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  • Question 1 - A 65-year-old gentleman gives a two week history of progressive lethargy and weakness....

    Incorrect

    • A 65-year-old gentleman gives a two week history of progressive lethargy and weakness. Eight weeks previously, he was treated for hypertensive heart failure with 120 mg furosemide and 5 mg enalapril daily. His haemoglobin at the time was 12.0, urea 14.2 mmol/l and creatinine 298 μmol/l. His blood pressure in clinic was 148/85 mmHg.

      His blood results are shown below:

      Hb 10.2g/dL,
      MCV 89.2 fl
      WCC 4.9 x 109/L,
      Plats 175 x 109/L,
      Na+ 135
      K+ 5.2 mmol/L,
      Urea 25.2 mmol/L,
      Creat 600 μmol/L,


      Assuming that he is not volume overloaded, what would be the most appropriate action?

      Your Answer: stop the furosemide

      Correct Answer: stop the enalapril and furosemide

      Explanation:

      The patient presents with worsened renal condition from the last consultation when he was started on enalapril (an ACE inhibitor) so this medication should be stopped. Because there is also no fluid overload; furosemide, a diuretic, should also be stopped.

    • This question is part of the following fields:

      • Nephrology
      2
      Seconds
  • Question 2 - A 30 year old female has been started on azathioprine after she was...

    Incorrect

    • A 30 year old female has been started on azathioprine after she was found to be intolerant of methotrexate. Routine blood monitoring shows the following values:
      Hb 7.9 g/dL,
      Plt 97*109/l,
      WBC 2.7*109/l.
      Azathioprine toxicity will most likely to occur in the presence of which of the following?

      Your Answer:

      Correct Answer: Thiopurine methyltransferase deficiency

      Explanation:

      Azathioprine therapy can cause acute myelosuppression. Toxicity is in part caused by the incorporation of azathioprine-derived 6-thioguanine nucleotides (6-TGN) into deoxyribonucleic acid (DNA). The enzyme thiopurine methyltransferase (TPMT) plays an important role in azathioprine catabolism.

    • This question is part of the following fields:

      • Rheumatology
      9
      Seconds
  • Question 3 - A 32 year old female is diagnosed with SLE based on her complaints...

    Incorrect

    • A 32 year old female is diagnosed with SLE based on her complaints of polyarthralgia, mouth ulcers and ANA positivity. Labs reveal normal urinalysis, urea and electrolytes. ESR is 90mm in the first hour. How will you manage this patient?

      Your Answer:

      Correct Answer: Hydroxychloroquine 200 mg/day

      Explanation:

      Hydroxychloroquine is used in the management of SLE as it prevents disease progression and has relatively mild side effects, for instance headache, nausea etc. Its use reduces the usage of corticosteroids. It is particularly effective when the disease is less severe and there is no organ involvement. Cyclophosphamide and prednisolone are indicated in cases of renal, neurological and lung involvement.

    • This question is part of the following fields:

      • Rheumatology
      0
      Seconds
  • Question 4 - A 41-year-old female is referred to medical assessment unit by her physician for...

    Incorrect

    • A 41-year-old female is referred to medical assessment unit by her physician for querying thrombotic thrombocytopenic purpura (TTP) after she presented with a temperature of 38.9C. Her subsequent urea and electrolytes showed deteriorating renal function with a creatinine 3 times greater than her baseline.

      What is the underlying pathophysiology of TTP?

      Your Answer:

      Correct Answer: Failure to cleave von Willebrand factor normally

      Explanation:

      Thrombotic thrombocytopenic purpura (TTP) is characterised by the von Willebrand factor (vWF) microthrombi within the vessels of multiple organs. In this condition, the ADAMTS13 metalloprotease enzyme which is responsible for the breakdown of vWF multimer, is deficient, causing its build-up and leading to platelet clots that then decreases the circulating platelets, leading to bleeding in the patient.

    • This question is part of the following fields:

      • Nephrology
      0
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  • Question 5 - A 22-year-old woman has ingested an unknown quantity of paracetamol tablets four hours...

    Incorrect

    • A 22-year-old woman has ingested an unknown quantity of paracetamol tablets four hours ago. She now presents with nausea, vomiting, anorexia and right subchondral pain.

      Which of the following features suggest that she should be transferred to the liver unit?

      Your Answer:

      Correct Answer: pH 7.25

      Explanation:

      The most widely used prognostic predictors for acetaminophen over-ingestion is King’s College Criteria, which is: arterial PH < 7.3 after fluid resuscitation, Cr level > 3.4, PT > 1.8x control or > 100s, or INR > 6.5, and Grave III or IV encephalopathy.

    • This question is part of the following fields:

      • Gastroenterology
      0
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  • Question 6 - A 28-year-old woman attends for review. She has a past history of a...

    Incorrect

    • A 28-year-old woman attends for review. She has a past history of a perianal abscess but nothing else of note. During the past few months she has twice presented to A&E complaining of grumbling abdominal pain. In addition, she has suffered intermittent episodes of bloody diarrhoea.

      Microcytic anaemia is found on blood testing and she has mild hypokalaemia. Albumin is reduced but other liver function tests are unremarkable. Barium imaging reveals a small bowel stricture with evidence of mucosal ulceration extending into the colon, interspersed with normal looking mucosa ‘skipping’.

      Given this clinical picture, which is the most likely diagnosis?

      Your Answer:

      Correct Answer: Crohn’s disease

      Explanation:

      The correct answer based on the clinical scenario is Crohn’s disease. Associated with this disease are abscesses and fistulas in the anorectal region, skip lesions, cobble stoning, stricturing, granulomas, and crypt distortion. The other answer choices are not correct. How to rule out ulcerative colitis: it only involves ileocolorectal regions, and this is above that level. You will not see crypt distortion and cobble stoning; it is a more superficial process.

    • This question is part of the following fields:

      • Gastroenterology
      0
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  • Question 7 - A 47-year-old woman complains of dyspnoea, occasional fevers and mild weight loss which...

    Incorrect

    • A 47-year-old woman complains of dyspnoea, occasional fevers and mild weight loss which have all gotten worse over the past months. She does not complain of a cough but remembered that she had coughed once and produced a twig-shaped mucoid sputum mass. She has no haemoptysis. She has no past medical history and is on no medications.
       
      Her chest X-ray reveals bilateral, perihilar, dense airspace shadowing. A HRCT of her thorax showed a ‘crazy paving’ pattern of extensive, dense, white infiltrates. Her spirometry was a restrictive pattern with reduced total lung capacity. She also had a bronchoscopy and lavage, which revealed periodic acid–Schiff (PAS)-positive proteinaceous fluid and elevated levels of surfactant proteins A and D.
       
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Pulmonary alveolar proteinosis

      Explanation:

      Pulmonary alveolar proteinosis (PAP) is a lung condition that is caused by a build-up of proteins and other substances in the alveoli. The alveoli are the part of the lungs that contain air. PAP has the following symptoms:
      Shortness of breath, also called dyspnoea
      Chest pain or tightness
      Fever
      Weight loss
      Cough (sometimes, but not always)
      Low levels of oxygen in the blood
      Nail clubbing (abnormal growth of toenails or fingernails)

      Serologic studies are generally not useful for PAP. Flexible bronchoscopy with bronchoalveolar lavage (BAL) remains the criterion standard. Elevated levels of the proteins SP-A and SP-D in serum and BAL fluid may be useful. Elevated titer of neutralizing autoantibody against GM-CSF (immunoglobulin G [IgG] isotype) in serum and BAL fluid may be useful. Recent studies have proposed that deficiency of GM-CSF causes pulmonary alveolar proteinosis (PAP); all patients studied had the antibody to GM-CSF. Serum lactate dehydrogenase (LDH) level is usually elevated, but this finding is nonspecific.

      High-resolution computed tomography (HRCT) scan of the chest demonstrates areas of patchy ground-glass opacification with smooth interlobular septal thickening and intralobular interstitial thickening, which produces a polygonal pattern referred to as crazy paving.

      Light microscopy of the lung parenchymal tissue shows alveoli filled with a granular PAS base-reactive and diastase-resistant eosinophilic material.

    • This question is part of the following fields:

      • Respiratory
      0
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  • Question 8 - A 55-year-old woman with established metastatic breast cancer is admitted to the A&E...

    Incorrect

    • A 55-year-old woman with established metastatic breast cancer is admitted to the A&E with hypercalcemia. She has a clear medical history, doesn't smoke and works in an office based job. At the A&E she's given intravenous fluids and bisphosphonates. She's finally discharged after normalization of her calcium levels. However, before leaving the hospital she's sent to the endocrinology department for consultation regarding outpatient care and serum calcium monitoring. What is the most appropriate and useful advice for this patient?

      Your Answer:

      Correct Answer: Increase fluid intake

      Explanation:

      NICE guidelines on hypercalcemia recommend that maintaining good hydration equals drinking 3-4 L of fluid/day, provided there are no contraindications. A low calcium diet is not necessary because intestinal absorption of calcium is reduced. The patient should avoid any other drugs or vitamins that could worsen the hypercalcemia. Mobilization is encouraged and any symptoms of hypercalcemia should be reported.

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 9 - A 32-year-old woman was diagnosed with Hodgkin disease 8 years ago. She was...

    Incorrect

    • A 32-year-old woman was diagnosed with Hodgkin disease 8 years ago. She was treated with radiotherapy which led to complete remission.

      What is the most likely long-term risk of radiotherapy?

      Your Answer:

      Correct Answer: Secondary cancer

      Explanation:

      The major delayed problem with radiotherapy is the development of secondary cancers. This risk begins to appear ten years after therapy.

    • This question is part of the following fields:

      • Haematology & Oncology
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  • Question 10 - A 60 yr. old female presented with difficulty in breathing. What is the...

    Incorrect

    • A 60 yr. old female presented with difficulty in breathing. What is the clinical sign that will indicate the presence of established pulmonary hypertension?

      Your Answer:

      Correct Answer: Raised jugular venous pressure

      Explanation:

      A prominent A wave is observed in the jugular venous pulse and this indicates the presence of established pulmonary hypertension. In addition the pulmonic component of the second heart sound (P2) may be increased and the P2 may demonstrate fixed or paradoxical splitting. The signs of right ventricular failure include a high-pitched systolic murmur of tricuspid regurgitation, hepatomegaly, a pulsatile liver, ascites, and peripheral oedema.

    • This question is part of the following fields:

      • Cardiology
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  • Question 11 - A 21-year-old gentleman presents with facial and ankle swelling. This has slowly been...

    Incorrect

    • A 21-year-old gentleman presents with facial and ankle swelling. This has slowly been developing over the past week. During the review of systems, he describes passing ‘frothy’ urine. A urine dipstick shows protein +++.
       
      What is the most likely cause of this presentation?

      Your Answer:

      Correct Answer: Minimal change disease

      Explanation:

      Minimal change glomerulonephritis usually presents as nephrotic syndrome wherein the patient (usually a young adult) will present with proteinuria, oedema, and impaired kidney function, which were evident in this patient.

    • This question is part of the following fields:

      • Nephrology
      0
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  • Question 12 - A 62year-old manpresents with exertional chest pain and is found to have extensive...

    Incorrect

    • A 62year-old manpresents with exertional chest pain and is found to have extensive coronary artery disease on angiogram. Which of the following cell types is most implicated in the development of coronary artery plaques?

      Your Answer:

      Correct Answer: Macrophages

      Explanation:

      An atheroma is an accumulation of degenerative material in the tunica intima (inner layer) of artery walls. The material consists of (mostly) macrophage cells, or debris, containing lipids (cholesterol and fatty acids), calcium and a variable amount of fibrous connective tissue.

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 13 - A 26 year old man with a history of 'brittle' asthma is admitted...

    Incorrect

    • A 26 year old man with a history of 'brittle' asthma is admitted with an asthma attack. High-flow oxygen and nebulised salbutamol have already been administered by the Paramedics. The patient is unable to complete sentences and he has a bilateral expiratory wheeze. He is also unable to perform a peak flow reading. His respiratory rate is 31/minute, sats 93% (on high-flow oxygen) and pulse 119/minute. Intravenous hydrocortisone is immediately administered and nebulised salbutamol given continuously. Intravenous magnesium sulphate is administered after six minutes of no improvement. These are the results from the blood gas sample that was taken after another six minutes:
      pH 7.32
      pCO2 6.8 kPa
      pO2 8.9 kPa

      What is the most appropriate therapy in this patient?

      Your Answer:

      Correct Answer: Intubation

      Explanation:

      The normal partial pressure reference values are: oxygen PaO2 more than 80 mmHg (11 kPa), and carbon dioxide PaCO2 lesser than 45 mmHg (6.0 kPa).
      This patient has an elevated PaCO2 of 6.8kPa which exceeds the normal value of less than 6.0kPa.
      The pH is also lower than 7.35 at 7.32

      In any patient with asthma, an increasing PaCO2 indicates severe airway obstruction that is leading to respiratory muscle fatigue and patient exhaustion.

      According to the British Thoracic Society guidelines:
      Indications for admission to intensive care or high-dependency units include
      patients requiring ventilatory support and those with acute severe or life-threatening asthma who are failing to respond to therapy, as evidenced by:
      • deteriorating PEF
      • persisting or worsening hypoxia
      • hypercapnia
      • arterial blood gas analysis showing fall in pH or rising hydrogen concentration
      • exhaustion, feeble respiration
      • drowsiness, confusion, altered conscious state
      • respiratory arrest

      Transfer to ICU accompanied by a doctor prepared to intubate if:
      • Deteriorating PEF, worsening or persisting hypoxia, or hypercapnia
      • Exhaustion, altered consciousness
      • Poor respiratory effort or respiratory arrest

      A single dose of intravenous magnesium sulphate is safe and may improve lung function and reduce intubation rates in patients with acute severe asthma. Intravenous magnesium sulphate may also reduce hospital admissions in adults with acute asthma who have had little or no response to standard treatment.

      Consider giving a single dose of intravenous magnesium sulphate to
      patients with acute severe asthma (PEF <50% best or predicted) who have not had a good initial response to inhaled bronchodilator therapy.
      Magnesium sulphate (1.2–2 g IV infusion over 20 minutes) should only be used following consultation with senior medical staff.

    • This question is part of the following fields:

      • Respiratory
      0
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  • Question 14 - A 28 year old female hiker begins complaining of headache and nausea after...

    Incorrect

    • A 28 year old female hiker begins complaining of headache and nausea after reaching a height of 5010 metres. Despite having the headache and feeling nauseous, she continues to hike but becomes progressively worse. She is seen staggering, complains of feeling dizzy and has an ataxic gait.

      Which of the following is the appropriate treatment of this patient?

      Your Answer:

      Correct Answer: Descent + dexamethasone

      Explanation:

      High Altitude Cerebral Oedema (HACE) is a severe and potentially fatal manifestation of high altitude illness and is often characterized by ataxia, fatigue, and altered mental status. HACE is often thought of as an extreme form/end-stage of Acute Mountain Sickness (AMS). Although HACE represents the least common form of altitude illness, it may progress rapidly to coma and death as a result of brain herniation within 24 hours, if not promptly diagnosed and treated.

      HACE generally occurs after 2 days above 4000m but can occur at lower elevations (2500m) and with faster onset. Some, but not all, individuals will suffer from symptoms of AMS such as headache, insomnia, anorexia, nausea prior to transitioning to HACE. Some may also have concomitant High Altitude Pulmonary Oedema (HAPE). HACE in isolation is rare, but the absence of concomitant HAPE or symptoms of AMS prior to deterioration does not rule-out the presence of HACE.

      Most cases develop as a progression of AMS and will include a history of recent ascent to altitude and prior complaints/findings of AMS including a headache, fatigue, nausea, insomnia, and/or light-headedness. Some may also have signs/symptoms of HAPE. Transition to HACE is heralded by signs of encephalopathy including ataxia (usually the earliest clinical finding) and altered mentation which may range from mild to severe. Other symptoms may include a more severe headache, difficulty speaking, lassitude, a decline in the level of consciousness, and/or focal neurological deficits or seizures.

      The mainstay of treatment is the immediate descent of at least 1000m or until symptoms improve. If descent is not an option, one may use a portable hyperbaric chamber and/or supplemental oxygen to temporize illness, but this should never replace or delay evaluation/descent when possible. If available, dexamethasone 8mg for one dose, followed by 4mg every 6 hours should be given to adults via PO, IM, or IV routes.
      Acetazolamide has proven to be beneficial in only a single clinical study. The suggested dosing regimen for Acetazolamide is 250 mg PO, given twice daily. Though effective in alleviating or temporizing symptoms, none of the adjunct treatment modalities are definitive or a replacement for an immediate descent.

    • This question is part of the following fields:

      • Respiratory
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  • Question 15 - A 35-year-old woman is referred to the acute medical unit with a 5...

    Incorrect

    • A 35-year-old woman is referred to the acute medical unit with a 5 day history of polyarthritis and a low-grade fever.

      Examination reveals shin lesions which the patient states are painful. Chest x-ray shows a bulky mediastinum.

      What is the most appropriate diagnosis?

      Your Answer:

      Correct Answer: Lofgren's syndrome

      Explanation:

      Lofgren’s syndrome is an acute form of sarcoidosis characterized by erythema nodosum, bilateral hilar lymphadenopathy (BHL), and polyarthralgia or polyarthritis. Other symptoms include anterior uveitis, fever, ankle periarthritis, and pulmonary involvement.

      Löfgren syndrome is usually an acute disease with an excellent prognosis, typically resolving spontaneously from 6-8 weeks to up to 2 years after onset. Pulmonologists, ophthalmologists, and rheumatologists often define this syndrome differently, describing varying combinations of arthritis, arthralgia, uveitis, erythema nodosum, hilar adenopathy, and/or other clinical findings.

    • This question is part of the following fields:

      • Respiratory
      0
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  • Question 16 - From the options provided below, which intervention plays the greatest role in increasing...

    Incorrect

    • From the options provided below, which intervention plays the greatest role in increasing survival in patients with COPD?

      Your Answer:

      Correct Answer: Smoking cessation

      Explanation:

      Smoking cessation is the most effective intervention in stopping the progression of COPD, as well as increasing survival and reducing morbidity. This is why smoking cessation should be the top priority in the treatment of COPD. Long term oxygen therapy (LTOT) may increase survival in hypoxic patients. The rest of the options dilate airways, reduce inflammation and thereby improve symptoms but do not necessarily increase survival.

    • This question is part of the following fields:

      • Respiratory
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  • Question 17 - A 78 year old male presents to the emergency department with shortness of...

    Incorrect

    • A 78 year old male presents to the emergency department with shortness of breath that has developed gradually over the last 4 days. His symptoms include fever and cough productive of greenish sputum. Past history is notable for COPD for which he was once admitted to the ICU, 2 years back. He now takes nebulizers (ipratropium bromide) at home. The patient previously suffered from myocardial infarction 7 years ago. He also has Diabetes Mellitus type II controlled by lifestyle modification.
      On examination, the following vitals are obtained.
      BP : 159/92 mmHg
      Pulse: 91/min (regular)
      Temp: Febrile
      On auscultation, there are scattered ronchi bilaterally and right sided basal crackles. Cardiovascular and abdominal examinations are unremarkable.
      Lab findings are given below:
      pH 7.31
      pa(O2) 7.6 kPa
      pa(CO2) 6.3 kPa
      Bicarbonate 30 mmol/L,
      Sodium 136 mmol/L,
      Potassium 3.7 mmol/L,
      Urea 7.0 mmol/L,
      Creatinine 111 μmol/L,
      Haemoglobin 11.3 g/dL,
      Platelets 233 x 109 /l
      Mean cell volume (MCV) 83 fl
      White blood cells (WBC) 15.2 x 109 /l.
      CXR shows an opacity obscuring the right heart border.

      Which of the following interventions should be started immediately while managing this patient?

      Your Answer:

      Correct Answer: Salbutamol and ipratropium bromide nebulisers

      Explanation:

      Acute exacerbations of chronic obstructive pulmonary disease (COPD) are immediately treated with inhaled beta2 agonists and inhaled anticholinergics, followed by antibiotics (if indicated) and systemic corticosteroids. Methylxanthine therapy may be considered in patients who do not respond to other bronchodilators.
      High flow oxygen would worsen his symptoms. Usually titrated oxygen (88 to 92 %) is given in such patients to avoid the risk of hyperoxic hypercarbia in which increasing oxygen saturation in a chronic carbon dioxide retainer can inadvertently lead to respiratory acidosis and death.

    • This question is part of the following fields:

      • Respiratory
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  • Question 18 - Which one of the following statements regarding hepatocellular carcinoma is correct? ...

    Incorrect

    • Which one of the following statements regarding hepatocellular carcinoma is correct?

      Your Answer:

      Correct Answer: Diabetes mellitus is a risk factor

      Explanation:

      Diabetes is a risk factor for hepatocellular carcinoma. Screening has been shown to be effective. Bevacizumab is not used for advanced cases. The incidence is higher in men. Alcohol is not the most common underlying cause worldwide; this is from cirrhosis from diseases like hepatitis B and C.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 19 - Of the following disorders, which one causes acute tubular damage? ...

    Incorrect

    • Of the following disorders, which one causes acute tubular damage?

      Your Answer:

      Correct Answer: Myoglobinuria

      Explanation:

      Myoglobinuria is the condition when there is degeneration of necrosed muscle that it is excreted in the urine. This condition would then cause acute tubular damage leading to renal failure.

    • This question is part of the following fields:

      • Nephrology
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  • Question 20 - A 25-year-old male presents to the emergency department with fever, sweating, hyperventilation and...

    Incorrect

    • A 25-year-old male presents to the emergency department with fever, sweating, hyperventilation and breathing difficulty. He also complains of a continuous ringing sensation in both his ears for the past couple of days. He admits to consuming a lot of over the counter painkillers for the past few days. Which of the following drugs is the most likely cause of these symptoms?

      Your Answer:

      Correct Answer: Aspirin

      Explanation:

      The presence of tinnitus, fever and hyperventilation are clues for aspirin (salicylate) toxicity.
      Clinical Presentation of salicylate toxicity can include:
      • Pulmonary manifestations include: Hyperventilation, hyperpnea, severe dyspnoea due to noncardiogenic pulmonary oedema, fever and dyspnoea due to aspiration pneumonitis
      • Auditory symptoms caused by the ototoxicity of salicylate poisoning include: Hard of hearing and deafness, and tinnitus (commonly encountered when serum salicylate concentrations exceed 30 mg/dL).
      • Cardiovascular manifestations include: Tachycardia, hypotension, dysrhythmias – E.g., ventricular tachycardia, ventricular fibrillation, multiple premature ventricular contractions, asystole – with severe intoxication, Electrocardiogram (ECG) abnormalities – E.g., U waves, flattened T waves, QT prolongation may reflect hypokalaemia.
      • Neurologic manifestations include: CNS depression, with manifestations ranging from somnolence and lethargy to seizures and coma, tremors, blurring of vision, seizures, cerebral oedema – With severe intoxication, encephalopathy
      • GI manifestations include: Nausea and vomiting, which are very common with acute toxicity, epigastric pain, GI haemorrhage – More common with chronic intoxication, intestinal perforation, pancreatitis, hepatitis – Generally in chronic toxicity; rare in acute toxicity, Oesophageal strictures – Reported as a very rare delayed complication
      • Genitourinary manifestations include: Acute kidney injury (NSAID induced Nephropathy) is an uncommon complication of salicylate toxicity, renal failure may be secondary to multisystem organ failure.
      • Hematologic effects may include prolongation of the prothrombin and bleeding times and decreased platelet adhesiveness. Disseminated intravascular coagulation (DIC) may be noted with multisystem organ failure in association with chronic salicylate toxicity.
      • Electrolyte imbalances like: Dehydration, hypocalcaemia, acidaemia, Syndrome of inappropriate antidiuretic hormone secretion (SIADH), hypokalaemia
      Management of these patients should be done in the following manner:
      • Secure Airway, Breathing, and Circulation
      • Supportive therapy
      • GI decontamination
      • Urinary excretion and alkalization
      • Haemodialysis

    • This question is part of the following fields:

      • Pharmacology
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  • Question 21 - A 60-year-old gentleman is found dead in his apartment. He was known to...

    Incorrect

    • A 60-year-old gentleman is found dead in his apartment. He was known to be suffering from primary systemic amyloidosis. What is the most probable cause for his death?

      Your Answer:

      Correct Answer: Cardiac involvement

      Explanation:

      Primary amyloidosis is characterised by abnormal protein build-up in the tissues and organ such as the heart, liver, spleen, kidneys, skin, ligaments, and nerves. However, the most common cause of death in patients with primary amyloidosis is heart failure.

    • This question is part of the following fields:

      • Nephrology
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  • Question 22 - An 80-year-old woman with advanced COPD has been admitted to the medicine ward...

    Incorrect

    • An 80-year-old woman with advanced COPD has been admitted to the medicine ward in an unconscious state. She appears to have an acute lower respiratory tract infection. After consulting with an anaesthesiologist it was concluded that she was not a candidate for intensive care unit admission and thus, a decision was made to start the patient on doxapram therapy. Which of the following best fits the characteristics of doxapram?

      Your Answer:

      Correct Answer: It is contraindicated in hyperthyroidism

      Explanation:

      The two statements that fit the characteristics of doxapram are, epilepsy is a contraindication for doxapram use and concurrent use with theophylline may increase agitation.

      Doxapram is a central respiratory stimulant. In clinical practice, doxapram is usually used for patients who have an acute exacerbation of chronic obstructive pulmonary disease (COPD) who are unsuitable for admission to the intensive therapy unit for ventilatory support. Doxapram infusion may buy an extra 24 h to allow for recovery.

      Contraindications include: ischaemic heart disease, epilepsy, cerebral oedema, acute stroke, asthma, hypertension, hyperthyroidism, and pheochromocytoma.
      The infusion may worsen agitation and dyspnoea and lead to hypertension, nausea, vomiting and urinary retention.

      Drug interactions:
      Concomitant administration of doxapram and aminophylline (theophylline) can cause increased skeletal muscle activity, agitation, and hyperactivity.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 23 - A 54-year-old plumber presents with general deterioration. He drinks approximately 25 units of...

    Incorrect

    • A 54-year-old plumber presents with general deterioration. He drinks approximately 25 units of alcohol each week and is a smoker of five cigarettes daily. Examination reveals that he is jaundiced, has numerous spider naevi on his chest and he has a temperature of 37.2°C. Abdominal examination reveals hepato-splenomegaly.

      Investigations reveal:
      Bilirubin 100 micromol/L (1-22),
      Alkaline phosphatase 310 iu/l (45 – 105),
      ALT 198 iu/l (5 – 35),
      AST 158 iu/l (1 – 31),
      Albumin 25 g/L (37 – 49),

      Hepatitis B virus surface antigen positive,
      Hepatitis B virus e antigen negative,
      Hepatitis B virus DNA awaited.

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Chronic hepatitis B infection

      Explanation:

      The clinical scenario describes a man in liver failure. Given the serological results, he is most likely to have a chronic hepatitis B infection. In chronic hepatitis B infection, you have +HBsAg, +anti-HBc, (-)IgM antiHBc, and (-) anti-HBs. In acute hepatitis B infection, you have +HBsAg, +anti-HBc, +IgM anti-HBc, and negative anti-HBs. in immunity due to natural infection, you have negative HBsAg, +anti-HBc, and + anti-HBs. In immunity due to vaccination, you have negative HBsAg, negative anti-HBc, and positive anti-HBs. While he could have a superimposed hepatitis D infection on top of hepatitis B, there is no mention of hepatitis D serology, make this an incorrect answer. The other choices do not involve hepatitis serologies.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 24 - A 6-year-old boy with fever and malaise for 2 days recently developed bloody...

    Incorrect

    • A 6-year-old boy with fever and malaise for 2 days recently developed bloody diarrhoea. What is the most probable aetiology?

      Your Answer:

      Correct Answer:

      Explanation:

      The most likely organism is enterohemorrhagic verotoxin-producing E.coli. It usually causes haemolytic uremic syndrome.
      Crohn’s disease rarely manifests in an acute manner.
      Polio and giardiasis usually manifest with non-bloody diarrhoea.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 25 - A 46-year-old nurse presents with a short history of epistaxis and bleeding gums....

    Incorrect

    • A 46-year-old nurse presents with a short history of epistaxis and bleeding gums. Her complete blood count, coagulation profile, and blood film are requested. The results are as follows:

      Hb: 8.6 g/dL,
      WCC: 2.3 x 10^9/L,
      Plts: 18 x 10^9/L,
      Coagulation profile: deranged,
      Blood film: bilobed large mononuclear cells.

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Acute myeloid leukaemia

      Explanation:

      This is a picture of bone marrow failure secondary to acute myeloid leukaemia (AML). AML is the acute expansion of the myeloid stem line, which may occur as a primary disease or follow the secondary transformation of a myeloproliferative disorder. It is more common over the age of 45 and is characterized by signs and symptoms largely related to bone marrow failure such as anaemia (pallor, lethargy), frequent infections due to neutropenia (although the total leucocyte count may be very high), thrombocytopaenia (bleeding), ostealgia, and splenomegaly.

      The disease has poor prognosis if:
      1. Age of the patient >60 years
      2. >20% blasts seen after the first course of chemotherapy
      3. Chromosomal aberration with deletion of part of chromosome 5 or 7.

      Acute promyelocytic leukaemia (APL) is an aggressive form of AML.

      Other listed options are ruled out because:
      1. Von Willebrand disease: may present with epistaxis and bleeding gums in severe cases but rarely with abnormalities on blood results.

      2. Acute lymphoblastic leukaemia: mostly seen in children.

      3. Lymphoma: usually presents with rubbery enlargement of lymph nodes.

      4. Warfarin overdose: no bilobed large mononuclear cells seen on blood film.

    • This question is part of the following fields:

      • Haematology & Oncology
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  • Question 26 - A 14 year old known asthmatic presents to the A&E department with difficulty...

    Incorrect

    • A 14 year old known asthmatic presents to the A&E department with difficulty breathing. She was seen by her regular doctor the day before with a sore throat which he diagnosed as tonsillitis and was prescribed oral Amoxicillin for 5 days.

      Past medical history:
      Ulcerative colitis diagnosed four years ago.

      Current medications:
      Inhaled salbutamol and beclomethasone
      Mesalazine 400 mg TDS

      She was observed to be alert and oriented but she had laboured breathing. Inspiratory wheeze was noted. She was pale, sweaty and cyanosed. Her temperature was 36.7ºC, pulse 121/minute and blood pressure 91/40 mmHg. The lungs were clear and the remainder of the examination was normal. She was given high-flow oxygen through a face mask but despite this her breathing became increasingly difficult.
       
      What is the most likely causative agent?

      Your Answer:

      Correct Answer: Haemophilus influenzae

      Explanation:

      Acute epiglottitis is a life-threatening disorder with serious implications to the anaesthesiologist because of the potential for laryngospasm and irrevocable loss of the airway. There is inflammatory oedema of the arytenoids, aryepiglottic folds and the epiglottis; therefore, supraglottitis may be used instead or preferred to the term acute epiglottitis.

      Acute epiglottitis can occur at any age. The responsible organism used to be Hemophilus influenzae type B (Hib), but infection with group A b-haemolytic Streptococci has become more frequent after the widespread use of Hemophilus influenzae vaccination.

      The typical presentation in epiglottitis includes acute occurrence of high fever, severe sore throat and difficulty in swallowing with the sitting up and leaning forward position in order to enhance airflow. There is usually drooling because of difficulty and pain on swallowing. Acute epiglottitis usually leads to generalized toxaemia. The most common differential diagnosis is croup and a foreign body in the airway. A late referral to an acute care setting with its serious consequences may result from difficulty in differentiation between acute epiglottitis and less urgent causes of a sore throat, shortness of breath and dysphagia.

    • This question is part of the following fields:

      • Respiratory
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  • Question 27 - A 25-year-old man presents with bloody diarrhoea associated with systemic upset. Blood tests...

    Incorrect

    • A 25-year-old man presents with bloody diarrhoea associated with systemic upset. Blood tests show the following:


      Hb 13.4 g/dL,
      Platelets 467 * 109/L,
      WBC 8.2 * 109/L,
      CRP 89 mg/l

      A diagnosis of ulcerative colitis is suspected. Which part of the bowel is most likely to be affected?

      Your Answer:

      Correct Answer: Rectum

      Explanation:

      The most COMMON site of inflammation from ulcerative colitis is the rectum, making this the correct answer. This is simply a fact you need to memorize. In general, ulcerative colitis only occurs in colorectal regions– nothing in the small bowel (unless there is backwash into the terminal ileum) and nothing further up the GI tract. In Crohn’s it can affect the entire GI tract from mouth to anus.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 28 - A 70 yr. old man underwent temporary transvenous pacing. While in the coronary...

    Incorrect

    • A 70 yr. old man underwent temporary transvenous pacing. While in the coronary care unit he developed pre-syncope. His pulse rate was 30 bpm. His ECG showed pacing spikes which were not related to QRS complexes. What is the most appropriate action that can be taken?

      Your Answer:

      Correct Answer: Increase the pacing voltage to a maximum

      Explanation:

      Pacemaker spikes on the ECG indicate that pacemaker is functioning. The most probable cause for this presentation is the change of the position of the tip of the pacing wire. Increasing the voltage will solve the problem. If it works, repositioning of the pacing wire should be done.

    • This question is part of the following fields:

      • Cardiology
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  • Question 29 - Intracellular proteins tagged with ubiquitination are destined to which of the following organelles?...

    Incorrect

    • Intracellular proteins tagged with ubiquitination are destined to which of the following organelles?

      Your Answer:

      Correct 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 30 - Which one of the following types of thyroid cancer is associated with the...

    Incorrect

    • Which one of the following types of thyroid cancer is associated with the RET oncogene?

      Your Answer:

      Correct Answer: Medullary

      Explanation:

      RET (rearranged during transfection) is a receptor tyrosine kinase involved in the development of neural crest derived cell lineages, kidney, and male germ cells. Different human cancers, including papillary and medullary thyroid carcinomas, lung adenocarcinomas, and myeloproliferative disorders display gain-of-function mutations in RET.
      In over 90% of cases, MEN2 syndromes are due to germline missense mutations of the RET gene.
      Multiple endocrine neoplasias type 2 (MEN2) is an inherited disorder characterized by the development of medullary thyroid cancer (MTC), parathyroid tumours, and pheochromocytoma.

    • This question is part of the following fields:

      • Endocrinology
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