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Question 1
Incorrect
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Which of the following serum tumour markers is the most essential for monitoring the clinical progression of a man with teratoma of the testis following chemotherapy?
Your Answer: Carcinoembryonic antigen
Correct Answer: Alpha-fetoprotein
Explanation:Testicular teratomas are best monitored with the following tumour markers: Alpha-fetoprotein (AFP), beta-hCG, and PLAP (placental like isoenzyme of alkaline phosphatase). For ovarian tumours, we use CA125, pancreatic tumours we use CA19-9, CA15-3 for breast carcinoma and carcinoembryonic antigen (CEA) for colonic tumours.
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This question is part of the following fields:
- Men's Health
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Question 2
Correct
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A 55-year-old male, known hypertensive on antihypertensive medications, presented with complaints of dizziness and lethargy, especially when rising from the chair. The most appropriate test would be?
Your Answer: Ambulatory blood pressure
Explanation:Ambulatory blood pressure recording is used to monitor BP for 24 hours whilst continuing the daily routine activities.
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This question is part of the following fields:
- Nervous System
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Question 3
Incorrect
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An old woman complains of sudden bilateral complete visual loss. Her pupillary reaction to light is preserved and there are no noted abnormalities on the anterior chamber or the retina. Which is the most likely site of arterial occlusion?
Your Answer: Superior division of middle cerebral artery (dominant hemisphere)
Correct Answer: Posterior cerebral arteries
Explanation:Cortical blindness is due to a bilateral infarction in the area covered by the distal posterior cerebral arteries and pupillary reflex is preserved. Patients may not notice this blindness (called Anton’s syndrome). Anton-Babinski syndrome, also known as Anton’s blindness and visual anosognosia, is a rare symptom of brain damage occurring in the occipital lobe. Those who have it are cortically blind, but affirm that they are capable of seeing.
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This question is part of the following fields:
- Nervous System
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Question 4
Incorrect
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Ciprofloxacin is used to treat many infectious diseases. It acts by which of the following mechanisms?
Your Answer: Cell wall inhibition
Correct Answer: Interference with DNA replication
Explanation:Ciprofloxacin disturbs the functioning of DNA gyrase and interferes in the DNA replication process.
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This question is part of the following fields:
- Pharmacology
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Question 5
Correct
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A 50-year-old smoker with a history of hypertension presented with acute severe chest pain and acute myocardial infarction was diagnosed. Which of the following is a contraindication for thrombolysis?
Your Answer: History of likely ischaemic stroke within the past month
Explanation:Absolute contraindications for fibrinolytic use in STEMI
Prior intracranial haemorrhage (ICH)
Known structural cerebral vascular lesion
Known malignant intracranial neoplasm
Ischemic stroke within 3 months
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed head trauma or facial trauma within 3 months
Intracranial or intraspinal surgery within 2 months
Severe uncontrolled hypertension (unresponsive to emergency therapy)
For streptokinase, prior treatment within the previous 6 months -
This question is part of the following fields:
- Cardiovascular System
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Question 6
Incorrect
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A smoker male presenting with weight loss is found to have a normal chest x-ray but a positive sputum cytology for carcinomatous cells. Which of the following would be the likely TNM classification?
Your Answer: T1, N0, M0
Correct Answer: TX, N0, M0
Explanation:The TNM system is a means to describe the amount and spread of cancer in a patient’s body. T describes the size of the tumour and any spread of cancer into nearby tissue; N describes spread of cancer to nearby lymph nodes; and M describes metastasis (spread of cancer to other parts of the body).
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This question is part of the following fields:
- Respiratory System
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Question 7
Correct
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A 45-year-old female presented in the OPD with complaints of tiredness and lethargy. On examination, her BP was 160/100 mmHg. On lab examination her Na+=142 mmol/L, K+=3.0mmol/L. Which is the most likely diagnosis?
Your Answer: Conn's syndrome
Explanation:In Conn’s syndrome hypokalaemia and hypertension are present due to high levels of aldosterone with normal to high sodium levels. In this disease, the patient presents with hypertension and feelings of tiredness or fatigue.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 8
Incorrect
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A 35-year-old lady was brought to the emergency department in an unconscious state. She is a known drug addict and has a 1 day history of anuria. CXR revealed pulmonary oedema. Serum electrolytes showed hyperkalaemia. The next management step would be?
Your Answer: Urgent haemodialysis
Correct Answer: IV calcium gluconate
Explanation:IV calcium gluconate is the drug of choice in hyperkalaemia, as it is a life threatening condition and prompt management is required.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 9
Correct
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A 17-year-old girl presented with fever, headache and photophobia. Cerebrospinal fluid examination reveals:
Opening pressure 260 mm H20 (50-180)
Total protein 0.8 g/l (0.15-0.45)
Glucose 4.2 mmol/l (3.3-4.4)
White cell count 60 per ml (<5)
Lymphocytes 90%
Plasma glucose 6.4 mmol/l (3.0-6.0)
Which of the following is the most likely diagnosis?Your Answer: Viral meningitis
Explanation:Normal cerebrospinal fluid (CSF) glucose together with lymphocytosis, an increased opening pressure and raised CSF protein are typical of a viral meningitis.
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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 42-year-old female presents with morning stiffness that usually takes an hour to settle and a one year history of intermittent pain and swelling of the small joints of her hands. Examination reveals symmetric soft tissue swelling over the PIP and MCP joints and rheumatoid nodules on the elbows. There is also an effusion of both wrists. Lab results are positive for rheumatoid factor. X-ray of the wrists and hands shows erosions and bony decalcification. NSAIDs are started and the patient is referred to a rheumatologist for consideration of DMARD. Previous history is significant for TB. Which of the following should be avoided?
Your Answer: Methotrexate
Correct Answer: Infliximab
Explanation:Anti-TNF-? therapy is effective for patients with arthritis but it can oftentimes lead to the reactivation of latent TB. Hence it should be used with great caution in patients with a past history of TB or current infection.
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This question is part of the following fields:
- Musculoskeletal System
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Question 11
Correct
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A 48-year-old male with a history of bipolar disorder presents with acute confusion. In-transit to hospital he had a generalized seizure which terminated spontaneously after around 30 seconds. On arrival to the emergency department, his GCS is 14/15 and he is noted to have a coarse tremor. Suspecting a diagnosis of lithium toxicity, intravenous access is obtained, a blood sample was drawn for investigations and a saline infusion is started. The blood investigations revealed:
Lithium level: 4.2 mmol/l
Na+: 136 mmol/l
K+: 4.6 mmol/l
Urea: 8.1 mmol/l
Creatinine: 99 µmol/l
Bicarbonate: 18 mmol/l
What is the most appropriate management for the patient?Your Answer: Arrange haemodialysis
Explanation: -
This question is part of the following fields:
- Fluids & Electrolytes
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Question 12
Correct
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A 27-year-old woman presents with a history of weight loss and palpitations. Examination reveals unilateral proptosis. She also admits that despite having a healthy appetite she has difficulty putting on weight. What is the most probable diagnosis?
Your Answer: Thyroid-associated ophthalmopathy
Explanation:The patient’s age and symptoms suggest Grave’s disease with thyroid-associated ophthalmopathy. In Grave’s disease, weight loss is noticed regardless of normal eating habits of the patient. Palpitations are also typical and may be confused with a panic attack. Proptosis is usually bilateral, but unilateral is also possible.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 13
Incorrect
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A young man has ingested 25 tablets of paracetamol 500 mg. What is the suggested minimum time interval between ingestion and measuring the blood plasma paracetamol levels?
Your Answer: 6 hours
Correct Answer: 4 hours
Explanation:The post-ingestion plasma level, which is required in order to guide the treatment, reaches a peak at 4 hours. Levels requiring antidote (N-acetyl cysteine) include: 100 mcg per ml at 4 hours, 35 mcg per ml at 10 hours and 25 mcg per ml at 12 hours. These levels are in conjunction with the levels recorded and they should all be put down on a treatment nomogram.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 14
Correct
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A 43-year-old man is reviewed in the gastroenterology clinic. He has had troublesome dyspepsia for the past six months which has not settled with proton pump inhibitor (PPI) therapy. During the review of his systems he also reports passing 6-7 watery stools per day. An OGD 3 weeks ago showed gastric erosions and ulcers.
Which one of the following investigations is most likely to be diagnostic?Your Answer: Fasting gastrin
Explanation:This case describes Zollinger-Ellison syndrome. It is characterized by refractory peptic ulcer disease, often multiple ulcers. This is typically caused by secretion of gastrin from a gastrinoma, a neuroendocrine tumour. The most common site of ulceration is the duodenum. A symptom of a pancreatic gastrinoma may be steatorrhea from the hypersecretion of gastrin. Serum gastrin levels > 1000 and a pH < 2 are diagnostic of pancreatic gastrinoma. None of the other answer choices are a better answer than this. CT abdomen may potentially show a tumour, but this is not diagnostic for type.
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This question is part of the following fields:
- Gastrointestinal System
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Question 15
Incorrect
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A 63-year-old man, known to have small cell lung cancer and ischaemic heart disease (IHD), presents with increasing shortness of breath for the past 7 days. It becomes worse at night and is associated with an occasional non-productive cough. He has also noticed that his wedding ring feels tight. His cancer was diagnosed five months ago and he has recently completed a course of chemotherapy. From a cardiac point of view, he had a myocardial infarction (MI) two years ago following which he had primary angioplasty with stent placement. He has had no episode of angina since then.
Clinical examination of his chest is unremarkable. He does, however, have distended neck veins and periorbital oedema.
What is the most likely diagnosis?Your Answer: Heart failure secondary to chemotherapy
Correct Answer: Superior vena cava obstruction
Explanation:Superior vena cava (SVC) obstruction is an oncological emergency caused by compression of the SVC and is most commonly associated with lung cancer.
Some causes of the condition include:
1. Common malignancies: non small cell lung cancer, lymphoma
2. Other malignancies: metastatic seminoma, Kaposi’s sarcoma, breast cancer
3. Aortic aneurysm
4. Mediastinal fibrosisClinical features of SVC obstruction include:
1. Dyspnoea: most common
2. Swelling of the face, neck, and arms: conjunctival and periorbital oedema may be seen
3. Headache: often worse in the morning
4. Visual disturbances
5. Pulseless jugular venous distensionManagement options are:
1. General: dexamethasone, balloon venoplasty, stenting
2. Small cell lung cancer: chemotherapy and radiotherapy
3. Non small cell lung cancer: radiotherapy -
This question is part of the following fields:
- Haematology & Oncology
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Question 16
Incorrect
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A 28-year-old woman is investigated for bloody diarrhoea which started around six weeks ago. She is currently passing 3-4 loose stools a day which normally contain a small amount of blood. Other than feeling lethargic she remains systemically well with no fever or significant abdominal pain. A colonoscopy is performed which shows inflammatory changes in the ascending colon consistent with ulcerative colitis. Bloods show the following:
Hb: 14.2 g/dl
Platelets: 323 * 109/l
WBC: 8.1 * 109/l
CRP: 22 mg/l
What is the most appropriate first-line medication to induce remission?Your Answer: Rectal aminosalicylate
Correct Answer: Oral aminosalicylate
Explanation:Given she is not showing signs of systemic illness, you do not need to treat for an acute flair (which would be steroids), but you need to put her on maintenance medication. Oral ASA would be the best option for this, it is first line. You cannot give rectal ASA because the location of her disease is in the ascending colon and the enema will not reach.
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This question is part of the following fields:
- Gastrointestinal System
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Question 17
Correct
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A 26-year-old man with type-1 diabetes presents for review. His HbA1c is 6.8% yet he is concerned that his morning blood sugar levels are occasionally as high as 24 mmol/l. He is currently managed on a bd mixed insulin regimen.
He was sent for continuous glucose monitoring and his glucose profile reveals dangerous dipping in blood glucose levels during the early hours of the morning.
Which of the following changes to his insulin regime is most appropriate?Your Answer: Move him to a basal bolus regime
Explanation:The patients high morning blood sugar levels are suggestive to Somogyi Phenomenon which suggests that hypoglycaemia during the late evening induced by insulin could cause a counter regulatory hormone response that produces hyperglycaemia in the early morning.
Substitution of regular insulin with an immediate-acting insulin analogue, such as Humulin lispro, may be of some help. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 18
Incorrect
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A 28-year-old female presents to her GP with joint pain , fever, a butterfly rash and fatigue. She has marked peripheral oedema. She is found to be hypertensive, in acute renal failure, low albumin levels and proteinuria.
A renal biopsy is performed and reveals focal glomerulonephritis with subendothelial and mesangial immune deposits.
What is the most likely diagnosis?Your Answer: Lupus nephritis class I
Correct Answer: Lupus nephritis Class III
Explanation:This case presents with characteristic symptoms of SLE and with her renal biopsy results of focal glomerulonephritis, this is clearly Class III SLE.
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This question is part of the following fields:
- Renal System
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Question 19
Correct
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A 58-year-old female patient is being investigated for breathlessness, cough, and severe weight loss. On the medical ward round, her CXR is reviewed showing hilar lymphadenopathy and multiple peripheral lung metastases.
Which of the following tumours is least likely to be the underlying cause of this lung appearance?Your Answer: Brain
Explanation:All of the aforementioned listed tumours, except brain tumours, can metastasise to lungs and produce the typical CXR picture consisting of hilar lymphadenopathy with either diffuse multinodular shadows resembling miliary disease or multiple large well-defined masses (canon balls). Occasionally, cavitation or calcification may also be seen.
Most brain tumours, however, do not metastasise. Some, derived form neural elements, do so but in these cases, intraparenchymal metastases generally precede distant haematogenous spread.
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This question is part of the following fields:
- Haematology & Oncology
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Question 20
Incorrect
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A 33-year-old male presented with complaints of arthritis involving the knee joint. O/E the overlying joint was red, swollen and tender. The patient also gave a history of constipation and noting a change in his shoe size. The most likely diagnosis in this patient would be?
Your Answer: Gout
Correct Answer: Pseudogout
Explanation:Pseudogout is caused by the deposition of calcium pyrophosphate crystals and effects the large joints, as compared to gout where the small joints are usually involved. The joint tends to be tender, swollen and warm, giving a picture of cellulitis. Pseudogout has an association with hypothyroidism, therefore symptoms of dry skin and constipation can also be present.
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This question is part of the following fields:
- Musculoskeletal System
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Question 21
Correct
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A 3-year-old boy has been brought to the hospital by his mother with pallor, lethargy and abdominal enlargement. His mother said she only noticed these symptoms two weeks ago but further questioning reveals that they have been progressively worsening over a longer period of time. The boy was born naturally following an uncomplicated pregnancy. Past and family histories are not significant and the family hasn't been on any vacations recently. However, the mother mentions a metabolic disorder present in the family history but couldn't remember the exact name. Clinical examination reveals generalised pallor, abdominal enlargement, massive splenomegaly and hepatomegaly. The spleen is firm but not tender and there is no icterus or lymphadenopathy. What is the most probable diagnosis?
Your Answer: Gaucher's disease
Explanation:Gaucher’s disease is characterized by hepatosplenomegaly, cytopenia, sometimes severe bone involvement and, in certain forms, neurological impairment. The variability in the clinical presentations of GD may be explained by the continuum of phenotypes. However, three major phenotypic presentations can usually be distinguished. Type-1 GD is usually named non-neuronopathic GD; type-2 and type-3 are termed neuronopathic-GD. Gaucher disease (GD, ORPHA355) is a rare, autosomal recessive genetic disorder. It is caused by a deficiency of the lysosomal enzyme, glucocerebrosidase, which leads to an accumulation of its substrate, glucosylceramide, in macrophages.
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This question is part of the following fields:
- Gastrointestinal System
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Question 22
Incorrect
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A 42-year-old man presented with palpitations and shortness of breath on exertion. On examination his lungs were clear and heart sounds were normal. There was a left sided parasternal heave. His electrocardiogram (ECG) revealed atrial fibrillation with right axis deviation. Echocardiography showed dilated right heart chambers. Left and right heart catheterisation study revealed the following
Inferior vena cava Oxygen saturations 63 %
Superior vena cava Oxygen saturations 59 %
Right atrium Oxygen saturations 77 %
Right ventricle Oxygen saturations 78 %
Pulmonary artery Oxygen saturations 82 %
Arterial saturation Oxygen saturations 98 %
What is the most likely diagnosis from the following answers?Your Answer: Pulmonary stenosis
Correct Answer: Atrial septal defect
Explanation:Right ventricular volume overload is indicated by a parasternal heave and right axis deviation. Oxygen saturation in right atrium is higher than oxygen saturation of the inferior and superior vena cavae. So the most probable diagnosis is atrial septal defect.
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This question is part of the following fields:
- Cardiovascular System
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Question 23
Incorrect
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How would you advise your patient to apply an emollient and a steroid cream, in order to treat her eczema?
Your Answer: Apply steroids, then emollient
Correct Answer: First use emollient then steroids.
Explanation:If steroid is applied first, applying an emollient after could spread it from where it had been applied. If steroid is applied immediately after the emollient then it cannot be absorbed, this is why there should be a time interval of around thirty minutes between these two treatments in order for them to be effective.
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This question is part of the following fields:
- The Skin
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Question 24
Correct
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Organophosphates, such as Sarin, have been used as chemical-warfare agents by terrorists.
Which of the following statements is true concerning organophosphate poisoning?Your Answer: Atropine is useful in the management of organophosphate poisoning
Explanation:The principal action of organophosphates is the inhibition of acetylcholinesterase’s, therefore leading to the accumulation of acetylcholine at muscarinic receptors (miosis, hypersalivation, sweating, diarrhoea, excessive bronchial secretions), nicotinic receptors (muscle fasciculations and tremor) and in the central nervous system (anxiety, loss of memory, headache, coma).
Removal from the source of the organophosphate, adequate decontamination, supplemental oxygen and atropine are the initial treatment measures. Pralidoxime, an activator of cholinesterase, should be given to all symptomatic patients.
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This question is part of the following fields:
- Pharmacology
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Question 25
Incorrect
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Which type of cell is responsible for the production of surfactant?
Your Answer: Type I pneumocyte
Correct Answer: Type II pneumocyte
Explanation:Type I pneumocyte: The cell responsible for the gas (oxygen and carbon dioxide) exchange that takes place in the alveoli. It is a very thin cell stretched over a very large area. This type of cell is susceptible to a large number of toxic insults and cannot replicate itself.
Type II pneumocyte: The cell responsible for the production and secretion of surfactant (the molecule that reduces the surface tension of pulmonary fluids and contributes to the elastic properties of the lungs). The type 2 pneumocyte is a smaller cell that can replicate in the alveoli and will replicate to replace damaged type 1 pneumocytes. Alveolar macrophages are the primary phagocytes of the innate immune system, clearing the air spaces of infectious, toxic, or allergic particles that have evaded the mechanical defences of the respiratory tract, such as the nasal passages, the glottis, and the mucociliary transport system. The main role of goblet cells is to secrete mucus in order to protect the mucous membranes where they are found. Goblet cells accomplish this by secreting mucins, large glycoproteins formed mostly by carbohydrates. -
This question is part of the following fields:
- Respiratory System
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Question 26
Correct
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A 35-year-old woman is referred to the acute medical unit with a 5 day history of polyarthritis and a low-grade fever.
Examination reveals shin lesions which the patient states are painful. Chest x-ray shows a bulky mediastinum.
What is the most appropriate diagnosis?Your Answer: Lofgren's syndrome
Explanation:Lofgren’s syndrome is an acute form of sarcoidosis characterized by erythema nodosum, bilateral hilar lymphadenopathy (BHL), and polyarthralgia or polyarthritis. Other symptoms include anterior uveitis, fever, ankle periarthritis, and pulmonary involvement.
Löfgren syndrome is usually an acute disease with an excellent prognosis, typically resolving spontaneously from 6-8 weeks to up to 2 years after onset. Pulmonologists, ophthalmologists, and rheumatologists often define this syndrome differently, describing varying combinations of arthritis, arthralgia, uveitis, erythema nodosum, hilar adenopathy, and/or other clinical findings.
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This question is part of the following fields:
- Respiratory System
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Question 27
Incorrect
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A 65-year-old man known to have renal cell carcinoma, is currently undergoing treatment. He presents to the acute medical ward with one month history of worsening central lower back pain, which becomes worse at night and cannot be managed with an analgesia at home. He has no other new symptoms.
Out of the following, which investigation should be performed next?Your Answer: MRI lumbar spine
Correct Answer: MRI whole spine
Explanation:An MRI whole spine should be performed in a patient suspected of spinal metastasis which can occur before developing metastatic spinal cord compression. This patient has renal cell carcinoma, which readily metastasises to the bones and also has progressive back pain. He, therefore, needs urgent imaging of his spine before any neurological compromise develops. MRI whole spine is preferable because patients with spinal metastasis often have metastases at multiple levels within the spine. Plain radiographs and CT scans should not be performed as they have a lower sensitivity for revealing lesions and cannot exclude cord compression.
In general, imaging should be performed within one week if symptoms suspicious of spinal metastasis without neurological symptoms are present. If there are symptoms suggestive of malignant spinal cord compression, then imaging should be done within 24 hours.
The signs and symptoms of spinal metastases include:
1. Unrelenting lumbar back pain
2. Thoracic or cervical back pain
3. Pain associated with tenderness and worsens with sneezing, coughing, or straining
4. Nocturnal pain -
This question is part of the following fields:
- Haematology & Oncology
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Question 28
Incorrect
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Choose the standard method for comparing distributions in data sets (such as between the expected frequency of an event and the observed frequency of an event) from the list of options.
Your Answer: Linear regression
Correct Answer: Chi squared (X²) test
Explanation:The Chi-squared test evaluates if two variables are related. The other statistical tests mentioned do not perform this function.
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This question is part of the following fields:
- Evidence Based Medicine
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Question 29
Correct
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A 33-year-old lady presented with complaints of an erythematous rash over her shins, along with arthritis and painful swollen knees. What will be the single most likely finding on her chest X-ray?
Your Answer: Bilateral hilar lymphadenopathy
Explanation:Lofgren’s syndrome is characterised by a triad of erythema nodosum, arthritis and bilateral lymphadenopathy. It is a variant of sarcoidosis.
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This question is part of the following fields:
- Respiratory System
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Question 30
Incorrect
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A homeless woman presented with a cough and fever for the last 3 months. She also complained of night sweats and weight loss. Her CXR showed lung opacities. What is the next appropriate step for this patient?
Your Answer: Bronchoscopy
Correct Answer: Acid fast bacilli
Explanation:History and CXR are suggestive of tuberculosis. Acid fast bacilli should be seen on microscopy to confirm the diagnosis.
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This question is part of the following fields:
- Infectious Diseases
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SESSION STATS - PERFORMANCE PER SPECIALTY
