-
Question 1
Correct
-
A 67 year-old attorney presents with a 2 month history of tremors affecting his left arm. He suffers from depressive psychosis for the last 10 years, for which he has been receiving intermittent chlorpromazine and amitriptyline but has not been on any therapy for the last 4 months. He describes that his two brothers also had tremors. Upon examination, he has a resting tremor of his left hand with cogwheel rigidity of that arm and mild generalized bradykinesia. Which of the following is the most likely diagnosis?
Your Answer: Idiopathic Parkinson's disease
Explanation:The most likely diagnosis is idiopathic Parkinson’s disease because of the unilateral presentation. In addition, cogwheel rigidity is a classic presenting symptom. Neuroleptic-induced parkinsonism is usually bilateral and symmetrical. Essential tremors do not cause rest tremors.
-
This question is part of the following fields:
- Nervous System
-
-
Question 2
Correct
-
A 25-year-old patient has presented with symptoms which all point to the cerebellopontine angle (CPA) a tumour. These are numbness in the face, vertigo, and tinnitus. Choose the most appropriate investigation from the list of options.
Your Answer: MRI Brain
Explanation:MRI scans are used to diagnose tumours in the cerebellopontine angle.
-
This question is part of the following fields:
- Nervous System
-
-
Question 3
Incorrect
-
Out of the following, which malignant tumour has the highest predilection for dissemination to the bones?
Your Answer: Lung
Correct Answer: Prostate
Explanation:Prostate cancer is the most common primary tumour that metastasises to the bone.
Most common tumours causing bone metastasis (in descending order):
1. Prostate (32%)
2. Breast (22%)
3. Kidneys (16%)
4. Lungs
5. ThyroidMost common sites of bone metastasis (in descending order):
1. Spine
2. Pelvis
3. Ribs
4. Skull
5. Long bones -
This question is part of the following fields:
- Haematology & Oncology
-
-
Question 4
Correct
-
A 28-year-old female presents to her GP with joint pain , fever, a butterfly rash and fatigue. She has marked peripheral oedema. She is found to be hypertensive, in acute renal failure, low albumin levels and proteinuria.
A renal biopsy is performed and reveals focal glomerulonephritis with subendothelial and mesangial immune deposits.
What is the most likely diagnosis?Your Answer: Lupus nephritis Class III
Explanation:This case presents with characteristic symptoms of SLE and with her renal biopsy results of focal glomerulonephritis, this is clearly Class III SLE.
-
This question is part of the following fields:
- Renal System
-
-
Question 5
Correct
-
A 6 week old female patient was brought by her mother to the emergency department with icterus. Although she's had a good appetite, and breast-feeding well, she hasn't gained any weight. Her mother noticed that her stools are pale while her urine is noticeably dark. What is the most probable diagnosis?
Your Answer: Biliary atresia
Explanation:Biliary atresia is a rare condition that usually becomes symptomatic 2 to 8 weeks after birth. It can be congenital or acquired. Typical symptoms include jaundice, weight loss, dark urine and pale stools.
-
This question is part of the following fields:
- Hepatobiliary System
-
-
Question 6
Incorrect
-
A 69-year-old male with a history of Hepatitis C liver cirrhosis presented with spontaneous bacterial peritonitis. He had no symptoms of hypovolaemia. Choose the best treatment option to prevent the patient from developing hepatorenal syndrome.
Your Answer: Neomycin
Correct Answer: Intravenous albumin administration
Explanation:In randomised controlled trials, the administration of albumin has been shown to lower the risk of the hepatorenal syndrome – this is thought to be due to its positive effect on circulatory systems. Diuretics can aid in the prevention of renal failure, but this patient is not showing signs of hypovolaemia. Synthetic disaccharide lactulose is primarily used for the prevention of hepatic encephalopathy, which has no function in preventing hepatorenal syndrome. Limited evidence is available for the use of Neomycin as a treatment for hepatic encephalopathy, but is associated with nephrotoxicity and ototoxicity.
-
This question is part of the following fields:
- Renal System
-
-
Question 7
Correct
-
A 43-year-old right-handed migraineur is admitted to hospital having developed paraesthesia affecting her left arm. This came on suddenly during a migrainous attack while out shopping. The paraesthesia appeared to affect the entire left arm and in the last few hours, has spread to involve the left side of the face. She had had a similar episode several months ago whereby she developed some right-sided leg and arm weakness while at work. The weakness lasted several minutes and subsequently abated. At the time, she was also having one of her migraines. She has a long-standing history of migraines, which typically start with a prolonged aura and fortification spectra. Other than migraines, for which she has been taking pizotifen, she has no other past medical history. Her sister also suffers from migraines, and her mother has a history of dementia in her 50s. She is a non-smoker and drinks minimal alcohol.
On examination she was orientated but apathetic. Her blood pressure was 130/65 mmHg, pulse 62/min, and temperature 36.2ºC. There were no carotid bruits and heart sounds were entirely normal. There was reduced sensation to all modalities over the left side of the face extending to the vertex and the entire left arm. Tone and reflexes appeared intact; however, handgrip was reduced on the left due to numbness. The lower limb appeared entirely normal.
Magnetic resonance (MR) scan showed bilateral, multifocal, T2/FLAIR (fluid attenuated inversion recovery ) hyperintensities in the deep white matter. MR Spinal cord was normal.
What is the diagnosis?Your Answer: CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy)
Explanation:CADASIL is the most common form of hereditary stroke disorder. This case has a strong history of migraine with aura with stroke-like episodes, characteristic of CADASIL. Additionally, there is positive family history of migraine and early dementia but no other vascular risk factors like hypertension, diabetes, or hypercholesterolaemia, which all confirm the suspicion of CADASIL, an arteriopathy where there is thickening of the smooth muscle cells in the blood vessels.
-
This question is part of the following fields:
- Nervous System
-
-
Question 8
Correct
-
Choose the correct statement regarding hyponatremia:
Your Answer: Hyperlipidaemia may cause pseudohyponatraemia
Explanation:The Hyperlipidaemia Effect: Pseudohyponatremia in Pancreatic Cancer; Patients who have disorders of cholestasis commonly present with volume depletion due to vomiting and poor oral intake, which, in turn, often leads to hypovolemic hyponatremia. It is less well known that disorders of cholestasis, including tumours of the hepatobiliary system, can be accompanied by hyperlipidaemia.
-
This question is part of the following fields:
- Fluids & Electrolytes
-
-
Question 9
Incorrect
-
An 86-year-old woman accidentally inhaled her hearing aid due to her advanced Alzheimer's dementia. Upon clinical examination, her respiratory rate is found to be 35, and thus a bronchoscopy is recommended. According to which of the following would you obtain consent for this patient?
Your Answer: Relatives/next of kin will have to consent for the patient
Correct Answer: The procedure does not require a written consent
Explanation:This is an emergency case regarding a patient with impaired cognitive functioning. This is why the procedure does not require a written consent. In any other case where the patient has a normal mental capacity, the consent would be obtained as an informed written consent. In this case however, the suggested procedure is almost a matter of life and death, the doctor being required to act on behalf of the patient to her optimal advantage. Under English law no other person can consent to treatment on behalf of an adult, though it is desirable that next of kin are consulted before treating an adult without consent. Recent legislation gives legal authority to people appointed by the patient, or by the state, or a relative or carer, to consent (or refuse) on behalf of the patient. A mini-mental score may not adequately identify those unable to give consent.
-
This question is part of the following fields:
- Geriatric Medicine
-
-
Question 10
Correct
-
What does Caplan's syndrome refer to?
Your Answer: Rheumatoid lung nodules and pneumoconiosis
Explanation:Caplan’s syndrome is defined as the association between silicosis and rheumatoid arthritis (RA). It is rare and usually diagnosed in an advanced stage of RA. It generally affects patients with a prolonged exposure to silica.
Caplan’s syndrome presents with rheumatoid lung nodules and pneumoconiosis. Originally described in coal miners with progressive massive fibrosis, it may also occur in asbestosis, silicosis and other pneumoconiosis. Chest radiology shows multiple, round, well defined nodules, usually 0.5 – 2.0 cm in diameter, which may cavitate and resemble tuberculosis.
-
This question is part of the following fields:
- Respiratory System
-
-
Question 11
Incorrect
-
A west Indian man complains of limb and abdominal pain. He is also anaemic and has frequent infections, which precipitate these symptoms. On examination, his spleen is not palpable and he has a mild jaundice. What is your most probable diagnosis?
Your Answer: Beta thalassemia major
Correct Answer: Sickle cell disease
Explanation:Sickle cell disease (SCD) and its variants are genetic disorders resulting from the presence of a mutated form of haemoglobin, haemoglobin S (HbS). This leads to a rigid, sickle-like shape of red blood cells under certain circumstances which can result in attacks of pain (sickle cell crisis), anaemia, swelling in the hands and feet, bacterial infections and stroke. Anaemia and jaundice happen due to insufficient healthy red blood cell capacity and increased breakdown of haem groups by the liver.
-
This question is part of the following fields:
- Gastrointestinal System
-
-
Question 12
Correct
-
Which of the following nail changes are present in ulcerative colitis?
Your Answer: Clubbing
Explanation:Clubbing of the fingers can be present in many clinical conditions like CLD, bronchiectasis, lung abscess, Ulcerative colitis and Crohn’s Disease. Koilonychia or spoon shaped nails are a typical finding in iron deficiency anaemia. Splinter haemorrhages are pin point haemorrhages found in infective endocarditis and secondary to trauma. Yellow nails are present in pulmonary and renal diseases.
-
This question is part of the following fields:
- The Skin
-
-
Question 13
Correct
-
A 42-year-old previously well woman presented with acute severe central chest pain for the past 2 hours. She has a family history of premature coronary artery disease. Her husband passed away recently due to prostate cancer. On examination her blood pressure was 130/80 mmHg and pulse rate was 80 bpm. Her ECG showed ST segment elevation and her troponin was slightly elevated. Emergency angiogram revealed slight wall irregularities with no luminal obstruction. Cardiovascular MR showed an apical ballooning of the myocardium resembling an octopus pot. Which of the following is the most likely cause for the ST segment elevation?
Your Answer: Takotsubo cardiomyopathy
Explanation:Causes for ST segment elevation other than myocardial infarction
Natural variants
-Early repolarization
-Left ventricular hypertrophy and hypertrophic cardiomyopathy
-Left bundle branch block
Artefacts
-Leads mispositioning
-Electrical cardioversion
Cardiovascular diseases
-Pericarditis/ Myocarditis
-Aortic dissection
-Prinzmetal’s angina
-Takotsubo Cardiomyopathy
-Brugada Syndrome and arrhythmogenic right ventricular cardiomyopathy/dysplasia
Pulmonary diseases
-Pulmonary thromboembolism
-Pneumothorax
-Atelectasis and pulmonary metastases
Gastrointestinal diseases
-Acute pancreatitis
-Acute cholecystitis
Other conditions
-Hyperkalaemia
-Drug induced ST segment elevation (e.g. – clozapine)
-Haemorrhagic cerebrovascular diseaseCoronary artery disease and myocardial infarction can be excluded with a negative angiogram and a slightly elevated troponin. Hypertrophic cardiomyopathy can be excluded with cardiovascular MR findings. Left ventricular aneurysm usually occurs following a myocardial infarction, but there is no positive history for that. The characteristic findings on cardiovascular MR confirms the diagnosis of Takotsubo cardiomyopathy.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 14
Incorrect
-
What is the mode of spread of chickenpox?
Your Answer: Close contact
Correct Answer: Airborne
Explanation:Chickenpox is a highly communicable viral disease caused by human (alpha) herpesvirus 3 (varicella-zoster virus, VZV). It is transmitted from person to person by direct contact (touching the rash), droplet or air born spread (coughing and sneezing).
-
This question is part of the following fields:
- Infectious Diseases
-
-
Question 15
Incorrect
-
A 65-year-old gentleman presented with 2 weeks history of exertional dyspnoea, orthopnoea and chest pain. Past history revealed that a few years ago, he had been treated with antibiotics for complaints of fever, joint pains and chest pain. The most likely diagnosis will be?
Your Answer: Mitral valve prolapse
Correct Answer: Mitral valve stenosis
Explanation:The commonest symptom of mitral valve stenosis is dyspnoea, and it is one of the most common clinical findings which can be seen in rheumatic fever.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 16
Correct
-
A 30-year-old male presented with exercise related syncope and dyspnoea for 2 weeks. His father passed away at the age of 40, due to sudden cardiac death. His ECG showed left ventricular hypertrophy with widespread T wave inversions. Which of the following is the most appropriate next investigation to confirm the diagnosis?
Your Answer: Transthoracic echo
Explanation:The most likely diagnosis is hypertrophic obstructive cardiomyopathy which is suggestive by the history, positive family history and ECG findings. Two-dimensional echocardiography is diagnostic for hypertrophic cardiomyopathy. In general, a summary of echocardiography findings includes abnormal systolic anterior leaflet motion of the mitral valve, LV hypertrophy, left atrial enlargement, small ventricular chamber size, septal hypertrophy with septal-to-free wall ratio greater than 1.4:1, mitral valve prolapse and mitral regurgitation, decreased midaortic flow, and partial systolic closure of the aortic valve in midsystole.
-
This question is part of the following fields:
- Cardiovascular System
-
-
Question 17
Correct
-
A 28-year-old patient presents with inflammatory bowel disease. 5-ASA would be most appropriate in treating which condition?
Your Answer: Maintenance therapy for ulcerative colitis
Explanation:5-ASA is not an acute treatment; it is for maintenance therapy for ulcerative colitis and/or Crohn’s. The most benefit is seen in patients with ulcerative colitis.
-
This question is part of the following fields:
- Gastrointestinal System
-
-
Question 18
Correct
-
A 70-year-old male patient presents with a history hematochezia and rectal tenesmus for the last six months. What is most probable diagnosis?
Your Answer: Colorectal adenocarcinoma
Explanation:The patient presents with symptoms of possible colorectal adenocarcinoma. When located in the left colon, it typically presents with tenesmus and bleeding. On the right side usually presents with anaemia, weight loss and abdominal pain.
-
This question is part of the following fields:
- Gastrointestinal System
-
-
Question 19
Correct
-
A 20-year-old woman who is sexually active is having deep dyspareunia and vaginal discharge. She has a negative smear for Gonococcus. Which of the following is the most likely diagnosis?
Your Answer: Chlamydial trachomatis
Explanation:This case is highly suggested of PID or Pelvic Inflammatory disease with chlamydia as the more common infective agent. Tetracyclines are used for treatment.
-
This question is part of the following fields:
- Infectious Diseases
-
-
Question 20
Incorrect
-
Out of the following, which condition is not associated with hyposplenism?
Your Answer: Coeliac disease
Correct Answer: Liver cirrhosis
Explanation:Liver cirrhosis is not associated with hyposplenism.
Hyposplenism is caused by a variety of conditions. These are:
1. Splenectomy
2. Sickle cell anaemia
3. Coeliac disease, dermatitis herpetiformis
4. Graves’ disease
5. Systemic lupus erythematosus (SLE) -
This question is part of the following fields:
- Haematology & Oncology
-
-
Question 21
Correct
-
An 18-year-old girl presents with short history of marked, right hip pain and an associated limp. She has a history of acute lymphoblastic leukaemia for which she completed treatment for last six months.
Your Answer: Avascular necrosis of the femoral head
Explanation:Avascular necrosis (AVN) of the femoral head is a pathological process that results from disruption of the blood supply to the bone and occurs most commonly in the femoral epiphysis. Patients usually present with pain and limited joint motion. The mechanism involves impaired circulation to a specific area that ultimately becomes necrotic. AVN is most frequently associated with high doses of oral and intravenous corticosteroids and prolonged duration of therapy. Cancer patients receiving chemotherapy are usually also treated with corticosteroids.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 22
Correct
-
A 56-year-old woman taking procainamide develops drug induced erythematosus. Which of the following features is the most characteristic of this condition?
Your Answer: It may occur with chlorpromazine
Explanation:Drug induced lupus is usually positive for antinuclear and antihistone antibodies, typically without renal or neurologic involvement. However, pulmonary involvement is common. Drugs that can induce lupus include isoniazid, hydralazine, procainamide, chlorpromazine, and other anticonvulsants.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 23
Incorrect
-
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: Bladder
Correct 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.
-
This question is part of the following fields:
- Haematology & Oncology
-
-
Question 24
Incorrect
-
A 50-year-old lung cancer patient presents with diminished reflexes, retention of urine, postural hypotension and sluggish pupillary reaction. What is the most likely explanation for her symptoms?
Your Answer: Brain Metastasis
Correct Answer: Paraneoplastic syndrome
Explanation:Paraneoplastic syndromes are more common in patients with lung cancer. Signs and symptoms include inappropriate antidiuretic hormone secretion, finger clubbing, hypercoagulability and Eaton-Lambert syndrome.
-
This question is part of the following fields:
- Respiratory System
-
-
Question 25
Correct
-
A 30-year-old woman is referred to endocrinology with thyrotoxicosis. Following a discussion of management options, she chooses to have radioiodine therapy. Which one of the following is the most likely adverse effect?
Your Answer: Hypothyroidism
Explanation:Approximately one third of patients treated with radioiodine therapy develop transient hypothyroidism. Unless a patient is highly symptomatic, thyroxine replacement may be withheld if hypothyroidism occurs within the first 2 months of therapy. If it persists for longer than 2 months, permanent hypothyroidism is likely and replacement with T4 should be initiated.
-
This question is part of the following fields:
- Endocrine System & Metabolism
-
-
Question 26
Incorrect
-
A 45-year-old man presents with fever, malaise, weight loss and myalgias that have been occurring for a month. You suspect polyarteritis nodosa and arrange for some lab investigations. Which of the following abnormality would most likely be present?
Your Answer: Anaemia
Correct Answer: Elevated creatinine
Explanation:People with polyarteritis nodosa often exhibit anaemia of chronic disease. Leucocytosis and eosinophilia may also be present. ANCA is only rarely positive. As polyarteritis nodosa affects the kidneys as well, the creatinine is elevated in most cases.
-
This question is part of the following fields:
- Musculoskeletal System
-
-
Question 27
Incorrect
-
A 16-year-old female has been admitted to hospital after overdosing on paracetamol 4 hours ago. She has also consumed a large amount of alcohol. Her plasma paracetamol concentration is only just below a level which requires treatment. From the list of options, choose the most appropriate treatment option for this patient.
Your Answer: N-acetylcysteine
Correct Answer: Refer to psychiatry ward
Explanation:As her paracetamol level is under the required treatment threshold, she requires no medical treatment. However, she has taken a simultaneous drug overdose and excessive alcohol consumption. These two factors together require psychiatric evaluation and so she should be referred to the psychiatry ward.
-
This question is part of the following fields:
- Emergency & Critical Care
-
-
Question 28
Correct
-
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.
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.
What is the pathological hallmark of this condition?Your 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.
-
This question is part of the following fields:
- Renal System
-
-
Question 29
Incorrect
-
A 27-year-old woman presents with recurrent headaches and sweating. On examination, a nodule is felt in the region of the thyroid gland. She mentions that her mother had kidney stones and died following a tumour in her neck. A surgeon recommends complete thyroidectomy as her treatment of choice.
What is the most important investigation to be done before the surgery?Your Answer: Serum calcium
Correct Answer: 24-hour urinary catecholamines
Explanation:The patient is most likely to have Medullary Thyroid Carcinoma (MTC).
Sporadic, or isolated MTC accounts for 75% of cases and inherited MTC constitutes the rest.
Inherited MTC occurs in association with multiple endocrine neoplasia (MEN) type 2A and 2B syndromes, but non-MEN familial MTC also occurs.
A 24-hour urinalysis for catecholamine metabolites (e.g., vanillylmandelic acid [VMA], metanephrine) has to be done to rule out concomitant pheochromocytoma in patients with MEN type 2A or 2B, as Pheochromocytoma must be treated before MTC. -
This question is part of the following fields:
- Endocrine System & Metabolism
-
-
Question 30
Correct
-
A 23-year-old man is being investigated for excessive bleeding following a tooth extraction.
His coagulation profile shows:
Plts: 173 x 10^9/L
PT: 12.9 secs
APTT: 84 secs
Which clotting factor is he most likely deficient in?Your Answer: Factor VIII
Explanation:The patient is most likely a case of haemophilia A which is the genetic deficiency of clotting factor VIII in blood.
Haemophilia is an X-linked recessive disorder of coagulation. Up to 30% of patients have no family history of the condition. Haemophilia A is more common than haemophilia B and accounts for 90% of the cases. In haemophilia B (Christmas disease), there is a deficiency of clotting factor IX.
Characteristic features of haemophilia include hemarthrosis, haematomas, and prolonged bleeding following trauma or surgery. Coagulation profile of a haemophiliac person shows prolonged bleeding time, activated partial thromboplastin time (APTT), thrombin time (TT), but a normal prothrombin time (PT).
-
This question is part of the following fields:
- Haematology & Oncology
-
SESSION STATS - PERFORMANCE PER SPECIALTY
