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Question 1
Incorrect
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A patient presented with acute onset of mild right hemiparesis affecting the body. He also has evidence of sensory loss on the right hand side. There is evidence of Horner's syndrome and sensory loss on the face on the left hand side.
Which of the following structures are involved?Your Answer: Medial temporal lobe
Correct Answer: Brain stem
Explanation:The patient is presenting with symptoms of lateral medullary syndrome also known as Wallenberg’s syndrome or posterior inferior cerebellar artery syndrome, where the symptoms are due to an ischemia in the brainstem. The classical symptoms include contralateral sensory deficits of the trunk region paired with ipsilateral facial sensory deficits.
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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 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: Psittacosis
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 3
Correct
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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: 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 4
Correct
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Briefly state the mechanism of action of salbutamol.
Your Answer: Beta2 receptor agonist which increases cAMP levels and leads to muscle relaxation and bronchodilation
Explanation:Salbutamol stimulates beta-2 adrenergic receptors, which are the predominant receptors in bronchial smooth muscle (beta-2 receptors are also present in the heart in a concentration between 10% and 50%).
Stimulation of beta-2 receptors leads to the activation of enzyme adenyl cyclase that forms cyclic AMP (adenosine-mono-phosphate) from ATP (adenosine-tri-phosphate). This increase of cyclic AMP relaxes bronchial smooth muscle and decrease airway resistance by lowering intracellular ionic calcium concentrations. Salbutamol relaxes the smooth muscles of airways, from trachea to terminal bronchioles.
Increased cyclic AMP concentrations also inhibits the release of bronchoconstrictor mediators such as histamine and leukotriene from the mast cells in the airway.
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This question is part of the following fields:
- Respiratory System
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Question 5
Correct
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A 44-year-old woman is investigated for hot flushes and night sweats. Her blood tests show a significantly raised FSH level and her symptoms are attributed to menopause. Following discussions with the patient, she elects to have hormone replacement treatment. What is the most significant risk of prescribing an oestrogen-only preparation rather than a combined oestrogen-progestogen preparation?
Your Answer: Increased risk of endometrial cancer
Explanation:The use of hormone replacement therapy (HRT) based on unopposed oestrogen increases the risk of endometrial cancer, and uterine hyperplasia or cancer.
Evidence from randomized controlled studies showed a definite association between HRT and uterine hyperplasia and cancer. HRT based on unopposed oestrogen is associated with this observed risk, which is unlike the increased risk of breast cancer linked with combined rather than unopposed HRT. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 6
Correct
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You are working as a junior doctor in a medical ward when the pharmacist approaches you and informs you that Mr. Henry is documented as allergic to penicillin but you have prescribed him amoxicillin. The patient has received 3 doses without any reaction. The pharmacist has assured you he will not tell anyone about this incident. Which of the following is the most appropriate step now?
Your Answer: Inform the patient of your mistake
Explanation:The patient should be informed about the mistake. The antibiotic should also be changed and the incident should be documented. Thank the pharmacist for his courteous behaviour but do not encourage his attempt to cover up the matter.
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This question is part of the following fields:
- Ethical & Legal
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Question 7
Correct
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A 34-year-old male has been brought to accident and emergency after being involved in a road collision. After his initial evaluation, his score on the Glasgow Coma Scale is 6. What is the most appropriate next step in his treatment?
Your Answer: Secure airway
Explanation:The appropriate next step in this patient’s treatment is to secure his airway.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 8
Correct
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A 72-year-old retired fisherman presents with weakness of shoulders and hips over the last four months. Finger flexion is also weak but the extension is normal. There has been some difficulty swallowing liquids. Past medical history is not significant except for sexually transmitted disease that he caught some 40 years ago in South Pacific and got treated with antibiotics. He smokes and drinks one or two tots of rum at the weekend. Creatine kinase level is 125. Which of the following investigations is most significant in establishing a diagnosis?
Your Answer: Muscle biopsy with electron microscopy
Explanation:Inclusion body myositis (IBM) is a progressive muscle disorder characterized by muscle inflammation, weakness, and atrophy (wasting). It is a type of inflammatory myopathy. IBM develops in adulthood, usually after age 50. The symptoms and rate of progression vary from person to person. The most common symptoms include progressive weakness of the legs, arms, fingers, and wrists. Some people also have weakness of the facial muscles (especially muscles controlling eye closure), or difficulty swallowing (dysphagia). Muscle cramping and pain are uncommon, but have been reported in some people. The underlying cause of IBM is poorly understood and likely involves the interaction of genetic, immune-related, and environmental factors. Some people may have a genetic predisposition to developing IBM, but the condition itself typically is not inherited. Elevated creatine kinase (CK) levels in the blood (at most ,10 times normal) are typical in IBM. Muscle biopsy may display several common findings including; inflammatory cells invading muscle cells, vacuolar degeneration, inclusions or plaques of abnormal proteins.
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This question is part of the following fields:
- Musculoskeletal System
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Question 9
Incorrect
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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: Admit and repeat chest x ray in 24 hours
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 10
Correct
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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: 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 11
Correct
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While investigating a patient with hepatocellular carcinoma (HCC), blood tests reveal a raised level of serum ferritin. What would be the most probable cause for HCC in this patient?
Your Answer: Haemochromatosis
Explanation:Haemochromatosis is the excessive accumulation of iron in the body mainly involving the liver, pancreas, testes, skin etc. Serum ferritin is high indicating iron overload. Haemochromatosis is a known cause for chronic liver cell disease, cirrhosis and HCC.
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This question is part of the following fields:
- Gastrointestinal System
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Question 12
Correct
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A 74-year-old man presents with left-sided lower abdominal pain. He is obese and admits to a dislike of high fibre foods. The pain has been grumbling for the past couple of weeks and is partially relieved by defecation. He has suffered intermittent diarrhoea.
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Blood testing reveals a neutrophilia, and there is also a microcytic anaemia. Barium enema shows multiple diverticula, more marked on the left-hand side of the colon.
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Which diagnosis fits best with this clinical picture?Your Answer: Diverticular disease
Explanation:Given that he has diverticula in the clinical scenario combined with his presenting symptoms, it is likely that he has diverticular disease. A low fibre diet would support this diagnosis. Acute diverticulitis would require treatment with antibiotics. Depending on the severity (Hinchey classification) would determine if he needs oral or IV antibiotics, hospital admission or outpatient treatment. Sometimes abscesses or micro perforations occur, which typical require drainage and possibly surgical intervention. Diverticular disease is clearly a better answer than other possible answer choices, simply based on the symptoms presented in the prompt (and mention of low fibre).
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This question is part of the following fields:
- Gastrointestinal System
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Question 13
Correct
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A 32-year-old male with a history of smoking half a pack of cigarettes per day complains of worsening breathlessness on exertion. He was working as a salesman until a few months ago. His father passed away due to severe respiratory disease at a relatively young age. Routine blood examination reveals mild jaundice with bilirubin level of 90 µmol/l. AST and ALT are also raised. Chest X-ray reveals basal emphysema. Which of the following explanation is most likely the cause of these symptoms?
Your Answer: ?-1-Antitrypsin deficiency
Explanation:Alpha-1 antitrypsin deficiency is an inherited disorder that may cause lung and liver disease. The signs and symptoms of the condition and the age at which they appear vary among individuals. This would be the most likely option as it is the only disease that can affect both liver and lung functions.
People with alpha-1 antitrypsin deficiency usually develop the first signs and symptoms of lung disease between ages 20 and 50. The earliest symptoms are shortness of breath following mild activity, reduced ability to exercise, and wheezing. Other signs and symptoms can include unintentional weight loss, recurring respiratory infections, fatigue, and rapid heartbeat upon standing. Affected individuals often develop emphysema. Characteristic features of emphysema include difficulty breathing, a hacking cough, and a barrel-shaped chest. Smoking or exposure to tobacco smoke accelerates the appearance of emphysema symptoms and damage to the lungs.
About 10 percent of infants with alpha-1 antitrypsin deficiency develop liver disease, which often causes yellowing of the skin and sclera (jaundice). Approximately 15 percent of adults with alpha-1 antitrypsin deficiency develop liver damage (cirrhosis) due to the formation of scar tissue in the liver. Signs of cirrhosis include a swollen abdomen, swollen feet or legs, and jaundice. Individuals with alpha-1 antitrypsin deficiency are also at risk of developing hepatocellular carcinoma. -
This question is part of the following fields:
- Respiratory System
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Question 14
Correct
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A 26-year-old patient, previously fit and well, is admitted with fluctuating confusion and frank haematuria. He has recently been complaining of generalised malaise and joint pains. Examination reveals jaundice, splenomegaly, and petechiae. His blood pressure is 155/84 mmHg, temperature 37.9oC.
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Initial investigations reveal:
Haemoglobin 9.5 g/dl
White cell count 12 × 109/l
Platelets 40 × 109/l
Creatinine 142 μmol/l
Sodium 139 mmol/l
Potassium 4.5 mmol/l
Urea 9.2 mmol/l
Lactate dehydrogenase 495 U/l (10-250)
Urinalysis Protein ++, blood +++
Blood film shows schistocytes
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What treatment should NOT be given to this patient?Your Answer: Platelet transfusion
Explanation:There is a strong suspicion of Thrombotic Thrombocytopenic Purpura (TTP) in this patient as he presents with neurological changes (from confusion to convulsions and coma), fever, haemolysis, thrombocytopenia, and renal failure. Additionally, TTP cases may present with jaundice, splenomegaly, and hypertension as seen in this patient. With a diagnosis of TTP, recent studies have shown that platelet transfusion is not recommended in this case because it has been shown to increase the risk for arterial thrombosis and mortality possibly due to increased aggregations.
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This question is part of the following fields:
- Renal System
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Question 15
Incorrect
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A 20-year-old male, who was otherwise completely healthy, has developed severe and sudden pain in his lower back. It started after getting up from his bed. What is the most probable diagnosis in this case?
Your Answer: Spondylosis
Correct Answer: PID
Explanation:Sudden onset of severe lower back pain whilst is felt more when bending (such as getting up from a bed) is consistent with a diagnosis of a prolapsed intervertebral disc.
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This question is part of the following fields:
- Musculoskeletal System
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Question 16
Incorrect
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Which one of the following medications is most useful for helping to prevent attacks of Meniere's disease?
Your Answer: Promethazine
Correct Answer: Betahistine
Explanation:Betahistine is a histamine analogue that has been the mainstay treatment drug for Meniere’s disease.
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This question is part of the following fields:
- Nervous System
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Question 17
Incorrect
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A 59-year-old scientist is referred to you with a 2-year history of ascending lower limb numbness and, more recently, foot drop. In the last 6 months he has also developed numbness in his fingers. He has a distal reduction to pinprick and relatively preserved muscle power, except for ankle dorsiflexion and hyporeflexia in his legs. The GP has already organised nerve conduction studies and the report is sent along with the patient. Which of the following would be suggestive of an axonal neuropathy?
Your Answer: Abnormally slow F-response
Correct Answer: Reduced compound muscle action potential amplitude
Explanation:Reduced conduction velocity is associated with demyelinating neuropathies. An abnormally slow response is associated with very proximal disease, i.e. radiculopathies. Delayed P100 latency is a feature of performing visual evoked potentials in those with optic nerve disease. Conduction block is usually associated with certain types of demyelinating neuropathy.
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This question is part of the following fields:
- Nervous System
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Question 18
Incorrect
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A 28-year-old male arrives at the clinic complaining of fever, arthralgia and urethritis. On examination, the ankle is swollen and there is a pustular rash on the dorsal foot. What is the most likely diagnosis?
Your Answer: Reactive arthritis
Correct Answer: Disseminated gonorrhoea
Explanation:DGI presents as two syndromes: 1) a bacteremic form that includes a triad of tenosynovitis, dermatitis, and polyarthralgias without purulent arthritis and 2) a septic arthritis form characterized as a purulent arthritis without associated skin lesions. Many patients will have overlapping features of both syndromes. Time from infection to clinical manifestations may range from 1 day to 3 months. There is no travel history and the rash of Lyme disease is not purulent. Reactive arthritis presents with conjunctivitis, urethritis and arthritis usually with a red hot tender and swollen joint.
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This question is part of the following fields:
- Musculoskeletal System
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Question 19
Correct
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A 19-year-old woman is diagnosed with acute purulent meningitis after returning from a recent holiday abroad. Which of the following investigations is the least relevant?
Your Answer: PCR of CSF for Mycobacterium TB
Explanation:Amoebic, bacterial and fungal meningitis may present acutely but this is not common in tuberculous meningitis. Amoebic meningitis is caused by Naegleria fowleri as a result of swimming in infected freshwater. The organism may be found in fresh CSF specimens with phase contrast microscopy.
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This question is part of the following fields:
- Infectious Diseases
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Question 20
Correct
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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: Decreased renal excretion of uric acid
Explanation:Primary gout is related more often to underexcretion of uric acid or overproduction.
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This question is part of the following fields:
- Musculoskeletal System
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Question 21
Incorrect
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Which of the following enzymes are involved in Phase I drug metabolism?
Your Answer: Pyruvate carboxylase
Correct Answer: Alcohol dehydrogenase
Explanation:Drug metabolism can be broadly classified into:
Phase I (functionalization) reactions: also termed non-synthetic reactions, they include oxidation, reduction, hydrolysis, cyclization and de-cyclization. The most common and vital reactions are oxidation reactions. (Of the given enzymes only Alcohol dehydrogenase is involved in phase I drug metabolism. Succinate dehydrogenase, is a vital enzyme involved in the Kreb’s cycle and the mitochondrial electron transport chain). They are mainly catalysed by Cytochrome P-450 enzyme.Phase II (conjugation) reactions: occur following phase I reactions, they include reactions: glucuronidation and sulphate conjugation, etc. They are mostly catalysed by UDP-glucuronosyltransferase enzyme. Other phase II enzymes include: sulfotransferases, N-acetyltransferases, glutathione S-transferases and methyltransferases.
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This question is part of the following fields:
- Pharmacology
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Question 22
Incorrect
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Which one of the following features is most helpful in distinguishing beta thalassaemia trait from iron deficiency anaemia?
Your Answer: Target cells on peripheral blood film examination
Correct Answer: Haemoglobin A2 levels
Explanation:Elevated haemoglobin A2 level is seen in beta thalassaemia trait, whereas, it is typically low in iron deficiency anaemia unless the patient has received a recent blood transfusion.
Low mean corpuscular volume (MCV) and reduced haematocrit (Ht) are encountered in both conditions. Peripheral blood smear is grossly abnormal in both beta thalassaemia and severe iron deficiency anaemia, showing bizarre morphology, target cells, and a small number of nucleated red blood cells.
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This question is part of the following fields:
- Haematology & Oncology
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Question 23
Correct
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A 25-year-old youth was brought to the A&E following a stab injury to the right back of the chest. On examination he was dyspnoeic, his trachea was deviated to the left side and there were engorged veins and absent breath sounds on the right side. Which of the following is the most probable diagnosis?
Your Answer: Tension pneumothorax
Explanation:History is suggestive of right sided tension pneumothorax. It can’t be a simple pneumothorax because of tracheal deviation and engorged veins.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 24
Incorrect
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A 57-year-old homeless man presents with fever and a productive cough which has green sputum with streaks of blood. A chest x-ray reveals consolidation in the right upper lobe with evidence of cavitation. He is a known alcoholic.
What is the most likely causative agent?Your Answer: Staphylococcus aureus
Correct Answer: Klebsiella Pneumoniae
Explanation:Infection with Klebsiella organisms occurs in the lungs, where they cause destructive changes. Necrosis, inflammation, and haemorrhage occur within lung tissue, sometimes producing a thick, bloody, mucoid sputum described as currant jelly sputum.
The illness typically affects middle-aged and older men with debilitating diseases such as alcoholism, diabetes, or chronic bronchopulmonary disease. An increased tendency exists toward abscess formation, cavitation, empyema, and pleural adhesions. -
This question is part of the following fields:
- Respiratory System
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Question 25
Correct
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A defect in DNA gyrase can lead to which of the following cancerous conditions?
Your Answer: Xeroderma pigmentosum
Explanation:Xeroderma pigmentosum is an X-linked recessive condition, which is caused by mutations in DNA gyrase which further encodes the XP gene. The defect may lead to skin cancer at an early stage of life, especially at photo exposed sites.
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This question is part of the following fields:
- The Skin
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Question 26
Incorrect
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A 85-year-old previously well man was found to have a BP of 155/90 mmHg. His average reading from the monitoring of his ambulatory BP was 147/92 mmHg. His calculated 10 year cardiovascular risk was 15%. Which of the following is the most appropriate management of this patient?
Your Answer: Start a calcium channel blocker
Correct Answer: Give lifestyle advice and repeat blood pressure in 6 months
Explanation:According to different guidelines for patients above 80 years, the targeted systolic blood pressure varies from 140-150 mmHg. As this patient’s BP is within that range, he can be kept under observation.
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This question is part of the following fields:
- Cardiovascular System
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Question 27
Incorrect
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Which one of the following types of thyroid cancer is associated with the RET oncogene?
Your Answer: Follicular
Correct 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
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Question 28
Correct
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A 23-year-old man is referred to the pneumologist with a suspicion of bronchiectasis. History reveals he's been having recurrent pulmonary infections his whole life together with difficulties gaining weight. He's a non-smoker with a clear family history and he admits inhalers haven't helped him in the past. He is finally suspected of having cystic fibrosis. What is the normal function of the cystic fibrosis transmembrane regulator?
Your Answer: Chloride channel
Explanation: -
This question is part of the following fields:
- Respiratory System
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Question 29
Correct
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A 48-year-old woman presented to you with a history of left side weakness that resolved within 2 hours. A CT scan was done showing reduced blood flow in a certain area. What is the next step regarding investigations?
Your Answer: Carotid Doppler plus angiography
Explanation:This is a case of a transient ischemic attack. It is better investigated by carotid duplex to exclude carotid artery stenosis or atherosclerotic changes.
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This question is part of the following fields:
- Nervous System
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Question 30
Correct
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A 40-year-old male is awaiting a liver biopsy. Which of the following is the most important investigation that has to be performed prior to the procedure?
Your Answer: Coagulation profile
Explanation:As the liver is highly vascular, there is a high risk of bleeding during and after the procedure. Patients may have existing liver diseases, which affect the production of clotting factors. So a coagulation profile is necessary to detect any abnormality and correct them prior to the liver biopsy.
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This question is part of the following fields:
- Hepatobiliary System
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Question 31
Correct
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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: 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.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 32
Incorrect
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A husband visits the clinic with his wife because he wants to be screened for cystic fibrosis. His brother and wife had a child with cystic fibrosis so he is concerned. His wife is currently 10 weeks pregnant. When screened, he was found to be a carrier of the DF508 mutation for cystic fibrosis but despite this result, the wife declines testing. What are the chances that she will have a child with cystic fibrosis, given that the gene frequency for this mutation in the general population is 1/20?
Your Answer: 1/30
Correct Answer: Jan-80
Explanation:The chance of two carriers of a recessive gene having a child that is homozygous for that disease (that is both genes are transmitted to the child) is 25%. Therefore, the chances of this couple having a child with CF are 25%(1/4) x 1/20 = 1/80.
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This question is part of the following fields:
- Respiratory System
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Question 33
Correct
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The immunoglobulin found in the highest concentration in humans is
Your Answer: IgG
Explanation:Representing approximately 75% of serum antibodies in humans, IgG is the most common type of antibody found in the circulation. IgG molecules are created and released by plasma B cells.
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This question is part of the following fields:
- Immune System
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Question 34
Incorrect
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A 8-year-old girl with suspected patent foramen ovale, presented with her parents for the confirmation of the diagnosis. Which of the following is the best investigation to confirm the diagnosis?
Your Answer: Bubble Echocardiography
Correct Answer: Transoesophageal Echocardiography
Explanation:A 3-dimensional transoesophageal echocardiography (3D TEE) provides direct visualization of the entire PFO anatomy and surrounding structures. It allows more accurate diagnosis.
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This question is part of the following fields:
- Cardiovascular System
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Question 35
Correct
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A 78-year-old male with long-standing Alzheimer's disease is being reviewed in your clinic. Which among the following is true regarding memantine, a drug which has been approved for the management of dementia in the UK?
Your Answer: It is an NMDA-receptor agonist
Explanation:Memantine is an antagonist of the NMDA (N-Methyl-D-Aspartate)-receptor subtype of glutamate receptor. It is used to slow the neurotoxicity thought to be involved in Alzheimer’s disease and other neurodegenerative diseases.
Drug interactions:
When given concomitantly with other NMDA-receptor antagonists (e.g., ketamine, amantadine) increase the risk of psychosis.
Dopamine agonists, L-dopa, and anticholinergics enhance effects of memantine.
Antispasmodics (e.g., baclofen)Â enhance effects, as memantine has some antispasmodic effects.
Drugs excreted by cationic transporters in the kidney (e.g. quinine, cimetidine, ranitidine) reduce excretion.Common adverse effects include dizziness, headache, confusion, diarrhoea, and constipation.
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This question is part of the following fields:
- Pharmacology
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Question 36
Incorrect
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Type 2 hypersensitivity is mediated by:
Your Answer: IgE and mast cells
Correct Answer: IgG, IgM & complement
Explanation:In type II hypersensitivity the antibodies, IgG and IgM bind to antigens to form complexes that activate the classical pathway of complement to eliminate cells presenting foreign antigens.
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This question is part of the following fields:
- Immune System
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Question 37
Correct
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A 27-year-old gentleman presents with a 2 year history of involuntary neck movements. There is no history of trauma. He is on no drugs. There is no relevant family history.
On examination he has an episodic right torticollis. The rest of his neurological examination is normal. MRI of his cervical spine is normal. The neurologist in the Movement Disorders Clinic has diagnosed cervical dystonia.
Which of the following treatments will be most beneficial?Your Answer: Botulinum toxin
Explanation:Botulinum toxin is a neurotoxic protein from Clostridium botulinum that causes flaccid paralysis as it acts by preventing the release of Ach at the neuromuscular joint. It is the first-line treatment for cervical dystonia (torticollis) because the condition is a neurological disorder characterised by unusual muscle contractions of the neck. With the use of Botulinum toxin, the contractions would be released.
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This question is part of the following fields:
- Nervous System
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Question 38
Correct
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A 28-year-old woman presents with easy bruising. She has no history of mucosal bleeding and is generally well apart from occasional diarrhoea. She has previously attended a psychiatric unit for self-harming behaviour and is now brought in by her mother having consumed a number of pills. Her mother has had recurrent venous thromboses, but there is no family history of a bleeding disorder.
Her full blood count (FBC) is normal, but her coagulation profile shows:
Activated partial thromboplastin time (APTT): 60 secs (28-38 secs)
Prothrombin time (PT): no clot after 120 secs (10-14 secs)
Fibrinogen: 3.6 g/L (2-4 g/L)
What is the most likely explanation?Your Answer: Warfarin overdose
Explanation:Warfarin inhibits the vitamin K-dependent procoagulants II, VII, IX, and X as well as anticoagulant protein C and S. It is highly protein-bound and can be displaced by a wide variety of drugs. It has a half-life of 36-48 hours.
Bleeding is the major side effect. Easy bruising, as seen in this case, is commonly seen in patients of warfarin overdose. Grossly prolonged PT and lesser increase in APTT may be seen in such cases.
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This question is part of the following fields:
- Haematology & Oncology
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Question 39
Correct
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A 41-year-old female is referred to medical assessment unit by her physician for querying thrombotic thrombocytopenic purpura (TTP) after she presented with a temperature of 38.9C. Her subsequent urea and electrolytes showed deteriorating renal function with a creatinine 3 times greater than her baseline.
What is the underlying pathophysiology of TTP?Your Answer: Failure to cleave von Willebrand factor normally
Explanation:Thrombotic thrombocytopenic purpura (TTP) is characterised by the von Willebrand factor (vWF) microthrombi within the vessels of multiple organs. In this condition, the ADAMTS13 metalloprotease enzyme which is responsible for the breakdown of vWF multimer, is deficient, causing its build-up and leading to platelet clots that then decreases the circulating platelets, leading to bleeding in the patient.
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This question is part of the following fields:
- Renal System
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Question 40
Correct
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Which of the following drugs does not cause broncho-dilatation?
Your Answer: Atenolol
Explanation:Atenolol is a beta-selective (cardio selective) adrenoceptor blocking drug without partial agonist or membrane stabilising activity. Higher doses of Atenolol causes broncho-constriction.
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This question is part of the following fields:
- Pharmacology
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Question 41
Correct
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A 20-year-old woman presents to casualty with flank pain and a 48 hour history of dysuria. Her past medical history includes polycystic ovarian syndrome. She is not in a steady relationship at present. There is haematuria and proteinuria on urine dipstick testing.
Examination reveals a pyrexia of 38.1 °C and flank pain.
What diagnosis fits best with this clinical picture?Your Answer: Pyelonephritis
Explanation:The patient presents with flank pain and fever with haematuria and proteinuria associated with a social history of not being in a steady relationship. This patient is a young presumably sexually active female, so the diagnosis is most likely pyelonephritis which has an increased incidence in young sexually active women or men of >50 years of age.
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This question is part of the following fields:
- Renal System
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Question 42
Correct
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A 51 year-old teacher presents complaining of numerous falls. He states he has difficulty walking up stairs, and he thinks it is because of his weak legs rather than blackouts. He is hypertensive and has suffered chronic back pain for many years. He has smoked for many years as well and has a chronic smokers cough. Upon examination, he has weakness of hip flexion and particularly knee extension. He is unable to keep his fingers flexed against force, with the right being weaker than the left. There are no sensory abnormalities and reflexes are preserved bilaterally. Which of the following is the most likely diagnosis?
Your Answer: Inclusion body myositis
Explanation:The pattern of muscle involvement seen with quadriceps and long-finger flexors is characteristic of inclusion body myositis, an inflammatory myopathy. Polymyositis is likely to cause a predominantly proximal weakness, associated with muscle pain. The signs and symptoms are not consistent with upper cord compression, as there would likely be sensory signs, reflex changes, and possible urinary symptoms. Motor neuron disease cannot be ruled out, but there are no findings of upper motor neuron or bulbar features.
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This question is part of the following fields:
- Nervous System
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Question 43
Correct
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A 31-year-old homosexual male is complaining of recent weight loss and blurred vision. A fundoscope was performed showing retinal haemorrhage. What is the single most appropriate option?
Your Answer: Cytomegalovirus (CMV)
Explanation:CMV is the best answer . Weight loss is mostly caused by HIV, which commonly presents with retinal haemorrhage and retinopathy when associated with CMV.
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This question is part of the following fields:
- Infectious Diseases
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Question 44
Correct
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A 52-year-old hypertensive, smoker presents to ER with right side weakness. He gives a history of multiple falls and lack of concentration. What is the most appropriate diagnosis?
Your Answer: Multi-infarct dementia
Explanation:The patient is a heavy smoker and hypertensive which are risk factors of atherosclerosis and cerebrovascular diseases. The acute onset of the weakness and the lateralization indicates a cerebral infarction.
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This question is part of the following fields:
- Nervous System
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Question 45
Incorrect
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Causes of dilated pupils include which of the following?
Your Answer: Myotonic dystrophy
Correct Answer: Ethylene glycol poisoning
Explanation:Ethylene glycol poisoning is the only poison listed that will cause dilation of the pupils whereas all the other listed conditions and poisons will present with small pupils other than in the case of Myotonic dystrophy wherein the patient will present with a cortical cataract.
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This question is part of the following fields:
- Nervous System
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Question 46
Incorrect
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A 28-year-old female presents with postnatal depression and refuses treatment. Which form of consent should be obtained in order to treat this patient?
Your Answer: Consent from carer
Correct Answer: No consent required
Explanation:The patient is in an altered psychological state; thus, no verbal nor a written consent is required from her. Consent from the carer or the court of law can be obtained but this will require some time while a prompt action is needed in this case and the carer is also unable to make a decision on the behalf of the patient. Therefore, the doctor should act without consent.
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This question is part of the following fields:
- Ethical & Legal
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Question 47
Correct
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A 45-year-old man presents with fever, malaise, weight loss and myalgias that have been occurring for a month. You suspect polyarteritis nodosa and arrange for some lab investigations. Which of the following abnormality would most likely be present?
Your Answer: Elevated creatinine
Explanation:People with polyarteritis nodosa often exhibit anaemia of chronic disease. Leucocytosis and eosinophilia may also be present. ANCA is only rarely positive. As polyarteritis nodosa affects the kidneys as well, the creatinine is elevated in most cases.
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This question is part of the following fields:
- Musculoskeletal System
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Question 48
Correct
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A hypertensive man presents to the emergency in a state of restlessness and shock. He has a history of a pulsatile abdominal mass. Pulse is calculated to be 120/min and the BP: 70/40 mmHg. How should he be managed?
Your Answer: IV fluids 0.9% NS crystalloids to bring SBP to 90mmHg
Explanation:Pre-operative hemodynamic stability is directly associated with the patient’s mortality, and pre-operative shock is the most serious risk factor affecting survival after a ruptured abdominal aortic aneurysm (AAA). For this reason, it is important to stabilize the patient’s blood pressure. However, aggressive fluid resuscitation before achieving control of the proximal aorta can lead to further haemorrhaging, which may result in an increased risk of mortality. Thus, the primary goal in the initial management of patients with AAA is achieving hemodynamic stability to allow perfusion of the vital organs. This is the concept underlying permissive hypotension. This usually involves maintaining a systolic blood pressure of 70 to 90 mmHg, and avoiding aggressive resuscitation to pressures higher than 100 mmHg.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 49
Correct
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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: 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 50
Correct
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A 19-year-old lady with established anorexia nervosa is admitted with a BMI of 16. However, she gives the consent to be fed by a nasogastric tube. Which of the following electrolyte disturbances are you most likely to find?
Your Answer: Hypophosphataemia
Explanation:Refeeding syndrome can be defined as the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding (whether enterally or parenterally). These shifts result from hormonal and metabolic changes and may cause serious clinical complications. The hallmark biochemical feature of refeeding syndrome is hypophosphatemia. However, the syndrome is complex and may also feature abnormal sodium and fluid balance; changes in glucose, protein, and fat metabolism; thiamine deficiency; hypokalaemia; and hypomagnesaemia.
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This question is part of the following fields:
- Fluids & Electrolytes
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SESSION STATS - PERFORMANCE PER SPECIALTY
