-
Question 1
Correct
-
An 80 year-old Zimbabwean woman with known rheumatoid arthritis was admitted to hospital with a four week history of weight loss, night sweats and cough. She was given a course of Amoxicillin for the past week but her condition deteriorated and she was referred to the hospital when she developed haemoptysis.
Â
She was on maintenance prednisolone 10 mg once per day and four weeks earlier, she had received infliximab for a flare up of rheumatoid arthritis. She lived with her husband but had been admitted to hospital himself with influenza four days earlier. She was a lifelong non-smoker and worked most of her life as a missionary in Zimbabwe and South Africa.
Â
On examination she looked cachexic and was pyrexial with a temperature of 38.5°C. Her blood pressure was 181/101 mmHg, pulse 121 beats per minute and oxygen saturations of 89% on room air. Her heart sounds were normal and there were no audible murmurs. Auscultation of her lung fields revealed bronchial breath sounds in the left upper zone. Examination of her abdomen was normal.
Â
Mantoux test < 5mm (after 48 hours)
A chest radiograph revealed cavitating left upper lobe consolidation.
Â
What is the most likely diagnosis?Your Answer: Post-primary tuberculosis
Explanation:Post-primary pulmonary tuberculosis is a chronic disease commonly caused by either endogenous reactivation of a latent infection or exogenous re-infection by Mycobacterium tuberculosis.
Post-primary pulmonary tuberculosis (also called reactivation tuberculosis) develops in 5%-20% of patients infected with M. tuberculosis.Found mainly in adults, this form of tuberculosis arises from the reactivation of bacilli that lay dormant within a fibrotic area of the lung. In adults, reinfection with a strain of mycobacterium that differs from that which caused the primary infection is also possible. Predisposing factors include immunosuppression, diabetes, malnutrition and alcoholism.
Infliximab is a monoclonal antibody against tumour necrosis factor ? (TNF-?). It is FDA approved for many autoimmune conditions, including rheumatoid arthritis and Crohn’s disease. One of the many known side effects of infliximab therapy is reactivation of latent tuberculosis (TB). Because of the resemblances in clinical and radiological features, tubercular lesions in the lung may mimic malignancy. TB accounts for 27% of all infections initially presumed to be lung cancer on imaging studies.
-
This question is part of the following fields:
- Respiratory System
-
-
Question 2
Incorrect
-
A study is performed to assess a new proton pump inhibitor (PPI) in 120 elderly patients who are receiving aspirin. A control group of 240 elderly patients is given the standard PPI. The final evaluation after five years revealed that 24 individuals receiving the new PPI experienced an upper GI bleed. What is the absolute risk reduction if 60 individuals receiving the standard PPI experienced the same condition?
Your Answer: 12%
Correct Answer: 0.05
Explanation:Absolute risk reduction (ARR) – also called risk difference (RD) – is the most useful way of presenting research results to help your decision-making. Absolute risk reduction = (Control event rate) – (Experimental event rate) = 0.05 = 5% reduction
-
This question is part of the following fields:
- Evidence Based Medicine
-
-
Question 3
Incorrect
-
A 65-year-old male patient presents with a non-explosive cough, muscle twitching on the level of the tongue and aspiration pneumonia. He also claims that occasionally the food he swallows comes back through his nose. What is the most likely cause of dysphagia in this case?
Your Answer: Pseudobulbar palsy
Correct Answer: Bulbar palsy
Explanation:Bulbar palsy and pseudobulbar palsy are rare types of a motor neuron disease that affect the cranial motor nerves. Bulbar palsy is a lower motor neuron palsy that affects the nuclei of the 9th to 12th cranial nerves. Pseudobulbar palsy is an upper motor neuron palsy that affects the corticobulbar tracts of the 5th, 7th and 9th to 12th cranial nerves. Any condition which disrupts or damages the cranial nerve nuclei or corticobulbar tracts can cause bulbar or pseudobulbar palsy (e.g., stroke, multiple sclerosis, infections, brain stem tumours). Both bulbar and pseudobulbar palsy are seen mainly in men over 75 years old and present with progressive dysarthria and dysphagia. In addition, patients with pseudobulbar palsy present with a lack of facial expression, difficulty chewing, and emotional lability. Lower motor neuron signs (atrophy and fasciculations of the tongue, absent gag reflex) differentiate bulbar palsy from pseudobulbar palsy, which presents with upper motor neuron signs (spastic tongue, exaggerated gag, and jaw jerk reflexes). Diagnosis is mainly clinical and treatment mostly supportive with a poor prognosis. Life expectancy is around 1-3 years following diagnosis.
-
This question is part of the following fields:
- Haematology & Oncology
-
-
Question 4
Incorrect
-
Which one of the following is the most common cause of hypothyroidism in the UK?
Your Answer: Dietary iodine deficiency
Correct Answer: Hashimoto's thyroiditis
Explanation:Hashimoto thyroiditis is the most common cause of hypothyroidism in developed countries. In contrast, worldwide, the most common cause of hypothyroidism is an inadequate dietary intake of iodine. This disease is also known as chronic autoimmune thyroiditis and chronic lymphocytic thyroiditis.
-
This question is part of the following fields:
- Endocrine System & Metabolism
-
-
Question 5
Incorrect
-
From the list of options, choose the least useful therapy in preventing oesophageal variceal bleeding in portal hypertension.
Your Answer: Isosorbide dinitrate
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.
-
This question is part of the following fields:
- Gastrointestinal System
-
-
Question 6
Incorrect
-
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: Systemic lupus erythematous
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.
-
This question is part of the following fields:
- Respiratory System
-
-
Question 7
Correct
-
You are asked to fill the first part of a cremation form. Which of the following would need to be removed prior to cremation?
Your Answer: Pacemaker
Explanation:Pacemakers have small electrical parts installed in them that can explode when exposed to extreme heat and pressure.
-
This question is part of the following fields:
- Ethical & Legal
-
-
Question 8
Incorrect
-
A 28-year-old male was admitted with severe central abdominal pain managed as an acute pancreatitis due to his serum amylase being markedly elevated. He is a known epileptic patient and has been on anti-epileptics. What would be the antiepileptic drug responsible for this clinical presentation?
Your Answer: Phenytoin
Correct Answer: Sodium valproate/Carbamazepine
Explanation:Both Sodium valproate and Carbamazepine are correct. These drugs can cause drug induced pancreatitis however more cases have been reported with Sodium valproate.
-
This question is part of the following fields:
- Gastrointestinal System
-
-
Question 9
Correct
-
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: 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%.
-
This question is part of the following fields:
- Women's Health
-
-
Question 10
Correct
-
Which one of the following types of thyroid cancer is associated with the RET oncogene?
Your Answer: Medullary
Explanation:RET (rearranged during transfection) is a receptor tyrosine kinase involved in the development of neural crest derived cell lineages, kidney, and male germ cells. Different human cancers, including papillary and medullary thyroid carcinomas, lung adenocarcinomas, and myeloproliferative disorders display gain-of-function mutations in RET.
In over 90% of cases, MEN2 syndromes are due to germline missense mutations of the RET gene.
Multiple endocrine neoplasias type 2 (MEN2) is an inherited disorder characterized by the development of medullary thyroid cancer (MTC), parathyroid tumours, and pheochromocytoma. -
This question is part of the following fields:
- Endocrine System & Metabolism
-
-
Question 11
Incorrect
-
In which condition are β-blockers not recommended as the first line of therapy?
Your Answer: Chronic heart failure
Correct Answer: Hypertension
Explanation:For patients with hypertension, ACE inhibitors, diuretics, or calcium-channel blockers are given as first-line pharmacological agents. Patients with angina, chronic heart failure, myocardial infarction, and permanent atrial fibrillation with rapid ventricular rate, are given β-blockers as first-line therapy. In these cases, increased cardiac activity can not be met by the amount of blood being supplied to the heart. Giving β-blockers will reduce the workload of the heart and slow down the cardiac activity.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 12
Incorrect
-
A 68-year-old man presents with acute symptoms of gout on his first metatarsophalangeal joint. Which option best explains the underlying mechanism of gout?
Your Answer: Too much protein in diet
Correct Answer: Decreased renal excretion of uric acid
Explanation:Primary gout is related more often to underexcretion of uric acid or overproduction.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 13
Incorrect
-
A man was admitted with galactorrhoea. History reveals that the patient has been having problems with getting and maintaining an erection. He also admits he's noticed a decrease in the quantity of his facial hair. What is the most likely diagnosis?
Your Answer: Cushing's syndrome
Correct Answer: Hyper prolactinaemia
Explanation:Increased levels of prolactin in men can lead to erectile dysfunction, reduced facial and body hair and on rare occasion gynecomastia with galactorrhoea.
-
This question is part of the following fields:
- Endocrine System & Metabolism
-
-
Question 14
Correct
-
A 23-year-old woman presents with hirsutism and oligomenorrhea for the last five years. She is very anxious about her irregular menses and worried as her mother was diagnosed with uterine cancer recently. She is a lawyer and does not want to conceive, at least for the next couple of years.
The examination is essentially normal except for coarse dark hair being noticed under her chin and over her lower back.
Investigations done during the follicular phase:
Serum androstenedione 10.1 nmol/l (0.6-8.8)
Serum dehydroepiandrosterone sulphate 11.6 Ù‰mol/l (2-10)
Serum 17-hydroxyprogesterone 5.6 nmol/l (1-10)
Serum oestradiol 220 pmol/l (200-400)
Serum testosterone 3.6 nmol/l (0.5-3)
Serum sex hormone binding protein 32 nmol/l (40-137)
Plasma luteinising hormone 3.3 U/l (2.5-10)
Plasma follicle-stimulating hormone 3.6 U/l (2.5-10)
What is the most appropriate treatment?Your Answer: Combined OCP
Explanation:This patient has polycystic ovarian syndrome (PCOS). Medical management of PCOS is aimed at the treatment of metabolic derangements, anovulation, hirsutism, and menstrual irregularity.
First-line medical therapy usually consists of an oral contraceptive to induce regular menses. The contraceptive not only inhibits ovarian androgen production but also increases sex hormone-binding globulin (SHBG) production. The American College of Obstetricians and Gynaecologists (ACOG) recommends the use of combination low-dose hormonal contraceptive agents for long-term management of menstrual dysfunction.
If symptoms such as hirsutism are not sufficiently alleviated, an androgen-blocking agent may be added. Pregnancy should be excluded before therapy with oral contraceptives or androgen-blocking agents are started.
First-line treatment for ovulation induction when fertility is desired is clomiphene citrate. Second-line strategies may be equally effective in infertile women with clomiphene citrate-resistant PCOS. -
This question is part of the following fields:
- Endocrine System & Metabolism
-
-
Question 15
Incorrect
-
A 45-year-old male presents with lower backache and pain in his hips. Blood tests are normal except for elevated serum alkaline phosphatase which is 1200 IU/l (45-105). Radiological examination shows combined osteolytic and osteosclerotic lesions. What is the most common site of occurrence of this disease?
Your Answer: Femur
Correct Answer: Pelvis
Explanation:The patient most likely suffers from Paget’s disease of the bone as his radiological examination shows both osteolytic and osteosclerotic lesions. Any bone or bones can be affected, but Paget’s disease occurs most frequently in the pelvis > lumbar spine > femur > thoracic spine > sacrum > skull > tibia.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 16
Incorrect
-
A 7-year-old child presented to the paediatric clinic with a swollen face, hands and feet. She gained 2 kilograms over the last month despite poor feeding. What is the investigation of choice in this case?
Your Answer: Thyroid function tests
Correct Answer: Urinary albumin
Explanation:This is a case of nephrotic syndrome that can be confirmed by the presence of urinary albumin. It should be further investigated by a tissue sample to confirm the diagnosis.
-
This question is part of the following fields:
- Renal System
-
-
Question 17
Incorrect
-
A 70-year-old man presents to the emergency department acutely unwell. He is shocked, drowsy and confused.
He is known to be type-2 diabetic maintained on metformin.
Blood tests reveal a metabolic acidosis with an anion gap of 24 mmol/l. Ketones are not significantly elevated and random blood glucose was 8.7 mmol/l.
What is the mainstay of treatment for this condition?Your Answer: 1.26% sodium bicarbonate iv
Correct Answer: Rehydration
Explanation:Lactic acidosis is occasionally responsible for metabolic acidosis in diabetics. It may occur in the presence of normal blood levels of the ketone bodies, and such cases are often described as having non-ketotic diabetic acidosis.
It is most commonly associated with tissue hypoperfusion and states of acute circulatory failure.
Appropriate measures include treatment of shock, restoration of circulating fluid volume, improved cardiac function, identification of sepsis source, early antimicrobial intervention, and resection of any potential ischemic regions. Reassessment of lactate levels for clearance assists ongoing medical management. -
This question is part of the following fields:
- Endocrine System & Metabolism
-
-
Question 18
Incorrect
-
A 33-year-old lady who is known hepatitis C positive comes to your clinic. She is 28 weeks pregnant and her obstetrician wants you to assess her and provide medical advice for the mother and child.
Which of the following statements concerning hepatitis C are most accurate in her case?Your Answer: A high viral load at delivery increases the risk of transmission
Correct Answer: Breast-feeding does not increase the risk of transmission
Explanation:Breast feeding has not been shown to increase the risk of transmission of HCV from mother to baby. This is simply a fact to memorize. The other answer choices are not the most accurate as there is no evidence-proven way to decrease the chance that baby will get HCV from the mother during the birth. About 5 out of every 100 infants born to HCV infected mothers become infected.
-
This question is part of the following fields:
- Infectious Diseases
-
-
Question 19
Incorrect
-
A 51-year-old man was admitted with right-sided hemiparesis and right upper motor neuron facial nerve palsy. He was known to be on warfarin for a mitral valve replacement and had been adequately anticoagulated. He was also taking furosemide and had recently been started on St John's wort for low mood.
On examination, his pulse was 90 bpm and regular, and his blood pressure was 150/80 mmHg. Cardiac examination demonstrated normal prosthetic valve sounds with an ejection systolic murmur at the left sternal edge. CT scan showed evidence of a left middle cerebral artery infarction.
What is the possible explanation for the presentation?Your Answer: St John's wort is prothrombotic
Correct Answer: St John's wort reduces the activity of warfarin
Explanation:St John’s wort interferes with warfarin by increasing its breakdown and decreasing its effectiveness. This leads to the need for adjustment in the dose of warfarin and careful attention to monitoring if the patient decides to continue with the drug. Ideally, an alternative antidepressant should also be considered.
-
This question is part of the following fields:
- Haematology & Oncology
-
-
Question 20
Incorrect
-
A patient with chronic renal failure, treated with regular haemodialysis, attends the renal clinic. He has been treated for six months with oral ferrous sulphate, 200 mg three times a day. His haemoglobin at this clinic attendance is 7.6. His previous result was 10.6 six months ago.
Â
Which of the following is the most appropriate treatment?Your Answer: Blood transfusion
Correct Answer: IV iron and subcutaneous erythropoietin
Explanation:The patient should be prescribed IV iron and subcutaneous erythropoietin to enhance erythropoiesis to address the dropped haemoglobin.
-
This question is part of the following fields:
- Renal System
-
-
Question 21
Incorrect
-
Vancomycin is a glycopeptide. It acts by which mechanism?
Your Answer: Interference with DNA replication
Correct Answer: Cell wall inhibition
Explanation:Peptidoglycans are a component of bacterial cell wall and are inhibited by this antibiotic.
-
This question is part of the following fields:
- Pharmacology
-
-
Question 22
Correct
-
If a patient has HIV what is the most likely cause of persistent watery diarrhoea?
Your Answer: Cryptosporidium
Explanation:When you have a patient with HIV and diarrhoea on the exam, think Cryptosporidium. In those who are immunocompetent this organism doesn’t usually cause symptoms, but in immunocompromised people like those with HIV, it causes infection and diarrhoea. Typically those with CD4 counts of <100 cells/µL1 have the greatest risk for prolonged, severe, or extraintestinal cryptosporidiosis.
-
This question is part of the following fields:
- Infectious Diseases
-
-
Question 23
Incorrect
-
A 24-year-old waiter applies for a job at a cafeteria. He gives a history of having had enteric fever 2 years ago. Which of the following investigations is most likely to indicate a chronic carrier status?
Your Answer: Blood culture
Correct Answer: Culture of intestinal secretions
Explanation:The chronic asymptomatic carrier state is thought to be why there is continued appearance of the bacterium in human populations. As shedding of the organism is intermittent and sometimes at low levels, methods to detect it have been limited. The Salmonella typhi may be cultured from intestinal secretions, faeces or urine in chronic carriers and is recommended to confirm the diagnosis. Vi agglutination test can also be high in normal people in areas with typhoid endemic. Full blood count or blood culture would not be helpful to determine carrier status. Widal antigen test is unable to differentiate carriers from people with a hx of prior infection.
-
This question is part of the following fields:
- Gastrointestinal System
-
-
Question 24
Incorrect
-
A 72-year-old female patient with a history of atrial fibrillation was admitted with recurrent episodes of syncopal attacks. Her ECG showed torsade de pointes. What is the drug which does not cause the above presentation?
Your Answer: Domperidone
Correct Answer: Omeprazole
Explanation:Drugs causing torsades de pointes are Amiodarone, Chlorpromazine, Clarithromycin, Disopyramide, Dofetilide, Erythromycin, Haloperidol, Methadone, Procainamide, Quinidine, Sotalol, Levofloxacin, Moxifloxacin, Nilotinib, Ondansetron, Ranolazine, Sunitinib, Ziprasidone, Amitriptyline, Ciprofloxacin, Imipramine, Chlorthalidone, Dasatinib, Hydrochlorothiazide, Furosemide.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 25
Incorrect
-
A 55-year-old female presents with complaints of retrosternal chest pain and dysphagia (which is intermittent and unpredictable in nature). When she swallows, food very suddenly 'sticks' in her chest. She is able to clear it when she drinks water, and then can finish the meal without any further incidence. A barium meal shows she has a corkscrew oesophagus. What is the most likely type of dysphagia here?
Your Answer: Oesophageal carcinoma
Correct Answer: Oesophageal spasm
Explanation:All of the symptoms observed in this patient are typical of uncoordinated irregular oesophageal peristalsis – this is characteristic of oesophageal spasm. The cork-screw oesophagus is also diagnostic of the condition.
-
This question is part of the following fields:
- Gastrointestinal System
-
-
Question 26
Incorrect
-
A 70-year-old man underwent temporary transvenous pacing. While in the coronary care unit he developed presyncope. His pulse rate was 30 bpm. His ECG showed pacing spikes which were not related to QRS complexes. What is the most appropriate action that can be taken?
Your Answer: Arrange for an urgent permanent pacemaker
Correct Answer: Increase the pacing voltage to a maximum
Explanation:Pacemaker spikes on the ECG indicate that pacemaker is functioning. The most probable cause for this presentation is the change of the position of the tip of the pacing wire. Increasing the voltage will solve the problem. If it works, repositioning of the pacing wire should be done.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 27
Incorrect
-
A 46-year-old gentleman diagnosed with type 2 diabetes, hypertension, and proteinuria is started on Ramipril to prevent development of renal disease. He reports to his GP that he has developed a troublesome cough since starting the medication. He has no symptoms of lip swelling, wheeze and has no history of underlying respiratory disease.
Â
What increased chemical is thought to be the cause of his cough?Your Answer: Capsaicin
Correct Answer: Bradykinin
Explanation:Ramipril is an ACE inhibitor that blocks the conversion of angiotensin I to angiotensin II as well as preventing the breakdown of bradykinin, leading to blood vessel dilatation and decreased blood pressure. However, bradykinin also causes smooth muscles in the lungs to contract, so the build-up of bradykinin is thought to cause the dry cough that is a common side-effect in patients that are on ACE inhibitors.
-
This question is part of the following fields:
- Renal System
-
-
Question 28
Incorrect
-
A 45-year-old man who had a liver transplant just over 3 months ago, now has primary sclerosing cholangitis. He complains of fever, abdominal pain and diarrhoea, which has come on over the last week. He has a platelet count of 60 x 109/L and alanine transaminase (ALT) of 300 U/L with a normal bilirubin.
He is taking tacrolimus and prednisolone for immunosuppression, and tells you that he recently stopped taking valganciclovir.
What is the most likely diagnosis?Your Answer: Recurrence of primary sclerosing cholangitis
Correct Answer: Donor-acquired cytomegalovirus
Explanation:The fact that he has recently stopped taking his valganciclovir, anti-viral, is key to the answer to this question. This makes the answer quite plainly donor-acquired CMV infection over all of the other answer choices. He needs to stay on prophylaxis against this, particularly in the first 3 months after transplant. Symptoms and presentations of CMV infection can include fever, abdominal pain, diarrhoea, pneumonitis, hepatitis, hematologic abnormalities, retinitis, and esophagitis.
-
This question is part of the following fields:
- Hepatobiliary System
-
-
Question 29
Incorrect
-
Which of the following statements is the most characteristic of primary Raynaud's phenomenon?
Your Answer: Nail fold capillary scope shows dilated vessels
Correct Answer: Fingers are symmetrically involved during an attack
Explanation:A typical attack may last less than an hour but can also persist for longer. In primary Raynaud’s, attacks are more likely symmetric, episodic, and without evidence of peripheral vascular disease. Patients more commonly have a negative ANA and normal inflammatory markers. There should be no evidence of tissue gangrene, digital pitting, or tissue injury in primary Raynaud’s. In contrast, patients with secondary Raynaud’s will describe attacks that are more frequent, painful, often asymmetric and may lead to digital ulcerations.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 30
Incorrect
-
A 70-year-old woman had a major surgery for removal of cancer of the ovary and lymph node dissection 6 days ago. She had not passed any flatus or stool since then. She recently developed recurrent vomiting and severe abdominal distention. What is the next step of management?
Your Answer: Laparotomy
Correct Answer: NG tube suction and IV fluids
Explanation:This patient developed paralytic ileus. It should be treated conservatively using IV fluids and NG tube.
-
This question is part of the following fields:
- Emergency & Critical Care
-
SESSION STATS - PERFORMANCE PER SPECIALTY
