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  • Question 1 - An 18-year-old young lady is brought to the ER by her mother. She...

    Incorrect

    • An 18-year-old young lady is brought to the ER by her mother. She was found, lying on the floor having consumed an unidentified quantity of her mother's prescription pills with alcohol. The patient's mother is a known hypertensive under treatment. On examination, the patient was found to be lethargic, hypotensive with a BP of 70/50 mmHg, and bradycardic with a pulse rate of 38 bpm. A finger prick glucose is 3.2 mmol/L. Which TWO among the following are the most appropriate steps for the initial management of this patient?

      Your Answer: Noradrenalin and isoprenaline

      Correct Answer: Glucagon and isoprenaline

      Explanation:

      The most appropriate steps of initial management include iv glucagon and iv isoprenaline.

      The most likely diagnosis in the above scenario (decreased conscious level, profound hypertension, and bradycardia) is β-blocker toxicity/overdose.
      Bronchospasm rarely occurs in an overdose of β-blockers, except where there is a history of asthma.

      Immediate management is to give iv glucagons (50–150μg/kg) followed by infusion to treat hypotension and isoprenaline or atropine to treat bradycardia.
      Where patients fail to respond to these measures, temporary pacing may be required.
      If the patient is seen within the first 4 hours of the overdose, gastric lavage may be of value.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 2 - A 20-year-old female has been admitted with an acute infection. She gives a...

    Incorrect

    • A 20-year-old female has been admitted with an acute infection. She gives a history suggestive of hypersensitivity to amoxicillin. After consultation with the allergy specialist, she has now been diagnosed with an IgE mediated penicillin allergy. Which of the following drugs should be avoided in this patient?

      Your Answer:

      Correct Answer: Cefalexin

      Explanation:

      Cefalexin should be avoided in this patient.
      This patient is known to have a severe penicillin allergy. None of the above antibiotics are penicillin based. However, 0.5 – 6.5% of patients who are proven to have an IgE mediated penicillin allergy will also be allergic to cephalosporins, including cefalexin.

      Penicillin, cephalosporins, and carbapenems are all members of the beta-lactam group of antibiotics and share a common beta-lactam ring. There is, therefore, a small risk of allergy cross-over between all these antibiotics. The rates of allergy cross-over are lower with second and third-generation cephalosporins than first-generation cephalosporins such as cefalexin.

      It is important to question the patient carefully to ascertain what symptoms they had on exposure to penicillin. Symptoms such as an urticarial rash or itching make it more likely that they have an IgE mediated allergy.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 3 - 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 4 - A 72-year-old woman presents with a 3 month history of colicky abdominal pain...

    Incorrect

    • A 72-year-old woman presents with a 3 month history of colicky abdominal pain after eating, and diarrhoea. She has lost 7 kg in weight over the last few months. A recent gastroscopy and colonoscopy were normal. Her past medical history includes angina and a right carotid endarterectomy at the age of 62 years. Her current medication includes aspirin, atenolol, simvastatin and losartan.

      right carotid endarterectomy at the age of 62 years. Her current medication includes aspirin, atenolol, simvastatin and losartan.
      Blood tests revealed:
      Haemoglobin (Hb) 118 g/l,
      Mean corpuscular volume (MCV) 80 fl,
      White cell count (WCC) 12.3 x 109/L,
      Platelets 210 x 109/L,
      Na+ 133 mmol/L,
      K+ 5.2 mmol/L,
      Urea 8.1 mmol/L,
      Creatinine 134 mmol/L.

      Select the most appropriate further investigations.

      Your Answer:

      Correct Answer: Contrast-enhanced computed tomography (CT) of the abdomen

      Explanation:

      The patient is 74 years old. She has had a recent gastroscopy and colonoscopy. She has a history of angina and a right CEA. She is having colicky abdominal pain after meals and weight loss, which points to a possible diagnosis of chronic mesenteric ischemia. Thus, you would want to do a contrast-enhanced CT scan of the abdomen to look for this. A 24 hour cardiac monitor would also be helpful to look for any abnormal rhythm that could be a potential aetiology of her disease.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 5 - A 61-year old mechanic recently attended A&E, with a 3 month history of...

    Incorrect

    • A 61-year old mechanic recently attended A&E, with a 3 month history of bilateral paraesthesia's and twitching affecting the thumb, first finger and lateral forearm. He denied any trauma. An MRI scan of his spine was performed and revealed cervical canal stenosis with mild cord compression. He was discharged and advised to see his GP for follow-up. Which of the following is the most appropriate initial step in management?

      Your Answer:

      Correct Answer: Refer to spinal surgery services

      Explanation:

      Bilateral median nerve dysfunction is suggestive of degenerative cervical myelopathy (DCM) rather than bilateral carpal tunnel syndrome. DCM should be suspected in elderly patients presenting with limb neurology. This patient’s twitches are probably fibrillations, a sign of lower motor neuron dysfunction.
      Degenerative cervical myelopathy is associated with a delay in diagnosis. It is most commonly misdiagnosed as carpal tunnel syndrome. In one study, 43% of patients who underwent surgery for degenerative cervical myelopathy had been initially diagnosed with carpal tunnel syndrome.
      Management of these patients should be by specialist spinal services (neurosurgery or orthopaedic spinal surgery). Decompressive surgery is the mainstay of treatment and has been shown to stop disease progression. Physiotherapy and analgesia do not replace surgical opinion, though they may be used alongside. Nerve root injections do not have a role in management.

    • This question is part of the following fields:

      • Neurology
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  • Question 6 - A 37-year-old teacher with multiple sclerosis complains that her vision becomes blurred during...

    Incorrect

    • A 37-year-old teacher with multiple sclerosis complains that her vision becomes blurred during a hot bath. Which of the following explain this?

      Your Answer:

      Correct Answer: Uhthoff's phenomenon

      Explanation:

      Uhthoff’s phenomenon is worsening of vision following a rise in body temperature.
      Lhermitte’s sign describes paraesthesia in the limbs on neck flexion.
      Oppenheim’s sign is seen when scratching of the inner side of leg leads to extension of the toes. It is a sign of cerebral irritation and is not related to multiple sclerosis.
      Werdnig-Hoffman’s disease is also known as spinal muscular atrophy.

    • This question is part of the following fields:

      • Neurology
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  • Question 7 - Intracellular proteins tagged with ubiquitination are destined to which of the following organelles?...

    Incorrect

    • Intracellular proteins tagged with ubiquitination are destined to which of the following organelles?

      Your Answer:

      Correct Answer: Proteasome

      Explanation:

      Delivery of ubiquitinated substrates to the proteasome.
      Ubiquitinated proteins are delivered to the proteasome by various routes and the complete picture of how these pathways fit together has yet to emerge, reviewed in. Some substrates bind directly to the proteasome by interacting with the 19S regulatory particle subunits Rpn1028 or Rpn1329, and probably Rpt530. Alternatively, ubiquitinated substrates can be brought to the proteasome by adaptors that bind both the proteasome and the ubiquitin chain on the substrate to deliver it for degradation.

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 8 - A patient has been diagnosed with multi-drug resistant tuberculosis and is currently bring...

    Incorrect

    • A patient has been diagnosed with multi-drug resistant tuberculosis and is currently bring treated with rifampicin, isoniazid, and pyrazinamide. He is commenced on streptomycin.
      Which among the following is the most likely neurological side-effect of streptomycin?

      Your Answer:

      Correct Answer: Vestibular damage

      Explanation:

      Vestibular damage is a neurological side effect of streptomycin.

      Streptomycin is an aminoglycoside bactericidal antibiotic. It is used in the treatment of tularaemia and resistant mycobacterial infections.
      The most common neurological side-effect is vestibular damage leading to vertigo and vomiting.
      Cochlear damage is less frequent and results in deafness.
      Other side-effects include rashes, angioneurotic oedema, and nephrotoxicity.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 9 - A 34-year-old Nigerian woman who is a known case of sickle cell anaemia...

    Incorrect

    • A 34-year-old Nigerian woman who is a known case of sickle cell anaemia presents with fever and worsening of recurrent back pain. There is no history of weight loss or night sweats.

      The investigations done on her arrival show:
      Hb: 7.8 g/dL,
      WCC: 10.1 x10^9/L,
      Plts: 475 x10^9/L,
      Reticulocytes: 12%,
      Serum total bilirubin: 88 μmol/L.

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Vaso-occlusive event

      Explanation:

      This patient is having vaso-occlusive event/crisis (thrombotic crisis) which is a type of sickle cell crisis. It may be associated with ostealgia.

      There is no evidence of an aplastic crisis in this case as the haemoglobin level is reasonable with a good reticulocyte count. Conversely, the haemoglobin is not low enough and reticulocyte count and bilirubin are not high enough for a haemolytic crisis.

      Sickle cell anaemia is characterised by periods of good health with intervening crises. The four main types of sickle cell crises are thrombotic crisis (painful or vaso-occlusive crisis), sequestration crisis, aplastic crisis, and haemolytic crisis.

      Thrombotic crisis is precipitated by infection, dehydration, alcohol, change in temperature, and deoxygenation. Sequestration crisis is characterised by acute chest syndrome (i.e. fever, dyspnoea, chest/rib pain, low pO2, and pulmonary infiltrates). Aplastic crisis is characterised by a sudden fall in haemoglobin without marked reticulocytosis. It usually occurs secondary to parvovirus infection. In haemolytic crisis, a fall in haemoglobin occurs secondary to haemolysis. It is a rare type of sickle cell crisis.

    • This question is part of the following fields:

      • Haematology & Oncology
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  • Question 10 - A 45-year-old man was referred for abnormal liver biochemistry. Investigations showed he had...

    Incorrect

    • A 45-year-old man was referred for abnormal liver biochemistry. Investigations showed he had an ALT of 98 U/l and was Hep B surface antigen positive.

      Which of the following is true of chronic active hepatitis due to the hepatitis B virus?

      Your Answer:

      Correct Answer: It carries an increased risk of subsequent hepatocellular carcinoma

      Explanation:

      Chronic hepatitis B patients have an increased risk of hepatocellular carcinoma. In chronic hepatitis B infection, you have +HBsAg, +anti-HBc, (-)IgM antiHBc, and (-) anti-HBs. In acute hepatitis B infection, you have+HBsAg, + anti-HBc, + IgM anti-HBc, and negative anti-HBs. In immunity due to natural infection, you have negative HBsAg, +anti-HBc, and + anti-HBs. In immunity due to vaccination, you have negative HBsAg, negative anti-HBc, and positive anti-HBs. It is important to remember these serologies, it will get you a lot of points on the test.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 11 - A 41-year-old female is referred to medical assessment unit by her physician for...

    Incorrect

    • A 41-year-old female is referred to medical assessment unit by her physician for querying thrombotic thrombocytopenic purpura (TTP) after she presented with a temperature of 38.9C. Her subsequent urea and electrolytes showed deteriorating renal function with a creatinine 3 times greater than her baseline.

      What is the underlying pathophysiology of TTP?

      Your Answer:

      Correct Answer: Failure to cleave von Willebrand factor normally

      Explanation:

      Thrombotic thrombocytopenic purpura (TTP) is characterised by the von Willebrand factor (vWF) microthrombi within the vessels of multiple organs. In this condition, the ADAMTS13 metalloprotease enzyme which is responsible for the breakdown of vWF multimer, is deficient, causing its build-up and leading to platelet clots that then decreases the circulating platelets, leading to bleeding in the patient.

    • This question is part of the following fields:

      • Nephrology
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  • Question 12 - A 19-year-old female is admitted with a headache, photophobia, fever and confusion. She...

    Incorrect

    • A 19-year-old female is admitted with a headache, photophobia, fever and confusion. She is managed with antibiotics. What is the mechanism of action of the most commonly used first line antibiotic class?

      Your Answer:

      Correct Answer: Inhibition of cell wall synthesis

      Explanation:

      In adults, the most common symptom of meningitis is a severe headache, occurring in almost 90% of cases of bacterial meningitis, followed by nuchal rigidity (the inability to flex the neck forward passively due to increased neck muscle tone and stiffness). Other signs commonly associated with meningitis include photophobia (intolerance to bright light) and phonophobia (intolerance to loud noises).
      In the United Kingdom empirical treatment consists of a third-generation cefalosporin such as cefotaxime or ceftriaxone. In the USA, where resistance to cefalosporins is increasingly found in streptococci, addition of vancomycin to the initial treatment is recommended. Penicillins, cephalosporins, carbapenems and monobactams all act via inhibition of cell wall synthesis.

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 13 - 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 14 - A 33-year-old Afro–Caribbean gentleman with a 5 year history of HIV infection presents...

    Incorrect

    • A 33-year-old Afro–Caribbean gentleman with a 5 year history of HIV infection presents with swollen ankles. He has been treated with highly active antiretroviral therapy (HAART) for 2 years, with partial response.

      His plasma creatinine concentration is 358 μmol/l, albumin is 12 g/dl, CD4 count is 35/μl and 24 hour urine protein excretion rate is 6.8 g. Renal ultrasound shows echogenic kidneys 13.5 cm in length.

      What would a renal biopsy show?

      Your Answer:

      Correct Answer: Microcystic tubular dilatation and collapsing FSGS

      Explanation:

      HIV-associated nephropathy (HIVAN) show typical findings of scarring called focal segmental glomerulosclerosis (FSGS) and microcystic tubular dilatation, prominent podocytes, and collapsing capillary loops.

    • This question is part of the following fields:

      • Nephrology
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  • Question 15 - A 32-year-old patient that has just returned from India, complains of dyspnoea. On...

    Incorrect

    • A 32-year-old patient that has just returned from India, complains of dyspnoea. On examination, you notice grey membranes on the uvula and tonsils and a low-grade fever. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Diphtheria

      Explanation:

      Characteristic findings on patients suffering from diphtheria are the grey membrane on the uvula and tonsils together with the low grade fever and dyspnoea. It’s of great importance that the patient has recently been to India where there is a know prevalence.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 16 - A 19-year-old woman comes to the endocrine clinic with excessive hairiness and acne....

    Incorrect

    • A 19-year-old woman comes to the endocrine clinic with excessive hairiness and acne. She tells you that she has a period only every few months and when she has one it tends to be very heavy.
      On examination, she has obvious facial acne. Her BP is 142/78 mmHg, her pulse is 72bpm and regular and her BMI is 30. There is facial hair and hair around her upper chest and breasts.

      Investigations show:
      Haemoglobin 11.9 g/dl (11.5-16.0),
      White cell count 6.0 x 10(9)/l (4-11),
      Platelets 202 x 10(9)/l (150-400),
      Sodium 137 mmol/l (135-146),
      Potassium 3.9 mmol/l (3.5-5),
      Creatinine 90 µmol/l (79-118),
      Total testosterone normal,
      Free androgen index elevated,
      LH / FSH ratio 2.2.

      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Polycystic ovarian syndrome

      Explanation:

      Rotterdam criteria for the diagnosis of polycystic ovary syndrome:
      Two of the following three criteria are required:
      1. Oligo/anovulation
      2. Hyperandrogenism
      – Clinical (hirsutism or less commonly male pattern alopecia) or
      – Biochemical (raised FAI or free testosterone)
      3. Polycystic ovaries on ultrasound
      Other aetiologies must be excluded such as congenital adrenal hyperplasia, androgen-secreting tumours, Cushing syndrome, thyroid dysfunction and hyperprolactinaemia.
      Cushing’s is excluded because there would have been marked obesity, hypertension and other related features.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 17 - A 40-year-old non-smoker is diagnosed as having emphysema. Further tests reveal that he...

    Incorrect

    • A 40-year-old non-smoker is diagnosed as having emphysema. Further tests reveal that he has alpha-1 antitrypsin deficiency. What is the main role of alpha-1 antitrypsin in the body?

      Your Answer:

      Correct Answer: Protease inhibitor

      Explanation:

      Alpha-1-antitrypsin (AAT) is a member of the serine proteinase inhibitor (serpin) family of proteins with a broad spectrum of biological functions including inhibition of proteases, immune modulatory functions, and the transport of hormones.

    • This question is part of the following fields:

      • Respiratory
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  • Question 18 - A 25-year-old man asks to be referred to a plastic surgeon as he...

    Incorrect

    • A 25-year-old man asks to be referred to a plastic surgeon as he claims that his ears are too big in proportion to his face and he seldom leaves the house because of this. His records show that he was treated for anxiety and depression with fluoxetine previously and has been off work with back pain for the past 4 months. On examination, his ears appear to be normal.
      What is the most appropriate term of this behaviour?

      Your Answer:

      Correct Answer: Dysmorphophobia

      Explanation:

      The most probable diagnosis in the given scenario would be body dysmorphic disorder or dysmorphophobia

      It is a mental disorder where patients have a significantly distorted body image.

      Diagnostic and Statistical Manual (DSM) IV criteria:
      Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.
      The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
      The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa).

      Treatment:
      Cognitive-behavioural therapy (CBT) is the most commonly used and most empirically supported intervention to improve body image.
      Several drugs have been targets of study in anorexia nervosa treatment, including selective serotonin reuptake inhibitors, antidepressants, antipsychotics, nutritional supplementation, and hormonal medications.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 19 - A 74-year-old man who has been diagnosed with atrial fibrillation and heart failure...

    Incorrect

    • A 74-year-old man who has been diagnosed with atrial fibrillation and heart failure is being started on digoxin. What is the mechanism of action of digoxin?

      Your Answer:

      Correct Answer:

      Explanation:

      Digoxin acts by inhibiting the Na+/K+ ATPase pump.
      Digoxin is a cardiac glycoside now mainly used for rate control in the management of atrial fibrillation. As it has positive inotropic properties it is sometimes used for improving symptoms (but not mortality) in patients with heart failure.

      Mechanism of action:
      It decreases the conduction through the atrioventricular node which slows the ventricular rate in atrial fibrillation and atrial flutter.
      It increases the force of cardiac muscle contraction due to inhibition of the Na+/K+ ATPase pump. It also stimulates the vagus nerve.

      Digoxin toxicity:
      Plasma concentration alone does not determine whether a patient has developed digoxin toxicity. The likelihood of toxicity increases progressively from 1.5 to 3 mcg/l.
      Clinical feature of digoxin toxicity include a general feeling of unwell, lethargy, nausea & vomiting, anorexia, confusion, xanthopsia, arrhythmias (e.g. AV block, bradycardia), and gynaecomastia

      Precipitating factors:
      Hypokalaemia
      Increasing age
      Renal failure
      Myocardial ischemia
      Hypomagnesaemia, hypercalcemia, hypernatremia, acidosis
      Hypoalbuminemia
      Hypothermia
      Hypothyroidism
      Drugs: amiodarone, quinidine, verapamil, diltiazem, spironolactone (competes for secretion in the distal convoluted tubule, therefore, reduce excretion), ciclosporin. Also, drugs that cause hypokalaemia e.g. thiazides and loop diuretics.

      Management of digoxin toxicity:
      Digibind
      Correct arrhythmias
      Monitor and maintain potassium levels within the normal limits.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 20 - A 30-year-old male presented with a history of bloody and mucoid diarrhoea since...

    Incorrect

    • A 30-year-old male presented with a history of bloody and mucoid diarrhoea since that morning. He is also complaining of abdominal spasm and bloating. Which of the following investigations is the most suitable one in this case?

      Your Answer:

      Correct Answer: Stool culture and sensitivity

      Explanation:

      In a case of sudden bloody and mucoid diarrhoea, stool culture and sensitivity are required to access which organism is causing the problem and to discuss appropriate antibiotics.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 21 - An 18 year old boy, thin with a tall stature, and a high...

    Incorrect

    • An 18 year old boy, thin with a tall stature, and a high arched palate arrives at the hospital with a spontaneous pneumothorax. He is accompanied by his brother who has a similar appearance. You suspect Marfan's Syndrome.
      The gene encoding which of the following proteins is defective in this condition?

      Your Answer:

      Correct Answer: Fibrillin-1

      Explanation:

      A variety of proteins compose the structure of microfibrils, the most prominent of which are the two fibrillins. Fibrillin-1 a scaffolding protein is encoded by FBN1 on human chromosome 15q21 and fibrillin-2 is encoded by FBN2 on 5q23. Mutations in FBN1 produce Marfan syndrome, a pleiotropic autosomal dominant connective tissue disorder with prominent manifestations in the skeleton, eye and cardiovascular system. A number of conditions related to Marfan syndrome are also due to FBN1 mutations.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 22 - A 34-year-old's chest x-ray showed diffuse bilateral alveolar shadows. He also suffers from...

    Incorrect

    • A 34-year-old's chest x-ray showed diffuse bilateral alveolar shadows. He also suffers from shortness of breath, weight loss and dry cough due to Kaposi's sarcoma but no fever was noted. Which is the most likely causative organism?

      Your Answer:

      Correct Answer: Pneumocystis jiroveci

      Explanation:

      Pneumocystis Jiroveci. This causative organism is responsible for pneumonia in individuals that have a compromised immune system. Symptoms include cyanosis, dry cough and in some cases, diffuse bilateral alveolar shadows on CXR. Co-trimoxazole is normally the treatment for this.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 23 - A 14-year-old girl presents with primary amenorrhoea. She is an athlete who is...

    Incorrect

    • A 14-year-old girl presents with primary amenorrhoea. She is an athlete who is currently training for a national athletics championship.

      What is the best treatment option for her?

      Your Answer:

      Correct Answer: Adequate diet and observation

      Explanation:

      Intensive physical training and participation in competitive sports during childhood and early adolescence may affect athletes’ pubertal development.
      Female athletes who do not begin secondary sexual development by the age of 14 or menstruation by the age of 16 warrant a comprehensive evaluation and treatment.
      Since she is still 14, adequate diet and observation are enough.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 24 - A 30 year old female has been started on azathioprine after she was...

    Incorrect

    • A 30 year old female has been started on azathioprine after she was found to be intolerant of methotrexate. Routine blood monitoring shows the following values:
      Hb 7.9 g/dL,
      Plt 97*109/l,
      WBC 2.7*109/l.
      Azathioprine toxicity will most likely to occur in the presence of which of the following?

      Your Answer:

      Correct Answer: Thiopurine methyltransferase deficiency

      Explanation:

      Azathioprine therapy can cause acute myelosuppression. Toxicity is in part caused by the incorporation of azathioprine-derived 6-thioguanine nucleotides (6-TGN) into deoxyribonucleic acid (DNA). The enzyme thiopurine methyltransferase (TPMT) plays an important role in azathioprine catabolism.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 25 - A 65 yr. old previously well man was referred due to an abnormal...

    Incorrect

    • A 65 yr. old previously well man was referred due to an abnormal heart sound which was detected during a medical check up. On examination he looked well. His blood pressure was 120/70 mmHg and pulse rate was 68 bpm which was regular. His jugular venous pressure was not elevated and he didn't have ankle oedema. He had an early diastolic murmur, best heard at the left sternal edge, which was more clear in expiration when the patient leant forward. His lungs were clear. His FBC, Urea and electrolytes, LFTs and lipid profile were normal. His ECG showed sinus rhythm. His chest X-ray was normal. Echocardiography showed mild to moderate aortic regurgitation with normal left ventricular size and normal function.
      Which of the following is the most appropriate way of managing this patient?

      Your Answer:

      Correct Answer: Start him on an angiotensin-converting enzyme (ACE) inhibitor

      Explanation:

      Although this patient’s left ventricular function is normal at the time of examination, there is chance of deterioration of it due to aortic regurgitation. It is found that ACE inhibitors slow the development of left ventricular dysfunction. So this patient should be started on an ACE inhibitor.

    • This question is part of the following fields:

      • Cardiology
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  • Question 26 - A 23-year-old designer is requesting the combined oral contraceptive pill. During the history...

    Incorrect

    • A 23-year-old designer is requesting the combined oral contraceptive pill. During the history taking, she states that in the past she has had migraines with aura. She asks why the combined oral contraceptive pill is contraindicated. Which of the following is the most appropriate response?

      Your Answer:

      Correct Answer: Significantly increased risk of ischaemic stroke

      Explanation:

      SIGN produced guidelines in 2008 on the management of migraines. Key points include that if patients have migraines with aura then the combined oral contraceptive (COC) is absolutely contraindicated due to an increased risk of stroke (relative risk 8.72).

    • This question is part of the following fields:

      • Neurology
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  • Question 27 - A 43-year-old man is about to be started on chemotherapy for a high-grade...

    Incorrect

    • A 43-year-old man is about to be started on chemotherapy for a high-grade lymphoma. He is given intravenous rasburicase to help lower the risk of tumour lysis syndrome (TLS).

      What is the mechanism of action of this drug?

      Your Answer:

      Correct Answer: Converts uric acid to allantoin

      Explanation:

      Rasburicase is a recombinant version of urate oxidase which is an enzyme that metabolizes uric acid to allantoin.

      TLS is a potentially fatal condition occurring as a complication during the treatment of high-grade lymphomas and leukaemias. It occurs from the simultaneous breakdown (lysis) of the tumour cells and subsequent release of chemicals into the bloodstream. This leads to hyperkalaemia and hyperphosphatemia in the presence of hyponatraemia. TLS can occur in the absence of chemotherapy, but it is usually triggered by the introduction of combination chemotherapy. Awareness of the condition is critical for its prophylactic management.

      Patients at high risk of TLS should be given IV rasburicase or IV allopurinol immediately prior to and during the first few days of chemotherapy. Allantoin is much more water soluble than uric acid and is therefore more easily excreted by the kidneys. Patients in lower-risk groups should be given oral allopurinol during cycles of chemotherapy in an attempt to avoid the condition.

      TLS is graded according to the Cairo-Bishop scoring system as:
      1. Laboratory tumour lysis syndrome
      2. Clinical tumour lysis syndrome

    • This question is part of the following fields:

      • Haematology & Oncology
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  • Question 28 - A keratitis with dendritic ulceration of the cornea is diagnosed in a 32-year-old...

    Incorrect

    • A keratitis with dendritic ulceration of the cornea is diagnosed in a 32-year-old patient. What is the most likely cause?

      Your Answer:

      Correct Answer: Herpes simplex virus

      Explanation:

      The dendritic ulceration seen on fluorescein staining of the eye is pathopneumonic for keratitis caused by HSV (herpes simplex virus). Presentation is that of blepharoconjunctivitis. Treatment is required, the treatment is typically topical acyclovir. Topical steroids can make the infection worse. The other answer choices would not have this dendritic pattern seen on fluorescein staining.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 29 - A 4-year-old girl is diagnosed with acute lymphoblastic leukaemia after presenting with lethargy...

    Incorrect

    • A 4-year-old girl is diagnosed with acute lymphoblastic leukaemia after presenting with lethargy and easy bruising. Which of the following is a marker of a bad prognosis in this disease?

      Your Answer:

      Correct Answer: Philadelphia chromosome positive

      Explanation:

      Philadelphia translocation, t(9;22), is a marker of poor prognosis in acute lymphoblastic leukaemia (ALL).

      ALL is the malignancy of lymphoid progenitor cells affecting B or T cell lineage. This results in the arrest of lymphoid cell maturation and proliferation of immature blast cells (lymphoblasts), leading to bone marrow and tissue infiltration.

      ALL is the most common type of childhood cancers. Its peak incidence is between two to three years of age.

      Acute B lymphoblastic leukaemia (B-ALL) is the most common type of ALL, involving overproduction of B-cell lymphoblasts. It is manifested by low initial WCC and is associated with a good prognosis.

      Poor prognostic factors for ALL include:
      1. Pre-B cell or T-cell ALL (T-ALL)
      2. Philadelphia translocation, t(9;22)
      3. Age <2 years or >10 years
      4. Male sex
      5. CNS involvement
      6. High initial WBC (e.g. >100 x 10^9/L)
      7. non-Caucasian

    • This question is part of the following fields:

      • Haematology & Oncology
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  • Question 30 - A 23 year old man presents with a painful right elbow and left...

    Incorrect

    • A 23 year old man presents with a painful right elbow and left Achilles tendon. He also gives history of dysuria, fever and conjunctivitis. Examination reveals macules and pustules on his hands. He has returned from a trip to Far East 3 weeks ago and admits to having unprotected sex. Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Reactive arthritis

      Explanation:

      Reactive arthritis, (formerly known as Reiter’s syndrome), is an autoimmune condition that occurs after a bacterial infection of the gastrointestinal or urinary tract. It is categorized as a seronegative spondylarthritis because of its association with HLA-B27. Reactive arthritis primarily affects young men and usually presents with musculoskeletal or extra‑articular symptoms. The characteristic triad consists of arthritis, conjunctivitis, and urethritis. The diagnosis is based on clinical features such as patient history and physical examination; there are no specific tests for reactive arthritis. Treatment is primarily symptomatic and consists of the administration of NSAIDs, as most patients recover spontaneously. extraarticular dermatologic manifestations include skin lesions of the glans resembling psoriasis (balanitis circinata); hyperkeratinisation of the palms and soles (keratoderma blenorrhagicum), oral ulcers. Other STDs including HIV, syphilis have different presentations. Psoriatic arthritis is not commonly associated with urethritis and conjunctivitis.

    • This question is part of the following fields:

      • Rheumatology
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