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Question 1
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A 18-year-old male was screened for hypertrophic cardiomyopathy (HOCM) as his brother had the same condition. What is the echocardiographic finding that is related to the highest risk of sudden cardiac death?
Your Answer: Significant thickening of the interventricular septum
Explanation:There are five prognostic factors which indicate poor prognosis in HOCM:
-family history of HOCM-related sudden cardiac death
-unexplained recent syncope
-large left ventricular wall thickness (MLVWT > 30 mm)
-multiple bursts of nsVT on ambulatory electrocardiography
-hypotensive or attenuated blood pressure response to exercise -
This question is part of the following fields:
- Cardiovascular System
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Question 2
Correct
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A 60-year-old patient with type 2 diabetes mellitus is advised to start taking an ACE-inhibitor in order to control his hypertension. However, he also needs to monitor his renal function. Keeping in mind that he just started an ACE-inhibitor, how long should he wait until he undergoes a blood test to check creatinine and potassium levels?
Your Answer: One to two weeks after starting the medication
Explanation:ACE inhibitors effectively reduce systemic vascular resistance in patients with hypertension, heart failure or chronic renal disease. This antihypertensive efficacy probably accounts for an important part of their long term renoprotective effects in patients with diabetic and non-diabetic renal disease. Systemic and renal haemodynamic effects of ACE inhibition, both beneficial and adverse, are potentiated by sodium depletion. Consequently, sodium repletion contributes to the restoration of renal function in patients with ACE inhibitor-induced acute renal failure. On the other hand, co-treatment with diuretics and sodium restriction can improve therapeutic efficacy in patients in whom the therapeutic response of blood pressure or proteinuria is insufficient. Patients at the greatest risk for renal adverse effects (those with heart failure, diabetes mellitus and/or chronic renal failure) also can expect the greatest benefit. Therefore, ACE inhibitors should not be withheld in these patients, but dosages should be carefully titrated, with monitoring of renal function and serum potassium levels. The optimum period to check this is one to two weeks after starting the medication.
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This question is part of the following fields:
- Renal System
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Question 3
Incorrect
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Cocaine abuse has many serious side effects. Which of the following is not a notable side effect of chronic cocaine abuse?
Your Answer: Hallucinations
Correct Answer: Hyponatraemia
Explanation:Chronic cocaine abuse can produce many serious side effects such as erectile dysfunction, ejaculatory dysfunction, hypersomnia, anxiety, hallucinations etc.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 4
Correct
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A 32-year-old patient that has just returned from India, complains of dyspnoea. On examination, you notice grey membranes on the uvula and tonsils and a low-grade fever. What is the most likely diagnosis?
Your Answer: Diphtheria
Explanation:Characteristic findings on patients suffering from diphtheria are the grey membrane on the uvula and tonsils together with the low grade fever and dyspnoea. It’s of great importance that the patient has recently been to India where there is a know prevalence.
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This question is part of the following fields:
- Infectious Diseases
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Question 5
Correct
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Which complication of chronic renal failure is most likely associated with the accumulation of aluminium?
Your Answer: Dialysis dementia
Explanation:Dialysis dementia is a unique neurological syndrome associated with chronic dialysis. Aluminium toxicity is probably the major factor in the pathogenesis of the dementia, which is due to aluminium-containing compounds in the dialysis fluid. Patients with dialysis dementia present with progressive dementia, dysarthria and seizures.
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This question is part of the following fields:
- Renal System
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Question 6
Incorrect
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An 83-year-old retired musician is examined for progressive cognitive impairment. Which one of the following features is most suggestive of Lewy body dementia?
Your Answer: Urinary incontinence
Correct Answer: Symptoms worsen with neuroleptics
Explanation:Lewy body dementia is an increasingly recognised cause of dementia, accounting for up to 20% of cases. The characteristic pathological feature is alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas. Neuroleptics should be avoided in Lewy body dementia as patients are extremely sensitive and may develop irreversible parkinsonism. Questions may give a history of a patient who has deteriorated following the introduction of an antipsychotic agent.
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This question is part of the following fields:
- Nervous System
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Question 7
Correct
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A 60-year-old gentleman presents with symptoms of nocturia and difficulty in passing urine. He is not known to have any previous prostatic problems and denies any dysuria. Following a digital rectal examination, he is started on Finasteride and Tamsulosin. Three months later he presents to the emergency department with urinary retention and is catheterized, and a craggy mass is felt on rectal examination. He is referred to a urologist, and a prostatic ultrasound and needle biopsy are arranged, and prostate serum antigen (PSA) is requested.
Which of the following factors is most likely to give a false negative PSA?Your Answer: Finasteride
Explanation:Finasteride is often prescribed for patients with Benign Prostatic Hyperplasia (BPH) or enlarged prostate. However, it has been known to cause a decrease in Prostatic Specific Antigen (PSA) levels in patients with BPH, which may lead to false negatives in a case like this, where a palpable mass has been detected and malignancy is suspected.
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This question is part of the following fields:
- Renal System
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Question 8
Correct
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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: 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 9
Incorrect
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A 60-year-old lady has been admitted to the stroke ward following a sudden onset of dizziness and visual disturbances, which started yesterday morning. She initially thought she was just dehydrated, however, later realised she was unable to read her own shopping list. On the ward rounds, the consultant examines her and finds she is indeed unable to read. She is, however, able to write. When she writes a sentence it makes perfect sense, although she is again unable to read it out. She has no problems with her speech and is able to converse normally. She has no motor focal neurological deficit. The consultant asks you where the lesion is likely to be?
Your Answer: Wernicke's area
Correct Answer: Corpus callosum
Explanation:The patient presents with sudden onset of alexia (the inability to read) WITHOUT agraphia (inability to write) which is consistent with lesions of the corpus callosum where there is a disconnect syndrome and the patient’s language and visual centres are actually in tact, but are unable to communicate between hemispheres. In this case, the damage due to the stroke is most likely in the left visual cortex, leaving visual processing to the intact right hemisphere which unfortunately cannot communicate the information to the language centres (Broca and Wernicke’s) in the left hemisphere, hence the alexia. Alternatively, the speech and writing are unaffected as the language centres can still communicate with the primary motor cortex.
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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 73-year-old woman attends COPD clinic for review. Her blood gases were checked on her last visit two months back. The test was repeated again today.
The paO2 on both occasions was 6.8 kPa. There is no CO2 retention on 28% O2. She stopped smoking around 6 months ago and is maintained on combination inhaled steroids and long acting b2-agonist therapy.
What is the next best step in management?Your Answer: Continue her current treatment and review in 4 months time
Correct Answer: Suggest she uses an oxygen concentrator for at least 19 h per day
Explanation:Long-term oxygen therapy (LTOT) > 15 h/day improves survival in hypoxemic chronic obstructive pulmonary disease (COPD). It significantly helps in reducing pulmonary hypertension associated with COPD and treating underlying pathology of future heart failure. There is little to no benefit of oxygen therapy for less than 15 hours.
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This question is part of the following fields:
- Respiratory System
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Question 11
Incorrect
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A 67-year-old man reports weight loss. Labs show a raised alkaline phosphatase at 290 U/L (normal range 35-120). Plain radiographs reveal sclerotic lesions of the bone. Which of the following is the most likely cause of these findings?
Your Answer: Osteomalacia
Correct Answer: Prostate cancer
Explanation:Osteoblastic (or sclerotic) bony metastases, characterized by deposition of new bone, present in prostate cancer, carcinoid, small cell lung cancer, Hodgkin lymphoma or medulloblastoma. The other cancers listed in the options are osteolytic.
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This question is part of the following fields:
- Musculoskeletal System
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Question 12
Correct
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Which one of the following interventions has the least role in management of acne rosacea?
Your Answer: Low-dose topical corticosteroids
Explanation:Mild cases are often not treated at all, or are simply covered up with normal cosmetics and avoiding sun exposure. Therapy for the treatment of rosacea is not curative, and is best measured in terms of reduction in the amount of facial redness and inflammatory lesions. The two primary modalities of rosacea treatment are topical and oral antibiotic agents (including metronidazole and tetracyclines). Laser therapy may be appropriate for patients with prominent telangiectasia.
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This question is part of the following fields:
- The Skin
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Question 13
Correct
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A 28-year-old woman presents with painful genital ulceration. She reports that these attacks have been recurrent over the past 4 years. She has been treated previously with oral acyclovir but this has had little effect on the duration of her symptoms. Over the past year, she has noticed almost weekly attacks of mouth ulcers that heal slowly. Past medical history is significant for treatment of thrombophlebitis two years ago. Which of the following is the most likely diagnosis?
Your Answer: Behcet's syndrome
Explanation:Behçet disease is a rare vasculitic disorder that is characterized by a triple-symptom complex of recurrent oral aphthous ulcers, genital ulcers, and uveitis. The systemic manifestations can be variable. Ocular disease has the greatest morbidity, followed by vascular disease generally from active vasculitis. Cutaneous manifestations can occur in up 75% of patients with Behcet disease and can range from acneiform lesions, to nodules and erythema nodosum. GI manifestations can be severe. Differentiating Behçet disease from active inflammatory bowel disease can be clinically difficult. Herpes would have ideally responded to acyclovir. Sarcoidosis does not have genital and oral ulcerations.
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This question is part of the following fields:
- Musculoskeletal System
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Question 14
Correct
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A 42-year-old female presented with pain in her calves during walking which settled after resting. On examination there were orange colour deposits in the her palmar creases. Her fasting lipid profile showed a total cholesterol of 9.2 mmol/l (<5) and triglycerides of 7.0 mmol/l (<2). Which of the following is the most likely diagnosis?
Your Answer: Type III hyperlipidaemia
Explanation:Palmar xanthomas are found in type III hyperlipoproteinemia. Her total cholesterol level and triglyceride level support the diagnosis.
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This question is part of the following fields:
- Cardiovascular System
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Question 15
Correct
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A 32-year-old man complains of fever, rash and photophobia. The physician suspects this to be a case of meningitis. Which of the following medication would be ideally used in this patient?
Your Answer: Cefotaxime
Explanation:Broad-spectrum cephalosporins, especially cefotaxime and ceftriaxone, are widely used in the treatment of suspected pneumococcal meningitis and are considered the treatment of choice for meningitis caused by partially penicillin-resistant pneumococcal strains.
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This question is part of the following fields:
- Pharmacology
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Question 16
Incorrect
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A 21-year-old student presents with yellowish discolouration of her sclera. She says she has had severe headaches over the last few weeks for which she has been taking paracetamol. What is the most likely cause of her jaundice?
Your Answer:
Correct Answer: Gilbert's syndrome
Explanation:Gilbert’s syndrome is a mild liver disorder in which the liver does not properly process bilirubin. Many people never have symptoms. Occasionally a slight yellowish colour of the skin or whites of the eyes may occur. Other possible symptoms include feeling tired, weakness, and abdominal pain.
The enzymes that are defective in Gilberts – UDP glucuronosyltransferase 1 family, polypeptide A1 (UGT1A1) – are also responsible for some of the liver’s ability to detoxify certain drugs. While paracetamol (acetaminophen) is not metabolized by UGT1A1,[10] it is metabolized by one of the other enzymes also deficient in some people with Gilberts. Therefore a subset of people with Gilberts may have an increased risk of paracetamol toxicity. -
This question is part of the following fields:
- Hepatobiliary System
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Question 17
Incorrect
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A 71-year old gentleman presents with a subacute history of intermittent difficulty in walking, dry mouth, and variable slurring of speech. When the latter is severe he also has difficulty in swallowing. He has lost 3 kg in weight in the last 2 months.
On examination he has bilateral mild ptosis, dysarthria, and proximal weakness of the upper and lower limbs, and he is areflexic. The degree of weakness is variable. Nerve conduction studies confirm the clinical suspicion of a neuromuscular junction disorder.
Which of the following autoantibodies is likely to be the underlying cause of his neurological symptoms?Your Answer:
Correct Answer: Anti-voltage-gated, calcium-channel antibody
Explanation:The clinical picture points to Lambert- Eaton myasthenic syndrome (LEMS) which often presents with weakness of the arms and legs. In LEMS, antibodies against voltage-gated calcium channels (VGCC) decrease the amount of calcium that can enter the nerve ending, causing autonomic symptoms like dry mouth and slurring of speech, as seen in this patient.
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This question is part of the following fields:
- Nervous System
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Question 18
Incorrect
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A 75-year-old man was admitted with urinary dribbling and incontinence. Upon examination, there is a palpable mass up to the umbilicus. His clothes smell of ammonia and he is known to be a chronic alcoholic. What is the next most appropriate step?
Your Answer:
Correct Answer: Urethral catheter
Explanation:It is obvious in this case that chronic alcohol use has contributed to the patient’s urinary incontinence which requires a urethral catheter. Suprapubic catheters are usually preferred in cases of acute urinary retention while condom catheters are indicated in less severe cases of urinary incontinence. We would administer antibiotics if we suspected a urinary infection causing the urinary incontinence, but in this case the cause is obvious.
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This question is part of the following fields:
- Renal System
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Question 19
Incorrect
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A 25-year-old youth was brought to the A&E following a stab injury to the right back of the chest. On examination he was dyspnoeic, his trachea was deviated to the left side and there were engorged veins and absent breath sounds on the right side. Which of the following is the most probable diagnosis?
Your Answer:
Correct Answer: Tension pneumothorax
Explanation:History is suggestive of right sided tension pneumothorax. It can’t be a simple pneumothorax because of tracheal deviation and engorged veins.
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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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In which condition are β-blockers not recommended as the first line of therapy?
Your Answer:
Correct Answer: Hypertension
Explanation:For patients with hypertension, ACE inhibitors, diuretics, or calcium-channel blockers are given as first-line pharmacological agents. Patients with angina, chronic heart failure, myocardial infarction, and permanent atrial fibrillation with rapid ventricular rate, are given β-blockers as first-line therapy. In these cases, increased cardiac activity can not be met by the amount of blood being supplied to the heart. Giving β-blockers will reduce the workload of the heart and slow down the cardiac activity.
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This question is part of the following fields:
- Cardiovascular System
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Question 21
Incorrect
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A 68-year-old man is admitted with an infective exacerbation of chronic obstructive pulmonary disease (COPD).
Investigations: blood gas taken whilst breathing 28% oxygen on admission:
pH 7.30
p(O2) 7.8 kPa
p(CO2) 7.4 kPa
Which condition best describes the blood gas picture?Your Answer:
Correct Answer: Decompensated type-2 respiratory failure
Explanation:The normal partial pressure reference values are:
– PaO2 more than 80 mmHg (11 kPa)
– PaCO2 less than 45 mmHg (6.0 kPa).
This patient has an elevated PaCO2 (7.4kPa)
Hypoxemia (PaO2 <8kPa) with hypercapnia (PaCO2 >6.0kPa).
The pH is also lower than 7.35 at 7.3Type 2 respiratory failure is caused by inadequate alveolar ventilation; both oxygen and carbon dioxide are affected. Defined as the build-up of carbon dioxide levels (PaCO2) that has been generated by the body but cannot be eliminated. The underlying causes include:
– Increased airways resistance (chronic obstructive pulmonary disease, asthma, suffocation)
– Reduced breathing effort (drug effects, brain stem lesion, extreme obesity)
– A decrease in the area of the lung available for gas exchange (such as in chronic bronchitis)
– Neuromuscular problems (Guillain-Barre syndrome, motor neuron disease)
– Deformed (kyphoscoliosis), rigid (ankylosing spondylitis), or flail chest. -
This question is part of the following fields:
- Respiratory System
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Question 22
Incorrect
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A 35-year-old man was brought to the ER with acute confusion. He's a known case of bipolar disorder under treatment with mood stabilizers. Blood investigations revealed lithium toxicity. A decision is made to start the patient on sodium bicarbonate. What is the rationale behind the use of sodium bicarbonate in this patient?
Your Answer:
Correct Answer: Increases urine alkalinity
Explanation:The rationale behind the use of sodium bicarbonate is that it increases the alkalinity of the urine promoting lithium excretion. The preferred treatment in severe cases would be haemodialysis.
Lithium is a mood-stabilizing drug used most commonly prophylactically in bipolar disorder but also as an adjunct in refractory depression. It has a very narrow therapeutic range (0.4-1.0 mmol/L) and a long plasma half-life being excreted primarily by the kidneys. Lithium toxicity generally occurs following concentrations > 1.5 mmol/L.
Toxicity may be precipitated by dehydration, renal failure, diuretics (especially Bendroflumethiazide), ACE inhibitors, NSAIDs and metronidazole.
Features of toxicity
Coarse tremor (a fine tremor is seen in therapeutic levels)
Hyperreflexia
Acute confusion
Seizure
ComaManagement
Mild-moderate toxicity may respond to volume resuscitation with normal saline
Haemodialysis may be needed in severe toxicity
Sodium bicarbonate is sometimes used but there is limited evidence to support this. By increasing the alkalinity of the urine it promotes lithium excretion. -
This question is part of the following fields:
- Emergency & Critical Care
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Question 23
Incorrect
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A 11-year-old is referred to neurology due to episodes her GP feels are epileptiform. Her mother reports that she appears to just 'stop', sometimes even in mid conversation, for several seconds at random times during the day. During these episodes, she can be unresponsive to questioning and has no recollection of them.
Which of these drugs is contraindicated in this condition?Your Answer:
Correct Answer: Carbamazepine
Explanation:The patient’s history points to absence seizures. Carbamazepine has been shown to aggravate generalized seizure types, especially absence seizures, because it acts directly on the ventrobasal complex of the thalamus which is critical to the neurophysiology of absence seizures.
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This question is part of the following fields:
- Nervous System
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Question 24
Incorrect
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A 23-year-old woman complains of a tender lump that is smooth and mobile in her left breast measuring 1-2 cm. What is the most likely diagnosis?
Your Answer:
Correct Answer: Fibroadenoma
Explanation:Fibroadenoma usually occurs in younger women. These non-tender masses can be removed for aesthetic purposes. Breast cysts are common shifting masses inside the breast tissue more common in women over the age of 35.
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This question is part of the following fields:
- Women's Health
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Question 25
Incorrect
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A 60-year-old man presents to his GP complaining of a cough and breathlessness for 2 weeks. He reports that before the onset of these symptoms, he was fit and well and was not on any medication. He is a known smoker of 10 cigarettes per day and has been smoking for over 25 years.
On examination, the GP diagnosed a mild viral chest infection and reassured the patient that the symptoms would settle of their own accord.
Two weeks later, the patient presented again to the GP, this time complaining of thirst, polyuria and generalised muscle weakness. The GP noticed the presence of ankle oedema.
A prick test confirmed the presence of hyperglycaemia and the patient was referred to the hospital for investigations where the medical registrar ordered a variety of blood tests.
Some of these results are shown below:
Na 144 mmol/l
K 2.2 mmol/l
Bicarbonate 34 mmol/l
Glucose 16 mmol/l
What is the most likely diagnosis?Your Answer:
Correct Answer: Ectopic ACTH production
Explanation:The patient has small cell lung cancer presented by paraneoplastic syndrome; Ectopic ACTH secretion.
Small cell lung cancer (SCLC), previously known as oat cell carcinoma is a neuroendocrine carcinoma that exhibits aggressive behaviour, rapid growth, early spread to distant sites, exquisite sensitivity to chemotherapy and radiation, and a frequent association with distinct paraneoplastic syndromes.
Common presenting signs and symptoms of the disease, which very often occur in advanced-stage disease, include the following:
– Shortness of breath
– Cough
– Bone pain
– Weight loss
– Fatigue
– Neurologic dysfunction
Most patients with this disease present with a short duration of symptoms, usually only 8-12 weeks before presentation. The clinical manifestations of SCLC can result from local tumour growth, intrathoracic spread, distant spread, and/or paraneoplastic syndromes.
SIADH is present in 15% of the patients and Ectopic secretion of ACTH is present in 2-5% of the patients leading to ectopic Cushing’s syndrome. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 26
Incorrect
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A 40-year-old female patient with a history of rheumatoid arthritis is diagnosed with type 1 renal tubular acidosis. What is the most probable sequela of this condition?
Your Answer:
Correct Answer: Nephrocalcinosis
Explanation:Distal renal tubular acidosis is due to defective proton secretion from the alpha intercalated cells of the distal tubule caused by dysfunction of the H+/K+ antiporter on the apical membrane. This leads to failure of H+ excretion thereby causing systemic acidosis and potassium depletion. Inability to lower the urine pH below 5.3 in the presence of systemic acidosis is the diagnostic hallmark of type I or distal renal tubular acidosis. Hypercalciuria, hypocitraturia and elevated urinary pH observed in distal renal tubular acidosis can lead to nephrocalcinosis and may cause renal calculi, obstructive uropathy and renal failure necessitating surgical or endoscopic stone extraction.
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This question is part of the following fields:
- Renal System
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Question 27
Incorrect
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A 17-year-old boy presents with a 2 day history of colicky abdominal pain, vomiting and diarrhoea. He has been passing blood mixed with diarrhoea. He has no significant past medical history and takes no regular medication.
On examination he is pyrexial and clinically dehydrated. Cardiorespiratory and abdominal examinations are normal.
What is the most likely diagnosis?Your Answer:
Correct Answer: Campylobacter infection
Explanation:The patient has bloody diarrhoea that sounds like a food poisoning in the clinical scenario. Campylobacter is the most common cause of this in the United Kingdom. This is then followed by Salmonella and Shigella. The symptoms are usually self limiting. This is more likely to be bacterial from the food than a viral gastroenteritis.
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This question is part of the following fields:
- Gastrointestinal System
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Question 28
Incorrect
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A 60-year-old man complains of weight loss, fatigue, fever and abdominal discomfort. Abdominal ultrasound reveals massive splenomegaly and the lab results return the following: WBC=127, Hgb=8.7, Plt=138. Basophils were also found on the peripheral blood film. What is the most likely diagnosis?
Your Answer:
Correct Answer: CML
Explanation:CML is a myeloproliferative disorder involving neoplastic proliferation of mature myeloid cells, especially granulocytes and their precursors. The non-acute symptoms of marked splenomegaly and anaemia accompanied by of fever and abdominal discomfort rules out the other conditions.
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This question is part of the following fields:
- Haematology & Oncology
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Question 29
Incorrect
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A 60-year-old male presents with intermittent haemoptysis and chronic, productive cough. He has a strong history of smoking and has recently lost weight. What is the patient most likely suffering from?
Your Answer:
Correct Answer: Bronchogenic carcinoma
Explanation:The combination of haemoptysis, chronic productive cough, and recent weight loss in a smoker is a strong indication of bronchogenic carcinoma.
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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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Which of the following enzymes are involved in Phase I drug metabolism?
Your Answer:
Correct Answer: Alcohol dehydrogenase
Explanation:Drug metabolism can be broadly classified into:
Phase I (functionalization) reactions: also termed non-synthetic reactions, they include oxidation, reduction, hydrolysis, cyclization and de-cyclization. The most common and vital reactions are oxidation reactions. (Of the given enzymes only Alcohol dehydrogenase is involved in phase I drug metabolism. Succinate dehydrogenase, is a vital enzyme involved in the Kreb’s cycle and the mitochondrial electron transport chain). They are mainly catalysed by Cytochrome P-450 enzyme.Phase II (conjugation) reactions: occur following phase I reactions, they include reactions: glucuronidation and sulphate conjugation, etc. They are mostly catalysed by UDP-glucuronosyltransferase enzyme. Other phase II enzymes include: sulfotransferases, N-acetyltransferases, glutathione S-transferases and methyltransferases.
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This question is part of the following fields:
- Pharmacology
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SESSION STATS - PERFORMANCE PER SPECIALTY
