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  • Question 1 - A 72-year-old man presents with chronic back and right hip pain which has...

    Correct

    • 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: 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 2 - Which one of these features is typical of dermatomyositis? ...

    Incorrect

    • Which one of these features is typical of dermatomyositis?

      Your Answer:

      Correct Answer: Gottron's papules over knuckles of fingers

      Explanation:

      The main symptom of dermatomyositis include skin rash and symmetric proximal muscle weakness (in over 90% of patients) which may be accompanied by pain and tenderness. It occurs more commonly in females. Skin findings include:
      Gottron’s sign – an erythematous, scaly eruption occurring in symmetric fashion over the MCP and interphalangeal joints
      Heliotrope or lilac rash – a violaceous eruption on the upper eyelids and in rare cases on the lower eyelids as well, often with itching and swelling
      Shawl (or V-) sign is a diffuse, flat, erythematous lesion over the back and shoulders or in a V over the posterior neck and back or neck and upper chest, which worsens with UV light.
      Erythroderma is a flat, erythematous lesion similar to the shawl sign but located in other areas, such as the malar region and the forehead.
      Periungual telangiectasias and erythema occur.

    • This question is part of the following fields:

      • Dermatology
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  • Question 3 - A 20-year-old boy returning from vacation in India presented with a history of...

    Incorrect

    • A 20-year-old boy returning from vacation in India presented with a history of fever, myalgia, headache and abdominal pain for 4 days duration. He revealed that he had bathed in a river during his vacation. On examination, he had severe muscle tenderness, hypotension (BP - 80/60mmHg) and tachycardia (140 bpm). What would be the first step in management?

      Your Answer:

      Correct Answer: IV normal saline

      Explanation:

      The history is suggestive of leptospirosis. This is a zoonotic infection caused by a spirochete. As the patient is in shock, resuscitation with IV fluids is the first step in the management. IV antibiotics should be started (Doxycycline or Penicillin) as soon as possible. Other investigations mentioned are important during the management to rule out other possible diagnoses.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 4 - 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 5 - An 88-year-old retired firefighter presents with loss of vision in his left eye...

    Incorrect

    • An 88-year-old retired firefighter presents with loss of vision in his left eye since this morning. He is otherwise asymptomatic and of note has had no associated eye pain or headaches. His past medical history includes ischaemic heart disease but he is otherwise well. On examination he has no vision in his left eye. The left pupil responds poorly to light but the consensual light reaction is normal. Fundoscopy reveals a red spot over a pale and opaque retina. Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Central retinal artery occlusion

      Explanation:

      The most common causes of a sudden painless loss of vision are:
      – ischaemic optic neuropathy
      – occlusion of central retinal vein or artery
      – vitreous haemorrhage
      – retinal detachment.
      Central retinal artery occlusion is due to thromboembolism (from atherosclerosis) or arteritis (e.g. temporal arteritis). Features include afferent pupillary defects, and a ‘cherry red’ spot on a pale retina.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 6 - A 76-year-old woman is admitted with a productive cough and pyrexia. Chest x-ray...

    Incorrect

    • A 76-year-old woman is admitted with a productive cough and pyrexia. Chest x-ray shows a pneumonia and she is commenced on intravenous ceftriaxone. Following admission a stool sample is sent because of diarrhoea. This confirms the suspected diagnosis of Clostridium difficile diarrhoea and a 10-day course of oral metronidazole is started. After 10 days her diarrhoea is ongoing but she remains clinically stable. What is the most appropriate treatment?

      Your Answer:

      Correct Answer: Oral vancomycin for 14 days

      Explanation:

      When a patient fails treatment with metronidazole (Flagyl) treatment, the next course of action is to change to oral vancomycin, which is shown to be effective in the treatment of c diff colitis. Oral rifampicin is not a treatment for c diff. Oral metronidazole is not resolving her symptoms so is not the correct answer. clindamycin is a cause of c diff colitis, not a treatment. IV Vanc is not active in the gut so is not the treatment; oral is active in the gut.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 7 - The chorda tympani of the facial nerve (CN VII) carries: ...

    Incorrect

    • The chorda tympani of the facial nerve (CN VII) carries:

      Your Answer:

      Correct Answer: parasympathetic fibres to the submandibular and sublingual glands and taste fibres from the anterior two-thirds of the tongue

      Explanation:

      In the petrous temporal bone the facial nerve produces three branches:
      1. The greater petrosal nerve, which transmits preganglionic parasympathetic fibres to the sphenopalatine ganglion. These postganglionic fibres supply the lacrimal gland and the glands in the nasal cavity;
      2. The nerve to stapedius;
      3. Parasympathetic fibres to the submandibular and sublingual glands and taste fibres from the anterior two-thirds of the tongue.

    • This question is part of the following fields:

      • Neurology
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  • Question 8 - A 32-year-old man, originally from Pakistan, was admitted with ascites and weight loss....

    Incorrect

    • A 32-year-old man, originally from Pakistan, was admitted with ascites and weight loss. The protein level on ascitic tap was 9 g/l.

      Which of the following is the most likely cause of this presentation?

      Your Answer:

      Correct Answer: Hepatic cirrhosis

      Explanation:

      This is a low protein level, indicating the fluid is transudative. The only answer choice that is a transudative fluid is in hepatic cirrhosis. Exudative fluid would be seen in tuberculous peritonitis, peritoneal lymphoma, with liver mets, and with intra-abdominal malignancy.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 9 - A 65 yr. male patient was started on warfarin for chronic atrial fibrillation...

    Incorrect

    • A 65 yr. male patient was started on warfarin for chronic atrial fibrillation (AF). Which of the following clotting factors is not affected by warfarin?

      Your Answer:

      Correct Answer: Factor XII

      Explanation:

      Carboxylation of factor II, VII, IX, X and protein C is affected by warfarin. Factor XII is not affected.

    • This question is part of the following fields:

      • Cardiology
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  • Question 10 - A 30-year-old female presents with a 4-day history of diarrhoea and vomiting. She...

    Incorrect

    • A 30-year-old female presents with a 4-day history of diarrhoea and vomiting. She has been unable to keep fluids down for 4 days and has been treated with metoclopramide. She develops a dystonic reaction.
      What is the most appropriate treatment for the woman?

      Your Answer:

      Correct Answer: Benztropine

      Explanation:

      Acute dystonic reactions (extrapyramidal symptoms) such as spasmodic torticollis, trismus, and oculogyric crises can occur following the administration of metoclopramide or stemetil and thus, neither is recommended for the treatment of nausea in young women.

      Such reactions respond well to treatment with benztropine or procyclidine.
      – Benztropine: It is an anticholinergic medication with significant CNS penetration.
      A single dose of benztropine 1 to 2 mg IV followed by 1 to 2 mg p.o twice a day for up to 7 days to prevent a recurrence. Subsequently, both the offending agent and those from the same group should be avoided.
      – Alternatively, diphenhydramine can be used intravenously (up to a dose of 50mg) or intramuscularly followed by p.o therapy every 6 hours for 1 to 2 to prevent a recurrence.
      – Second-line therapy with IV benzodiazepines is reserved for those patients who do not respond to anticholinergics.

    • This question is part of the following fields:

      • Pharmacology
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