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  • Question 1 - A 78-year-old retired journalist known to have prostatic carcinoma presents to the ED...

    Incorrect

    • A 78-year-old retired journalist known to have prostatic carcinoma presents to the ED complaining of pain in the spine and the onset of severe lower-leg weakness accompanied by a loss of sensation. On examination, he is found to have percussion tenderness of his spine, loss of sensation up to the umbilicus and a distended bladder. He has markedly reduced power of the lower legs with hyperreflexia. Which of the following should not be part of your management of this patient?

      Your Answer: Chest X-rays

      Correct Answer: Spinal X-rays

      Explanation:

      Acute cord compression is a medical emergency. Typically, signs of segmental damage at the level of compression are usually combined with corticospinal tract dysfunction (e.g., hyperreflexia, Babinski’s sign and weakness) and sensory deficits below the level of compression. Symptoms include spinal pain that precedes the development of weak legs and sensory loss. There may be loss of bladder (and anal) sphincter control, manifesting as hesitancy, frequency and, finally, painless retention.
      Spinal X-rays are rarely diagnostic. MRI is usually the investigation of choice and should not be delayed, but if not available consider doing a CT scan and myelography to confirm cord compression and fully define the level and extent of the lesion. If malignancy is the cause, it is important to give dexamethasone (oral or intravenous) while considering therapy more specific to the cause.

    • This question is part of the following fields:

      • Neurology
      5
      Seconds
  • Question 2 - Which of the following is most helpful in differentiating chronic from acute renal...

    Incorrect

    • Which of the following is most helpful in differentiating chronic from acute renal failure?

      Your Answer:

      Correct Answer: Kidney size at ultrasound scan

      Explanation:

      The size of the kidneys on ultrasound would differentiate chronic from acute renal failures. Chronic renal failure is more associated with small-sized kidneys.

    • This question is part of the following fields:

      • Nephrology
      7
      Seconds
  • Question 3 - A 32 year old woman presents with a painful elbow which she has...

    Incorrect

    • A 32 year old woman presents with a painful elbow which she has been feeling for the past two weeks. Which of the following will be consistent with a diagnosis of tennis elbow?

      Your Answer:

      Correct Answer: Pain on wrist extension against resistance

      Explanation:

      Lateral epicondylitis (tennis elbow) is an overuse injury of the hand and finger extensor tendons that originate in the lateral humeral epicondyle that occurs following repeated or excessive pronation/supination and extension of the wrist (e.g., in racquet sports). Clinical features include pain and tenderness over the lateral epicondyle and along extensor muscles and thickening of the tendons. The examiner holds the patient’s hand with the thumb placed over the lateral epicondyle – The patient makes a fist, supinates the forearm, deviates radially, and extends the fist against the examiner’s resistance which will result in pain over the lateral epicondyle. Conservative treatment includes rest, physiotherapy and orthotic braces. If this fails corticosteroids and lidocaine injections are employed. Surgery is indicated in patients with persistent symptoms despite 6 months of conservative treatment. Excision of abnormal tendon tissue; longitudinal incisions (tenotomies) in scarred and fibrotic areas to promote healing.

    • This question is part of the following fields:

      • Rheumatology
      0
      Seconds
  • Question 4 - A 72-year-old woman presents with 18 month history of gait ataxia, dysarthria, and...

    Incorrect

    • A 72-year-old woman presents with 18 month history of gait ataxia, dysarthria, and dysphagia.
      On examination there is down beating nystagmus and slurred speech. There is past pointing in both upper limbs and a wide-based ataxic gait. Reflexes and sensation are normal. There is no wasting or fasciculations. Plantar response is flexor bilaterally.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Arnold-Chiari malformation

      Explanation:

      Downbeat nystagmus (DBN) suggests a lesion in the lower part of the medulla. Arnold-Chiari malformation usually presents with symptoms due to brainstem and lower cranial nerve dysfunction such as DBN.

    • This question is part of the following fields:

      • Neurology
      0
      Seconds
  • Question 5 - What is the mode of spread of chickenpox? ...

    Incorrect

    • What is the mode of spread of chickenpox?

      Your Answer:

      Correct Answer: Airborne

      Explanation:

      Chickenpox is a highly communicable viral disease caused by human (alpha) herpesvirus 3 (varicella-zoster virus, VZV). It is transmitted from person to person by direct contact (touching the rash), droplet or air born spread (coughing and sneezing).

    • This question is part of the following fields:

      • Infectious Diseases
      0
      Seconds
  • Question 6 - Which of the following involving the scalp may produce alopecia (hair loss)? ...

    Incorrect

    • Which of the following involving the scalp may produce alopecia (hair loss)?

      Your Answer:

      Correct Answer: Discoid lupus erythematosus

      Explanation:

      Infective causes of hair loss include:
      Dissecting cellulitis
      Fungal infections (such as tinea capitis)
      Folliculitis
      Secondary syphilis
      Demodex folliculorum
      Lupus erythematosus (hair loss may be permanent due to scarring of the hair follicles).
      Psoriasis and seborrheic dermatitis commonly involve the scalp but do not produce hair loss.

    • This question is part of the following fields:

      • Dermatology
      0
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  • Question 7 - Which one of the following statements regarding nitric oxide is incorrect? ...

    Incorrect

    • Which one of the following statements regarding nitric oxide is incorrect?

      Your Answer:

      Correct Answer: Promotes platelet aggregation

      Explanation:

      Nitric oxide, known as an endothelium-derived relaxing factor (EDRF), is biosynthesized endogenously from L-arginine, oxygen, and NADPH by various nitric oxide synthase (NOS) enzymes and is a signaling molecule in many physiological and pathological processes in humans.
      One of the main enzymatic targets of nitric oxide is guanylyl cyclase. The binding of nitric oxide to the haem region of the enzyme leads to activation, in the presence of iron.

    • This question is part of the following fields:

      • Clinical Sciences
      0
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  • Question 8 - A 32 year-old man presents with his first generalized tonic-clonic seizure (GTCS). He...

    Incorrect

    • A 32 year-old man presents with his first generalized tonic-clonic seizure (GTCS). He has been complaining of headaches for the past 2 weeks, although he has been able to continue working at his job. Upon examination, he has mild left hemiparesis and bilateral extensor plantar responses. General examination is otherwise unremarkable. An urgent CT scan of the brain shows a 5cm multicentric mass lesion in the right frontal lobe with surrounding vasogenic oedema and some hemisphere shift. Which of the following is the most likely underlying pathology?

      Your Answer:

      Correct Answer: Glioblastoma

      Explanation:

      Glioblastoma multiforme, also considered as grade IV astrocytoma, is the most malignant form of the tumour and accounts for about 20% of all cerebral tumours. These often remain clinically silent until they have reached a large enough size. In adults, glioblastoma multiforme usually occurs in the cerebral hemispheres, especially the frontal and temporal lobes of the brain. About half occupy more than one hemisphere at presentation, and some are multicentric. Biopsy shows high cellularity with mitoses, pleomorphism, and vascular hyperplasia. Prognosis is extremely poor, with only 20% surviving beyond 1 year and 10% beyond 2 years.

    • This question is part of the following fields:

      • Neurology
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      Seconds
  • Question 9 - Which of the following statements describe the mechanism of fibrates most accurately? ...

    Incorrect

    • Which of the following statements describe the mechanism of fibrates most accurately?

      Your Answer:

      Correct Answer: Increased lipoprotein lipase activity via PPAR-alpha

      Explanation:

      The main mechanism of fibrate drugs is activation of gene transcription factors known as PPARs, particularly PPAR-α, which regulate the expression of genes that control lipoprotein metabolism. There are several consequences of PPAR-α activation, which reduce circulating LDL cholesterol and triglycerides and increase HDL cholesterol.

    • This question is part of the following fields:

      • Cardiology
      0
      Seconds
  • Question 10 - A homeless woman presented with a cough and fever for the last 3...

    Incorrect

    • A homeless woman presented with a cough and fever for the last 3 months. She also complained of night sweats and weight loss. Her CXR showed lung opacities. What is the next appropriate step for this patient?

      Your Answer:

      Correct Answer: Acid fast bacilli

      Explanation:

      History and CXR are suggestive of tuberculosis. Acid fast bacilli should be seen on microscopy to confirm the diagnosis.

    • This question is part of the following fields:

      • Infectious Diseases
      0
      Seconds
  • Question 11 - A 50-year-old man is found incidentally to have hypercalcaemia during a routine health...

    Incorrect

    • A 50-year-old man is found incidentally to have hypercalcaemia during a routine health screen.
      Which one of the following biochemical findings would be most suggestive of primary hyperparathyroidism rather than any other cause of hypercalcaemia?

      Your Answer:

      Correct Answer: Serum PTH concentration within the normal range

      Explanation:

      Primary hyperparathyroidism (PHPT) is diagnosed based upon levels of blood calcium and parathyroid hormone (PTH). In most people with PHPT, both levels are higher than normal. Occasionally, a person may have an elevated calcium level and a normal or minimally elevated PTH level. Since PTH should normally be low when calcium is elevated, a minimally elevated PTH is considered abnormal and indicates PHPT.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 12 - A 74-year-old widow is undergoing haemodialysis for chronic renal failure. What is the...

    Incorrect

    • A 74-year-old widow is undergoing haemodialysis for chronic renal failure. What is the most common problem that can arise in this case?

      Your Answer:

      Correct Answer: Protein–calorie malnutrition

      Explanation:

      Protein-calorie malnutrition is observed in almost 50% of dialysis patients, contributing to increased morbidity and mortality. All the other complications listed can usually be prevented thanks to modern-day dialysis techniques.

    • This question is part of the following fields:

      • Nephrology
      0
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  • Question 13 - A 26-year-old woman is 24 weeks pregnant had a recent ultrasound that shows...

    Incorrect

    • A 26-year-old woman is 24 weeks pregnant had a recent ultrasound that shows the foetus large for dates.
      She has an oral glucose tolerance test (OGTT) which was requested due to a combination of her Asian ethnicity and background of obesity.
      The following results are obtained:
      (Time (hours) : Blood glucose (mmol/l)),
      0 : 9.2,
      2 : 14.2.

      What is the most appropriate management?

      Your Answer:

      Correct Answer: Start insulin

      Explanation:

      Insulin remains the standard of care for the treatment of uncontrolled gestational diabetes. Tight control maintained in the first trimester and throughout pregnancy plays a vital role in decreasing poor fetal outcomes, including structural anomalies, macrosomia, hypoglycaemia of the new-born, adolescent and adult obesity, and diabetes.
      The baby is already large for dates so nutritional therapy can not be used alone.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 14 - An 80 year-old Zimbabwean woman with known rheumatoid arthritis was admitted to hospital...

    Incorrect

    • An 80 year-old Zimbabwean woman with known rheumatoid arthritis was admitted to hospital with a four week history of weight loss, night sweats and cough. She was given a course of Amoxicillin for the past week but her condition deteriorated and she was referred to the hospital when she developed haemoptysis.
       
      She was on maintenance prednisolone 10 mg once per day and four weeks earlier, she had received infliximab for a flare up of rheumatoid arthritis. She lived with her husband but had been admitted to hospital himself with influenza four days earlier. She was a lifelong non-smoker and worked most of her life as a missionary in Zimbabwe and South Africa.
       
      On examination she looked cachexic and was pyrexial with a temperature of 38.5°C. Her blood pressure was 181/101 mmHg, pulse 121 beats per minute and oxygen saturations of 89% on room air. Her heart sounds were normal and there were no audible murmurs. Auscultation of her lung fields revealed bronchial breath sounds in the left upper zone. Examination of her abdomen was normal.
       
      Mantoux test < 5mm (after 48 hours)
      A chest radiograph revealed cavitating left upper lobe consolidation.
       
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Post-primary tuberculosis

      Explanation:

      Post-primary pulmonary tuberculosis is a chronic disease commonly caused by either endogenous reactivation of a latent infection or exogenous re-infection by Mycobacterium tuberculosis.
      Post-primary pulmonary tuberculosis (also called reactivation tuberculosis) develops in 5%–20% of patients infected with M. tuberculosis.

      Found mainly in adults, this form of tuberculosis arises from the reactivation of bacilli that lay dormant within a fibrotic area of the lung. In adults, reinfection with a strain of mycobacterium that differs from that which caused the primary infection is also possible. Predisposing factors include immunosuppression, diabetes, malnutrition and alcoholism.

      Infliximab is a monoclonal antibody against tumour necrosis factor α (TNF-α). It is FDA approved for many autoimmune conditions, including rheumatoid arthritis and Crohn’s disease. One of the many known side effects of infliximab therapy is reactivation of latent tuberculosis (TB). Because of the resemblances in clinical and radiological features, tubercular lesions in the lung may mimic malignancy. TB accounts for 27% of all infections initially presumed to be lung cancer on imaging studies.

    • This question is part of the following fields:

      • Respiratory
      0
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  • Question 15 - A 40-year-old man complains of impotence and reduced libido for 4 months. He...

    Incorrect

    • A 40-year-old man complains of impotence and reduced libido for 4 months. He has been married for 15 years and has two children. He smokes five cigarettes per day and drinks approximately 12 units of alcohol weekly.
      Examination reveals an obese man who is phenotypically normal with normal secondary sexual characteristics.
      Investigations are as follows:
      Hb 13.4 g/dl (13.0-18.0),
      WCC 6 x 109/l (4-11),
      Platelets 210 x 109/l (150-400),
      Electrolytes Normal,
      Fasting glucose 5.6 mmol/l (3.0-6.0),
      LFTs Normal,
      T4 12.7 pmol/l (10-22),
      TSH 2.1 mU/l (0.4-5),
      Prolactin 259 mU/l (<450),
      Testosterone 6.6 nmol/l (9-30),
      LH 23.7 mU/l (4-8),
      FSH 18.1 mU/l (4-10).

      What is the next investigation needed for this patient?

      Your Answer:

      Correct Answer: Ultrasound examination of the testes

      Explanation:

      The patient has primary Hypogonadism.
      Since he already had two children, Klinefelter syndrome is excluded and the patient does not need karyotyping.
      His lab results are normal indicating normal pituitary gland functions.
      So the next step is testicular ultrasound as testicular tumour, infiltration or idiopathic failure is suspected.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 16 - A 25-year-old man presents with bloody diarrhoea associated with systemic upset. Blood tests...

    Incorrect

    • A 25-year-old man presents with bloody diarrhoea associated with systemic upset. Blood tests show the following:


      Hb 13.4 g/dL,
      Platelets 467 * 109/L,
      WBC 8.2 * 109/L,
      CRP 89 mg/l

      A diagnosis of ulcerative colitis is suspected. Which part of the bowel is most likely to be affected?

      Your Answer:

      Correct Answer: Rectum

      Explanation:

      The most COMMON site of inflammation from ulcerative colitis is the rectum, making this the correct answer. This is simply a fact you need to memorize. In general, ulcerative colitis only occurs in colorectal regions– nothing in the small bowel (unless there is backwash into the terminal ileum) and nothing further up the GI tract. In Crohn’s it can affect the entire GI tract from mouth to anus.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 17 - Which of the following vaccines do not contain live organisms? ...

    Incorrect

    • Which of the following vaccines do not contain live organisms?

      Your Answer:

      Correct Answer: Polio (Salk)

      Explanation:

      Live virus vaccines include: Vaccinia (smallpox), Measles, Mumps, Rubella (MMR combined vaccine), Varicella (chickenpox), Influenza (nasal spray), Rotavirus, Zoster (shingles) and Yellow fever. Inactivated vaccines are Polio (IPV), Hepatitis A and Rabies.

    • This question is part of the following fields:

      • Infectious Diseases
      0
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  • Question 18 - A 44-year-old woman is investigated for hot flushes and night sweats. Her blood...

    Incorrect

    • A 44-year-old woman is investigated for hot flushes and night sweats. Her blood tests show a significantly raised FSH level and her symptoms are attributed to menopause. Following discussions with the patient, she elects to have hormone replacement treatment. What is the most significant risk of prescribing an oestrogen-only preparation rather than a combined oestrogen-progestogen preparation?

      Your Answer:

      Correct Answer: Increased risk of endometrial cancer

      Explanation:

      The use of hormone replacement therapy (HRT) based on unopposed oestrogen increases the risk of endometrial cancer, and uterine hyperplasia or cancer.
      Evidence from randomized controlled studies showed a definite association between HRT and uterine hyperplasia and cancer. HRT based on unopposed oestrogen is associated with this observed risk, which is unlike the increased risk of breast cancer linked with combined rather than unopposed HRT.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 19 - A 65 yr. old male presented with acute ST elevation myocardial infarction and...

    Incorrect

    • A 65 yr. old male presented with acute ST elevation myocardial infarction and thrombolysis was planned. Which of the following is an absolute contraindication for thrombolysis?

      Your Answer:

      Correct Answer: Intracerebral Haemorrhage

      Explanation:

      Absolute contraindications for fibrinolytic use in STEMI

      Prior intracranial haemorrhage (ICH)
      Known structural cerebral vascular lesion
      Known malignant intracranial neoplasm
      Ischemic stroke within 3 months
      Suspected aortic dissection
      Active bleeding or bleeding diathesis (excluding menses)
      Significant closed head trauma or facial trauma within 3 months
      Intracranial or intraspinal surgery within 2 months
      Severe uncontrolled hypertension (unresponsive to emergency therapy)
      For streptokinase, prior treatment within the previous 6 months

    • This question is part of the following fields:

      • Cardiology
      0
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  • Question 20 - What percentage of values lie within 3 standard deviations of the mean in...

    Incorrect

    • What percentage of values lie within 3 standard deviations of the mean in a normal distribution?

      Your Answer:

      Correct Answer: 99.70%

      Explanation:

      Normal distribution describes the spread of many biological and clinical measurements. Usually, 68.3% lies within 1 standard deviation (SD) of the mean, 95.4% lies within 2 SD of the mean and 99.7% lies within 3 SD of the mean.

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 21 - A 50-year-old male was under treatment for bipolar disease. He was brought to...

    Incorrect

    • A 50-year-old male was under treatment for bipolar disease. He was brought to the emergency department as he had become increasingly confused over the past two days. He had vomiting and diarrhoea. He was also consuming and passing a lot of water.
      On examination, he was disoriented. He had vertical nystagmus and was ataxic.
      What two investigations are likely to lead to the correct diagnosis?

      Your Answer:

      Correct Answer: Desmopressin test and serum lithium level

      Explanation:

      Desmopressin test (done to differentiate nephrogenic diabetes insipidus from central diabetes insipidus), and serum lithium levels can together confirm a diagnosis of lithium-induced nephrogenic diabetes insipidus.

      Bipolar disease is most often managed with mood stabilizers like lithium. This patient develops gastrointestinal symptoms followed by an acute confusional state associated with polyuria and polydipsia. These symptoms are suggestive of diabetes insipidus.

      In a case where these symptoms occur in a bipolar patient under treatment, lithium-induced nephrogenic diabetes insipidus should be considered as the most probable cause.

      Lithium intoxication can present with symptoms of nausea, vomiting, mental dullness, action tremor, weakness, ataxia, slurred speech, blurred vision, dizziness, especially vertical nystagmus and stupor or coma. Diffuse myoclonic twitching and nephrogenic diabetes insipidus can also occur. Such a clinical syndrome occurs above the serum level of lithium of 1.5–2.0 mEq/L.

      Management:
      – Correcting electrolyte abnormalities in patients with acute disease is critical and often life-saving.
      – Treatment should be initiated with parenteral fluids to replete hypovolemia (normal saline at 200-250 mL/h), followed by administration of hypotonic fluid (0.5% normal saline).
      – On the restoration of the volume status of the patient forced diuresis should be initiated by the administration of parenteral furosemide or bumetanide accompanied by continued intravenous hypotonic fluid administration to maintain volume status.
      – Polyuria is managed with hydrochlorothiazide combined with amiloride, acetazolamide.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 22 - A 20-year-old student presents to the university health service complaining of flu-like symptoms,...

    Incorrect

    • A 20-year-old student presents to the university health service complaining of flu-like symptoms, lethargy and jaundiced sclerae and an inability to eat due to a sore throat. He remembered that his father may have suffered from a liver condition. On further questioning a history of intravenous drug use on two occasions is identified.

      Investigations reveal:
      Alanine transaminase (ALT) 23 U/l,
      Aspartate transaminase (AST) 28 U/l,
      Bilirubin 78 μmol/L,
      Albumin 41g/l.

      Which of the following diagnoses fits best with this clinical picture?

      Your Answer:

      Correct Answer: Gilbert’s syndrome

      Explanation:

      When a patient presents with an illness (unrelated to the liver) or a stressful event on the body, and develops asymptomatic jaundice, think Gilbert’s syndrome. It is autosomal dominant. It is an unconjugated hyperbilirubinemia from impaired glucuronyl transferase. Classically, Crigler-Najjar would be in infants, and it would be symptomatic. It is also an unconjugated hyperbilirubinemia.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 23 - A 35-year-old gentleman presents to the Emergency Department with abdominal pain. This started...

    Incorrect

    • A 35-year-old gentleman presents to the Emergency Department with abdominal pain. This started earlier on in the day and is getting progressively worse. The pain is located on his left flank and radiates down into his groin. He has no history of this pain or any other condition. Examination reveals a gentleman who is flushed and sweaty but is otherwise unremarkable. What is the most suitable initial management?

      Your Answer:

      Correct Answer: IM diclofenac 75 mg

      Explanation:

      Because of the patient’s presentation with flank pain that radiates to the groin, we are suspecting renal colic. We should follow guidelines for acute renal management and prescribe IM diclofenac for immediate relief of pain.

    • This question is part of the following fields:

      • Nephrology
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  • Question 24 - Psoriatic arthropathy most commonly presents with which of the following types of arthritis?...

    Incorrect

    • Psoriatic arthropathy most commonly presents with which of the following types of arthritis?

      Your Answer:

      Correct Answer: Peripheral asymmetric oligoarthropathy

      Explanation:

      Most patients with psoriatic arthritis present with monoarthritis or asymmetric oligoarthritis. The most common form of the disease is the one involving a few joints of the peripheral skeleton with a distinct asymmetry of symptoms. Involvement of the smaller joints of the hands and feet, especially distal interphalangeal joints, seems to be a characteristic feature. Arthritis mutilans is a rare and severe complication of psoriatic arthritis.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 25 - A 20-year-old gentleman presents to the A&E department complaining of a sudden-onset occipital...

    Incorrect

    • A 20-year-old gentleman presents to the A&E department complaining of a sudden-onset occipital headache associated with vomiting. His symptoms started 2 hours previously and are continuing. He has a previous history of infrequent migraine without aura, which also causes nausea but not vomiting. He rated his current headache as much more severe than his usual migraine. Examination is unremarkable. In particular, there is no neck stiffness or photophobia.
      Which of the following management options would be the most appropriate?

      Your Answer:

      Correct Answer: CT brain scan, followed by lumbar puncture if CT normal

      Explanation:

      The patient presented with sudden-onset headache that is more painful than his usual migraine attacks. This gives a high suspicion of subarachnoid haemorrhage; thus, a CT brain scan should be ordered first to rule this out. However, a normal CT scan is apparent in 30% of patients with subarachnoid haemorrhage and should be referred for lumbar puncture to look for red blood cells.

    • This question is part of the following fields:

      • Neurology
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  • Question 26 - A 68 year old man who has chronic obstructive pulmonary disease (COPD) is...

    Incorrect

    • A 68 year old man who has chronic obstructive pulmonary disease (COPD) is reviewed. On examination, there is evidence of cor pulmonale with a significant degree of pedal oedema. His FEV1 is 44%. During a recent hospital stay his pO2 on room air was 7.4 kPa.

      Which one of the following interventions is most likely to increase survival in this patient?

      Your Answer:

      Correct Answer: Long-term oxygen therapy

      Explanation:

      Assess the need for oxygen therapy in people with:
      – very severe airflow obstruction (FEV1 below 30% predicted)
      – cyanosis (blue tint to skin)
      – polycythaemia
      – peripheral oedema (swelling)
      – a raised jugular venous pressure
      – oxygen saturations of 92% or less breathing air.

      Also consider assessment for people with severe airflow obstruction (FEV1 30–49% predicted).

      Consider long-term oxygen therapy for people with COPD who do not smoke and who:
      have a partial pressure of oxygen in arterial blood (PaO2) below 7.3 kPa when stable or have a PaO2 above 7.3 and below 8 kPa when stable, if they also have 1 or more of the following:
      – secondary polycythaemia
      – peripheral oedema
      – pulmonary hypertension.

    • This question is part of the following fields:

      • Respiratory
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  • Question 27 - What is northern blotting used for? ...

    Incorrect

    • What is northern blotting used for?

      Your Answer:

      Correct Answer: Detect RNA

      Explanation:

      Northern blotting’s purpose is to measure the size and amount of RNA transcribed from a specific gene of interest.

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 28 - A 66 year old man visits the clinic because he has been experiencing...

    Incorrect

    • A 66 year old man visits the clinic because he has been experiencing increasing breathlessness for the past five months while doing daily tasks. His exercise tolerance is now limited to 75 metres while on a flat surface and walking up the stairs makes him breathless. He sleeps on four pillows and has swollen ankles in the morning. He occasionally coughs up phlegm.

      Past Medical history of importance:
      36 pack year smoking history
      Hypertension
      Ischaemic heart disease
      Coronary artery stenting done 10 months ago

      Pulmonary function testing revealed:
      FEV1 0.90 L (1.80 – 3.02 predicted)
      FVC 1.87 L (2.16 – 3.58 predicted)
      Diffusion capacity 3.0 mmol/min/kPa (5.91 – 9.65 predicted)
      Total lung capacity 4.50 L (4.25 – 6.22 predicted)
      Residual volume 2.70 L (1.46 – 2.48 predicted)
       
      Which condition does he have?

      Your Answer:

      Correct Answer: Chronic obstructive pulmonary disease

      Explanation:

      Whilst asthma and COPD are different diseases they cause similar symptoms, which can present a challenge in identifying which of the two diseases a patient is suffering from. COPD causes chronic symptoms and narrowed airways which do not respond to treatment to open them up. In the case of asthma the constriction of the airways through inflammation tends to come and go and treatment to reduce inflammation and to open up the airways usually works well.

      COPD is more likely than asthma to cause a chronic cough with phlegm and is rare before the age of 35 whilst asthma is common in under-35s. Disturbed sleep caused by breathlessness and wheeze is more likely in cases of asthma, as is a history of allergies, eczema and hay fever. Differentiating between COPD and asthma requires a history of both symptoms and spirometry. The spirometry history should include post bronchodilator measurements, the degree of reversibility and, ideally, home monitoring which gives a history of diurnal variation.

      Airflow Obstruction: Both asthma and COPD are characterised by airflow obstruction. Airflow obstruction is defined as a reduced FEV1 and a reduced FEV1/FVC ratio, such that FEV1 is less than 80% of that predicted, and FEV1/FVC is less than 0.7.

      These episodes are usually associated with widespread, but variable, airflow obstruction within the lung that is often reversible either spontaneously or with treatment.

      COPD: COPD is a chronic, slowly progressive disorder characterised by airflow obstruction (reduced FEV1 and FEV1/VC ratio) that does not change markedly over several months. The airflow obstruction is not fully reversible.

      Spirometry COPD Asthma
      VC Reduced Nearly normal
      FEV1 Reduced Reduced in attack
      FVC (or FEV6) Reduced Nearly normal
      FEV1 Ratio
      (of VC/FVC/FEV6) Reduced in attack

      This man has a low FEV1 and FVC. His diffusions capacity is also low despite having a normal total lung capacity. These values confirm a diagnosis of COPD.

    • This question is part of the following fields:

      • Respiratory
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  • Question 29 - Which one of the following types of thyroid cancer is associated with the...

    Incorrect

    • Which one of the following types of thyroid cancer is associated with the RET oncogene?

      Your Answer:

      Correct Answer: Medullary

      Explanation:

      RET (rearranged during transfection) is a receptor tyrosine kinase involved in the development of neural crest derived cell lineages, kidney, and male germ cells. Different human cancers, including papillary and medullary thyroid carcinomas, lung adenocarcinomas, and myeloproliferative disorders display gain-of-function mutations in RET.
      In over 90% of cases, MEN2 syndromes are due to germline missense mutations of the RET gene.
      Multiple endocrine neoplasias type 2 (MEN2) is an inherited disorder characterized by the development of medullary thyroid cancer (MTC), parathyroid tumours, and pheochromocytoma.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 30 - All of the following statements regarding glucagon-like peptide-1 (GLP-1) are true, except? ...

    Incorrect

    • All of the following statements regarding glucagon-like peptide-1 (GLP-1) are true, except?

      Your Answer:

      Correct Answer: Increased levels are seen in type 2 diabetes mellitus

      Explanation:

      Glucagon-like peptide 1 (GLP-1) is a 30-amino acid peptide hormone produced in the intestinal epithelial endocrine L-cells by differential processing of proglucagon. GLP-1 is released in response to meal intake.
      The main actions of GLP-1 are to stimulate insulin secretion (i.e., to act as an incretin hormone) and to inhibit glucagon secretion, thereby contributing to limit postprandial glucose excursions. It also inhibits gastrointestinal motility and secretion and thus acts as an enterogastrone and part of the ileal brake mechanism. GLP-1 also appears to be a physiological regulator of appetite and food intake.
      Decreased secretion of GLP-1 may contribute to the development of obesity, and exaggerated secretion may be responsible for postprandial reactive hypoglycaemia.

    • This question is part of the following fields:

      • Endocrinology
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      Seconds
  • Question 31 - A 65-year-old gentleman gives a two week history of progressive lethargy and weakness....

    Incorrect

    • A 65-year-old gentleman gives a two week history of progressive lethargy and weakness. Eight weeks previously, he was treated for hypertensive heart failure with 120 mg furosemide and 5 mg enalapril daily. His haemoglobin at the time was 12.0, urea 14.2 mmol/l and creatinine 298 μmol/l. His blood pressure in clinic was 148/85 mmHg.

      His blood results are shown below:

      Hb 10.2g/dL,
      MCV 89.2 fl
      WCC 4.9 x 109/L,
      Plats 175 x 109/L,
      Na+ 135
      K+ 5.2 mmol/L,
      Urea 25.2 mmol/L,
      Creat 600 μmol/L,


      Assuming that he is not volume overloaded, what would be the most appropriate action?

      Your Answer:

      Correct Answer: stop the enalapril and furosemide

      Explanation:

      The patient presents with worsened renal condition from the last consultation when he was started on enalapril (an ACE inhibitor) so this medication should be stopped. Because there is also no fluid overload; furosemide, a diuretic, should also be stopped.

    • This question is part of the following fields:

      • Nephrology
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  • Question 32 - A 42 year old male undergoes a routine cranial nerve examination, which reveals...

    Incorrect

    • A 42 year old male undergoes a routine cranial nerve examination, which reveals the following findings:

      Rinne's test: Air conduction > bone conduction in both ears

      Weber's test: Localizes to the right side

      What do these test results imply?

      Your Answer:

      Correct Answer: Left sensorineural deafness

      Explanation:

      Weber’s test – if there is a sensorineural problem, the sound is localized to the unaffected side (right), indicating a problem on the left side.

    • This question is part of the following fields:

      • Neurology
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  • Question 33 - Which is the best source of vitamin D per average serving for a...

    Incorrect

    • Which is the best source of vitamin D per average serving for a woman with suspected Osteomalacia?

      Your Answer:

      Correct Answer: Cod liver oil

      Explanation:

      Serum vitamin D levels are influenced by sun exposure and diet. Cod liver oil is an important dietary vitamin D source in high-latitude countries like Norway where there is no sun-induced vitamin D production during the winter. 14 Norwegian Health Authorities have recommended 5 ml of cod liver oil daily (400 IU of vitamin D) for more than 60 years to prevent diseases like rickets, formerly more prevalent in areas with little access to vitamin D-rich fatty fish.

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 34 - A 34-year-old woman is admitted to the oncologist clinic for further investigations. She...

    Incorrect

    • A 34-year-old woman is admitted to the oncologist clinic for further investigations. She has experienced fever, sometimes glandular and night sweats. Clinical examination reveals lymphadenopathy and a biopsy is performed. The biopsy reveals the presence of Reed-Sternberg cells, confirming what was suspected to be a Hodgkin's lymphoma. Which cell surface marker is associated with this condition?

      Your Answer:

      Correct Answer: CD15

      Explanation:

      The CD15 antigen, also known as Lewis (hapten)X, serves as an immuno-phenotypic marker for Reed-Sternberg cells and its expression has diagnostic, but also prognostic significance in Hodgkin Lymphoma.

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 35 - A 53-year-old gentleman presents with several months’ history of generalised swelling, fatigue, dyspnoea...

    Incorrect

    • A 53-year-old gentleman presents with several months’ history of generalised swelling, fatigue, dyspnoea and several episodes of haemoptysis. There is no significant past medical history and he did not take any regular medication. He smokes 20 cigarettes per day and drinks 14 units of alcohol per week.

      On examination, he is grossly oedematous and has ascites. Cardiorespiratory examination is unremarkable and there are no neurological signs or rashes.

      Investigation results are below:

      Haemoglobin (Hb) 10.2 g/dL,
      White cell count (WCC) 6.0 × 109/L,
      Platelets 380 × 109/L,
      Mean corpuscular volume (MCV) 90fl
      Na+ 145 mmol/L,
      K+ 3.7 mmol/L,
      Urea 8.2 mmol/L,
      Bilirubin 16 μmol/L,
      Creatinine 180 μmol/L,
      Albumin 22 g/l
      Aspartate transaminase 32 iu/l
      Alkaline phosphatase 120 iu/l
      Urinalysis: Protein +++
      24 h urinary protein excretion: 5g
      Chest radiograph: Enlarged right hilum
      Echocardiogram: Mild left ventricular impairment, no valve lesion
      Abdominal ultrasound scan: Normal-sized kidneys, no abnormality seen


      A renal biopsy was performed. What is it most likely to show?

      Your Answer:

      Correct Answer: Thickened glomerular basement membrane with deposits of IgG and C3

      Explanation:

      Renal biopsy in this patient will most likely show thickened glomerular basement membrane with deposits of IgG and C3 as a result of membranous glomerulonephritis that has caused the nephrotic syndrome in this patient. Membranous glomerulonephritis in this case is most likely associated with an underlying bronchial carcinoma, consistent with the patient’s smoking history and physical presentation.

    • This question is part of the following fields:

      • Nephrology
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  • Question 36 - A 85 yr. old male with a history of hypertension presented with a...

    Incorrect

    • A 85 yr. old male with a history of hypertension presented with a couple of pre-syncopal episodes. He describes these episodes as him having felt as if he was going to faint and he has had to sit down. There were no precipitating factors, associated chest pain or palpitations. He doesn't have chest pain, shortness of breath on exertion, orthopnoea or paroxysmal nocturnal dyspnoea. On examination he looked well. Blood pressure was 140/80 mmHg and pulse rate was 78 bpm which was irregular. His lungs were clear and heart sounds were normal. ECG showed sinus rhythm with occasional ventricular ectopic beats. Which of the following is an indication for permanent pacemaker implantation?

      Your Answer:

      Correct Answer: Second-degree block associated with symptoms

      Explanation:

      Indications for permanent pacemaker implantation

      -Sinus node dysfunction
      -Acquired Atrioventricular(AV) block (Complete third-degree AV block with or without symptoms, Symptomatic second degree AV block, Mobitz type I and II, Exercise-induced second or third degree AV block in the absence of myocardial infarction, Mobitz II with widened QRS complex)
      -Chronic bifascicular block
      -After acute phase of myocardial infarction
      -Neurocardiogenic syncope and hypersensitive carotid sinus syndrome
      -Post cardiac transplantation
      -Hypertrophic cardiomyopathy
      -Pacing to detect and terminate tachycardia
      -Cardiac resynchronization therapy in patients with severe systolic heart failure
      -Patients with congenital heart disease

    • This question is part of the following fields:

      • Cardiology
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  • Question 37 - A young man is reviewed for difficulty breathing. Lung function tests showed that...

    Incorrect

    • A young man is reviewed for difficulty breathing. Lung function tests showed that his peak expiratory flow rate is 54% below the normal range for his age and height. What is a possible diagnosis?

      Your Answer:

      Correct Answer: Asthma

      Explanation:

      Peak Expiratory Flow (PEF), also called Peak Expiratory Flow Rate (PEFR) is a person’s maximum speed of expiration, as measured with a peak flow meter. Measurement of PEFR requires some practise to correctly use a meter and the normal expected value depends on a patient’s gender, age and height.
      It is classically reduced in obstructive lung disorders, such as Asthma, COPD or Cystic Fibrosis.

    • This question is part of the following fields:

      • Respiratory
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  • Question 38 - A 30 yr. old male was brought in with a history of a...

    Incorrect

    • A 30 yr. old male was brought in with a history of a stab injury to left chest. He was complaining of chest pain. On examination he was tachycardic, hypotensive and had an elevated JVP, pulsus paradoxus and muffled heart sounds. Respiratory examination was unremarkable. Which of the following is most probable diagnosis?

      Your Answer:

      Correct Answer: Cardiac tamponade

      Explanation:

      Becks triad (hypotension, elevated systemic venous pressure, often with jugular venous distention and muffled heart sounds) is a characteristic collection of clinical findings found in cardiac tamponade. Pulsus paradoxus is also associated with it. The history and clinical findings in this scenario are compatible with the diagnosis of cardica tamponade. The normal respiratory examination excludes tension pneumothorax.

    • This question is part of the following fields:

      • Cardiology
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  • Question 39 - A 32-year-old gentleman presents to his GP with a 2 month history of...

    Incorrect

    • A 32-year-old gentleman presents to his GP with a 2 month history of constant abdominal pain and early satiety. He has hypertension for which he takes enalapril.

      On examination, he has mild tenderness on both flanks. Well-circumscribed masses are palpable in both the left and right flanks. A soft systolic murmur is heard loudest at the apex.

      His observations are heart rate 67/min, blood pressure 152/94mmHg, temperature 37.2C, respiratory rate 14/min, saturations 97%.

      Which additional feature is most likely to be found in this patient?

      Your Answer:

      Correct Answer: Hepatomegaly

      Explanation:

      This patient shows classic symptoms of autosomal-dominant polycystic kidney disease (ADPKD). The abdominal pain and early satiety is caused by the enlarged kidneys that were apparent from the physical examination. Additionally, hypertension is a common symptom along with the systolic murmur that was heard, suggesting mitral valve involvement. In ADPKD cases, the most common extra-renal manifestation is the development of liver cysts which are associated with hepatomegaly.

    • This question is part of the following fields:

      • Nephrology
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  • Question 40 - A 37-year old female nurse presents with severe generalized itching, claiming that she...

    Incorrect

    • A 37-year old female nurse presents with severe generalized itching, claiming that she had previously applied cream to the body of a patient with similar symptoms. What is the mechanism that produces her itch?

      Your Answer:

      Correct Answer: Allergic reaction

      Explanation:

      Contact dermatitis is a red, itchy rash caused by direct contact with a substance or an allergic reaction to it. The entry of allergen into the epidermis or dermis causes a localized allergic reaction. Local mast-cell activation in the skin leads immediately to a local increase in vascular permeability, which causes extravasation of fluid and swelling. Histamine released by mast cells activated by allergen in the skin causes large, itchy, red swellings of the skin.

    • This question is part of the following fields:

      • Dermatology
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  • Question 41 - A 61 year old male is noted to be depressed following a recent...

    Incorrect

    • A 61 year old male is noted to be depressed following a recent heart attack. He has a history of ischaemic heart disease. Which antidepressant would be appropriate for this patient?

      Your Answer:

      Correct Answer: Sertraline

      Explanation:

      Major depression (MD) often occurs after MI and has been shown to be an independent predictor of poor cardiovascular (CV) outcome.

      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.

      Adverse effects to note:
      Sertraline – Diarrhoea (13-24%), Nausea (13-30%), Headache (20-25%),
      Insomnia (12-28%)
      Imipramine – ECG changes, orthostatic hypotension, tachycardia
      Confusion, extrapyramidal symptoms (EPS), dizziness, paraesthesia, tinnitus
      Flupentixol – seizures, irregular/fast heartbeat, increased sweating
      Paroxetine – Hypertension, Tachycardia, Emotional lability, Pruritus
      Venlafaxine – Abnormal vision (4-6%), Hypertension (2-5%), Paraesthesia (2-3%), Vasodilation (2-6%), Aneurism, Deep vein thrombophlebitis, Takotsubo cardiomyopathy

    • This question is part of the following fields:

      • Psychiatry
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  • Question 42 - A 39 year-old engineer presents with progressive weakness of his hands. Upon examination,...

    Incorrect

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

      Your Answer:

      Correct Answer: Loss of temperature sensation in the hands

      Explanation:

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

    • This question is part of the following fields:

      • Neurology
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  • Question 43 - A 77 year old mail carrier presents to the emergency department with severe...

    Incorrect

    • A 77 year old mail carrier presents to the emergency department with severe flinging movements of his right arm. Where would the causative lesion be located?

      Your Answer:

      Correct Answer: Right subthalamic nucleus

      Explanation:

      Hemiballismus is a movement disorder which manifests as unilateral involuntary flinging movements of the proximal upper limbs. The lesion is located in the ipsilateral subthalamic nucleus.

    • This question is part of the following fields:

      • Neurology
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  • Question 44 - A 72-year-old female presents with tiredness and weakness. On examination, she is pale...

    Incorrect

    • A 72-year-old female presents with tiredness and weakness. On examination, she is pale and has a haemoglobin of 72 g/L with an MCV of 68 fL. Which nail changes may be seen in association with this patient's condition?

      Your Answer:

      Correct Answer:

      Explanation:

      Koilonychia, known as spoon nails, is a condition of the nails bending inwards, taking the shape of a spoon. This is a strong indication of iron-deficiency anaemia (IDA). The rest of the patient’s symptoms further indicate IDA.

    • This question is part of the following fields:

      • Dermatology
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  • Question 45 - A woman who is 36 weeks pregnant presents with chickenpox. How should she...

    Incorrect

    • A woman who is 36 weeks pregnant presents with chickenpox. How should she be treated?

      Your Answer:

      Correct Answer: Acyclovir

      Explanation:

      Acyclovir is the correct answer. There has been no documented evidence of harm in pregnancy yet. Chickenpox can cause fetal abnormalities, and varicella zoster Immunoglobulin should be given to the infant immediately after birth (not the mother, won’t help). Steroids will actually make the chicken pox worse. Painkillers only, is obviously the wrong answer and pose severe risk to foetus.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 46 - Which of the following is the most common route of hepatitis B transmission...

    Incorrect

    • Which of the following is the most common route of hepatitis B transmission worldwide?

      Your Answer:

      Correct Answer: Perinatal transmission

      Explanation:

      Perinatal transmission is the most common cause of Hepatitis B infection worldwide. Post-exposure prophylaxis should be provided, which consists of hepatitis B immune globulin and hepatitis B vaccine within 12 hours of birth. Without this, about 40% will develop chronic infection.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 47 - Which of the following types of motor neuron diseases carries the worst prognosis?...

    Incorrect

    • Which of the following types of motor neuron diseases carries the worst prognosis?

      Your Answer:

      Correct Answer: Progressive bulbar palsy

      Explanation:

      Motor neuron disease is a neurological condition of unknown cause which can present with both upper and lower motor neuron signs. It rarely presents before 40 years and various patterns of disease are recognised including amyotrophic lateral sclerosis, primary lateral sclerosis, progressive muscular atrophy and progressive bulbar palsy. In some patients however, there is a combination of clinical patterns. In progressive bulbar palsy there is palsy of the tongue and muscles of chewing/swallowing and facial muscles due to loss of function of brainstem motor nuclei. This carries the worst prognosis.

    • This question is part of the following fields:

      • Neurology
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  • Question 48 - A 30-year-old male with a history of premature cardiovascular disease in the family...

    Incorrect

    • A 30-year-old male with a history of premature cardiovascular disease in the family has come for review of his lab investigations.
      His fasting cholesterol is 8.4 mmol/l with high-density lipoprotein (HDL) of 1.6 mmol/l.
      You elect to commence him on atorvastatin 20 mg PO daily.
      Which of the following best describes the mechanism of action of the statins?

      Your Answer:

      Correct Answer: They inhibit HMG CoA reductase

      Explanation:

      Statins are a selective, competitive inhibitor of hydroxymethylglutaryl-CoA (HMG-CoA) reductase, which is the enzyme responsible for the conversion of HMG-CoA to mevalonate in the cholesterol synthesis pathway.
      Statins are usually well tolerated with myopathy, rhabdomyolysis, hepatotoxicity, and diabetes mellitus being the most common adverse reactions.
      This is the rate-limiting step in cholesterol synthesis, that leads to increased hepatic low-density lipoprotein (LDL) receptors and reduced hepatic VLDL synthesis coupled with increased very-low-density lipoprotein (VLDL) clearance.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 49 - A 47-year-old woman diagnosed with oestrogen receptor positive breast cancer three months back...

    Incorrect

    • A 47-year-old woman diagnosed with oestrogen receptor positive breast cancer three months back was started on treatment with tamoxifen. Which of the following is most likely a complaint of this patient during her review today?

      Your Answer:

      Correct Answer: Hot flushes

      Explanation:

      The most likely complaint of this patient would be hot flushes.

      Alopecia and cataracts are listed in the BNF as possible side-effects. They are however not as prevalent as hot flushes, which are very common in pre-menopausal women.

      Tamoxifen is a Selective Oestrogen Receptor Modulator (SERM) which acts as an oestrogen receptor antagonist and partial agonist. It is used in the management of oestrogen receptor-positive breast cancer

      Adverse effects:
      Menstrual disturbance: vaginal bleeding, amenorrhoea
      Hot flushes – 3% of patients stop taking tamoxifen due to climacteric side-effects.
      Venous thromboembolism.
      Endometrial cancer
      Tamoxifen is typically used for 5 years following the removal of the tumour.

      Raloxifene is a pure oestrogen receptor antagonist and carries a lower risk of endometrial cancer.

      Although antagonistic with respects to breast tissue tamoxifen may serve as an agonist at other sites. Therefore the risk of endometrial cancer is increased cancer.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 50 - Which of the following would suggest an increase risk of suicide in a...

    Incorrect

    • Which of the following would suggest an increase risk of suicide in a patient with a history of depression?

      Your Answer:

      Correct Answer: History of arm cutting

      Explanation:

      Risk factors specific to depression:
      -Family history of mental disorder.
      -History of previous suicide attempts (this includes self-harm).
      -Severe depression.
      -Anxiety.
      -Feelings of hopelessness.
      -Personality disorder.
      -Alcohol abuse and/or drug abuse.
      -Male gender.

      Protective Factors for Suicide.
      Protective factors buffer individuals from suicidal thoughts and behaviour. To date, protective factors have not been studied as extensively or rigorously as risk factors. Identifying and understanding protective factors are, however, equally as important as researching risk factors.

      Protective Factors:
      -Effective clinical care for mental, physical, and substance abuse disorders
      -Easy access to a variety of clinical interventions and support for help seeking
      -Family and community support (connectedness)
      -Support from ongoing medical and mental health care relationships
      -Skills in problem solving, conflict resolution, and nonviolent ways of handling disputes
      -Cultural and religious beliefs that discourage suicide and support instincts for self-preservation

    • This question is part of the following fields:

      • Psychiatry
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  • Question 51 - A 60 year old male patient with a history of heavy smoking was...

    Incorrect

    • A 60 year old male patient with a history of heavy smoking was admitted complaining of acute severe central chest pain for the past one hour. His blood pressure was 150/90 mmHg and pulse rate was 88 bpm. His peripheral oxygen saturation was 93%. ECG showed ST elevation > 2mm in lead II, III and aVF. He was given loading doses of aspirin, clopidogrel and atorvastatin and face mask oxygen was given. Which one of the following investigations should be done and then depending on result, definitive treatment can be initiated?

      Your Answer:

      Correct Answer: None

      Explanation:

      The history and ECG findings are adequate to begin cardiac revascularization of this patient. There is no need for cardiac markers to confirm the diagnosis. Further delay in starting definite treatment is not recommended.

    • This question is part of the following fields:

      • Cardiology
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  • Question 52 - 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:

      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
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  • Question 53 - A 52-year-old woman is diagnosed as having acute myeloid leukaemia. What is the...

    Incorrect

    • A 52-year-old woman is diagnosed as having acute myeloid leukaemia. What is the single most important test in determining her prognosis?

      Your Answer:

      Correct Answer: Cytogenetics

      Explanation:

      All of the aforementioned options may be important however cytogenetics, for detecting chromosomal abnormalities, is the single most important test to determine her disease prognosis.

      Acute myeloid leukaemia (AML) is the acute expansion of the myeloid stem line, which may occur as a primary disease or follow the secondary transformation of a myeloproliferative disorder. It is more common over the age of 45 and is characterized by signs and symptoms largely related to bone marrow failure such as anaemia (pallor, lethargy), frequent infections due to neutropenia (although the total leucocyte count may be very high), thrombocytopaenia (bleeding), ostealgia, and splenomegaly.

      The disease has a poor prognosis if:
      1. Age of the patient >60 years
      2. >20% blasts seen after the first course of chemotherapy
      3. Chromosomal aberration with deletion of part of chromosome 5 or 7.

      Acute promyelocytic leukaemia (APL) is an aggressive form of AML.

    • This question is part of the following fields:

      • Haematology & Oncology
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  • Question 54 - A 54-year-old woman, with a long history of inflammatory bowel disease presents to...

    Incorrect

    • A 54-year-old woman, with a long history of inflammatory bowel disease presents to his GP with abnormal liver function tests. She has a raised alkaline phosphatase level but no symptoms of liver disease.

      Which of the following options is the best set of investigations to confirm the diagnosis?

      Your Answer:

      Correct Answer: MRCP and liver biopsy

      Explanation:

      In a patient with abnormal LFTs and UC, think primary sclerosing cholangitis (PSC). MRCP and liver biopsy is the best answer. MRCP will show classically beads on a string – intra and extrahepatic stricturing and dilation. Remember this finding!! Liver biopsy is required for official diagnosis (need tissue!).

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 55 - A 25-year-old female presents to the acute medical unit with several lumps in...

    Incorrect

    • A 25-year-old female presents to the acute medical unit with several lumps in her neck and under her arms, weight loss, vomiting, and low mood. She is investigated and is found to have several areas of suspicious lymphadenopathy including in the neck, both axillae, and mediastinum. She also has multiple lesions in her liver which are confirmed to be the manifestations of Hodgkin lymphoma after biopsy.

      Which stage of the disease is the patient currently at?

      Your Answer:

      Correct Answer: IV

      Explanation:

      The patient is on stage IV according to the Ann Arbor staging system for Hodgkin lymphoma (HL). The disease has spread beyond the lymph nodes into the liver (involvement of extra lymphatic organ).

      HL is a malignant proliferation of lymphocytes characterised by the presence of distinctive giant cells known as Reed-Sternberg cells. It has a bimodal age distribution being most common in the third and seventh decades of life.

      Staging of HL is done according to the Ann Arbor staging system:
      Stage
      I: Single lymph node region (I) or one extra lymphatic site (IE)

      II: Two or more lymph node regions on same side of the diaphragm (II) or local extra lymphatic extension plus one or more lymph node regions on same side of the diaphragm (IIE)

      III: Lymph node regions on both sides of the diaphragm (III) which may be accompanied by local extra lymphatic extension (IIIE)

      IV: Diffuse involvement of one or more extra lymphatic organs or sites

      Suffix
      A: No B symptoms

      B: Presence of at least one of the following: unexplained weight loss >10% baseline during 6 months before staging; recurrent unexplained fever >38°C; recurrent night sweats

    • This question is part of the following fields:

      • Haematology & Oncology
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  • Question 56 - 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 57 - Which of the following features is characteristic of acute intermittent porphyria? ...

    Incorrect

    • Which of the following features is characteristic of acute intermittent porphyria?

      Your Answer:

      Correct Answer: Increased urinary porphobilinogen between acute attacks

      Explanation:

      Urinary porphobilinogen is increased between attacks of acute intermittent porphyria (AIP) and even more so, between acute attacks.

      AIP is a rare autosomal dominant condition caused by a defect in porphobilinogen deaminase, an enzyme involved in the biosynthesis of haem. This results in the toxic accumulation of delta-aminolaevulinic acid and porphobilinogen.

      Abdominal and neuropsychiatric symptoms are characteristic of AIP especially in people between the ages of 20–40 years. The disease is more common in females than in males (5:1). Major signs and symptoms of AIP include abdominal pain, vomiting, motor neuropathy, hypertension, tachycardia, and depression.

      Diagnosis:
      1. Urine turns deep red on standing (classical picture of AIP)
      2. Raised urinary porphobilinogen (elevated between attacks and to a greater extent, between acute attacks)
      3. Raised serum levels of delta-aminolaevulinic acid and porphobilinogen
      4. Assay of red blood cells for porphobilinogen deaminase

    • This question is part of the following fields:

      • Haematology & Oncology
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  • Question 58 - A 43 year-old female artist with no past medical history presents to the...

    Incorrect

    • A 43 year-old female artist with no past medical history presents to the emergency department with a 2-day history of pins and needles in the lower limbs, and progressive walking difficulties. She states she had diarrhoea 1 week ago. On examination, there is a loss of pinprick sensation noted to the lower limbs from mid-thigh distally and in the upper limbs from MCP joints distally. There is bilateral weakness of ankle dorsiflexion, noted at 3/5, and knee flexion and extension weakness, noted at 4/5 bilaterally. Power in upper and lower limbs is otherwise normal. Knee and ankle deep tendon reflexes are absent. Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Guillain-Barre syndrome

      Explanation:

      Guillain-Barre syndrome is an immune mediated demyelination of the peripheral nervous system often triggered by an infection (classically Campylobacter jejuni). Characteristic features include progressive weakness of all four limbs, and it is classically ascending, affecting the lower extremities first. Sensory symptoms tend to be mild.

      Functional neurological syndrome can be discounted due to presence of hard neurological signs. Multiple sclerosis can be excluded because of the presence of lower motor neuron signs and absence of upper motor neuron signs. Chronic inflammatory demyelinating polyneuropathy is the chronic form of Guillain-Barre syndrome.

    • This question is part of the following fields:

      • Neurology
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  • Question 59 - Osteopetrosis occurs as a result of a defect in: ...

    Incorrect

    • Osteopetrosis occurs as a result of a defect in:

      Your Answer:

      Correct Answer: Osteoclast function

      Explanation:

      It is a metabolic bone disease caused by defective osteoclastic resorption of immature bone. Osteopetrosis is also known as marble bone disease. Osteoclasts are unable to adequately acidify bone matrix. Impaired bone resorption leads to overly dense bone that is more likely to fracture. It is usually treated with bone marrow transplant and high dose calcitriol.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 60 - A 50-year-old woman came to the diabetes clinic for her regular follow up.
    ...

    Incorrect

    • A 50-year-old woman came to the diabetes clinic for her regular follow up.
      The following results are obtained:
      Urine analysis: Protein+,
      HBA1c 86mmol/mol (10.0%).

      What is her average blood glucose level during the past 2 months?

      Your Answer:

      Correct Answer: 15

      Explanation:

      The level of haemoglobin A1c (HbA1c), also known as glycated haemoglobin, determines how well a patient’s blood glucose level has been controlled over the previous 8–12 weeks. Recent studies have been made to correlate between HbA1c and average glucose level.
      Using the following formula: Average blood glucose (mmol/l) = (1.98 x 1 HbA1c) – 4.29

    • This question is part of the following fields:

      • Endocrinology
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