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  • Question 1 - A 20-year-old woman presents to casualty with flank pain and a 48 hour...

    Correct

    • A 20-year-old woman presents to casualty with flank pain and a 48 hour history of dysuria. Her past medical history includes polycystic ovarian syndrome. She is not in a steady relationship at present. There is haematuria and proteinuria on urine dipstick testing.

      Examination reveals a pyrexia of 38.1 °C and flank pain.

      What diagnosis fits best with this clinical picture?

      Your Answer: Pyelonephritis

      Explanation:

      The patient presents with flank pain and fever with haematuria and proteinuria associated with a social history of not being in a steady relationship. This patient is a young presumably sexually active female, so the diagnosis is most likely pyelonephritis which has an increased incidence in young sexually active women or men of >50 years of age.

    • This question is part of the following fields:

      • Nephrology
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  • Question 2 - 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 3 - A 20 year old male student presents to the clinic with swelling of...

    Incorrect

    • A 20 year old male student presents to the clinic with swelling of his face, hands and feet along with diffuse abdominal pain. He has a history of similar recurrent episodes since he was 10 years old, with each episode lasting 2-3 days. Examination reveals swelling on face, hands, feet but no sign of urticaria. Family history is significant for similar episodes in the mother who experienced these since childhood, and a brother who passed away following respiratory distress at age of 8 during one such episode. Which of the following tests would be the most helpful in reaching the diagnosis?

      Your Answer:

      Correct Answer: C1 esterase inhibitor

      Explanation:

      Hereditary C1 inhibitor deficiency leads to recurrent angioedema without urticaria or pruritus. Physical triggers include dental work, surgery or intubation. Medical triggers include angiotensin-converting enzyme (ACE) inhibitor, tamoxifen, oestrogen-containing medications (e.g., hormone replacement therapy and oral contraceptives). It is diagnosed on the basis of low levels of C1 esterase inhibitor or elevated levels of dysfunctional C1 esterase inhibitor. C4 levels are low between attacks. IgE levels, eosinophils, skin prick tests and RASTs are helpful in other allergic conditions and asthma but not of use in this case.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 4 - A 4 year old child was brought in by his mother with complaints...

    Incorrect

    • A 4 year old child was brought in by his mother with complaints of vesicular eruption over his palms, soles and oral mucosa for the last 5 days. He was slightly febrile. There were no other signs. The most likely causative organism in this case would be?

      Your Answer:

      Correct Answer: Coxsackie

      Explanation:

      This patient is most likely suffering from hand, foot mouth disease which is caused by coxsackie virus A16. Its incubation period ranges from 5-7 days and only symptomatic treatment is required.

    • This question is part of the following fields:

      • Dermatology
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  • Question 5 - A 80 yr. old male patient with ischaemic heart disease, hypertension and dyslipidaemia...

    Incorrect

    • A 80 yr. old male patient with ischaemic heart disease, hypertension and dyslipidaemia presented with productive cough, fever with chills and loss of appetite for 4 days. On examination he was unwell and febrile with a temperature of 38.3. His blood pressure was 130/80mmHg and pulse rate was 140 bpm. Respiratory rate was 18 breaths per minute. On auscultation there were crepitations over the left lower zone of his chest. His abdomen was soft and non-tender. ECG showed an irregular narrow complex tachycardia. Which of the following is the most appropriate acute management to treat his tachycardia?

      Your Answer:

      Correct Answer: Antibiotics

      Explanation:

      The most likely diagnosis is acute atrial fibrillation (AF) precipitated by acute pneumonia. History of fever, cough and the auscultation findings support it. So the most appropriate management is treating the pneumonia with antibiotics. Treating the underlying cause will reduce the heart rate. Other responses are helpful in the management of chronic AF.

    • This question is part of the following fields:

      • Cardiology
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  • Question 6 - A 16 year old previously well male presents with a 4 day history...

    Incorrect

    • A 16 year old previously well male presents with a 4 day history of fever, lethargy and a generalized macular rash. There is no significant previous medical history and the patient has not travelled abroad either. Vitals are as follows:
      Temp: 38.5
      BP: 125/75mmHg
      Pulse: 100/min
      On auscultation the chest was clear and no heart murmur was heard. Examination also reveals a non blanching widespread macular rash over the chest and abdomen. There is swelling of interphalangeal joints of both hands and feet associated with mild tenderness. Lymph nodes are palpable over the supraclavicular, axillary and inguinal areas. Abdominal examination reveals palpable mass on both right and left hypochondrium. Lab results are given below:
      Haemoglobin (Hb) 13.5 g/dL,
      White cell count (WCC) 14.0 × 109/L,
      Platelets 380 × 109/L,
      Sodium 145 mmol/L,
      Potassium 4.8 mmol/L,
      Creatinine 89 μmol/L,
      Rheumatoid factor: Negative,
      Antinuclear antibody: Negative,
      Anti-dsDNA: Negative,
      ASO titre: Not detected.
      Electrocardiogram (ECG): Sinus rhythm.
      What is the most likely underlying diagnosis?

      Your Answer:

      Correct Answer: Systemic Still’s disease

      Explanation:

      People with Systemic Juvenile Idiopathic Arthritis (also known as Stills disease) can have recurrent fevers, a macular rash, joint pain, joint deformities, an enlarged liver and/or spleen, and can occasionally have polyserositis, lung involvement or pericardial effusions. Rheumatoid factor and antinuclear antibodies are usually negative. Treatment is with non-steroidal anti-inflammatory drugs (NSAIDs) and the prognosis is better than for adult rheumatoid arthritis.
      In pauciarticular Still’s disease, antinuclear antibodies are present. Large joints are affected and most patients develop classic features of seronegative spondylarthritis.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 7 - A 26-year-old patient, previously fit and well, is admitted with fluctuating confusion and...

    Incorrect

    • A 26-year-old patient, previously fit and well, is admitted with fluctuating confusion and frank haematuria. He has recently been complaining of generalised malaise and joint pains. Examination reveals jaundice, splenomegaly, and petechiae. His blood pressure is 155/84 mmHg, temperature 37.9oC.
       
      Initial investigations reveal:

      Haemoglobin 9.5 g/dL,
      White cell count 12 × 109/L,
      Platelets 40 × 109/L,
      Creatinine 142 μmol/L,
      Sodium 139 mmol/L,
      Potassium 4.5 mmol/L,
      Urea 9.2 mmol/L,
      Lactate dehydrogenase 495 U/l (10–250)
      Urinalysis Protein ++, blood +++
      Blood film shows schistocytes

       
      What treatment should NOT be given to this patient?

      Your Answer:

      Correct Answer: Platelet transfusion

      Explanation:

      There is a strong suspicion of Thrombotic Thrombocytopenic Purpura (TTP) in this patient as he presents with neurological changes (from confusion to convulsions and coma), fever, haemolysis, thrombocytopenia, and renal failure. Additionally, TTP cases may present with jaundice, splenomegaly, and hypertension as seen in this patient. With a diagnosis of TTP, recent studies have shown that platelet transfusion is not recommended in this case because it has been shown to increase the risk for arterial thrombosis and mortality possibly due to increased aggregations.

    • This question is part of the following fields:

      • Nephrology
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  • Question 8 - A 46 year old male, known with Rheumatoid Arthritis presents with a swollen...

    Incorrect

    • A 46 year old male, known with Rheumatoid Arthritis presents with a swollen and painful right ankle. No drug allergies are reported. On examination, the vitals are as follows:
      Temp: 38.8
      BP: 90/60 mmHg
      Pulse: 110/min.
      Right ankle examination reveals tenderness, warmth, erythema and tense joint effusion. Blood samples including blood cultures are collected and fluid resuscitation is initiated. Which of the following interventions would be most appropriate for this man?

      Your Answer:

      Correct Answer: Administer i.v. flucloxacillin, and arrange joint aspiration urgently

      Explanation:

      Although microscopic analysis of joint fluid aspirate and culture is the basis of septic arthritis diagnosis and should usually be collected before the administration of antibiotics, the patient is showing signs of septic shock. A delay in antibiotics might lead to worsening of symptoms so they are administered first.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 9 - 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 10 - A 35-year-old female has been recently diagnosed with hypertension. She's sexually active and...

    Incorrect

    • A 35-year-old female has been recently diagnosed with hypertension. She's sexually active and is not using any birth control other than barrier method. Which among the following antihypertensives is contraindicated in this patient?

      Your Answer:

      Correct Answer: Lisinopril

      Explanation:

      Among the following hypertensives, lisinopril (an ACE inhibitor) is contraindicated in patients who are planning for pregnancy.

      Per the NICE guidelines, when treating the woman in question, she should be treated as if she were pregnant given the absence of effective contraception.
      ACE inhibitors such as lisinopril are known teratogens and most be avoided.

      Drugs contraindicated in pregnancy:
      Antibiotics
      Tetracyclines
      Aminoglycosides
      Sulphonamides and trimethoprim
      Quinolones

      Other drugs:
      ACE inhibitors, angiotensin II receptor antagonists
      Statins
      Warfarin
      Sulfonylureas
      Retinoids (including topical)
      Cytotoxic agents
      The majority of antiepileptics including valproate, carbamazepine, and phenytoin are known to be potentially harmful.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 11 - A 64 year old woman who is of Asian descent and is diabetic...

    Incorrect

    • A 64 year old woman who is of Asian descent and is diabetic (controlled by diet) presents with generalized body aches and difficulty rising from sitting for the last few months. Her blood glucose levels are in the normal range. Lab examination reveals normal blood cell count, low serum phosphate, calcium at the lower range, and raised alkaline phosphatase levels. Radiological examination shows which of the following?

      Your Answer:

      Correct Answer: Linear areas of low density

      Explanation:

      Osteomalacia is a condition due to defective mineralization of osteoid. Occurs as a result of Vitamin D deficiency secondary to poor dietary intake and sun exposure, malabsorption e.g., inflammatory bowel disease and gastrointestinal bypass surgery. Radiological findings include reduced bone mineral density (a non specific finding), inability to radiologically distinguish vertebral body trabeculae (the film appears poor quality), looser pseudo fractures, fissures, or narrow radiolucent lines (these are the characteristic findings). Osteolytic or punched out lesions may be seen with multiple myeloma and bony metastases. Areas of sclerosis may be observed with conditions like osteosclerosis and Paget disease. A Brodie abscess is a subacute osteomyelitis, which may persist for years before progressing to a chronic, frank osteomyelitis.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 12 - A 27-year-old woman is admitted on the medical intake. She is 10 weeks...

    Incorrect

    • A 27-year-old woman is admitted on the medical intake. She is 10 weeks postpartum and has been generally unwell for two weeks with malaise, sweating and anxiety.
      On examination, she is haemodynamically stable and clinically euthyroid.
      TFTs show the following:
      Free T4 33 pmol/L (9-23),
      Free T3 8 nmol/L (3.5-6),
      TSH <0.02 mU/L (0.5-5).

      What is the appropriate management?

      Your Answer:

      Correct Answer: Propranolol 20 mg tds

      Explanation:

      The patient is most likely to have Postpartum thyroiditis which goes through 2 phases; hypothyroid and a hyperthyroid phase.
      The hyperthyroid phase of postpartum thyroiditis occurs between 2 and 10 months postpartum. Most commonly, it presents at 3 months. Symptoms more common in women with hyperthyroid postpartum thyroiditis include palpitations, fatigue, heat intolerance, and irritability/nervousness. The frequency of asymptomatic hyperthyroidism is 33%.
      Untreated, the hyperthyroidism resolves spontaneously within 2–3 months. This phase is diagnosed by the combination of a low serum TSH concentration in the presence of thyroid peroxidase antibodies, in women who are TSH receptor antibody-negative. Free T4 levels are typically elevated but may be normal.
      Treatment of hyperthyroidism, when necessary, is based on symptom severity and should be a joint decision of patient and physician. Beta-blockers such as propranolol are given to alleviate palpitations, irritability, and nervousness. The morbidity associated with treatment is the side effects of beta-blockade. The downside of withholding treatment is allowing the woman to remain symptomatic. Antithyroid medicines (thioureas) are not a potential treatment alternative, because the hyperthyroidism is caused by destructive thyroiditis resulting in the release of preformed thyroid hormone.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 13 - A 60 yr. old female presented with difficulty in breathing. What is the...

    Incorrect

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

      Your Answer:

      Correct Answer: Raised jugular venous pressure

      Explanation:

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

    • This question is part of the following fields:

      • Cardiology
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  • Question 14 - Which of the following drugs would be the safest to prescribe in a...

    Incorrect

    • Which of the following drugs would be the safest to prescribe in a 22 year old man with seropositive rheumatoid arthritis who is planning to start a family?

      Your Answer:

      Correct Answer: Prednisolone

      Explanation:

      Prednisolone although has many undesirable side effects it may be considered relatively safe compared to the drugs that are provided here. Prolonged treatment with sulphasalazine may depress semen quality and cause irreversible infertility. Methotrexate and leflunomide both inhibit purine/pyrimidine synthesis (the former by inhibiting folate metabolism) and are contraindicated in pregnancy or while trying to conceive. In males, a temporary or permanent decrease in sperm count may occur with cyclophosphamide. Because the recovery of fertility after cyclophosphamide therapy is variable, sperm banking should be considered before treatment is begun.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 15 - A 31 year old female complains of bilateral proximal muscle weakness. There is...

    Incorrect

    • A 31 year old female complains of bilateral proximal muscle weakness. There is marked blanching of fingers especially in response to cold weather. Lab results are as follows:
      Anti Jo-1: positive,
      ANA: positive,
      CK: 2000 U/L,
      ESR: 60mm/hr,
      EMG: myopathic changes.

      Presence of which of the following signifies the worst prognosis?

      Your Answer:

      Correct Answer: Interstitial lung disease

      Explanation:

      Polymyositis is an inflammatory disorder causing symmetrical, proximal muscle weakness. It is thought to be a T-cell mediated cytotoxic process directed against muscle fibres. It may be idiopathic or associated with connective tissue disorders. It may also be associated with malignancy for example small cell lung carcinoma.
      Dermatomyositis is a variant of the disease where skin manifestations are prominent, for example a purple (heliotrope) rash on the cheeks and eyelids.
      It typically affects middle-aged, female: male 3:1. Features include proximal muscle weakness +/- tenderness, Raynaud’s phenomenon, respiratory muscle weakness, interstitial lung disease: e.g. fibrosing alveolitis or organising pneumonia, dysphagia, dysphonia. Investigations: elevated creatine kinase, other muscle enzymes (lactate dehydrogenase (LD), aldolase, AST and ALT) are also elevated in 85-95% of patients, EMG, muscle biopsy. Anti-Jo-1 antibodies are seen in pattern of disease associated with lung involvement, Raynaud’s and fever. Interstitial lung disease plays a major role in morbidity and mortality in patients with polymyositis and is considered a major risk factor for premature death in patients with myositis.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 16 - A 23 year old male medical student presents to the A&E department with...

    Incorrect

    • A 23 year old male medical student presents to the A&E department with pleuritic chest pain. He does not have productive cough nor is he experiencing shortness of breath. He has no past medical history. A chest x-ray which was done shows a right-sided pneumothorax with a 1 cm rim of air and no mediastinal shift.

      What is the most appropriate treatment option?

      Your Answer:

      Correct Answer: Discharge with outpatient chest x-ray

      Explanation:

      Primary spontaneous pneumothorax is an abnormal accumulation of air in the space between the lungs and the chest cavity (called the pleural space) that can result in the partial or complete collapse of a lung. This type of pneumothorax is described as primary because it occurs in the absence of lung disease such as emphysema. Spontaneous means the pneumothorax was not caused by an injury such as a rib fracture. Primary spontaneous pneumothorax is likely due to the formation of small sacs of air (blebs) in lung tissue that rupture, causing air to leak into the pleural space. Air in the pleural space creates pressure on the lung and can lead to its collapse. A person with this condition may feel chest pain on the side of the collapsed lung and shortness of breath. Patients are typically aged 18-40 years, tall, thin, and, often, are smokers.

      In small pneumothoraxes with minimal symptoms, no active treatment is required. These patients can be safely discharged with early outpatient review and should be given written advice to return if breathlessness worsens. Patients who have been discharged without intervention should be advised that air travel should be avoided until a radiograph has confirmed resolution of the pneumothorax.

    • This question is part of the following fields:

      • Respiratory
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  • Question 17 - A 14 year old known asthmatic presents to the A&E department with difficulty...

    Incorrect

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

      Past medical history:
      Ulcerative colitis diagnosed four years ago.

      Current medications:
      Inhaled salbutamol and beclomethasone
      Mesalazine 400 mg TDS

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

      Your Answer:

      Correct Answer: Haemophilus influenzae

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Respiratory
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  • Question 18 - A 66 year-old marketing analyst presents to the respiratory clinic with a 2-month...

    Incorrect

    • A 66 year-old marketing analyst presents to the respiratory clinic with a 2-month history of progressive weakness and shortness of breath. He finds it difficult to stand from sitting, and struggles climbing stairs. He is an ex-smoker with chronic obstructive pulmonary disease (COPD). He had a recent exacerbation one month ago for which he was treated by the GP with a course of oral prednisolone, during which time his weakness transiently improved. On examination, you note a left-sided monophonic wheeze and reduced breath sounds at the left lung base. Blood tests and a chest x-ray are requested.

      Hb 145 g/L
      WCC10.5 109/L,
      Na+136 mmol/L,
      K+ 4.3 mmol/L,
      Urea 6.8 mmol/L,
      Creatinine 93 mmol/L,
      Calcium 2.62 mmol/L,
      Phosphate 1.44 mmol/L,


      Chest x-ray shows hyperinflated lungs, left lower lobe collapse and a bulky left hilum

      What is the most likely cause of this patient's weakness?

      Your Answer:

      Correct Answer: Lambert-Eaton myasthenic syndrome

      Explanation:

      This man has a small-cell lung cancer (SCLC) and associated Lambert-Eaton myasthenic syndrome – a well-recognized paraneoplastic manifestation of SCLC. This classically affects the proximal muscles, especially in the legs, causing difficulty in standing from a seated position and climbing stairs. In contrast to myasthenia gravis, eye involvement is uncommon. Treatment with steroids is often helpful, which explains his transient symptomatic improvement during treatment for his COPD exacerbation. Steroid myopathy does not fit as the symptoms started well before his course of prednisolone. Although the patient is mildly hypercalcaemic, this would not be sufficient to produce his presenting symptoms, although it does reinforce the suspicion of lung malignancy. Motor neurone disease would be unlikely in this context and would not improve with steroids. Myasthenia gravis could produce these symptoms, but in the context of a new lung mass is a less viable diagnosis.

    • This question is part of the following fields:

      • Neurology
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  • Question 19 - A 55 yr. old male with a history of myocardial infarction 4 years...

    Incorrect

    • A 55 yr. old male with a history of myocardial infarction 4 years ago, was admitted with a history of fever for the past 2 weeks. On investigation, his echocardiography revealed a small vegetation around the mitral valve. His blood culture was positive for Streptococcus viridans. Which of the following is the most appropriate antibiotic therapy?

      Your Answer:

      Correct Answer: IV benzylpenicillin

      Explanation:

      According to the American Heart Association (AHA) penicillin-susceptible S viridans, S bovis, and other streptococci (MIC of penicillin of ≤0.1 mcg/mL) should be treated with penicillin G or ceftriaxone or penicillin G + a gentamicin combination or vancomycin (if allergy to penicillin).

    • This question is part of the following fields:

      • Cardiology
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  • Question 20 - A 20-year-old gentleman presents with drop foot following a sports injury.
    On examination...

    Incorrect

    • A 20-year-old gentleman presents with drop foot following a sports injury.
      On examination there is weakness of ankle dorsiflexion and eversion, and weakness of extension of the big toe. He has some sensory loss restricted to the dorsum of his foot surrounding the base of his big toe. Other examination is within normal limits.
      Where is the most likely site of the lesion?

      Your Answer:

      Correct Answer: Common peroneal nerve at the head of the fibula

      Explanation:

      Peroneal nerve injury is also known as foot drop. The common peroneal nerve supplies the ankle and toe extensor muscle groups as well as sensation over the dorsum of the foot; thus, there is also loss of sensation in these cases.

    • This question is part of the following fields:

      • Neurology
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  • Question 21 - A 52 year old female, known case of rheumatoid arthritis presents to the...

    Incorrect

    • A 52 year old female, known case of rheumatoid arthritis presents to the clinic with dyspnoea, cough, and intermittent pleuritic chest pain. She was previously taking second line agents Salazopyrine and gold previously and has now started Methotrexate with folic acid replacement a few months back. Pulmonary function tests reveal restrictive lung pattern and CXR reveals pulmonary infiltrates.
      Which of the following treatments is most suitable in this case?

      Your Answer:

      Correct Answer: Stop methotrexate

      Explanation:

      Methotrexate lung disease (pneumonitis and fibrosis) is the specific etiological type of drug-induced lung disease. It can occur due to the administration of methotrexate which is an antimetabolite, which is given as disease-modifying antirheumatic drugs (DMARDs) in patients with rheumatoid arthritis. The typical clinical symptoms include progressive shortness of breath and cough, often associated with fever. Hypoxemia and tachypnoea are always present and crackles are frequently audible. Symptoms typically manifest within months of starting therapy. Methotrexate withdrawal is indicated in such cases.

    • This question is part of the following fields:

      • Respiratory
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  • Question 22 - A 36-year-old man is being investigated for recurrent gastric and duodenal ulceration diagnosed...

    Incorrect

    • A 36-year-old man is being investigated for recurrent gastric and duodenal ulceration diagnosed at endoscopy. He has suffered from bouts of abdominal pain and intermittent diarrhoea although his weight is stable.

      Some of his investigations results are:
      Basal acid secretion 20 mEq/h (1–5),
      Fasting gastrin 200 pg/ml (<100),

      Secretin test:
      Basal gastrin 200pg/ml,
      Post-secretin 500pg/ml.

      Which of the following are responsible for the elevated gastrin levels?

      Your Answer:

      Correct Answer: Gastrinoma

      Explanation:

      This case describes Zollinger-Ellison syndrome. It is characterized by refractory peptic ulcer disease, often multiple ulcers. This is typically caused by secretion of gastrin from a gastrinoma, a neuroendocrine tumour. The most common site of ulceration is the duodenum. A symptom of a pancreatic gastrinoma may be steatorrhea from hypersecretion of gastrin. Serum gastrin levels > 1000 and a pH < 2 are diagnostic of pancreatic gastrinoma. The secretin test is a test that can differentiate gastrinoma from other causes of high gastrin levels. Gastrin will rise after secretin injection if the patient has a gastrinoma.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 23 - A 64 year old female presents with sudden onset pain, swelling and stiffness...

    Incorrect

    • A 64 year old female presents with sudden onset pain, swelling and stiffness in her right knee. Her medical history is significant for osteoarthritis affecting her hand joints and diet controlled diabetes mellitus. On examination, the right knee is swollen, erythematous and tender. Which of the following tests would be most useful in the diagnosis of this case?

      Your Answer:

      Correct Answer: Aspiration and examination of the synovial fluid

      Explanation:

      Arthrocentesis should usually be done when there is a suspicion of pseudogout or septic arthritis as in this case which leads to an early diagnosis and prompt treatment. Polarized microscopy demonstrates weakly positively birefringent rhomboid crystals which are blue when parallel to light and yellow when perpendicular to light. Elevated serum uric acid levels that cause gout are usually found after large consumption of alcohol or meat, or post surgery. Autoimmune diseases like SLE, RA etc require an autoimmune screen.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 24 - A study is carried out to assess the efficacy of a rapid urine...

    Incorrect

    • A study is carried out to assess the efficacy of a rapid urine screening test developed to detect Chlamydia. The total number of people involved in the study were 200. The study compared the new test to the already existing NAAT techniques. The new test was positive in 20 patients that were Chlamydia positive and in 3 patients that were Chlamydia negative. For 5 patients that were Chlamydia positive and 172 patients that were Chlamydia negative the test turned out to be negative. Choose the correct value regarding the negative predictive value of the new test:

      Your Answer:

      Correct Answer: 172/177

      Explanation:

      The definition of negative predictive value is the probability that the individuals with truly negative screening test don’t have Chlamydia. The equation is the following: Negative predictive value = Truly negative/(truly negative + false negative) = 172 / (172 + 5) = 172 / 177

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 25 - A 23 year old male presents with a history of lower back pain...

    Incorrect

    • A 23 year old male presents with a history of lower back pain for the last one year. Presence of which of the following features most likely points towards ankylosing spondylitis?

      Your Answer:

      Correct Answer: Bilateral erosion of sacroiliac joints on X-ray

      Explanation:

      Bilateral erosions of the sacroiliac joints on pelvic radiographs of patients with ankylosing spondylitis are an important feature of the modified New York classification criteria. Although HLA-B27 is commonly associated with AS, it can also be found in normal individuals. Back stiffness is worse in the morning and gets better as the day progresses. Tenderness and limited lumbar motion can be associated with other spine problems as well and is not characteristic of rheumatoid arthritis.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 26 - A 72-year-old with varicose veins complains of swollen, red, itchy legs. Which is...

    Incorrect

    • A 72-year-old with varicose veins complains of swollen, red, itchy legs. Which is the most likely diagnosis?

      Your Answer:

      Correct Answer: Varicose eczema

      Explanation:

      Varicose eczema is a common problem, particularly in elderly patients due to stasis or blood pooling from insufficient venous return; the alternative name of varicose eczema comes from a common cause of this being varicose veins. It is often mistaken for cellulitis, but cellulitis is rarely bilateral and is painful rather than itchy.

    • This question is part of the following fields:

      • Dermatology
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  • Question 27 - A 60-year-old man with known ulcerative colitis and diverticular disease comes to clinic...

    Incorrect

    • 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:

      Correct 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
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  • Question 28 - Double-stranded DNA is found in which of the following cell organelles? ...

    Incorrect

    • Double-stranded DNA is found in which of the following cell organelles?

      Your Answer:

      Correct Answer: Mitochondria

      Explanation:

      Mitochondrial DNA (mtDNA) is a double-stranded molecule of 16.6 kb (Figure 1, lower panel). The two strands of mtDNA differ in their base composition, with one being rich in guanines, making it possible to separate a heavy (H) and a light (L) strand by density centrifugation in alkaline CsCl2 gradients.

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 29 - Which one of the following congenital infections is most characteristically associated with chorioretinitis?...

    Incorrect

    • Which one of the following congenital infections is most characteristically associated with chorioretinitis?

      Your Answer:

      Correct Answer: Toxoplasma gondii

      Explanation:

      The common congenital infections encountered are rubella, toxoplasmosis and cytomegalovirus. Cytomegalovirus is the most common congenital infection in the UK. Maternal infection is usually asymptomatic.
      Congenital toxoplasmosis is associated with fetal death and abortion, and in infants, it is associated with neurologic deficits, neurocognitive deficits, and chorioretinitis.

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 30 - A 55-year-old man develops central abdominal pain a few hours after having an...

    Incorrect

    • A 55-year-old man develops central abdominal pain a few hours after having an Endoscopic Retrograde Cholangiopancreatography (ERCP) performed. Investigations reveal the following:


      Amylase: 545 u/dL,
      Erect chest x-ray: Normal heart and lungs and no free air noted.

      What is the most appropriate management?

      Your Answer:

      Correct Answer: Intravenous fluids + analgesia

      Explanation:

      A very common complication after ERCP is post-ERCP pancreatitis, which based on the clinical scenario , this man has. The treatment for this is pain control, lots of intravenous fluids, and traditionally bowel rest, although more recent evidence suggests early feeding is better.

    • This question is part of the following fields:

      • Gastroenterology
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