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Question 1
Incorrect
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Which of the following statements regarding the clinical effects of long-term oxygen therapy (LTOT) is the most accurate?
Your Answer: No effect on mortality
Correct Answer: Reduced sympathetic outflow
Explanation:Studies have shown that benefits of Long-tern oxygen therapy (LTOT) include improved exercise tolerance, with improved walking distance, and ability to perform daily activities, reduction of secondary polycythaemia, improved sleep quality and reduced sympathetic outflow, with increased sodium and water excretion, leading to improvement in renal function.
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This question is part of the following fields:
- Respiratory
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Question 2
Incorrect
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Which features may suggest malignant changes in a melanocytic naevi?
Your Answer: Bleeding
Correct Answer: Decrease in size
Explanation:Melanocytic naevi are skin tumours produced by melanocytes. They usually present in childhood but increase during puberty. The mnemonic A-B-C-D, is used by institutions to assess for suspicion of malignancy. The letters stand for asymmetry, border, colour, and diameter. If a mole starts changing in size, colour, shape or, especially, if the border of a mole develops ragged edges or becomes larger than a pencil eraser, it would be an appropriate time to consult with a physician. Other warning signs include if it begins to crust over, bleed, itch, or become inflamed.
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This question is part of the following fields:
- Dermatology
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Question 3
Incorrect
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From which cells is somatostatin secreted?
Your Answer: G cells in stomach
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 4
Correct
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A 52-year-old woman with polycystic kidney disease and a slowly rising creatinine, which was 320 μmol/L at her last clinic visit 3 weeks ago, is brought into the Emergency Department having been found collapsed at home by her partner. She is now fully conscious but complains of a headache. What is the most likely diagnosis?
Your Answer: Subarachnoid haemorrhage
Explanation:One of the most important complications in patients with PKD is being affected by berry aneurysms that may burst, causing a subarachnoid haemorrhage, which seems to be the case in this patient.
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This question is part of the following fields:
- Nephrology
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Question 5
Incorrect
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A 30-year-old female is brought by her concerned mother. The patient reports that the president is secretly in love with her, despite the fact that there has never been any contact between them. What is the probable psychiatric condition from which the patient is suffering from?
Your Answer: Fregoli delusion
Correct Answer: De Clerambault's syndrome
Explanation:The most probable diagnosis in this patient is De Clerambault’s syndrome, also known as erotomania, which is a form of paranoid delusion with an amorous quality. The patient, often a single woman, believes that a famous person is in love with her.
Other options:
– Bouffée délirante is an acute psychotic disorder in which hallucinations, delusions or perceptual disturbances are obvious but markedly variable, changing from day to day or even from hour to hour.
– Fregoli delusion is the mistaken belief that some people currently present in the deluded person’s environment (typically a stranger) is a familiar person in disguise.
– Capgras delusion is the belief that significant others have been replaced by impostors, robots or aliens.
– Couvade is the common but poorly understood phenomenon whereby the expectant father experiences somatic symptoms during the pregnancy for which there is no recognized physiological basis. -
This question is part of the following fields:
- Psychiatry
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Question 6
Correct
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A 28-year-old woman presents with easy bruising. She has no history of mucosal bleeding and is generally well apart from occasional diarrhoea. She has previously attended a psychiatric unit for self-harming behaviour and is now brought in by her mother having consumed a number of pills. Her mother has had recurrent venous thromboses, but there is no family history of a bleeding disorder. Her full blood count (FBC) is normal, but her coagulation profile shows: Activated partial thromboplastin time (APTT): 60 secs (28–38 secs), Prothrombin time (PT): no clot after 120 secs (10–14 secs), Fibrinogen: 3.6 g/L (2–4 g/L). What is the most likely explanation?
Your Answer: Warfarin overdose
Explanation:Warfarin inhibits the vitamin K-dependent procoagulants II, VII, IX, and X as well as anticoagulant protein C and S. It is highly protein-bound and can be displaced by a wide variety of drugs. It has a half-life of 36–48 hours.
Bleeding is the major side effect. Easy bruising, as seen in this case, is commonly seen in patients of warfarin overdose. Grossly prolonged PT and lesser increase in APTT may be seen in such cases.
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This question is part of the following fields:
- Haematology & Oncology
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Question 7
Correct
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A 30 yr. old male, who is the brother of a patient with hypertrophic cardiomyopathy has come for the screening. Which of the following is the most appropriate method of screening?
Your Answer: Echocardiography
Explanation:12-lead electrocardiography and transthoracic echocardiography are recommended as a screening method for family members of patients with HCM.
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This question is part of the following fields:
- Cardiology
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Question 8
Correct
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A 54 yr. old patient presented with a dry cough after starting treatment for hypertension. He was prescribed ramipril 2.5mg and the dry cough started after that, which disturbed his sleep. His blood pressure was normal. Which of the following is the most appropriate management?
Your Answer: Stop the ramipril and prescribe candesartan
Explanation:ACE inhibitors are known to cause a dry cough and they should be stopped, to settle the cough. The next drug of choice is an angiotensin receptor blocker such as candesartan.
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This question is part of the following fields:
- Cardiology
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Question 9
Incorrect
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A 23-year-old male patient with a downward dislocation of the lens in his right eye is experiencing visual problems. The ophthalmologist notes a constellation of symptoms resembling those of Marfan Syndrome. The patient's history reveals learning disabilities and a diagnosis of homocystinuria is suspected. What is the pathophysiology of homocystinuria?
Your Answer: Deficiency of S-adenosyl-methionine
Correct Answer: Deficiency of cystathionine beta synthase
Explanation:Inherited metabolic disorders are often characterized by the lack of an essential enzyme and are currently treated by dietary restriction and other strategies to replace the substrates or products of the missing enzyme. Patients with homocystinuria lack the enzyme cystathionine β-synthase (CBS), and many of these individuals do not respond to current treatment protocols.
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This question is part of the following fields:
- Clinical Sciences
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Question 10
Correct
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Intracellular proteins tagged with ubiquitination are destined to which of the following organelles?
Your Answer: Proteasome
Explanation:Delivery of ubiquitinated substrates to the proteasome.
Ubiquitinated proteins are delivered to the proteasome by various routes and the complete picture of how these pathways fit together has yet to emerge, reviewed in. Some substrates bind directly to the proteasome by interacting with the 19S regulatory particle subunits Rpn1028 or Rpn1329, and probably Rpt530. Alternatively, ubiquitinated substrates can be brought to the proteasome by adaptors that bind both the proteasome and the ubiquitin chain on the substrate to deliver it for degradation. -
This question is part of the following fields:
- Clinical Sciences
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Question 11
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:
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 12
Incorrect
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A 60 yr. old female presented after an acute overdose of amiodarone. Her blood pressure was 110/70 mmHg and pulse rate was 35 bpm. She was given 500mcg of atropine but there was no response. Which of the following is the most appropriate next step?
Your Answer:
Correct Answer: Isoprenaline
Explanation:Permanent pacing is not indicated as the bradycardia is reversible. Temporary pacing is the definite treatment. Isoprenaline can be used until temporary pacing is available.
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This question is part of the following fields:
- Cardiology
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Question 13
Incorrect
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A 73 year old woman presents with severe emphysema. She is on maximal therapy including high dose Seretide and tiotropium. She tells you that she is so unwell that she can barely manage the walk the 160 metres to the bus stop. On examination she looks short of breath at rest. Her BP is 158/74 mmHg, pulse is 76 and regular. There are quiet breath sounds, occasional coarse crackles and wheeze on auscultation of the chest. Investigations show: Haemoglobin 14.2 g/dl (13.5-17.7) White cell count 8.4 x 109/l (4-11) Platelets 300 x 109/l (150-400) Sodium 137 mmol/l (135-146) Potassium 4.1 mmol/l (3.5-5) Creatinine 127 micromole/l (79-118) pH 7.4 (7.35-7.45) pCO2 7.5 kPa (4.8-6.1) pO2 9.7 kPa (10-13.3) Chest x-ray – Predominant upper lobe emphysema. FEV1 – 30% of predicted. Which of the features of her history, examination or investigations would preclude referral for lung reduction surgery?
Your Answer:
Correct Answer: pCO2 7.4
Explanation:Nice guidelines for lung reduction surgery:
FEV1 > 20% predicted
PaCO2 < 7.3 kPa
TLco > 20% predicted
Upper lobe predominant emphysemaThis patient has pCO2 of 7.4 so she is unsuitable for referral for lung reduction surgery.
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This question is part of the following fields:
- Respiratory
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Question 14
Incorrect
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A 35-year-old woman is referred to the oncology clinic by a general surgeon. She has undergone mastectomy for carcinoma of the right breast. Out of the following, which factor is associated with a poor prognosis in patients with breast cancer?
Your Answer:
Correct Answer: Young age
Explanation:Poor prognostic factors for breast cancer include:
1. Young age (<40 years)
2. Premenopausal at the time of diagnosis
3. Increased tumour size
4. High-grade tumour
5. Oestrogen and progesterone receptor-negative tumour
6. Positive lymph node status -
This question is part of the following fields:
- Haematology & Oncology
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Question 15
Incorrect
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Question 16
Incorrect
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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 1,200 patients receiving the new drug developed gout. The total number of the patients were 2,000 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:
Correct Answer: 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:
- Clinical Sciences
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Question 17
Incorrect
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A 18 yr. old male was screened for hypertrophic cardiomyopathy (HOCM) as his brother had the same condition. What is the echocardiographic finding that is related to the highest risk of sudden cardiac death?
Your Answer:
Correct Answer: Significant thickening of the interventricular septum
Explanation:There are five prognostic factors which indicate poor prognosis in HOCM:
-family history of HOCM-related sudden cardiac death
-unexplained recent syncope
-large left ventricular wall thickness (MLVWT ≥ 30 mm)
-multiple bursts of nsVT on ambulatory electrocardiography
-hypotensive or attenuated blood pressure response to exercise -
This question is part of the following fields:
- Cardiology
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Question 18
Incorrect
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A 14-year-old girl presents with primary amenorrhoea. She is an athlete who is currently training for a national athletics championship. What is the best treatment option for her?
Your Answer:
Correct Answer: Adequate diet and observation
Explanation:Intensive physical training and participation in competitive sports during childhood and early adolescence may affect athletes’ pubertal development.
Female athletes who do not begin secondary sexual development by the age of 14 or menstruation by the age of 16 warrant a comprehensive evaluation and treatment.
Since she is still 14, adequate diet and observation are enough. -
This question is part of the following fields:
- Endocrinology
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Question 19
Incorrect
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An 80 year old woman is brought to the ER with altered sensorium. She is accompanied by her daughter who noticed the acute change. The patient has had a nagging cough with purulent sputum and haemoptysis for the last few days. Previous history includes a visit to her GP two weeks back because of influenza. On examination, the patient appears markedly agitated with a respiratory rate of 35/min. Blood gases reveal that she is hypoxic. White blood cell count is 20 x 109/l, and creatinine is 250mmol/l. Chest X-ray is notable for patchy areas of consolidation, necrosis and empyema formation. Which of the following lead to the patient's condition?
Your Answer:
Correct Answer: Staphylococcus aureus pneumonia
Explanation:Though a common community pathogen, Staphylococcus Aureas is found twice as frequently in pneumonias in hospitalized patients. It often attacks the elderly and patients with CF and arises as a co-infection with influenza viral pneumonia. The clinical course is characterized by high fevers, chills, a cough with purulent bloody sputum, and rapidly progressing dyspnoea. The gross pathology commonly reveals an acute bronchopneumonia pattern that may evolve into a necrotizing cavity with congested lungs and airways that contain a bloody fluid and thick mucoid secretions.
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This question is part of the following fields:
- Respiratory
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Question 20
Incorrect
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A 35-year-old female has been recently diagnosed with hypertension. She's sexually active and is not using any birth control other than barrier method. Which among the following antihypertensives is contraindicated in this patient?
Your Answer:
Correct Answer: Lisinopril
Explanation:Among the following hypertensives, lisinopril (an ACE inhibitor) is contraindicated in patients who are planning for pregnancy.
Per the NICE guidelines, when treating the woman in question, she should be treated as if she were pregnant given the absence of effective contraception.
ACE inhibitors such as lisinopril are known teratogens and most be avoided.Drugs contraindicated in pregnancy:
Antibiotics
Tetracyclines
Aminoglycosides
Sulphonamides and trimethoprim
QuinolonesOther drugs:
ACE inhibitors, angiotensin II receptor antagonists
Statins
Warfarin
Sulfonylureas
Retinoids (including topical)
Cytotoxic agents
The majority of antiepileptics including valproate, carbamazepine, and phenytoin are known to be potentially harmful. -
This question is part of the following fields:
- Pharmacology
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Question 21
Incorrect
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A 21 year-old software developer undergoes a planned lumbar puncture (LP) as part of a neurological investigation for possible multiple sclerosis. During the consent process, she expresses concern about a post-LP headache. What is the mechanism of post-LP headaches?
Your Answer:
Correct Answer: Leaking cerebrospinal fluid from the dura
Explanation:Leaking of cerebrospinal fluid from the dura is the most likely explanation for post-lumbar puncture headaches. It is thought that ongoing leak of cerebrospinal fluid (CSF) through the puncture site causes ongoing CSF loss, leading to low pressure. A post-LP headache is typically frontal or occipital and occurs within three days. It is normally associated with worsening on standing and improvement when lying down. Treatment in severe cases includes an epidural blood patch, but most resolve on their own.
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This question is part of the following fields:
- Neurology
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Question 22
Incorrect
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A 18-year-old gentleman is referred to dermatology. He has around 10 hyperpigmented macules on his torso which vary in size from 1.5-5 cm in size. His GP also noted some freckles in the groin region. He is also currently under orthopaedic review due to a worsening scoliosis of the spine. His father suffered from similar problems before having a fatal myocardial infarction two years ago. Which chromosome is most likely to have a gene defect?
Your Answer:
Correct Answer: Chromosome 17
Explanation:The patient’s history and presentation and familial history, meets the diagnostic criteria for Neurofibromatosis type I, presenting with neurofibromas noted in this patient as hyperpigmented macules and freckles, musculoskeletal disorders like the scoliosis in this case, and a familial history. Neurofibromatosis type I is caused by a mutation on Chromosome 17.
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This question is part of the following fields:
- Neurology
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Question 23
Incorrect
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A 25-year-old lady with a history of ulcerative colitis presents to clinic. She had extensive colitis 10 years ago, which has improved with medical treatment. Last year she had been diagnosed with primary sclerosing cholangitis. Her last colonoscopy was 6 months ago, which detected no active disease, and random biopsies were normal. She is remaining well and asymptomatic. When should colonic screening be performed on this patient?
Your Answer:
Correct Answer: Colonoscopy should be performed annually
Explanation:Colonoscopy screening should begin 10 years after the first diagnosis in ulcerative colitis, given the increased risk for colon cancer. Given that she has developed primary sclerosing cholangitis, her risk of colon cancer is even higher. Colonoscopy screening should occur at 3 year intervals in the second decade, 2 year intervals in the third decade, and 1 year intervals by the first decade, making A the correct answer choice.
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This question is part of the following fields:
- Gastroenterology
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Question 24
Incorrect
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A 52 year old female, known case of rheumatoid arthritis presents to the clinic with dyspnoea, cough, and intermittent pleuritic chest pain. She was previously taking second line agents Salazopyrine and gold previously and has now started Methotrexate with folic acid replacement a few months back. Pulmonary function tests reveal restrictive lung pattern and CXR reveals pulmonary infiltrates. Which of the following treatments is most suitable in this case?
Your Answer:
Correct Answer: Stop methotrexate
Explanation:Methotrexate lung disease (pneumonitis and fibrosis) is the specific etiological type of drug-induced lung disease. It can occur due to the administration of methotrexate which is an antimetabolite, which is given as disease-modifying antirheumatic drugs (DMARDs) in patients with rheumatoid arthritis. The typical clinical symptoms include progressive shortness of breath and cough, often associated with fever. Hypoxemia and tachypnoea are always present and crackles are frequently audible. Symptoms typically manifest within months of starting therapy. Methotrexate withdrawal is indicated in such cases.
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This question is part of the following fields:
- Respiratory
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Question 25
Incorrect
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A 28-year-old female admitted for a course of chemotherapy, has been taking high dose steroids for a few days. The nurses report that she is very agitated and talks about trying to open the window of her room and jump out from the fourth floor. You review her notes and see that she admits to drinking a few glasses of wine per week and has smoked cannabis on a few occasions. On examination her BP is 145/88 mmHg, her pulse is 80 bpm. Blood investigations reveal: Haemoglobin: 12.1 g/dL (11.5-16.5) WBC count: 16.2 x 103/dL (4-11) Platelets: 200 x 109/L (150-400) C-reactive protein: 9 nmol/l (<10) Sodium: 140 mmol/l (135-146) Potassium: 3.9 mmol/l (3.5-5) Creatinine: 92 μmol/l (79-118) Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Corticosteroid-related psychosis
Explanation:Agitation, hypomania and suicidal intent within a few days after initiating corticosteroid therapy is highly suggestive of a diagnosis of corticosteroid-induced psychosis.
In some patients corticosteroid related psychosis has been diagnosed up to 12 weeks or more after commencing therapy.
Euphoria and hypomania are considered to be the most common psychiatric symptoms reported during short courses of steroids.
During long-term treatment, depressive symptoms were the most common.
Higher steroid doses appear to carry an increased risk for such adverse effects; however, there is no significant relationship between dose and time to onset, duration, and severity of symptoms.Management: Reduction or cessation of corticosteroids is the mainstay of treatment for steroid psychosis. For those patients who cannot tolerate this reduction/cessation of steroids, mood stabilizers may be of some benefit.
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This question is part of the following fields:
- Pharmacology
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Question 26
Incorrect
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A 15-year-old girl presents with vomiting and her investigations show: Sodium 115 mmol/L (137-144), Potassium 3.0 mmol/L (3.5-4.9), Urea 2.1 mmol/L (2.5-7.5), Urine sodium 2 mmol/L, Urine osmolality 750 mosmol/kg (350-1000). What is the most likely diagnosis?
Your Answer:
Correct Answer: Bulimia nervosa
Explanation:The patient is most likely to have Bulimia nervosa. A young girl with a low body mass contributes to the low urea. Hypokalaemia and hyponatraemia are due to vomiting. Her urine sodium is also low.
– In Addison’s diseases, there are low levels of sodium and high levels of potassium in the blood. In acute adrenal crisis: The most consistent finding is elevated blood urea nitrogen (BUN) and creatinine. Urinary and sweat sodium also may be elevated.
– In Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) there is hyponatremia with corresponding hypo-osmolality, continued renal excretion of sodium, urine less than maximally dilute and absence of clinical evidence of volume depletion. -
This question is part of the following fields:
- Endocrinology
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Question 27
Incorrect
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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:
Correct 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 28
Incorrect
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A 68-year-old male patient presents with haematemesis. Gastroscopy and biopsy reveal a carcinoma. Who is the one to inform the patient of his diagnosis?
Your Answer:
Correct Answer: The consultant in-charge of his care
Explanation:One of the questions the therapist poses himself while informing a patient is: whom shall I inform about the diagnosis, treatment and prognosis? If we unconditionally accepted the view that information belongs to the patient from an ethical and legal standpoint, we would automatically exclude the partner and the family. Therefore, the therapist should raise another question: what is the benefit to the patient? To answer the question and the resulting dilemma, we have to leverage the long experience of family therapy and tailor it to the cases we are dealing with. It should be taken into consideration that patient and family are a dynamic system which was balanced before the onset of the disease, but is now disrupted, entering into crisis. Therefore, the denial mechanisms and personality characteristics we have previously elaborated on, and communication among members play a crucial role in determining the information strategy and the way family should be approached. In this particular case, the most appropriate person to inform the patient is the consultant, meaning the one currently responsible for the patient’s care. The patient most probably has already developed some form of close and trustful relationship with his consultant.
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This question is part of the following fields:
- Clinical Sciences
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Question 29
Incorrect
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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:
Correct 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 30
Incorrect
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A 27 year old woman presents with diarrhoea. She has had a previous ileal resection for Crohn's Disease. Her inflammatory markers are normal. What is the most likely cause of her diarrhoea?
Your Answer:
Correct Answer: Bile Acid Malabsorption
Explanation:The question describes a patient who has had an ileal resection. Bile acids are reabsorbed in the distal ileum. Since this has been resected in this patient, one would expect her to have malabsorption of bile acids, causing her diarrhoea. This is a more likely correct answer than a Crohn’s flare, bacterial overgrowth, gastroenteritis, or tropical sprue, given the details included in the question prompt.
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This question is part of the following fields:
- Gastroenterology
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SESSION STATS - PERFORMANCE PER SPECIALTY
