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  • Question 1 - A 58-year-old lady was admitted to hospital with increasing thirst and generalised abdominal...

    Incorrect

    • A 58-year-old lady was admitted to hospital with increasing thirst and generalised abdominal pain. She was diagnosed with breast carcinoma three years previously and treated with a radical mastectomy.
       
      Investigations showed:

      Serum corrected calcium 3.5 mmol/L (NR 2.2-2.6)
      Serum alkaline phosphatase 1100 IU/L

       
      Her serum calcium was still elevated following 4 litres of 0.9% saline intravenous infusion.
       
      Which of the following is the most appropriate next step?

      Your Answer: Radiotherapy

      Correct Answer: Pamidronate 60 mg intravenously

      Explanation:

      This case has hypercalcaemia most likely associated with the bony metastases from her pre-existing breast carcinoma. The most appropriate next step is to give Pamidronate 60mg intravenously, a bisphosphonate, to immediately inhibit bone resorption and formation.

    • This question is part of the following fields:

      • Nephrology
      1
      Seconds
  • Question 2 - A 62-year-old woman with scleroderma and Reynaud’s phenomenon complains of weight loss and...

    Incorrect

    • A 62-year-old woman with scleroderma and Reynaud’s phenomenon complains of weight loss and has been referred for an opinion. Gastrointestinal associations of progressive systemic sclerosis include which of the following?

      Your Answer:

      Correct Answer: Oesophageal stricture

      Explanation:

      Oesophageal stricture is a complication of systemic sclerosis, think of the oesophagus as sclerosing (fibrosing) leading to stricture and you never forget. Based on the clinical presentation of systemic sclerosis this is more likely than pancreatic dysfunction, PSC, lymphoma, or diverticulitis. Additionally, CREST syndrome stands for: calcinosis cutis, Raynaud’s phenomenon (which the patient has), oesophageal dysmotility, sclerodactyly, and telangiectasias), this is a form of systemic sclerosis you should be familiar with.

    • This question is part of the following fields:

      • Gastroenterology
      6
      Seconds
  • Question 3 - A 62-year-old laboratory technician presents to the ophthalmology emergency department with sudden onset...

    Incorrect

    • A 62-year-old laboratory technician presents to the ophthalmology emergency department with sudden onset painless loss of vision in the right eye. He describes it as having a dense shadow over his vision, progressing from the periphery to the centre. He has no past medical history of note.

      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Retinal detachment

      Explanation:

      The most common causes of a sudden painless loss of vision are as follows:
      – Ischaemic optic neuropathy (e.g. temporal arteritis or atherosclerosis)
      – Occlusion of central retinal vein
      – Occlusion of central retinal artery
      – Vitreous haemorrhage
      – Retinal detachment

      Retinal detachment is a cause of sudden painless loss of vision. It is characterised by a dense shadow starting peripherally and progressing centrally.

      Vitreous haemorrhage usually presents with dark spots.

      Central retinal artery and central retinal vein occlusion do not usually present with progressing dense shadow.

      This man’s lack of ischaemic risk factors makes ischaemic optic neuropathy less likely.

    • This question is part of the following fields:

      • Ophthalmology
      0
      Seconds
  • Question 4 - A 37-year-old social worker is referred to you with a long history of...

    Incorrect

    • A 37-year-old social worker is referred to you with a long history of diarrhoea and abdominal discomfort. She was diagnosed with irritable bowel syndrome 10 years ago and takes mebeverine, peppermint tablets and Gaviscon. She is a vegetarian and rarely drinks or smokes.

      Examination of all systems is normal. Her blood tests show macrocytic anaemia. An upper gastrointestinal endoscopy reveals oesophagitis, hypertrophy of the gastric body and multiple duodenal ulcers.

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Zollinger–Ellison syndrome

      Explanation:

      This case describes Zollinger-Ellison syndrome. It is characterized by refractory peptic ulcer disease, often multiple ulcers. This is typically caused by secretion of gastrin from a gastrinoma, a neuroendocrine tumour. The most common site of ulceration is the duodenum. A symptom of a pancreatic gastrinoma may be steatorrhea from the hypersecretion of gastrin. Serum gastrin levels > 1000 and a pH < 2 are diagnostic of pancreatic gastrinoma. None of the other answer choices are a better answer than this. CT abdomen may potentially show a tumour, but this is not diagnostic for type.

    • This question is part of the following fields:

      • Gastroenterology
      0
      Seconds
  • Question 5 - A 25-year-old woman with Charcot-Marie-Tooth disease (type 1) asks how likely it is...

    Incorrect

    • A 25-year-old woman with Charcot-Marie-Tooth disease (type 1) asks how likely it is that any future children will have the disease. What is the most accurate answer?

      Your Answer:

      Correct Answer: 50%

      Explanation:

      Because Charcot-Marie-Tooth disease (type 1) is an autosomal dominant condition; therefore, there is a 50% chance that the children of this patient will be affected.

    • This question is part of the following fields:

      • Neurology
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  • Question 6 - A 40-year-old male has a 6-year history of hypertension. For two days, he...

    Incorrect

    • A 40-year-old male has a 6-year history of hypertension. For two days, he has been having extreme difficulty in seeing things clearly and now complains of cloudy vision. On fundoscopy, flame-shaped haemorrhages are found in the patient's right eye. Margins of the optic disc were also found to be blurred. Which of the following conditions is this patient most likely suffering from?

      Your Answer:

      Correct Answer: CRV thrombosis

      Explanation:

      Fundoscopy reveals flame-shaped haemorrhages which are specific to central retinal vein occlusion (CRVO). In CRA thrombosis, fundoscopy would show a cherry-red spot. A patient with retinal detachment would give a characteristic history of seeing flashes of light and floaters. Background retinopathy is associated with diabetes.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 7 - You want to compare a new oral hypoglycaemic drug with an existing treatment,...

    Incorrect

    • You want to compare a new oral hypoglycaemic drug with an existing treatment, which would also lower HbA1c. Which study design would you choose?

      Your Answer:

      Correct Answer: Superiority trial

      Explanation:

      When the aim of the randomized controlled trial (RCT) is to show that one treatment is superior to another, a statistical test is employed and the trial (test) is called a superiority trial (test).

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 8 - A 30 yr. old primigravida in her 23rd week of pregnancy presented with...

    Incorrect

    • A 30 yr. old primigravida in her 23rd week of pregnancy presented with palpitations. Her ECG showed supraventricular tachycardia (SVT). 15 minutes after admission the SVT spontaneously reverted to sinus rhythm. She had two episodes of SVT later which were associated with palpitations. Which of the following is the most appropriate treatment for this presentation?

      Your Answer:

      Correct Answer: Verapamil

      Explanation:

      Both long-acting calcium channel blockers and beta blockers improve symptoms of patients with SVT. Verapamil does not have adverse maternal or fetal side effects which would suggest that the use of verapamil in the treatment of supraventricular arrhythmias in pregnancy is safe and effective. Beta blockers are associated with intrauterine fetal growth restriction.

    • This question is part of the following fields:

      • Cardiology
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  • Question 9 - A 25-year-old gentleman presents to the hospital feeling unwell and breathless. History reveals...

    Incorrect

    • A 25-year-old gentleman presents to the hospital feeling unwell and breathless. History reveals that he has chronic renal failure, for which he receives haemodialysis three times per week. Since one week prior to consultation, he has been on vacation and has missed two dialysis sessions.

      Examination reveals pulmonary oedema. His ECG shows no P waves, broad QRS complexes and peaked T waves.

      What should you do?

      Your Answer:

      Correct Answer: Give 10 ml of 10% calcium gluconate intravenously

      Explanation:

      The patient is most likely complaining of the effects of hyperkalaemia, due to missing his dialysis sessions. Additionally, because the patient presents with a risk of cardiac arrest (based on pulmonary oedema and ECG findings), the best intervention is to give calcium gluconate that will address the hyperkalaemia as well as improve the cardiac condition.

    • This question is part of the following fields:

      • Nephrology
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  • Question 10 - A 75-year-old man has presented to the clinic with a complaint of disturbed...

    Incorrect

    • A 75-year-old man has presented to the clinic with a complaint of disturbed sleep. The physician has prescribed temazepam. Which of the following best describes the mechanism of action of this drug?

      Your Answer:

      Correct Answer: Enhances the effect of gamma-aminobutyric acid

      Explanation:

      Temazepam is an orally available benzodiazepine used in the therapy of insomnia.
      The soporific activity of the benzodiazepines is mediated by their ability to enhance gamma-aminobutyric acid (GABA) mediated inhibition of synaptic transmission through binding to the GABA-A receptor.
      The recommended initial dose for insomnia is 7.5 mg before bedtime, increasing as needed to a maximum dose of 30 mg.

      The most common side effects of temazepam are dose-related and include daytime drowsiness, lethargy, ataxia, dysarthria, and dizziness.
      Tolerance develops to these side effects, but tolerance may also develop to the effects on insomnia.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 11 - A 78 year old woman presents to the clinic complaining of left sided...

    Incorrect

    • A 78 year old woman presents to the clinic complaining of left sided temporal headaches and jaw claudication that has been going on for a month. A left temporal artery biopsy is negative. Results show:
      Hb: 130g/l
      Platelets: 359*109/L,
      WBC: 10*109/L,
      CRP: 89mg/l
      Which of the following options would be the next best step in the management of this patient?

      Your Answer:

      Correct Answer: Commence prednisolone

      Explanation:

      Temporal arteritis is a chronic large- and medium-sized vessel vasculitis that typically involves the temporal arteries. Classical symptoms include temporal headaches, jaw claudication, amaurosis fugax. Physical exam shows scalp tenderness, palpation of the temporal area may demonstrate an absent pulse, knot-like swelling and vision loss. Lab results reveal an increased erythematous sedimentation rate and C-reactive protein. Temporal artery biopsy confirms the diagnosis. Management approach: high-dose systemic corticosteroids should be promptly administered even before the diagnosis is established. Temporal artery biopsy confirms the diagnosis. Inability to manage this or administer glucocorticoids might lead to development of blindness.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 12 - A 65-year-old real estate broker presents with a tremor. Which one of the...

    Incorrect

    • A 65-year-old real estate broker presents with a tremor. Which one of the following features would suggest a diagnosis of essential tremor rather than Parkinson's disease?

      Your Answer:

      Correct Answer: Tremor is worse when the arms are outstretched

      Explanation:

      Difficulty in initiating movement (bradykinesia), postural instability and unilateral symptoms (initially) are typical of Parkinson’s. Essential tremor symptoms are usually worse if arms are outstretched and eased by rest and alcohol.

    • This question is part of the following fields:

      • Neurology
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  • Question 13 - Which of the following drugs would be the safest to prescribe in a...

    Incorrect

    • Which of the following drugs would be the safest to prescribe in a 22 year old man with seropositive rheumatoid arthritis who is planning to start a family?

      Your Answer:

      Correct Answer: Prednisolone

      Explanation:

      Prednisolone although has many undesirable side effects it may be considered relatively safe compared to the drugs that are provided here. Prolonged treatment with sulphasalazine may depress semen quality and cause irreversible infertility. Methotrexate and leflunomide both inhibit purine/pyrimidine synthesis (the former by inhibiting folate metabolism) and are contraindicated in pregnancy or while trying to conceive. In males, a temporary or permanent decrease in sperm count may occur with cyclophosphamide. Because the recovery of fertility after cyclophosphamide therapy is variable, sperm banking should be considered before treatment is begun.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 14 - A 54 year old male, with a smoking history of 15 pack years...

    Incorrect

    • A 54 year old male, with a smoking history of 15 pack years presents with worsening dyspnoea, fever and cough. He works at a foundry. Vitals are as follows:
      Respiratory rate: 28/min
      Heart rate: 80 bpm
      Temp: 37.6C
      Chest auscultation reveals bilateral crepitations throughout the lung fields.
      Calcified hilar nodules are visible on the chest X-ray. Further evaluation shows an eggshell calcification on HRCT.

      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Silicosis

      Explanation:

      Silicosis is a common occupational lung disease that is caused by the inhalation of crystalline silica dust. Silica is the most abundant mineral on earth. Workers that are involved for example in construction, mining, or glass production are among the individuals with the highest risk of developing the condition. Acute silicosis causes severe symptoms (e.g., exertional dyspnoea, cough with sputum) and has a very poor prognosis.
      Chronic silicosis has a very variable prognosis and affected individuals may remain asymptomatic for several decades. However, radiographic signs are usually seen early on. Typical radiographic findings are calcifications of perihilar lymph nodes, diffuse ground glass opacities, large numbers of rounded, solitary nodules or bigger, confluent opacities. Avoiding further exposure to silica is crucial, especially since the only treatment available is symptomatic (e.g., bronchodilators). Silicosis is associated with an increased risk of tuberculosis and lung cancer. Berylliosis typically affects individuals who are exposed to aerospace industry. Histoplasmosis and tuberculosis do not form eggshell calcifications.

    • This question is part of the following fields:

      • Respiratory
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  • Question 15 - A 41-year-old gentleman required high doses of intravenous diuretics after his renal transplant...

    Incorrect

    • A 41-year-old gentleman required high doses of intravenous diuretics after his renal transplant for the purposes of fluid management. Soon after administration he developed hearing loss, tinnitus, and vertigo.
       
      Which diuretic is most likely to have caused this?

      Your Answer:

      Correct Answer: Furosemide

      Explanation:

      Furosemide is a loop diuretic that is known to have significant ototoxicity side-effects although the mechanism is not fully known.

    • This question is part of the following fields:

      • Nephrology
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  • Question 16 - Which of the following parameters is increased as a result of asthma? ...

    Incorrect

    • Which of the following parameters is increased as a result of asthma?

      Your Answer:

      Correct Answer: Residual volume

      Explanation:

      In asthma, a reversible increase in residual volume (RV), functional residual capacity (FRC), and total lung capacity (TLC) may occur. There is a fall in FEV1, FVC and gas transfer.

    • This question is part of the following fields:

      • Respiratory
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  • Question 17 - A 34-year-old man was brought to the ER following a road-traffic-accident. An X-ray...

    Incorrect

    • A 34-year-old man was brought to the ER following a road-traffic-accident. An X-ray of his left thigh revealed a fractured shaft of the left femur. He has a known history of opioid abuse. You are called to the ward to assess him after he becomes unwell. Which of the following clinical features are NOT compatible with a diagnosis of opioid withdrawal?

      Your Answer:

      Correct Answer: Hypothermia

      Explanation:

      Among the options provided, hypothermia is not a symptom of opioid withdrawal.

      Symptoms of opioid withdrawal include dysphoric mood, yawning, insomnia, muscle aches, lacrimation/rhinorrhoea, papillary dilatation, piloerection, fever, sweating, nausea/vomiting, diarrhoea.
      If the patient is having an opioid withdrawal reaction, then give 10 mg of methadone syrup and wait about 60 min to determine its effect.

      COWS (Clinical Opioid Withdrawal Scale) assessment for opioid withdrawal is commonly used to determine the severity of opioid withdrawal.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 18 - Which type of cell is responsible for the production of surfactant? ...

    Incorrect

    • Which type of cell is responsible for the production of surfactant?

      Your Answer:

      Correct Answer: Type II pneumocyte

      Explanation:

      Type I pneumocyte: The cell responsible for the gas (oxygen and carbon dioxide) exchange that takes place in the alveoli. It is a very thin cell stretched over a very large area. This type of cell is susceptible to a large number of toxic insults and cannot replicate itself.
      Type II pneumocyte: The cell responsible for the production and secretion of surfactant (the molecule that reduces the surface tension of pulmonary fluids and contributes to the elastic properties of the lungs). The type 2 pneumocyte is a smaller cell that can replicate in the alveoli and will replicate to replace damaged type 1 pneumocytes. Alveolar macrophages are the primary phagocytes of the innate immune system, clearing the air spaces of infectious, toxic, or allergic particles that have evaded the mechanical defences of the respiratory tract, such as the nasal passages, the glottis, and the mucociliary transport system. The main role of goblet cells is to secrete mucus in order to protect the mucous membranes where they are found. Goblet cells accomplish this by secreting mucins, large glycoproteins formed mostly by carbohydrates.

    • This question is part of the following fields:

      • Respiratory
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  • Question 19 - A 20-year-old male presented to the clinic with a long term history of...

    Incorrect

    • A 20-year-old male presented to the clinic with a long term history of pins and needles sensation in both hands. He also has prognathism. He also gives a history of recent onset right upper quadrant pain after being started on a new medication for his condition.
      Which of the following medications acting on his endocrine system can be responsible for this adverse effect?

      Your Answer:

      Correct Answer: Octreotide

      Explanation:

      The patient (known case of acromegaly) seems to have developed cholelithiasis (presenting with right upper quadrant pain) probably due to octreotide.

      It is a long-acting analogue of somatostatin which is released from D cells of the pancreas and inhibits the release of growth hormone, glucagon, and insulin.

      Uses
      – Acute treatment of variceal haemorrhage
      – Acromegaly
      – Carcinoid syndrome
      – Prevent complications following pancreatic surgery
      – VIPomas
      – Refractory diarrhoea

      Adverse effects
      Gallstones (secondary to biliary stasis)

      Other options:
      – Bromocriptine – a dopamine agonist with side effects arising from its stimulation of the brain vomiting centre.
      – Desmopressin – predominantly used in patients with diabetes insipidus by increasing the presence of aquaporin channels in the distal collecting duct to increase water reabsorption from the kidneys. The main side effects include headache and facial flushing due to hypertension.
      – Metformin – mainly reduces hepatic gluconeogenesis in patients with type 2 diabetes, common side effects include diarrhoea, vomiting, and lactic acidosis
      – Levothyroxine – synthetic thyroxine used in patients with hypothyroidism, common side effects result from incorrect dosing and mimic the symptoms of hyperthyroidism.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 20 - A 24 year old presents with diarrhoea. She has had a previous ileal...

    Incorrect

    • A 24 year old presents with diarrhoea. She has had a previous ileal resection for Crohn's Disease. She has also had two recent episodes of loin to groin pain. Her bloods are normal including her inflammatory markers

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Short bowel syndrome

      Explanation:

      Given her history of bowel resections, the most likely answer in this case is short bowel syndrome. IBS is a diagnosis of exclusion and less likely. Bacterial overgrowth does not relate to resection history, so unlikely. Celiac disease or a flare of IBD are also less likely than short bowel syndrome in this case, simply given the history. Also her labs are normal making these unlikely. History, history, history!

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 21 - An elderly woman is admitted to the hospital with a community-acquired pneumonia (CAP)....

    Incorrect

    • An elderly woman is admitted to the hospital with a community-acquired pneumonia (CAP). Her medical notes state that she developed a skin rash after taking penicillin a few years ago. She has a CURB score of 4 and adverse prognostic features. Which of the following would be an appropriate empirical antibiotic choice?

      Your Answer:

      Correct Answer: Cefotaxime and erythromycin

      Explanation:

      Community-acquired pneumonia (CAP) is one of the most common infectious diseases and is an important cause of mortality and morbidity worldwide. Typical bacterial pathogens that cause CAP include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
      The CURB-65 is used as a means of deciding the action that is needed to be taken for that patient.
      Score 3-5: Requires hospitalization with consideration as to whether they need to be in the intensive care unit

      Recent studies have suggested that the use of a beta-lactam alone may be noninferior to a beta-lactam/macrolide combination or fluoroquinolone therapy in hospitalized patients.

      Therapy in ICU patients includes the following:
      – Beta-lactam (ceftriaxone, cefotaxime, or ampicillin/sulbactam) plus either a macrolide or respiratory fluoroquinolone
      – For patients with penicillin allergy, a respiratory fluoroquinolone and aztreonam

      Therefore the appropriate treatment would be Cefotaxime and erythromycin.

    • This question is part of the following fields:

      • Respiratory
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  • Question 22 - An 8-week-old baby was found to have bilateral cataracts. Further investigation revealed thrombocytopenia,...

    Incorrect

    • An 8-week-old baby was found to have bilateral cataracts. Further investigation revealed thrombocytopenia, a patent ductus arteriosus and hepatosplenomegaly. Which of the following is the most probable diagnosis?

      Your Answer:

      Correct Answer: Rubella

      Explanation:

      The clinical presentation is suggestive of congenital rubella syndrome. The classic triad of presenting symptoms includes sensorineural hearing loss, ocular abnormalities (cataract, infantile glaucoma, and pigmentary retinopathy) and congenital heart disease (patent ductus arteriosus and pulmonary artery stenosis). Other findings in congenital rubella syndrome include CNS abnormalities (mental retardation, behavioural disorders, encephalographic abnormalities, hypotonia, meningoencephalitis, and microcephaly), hepatosplenomegaly, and jaundice.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 23 - Which of the following is caused by vitamin D? ...

    Incorrect

    • Which of the following is caused by vitamin D?

      Your Answer:

      Correct Answer: Increased plasma phosphate

      Explanation:

      Intestinal phosphate absorption is mediated by both transcellular and paracellular routes. The 1,25(OH)2D increases intestinal transcellular phosphate absorption at least in part by enhancing expression of type 2b sodium–phosphate cotransporter, thus increasing plasma phosphate.

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 24 - A 32 year-old man presents with his first generalized tonic-clonic seizure (GTCS). He...

    Incorrect

    • A 32 year-old man presents with his first generalized tonic-clonic seizure (GTCS). He has been complaining of headaches for the past 2 weeks, although he has been able to continue working at his job. Upon examination, he has mild left hemiparesis and bilateral extensor plantar responses. General examination is otherwise unremarkable. An urgent CT scan of the brain shows a 5cm multicentric mass lesion in the right frontal lobe with surrounding vasogenic oedema and some hemisphere shift. Which of the following is the most likely underlying pathology?

      Your Answer:

      Correct Answer: Glioblastoma

      Explanation:

      Glioblastoma multiforme, also considered as grade IV astrocytoma, is the most malignant form of the tumour and accounts for about 20% of all cerebral tumours. These often remain clinically silent until they have reached a large enough size. In adults, glioblastoma multiforme usually occurs in the cerebral hemispheres, especially the frontal and temporal lobes of the brain. About half occupy more than one hemisphere at presentation, and some are multicentric. Biopsy shows high cellularity with mitoses, pleomorphism, and vascular hyperplasia. Prognosis is extremely poor, with only 20% surviving beyond 1 year and 10% beyond 2 years.

    • This question is part of the following fields:

      • Neurology
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  • Question 25 - A 63-year-old gentleman presents with left-sided eye pain and diplopia for the past...

    Incorrect

    • A 63-year-old gentleman presents with left-sided eye pain and diplopia for the past 2 days. Examination of his eyes shows his pupils equal and reactive to light with no proptosis. There is however an apparent palsy of the 6th cranial nerve associated with a partial 3rd nerve palsy on the left side. Examining the remaining cranial demonstrates hyperaesthesia of the upper face on the left side. Where is the likely lesion?

      Your Answer:

      Correct Answer: Cavernous sinus

      Explanation:

      A lesion on the cavernous sinus would explain the palsy observed on the III and VI cranial nerves because the cranial nerves III, IV, V, and VI pass through the cavernous sinus. Pain in the eye is due to the nearby ophthalmic veins that feeds the cavernous sinus. Additionally, the lesions in the other structures would have presented with pupil abnormalities and less localized pain and symptoms.

    • This question is part of the following fields:

      • Neurology
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  • Question 26 - A 27 year-old ballet instructor presents with 1-day history of left-sided facial weakness...

    Incorrect

    • A 27 year-old ballet instructor presents with 1-day history of left-sided facial weakness and an increased sensitivity to noise in her left ear. She is very anxious because 2 years ago she had some problems with her vision and was told that multiple sclerosis was a possibility. Her medical history is significant only for type 1 diabetes mellitus managed with insulin, and she is also taking a combined oral contraceptive pill. Upon examination, she has a lower motor neuron lesion of the left VII (facial) nerve with Bell's phenomenon present and difficulty closing her left eye. There is no objective hearing loss and no sensory signs. Examination of the auditory meatus and canal is unremarkable. The remainder of the neurological examination appears normal. The next management step in her care should be:

      Your Answer:

      Correct Answer: Eye patch and artificial tears

      Explanation:

      From the given history and physical examination findings, this patient has Bell’s palsy. There is no evidence to suggest involvement of any other cranial nerves, which might raise suspicion of a cerebello-pontine angle space-occupying lesion. With her history of possible optic neuritis, there is a possibility that the lesion is in fact a manifestation of multiple sclerosis, although this should be differentiated by examination of an upper motor neuron lesion (with sparing of the forehead facial muscles because of bilateral innervation). In light of her diabetes and the limited evidence of benefit from corticosteroid use, the most sensible first management step for her would be meticulous eye care to avoid corneal ulceration, as a result of the difficulty she is having closing her left eye.

    • This question is part of the following fields:

      • Neurology
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  • Question 27 - A 50-year-old male was under treatment for bipolar disease. He was brought to...

    Incorrect

    • A 50-year-old male was under treatment for bipolar disease. He was brought to the emergency department as he had become increasingly confused over the past two days. He had vomiting and diarrhoea. He was also consuming and passing a lot of water.
      On examination, he was disoriented. He had vertical nystagmus and was ataxic.
      What two investigations are likely to lead to the correct diagnosis?

      Your Answer:

      Correct Answer: Desmopressin test and serum lithium level

      Explanation:

      Desmopressin test (done to differentiate nephrogenic diabetes insipidus from central diabetes insipidus), and serum lithium levels can together confirm a diagnosis of lithium-induced nephrogenic diabetes insipidus.

      Bipolar disease is most often managed with mood stabilizers like lithium. This patient develops gastrointestinal symptoms followed by an acute confusional state associated with polyuria and polydipsia. These symptoms are suggestive of diabetes insipidus.

      In a case where these symptoms occur in a bipolar patient under treatment, lithium-induced nephrogenic diabetes insipidus should be considered as the most probable cause.

      Lithium intoxication can present with symptoms of nausea, vomiting, mental dullness, action tremor, weakness, ataxia, slurred speech, blurred vision, dizziness, especially vertical nystagmus and stupor or coma. Diffuse myoclonic twitching and nephrogenic diabetes insipidus can also occur. Such a clinical syndrome occurs above the serum level of lithium of 1.5–2.0 mEq/L.

      Management:
      – Correcting electrolyte abnormalities in patients with acute disease is critical and often life-saving.
      – Treatment should be initiated with parenteral fluids to replete hypovolemia (normal saline at 200-250 mL/h), followed by administration of hypotonic fluid (0.5% normal saline).
      – On the restoration of the volume status of the patient forced diuresis should be initiated by the administration of parenteral furosemide or bumetanide accompanied by continued intravenous hypotonic fluid administration to maintain volume status.
      – Polyuria is managed with hydrochlorothiazide combined with amiloride, acetazolamide.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 28 - Which of the following is correct regarding lead poisoning? ...

    Incorrect

    • Which of the following is correct regarding lead poisoning?

      Your Answer:

      Correct Answer: Causes a peripheral neuropathy due to demyelination

      Explanation:

      Lead can be absorbed through the skin and by inhalation. It is associated with iron deficiency and a microcytic anaemia. The most common gastrointestinal symptoms are abdominal colic and constipation.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 29 - A 30-year-old agitated male was brought to the emergency department by his friend....

    Incorrect

    • A 30-year-old agitated male was brought to the emergency department by his friend. Though there is little previous history, the friend believes that he has been suffering from depression for several years, and his medications have been changed by his general practitioner quite recently.
      On examination the patient is agitated and confused, his pupils are dilated. He also has tremors, excessive sweating, and grinding of teeth. His heart rate is 118 beats/min, which is regular, and is febrile with a temperature of 38.5°C.
      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Serotonin syndrome

      Explanation:

      The most probable diagnosis in this patient is serotonin syndrome.

      The serotonin syndrome is a cluster of symptoms and signs (range from barely perceptible tremor to life-threatening hyperthermia and shock).
      It may occur when SSRIs such as citalopram, escitalopram, fluoxetine, fluoxetine, paroxetine, and sertraline that impair the reuptake of serotonin from the synaptic cleft into the presynaptic neuron are taken in combination with monoamine oxidase inhibitors or tricyclic antidepressants. It has also been reported following an overdose of selective serotonin reuptake inhibitors (SSRIs) alone.

      Treatment:
      Most cases of serotonin syndrome are mild and will resolve with removal of the offending drug alone.
      After stopping all serotonergic drugs, management is largely supportive and aimed at preventing complications.
      Patients frequently require sedation, which is best facilitated with benzodiazepines.
      Antipsychotics should be avoided because of their anticholinergic properties, which may inhibit sweating and heat dissipation.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 30 - Which of the following is most helpful in differentiating chronic from acute renal...

    Incorrect

    • Which of the following is most helpful in differentiating chronic from acute renal failure?

      Your Answer:

      Correct Answer: Kidney size at ultrasound scan

      Explanation:

      The size of the kidneys on ultrasound would differentiate chronic from acute renal failures. Chronic renal failure is more associated with small-sized kidneys.

    • This question is part of the following fields:

      • Nephrology
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