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Question 1
Incorrect
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A 50-year-old man with a history of hyperlipidaemia, currently under treatment with simvastatin 10mg was found to have persistently high cholesterol levels. Previous attempts to increase the dose of simvastatin have resulted in myalgia. Given this history, which one of the following lipid-regulating drugs should definitely be avoided?
Your Answer: Cholestyramine
Correct Answer: Bezafibrate
Explanation:Both fibrates and nicotinic acid have been associated with myositis, especially when combined with a statin. However, the Committee on Safety of Medicines has produced guidance which specifically warns about the concomitant prescription of fibrates with statins concerning muscle toxicity.
Bezafibrate: It is a fibric acid derivative (fibrate) that has been used as a class of agents known to decrease triglyceride levels while substantially increasing HDL-C levels.
Pharmacological effects:
– Increases VLDL catabolism by increasing lipoprotein and hepatic triglyceride lipase.
– Decreases triglyceride synthesis by inhibiting acetyl-CoA reductase.
– Decreases cholesterol synthesis by inhibiting HMG-CoA reductase.Side effects:
– Hypersensitivity
– Primary biliary cirrhosis
– Pre-existing gallbladder disease
– Concurrent use with HMG-CoA inhibitors (statins) can produce myopathy
– Hepatic/renal impairment in a patient warrants dose adjustment as this drug is primarily excreted via the renal mechanism.Contraindications: Concurrent use of MAO inhibitors, hypersensitivity, pre-existing cholestasis, and pregnancy.
Use: It can be used to treat Barth syndrome (characterized by dilated cardiomyopathy, neutropenia (presenting with recurrent infections), skeletal myopathy and short stature)
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This question is part of the following fields:
- Pharmacology
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Question 2
Incorrect
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A 65-year-old female has complained she feels unsteady when she is walking. She is examined and is found to have pyramidal weakness of her left lower leg. She also has reduced pain and temperature sensation on her right leg and right side of her torso up to the umbilicus. Her joint position sense is also impaired in her left big toe but is found to be normal elsewhere. She has definite left extensor plantar response, and the right plantar response is equivocal. Where is the lesion?
Your Answer: Left cervical cord
Correct Answer: Left mid-thoracic cord
Explanation:In Brown-Sequard syndrome, there is paralysis and loss of proprioception, which occurs on the same (ipsilateral) side of the body, as the lesion. Loss of pain and temperature sensation, therefore, occurs on the opposite (contralateral) side of the body as the lesion.
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This question is part of the following fields:
- Geriatric Medicine
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Question 3
Correct
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Out of the following, which condition is not associated with hyposplenism?
Your Answer: Liver cirrhosis
Explanation:Liver cirrhosis is not associated with hyposplenism.
Hyposplenism is caused by a variety of conditions. These are:
1. Splenectomy
2. Sickle cell anaemia
3. Coeliac disease, dermatitis herpetiformis
4. Graves’ disease
5. Systemic lupus erythematosus (SLE) -
This question is part of the following fields:
- Haematology & Oncology
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Question 4
Correct
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A 61-year-old female presents to the A&E with malaise and muscle twitching. Her blood pressure is 114/78 mmHg and her pulse is 84/min. Blood exam reveals Calcium = 1.94 mmol/l and Albumin = 38 g/l. Which of the following tests is most useful in establishing her diagnosis?
Your Answer: Parathyroid hormone
Explanation: -
This question is part of the following fields:
- Emergency & Critical Care
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Question 5
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 6
Incorrect
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A 39-year-old woman with a history of rheumatoid arthritis has recently been switched from methotrexate to leflunomide. Monitoring of full blood count and LFTs has been carried out. Which of the following parameters should also be monitored in this case?
Your Answer: QT interval on ECG
Correct Answer: Blood pressure
Explanation:Blood pressure should be routinely measured as leflunomide may cause hypertension and thus an increase in BP. It doesn’t cause changes in blood sugar levels, peak expiratory flow rate or haematuria.
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This question is part of the following fields:
- Musculoskeletal System
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Question 7
Correct
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A keratitis with dendritic ulceration of the cornea is diagnosed in a 32-year-old patient. What is the most likely cause?
Your Answer: Herpes simplex virus
Explanation:The dendritic ulceration seen on fluorescein staining of the eye is pathopneumonic for keratitis caused by HSV (herpes simplex virus). Presentation is that of blepharoconjunctivitis. Treatment is required, the treatment is typically topical acyclovir. Topical steroids can make the infection worse. The other answer choices would not have this dendritic pattern seen on fluorescein staining.
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This question is part of the following fields:
- Infectious Diseases
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Question 8
Correct
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A 35-year-old female with systemic lupus erythematosus (SLE) was brought to Casualty, complaining of chest pain and worsening difficulty in breathing for the past 36 hrs. On examination she was tachypnoeic, her BP was 85/65 mmHg and peripheral oxygen saturation was 98% on air. Her cardiac examination was normal but her jugular venous pressure was elevated. She didn't have ankle oedema. Her ECG showed sinus tachycardia and her CXR showed clear lung fields with a slightly enlarged heart. Which of the following is the most appropriate next step?
Your Answer: Urgent transthoracic echocardiogram
Explanation:Acute breathlessness in SLE can be due to a pericardial effusion or a pulmonary embolism. Normal peripheral oxygen saturation and normal ECG, make the diagnosis of pulmonary embolism less likely. To exclude pericardial effusion, an urgent transthoracic echocardiogram is needed.
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This question is part of the following fields:
- Cardiovascular System
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Question 9
Incorrect
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Choose the single most appropriate landmark located above the mid-inguinal point from the list of options.
Your Answer: Femoral artery pulse felt
Correct Answer: Deep inguinal ring
Explanation:The deep inguinal ring is located above the mid-inguinal point.
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This question is part of the following fields:
- Musculoskeletal System
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Question 10
Incorrect
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A 40-year-old man presents with periorbital and pedal oedema. 24h urine shows 9g of protein/d and serum cholesterol of 7 mmol/L. What would be the most likely diagnosis?
Your Answer: IgA nephropathy
Correct Answer: Membranous glomerulonephropathy
Explanation:Membranous glomerulonephritis . However some authors believe FSGS a more commoner cause of nephrotic syndrome.
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This question is part of the following fields:
- Renal System
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Question 11
Incorrect
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A 60-year-old male with a history of diabetes and hypertension presented with left sided arm and leg weakness and loss of vision in the left eye for a brief period. His symptoms improved within a few hours. Which of the following is the most appropriate investigation that can be done at this stage?
Your Answer: CT brain
Correct Answer: Doppler USG
Explanation:Amaurosis fugax (transient ipsilateral visual loss) and transient ischemic attacks (TIAs) are presentations of atherosclerotic disease of the carotid artery which can be identified by carotid duplex ultrasonography (US), with or without colour. This is the screening test of choice to evaluate for carotid stenosis.
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This question is part of the following fields:
- Nervous System
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Question 12
Correct
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A 54-year-old female has complained of a sudden and severe pain on the left side of her skull. She is also experiencing pain in and around her jaw. What is the most appropriate next step in her treatment?
Your Answer: ESR
Explanation:A diagnosis of giant cell arteritis or temporal arteritis is likely here as many points favour it. She is over 50 years old, is female, has severe pain in the left half of her skull, and is complaining of pain around the jaw (jaw claudication).
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This question is part of the following fields:
- Emergency & Critical Care
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Question 13
Incorrect
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A 16-year-old girl was brought to the ED by her gym instructor after developing severe shortness of breath and chest pain at the gym. She has a history of asthma since childhood. Her skin colour looked normal; however, breath sounds were found to be diminished on auscultation of the right lung. Which investigation will you order first?
Your Answer: Capillary blood gases
Correct Answer: Chest x-ray
Explanation:Asthma patients have an increased risk of developing complications like pneumonia or collapsed lung. A clear visualization of the lungs through a CXR will define the management necessary for this patient.
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This question is part of the following fields:
- Respiratory System
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Question 14
Incorrect
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A 50-year-old male was taken to hospital after he experienced tightness in his chest and a chronic cough. Upon examination, he revealed that he has been smoking 20 cigarettes a day for the past 35 years, and was subsequently diagnosed with COPD. From the list of options, choose the most appropriate ABG picture.
Your Answer:
Correct Answer: Respiratory Acidosis
Explanation:COPD impairs the lung’s ability to remove CO2 from the blood, and this removes acid from the body. Excess CO2 causes the pH of the blood to increase, making it far too acidic, and causing respiratory acidosis.
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This question is part of the following fields:
- Respiratory System
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Question 15
Incorrect
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A 15-year-old girl is brought to the emergency after collapsing at a shopping mall. She is accompanied by her mother who reveals that she has had amenorrhea for the past 7 consecutive months. There is fine hair on her body. Which of the following investigations is mandatory in this case?
Your Answer:
Correct Answer: Urea & Electrolytes
Explanation:Although some individuals with Anorexia Nervosa exhibit no laboratory abnormalities, the semistarvation characteristic of this disorder can affect most major organ systems and produce a variety of disturbances. The induced vomiting and abuse of laxatives, diuretics, and enemas can also cause a number of disturbances leading to abnormal laboratory findings.
Haematology: Leukopenia and mild anaemia are common; thrombocytopenia occurs rarely.
Chemistry: Dehydration may be reflected by an elevated blood urea nitrogen (BUN). Hypercholesterolemia is common.
Liver function tests may be elevated.
Hypomagnesemia, hypozincaemia, hypophosphatemia, and hyperamylasaemia are occasionally found.
Induced vomiting may lead to metabolic alkalosis (elevated serum bicarbonate), hypochloraemia, and hypokalaemia, and laxative abuse may cause a metabolic acidosis.
Serum thyroxine levels are usually in the low-normal range; triiodothyronine levels are decreased.
Hyperadrenocorticism and abnormal responsiveness to a variety of neuroendocrine challenges are common.
In females, low serum oestrogen levels are present, whereas males have low levels of serum testosterone.
There is a regression of the hypothalamic-pituitary-gonadal axis in both sexes in that the 24-hour pattern of secretion of luteinizing hormone (LH) resembles that normally seen in prepubertal or pubertal individuals. -
This question is part of the following fields:
- Emergency & Critical Care
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Question 16
Incorrect
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A 72-year-old male with a history of type II diabetes mellitus and hypertension for 15 years, presented with gradual onset difficulty in breathing on exertion and bilateral ankle swelling for the past 3 months. On examination he had mild ankle oedema. His JVP was not elevated. His heart sounds were normal but he had bibasal crepitations on auscultation. Which of the following clinical signs has the greatest sensitivity in detecting heart failure in this patient?
Your Answer:
Correct Answer: Third heart sound
Explanation:The presence of a third heart sound is the most sensitive indicator of heart failure. All of the other signs can be found in heart failure with varying degrees.
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This question is part of the following fields:
- Cardiovascular System
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Question 17
Incorrect
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A 59-year-old man complains of weakness in his right lower and upper limb since 3 for a few hours. He is has been taking Digoxin for 2 years. What is the most definitive investigation for this condition?
Your Answer:
Correct Answer: Angiography
Explanation:Digoxin is a cardiac glycoside, having positive inotropic effects on the heart. It increases the strength of contractility of the heart, increasing the heart rate, but lowering blood pressure. This patient developed weakness in his limbs most likely caused by extremely low blood pressure that could be due to diseased blood vessels reacting to the side-effects of digoxin, therefore an angiography would be the best investigation.
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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 47-year-old hypertensive man presents with difficulty using his right arm, slow walking and occasional loss of balance. He has a broad-based gait with cogwheel rigidity and intention tremor of his right arm. His blood pressure is 140/80 mmHg sitting and 100/60 mmHg standing. Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Multiple system atrophy
Explanation:This patient presents with a combination of akinetic rigid syndrome, cerebellar signs and the suggestion of autonomic features. This is most indicative of a diagnosis of multiple system atrophy.
Multiple system atrophy (MSA) is a rare neurodegenerative disorder characterized by autonomic dysfunction, tremors, slow movement, muscle rigidity, and postural instability (collectively known as parkinsonism) and ataxia.
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This question is part of the following fields:
- Nervous System
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Question 19
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:
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 20
Incorrect
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A 70-year-old male presented in the OPD with a complaint of abdominal pain and blood in his stools for the last two days. He reports that the stools are black in colour and sometimes accompanied by fresh blood. There is also a history of significant weight loss. Blood tests revealed elevated CA 19-9. What is the patient most likely suffering from?
Your Answer:
Correct Answer: Colorectal carcinoma
Explanation:The patient’s symptoms along with his age indicates a diagnosis of colorectal cancer. Blood test marker CA-19-9 is a prognostic index for colorectal cancer which confirms the suspicion.
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This question is part of the following fields:
- Gastrointestinal System
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Question 21
Incorrect
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Which is the most common type of inherited colorectal cancer:
Your Answer:
Correct Answer: Hereditary non-polyposis colorectal carcinoma
Explanation:Hereditary non-polyposis syndrome (HNPCC) is the most common type of inherited colorectal cancer. It often presents in younger and younger generations down a family. FAP presents with 100’s-1000’s of polyps and is less common. Li-Fraumeni syndrome and Fanconi syndrome are rare. For Peutz-Jeghers syndrome, the thing you will look for in the question stem is discoloured spots on the lips, this is classic.
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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 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:
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 23
Incorrect
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A patient develops methemoglobinemia after being prescribed isosorbide mononitrate. Which enzyme is most likely to be deficient?
Your Answer:
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 24
Incorrect
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A 30-year-old patient with schizophrenia was brought to Emergency Department, due to reduced level of consciousness. On examination he was febrile, rigid and had tremors. Which of following does not support the diagnosis of neuroleptic malignant syndrome?
Your Answer:
Correct Answer: Usually occurs after prolonged treatment
Explanation:Neuroleptic Malignant Syndrome is a life-threatening condition associated with neuroleptic medications. It is characterized by severe muscular rigidity, hyperthermia, autonomic instability (tachycardia, tachypnoea etc) and changes in the level of consciousness. It usually occurs 4-14 days after the start of therapy. Renal failure and elevated creatinine kinase are also associated with this condition.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 25
Incorrect
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Which one of the following is not associated with non-alcoholic steatohepatitis?
Your Answer:
Correct Answer: Type 1 diabetes mellitus
Explanation:There are two types of Non-alcoholic fatty liver disease (NAFLD); simple fatty liver and non-alcoholic steatohepatitis (NASH). Simple fatty liver and NASH are two separate conditions.
Simple fatty liver, also called non-alcoholic fatty liver (NAFL), is a form of NAFLD in which you have fat in your liver but little or no inflammation or liver cell damage. Simple fatty liver typically does not progress to cause liver damage or complications.
Non-alcoholic steatohepatitis (NASH)
NASH is a form of NAFLD in which you have hepatitis and liver cell damage, in addition to fat in your liver. Inflammation and liver cell damage can cause fibrosis, or scarring, of the liver. NASH may lead to cirrhosis or liver cancer. Type I diabetes is not associated with NASH (non-alcoholic steatohepatitis), but type II diabetes is. Hyperlipidaemia, obesity, sudden weight loss/starvation and jejunoileal bypass are all associated with NASH. This is the most common cause of liver disease in the developed world. -
This question is part of the following fields:
- Hepatobiliary System
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Question 26
Incorrect
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A 62-year-old patient with shortness of breath has a chest x ray, which shows right lower lobe consolidation. Dyspnoea started one week ago. Which of the following would support admission of the patient?
Your Answer:
Correct Answer: A respiratory rate of 32/min
Explanation:CURB-65 is a clinical prediction score that has been validated for predicting mortality in community-acquired pneumonia. It is comprised of five features which are given a point if present on the patient.
C=confusion
U=urea >7mmol/L
R=respiratory rate >30/min or more
B=blood pressure (SBP)<90mmHg or (DBP)<60mmHg.
Lastly, the patient gets a point if he/she is 65-year-old or older. The score provides guidance for management:
0-1: Treat as an outpatient
2: Consider a short stay in hospital or watch very closely as an outpatient
3-5: Requires hospitalization with consideration as to whether they need to be in the intensive care unit. -
This question is part of the following fields:
- Respiratory System
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Question 27
Incorrect
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The ECG of a 48-year-old man shows broad complex tachycardia with a HR of 154 bpm 2 days after an MI. His BP is 90/60 mmHg and he is complaining of palpitations and dyspnoea. What is the most appropriate management?
Your Answer:
Correct Answer: DC Shock
Explanation:Dysrhythmias are the most frequent MI complication. The patient seems to have a post MI atrial fibrillation which is treated, in an emergency context, with DC shock.
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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 72-year-old woman who presented with headache and neck stiffness was started on IV ceftriaxone after undergoing a lumbar puncture. The CSF culture shows listeria monocytogenes. What is the treatment of choice?
Your Answer:
Correct Answer: Change to IV amoxicillin + gentamicin
Explanation:The best option would be the combination of ampicillin and gentamycin. Changing to IV amoxicillin+gentamycin is however the best among the given choices here.
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This question is part of the following fields:
- Infectious Diseases
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Question 29
Incorrect
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Which one of the following features is least associated with Waldenström's macroglobulinemia?
Your Answer:
Correct Answer: Bone pain
Explanation: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 weight loss and lethargy; monoclonal IgM paraproteinemia; hyperviscosity syndrome leading to bilateral central retinal vein occlusion (CRVO) and hence, visual disturbances; 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 30
Incorrect
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A 30-year-old patient has ataxia, nystagmus and vertigo with a history of headaches. Where is the most likely site of the lesion?
Your Answer:
Correct Answer: Cerebellum
Explanation:Damage to the cerebellum can cause asynergia, dysmetria, adiadochokinesia, intention tremor, staggering, ataxic gait, tendency toward falling, hypotonia, ataxic dysarthria and nystagmus.
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This question is part of the following fields:
- Nervous System
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SESSION STATS - PERFORMANCE PER SPECIALTY
