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Question 1
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A 33-year-old artist who recently arrived in the UK from New York presents in ED. He has a past history of insulin-dependant diabetes mellitus. He describes a few days of fever, headache and myalgia. Admission was prompted by worsening headache and back pain. While waiting in the medical receiving unit, he becomes progressively drowsier. Examination revealed flaccid paralysis and depressed tendon reflexes. He was reviewed by the intensive care team and arrangements were made for ventilation. A computerised tomography (CT) brain is performed that is normal.
Cerebrospinal fluid examination reveals:
Protein 0.9 g/l (<0.45 g/l)
Glucose 4 mmol/l
White cell count (WCC) 28/mm3 (mostly lymphocytes)
Blood testing reveals:
Haemoglobin (Hb) 14 g/dl (13-18)
Platelets 620 x 109/l (150-400 x 109)
WCC 12 x 109/l (4-11 x 109)
Sodium 135 mmol/l (137-144)
Potassium 4.6 mmol/l (3.5-4.9)
Urea 8 mmol/l (2.5-7.5)
Creatinine 120 mmol/l (60-110)
Glucose 6 mmol/l
Which of the following is the most likely infective process?Your Answer: Lyme disease
Correct Answer: West Nile disease
Explanation: -
This question is part of the following fields:
- Nervous System
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Question 2
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 3
Correct
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A 32-year-old male presents to the emergency after being involved in a horrific fire incident at home with 55% burns over is trunk, back and arms. He has an episode of 300ml of hematemesis which prompts endoscopy. Endoscopy reveals several ulcers in the stomach. How would you manage this patient?
Your Answer: IV PPI
Explanation:Curling’s ulcer is an acute gastric erosion resulting as a complication from severe burns when reduced plasma volume leads to ischemia and cell necrosis (sloughing) of the gastric mucosa. The medical management of patients with stress ulcers is more or less similar to the management of peptic ulcer disease in general. The medication targeting acid peptic disease includes proton pump inhibitors, antihistamines, and ulcer-healing drugs like sucralfate. Patients with overt GI bleeding from ulceration will require endoscopic evaluation and management of the stress ulcers. Endoscopic therapies may include epinephrine injection, electro-cauterization, or clipping of the bleeding vessels. Bleeding ulcers refractory to localized endoscopic treatment may need embolization of the culprit vessel or rarely surgical intervention as a last resort. Surgical interventions are commonly indicated for patients with refractory bleeding despite endoscopic or angiographic treatment or patients with unstable hemodynamics to undergo endoscopic or angiographic procedures. Surgeries are performed as an ultimate life-saving approach.
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This question is part of the following fields:
- Fluids & Electrolytes
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Question 4
Correct
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A 34-year-old known alcoholic male has been found unconscious near a pub. The paramedics that attended to him said he was sweating and surrounded by empty cans of cider. Choose the most appropriate initial investigation from the list of options.
Your Answer: Capillary blood sugar
Explanation:Capillary blood sugar should be tested as alcohol-induced hypoglycaemia can present itself in cases such as these.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 5
Correct
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A 16-year-old boy was stabbed in his right upper back and brought to the ED where he underwent an erect CXR. Findings suggest a homogenous opacity on the lower right lung with the trachea centrally placed. What would explain the those findings?
Your Answer: Haemothorax
Explanation:Findings suggest a haemothorax which is very likely to happen, in the absence of a haemo-pneumothorax.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 6
Incorrect
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Which of the following is not a tumour suppressor gene?
Your Answer: APC
Correct Answer: myc
Explanation:Myc is a family of regulator genes and proto-oncogenes that code for transcription factors.
A tumor suppressor gene, or antioncogene, is a gene that protects a cell from one step on the path to cancer. When this gene mutates to cause a loss or reduction in its function, the cell can progress to cancer, usually in combination with other genetic changes. Tumor suppressor genes can be grouped into categories including caretaker genes, gatekeeper genes, and landscaper genes; the classification schemes are continually evolving.
Examples include:
Gene Associated cancers
p53 Common to many cancers, Li-Fraumeni syndrome
APC Colorectal cancer
BRCA1 Breast and ovarian cancer
BRCA2 Breast and ovarian cancer
NF1 Neurofibromatosis
Rb Retinoblastoma
WT1 Wilm’s tumour -
This question is part of the following fields:
- Haematology & Oncology
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Question 7
Incorrect
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A 75-year-old woman experienced right sided weakness shortly after she woke up. However, the weakness resolved in 30 minutes and left no disability. Her CT and ECG appear normal. What extra actions should be taken if she is already on Aspirin, Simvastatin, Amlodipine and Bendroflumethiazide?
Your Answer: Clopidogrel + Dipyridamole
Correct Answer: Start Aspirin 300 mg for 2 weeks
Explanation:The patient has most probably experienced a transient ischemic attack which should be initially managed with aspirin 300 mg for two weeks.
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This question is part of the following fields:
- Nervous System
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Question 8
Incorrect
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A 48-year-old male patient presents with fever and signs of delirium. A few hours ago, blisters appeared on his trunk. His past history revealed nothing serious and he's not on any medication. He admits that he went to Italy five months ago on vacation. What is the most probable diagnosis?
Your Answer: Shingles
Correct Answer: Chicken pox
Explanation:Chicken pox in adults may manifest with acute encephalitis, causing the confusional syndrome known as delirium. Blisters on the trunk favour the diagnosis. The trip to Italy however seems unimportant since the incubation period of chicken pox is 10 to 21 days.
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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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A 32-year-old female presented with a lump in the upper outer quadrant of her left breast, which is 1.5cm in size and tender. What is the initial investigation to be done?
Your Answer: Mammogram
Correct Answer: Ultrasound
Explanation:Tenderness is usually suggestive of a benign breast mass such as a breast abscess. Ultrasound is used to distinguish solid from cystic structures and to direct needle aspiration for abscess drainage.
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This question is part of the following fields:
- Women's Health
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Question 10
Correct
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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: 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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 11
Correct
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A 42-year-old male with long history of diabetes is complaining of a red-hot tender lump near his anus. What is the most possible diagnosis?
Your Answer: Abscess
Explanation:A diabetic patient is a patient with depressed immunity. It is not uncommon to develop abscesses. Diabetic patients have a defected cellular innate immunity. On the other hand, bacteria become much more virulent in a high glucose environment in the interstitium.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 12
Incorrect
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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: Acute glomerulonephritis
Correct 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 13
Incorrect
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Which of the following skin conditions is not associated with diabetes mellitus?
Your Answer: Malum perforans
Correct Answer: Sweet's syndrome
Explanation:Diabetic dermadromes constitute a group of cutaneous conditions commonly seen in people with diabetes with longstanding disease. Conditions included in this group are:
– Acral dry gangrene
– Carotenosis
– Diabetic dermopathy
– Diabetic bulla
– Diabetic cheiroarthropathy
– Malum perforans
– Necrobiosis lipoidica
– Limited joint mobility
– Scleroderma
– Waxy skin is observed in roughly 50%. Sweet’s syndrome is also known as acute febrile neutrophilic dermatosis has a strong association with acute myeloid leukaemia. It is not associated with diabetes mellitus. -
This question is part of the following fields:
- The Skin
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Question 14
Incorrect
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A 51-year-old real estate agent takes hydrocortisone 20mg in the mornings and 5mg at night for Addison's disease. The endocrinology consultant would like her to take prednisolone instead.
What dose of prednisolone should be started?Your Answer: 5 mg
Correct Answer: 7 mg
Explanation:1mg Prednisolone = 4mg hydrocortisone, so the actual equivalent daily dose is 7mg.
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This question is part of the following fields:
- Pharmacology
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Question 15
Incorrect
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A 70-year-old male came to the OPD with complaints of nocturia, difficulty in initiating urination and continuous dribbling of urine afterwards. A transrectal US guided biopsy was performed and the diagnosis of BPH was made. His TURP was planned. Which of the following electrolyte imbalance is most likely to occur?
Your Answer: Hypernatremia
Correct Answer: Hyponatremia
Explanation:In a TURP procedure, fluid is used to irrigate the bladder and to remove blood clots. IV fluids are also given to the patient post-operatively. These factors will lead to dilutional hyponatremia.
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This question is part of the following fields:
- Fluids & Electrolytes
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Question 16
Correct
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A 3-year-old child choked on a foreign object, which was removed at the hospital. The parents are now asking for advice on how to manage future occurrences at home. What do you advise?
Your Answer: Turn the child on his back and give thumps
Explanation:Give up to five back blows: hit them firmly on their back between the shoulder blades. Back blows create a strong vibration and pressure in the airway, which is often enough to dislodge the blockage.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 17
Incorrect
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A 65-year-old heavy smoker presented with acute central chest pain for 2 hours. Which of the following ECG findings is an indication for thrombolysis in this patient?
Your Answer: 2 mm ST depression in all chest leads
Correct Answer: 1 mm ST elevation in 2 limb leads
Explanation:Thrombolytic therapy is indicated in patients with evidence of ST-segment elevation MI (STEMI) or presumably new left bundle-branch block (LBBB) presenting within 12 hours of the onset of symptoms if there are no contraindications to fibrinolysis. STEMI is defined as new ST elevation at the J point in at least two contiguous leads of 2 mm (0.2 mV) or more in men or 1.5 mm (0.15 mV) in women in leads V2-V3 and/or 1 mm (0.1 mV) or more in other contiguous limb leads.
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This question is part of the following fields:
- Cardiovascular System
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Question 18
Incorrect
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A 18-year-old male was screened for hypertrophic cardiomyopathy (HOCM) as his brother had the same condition. What is the echocardiographic finding that is related to the highest risk of sudden cardiac death?
Your Answer: Systolic anterior motion of the mitral valve
Correct Answer: Significant thickening of the interventricular septum
Explanation:There are five prognostic factors which indicate poor prognosis in HOCM:
-family history of HOCM-related sudden cardiac death
-unexplained recent syncope
-large left ventricular wall thickness (MLVWT > 30 mm)
-multiple bursts of nsVT on ambulatory electrocardiography
-hypotensive or attenuated blood pressure response to exercise -
This question is part of the following fields:
- Cardiovascular System
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Question 19
Correct
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A woman suffering from severe psoriasis has been undergoing treatment for it for the last 3 years. She now presents with lethargy and dizziness. Her blood film shows large red blood cells. What is the cause of these symptoms in this woman?
Your Answer: Methotrexate
Explanation:Methotrexate is also known as a DMARD (Disease Modifying Anti Rheumatic Drug). It reduces inflammation and suppresses the immune system, and is thought to cause folic acid deficiency leading to megaloblastic anaemia.
NSAIDS and Sulfasalazine are known to cause haemolytic but not megaloblastic anaemia.
Chronic disease might be accompanied with normocytic or microcytic anaemia as opposed to the macrocytic anaemia this patient is suffering from.
Steroids are not known to cause anaemia. -
This question is part of the following fields:
- Pharmacology
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Question 20
Incorrect
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A 20-year-old male student presents to the clinic with swelling of his face, hands and feet along with diffuse abdominal pain. He has a history of similar recurrent episodes since he was 10 years old, with each episode lasting 2-3 days. Examination reveals swelling on face, hands, feet but no sign of urticaria. Family history is significant for similar episodes in the mother who experienced these since childhood, and a brother who passed away following respiratory distress at age of 8 during one such episode. Which of the following tests would be the most helpful in reaching the diagnosis?
Your Answer: Eosinophil count in the blood
Correct Answer: C1 esterase inhibitor
Explanation:Hereditary C1 inhibitor deficiency leads to recurrent angioedema without urticaria or pruritus. Physical triggers include dental work, surgery or intubation. Medical triggers include angiotensin-converting enzyme (ACE) inhibitor, tamoxifen, oestrogen-containing medications (e.g., hormone replacement therapy and oral contraceptives). It is diagnosed on the basis of low levels of C1 esterase inhibitor or elevated levels of dysfunctional C1 esterase inhibitor. C4 levels are low between attacks. IgE levels, eosinophils, skin prick tests and RASTs are helpful in other allergic conditions and asthma but not of use in this case.
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This question is part of the following fields:
- Musculoskeletal System
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SESSION STATS - PERFORMANCE PER SPECIALTY
