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Question 1
Incorrect
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A 51-year-old man was admitted with right-sided hemiparesis and right upper motor neurone facial nerve palsy. He was known to be on warfarin for a mitral valve replacement and had been adequately anticoagulated. He was also taking furosemide and had recently been started on St John’s wort for low mood. On examination, his pulse was 90 bpm and regular, and his blood pressure was 150/80 mmHg. Cardiac examination demonstrated normal prosthetic valve sounds with an ejection systolic murmur at the left sternal edge. CT scan showed evidence of a left middle cerebral artery infarction. What is the possible explanation for the presentation?
Your Answer: Furosemide reduces the activity of warfarin in the presence of St John’s wort
Correct Answer: St John’s wort reduces the activity of warfarin
Explanation:St John’s wort interferes with warfarin by increasing its breakdown and decreasing its effectiveness. This leads to the need for adjustment in the dose of warfarin and careful attention to monitoring if the patient decides to continue with the drug. Ideally, an alternative antidepressant should also be considered.
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This question is part of the following fields:
- Haematology & Oncology
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Question 2
Incorrect
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A 75 yr. old male with rheumatoid arthritis underwent a colectomy 2 days ago for colon cancer. He was put on a prophylactic dose of low molecular weight heparin post operatively as well as prednisolone. Now he complains of central chest pain and his ECG revealed an acute ST elevation myocardial infarction. He was given aspirin and oxygen as the initial treatment. Which of the following is the most appropriate management for this patient?
Your Answer: IV diamorphine + thrombolysis
Correct Answer: IV diamorphine + arrange percutaneous coronary intervention
Explanation:There is a high risk of bleeding due to recent surgery and heparin. So thrombolysis is not an option. The most appropriate management is percutaneous coronary intervention.
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This question is part of the following fields:
- Cardiology
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Question 3
Incorrect
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A 43 year old man with hemochromatosis presents with a painful and swollen right knee. X-ray shows extensive chondrocalcinosis but no fracture. Given the most likely diagnosis, which of the following would be present in the joint fluid aspirate?
Your Answer: Monosodium urate crystals
Correct Answer: Positively birefringent rhomboid-shaped crystals
Explanation:Pseudogout is a paroxysmal joint inflammation due to calcium pyrophosphate crystal deposition (calcium pyrophosphate dihydrate). Arthrocentesis should be performed, especially in acute cases.
Polarized light microscopy: detection of rhomboid-shaped, positively birefringent CPPD crystals.
Synovial fluid findings: 10,000-50,000 WBCs/μL with > 90% neutrophils.
X-ray findings: cartilage calcification of the affected joint (chondrocalcinosis).
Fibrocartilage (meniscus, annulus fibrosus of intervertebral disc) and hyaline cartilage (joint cartilage) may be affected. -
This question is part of the following fields:
- Rheumatology
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Question 4
Correct
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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 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:
- Clinical Sciences
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Question 5
Incorrect
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Which one of the following is true of gamma delta T cells?
Your Answer: They are the mature form of alpha beta T cells
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 6
Correct
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A 67-year-old butcher presents with a six month history of a gradually increasing burning sensation in his feet. Examination reveals normal cranial nerves and higher mental function. He has normal bulk, tone, power, light touch, pinprick sensation, co-ordination and reflexes in upper and lower limbs. These clinical findings are consistent with which of the following?
Your Answer: Small fibre sensory neuropathy
Explanation:The burning sensation described is typical of a neuropathy affecting the small unmyelinated and thinly myelinated nerve fibres. General neurological examination and reflexes are usually normal in this type of neuropathy unless there is coexisting large (myelinated) fibre involvement. Neuropathy affecting the large myelinated sensory fibres generally causes glove and stocking sensory loss and loss of reflexes.
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This question is part of the following fields:
- Neurology
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Question 7
Incorrect
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A 70-year-old male patient presents to the urology clinic with a one-month history of passing frank haematuria. Flexible cystoscopy shows a mass of the bladder wall and biopsy reveals transitional cell carcinoma. Out of the following, which industry has he most likely worked in?
Your Answer: Refrigerant production before 1974
Correct Answer: Dyestuffs and pigment manufacture
Explanation:Exposure to aniline dyes is a risk factor for transitional cell carcinoma. Aniline dyes are used in dyestuffs and pigment manufacturing.
The other aforementioned options are ruled out because:
1. Feed production may expose to aflatoxin (hepatocellular carcinoma).2. Being a military personnel may expose to mustard gas (lung cancer).
3. Rubber industry may expose to nitrosamines (oesophageal and gastric cancer).
4. Refrigerant production before 1974 may expose to vinyl chloride (hepatic angiosarcoma).
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This question is part of the following fields:
- Haematology & Oncology
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Question 8
Correct
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A 40-year-old patient under treatment for gout gave a history of progressive weakness of his limbs over 2 months. He noticed that it was particularly difficult for him to get up from the toilet seat and to get out of his car. He also felt some tingling and numbness of his toes at night, which was distressing. He was taking several medications which included Ibuprofen, perindopril, colchicine, vitamin supplements, and indapamide. On examination his pulse was 85/min, blood pressure was 140/90 mmHg and fundi revealed arteriovenous nipping. He had proximal lower limb weakness of 4/5 and absent ankle reflexes. Plantar reflexes were upgoing on both sides. His serum creatinine phosphokinase level was normal. What is the most likely diagnosis?
Your Answer: Colchicine toxicity
Explanation:The given clinical scenario is suggestive of myo-neuropathy and is most likely to be caused by colchicine toxicity.
It gives rise to subacute proximal muscle weakness and on occasions can lead to an acute necrotizing myopathy. Creatine phosphokinase may be normal or may be elevated.
Weakness resolves when the drug is discontinued but the neuropathic features remain.
Death is usually a result of respiratory depression and cardiovascular collapse.
Treatment is symptomatic and supportive, and the treatment for colchicine poisoning includes lavage and measures to prevent shock. -
This question is part of the following fields:
- Pharmacology
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Question 9
Correct
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A 60-year-old man with type 1 diabetes is brought to the clinic with his wife. He is limping and his wife noticed that his ankle was abnormally-shaped after he stepped out of the shower. Examination of his right ankle reveals a painless warm swollen joint. There is crepitus and what appears to be palpable bone debris. X-ray reveals gross joint destruction and apparent dislocation. Joint aspiration fluid shows no microbes. Investigations: His CRP and white count are of normal values. Historical review of HB A1c reveals that it has rarely been below 9%. What is the most likely diagnosis?
Your Answer: Charcot’s ankle
Explanation:Charcot arthropathy is a progressive condition of the musculoskeletal system that is characterized by joint dislocations, pathologic fractures, and debilitating deformities. It results in progressive destruction of bone and soft tissues at weight-bearing joints. In its most severe form, it may cause significant disruption of the bony architecture.
Charcot arthropathy can occur at any joint; however, it occurs most commonly in the lower extremity, at the foot and ankle. Diabetes is now considered to be the most common aetiology of Charcot arthropathy. -
This question is part of the following fields:
- Endocrinology
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Question 10
Incorrect
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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: Positive ANCA
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.
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This question is part of the following fields:
- Rheumatology
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Question 11
Incorrect
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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: Tetralogy of Fallot
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:
- Clinical Sciences
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Question 12
Incorrect
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A 42-year-old man is a known case of Waldenström's macroglobulinemia and is admitted to the hospital with headache, visual disturbances, pale conjunctivae, and breathlessness. While in the assessment unit, he has had an episode of nosebleed that has been difficult to control. On examination, his heart rate is 120bpm, blood pressure is 115/65 mmHg, and he is febrile with a temperature of 37°C. Fundoscopy shows dilated retinal veins with a retinal haemorrhage in the right eye. What is the most appropriate next step of management?
Your Answer: Urgent ophthalmology referral
Correct Answer: Plasmapheresis
Explanation:The patient is displaying signs and symptoms of hyperviscosity syndrome, secondary to the Waldenström’s macroglobulinemia. Treatment of choice is plasmapheresis.
Waldenström’s macroglobulinemia (also called lymphoplasmacytic lymphoma) is an uncommon type of non-Hodgkin lymphoma seen in older people. It is a lymphoplasmacytoid malignancy characterised by the secretion of a monoclonal IgM paraprotein. Its features include monoclonal IgM paraproteinemia; hyperviscosity syndrome leading to bilateral central retinal vein occlusion (CRVO) and hence, visual disturbances; weight loss and lethargy; hepatosplenomegaly and lymphadenopathy; and cryoglobulinemia. It is not, however, associated with bone pain.
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This question is part of the following fields:
- Haematology & Oncology
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Question 13
Incorrect
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Osteopetrosis occurs as a result of a defect in:
Your Answer: Calcium resorption in proximal tubule
Correct Answer: Osteoclast function
Explanation:It is a metabolic bone disease caused by defective osteoclastic resorption of immature bone. Osteopetrosis is also known as marble bone disease. Osteoclasts are unable to adequately acidify bone matrix. Impaired bone resorption leads to overly dense bone that is more likely to fracture. It is usually treated with bone marrow transplant and high dose calcitriol.
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This question is part of the following fields:
- Rheumatology
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Question 14
Incorrect
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A 60-year old female suddenly started seeing a curtain-like shadow in her field of vision with flashes of lights and subsequent loss of vision, which prompted her to visit her ophthalmologist. What do you think is the most appropriate treatment in this case?
Your Answer: Peripheral iridectomy
Correct Answer:
Explanation:Flashes of light, presence of floaters and loss of vision (often described as a black curtain closing in on the visual field) are symptoms that strongly indicate retinal detachment. The fundoscopy findings of retinal tears support this diagnosis. Therefore, surgery of retina must be done to treat this patient.
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This question is part of the following fields:
- Ophthalmology
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Question 15
Incorrect
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An 18-year-old male was diagnosed with meningococcal meningitis, confirmed on lumbar puncture. After 6 months he presents in the infectious clinic with a second episode of meningitis. His past history is clear and he takes no regular medication. Which of the following is most probably deficient?
Your Answer: C3
Correct Answer: C5
Explanation:Pneumococcal meningitis is the most common and severe form of bacterial meningitis. Fatality rates are substantial, and long-term sequelae develop in about half of survivors. Disease outcome has been related to the severity of the proinflammatory response in the subarachnoid space. The complement system, which mediates key inflammatory processes, has been implicated as a modulator of pneumococcal meningitis disease severity in animal studies. C5 fragment levels in cerebrospinal fluid (CSF) of patients with bacterial meningitis correlated with several clinical indicators of poor prognosis.
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This question is part of the following fields:
- Clinical Sciences
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Question 16
Incorrect
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A 78-year-old retired journalist known to have prostatic carcinoma presents to the ED complaining of pain in the spine and the onset of severe lower-leg weakness accompanied by a loss of sensation. On examination, he is found to have percussion tenderness of his spine, loss of sensation up to the umbilicus and a distended bladder. He has markedly reduced power of the lower legs with hyperreflexia. Which of the following should not be part of your management of this patient?
Your Answer: Lumbar puncture
Correct Answer: Spinal X-rays
Explanation:Acute cord compression is a medical emergency. Typically, signs of segmental damage at the level of compression are usually combined with corticospinal tract dysfunction (e.g., hyperreflexia, Babinski’s sign and weakness) and sensory deficits below the level of compression. Symptoms include spinal pain that precedes the development of weak legs and sensory loss. There may be loss of bladder (and anal) sphincter control, manifesting as hesitancy, frequency and, finally, painless retention.
Spinal X-rays are rarely diagnostic. MRI is usually the investigation of choice and should not be delayed, but if not available consider doing a CT scan and myelography to confirm cord compression and fully define the level and extent of the lesion. If malignancy is the cause, it is important to give dexamethasone (oral or intravenous) while considering therapy more specific to the cause. -
This question is part of the following fields:
- Neurology
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Question 17
Correct
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A 33-year-old man with a known history of alcoholic liver disease is reviewed following a suspected oesophageal variceal haemorrhage. He has been resuscitated and intravenous terlipressin has been given. His blood pressure is now 104/60 mmHg and his pulse is 84/min. What is the most appropriate intervention?
Your Answer: Endoscopic variceal band ligation
Explanation:The correct course of action after giving terlipressin and resuscitating with IV fluids is to perform an EGD with endoscopic variceal band ligation. According to NICE: ‘Offer endoscopic variceal band ligation for the primary prevention of bleeding for people with cirrhosis who have medium to large oesophageal varices. There are serious complications of a TIPS procedure and it is not the first line treatment.
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This question is part of the following fields:
- Gastroenterology
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Question 18
Correct
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A 30-year-old man with type-1 diabetes mellitus on insulin presents in the A&E with fever, cough, vomiting and abdominal pain. Examination reveals a dry mucosa, decreased skin turgor and a temperature of 37.8 °C. Chest examination reveals bronchial breathing in the right lower lobe, and a chest X-ray shows it to be due to a right lower zone consolidation. Other investigations show: Blood glucose: 35 mmol/L, Na+: 132 mmol/L, K+: 5.5 mmol/L, urea: 8.0 mmol/L, creatinine: 120 μmol/L, pH: 7.15, HCO3: 12 mmol/L, p(CO2): 4.6 kPa, chloride: 106 mmol/l. Urinary ketones are positive (+++). The patient is admitted to the hospital and treated. Which of the following should not be used while treating him?
Your Answer: Bicarbonate
Explanation:Bicarbonate therapy is not indicated in mild and moderate forms of DKA because metabolic acidosis will correct with insulin therapy. The use of bicarbonate in severe DKA is controversial due to a lack of prospective randomized studies. It is thought that the administration of bicarbonate may actually result in peripheral hypoxemia, worsening of hypokalaemia, paradoxical central nervous system acidosis, cerebral oedema in children and young adults, and an increase in intracellular acidosis. Because severe acidosis is associated with worse clinical outcomes and can lead to impairment in sensorium and deterioration of myocardial contractility, bicarbonate therapy may be indicated if the pH is 6.9 or less.
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This question is part of the following fields:
- Endocrinology
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Question 19
Incorrect
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From which cells is somatostatin secreted?
Your Answer: S cells in upper small intestine
Correct Answer: D cells in the pancreas
Explanation:The somatostatin-secreting D-cells comprise ,5% of the cells of the pancreatic islets. The D-cells have a complex morphology and may, via cellular process, interact with many more islet cells than suggested by their low number. D-cells are equipped with ATP-sensitive potassium channels (KATP channels).
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This question is part of the following fields:
- Clinical Sciences
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Question 20
Correct
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A 33-year-old woman has missed her last two periods and has been lactating. Upon anamnesis, she claims she's lost weight and she's been suffering from vaginal dryness. The endocrinologist suggests that she checks her prolactin levels. Which of the following inhibits prolactin release from the hypophysis?
Your Answer: Dopamine
Explanation:Dopamine (DA) holds a predominant role in the regulation of prolactin (PRL) secretion. Through a direct effect on anterior pituitary lactotrophs, DA inhibits the basally high-secretory tone of the cell. It accomplishes this by binding to D2 receptors expressed on the cell membrane of the lactotroph, activation of which results in a reduction of PRL exocytosis and gene expression by a variety of intracellular signalling mechanisms.
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This question is part of the following fields:
- Clinical Sciences
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SESSION STATS - PERFORMANCE PER SPECIALTY
