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  • Question 1 - A young man complains that he feels paralysed and is unable to move...

    Incorrect

    • A young man complains that he feels paralysed and is unable to move when he wakes up and less often when he is falling asleep. He complains of having hallucinations and sees other strangers in the room. His anxiety has also increased with these episodes. What is his likely diagnosis?

      Your Answer: Acute schizophrenia

      Correct Answer: Sleep paralysis

      Explanation:

      Sleep paralysis is a temporary inability to move or speak that occurs when you’re waking up or falling asleep. Paralysis is often accompanied by hallucinations

      REM is a stage of sleep when the brain is very active and dreams often occur. The body is unable to move, apart from the eyes and muscles used in breathing, possibly to stop the person from acting out the dreams and hurting himself.

      It’s not clear why REM sleep can sometimes occur while one is awake, but it has been associated with:
      -not getting enough sleep (sleep deprivation or insomnia)
      -irregular sleeping patterns – for example, because of shift work or jet lag
      -narcolepsy – a long-term condition that causes a person to suddenly fall asleep at inappropriate times
      -a family history of sleep paralysis
      -sleeping on one’s back

    • This question is part of the following fields:

      • Psychiatry
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  • Question 2 - A 72-year-old man presents with chronic back and right hip pain which has...

    Incorrect

    • A 72-year-old man presents with chronic back and right hip pain which has been increasingly affecting him over the past few months. He finds it very difficult to mobilise in the mornings.

      Clinical examination is unremarkable, apart from a limitation of right hip flexion due to pain.
      Investigations show:
      Haemoglobin 12.1 g/dl (13.5-17.7),
      White cell count 8.2 x 109/l (4-11),
      Platelets 200 x 109/l (150-400),
      C reactive protein 9 nmol/l (<10),
      ESR 15 mm/hr (<20),
      Sodium 140 mmol/l (135-146),
      Potassium 3.9 mmol/l (3.5-5),
      Creatinine 92 µmol/l (79-118),
      Alanine aminotransferase 12 U/l (5-40),
      Alkaline phosphatase 724 U/l (39-117),
      Calcium 2.55 mmol/l (2.20-2.67).

      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Paget's disease

      Explanation:

      Paget disease is a localized disorder of bone remodelling that typically begins with excessive bone resorption followed by an increase in bone formation. This osteoclastic over activity followed by compensatory osteoblastic activity leads to a structurally disorganized mosaic of bone (woven bone), which is mechanically weaker, larger, less compact, more vascular, and more susceptible to fracture than normal adult lamellar bone.
      Approximately 70-90% of persons with Paget disease are asymptomatic; however, a minority of affected individuals experience various symptoms, including the following:
      – Bone pain (the most common symptom)
      – Secondary osteoarthritis (when Paget disease occurs around a joint)
      – Bony deformity (most commonly bowing of an extremity)
      – Excessive warmth (due to hypervascularity)
      – Neurologic complications (caused by the compression of neural tissues)
      Measurement of serum alkaline phosphatase—in some cases, bone-specific alkaline phosphatase (BSAP)—can be useful in the diagnosis of Paget disease. Elevated levels of urinary markers, including hydroxyproline, deoxypyridinoline, C-telopeptide, and N -telopeptide, may help identify patients with Paget disease.
      Serum calcium and phosphate levels should be within the reference range in patients with Paget disease.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 3 - Choose the correct formula to calculate the negative predictive value of a screening...

    Incorrect

    • Choose the correct formula to calculate the negative predictive value of a screening test:

      Your Answer:

      Correct Answer: TN / (TN + FN)

      Explanation:

      NPV = TN / FN+TN

      = TN (true negative) / FN+TN (false negative + true negative)

      = Probability (patient not having disease when test is negative)

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 4 - A 78-year-old male with long-standing Alzheimer's disease is being reviewed in your clinic....

    Incorrect

    • A 78-year-old male with long-standing Alzheimer's disease is being reviewed in your clinic. Which among the following is true regarding memantine, a drug which has been approved for the management of dementia in the UK?

      Your Answer:

      Correct Answer: It is an NMDA-receptor agonist

      Explanation:

      Memantine is an antagonist of the NMDA (N-Methyl-D-Aspartate)-receptor subtype of glutamate receptor. It is used to slow the neurotoxicity thought to be involved in Alzheimer’s disease and other neurodegenerative diseases.

      Drug interactions:
      When given concomitantly with other NMDA-receptor antagonists (e.g., ketamine, amantadine) increase the risk of psychosis.
      Dopamine agonists, L-dopa, and anticholinergics enhance effects of memantine.
      Antispasmodics (e.g., baclofen)  enhance effects, as memantine has some antispasmodic effects.
      Drugs excreted by cationic transporters in the kidney (e.g. quinine, cimetidine, ranitidine) reduce excretion.

      Common adverse effects include dizziness, headache, confusion, diarrhoea, and constipation.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 5 - A 30-year-old male is brought to the emergency department following his collapse in...

    Incorrect

    • A 30-year-old male is brought to the emergency department following his collapse in a night club. His friends who accompanied him admit that, of recent, he has been using increasing amounts of cocaine. Which among the following is commonly associated with cocaine overdose?

      Your Answer:

      Correct Answer: Metabolic acidosis

      Explanation:

      Metabolic acidosis is associated with cocaine overdose.
      In overdose, cocaine leads to agitation, tachycardia, hypertension, sweating, hallucinations, and finally convulsions.
      Metabolic acidosis, hyperthermia, rhabdomyolysis, and ventricular arrhythmias also occur.
      Chronic use may be associated with premature coronary artery disease, dilated cardiomyopathy, and increased risk of cerebral haemorrhage.
      There are 3 stages for acute cocaine toxicity:
      Stage I: CNS symptoms of headache, vertigo, pseudo hallucinations, hyperthermia, hypertension.
      Stage II: increased deep tendon reflexes, tachypnoea, irregular breathing, hypertension.
      Stage III: Areflexia, coma, fixed and dilated pupils, hypotension, ventricular fibrillation, apnoea, and respiratory failure.

      Treatment:
      – Airway, breathing, and circulation to be secured. The patient’s fever should be managed, and one should rule out hypoglycaemia as a cause of the neuropsychiatric symptoms.
      – Cardiovascular toxicity and agitation are best-treated first-line with benzodiazepines to decrease CNS sympathetic outflow.
      – The mixed beta/alpha blocker labetalol is safe and effective for treating concomitant cocaine-induced hypertension and tachycardia.
      – Non-dihydropyridine calcium channels blockers such as diltiazem and verapamil have been shown to reduce hypertension reliably, but not tachycardia.
      – Dihydropyridine agents such as nifedipine should be avoided, as reflex tachycardia may occur.
      – The alpha-blocker phentolamine has been recommended but only treats alpha-mediated hypertension and not tachycardia.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 6 - A 68 year old man is admitted with an infective exacerbation of chronic...

    Incorrect

    • A 68 year old man is admitted with an infective exacerbation of chronic obstructive pulmonary disease (COPD).

      Investigations: blood gas taken whilst breathing 28% oxygen on admission:
      pH 7.30
      p(O2) 7.8 kPa
      p(CO2) 7.4 kPa

      Which condition best describes the blood gas picture?

      Your Answer:

      Correct Answer: Decompensated type-2 respiratory failure

      Explanation:

      The normal partial pressure reference values are:
      – PaO2 more than 80 mmHg (11 kPa)
      – PaCO2 less than 45 mmHg (6.0 kPa).
      This patient has an elevated PaCO2 (7.4kPa)
      Hypoxemia (PaO2 <8kPa) with hypercapnia (PaCO2 >6.0kPa).
      The pH is also lower than 7.35 at 7.3

      Type 2 respiratory failure is caused by inadequate alveolar ventilation; both oxygen and carbon dioxide are affected. Defined as the build-up of carbon dioxide levels (PaCO2) that has been generated by the body but cannot be eliminated. The underlying causes include:
      – Increased airways resistance (chronic obstructive pulmonary disease, asthma, suffocation)
      – Reduced breathing effort (drug effects, brain stem lesion, extreme obesity)
      – A decrease in the area of the lung available for gas exchange (such as in chronic bronchitis)
      – Neuromuscular problems (Guillain–Barré syndrome, motor neuron disease)
      – Deformed (kyphoscoliosis), rigid (ankylosing spondylitis), or flail chest.

    • This question is part of the following fields:

      • Respiratory
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  • Question 7 - Which of the following is least likely to cause warm autoimmune haemolytic anaemia?...

    Incorrect

    • Which of the following is least likely to cause warm autoimmune haemolytic anaemia?

      Your Answer:

      Correct Answer: Mycoplasma infection

      Explanation:

      Mycoplasma infection causes cold autoimmune haemolytic anaemia (AIHA). The rest of the aforementioned options cause warm AIHA.

      AIHA may be divided into ‘warm’ and ‘cold’ types, according to the temperature at which the antibodies best cause haemolysis. It is most commonly idiopathic but may be secondary to a lymphoproliferative disorder, infection, or drugs.

      1. Warm AIHA:
      In warm AIHA, the antibody (usually IgG) causes haemolysis best at body temperature and tends to occur in extravascular sites, for example, spleen. Management options include steroids, immunosuppression, and splenectomy. It is caused by autoimmune diseases such as SLE (rarely causes mixed-type AIHA), cancers such as lymphomas and CLL, and drugs such as methyldopa.

      2. Cold AIHA:
      The antibody in cold AIHA is usually IgM and causes haemolysis best at 4°C and occurs more commonly intravascularly. Features may include symptoms of Raynaud’s disease and acrocyanosis. Patients do not respond well to steroids. Cold AIHA is caused by cancers such as lymphomas, and infections such as mycoplasma and EBV.

    • This question is part of the following fields:

      • Haematology & Oncology
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  • Question 8 - A 54-year-old female patient presents with a one week history of bloody diarrhoea,...

    Incorrect

    • A 54-year-old female patient presents with a one week history of bloody diarrhoea, fever and abdominal pain. She has a history of rheumatoid arthritis which she controls with methotrexate. Her stool sample shows Campylobacter jejuni. What is the single most appropriate management?

      Your Answer:

      Correct Answer: Fluids + clarithromycin

      Explanation:

      This woman is receiving methotrexate, an immunosuppressant, to control her rheumatoid arthritis. In such immunocompromised patients, BNF suggests clarithromycin as first-line management.

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 9 - Choose the correct statement regarding hyponatremia: ...

    Incorrect

    • Choose the correct statement regarding hyponatremia:

      Your Answer:

      Correct Answer: Hyperlipidaemia may cause pseudohyponatraemia

      Explanation:

      The Hyperlipidaemia Effect: Pseudohyponatremia in Pancreatic Cancer; Patients who have disorders of cholestasis commonly present with volume depletion due to vomiting and poor oral intake, which, in turn, often leads to hypovolemic hyponatremia. It is less well known that disorders of cholestasis, including tumours of the hepatobiliary system, can be accompanied by hyperlipidaemia.

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 10 - A 45 yr. old male was discharged recently after treatment of bleeding peptic...

    Incorrect

    • A 45 yr. old male was discharged recently after treatment of bleeding peptic ulcers. 3 days after discharge he was readmitted complaining of acute severe chest pain for the past 1 hour. His ECG showed an acute ST elevation myocardial infarction. His FBC, blood urea, serum electrolytes and serum creatinine were within normal ranges. Faecal occult blood was negative. Which of the following is the most appropriate management for this patient?

      Your Answer:

      Correct Answer: Primary angioplasty

      Explanation:

      The patient has a recent history of bleeding peptic ulcer disease, which is an absolute contraindication for thrombolysis. So he should be offered primary angioplasty.

    • This question is part of the following fields:

      • Cardiology
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  • Question 11 - A 28 yr. old primigravida in her 24th week of pregnancy came for...

    Incorrect

    • A 28 yr. old primigravida in her 24th week of pregnancy came for the routine follow up. She was asymptomatic at the time of examination. Her blood pressure was 152/92 mmHg and pulse rate was 90 bpm. Her blood pressure at the booking visit had been 132/80 mmHg. Her other examination findings were normal. Which of the following is the best method to use to treat her?

      Your Answer:

      Correct Answer: Labetalol

      Explanation:

      Methyldopa is the drug of first choice for the control of mild to moderate hypertension in pregnancy. Labetalol is also considered as a first line drug for hypertension in pregnancy. Calcium channel blockers and hydralazine are considered as second line drugs. Beta-blockers (except labetalol), angiotensin receptor blockers, angiotensin-converting enzyme inhibitors and thiazides are not recommended.

    • This question is part of the following fields:

      • Cardiology
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  • Question 12 - 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
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  • Question 13 - A 72 yr. old male presented to the Emergency Department with a broad...

    Incorrect

    • A 72 yr. old male presented to the Emergency Department with a broad complex tachycardia. Which of the following features is more suggestive that this has resulted because of a supraventricular tachycardia (SVT) rather than a ventricular tachycardia (VT)?

      Your Answer:

      Correct Answer: Absence of QRS concordance in chest leads on ECG

      Explanation:

      To differentiate ventricular tachycardia (VT) from supraventricular tachycardia (SVT) with aberrant conduction the following electrocardiographic features should be looked for:

      Evidence of preceding atrial activity for SVT. Oesophageal leads are helpful if P waves are hidden in the QRS complex.
      QRS duration more than 140 ms for VT.
      QRS morphology: Features of QRS morphology that favour SVT are RBBB or triphasic patterns like rSR in V1 and qRS in V6. Monophasic pattern like R or qR in V1 and rS or QS in V6 or multiple morphology QRS complexes favour VT.
      AV dissociation for VT.

    • This question is part of the following fields:

      • Cardiology
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  • Question 14 - A 53-year-old woman presents with upper GI haemorrhage. She has a history of...

    Incorrect

    • A 53-year-old woman presents with upper GI haemorrhage. She has a history of rheumatoid arthritis for which she is managed with low dose prednisolone, diclofenac and codeine phosphate.

      On examination in the Emergency ward her BP is 90/60 mmHg, pulse 100/min. You fluid resuscitate her and her BP improves to 115/80 mmHg, with a pulse of 80/min.

      Investigations;
      Hb 10.4 g/dL,
      WCC 6.1 x109/L,
      PLT 145 x109/L,
      Na+ 139 mmol/L,
      K+ 4.9 mmol/L,
      Creatinine 180 μmol/L,

      ECG – Lateral ST depression , Upper GI endoscopy reveals a large bleeding ulcer on the posterior aspect of the duodenum. It cannot be easily reached with the endoscope, and you decide to attempt embolization.

      Which of the following is the artery that should be targeted?

      Your Answer:

      Correct Answer: Posterior superior Pancreaticoduodenal artery

      Explanation:

      The most common location for a duodenal ulcer bleed is the posterior duodenum (remember: posterior bleeds, anterior perforates). The perfusion to this area is most specifically from the posterior superior pancreaticoduodenal artery.

      The anterior superior pancreaticoduodenal artery supplies the anterior region. The gastroepiploic artery supplies mostly the stomach. The splenic artery goes, obviously, toward the spleen, in the other direction. The gastroduodenal artery is a branch of the celiac artery, and it’s branches are the anterior superior pancreaticoduodenal artery and posterior superior pancreaticoduodenal artery.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 15 - 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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  • Question 16 - A 50 year old doctor developed a fever of 40.2 °C which lasted...

    Incorrect

    • A 50 year old doctor developed a fever of 40.2 °C which lasted for two days. He has had diarrhoea for a day, shortness of breath and dry cough.
      His blood results reveal a hyponatraemia and deranged LFTs. His WBC count is 10.4 × 109/L and CX-ray shows bibasal consolidation.
       
      Which treatment would be the most effective for his condition?

      Your Answer:

      Correct Answer: Clarithromycin

      Explanation:

      Pneumonia is the predominant clinical manifestation of Legionnaires disease (LD). After an incubation period of 2-10 days, patients typically develop the following nonspecific symptoms:
      Fever
      Weakness
      Fatigue
      Malaise
      Myalgia
      Chills

      Respiratory symptoms may not be present initially but develop as the disease progresses. Almost all patients develop a cough, which is initially dry and non-productive, but may become productive, with purulent sputum and, (in rare cases) haemoptysis. Patients may experience chest pain.
      Common GI symptoms include diarrhoea (watery and non bloody), nausea, vomiting, and abdominal pain.

      Fever is typically present (98%). Temperatures exceeding 40°C occur in 20-60% of patients. Lung examination reveals rales and signs of consolidation late in the disease course.

      Males are more than twice as likely as females to develop Legionnaires disease.

      Age
      Middle-aged and older adults have a high risk of developing Legionnaires disease while it is rare in young adults and children. Among children, more than one third of reported cases have occurred in infants younger than 1 year.

      Situations suggesting Legionella disease:
      -Gram stains of respiratory samples revealing many polymorphonuclear leukocytes with few or no organisms

      -Hyponatremia

      -Pneumonia with prominent extrapulmonary manifestations (e.g., diarrhoea, confusion, other neurologic symptoms)

      Specific therapy includes antibiotics capable of achieving high intracellular concentrations (e.g., macrolides, quinolones, ketolides, tetracyclines, rifampicin).
      Clarithromycin, a new macrolide antibiotic, is at least four times more active in vitro than erythromycin against Legionella pneumophila. In this study the safety and efficacy of orally administered clarithromycin (500 to 1,000 mg bid) in the treatment of Legionella pneumonia were evaluated.
      Clarithromycin is a safe effective treatment for patients with severe chest infections due to Legionella pneumophila.

    • This question is part of the following fields:

      • Respiratory
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  • Question 17 - A 46-year-old gentleman diagnosed with type 2 diabetes, hypertension, and proteinuria is started...

    Incorrect

    • A 46-year-old gentleman diagnosed with type 2 diabetes, hypertension, and proteinuria is started on Ramipril to prevent development of renal disease. He reports to his GP that he has developed a troublesome cough since starting the medication. He has no symptoms of lip swelling, wheeze and has no history of underlying respiratory disease.
       
      What increased chemical is thought to be the cause of his cough?

      Your Answer:

      Correct Answer: Bradykinin

      Explanation:

      Ramipril is an ACE inhibitor that blocks the conversion of angiotensin I to angiotensin II as well as preventing the breakdown of bradykinin, leading to blood vessel dilatation and decreased blood pressure. However, bradykinin also causes smooth muscles in the lungs to contract, so the build-up of bradykinin is thought to cause the dry cough that is a common side-effect in patients that are on ACE inhibitors.

    • This question is part of the following fields:

      • Nephrology
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  • Question 18 - A 21 year-old male, who is a known alcoholic, presents with a fever,...

    Incorrect

    • A 21 year-old male, who is a known alcoholic, presents with a fever, haemoptysis, green sputum and an effusion clinically. There is concern that it may be an empyema.
       
      Which test would be most useful to resolve the suspicion?

      Your Answer:

      Correct Answer: Pleural fluid pH

      Explanation:

      If a pleural effusion is present, a diagnostic thoracentesis may be performed and analysed for pH, lactate dehydrogenase, glucose levels, specific gravity, and cell count with differential. Pleural fluid may also be sent for Gram stain, culture, and sensitivity. Acid-fast bacillus testing may also be considered and the fluid may be sent for cytology if cancer is suspected.

      The following findings are suggestive of an empyema or parapneumonic effusion that will likely need a chest tube or pigtail catheter for complete resolution:
      -Grossly purulent pleural fluid
      -pH level less than 7.2
      -WBC count greater than 50,000 cells/µL (or polymorphonuclear leukocyte count of 1,000 IU/dL)
      -Glucose level less than 60 mg/dL
      -Lactate dehydrogenase level greater than 1,000 IU/mL
      -Positive pleural fluid culture

      The most often used golden criteria for empyema are pleural effusion with macroscopic presence of pus, a positive Gram stain or culture of pleural fluid, or a pleural fluid pH under 7.2 with normal peripheral blood ph.

    • This question is part of the following fields:

      • Respiratory
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  • Question 19 - A paediatrician has concerns that a 6-month-old baby is deaf. His mom gives...

    Incorrect

    • A paediatrician has concerns that a 6-month-old baby is deaf. His mom gives history of her having a sore throat, fever and lymphadenitis during pregnancy. Which organism causes such manifestations?

      Your Answer:

      Correct Answer:

      Explanation:

      The best answer is cytomegalovirus. The mother was infected during the pregnancy and the baby has developed cytomegalo-inclusion syndrome. Histologically, it is identified by viral particles surrounded by lysosomes.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 20 - 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 21 - A 55-year-old man with a three-year history of type 2 diabetes comes to...

    Incorrect

    • A 55-year-old man with a three-year history of type 2 diabetes comes to the clinic for review. He is currently managed with metformin 1 g BD and feels that his home blood glucose monitoring has deteriorated over the past few months. There is a history of hypertension and dyslipidaemia for which he takes Ramipril 10 mg daily and atorvastatin 20 mg.
      On examination, his BP is 155/82 mmHg, his pulse is 71 and regular. His chest is clear. His BMI is 32.

      Investigations show:
      Haemoglobin 12.9 g/dl (13.5 – 17.7),
      White cell count 5.0 x109/l (4 – 11),
      Platelets 180 x109/l (150 – 400),
      Sodium 140 mmol/l (135 – 146),
      Potassium 5.0 mmol/l (3.5 – 5),
      Creatinine 123 mmol/l (79 – 118),
      HbA1c 8.0% (<7.0).

      He would like to start sitagliptin.
      Which of the following adverse effects would you warn him about?

      Your Answer:

      Correct Answer: Pancreatitis

      Explanation:

      Sitagliptin-induced pancreatitis can occur at any time after the initiation of therapy, even after several years. Patients taking sitagliptin who present with signs and symptoms of mild or severe pancreatitis should immediately discontinue sitagliptin and use an alternate medication regimen for control of type 2 diabetes.
      In response to pancreatitis reported in post-marketing surveillance through the Adverse Event Reporting System (AERS), the FDA has issued revised prescribing information for sitagliptin stating that cases of acute pancreatitis have been reported with use, to monitor closely for signs and symptoms of pancreatitis, and to use sitagliptin with caution in patients with a history of pancreatitis.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 22 - A 75-year-old retired tailor is examined for involuntary, jerking movements of his arms....

    Incorrect

    • A 75-year-old retired tailor is examined for involuntary, jerking movements of his arms. His symptoms seem to resolve when he is asleep. Damage to which one of the following structures may lead to hemiballism?

      Your Answer:

      Correct Answer: Subthalamic nucleus

      Explanation:

      Hemiballismus or hemiballism in its unilateral form is a very rare movement disorder. It is a type of chorea caused in most cases by a decrease in activity of the subthalamic nucleus of the basal ganglia, resulting in the appearance of flailing, ballistic, undesired movements of the limbs. Symptoms may decrease while the patient is asleep. Antidopaminergic agents (e.g. Haloperidol) are the mainstay of treatment.

    • This question is part of the following fields:

      • Neurology
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  • Question 23 - A 26-year-old man with type-1 diabetes presents for review. His HbA1c is 6.8%...

    Incorrect

    • A 26-year-old man with type-1 diabetes presents for review. His HbA1c is 6.8% yet he is concerned that his morning blood sugar levels are occasionally as high as 24 mmol/l. He is currently managed on a bd mixed insulin regime.
      He was sent for continuous glucose monitoring and his glucose profile reveals dangerous dipping in blood glucose levels during the early hours of the morning.
      Which of the following changes to his insulin regime is most appropriate?

      Your Answer:

      Correct Answer: Move him to a basal bolus regime

      Explanation:

      The patients high morning blood sugar levels are suggestive to Somogyi Phenomenon which suggests that hypoglycaemia during the late evening induced by insulin could cause a counter regulatory hormone response that produces hyperglycaemia in the early morning.
      Substitution of regular insulin with an immediate-acting insulin analogue, such as Humulin lispro, may be of some help.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 24 - A 60 yr. old man with atrial fibrillation (AF) who is on warfarin...

    Incorrect

    • A 60 yr. old man with atrial fibrillation (AF) who is on warfarin and is awaiting tooth extraction. Recent INR was 2.7 and his target INR was 2.0-3.0. Which of the following is the most appropriate management?

      Your Answer:

      Correct Answer:

      Explanation:

      The latest reserches say that simple tooth extraction in patients on warfarin treatment can be performed safely without high risk of bleeding, providing that the INR is equal to or less than 3.5 on the day of extraction. A close follow-up and monitoring of patients taking warfarin is mandatory after dental extraction.

    • This question is part of the following fields:

      • Cardiology
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  • Question 25 - A 39 year-old engineer presents with progressive weakness of his hands. Upon examination,...

    Incorrect

    • A 39 year-old engineer presents with progressive weakness of his hands. Upon examination, you notice wasting of the small muscles of the hand. A diagnosis of syringomyelia is suspected. Which one of the following features would most support this diagnosis?

      Your Answer:

      Correct Answer: Loss of temperature sensation in the hands

      Explanation:

      Syringomyelia is a development of a cavity (syrinx) within the spinal cord. Signs and symptoms include loss of feeling, paralysis, weakness, and stiffness in the back, shoulders, and extremities. Syringomyelia may also cause a loss of the ability to feel extremes of hot or cold, especially in the hands. Symptoms typically vary depending on the extent and, often more critically, on the location of the syrinx within the spinal cord.

    • This question is part of the following fields:

      • Neurology
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  • Question 26 - A 55 year old lady who a known case of normal pressure hydrocephalus...

    Incorrect

    • A 55 year old lady who a known case of normal pressure hydrocephalus (NPH) presented with complaints of weakness in her lower limbs, urinary incontinence and progressively worsening confusion. Which of the following statements is true regarding NPH?

      Your Answer:

      Correct Answer: Is associated with gait disturbance

      Explanation:

      Normal pressure hydrocephalus is a form of communicating hydrocephalus characterised by enlarged ventricles with normal opening pressure on lumbar puncture. For diagnostic purposes, a triad of urinary incontinence, gait abnormality and dementia is necessary. It is necessary to diagnose the condition early because it is reversible by placing a ventriculoperitoneal shunt. It is most common in patients aged more than 60 years.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 27 - A 21-year-old patient is referred to the tertiary neurology clinic because of a...

    Incorrect

    • A 21-year-old patient is referred to the tertiary neurology clinic because of a possible diagnosis of Juvenile Parkinson’s disease. His symptoms began predominantly with dystonia affecting the lower limbs, but he now has more classical signs of older onset Parkinson’s including tremor, bradykinesia, and rigidity.
      You map out his family tree and understand that his sister developed Parkinson’s at the age of 16 but that his parents do not have signs of Parkinson’s.
      Which of the following is the most likely mode of inheritance?

      Your Answer:

      Correct Answer: Autosomal recessive

      Explanation:

      Juvenile Onset Parkinson’s is an autosomal recessive condition that usually presents in late childhood to early adulthood, initially with gait disorders caused by lower limb dystonia that later develops to the more classical signs Parkinson’s.

    • This question is part of the following fields:

      • Neurology
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  • Question 28 - Choose the correct statement regarding endothelin: ...

    Incorrect

    • Choose the correct statement regarding endothelin:

      Your Answer:

      Correct Answer: Endothelin antagonists are useful in primary pulmonary hypertension

      Explanation:

      Current guidelines recommend the use of ambrisentan, Bosentan (recommendation I, level of evidence A) and macitentan (I, B) in patients with PAH and WHO functional class II and III. In WHO functional class IV, the first-line drug is Epoprostenol and the recommendation for Endothelin receptor antagonists is weaker (IIb, C).

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 29 - A 28 year old woman presents with painful genital ulceration. She reports that...

    Incorrect

    • A 28 year old woman presents with painful genital ulceration. She reports that these attacks have been recurrent over the past 4 years. She has been treated previously with oral acyclovir but this has had little effect on the duration of her symptoms. Over the past year, she has noticed almost weekly attacks of mouth ulcers that heal slowly. Past medical history is significant for treatment of thrombophlebitis two years ago. Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Behcet's syndrome

      Explanation:

      Behçet disease is a rare vasculitic disorder that is characterized by a triple-symptom complex of recurrent oral aphthous ulcers, genital ulcers, and uveitis. The systemic manifestations can be variable. Ocular disease has the greatest morbidity, followed by vascular disease generally from active vasculitis. Cutaneous manifestations can occur in up 75% of patients with Behcet disease and can range from acneiform lesions, to nodules and erythema nodosum. GI manifestations can be severe. Differentiating Behçet disease from active inflammatory bowel disease can be clinically difficult. Herpes would have ideally responded to acyclovir. Sarcoidosis does not have genital and oral ulcerations.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 30 - Out of the following, which malignant tumour has the highest predilection for dissemination...

    Incorrect

    • Out of the following, which malignant tumour has the highest predilection for dissemination to the bones?

      Your Answer:

      Correct Answer: Prostate

      Explanation:

      Prostate cancer is the most common primary tumour that metastasises to the bone.

      Most common tumours causing bone metastasis (in descending order):
      1. Prostate (32%)
      2. Breast (22%)
      3. Kidneys (16%)
      4. Lungs
      5. Thyroid

      Most common sites of bone metastasis (in descending order):
      1. Spine
      2. Pelvis
      3. Ribs
      4. Skull
      5. Long bones

    • This question is part of the following fields:

      • Haematology & Oncology
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