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Question 1
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 2
Incorrect
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A 76-year-old man complains of painful microscopic haematuria and urgency. On examination of the abdomen, there is suprapubic tenderness but no palpable abnormality. He is apyrexial, inflammatory markers and PSA in the blood are normal. Which is the most likely diagnosis?
Your Answer: Bladder cancer
Correct Answer: Bladder calculi
Explanation:Painful haematuria suggests trauma, infection or calculi, whereas painless haematuria suggests a possible occult malignancy. This man is apyrexial with normal WCC and CRP which should effectively exclude infection as a cause for his symptoms. There is no history of trauma in this scenario (often catheter-associated) which makes this cause unlikely. It is worth noting that haematuria associated with injury tends to be macroscopic. Therefore, bladder calculi are the most likely source of his symptoms. Imaging will help to determine the presence of calculi.
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This question is part of the following fields:
- Renal System
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Question 3
Correct
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A 52-year-old man has squamous-cell carcinoma of his lower lip. Which of the following is most likely to be a feature of this type of carcinoma?
Your Answer: It is capable of metastasising via the lymphatics
Explanation:Squamous-cell skin cancer usually presents as a hard lump with a scaly top but can also form an ulcer. Onset is often over months and it is more likely to spread to distant areas than basal cell cancer vie the lymphatics. The greatest risk factor is high total exposure to ultraviolet radiation from the Sun. Other risks include prior scars, chronic wounds, actinic keratosis, lighter skin, Bowen’s disease, arsenic exposure, radiation therapy, poor immune system function, previous basal cell carcinoma, and HPV infection. While prognosis is usually good, if distant spread occurs five-year survival is ,34%
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This question is part of the following fields:
- The Skin
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Question 4
Correct
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Which of the following drugs is NOT used in the treatment of MRSA?
Your Answer: Ceftriaxone
Explanation:Cephalosporins, such as ceftriaxone, do not cover methicillin-resistant staph aureus. They do cover some gram positives and gram negatives. Vancomycin and teicoplanin given intravenously have good coverage of MRSA and other gram positive bacteria. Rifampicin and doxycycline, although not the best treatment, can be used for outpatients if there are no systemic signs of illness.
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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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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: 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 6
Correct
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A 32-year-old female patient has the following signs and symptoms: smooth goitre, lid lag and bilateral exophthalmos with puffy eyelids and conjunctival injections. She has a history of thyrotoxicosis but wants to fall pregnant. What would be the most appropriate treatment for her?
Your Answer: 18m of Propylthiouracil (PTU) alone
Explanation:Propylthiouracil (PTU) is a safe choice for a woman that is planning a pregnancy because it does not have the teratogenic effects as carbimazole does. Methimazole (MMI) and propylthiouracil (PTU) are the standard anti-thyroid drugs used in the treatment of hyperthyroidism in pregnancy. Carbimazole can cause spina bifida, CV malformations as well as hypospadia.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 7
Correct
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A 28-year-old male is involved in a motorcycle accident. He sustained a direct blow to his lower chest. His blood pressure is 83/48, HR 113 bpm. On examination, there are multiple bruises on the chest with bowel sounds heard on auscultation of his chest. The single most likely diagnosis is?
Your Answer: Diaphragmatic rupture
Explanation:Ruptured diaphragm is a serious condition that is very difficult to diagnose and requires rapid intervention. The presence of bowel sounds on chest auscultation is highly suggestive of this.
Ruptured oesophagus is excluded by the absence of haematemesis and normal intestinal sounds.
Fractured ribs could be life threatening if associated with a tension pneumothorax which is excluded by a normal chest auscultation.
Flail chest is characterised by paradoxical breathing and respiratory failure. -
This question is part of the following fields:
- Respiratory System
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Question 8
Correct
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In a patient with cardiomyopathy, which one of the following statements would be aetiologically significant?
Your Answer: The presence of diabetes mellitus in a tanned patient
Explanation:Hemochromatosis is a condition that leads to abnormal iron deposition in specific organs. There are two main types: primary (hereditary) and secondary (e.g., transfusion-related). The most common form is hereditary autosomal recessive hemochromatosis type 1, which is caused by an underlying genetic defect that results in partially uninhibited absorption of iron in the small intestine.
Hemochromatosis is mostly asymptomatic but can become symptomatic, usually between the third and fifth decade of life, when poisonous levels of iron have had time to accumulate in the body. Symptoms include fatigue, hyperpigmentation, diabetes mellitus (bronze diabetes), and arthralgia. The deposits may lead to various organ diseases, the most typical being the development of liver cirrhosis, which is accompanied by an increased risk of hepatocellular carcinoma (HCC). Serum ferritin and transferrin saturation levels are typically elevated. Molecular genetic testing or a liver biopsy may be used to confirm the diagnosis. Treatment primarily consists of repeated phlebotomy to reduce iron levels. In addition, dietary changes and drug therapy (chelating agents such as deferoxamine) may be used to influence the amount of iron in the body. -
This question is part of the following fields:
- Cardiovascular System
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Question 9
Correct
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A 60-year-old male presented in the OPD with a severe pain in the chest, which radiated to the jaw and his left shoulder. What is your diagnosis?
Your Answer: MI
Explanation:Risk of myocardial infarction is high in patients with diabetes mellitus. High levels of sugar in the blood can damage the arteries and lead to an increased risk of atherosclerosis of the coronary arteries. This is why diabetic patients have an increased risk of Myocardial Infarction.
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This question is part of the following fields:
- Cardiovascular System
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Question 10
Correct
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A 54-year-old heavy smoker presented with acute chest pain for 3 hrs which associated with excessive sweating and vomiting. His past medical history was unremarkable but his father has passed away due to a heart attack at the age of 50. Examination findings were normal and ECG was also normal. He was pain free after 12 hours from admission. What is the most appropriate investigation that can be done at this moment?
Your Answer: Troponin T
Explanation:The positive family history and the smoking make him an ideal candidate for a myocardial infarction. The chest pain is also a suggestive symptom. So troponin is needed to rule out MI.
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This question is part of the following fields:
- Cardiovascular System
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Question 11
Correct
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A literature review of a number of studies was conducted to assess the potential efficacy of a new drug, which may reduce the chance of patients with chronic kidney disease (CKD) developing gout. In one study 120 out of 1200 patients receiving the new drug developed gout. The total number of the patients were 2000 and the remaining 800 individuals received a placebo. From the patients that had received the placebo, 200 developed gout. What is the absolute risk reduction of developing gout?
Your Answer: 0.15
Explanation:Absolute risk reduction (ARR) – also called risk difference (RD) – is the most useful way of presenting research results to help your decision-making. Absolute risk reduction = (Control event rate) – (Experimental event rate) = 0.15 = 15%
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This question is part of the following fields:
- Evidence Based Medicine
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Question 12
Correct
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A 55-year-old man attends follow-up for liver cirrhosis, which reveals a large dominant nodule in the right lobe of liver on CT Scan. Which tumour marker would most likely be elevated?
Your Answer: Alpha feto-protein (AFP)
Explanation:A considerably increased serum AFP is characteristic of hepatocellular cancer. A distinct nodule for cirrhotic patients should be investigated to rule out hepatocellular cancer.
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This question is part of the following fields:
- Gastrointestinal System
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Question 13
Correct
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A 17-year-old man presents with fever and extensive preauricular swelling on the right side of his face. However, tenderness is present bilaterally. He also complains of acute pain and otalgia on the right aspect of the face. What is the most likely diagnosis?
Your Answer: Mumps
Explanation:Mumps presents with a prodromal phase of general malaise and fever. On examination there is usually painful parotid swelling which has high chances of becoming bilateral. In OM with effusion there are no signs of infection and the only symptom is usually hearing loss. Acute otitis externa produces otalgia as well as ear discharge and itching. Acute OM produces otalgia and specific findings upon otoscopy. In acute mastoiditis the patient experiences ear discharge, otalgia, headache, hearing loss and other general signs of inflammation.
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This question is part of the following fields:
- Infectious Diseases
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Question 14
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 15
Correct
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A 30-year-old male with a history of premature cardiovascular disease in the family has come for review of his lab investigations.
His fasting cholesterol is 8.4 mmol/l with high-density lipoprotein (HDL) of 1.6 mmol/l.
You elect to commence him on atorvastatin 20 mg PO daily.
Which of the following best describes the mechanism of action of the statins?Your Answer: They inhibit HMG CoA reductase
Explanation:Statins are a selective, competitive inhibitor of hydroxymethylglutaryl-CoA (HMG-CoA) reductase, which is the enzyme responsible for the conversion of HMG-CoA to mevalonate in the cholesterol synthesis pathway.
Statins are usually well tolerated with myopathy, rhabdomyolysis, hepatotoxicity, and diabetes mellitus being the most common adverse reactions.
This is the rate-limiting step in cholesterol synthesis, that leads to increased hepatic low-density lipoprotein (LDL) receptors and reduced hepatic VLDL synthesis coupled with increased very-low-density lipoprotein (VLDL) clearance. -
This question is part of the following fields:
- Pharmacology
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Question 16
Correct
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A 60-year-old Muslim man with type 2 diabetes comes to the clinic for advice. He is about to start fasting for Ramadan and he is not sure how to modify the administration of his diabetes medications. He is currently on metformin 500mg tds.
What is the most appropriate advice?Your Answer: 500 mg at the predawn meal + 1000 mg at the sunset meal
Explanation:Biguanides (Metformin):
People who take metformin alone should be able to fast safely given that the possibility of hypoglycaemia is minimal. However, patients should modify its dose and administration timing to provide two-thirds of the total daily dose, which should be taken immediately with the sunset meal, while the other third is taken before the predawn meal.Thiazolidinediones: No change needed.
Sulfonylurea:
Once-daily sulfonylurea (such as glimepiride or gliclazide MR): the total daily dose should be taken with the sunset meal.
Shorter-acting sulfonylurea (such as gliclazide twice daily): the same daily dose remains unchanged, and one dose should be taken at the sunset meal and the other at the predawn meal.
Long-acting sulfonylurea (such as glibenclamide): these agents should be avoided.It is important that diabetic patients to eat a healthy balanced diet and choose foods with a low glycaemic index (such as complex carbohydrates), which can help to maintain blood glucose levels during fasting. Moreover, it is crucial to consume adequate fluids to prevent dehydration. Physical activity is encouraged, especially during non-fasting periods.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 17
Correct
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A 74-year-old man presents with left-sided lower abdominal pain. He is obese and admits to a dislike of high fibre foods. The pain has been grumbling for the past couple of weeks and is partially relieved by defecation. He has suffered intermittent diarrhoea.
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Blood testing reveals a neutrophilia, and there is also a microcytic anaemia. Barium enema shows multiple diverticula, more marked on the left-hand side of the colon.
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Which diagnosis fits best with this clinical picture?Your Answer: Diverticular disease
Explanation:Given that he has diverticula in the clinical scenario combined with his presenting symptoms, it is likely that he has diverticular disease. A low fibre diet would support this diagnosis. Acute diverticulitis would require treatment with antibiotics. Depending on the severity (Hinchey classification) would determine if he needs oral or IV antibiotics, hospital admission or outpatient treatment. Sometimes abscesses or micro perforations occur, which typical require drainage and possibly surgical intervention. Diverticular disease is clearly a better answer than other possible answer choices, simply based on the symptoms presented in the prompt (and mention of low fibre).
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This question is part of the following fields:
- Gastrointestinal System
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Question 18
Incorrect
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Tumour suppressor genes MLH1 and MSH2 are affected in which familial cancer?
Your Answer: Li-Fraumeni syndrome
Correct Answer: Hereditary non-polyposis colonic carcinoma (HNPCC)
Explanation:In hereditary non-polyposis colonic carcinoma (HNPCC), mutations in MSH2, MSH6, PMS2 or MLH1 genes are found.
Ataxia telangiectasia – ATM gene is affected.
Familial adenomatous polyposis – APC gene is affected.
Li-Fraumeni syndrome – mutation of the TP53 tumour suppressor gene. Neurofibromatosis – mutation in or a deletion of the NF1 gene -
This question is part of the following fields:
- Haematology & Oncology
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Question 19
Correct
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There is a measure of dispersion of a set of data from its mean. Which of following is the best term which can describe the above?
Your Answer: Standard deviation (root mean square deviation)
Explanation:Standard deviation is defined as the measure of dispersion of a set of data from its mean. It measures the absolute variability of a distribution; the higher the dispersion or variability, the greater is the standard deviation and greater will be the magnitude of the deviation of the value from their mean.
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This question is part of the following fields:
- Evidence Based Medicine
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Question 20
Correct
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In an emergency bowel procedure, which among these antibiotics are indicated during anaesthetic induction?
Your Answer: Metronidazole
Explanation:Antibiotic prophylaxis is utilized to avert infection and is based on the degree of contamination involved in the surgical procedure. Operations where the wound is contained with minimal risk of contamination, antibiotic prophylaxis is questionable. In this case there is a high risk of contamination.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 21
Correct
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A 45-year-old woman has been diagnosed with T1N1M1 malignancy in the left breast, with metastases detectable in the lower thoracic vertebrae and the left lung. Before the initiation of treatment of this patient with trastuzumab, which is the most important investigation to perform?
Your Answer: Echo
Explanation:Before the initiation of trastuzumab, an echocardiography is a must to rule out any pre-existing cardiac abnormalities as trastuzumab is cardiotoxic.
Trastuzumab (Herceptin) is a monoclonal antibody directed against the HER2/neu receptor. It is used mainly in metastatic breast cancer although some patients with early disease are now also given trastuzumab.
Adverse effects include:
Flu-like symptoms and diarrhoea are common.
Cardiotoxicity:
– Risk increases when anthracyclines are used concomitantly.
– Trastuzumab-induced cardiac dysfunctions are regarded as less severe and largely reversible because primary cardiomyocyte do not show ultrastructure changes unlike those associated with anthracycline-induced cardiotoxicity.
– Primary myocyte injury does not occur in patients who were treated with trastuzumab. -
This question is part of the following fields:
- Women's Health
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Question 22
Correct
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A 43-year-old female presented with a 5 day history of a productive cough with rusty coloured sputum. Chest X-ray showed lobar consolidation on her left side. The most likely causative organism would be?
Your Answer: Streptococcus pneumoniae
Explanation:Streptococcus pneumonia is the chief causative organism for lobar pneumonia in this age group patients. Typically patients present with rusty coloured sputum and a cough. Pneumocystis jiroveci is responsible for causing pneumocystis pneumonia among immunocompromised patients.
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This question is part of the following fields:
- Infectious Diseases
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Question 23
Correct
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A 23-year-old designer is requesting the combined oral contraceptive pill. During the history taking, she states that in the past she has had migraines with aura. She asks why the combined oral contraceptive pill is contraindicated. Which of the following is the most appropriate response?
Your Answer: Significantly increased risk of ischaemic stroke
Explanation:SIGN produced guidelines in 2008 on the management of migraines. Key points include that if patients have migraines with aura then the combined oral contraceptive (COC) is absolutely contraindicated due to an increased risk of stroke (relative risk 8.72).
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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 16-year-old patient was admitted with walking difficulties and knee pain. Upon examination, his leg is externally rotated and is 2 cm shorter. His ability to flex, abduct and medially rotate his leg is limited and when he flexes his hip, external rotation is increased. What is the most probable diagnosis?
Your Answer: Slipped femoral epiphysis
Explanation:The clinical presentation is typical of a slipped femoral epiphysis, which refers to a fracture through the growth plate (physis), resulting in slippage of the overlying end of the femur. It is the most common hip disorder in adolescence. SCFEs usually cause groin pain on the affected side, but sometimes cause knee or thigh pain. The range of motion in the hip is restricted in internal (medial) rotation, abduction, and flexion.
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This question is part of the following fields:
- Musculoskeletal System
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Question 25
Incorrect
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A 26-year-old male presents with right sided elbow and wrist pain and left sided knee and ankle pain that has persisted for about two weeks. He recently returned from a trip to Thailand that last for two weeks. The patient admits to having unprotected sex while on holiday. Examination reveals swelling and tenderness of tendons around joints but no inflammation of the joints. A vesiculopustular skin rash is also observed. What is the most likely cause?
Your Answer: Reactive arthritis
Correct Answer: Gonococcal arthritis
Explanation:Patients with disseminated gonococcal arthritis may present with dermatitis-arthritis syndrome (60%) of with localized septic arthritis. (40%). Arthritis-dermatitis syndrome includes the classic triad of dermatitis, tenosynovitis, and migratory polyarthritis. Gout usually involves a singe joint and does not cause vesicopustular skin rash. Reactive arthritis has ocular symptoms (conjunctivitis), urethritis, and arthritis. Fungal arthritis occurs rarely and it may occur after a surgical infection or fungal spread hematogenously. it presents with tender, red, hot and swollen joint with loss of range of motion.
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This question is part of the following fields:
- Musculoskeletal System
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Question 26
Correct
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A 55-year-old woman was found to have splenomegaly with her spleen palpable up to the umbilicus. Blood tests revealed the following results: Hb=8.7g/dl, Platelets=72 and WBC=100. What is the most probable diagnosis?
Your Answer: Chronic myeloid leukaemia
Explanation:Patients with chronic myeloid leukaemia (CML) can initially be asymptomatic but as the disease progresses, they appear to have elevated WBCs with anaemia and a lower than normal platelet count. The blood test results in addition to the profound splenomegaly, which is the most common finding in patients with CML, make CML the most possible diagnosis.
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This question is part of the following fields:
- Haematology & Oncology
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Question 27
Incorrect
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A 15-year-old child with learning difficulties is referred to the endocrine clinic for review. His lab results show hypocalcemia and increased serum concentration of parathyroid hormone. On examination, there is subcutaneous calcification and a short fifth metacarpal in each hand.
What is the treatment of choice in this case?Your Answer: Parathyroidectomy
Correct Answer: Calcium and vitamin D supplementation
Explanation:This child has pseudo hypoparathyroidism. It is a heterogeneous group of rare endocrine disorders characterized by normal renal function and resistance to the action of parathyroid hormone (PTH), manifesting with hypocalcaemia, hyperphosphatemia, and increased serum concentration of PTH.
Patients with pseudo hypoparathyroidism type 1a present with a characteristic phenotype collectively called Albright hereditary osteodystrophy (AHO). The constellation of findings includes the following:
Short stature
Stocky habitus
Obesity
Developmental delay
Round face
Dental hypoplasia
Brachymetacarpals
Brachymetatarsals
Soft tissue calcification/ossification
The goals of therapy are to maintain serum total and ionized calcium levels within the reference range to avoid hypercalcaemia and to suppress PTH levels to normal. This is important because elevated PTH levels in patients with PHP can cause increased bone remodelling and lead to hyper-parathyroid bone disease.
The goals of pharmacotherapy are to correct calcium deficiency, to prevent complications, and to reduce morbidity. Intravenous calcium is the initial treatment for all patients with severe symptomatic hypocalcaemia. Administration of oral calcium and 1alpha-hydroxylated vitamin D metabolites, such as calcitriol, remains the mainstay of treatment and should be initiated in every patient with a diagnosis of pseudo hypoparathyroidism. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 28
Incorrect
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A patient with chronic renal failure, treated with regular haemodialysis, attends the renal clinic. He has been treated for six months with oral ferrous sulphate, 200 mg three times a day. His haemoglobin at this clinic attendance is 7.6. His previous result was 10.6 six months ago.
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Which of the following is the most appropriate treatment?Your Answer: Commence SC erythropoietin
Correct Answer: IV iron and subcutaneous erythropoietin
Explanation:The patient should be prescribed IV iron and subcutaneous erythropoietin to enhance erythropoiesis to address the dropped haemoglobin.
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This question is part of the following fields:
- Renal System
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Question 29
Correct
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A 35-year-old woman is referred to the acute medical unit with a 5 day history of polyarthritis and a low-grade fever.
Examination reveals shin lesions which the patient states are painful. Chest x-ray shows a bulky mediastinum.
What is the most appropriate diagnosis?Your Answer: Lofgren's syndrome
Explanation:Lofgren’s syndrome is an acute form of sarcoidosis characterized by erythema nodosum, bilateral hilar lymphadenopathy (BHL), and polyarthralgia or polyarthritis. Other symptoms include anterior uveitis, fever, ankle periarthritis, and pulmonary involvement.
Löfgren syndrome is usually an acute disease with an excellent prognosis, typically resolving spontaneously from 6-8 weeks to up to 2 years after onset. Pulmonologists, ophthalmologists, and rheumatologists often define this syndrome differently, describing varying combinations of arthritis, arthralgia, uveitis, erythema nodosum, hilar adenopathy, and/or other clinical findings.
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This question is part of the following fields:
- Respiratory System
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Question 30
Correct
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A 45-year-old male presents to A&E, after hitting his car multiple times when reversing. He complains of double vision when he looked back during reversing. He also complains of double vision when looking with an outward gaze. Which is the nerve involved in this patient?
Your Answer: Abducent nerve
Explanation:This nerve is responsible for the side to side movement of the eye, hence why damage can cause double vision.
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This question is part of the following fields:
- Nervous System
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Question 31
Incorrect
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A 28-year-old male arrives at the clinic complaining of fever, arthralgia and urethritis. On examination, the ankle is swollen and there is a pustular rash on the dorsal foot. What is the most likely diagnosis?
Your Answer: Reactive arthritis
Correct Answer: Disseminated gonorrhoea
Explanation:DGI presents as two syndromes: 1) a bacteremic form that includes a triad of tenosynovitis, dermatitis, and polyarthralgias without purulent arthritis and 2) a septic arthritis form characterized as a purulent arthritis without associated skin lesions. Many patients will have overlapping features of both syndromes. Time from infection to clinical manifestations may range from 1 day to 3 months. There is no travel history and the rash of Lyme disease is not purulent. Reactive arthritis presents with conjunctivitis, urethritis and arthritis usually with a red hot tender and swollen joint.
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This question is part of the following fields:
- Musculoskeletal System
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Question 32
Correct
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A 23-year-old man is referred to the pneumologist with a suspicion of bronchiectasis. History reveals he's been having recurrent pulmonary infections his whole life together with difficulties gaining weight. He's a non-smoker with a clear family history and he admits inhalers haven't helped him in the past. He is finally suspected of having cystic fibrosis. What is the normal function of the cystic fibrosis transmembrane regulator?
Your Answer: Chloride channel
Explanation: -
This question is part of the following fields:
- Respiratory System
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Question 33
Correct
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A 60-year-old patient was admitted to the surgery department for elective herniorrhaphy. Due to a problem in his history, his operation was postponed. Which of the following is the most likely cause for this postponement?
Your Answer: MI 2 months ago
Explanation:After an MI, elective surgeries are recommended to be delayed for at least 6 months. This will help the patient become physically fit for the stress of surgery. Any surgery before this can carry a significant increased risk of mortality.
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This question is part of the following fields:
- Cardiovascular System
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Question 34
Correct
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A 44-year-old obese woman presented with severe abdominal pain in her right hypochondrium. An US abdomen was done which showed the presence of gallstones. The next step in management would be?
Your Answer: Laparoscopic Cholecystectomy
Explanation:With patients who are obese and have gallstones, the best procedure to be done is a laparoscopic cholecystectomy. Reassurance and low fat diets would not have much affect because these symptoms would recur if a cholecystectomy is not done.
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This question is part of the following fields:
- Hepatobiliary System
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Question 35
Correct
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Choose the molecule that acts as the co-receptor for cells expressing antigens linked with MHC class I molecules:
Your Answer: CD8
Explanation:CD8+ T cells recognize antigens in the form of short peptide fragments bound to major histocompatibility complex class I (MHCI) molecules on the target cell surface.1 Specific engagement of peptide-MHCI (pMHCI) complexes via the clonotypically expressed ?β T-cell receptor (TCR) triggers a range of effector functions that play a critical role in protective immunity against intracellular infections and various malignancies.
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This question is part of the following fields:
- Immune System
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Question 36
Correct
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A 51-year-old man speaks fast and does not take enough breaths before speaking again. He ignores interruptions and does not want to pause in between. What best describes this kind of speech?
Your Answer: Pressure of speech
Explanation:A pressured speech is too fast for the listener to understand and is very difficult to interrupt.
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This question is part of the following fields:
- Nervous System
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Question 37
Correct
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A 30-year-old female presents with polyuria and is passing 4 litres of urine per day. She was recently started on a new medication.
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Results show:
Serum sodium 144 mmol/L (137-144)
Plasma osmolality 299 mosmol/L (275-290)
Urine osmolality 210 mosmol/L (350-1000)
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Which of the following drugs was prescribed?Your Answer: Lithium
Explanation:The patient’s presentation is consistent with diabetes insipidus: eunatreaemia, high serum osmolality, and inappropriately dilute urine, which leads to the suspicion of lithium-induced diabetes insipidus.
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This question is part of the following fields:
- Renal System
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Question 38
Incorrect
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Which of the following may cause a downbeat nystagmus?
Your Answer: Central cerebellar lesion
Correct Answer: Chiari type I malformation
Explanation:Downbeat nystagmus (DBN) suggests a lesion in the lower part of the medulla. Chiari Type I malformation usually presents with symptoms due to brain stem and lower cranial nerve dysfunction, which includes DBN.
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This question is part of the following fields:
- Nervous System
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Question 39
Correct
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Which of the following is most commonly associated with the development of pseudomembranous colitis?
Your Answer: Cefuroxime
Explanation:Pseudomembranous colitis is caused by a C. difficile infection that causes membranes to form on the colon wall. It is caused most commonly by broad-spectrum antibiotics. This would include cephalosporins, broad-spectrum penicillin, and clindamycin. Macrolides and quinolones have also been reported as potential aetiologies, but much less commonly.
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This question is part of the following fields:
- Gastrointestinal System
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Question 40
Incorrect
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A 65-year-old female complains of pain and stiffness in her shoulders. She also finds it difficult to get out of her chair. From the list of symptoms below, choose the one most likely to support the diagnosis of polymyalgia rheumatica.
Your Answer: Muscle tenderness
Correct Answer: Low grade fever
Explanation:Polymyalgia rheumatica is an inflammatory disease which usually causes stiffness and pain in the shoulder – this can also occur in the pelvic girdle muscles. Its onset can either be subacute or acute and is associated with a systemic inflammatory response. This, therefore, causes symptoms such as fever, weight loss, anorexia, and malaise. Polymyalgia rheumatica is unpredictable in its course and it is known that 30 per cent of patients also present with giant cell arteritis. The cause of this disease is unknown but studies have shown it have infectious origins. Diagnosis of polymyalgia rheumatica can be difficult and other inflammatory diseases have to be excluded first. Patients with this disease are usually over 60 years of age (it is very rarely seen in those under 50). Muscle weakness does not present, although this can be hard to assess when the patient is in pain. Low-grade fever and weight loss are typical of this disease due to chronic inflammation. As such, weight gain is very rare and peripheral joints are usually not affected (they can be affected but it is very rare). Also, muscle tenderness is not a specific symptom of the disease – it is therefore not a classical finding of polymyalgia rheumatica. Although patients usually complain of stiffness and pain, the muscles are usually not significantly tender – this is usually more associated with fibromyalgia or myositis. When investigated, a normochromic/normocytic anaemia; a raised erythrocyte sedimentation rate often over 50 mm/hr., and raised C reactive protein are usually revealed. Symptoms of giant cell arteritis should also be sought, such as headaches, visual disturbances, TIAs (transient ischemic attacks), jaw claudication, and thickened temporal arteries. The patient response to a moderate dose of steroids is useful when confirming a diagnosis of polymyalgia rheumatica. The maximum dose of prednisolone should not exceed 20mg once a day. After treatment, patients should show a 70 per cent improvement in symptoms within a month (between 3-4 weeks). Inflammatory markers should also fall back to their normal levels. Non-steroidal anti-inflammatories are of little use and are associated with morbidity. There is also little evidence for the use of steroidal-sparing agents.
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This question is part of the following fields:
- Geriatric Medicine
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Question 41
Correct
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A 65-year-old man presents to you three weeks after initiating metformin for type 2 diabetes mellitus. His body mass index is 27.5 kg/m^2. At a dose of 500mg TDS the patient has experienced significant diarrhoea. Even on reducing the dose to 500mg BD his symptoms persisted. What is the most appropriate next step in this patient?
Your Answer: Start modified release metformin 500mg od with evening meal
Explanation:Here, the patient seems to be intolerant to standard metformin. In such cases, modified-release preparations is considered as the most appropriate next step.
There is some evidence that these produce fewer gastrointestinal side-effects in patients intolerant of standard-release metformin.Metformin is a biguanide and reduces blood glucose levels by decreasing the production of glucose in the liver, decreasing intestinal absorption and increasing insulin sensitivity.
Metformin decreases both the basal and postprandial blood glucose.
Other uses: In Polycystic Ovarian Syndrome (PCOS), Metformin decreases insulin levels, which then decreases luteinizing hormone and androgen levels. Thus acting to normalize the menstruation cycle.Note:
Metformin is contraindicated in patients with severe renal dysfunction, which is defined as a glomerular filtration rate (GFR) less than 30 ml/min/1.732m2.
Metformin overdose has been associated with hypoglycaemia and lactic acidosis, for this reason, it has a black box warning for lactic acidosis. -
This question is part of the following fields:
- Pharmacology
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Question 42
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: Cushing's syndrome
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 43
Correct
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A 23-year-old pregnant woman presents with glycosuria. What is the most likely mechanism?
Your Answer: Reduced renal reabsorption
Explanation:Throughout pregnancy the tubular reabsorption of glucose is less effective than in the non-pregnant state, this leads to glycosuria.
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This question is part of the following fields:
- Renal System
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Question 44
Correct
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A 30-year-old male with Down's Syndrome was found to have a systolic murmur during routine clinical examination. Which of the following is the most common cardiac defect associated with Down's Syndrome which will explain this finding?
Your Answer: Endocardial cushion defect
Explanation:Atrioventricular septal defect (AVSD) also known as endocardial cushion defect is the most common cardiac abnormality in Down’s Syndrome.
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This question is part of the following fields:
- Cardiovascular System
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Question 45
Correct
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A 37-year-old woman presents with sudden blindness. She claims she had a similar episode last year which resolved in three months. Fundoscopy is normal. Upon examination, mild weakness of the right upper limb is found. Reflexes on the same limb are exaggerated. What is the best treatment?
Your Answer: Corticosteroids
Explanation:The age of the patients together with sudden loss of vision, remission and relapse of optic neuritis, focal neurological symptoms and exaggerated reflexes all suggest multiple sclerosis. This is treated with corticosteroids.
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This question is part of the following fields:
- Nervous System
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Question 46
Correct
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A 66-year-old man visits the clinic because he has been experiencing increasing breathlessness for the past five months while doing daily tasks. His exercise tolerance is now limited to 75 metres while on a flat surface and walking up the stairs makes him breathless. He sleeps on four pillows and has swollen ankles in the morning. He occasionally coughs up phlegm.
Past Medical history of importance:
36 pack year smoking history
Hypertension
Ischaemic heart disease
Coronary artery stenting done 10 months ago
Pulmonary function testing revealed:
FEV1 0.90 L (1.80 - 3.02 predicted)
FVC 1.87 L (2.16 - 3.58 predicted)
Diffusion capacity 3.0 mmol/min/kPa (5.91 - 9.65 predicted)
Total lung capacity 4.50 L (4.25 - 6.22 predicted)
Residual volume 2.70 L (1.46 - 2.48 predicted)
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Which condition does he have?Your Answer: Chronic obstructive pulmonary disease
Explanation:Whilst asthma and COPD are different diseases they cause similar symptoms, which can present a challenge in identifying which of the two diseases a patient is suffering from. COPD causes chronic symptoms and narrowed airways which do not respond to treatment to open them up. In the case of asthma the constriction of the airways through inflammation tends to come and go and treatment to reduce inflammation and to open up the airways usually works well.
COPD is more likely than asthma to cause a chronic cough with phlegm and is rare before the age of 35 whilst asthma is common in under-35s. Disturbed sleep caused by breathlessness and wheeze is more likely in cases of asthma, as is a history of allergies, eczema and hay fever. Differentiating between COPD and asthma requires a history of both symptoms and spirometry. The spirometry history should include post bronchodilator measurements, the degree of reversibility and, ideally, home monitoring which gives a history of diurnal variation.
Airflow Obstruction: Both asthma and COPD are characterised by airflow obstruction. Airflow obstruction is defined as a reduced FEV1 and a reduced FEV1/FVC ratio, such that FEV1 is less than 80% of that predicted, and FEV1/FVC is less than 0.7.
These episodes are usually associated with widespread, but variable, airflow obstruction within the lung that is often reversible either spontaneously or with treatment.
COPD: COPD is a chronic, slowly progressive disorder characterised by airflow obstruction (reduced FEV1 and FEV1/VC ratio) that does not change markedly over several months. The airflow obstruction is not fully reversible.
Spirometry COPD Asthma
VC Reduced Nearly normal
FEV1 Reduced Reduced in attack
FVC (or FEV6) Reduced Nearly normal
FEV1 Ratio
(of VC/FVC/FEV6) Reduced in attackThis man has a low FEV1 and FVC. His diffusions capacity is also low despite having a normal total lung capacity. These values confirm a diagnosis of COPD.
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This question is part of the following fields:
- Respiratory System
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Question 47
Incorrect
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A 22-year-old female presents to the ER with a respiratory infection for which the physician prescribes her azithromycin. She, however, is currently on combined oral contraceptive pills. Regarding her contraception, what should be advised to this patient?
Your Answer: Using 14d condoms after antibiotics and avoid pill free break
Correct Answer: No extra precaution
Explanation:Rifampicin is the only antibiotic that has been reported to reduce plasma oestrogen concentrations. When taking Rifampicin, oral contraceptives cannot be relied upon and a second method of contraception is mandatory. Amoxicillin, ampicillin, griseofulvin, metronidazole and tetracycline have been rarely associated with contraceptive failure. When these agents are used, the clinician should discuss the available data with the patient and suggest a second form of birth control. Other antibiotics are most likely safe to use concomitantly with oral contraceptives.
The danger with COCP is enzyme inducers which can lower the levels of the hormone in he blood, azithromycin is not an enzyme inducer. No additional precautions are required to maintain contraceptive efficacy when using antibiotics that are not enzyme inducers with combined hormonal methods for durations of 3 weeks or less. The only proviso would be that if the antibiotics (and/or the illness) caused vomiting or diarrhoea, then the usual additional precautions relating to these conditions should be observed.Inducers: RASAG
– Rifampicin
– Anticonvulsants, particularly phenytoin, carbamazepine, phenobarbitone and primidone
– Spironolactone, St Johns wort
– Alcohol, long term
– Griseofulvin -
This question is part of the following fields:
- Women's Health
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Question 48
Correct
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A 62-year-old male patient with long standing COPD presented with reduced vision of his right eye. He had been on multiple medications. Which of the following drugs is responsible for his visual deterioration?
Your Answer: Corticosteroid
Explanation:Prolonged use of corticosteroids causes cataracts and this would be the reason for his presentation. B2 agonists, diuretics and Theophylline can cause blurred vision.
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This question is part of the following fields:
- Pharmacology
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Question 49
Correct
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A 61-year-old woman with a history of fluent dysphasia is brought by her husband because she's no longer able to understand instructions. Which is the most probable site of arterial occlusion?
Your Answer: Inferior division of middle cerebral artery (dominant hemisphere)
Explanation:The condition described is called Wernicke’s aphasia and is the result of occlusion of the inferior division of the middle cerebral artery. This type of aphasia is classified as fluent aphasia in which understanding is impaired.
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This question is part of the following fields:
- Nervous System
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Question 50
Correct
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A 70-year-old woman had a major surgery for removal of cancer of the ovary and lymph node dissection 6 days ago. She had not passed any flatus or stool since then. She recently developed recurrent vomiting and severe abdominal distention. What is the next step of management?
Your Answer: NG tube suction and IV fluids
Explanation:This patient developed paralytic ileus. It should be treated conservatively using IV fluids and NG tube.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 51
Correct
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A 61-year-old man presents post seizure. On examination, he is oriented and alert with hyperreflexia of the left arm, and inattention on the left side of the body. What is the most probable diagnosis?
Your Answer: Cerebral tumour
Explanation:Brain tumour symptoms include gradual paralysis on one side of the body, extreme headaches, and seizures. Hyperreflexia is defined as overactive reflexes including twitching or spastic tendencies, which are indicative of upper motor neuron disease.
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This question is part of the following fields:
- Nervous System
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Question 52
Correct
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A 57-year-old diabetic, smoker complains of non-healing ulcers and cramp-like pain in the calves relieved by rest. Examination results are as follows: absent distal pulses, and cold extremities with hair loss around the ankles. What is the most probable diagnosis?
Your Answer: Chronic ischemia of the limbs
Explanation:Chronic Limb Ischaemia presents with calf pain that is relieved by rest.
Intermittent claudication is not a diagnosis but a symptom and is not necessarily associated with diabetes.
Buerger’s disease occurs in younger heavy smokers (usually before age of 50).
DVT causes pain that is consistent, not intermittent as in claudication. -
This question is part of the following fields:
- Musculoskeletal System
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Question 53
Correct
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A 58-year-old female patient is being investigated for breathlessness, cough, and severe weight loss. On the medical ward round, her CXR is reviewed showing hilar lymphadenopathy and multiple peripheral lung metastases.
Which of the following tumours is least likely to be the underlying cause of this lung appearance?Your Answer: Brain
Explanation:All of the aforementioned listed tumours, except brain tumours, can metastasise to lungs and produce the typical CXR picture consisting of hilar lymphadenopathy with either diffuse multinodular shadows resembling miliary disease or multiple large well-defined masses (canon balls). Occasionally, cavitation or calcification may also be seen.
Most brain tumours, however, do not metastasise. Some, derived form neural elements, do so but in these cases, intraparenchymal metastases generally precede distant haematogenous spread.
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This question is part of the following fields:
- Haematology & Oncology
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Question 54
Correct
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A 25-year-old male presents to the emergency department with fever, sweating, hyperventilation and breathing difficulty. He also complains of a continuous ringing sensation in both his ears for the past couple of days. He admits to consuming a lot of over the counter painkillers for the past few days. Which of the following drugs is the most likely cause of these symptoms?
Your Answer: Aspirin
Explanation: -
This question is part of the following fields:
- Emergency & Critical Care
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Question 55
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 56
Correct
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A 42-year-old woman who has been a smoker since she was a teenager has the following blood result: Hgb=19. What hormone should you check?
Your Answer: Erythropoietin
Explanation:An increase in the patient’s haemoglobin tells us that the patient might be having an increased number of red blood cells. Smoking causes raised carboxyhaemoglobin levels and thus hypoxemia. Hypoxemia will increase the erythropoietin levels in the blood.
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This question is part of the following fields:
- Haematology & Oncology
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Question 57
Correct
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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: 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 58
Correct
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A 32-year-old lady is found to be hepatitis B surface antigen positive. This positive result has persisted for more than six months. Hepatitis B envelope antigen (HBeAg) is negative. HBV DNA is negative. Her liver function tests are all entirely normal.
Which of the following options would be the best for further management?Your Answer: No antiviral therapy but monitor serology
Explanation:Again, remember the Hepatitis B serologies: In chronic hepatitis B infection, you have +HBsAg, +anti-HBc, (-)IgM antiHBc, and (-) anti-HBs. In acute hepatitis B infection, you have +HBsAg, + anti-HBc, + IgM anti-HBc, and negative anti-HBs. In immunity due to natural infection, you have negative HBsAg, + anti-HBc, and + anti-HBs. In immunity due to vaccination, you have negative HBsAg, negative anti-HBc, and positive anti-HBs. IN THIS CASE, the person is HBsAg+ for 6 months and everything else is negative, normal transaminase. They do not need antiviral therapy, but their serology should be monitored serially. There would be no reason to do a liver biopsy.
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This question is part of the following fields:
- Gastrointestinal System
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Question 59
Incorrect
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A 34-year-old male presented with exertional dyspnoea and chest pain for the past 2 weeks. On examination there was a mid-systolic murmur which is best heard at the apex and double apical impulse. His ECG showed left ventricular hypertrophy (LVH). What is the risk factor which would be most indicative of the potential for sudden death in this patient?
Your Answer: Asymmetrical septal hypertrophy
Correct Answer: Degree of left ventricular hypertrophy
Explanation:The history is suggestive of hypertrophic obstructive cardiac myopathy. The degree of left ventricular hypertrophy is strongly associated with sudden cardiac death.
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This question is part of the following fields:
- Cardiovascular System
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Question 60
Correct
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Question 61
Correct
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A 65-year-old, heavily alcohol dependent man came to the hospital with bleeding gums and petechiae upon examination. Which of the following is the likely vitamin deficiency?
Your Answer: C
Explanation:Vitamin deficiencies can happen in alcoholics due to malabsorption. Vitamin C deficiency or scurvy can result in bleeding gums and early symptoms including body weakness and lethargy. Other vitamin deficiencies can cause the following:
B1 or thiamine – Wernicke’s encephalopathy
B12 or cyanocobalamin – spinal cord degeneration
Vitamin K – anticoagulant effects
Vitamin E – neuropathies. -
This question is part of the following fields:
- Gastrointestinal System
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Question 62
Correct
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A diabetic 50-year-old male presented in the emergency room with ischaemic gangrene of the lower leg, ulceration over the medial malleolus and infection spreading proximally. Which of the following types of amputation is most suitable in this patient?
Your Answer: Below knee amputation
Explanation:The type of amputation depends on the degree of gangrene, ischaemia and the extent of involvement of the foot, leg, knee etc. In this case, below-knee amputation is the most appropriate choice.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 63
Correct
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A phrenic nerve palsy is caused by which of the following?
Your Answer: Aortic aneurysm
Explanation:Phrenic nerve palsy causing hemidiaphragm paralysis is a very uncommon feature of thoracic aortic aneurysm.
Thoracic aortic aneurysms are usually asymptomatic however chest pain is most commonly reported symptom. Left hemidiaphragm paralysis, because of left phrenic nerve palsy, is a very rare presentation of thoracic aortic aneurysm.
Thoracic aortic aneurysm may present atypical symptoms such as dysphagia due to compression of the oesophagus; hoarseness due to vocal cord paralysis or compression of the recurrent laryngeal nerve; superior vena cava syndrome due to compression of the superior vena cava; cough, dyspnoea or both due to tracheal compression; haemoptysis due to rupture of the aneurysm into a bronchus; and shock due to rupture of the aneurysm.
Common causes of phrenic nerve palsy include malignancy such as bronchogenic carcinoma, as well as mediastinal and neck tumours. Phrenic nerve palsy can also occur due to a penetrating injury or due to iatrogenic causes arising, for example, during cardiac surgery and central venous catheterization. Many cases or phrenic nerve palsy are idiopathic. -
This question is part of the following fields:
- Respiratory System
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Question 64
Incorrect
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A 60-year-old patient diagnosed with Type-2 diabetes mellitus is not responding to dietary modifications and weight reduction. He needs to be started on an oral hypoglycemic agent. Which among the following statements regarding oral hypoglycaemic agents is true?
Your Answer: Pioglitazone is strongly associated with significant hepatotoxicity
Correct Answer: Acarbose inhibits ?-glucosidase
Explanation: -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 65
Incorrect
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Following a road traffic accident, a gentleman is brought to A&E. He is found to have oliguria and diagnosed with acute renal tubular necrosis.
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What is the most common complication and cause of death in this condition?Your Answer: Electrolyte abnormalities
Correct Answer: Infection
Explanation:In patients with acute renal tubular necrosis, infection in the form of gram-negative septicaemia is the most common cause of death, especially while the patient is awaiting spontaneous recovery of their renal function.
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This question is part of the following fields:
- Renal System
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Question 66
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 67
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: Decompensated type-1 respiratory failure
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 68
Incorrect
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Which area in the body controls the hypoxic drive to breathe?
Your Answer: Areas on ventrolateral surface of the medulla
Correct Answer: Carotid body
Explanation:The carotid body consists of chemosensitive cells at the bifurcation of the common carotid artery that respond to changes in oxygen tension and, to a lesser extent, pH. In contrast to central chemoreceptors (which primarily respond to PaCO2) and the aortic bodies (which primarily have circulatory effects: bradycardia, hypertension, adrenal stimulation, and also bronchoconstriction), carotid bodies are most sensitive to PaO2. At a PaO2 of approximately 55-60 mmHg, they send their impulses via CN IX to the medulla, increasing ventilatory drive (increased respiratory rate, tidal volume, and minute ventilation). Thus, patients who rely on hypoxic respiratory drive will typically have a resting PaO2 around 60 mm Hg.
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This question is part of the following fields:
- Respiratory System
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Question 69
Correct
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A 45-year-old male suffers multiple injuries in a road traffic accident. He complains of inability to urinate for the past 4 hours. Radiological examination reveals a fractured pelvis. Which of the following will be the most appropriate step in the management of this patient?
Your Answer: Suprapubic catheter
Explanation:When faced with urethral trauma, initial management decisions must be made in the context of other injuries and patient stability. These patients often have multiple injuries, and management must be coordinated with other specialists, usually trauma, critical care, and orthopaedic specialists. Life-threatening injuries must be corrected first in any trauma algorithm. Initial emergent treatment remains controversial, but mainstays of therapy include drainage of the urinary bladder, often with placement of a suprapubic catheter (SPT) and primary endoscopic realignment of the urethra if possible.
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This question is part of the following fields:
- Renal System
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Question 70
Correct
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A 52-year-old cancer patient that recently had an anterior resection of the rectum is concerned about postoperative pain control. What is the most appropriate management choice in his case?
Your Answer: IM morphine
Explanation:Post-operative pain is usually severe and strong analgesia is needed with IM morphine.
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This question is part of the following fields:
- Pharmacology
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Question 71
Correct
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A 47-year-old woman is being treated with steroids for her diagnosis of giant cell arteritis (GCA). What is the other drug that can be added to this?
Your Answer: Aspirin
Explanation:Low dose aspirin is proven efficient in aversion of complications connected with giant cell arteritis such as stroke.
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This question is part of the following fields:
- Pharmacology
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Question 72
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 73
Incorrect
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Which of the following cancers is responsible in producing osteoblastic bone metastases instead of osteolytic?
Your Answer: Endometrial adenocarcinoma
Correct Answer: Prostate adenocarcinoma
Explanation:Osteoblastic (or sclerotic) bone metastases, characterized by deposition of new bone, present in prostate cancer, carcinoid, small cell lung cancer, Hodgkin lymphoma or medulloblastoma.
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This question is part of the following fields:
- Musculoskeletal System
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Question 74
Correct
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A 75-year-old man was brought to the clinic by his wife because lately he has lost interest in activities he previously enjoyed. His wife is worried and claims he's generally withdrawn. What would exclude depression in favour of dementia?
Your Answer: Urinary incontinence
Explanation:Urinary incontinence is not a usual symptom of depression. A depressed patient is usually capable of maintaining control of his body sphincters. In dementia, however, urinary incontinence is an important and late symptom of the disease, non-related to any urinary tract pathology. It is rather related to the cognitive impairment caused by dementia.
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This question is part of the following fields:
- Geriatric Medicine
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Question 75
Incorrect
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A 43-year-old police officer is admitted with a history of unsteadiness and slurring of speech. This has worsened over a period of three months. He complains of a tremor affecting his right hand and diplopia on right lateral gaze. He smokes 30 cigarettes a day and takes regular diclofenac for his arthritis. On examination, he is dysarthric and feels nauseated. Fundoscopy is normal, however there is marked horizontal nystagmus and evidence of a right VI nerve palsy. There also appears to be some mild facial weakness on the right side. Upon conducting Weber's test, a louder tone is heard in the left ear. On conducting the Rinne test, both ears are normal. On examination of the upper limb, there is a right intention tremor and dysdiadochokinesis. Tone, power and reflexes are normal. On examination of the lower limb, tone, power and reflexes are normal, however he appears to walk with a broad-based gait and is leaning to the right.
Lumbar puncture:
Opening pressure 13 cm H20 (5-18)
Protein 0.67 g/l (0.15-0.45)
WCC 3 cells/ml (<5)
Red cell count (RCC) 2 cells/ml (<5)
Glucose 3.2 mmol/l (3.3-4.4)
Blood glucose 5.8 mmol/l (3.0-6.0)
Oligoclonal bands Present
Serum oligoclonal bands Present
Magnetic resonance scan shows a calcified lesion broadly attached to the petrous part of the temporal bone. In view of the above history and findings, what is the likely cause of this patient's symptoms?Your Answer: Primary progressive multiple sclerosis
Correct Answer: Meningioma of the cerebellar pontine angle
Explanation:This patient has a combination of right cerebellar dysfunction with right-sided cranial nerve palsies (VI, VII, and VIII). The magnetic resonance imaging (MRI) shows a calcified meningioma within the right cerebellar pontine area, which would account for these findings. The cerebrospinal fluid (CSF) analysis shows oligoclonal bands, however, these are matched in the serum, which reflects a systemic inflammatory response from his rheumatoid arthritis.
The MRI scan and CSF analysis would not be consistent with progressive multiple sclerosis. The progressive nature of her symptoms would be against a diagnosis of brainstem infarct, and one would expect more pyramidal signs in the peripheral nervous system.
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This question is part of the following fields:
- Nervous System
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Question 76
Correct
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A 20-year-old male presented after an episode where he had collapsed. This was the second time he has collapsed during the past 3 weeks. His father passed away at the age of 40 due to sudden cardiac death. Echocardiography showed evidence of hypertrophic cardiomyopathy. His 24 hr ECG revealed several short runs of nonsustained ventricular tachycardia (VT). Which of the following is the most appropriate management for this patient?
Your Answer: Implantable cardiovertor defibrillator
Explanation:This patient has a high risk of sudden cardiac death due to a strong family history and non sustained VT. So the most appropriate management is implantable cardiovertor defibrillator.
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This question is part of the following fields:
- Cardiovascular System
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Question 77
Correct
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A 65-year-old man known to have renal cell carcinoma, is currently undergoing treatment. He presents to the acute medical ward with one month history of worsening central lower back pain, which becomes worse at night and cannot be managed with an analgesia at home. He has no other new symptoms.
Out of the following, which investigation should be performed next?Your Answer: MRI whole spine
Explanation:An MRI whole spine should be performed in a patient suspected of spinal metastasis which can occur before developing metastatic spinal cord compression. This patient has renal cell carcinoma, which readily metastasises to the bones and also has progressive back pain. He, therefore, needs urgent imaging of his spine before any neurological compromise develops. MRI whole spine is preferable because patients with spinal metastasis often have metastases at multiple levels within the spine. Plain radiographs and CT scans should not be performed as they have a lower sensitivity for revealing lesions and cannot exclude cord compression.
In general, imaging should be performed within one week if symptoms suspicious of spinal metastasis without neurological symptoms are present. If there are symptoms suggestive of malignant spinal cord compression, then imaging should be done within 24 hours.
The signs and symptoms of spinal metastases include:
1. Unrelenting lumbar back pain
2. Thoracic or cervical back pain
3. Pain associated with tenderness and worsens with sneezing, coughing, or straining
4. Nocturnal pain -
This question is part of the following fields:
- Haematology & Oncology
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Question 78
Correct
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A 17-year-old boy was brought to clinic, as his parents were concerned regarding possible delayed puberty. He was otherwise well, played sports regularly and his academic performance was good. His height was 1.7m and weight was 70 kg. On examination, he had a small penis and testes, absent pubic hair, but no other abnormalities. Investigations revealed: Serum testosterone 4 nmol/L (9-35) Plasma follicle stimulating hormone (FSH) 1 U/L (1-7) Plasma luteinising hormone (LH) 1 U/L (1-10) Plasma prolactin 300 mU/L (<450) Plasma TSH 2 mU/L (0.5-5) Which one of the following is the most likely cause?
Your Answer: Kallman's syndrome
Explanation:Klinefelter’s syndrome: The low follicle-stimulating hormone (FSH) and luteinising hormone (LH), together with the low testosterone, suggests a hypogonadotropic hypogonadism. We know that there is no mental retardation, and we are told that physical examination is normal and sense of smell would usually not be tested. Consequently a diagnosis of Kallman’s is suggested. We are not told of a family history of growth delay, thus this is unlikely to be constitutional delay. The thyroid-stimulating hormone (TSH) is normal, making hypothyroidism unlikely and this together with the normal prolactin make hypopituitarism most unlikely.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 79
Correct
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What is the rationale concerning the use of sodium cromoglycate in the prophylaxis of bronchial asthma?
Your Answer: Inhibition of mast-cell degranulation
Explanation:Sodium cromoglycate principally acts by inhibiting the degranulation of mast cells triggered by the interaction of antigen and IgE.
The inhibitory effect on mast cells appears to be cell-type specific since cromoglycate has little inhibitory effect on mediator release from human basophils.
Thus, it inhibits the release of histamine, leukotrienes, and slow-reacting substance of anaphylaxis from mast cells by inhibiting degranulation following exposure to reactive antigens.Adverse effects include cough, flushing, palpitation, chest pain, nasal congestion, nausea, fatigue, migraine, etc.
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This question is part of the following fields:
- Pharmacology
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Question 80
Correct
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A 60-year-old previously well male patient was admitted with acute severe central chest pain associated with excessive sweating and nausea for the past 45 minutes. On examination he was found to have xanthelasma. His blood pressure was 170/100 mmHg and pulse rate was 104 bpm. His ECG showed ST elevation more than 2mm in leads II, III and aVF. His troponin T was 120 ng/ml. His FBC and renal functions were normal. He was given aspirin, clopidogrel, morphine and IV 5 mg of atenolol. Which of the following is the most appropriate next step?
Your Answer: Immediate referral to cardiologist for primary angioplasty
Explanation:The diagnosis is acute inferior ST elevation myocardial infarction so the most appropriate management is primary angioplasty.
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This question is part of the following fields:
- Cardiovascular System
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Question 81
Incorrect
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Which one of the following is true of gamma delta T cells?
Your Answer: They develop in the peripheral lymph nodes
Correct Answer: They play a role in the skin and gut
Explanation:Gamma delta T cells are of low abundance in the body, are found in the gut mucosa, skin, lungs and uterus, and are involved in the initiation and propagation of immune responses. Their ligands are not known in detail, but the gamma delta T cell receptors recognise intact proteins rather than MHC-presented peptides. Like alpha beta T cells, they develop in the thymus.
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This question is part of the following fields:
- Haematology & Oncology
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Question 82
Incorrect
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Cholecystokinin is secreted from:
Your Answer: G cells in stomach
Correct Answer: I cells in upper small intestine
Explanation:Cholecystokinin (CCK) was discovered in 1928 in jejunal extracts as a gallbladder contraction factor. It was later shown to be member of a peptide family, which are all ligands for the CCK1 and CCK2 receptors. CCK peptides are known to be synthetized in the small intestinal endocrine I-cells and cerebral neurons.
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This question is part of the following fields:
- Gastrointestinal System
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Question 83
Correct
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A 44-year-old alcoholic man was operated on for a strangulated abdominal hernia, however a few days after the operation he became agitated. According to the patient, he used to see snakes curling over his body. O/E he was agitated, tachycardiac and confused. The most likely diagnosis would be?
Your Answer: Delirium tremens
Explanation:Delirium tremens occurs due to alcohol withdrawal and presents clinically with hallucinations, agitations, confusion and hyperthermia. Wernicke’s encephalopathy is characterised by encephalopathy, oculomotor dysfunction and ataxic gait. In Korsakoff’s syndrome, there is marked short term memory loss, however the long term memory is preserved & the sensorium is also intact.
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This question is part of the following fields:
- Nervous System
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Question 84
Correct
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A 44-year-old female is admitted to the emergency with dyspnoea, syncope, fever and arthropathy. She was recently diagnosed with pulmonary emboli. Cardiovascular examination reveals an early diastolic sound with a mid diastolic rumble. The JVP is found to be elevated and there are prominent a waves. Which of the following would be the most likely cause of her symptoms?
Your Answer: Atrial myxoma
Explanation:Cardiac myxomas are the most common type of primary tumour of the heart. They are usually benign and arise from primary connective tissue. Most cardiac myxomas arise sporadically; however, 10% are hereditary (following an autosomal dominant pattern). Even though they may develop in any chamber of the heart, most (+-75 %) cardiac myxomas arise in the left atrium, usually from the interatrial septum, while the rest occur in the right atrium (ventricular myxomas are rare). Clinical features are primarily caused by obstruction of the blood flow through the heart and include dyspnoea on exertion, palpitations, syncope, weight loss, or even sudden death. Rarely, life-threatening conditions (e.g., stroke) may result from an embolization from the myxoma. Typical examination findings include abnormal heart sounds, such as a rumbling diastolic murmur over the apex or a characteristic tumour plop.
The diagnosis is not easily established clinically because of the nonspecific nature of symptoms. Echocardiography is the diagnostic procedure of choice. Surgical resection of the tumour is the curative treatment of choice. The prognosis is usually favourable, but tumours can recur after inadequate resection. -
This question is part of the following fields:
- Cardiovascular System
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Question 85
Incorrect
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A 28-year-old woman is investigated for bloody diarrhoea which started around six weeks ago. She is currently passing 3-4 loose stools a day which normally contain a small amount of blood. Other than feeling lethargic she remains systemically well with no fever or significant abdominal pain. A colonoscopy is performed which shows inflammatory changes in the ascending colon consistent with ulcerative colitis. Bloods show the following:
Hb: 14.2 g/dl
Platelets: 323 * 109/l
WBC: 8.1 * 109/l
CRP: 22 mg/l
What is the most appropriate first-line medication to induce remission?Your Answer: Rectal aminosalicylate
Correct Answer: Oral aminosalicylate
Explanation:Given she is not showing signs of systemic illness, you do not need to treat for an acute flair (which would be steroids), but you need to put her on maintenance medication. Oral ASA would be the best option for this, it is first line. You cannot give rectal ASA because the location of her disease is in the ascending colon and the enema will not reach.
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This question is part of the following fields:
- Gastrointestinal System
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Question 86
Correct
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Which of the following is not associated with right axis deviation?
Your Answer: Wolf-Parkinson-White syndrome with right-sided accessory pathway
Explanation:Causes for right axis deviation:
-Right ventricular hypertrophy and Left posterior fascicular block
-Lateral myocardial infarction.
-Acute or chronic lung diseases: Pulmonary embolism, pulmonary hypertension, chronic obstructive pulmonary disease (COPD), cor pulmonale.
-Congenital heart disease (e.g., dextrocardia, secundum atrial septal defect).
-Wolff-Parkinson-White syndrome.
-Ventricular ectopic rhythms (e.g., ventricular tachycardia). -
This question is part of the following fields:
- Cardiovascular System
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Question 87
Incorrect
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A 45-year-old obese patient arrives at the clinic for a regular health check up. His labs are as follows: Fasting blood sugar: 6 mmol/l, Oral glucose tolerance test (OGTT): 10 mmol/L. What is the most likely diagnosis?
Your Answer: Type 2 Diabetes Mellitus
Correct Answer: Impaired glucose tolerance
Explanation:Impaired glucose tolerance means that blood glucose is raised beyond normal levels, but not high enough to warrant a diabetes diagnosis. With impaired glucose tolerance you face a much greater risk of developing diabetes and cardiovascular disease. Impaired glucose tolerance is defined as 2-hour glucose levels of 140 to 199 mg per dL (7.8 to 11.0 mmol) on the 75-g oral glucose tolerance test, and impaired fasting glucose is defined as glucose levels of 100 to 125 mg per dL (5.6 to 6.9 mmol per L) in fasting patients.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 88
Incorrect
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A 32-year-old woman was referred for endoscopy and found to have a duodenal ulcer and a positive urease test. She was given lansoprazole, amoxicillin and clarithromycin for 7 days.
Which of the following is the most appropriate way of determining the successful eradication of H. pylori?Your Answer: Faecal antigen testing
Correct Answer: Urea breath test
Explanation:Urea breath test is the most sensitive test to determine if there has been RESOLUTION/ERADICATION of the infection with H. pylori. The best test for initial diagnosis would be EGD with biopsy.
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This question is part of the following fields:
- Gastrointestinal System
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Question 89
Correct
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A 60-year-old male presented in OPD with a complaint of inability to walk properly because of his left foot. History reveals he has undergone left knee surgery to for severe arthritis. On examination, dorsiflexion of his left foot was found to be compromised, and sensation over the dorsum of his left foot was impaired. Which of the following conditions is this man most likely suffering from?
Your Answer: Compression of common peroneal nerve
Explanation:The branches of the common peroneal nerve innervate the skin of the dorsum of the foot as well as the muscles which help to carry out dorsiflexion of the foot. Compression of the common peroneal nerve cause foot drop as well as the loss in sensation of the skin on the dorsum of the foot.
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This question is part of the following fields:
- Nervous System
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Question 90
Correct
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A 74-year-old female complains of coarse tremors. Which of the following drugs may be the cause?
Your Answer: Lithium
Explanation:The most common adverse effect of lithium is fine hand tremors. It is also an early sign of toxicity.
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This question is part of the following fields:
- Pharmacology
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Question 91
Correct
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A 50-year-old smoker with a history of hypertension presented with acute severe chest pain and acute myocardial infarction was diagnosed. Which of the following is a contraindication for thrombolysis?
Your Answer: History of likely ischaemic stroke within the past month
Explanation:Absolute contraindications for fibrinolytic use in STEMI
Prior intracranial haemorrhage (ICH)
Known structural cerebral vascular lesion
Known malignant intracranial neoplasm
Ischemic stroke within 3 months
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed head trauma or facial trauma within 3 months
Intracranial or intraspinal surgery within 2 months
Severe uncontrolled hypertension (unresponsive to emergency therapy)
For streptokinase, prior treatment within the previous 6 months -
This question is part of the following fields:
- Cardiovascular System
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Question 92
Correct
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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: 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 93
Correct
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A 14 year-old is brought to the ED after being hit on the head with a cricket ball during a match. His teacher describes that he initially collapsed on the ground and complained of a sore head. Two minutes later, he got up and said he felt OK and continued playing. However, 30 minutes later he suddenly collapsed and lost consciousness. What injury is he most likely to have sustained?
Your Answer: Extradural haematoma
Explanation:A lucid interval, in which the patient portrays a temporary improvement in condition after a traumatic brain injury, is especially indicative of an epidural haematoma.
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This question is part of the following fields:
- Nervous System
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Question 94
Incorrect
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A 55-year-old male presented with a mass in his right groin. On examination there was a pulsatile mass just below the midpoint of the inguinal ligament. Which of the following is the most probable diagnosis?
Your Answer: Femoral aneurysm
Correct Answer: Femoral hernia
Explanation:Midpoint of the inguinal ligament is halfway between the pubic tubercle and the anterior superior iliac spine (the two attachments of the inguinal ligament). The opening to the inguinal canal is located just above this point. The femoral artery is at the mid-inguinal point which is halfway between the pubic symphysis and the anterior superior iliac spine. As the mass is at the midpoint of the inguinal ligament, the most probable answer is a femoral hernia. A femoral aneurysm is also a possibility.
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This question is part of the following fields:
- Musculoskeletal System
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Question 95
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: Minimal change disease
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 96
Incorrect
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A 75-year-old man presented to hospital after suffering a stroke. The doctor admitted him and advised of the Barthel score index. During rehabilitation, which one of the following limitations are best described by Barthel score index?
Your Answer: It is not very sensitive
Correct Answer: Floor and ceiling effects
Explanation:Barthel scoring has floor and ceiling effects which is the most widely recognised limitation. Floor effect means that the patient who is bed bound can score initially low, whereas the ceiling effect shows that despite being bed bound, a patient can achieve a maximum score i.e. 100. The test is easy to perform and correlates well with other prognostic scales.
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This question is part of the following fields:
- Geriatric Medicine
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Question 97
Incorrect
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A 24-year-old male with a history of a cardiac murmur which was not properly followed up, presented with right sided hemiparesis. His blood pressure was 120/70 mmHg. His ECG revealed right bundle branch block with right axis deviation. Which of the following is the most likely cause for this presentation?
Your Answer: Ostium primum atrial septal defect
Correct Answer: Ostium secundum atrial septal defect
Explanation:Ostium secundum atrial septal defects are known to cause stroke due to the passage of emboli from the right sided circulation to the left sided circulation. ECG shows tall, peaked P waves (usually best seen in leads II and V2) and prolongation of the PR interval, rSR pattern in leads V3 R and V1 as well as right axis deviation.
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This question is part of the following fields:
- Cardiovascular System
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Question 98
Incorrect
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A 68-year-old palliative care patient with bronchial cancer is suffering from recurrent, distressing cough because he cannot cough up his secretions. Which of the following drugs would most likely be helpful?
Your Answer: Pilocarpine
Correct Answer: Scopolamine
Explanation:When death is imminent, oral and respiratory secretions become salient symptoms. It is important to separate the nursing concerns of frequent suctioning, the family concerns of chest crackles, and the true symptoms of dyspnoea or cough sensed by the patient. While opioids are the most successful agents for management of dyspnoea, anticholinergic agents such as scopolamine and glycopyrrolate are preferred for control of copious secretions. Symptoms such as pain and dyspnoea that do not respond to initial therapy should prompt referral to palliative care and pain management specialists, from the time of presentation until the last days of life.
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This question is part of the following fields:
- Geriatric Medicine
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Question 99
Incorrect
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A 34-year-old man presents with haemoptysis and weight loss. History reveals he suffers from night sweats and upon auscultation you notice reduced breath sounds over the apex of his right lung and significant nail clubbing. You refer him to a pneumologist who administers the following antibiotics: rifampicin, ethambutol, pyrazinamide and isoniazid. What is the mechanism of action of the first drug?
Your Answer: Inhibit DNA synthesis
Correct Answer: Inhibit RNA synthesis
Explanation:Rifampicin specifically inhibits bacterial RNA polymerase, the enzyme responsible for DNA transcription, by forming a stable drug-enzyme complex with a binding constant of 10(-9) M at 37 C.
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This question is part of the following fields:
- Infectious Diseases
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Question 100
Incorrect
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A 45-year-old male, chronic smoker presented with a 6 month history of a productive cough with blood stained sputum and shortness of breath. The most likely diagnosis would be?
Your Answer: Lung Cancer
Correct Answer: Bronchiectasis
Explanation:Bronchiectasis is characterised by a blood stained productive cough with copious amount of sputum production, along with dyspnoea.
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This question is part of the following fields:
- Respiratory System
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Question 101
Incorrect
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A 19-year-old male presented with a fever and fatigue. On examination, he had multiple lesions on his back and abdomen in various forms. Which of the following is the most probable diagnosis?
Your Answer: None of the above
Correct Answer: Varicella zoster
Explanation:Patients with varicella zoster infection present with general fatigue and fever along with multiple lesions which do not appear to be identical.
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This question is part of the following fields:
- Infectious Diseases
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Question 102
Correct
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A thin 18-year-old girl has bilateral parotid swelling with thickened calluses on the dorsum of her hand. What is the single most likely diagnosis?
Your Answer: Bulimia nervosa
Explanation:Bulimia nervosa is a condition in which a person is involved in binge eating and then purging. This patient has swollen parotid glands. The glands swell in order to increase saliva production so that the saliva lost in the vomiting is compensated. This patient also has thickened calluses on the back of her hand. This is known as Russell’s sign. This occurs because of putting fingers in the mouth again and again to induce the gag reflex and vomit. The knuckles get inflamed in the process after coming in contact with the teeth multiple times.
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This question is part of the following fields:
- Gastrointestinal System
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Question 103
Incorrect
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A study is developed to assess a new mandibular advancement device designed to reduce snoring. A 10 point scale was used to assess the severity of snoring before and after applying of the device by the respective partner. The number of the people involved in the study was 50. What test would you apply in this particular study?
Your Answer: Pearson's product-moment coefficient
Correct Answer: Wilcoxon signed-rank test
Explanation:Steps required in performing the Wilcoxon signed rank test:
1 State the null hypothesis and, in particular, the hypothesized value for comparison
2 Rank all observations in increasing order of magnitude, ignoring their sign. Ignore any observations that are equal to the hypothesized value. If two observations have the same magnitude, regardless of sign, then they are given an average ranking
3 Allocate a sign (+ or -) to each observation according to whether it is greater or less than the hypothesized value (as in the sign test)
4 Calculate:
R+ = sum of all positive ranks
R- = sum of all negative ranks
R = smaller of R+ and R-
5 Calculate an appropriate P value What makes this test the most appropriate for this study is that the data is non-parametric, paired and comes from the same population. -
This question is part of the following fields:
- Evidence Based Medicine
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Question 104
Incorrect
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From the options provided below, which intervention plays the greatest role in increasing survival in patients with COPD?
Your Answer: Long-term oxygen therapy
Correct Answer: Smoking cessation
Explanation:Smoking cessation is the most effective intervention in stopping the progression of COPD, as well as increasing survival and reducing morbidity. This is why smoking cessation should be the top priority in the treatment of COPD. Long term oxygen therapy (LTOT) may increase survival in hypoxic patients. The rest of the options dilate airways, reduce inflammation and thereby improve symptoms but do not necessarily increase survival.
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This question is part of the following fields:
- Respiratory System
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Question 105
Incorrect
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A 70-year-old male patient was started on gentamicin after developing a pseudomonas aeruginosa infection. Which of the following is associated with aminoglycoside nephrotoxicity?
Your Answer: Post-antibiotic effect
Correct Answer: Frequency of aminoglycoside dosing
Explanation:Aminoglycosides can induce acute kidney injury by damaging the cells of the proximal tubule which is its site of reabsorption after glomerular filtration. When the aminoglycoside is administered less frequently, the kidney has more time to recover by eliminating the drug and preventing its accumulation and possible toxic effects.
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This question is part of the following fields:
- Renal System
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Question 106
Incorrect
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Ciprofloxacin is used to treat many infectious diseases. It acts by which of the following mechanisms?
Your Answer: Inhibition of protein synthesis (translation)
Correct Answer: Interference with DNA replication
Explanation:Ciprofloxacin disturbs the functioning of DNA gyrase and interferes in the DNA replication process.
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This question is part of the following fields:
- Pharmacology
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Question 107
Incorrect
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A 45-year-old man with diabetes comes to the clinic for his annual review.
He has had diabetes for eight years and he is also being treated for hypertension. He is on the following medications: metformin 500 mg tds, gliclazide 80 mg daily, atorvastatin 10 mg/d, Ramipril 10 mg/d and Bendroflumethiazide 2.5 mg/d.
He is noted to be obese (130kg). Physical examination is otherwise unremarkable.
Investigations reveal:
HbA1c 8.1% (3.8-6.4)
Fasting glucose 9 mmol/L (3.0-6.0)
24 hr Urine free cortisol 354 mmol/d (<250)
9am Plasma ACTH 4 ng/dL (10-50)
CT abdomen 3 cm right adrenal mass
Which of the following is most likely to be the adrenal mass?Your Answer:
Correct Answer: Cortisol secreting adenoma
Explanation:The patient has Cushing syndrome suggested by the elevated 24hr urine free cortisol. Hence, the mass is most probably a cortisol secreting adenoma.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 108
Incorrect
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A 30-year-old previously well female presented with yellowish discolouration of her sclera. Investigations revealed low haemoglobin, a retic count of 8% and the occasional spherocyte on blood film. Which of the following is the most appropriate single investigation?
Your Answer:
Correct Answer: Direct coombs test
Explanation:A low haemoglobin and a high retic count is suggestive of a haemolytic anaemia. Occasional spherocytes can be seen on blood film during haemolysis and it is not a specific finding. Direct Coombs test will help to identify autoimmune haemolytic anaemia, where there are antibodies attached to RBCs.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 109
Incorrect
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A 74-year-old man presents with a history of falls and enuresis. Recently his behaviour has been bizarre but the falling has persisted for the last 12 months. Upon examination he's found to be disorientated for time and place. His gait is clumsy and broad-based. What is the most likely diagnosis?
Your Answer:
Correct Answer: Normal pressure hydrocephalus
Explanation:The patient has a history of:
1 – Balance and gait disturbance – falls and broad based clumsy gait
2 – Dementia – strange behaviour and disorientation to time and place
3 – Urinary incontinence – episodes of enuresis.
All of the symptoms constitute the classic triad of normal pressure hydrocephalus. -
This question is part of the following fields:
- Nervous System
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Question 110
Incorrect
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A 55-year-old woman diagnosed with type 2 diabetes presents with vomiting and diarrhoea after eating a meal of chicken and chips. She said her stool had small amounts of blood in. Campylobacter Jejuni was found on her stool culture exam. Which of the following is the most appropriate therapy?
Your Answer:
Correct Answer: IV fluids
Explanation:Campylobacter is the most likely cause of diarrheal illness often due to undercooked meat being ingested. It is also a major cause of traveller’s diarrhoea. Sufficient fluid replacement and anti-emetics are indicated first followed by the antibiotic, Erythromycin although antibiotic treatment in adults is still in question. Ciprofloxacin and Tetracycline may also be effective.
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This question is part of the following fields:
- Infectious Diseases
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Question 111
Incorrect
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A 70-year-old male diagnosed previously with villous adenoma presented in the OPD with severe diarrhoea. Which of the following electrolyte or fluid imbalances is most commonly associated with such a condition?
Your Answer:
Correct Answer: Hypokalaemia
Explanation:Lower GIT fluid is rich in potassium. So, in the case of severe diarrhoea, potassium loss occurs leading to hypokalaemia. Loss of bicarbonate ions also occurs. Both of these disturbances will lead to hyperchloremic metabolic acidosis.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 112
Incorrect
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A 54-year-old female presents with shortness of breath that has been going on for the last 10 months. Physical examination shows that she has an irregularly irregular pulse and a loud P2 with fixed splitting accompanied by a systolic ejection murmur in the 2nd left intercostal space. Which of the following would be the most likely diagnosis?
Your Answer:
Correct Answer: Atrial septal defect (ASD)
Explanation:Atrial septal defect (ASD) is one of the more commonly recognized congenital cardiac anomalies presenting in adulthood. ASD is characterized by a defect in the interatrial septum allowing pulmonary venous return from the left atrium to pass directly to the right atrium. Depending on the size of the defect, size of the shunt, and associated anomalies, this can result in a spectrum of disease ranging from no significant cardiac sequelae to right-sided volume overload, pulmonary arterial hypertension, and even atrial arrhythmias.
With the routine use of echocardiography, the detection and, therefore, the incidence of ASD is increased compared to earlier incidence studies using catheterization, surgery, or autopsy for diagnosis. The subtle physical examination findings and often minimal symptoms during the first 2-3 decades of life contribute to a delay in diagnosis until adulthood, the majority (more than 70%) of which is detected by the fifth decade of life.
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This question is part of the following fields:
- Cardiovascular System
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Question 113
Incorrect
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A 23-year-old woman presents with hirsutism and oligomenorrhea for the last five years. She is very anxious about her irregular menses and worried as her mother was diagnosed with uterine cancer recently. She is a lawyer and does not want to conceive, at least for the next couple of years.
The examination is essentially normal except for coarse dark hair being noticed under her chin and over her lower back.
Investigations done during the follicular phase:
Serum androstenedione 10.1 nmol/l (0.6-8.8)
Serum dehydroepiandrosterone sulphate 11.6 Ù‰mol/l (2-10)
Serum 17-hydroxyprogesterone 5.6 nmol/l (1-10)
Serum oestradiol 220 pmol/l (200-400)
Serum testosterone 3.6 nmol/l (0.5-3)
Serum sex hormone binding protein 32 nmol/l (40-137)
Plasma luteinising hormone 3.3 U/l (2.5-10)
Plasma follicle-stimulating hormone 3.6 U/l (2.5-10)
What is the most appropriate treatment?Your Answer:
Correct Answer: Combined OCP
Explanation:This patient has polycystic ovarian syndrome (PCOS). Medical management of PCOS is aimed at the treatment of metabolic derangements, anovulation, hirsutism, and menstrual irregularity.
First-line medical therapy usually consists of an oral contraceptive to induce regular menses. The contraceptive not only inhibits ovarian androgen production but also increases sex hormone-binding globulin (SHBG) production. The American College of Obstetricians and Gynaecologists (ACOG) recommends the use of combination low-dose hormonal contraceptive agents for long-term management of menstrual dysfunction.
If symptoms such as hirsutism are not sufficiently alleviated, an androgen-blocking agent may be added. Pregnancy should be excluded before therapy with oral contraceptives or androgen-blocking agents are started.
First-line treatment for ovulation induction when fertility is desired is clomiphene citrate. Second-line strategies may be equally effective in infertile women with clomiphene citrate-resistant PCOS. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 114
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:
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 115
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 116
Incorrect
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A 45-year-old male patient who was initially investigated for having an abdominal mass is diagnosed as having Burkitt lymphoma. He is due to start chemotherapy today.
Which one of the following should be given prior to his chemotherapy in order to reduce the risk of tumour lysis syndrome?Your Answer:
Correct Answer: Rasburicase
Explanation:Rasburicase should be given prior to chemotherapy in order to reduce the risk of tumour lysis syndrome (TLS). Rasburicase is a recombinant version of urate oxidase which is an enzyme that metabolizes uric acid to allantoin. Allantoin is 5-10 times more soluble than uric acid, hence, renal excretion is more effective.
TLS is a potentially fatal condition occurring as a complication during the treatment of high-grade lymphomas and leukaemias. It occurs from the simultaneous breakdown (lysis) of the tumour cells and subsequent release of chemicals into the bloodstream. This leads to hyperkalaemia and hyperphosphatemia in the presence of hyponatraemia. TLS can occur in the absence of chemotherapy, but it is usually triggered by the introduction of combination chemotherapy. Awareness of the condition is critical for its prophylactic management.
Burkitt lymphoma is a high-grade B-cell neoplasm. There are two major forms:
1. Endemic (African) form: typically involves maxilla or mandible.
2. Sporadic form: abdominal (e.g. ileocaecal) tumours are the most common form. More common in patients with HIV.Burkitt lymphoma is associated with the c-myc gene translocation, usually t(8;14). The Epstein-Barr virus (EBV) is strongly implicated in development of the African form of Burkitt lymphoma and to a lesser extent, the sporadic form.
Management of the lymphoma is with chemotherapy. This tends to produce a rapid response which may cause TLS.
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This question is part of the following fields:
- Haematology & Oncology
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Question 117
Incorrect
-
A 64-year-old woman presents with malaise, ankle swelling and shortness of breath. Her blood pressure is 215/140 mmHg, she has +2 peripheral oedema and the skin over her fingers appears very tight. Fundoscopy discloses bilateral papilledema.
Â
Plasma creatinine concentration is 370 μmol/l, potassium is 4.9 mmol/l, haemoglobin is 8.9 g/dl and her platelet count is 90 x 109 /ml.
Â
What is the pathological hallmark of this condition?Your Answer:
Correct Answer: Mucoid intimal thickening of vascular endothelium
Explanation:The history is suggestive of scleroderma renal crisis, where we would expect thrombotic microangiopathy process with vascular endothelium involvement manifesting as mucoid intimal thickening or onion skin effect.
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This question is part of the following fields:
- Renal System
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Question 118
Incorrect
-
A 35-year-old female presented with complaints of earache and a high-grade fever. During examination, numerous small vesicles were found within the ear canal and her ear is very tender. Which one of the following organisms is most likely to be responsible for such a condition?
Your Answer:
Correct Answer: Herpes zoster
Explanation:Herpes zoster is a viral disorder in which painful vesicular lesions are present in a specific dermatome area. High-grade fever may present as well due to infection. Varicella zoster, measles, herpes simplex and HIV do not present with tender lesions of a limited area.
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This question is part of the following fields:
- Infectious Diseases
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Question 119
Incorrect
-
A 2-day-old girl is admitted by her mother because she gets cyanotic upon feeding and she wouldn't stop crying. The doctors suspect a congenital heart disease. What is the most probable aetiology?
Your Answer:
Correct Answer: Transposition of the great arteries
Explanation:Transposition of the great arteries results in a significant hypoxemic status that is observed clinically by central cyanosis. The bluish discoloration of the skin and mucous membranes is therefore the basic pattern of clinical presentation in transposition. Its onset and severity depend on anatomical and functional variants that influence the degree of mixing between the two circulations. Limited intercirculatory mixing, usually present if the ventricular septum is intact or the atrial septal defect is restrictive, is related to progressive and profound central cyanosis evident within the first hours of life. Tachypnoea, tachycardia, diaphoresis, poor weight gain, a gallop rhythm, and eventually hepatomegaly can be then detected later on during infancy. Heart murmurs associated with left outflow tract obstruction, due to a persistent arterial duct or a septal defect may be heard, but they are not a constant finding.
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This question is part of the following fields:
- Cardiovascular System
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Question 120
Incorrect
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Which of the following treatments would you advise for a young, 21-year-old student who has ankylosing spondylitis and complains of worsening back pain and morning stiffness?
Your Answer:
Correct Answer: Oral NSAIDs
Explanation:NSAIDs are considered as the first line of treatment for managing pain and stiffness associated with ankylosing spondylitis. Other useful medications include TNF-alpha inhibitors. Other drugs like paracetamol, colchicine, and steroids are not routinely used. Bilateral total hip replacement might be indicated in advanced disease contrary to complicated spinal surgery.
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This question is part of the following fields:
- Musculoskeletal System
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Question 121
Incorrect
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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:
Correct 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 122
Incorrect
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A 13-year-old male, who is otherwise healthy, has presented with recurrent episodes of swelling in his face and tongue. He also complains of abdominal pain. His father has had similar episodes. Choose the most likely diagnosis for this patient.
Your Answer:
Correct Answer: C1 esterase deficiency
Explanation:C1 esterase deficiency is most often associated with swelling of the peripheries and laryngeal oedema. Severe pain in the abdomen is also consistent with this diagnosis. It is also an autosomal dominant condition.
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This question is part of the following fields:
- Immune System
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Question 123
Incorrect
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Which of the following features is characteristic of immune thrombocytopenic purpura?
Your Answer:
Correct Answer: Autoimmune haemolytic anaemia is a recognised association
Explanation:Immune thrombocytopenic purpura (ITP) refers to thrombocytopaenia occurring in the absence of toxic exposure or other diseases associated with low platelets and involves IgG-type antibodies. It is characterised by normal or increased marrow megakaryocytes, shortened platelet survival, and the absence of splenomegaly. Autoimmune haemolytic anaemia (AIHA) occurs commonly in association with ITP. Leukemic transformation, however, does not occur in ITP.
In neonatal ITP, IgG antibodies are passively transferred across the placenta. The infant platelet count may be normal at birth but decreases within 12-24 hours. It is rarely severe enough to induce bleeding diathesis in the infant.
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This question is part of the following fields:
- Haematology & Oncology
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Question 124
Incorrect
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A defect in DNA gyrase can lead to which of the following cancerous conditions?
Your Answer:
Correct Answer: Xeroderma pigmentosum
Explanation:Xeroderma pigmentosum is an X-linked recessive condition, which is caused by mutations in DNA gyrase which further encodes the XP gene. The defect may lead to skin cancer at an early stage of life, especially at photo exposed sites.
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This question is part of the following fields:
- The Skin
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Question 125
Incorrect
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A 46-year-old man presents with a swollen, red, and painful left calf. He does not have a history of any recent surgery or a long-haul flight. He is generally fit and well and takes no regular medication other than propranolol for migraine prophylaxis. There is also no history of venous thromboembolism (VTE) in his family.
The patient is referred to the deep vein thrombosis (DVT) clinic where he is diagnosed with a proximal DVT in his left calf. Following the diagnosis, he is started on low-molecular-weight heparin (LMWH) whilst awaiting review by the warfarin clinic.
Other than commencing warfarin, what further action, if any, is required?Your Answer:
Correct Answer: Investigate for underlying malignancy + check antiphospholipid antibodies
Explanation: -
This question is part of the following fields:
- Haematology & Oncology
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Question 126
Incorrect
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Which one of the following responses is the least likely to be associated with primary pulmonary hypertension?
Your Answer:
Correct Answer: Recurrent pulmonary embolism
Explanation:Connective-tissue diseases, liver cirrhosis, exposure to anorexigens and likely other alpha-adrenergic stimulants [e.g., cocaine, amphetamines] and HIV infection are associated with primary pulmonary hypertension. Recurrent pulmonary emboli, chronic lung diseases, left heart diseases are causes for secondary pulmonary hypertension. Pulmonary vascular hypertension after use of fenfluramine is rarely reported.
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This question is part of the following fields:
- Cardiovascular System
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Question 127
Incorrect
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A 42-year-old male arrives at the clinic due to cough and haemoptysis. Examination shows nasal mucosal ulceration. The doctor suspects Wegener's granulomatosis. Which anatomical area would be most commonly involved in this condition?
Your Answer:
Correct Answer: Lungs
Explanation:Granulomatosis with polyangiitis (GPA, previously known as Wegener’s granulomatosis) is a systemic vasculitis that affects both small and medium-sized vessels. Patients typically initially suffer from a limited form that may consist of constitutional symptoms and localized manifestations such as chronic sinusitis, rhinitis, otitis media, ocular conditions. In later stages, more serious manifestations may arise, including pulmonary complications and glomerulonephritis, although the skin, eyes, and heart may also be involved but these lesions are less common.
Diagnosis is based on laboratory testing (positive for PR3-ANCA/c-ANCA), imaging, and biopsy of affected organs, which demonstrate necrotizing granulomatous inflammation. GPA is treated with immunosuppressive drugs, typically consisting of glucocorticoids combined with methotrexate, cyclophosphamide, or rituximab. Relapses are common and the following systems are affected: Lower respiratory tract (95% of cases), renal involvement (80% of cases), skin lesions (45% of cases), ocular involvement (45% of cases) and cardiac involvement (33% of cases). -
This question is part of the following fields:
- Musculoskeletal System
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Question 128
Incorrect
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A 30-year-old male patient presented with palpitations that occur randomly at rest. There have however been episodes of fast palpitations and dizziness on exertion. On examination there was a systolic murmur at the apex as well as a prominent apex beat and the chest was clear. Which of the following is LEAST likely to suggest a diagnosis of hypertrophic cardiomyopathy?
Your Answer:
Correct Answer: A history of hypertension for 10 years
Explanation:Hypertrophic cardiomyopathy is an autosomal dominant condition. Patients present with sudden cardiac death, dyspnoea, syncope and presyncope, angina, palpitations, orthopnoea and paroxysmal nocturnal dyspnoea, Congestive heart failure and dizziness. Physical findings include double or triple apical impulse, prominent a wave in the JVP, an ejection systolic crescendo-decrescendo murmur and a holosystolic murmur at the apex and axilla of mitral regurgitation.
ECG shows ST-T wave abnormalities and LVH, axis deviation (right or left), conduction abnormalities (P-R prolongation, bundle-branch block), sinus bradycardia with ectopic atrial rhythm, atrial enlargement, abnormal and prominent Q wave in the anterior precordial and lateral limb leads.
2D echocardiography shows abnormal systolic anterior leaflet motion of the mitral valve, LVH, 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, partial systolic closure of the aortic valve in midsystole -
This question is part of the following fields:
- Cardiovascular System
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Question 129
Incorrect
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A 63-year-old man presents with painless jaundice and weight loss over the last few months. He is a heavy smoker and has a past medical history of COPD. On examination his abdomen is soft and non tender and he is clearly icteric.
His bloods reveal deranged LFTs with an alkaline phosphates of 240 and a bilirubin of 92, ALT and AST are both around 200. An ultrasound of his abdomen is performed and shows both intra and extrahepatic bowel duct dilatation within the liver.
What's the first line investigation of his case?Your Answer:
Correct Answer: MRCP
Explanation:When you hear painless jaundice and weight loss in the same sentence, the first thing you should think is cancer. Likely cholangiocarcinoma here or some other biliary tract obstructing cancer. The first line imaging for this would be MRCP because you’re looking for obstruction– the dilatation of the intra and extrahepatic ducts suggests this. This is less invasive than an ERCP or a liver biopsy. CT C/A/P will likely be needed for staging later but it is asking for the initial test.
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This question is part of the following fields:
- Hepatobiliary System
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Question 130
Incorrect
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A 85-year-old previously well man was found to have a BP of 155/90 mmHg. His average reading from the monitoring of his ambulatory BP was 147/92 mmHg. His calculated 10 year cardiovascular risk was 15%. Which of the following is the most appropriate management of this patient?
Your Answer:
Correct Answer: Give lifestyle advice and repeat blood pressure in 6 months
Explanation:According to different guidelines for patients above 80 years, the targeted systolic blood pressure varies from 140-150 mmHg. As this patient’s BP is within that range, he can be kept under observation.
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This question is part of the following fields:
- Cardiovascular System
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Question 131
Incorrect
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A 25-year-old female presents with diarrhoea and 8 kg weight loss over the last 3 months. She has also experienced amenorrhea for the past 12 weeks. Which of the following is the next best step in the management of this patient?
Your Answer:
Correct Answer: Thyroid Function Test
Explanation:Weight loss is most commonly linked to hyperthyroidism. An overactive thyroid gland (hyperthyroidism) or underactive thyroid gland (hypothyroidism) can cause menstrual irregularities, including amenorrhea. In this scenario, we would carry out thyroid function tests.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 132
Incorrect
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A 48-year-old male presents to the clinic complaining of a swelling in his left groin that disappears on lying down. He also reports occasional haematuria and a mass in his left loin. On examination, the swelling is bluish in colour and has an appearance and consistency like that of a 'bag of worms'. What is the most likely diagnosis?
Your Answer:
Correct Answer: Left sided renal cell carcinoma
Explanation:Renal cell carcinoma (RCC) may remain clinically occult for most of its course. The classic triad of flank pain, haematuria, and flank mass is uncommon (10%) and is indicative of advanced disease. A varicocele, usually left sided, is due to obstruction of the testicular vein.
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This question is part of the following fields:
- Men's Health
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Question 133
Incorrect
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A 62 year male presented with epistaxis, nasal blockage, double vision, ear fullness and left sided conductive deafness for 1 week. He was a heavy smoker and alcoholic. Which of the following is the most probable diagnosis?
Your Answer:
Correct Answer: Nasopharyngeal ca
Explanation:Because of the involvement of nose, ear and vision, the most probable diagnosis is nasopharyngeal carcinoma. Both smoking and alcohol are risk factors.
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This question is part of the following fields:
- Respiratory System
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Question 134
Incorrect
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A 1-month-old boy was brought to the ED by his mother because he has been irritable and feeding poorly for the last 24 hours. His CXR shows cardiomegaly but with clear lung fields while his ECG shows a regular narrow complex tachycardia with difficulty identifying the P wave. The boy is conscious but has cold extremities. What is the most appropriate next step?
Your Answer:
Correct Answer: Synchronized DC cardio-version
Explanation:The most possible diagnosis is SVT. The boy is suffering from hemodynamic instability, as indicated by his cold extremities. DC cardioversion is the treatment of choice.
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This question is part of the following fields:
- Cardiovascular System
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Question 135
Incorrect
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A 61-year old mechanic recently attended A&E, with a 3 month history of bilateral paresthesia and twitching affecting the thumb, first finger and lateral forearm. He denied any trauma. An MRI scan of his spine was performed and revealed cervical canal stenosis with mild cord compression. He was discharged and advised to see his GP for follow-up. Which of the following is the most appropriate initial step in management?
Your Answer:
Correct Answer: Refer to spinal surgery services
Explanation:Bilateral median nerve dysfunction is suggestive of degenerative cervical myelopathy (DCM) rather than bilateral carpal tunnel syndrome. DCM should be suspected in elderly patients presenting with limb neurology. This patient’s twitches are probably fibrillations, a sign of lower motor neuron dysfunction.
Degenerative cervical myelopathy is associated with a delay in diagnosis. It is most commonly misdiagnosed as carpal tunnel syndrome. In one study, 43% of patients who underwent surgery for degenerative cervical myelopathy had been initially diagnosed with carpal tunnel syndrome.
Management of these patients should be by specialist spinal services (neurosurgery or orthopaedic spinal surgery). Decompressive surgery is the mainstay of treatment and has been shown to stop disease progression. Physiotherapy and analgesia do not replace surgical opinion, though they may be used alongside. Nerve root injections do not have a role in management. -
This question is part of the following fields:
- Nervous System
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Question 136
Incorrect
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Which of the following is not a tumour suppressor gene?
Your Answer:
Correct Answer: myc
Explanation:Myc is a family of regulator genes and proto-oncogenes that code for transcription factors.
A tumor suppressor gene, or antioncogene, is a gene that protects a cell from one step on the path to cancer. When this gene mutates to cause a loss or reduction in its function, the cell can progress to cancer, usually in combination with other genetic changes. Tumor suppressor genes can be grouped into categories including caretaker genes, gatekeeper genes, and landscaper genes; the classification schemes are continually evolving.
Examples include:
Gene Associated cancers
p53 Common to many cancers, Li-Fraumeni syndrome
APC Colorectal cancer
BRCA1 Breast and ovarian cancer
BRCA2 Breast and ovarian cancer
NF1 Neurofibromatosis
Rb Retinoblastoma
WT1 Wilm’s tumour -
This question is part of the following fields:
- Haematology & Oncology
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Question 137
Incorrect
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A 60-year-old male patient with a history of heavy smoking was admitted complaining of acute severe central chest pain for the past one hour. His blood pressure was 150/90 mmHg and pulse rate was 88 bpm. His peripheral oxygen saturation was 93%. ECG showed ST elevation > 2 mm in lead II, III and aVF. He was given loading doses of aspirin, clopidogrel and atorvastatin and face mask oxygen was given. Which one of the following investigations should be done and then depending on result, definitive treatment can be initiated?
Your Answer:
Correct Answer: None
Explanation:The history and ECG findings are adequate to begin cardiac revascularization of this patient. There is no need for cardiac markers to confirm the diagnosis. Further delay in starting definite treatment is not recommended.
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This question is part of the following fields:
- Cardiovascular System
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Question 138
Incorrect
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A 45-year-old man was referred for abnormal liver biochemistry. Investigations showed he had an ALT of 98 U/l and was Hep B surface antigen positive.
Which of the following is true of chronic active hepatitis due to the hepatitis B virus?Your Answer:
Correct Answer: It carries an increased risk of subsequent hepatocellular carcinoma
Explanation:Chronic hepatitis B patients have an increased risk of hepatocellular carcinoma. In chronic hepatitis B infection, you have +HBsAg, +anti-HBc, (-)IgM antiHBc, and (-) anti-HBs. In acute hepatitis B infection, you have+HBsAg, + anti-HBc, + IgM anti-HBc, and negative anti-HBs. In immunity due to natural infection, you have negative HBsAg, +anti-HBc, and + anti-HBs. In immunity due to vaccination, you have negative HBsAg, negative anti-HBc, and positive anti-HBs. It is important to remember these serologies, it will get you a lot of points on the test.
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This question is part of the following fields:
- Hepatobiliary System
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Question 139
Incorrect
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A 55-year-old lady who a known case of normal pressure hydrocephalus (NPH) presented with complaints of weakness in her lower limbs, urinary incontinence and progressively worsening confusion. Which of the following statements is true regarding NPH?
Your Answer:
Correct Answer: Is associated with gait disturbance
Explanation:Normal pressure hydrocephalus is a form of communicating hydrocephalus characterised by enlarged ventricles with normal opening pressure on lumbar puncture. For diagnostic purposes, a triad of urinary incontinence, gait abnormality and dementia is necessary. It is necessary to diagnose the condition early because it is reversible by placing a ventriculoperitoneal shunt. It is most common in patients aged more than 60 years.
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This question is part of the following fields:
- Infectious Diseases
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Question 140
Incorrect
-
A 62-year-old software developer with lung cancer is currently taking MST 30 mg bd for pain relief.
What dose of oral morphine solution should he be prescribed for breakthrough pain?Your Answer:
Correct Answer: 10 mg
Explanation:The total daily morphine dose is 30 x 2 = 60 mg. Therefore, the breakthrough dose should be one-sixth of this, 10 mg.
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This question is part of the following fields:
- Haematology & Oncology
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Question 141
Incorrect
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A 3 month old infant born to HIV positive mother presented with jaundice, epileptic seizures and microcephaly. The most likely cause will be?
Your Answer:
Correct Answer: Cytomegalovirus
Explanation:Congenital cytomegalovirus infection causes; jaundice, hepatosplenomegaly, petechia, microcephaly, hearing loss and seizures.
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This question is part of the following fields:
- Infectious Diseases
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Question 142
Incorrect
-
A 54-year-old male, with a smoking history of 15 pack years presents with worsening dyspnoea, fever and cough. He works at a foundry. Vitals are as follows:
Respiratory rate: 28/min
Heart rate: 80 bpm
Temp: 37.6C
Chest auscultation reveals bilateral crepitations throughout the lung fields.
Calcified hilar nodules are visible on the chest X-ray. Further evaluation shows an eggshell calcification on HRCT.
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Silicosis
Explanation:Silicosis is a common occupational lung disease that is caused by the inhalation of crystalline silica dust. Silica is the most abundant mineral on earth. Workers that are involved for example in construction, mining, or glass production are among the individuals with the highest risk of developing the condition. Acute silicosis causes severe symptoms (e.g., exertional dyspnoea, cough with sputum) and has a very poor prognosis.
Chronic silicosis has a very variable prognosis and affected individuals may remain asymptomatic for several decades. However, radiographic signs are usually seen early on. Typical radiographic findings are calcifications of perihilar lymph nodes, diffuse ground glass opacities, large numbers of rounded, solitary nodules or bigger, confluent opacities. Avoiding further exposure to silica is crucial, especially since the only treatment available is symptomatic (e.g., bronchodilators). Silicosis is associated with an increased risk of tuberculosis and lung cancer. Berylliosis typically affects individuals who are exposed to aerospace industry. Histoplasmosis and tuberculosis do not form eggshell calcifications. -
This question is part of the following fields:
- Respiratory System
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Question 143
Incorrect
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A 49-year-old female is admitted to the hospital with shortness of breath and pleuritic chest pain. She also complains of loss of appetite for the past four months. Her admission CXR shows right-sided pleural effusion. An underlying malignancy is suspected and a series of tumour markers are requested, the results of which are:
CA 19-9: 36 IU/mL (<40)
CA 125: 654 IU/ml (<30)
CA 15-3: 9 IU/ml (<40)
What is the most likely underlying diagnosis?Your Answer:
Correct Answer: Ovarian fibroma
Explanation:The patient has Meigs syndrome. Meigs syndrome is defined as a triad of benign ovarian tumour with ascites and pleural effusion that resolves after resection of the tumour. Ovarian fibromas constitute the majority of the benign tumours seen in Meigs syndrome.
Tumour markers can be divided into:
1. Monoclonal antibodies
CA 125: Ovarian cancer, primary peritoneal cancer
CA 19-9: Pancreatic cancer
CA 15-3: Breast cancer2. Tumour specific antigens
Prostate specific antigen (PSA): Prostatic carcinoma
Alpha-feto protein (AFP): Hepatocellular carcinoma, teratoma
Carcinoembryonic antigen (CEA): Colorectal cancer
S-100: Melanoma, schwannomas
Bombesin: Small cell lung carcinoma, gastric cancer3. Enzymes
Alkaline phosphatase (ALP)
Neuron specific enolase (NSE)4. Hormones
Calcitonin
Antidiuretic hormone (ADH)
Human chorionic gonadotropin (hCG) -
This question is part of the following fields:
- Haematology & Oncology
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Question 144
Incorrect
-
A 50-year-old male was brought to the ER after the accidental consumption of 300 ml of diethylene glycol. Blood investigations were suggestive of metabolic acidosis and renal failure. What is the appropriate management in this patient?
Your Answer:
Correct Answer: Haemodialysis and oral ethanol
Explanation:Among the given options the most appropriate management in this patient would be ethanol and haemodialysis.
Ethanol competes with ethylene glycol for alcohol dehydrogenase and thus, helps manage a patient with ethylene glycol toxicity.
Ethylene glycol is a type of alcohol used as a coolant or antifreeze
Features of toxicity are divided into 3 stages:
Stage 1: (30 min to 12 hours after exposure) Symptoms similar to alcohol intoxication: confusion, slurred speech, dizziness (CNS depression)
Stage 2: (12 – 48 hours after exposure) Metabolic acidosis with a high anion gap and high osmolar gap. Also tachycardia, hypertension
Stage 3: (24 – 72 hours after exposure) Acute renal failureManagement has changed in recent times:
Fomepizole, an inhibitor of alcohol dehydrogenase, is now used first-line in preference to ethanol.
Ethanol has been used for many years works by competing with ethylene glycol for the enzyme alcohol dehydrogenase this limits the formation of toxic metabolites (e.g. glycolaldehyde and glycolic acid) which are responsible for the hemodynamic/metabolic features of poisoning.
Haemodialysis has a role in refractory cases. -
This question is part of the following fields:
- Emergency & Critical Care
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Question 145
Incorrect
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A 60-year-old male has complained of a recent onset of postural syncope, impotence, diarrhoea, and profuse sweating. He also has diabetes. In this patient, what is the most likely cause of syncope?
Your Answer:
Correct Answer: Autonomic neuropathy
Explanation:Due to the symptoms, a diabetic autonomic neuropathy should be a suspect as a cause for the syncope. Unless associated with atrial fibrillation, mitral regurgitation is not usually expected to cause syncope. PAF can sometimes present with palpitations and a feeling of light-headedness followed by syncope, but is not always the case.
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This question is part of the following fields:
- Cardiovascular System
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Question 146
Incorrect
-
A 4-year-old child was brought in by his mother with complaints of vesicular eruption over his palms, soles and oral mucosa for the last 5 days. He was slightly febrile. There were no other signs. The most likely causative organism in this case would be?
Your Answer:
Correct Answer: Coxsackie
Explanation:This patient is most likely suffering from hand, foot mouth disease which is caused by coxsackie virus A16. Its incubation period ranges from 5-7 days and only symptomatic treatment is required.
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This question is part of the following fields:
- The Skin
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Question 147
Incorrect
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A 25-year-old male presented with acute severe central chest pain which radiated backwards between his scapulae. He didn't have difficulty in breathing and the pain wasn't exacerbated by deep inspiration or a change in position. His father had died due to a heart disease when he was small. He also has a cardiac murmur which was never properly investigated. On examination he was tachycardic with a BP of 165/60 mmHg. There was a diastolic murmur at lower left sternal border which is best heard with the patient sitting forward. Which of the following is the most probable cause for his chest pain?
Your Answer:
Correct Answer: Aortic dissection
Explanation:The most probable diagnosis is Marfan’s syndrome because of a family history of cardiac death and heart murmurs. A characteristic feature is pain which radiates to the back. A wide pulse pressure and a diastolic heart murmur is suggestive of aortic dissection.
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This question is part of the following fields:
- Cardiovascular System
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Question 148
Incorrect
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All of the following statements regarding iron metabolism are correct EXCEPT?
Your Answer:
Correct Answer: In iron deficiency anaemia total iron binding capacity and transferrin saturation will both be decreased
Explanation:Iron deficiency anaemia is characterised by decreased iron stores, however there is increased iron binding capacity. Transferrin is the iron transporting protein. Because of the decreased presence of iron in blood, the transferrin saturation is decreased. Ferritin is an iron storage protein that is affected according to the iron stores but its also an acute phase reactant and levels can be effected by other conditions. Each unit of packed RBCs transfused to an adult contains 200 ml of RBCs and 200mg of iron. Only 5-10% of dietary iron is absorbed in the portal circulation which can be increased by the intake of vitamin C, animal foods and amino acids.
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This question is part of the following fields:
- Gastrointestinal System
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Question 149
Incorrect
-
A 67-year-old male presented with a history of chronic backache and altered sensation over the lateral side of his right calf and foot. Which of the following nerve roots will most likely be involved in this patient?
Your Answer:
Correct Answer: L5-S1
Explanation:Lesions in L5-S1 region leads to altered sensation on the lateral side of calf and foot, along with back pain. There might be difficulty in extension of the leg, foot inversion, plantar flexion and toe flexion, as muscles controlling these functions are supplied by S1.
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This question is part of the following fields:
- Nervous System
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Question 150
Incorrect
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Regarding haemochromatosis, which of the following is true?
Your Answer:
Correct Answer: Haemochromatosis may be treated with therapeutic phlebotomy
Explanation:Haemochromatosis is an abnormally high rate of the production of haemoglobin. It is an autosomal recessive disease copied on chromosome 6. It is associated with hepatic disorders, cardiac diseases and skin pigmentation. It is treated by regular venesection.
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This question is part of the following fields:
- Haematology & Oncology
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Question 151
Incorrect
-
A 50-year-old woman diagnosed with non-Hodgkin's Lymphoma is about to be started on the CHOP regimen (cyclophosphamide, hydroxydaunorubicin, vincristine, and prednisolone). Her pre-chemotherapy blood investigations show:
Hb: 11.8 g/dl
Platelets: 423 x 109/l
WBC: 11.2 x 109/l
Na+: 143 mmol/l
K+: 3.9 mmol/l
Urea: 6.2 mmol/l
Creatinine: 78 μmol/l
Uric acid: 0.45 mmol/l
Ciprofloxacin is prescribed in addition to the CHOP regimen to reduce the risk of neutropenic sepsis. Which of the following drugs should be added to lower the risk of other complications?Your Answer:
Correct Answer: Allopurinol
Explanation: -
This question is part of the following fields:
- Haematology & Oncology
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Question 152
Incorrect
-
A 22-year-old male presents with loose stools and abdominal pain that is vague in nature. He previously had an episode of lower abdominal pain that was associated with pyrexia which settled on its own. He has also experienced mild weight loss recently. On examination, he is pale and has an ill defined mass in the right iliac fossa. What is the most likely diagnosis?
Your Answer:
Correct Answer: Crohn's disease
Explanation:Crohn’s Disease (CD) is an inflammatory bowel disease, the pathogenesis of which is not fully understood. The clinical presentation of CD may be similar to ulcerative colitis (UC), the other most common inflammatory bowel disease. CD mostly affects young adults and adolescents between the ages of 15 and 35. It is typically located in the terminal ileum, but can discontinuously affect the entire gastrointestinal tract and commonly leads to complications such as fistulas, abscesses, and stenosis. Clinical features include diarrhoea, weight loss, and abdominal pain in the right lower quadrant (RLQ), as well as extraintestinal manifestations in the eyes, joints, or skin. It is often difficult to diagnose because there is no confirmatory test. Diagnosis is therefore based on the patient’s medical history, physical examination, lab tests, imaging (e.g., MRI), endoscopy, and serological testing. Acute episodes are treated with corticosteroids, and in severe cases, immunosuppressants may be indicated. Antibiotics and surgical intervention may be needed to help treat complications. Because the entire gastrointestinal tract may be affected, Crohn disease cannot be cured (in contrast to ulcerative colitis). The goal of treatment is thus to avoid the progression and recurrence of inflammatory episodes.
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This question is part of the following fields:
- Gastrointestinal System
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Question 153
Incorrect
-
A 48-year-old hairdresser presents to the GP with loss of sensation over the lateral three and a half fingers of her right hand, tenderness over her right forearm, and inability to make a tight fist. She complains of pain in her right arm when twisting door handles anticlockwise. Phalen's and Tinel's tests are negative. She is otherwise neurologically intact. Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Pronator teres syndrome
Explanation:Entrapment of the median nerve by pronator teres causes a median nerve neuropathy, which is worse during pronation of the forearm. Examination should involve excluding carpal tunnel syndrome and pronation of the affected forearm against resistance, which brings on the pain. Unlike carpal tunnel syndrome, the median nerve proximal to the wrist may be tender to palpation.
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This question is part of the following fields:
- Nervous System
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Question 154
Incorrect
-
A 54-year-old gentleman presented with a 3 month history of a nodular growth over the dorsum of the his nose, about 0.6 cm in size. The base of nodule is slightly ulcerated and its margins are raised. The most likely diagnosis would be?
Your Answer:
Correct Answer: Basal cell carcinoma
Explanation:Basal cell carcinoma is usually located on sun exposed sites. It has got many variants and clinically it presents as a slow growing mass/nodule with rolled margins and an ulcerated base.
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This question is part of the following fields:
- The Skin
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Question 155
Incorrect
-
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 156
Incorrect
-
A 50-year-old man undergoes a colonoscopy due to the finding of blood in his stools. The colonoscopy revealed four polyps which were variable in size from one at 0.5cm, 2 at approximately 1.5cm and one at 2 cm.
When should this patient have a follow up colonoscopy?Your Answer:
Correct Answer: 3 years
Explanation:According to the British Society of Gastroenterology guidelines – this patient has 3-4 adenomas with 3 of them > 1 cm in size. This places him at medium risk and the recommendation is for a 3-year follow up period.
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This question is part of the following fields:
- Gastrointestinal System
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Question 157
Incorrect
-
A 28-year-old male was screened for hypertrophic cardiomyopathy (HOCM). His father has passed away recently at the age of 48 and found to have HOCM during post mortem examination. On examination of this patient his BP was 142/84 mmHg and pulse rate was 68 bpm which was regular. There was a mid systolic murmur and a double apex beat. Echocardiography showed a septal wall thickness of 3.3 cm. What is the factor most closely linked to his 20 year risk of sudden cardiac death?
Your Answer:
Correct Answer: Septal wall thickness of 3.3 cm
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 158
Incorrect
-
A non-cyanosed 1-year-old female patient has a continuous murmur which is loudest at the left sternal edge. What pulse abnormality is most associated with patent ductus arteriosus if that's her suspected diagnosis?
Your Answer:
Correct Answer: Collapsing pulse
Explanation:DIAGNOSIS:
A consensus definition for hemodynamically significant PDA is lacking. The diagnosis is often suspected clinically, when an infant demonstrates signs of excessive shunting from the arterial to pulmonary circulation. Continuous or a systolic murmur; note, a silent PDA may also occur when the ductus shunt is large enough that nonturbulent flow fails to generate a detectible murmur.
A low diastolic blood pressure (due to runoff into the ductus during diastole, more frequent in the most premature infants).
A wide pulse pressure (due to ductus runoff or steal)Hypotension (especially in the most premature infants)
Bounding pulses
Increased serum creatinine concentration or oliguria
Hepatomegaly -
This question is part of the following fields:
- Cardiovascular System
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Question 159
Incorrect
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A 45-year-old appears at the OPD with symptoms of persistent cough and purulent sputum. He is a chronic smoker and had measles in the past. Upon auscultation, inspiratory crepitation and finger clubbing are noted. What is the single most likely diagnosis?
Your Answer:
Correct Answer: Bronchiectasis
Explanation:A history of measles, whooping cough, or other severe lung infections like tuberculosis (TB) and pneumonia can lead to airway damage and possibly bronchiectasis.
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This question is part of the following fields:
- Respiratory System
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Question 160
Incorrect
-
A 50-year-old woman was investigated following an osteoporotic hip fracture. The following results are obtained:
TSH < 0.05 mu/l
Free T4 29 pmol/l
Which of the following autoantibodies is most likely to be present?Your Answer:
Correct Answer: TSH receptor stimulating autoantibodies
Explanation:The patient has hyperthyroidism and its most common cause is Grave’s Disease.
Grave’s Disease is an autoimmune disease due to circulating autoantibodies known as TSH receptor stimulating autoantibodies or Thyroid-stimulating immunoglobulins (TSIs) that bind to and activate thyrotropin receptors, causing the thyroid gland to grow and the thyroid follicles to increase the synthesis of thyroid hormone. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 161
Incorrect
-
The family of a 10-year-old boy was advised to take the boy to see an oncologist, for suspected lymphoma. The boy had lymphadenopathy on presentation. His mother says that he's had a fever, night sweats and has experienced weight loss. The boy underwent a lymph node biopsy at the oncologist which suggests Burkitt's lymphoma. Which oncogene are you expecting to see after molecular testing?
Your Answer:
Correct Answer: c-MYC
Explanation:Burkitt lymphoma is a germinal centre B-cell-derived cancer that was instrumental in the identification of MYC as an important human oncogene more than three decades ago. Recently, new genomics technologies have uncovered several additional oncogenic mechanisms that cooperate with MYC to create this highly aggressive cancer.
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This question is part of the following fields:
- Haematology & Oncology
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Question 162
Incorrect
-
A 21-year-old patient presents with multiple itchy wheals on his skin. The wheals are of all sizes and they are exacerbated by scratching. The symptoms started after a viral infection and can last up to an hour. What is the most likely diagnosis?
Your Answer:
Correct Answer: Urticaria
Explanation:Urticaria is a group of disorders that share a distinct skin reaction pattern, namely the occurrence of itchy wheals anywhere on the skin. Wheals are short-lived elevated erythematous lesions ranging from a few millimetres to several centimetres in diameter and can become confluent. The itching can be prickling or burning and is usually worse in the evening or night time. Triggering of urticaria by infections has been discussed for many years but the exact role and pathogenesis of mast cell activation by infectious processes is unclear.
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This question is part of the following fields:
- The Skin
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Question 163
Incorrect
-
A 70-year-old smoker was recently diagnosed with small cell lung cancer. Which of the following electrolyte combinations confirms the diagnosis of SIADH?
Your Answer:
Correct Answer: Low serum Na, low serum osmolarity, high urine osmolarity
Explanation:Due to the high amount of ADH in their blood, patient is voiding a low volume of urine with high osmolarity and as a result low levels of electrolytes will be present in the serum.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 164
Incorrect
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Which of the following is true concerning baclofen?
Your Answer:
Correct Answer: Causes hallucinations when withdrawn
Explanation:Baclofen is used to treat spastic movement symptoms such as those seen in cerebral palsy and multiple sclerosis. It is known to be associated with a withdrawal syndrome similar to alcohol withdrawal; thus, gradual withdrawal is necessary to avoid this.
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This question is part of the following fields:
- Nervous System
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Question 165
Incorrect
-
A 52-year-old chef presents to the ED with acute visual changes. He has a past medical history of hypertension and type 2 diabetes mellitus. On neurological examination, his upper and lower limbs are normal however he has a homonymous hemianopia with central preservation. Where is the most likely cause of his problems within the central nervous system?
Your Answer:
Correct Answer: Optic radiation
Explanation:Lesions in the optic radiation can cause a homonymous hemianopia with macular sparing, as a result of collateral circulation offered to macular tracts by the middle cerebral artery.
Lesions in the optic tract also cause a homonymous hemianopia, but without macular sparing.
Lesions in the optic chiasm, optic nerve, and temporal lobe cause bitemporal hemianopia, ipsilateral complete blindness, and superior homonymous quadrantanopia respectively. -
This question is part of the following fields:
- Nervous System
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Question 166
Incorrect
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A 60-year-old man presents with asymptomatic enlargement of his cervical lymph nodes. Full blood count shows low-grade anaemia, leukocytosis, and thrombocytopenia. Lymph node biopsy is suggestive of a low-grade non-Hodgkin lymphoma.
Which two of the following statements fit best with this condition?Your Answer:
Correct Answer: Extra-nodal presentation is more common than in Hodgkin's disease
Explanation:Extra-nodal presentation is more common in non-Hodgkin lymphoma (NHL) than in Hodgkin lymphoma (HL). Bone marrow infiltration is more common in low-grade than in high-grade NHLs.
Low-grade NHL is predominantly a disease of older people. Most present with advanced disease, bone marrow infiltration being almost invariable. Anaemia, leucocytosis, and/or thrombocytopaenia in a patient are suggestive of bone marrow involvement. For definitive diagnosis, lymph node biopsy is sufficient.
The other aforementioned statements are ruled out because:
1. Renal impairment in NHL usually occurs as a consequence of ureteric obstruction secondary to intra-abdominal or pelvic lymph node enlargement.2. Burkitt lymphoma is a high-grade NHL, which was first described in children in West Africa who presented with a jaw tumour, extra-nodal abdominal involvement, and ovarian tumours. It develops most often in children or young adults and is uncommon in older people.
3. High-grade lymphomas are potentially curable. They have a better prognosis and are responsive to chemotherapy unlike low-grade lymphomas, which are incurable with conventional therapy.
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This question is part of the following fields:
- Haematology & Oncology
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Question 167
Incorrect
-
A social worker has been diagnosed with hepatitis C infection. Which test will conclusively establish the presence of this infection?
Your Answer:
Correct Answer: HCV RNA
Explanation:The most sensitive test for detecting Hepatitis C infection (acute) is HCA RNA; it can be detected 1-2 weeks after infection. Anti-HCV antibodies take at least 6 weeks to develop and be positive.
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This question is part of the following fields:
- Infectious Diseases
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Question 168
Incorrect
-
A 15-year-old girl is admitted to hospital following a ruptured ectopic pregnancy. She comes from a family of Jehovah's Witnesses. Her haemoglobin on admission is 6.7 g/dl. She consents to a blood transfusion but her mother refuses. What is the most appropriate course of action?
Your Answer:
Correct Answer: Give the blood transfusion
Explanation:People aged 16 or over are entitled to consent to their own treatment. This can only be overruled in exceptional circumstances. Children under the age of 16 can consent to their own treatment if they’re believed to have enough intelligence, competence and understanding to fully appreciate what’s involved in their treatment. This is known as being Gillick competent.
Otherwise, someone with parental responsibility can consent for them.
This could be:
the child’s mother or father
the child’s legally appointed guardian
a person with a residence order concerning the child
a local authority designated to care for the child
a local authority or person with an emergency protection order for the child.
Giving the blood transfusion is therefore both clinically and ethically the right course of action.
Jehovah’s Witnesses frequently carry a signed and witnessed Advance Decision Document listing the blood products and autologous procedures that are, or are not, acceptable to them It is appropriate to have a frank, confidential discussion with the patient about the potential risks of their decision and the possible alternatives to transfusion, but the freely expressed wish of a competent adult must always be respected. -
This question is part of the following fields:
- Ethical & Legal
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Question 169
Incorrect
-
A 55-year-old woman admitted to the hospital with her third urinary tract infection in as many months. She has type-2 diabetes and started Empagliflozin (a sodium glucose co-transporter 2 inhibitor) 4 months ago. You suspect recurrent urinary tract infections secondary to her empagliflozin.
Where is the main site of action of the drug?Your Answer:
Correct Answer: Early proximal convoluted tubule
Explanation:Selective sodium-glucose transporter-2 (SGLT2) is expressed in the proximal renal tubules and is responsible for the majority of the reabsorption of filtered glucose from the tubular lumen.
Empagliflozin; SGLT2 inhibitors reduce glucose reabsorption and lower the renal threshold for glucose, thereby increasing urinary glucose excretion, thus increasing the risk of urinary tract infections. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 170
Incorrect
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A 59-year-old scientist is referred to you with a 2-year history of ascending lower limb numbness and, more recently, foot drop. In the last 6 months he has also developed numbness in his fingers. He has a distal reduction to pinprick and relatively preserved muscle power, except for ankle dorsiflexion and hyporeflexia in his legs. The GP has already organised nerve conduction studies and the report is sent along with the patient. Which of the following would be suggestive of an axonal neuropathy?
Your Answer:
Correct Answer: Reduced compound muscle action potential amplitude
Explanation:Reduced conduction velocity is associated with demyelinating neuropathies. An abnormally slow response is associated with very proximal disease, i.e. radiculopathies. Delayed P100 latency is a feature of performing visual evoked potentials in those with optic nerve disease. Conduction block is usually associated with certain types of demyelinating neuropathy.
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This question is part of the following fields:
- Nervous System
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Question 171
Incorrect
-
As the SHO of a hospital, you come across the lab report of a patient. It shows the following: glucose 4 mmol/L, K 5.2mmol/L, Na 129 mmol/L. How would you manage this patient?
Your Answer:
Correct Answer: Normal Saline 0.9%
Explanation:This patient’s blood glucose levels are within the normal range. From their lab report, they are suffering from milk hyperkalaemia and hypernatremia. Thus, normal saline 0.9 per cent is most appropriate in this case.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 172
Incorrect
-
An 87-year-old woman had to double up her dosage of morphine 60mg into 120mg twice a day, in addition to another 10mg oral Morphine 6 times a day. What is the best method of management?
Your Answer:
Correct Answer: Subcutaneous morphine infusion
Explanation:Stable dose of Morphine is essential for chronic cases of pain that are non-malignant in origin. Using the SC route avoids having to intravenously cannulate a patient and allows for a continuous infusion of drugs over a calculated period of time providing constant dosing A significant advantage is that plasma levels of a drug are much more stable, and appropriate symptom control can be achieved without the toxic effects of the peaks and troughs resulting from episodic drug administration.
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This question is part of the following fields:
- Geriatric Medicine
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Question 173
Incorrect
-
A 35-year-old female complains of headache at the back of her head that has been occurring for several days and pain on neck flexion. She works as a housemaid. Which of the following is the most likely cause of her presentation?
Your Answer:
Correct Answer: Cervical spondylosis
Explanation:Cervical spondylosis is a general term for age-related wear and tear affecting the spinal disks in your neck. As the disks dehydrate and shrink, signs of osteoarthritis develop, including bony projections along the edges of bones (bone spurs). Cervical spondylosis is very common and worsens with age.
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This question is part of the following fields:
- Musculoskeletal System
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Question 174
Incorrect
-
Which of the following is suggestive of co-existence of mitral regurgitation and mitral stenosis?
Your Answer:
Correct Answer: Displaced apex beat
Explanation:Apex beat displacement is caused by mitral regurgitation and because it is not found in mitral stenosis, it is suggestive of mixed mitral disease. The other given responses occur in mitral stenosis.
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This question is part of the following fields:
- Cardiovascular System
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Question 175
Incorrect
-
A 74-year-old man presents with 12 kg weight loss and persistent back pain that is unrelated to activity for the past several months. Laboratory findings show :
WCC: 6.7 x 109/l (5.4 neutrophils, 1.2 lymphocytes and 0.2 monocytes)
Haemoglobin: 11.2 g/dl
haematocrit: 33.3%
MCV: 88 fl
Platelet count: 89 x 109/l.
The biochemistry shows:
sodium 144 mmol/l
potassium 4.5 mmol/l
chloride 100 mmol/l
bicarbonate 26 mmol/l
urea 14 mmol/l
creatinine 90 μmol/l
a glucose of 5.4 mmol/l.
A CT scan of the spine reveals scattered 0.4 to 1.2 cm bright lesions in the vertebral bodies.
Which of the following additional laboratory test findings is he most likely to have?Your Answer:
Correct Answer: Serum prostate specific antigen of 35 microgram/l
Explanation:Old age, persistent backache, weight loss, and osteosclerotic lesions make prostatic adenocarcinoma the most likely diagnosis. The sequelae include severe pain, pathological fractures, hypercalcemia and cord compression. Prostatic adenocarcinoma is detected by elevated levels of prostate specific antigen. Positive serology for borrelia burgdorferi would hint at Lyme disease which does not cause osteosclerotic bone lesions, neither would Neisseria gonorrhoeae have such a presentation.
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This question is part of the following fields:
- Musculoskeletal System
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Question 176
Incorrect
-
While investigating a patient with hepatocellular carcinoma (HCC), blood tests reveal a raised level of serum ferritin. What would be the most probable cause for HCC in this patient?
Your Answer:
Correct Answer: Haemochromatosis
Explanation:Haemochromatosis is the excessive accumulation of iron in the body mainly involving the liver, pancreas, testes, skin etc. Serum ferritin is high indicating iron overload. Haemochromatosis is a known cause for chronic liver cell disease, cirrhosis and HCC.
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This question is part of the following fields:
- Gastrointestinal System
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Question 177
Incorrect
-
A 61-year-old man presented with a TIA and loss of consciousness for 30 min. His CT brain scan is normal and his ECG shows atrial fibrillation. Which risk assessment score is best used in this case?
Your Answer:
Correct Answer: CHADS2
Explanation:CHADS2 score provides a comprehensive prediction of thromboembolic events in avalvular AF patients:
C Congestive heart failure – 1
H Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication) – 1
A Age >75 years – 1
D Diabetes mellitus – 1
S2 Prior Stroke or TIA or Thromboembolism – 2 -
This question is part of the following fields:
- Nervous System
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Question 178
Incorrect
-
With respect to liver cirrhosis, which of the following statements is correct?
Your Answer:
Correct Answer: The final common pathway of hepatic fibrosis is mediated by the hepatic stellate cell
Explanation:The development of hepatic fibrosis reflects an alteration in the normally balanced processes of extracellular matrix production and degradation. [6] The extracellular matrix, the normal scaffolding for hepatocytes, is composed of collagens (especially types I, III, and V), glycoproteins, and proteoglycans. Increased collagen in the space of Disse (space b/w sinusoids and hepatocytes) leads to capillarization of sinusoids, and stellate cells also have contractile properties when activated. This is fibrosis processes. This can lead to the development of portal hypertension.
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This question is part of the following fields:
- Hepatobiliary System
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Question 179
Incorrect
-
A 48-year-old patient with type 1 diabetes and chronic kidney disease attends for review. His blood tests show:
Haemoglobin 11.2 g/dl (13.0 - 18.0 g/dL)
MCV 87 fl (80 - 96 fL)
Sodium 133 mmol/l (137 - 144 mmol/L)
Potassium 4.3 mmol/l (3.5 - 4.9 mmol/L)
Urea 19.1 mmol/l (2.5 - 7.5 mmol/L)
Creatinine 267 μmol/l (60 - 110 μmol/L)
Ferritin 150 μg/l (15 - 300 μg/L)
C reactive protein <5 mg/l (< 10 mg/L)
Â
What is the most appropriate management of his anaemia?Your Answer:
Correct Answer: Monitor haemoglobin, no treatment required at present
Explanation:Because the patient has chronic kidney disease, we need to consider the associated adverse effects of trying to maintain normal haemoglobin levels (14-18g/dl in this patient) and instead only instigate therapy when the level falls below 11 g/dl. Thus, in this case we should just monitor the haemoglobin levels and not initiate therapy just yet.
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This question is part of the following fields:
- Renal System
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Question 180
Incorrect
-
A 31-year-old homosexual male is complaining of recent weight loss and blurred vision. A fundoscope was performed showing retinal haemorrhage. What is the single most appropriate option?
Your Answer:
Correct Answer: Cytomegalovirus (CMV)
Explanation:CMV is the best answer . Weight loss is mostly caused by HIV, which commonly presents with retinal haemorrhage and retinopathy when associated with CMV.
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This question is part of the following fields:
- Infectious Diseases
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Question 181
Incorrect
-
A 13-year-old girl is brought by her mother to the A&E with breathlessness, fatigue and palpitations. Anamnesis does not reveal any syncope or chest pain in the past. on the other hand, these symptoms were present intermittently for a year. Clinical examination reveals a pan-systolic murmur associated with giant V waves in the jugular venous pulse. Chest auscultation and resting ECG are normal. 24 hour ECG tape shows a short burst of supraventricular tachycardia. What is the most probable diagnosis?
Your Answer:
Correct Answer: Ebstein's anomaly
Explanation:Ebstein’s anomaly is characterised by apical displacement and adherence of the septal and posterior leaflets of the tricuspid valve to the underlying myocardium, thereby displacing the functional tricuspid orifice apically and dividing the right ventricle into two portions. The main haemodynamic abnormality leading to symptoms is tricuspid valve incompetence. The clinical spectrum is broad; patients may be asymptomatic or experience right-sided heart failure, cyanosis, arrhythmias and sudden cardiac death (SCD). Many Ebstein’s anomaly patients have an interatrial communication (secundum atrial septal defect (ASD II) or patent foramen ovale). Other structural anomalies may also be present, including a bicuspid aortic valve (BAV), ventricular septal defect (VSD), and pulmonary stenosis. The morphology of the tricuspid valve in Ebstein anomaly, and consequently the clinical presentation, is highly variable. The tricuspid valve leaflets demonstrate variable degrees of failed delamination (separation of the valve tissue from the myocardium) with fibrous attachments to the right ventricular endocardium.
The displacement of annular attachments of septal and posterior (inferior) leaflets into the right ventricle toward the apex and right ventricular outflow tract is the hallmark finding of Ebstein anomaly. -
This question is part of the following fields:
- Cardiovascular System
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Question 182
Incorrect
-
A 30 year male admitted following a stab injury to his left upper chest. He complained of difficulty in breathing. On examination his chest movements were unequal on the left side. Which of the following nerves is most likely to be damaged?
Your Answer:
Correct Answer: Left phrenic nerve
Explanation:Difficulty in breathing and unequal chest movements are due to paralysis of the diaphragm. So the nerve affected is the left phrenic nerve.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 183
Incorrect
-
A 65-year-old male was admitted for surgery 4 days ago. He suddenly became confused and aggressive. His attention span was reduced, and he became very restless. Which single option from the history best explains his condition?
Your Answer:
Correct Answer: Alcohol consumption
Explanation:Patient was dependent on alcohol. After 4 days of admission he developed signs of alcohol withdrawal.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 184
Incorrect
-
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:
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 185
Incorrect
-
A middle-aged female has undergone axillary lymph node clearance after being diagnosed with breast carcinoma. She was stung by a bee and developed a swollen arm. What is the most probable mechanism behind this arm swelling?
Your Answer:
Correct Answer: Lymphoedema
Explanation:Lymph nodes are necessary for the drainage of interstitial fluid to avoid swelling after some histamine reactions. In this case no lymph nodes are present and lymphoedema developed.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 186
Incorrect
-
A 50-year-old patient was admitted to the hospital for elective herniorrhaphy. Which of the following options will lead to a postponement of his operation?
Your Answer:
Correct Answer: Myocardial infarction two months ago
Explanation:Patients with a recent cerebrovascular incident (less than 60 days) are at very high risk of cardiac complications when under general anaesthesia. Complications like MI, heart failure and even death. Elective surgery should be postponed till stabilization of the cardiac condition is achieved.
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This question is part of the following fields:
- Cardiovascular System
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Question 187
Incorrect
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A 60-year-old male was diagnosed as diabetic (DM type 2). He has a BMI=32. Lifestyle modification and exercise have failed to control his blood glucose levels. His labs were: urea=3.5mmol/l, creatinine=90 mmol/l, HbA1c=7.5g/dl. What will be the next management step?
Your Answer:
Correct Answer: Biguanide
Explanation:For type 2 diabetics, biguanides are the treatment of choice.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 188
Incorrect
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During the peri-infarct period, which of these drug classes have been shown to have the greatest favourable benefit?
Your Answer:
Correct Answer: Beta blockers
Explanation:Statins and ACE inhibitors are beneficial initially for the first 24 hours but not proven to have a benefit in the post infarct period. Statins have plaque stabilising functions when activated early following infarction. In contrast, when started immediately, beta blockers are the most beneficial. Nitrates have not been proven beneficial for survival and some calcium channel blockers actually increased the mortality rate.
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This question is part of the following fields:
- Cardiovascular System
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Question 189
Incorrect
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An elderly woman is referred with worsening chronic pulmonary disease (COPD). She smokes seven cigarettes per day. Her exercise tolerance is only a few yards around the house now. Her FEV1 is 37% of predicted.
What is the most appropriate intervention for this patient?Your Answer:
Correct Answer: Give regular high-dose inhaled fluticasone and inhaled long-acting β-agonist
Explanation: -
This question is part of the following fields:
- Respiratory System
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Question 190
Incorrect
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A 19-year-old woman comes to the endocrine clinic with excessive hairiness and acne. She tells you that she has a period only every few months and when she has one it tends to be very heavy.
On examination, she has obvious facial acne. Her BP is 142/78 mmHg, her pulse is 72 bpm and regular and her BMI is 30. There is facial hair and hair around her upper chest and breasts.
Investigations show:
Haemoglobin 11.9 g/dl (11.5-16.0)
White cell count 6.0 x 10(9)/l (4-11)
Platelets 202 x 10(9)/l (150-400)
Sodium 137 mmol/l (135-146)
Potassium 3.9 mmol/l (3.5-5)
Creatinine 90 µmol/l (79-118)
Total testosterone normal
Free androgen index elevated
LH / FSH ratio 2.2
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Polycystic ovarian syndrome
Explanation:Rotterdam criteria for the diagnosis of polycystic ovary syndrome:
Two of the following three criteria are required:
1. Oligo/anovulation
2. Hyperandrogenism
– Clinical (hirsutism or less commonly male pattern alopecia) or
– Biochemical (raised FAI or free testosterone)
3. Polycystic ovaries on ultrasound
Other aetiologies must be excluded such as congenital adrenal hyperplasia, androgen-secreting tumours, Cushing syndrome, thyroid dysfunction and hyperprolactinaemia.
Cushing’s is excluded because there would have been marked obesity, hypertension and other related features. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 191
Incorrect
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A 21-year-old male was brought in unconscious state with high fever, swollen nasal mucosa and constricted pupils. Which of the following substances can cause this presentation?
Your Answer:
Correct Answer: Cocaine
Explanation:This presentation is suggestive of cocaine toxicity. The major effects of cocaine poisoning include CNS effects such as agitation, seizures and psychosis, and cardiovascular effects such as dysrhythmias, myocardial infarction and cardiovascular collapse. The common route for cocaine ingestion is through the nose, hence the irritated swollen septum.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 192
Incorrect
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An 18-year-old boy with a history of bloody diarrhoea and fever, presents with a skin rash and low urine output. Blood tests and urinalysis reveal increased levels of urea and creatinine and haematuria. What is the most probable diagnosis?
Your Answer:
Correct Answer: Haemolytic Uraemic Syndrome
Explanation:Signs and symptoms of haemolytic uremic syndrome can include bloody diarrhoea, low urine output, nausea, vomiting, abdominal pain and general fatigue. Increased values of urea and creatinine are also typical.
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This question is part of the following fields:
- Haematology & Oncology
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Question 193
Incorrect
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A collapsed patient comes into A&E. He has a steroid user card and empty boxes of prednisolone. He has obvious rheumatoid features on examination and some unilateral consolidation on his chest X-ray. He is given intravenous fluids and broad-spectrum antibiotics.
Which one of the following would be the most useful addition to the current management?Your Answer:
Correct Answer: IV hydrocortisone 100 mg
Explanation:The empty boxes indicate that the patient has run out of his medication.
Chronic administration of high doses of glucocorticoids (GCs) (e.g., prednisone or prednisolone) and also other hormones such as oestrogens, progestins, androgens and growth hormone induce varying degrees of tolerance, resulting in a progressively decreased response to the effect of the drug, followed by dependence and rarely addiction.
The glucocorticoid withdrawal syndrome (GWS) has been considered a withdrawal reaction due to established physical dependence on supraphysiological GC levels.
The severity of GWS depends on the genetics and developmental history of the patient, on his environment, and on the phase and degree of dependence the patient has reached. Its management should include a temporary increase in the dose of GCs followed by gradual, slow tapering to a maintenance dose. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 194
Incorrect
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A 69-year-old diabetic female presents for a regular outpatient visit. Her BMI is calculated to be 33. Lab results: GFR=29, Urea=13, Creatinine=390 mmol/L. Which of the following drugs should ideally be used by this patient?
Your Answer:
Correct Answer: Insulin
Explanation:The management of patients with diabetes and nephropathy necessitates attention to several aspects of care. Importantly, glycaemic control should be optimized for the patient, attaining the necessary control to reduce complications but done in a safe, monitored manner. Screening for development of nephropathy should be performed on a regular basis to identify microalbuminuria or reductions in GFR and if identified, the diabetes regimen should be tailored accordingly. Prevention and treatment of diabetic nephropathy and other complications necessitates a multifactorial approach. From the options provided insulin is the most suitable as sulfonylureas and biguanides are contraindicated in renal failure. Glitazones are known to cause many side effects including fluid retention and oedema. Hence, insulin will be the best option in this scenario.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 195
Incorrect
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A 63-year-old gentleman with chronic kidney disease secondary to diabetes mellitus is reviewed. When assessing his estimated glomerular filtration rate (eGFR), which one of the following variables is not required by the Modification of Diet in Renal Disease (MDRD) equation?
Your Answer:
Correct Answer: Serum urea
Explanation:A formula for estimating glomerular filtration rate (eGFR) is the Modification Diet of Renal Disease (MDRD) equation which takes into account the following variables: serum creatinine, age, gender, and ethnicity. Thus, serum urea is not required in this formula.
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This question is part of the following fields:
- Renal System
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Question 196
Incorrect
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A 58-year-old woman with a longstanding history of hypertension arrives at the hospital complaining of recurrent falls when trying to get out of bed or get up from sitting. She is currently on an antihypertensive regimen? What do you think is most likely responsible for her falls?
Your Answer:
Correct Answer: Thiazide
Explanation:The causes of orthostatic hypotension include the following: Hypovolemia (a drop in the volume of blood) and dehydration (low fluid volume in the body). Common causes of these are bleeding, elevated sugar, diarrhoea, vomiting, and medications like thiazide diuretics (HCTZ) and loop diuretics (furosemide, bumetanide)
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This question is part of the following fields:
- Emergency & Critical Care
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Question 197
Incorrect
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A patient presented with complaints of difficulty in swallowing, diplopia on left lateral gaze and ptosis of his left eye. The investigation of choice would be?
Your Answer:
Correct Answer: Serum anti-acetylcholine receptor antibodies
Explanation:Myasthenia gravis clinically manifests with ptosis, diplopia and difficulty in swallowing. The initial investigation which is needed to confirm the diagnosis would be serum anti-acetylene receptor antibodies, after which other investigations like an EMG should be done.
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This question is part of the following fields:
- Nervous System
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Question 198
Incorrect
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A 50-year-old woman presents with coughing up copious sputum with blood streaks, increased breathlessness, and finger clubbing. She has a history of chronic cough. What is the initial investigation?
Your Answer:
Correct Answer: Chest x-ray
Explanation:Finger clubbing and past history suggest a chronic pulmonary process going on. A CXR will allow the pathology to be visualised including any infective or cancerous causes.
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This question is part of the following fields:
- Respiratory System
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Question 199
Incorrect
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What is the mechanism of action of sildenafil citrate?
Your Answer:
Correct Answer: Inhibition of phosphodiesterase V
Explanation: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. -
This question is part of the following fields:
- Pharmacology
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Question 200
Incorrect
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A 65-year-old male patient is found to have an elevated serum paraprotein level of 35 g/L. Bone marrow aspirate reveals 32% monoclonal plasma cell infiltrate. He has no evidence of anaemia, renal impairment, hypercalcaemia, or lytic lesions.
What should be the next step in management?Your Answer:
Correct Answer: Observe and monitor
Explanation:The patient is asymptomatic but matches the diagnostic criteria for multiple myeloma (MM). Therefore, the underlying diagnosis of this condition is smouldering multiple myeloma (SMM). SMM is an early precursor to MM. Its treatment is typically to watch and wait.
MM is a neoplasm of the bone marrow plasma cells. Peak incidence is in patients aged 60-70 years.
Clinical features of MM include:
1. Ostealgia, osteoporosis, pathological fractures (typically vertebral), and osteolytic lesions
2. Lethargy
3. Infections
4. Hypercalcaemia
5. Renal failure
6. Other features: amyloidosis e.g. macroglossia, carpal tunnel syndrome; neuropathy; hyperviscosityDiagnosis 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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SESSION STATS - PERFORMANCE PER SPECIALTY
