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  • Question 1 - A 41-year-old gentleman undergoes a temporal lobectomy after the discovery of a brain...

    Incorrect

    • A 41-year-old gentleman undergoes a temporal lobectomy after the discovery of a brain tumour. Which one of the following consequences would be least likely to develop?

      Your Answer: Superior homonymous quadrantanopia

      Correct Answer: Astereognosis

      Explanation:

      Astereognosis is associated with lesions to the parietal lobe, not the temporal lobe, so this symptom would not arise in this patient.

    • This question is part of the following fields:

      • Neurology
      2
      Seconds
  • Question 2 - A 61-year-old chef with a known history of Paget's disease is noted to...

    Incorrect

    • A 61-year-old chef with a known history of Paget's disease is noted to have irregular dark red lines radiating from the optic nerve. Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Angioid retinal streaks

      Explanation:

      Angioid retinal streaks are seen on fundoscopy as irregular dark red streaks radiating from the optic nerve head. They are caused by degeneration, calcification and breaks in Bruch’s membrane. They are typically associated with Paget’s disease.

    • This question is part of the following fields:

      • Ophthalmology
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      Seconds
  • 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 - An 18 year old prospective medical student is tested for hepatitis B. Her...

    Incorrect

    • An 18 year old prospective medical student is tested for hepatitis B. Her liver tests show alanine transaminase (ALT) 120 U/L and serology shows her to be positive for HBsAg, HBcAb and HBeAg, with a viral load of 105 genome equivalents/mL.

      A liver biopsy is reported as showing early fibrosis with evidence of moderate inflammation.

      Which of the following treatments should be offered?

      Your Answer:

      Correct Answer: Interferon alfa 2b

      Explanation:

      Interferon alfa alone, not interferon alfa and ribavirin, has been shown to achieve HBeAg seroconversion for patients with HBeAg-positive chronic hepatitis B.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 5 - A 28 yr. old male was screened for hypertrophic cardiomyopathy (HOCM). His father...

    Incorrect

    • A 28 yr. old male was screened for hypertrophic cardiomyopathy (HOCM). His father has passed away recently at the age of 48 and found to have HOCM during post mortem examination. On examination of this patient his BP was 142/84 mmHg and pulse rate was 68 bpm which was regular. There was a mid systolic murmur and a double apex beat. Echocardiography showed a septal wall thickness of 3.3 cm. What is the factor most closely linked to his 20 year risk of sudden cardiac death?

      Your Answer:

      Correct Answer: Septal wall thickness of 3.3 cm

      Explanation:

      There are five prognostic factors which indicate poor prognosis in HOCM:
      -family history of HOCM-related sudden cardiac death
      -unexplained recent syncope
      -large left ventricular wall thickness (MLVWT ≥ 30 mm)
      -multiple bursts of nsVT on ambulatory electrocardiography
      -hypotensive or attenuated blood pressure response to exercise

    • This question is part of the following fields:

      • Cardiology
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  • Question 6 - Which one of the following statements regarding hepatocellular carcinoma is correct? ...

    Incorrect

    • Which one of the following statements regarding hepatocellular carcinoma is correct?

      Your Answer:

      Correct Answer: Diabetes mellitus is a risk factor

      Explanation:

      Diabetes is a risk factor for hepatocellular carcinoma. Screening has been shown to be effective. Bevacizumab is not used for advanced cases. The incidence is higher in men. Alcohol is not the most common underlying cause worldwide; this is from cirrhosis from diseases like hepatitis B and C.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 7 - Drug-induced lupus erythematosus most often occurs after taking which of the following drugs?...

    Incorrect

    • Drug-induced lupus erythematosus most often occurs after taking which of the following drugs?

      Your Answer:

      Correct Answer: Procainamide

      Explanation:

      Many drugs are responsible for causing drug induced lupus. However, it is most commonly associated with hydralazine, procainamide and quinidine.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 8 - A 28 year old man was rushed to the hospital after experiencing sudden...

    Incorrect

    • A 28 year old man was rushed to the hospital after experiencing sudden onset chest pain while playing football. He has never felt such pain in the past. However, one of his uncles had a similar sudden discomfort at a young age and he passed away following a heart problem.
      The following vitals are recorded on examination:
      BP: 101/74 mmHg
      RR: 22 breaths/min
      PR: 87 beats/min
      Physical examination reveals abnormally long fingers and on asking the man to hold the opposite wrist, the thumb and little finger overlap each other. He is not taking any medication regularly and past medical/surgical history is not significant. He admits to smoking half pack of cigarettes/day for the last 10 years but denies abusing any illicit drugs.
      Which of the following explanation most likely explains the disease process in this man?

      Your Answer:

      Correct Answer: A defect of the glycoprotein structure which usually wraps around elastin

      Explanation:

      Aortic dissection is defined as separation of the layers within the aortic wall. Tears in the intimal layer result in the propagation of dissection (proximally or distally) secondary to blood entering the intima-media space. This can be caused as a result of both congenital or acquired factors like chronic uncontrolled hypertension. This patient shows no sign of hypertension but his physical examination hints towards Marfan Syndrome. Marfan syndrome (MFS) is an autosomal dominant connective tissue disorder affecting the microfibrils and elastin in connective tissue throughout the body. MFS is associated with pathological manifestations in the cardiovascular system (e.g., mitral valve prolapse, aortic aneurysm, and dissection), the musculoskeletal system (e.g., tall stature with disproportionately long extremities, joint hypermobility), and the eyes (e.g., subluxation of the lens of the eye). Decreased collagen production occurs in ageing, hydroxylation defects are present in vitamin C deficiency, copper deficiency affecting lysyl oxidase enzyme occurs in Menke’s disease.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 9 - 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 10 - A 45-year-old male patient who was initially investigated for having an abdominal mass...

    Incorrect

    • A 45-year-old male patient who was initially investigated for having an abdominal mass is diagnosed as having Burkitt lymphoma. He is due to start chemotherapy today.

      Which one of the following should be given prior to his chemotherapy in order to reduce the risk of tumour lysis syndrome?

      Your Answer:

      Correct Answer: Rasburicase

      Explanation:

      Rasburicase should be given prior to chemotherapy in order to reduce the risk of tumour lysis syndrome (TLS). Rasburicase is a recombinant version of urate oxidase which is an enzyme that metabolizes uric acid to allantoin. Allantoin is 5–10 times more soluble than uric acid, hence, renal excretion is more effective.

      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.

      Burkitt lymphoma is a high-grade B-cell neoplasm. There are two major forms:
      1. Endemic (African) form: typically involves maxilla or mandible.
      2. Sporadic form: abdominal (e.g. ileocaecal) tumours are the most common form. More common in patients with HIV.

      Burkitt lymphoma is associated with the c-myc gene translocation, usually t(8;14). The Epstein-Barr virus (EBV) is strongly implicated in development of the African form of Burkitt lymphoma and to a lesser extent, the sporadic form.

      Management of the lymphoma is with chemotherapy. This tends to produce a rapid response which may cause TLS.

    • This question is part of the following fields:

      • Haematology & Oncology
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  • Question 11 - Regarding the pathophysiology of diabetes mellitus, which of the following is true? ...

    Incorrect

    • Regarding the pathophysiology of diabetes mellitus, which of the following is true?

      Your Answer:

      Correct Answer: Concordance between identical twins is higher in type 2 diabetes mellitus than type 1

      Explanation:

      Type 1 diabetes is a chronic illness characterized by the body’s inability to produce insulin due to the autoimmune destruction of the beta cells in the pancreas. Approximately 95% of patients with type 1 DM have either HLA-DR3 or HLA-DR4. Although the genetic aspect of type 1 DM is complex, with multiple genes involved, there is a high sibling relative risk. Whereas dizygotic twins have a 5-6% concordance rate for type 1 DM, monozygotic twins will share this diagnosis more than 50% of the time by the age of 40 years.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 12 - A 35-year-old female presented with complaints of earache and a high-grade fever. During...

    Incorrect

    • A 35-year-old female presented with complaints of earache and a high-grade fever. During examination, numerous small vesicles were found within the ear canal and her ear is very tender. Which one of the following organisms is most likely to be responsible for such a condition?

      Your Answer:

      Correct Answer: Herpes zoster

      Explanation:

      Herpes zoster is a viral disorder in which painful vesicular lesions are present in a specific dermatome area. High-grade fever may present as well due to infection. Varicella zoster, measles, herpes simplex and HIV do not present with tender lesions of a limited area.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 13 - A 27-year-old man with a history of asthma presents for review. He has...

    Incorrect

    • A 27-year-old man with a history of asthma presents for review. He has recently been discharged from hospital following an acute exacerbation and reports generally poor control with a persistent night time cough and exertional wheeze.

      His current asthma therapy is:
      salbutamol inhaler 100mcg prn
      Clenil (beclomethasone dipropionate) inhaler 800mcg bd
      salmeterol 50mcg bd

      He has a history of missing appointments and requests a prescription with as few side-effects as possible. What is the most appropriate next step in management?

      Your Answer:

      Correct Answer: Leukotriene receptor antagonist

      Explanation:

      The NICE 2019 guidelines states that in patients who are uncontrolled with a SABA (Salbutamol) and ICS (Beclomethasone), LTRA should be added.
      If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS as maintenance therapy, offer a leukotriene receptor antagonist (LTRA) in addition to the ICS and review the response to treatment in 4 to 8 weeks.

    • This question is part of the following fields:

      • Respiratory
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  • Question 14 - A 28 year old man presents to the clinic with fatigue, exertional dyspnoea,...

    Incorrect

    • A 28 year old man presents to the clinic with fatigue, exertional dyspnoea, abdominal discomfort, xerophthalmia and xerostomia. Examination reveals enlargement of the parotid glands bilaterally, hepatomegaly and peripheral motor neuropathy. Lab results are negative for RF, ANA, SS-A and SS-B antibodies. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Diffuse infiltrative lymphocytic syndrome (DILS)

      Explanation:

      The Diffuse Infiltrative Lymphocytosis Syndrome (DILS) is a rare multisystemic syndrome described in HIV-infected patients. It is characterised by CD8(+) T-cell lymphocytosis associated with a CD8(+) T-cell infiltration of multiple organs. DILS is usually seen in uncontrolled or untreated HIV infection but can also manifest itself independently of CD4(+) T-cell counts. The syndrome may present as a Sjögren-like disease that generally associates sicca signs with bilateral parotiditis, lymphadenopathy, and extra glandular organ involvement. The latter may affect the lungs, nervous system, liver, kidneys, and digestive tract. Anomalies of the respiratory system are often identified as lymphocytic interstitial pneumonia. Facial nerve palsy, aseptic meningitis or polyneuropathy are among the more frequent neurological features. Hepatic lymphocytic infiltration, lymphocytic interstitial nephropathy and digestive tract lymphocytic infiltration account for more rarely noted complications. Sicca syndrome, organomegaly and/or organ dysfunction associated with polyclonal CD8(+) T-cell organ-infiltration are greatly suggestive of DILS in people living with HIV.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 15 - A 3-year-old boy presents with recurrent urinary tract infections. What is the most...

    Incorrect

    • A 3-year-old boy presents with recurrent urinary tract infections. What is the most common cause for this problem in a child of this age?

      Your Answer:

      Correct Answer: Vesicoureteric reflux

      Explanation:

      Vesicoureteral reflux is the condition when the urine flows backwards from the bladder into the kidneys, which is the most common cause of UTI in patients this age.

    • This question is part of the following fields:

      • Nephrology
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  • Question 16 - Which of the following diseases correctly matches the incubation period? ...

    Incorrect

    • Which of the following diseases correctly matches the incubation period?

      Your Answer:

      Correct Answer:

      Explanation:

      The incubation periods of disorders is extremely important to diagnose, treat, prevent or attenuate a disease.
      Chickenpox: 7-21 days.
      Whooping cough: 10-14 days.
      Hand, foot and mouth disease: 2-6 days. German measles: 14-21 days.
      Mumps: 14-18 days.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 17 - A 77-year-old woman is admitted in an unconscious state. On examination in casualty,...

    Incorrect

    • A 77-year-old woman is admitted in an unconscious state. On examination in casualty, her temperature is 33 °C and she was in left ventricular failure.
      Her blood glucose level is 5.7 mmol/l and random cortisol is elevated. Free T4 is 4.4 pmol/l.
      A CT scan of her brain reveals no focal lesion and a cursory assessment reveals no gross focal neurology.

      Which diagnosis fits best with this woman’s clinical picture?

      Your Answer:

      Correct Answer: Profound hypothyroidism

      Explanation:

      Elderly patients with severe hypothyroidism often present with variable symptoms that may be masked or potentiated by co-morbid conditions. Characteristic symptoms may include fatigue, weight gain, cold intolerance, hoarseness, constipation, and myalgias. Neurologic symptoms may include ataxia, depression, and mental status changes ranging from mild confusion to overt dementia.
      Clinical findings that may raise suspicion of thyroid hormone deficiency include hypothermia, bradycardia, goitrous enlargement of the thyroid, cool dry skin, myxoedema, delayed relaxation of deep tendon reflexes, a pericardial or abdominal effusion, hyponatremia, and hypercholesterolemia.

      The patient has a greatly reduced free T4 concentration, is hypothermic, unconscious and has evidence of associated heart failure. All of those support the diagnosis of profound hypothyroidism.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 18 - A 50-year-old woman diagnosed with non-Hodgkin's Lymphoma is about to be started on...

    Incorrect

    • A 50-year-old woman diagnosed with non-Hodgkin's Lymphoma is about to be started on the CHOP regimen (cyclophosphamide, hydroxydaunorubicin, vincristine, and prednisolone). Her pre-chemotherapy blood investigations show:

      Hb: 11.8 g/dL,
      Platelets: 423 x 109/L,
      WBC: 11.2 x 109/L,
      Na+: 143 mmol/L,
      K+: 3.9 mmol/L,
      Urea: 6.2 mmol/L,
      Creatinine: 78 μmol/L,
      Uric acid: 0.45 mmol/L,

      Ciprofloxacin is prescribed in addition to the CHOP regimen to reduce the risk of neutropenic sepsis. Which of the following drugs should be added to lower the risk of other complications?

      Your Answer:

      Correct Answer: Allopurinol

      Explanation:

      Tumour lysis syndrome (TLS) occurs most notably in patients with haematological malignancies including, Non-Hodgkin’s Lymphoma (NHL) and Acute Lymphocytic Leukaemia (ALL).
      Risk factors for TLS include:
      • Large tumour burden
      • Sensitivity of the tumour to chemotherapy
      • Rapid tumour growth rate
      TLS is characterized by:
      • Hyperuricemia
      • Hyperkalaemia
      • Hyperphosphatemia
      • Hypocalcaemia
      Treatment of TLS:
      • Allopurinol: It is a xanthine oxidase inhibitor, it reduces the conversion of nucleic acid by-products to uric acid. Thus, it prevents urate nephropathy and subsequent oliguric renal failure. Note: dose reduction is essential in renal failure or if given along with mercaptopurine or azathioprine.
      Alternatives to Allopurinol: Febuxostat; Rasburicase are useful in patients with hyperuricemia.
      • Hydration
      • Diuresis: Should be considered in well hydrated patients with insufficient urine output. Furosemide to be considered in normo-volemic patients with hyperkalaemia. Urine alkalization can be considered for promoting alkaline diuresis.
      • Treatment of electrolyte imbalances including hyperkalaemia, hyperphosphatemia, and hypocalcaemia.
      • Dialysis can be considered in refractory cases.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 19 - A 30-year-old female was brought to the ER in a confused state. The...

    Incorrect

    • A 30-year-old female was brought to the ER in a confused state. The patient works in a photograph development laboratory. On admission, she was hypoxic and hypotensive. A provisional diagnosis of cyanide poisoning was made. What is the definitive treatment?

      Your Answer:

      Correct Answer: Hydroxocobalamin

      Explanation:

      Cyanide poisoning:
      Aetiology:
      Smoke inhalation, suicidal ingestion, and industrial exposure (specific industrial processes involving cyanide include metal cleaning, reclaiming, or hardening; fumigation; electroplating; and photo processing) are the most frequent sources of cyanide poisoning. Treatment with sodium nitroprusside or long-term consumption of cyanide-containing foods is a possible source.
      Cyanide exposure most often occurs via inhalation or ingestion, but liquid cyanide can be absorbed through the skin or eyes. Once absorbed, cyanide enters the blood stream and is distributed rapidly to all organs and tissues in the body. 

      Pathophysiology:
      Inside cells, cyanide attaches itself to ubiquitous metalloenzymes, rendering them inactive. Its principal toxicity results from inactivation of cytochrome oxidase (at cytochrome a3), thus uncoupling mitochondrial oxidative phosphorylation and inhibiting cellular respiration, even in the presence of adequate oxygen stores.

      Presentation:
      • ‘Classical’ features: brick-red skin, smell of bitter almonds
      • Acute: hypoxia, hypotension, headache, confusion
      • Chronic: ataxia, peripheral neuropathy, dermatitis

      Management:
      • Supportive measures: 100% oxygen, ventilatory assistance in the form of intubation if required.
      • Definitive: Hydroxocobalamin (iv) is considered the drug of choice and is approved by the FDA for treating known or suspected cyanide poisoning.
      • Coadministration of sodium thiosulfate (through a separate line or sequentially) has been suggested to have a synergistic effect on detoxification.
      Mechanism of action of hydroxocobalamin:
      • Hydroxocobalamin combines with cyanide to form cyanocobalamin (vitamin B-12), which is renally cleared.
      • Alternatively, cyanocobalamin may dissociate from cyanide at a slow enough rate to allow for cyanide detoxification by the mitochondrial enzyme rhodanese.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 20 - A 70-year-old male with advanced COPD currently on treatment with salbutamol (as required)...

    Incorrect

    • A 70-year-old male with advanced COPD currently on treatment with salbutamol (as required) presents for review. After a complete history and examination, you conclude that he requires to be stepped up in his inhalational therapy. The decision to add tiotropium bromide to his regime was taken. Which of the following best describe the mechanism of action of tiotropium?

      Your Answer:

      Correct Answer: It is a long-acting anticholinergic agent

      Explanation:

      Tiotropium is a specific long-acting antimuscarinic agent indicated as maintenance therapy for patients with COPD (chronic obstructive pulmonary disease).
      It should be used cautiously in patients with narrow-angle glaucoma, prostatic hyperplasia or bladder neck obstruction.
      The most frequently encountered adverse effects of tiotropium include pharyngitis, bronchitis, sinusitis, dry mouth, cough, and headaches. Paradoxical bronchospasm may also occur as a rare side-effect.
      Dry mouth occurs in up to 14% of patients taking tiotropium, in keeping with its anticholinergic profile.
      Rarer side-effects include tachycardia, blurred vision, urinary retention, and constipation.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 21 - A 63-year-old man, known to have small cell lung cancer and ischaemic heart...

    Incorrect

    • A 63-year-old man, known to have small cell lung cancer and ischaemic heart disease (IHD), presents with increasing shortness of breath for the past 7 days. It becomes worse at night and is associated with an occasional non-productive cough. He has also noticed that his wedding ring feels tight. His cancer was diagnosed five months ago and he has recently completed a course of chemotherapy. From a cardiac point of view, he had a myocardial infarction (MI) two years ago following which he had primary angioplasty with stent placement. He has had no episode of angina since then.

      Clinical examination of his chest is unremarkable. He does, however, have distended neck veins and periorbital oedema.

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Superior vena cava obstruction

      Explanation:

      Superior vena cava (SVC) obstruction is an oncological emergency caused by compression of the SVC and is most commonly associated with lung cancer.

      Some causes of the condition include:
      1. Common malignancies: non small cell lung cancer, lymphoma
      2. Other malignancies: metastatic seminoma, Kaposi’s sarcoma, breast cancer
      3. Aortic aneurysm
      4. Mediastinal fibrosis

      Clinical features of SVC obstruction include:
      1. Dyspnoea: most common
      2. Swelling of the face, neck, and arms: conjunctival and periorbital oedema may be seen
      3. Headache: often worse in the morning
      4. Visual disturbances
      5. Pulseless jugular venous distension

      Management options are:
      1. General: dexamethasone, balloon venoplasty, stenting
      2. Small cell lung cancer: chemotherapy and radiotherapy
      3. Non small cell lung cancer: radiotherapy

    • This question is part of the following fields:

      • Haematology & Oncology
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  • Question 22 - A 69-year-old woman is admitted with confusion. She's known to have a history...

    Incorrect

    • A 69-year-old woman is admitted with confusion. She's known to have a history of multiple myeloma. Blood exam reveals the following: Na+ = 147 mmol/l, K+ = 4.7 mmol/l, Urea = 14.2 mmol/l, Creatinine = 102 μmol/l, Adjusted calcium = 3.9 mmol/l. What is the single most appropriate management?

      Your Answer:

      Correct Answer: IV 0.9% saline

      Explanation:

      NICE guidelines on hypercalcemia recommend that maintaining good hydration equals drinking 3-4 L of fluid/day, provided there are no contraindications. A low calcium diet is not necessary because intestinal absorption of calcium is reduced. The patient should avoid any other drugs or vitamins that could worsen the hypercalcemia. Mobilization is encouraged and any symptoms of hypercalcemia should be reported.

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 23 - A 49 year old man states that he is feeling down and has...

    Incorrect

    • A 49 year old man states that he is feeling down and has not been sleeping well. An assessment is done using a validated symptom measure which indicates that he is moderately depressed. He is currently taking Ramipril, Simvastatin and Aspirin for ischaemic heart disease. What is the most appropriate course of action?

      Your Answer:

      Correct Answer: Start sertraline + lansoprazole

      Explanation:

      Results of a randomized trial confirm that the antidepressant sertraline can be used safely in patients with recent MI or unstable angina and is effective in relieving depression in these patients.

      There are theoretical reasons for believing that selective serotonin reuptake inhibitors (SSRIs), widely used to treat depression, might increase the risk of gastrointestinal bleeding. Gastroprotective drugs are advocated for high risk patients taking non-steroidal anti-inflammatory drugs, another class of drug that causes gastrointestinal bleeding.

      Serotonin is released from platelets in response to vascular injury and promotes vasoconstriction and a change in the shape of the platelets that leads to aggregation. Platelets cannot themselves synthesise serotonin. SSRIs inhibit the serotonin transporter, which is responsible for the uptake of serotonin into platelets. It could thus be predicted that SSRIs would deplete platelet serotonin, leading to a reduced ability to form clots and a subsequent increase in the risk of bleeding.

      The well established association between nonsteroidal anti-inflammatory drugs and upper gastrointestinal bleeding is estimated to result in 700-2000 deaths/year in the UK. This has led to the recommendation that patients in high risk groups should receive gastroprotection in the form of an H2 antagonist, proton pump inhibitor (lansoprazole), or misoprostol.

      Proton pump inhibitors have been shown to reduce endoscopically diagnosed mucosal damage and heal ulcers induced by non-steroidal anti-inflammatory drugs but not to reduce the incidence of severe gastrointestinal bleeds.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 24 - A 74-year-old woman is admitted with headaches, polyuria and polydipsia of recent onset....

    Incorrect

    • A 74-year-old woman is admitted with headaches, polyuria and polydipsia of recent onset. She has a history of mastectomy for breast cancer. A CT head scan shows multiple cerebral metastases.

      Her admission biochemistry results are as follows:
      Sodium 153 mmol/l,
      Potassium 4.0 mmol/L,
      Urea 5.0 mmol/L,
      Creatinine 110 micromol/L,
      Glucose 5mmol/l.
      Over the next 24 hours, she has a urinary volume of 4.4 litres and further tests reveal plasma osmolality 320mOsm/kg and urinary osmolality: 254mOsm/kg.

      Which one of the following treatments should be used?

      Your Answer:

      Correct Answer: Desmopressin (DDAVP)

      Explanation:

      Diabetes insipidus (DI) is defined as the passage of large volumes (>3 L/24 hr) of dilute urine (< 300 mOsm/kg). It has the following 2 major forms:
      – Central (neurogenic, pituitary, or neurohypophyseal) DI, characterized by decreased secretion of antidiuretic hormone (ADH; also referred to as arginine vasopressin [AVP])
      – Nephrogenic DI, characterized by decreased ability to concentrate urine because of resistance to ADH action in the kidney
      This patient has the central type from metastases.
      In patients with central DI, desmopressin is the drug of choice. It is a synthetic analogue of antidiuretic hormone (ADH). It is available in subcutaneous, IV, intranasal, and oral preparations. Generally, it can be administered 2-3 times per day. Patients may require hospitalization to establish fluid needs. Frequent electrolyte monitoring is recommended during the initial phase of treatment.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 25 - A 60 yr. old man with atrial fibrillation (AF) who is on warfarin...

    Incorrect

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

      Your Answer:

      Correct Answer:

      Explanation:

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

    • This question is part of the following fields:

      • Cardiology
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  • Question 26 - A 63-year-old male presents with behavioural disturbances. He has a history of chronic...

    Incorrect

    • A 63-year-old male presents with behavioural disturbances. He has a history of chronic alcohol intake and previous Wernicke's encephalopathy. He has not consumed alcohol in the past 2 years.
      Which among the following phenomena is he likely to display on further assessment?

      Your Answer:

      Correct Answer: Confabulation

      Explanation:

      In a patient with chronic alcoholism, one can expect confabulations, which point towards a diagnosis of Korsakoff’s syndrome.

      Korsakoff’s is characterized by confabulation and amnesia, typically occurring in alcoholics secondary to chronic vitamin B1 (thiamine) deficiency.

      Other options:
      Dysthymia refers to mild depression.
      Hydrophobia is a feature of rabies
      Lilliputians may be observed in delirium tremens.
      Perseveration is repetitive speech patterns, commonly seen after traumatic brain injury.

      According to the Caine criteria, the presence of any two among the four following criteria can be used to clinically diagnose Wernicke’s Encephalopathy:
      Dietary deficiency
      Oculomotor abnormalities
      Cerebellar dysfunction
      Either altered mental status or mild memory impairment
      Korsakoff psychosis:
      Altered mental status – disorientation, confabulations
      Oculomotor findings – most often horizontal nystagmus, ophthalmoplegia, cranial nerve IV palsy, conjugate gaze
      Ataxia – wide-based gait

      Treatment:
      The mainstay of treatment in an acute presentation is thiamine replacement.
      Electrolyte abnormalities should be corrected and fluids replaced.
      In particular, magnesium requires replacement, as thiamine-dependent enzymes cannot operate in a magnesium-deficient state.
      After the acute phase of vitamin and electrolyte replacement, memory rehabilitation is beneficial in Korsakoff syndrome.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 27 - Choose the wrong statement regarding hypocalcaemia: ...

    Incorrect

    • Choose the wrong statement regarding hypocalcaemia:

      Your Answer:

      Correct Answer: Chvostek's sign is more sensitive and specific than Trousseau's sign

      Explanation:

      Chvostek and Trousseau signs can be elicited in patients with hypocalcaemia. Chvostek sign is the twitching of the upper lip with tapping on the cheek 2 cm anterior to the earlobe, below the zygomatic process overlying the facial nerve. Trousseau sign (a more reliable sign present in 94% of hypokalaemic individuals and only 1% to 4% of healthy people) is the presence of carpopedal spasm observed following application of an inflated blood pressure cuff over systolic pressure for 3 minutes in hypokalaemic patients.

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 28 - A 55 year old female presents with progressive dyspnoea, dry cough and fever....

    Incorrect

    • A 55 year old female presents with progressive dyspnoea, dry cough and fever. She started methotrexate therapy six weeks ago. The current regimen includes methotrexate 15 mg/ week, folic acid 5 mg/day and aspirin 75 mg/day. There is no history of any other chronic illness. Vitals are as follows: Temp: 37.8C, pulse: 100 beats/min, BP: 110/80mmHg and SaO2: 90% on air. Examination reveals synovitis in both wrists, and metacarpophalangeal joints. On auscultation, there are scattered crepitations. Blood test reports are given below:
      Haemoglobin: 13.1g/dl (13.0 – 18.0 g/dL),
      WBC: 8.2 x109/l (4 – 11 x 109/l),
      Neutrophils: 5.1×109/l (1.5 – 7 x 109/l),
      Platelets: 280 x109/l (150 – 400 x 109/L),
      ESR: 48 mm/hr (0 – 30 mm/1st hr),
      Urea, electrolytes and creatinine: normal.
      CXR: patchy airspace shadows bilaterally

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Methotrexate pneumonitis

      Explanation:

      Pneumonitis is a serious and unpredictable side-effect of treatment with methotrexate (MTX) that may become life-threatening. The typical clinical symptoms include progressive shortness of breath and cough, often associated with fever. Hypoxaemia and tachypnoea are always present and crackles are frequently audible. Chest radiography reveals a diffuse interstitial or mixed interstitial and alveolar infiltrate, with a predilection for the lower lung fields. Pulmonary function tests show a restrictive pattern with diminished diffusion capacity. Lung biopsy reveals cellular interstitial infiltrates, granulomas or a diffuse alveolar damage pattern accompanied by perivascular inflammation. Most patients present in the first few months of starting methotrexate. It is important that all patients receiving methotrexate be educated concerning this potential adverse reaction and instructed to contact their physicians should significant new pulmonary symptoms develop while undergoing therapy. If methotrexate pneumonitis is suspected, methotrexate should be discontinued, supportive measures instituted and careful examination for different causes of respiratory distress conducted. This may be treated with corticosteroids once underlying infection has been excluded.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 29 - A 17-year-old girl presented with fever, headache and photophobia. Cerebrospinal fluid examination reveals:
    ...

    Incorrect

    • A 17-year-old girl presented with fever, headache and photophobia. Cerebrospinal fluid examination reveals:

      Opening pressure 260 mm H20 (50-180)
      Total protein 0.8 g/l (0.15-0.45)
      Glucose 4.2 mmol/l (3.3-4.4)
      White cell count 60 per ml (<5)
      Lymphocytes 90%
      Plasma glucose 6.4 mmol/l (3.0-6.0)

      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Viral meningitis

      Explanation:

      Normal cerebrospinal fluid (CSF) glucose together with lymphocytosis, an increased opening pressure and raised CSF protein are typical of a viral meningitis.

    • This question is part of the following fields:

      • Neurology
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  • Question 30 - A 36-year-old man with diabetes is referred with abnormal liver biochemistry. Which of...

    Incorrect

    • A 36-year-old man with diabetes is referred with abnormal liver biochemistry. Which of the following is in keeping with a diagnosis of haemochromatosis?

      Your Answer:

      Correct Answer: Transferrin saturation 78% (20-50)

      Explanation:

      A high transferrin saturation is seen in hemochromatosis, as well as a high iron level (>30), a high ferritin level, and a LOW TIBC (<20). Think of it like the opposite findings of iron deficiency anaemia which is a low iron, low ferritin, high TIBC.

    • This question is part of the following fields:

      • Gastroenterology
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