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Question 1
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An 80-year-old male has been receiving treatment for prostate cancer. He has complained of pain in his pelvis and, following radiological investigations, is shown to have pelvic metastases. Choose the most appropriate course of investigation for this patient.
Your Answer: Palliative radiotherapy
Explanation:The patient could respond well to palliative radiotherapy. This course of action is likely to shrink the cancer and will, therefore, reduce the pain felt. Analgesics should then be used to control the symptoms.
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This question is part of the following fields:
- Haematology & Oncology
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Question 2
Correct
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An 18-year-old woman has been diagnosed with human papillomavirus infection. What is the most significant long-term risk following this infection?
Your Answer: Cervical cancer
Explanation:Human-papilloma virus (HPV) can lead to cervical cancer. There are many different types, but the types associated with cervical cancer most commonly are 16, 18, 31, 33, and 35. The vaccination against HPV protects against the most common types of HPV that are seen in cervical cancer and is recommended for children/young teens. Cervical cancer has a clear association with HPV, making this the best answer over all of the other answer choices.
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This question is part of the following fields:
- Infectious Diseases
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Question 3
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A 12-year-old boy has a history of fever for one week (39C), with no other symptoms leading up to the fever. He recently had a surgical extraction of one of his incisors two weeks before consultation. On examination of CVS, a mid-systolic click followed by a late systolic murmur is heard. Which of the following is the most probable diagnosis?
Your Answer: Infection
Explanation:Tooth extraction or any surgical procedure may introduce bacteria into the blood stream. The most commonly involved organisms include Staphylococcus aureus and Streptococcus viridans. Once in the blood, these organisms have a very high tendency of attaching to the walls of the heart and causing inflammation known as endocarditis.
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This question is part of the following fields:
- Cardiovascular System
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Question 4
Incorrect
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A 59-year-old woman has an 11mm skin lesion on her right forearm, which bleeds easily on contact and has changed in appearance over the last 11 months.
Your Answer: Squamous cell carcinoma
Correct Answer: Malignant melanoma
Explanation:Melanoma is more common in men than women. Reasons for the disease includes: UV light and genetic predisposition or mutations. Diagnosis is by biopsy and analysis of any skin lesion that has signs of being potentially cancerous.
Early warning signs of melanoma ABCDE:
Asymmetry
Borders (irregular with edges and corners)
Colour (variegated)
Diameter (greater than 6 mm)
Evolving over time -
This question is part of the following fields:
- The Skin
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Question 5
Correct
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Regarding neonatal meningitis, which of the following statements is true?
Your Answer: Has an above average incidence in babies with a meningomyelocele
Explanation:The commonest time for bacterial meningitis is in the 1st month of life and group B Streptococcus is the commonest organism. The anterior fontanelle is full, but does not bulge with normal flexion. Neurological manifestations include seizures, irritability, poor tone, lethargy and tremors, however no findings of sensorineural deafness have been noted. One of the risk factors for introduction of meningeal infection is Meningomyelocele.
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This question is part of the following fields:
- Infectious Diseases
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Question 6
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 7
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 8
Correct
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An 8-year-old boy is admitted to the ward with renal colic. Family history is significant for similar renal calculi in his mother. Which of the following is the most likely explanation for this recurrent colic in both mother and child?
Your Answer: Idiopathic hypercalciuria
Explanation:Idiopathic hypercalciuria (IH) is the commonest metabolic abnormality in patients with calcium kidney stones. It is characterized by normocalcemia, absence of diseases that cause increased urine calcium, and calcium excretion that is above 250 mg/day in women and 300 mg/day in men. Subjects with IH have a generalized increase in calcium turnover, which includes increased gut calcium absorption, decreased renal calcium reabsorption, and a tendency to lose calcium from bone. Despite the increase in intestinal calcium absorption, negative calcium balance is commonly seen in balance studies, especially on a low calcium diet. The mediator of decreased renal calcium reabsorption is not clear; it is not associated with either an increase in filtered load of calcium or altered PTH levels. There is an increased incidence of hypercalciuria in first-degree relatives of those with IH, but IH appears to be a complex polygenic trait with a large contribution from diet to expression of increased calcium excretion. Increased tissue vitamin D response may be responsible for the manifestations of IH in at least some patients.
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This question is part of the following fields:
- Renal System
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Question 9
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 10
Correct
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A girl suffered full thickness circumferential burn to her right arm. What is best step in management?
Your Answer: Escharotomy
Explanation:An escharotomy is a surgical procedure used to treat full-thickness (third-degree) circumferential burns. In full-thickness burns, both the epidermis and the dermis are destroyed along with sensory nerves in the dermis. The tough leathery tissue remaining after a full-thickness burn has been termed eschar.
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This question is part of the following fields:
- The Skin
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Question 11
Correct
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When considering the anatomical location of intracranial meningiomas, which of the following relations is well recognised?
Your Answer: Parasagittal - spastic paraparesis
Explanation:The localisation of intracranial lesions (based on both history and examination) is crucial. Meningiomas are slow in growth, and its subtle effects are very different from the more aggressive, intrinsic lesions. Olfactory groove lesions affect the sense of smell and may produce ipsilateral optic atrophy. Sphenoid ridge lesions will produce exophthalmos. Chiasmal lesions usually produce bitemporal hemianopia.
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This question is part of the following fields:
- Nervous System
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Question 12
Incorrect
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A 55-year-old diabetic male presents with a feeling of generally being unwell. He also has a history of atrial fibrillation and epilepsy. His main complaint is a blue tinge to his vision. Which one of his medications is most likely to be responsible?
Your Answer: Phenytoin
Correct Answer: Sildenafil
Explanation:Blue tinge of vision/cyanopsia is caused due to the intake of sildenafil citrate.
Sildenafil citrate (Viagra) is the first oral drug to be widely approved for the treatment of erectile dysfunction.
It is a potent and selective inhibitor of type-V phosphodiesterase, the primary form of the enzyme found in human penile erectile tissue, thereby preventing the breakdown of cyclic guanosine monophosphate (cGMP), the intracellular second messenger of nitric oxide.Uses:
It is used for the treatment of erectile dysfunction, idiopathic pulmonary hypertension, premature ejaculation, high altitude illness, penile rehabilitation after radical prostatectomy, angina pectoris, and lower urinary tract symptoms.Adverse effects:
Mild headache, flushing, dyspepsia, cyanopsia, back pain, and myalgias – due to a high concentration of PDE11 enzyme in skeletal muscle, which shows significant cross-reactivity with the use of tadalafil.
It can also cause hypotension, dizziness, and rhinitis.Note: Xanthopsia (yellow-green vision) may occur secondary to treatment with digoxin.
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This question is part of the following fields:
- Pharmacology
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Question 13
Incorrect
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A 40-year-old female is receiving a course of chemotherapy for breast cancer. She is, however, experiencing troublesome vomiting which is not responding to domperidone.
Which of the following is the most appropriate next step of management?Your Answer: Add a 5-HT2 antagonist
Correct Answer: Add a 5-HT3 antagonist
Explanation:Nausea and vomiting are the common side effects of chemotherapy. Risk factors for the development of these symptoms include age<50 years, anxiety, concurrent use of opioids, and the type of chemotherapy administered. For patients at low risk of these symptoms, drugs such as metoclopramide may be used. For high-risk patients, however, 5-HT3 receptor antagonists such as ondansetron are often effective, especially if combined with dexamethasone.
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This question is part of the following fields:
- Haematology & Oncology
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Question 14
Correct
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A paediatrician has concerns that a 6-month-old baby is deaf. His mom gives history of her having a sore throat, fever and lymphadenitis during pregnancy. Which organism causes such manifestations?
Your Answer: Cytomegalovirus (CMV)
Explanation:The best answer is cytomegalovirus. The mother was infected during the pregnancy and the baby has developed cytomegalo-inclusion syndrome. Histologically, it is identified by viral particles surrounded by lysosomes.
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This question is part of the following fields:
- Infectious Diseases
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Question 15
Correct
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Which of the following options is true of patients with oesophageal varices?
Your Answer: In spontaneous bacterial peritonitis cefotaxime appears to be a useful antibiotic
Explanation:Spironolactone has been shown to have no effect on the mechanisms of portal hypertension. Also, chronic use of propranolol can reduce the risk of variceal bleeding. The banding of large varices has been shown to be effective, too. Octreotide and terlipressin are also both used to prevent secondary haemorrhage. Cefotaxime is the most commonly used cephalosporin when treating spontaneous bacterial peritonitis. Spironolactone helps to combat secondary hyperaldosteronism which is related to liver failure. It also helps to treat salt and water retention, which both contribute to portal hypertension.
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This question is part of the following fields:
- Gastrointestinal System
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Question 16
Incorrect
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Which of the following is consistent with a diagnosis of insulinoma?
Your Answer: Low fasting glucose, high insulin, low C peptide
Correct Answer: Low fasting glucose, high insulin, high C peptide
Explanation:Insulinoma is associated with LOW fasting glucose, HIGH insulin level, and HIGH C peptide. Insulin-abuse or overdose will cause HGH insulin levels and a LOW C peptide. If the C peptide is low, be suspicious.
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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 42-year-old man is a known case of Waldenström's macroglobulinemia and is admitted to the hospital with headache, visual disturbances, pale conjunctivae, and breathlessness. While in the assessment unit, he has had an episode of nosebleed that has been difficult to control. On examination, his heart rate is 120 bpm, blood pressure is 115/65 mmHg, and he is febrile with a temperature of 37°C. Fundoscopy shows dilated retinal veins with a retinal haemorrhage in the right eye.
What is the most appropriate next step of management?Your Answer: Plasmapheresis
Explanation:The patient is displaying signs and symptoms of hyperviscosity syndrome, secondary to the Waldenström’s macroglobulinemia. Treatment of choice is plasmapheresis.
Waldenström’s macroglobulinemia (also called lymphoplasmacytic lymphoma) is an uncommon type of non-Hodgkin lymphoma seen in older people. It is a lymphoplasmacytoid malignancy characterised by the secretion of a monoclonal IgM paraprotein. Its features include monoclonal IgM paraproteinemia; hyperviscosity syndrome leading to bilateral central retinal vein occlusion (CRVO) and hence, visual disturbances; weight loss and lethargy; hepatosplenomegaly and lymphadenopathy; and cryoglobulinemia. It is not, however, associated with bone pain.
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This question is part of the following fields:
- Haematology & Oncology
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Question 18
Correct
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A 35-year-old female has been recently diagnosed with hypertension. She's sexually active and is not using any birth control other than barrier method. Which among the following antihypertensives is contraindicated in this patient?
Your Answer: Lisinopril
Explanation:Among the following hypertensives, lisinopril (an ACE inhibitor) is contraindicated in patients who are planning for pregnancy.
Per the NICE guidelines, when treating the woman in question, she should be treated as if she were pregnant given the absence of effective contraception.
ACE inhibitors such as lisinopril are known teratogens and most be avoided.Drugs contraindicated in pregnancy:
Antibiotics
Tetracyclines
Aminoglycosides
Sulphonamides and trimethoprim
QuinolonesOther drugs:
ACE inhibitors, angiotensin II receptor antagonists
Statins
Warfarin
Sulfonylureas
Retinoids (including topical)
Cytotoxic agents
The majority of antiepileptics including valproate, carbamazepine, and phenytoin are known to be potentially harmful. -
This question is part of the following fields:
- Pharmacology
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Question 19
Correct
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A 19-year-old patient in casualty only opens her eyes upon painful stimuli, extends her limbs, and occasionally says inappropriate words. What is her Glasgow coma score?
Your Answer: 7
Explanation:The Glasgow Coma Scale provides a score for assessment of impaired consciousness in response to specific stimuli considering the eye opening, verbal response and motor response. The score runs from 3 to 15, a coma being defined as a GCS of 8 or less. According to this patient’s responses and the respective points for each response, the score is 7 and the patient is in a coma.
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This question is part of the following fields:
- Nervous System
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Question 20
Incorrect
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A 39-year-old female had surgery for the removal of thyroid carcinoma. One week later, she presented in the OPD with complaints of numbness, tingling, involuntary spasm of the upper extremities, paraesthesia and respiratory stridor. Which of the following is the most likely cause?
Your Answer: Hyperparathyroidism
Correct Answer: Hypocalcaemia
Explanation:Hypocalcaemia presents with such symptoms. It probably happened due to accidental removal of a parathyroid gland during the thyroid surgery. Hypocalcaemia causes laryngospasm which produces stridor.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 21
Incorrect
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A COPD patient presented with shortness of breath, a cough and wheezing. He didn't respond to salbutamol, IV hydrocortisone or oxygen therapy. Following this initial treatment, he was given IV aminophylline and atem+ventolin nebulization. ABGs showed an acidotic pH. The next step in management would be?
Your Answer: Intubation and ventilation
Correct Answer: Nasal intermittent positive pressure ventilation
Explanation:Nasal IPPV is given to the patients when all other techniques have failed. It is a non invasive procedure to improve the oxygenation of the patients suffering from lung disease.
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This question is part of the following fields:
- Respiratory System
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Question 22
Correct
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A 11-year-old boy is admitted to the hospital with diarrhoea and lethargy. There is a known local outbreak of E coli 0157:H7, and his initial bloods show evidence of acute renal failure. Given the likely diagnosis, which one of the following investigation results would be expected?
Your Answer: Fragmented red blood cells
Explanation:The likely diagnosis in this case is Haemolytic Uremic Syndrome (HUS), which is generally seen in young children presenting with a triad of symptoms, namely: acute renal failure, microangiopathic haemolytic anaemia, and thrombocytopenia. The typical cause of HUS is ingestion of a strain of Escherichia coli. The laboratory results will usually include fragmented RBCs, decreased serum haptoglobin, reduced platelet count, nonspecific WBC changes, and normal coagulation tests (PTT included).
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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 27-year-old lady presents with severe morning headaches associated with nausea. Head MRI reveals a large compressive tumour arising from the falx cerebri. The tumour is well delineated. What is the most probable diagnosis?
Your Answer: Meningioma
Explanation:Meningiomas are the most common benign tumours of the brain. Their name is derived from the fact that they arise from the dura mater which together with the pia matter and arachnoid mater form the meninges. The chances that a meningioma is benign are almost 98%. They are non-invasive and well delineated, causing sign and symptoms of brain compression.
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This question is part of the following fields:
- Nervous System
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Question 24
Correct
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A 70-year-old male patient presented with chronic congestive heart failure. Which of the following is the most important factor to consider when prescribing drugs for this patient?
Your Answer: Administration of a B-blocker reduces the time spent in hospital
Explanation:It is proven that spironolactone has survival benefits and loop diuretics only give symptomatic relief. Beta blockers are however, known to improve exercise tolerance, left ventricular function and reduce symptoms. They also reduce the mortality associated with heart failure. So administration of beta blockers will reduce the time spent in hospital by improving symptoms.
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This question is part of the following fields:
- Cardiovascular System
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Question 25
Incorrect
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An 81-year-old male patient was admitted after an ischaemic stroke. Physical examination reveals left hemiparesis. How would you classify this hemiparesis based on the WHO International Classification of Functioning, Disability and Health?
Your Answer: Activity limitation
Correct Answer: Impairment of body function
Explanation:Symptoms and signs are classified as ‘impairment of body function’.
The types of impairment classified as ‘activity limitation’ include difficulties that a patient may have in executing certain activities.
The type of impairment classified as ‘participation restriction’ are problems a patient may have in social roles.
The type of impairment classified as ‘pathology’ would be the diagnosis/disease.
Right total anterior circulation infarct relates to the Oxford Bamford classification for stroke. -
This question is part of the following fields:
- Geriatric Medicine
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Question 26
Correct
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A 70-year-old male tells doctors he has been exposed to asbestos 20 years ago and has attempted to quit smoking. He has lost a lot of weight and his voice is very hoarse. Choose the most likely cancer diagnosis in this patient.
Your Answer: Bronchial Carcinoma
Explanation:A hoarse voice, exposure to asbestos, and smoking are all consistent with bronchial carcinoma in this patient.
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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-male patient was started on warfarin for chronic atrial fibrillation (AF). Which of the following clotting factors is not affected by warfarin?
Your Answer: Factor X
Correct Answer: Factor XII
Explanation:Carboxylation of factor II, VII, IX, X and protein C is affected by warfarin. Factor XII is not affected.
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This question is part of the following fields:
- Cardiovascular System
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Question 28
Incorrect
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A 24-year-old woman presents as an emergency to her GP with acute vomiting which began some 3-4 hours after attending an afternoon meeting. Cream cakes were served during the coffee break.
Which of the following organisms is the most likely cause of this acute attack of vomiting?Your Answer: Yersinia enterocolitica
Correct Answer: Staphylococcus aureus
Explanation:Staph. aureus is the most likely cause. It is found in foods like dairy products, cold meats, or mayonnaise. It produces a heat-stable ENDOTOXIN (remember this) that causes nausea, vomiting, and diarrhoea 1-6 hours after ingestion of contaminated food. B. cereus is classically associated with fried rice being reheated. Salmonella is typical with raw eggs and undercooked poultry. Campylobacter which is most commonly associated with food poisoning, is seen with poultry 50% of the time. Yersinia enterocolitica is seen with raw or undercooked pork, and may be a case presenting with mesenteric adenitis.
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This question is part of the following fields:
- Gastrointestinal System
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Question 29
Correct
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A 20-year-old woman who is sexually active is having deep dyspareunia and vaginal discharge. She has a negative smear for Gonococcus. Which of the following is the most likely diagnosis?
Your Answer: Chlamydial trachomatis
Explanation:This case is highly suggested of PID or Pelvic Inflammatory disease with chlamydia as the more common infective agent. Tetracyclines are used for treatment.
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This question is part of the following fields:
- Infectious Diseases
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Question 30
Incorrect
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A 23-year-old woman presents to the A&E with a 24-hour-history of gradual-onset fever, light sensitivity and headache. Clinical examination reveals neck stiffness and an area of rash which does not disappear upon pressure on her right shin. Anamnesis reveals a history of 3 episodes of meningococcal meningitis in the past and she was started on ceftriaxone for another suspected meningitis. However, you suspect that the patients might be immunodeficient. Which immunodeficiency does she most probably have?
Your Answer: C1q, C1rs, C2, C4 deficiency
Correct Answer: C5-9 deficiency
Explanation:Pneumococcal meningitis is the most common and severe form of bacterial meningitis. Fatality rates are substantial, and long-term sequelae develop in about half of survivors. Disease outcome has been related to the severity of the proinflammatory response in the subarachnoid space. The complement system, which mediates key inflammatory processes, has been implicated as a modulator of pneumococcal meningitis disease severity in animal studies. C5 fragment levels in cerebrospinal fluid (CSF) of patients with bacterial meningitis correlated with several clinical indicators of poor prognosis. The common terminal pathway consists of complement components C5-C9, and activation forms the anaphylatoxin C5a, a strong proinflammatory mediator, and the membrane attack complex (MAC), which creates pores in the bacterial cell wall (12). Deficiencies in these late complement components have been recognized as a cause of recurrent and familial meningococcal infections.
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This question is part of the following fields:
- Emergency & Critical Care
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SESSION STATS - PERFORMANCE PER SPECIALTY
