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Question 1
Correct
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A 77 year old lady presents to ED with her left leg shortened and externally rotated following slipping and falling on a wet bathroom floor. There is an intracapsular fracture of the neck of femur seen on imaging studies. She is at risk of avascular necrosis of the head of femur. This is caused by lack of blood supply from which of these arteries?
Your Answer: Medial circumflex artery
Explanation:The primary blood supply to the head of the femur is from branches of the medial femoral circumflex artery. The superior and inferior gluteal arteries supply the hip joint but not the head of femur.The lateral circumflex artery anastomoses with the medial femoral circumflex artery and assists in supplying the head of femur. The obturator artery is an important source of blood supply in children up to about 8 years. It gives rise to the artery of the head of femur which runs in the ligamentum teres and is insufficient to supply the head of femur in adults.
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This question is part of the following fields:
- Anatomy
- Lower Limb
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Question 2
Correct
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Which of the following statements is true about percutaneous needle aspiration?
Your Answer: The needle should be inserted just above the upper border of the chosen rib
Explanation:Pleural aspiration describes a procedure whereby pleural fluid or air may be aspirated via a system inserted temporarily into the pleural space. This may be for diagnostic purposes (usually removing 20–50 ml fluid) or therapeutic to relieve symptoms. In the literature it is varyingly called thoracocentesis, thoracentesis or pleural aspiration.In determining the correct patient position and site of insertion, it is important for the operator to be aware of the normal anatomy of the thorax and the pathology of the patient. Patient position is dependent on the operator preference and the site of the pathology. In the case of a posterior lying locule, this may be specific to the image-guided spot where fluid is most likely to be obtained. In most circumstances, however, the site of insertion of the needle is either in the triangle of safety or the second intercostal space in the midclavicular line. The patient may therefore either sit upright leaning forward with arms elevated but resting on a table or bed, thereby exposing the axilla, or lying on a bed in a position. The needle is inserted in the space just above the chosen rib to avoid damaging the neurovascular bundle. It is common practice to insert the needle more posteriorly for a pleural aspiration, but it should be noted that the neurovascular bundle may not be covered by the lower flange of the rib in this position and a more lateral or anterior site of insertion is considered safer.
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This question is part of the following fields:
- Anatomy
- Thorax
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Question 3
Incorrect
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Which of the following infections is vancomycin most likely prescribed for?
Your Answer: Meningococcal meningitis
Correct Answer: Clostridium difficile colitis
Explanation:125 mg PO q6hr for 10 days is indicated for treatment of Clostridium difficile (C. difficile)-associated diarrhoea
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This question is part of the following fields:
- Infections
- Pharmacology
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Question 4
Incorrect
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The sensation produced by touching the arm with a vibrating tuning fork during a neurological examination is mediated by which of the following spinal tracts:
Your Answer: Anterior spinothalamic tract
Correct Answer: Posterior column
Explanation:Fine-touch, proprioception and vibration sensation are mediated by the posterior column-medial lemniscus pathway.
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This question is part of the following fields:
- Anatomy
- Central Nervous System
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Question 5
Incorrect
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A 54-year-old man with a long history of poorly controlled hypertension complains of a headache and vision blurring today. In triage, his blood pressure is 210/192 mmHg. A CT head scan is scheduled to rule out the possibility of an intracranial haemorrhage. You make the diagnosis of hypertensive encephalopathy and rush the patient to reus to begin blood pressure-lowering treatment. He has a history of brittle asthma, for which he has been admitted to the hospital twice in the last year.Which of the following is the patient's preferred drug treatment?
Your Answer: 10% of the systolic pressure over the first hour
Correct Answer: 25% of the mean arterial pressure over the first hour
Explanation:End-organ damage (e.g. encephalopathy, intracranial haemorrhage, acute myocardial infarction or ischaemia, dissection, pulmonary oedema, nephropathy, eclampsia, papilledema, and/or angiopathic haemolytic anaemia) characterises a hypertensive emergency (also known as ‘accelerated hypertension’ or malignant hypertension’ It’s a life-threatening condition that necessitates rapid blood pressure reduction to avoid end-organ damage and a negative outcome.Hypertensive encephalopathy is a syndrome that includes headaches, seizures, visual changes, and other neurologic symptoms in people who have high blood pressure. It is reversible if treated quickly, but it can progress to coma and death if not treated properly.Any patient with suspected hypertensive encephalopathy should have an urgent CT scan to rule out an intracranial haemorrhage, as rapid blood pressure reduction could be dangerous in these circumstances.The drug of choice is labetalol, which reduces blood pressure steadily and consistently without compromising cerebral blood flow.An initial reduction of approximately 25% in mean arterial pressure (MAP) over an hour should be aimed for, followed by a further controlled MAP reduction over the next 24 hours. In patients who are unable to take beta-blockers, nicardipine can be used as a substitute.
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This question is part of the following fields:
- Cardiovascular Pharmacology
- Pharmacology
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Question 6
Correct
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A patient who has a nerve injury has sparing of the upper half of the orbicularis oculi muscle but not the lower half. Which branch of the facial nerve supplies the lower half of the orbicularis oculi?
Your Answer: Zygomatic branch
Explanation:The facial nerve divides into five terminal branches once in the parotid gland. 1. The temporal branch innervates muscles in the temple, forehead and supraorbital areas.2. The zygomatic branch innervates muscles in the infraorbital area, the lateral nasal area and the upper lip.3. The buccal branch innervates muscles in the cheek, the upper lip and the corner of the mouth. 4. The marginal mandibular branch innervates muscles of the lower lip and chin. 5. The cervical branch innervates the platysma muscle.
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This question is part of the following fields:
- Anatomy
- Cranial Nerve Lesions
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Question 7
Correct
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Question 8
Correct
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A six-year-old boy presents with coryzal symptoms that have persisted for more than two weeks. He was born and raised in the Middle East. His mother claims he has been tired and has complained of various 'aches and pains.' On examination, you find splenomegaly and enlarged cervical lymph nodes. His legs and arms are covered in petechiae.In this case, what is the most likely diagnosis?
Your Answer: Acute lymphoblastic leukaemia (ALL)
Explanation:ALL is the most common leukaemia in children, with a peak incidence between the ages of 2 and 5.ALL has a wide range of clinical symptoms, but many children present with an acute illness that resembles coryza or a viral infection. ALL also has the following features:Weakness and sluggishness all overMuscle, joint, and bone pain that isn’t specificAnaemiaPetechiae and unexplained bruisingOedemaLymphadenopathyHepatosplenomegalyThe following are typical features of a full blood count in patients with ALL:Anaemia (normocytic or macrocytic)Leukopenia affects about half of the patients (WCC 4 x 109/l).Around 25% of patients have leucocytosis (WCC > 10 x 109/l).Around 25% of patients have hyperleukocytosis (WCC > 50 x 109/l).Thrombocytopaenia
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This question is part of the following fields:
- Haematology
- Pathology
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Question 9
Correct
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Regarding hypertensive crises, which of the following statements is CORRECT:
Your Answer: In a hypertensive emergency, blood pressure should be reduced by 20 - 25% within 2 hours.
Explanation:A hypertensive emergency is defined as severe hypertension (blood pressure ≥ 180/110 mmHg) with acute damage to the target organs. Prompt treatment with intravenous antihypertensive therapy is generally required; over the first few minutes or within 2 hours, blood pressure should be reduced by 20 – 25%. Severe hypertension without acute target organ damage is defined as hypertensive urgency.; blood pressure should be reduced gradually over 24 – 48 hours with oral antihypertensive therapy. If blood pressure is reduced too quickly in the management of hypertensive crises, there is a risk of reduced organ perfusion leading to cerebral infarction, blindness, deterioration in renal function, and myocardial ischaemia.
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This question is part of the following fields:
- Cardiovascular
- Pharmacology
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Question 10
Incorrect
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A 36-year-old woman is 22-weeks pregnant and is investigated for a possible thyroid disorder. When her total thyroid hormone levels does not correlate with her thyrometabolic status, her thyroid-binding globulin levels are checked.What percentage of circulating thyroid hormones is bound to thyroid-binding globulin?
Your Answer: 40%
Correct Answer: 70%
Explanation:Only a very small fraction of the thyroid hormones circulating in the blood are free. The majority is bound to transport proteins. Only the free thyroid hormones are biologically active, and measurement of total thyroid hormone levels can be misleading. The relative percentages of bound and unbound thyroid hormones are:Bound to thyroid-binding globulin -70%Bound to albumin -15-20%Bound to transthyretin -10-15%Free T3 -0.3%Free T4 -0.03%
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This question is part of the following fields:
- Endocrine Physiology
- Physiology
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Question 11
Incorrect
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Regarding saliva, which of the following statements is CORRECT:
Your Answer: Saliva normally has a very low pH to enhance breakdown of food in the mouth.
Correct Answer: Saliva production is decreased by inhibition of the parasympathetic nervous system.
Explanation:At rest, saliva is predominantly produced by the submandibular gland (65%) but when stimulated, the parotid glands produce a higher proportion of the total saliva production (50%) than at rest. Saliva is alkaline and hypotonic to plasma. The predominant digestive enzymes in saliva are alpha-amylase and lingual lipase; lingual lipase is not functionally very important, but alpha-amylase is important for the initiation of starch digestion. Saliva production is decreased by inhibition of the parasympathetic nervous system e.g. by sleep, dehydration, anticholinergic drugs and fear.
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This question is part of the following fields:
- Gastrointestinal
- Physiology
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Question 12
Correct
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Which of the following laboratory findings are indicative of von Willebrand disease (VWD):
Your Answer: Prolonged APTT
Explanation:Laboratory results often show that:PFA-100 test results are abnormal.Low levels of factor VIII (if a factor VIII/VWF binding assay is conducted)APTT is Prolonged (or normal)PT is normalVWF values are low.Defective Platelet aggregationThe platelet count is normal.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 13
Correct
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An analytical cohort study is done to compare the relationship between omega 3 intake and occurrence of myocardial infarction (MI) among males aged over 65 years. The following are the data from the study:No. of subjects taking placebo: 100 menNo. of subjects taking placebo who suffered an MI: 15 menNo. of subjects taking omega 3: 100 menNo. of subjects taking omega 3 who suffered an MI: 5 menCompute for the absolute risk in the treatment (omega 3) group.
Your Answer: 0.05
Explanation:The absolute risk (AR) is the probability or chance of an event. It is computed as the number of events in treated or control groups, divided by the number of people in that group.AR = 5/100 = 0.05
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This question is part of the following fields:
- Evidence Based Medicine
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Question 14
Correct
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In the emergency room, a patient was diagnosed with acute bacterial tonsillitis. Which of the following postinfectious complications is most commonly linked to Streptococcus pyogenes:
Your Answer: Glomerulonephritis
Explanation:Poststreptococcal glomerulonephritis (PSGN) is caused by prior infection with specific nephritogenic strains of group A beta-haemolytic streptococcus. The clinical presentation of PSGN varies from asymptomatic, microscopic haematuria to the full-blown acute nephritic syndrome, characterized by red to brown urine, proteinuria (which can reach the nephrotic range), oedema, hypertension, and acute kidney injury.
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This question is part of the following fields:
- Microbiology
- Pathogens
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Question 15
Correct
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In the United Kingdom, which of the following is the most often used intravenous aesthetic:
Your Answer: Propofol
Explanation:In the United Kingdom, propofol is the most widely used intravenous anaesthetic. In adults and children, it can be used to induce or maintain anaesthesia, although it is not commonly used in newborns. It can also be used to sedate individuals in intensive care and for sedation during operations.
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This question is part of the following fields:
- Anaesthesia
- Pharmacology
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Question 16
Correct
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A 50-year-old man presents with headaches, lethargy, hypertension, and electrolyte disturbance. A diagnosis of primary hyperaldosteronism is made.Which biochemical pictures would best support this diagnosis?
Your Answer: Hypokalaemic metabolic alkalosis
Explanation:When there are excessive levels of aldosterone outside of the renin-angiotensin axis, primary hyperaldosteronism occurs. High renin levels will lead to secondary hyperaldosteronism. The classical presentation of hyperaldosteronism when symptoms are present include:HypokalaemiaMetabolic alkalosisHypertensionNormal or slightly raised sodium levels
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This question is part of the following fields:
- Endocrine Physiology
- Physiology
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Question 17
Correct
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Which of the following statements about vitamin B12 absorption is TRUE:
Your Answer: On ingestion, vitamin B12 is bound to R protein which protects it from digestion in the stomach.
Explanation:The substance intrinsic factor,essential for absorption of vitamin B12 in the ileum, issecreted by the parietal cells along with the secretion ofhydrochloric acid. When the acid-producing parietalcells of the stomach are destroyed, which frequentlyoccurs in chronic gastritis, the person develops not onlyachlorhydria (lack of stomach acid secretion) but oftenalso pernicious anaemia because of failure of maturationof the red blood cells in the absence of vitamin B12 stimulation of the bone marrow.
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This question is part of the following fields:
- Gastrointestinal
- Physiology
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Question 18
Incorrect
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You see a patient in the ED with photophobia, petechial rash, headache and neck stiffness, and suspect a diagnosis of meningococcal meningitis.What is the most appropriate initial management?
Your Answer: Perform an LP and await results of Gram-staining
Correct Answer: Give ceftriaxone 2 g IV
Explanation:Treatment should be commenced with antibiotics immediately before laboratory confirmation due to the potentially life-threatening nature of the disease.In a hospital setting, 2g of IV ceftriaxone (80 mg/kg for a child) or IV cefotaxime (2 g adult; 80 mg/kg child) are the drugs of choice. In the prehospital setting, IM benzylpenicillin can be given as an alternative.
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This question is part of the following fields:
- Microbiology
- Specific Pathogen Groups
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Question 19
Incorrect
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A 6-year-old girl is brought into the paediatric emergency room by her mother in a state of high-grade fever and extreme irritability. She is also reluctant to urinate as it is associated with lower abdominal pain and stinging. She has no history of any UTIs requiring antibiotics in the past 12 months. The urine sensitivity test report is still unavailable. A clean catch urine sample is taken for urine dipstick, which reveals the presence of blood, protein, leukocytes and nitrites. Fresh blood tests were sent, and her estimated GFR is calculated to be 40 ml/minute. Out of the following, which antibiotic is most appropriate to be prescribed to this patient?
Your Answer: Co-amoxiclav
Correct Answer: Trimethoprim
Explanation:The NICE guidelines for children and young people under 16 years lower UTIs are:1. Get a urine sample before antibiotics are taken, and do a dipstick test OR send for culture and susceptibility2. Assess and manage children under 5 with lower UTI with fever as recommended in the NICE guideline on fever in under 5s.3. Prescribe an immediate antibiotic prescription and take into account the previous urine culture and susceptibility results, previous antibiotic use, which may have led to resistant bacteria4. If urine culture and susceptibility report is sent- Review the choice of antibiotic when the results are available AND- change the antibiotic according to susceptibility results if the bacteria are resistant and symptoms are not improving, using a narrow-spectrum antibiotic wherever possibleThe choice of antibiotics for non-pregnant young people under 16 years with lower UTI is summarised below:1. Children under 3 months:- Refer to paediatric specialist and treat with intravenous antibiotic in line with NICE guideline on fever in under 5s2. Children over 3 months: – First-choice Nitrofurantoin – if eGFR >45 ml/minuteTrimethoprim – (if low risk of resistance*)- Second-choice (no improvement in lower UTI symptoms on first-choice for at least 48 hours, or when first-choice not suitable)Nitrofurantoin – if eGFR >45 ml/minute and not used as first-choiceAmoxicillin (only if culture results available and susceptible)Cefalexin
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This question is part of the following fields:
- Infections
- Pharmacology
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Question 20
Correct
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Before a patient is discharged, you are asked to review them. He is a 59-year-old man who was seen with epigastric pain that has since subsided, and he will be seen by his GP in the coming days. He's been hearing a lot about aspirin lately and wants to learn more about it.Which of the following statements about aspirin's mechanism of action is correct?
Your Answer: Inhibition of cyclo-oxygenase
Explanation:Aspirin works by inhibiting cyclo-oxygenase in an irreversible manner, resulting in a decrease in prostaglandin and thromboxane production. As a result, platelet activation and aggregation are reduced.
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This question is part of the following fields:
- Cardiovascular Pharmacology
- Pharmacology
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Question 21
Correct
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Pancreatic acinar digestive enzyme secretion is mainly stimulated by which of the following hormones:
Your Answer: Cholecystokinin
Explanation:Exocrine pancreatic secretion is controlled by:Parasympathetic stimulation which enhances secretion of both the enzyme and aqueous componentsSympathetic stimulation which inhibits pancreatic secretionSecretin which stimulates secretion of the alkaline-rich fluid from ductal cellsCholecystokinin which stimulates secretion of the enzyme-rich fluid from acinar cellsSomatostatin which inhibits secretion from both acinar and ductal cellsGastrin which stimulates pancreatic acinar cells to secrete digestive enzymes
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This question is part of the following fields:
- Gastrointestinal
- Physiology
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Question 22
Incorrect
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A 62-year-old woman presents with cold sensitivity, tiredness, and weight gain. A series of blood tests done shows a grossly elevated TSH level and a diagnosis of hypothyroidism is made.What is the commonest cause of hypothyroidism worldwide?
Your Answer: Autoimmune thyroiditis
Correct Answer: Iodine deficiency
Explanation:Hypothyroidism occurs when there is a deficiency of circulating thyroid hormones. It is commoner in women and is most frequently seen in the age over 60.Iodine deficiency is the commonest cause of hypothyroidism worldwide.In the UK and other developed countries, iodine deficiency is not a problem and autoimmune thyroiditis is the commonest cause.
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This question is part of the following fields:
- Endocrine Physiology
- Physiology
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Question 23
Correct
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Which of the following is NOT an advantage of a cohort study used to investigate the relationship between exposure to a risk factor and a future outcome:
Your Answer: Particularly suitable for rare diseases
Explanation:Advantages: ideal for studying associations between an exposure and an outcome when the exposure is uncommon, the time sequence of events can be assessed, they can provide information on a wide range of disease outcomes, the absolute and relative risk of disease can be measured directly, they can give a direct estimation of disease incidence ratesDisadvantages: costly and can take long periods of time if the outcome is delayed, subject to subject-selection and loss to follow-up bias, large sample size required for rare outcome of interest so it is not useful for rare diseases, prone to confounding
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This question is part of the following fields:
- Evidence Based Medicine
- Study Methodology
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Question 24
Incorrect
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The myocardium is responsible for creating the force with which the atrial and ventricular muscles contract. It is made up of myocytes, which are heart muscle cells.Which of the following statements about cardiac muscle anatomy is correct?Â
Your Answer: Cardiac muscle is non-striated
Correct Answer: Cardiac myocytes have intercalated discs
Explanation:Typically, granuloma has Langerhan’s cells (large multinucleated cells ) surrounded by epithelioid cell aggregates, T lymphocytes and fibroblasts.Antigen presenting monocytic cells found in the skin are known as Langerhan’s cells.
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This question is part of the following fields:
- Basic Cellular Physiology
- Physiology
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Question 25
Correct
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Which of the following statement is correct with regards to the female urethra?
Your Answer: The urethra opens in the vestibule that lies between the labia minora.
Explanation:The urethra in women is short (about 4 cm long), and begins at the base of the bladder. Its course runs inferiorly through the urogenital diaphragm, then into the perineum. It then opens in the vestibule which lies between the labia minora. The inferior aspect of the urethra is bound to the anterior surface of the vagina. The urethral opening is anterior to the vaginal opening in the vestibule. As the urethra passes through the pelvic floor, it is surrounded by the external urethral sphincter.
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This question is part of the following fields:
- Abdomen
- Anatomy
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Question 26
Correct
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An 11-year-old presented to a GP with a history of headache, neck stiffness and photophobia. On examination, HR is 122, BP is 87/42, RR is 28, SaO 2 is 95%, temperature is 39.4 o C. There is a recent petechial rash on legs and arms. The GP administered a dose of antibiotics in the prehospital setting before transferring to the Emergency Department.Which of these would the GP have administered?
Your Answer: IM benzylpenicillin 1.2 g
Explanation:General Practitioners are advised to give a single injection of benzylpenicillin by intravenous or intramuscular injection before transferring the patient urgently to the ED when bacterial meningitis is suspected.The recommended doses are:Infants under 1 year: 300 mgChildren ages 1 to 9 years: 600 mgChildren aged 10 years and over: 1.2gAdults: 1.2g
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This question is part of the following fields:
- Infections
- Pharmacology
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Question 27
Incorrect
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Regarding haemophilia A, which of the following statements is INCORRECT:
Your Answer: Haemophilia A is caused by a deficiency of factor VIII.
Correct Answer: In haemophilia both the APTT and PT are prolonged.
Explanation:Haemophilia A is the most common of the hereditary clotting factor deficiencies. The inheritance is sex-linked but up to one-third of patients have no family history and these cases result from recent mutation. The vast majority of cases are inherited in an X-linked recessive fashion, affecting males born to carrier mothers. Females born to affected fathers can also, rarely, be affected due to homozygosity for the gene, where there is marriage to close relatives. The defect is an absence or low level of plasma factor VIII. The APTT is prolonged but the PT is normal. Recurrent painful haemarthroses and muscle haematomas dominate the clinical course of severely affected patients and if inadequately treated, lead to progressive joint deformity and disability. Local pressure can cause entrapment neuropathy or ischaemic necrosis. Prolonged bleeding occurs after dental extractions or post-trauma. Spontaneous haematuria and gastrointestinal haemorrhage may occur. The clinical severity of the disease correlates inversely with the factor VIII level. Operative and post-traumatic haemorrhage are life-threatening both in severely and mildly affected patients.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 28
Correct
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If a lesion is observed in Broca's area, which function is expected to become affected?
Your Answer: Formation of words
Explanation:The primary functions of the Broca area are both language production and comprehension. While the exact role in the production is still unclear, many believe that it directly impacts the motor movements to allow for speech. Although originally thought to only aid in speech production, lesions in the area can rarely be related to impairments in the comprehension of language. Different regions of the Broca area specialize in various aspects of comprehension. The anterior portion helps with semantics, or word meaning, while the posterior is associated with phonology, or how words sound. The Broca area is also necessary for language repetition, gesture production, sentence grammar and fluidity, and the interpretation of others’ actions.Broca’s aphasia is a non-fluent aphasia in which the output of spontaneous speech is markedly diminished and there is a loss of normal grammatical structure. Specifically, small linking words, conjunctions, such as and, or, and but, and the use of prepositions are lost. Patients may exhibit interjectional speech where there is a long latency, and the words that are expressed are produced as if under pressure. The ability to repeat phrases is also impaired in patients with Broca’s aphasia. Despite these impairments, the words that are produced are often intelligible and contextually correct. In pure Broca’s aphasia, comprehension is intact.
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This question is part of the following fields:
- Anatomy
- Central Nervous System
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Question 29
Correct
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Which of the following is NOT a typical clinical feature of hypoglycaemia:
Your Answer: Polyuria
Explanation:Clinical features of hypoglycaemia: Autonomic symptoms: Sweating, feeling hot, anxiety/agitation, palpitations, shaking, paraesthesia, dizzinessNeuroglycopaenic symptoms: Weakness, blurred vision, difficulty speaking, poor concentration, poor coordination, drowsiness, confusion, seizures, comaOther symptoms: Nausea, fatigue, hunger
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This question is part of the following fields:
- Endocrine
- Physiology
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Question 30
Incorrect
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A 25 year old woman who is a known diabetic is brought to the ED with diabetic ketoacidosis. She promptly received an insulin infusion. Which of the following are expected to increase upon infusion of insulin?
Your Answer: Urine glucose concentration
Correct Answer: Blood pH
Explanation:Ketoacidosis is characterized by hyperglycaemia, glycosuria, hyperkalaemia, and metabolic acidosis with respiratory compensation. An insulin infusion would be able to address these by lowering blood glucose through increased insulin-mediated cellular uptake, lowering urine glucose concentration as cellular glucose uptake is increased, decreasing K+ in her blood by shifting it into cells, and increasing blood ph by addressing the metabolic acidosis. The metabolic acidosis is addressed by the reduction of ketoacids production thereby returning her blood ph to normal and reducing the need for compensatory hyperventilation.
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This question is part of the following fields:
- Endocrine
- Physiology
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SESSION STATS - PERFORMANCE PER SPECIALTY
