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  • Question 1 - A 55 yr. old female with a history of hypertension presented with severe...

    Incorrect

    • A 55 yr. old female with a history of hypertension presented with severe central chest pain for the past one hour, associated with sweating and vomiting. Her ECG showed ST elevation myocardial infarction, evident in leads V2-V4. Which of the following is an absolute contraindication for thrombolysis?

      Your Answer: Ischaemic stroke 2 years previously

      Correct Answer: Intracranial neoplasm

      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
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      Seconds
  • Question 2 - A 60 yr. old male patient with NSTEMI was started on low dose...

    Incorrect

    • A 60 yr. old male patient with NSTEMI was started on low dose aspirin as secondary prevention. Which of the following, describe the action of aspirin as an antiplatelet agent?

      Your Answer:

      Correct Answer: Inhibits the production of thromboxane A2

      Explanation:

      The antithrombotic action of aspirin is due to inhibition of platelet function by acetylation of the platelet cyclooxygenase (COX) at the functionally important amino acid serine529. This prevents the access of the substrate (arachidonic aid) to the catalytic site of the enzyme at tyrosine385 and results in an irreversible inhibition of platelet-dependent thromboxane formation.

    • This question is part of the following fields:

      • Cardiology
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      Seconds
  • Question 3 - A 60 yr. old man presented with severe central chest pain for the...

    Incorrect

    • A 60 yr. old man presented with severe central chest pain for the last 2 hours. He was on insulin for diabetes mellitus and he was dependent on haemodialysis because of end stage renal failure. He had undergone haemodialysis 48 hours prior to this presentation. His ECG showed an acute inferior myocardial infarction. Despite thrombolysis and other appropriate treatment, he continued to have chest pain after 6 hours from the initial presentation. His blood pressure was 88/54 mmHg and he had bibasal crepitations. His investigation results are given below.
      Serum sodium 140 mmol/l (137-144),
      Serum potassium 6.6 mmol/l (3.5-4.9),
      Serum urea 50 mmol/l (2.5-7.5),
      Serum creatinine 940 μmol/l (60-110),
      Haemoglobin 10.2g/dl (13.0-18.0),
      Troponin T >24 g/l (<0.04),
      Left ventricular ejection fraction was 20%.

      What is the most appropriate management for this patient?

      Your Answer:

      Correct Answer: Coronary angiography and rescue PCI

      Explanation:

      According to the history the patient has cardiogenic shock and pulmonary oedema. On-going ischaemia is indicated by persisting symptoms. So the most appropriate management is coronary angiography and rescue PCI. There are no indications for blood transfusion at this moment and it will aggravate the pulmonary oedema. Haemodialysis, beta blockers and furosemide cannot be given due to low blood pressure.

    • This question is part of the following fields:

      • Cardiology
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  • Question 4 - A 72 year old female, known with rheumatoid arthritis for last 17 years,...

    Incorrect

    • A 72 year old female, known with rheumatoid arthritis for last 17 years, presents with recurrent attacks of red eyes with a sensation of grittiness. Which of the following is most likely cause of the red eyes?

      Your Answer:

      Correct Answer: keratoconjunctivitis sicca

      Explanation:

      Rheumatoid arthritis is an inflammatory systemic disease associated with some extraarticular manifestations. Keratoconjunctivitis sicca, episcleritis, scleritis, corneal changes, and retinal vasculitis are the most common ocular complications among extraarticular manifestations of RA. The overall prevalence of keratoconjunctivitis sicca also known as dry eye syndrome among patients of RA is 21.2% and is the most common with sense of grittiness in the eyes.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 5 - A 77-year-old retired engineer presents with a burning sensation around his right eye....

    Incorrect

    • A 77-year-old retired engineer presents with a burning sensation around his right eye. On examination, an erythematous blistering rash can be seen in the right trigeminal distribution. Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Herpes zoster ophthalmicus

      Explanation:

      Herpes zoster ophthalmicus (HZO) describes the reactivation of the varicella zoster virus in the area supplied by the ophthalmic division of the trigeminal nerve. It accounts for around 10% of case of shingles. Features include a vesicular rash around the eye, which may or may not involve the actual eye itself, and Hutchinson’s sign: a rash on the tip or side of the nose, indicating nasociliary involvement and is a strong risk factor for ocular involvement.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 6 - 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 7 - A 32-year-old woman presents to the GP with tiredness and anxiety during the...

    Incorrect

    • A 32-year-old woman presents to the GP with tiredness and anxiety during the third trimester of her second pregnancy.
      The Examination is unremarkable, with a BP of 110/70 mmHg and a pulse of 80. Her BMI is 24 and she has an abdomen consistent with a 31-week pregnancy. The GP decides to check some thyroid function tests.
      Which of the following is considered to be normal?

      Your Answer:

      Correct Answer: Elevated total T4

      Explanation:

      During pregnancy, profound changes in thyroid physiology occur to provide sufficient thyroid hormone (TH) to both the mother and foetus. This is particularly important during early pregnancy because the fetal thyroid starts to produce considerable amounts of TH only from approximately 20 weeks of gestation, until which time the foetus heavily depends on the maternal supply of TH. This supply of TH to the foetus, as well as increased concentrations of TH binding proteins (thyroxine-binding globulin) and degradation of TH by placental type 3 iodothyronine deiodinase, necessitate an increased production of maternal TH. This requires an intact thyroid gland and adequate availability of dietary iodine and is in part mediated by the pregnancy hormone human chorionic gonadotropin, which is a weak agonist of the thyroid-stimulating hormone (TSH) receptor. As a consequence, serum-free thyroxine (FT4) concentrations increase and TSH concentrations decrease from approximately the eighth week throughout the first half of pregnancy, resulting in different reference intervals for TSH and FT4 compared to the non-pregnant state.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 8 - A neonate was brought in by her mother, for a skin lesion present...

    Incorrect

    • A neonate was brought in by her mother, for a skin lesion present over the neonate's back which is bluish in colour, but otherwise asymptomatic. The most appropriate course of action will be?

      Your Answer:

      Correct Answer: Reassure

      Explanation:

      A Mongolian spot can be present in new born babies which usually appears over the back and fades with time. There is nothing to worry about.

    • This question is part of the following fields:

      • Dermatology
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  • Question 9 - A 71-year old gentleman presents with a subacute history of intermittent difficulty in...

    Incorrect

    • A 71-year old gentleman presents with a subacute history of intermittent difficulty in walking, dry mouth, and variable slurring of speech. When the latter is severe he also has difficulty in swallowing. He has lost 3 kg in weight in the last 2 months.
      On examination he has bilateral mild ptosis, dysarthria, and proximal weakness of the upper and lower limbs, and he is areflexic. The degree of weakness is variable. Nerve conduction studies confirm the clinical suspicion of a neuromuscular junction disorder.
      Which of the following autoantibodies is likely to be the underlying cause of his neurological symptoms?

      Your Answer:

      Correct Answer: Anti-voltage-gated, calcium-channel antibody

      Explanation:

      The clinical picture points to Lambert– Eaton myasthenic syndrome (LEMS) which often presents with weakness of the arms and legs. In LEMS, antibodies against voltage-gated calcium channels (VGCC) decrease the amount of calcium that can enter the nerve ending, causing autonomic symptoms like dry mouth and slurring of speech, as seen in this patient.

    • This question is part of the following fields:

      • Neurology
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  • Question 10 - A 52-year-old man has squamous-cell carcinoma of his lower lip. Which of the...

    Incorrect

    • A 52-year-old man has squamous-cell carcinoma of his lower lip. Which of the following is most likely to be a feature of this type of carcinoma?

      Your Answer:

      Correct Answer: It is capable of metastasising via the lymphatics

      Explanation:

      Squamous-cell skin cancer usually presents as a hard lump with a scaly top but can also form an ulcer. Onset is often over months and it is more likely to spread to distant areas than basal cell cancer vie the lymphatics. The greatest risk factor is high total exposure to ultraviolet radiation from the Sun. Other risks include prior scars, chronic wounds, actinic keratosis, lighter skin, Bowen’s disease, arsenic exposure, radiation therapy, poor immune system function, previous basal cell carcinoma, and HPV infection. While prognosis is usually good, if distant spread occurs five-year survival is ,34%

    • This question is part of the following fields:

      • Dermatology
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  • Question 11 - A 52-year-old chef presents to the ED with acute visual changes. He has...

    Incorrect

    • A 52-year-old chef presents to the ED with acute visual changes. He has a past medical history of hypertension and type 2 diabetes mellitus. On neurological examination, his upper and lower limbs are normal however he has a homonymous hemianopia with central preservation. Where is the most likely cause of his problems within the central nervous system?

      Your Answer:

      Correct Answer: Optic radiation

      Explanation:

      Lesions in the optic radiation can cause a homonymous hemianopia with macular sparing, as a result of collateral circulation offered to macular tracts by the middle cerebral artery.
      Lesions in the optic tract also cause a homonymous hemianopia, but without macular sparing.
      Lesions in the optic chiasm, optic nerve, and temporal lobe cause bitemporal hemianopia, ipsilateral complete blindness, and superior homonymous quadrantanopia respectively.

    • This question is part of the following fields:

      • Neurology
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  • Question 12 - A 15-year-old girl is referred to the paediatric unit with reduced urine output...

    Incorrect

    • A 15-year-old girl is referred to the paediatric unit with reduced urine output and lethargy. She has been passing bloody diarrhoea for the past four days. On admission she appears dehydrated. Bloods show the following:


      Na+ 142 mmol/L,
      K+ 4.8 mmol/L,
      Bicarbonate 22 mmol/L,
      Urea 10.1 mmol/L,
      Creatinine 176 µmol/L,


      Hb 10.4 g/dL,
      MCV 90 fl
      Plt 91 * 109/L,
      WBC 14.4 * 109/L,

      Given the likely diagnosis, which one of the following organisms is the most likely cause?

      Your Answer:

      Correct Answer: E. coli

      Explanation:

      The likely diagnosis in this case is Haemolytic Uremic Syndrome (HUS), which is generally seen in young children presenting with a triad of symptoms, namely: acute renal failure, microangiopathic haemolytic anaemia, and thrombocytopenia. The typical cause of HUS is ingestion of a strain of Escherichia coli.

    • This question is part of the following fields:

      • Nephrology
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  • Question 13 - A 62-year-old laboratory technician presents to the ophthalmology emergency department with sudden onset...

    Incorrect

    • A 62-year-old laboratory technician presents to the ophthalmology emergency department with sudden onset painless loss of vision in the right eye. He describes it as having a dense shadow over his vision, progressing from the periphery to the centre. He has no past medical history of note.

      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Retinal detachment

      Explanation:

      The most common causes of a sudden painless loss of vision are as follows:
      – Ischaemic optic neuropathy (e.g. temporal arteritis or atherosclerosis)
      – Occlusion of central retinal vein
      – Occlusion of central retinal artery
      – Vitreous haemorrhage
      – Retinal detachment

      Retinal detachment is a cause of sudden painless loss of vision. It is characterised by a dense shadow starting peripherally and progressing centrally.

      Vitreous haemorrhage usually presents with dark spots.

      Central retinal artery and central retinal vein occlusion do not usually present with progressing dense shadow.

      This man’s lack of ischaemic risk factors makes ischaemic optic neuropathy less likely.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 14 - How should DVT during pregnancy be managed? ...

    Incorrect

    • How should DVT during pregnancy be managed?

      Your Answer:

      Correct Answer: Dalteparin

      Explanation:

      Deep vein thrombosis (DVT) is a serious condition in which a blood clot forms in a deep vein, usually in the leg.

      Subcutaneous low molecular weight heparin (LMWH) is the preferred treatment for most patients with acute DVT, including in pregnancy. A large meta-analyses comparing LMWH to unfractionated heparin (UFH) showed that LMWH decreased the risk of mortality, recurrent veno-thrombo embolism (VTE), and haemorrhage compared with heparin. Other advantages of LMWH may include more predictable therapeutic response, ease of administration and monitoring, and less heparin-induced thrombocytopenia. Disadvantages of LMWH include cost and longer half-life compared with heparin.

      Warfarin, which is administered orally, is used if long-term anticoagulation is needed. The international normalized ratio (INR) is followed, with a target range of 2-3. Warfarin crosses the placenta and is teratogenic, causing a constellation of anomalies known as warfarin embryopathy, with greatest risk between the sixth and twelfth week of gestation.
      Other options are not indicated for use.

    • This question is part of the following fields:

      • Respiratory
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  • Question 15 - A 28 year old male arrives at the clinic complaining of fever, arthralgia...

    Incorrect

    • A 28 year old male arrives at the clinic complaining of fever, arthralgia and urethritis. On examination, the ankle is swollen and there is a pustular rash on the dorsal foot. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Disseminated gonorrhoea

      Explanation:

      DGI presents as two syndromes: 1) a bacteremic form that includes a triad of tenosynovitis, dermatitis, and polyarthralgias without purulent arthritis and 2) a septic arthritis form characterized as a purulent arthritis without associated skin lesions. Many patients will have overlapping features of both syndromes. Time from infection to clinical manifestations may range from 1 day to 3 months. There is no travel history and the rash of Lyme disease is not purulent. Reactive arthritis presents with conjunctivitis, urethritis and arthritis usually with a red hot tender and swollen joint.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 16 - A 35-year-old woman is referred to the oncology clinic by a general surgeon....

    Incorrect

    • A 35-year-old woman is referred to the oncology clinic by a general surgeon. She has undergone mastectomy for carcinoma of the right breast.

      Out of the following, which factor is associated with a poor prognosis in patients with breast cancer?

      Your Answer:

      Correct Answer: Young age

      Explanation:

      Poor prognostic factors for breast cancer include:
      1. Young age (<40 years)
      2. Premenopausal at the time of diagnosis
      3. Increased tumour size
      4. High-grade tumour
      5. Oestrogen and progesterone receptor-negative tumour
      6. Positive lymph node status

    • This question is part of the following fields:

      • Haematology & Oncology
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  • Question 17 - A 76-year-old woman is admitted with a productive cough and pyrexia. Chest x-ray...

    Incorrect

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

      Your Answer:

      Correct Answer: Oral vancomycin for 14 days

      Explanation:

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

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 18 - A 23-year-old woman presents to the A&E with a 24-hour-history of gradual-onset fever,...

    Incorrect

    • A 23-year-old woman presents to the A&E with a 24-hour-history of gradual-onset fever, light sensitivity and headache. Clinical examination reveals neck stiffness and an area of rash which does not disappear upon pressure on her right shin. Anamnesis reveals a history of 3 episodes of meningococcal meningitis in the past and she was started on ceftriaxone for another suspected meningitis. However, you suspect that the patients might be immunodeficient. Which immunodeficiency does she most probably have?

      Your Answer:

      Correct Answer: C5-9 deficiency

      Explanation:

      Pneumococcal meningitis is the most common and severe form of bacterial meningitis. Fatality rates are substantial, and long-term sequelae develop in about half of survivors. Disease outcome has been related to the severity of the proinflammatory response in the subarachnoid space. The complement system, which mediates key inflammatory processes, has been implicated as a modulator of pneumococcal meningitis disease severity in animal studies. C5 fragment levels in cerebrospinal fluid (CSF) of patients with bacterial meningitis correlated with several clinical indicators of poor prognosis. The common terminal pathway consists of complement components C5–C9, and activation forms the anaphylatoxin C5a, a strong proinflammatory mediator, and the membrane attack complex (MAC), which creates pores in the bacterial cell wall (12). Deficiencies in these late complement components have been recognized as a cause of recurrent and familial meningococcal infections.

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 19 - A 50 year old retired coal miner with simple silicosis presented with shortness...

    Incorrect

    • A 50 year old retired coal miner with simple silicosis presented with shortness of breath. He had been short of breath for 3 months. Around 3 months ago he began keeping turtle doves as pets.

      On auscultation he had basal crepitations and chest x-ray showed fine nodular shadowing in the apices.
       
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Extrinsic allergic alveolitis

      Explanation:

      Extrinsic allergic alveolitis (EAA) refers to a group of lung diseases that can develop after exposure to certain substances. The name describes the origin and the nature of these diseases:

      ‘extrinsic’ – caused by something originating outside the body
      ‘allergic’ – an abnormally increased (hypersensitive) body reaction to a common substance
      ‘alveolitis’ – inflammation in the small air sacs of the lungs (alveoli)

      Symptoms can include: fever, cough, worsening breathlessness and weight loss. The diagnosis of the disease is based on a history of symptoms after exposure to the allergen and a range of clinical tests which usually includes: X-rays or CT scans, lung function and blood tests.

      EAA is not a ‘new’ occupational respiratory disease and occupational causes include bacteria, fungi, animal proteins, plants and chemicals.

      Examples of EAA include:

      Bird fancier’s lung (BFL) is a type of hypersensitivity pneumonitis (HP). It is triggered by exposure to avian proteins present in the dry dust of the droppings and sometimes in the feathers of a variety of birds. The lungs become inflamed, with granuloma formation. Birds such as pigeons, parakeets, cockatiels, shell parakeets (budgerigars), parrots, turtle doves, turkeys and chickens have been implicated.

      People who work with birds or own many birds are at risk. Bird hobbyists and pet store workers may also be at risk. This disease is an inflammation of the alveoli in the lungs caused by an immune response to inhaled allergens from birds. Initial symptoms include shortness of breath (dyspnoea), especially after sudden exertion or when exposed to temperature change, which can resemble asthma, hyperventilation syndrome or pulmonary embolism. Chills, fever, non-productive cough and chest discomfort may also occur.

      A definitive diagnosis can be difficult without invasive testing, but extensive exposure to birds combined with reduced diffusing capacity are strongly suggestive of this disease. X-ray or CT scans will show physical changes to the lung structure (a ground glass appearance) as the disease progresses. Precise distribution and types of tissue damage differ among similar diseases, as does response to treatment with Prednisone.

    • This question is part of the following fields:

      • Respiratory
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  • Question 20 - 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 21 - A 77-year-old female who is a known to have COPD and metastatic lung...

    Incorrect

    • A 77-year-old female who is a known to have COPD and metastatic lung cancer is admitted with increasing shortness of breath. Following discussion with her family, it is decided to withdraw active treatment including fluids and antibiotics as the admission likely represents a terminal event. Two days after admission, she becomes agitated and restless.

      What is the most appropriate management for her agitation and confusion?

      Your Answer:

      Correct Answer: Subcutaneous midazolam

      Explanation:

      Generally, underlying causes of confusion need to be looked for and treated as appropriate, for example, hypercalcaemia, infection, urinary retention, and medication. If specific treatments fail, the following may be tried:

      1. First choice: haloperidol
      2. Other options: chlorpromazine, levomepromazine

      In the terminal phase of the illness, agitation or restlessness is best treated with midazolam.

    • This question is part of the following fields:

      • Haematology & Oncology
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  • Question 22 - Which one of the following statements regarding the normal distribution is correct? ...

    Incorrect

    • Which one of the following statements regarding the normal distribution is correct?

      Your Answer:

      Correct Answer: Mean = mode = median

      Explanation:

      Normal distribution, also known as the Gaussian distribution, is a probability distribution that is symmetric about the mean. The normal distribution has the following properties:
      – It is symmetric around the mode, the median and the mean of the distribution.
      – It is unimodal
      – The area under the curve and over the x-axis is unity (i.e. equal to one).
      – Its density has two inflection points.
      – Its density is log-concave.
      The standard deviation (SD) is a measure of how much dispersion exists from the mean. SD = square root (variance)

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 23 - A 64-year-old woman with metastatic breast cancer has developed progressive back pain over...

    Incorrect

    • A 64-year-old woman with metastatic breast cancer has developed progressive back pain over the last 2 days. She also reports of weakness of her lower limbs and difficulty in walking. On examination, she has reduced power in both legs and increased tone associated with brisk knee and ankle reflexes. There is some sensory loss in the lower limbs and feet but perianal sensation is normal.

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Spinal cord compression at T10

      Explanation:

      The upper motor neurone signs in this patient point towards a diagnosis of spinal cord compression above the level of L1 and rules out cauda equina syndrome.

      Spinal cord compression is an oncological emergency and affects up to 5% of cancer patients. Extradural compression accounts for the majority of cases, usually due to vertebral body metastases. One of the most common causes of spinal cord compression is osteoarthritis. It is also more commonly seen in patients with lung, breast, or prostate cancer.

      Clinical features include:
      1. Back pain: the earliest and most common symptom, may worsen on lying down or coughing
      2. Lower limb weakness
      3. Sensory changes: sensory loss and numbness
      4. Neurological signs: depending on the level of the lesion.
      Lesions above L1 usually result in upper motor neurone signs in the legs. Lesions below L1 usually cause lower motor neurone signs in the legs and perianal numbness. Tendon reflexes are increased below the level of the lesion and absent at the level of the lesion.

      Management options are:
      1. High-dose oral dexamethasone
      2. Urgent MRI for consideration of radiotherapy or surgery

    • This question is part of the following fields:

      • Haematology & Oncology
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  • Question 24 - Which one of the following is a contraindication to the use of a...

    Incorrect

    • Which one of the following is a contraindication to the use of a triptan in the management of migraine?

      Your Answer:

      Correct Answer: A history of ischaemic heart disease

      Explanation:

      A history of ischaemic heart disease in a contraindication for prescribing triptans because they act by constricting cerebral and also coronary vessels, increasing the risk of stroke.

    • This question is part of the following fields:

      • Neurology
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  • Question 25 - A 20 year old male student presents to the clinic with swelling of...

    Incorrect

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

      Your Answer:

      Correct Answer: C1 esterase inhibitor

      Explanation:

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

    • This question is part of the following fields:

      • Rheumatology
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  • Question 26 - A 20 year old woman presents to the hospital with sharp, left-sided chest...

    Incorrect

    • A 20 year old woman presents to the hospital with sharp, left-sided chest pain and shortness of breath.

      On examination her pulse is 101 beats per minute and blood pressure is 124/61 mmHg. She is seen to be mildly breathless at rest but her oxygen saturation on air was 98%.

      CXR reveals a left pneumothorax with a 4 cm rim of air visible.

      Which management strategy is appropriate in this patient?

      Your Answer:

      Correct Answer: Needle aspiration

      Explanation:

      Pneumothorax is defined as air in the pleural space and may be classified as spontaneous, traumatic or iatrogenic. Primary spontaneous pneumothorax occurs in patients without clinically apparent lung disease.
      Primary pneumothorax has an incidence of 18-28 per 100,000 per year for men and 1.2-6 per 100,000 per year for women. Most patients present with ipsilateral pleuritic chest pain and acute shortness of breath. Shortness of breath is largely dependent on the size of the pneumothorax and whether there is underlying chronic lung disease.

      Young patients may have chest pain only. Most episodes of pneumothorax occur at rest. Symptoms may resolve within 24 hours in patients with primary spontaneous pneumothorax. The diagnosis of a pneumothorax is confirmed by finding a visceral pleural line displaced from the chest wall, without distal lung markings, on a posterior-anterior chest radiograph.

      Breathless patients should not be left without intervention regardless of the size of pneumothorax. If there is a rim of air >2cm on the chest X-ray, this should be aspirated.
      Aspiration is successful in approximately 70 per cent of patients; the patient may be discharged subsequently. A further attempt at aspiration is recommended if the patient remains symptomatic and a volume of less than 2.5 litres has been aspirated on the first attempt.

      If unsuccessful, an intercostal drain is inserted. This may be removed after 24 hours after full re-expansion or cessation of air leak without clamping and discharge may be considered.

    • This question is part of the following fields:

      • Respiratory
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  • Question 27 - Which one of the following congenital infections is most characteristically associated with chorioretinitis?...

    Incorrect

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

      Your Answer:

      Correct Answer: Toxoplasma gondii

      Explanation:

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

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 28 - A 66-year-old gentleman is seen in the Emergency Department complaining of muscle weakness...

    Incorrect

    • A 66-year-old gentleman is seen in the Emergency Department complaining of muscle weakness and lethargy. Admission bloods show the following:


      Na+ 138 mmol/L,
      K+ 6.6 mmol/L,
      Bicarbonate 15 mmol/L,
      Urea 9.2 mmol/L,
      Creatinine 110 µmol/L,

      An ECG is done which shows no acute changes.

      What is the most appropriate initial treatment to lower the serum potassium level?

      Your Answer:

      Correct Answer: Insulin/dextrose infusion

      Explanation:

      Insulin/dextrose infusion will increase the activity of the sodium-potassium pump in the cells, which will in turn decrease serum potassium levels.

    • This question is part of the following fields:

      • Nephrology
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  • Question 29 - A 55-year-old female inpatient in a psychiatric hospital has stopped eating or drinking...

    Incorrect

    • A 55-year-old female inpatient in a psychiatric hospital has stopped eating or drinking as she believes she is dead and does not require food anymore. Which syndrome is characteristic of this finding?

      Your Answer:

      Correct Answer: Cotard syndrome

      Explanation:

      The most probable diagnosis of this patient is Cotard syndrome.

      Cotard syndrome is a rare mental disorder where the affected patient believes that they (or in some cases just a part of their body) is either dead or non-existent. This delusion is often difficult to treat and can result in significant problems due to patients stopping eating or drinking as they deem it not necessary. Cotard syndrome is often associated with severe depression and psychotic disorders.

      Other delusional syndromes:
      – Othello syndrome is a delusional belief that a patients partner is committing infidelity despite no evidence of this. It can often result in violence and controlling behaviour.
      – De Clerambault syndrome (otherwise known as erotomania), is where a patient believes that a person of higher social or professional standing is in love with them. Often this presents with people who believe celebrities are in love with them.
      – Capgras syndrome is characterised by a person believing their friend or relative had been replaced by an exact double.
      – Couvade syndrome is also known as ‘sympathetic pregnancy’. It affects fathers, particularly during the first and third trimesters of pregnancy, who suffer the somatic features of pregnancy.
      – Ekbom syndrome is also known as delusional parasitosis and is the belief that they are infected with parasites or have ‘bugs’ under their skin. This can vary from the classic psychosis symptoms in narcotic use where the user can ‘see’ bugs crawling under their skin or can be a patient who believes that they are infested with snakes.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 30 - A 57-year-old man, who suffers from biventricular cardiac failure, comes to his doctor...

    Incorrect

    • A 57-year-old man, who suffers from biventricular cardiac failure, comes to his doctor for a review. His symptoms are currently well controlled; he is taking Ramipril 10mg, Spironolactone 25mg, Bisoprolol 10mg, and Furosemide 40mg. His main complaint is of painful gynaecomastia that he says has developed over the past 6 months. Physical exam reveals a blood pressure of 125/80 mmHg and no residual signs of cardiac failure. Renal function is unchanged from 6 months earlier, with stable creatinine at 125 µmol/l.

      Which of the following is the most appropriate next step?

      Your Answer:

      Correct Answer: Change the spironolactone to eplerenone

      Explanation:

      Spironolactone is an aldosterone antagonist diuretic that is well-known to cause gynaecomastia because it increases testosterone clearance and oestradiol production. The patient’s primary complaint of gynaecomastia should immediately prompt discontinuation of spironolactone and replacement with Eplerenone, which lacks the antiandrogenic effects, and thus there is less risk of gynaecomastia.

    • This question is part of the following fields:

      • Nephrology
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