology and culture and sensitivity
Explanation:Rheumatoid arthritis can affect any joint of the body. Aspirate will reveal increased TLC, and it will be sterile.
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This question is part of the following fields:
- Immune System
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Question 167
Incorrect
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A 50-year-old doctor developed a fever of 40.2 °C which lasted for two days. He has had diarrhoea for a day, shortness of breath and dry cough.
His blood results reveal a hyponatraemia and deranged LFTs. His WBC count is 10.4 × 109/L and CX-ray shows bibasal consolidation.
Â
Which treatment would be the most effective for his condition?Your Answer:
Correct Answer: Clarithromycin
Explanation:Pneumonia is the predominant clinical manifestation of Legionnaires disease (LD). After an incubation period of 2-10 days, patients typically develop the following nonspecific symptoms:
Fever
Weakness
Fatigue
Malaise
Myalgia
ChillsRespiratory symptoms may not be present initially but develop as the disease progresses. Almost all patients develop a cough, which is initially dry and non-productive, but may become productive, with purulent sputum and, (in rare cases) haemoptysis. Patients may experience chest pain.
Common GI symptoms include diarrhoea (watery and non bloody), nausea, vomiting, and abdominal pain.Fever is typically present (98%). Temperatures exceeding 40°C occur in 20-60% of patients. Lung examination reveals rales and signs of consolidation late in the disease course.
Males are more than twice as likely as females to develop Legionnaires disease.
Age
Middle-aged and older adults have a high risk of developing Legionnaires disease while it is rare in young adults and children. Among children, more than one third of reported cases have occurred in infants younger than 1 year.Situations suggesting Legionella disease:
-Gram stains of respiratory samples revealing many polymorphonuclear leukocytes with few or no organisms-Hyponatremia
-Pneumonia with prominent extrapulmonary manifestations (e.g., diarrhoea, confusion, other neurologic symptoms)
Specific therapy includes antibiotics capable of achieving high intracellular concentrations (e.g., macrolides, quinolones, ketolides, tetracyclines, rifampicin).
Clarithromycin, a new macrolide antibiotic, is at least four times more active in vitro than erythromycin against Legionella pneumophila. In this study the safety and efficacy of orally administered clarithromycin (500 to 1,000 mg bid) in the treatment of Legionella pneumonia were evaluated.
Clarithromycin is a safe effective treatment for patients with severe chest infections due to Legionella pneumophila. -
This question is part of the following fields:
- Respiratory System
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Question 168
Incorrect
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A 35-year-old male is admitted following a collapse while competing in an iron man triathlon. His blood results are as follows:
Na+ 122 mmol/l
K+ 3.4 mmol/l
Urea 3.2 mmol/l
Creatinine 69 umol/l
During assessment he becomes increasingly obtunded and goes on to have multiple tonic clonic seizures. What is the most appropriate treatment from the list below to improve his neurological status?Your Answer:
Correct Answer: Hypertonic saline
Explanation:Over consumption of fluids, prolonged race duration and inadequate training all can predispose to acute hyponatraemia.
Mild symptoms include a decreased ability to think, headaches, nausea, and an increased risk of falls. Severe symptoms include confusion, seizures, and coma. Normal serum sodium levels are 135 – 145 mEq/liter (135 – 145 mmol/L). Hyponatremia is generally defined as a serum sodium level of less than 135 mEq/L and is considered severe when the level is below 120 mEq/L.
The correct treatment to give is hypertonic saline. Decompressive craniotomy would help alleviate raised intracranial pressure due to cerebral oedema however is not an appropriate first line treatment. Demeclocycline is used for SIADH and mannitol is more likely to be used in the context of traumatic brain injury.
Hyponatremia is corrected slowly, to lessen the risk of the development of central pontine myelinolysis (CPM), a severe neurological disease involving a breakdown of the myelin sheaths covering parts of nerve cells. During treatment of hyponatremia, the serum sodium (salt level in the blood) should not rise by more than 8 mmol/L over 24 hours. -
This question is part of the following fields:
- Emergency & Critical Care
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Question 169
Incorrect
-
Impaired glucose tolerance is indicated by what glucose venous plasma level 2 hours after taking the OGTT test?
Your Answer:
Correct Answer: Between 7.8-11.0mmol/l
Explanation:According to the criteria of the World Health Organization and the American Diabetes Association, impaired glucose tolerance is defined as:
two-hour glucose levels of 140 to 199 mg per dL (7.8 to 11.0 mmol/l) on the 75-g oral glucose tolerance test. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 170
Incorrect
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A young woman presents to the emergency after being involved in a fight where she was stabbed in the neck. On examination, her tongue deviates to the right side on protrusion. Which of the following nerves is involved?
Your Answer:
Correct Answer: Hypoglossal nerve injury
Explanation:The motor functions of the intrinsic tongue muscles, as well as the genioglossus, hyoglossus, and styloglossus muscles, are all innervated by the hypoglossal nerve. These muscles are essential for swallowing and speech. To test nerve function, the physical examiner has a patient protrude his or her tongue. In intranuclear, or lower motor neuron lesions, the tongue deviates toward the injured side, as the contralateral genioglossus is acting unopposed. In contrast, supranuclear (upper motor neuron) lesions result in deviation away from the lesion. In addition to causing deviation toward the lesion, an injury involving a hypoglossal nucleus may result in tongue atrophy and fasciculation
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This question is part of the following fields:
- Nervous System
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Question 171
Incorrect
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A 30-year-old female presented with complaints of anxiety, tremors, sweating, tachycardia and weight loss despite increased appetite. Which of the following pathogenesis is responsible for such symptoms?
Your Answer:
Correct Answer: Increased metabolic rate
Explanation:These symptoms are suggestive of thyrotoxicosis. In this disease, the basal metabolic rate of the patients is increased due to excessive thyroid hormones in the blood.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 172
Incorrect
-
A 23-year-old woman comes for the advice regarding contraceptives. Her mother passed away due to cervical cancer and she worries about cervical cancer. Which of the following is the most suitable contraceptive method for her?
Your Answer:
Correct Answer: Barrier method
Explanation:Cervical cancer results from genital infection with HPV. PV infections can be transmitted via nonsexual routes, but the result from sexual contact. So the best contraceptive method in relation to prevention of cervical cancer is the barrier method. But it will not prevent cervical cancer a 100%.
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This question is part of the following fields:
- Women's Health
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Question 173
Incorrect
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A 63-year-old man, known to have small cell lung cancer and ischaemic heart disease (IHD), presents with increasing shortness of breath for the past 7 days. It becomes worse at night and is associated with an occasional non-productive cough. He has also noticed that his wedding ring feels tight. His cancer was diagnosed five months ago and he has recently completed a course of chemotherapy. From a cardiac point of view, he had a myocardial infarction (MI) two years ago following which he had primary angioplasty with stent placement. He has had no episode of angina since then.
Clinical examination of his chest is unremarkable. He does, however, have distended neck veins and periorbital oedema.
What is the most likely diagnosis?Your Answer:
Correct Answer: Superior vena cava obstruction
Explanation:Superior vena cava (SVC) obstruction is an oncological emergency caused by compression of the SVC and is most commonly associated with lung cancer.
Some causes of the condition include:
1. Common malignancies: non small cell lung cancer, lymphoma
2. Other malignancies: metastatic seminoma, Kaposi’s sarcoma, breast cancer
3. Aortic aneurysm
4. Mediastinal fibrosisClinical features of SVC obstruction include:
1. Dyspnoea: most common
2. Swelling of the face, neck, and arms: conjunctival and periorbital oedema may be seen
3. Headache: often worse in the morning
4. Visual disturbances
5. Pulseless jugular venous distensionManagement options are:
1. General: dexamethasone, balloon venoplasty, stenting
2. Small cell lung cancer: chemotherapy and radiotherapy
3. Non small cell lung cancer: radiotherapy -
This question is part of the following fields:
- Haematology & Oncology
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Question 174
Incorrect
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A 27-year-old woman presents with a 4cm bleeding ulcer on her labia minora. The woman admits she is sexually active. Which lymph nodes will the ulcer drain to?
Your Answer:
Correct Answer: Superficial inguinal
Explanation:The woman seems to have a chancroid, which may or may not drain to the lymph nodes of the groin. These nodes are the superficial inguinal lymph nodes.
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This question is part of the following fields:
- Infectious Diseases
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Question 175
Incorrect
-
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:
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 176
Incorrect
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A 60-year-old man with a history of chronic lymphocytic leukaemia is admitted to the acute medical unit for pneumonia. This is his fourth admission for pneumonia in the past six months.
Which of the following factors is most likely to be responsible?Your Answer:
Correct Answer: Hypogammaglobulinaemia
Explanation:Hypogammaglobulinemia is a complication of chronic lymphocytic leukaemia (CLL) that leads to recurrent infections.
CLL is a type of cancer caused by monoclonal proliferation of well-differentiated lymphocytes, typically B cells (99%). Onset of the disease is usually asymptomatic and later constitutes anorexia, weight loss, bleeding, and recurrent infections. Lymphadenopathy is more marked in CLL than in chronic myelogenous leukaemia (CML).
Investigations to diagnose CLL include blood film and immunophenotyping. Smudge cells (also known as smear cells) seen on the blood film point towards CLL. Complications of the disease include hypogammaglobulinemia leading to recurrent infections, autoimmune haemolytic anaemia in 10-15% of the patients, and transformation to high-grade lymphoma (Richter’s transformation).
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This question is part of the following fields:
- Haematology & Oncology
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Question 177
Incorrect
-
A 40-year-old male was diagnosed with HIV. He had had multiple sexual partners. He was not willing to change his lifestyle, nor was he willing to inform any of his former partners. What is the most suitable next step for the doctor?
Your Answer:
Correct Answer: Give general advice
Explanation:General advice should be given to the patient as HIV is not a notifiable disease. Informing someone about the disease without the patient’s consent will breach the confidentiality.
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This question is part of the following fields:
- Ethical & Legal
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Question 178
Incorrect
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A 40-year-old female is receiving a course of chemotherapy for breast cancer. She is, however, experiencing troublesome vomiting which is not responding to domperidone.
Which of the following is the most appropriate next step of management?Your Answer:
Correct Answer: Add a 5-HT3 antagonist
Explanation:Nausea and vomiting are the common side effects of chemotherapy. Risk factors for the development of these symptoms include age<50 years, anxiety, concurrent use of opioids, and the type of chemotherapy administered. For patients at low risk of these symptoms, drugs such as metoclopramide may be used. For high-risk patients, however, 5-HT3 receptor antagonists such as ondansetron are often effective, especially if combined with dexamethasone.
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This question is part of the following fields:
- Haematology & Oncology
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Question 179
Incorrect
-
From the following responses, what is the commonest cardiovascular abnormality associated with Marfan's syndrome of an adult?
Your Answer:
Correct 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 180
Incorrect
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A 48-year-old man with a two year history of ulcerative colitis, has been receiving parenteral nutrition for 4 months. He has developed a dermatitis and has noticed some loss of hair. Serum biochemistry shows a marginally raised glucose concentration and a lower alkaline phosphatase activity.
Which of the following is the most likely?Your Answer:
Correct Answer: Zinc deficiency
Explanation:Zinc deficiency can present with alopecia, dermatitis, poor growth, increased susceptibility to infection, and cognitive deficiency. Magnesium deficiency can cause fatigue, cramping and an irregular EKG. Copper deficiency can present with fatigue and weakness. Chromium deficiency can present with hyperglycaemia.
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This question is part of the following fields:
- Gastrointestinal System
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Question 181
Incorrect
-
A 4-year-old boy admitted with fever for 2 days had a left sided focal fits, which persisted for 4 minutes. There was no history of head injury. On examination, he was drowsy but there were no focal neurological signs. Urine dipstick was negative. What is the investigation of choice that can be done at this stage to arrive at a diagnosis?
Your Answer:
Correct Answer: CSF analysis
Explanation:This presentation could be due to either a meningitis or encephalitis, which are clinically not distinguishable from the given history. Encephalitis is mostly viral and in UK herpes simplex virus is the main cause. Advanced neuro imaging and EEG will help to differentiate them however from the given answers CSF analysis is the most appropriate, provided that intracranial pressure is not raised. CSF analysis will help to differentiate a pyogenic meningitis from other forms of meningitis and encephalitis.
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This question is part of the following fields:
- Infectious Diseases
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Question 182
Incorrect
-
A 54-year-old patient presented with a dry cough after starting treatment for hypertension. He was prescribed ramipril 2.5mg and the dry cough started after that, which disturbed his sleep. His blood pressure was normal. Which of the following is the most appropriate management?
Your Answer:
Correct Answer: Stop the ramipril and prescribe candesartan
Explanation:ACE inhibitors are known to cause a dry cough and they should be stopped, to settle the cough. The next drug of choice is an angiotensin receptor blocker such as candesartan.
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This question is part of the following fields:
- Cardiovascular System
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Question 183
Incorrect
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Of the following options, which is an absolute contraindication to β blockers?
Your Answer:
Correct Answer: Heart block
Explanation:The Joint British Societies’ 2005 guidelines list asthma and heart block as ‘compelling contraindications’ to β blockers – this is because complications can occur which can prove to be fatal. All of the other options listed may be exacerbated by β blockers, and so are only considered to be ‘relative’ contraindications.
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This question is part of the following fields:
- Cardiovascular System
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Question 184
Incorrect
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A 53-year-old male underwent a partial gastrectomy 15 years ago for a complicated peptic ulcer. Which of the following elements may be deficient in this man?
Your Answer:
Correct Answer: Iron
Explanation:The proper gastric acidity is required to transform iron from ferric to ferrous state in order to be absorbable. Even partial gastrectomy may cause dumping syndrome. Malabsorption is rare.
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This question is part of the following fields:
- Gastrointestinal System
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Question 185
Incorrect
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A 52-year-old shopkeeper presents with pain in her hands. Examination reveals plaques on the extensor surfaces of her upper limbs and a telescoping deformity of both index fingers. Nails show pitting and horizontal ridging. The patient is most likely suffering from which of the following?
Your Answer:
Correct Answer: Arthritis mutilans
Explanation:Arthritis mutilans is a rare (occurs in only 5% of the patients) and extremely severe form psoriatic arthritis characterized by resorption of bones and the consequent collapse of soft tissue. When this affects the hands, it can cause a phenomenon sometimes referred to as ‘telescoping fingers.’ The associated nail changes are also characteristic of arthritis.
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This question is part of the following fields:
- Musculoskeletal System
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Question 186
Incorrect
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From the following options, choose the one which is not a cause of liver cirrhosis.
Your Answer:
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 187
Incorrect
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A 48-year-old chronic smoker who smokes 20 cigarettes per day, presented with a persistent cough, wheezing and difficulty in breathing. He was treated with oxygen but the symptoms did not improve. Which of the following is the next step?
Your Answer:
Correct Answer: Check ABG
Explanation:The history is suggestive of a COPD exacerbation. As he is not responding to oxygen, an ABG should be performed to assess the level of hypoxaemia and then a decision about further management can be made. A CXR and salbutamol are also important in the acute management.
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This question is part of the following fields:
- Respiratory System
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Question 188
Incorrect
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Which one of the following immunological changes is seen in progressive HIV infection?
Your Answer:
Correct Answer: Increase in B2-microglobulin levels
Explanation:The immunological changes in HIV include depletion in CD4+ T cell, cytokine dysregulation and immune dysfunction. The dominant immunologic feature of HIV infection is progressive depletion of the helper T cell (CD4+ T cell), which reverses the normal CD4:CD8 ratio and subsequently lead to immunodeficiency. Other imuunological changes include:
increased B2-microglobulin
decreased IL-2 production
polyclonal B-cell activation
decreased NK cell function
reduced delayed hypersensitivity responses -
This question is part of the following fields:
- Infectious Diseases
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Question 189
Incorrect
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A 27-year-old woman is admitted on the medical intake. She is 10 weeks postpartum and has been generally unwell for two weeks with malaise, sweating and anxiety.
On examination, she is hemodynamically stable and clinically euthyroid.
TFTs show the following:
Free T4 33 pmol/L (9-23)
Free T3 8 nmol/L (3.5-6)
TSH <0.02 mU/L (0.5-5)
What is the appropriate management?Your Answer:
Correct Answer: Propranolol 20 mg tds
Explanation:The patient is most likely to have Postpartum thyroiditis which goes through 2 phases; hypothyroid and a hyperthyroid phase.
The hyperthyroid phase of postpartum thyroiditis occurs between 2 and 10 months postpartum. Most commonly, it presents at 3 months. Symptoms more common in women with hyperthyroid postpartum thyroiditis include palpitations, fatigue, heat intolerance, and irritability/nervousness. The frequency of asymptomatic hyperthyroidism is 33%.
Untreated, the hyperthyroidism resolves spontaneously within 2-3 months. This phase is diagnosed by the combination of a low serum TSH concentration in the presence of thyroid peroxidase antibodies, in women who are TSH receptor antibody-negative. Free T4 levels are typically elevated but may be normal.
Treatment of hyperthyroidism, when necessary, is based on symptom severity and should be a joint decision of patient and physician. Beta-blockers such as propranolol are given to alleviate palpitations, irritability, and nervousness. The morbidity associated with treatment is the side effects of beta-blockade. The downside of withholding treatment is allowing the woman to remain symptomatic. Antithyroid medicines (thioureas) are not a potential treatment alternative, because the hyperthyroidism is caused by destructive thyroiditis resulting in the release of preformed thyroid hormone. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 190
Incorrect
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A 61-year-old gentleman presents with heart failure and pedal oedema. The oedema occurs due to:
Your Answer:
Correct Answer: Increased release of renin
Explanation:The oedema is an effect of the a decreased cardiac output that increases renin release which leads to vasoconstriction and sodium and water retention.
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This question is part of the following fields:
- Renal System
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Question 191
Incorrect
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A 27-year-old woman was admitted with vaginal bleeding and left sided pelvic pain for 2 days. There was no history of fever. She gave a history of absent periods for past 8 weeks. Abdominal examination revealed guarding and rebound tenderness in left iliac region. There was left sided cervical excitation on vaginal examination. What is the most probable diagnosis?
Your Answer:
Correct Answer: Ectopic pregnancy
Explanation:The history of amenorrhoea, pelvic pain and vaginal bleeding with peritonism and cervical excitation is more suggestive of an ectopic pregnancy. Endometriosis usually has a chronic presentation and dysmenorrhoea. Salpingitis usually presents with a fever. Ovarian torsion and ovarian tumours have different clinical presentations including increased abdominal size and persistent bloating.
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This question is part of the following fields:
- Women's Health
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Question 192
Incorrect
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A 26-year-old patient without a known medical history presents to casualty unconscious. What should be done as soon as possible?
Your Answer:
Correct Answer: Blood Glucose
Explanation:Blood glucose should be evaluated immediately in order to investigate for diabetic coma triggered by hyperglycaemia or hypoglycaemia.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 193
Incorrect
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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:
Correct 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 194
Incorrect
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A 4-year-old baby was brought in by her mother with complaints of generalized pallor, loss of weight and loose stools. The baby's stools were frothy in nature and difficult to flush. Which investigation can help in diagnosing this patient?
Your Answer:
Correct Answer: Anti-endomysial antibodies
Explanation:The presence of anti-endomysial antibodies confirms the diagnosis of Celiac disease, which is the primary cause of illness in this patient. The sweat chloride test is performed with cystic fibrosis.
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This question is part of the following fields:
- Gastrointestinal System
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Question 195
Incorrect
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A 28-year-old male is involved in a motorcycle accident. He sustained a direct blow to his lower chest. His blood pressure is 83/48, HR 113 bpm. On examination, there are multiple bruises on the chest with bowel sounds heard on auscultation of his chest. The single most likely diagnosis is?
Your Answer:
Correct Answer: Diaphragmatic rupture
Explanation:Ruptured diaphragm is a serious condition that is very difficult to diagnose and requires rapid intervention. The presence of bowel sounds on chest auscultation is highly suggestive of this.
Ruptured oesophagus is excluded by the absence of haematemesis and normal intestinal sounds.
Fractured ribs could be life threatening if associated with a tension pneumothorax which is excluded by a normal chest auscultation.
Flail chest is characterised by paradoxical breathing and respiratory failure. -
This question is part of the following fields:
- Respiratory System
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Question 196
Incorrect
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A 50-year-old man is found incidentally to have hypercalcaemia during a routine health screen.
Which one of the following biochemical findings would be most suggestive of primary hyperparathyroidism rather than any other cause of hypercalcaemia?Your Answer:
Correct Answer: Serum PTH concentration within the normal range
Explanation:Primary hyperparathyroidism (PHPT) is diagnosed based upon levels of blood calcium and parathyroid hormone (PTH). In most people with PHPT, both levels are higher than normal. Occasionally, a person may have an elevated calcium level and a normal or minimally elevated PTH level. Since PTH should normally be low when calcium is elevated, a minimally elevated PTH is considered abnormal and indicates PHPT.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 197
Incorrect
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Which one of the following is most suggestive of Wilson's disease?
Your Answer:
Correct Answer: Reduced serum caeruloplasmin
Explanation:In Wilson’s disease, serum caeruloplasmin is decreased. Skin pigmentation is not increased, but may become jaundiced. 24 hour urine copper excretion is increased. Hepatic copper concentration is increased. Serum copper level is also increased. Key point: high copper. Remember Kayser-Fleisher rings for the eyes in Wilson’s disease.
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This question is part of the following fields:
- Gastrointestinal System
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Question 198
Incorrect
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A 70-year-old man presents with nocturia, hesitancy and terminal dribbling of urine.
Prostate examination reveals a moderately enlarged prostate with no irregular features and a well-defined median sulcus. Blood investigations show a PSA level of 1.3 ng/mL. Among the options provided below what is the most appropriate management for this patient?Your Answer:
Correct Answer: Alpha-1 antagonist
Explanation: -
This question is part of the following fields:
- Pharmacology
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Question 199
Incorrect
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A 60-year-old male presents with intermittent haemoptysis and chronic, productive cough. He has a strong history of smoking and has recently lost weight. What is the patient most likely suffering from?
Your Answer:
Correct Answer: Bronchogenic carcinoma
Explanation:The combination of haemoptysis, chronic productive cough, and recent weight loss in a smoker is a strong indication of bronchogenic carcinoma.
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This question is part of the following fields:
- Respiratory System
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Question 200
Incorrect
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A 22-year-old man who has recently returned from a trip to Far East presents with sore eyes and symmetrical joint pain in his knees, ankles and feet. Labs reveal an elevated ESR. The synovial fluid aspirate is sterile and has a high neutrophil count. What is the most likely diagnosis?
Your Answer:
Correct Answer: Reactive arthropathy
Explanation: -
This question is part of the following fields:
- Musculoskeletal System
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SESSION STATS - PERFORMANCE PER SPECIALTY
