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Question 1
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A 56-year-old female patient is complaining of a swollen upper limb after an insect bite. Although the bite site looks better, the gross oedema is still present. What is the most likely aetiology? Keep in mind that she has a history of breast cancer and radical mastectomy with axillary lymphadenectomy 10 years ago.
Your Answer: Lymphedema
Explanation:Lymphedema is most commonly the result of removal or damage to lymph nodes.
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This question is part of the following fields:
- The Skin
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Question 2
Correct
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A 64-year-old woman with ankylosing spondylitis presents with cough, weight loss and tiredness. Her chest x-ray shows longstanding upper lobe fibrosis. Three sputum tests stain positive for acid fast bacilli (AFB) but are consistently negative for Mycobacterium tuberculosis on culture.
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Which of the following is the most likely causative agent?Your Answer: Mycobacterium avium intracellular complex
Explanation:Pulmonary mycobacterium avium complex (MAC) infection in immunocompetent hosts generally manifests as cough, sputum production, weight loss, fever, lethargy, and night sweats. The onset of symptoms is insidious.
In patients who may have pulmonary infection with MAC, diagnostic testing includes acid-fast bacillus (AFB) staining and culture of sputum specimens.The ATS/IDSA guidelines include clinical, radiographic, and bacteriologic criteria to establish a diagnosis of nontuberculous mycobacterial lung disease.
Clinical criteria are as follows:
Pulmonary signs and symptoms such as cough, fatigue, weight loss; less commonly, fever and weight loss; dyspnoea
Appropriate exclusion of other diseases (e.g., carcinoma, tuberculosis).
At least 3 sputum specimens, preferably early-morning samples taken on different days, should be collected for AFB staining and culture. Sputum AFB stains are positive for MAC in most patients with pulmonary MAC infection. Mycobacterial cultures grow MAC in about 1-2 weeks, depending on the culture technique and bacterial burden.
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This question is part of the following fields:
- Respiratory System
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Question 3
Correct
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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: 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 4
Incorrect
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A 60-year-old man suffers from depression, poor concentration and inability to sleep. A few months earlier, he had a few episodes of debauchery and tantrums. Which drug is most likely to benefit him?
Your Answer:
Correct Answer: Carbamazepine
Explanation:Carbamazepine would be the drug of choice in this case because it is an anti-convulsant. It helps to restore the normal levels of nerve activity in the brain.
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This question is part of the following fields:
- Pharmacology
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Question 5
Incorrect
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A 60-year-old previously well male was admitted with a suspected pulmonary embolism. On examination his BP was 130/80 mmHg and pulse rate was 88 bpm. His CXR was normal. He was treated with low molecular weight heparin. Which of the following is the most appropriate initial lung investigation for this patient?
Your Answer:
Correct Answer: Computed tomographic pulmonary angiography
Explanation:Computed tomographic pulmonary angiography (CTPA) is the standard investigative tool, used for diagnosing a pulmonary embolism. Pulmonary angiography is indicated if CTPA is not available.
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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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A 36-year-old man presents with severe pain in his right big toe which is erythematous and swollen. He recently had an appendicectomy. Personal history reveals that he consumes 30 units of alcohol per week. Choose the most likely diagnosis.
Your Answer:
Correct Answer: Gout
Explanation:Chronic alcoholism leads to increased levels of uric acid in the blood. Gout is caused by high levels of uric acid.
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This question is part of the following fields:
- Musculoskeletal System
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Question 7
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 8
Incorrect
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A 25-year-old pregnant mother who is known to have hepatitis B gave birth to a male infant. She is now concerned about her child contracting hep B. Which of the following is the most suitable option for the baby in this case?
Your Answer:
Correct Answer: HepB full vaccine and Ig
Explanation:Hepatitis B full vaccine and Ig should be given to babies born to hepatitis B positive mothers. Hepatitis B vaccine alone or Ig alone is not sufficient to prevent the infection in the new-born baby.
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This question is part of the following fields:
- Infectious Diseases
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Question 9
Incorrect
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When considering the anatomical location of intracranial meningiomas, which of the following relations is well recognised?
Your Answer:
Correct Answer: Parasagittal - spastic paraparesis
Explanation:The localisation of intracranial lesions (based on both history and examination) is crucial. Meningiomas are slow in growth, and its subtle effects are very different from the more aggressive, intrinsic lesions. Olfactory groove lesions affect the sense of smell and may produce ipsilateral optic atrophy. Sphenoid ridge lesions will produce exophthalmos. Chiasmal lesions usually produce bitemporal hemianopia.
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This question is part of the following fields:
- Nervous System
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Question 10
Incorrect
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A 32-year-old male who was on methadone has suddenly collapsed while running and was found dead. What is the most likely cause for his death?
Your Answer:
Correct Answer: Prolonged QT
Explanation:Methadone and cocaine can cause QT prolongation through the direct effects on the resting membrane potential. Methadone can increase QT dispersion in addition to QT interval. Methadone inhibits the Human Ether-a-go-go Related Gene (hERG) and causes QTc prolongation and development of Torsades de point. Brugada-like syndrome is another condition found in methadone users which predisposes the users to life-threatening ventricular tachycardia and sudden cardiac death.
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This question is part of the following fields:
- Cardiovascular System
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Question 11
Incorrect
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A 25-year-old female presents to the acute medical unit with several lumps in her neck and under her arms, weight loss, vomiting, and low mood. She is investigated and is found to have several areas of suspicious lymphadenopathy including in the neck, both axillae, and mediastinum. She also has multiple lesions in her liver which are confirmed to be the manifestations of Hodgkin lymphoma after biopsy.
Which stage of the disease is the patient currently at?Your Answer:
Correct Answer: IV
Explanation:The patient is on stage IV according to the Ann Arbor staging system for Hodgkin lymphoma (HL). The disease has spread beyond the lymph nodes into the liver (involvement of extra lymphatic organ).
HL is a malignant proliferation of lymphocytes characterised by the presence of distinctive giant cells known as Reed-Sternberg cells. It has a bimodal age distribution being most common in the third and seventh decades of life.
Staging of HL is done according to the Ann Arbor staging system:
Stage
I: Single lymph node region (I) or one extra lymphatic site (IE)II: Two or more lymph node regions on same side of the diaphragm (II) or local extra lymphatic extension plus one or more lymph node regions on same side of the diaphragm (IIE)
III: Lymph node regions on both sides of the diaphragm (III) which may be accompanied by local extra lymphatic extension (IIIE)
IV: Diffuse involvement of one or more extra lymphatic organs or sites
Suffix
A: No B symptomsB: Presence of at least one of the following: unexplained weight loss >10% baseline during 6 months before staging; recurrent unexplained fever >38°C; recurrent night sweats
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This question is part of the following fields:
- Haematology & Oncology
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Question 12
Incorrect
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A 41-year-old male experiences hand tremors that are absent at rest, but aggravated on extension and continuous with movement. What is the most probable diagnosis?
Your Answer:
Correct Answer: Benign essential tremor
Explanation:Tremors that linger on movement, seen on an outstretched hand, and absent on rest are called benign essential tremors.
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This question is part of the following fields:
- Nervous System
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Question 13
Incorrect
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A 55-year-old alcoholic is admitted with portal hypertension. The wedged hepatic venous pressure is recorded. This pressure is reflective of which part of the hepatic vascular system?
Your Answer:
Correct Answer: Sinusoids
Explanation:The wedged hepatic venous pressure is a reflection of the portal venous pressure in the hepatic sinusoids. This is a fact to remember. Here is a great but concise explanation as to why: https://www.ncbi.nlm.nih.gov/pubmed/18695309
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This question is part of the following fields:
- Hepatobiliary System
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Question 14
Incorrect
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Which of the following may cause a downbeat nystagmus?
Your Answer:
Correct Answer: Chiari type I malformation
Explanation:Downbeat nystagmus (DBN) suggests a lesion in the lower part of the medulla. Chiari Type I malformation usually presents with symptoms due to brain stem and lower cranial nerve dysfunction, which includes DBN.
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This question is part of the following fields:
- Nervous System
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Question 15
Incorrect
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A 52-year-old cancer patient that recently had an anterior resection of the rectum is concerned about postoperative pain control. What is the most appropriate management choice in his case?
Your Answer:
Correct Answer: IM morphine
Explanation:Post-operative pain is usually severe and strong analgesia is needed with IM morphine.
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This question is part of the following fields:
- Pharmacology
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Question 16
Incorrect
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A 30-year-old previously well female presented with yellowish discolouration of her sclera. Investigations revealed low haemoglobin, a retic count of 8% and the occasional spherocyte on blood film. Which of the following is the most appropriate single investigation?
Your Answer:
Correct Answer: Direct coombs test
Explanation:A low haemoglobin and a high retic count is suggestive of a haemolytic anaemia. Occasional spherocytes can be seen on blood film during haemolysis and it is not a specific finding. Direct Coombs test will help to identify autoimmune haemolytic anaemia, where there are antibodies attached to RBCs.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 17
Incorrect
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A 30-year-old male presented with exercise related syncope and dyspnoea for 2 weeks. His father passed away at the age of 40, due to sudden cardiac death. His ECG showed left ventricular hypertrophy with widespread T wave inversions. Which of the following is the most appropriate next investigation to confirm the diagnosis?
Your Answer:
Correct Answer: Transthoracic echo
Explanation:The most likely diagnosis is hypertrophic obstructive cardiomyopathy which is suggestive by the history, positive family history and ECG findings. Two-dimensional echocardiography is diagnostic for hypertrophic cardiomyopathy. In general, a summary of echocardiography findings includes abnormal systolic anterior leaflet motion of the mitral valve, LV hypertrophy, left atrial enlargement, small ventricular chamber size, septal hypertrophy with septal-to-free wall ratio greater than 1.4:1, mitral valve prolapse and mitral regurgitation, decreased midaortic flow, and partial systolic closure of the aortic valve in midsystole.
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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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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 19
Incorrect
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Which of the following procedures does not require antibiotic prophylaxis?
Your Answer:
Correct Answer: Dental procedure for a patient with an atrial septal defect
Explanation:According to latest NICE guidelines, patients with isolated atrial septal defects do not require prophylactic antibiotics originally used in prevention of infective endocarditis in dental procedures.
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This question is part of the following fields:
- Infectious Diseases
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Question 20
Incorrect
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A 50-year-old male presented with acute severe central chest pain and acute ST elevation myocardial infarction was diagnosed. He was treated with streptokinase. 2 days later he was sweating excessively and he was found to be hypotensive. Which of the following cannot be considered as a reason for this presentation?
Your Answer:
Correct Answer: Hypotensive effect of streptokinase
Explanation:Hypotensive effect of streptokinase occurs during the streptokinase infusion which is usually transient. Acute mitral regurgitation due to rupture of papillary muscles, ventricular septal defects and reinfarctions (left or right) are known to cause hypotension after 24 hrs. Pulmonary embolism is less likely but cannot be excluded.
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This question is part of the following fields:
- Cardiovascular System
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Question 21
Incorrect
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A 34-year-old Nigerian woman who is a known case of sickle cell anaemia presents with fever and worsening of recurrent back pain. There is no history of weight loss or night sweats.
The investigations done on her arrival show:
Hb: 7.8 g/dL
WCC: 10.1 x10^9/L
Plts: 475 x10^9/L
Reticulocytes: 12%
Serum total bilirubin: 88 μmol/L
What is the most likely diagnosis?Your Answer:
Correct Answer: Vaso-occlusive event
Explanation:This patient is having vaso-occlusive event/crisis (thrombotic crisis) which is a type of sickle cell crisis. It may be associated with ostealgia.
There is no evidence of an aplastic crisis in this case as the haemoglobin level is reasonable with a good reticulocyte count. Conversely, the haemoglobin is not low enough and reticulocyte count and bilirubin are not high enough for a haemolytic crisis.
Sickle cell anaemia is characterised by periods of good health with intervening crises. The four main types of sickle cell crises are thrombotic crisis (painful or vaso-occlusive crisis), sequestration crisis, aplastic crisis, and haemolytic crisis.
Thrombotic crisis is precipitated by infection, dehydration, alcohol, change in temperature, and deoxygenation. Sequestration crisis is characterised by acute chest syndrome (i.e. fever, dyspnoea, chest/rib pain, low pO2, and pulmonary infiltrates). Aplastic crisis is characterised by a sudden fall in haemoglobin without marked reticulocytosis. It usually occurs secondary to parvovirus infection. In haemolytic crisis, a fall in haemoglobin occurs secondary to haemolysis. It is a rare type of sickle cell crisis.
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This question is part of the following fields:
- Haematology & Oncology
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Question 22
Incorrect
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Question 23
Incorrect
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A collapsed patient comes into A&E. He has a steroid user card and empty boxes of prednisolone. He has obvious rheumatoid features on examination and some unilateral consolidation on his chest X-ray. He is given intravenous fluids and broad-spectrum antibiotics.
Which one of the following would be the most useful addition to the current management?Your Answer:
Correct Answer: IV hydrocortisone 100 mg
Explanation:The empty boxes indicate that the patient has run out of his medication.
Chronic administration of high doses of glucocorticoids (GCs) (e.g., prednisone or prednisolone) and also other hormones such as oestrogens, progestins, androgens and growth hormone induce varying degrees of tolerance, resulting in a progressively decreased response to the effect of the drug, followed by dependence and rarely addiction.
The glucocorticoid withdrawal syndrome (GWS) has been considered a withdrawal reaction due to established physical dependence on supraphysiological GC levels.
The severity of GWS depends on the genetics and developmental history of the patient, on his environment, and on the phase and degree of dependence the patient has reached. Its management should include a temporary increase in the dose of GCs followed by gradual, slow tapering to a maintenance dose. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 24
Incorrect
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A 70-year-old male presents with chest pain. His past medical history includes hypertension and angina. He continues to smoke about 20 cigarettes per day despite being advised about lifestyle modifications.
Blood investigations obtained in the emergency department show:
Na+: 133 mmol/l
K+: 3.3 mmol/l
Urea: 4.5 mmol/l
Creatinine: 90 μmol/l
Which among the following is the most likely explanation for the abnormalities seen in the above investigations?Your Answer:
Correct Answer: Bendroflumethiazide therapy
Explanation:The blood investigations in this patient reveal hyponatremia as well as hypokalaemia. Among the options provided, Bendroflumethiazide therapy can cause the above presentation with the electrolyte disturbances.
Note:
– Spironolactone is a potassium-sparing diuretic that is associated with hyperkalaemia.
– Enalapril therapy can cause side effects of dizziness, hypotension, cough, and rarely a rash.
– Felodipine therapy can cause side effects of dizziness, headache, cough, and palpitations. -
This question is part of the following fields:
- Emergency & Critical Care
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Question 25
Incorrect
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Bicuspid aortic valve is in association with which of the following.
Your Answer:
Correct Answer: Coarctation of the aorta
Explanation:Bicuspid aortic valve is the most common congenital cardiovascular anomaly, occurring in 1-2% of the population. Coarctation and bicuspid aortic valve occur more frequently in males with a prevalence of approximately 4:1. A high prevalence of these same cardiovascular lesions is also found in women with Turner’s syndrome.
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This question is part of the following fields:
- Cardiovascular System
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Question 26
Incorrect
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Which of the following drugs is NOT used in the treatment of MRSA?
Your Answer:
Correct Answer: Ceftriaxone
Explanation:Cephalosporins, such as ceftriaxone, do not cover methicillin-resistant staph aureus. They do cover some gram positives and gram negatives. Vancomycin and teicoplanin given intravenously have good coverage of MRSA and other gram positive bacteria. Rifampicin and doxycycline, although not the best treatment, can be used for outpatients if there are no systemic signs of illness.
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This question is part of the following fields:
- Infectious Diseases
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Question 27
Incorrect
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A 50-year-old woman under treatment for manic-depressive psychosis presents in an unconscious state after an episode of seizure on the street. Her husband who accompanied her into the ER reported that they argued about 6-7 hours ago. On examination, she is found to be hypertonic with a GCS of 8, BP: 90/60 mmHg and a pulse of 105 bpm. Blood investigations revealed a lithium level of 3.2 mmol/L. She was intubated and ventilated. Which of the following interventions is most appropriate in this case?
Your Answer:
Correct Answer: Gastric lavage and normal saline infusion
Explanation:Among the above statements, gastric lavage and normal saline IV infusion are the most appropriate interventions for a patient of acute lithium toxicity.
Activated charcoal is not effective after lithium overdose, although gastric lavage should be considered if patients present within 6-8 h.
Where levels are above 3 mmol/l, the use of normal saline to induce diuresis should be considered, although careful monitoring of fluid balance is necessary.
Where levels of lithium are above 4 mmol/l, dialysis is often required. Haemodialysis is preferred, but in a facility where haemodialysis is not possible, peritoneal dialysis may be considered.
Patients should not be discharged until they are asymptomatic and have a serum lithium level less than 1.5 mEq/L. -
This question is part of the following fields:
- Pharmacology
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Question 28
Incorrect
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A 65-year-old female presented with episodes of unilateral blindness, which spontaneously resolved. Her cardiovascular examination was normal. What is the single most appropriate investigation that can be performed to arrive at a diagnosis?
Your Answer:
Correct Answer: Carotid duplex ultrasonography
Explanation:Amaurosis fugax (transient ipsilateral visual loss) and transient ischemic attacks (TIAs) are presentations of atherosclerotic disease of the carotid artery which can be identified by carotid duplex ultrasonography (US), with or without colour, which is the screening test of choice to evaluate for carotid stenosis.
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This question is part of the following fields:
- Nervous System
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Question 29
Incorrect
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A 25-year-old woman comes to the endocrine clinic for her regular follow up. She has hypertension, controlled by a combination of Ramipril and indapamide and was diagnosed with 11-beta hydroxylase deficiency since birth when she was found to have clitoromegaly.
Which of the following is most likely to be elevated?Your Answer:
Correct Answer: 11-Deoxycortisol
Explanation:11-beta hydroxylase is stimulated by ACTH and responsible for conversion of 11-deoxycortisol to cortisol and deoxycorticosterone to corticosterone.
In 11-beta hydroxylase deficiency, the previously mentioned conversions are partially blocked, leading to:
– Increased levels of ACTH
– Accumulation of 11-deoxycortisol (which has limited biological activity) and deoxycorticosterone (which has mineralocorticoid activity)
– Overproduction of adrenal androgens (DHEA, androstenedione, and testosterone) -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 30
Incorrect
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A non-cyanosed 1-year-old female patient has a continuous murmur which is loudest at the left sternal edge. What pulse abnormality is most associated with patent ductus arteriosus if that's her suspected diagnosis?
Your Answer:
Correct Answer: Collapsing pulse
Explanation:DIAGNOSIS:
A consensus definition for hemodynamically significant PDA is lacking. The diagnosis is often suspected clinically, when an infant demonstrates signs of excessive shunting from the arterial to pulmonary circulation. Continuous or a systolic murmur; note, a silent PDA may also occur when the ductus shunt is large enough that nonturbulent flow fails to generate a detectible murmur.
A low diastolic blood pressure (due to runoff into the ductus during diastole, more frequent in the most premature infants).
A wide pulse pressure (due to ductus runoff or steal)Hypotension (especially in the most premature infants)
Bounding pulses
Increased serum creatinine concentration or oliguria
Hepatomegaly -
This question is part of the following fields:
- Cardiovascular System
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SESSION STATS - PERFORMANCE PER SPECIALTY
