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  • Question 1 - A 70-year-old male with advanced COPD currently on treatment with salbutamol (as required)...

    Incorrect

    • A 70-year-old male with advanced COPD currently on treatment with salbutamol (as required) presents for review. After a complete history and examination, you conclude that he requires to be stepped up in his inhalational therapy. The decision to add tiotropium bromide to his regime was taken. Which of the following best describe the mechanism of action of tiotropium?

      Your Answer: It is a long-acting β2-agonist

      Correct Answer: It is a long-acting anticholinergic agent

      Explanation:

      Tiotropium is a specific long-acting antimuscarinic agent indicated as maintenance therapy for patients with COPD (chronic obstructive pulmonary disease).
      It should be used cautiously in patients with narrow-angle glaucoma, prostatic hyperplasia or bladder neck obstruction.
      The most frequently encountered adverse effects of tiotropium include pharyngitis, bronchitis, sinusitis, dry mouth, cough, and headaches. Paradoxical bronchospasm may also occur as a rare side-effect.
      Dry mouth occurs in up to 14% of patients taking tiotropium, in keeping with its anticholinergic profile.
      Rarer side-effects include tachycardia, blurred vision, urinary retention, and constipation.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 2 - 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 3 - A 76-year-old male presents with recurrent episodes of hallucinations. He often sees faces...

    Incorrect

    • A 76-year-old male presents with recurrent episodes of hallucinations. He often sees faces smaller than normal or other objects out of proportion. He says he knows they're not real. His past medical history includes macular degeneration and an episode of depression 15 years ago following the death of his wife. Neurological examination is unremarkable. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Charles-Bonnet syndrome

      Explanation:

      The most probable diagnosis in the given scenario would be Charles-Bonnet syndrome.

      Charles-Bonnet syndrome (CBS) is characterized by persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness. This is generally against a background of visual impairment (although visual impairment is not mandatory for a diagnosis). Insight is usually preserved. This must occur in the absence of any other significant neuropsychiatric disturbance.

      Risk factors include:
      Advanced age
      Peripheral visual impairment
      Social isolation
      Sensory deprivation
      Early cognitive impairment

      CBS is equally distributed between sexes and does not show any familial predisposition. The most common ophthalmological conditions associated with this syndrome are age-related macular degeneration, followed by glaucoma and cataract.

      Well-formed complex visual hallucinations are thought to occur in 10-30 percent of individuals with severe visual impairment. The prevalence of CBS in visually impaired people is thought to be between 11 and 15 percent.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 4 - A 55-year-old diabetic male presents with a feeling of generally being unwell. He...

    Incorrect

    • A 55-year-old diabetic male presents with a feeling of generally being unwell. He also has a history of atrial fibrillation and epilepsy. His main complaint is a blue tinge to his vision. Which one of his medications is most likely to be responsible?

      Your Answer:

      Correct Answer: Sildenafil

      Explanation:

      Blue tinge of vision/cyanopsia is caused due to the intake of sildenafil citrate.

      Sildenafil citrate (Viagra) is the first oral drug to be widely approved for the treatment of erectile dysfunction.
      It is a potent and selective inhibitor of type-V phosphodiesterase, the primary form of the enzyme found in human penile erectile tissue, thereby preventing the breakdown of cyclic guanosine monophosphate (cGMP), the intracellular second messenger of nitric oxide.

      Uses:
      It is used for the treatment of erectile dysfunction, idiopathic pulmonary hypertension, premature ejaculation, high altitude illness, penile rehabilitation after radical prostatectomy, angina pectoris, and lower urinary tract symptoms.

      Adverse effects:
      Mild headache, flushing, dyspepsia, cyanopsia, back pain, and myalgias – due to a high concentration of PDE11 enzyme in skeletal muscle, which shows significant cross-reactivity with the use of tadalafil.
      It can also cause hypotension, dizziness, and rhinitis.

      Note: Xanthopsia (yellow-green vision) may occur secondary to treatment with digoxin.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 5 - A 30-year-old woman who underwent a live related renal transplant for end-stage renal...

    Incorrect

    • A 30-year-old woman who underwent a live related renal transplant for end-stage renal failure secondary to chronic pyelonephritis, 12 weeks previously, attends the clinic for routine follow up. She is taking tacrolimus and mycophenolate mofetil (MMF).

      Her urea and electrolytes are below:

      Na+ 136 mmol/L,
      K+ 3.7 mmol/L,
      Urea 7.2 mmol/L,
      Creatinine 146 μmol/L,


      She was last seen in clinic 2 weeks previously when her urea was 4.2 mmol/l and creatinine 98 μmol/l. She is clinically well and asymptomatic.

      On examination she was apyrexial and normotensive. Her transplant site was non-tender with no swelling and there were no other signs to be found.

      Which THREE initial investigations are the most important to perform?

      Your Answer:

      Correct Answer:

      Explanation:

      After renal transplant, asymptomatic patients can still have graft dysfunction as an early complication, with rising serum creatinine; therefore, urine and blood cultures should be ordered first. This should be followed by measuring the Tacrolimus levels, as this drug can be directly nephrotoxic. Next, a Doppler ultrasound of the transplant site should be ordered, to check for any obstructions or occlusions.

    • This question is part of the following fields:

      • Nephrology
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  • Question 6 - A 59-year-old marketing manager presents with a persistent watery left eye for the...

    Incorrect

    • A 59-year-old marketing manager presents with a persistent watery left eye for the past 4 days. On examination there is erythema and swelling of the inner canthus of the left eye. Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Dacryocystitis

      Explanation:

      Dacryocystitis is an infection of the lacrimal sac, secondary to obstruction of the nasolacrimal duct at the junction of lacrimal sac. It causes pain, redness, a watering eye (epiphora), and swelling and erythema at the inner canthus of the eye. Management is with systemic antibiotics. IV antibiotics are indicated if there is associated periorbital cellulitis.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 7 - A patient who has recently been diagnosed with SLE undergoes serum testing. A...

    Incorrect

    • A patient who has recently been diagnosed with SLE undergoes serum testing. A rise in which of the following antibodies would indicate severe systemic involvement?

      Your Answer:

      Correct Answer: Anti double-stranded DNA antibodies

      Explanation:

      Anti ds-DNA antibodies are very specific for SLE and their presence most often indicates systemic spread of the disease. These antibodies are present in about 30 percent of the total cases of SLE.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 8 - A study was developed to assess a new oral antithrombotic drug on the...

    Incorrect

    • A study was developed to assess a new oral antithrombotic drug on the chance of stroke in high-risk patients, compared to warfarin. The total number of patients receiving the new drug were 200 compared to 600 who were receiving warfarin. From the ones receiving the new drug, 10 patients had a stroke within 3 years, compared to 12 patients who were receiving warfarin and had a stroke. What is the relative risk of having a stroke within 3 years for patients receiving the new drug?

      Your Answer:

      Correct Answer: 2.5

      Explanation:

      Relative Risk = (Probability of event in exposed group) / (Probability of event in not exposed group)
      Experimental event rate, EER = 10 / 200 = 0.05

      Control event rate, CER = 12 / 600 = 0.02

      Therefore the relative risk = EER / CER = 0.05 / 0.02 = 2.5

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 9 - One of your colleagues shares with you the fact that he is HBV...

    Incorrect

    • One of your colleagues shares with you the fact that he is HBV positive. He's a general surgeon in the local hospital and he's afraid that if people know he might lose his job. However, you try to convince him that it's important to inform occupational health but he explicitly refuses. What is the most appropriate management?

      Your Answer:

      Correct Answer: Inform your colleague's employing body

      Explanation:

      According to the updated GMC guidelines, patient safety is more important than anything else, thus the correct thing to do is inform your colleague’s employing body.

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 10 - A 70-year-old retired software developer with a history of primary open-angle glaucoma presents...

    Incorrect

    • A 70-year-old retired software developer with a history of primary open-angle glaucoma presents with sudden painless loss of vision in his right eye. On examination of the right eye, the optic disc is swollen with multiple flame-shaped and blot haemorrhages. Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Occlusion of central retinal vein

      Explanation:

      Central retinal vein occlusion includes features such as sudden painless loss of vision, but is distinguished from central retinal artery occlusion by the presence of severe retinal haemorrhages on fundoscopy examination.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 11 - Which of the following forms of acute viral hepatitis has a much higher...

    Incorrect

    • Which of the following forms of acute viral hepatitis has a much higher mortality in pregnant than non-pregnant females?

      Your Answer:

      Correct Answer: Hepatitis E

      Explanation:

      Pregnant patient in a third world country with hepatitis: The answer is most likely Hepatitis E. The mortality for Hepatitis E in pregnant women is very high. It is transmitted faecal-orally. There is no hepatitis G. Hepatitis C, B, A are less likely to be the correct answer than E given it’s classic association with pregnancy and poor living conditions.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 12 - An 83-year-old gentleman presents to his GP with increasing oedema and ascites. He...

    Incorrect

    • An 83-year-old gentleman presents to his GP with increasing oedema and ascites. He is hypertensive, for which he takes amlodipine. There is shortness of breath on exercise. His alcohol history is two cans of stout per day.
       
      ECG is normal, and CXR reveals normal heart size and no signs of cardiac failure. Serum albumin is 23 g/dl; urinary albumin excretion is 7 g/24 h, with no haematuria. He has mild anaemia with a normal MCV. Total cholesterol is elevated.
       
      What diagnosis fits best with this clinical picture?

      Your Answer:

      Correct Answer: Nephrotic syndrome

      Explanation:

      Nephrotic syndrome usually presents with the symptoms in this patient: low albumin, abnormal cholesterol, increased urinary albumin excretion, oedema, and as a consequence, hypertension as well.

    • This question is part of the following fields:

      • Nephrology
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  • Question 13 - A 55-year-old obese woman presents to casualty. She has rigors and reports a...

    Incorrect

    • A 55-year-old obese woman presents to casualty. She has rigors and reports a fever. On examination there is jaundice and tenderness over the right upper quadrant of her abdomen.

      She has an elevated white blood cell count and a markedly raised alkaline phosphatase level; transaminases and bilirubin are also abnormal.

      Which of these diagnoses best fits the clinical picture?

      Your Answer:

      Correct Answer: Ascending cholangitis

      Explanation:

      This question describes Charcot’s triad– fever, RUQ pain, and jaundice, which is seen in ascending cholangitis. Reynold’s pentad is a worsened version of this, where you have RUQ pain, fever, jaundice, hypotension, and altered mental status. Risk factors for gallstones are the 4F’s- female, fat, forty, and fertile. You would not have the elevated bilirubin, ALP, transaminases with a kidney stone or in peptic ulcer disease. Hepatitis would not cause elevation of bilirubin.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 14 - A 32 year old male who has recently returned from a trip to...

    Incorrect

    • A 32 year old male who has recently returned from a trip to Thailand presents with congestion of eyes and swelling of the knee joint. He completed a course of antibiotics for dysentery 4 weeks back. He experiences no dysuria and urine examination is normal. Which further information would be most useful in establishing a diagnosis?

      Your Answer:

      Correct Answer: History and physical examination

      Explanation:

      The patient most likely has reactive arthritis which is usually diagnosed on history and clinical examination. The classic triad of symptoms include conjunctivitis, urethritis and arthritis. Arthritis and conjunctivitis may occur 4-6 weeks after a gastrointestinal or genitourinary infection. Arthritis usually occurs acutely, mostly involving the lower limb and is asymmetrical. Blood culture, urine culture and arthrocentesis (joint aspiration) will not yield positive results.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 15 - A 41 year old woman who has a history of SLE presents with...

    Incorrect

    • A 41 year old woman who has a history of SLE presents with a dry cough, dyspnoea and fever. She is being treated with a monthly dose of IV cyclophosphamide for Grade IV nephropathy. The last cyclophosphamide dose was 10 years ago. Lab investigations are as follows:
      WCC: 2.3 (lymphocyte count 0.7),
      Platelets: 81,
      Hb: 10.5,
      ESR: 56,
      CRP: 43,
      PO2: 7.2 kPa, PCO2: 3.6 kPa after walking out to the toilet.

      Chest X ray was unremarkable apart from some patchy pulmonary infiltration.
      What is the likely diagnosis?

      Your Answer:

      Correct Answer: Pneumocystis carinii pneumonia (PCP)

      Explanation:

      Pneumocystis carinii pneumonia, is an opportunistic fungal lung infection occurring almost exclusively in immunocompromised individuals. In 50% of cases, PCP is the first manifestation of AIDS (acquired immune deficiency syndrome), but it may be caused by other immunodeficiency disorders. PCP should be suspected in patients with a history of progressive dyspnoea and a dry cough with resistance to standard antibiotic treatment. Signs that support this diagnosis include a CD4 count < 200/μL, an increased beta-D-glucan level, and diffuse bilateral infiltrates on chest x-ray. Management of PCP includes high-dose trimethoprim/sulfamethoxazole (TMP/SMX), treatment of the underlying immunodeficiency disorder, and steroids in the case of severe respiratory insufficiency. TB is less likely to be present in this case as ESR is relatively low and chest x-ray appeared normal.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 16 - A 45-year-old woman is HIV positive. She is very concerned that she is...

    Incorrect

    • A 45-year-old woman is HIV positive. She is very concerned that she is at increased risk of cancer. Which one of the following cancers is NOT increased in HIV positive people?

      Your Answer:

      Correct Answer: Breast cancer

      Explanation:

      Breast cancer has a lower incidence in HIV positive patients. Seminoma, Hodgkin’s disease, anal cancer, and non-small cell lung cancer are all increased incidence. Memorize this breast cancer fact.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 17 - A 30-year-old woman presents with amenorrhoea and galactorrhoea. She has normal visual fields....

    Incorrect

    • A 30-year-old woman presents with amenorrhoea and galactorrhoea. She has normal visual fields. You are concerned that she may have a prolactinoma.
      Investigations were done and the results are as shown below:

      Hb 12.5 g/dL,
      WCC 4.9 x109/L,
      PLT 199 x109/L,
      Na+ 140 mmol/L,
      K+ 4.9 mmol/L,
      Creatinine 90 ىmol/L,
      Prolactin 1150 mU/l.

      MRI shows a 7 mm pituitary microadenoma.

      Which of the following hormones would you expect to be lower than normal?

      Your Answer:

      Correct Answer: LH

      Explanation:

      Prolactinomas, benign lesions that produce the hormone prolactin, are the most common hormone-secreting pituitary tumours.
      Based on its size, a prolactinoma can be classified as a microprolactinoma (< 10 mm diameter) or a macroprolactinoma (>10 mm diameter). If the prolactinoma is large enough to compress the surrounding normal hormone-secreting pituitary cells, it may result in deficiencies of one or more hormones (e.g., thyroid-stimulating hormone [TSH], growth hormone [GH], adrenocorticotropic hormone). However, the patient has microadenoma so it is unlikely to cause compression manifestations.
      Hyperprolactinemia inhibits GnRH secretion from the medial basal hypothalamus and LH release from the pituitary.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 18 - A 66 year old man visits the clinic because he has been experiencing...

    Incorrect

    • A 66 year old man visits the clinic because he has been experiencing increasing breathlessness for the past five months while doing daily tasks. His exercise tolerance is now limited to 75 metres while on a flat surface and walking up the stairs makes him breathless. He sleeps on four pillows and has swollen ankles in the morning. He occasionally coughs up phlegm.

      Past Medical history of importance:
      36 pack year smoking history
      Hypertension
      Ischaemic heart disease
      Coronary artery stenting done 10 months ago

      Pulmonary function testing revealed:
      FEV1 0.90 L (1.80 – 3.02 predicted)
      FVC 1.87 L (2.16 – 3.58 predicted)
      Diffusion capacity 3.0 mmol/min/kPa (5.91 – 9.65 predicted)
      Total lung capacity 4.50 L (4.25 – 6.22 predicted)
      Residual volume 2.70 L (1.46 – 2.48 predicted)
       
      Which condition does he have?

      Your Answer:

      Correct Answer: Chronic obstructive pulmonary disease

      Explanation:

      Whilst asthma and COPD are different diseases they cause similar symptoms, which can present a challenge in identifying which of the two diseases a patient is suffering from. COPD causes chronic symptoms and narrowed airways which do not respond to treatment to open them up. In the case of asthma the constriction of the airways through inflammation tends to come and go and treatment to reduce inflammation and to open up the airways usually works well.

      COPD is more likely than asthma to cause a chronic cough with phlegm and is rare before the age of 35 whilst asthma is common in under-35s. Disturbed sleep caused by breathlessness and wheeze is more likely in cases of asthma, as is a history of allergies, eczema and hay fever. Differentiating between COPD and asthma requires a history of both symptoms and spirometry. The spirometry history should include post bronchodilator measurements, the degree of reversibility and, ideally, home monitoring which gives a history of diurnal variation.

      Airflow Obstruction: Both asthma and COPD are characterised by airflow obstruction. Airflow obstruction is defined as a reduced FEV1 and a reduced FEV1/FVC ratio, such that FEV1 is less than 80% of that predicted, and FEV1/FVC is less than 0.7.

      These episodes are usually associated with widespread, but variable, airflow obstruction within the lung that is often reversible either spontaneously or with treatment.

      COPD: COPD is a chronic, slowly progressive disorder characterised by airflow obstruction (reduced FEV1 and FEV1/VC ratio) that does not change markedly over several months. The airflow obstruction is not fully reversible.

      Spirometry COPD Asthma
      VC Reduced Nearly normal
      FEV1 Reduced Reduced in attack
      FVC (or FEV6) Reduced Nearly normal
      FEV1 Ratio
      (of VC/FVC/FEV6) Reduced in attack

      This man has a low FEV1 and FVC. His diffusions capacity is also low despite having a normal total lung capacity. These values confirm a diagnosis of COPD.

    • This question is part of the following fields:

      • Respiratory
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  • Question 19 - Regarding the thymus, which of the following is true? ...

    Incorrect

    • Regarding the thymus, which of the following is true?

      Your Answer:

      Correct Answer: DiGeorge’s syndrome is a developmental abnormality affecting the thymus

      Explanation:

      The thymus is a lymphoid organ located in the anterior mediastinum. In early life, the thymus is responsible for the development and maturation of cell-mediated immunologic functions. The thymus is composed predominantly of epithelial cells and lymphocytes. Precursor cells migrate to the thymus and differentiate into lymphocytes. Most of these lymphocytes are destroyed, with the remainder of these cells migrating to tissues to become T cells.
      DiGeorge’s syndrome (DGS) is a developmental abnormality affecting the thymus. The classic triad of features of DGS on presentation is conotruncal cardiac anomalies, hypoplastic thymus, and hypocalcaemia (resulting from parathyroid hypoplasia).

    • This question is part of the following fields:

      • Endocrinology
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  • Question 20 - A 64-year-old woman with metastatic breast cancer has developed progressive back pain over...

    Incorrect

    • A 64-year-old woman with metastatic breast cancer has developed progressive back pain over the last 2 days. She also reports of weakness of her lower limbs and difficulty in walking. On examination, she has reduced power in both legs and increased tone associated with brisk knee and ankle reflexes. There is some sensory loss in the lower limbs and feet but perianal sensation is normal.

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Spinal cord compression at T10

      Explanation:

      The upper motor neurone signs in this patient point towards a diagnosis of spinal cord compression above the level of L1 and rules out cauda equina syndrome.

      Spinal cord compression is an oncological emergency and affects up to 5% of cancer patients. Extradural compression accounts for the majority of cases, usually due to vertebral body metastases. One of the most common causes of spinal cord compression is osteoarthritis. It is also more commonly seen in patients with lung, breast, or prostate cancer.

      Clinical features include:
      1. Back pain: the earliest and most common symptom, may worsen on lying down or coughing
      2. Lower limb weakness
      3. Sensory changes: sensory loss and numbness
      4. Neurological signs: depending on the level of the lesion.
      Lesions above L1 usually result in upper motor neurone signs in the legs. Lesions below L1 usually cause lower motor neurone signs in the legs and perianal numbness. Tendon reflexes are increased below the level of the lesion and absent at the level of the lesion.

      Management options are:
      1. High-dose oral dexamethasone
      2. Urgent MRI for consideration of radiotherapy or surgery

    • This question is part of the following fields:

      • Haematology & Oncology
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  • Question 21 - Which of the following diseases correctly matches the incubation period? ...

    Incorrect

    • Which of the following diseases correctly matches the incubation period?

      Your Answer:

      Correct Answer:

      Explanation:

      The incubation periods of disorders is extremely important to diagnose, treat, prevent or attenuate a disease.
      Chickenpox: 7-21 days.
      Whooping cough: 10-14 days.
      Hand, foot and mouth disease: 2-6 days. German measles: 14-21 days.
      Mumps: 14-18 days.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 22 - Which is the most severe form among the following? ...

    Incorrect

    • Which is the most severe form among the following?

      Your Answer:

      Correct Answer: Class IV: diffuse proliferative glomerulonephritis

      Explanation:

      The classes refer to the WHO classification of glomerulonephritis in SLE patients.
      class I: normal kidney
      class II: mesangial glomerulonephritis
      class III: focal (and segmental) proliferative glomerulonephritis
      class IV: diffuse proliferative glomerulonephritis
      class V: diffuse membranous glomerulonephritis
      class VI: sclerosing glomerulonephritis

      Class IV: diffuse proliferative glomerulonephritis is the most common and the most severe form, where more than 50% of the glomeruli are involved.

    • This question is part of the following fields:

      • Nephrology
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  • Question 23 - A 25-year-old male presented to accident and emergency 4 days ago, following an...

    Incorrect

    • A 25-year-old male presented to accident and emergency 4 days ago, following an intentional paracetamol overdose. He had taken 20x 500mg tablets, all at once. He denies any alcohol intake. Blood investigations 4 hours after ingestion showed:
      Paracetamol: 14 mg/l
      INR: 1
      Liver enzymes: No abnormality detected
      Bilirubin: Mild elevation

      He was seen by the mental health team and discharged. The blood investigations were repeated:

      Bilirubin: Within normal limits
      Urea: 21 mmol/L,
      Creatinine: 300 µmol/L,

      What is the likely cause of these results?

      Your Answer:

      Correct Answer: Delayed paracetamol nephrotoxicity

      Explanation:

      The most likely cause for these results is delayed paracetamol nephrotoxicity.

      The blood investigations of this patient are highly suggestive of acute kidney injury.
      Paracetamol overdose is well known to cause hepatotoxicity, but not for its delayed nephrotoxicity, especially in significant overdose. Appropriate monitoring of a patient’s blood tests is important.

      Management:
      NAC (N-Acetyl cysteine) has a clear role in preventing acetaminophen-induced liver necrosis. Although NAC has not been proven to be harmful to the kidney, its role in patients without hepatoxicity and only isolated renal dysfunction is uncertain.

      Other options:
      -There are no features in the history that are suggestive of dehydration and pre-renal AKI presenting in this manner in a 25-year-old would be very unusual.
      – Minimal change nephropathy typically presents with a nephrotic picture of kidney injury.
      – Berger’s more commonly presents with isolated haematuria.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 24 - Which one of the following is a contraindication to the use of a...

    Incorrect

    • Which one of the following is a contraindication to the use of a triptan in the management of migraine?

      Your Answer:

      Correct Answer: A history of ischaemic heart disease

      Explanation:

      A history of ischaemic heart disease in a contraindication for prescribing triptans because they act by constricting cerebral and also coronary vessels, increasing the risk of stroke.

    • This question is part of the following fields:

      • Neurology
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  • Question 25 - 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 26 - A 42-year-old man with alcoholic liver disease is admitted with pyrexia. He has...

    Incorrect

    • A 42-year-old man with alcoholic liver disease is admitted with pyrexia. He has been unwell for the past three days and has multiple previous admissions before with variceal bleeding. Examination shows multiple stigmata of chronic liver disease, ascites and jaundice.

      Paracentesis is performed with the following results: Neutrophils 487 cells/ul.

      What is the most appropriate treatment?

      Your Answer:

      Correct Answer: Intravenous cefotaxime

      Explanation:

      This describes a clinical scenario of spontaneous bacterial peritonitis. The diagnosis is made when fluid removed (ascites) is found to have > 250/mm cubed of PMNs (polymorphonuclear leukocytes). Cefotaxime or another third generation cephalosporin is the treatment of choice.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 27 - A 45-year-old man presents with tiredness and central weight gain.
    He underwent pituitary...

    Incorrect

    • A 45-year-old man presents with tiredness and central weight gain.
      He underwent pituitary surgery for a non-functional pituitary tumour two years ago. Although he recovered from his pituitary surgery well, he has been found to have complete anterior hypopituitarism. Accordingly he is receiving stable replacement therapy with testosterone monthly injections, thyroxine and hydrocortisone.
      On examination, there are no specific abnormalities, his vision is 6/9 in both eyes and he has no visual field defects.
      From his notes, you see that he has gained 8 kg in weight over the last six months and his BMI is 31. His blood pressure is 122/72 mmHg.
      Thyroid function tests and testosterone concentrations have been normal. A post-operative MRI scan report shows that the pituitary tumour has been adequately cleared with no residual tissue.

      Which of the following is the most likely cause of his current symptoms?

      Your Answer:

      Correct Answer: Growth hormone deficiency

      Explanation:

      The somatotroph cells of the anterior pituitary gland produce growth hormone (GH).
      GH deficiency in adults usually manifests as reduced physical performance and impaired psychological well-being. It results in alterations in the physiology of different systems of the body, manifesting as altered lipid metabolism, increased subcutaneous and visceral fat, decreased muscle mass, decreased bone density, low exercise performance, and reduced quality of life.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 28 - Which one of the following paraneoplastic features is less likely to be seen...

    Incorrect

    • Which one of the following paraneoplastic features is less likely to be seen in patients with squamous cell lung cancer?

      Your Answer:

      Correct Answer: Lambert-Eaton syndrome

      Explanation:

      Lambert-Eaton myasthenic syndrome (LEMS) is a rare presynaptic disorder of neuromuscular transmission in which release of acetylcholine (ACh) is impaired, causing a unique set of clinical characteristics, which include proximal muscle weakness, depressed tendon reflexes, post-tetanic potentiation, and autonomic changes.

      In 40% of patients with LEMS, cancer is present when the weakness begins or is found later. This is usually a small cell lung cancer (SCLC). However, LEMS has also been associated with non-SCLC, lymphosarcoma, malignant thymoma, or carcinoma of the breast, stomach, colon, prostate, bladder, kidney, or gallbladder.

    • This question is part of the following fields:

      • Respiratory
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  • Question 29 - A 22-year-old male has had complex tics since childhood. He repeatedly bends his...

    Incorrect

    • A 22-year-old male has had complex tics since childhood. He repeatedly bends his knees and rubs his nose. He is prone to loud vocalisations, sometimes including swear-words. A diagnosis of Gilles de la Tourette syndrome has been made. Which of the following is the best treatment option?

      Your Answer:

      Correct Answer: Risperidone

      Explanation:

      Gilles de la Tourette syndrome is the most severe and rare of the tic syndromes, consisting of multiple tics involving both motor actions and vocalisation. Onset is usually in childhood. Symptoms include utterance of obscenities (coprolalia); echolalia (repetition of another person’s spoken words) and palilalia (involuntary repetition of words, phrases, or sentences).
      The underlying cause is unknown, with no particular imaging or standard histopathological abnormalities having been identified. The EEG shows non-specific abnormalities in about half of patients. However, more recent immunocytochemical studies have suggested altered dopamine uptake in the striatal system.
      Risperidone is an effective therapeutic option without the effects associated with chlorpromazine and haloperidol.

    • This question is part of the following fields:

      • Neurology
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  • Question 30 - A 24 year old female, 28 weeks pregnant presents to the clinic complaining...

    Incorrect

    • A 24 year old female, 28 weeks pregnant presents to the clinic complaining of shortness of breath and right sided pleuritic chest pain. The doctor suspects pulmonary embolism.
      Which of the following statement is incorrect regarding the management of this case?

      Your Answer:

      Correct Answer:

      Explanation:

      V/Q scanning carries a slightly increased risk of childhood cancer compared with CTPA – 1/280,000 versus less than 1/1,000,000 – but carries a lower risk of maternal breast cancer. The rest of the options are true.

    • This question is part of the following fields:

      • Respiratory
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