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  • Question 1 - Regarding neonatal meningitis, which of the following statements is true? ...

    Incorrect

    • Regarding neonatal meningitis, which of the following statements is true?

      Your Answer: Is a risk factor for later conductive deafness

      Correct Answer: Has an above average incidence in babies with a meningomyelocele

      Explanation:

      The commonest time for bacterial meningitis is in the 1st month of life and group B Streptococcus is the commonest organism. The anterior fontanelle is full, but does not bulge with normal flexion. Neurological manifestations include seizures, irritability, poor tone, lethargy and tremors, however no findings of sensorineural deafness have been noted. One of the risk factors for introduction of meningeal infection is Meningomyelocele.

    • This question is part of the following fields:

      • Infectious Diseases
      2
      Seconds
  • Question 2 - A 60-year-old man with known ulcerative colitis and diverticular disease comes to clinic...

    Correct

    • A 60-year-old man with known ulcerative colitis and diverticular disease comes to clinic complaining of passing faeces per urethra. Cystoscopy confirms a fistula between his bladder and bowel.

      Which treatment is most likely to be effective?

      Your Answer: surgery

      Explanation:

      The best treatment for a colovesicular fistula is surgery. This is the only definitive treatment. If the patient is a poor surgical candidate, there can be an attempt to manage them non-operatively, but this is absolutely NOT the MOST EFFECTIVE therapy.

    • This question is part of the following fields:

      • Gastroenterology
      5
      Seconds
  • Question 3 - 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
      Seconds
  • Question 4 - Which of the following is the drug of choice for the treatment of...

    Incorrect

    • Which of the following is the drug of choice for the treatment of Chlamydia trachomatis infection during pregnancy?

      Your Answer:

      Correct Answer: Amoxicillin

      Explanation:

      Tetracycline is not recommended in pregnancy because of the risk to fetal development (bones, teeth!). Metronidazole in pregnancy: currently not thought to be an increased risk in pregnancy; however this is not effective against chlamydia. Amoxicillin is shown to be an adequate treatment for chlamydia, so this is the correct answer.

    • This question is part of the following fields:

      • Infectious Diseases
      0
      Seconds
  • Question 5 - A 35-year-old woman was on a camping holiday in Spain. She awoke at...

    Incorrect

    • A 35-year-old woman was on a camping holiday in Spain. She awoke at three o’clock one morning with severe neck pain radiating down into her left shoulder and down to her forearm. The next day it spread to the dorsal aspect of the forearm. She was otherwise well. Her symptoms resolved after 24 hours. She noticed that after a week she was unable to wind down the car window with her left arm.
      On examination of the left arm there was wasting of brachioradialis, shoulder, biceps and winging of left scapula.
      What is the diagnosis?

      Your Answer:

      Correct Answer: Amyotrophic neuralgia

      Explanation:

      This patient present with the classical symptoms of Amyotrophic neuralgia, characterised by sudden onset of pain in the shoulders that radiate down to the forearms and later resolve spontaneously but is followed by muscle wasting.

    • This question is part of the following fields:

      • Neurology
      0
      Seconds
  • Question 6 - A 39 year old woman with a history of rheumatoid arthritis has recently...

    Incorrect

    • A 39 year old woman with a history of rheumatoid arthritis has recently been switched from methotrexate to leflunomide. Monitoring of full blood count and LFTs has been carried out. Which of the following parameters should also be monitored in this case?

      Your Answer:

      Correct Answer: Blood pressure

      Explanation:

      Blood pressure should be routinely measured as leflunomide may cause hypertension and thus an increase in BP. It doesn’t cause changes in blood sugar levels, peak expiratory flow rate or haematuria.

    • This question is part of the following fields:

      • Rheumatology
      0
      Seconds
  • Question 7 - A 56 year old man who is a known alcoholic presents to the...

    Incorrect

    • A 56 year old man who is a known alcoholic presents to the clinic with a fever and cough. Past medical history states that he has a long history of smoking and is found to have a cavitating lesion on his chest x-ray.
       
      Which organism is least likely to be the cause of his pneumonia?

      Your Answer:

      Correct Answer: Enterococcus faecalis

      Explanation:

      Cavitating pneumonia is a complication that can occur with a severe necrotizing pneumonia and in some publications it is used synonymously with the latter term. It is a rare complication in both children and adults. Albeit rare, cavitation is most commonly caused by Streptococcus pneumoniae, and less frequently Aspergillus spp., Legionella spp. and Staphylococcus aureus.

      In children, cavitation is associated with severe illness, although cases usually resolve without surgical intervention, and long-term follow-up radiography shows clear lungs without pulmonary sequelae
      Although the absolute cavitary rate may not be known, according to one series, necrotizing changes were seen in up to 6.6% of adults with pneumococcal pneumonia. Klebsiella pneumoniae is another organism that is known to cause cavitation.

      Causative agents:
      Mycobacterium tuberculosis
      Klebsiella pneumoniae
      Streptococcus pneumoniae
      Staphylococcus aureus

      Enterococcus faecalis was not found to be a causative agent.

    • This question is part of the following fields:

      • Respiratory
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  • Question 8 - A 25-year-old woman was admitted to hospital with a 3 day history of...

    Incorrect

    • A 25-year-old woman was admitted to hospital with a 3 day history of feeling generally unwell, with fatigue, arthralgia and pruritis. She had recently finished a 5 day course of antibiotics for a urinary tract infection but there was no other significant past medical history. She had no significant findings on clinical examination except for a widespread erythematous rash.

      Investigation results are below:

      Haemoglobin (Hb) 12.6 g/dL,
      White cell count (WCC) 13.0 × 109/l (eosinophilia)
      Platelets 390 × 109/L,
      Creatinine 720 μmol/L,
      Na+ 135 mmol/L,
      K+ 5.2 mmol/L,
      Urea 22.0 mmol/L,
      Urinalysis Protein ++ blood +


      What is the most important investigation to establish the diagnosis?

      Your Answer:

      Correct Answer: Renal biopsy

      Explanation:

      There is a strong suspicion of drug-induced acute tubulo-interstitial nephritis with the classic triad of symptoms of rash, joint pain and eosinophils in the blood, associated with non-specific symptoms of fever and fatigue. This can be confirmed with renal biopsy showing interstitial oedema with a heavy infiltrate of inflammatory cells and variable tubular necrosis.

    • This question is part of the following fields:

      • Nephrology
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  • Question 9 - Which of the following types of renal stones are said to have a...

    Incorrect

    • Which of the following types of renal stones are said to have a semi-opaque appearance on x-ray?

      Your Answer:

      Correct Answer: Cystine stones

      Explanation:

      Only cystine stones are semi-opaque because they contain sulphur. All the other stones will appear either radio-lucent or radio-opaque.

    • This question is part of the following fields:

      • Nephrology
      0
      Seconds
  • Question 10 - A 35 yr. old female with systemic lupus erythematosus (SLE) was brought to...

    Incorrect

    • A 35 yr. old female with systemic lupus erythematosus (SLE) was brought to Casualty, complaining of chest pain and worsening difficulty in breathing for the past 36 hrs. On examination she was tachypnoeic, her BP was 85/65 mmHg and peripheral oxygen saturation was 98% on air. Her cardiac examination was normal but her jugular venous pressure was elevated. She didn't have ankle oedema. Her ECG showed sinus tachycardia and her CXR showed clear lung fields with a slightly enlarged heart. Which of the following is the most appropriate next step?

      Your Answer:

      Correct Answer: Urgent transthoracic echocardiogram

      Explanation:

      Acute breathlessness in SLE can be due to a pericardial effusion or a pulmonary embolism. Normal peripheral oxygen saturation and normal ECG, make the diagnosis of pulmonary embolism less likely. To exclude pericardial effusion, an urgent transthoracic echocardiogram is needed.

    • This question is part of the following fields:

      • Cardiology
      0
      Seconds
  • Question 11 - A 19-year-old woman is admitted with diabetic ketoacidosis (DKA). It is her fourth...

    Incorrect

    • A 19-year-old woman is admitted with diabetic ketoacidosis (DKA). It is her fourth episode in the past two months and she's known to be a type 1 diabetes mellitus patient. The doctors suspects she's non-compliant with her treatment to keep her weight down. She often self-discharges after 24 hours. What is the single most appropriate management?

      Your Answer:

      Correct Answer: Have a chat after the ward round about why she thinks her control is so bad

      Explanation:

      In many Western countries and health plans in the United States, patients have a primary care physician who acts as a formal gatekeeper for medical specialist care and thereby determines together with the patient whether or not a patient requires medical specialist care. Ideally in such systems, patients are treated in primary care if possible, and referred to medical specialist care if necessary. For the gatekeeper system to be effective, it is vital that adequate decisions are made about when and who to refer. But it is also important that referred patients comply with the referral by consulting a medical specialist. In this case, the GP should discuss with the patient the reasons why she cannot follow the treatment plan. In other words, the GP should detect why the patient is being non-compliant.

    • This question is part of the following fields:

      • Clinical Sciences
      0
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  • Question 12 - An 12 year old girl is taken to the clinic for a review....

    Incorrect

    • An 12 year old girl is taken to the clinic for a review. Despite being normally fit and well and not visiting a doctor for the past four years, her father is concerned about her behaviour in the past week. The girl has expressed plans to run for president, is active with planning all through the night and seems overtly excited. When asked, she admits to smoking cannabis once a few months ago and has drank alcohol a few times in the past year. The last time she had alcohol was a week ago. Prior to her deterioration a few weeks ago her father describes her as a happy, well-adjusted, sociable girl. Which one of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Mania

      Explanation:

      Mania is a state of extreme physical and emotional elation. A person experiencing mania or a manic episode may present with the following symptoms:
      -Elevated mood. The person feels extremely ‘high’, happy and full of energy; he or she may describe the experience as feeling on top of the world and invincible. The person may shift rapidly from an elevated,
      happy mood to being angry and irritable if they perceive they have been obstructed.
      -Increased energy and overactivity. The person may have great difficulty remaining still.
      -Reduced need for sleep or food. The person may be too active to eat or sleep.
      -Irritability. The person may become angry and irritated with those who disagree with or dismiss his or her sometimes unrealistic plans or ideas.
      -Rapid thinking and speech. The person’s thoughts and speech are more rapid than usual.
      -Grandiose plans and beliefs. It is quite common for a person in a hypomanic or manic state to believe that he or she is unusually talented or gifted or has special friends in power. For example, the person may believe that he or she is on a special mission from God.
      -Lack of insight. A person in a hypomanic or manic state may understand that other people see his or her ideas and actions as inappropriate, reckless or irrational. However, he or she is unlikely to personally accept that the behaviour is inappropriate, due to a lack of insight.
      – Distractibility. The person has difficulty maintaining attention and may not be able to filter out external stimuli.

      Careful assessment to rule out organic conditions is an important first step in the management of mania. Often hospitalisation is required for someone who is experiencing acute mania. Both mood-stabilising agents such as lithium carbonate or sodium valproate and an antipsychotic may be needed to treat psychotic symptoms, agitation, thought disorder and sleeping difficulties. Benzodiazepines may be useful to reduce hyperactivity. Treatment with lithium alone may have a relatively slow response rate (up to two weeks after a therapeutic blood level is established), so that adjunctive medication such as sodium valproate is usually required. Regular monitoring of blood levels for lithium and valproate is essential because of the potential for toxicity.

      The symptoms of hypomania are similar to those of mania: elevated mood, inflated self-esteem, decreased need for sleep, etc. except that they don’t significantly impact a person’s daily function and never include any psychotic symptoms.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 13 - A 50 yr. old male with a history of type II diabetes mellitus...

    Incorrect

    • A 50 yr. old male with a history of type II diabetes mellitus and hypertension presented with exertional dyspnoea and chest pain for 2 weeks. On examination his blood pressure was 145/80 mmHg. On auscultation reversed splitting of the second heart sound and bibasal crepitations were detected. What would be the most likely finding on his ECG?

      Your Answer:

      Correct Answer: Left bundle branch block

      Explanation:

      When closure of the pulmonary valve occurs before the aortic valve, reversed splitting occurs. The causes of reversed splitting are aortic stenosis, hypertrophic cardiomyopathy, left bundle branch block (LBBB), and a ventricular pacemaker.

    • This question is part of the following fields:

      • Cardiology
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  • Question 14 - A 52-year-old man is referred to the oncology clinic by his GP. He...

    Incorrect

    • A 52-year-old man is referred to the oncology clinic by his GP. He recently suffered a fracture of his right humerus with minimal trauma.

      The results of the blood tests, taken on his arrival, prompted the referral:
      Hb: 8.9 g/dL,
      WCC: 9.5 x 10^9/L,
      Plts: 140 x 10^9/L,
      MCV: 86 fL,
      ESR: 60mm/1st hour,
      Na+: 149 mmol/L,
      K+: 3.6 mmol/L,
      Urea: 15 mmol/L,
      Creatinine: 160 mmol/L,
      Calcium (corrected): 2.89 mmol/L,
      Albumin: 28g/L,
      Total protein: 89 g/L.

      X-ray of right humerus reported a possible pathological fracture. Which of the following investigations would help best in confirming the most likely diagnosis?

      Your Answer:

      Correct Answer: Protein electrophoresis

      Explanation:

      The most likely diagnosis with anaemia, raised erythrocyte sedimentation rate (ESR), hypercalcaemia, renal impairment, and raised total protein with low albumin is multiple myeloma (MM). Protein electrophoresis will confirm the presence of monoclonal band of paraprotein. Of note, a radioisotope bone scan is not a good test for picking up the lytic lesions of MM.

      Diagnosis of MM is based on the confirmation of (a) one major criterion and one minor criterion or (b) three minor criteria in an individual who has signs or symptoms of multiple myeloma.

      Major criteria:
      1. >30% plasma cells on bone marrow biopsy
      2. Monoclonal band of paraprotein on electrophoresis: >35g/L for IgG, 20g/L for IgA, or >1g of light chains excreted in the urine per day

      Minor criteria:
      1. 10–30% plasma cells on bone marrow biopsy
      2. Abnormal monoclonal band but levels less than listed above
      3. Lytic bone lesions observed radiographically
      4. Immunosuppression

    • This question is part of the following fields:

      • Haematology & Oncology
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  • Question 15 - 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 16 - A 45-year-old male is brought to the emergency department after being found collapsed,...

    Incorrect

    • A 45-year-old male is brought to the emergency department after being found collapsed, outside a nightclub. The ER team found an empty bottle of amyl nitrate in his pocket. The patient is hypoxic with an O2 saturation of 84% and is confused. Which of the following is the best treatment for this patient?

      Your Answer:

      Correct Answer: Methylene blue

      Explanation:

      The best treatment for the patient in question would be methylene blue.
      The most probable diagnosis in this patient is methemoglobinemia due to the ingestion of amyl nitrate.

      Amyl nitrate promotes the formation of methaemoglobin, which avidly conserves oxygen and leads to decreased tissue oxygen saturations.

      Treatment of choice includes methylene blue and vitamin C.

      Adverse effects:
      Benign side effects include green or blue discoloration of urine and patients should be forewarned.
      Significant side effects are based on methylene blue, itself, being an oxidizing agent and an inhibitor of monoamine oxidase A (MAO-A).
      As an oxidizing agent, methylene blue can actually precipitate methemoglobinemia or haemolysis in high doses or when ineffectively reduced.
      Methylene blue administration in a patient taking a serotonergic agents may predispose to serotonin syndrome.

      Note: Although methylene blue administration is controversial in the setting of G6PD-deficiency due to reduced levels of NADPH, it is not contraindicated and should be administered cautiously and judiciously.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 17 - Café-au-lait spots are seen in each of the following, except: ...

    Incorrect

    • Café-au-lait spots are seen in each of the following, except:

      Your Answer:

      Correct Answer: Friedreich's ataxia

      Explanation:

      Café-au-lait spots is hyperpigmented lesions that vary in colour from light brown to dark brown, with borders that may be smooth or irregular. Causes include:
      Neurofibromatosis type I
      McCune–Albright syndrome
      Legius syndrome
      Tuberous sclerosis
      Fanconi anaemia
      Idiopathic
      Ataxia-telangiectasia
      Basal cell nevus syndrome
      Benign congenital skin lesion
      Bloom syndrome
      Chediak-Higashi syndrome
      Congenital nevus
      Gaucher disease
      Hunter syndrome
      Maffucci syndrome
      Multiple mucosal neuroma syndrome
      Noonan syndrome
      Pulmonary Stenosis
      Silver–Russell syndrome
      Watson syndrome
      Wiskott–Aldrich syndrome

    • This question is part of the following fields:

      • Dermatology
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  • Question 18 - A 50 year old woman with a 30 pack year history of smoking...

    Incorrect

    • A 50 year old woman with a 30 pack year history of smoking presents with a persistent cough and occasional haemoptysis. A chest x-ray which is done shows no abnormality. What percentage of recent chest x-rays were reported as normal in patients who are subsequently diagnosed with lung cancer?

      Your Answer:

      Correct Answer: 10%

      Explanation:

      A retrospective cohort study of the primary care records of 247 lung cancer patients diagnosed between 1998–2002 showed that 10% of the X-rays were reported as normal.
      Other tests may include:
      – Imaging tests: A CT scan can reveal small lesions in your lungs that might not be detected on an X-ray.
      – Sputum cytology: sputum may reveal the presence of lung cancer cells.
      – Tissue sample (biopsy): A sample of abnormal cells may be removed for histological analysis. A biopsy may be performed in a number of ways, including bronchoscopy, mediastinoscopy and needle biopsy. A biopsy sample may also be taken from adjacent lymph nodes.

    • This question is part of the following fields:

      • Respiratory
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  • Question 19 - A 40-year-old woman presents to her GP with malaise, anorexia, and weight loss....

    Incorrect

    • A 40-year-old woman presents to her GP with malaise, anorexia, and weight loss. Screening blood samples reveals urea of 50.1 mmol/l and serum creatinine of 690 μmol/l. Her past history includes frequent headaches, but nothing else of note. She has, however, failed to attend her routine ‘well-woman’ appointments.
       
      Ultrasound reveals bilateral hydronephrosis and a suspicion of a central pelvic mass.
       
      What diagnosis is most likely to be responsible for this woman’s hydronephrosis?

      Your Answer:

      Correct Answer: Cervical carcinoma

      Explanation:

      The patient’s history of recent weight loss and malaise, paired with enlarged kidneys and renal failure, as well as a suspected central pelvic mass on ultrasound, gives a suspicion of cervical carcinoma.

    • This question is part of the following fields:

      • Nephrology
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  • Question 20 - A 52 yr. old female who was a smoker, with a history of...

    Incorrect

    • A 52 yr. old female who was a smoker, with a history of asymptomatic atrial septal defect (ASD) presented with difficulty in breathing on exertion and ankle oedema for the past 2 weeks. She has defaulted on her follow up for ASD. On examination she was cyanosed and clubbing was noted. Her pulse rate was 92 and blood pressure was 100/60 mmHg. Echocardiography revealed a dilated right ventricle of the heart. The right ventricular pressure was 90 mmHg. Significant tricuspid and pulmonary regurgitation were also noted. Which of the following is the most probable diagnosis?

      Your Answer:

      Correct Answer: Eisenmenger’s syndrome

      Explanation:

      According to echocardiography findings pulmonary pressure is closer to systemic blood pressure and it is evidence of pulmonary hypertension. Because of the reversal of shunt due to pulmonary hypertension, cyanosis and clubbing have developed. So the most probable diagnosis is Eisenmenger’s syndrome.

    • This question is part of the following fields:

      • Cardiology
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  • Question 21 - Following a head injury, a 22-year-old patient develops polyuria and polydipsia. He is...

    Incorrect

    • Following a head injury, a 22-year-old patient develops polyuria and polydipsia. He is suspected to have cranial diabetes insipidus so he undergoes a water deprivation test.
      Which one of the following responses would most indicate a positive (abnormal) result?

      Your Answer:

      Correct Answer: Failure to concentrate the urine during water deprivation, but achievement of urine osmolality of 720 mmol/kg following the administration of desmopressin

      Explanation:

      The water deprivation test (i.e., the Miller-Moses test), is a semiquantitative test to ensure adequate dehydration and maximal stimulation of ADH for diagnosis. It is typically performed in patients with more chronic forms of Diabetes Insipidus (DI). The extent of deprivation is usually limited by the patient’s thirst or by any significant drop in blood pressure or related clinical manifestation of dehydration.

      In healthy individuals, water deprivation leads to a urinary osmolality that is 2-4 times greater than plasma osmolality. Additionally, in normal, healthy subjects, administration of ADH produces an increase of less than 9% in urinary osmolality. The time required to achieve maximal urinary concentration ranges from 4-18 hours.

      In central and nephrogenic DI, urinary osmolality will be less than 300 mOsm/kg after water deprivation. After the administration of ADH, the osmolality will rise to more than 750 mOsm/kg in central DI but will not rise at all in nephrogenic DI. In primary polydipsia, urinary osmolality will be above 750 mOsm/kg after water deprivation.
      A urinary osmolality that is 300-750 mOsm/kg after water deprivation and remains below 750 mOsm/kg after administration of ADH may be seen in partial central DI, partial nephrogenic DI, and primary polydipsia.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 22 - A 22-year-old gentleman presents to A&E for the third time with recurrent urinary...

    Incorrect

    • A 22-year-old gentleman presents to A&E for the third time with recurrent urinary stones. There appear to be no predisposing factors, and he is otherwise well; urine culture is unremarkable. The urine stones turn out to be cystine stones.
       
      What is the most likely diagnosis in this case?

      Your Answer:

      Correct Answer: Cystinuria

      Explanation:

      Cystinuria is strongly suspected because of the recurrent passing of cystine stones and otherwise non-remarkable medical history of this young adult patient. Like Cystinuria, all the conditions listed are also inherited disorders, however, the other differentials usually present in the early years of childhood, usually with failure to thrive.

    • This question is part of the following fields:

      • Nephrology
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  • Question 23 - Which of the following is consistent with a diagnosis of insulinoma? ...

    Incorrect

    • Which of the following is consistent with a diagnosis of insulinoma?

      Your Answer:

      Correct Answer: Low fasting glucose, high insulin, high C peptide

      Explanation:

      Insulinoma is associated with LOW fasting glucose, HIGH insulin level, and HIGH C peptide. Insulin-abuse or overdose will cause HGH insulin levels and a LOW C peptide. If the C peptide is low, be suspicious.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 24 - A 41-year-old gentleman underwent kidney transplantation for end-stage renal disease. Now, 2 months...

    Incorrect

    • A 41-year-old gentleman underwent kidney transplantation for end-stage renal disease. Now, 2 months after the operation, he has developed fever and features suggestive of bilateral diffuse interstitial pneumonia.
       
      What is the most likely aetiological cause?

      Your Answer:

      Correct Answer: Cytomegalovirus

      Explanation:

      After renal transplantation, cytomegalovirus has been identified to affect 1/4 of the post-op patients. It is the most common viral infection causing morbidity and mortality in post-op patients in the first 3 months.

    • This question is part of the following fields:

      • Nephrology
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  • Question 25 - A 80 yr. old male was found on the floor. His blood pressure...

    Incorrect

    • A 80 yr. old male was found on the floor. His blood pressure was 100/60 mmHg. His core temperature was 31ºC. His FBC and serum electrolytes were within normal limits. Which of the following would be found in his ECG?

      Your Answer:

      Correct Answer: Long QT interval

      Explanation:

      Hypothermia is defined as a core body temperature of < 35 °C.
      Hypothermia may produce the following ECG changes:
      -Bradyarrhythmia
      -Osborne Waves (= J waves)
      -Prolonged PR, QRS and QT intervals
      -Shivering artefact
      -Ventricular ectopics
      -Cardiac arrest due to VT, VF or asystole

    • This question is part of the following fields:

      • Cardiology
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  • Question 26 - A 51 year-old teacher presents complaining of numerous falls. He states he has...

    Incorrect

    • A 51 year-old teacher presents complaining of numerous falls. He states he has difficulty walking up stairs, and he thinks it is because of his weak legs rather than blackouts. He is hypertensive and has suffered chronic back pain for many years. He has smoked for many years as well and has a chronic smokers cough. Upon examination, he has weakness of hip flexion and particularly knee extension. He is unable to keep his fingers flexed against force, with the right being weaker than the left. There are no sensory abnormalities and reflexes are preserved bilaterally. Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Inclusion body myositis

      Explanation:

      The pattern of muscle involvement seen with quadriceps and long-finger flexors is characteristic of inclusion body myositis, an inflammatory myopathy. Polymyositis is likely to cause a predominantly proximal weakness, associated with muscle pain. The signs and symptoms are not consistent with upper cord compression, as there would likely be sensory signs, reflex changes, and possible urinary symptoms. Motor neuron disease cannot be ruled out, but there are no findings of upper motor neuron or bulbar features.

    • This question is part of the following fields:

      • Neurology
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  • Question 27 - A 11 year old girl with a history of recurrent chest infections, was...

    Incorrect

    • A 11 year old girl with a history of recurrent chest infections, was admitted with a fever, productive cough, anorexia and weight loss. On examination she was febrile and tachycardic. Her mother said that the girl was not thriving well. Which of the following organisms is responsible for this presentation?

      Your Answer:

      Correct Answer: Pseudomonas

      Explanation:

      History of recurrent infections and failure to thrive (probably due to pancreatic enzyme insufficiency) is highly suggestive of cystic fibrosis. Pseudomonas has been identified as an important respiratory pathogen in patients with cystic fibrosis.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 28 - A 60 year old male presents with thickened patches of skin over his...

    Incorrect

    • A 60 year old male presents with thickened patches of skin over his knuckles and extensor surfaces that are consistent with Gottron's papules. Results reveal an elevated creatine kinase. Diagnosis of dermatomyositis is suspected. Which of the following autoantibody is most specific for this condition?

      Your Answer:

      Correct Answer: Anti-Mi-2 antibodies

      Explanation:

      Anti–Mi-2 antibodies are highly specific for dermatomyositis, but sensitivity is low; only 25% of patients with dermatomyositis demonstrate these antibodies. A positive antinuclear antibody (ANA) finding is common in patients with dermatomyositis, but is not necessary for diagnosis. Anti-Jo-1 antibodies are mostly associated with polymyositis. Anti Scl-70 antibodies and anti centromere antibodies are most commonly found in systemic scleroderma.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 29 - A 43-year-old police officer is admitted with a history of unsteadiness and slurring...

    Incorrect

    • A 43-year-old police officer is admitted with a history of unsteadiness and slurring of speech. This has worsened over a period of three months. He complains of a tremor affecting his right hand and diplopia on right lateral gaze. He smokes 30 cigarettes a day and takes regular diclofenac for his arthritis. On examination, he is dysarthric and feels nauseated. Fundoscopy is normal, however there is marked horizontal nystagmus and evidence of a right VI nerve palsy. There also appears to be some mild facial weakness on the right side. Upon conducting Weber’s test, a louder tone is heard in the left ear. On conducting the Rinne test, both ears are normal. On examination of the upper limb, there is a right intention tremor and dysdiadochokinesis. Tone, power and reflexes are normal. On examination of the lower limb, tone, power and reflexes are normal, however he appears to walk with a broad-based gait and is leaning to the right.

      Lumbar puncture:

      Opening pressure 13 cm H20 (5–18)
      Protein 0.67 g/l (0.15–0.45)
      WCC 3 cells/ml (<5)
      Red cell count (RCC) 2 cells/ml (<5)
      Glucose 3.2 mmol/l (3.3–4.4)
      Blood glucose 5.8 mmol/l (3.0–6.0)
      Oligoclonal bands Present
      Serum oligoclonal bands Present

      Magnetic resonance scan shows a calcified lesion broadly attached to the petrous part of the temporal bone. In view of the above history and findings, what is the likely cause of this patient’s symptoms?

      Your Answer:

      Correct Answer: Meningioma of the cerebellar pontine angle

      Explanation:

      This patient has a combination of right cerebellar dysfunction with right-sided cranial nerve palsies (VI, VII, and VIII). The magnetic resonance imaging (MRI) shows a calcified meningioma within the right cerebellar pontine area, which would account for these findings. The cerebrospinal fluid (CSF) analysis shows oligoclonal bands, however, these are matched in the serum, which reflects a systemic inflammatory response from his rheumatoid arthritis.

      The MRI scan and CSF analysis would not be consistent with progressive multiple sclerosis. The progressive nature of her symptoms would be against a diagnosis of brainstem infarct, and one would expect more pyramidal signs in the peripheral nervous system.

    • This question is part of the following fields:

      • Neurology
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  • Question 30 - A 20-year-old woman presents for review. She is concerned due to absence of...

    Incorrect

    • A 20-year-old woman presents for review. She is concerned due to absence of menstruation for 5 months.
      She is 1.76 m in height and weighs only 43.7 kg (7 stone).
      A pregnancy test is negative and thyroid function testing is normal.

      Which of the following is the diagnosis of this case?

      Your Answer:

      Correct Answer: Weight-related amenorrhoea

      Explanation:

      Low body weight. Excessively low body weight — about 10 percent under normal weight — interrupts many hormonal functions in your body, potentially halting ovulation.
      In Polycystic ovaries there is excess weight gain.

    • This question is part of the following fields:

      • Endocrinology
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