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Question 1
Correct
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A 30-year-old male presented with exercise related syncope and dyspnoea for 2 weeks. His father passed away at the age of 40, due to sudden cardiac death. His ECG showed left ventricular hypertrophy with widespread T wave inversions. Which of the following is the most appropriate next investigation to confirm the diagnosis?
Your Answer: Transthoracic echo
Explanation:The most likely diagnosis is hypertrophic obstructive cardiomyopathy which is suggestive by the history, positive family history and ECG findings. Two-dimensional echocardiography is diagnostic for hypertrophic cardiomyopathy. In general, a summary of echocardiography findings includes abnormal systolic anterior leaflet motion of the mitral valve, LV hypertrophy, left atrial enlargement, small ventricular chamber size, septal hypertrophy with septal-to-free wall ratio greater than 1.4:1, mitral valve prolapse and mitral regurgitation, decreased midaortic flow, and partial systolic closure of the aortic valve in midsystole.
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This question is part of the following fields:
- Cardiovascular System
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Question 2
Incorrect
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A 65-year-old gentleman with a history of chronic renal failure due to diabetes comes to the clinic for review. He has reported increasing bone and muscle aches over the past few weeks.
Medications include ramipril, amlodipine and indapamide for blood pressure control, atorvastatin for lipid management, and insulin for control of his blood sugar. On examination his BP is 148/80 mmHg, his pulse is 79 and regular. His BMI is 28.
Investigations show:
Haemoglobin 10.7 g/dl (13.5-17.7)
White cell count 8.2 x 10(9)/l (4-11)
Platelets 202 x 10(9)/l (150-400)
Serum sodium 140 mmol/l (135-146)
Serum potassium 5.0 mmol/l (3.5-5)
Creatinine 192 μmol/l (79-118)
Calcium 2.18 mmol/l (2.2-2.67)
Phosphate 1.9 mmol/l (0.7-1.5)
He has tried following a low phosphate diet.
Which of the following would be the next most appropriate step in controlling his phosphate levels?Your Answer: Aluminium hydroxide
Correct Answer: Sevelamer
Explanation:Sevelamer is a phosphate-binding drug that can lower raised serum phosphate levels in chronic kidney disease. Because of its aluminium-related side-effects, aluminium hydroxide is no longer the drug of choice.
The other options are calcium-containing salts that may increase risks of tissue calcification. -
This question is part of the following fields:
- Renal System
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Question 3
Correct
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A 57-year-old male presented to the OPD with a complaint of fever, cough and chest pain for 3 days. The right lung base was dull on percussion and the breath sounds were reduced in intensity. Which of the following investigations is most appropriate?
Your Answer: CXR
Explanation:Because of the patient’s acute presentation of symptoms accompanied by lung abnormalities observed on physical examination, the next step is to visualize the suspected acute inflammatory process by ordering a CXR. Bronchoscopy, CT and MRI are done in cases in which there is suspicion of any tumour formation. V/Q scan is done in cases where pulmonary embolism is suspected.
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This question is part of the following fields:
- Respiratory System
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Question 4
Incorrect
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A 45-year-old male presents with lower backache and pain in his hips. Blood tests are normal except for elevated serum alkaline phosphatase which is 1200 IU/l (45-105). Radiological examination shows combined osteolytic and osteosclerotic lesions. What is the most common site of occurrence of this disease?
Your Answer: Lumbar spine
Correct Answer: Pelvis
Explanation:The patient most likely suffers from Paget’s disease of the bone as his radiological examination shows both osteolytic and osteosclerotic lesions. Any bone or bones can be affected, but Paget’s disease occurs most frequently in the pelvis > lumbar spine > femur > thoracic spine > sacrum > skull > tibia.
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This question is part of the following fields:
- Musculoskeletal System
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Question 5
Correct
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A 40-year-old man presents with recurrent headaches, 2-3 times a day, associated with sweating and palpitations.
His blood pressure during the attacks is around 220/120 mmHg.
Given the likely diagnosis, what is the next appropriate investigation?Your Answer: 24 hour urinary collection of metanephrines
Explanation:Classically, pheochromocytoma manifests with the following 4 characteristics:
– Headaches
– Palpitations
– Sweating
– Severe hypertensionThe Endocrine Society, the American Association for Clinical Chemistry, and the European Society of Endocrinology have released clinical practice guidelines for the diagnosis and management of pheochromocytoma.
Biochemical testing via measurement of plasma free metanephrines or urinary fractionated metanephrines should be performed in patients suspected of having pheochromocytoma.Catecholamines produced by pheochromocytomas are metabolized within chromaffin cells. Norepinephrine is metabolized to normetanephrine and epinephrine is metabolized to metanephrine. Because this process occurs within the tumour, independently of catecholamine release, pheochromocytomas are best diagnosed by measurement of these metabolites rather than by measurement of the parent catecholamines.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 6
Incorrect
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A patient who is on morphine therapy for terminal cancer presents with complaints of rattling breath sounds. Which of the following should be administered to him?
Your Answer: Naloxone
Correct Answer: Anti-Muscarinic
Explanation:Respiratory depression is the most well-known and dangerous side-effect of opioid analgesics. The prevalence of such side effects is influenced by the extent of disease, the patient’s age, the presence of coexistent renal and hepatic disease, pulmonary disease, and cognitive dysfunction, a prior opioid history, use of polypharmacy, dose of opioid drug being administered, and the route of administration. Anticholinergics are usually given for the respiratory symptoms.
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This question is part of the following fields:
- Pharmacology
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Question 7
Incorrect
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A patient develops methemoglobinemia after being prescribed isosorbide mononitrate. Which enzyme is most likely to be deficient?
Your Answer: Glucose-6-phosphate dehydrogenase
Correct Answer: NADH methaemoglobin reductase
Explanation:Methemoglobinemia is a rare condition in which the haemoglobin iron is in oxidized or ferric state (Fe3+) and cannot reversibly bind oxygen. Normally, the conversion of ferrous form of iron (Fe2+) to its ferric form (Fe3+) is regulated by NADH methaemoglobin reductase, which results in the reduction of methaemoglobin to haemoglobin. Disruption in the enzyme leads to increased methaemoglobin in the blood. There is tissue hypoxia as Fe3+ cannot bind oxygen, and hence the oxygen-haemoglobin dissociation curve is shifted to the left.
Methemoglobinemia can occur due to congenital or acquired causes. Congenital causes include haemoglobin variants such as HbM and HbH, and deficiency of NADH methaemoglobin reductase. Acquired causes are drugs (e.g. sulphonamides, nitrates, dapsone, sodium nitroprusside, and primaquine) and chemicals (such as aniline dyes).
The features of methemoglobinemia are cyanosis, dyspnoea, anxiety, headache, severe acidosis, arrhythmias, seizures, and loss of consciousness. Patients have normal pO2 but oxygen saturation is decreased. Moreover, presence of chocolate-brown coloured arterial blood (colour does not change with addition of O2) and brown urine also point towards the diagnosis of methemoglobinemia.
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This question is part of the following fields:
- Haematology & Oncology
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Question 8
Incorrect
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Which of the following is most consistent with congenital adrenal hyperplasia (CAH)?
Your Answer: Delayed puberty
Correct Answer: Premature epiphyseal closure
Explanation:Exposure to excessive androgens is usually accompanied by premature epiphyseal maturation and closure, resulting in a final adult height that is typically significantly below that expected from parental heights.
congenital adrenal hyperplasia (CAH) is associated with precocious puberty caused by long term exposure to androgens, which activate the hypothalamic-pituitary-gonadal axis. Similarly, CAH is associated with hyperpigmentation and hyperreninemia due to sodium loss and hypovolaemia.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 9
Correct
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A 50-year-old male patient presented with acute chest pain and a non ST elevation myocardial infarction (NSTEMI) was diagnosed. He was treated with aspirin 300 mg and 2 puffs of Glyceryl trinitrate (GTN) spray. According to NICE guidelines, which of the following categories of patients should receive clopidogrel?
Your Answer: All patients
Explanation:According to NICE guidelines (2013) all people who have had an acute MI treatment should be offered with ACE inhibitor, dual antiplatelet therapy (aspirin plus a second antiplatelet agent), a beta-blocker and a statin.
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This question is part of the following fields:
- Cardiovascular System
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Question 10
Incorrect
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An 18-year-old prospective medical student is tested for hepatitis B. Her liver tests show alanine transaminase (ALT) 120 U/L and serology shows her to be positive for HBsAg, HBcAb and HBeAg, with a viral load of 105 genome equivalents/mL.
A liver biopsy is reported as showing early fibrosis with evidence of moderate inflammation.
Which of the following treatments should be offered?Your Answer: Entecavir
Correct Answer: Interferon alfa 2b
Explanation:Interferon alfa alone, not interferon alfa and ribavirin, has been shown to achieve HBeAg seroconversion for patients with HBeAg-positive chronic hepatitis B.
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This question is part of the following fields:
- Infectious Diseases
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Question 11
Correct
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Following a head injury, a 22-year-old patient develops polyuria and polydipsia. He is suspected to have cranial diabetes insipidus so he undergoes a water deprivation test.
Which one of the following responses would most indicate a positive (abnormal) result?Your Answer: Failure to concentrate the urine during water deprivation, but achievement of urine osmolality of 720 mmol/kg following the administration of desmopressin
Explanation:The water deprivation test (i.e., the Miller-Moses test), is a semiquantitative test to ensure adequate dehydration and maximal stimulation of ADH for diagnosis. It is typically performed in patients with more chronic forms of Diabetes Insipidus (DI). The extent of deprivation is usually limited by the patient’s thirst or by any significant drop in blood pressure or related clinical manifestation of dehydration.
In healthy individuals, water deprivation leads to a urinary osmolality that is 2-4 times greater than plasma osmolality. Additionally, in normal, healthy subjects, administration of ADH produces an increase of less than 9% in urinary osmolality. The time required to achieve maximal urinary concentration ranges from 4-18 hours.
In central and nephrogenic DI, urinary osmolality will be less than 300 mOsm/kg after water deprivation. After the administration of ADH, the osmolality will rise to more than 750 mOsm/kg in central DI but will not rise at all in nephrogenic DI. In primary polydipsia, urinary osmolality will be above 750 mOsm/kg after water deprivation.
A urinary osmolality that is 300-750 mOsm/kg after water deprivation and remains below 750 mOsm/kg after administration of ADH may be seen in partial central DI, partial nephrogenic DI, and primary polydipsia. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 12
Incorrect
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An soccer player suddenly collapsed on the field and started coughing along with shortness of breath. The investigation of choice in this case would be?
Your Answer: CT pulmonary angiogram (CTPA)
Correct Answer: Chest x-ray
Explanation:Exercise induced asthma is characterised by sudden onset wheezing, cough and shortness of breath while performing hectic physical activity. The best investigation to perform is a chest X-ray.
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This question is part of the following fields:
- Respiratory System
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Question 13
Correct
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A 70-year-old male presented in the emergency department with urosepsis. Gentamicin (7 mg/kg once daily) was administered to treat the infection. One day after administration, his gentamicin levels were more than 2 mg/L. Which of the following side effects is most likely to occur in such a case?
Your Answer: Nephrotoxicity
Explanation:Gentamicin is a nephrotoxic agent. Its dose should be monitored carefully in elderly or renal patients. If gentamicin starts accumulating in the body (above 2mg/L) then the next dose of gentamicin should be stopped. Otherwise it may cause acute tubular necrosis of the kidneys. Hepatotoxicity, retinopathy, peripheral neuropathy and encephalopathy are not usually associated with gentamicin toxicity.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 14
Incorrect
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Which of the following is most likely linked to male infertility in cystic fibrosis?
Your Answer: Decreased spermatogenesis
Correct Answer: Failure of development of the vas deferens
Explanation:The vas deferens is a long tube that connects the epididymis to the ejaculatory ducts. It acts as a canal through which mature sperm may pass through the penis during ejaculation.
Most men with CF (97-98 percent) are infertile because of a blockage or absence of the vas deferens, known as congenital bilateral absence of the vas deferens (CBAVD). The sperm never makes it into the semen, making it impossible for them to reach and fertilize an egg through intercourse. The absence of sperm in the semen can also contribute to men with CF having thinner ejaculate and lower semen volume.
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This question is part of the following fields:
- Respiratory System
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Question 15
Correct
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A 24-year-old male was involved in a traffic collision. X-rays indicated that the neck of the humerus had suffered a fracture. Choose the single most associated nerve injury from the list of options.
Your Answer: Axillary nerve
Explanation:Fractures in the neck of the humerus are well documented to cause damage to the auxiliary nerve.
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This question is part of the following fields:
- Nervous System
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Question 16
Incorrect
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A study is done on 1000 patients to assess the specificity of a new rapid finger-prick blood test developed to help diagnose deep vein thrombosis (DVT). The new test was positive on 200 patients with DVT and on 100 patients without DVT. It was also negative on 20 patients with DVT and 680 without DVT. What is the specificity of the new test?
Your Answer: 680/700
Correct Answer: 680/780
Explanation: -
This question is part of the following fields:
- Evidence Based Medicine
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Question 17
Correct
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Question 18
Incorrect
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A 67 year-old attorney presents with a 2 month history of tremors affecting his left arm. He suffers from depressive psychosis for the last 10 years, for which he has been receiving intermittent chlorpromazine and amitriptyline but has not been on any therapy for the last 4 months. He describes that his two brothers also had tremors. Upon examination, he has a resting tremor of his left hand with cogwheel rigidity of that arm and mild generalized bradykinesia. Which of the following is the most likely diagnosis?
Your Answer: Drug-induced parkinsonism
Correct Answer: Idiopathic Parkinson's disease
Explanation:The most likely diagnosis is idiopathic Parkinson’s disease because of the unilateral presentation. In addition, cogwheel rigidity is a classic presenting symptom. Neuroleptic-induced parkinsonism is usually bilateral and symmetrical. Essential tremors do not cause rest tremors.
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This question is part of the following fields:
- Nervous System
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Question 19
Correct
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A 40-year-old female presented with pain and whitening of the hands on exposure to cold. She has difficulty in swallowing solid foods so she has started swallowing only liquids. She developed shortness of breath on exertion and, subsequently, at rest. Which of the following is the most likely cause for dysphagia in this patient?
Your Answer: Systemic sclerosis
Explanation:Difficulty in swallowing which improves with liquids is mainly due to an obstructive lesion in oesophagus. But pulmonary involvement (breathlessness on exertion and later on rest) and Raynaud’s phenomena can only be described by systemic sclerosis.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 20
Incorrect
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A 50-year-old man is found incidentally to have hypercalcaemia during a routine health screen.
Which one of the following biochemical findings would be most suggestive of primary hyperparathyroidism rather than any other cause of hypercalcaemia?Your Answer: Elevated serum alkaline phosphatase activity
Correct Answer: Serum PTH concentration within the normal range
Explanation:Primary hyperparathyroidism (PHPT) is diagnosed based upon levels of blood calcium and parathyroid hormone (PTH). In most people with PHPT, both levels are higher than normal. Occasionally, a person may have an elevated calcium level and a normal or minimally elevated PTH level. Since PTH should normally be low when calcium is elevated, a minimally elevated PTH is considered abnormal and indicates PHPT.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 21
Correct
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A 52-year-old man is referred to the oncology clinic by his GP. He recently suffered a fracture of his right humerus with minimal trauma.
The results of the blood tests, taken on his arrival, prompted the referral:
Hb: 8.9 g/dL
WCC: 9.5 x 10^9/L
Plts: 140 x 10^9/L
MCV: 86 fL
ESR: 60mm/1st hour
Na+: 149 mmol/L
K+: 3.6 mmol/L
Urea: 15 mmol/L
Creatinine: 160 mmol/L
Calcium (corrected): 2.89 mmol/l
Albumin: 28g/L
Total protein: 89 g/L
X-ray of right humerus reported a possible pathological fracture. Which of the following investigations would help best in confirming the most likely diagnosis?Your Answer: Protein electrophoresis
Explanation:The most likely diagnosis with anaemia, raised erythrocyte sedimentation rate (ESR), hypercalcaemia, renal impairment, and raised total protein with low albumin is multiple myeloma (MM). Protein electrophoresis will confirm the presence of monoclonal band of paraprotein. Of note, a radioisotope bone scan is not a good test for picking up the lytic lesions of MM.
Diagnosis of MM is based on the confirmation of (a) one major criterion and one minor criterion or (b) three minor criteria in an individual who has signs or symptoms of multiple myeloma.
Major criteria:
1. >30% plasma cells on bone marrow biopsy
2. Monoclonal band of paraprotein on electrophoresis: >35g/L for IgG, 20g/L for IgA, or >1g of light chains excreted in the urine per dayMinor criteria:
1. 10-30% plasma cells on bone marrow biopsy
2. Abnormal monoclonal band but levels less than listed above
3. Lytic bone lesions observed radiographically
4. Immunosuppression -
This question is part of the following fields:
- Haematology & Oncology
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Question 22
Correct
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A team of physicians presented their audit of fluid management for dengue haemorrhagic fever one year ago. A number of recommendations were made at that time and changes were implemented. Which of the following is the most appropriate next step that this team should take?
Your Answer: Re-audit
Explanation:Clinical audit is defined as a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. To see whether the recommendations have been implemented, a re-audit has to be performed.
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This question is part of the following fields:
- Ethical & Legal
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Question 23
Correct
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A 58-year-old lady was admitted to hospital with increasing thirst and generalised abdominal pain. She was diagnosed with breast carcinoma three years previously and treated with a radical mastectomy.
Investigations showed:
Serum corrected calcium 3.5 mmol/L (NR 2.2-2.6)
Serum alkaline phosphatase 1100 IU/L
Her serum calcium was still elevated following 4 litres of 0.9% saline intravenous infusion.
Which of the following is the most appropriate next step?Your Answer: Pamidronate 60 mg intravenously
Explanation:This case has hypercalcaemia most likely associated with the bony metastases from her pre-existing breast carcinoma. The most appropriate next step is to give Pamidronate 60mg intravenously, a bisphosphonate, to immediately inhibit bone resorption and formation.
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This question is part of the following fields:
- Renal System
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Question 24
Correct
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The phonocardiogram of a 40-year-old male patient showed a normal S1 but an abnormal S2. S2 was fixed and widely split. Out of the following, which condition do you think this patient most likely suffering from?
Your Answer: Secundum atrial septal defect
Explanation:The second heart sound (S2) corresponds to the closing of the semilunar valves, first the aortic and then the pulmonary valve. The gap between the closure of these two valves is normally insignificant and is heard as a single heart sound. In certain pathological conditions, this gap increases when there is a delay in right ventricular emptying, but in cases other than an atrial septal defect, the sound is not fixed. In an atrial septal defect, the right ventricle continuously receives blood, causing a delay and a fixed and split S2.
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This question is part of the following fields:
- Cardiovascular System
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Question 25
Correct
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A 38-year-old woman with a history of multiple joint pain and red painful skin lesions complained of a chronic non-productive cough. CXR shows symmetric hilar and mediastinal lymphadenopathy. What is the most probable diagnosis?
Your Answer: Sarcoidosis
Explanation:Sarcoidosis is a chronic inflammatory condition that can affect any organ but mainly affects the lungs and lymph nodes. Cough can be due to any of the given conditions. Polyarthritis, erythema nodosum (erythematous painful subcutaneous nodules) and symmetric hilar and mediastinal lymphadenopathy are classical signs of sarcoidosis. This triad is known as Lofgren syndrome.
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This question is part of the following fields:
- Respiratory System
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Question 26
Correct
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A patient presents with occasionally severe retrosternal chest pain and dysphagia for both solids and liquids. What would be the best management option if the barium swallow showed a dilated oesophagus which tapers to a fine distal end?
Your Answer: Dilatation of the LES
Explanation:Dysphagia for both solids and liquids indicates either obstruction or impaired oesophageal peristalsis which is usually due to neuromuscular causes such as achalasia. Achalasia is the failure of smooth muscle fibres to relax, which can cause the lower oesophageal sphincter to remain closed. The lower part of the oesophagus is more narrow than normal and presents as a birds beak appearance on barium swallow. If dysphagia was present only on solid food consumption, a benign or malignant tumour must be suspected.
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This question is part of the following fields:
- Gastrointestinal System
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Question 27
Correct
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Question 28
Correct
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A 25-year-old man presents with bloody diarrhoea associated with systemic upset. Blood tests show the following:
Hb 13.4 g/dl
Platelets 467 * 109/l
WBC 8.2 * 109/l
CRP 89 mg/l
A diagnosis of ulcerative colitis is suspected. Which part of the bowel is most likely to be affected?Your Answer: Rectum
Explanation:The most COMMON site of inflammation from ulcerative colitis is the rectum, making this the correct answer. This is simply a fact you need to memorize. In general, ulcerative colitis only occurs in colorectal regions– nothing in the small bowel (unless there is backwash into the terminal ileum) and nothing further up the GI tract. In Crohn’s it can affect the entire GI tract from mouth to anus.
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This question is part of the following fields:
- Gastrointestinal System
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Question 29
Incorrect
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A 35-year-old male was brought to you in a confused state. Although not your patient, you can make out that the man has a history of schizophrenia, and has recently had his medications altered. Clinically, you find evidence of a lower respiratory tract infection, and blood investigations indicate a neutropenic picture.
What is the most likely drug causing the neutropenia?Your Answer: Olanzapine
Correct Answer: Clozapine
Explanation:Clozapine can cause neutropenia or agranulocytosis.
Clozapine is an atypical antipsychotic used in the treatment of schizophrenia, and in patients who are intolerant to, or unresponsive to other antipsychotics.
It is a weak D2-receptor and D1-receptor blocking activity, with noradrenolytic, anticholinergic, and antihistaminic properties.
Many antipsychotic drugs can occasionally cause bone marrow depression, but agranulocytosis is particularly associated with clozapine.
Other side effects include:
Hypotension, tachycardia
Fever, sedation, seizures (with high doses)
Appetite increase
Constipation
Heartburn
Weight gain
Extrapyramidal symptoms
Agranulocytosis
Neuroleptic malignant syndrome -
This question is part of the following fields:
- Pharmacology
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Question 30
Incorrect
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A 52-year-old woman with polycystic kidney disease and a slowly rising creatinine, which was 320 μmol/L at her last clinic visit 3 weeks ago, is brought into the Emergency Department having been found collapsed at home by her partner. She is now fully conscious but complains of a headache.
What is the most likely diagnosis?Your Answer: Pulmonary embolism
Correct Answer: Subarachnoid haemorrhage
Explanation:One of the most important complications in patients with PKD is being affected by berry aneurysms that may burst, causing a subarachnoid haemorrhage, which seems to be the case in this patient.
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This question is part of the following fields:
- Renal System
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SESSION STATS - PERFORMANCE PER SPECIALTY
