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Question 1
Incorrect
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A 28-year-old female presents with postnatal depression and refuses treatment. Which form of consent should be obtained in order to treat this patient?
Your Answer: Written consent required
Correct Answer: No consent required
Explanation:The patient is in an altered psychological state; thus, no verbal nor a written consent is required from her. Consent from the carer or the court of law can be obtained but this will require some time while a prompt action is needed in this case and the carer is also unable to make a decision on the behalf of the patient. Therefore, the doctor should act without consent.
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Question 2
Incorrect
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A 35-year-old chronic smoker complains of pain in the calf while walking. This symptom has been increasing in severity for 4 months. There is a painful ulcer at the base of left first toe, which despite treatment has not improved. Dorsalis pedis and posterior tibial pulses were absent on the same side. What is the most compatible diagnosis of this presentation?
Your Answer:
Correct Answer: Thromboangitis Obliterans
Explanation:Thromboangitis obliterans or Buerger’s disease is an inflammatory vasculopathy which is characterized by an inflammatory endarteritis and mainly affects small and medium-sized arteries as well as veins of the upper and lower extremities. It is caused by a prothrombotic state and subsequent obstruction of blood vessels. Ischemic pain, features of inflammation along the vein affected, Raynaud’s phenomenon and painful non-healing ulcers are common presentations.
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Question 3
Incorrect
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A 66-year-old woman comes to you with a tender lump near the anal opening and a fever. She has history of T1DM for the last 20 years. What treatment should she get?
Your Answer:
Correct Answer: I&D + antibiotics
Explanation:Surgical incision and drainage is the most common treatment for anal abscesses. About 50% of patients with an anal abscess will develop a complication called a fistula. Diabetes is a risk factor for an anal abscess.
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Question 4
Incorrect
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A 50-year-old patient was admitted to the hospital for elective herniorrhaphy. Which of the following options will lead to a postponement of his operation?
Your Answer:
Correct Answer: Myocardial infarction two months ago
Explanation:Patients with a recent cerebrovascular incident (less than 60 days) are at very high risk of cardiac complications when under general anaesthesia. Complications like MI, heart failure and even death. Elective surgery should be postponed till stabilization of the cardiac condition is achieved.
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Question 5
Incorrect
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A 8 year old boy presented with acute onset of nasal obstruction. His parents gave a recent history of nasal trauma. On examination he was febrile and his nasal bones were straight. Which of the following is the most probable diagnosis?
Your Answer:
Correct Answer: Septal abscess
Explanation:History of fever is suggestive of an infective focus. A straight nasal bones excludes a nasal bone fracture. A nasal septal abscess is defined as a collection of pus between the cartilage or bony septum and it is an uncommon disease which should be suspected in a patient with acute onset of nasal obstruction and recent history of nasal trauma.
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Question 6
Incorrect
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A father brought his 6-year-old son with cystic fibrosis to the ER department due to massive hematemesis. He is hypotensive and has a tachycardia. Which is the most likely diagnosis?
Your Answer:
Correct Answer: Bleeding oesophageal varices
Explanation:Bleeding oesophageal varices secondary to portal hypertension can cause a massive gastrointestinal haemorrhage resulting in shock. Perforated ulcer is less likely in this age group. Mallory Weiss tear would not likely result in a massive haemorrhage. Aorto-intestinal fistula is more common in older patients with abdominal aneurysms. Boerhaave’s syndrome is a result of a ruptured oesophagus following excessive vomiting.
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Question 7
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A 55 year old female presents with progressive dyspnoea, dry cough and fever. She started methotrexate therapy six weeks ago. The current regimen includes methotrexate 15 mg/ week, folic acid 5 mg/day and aspirin 75 mg/day. There is no history of any other chronic illness. Vitals are as follows: Temp: 37.8C, pulse: 100 beats/min, BP: 110/80mmHg and SaO2: 90% on air. Examination reveals synovitis in both wrists, and metacarpophalangeal joints. On auscultation, there are scattered crepitations. Blood test reports are given below:
Haemoglobin: 13.1g/dl (13.0 – 18.0 g/dL),
WBC: 8.2 x109/l (4 – 11 x 109/l),
Neutrophils: 5.1×109/l (1.5 – 7 x 109/l),
Platelets: 280 x109/l (150 – 400 x 109/L),
ESR: 48 mm/hr (0 – 30 mm/1st hr),
Urea, electrolytes and creatinine: normal.
CXR: patchy airspace shadows bilaterally.
What is the most likely diagnosis?Your Answer:
Correct Answer: Methotrexate pneumonitis
Explanation:Pneumonitis is a serious and unpredictable side-effect of treatment with methotrexate (MTX) that may become life-threatening. The typical clinical symptoms include progressive shortness of breath and cough, often associated with fever. Hypoxaemia and tachypnoea are always present and crackles are frequently audible. Chest radiography reveals a diffuse interstitial or mixed interstitial and alveolar infiltrate, with a predilection for the lower lung fields. Pulmonary function tests show a restrictive pattern with diminished diffusion capacity. Lung biopsy reveals cellular interstitial infiltrates, granulomas or a diffuse alveolar damage pattern accompanied by perivascular inflammation. Most patients present in the first few months of starting methotrexate. It is important that all patients receiving methotrexate be educated concerning this potential adverse reaction and instructed to contact their physicians should significant new pulmonary symptoms develop while undergoing therapy. If methotrexate pneumonitis is suspected, methotrexate should be discontinued, supportive measures instituted and careful examination for different causes of respiratory distress conducted. This may be treated with corticosteroids once underlying infection has been excluded.
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Question 8
Incorrect
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A 22 year old woman is being followed up 6 weeks after a surgical procedure to evacuate the uterus following a miscarriage. The histology has shown changes consistent with a hydatidiform mole. What is the single most appropriate investigation in this case?
Your Answer:
Correct Answer: Serum B-HCG
Explanation:The most appropriate test for a hydatiform mole is serum beta hCG levels, which are consistently raised in these patients. The levels return to normal when the pregnancy is terminated.
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Question 9
Incorrect
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A 60-year-old patient with type 2 diabetes mellitus is advised to start taking an ACE-inhibitor in order to control his hypertension. However, he also needs to monitor his renal function. Keeping in mind that he just started an ACE-inhibitor, how long should he wait until he undergoes a blood test to check creatinine and potassium levels?
Your Answer:
Correct Answer:
Explanation:ACE inhibitors effectively reduce systemic vascular resistance in patients with hypertension, heart failure or chronic renal disease. This antihypertensive efficacy probably accounts for an important part of their long term renoprotective effects in patients with diabetic and non-diabetic renal disease. Systemic and renal haemodynamic effects of ACE inhibition, both beneficial and adverse, are potentiated by sodium depletion. Consequently, sodium repletion contributes to the restoration of renal function in patients with ACE inhibitor-induced acute renal failure. On the other hand, co-treatment with diuretics and sodium restriction can improve therapeutic efficacy in patients in whom the therapeutic response of blood pressure or proteinuria is insufficient. Patients at the greatest risk for renal adverse effects (those with heart failure, diabetes mellitus and/or chronic renal failure) also can expect the greatest benefit. Therefore, ACE inhibitors should not be withheld in these patients, but dosages should be carefully titrated, with monitoring of renal function and serum potassium levels. The optimum period to check this is one to two weeks after starting the medication.
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Question 10
Incorrect
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A 32-year-old man on psychiatric medications complains of the inability to ejaculate. Which drug is most likely to cause these symptoms?
Your Answer:
Correct Answer: Fluoxetine
Explanation:SSRIs such as fluoxetine are commonly associated with delayed ejaculation.
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Question 11
Incorrect
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A 22 year old woman had a C-section two hours ago. However, she has not urinated since then and claims she had no urinary complaints before the operation. Upon inspection she appears unwell and her abdomen is distended and tender suprapubically and in the left flank. Auscultation reveals no bowel sounds. Further examination reveals the following: Temp=37.5C, BP=94/73mmHg, Pulse=116bpm, Sat=97%. What's the most likely complication?
Your Answer:
Correct Answer: Urinary tract injury
Explanation:Urologic injury is the most common injury at the time of either obstetric or gynaecologic surgery, with the bladder being the most frequent organ damaged. Risk factors for bladder injury during caesarean section include previous caesarean delivery, adhesions, emergency caesarean delivery, and caesarean section performed during the second stage of labour.
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Question 12
Incorrect
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A 56 year old, postmenopausal female complains of vaginal bleeding. Transvaginal ultrasound is done which reveals the thickness of endometrium to be 10mm. Which further investigation would be most appropriate in this case?
Your Answer:
Correct Answer: Hysteroscopy and D&C
Explanation:Endometrial hyperplasia most often is caused by excess oestrogen without progesterone. If ovulation does not occur, progesterone is not made, and the lining is not shed. The endometrium may continue to grow in response to oestrogen. The cells that make up the lining may crowd together and may become abnormal. This condition, called hyperplasia, may lead to cancer in some women. Endometrial hyperplasia usually occurs after menopause, when ovulation stops and progesterone is no longer made. It also can occur during peri-menopause, when ovulation may not occur regularly. Listed as follows are other situations in which women may have high levels of oestrogen and not enough progesterone:
– Use of medications that act like oestrogen
– Long-term use of high doses of oestrogen after menopause (in women who have not had a hysterectomy)
– Irregular menstrual periods, especially associated with polycystic ovary syndrome or infertility
– ObesityTransvaginal ultrasound may be done to measure the thickness of the endometrium. To exclude carcinoma an endometrial biopsy, dilation and curettage, or hysteroscopy may be done.
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Question 13
Incorrect
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A baby is born with complications including microcephaly, hepatosplenomegaly and elevated total bilirubin. Which of the following is the most likely diagnosis in this case?
Your Answer:
Correct Answer: Cytomegalovirus (CMV)
Explanation:CMV infection is usually asymptomatic in adults. However, if the mother is infected for the first time during pregnancy then there is high chances of this infection passing on to the foetus. CMV infection can cause blindness, deafness, learning difficulties, restricted growth etc. Hepatitis B, herpes simplex, syphilis and HIV do not present with these classical signs of CMV infection in new-borns. It is estimated that 10 stillbirths occur in England and Wales every year due to CMV infection. The foetus is most at risk in early pregnancy. There is no effective prevention.
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Question 14
Incorrect
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A 23 year old patient with epilepsy, presented with fits. Investigations revealed profound hyponatraemia. Which of the following drug will cause this presentation?
Your Answer:
Correct Answer: Carbamazepine
Explanation:Carbamazepine and oxcarbazepine are the most common antiepileptics which induce hyponatremia in patients with epilepsy. Other antiepileptics such as eslicarbazepine, sodium valproate, lamotrigine, levetiracetam and gabapentin have also been reported to cause hyponatremia. So the most suitable answer is Carbamazepine.
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Question 15
Incorrect
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A 56 year old male has presented with visual loss on his left side and a history of right sided weakness. Where is the occlusion in this patient?
Your Answer:
Correct Answer: Carotid artery
Explanation:The carotid artery divides itself into two parts: the internal carotid and the external carotid. The internal carotid continues down as the middle cerebral and gives rise to the ophthalmic branch. For this reason, middle cerebral occlusion may give rise to partial visual loss but not complete mono-ocular blindness. Middle cerebral artery occlusion causes paralysis or weakness of contralateral face and arm (faciobracheal). It also causes sensory loss of the contralateral face and arm. Anterior cerebral artery occlusion causes paralysis or weakness of the contralateral foot and leg. Again, sensory loss is experienced at the contralateral foot and leg.
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Question 16
Incorrect
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Concerning the functional unit of the liver, which segment is most susceptible to hypoxic damage?
Your Answer:
Correct Answer: Zone 3
Explanation:From a metabolic perspective, the functional unit is the hepatic acinus (terminal acinus), each of which is centred on the line connecting two portal triads and extends outwards to the two adjacent central veins. The periportal zone I is nearest to the entering vascular supply and receives the most oxygenated blood, making it least sensitive to ischemic injury while making it very susceptible to viral hepatitis. Conversely, the centrilobular zone III has the poorest oxygenation, and will be most affected during a time of ischemia.
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Question 17
Incorrect
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Which of the following portocaval anastomoses can cause problems in preterm infants?
Your Answer:
Correct Answer: Patent ductus venosus.
Explanation:The ductus venosus is open at the time of the birth and closes during the first week of life in most full-term neonates; however, it may take much longer to close in pre-term neonates. After it closes, the remnant is known as ligamentum venosum. If the ductus venosus fails to occlude after birth, it remains patent (open), and the individual is said to have a patent ductus venosus and thus an intrahepatic portosystemic shunt (PSS).
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Question 18
Incorrect
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A 70 year old male presents with hoarseness of the voice and breathing difficulties for the past 3 months. A chest x-ray, showed a unilateral opacity in hilum. He has no history of smoking. Choose the most probable diagnosis.
Your Answer:
Correct Answer: Bronchial carcinoma
Explanation:All of the symptoms observed in this patient are typical of bronchial carcinoma.
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Question 19
Incorrect
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An 18 year old boy, thin with a tall stature, and a high arched palate arrives at the hospital with a spontaneous pneumothorax. He is accompanied by his brother who has a similar appearance. You suspect Marfan's Syndrome.
The gene encoding which of the following proteins is defective in this condition?Your Answer:
Correct Answer: Fibrillin-1
Explanation:A variety of proteins compose the structure of microfibrils, the most prominent of which are the two fibrillins. Fibrillin-1 a scaffolding protein is encoded by FBN1 on human chromosome 15q21 and fibrillin-2 is encoded by FBN2 on 5q23. Mutations in FBN1 produce Marfan syndrome, a pleiotropic autosomal dominant connective tissue disorder with prominent manifestations in the skeleton, eye and cardiovascular system. A number of conditions related to Marfan syndrome are also due to FBN1 mutations.
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Question 20
Incorrect
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A 25-year-old male had an emergency appendicectomy. His doctor prescribed him prophylactic antibiotics to avoid infection after the surgery. Which of the following antibiotics is the best choice for post abdominal surgery?
Your Answer:
Correct Answer: Cefuroxime
Explanation:Cefuroxime is the best choice in the case of gut surgery as it is very effective in preventing infections against gut anaerobes, enterococci and coliforms.
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Question 21
Incorrect
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A lethargic 2-month child was brought in with symptoms of diarrhoea and vomiting for 6 days. What is the appropriate initial investigations?
Your Answer:
Correct Answer: Urea and electrolytes
Explanation:The most commonly requested biochemistry tests for renal function are the urea and electrolytes. They supply important information when it comes to homeostasis and excretion. Glomerular filtration rate is also the essential standard marker of kidney health and is assessed by checking the creatinine levels. In this case as the child has lost fluids and electrolytes, this test will indicate the extent of the loss and allow for more appropriate replacement.
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Question 22
Incorrect
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A patient shows reduced central vision upon visual acuity test. He is advised to undergo a fundoscopy, which turns out to be normal. Which drug could be responsible for his symptoms?
Your Answer:
Correct Answer: Corticosteroids
Explanation:Corticosteroids are well known for their ocular complications such as glaucoma and cataracts.
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Question 23
Incorrect
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A 62-year-old male patient with long standing COPD presented with reduced vision of his right eye. He had been on multiple medications. Which of the following drugs is responsible for his visual deterioration?
Your Answer:
Correct Answer: Corticosteroid
Explanation:Prolonged use of corticosteroids causes cataracts and this would be the reason for his presentation. B2 agonists, diuretics and Theophylline can cause blurred vision.
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Question 24
Incorrect
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A 79 year old nursing home resident presents to the clinic with an intensely itchy rash. Examination reveals white linear lesions on the wrists and elbows, and red papules on the penile surface. Which of the following will be the most suitable management plan for this patient?
Your Answer:
Correct Answer: Topical permethrin
Explanation:Scabies is a parasitic skin infestation caused by Sarcoptes scabiei mite, which is primarily transmitted via direct human-to-human contact. The female scabies mite burrows into the superficial skin layer, causing severe pruritus, particularly at night. Primary lesions commonly include erythematous papules, vesicles, or burrows. Treatment involves topical medical therapy (e.g. permethrin) and decontamination of all clothing and textiles.
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Question 25
Incorrect
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The ECG of a 48-year-old man shows broad complex tachycardia with a HR of 154bpm 2 days after an MI. His BP is 90/60mmHg and he is complaining of palpitations and dyspnoea. What is the most appropriate management?
Your Answer:
Correct Answer: DC Shock
Explanation:Dysrhythmias are the most frequent MI complication. The patient seems to have a post MI atrial fibrillation which is treated, in an emergency context, with DC shock.
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Question 26
Incorrect
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An 19 year old pregnant woman wants to terminate her pregnancy. She's in her 12th week of gestation and she's never been pregnant before. What is the most appropriate management?
Your Answer:
Correct Answer: Suction curettage
Explanation:Between 9-12weeks of gestation, suction curettage is usually the most appropriate method of termination of pregnancy. Termination of pregnancy must be decided and performed as early as possible. An abortion after 24 weeks of gestation is illegal in the UK.
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Question 27
Incorrect
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In the treatment of infants with gastroenteritis, which of the following statements is the most accurate one?
Your Answer:
Correct Answer:
Explanation:The main problem with infants having gastroenteritis is dehydration. So they should be admitted to the hospital for IV fluids if they are not tolerating oral fluids.
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Question 28
Incorrect
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A child presents with hypothyroidism. Which of the following features is characteristic of hypothyroidism?
Your Answer:
Correct Answer: Prolonged neonatal jaundice
Explanation:Congenital hypothyroidism is one of the most important diseases of the new-born, which may lead to mental and physical retardation when treatment is delayed or an appropriate dosage of thyroxine is not administered. The most alarming and earliest sign is jaundice, especially when it is prolonged, during the neonatal period.
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Question 29
Incorrect
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An ECG taken on a patient shows dominant R wave in V1. Which of the following cannot be the reason for above ECG change?
Your Answer:
Correct Answer: Primary pulmonary hypertension
Explanation:Dominant R wave in V1 can be a normal variant in children and young adults. Other causes are right ventricular hypertrophy, pulmonary embolus, persistence of left to right shunt, Right Bundle Branch Block (RBBB), posterior myocardial infarction (ST elevation in Leads V7, V8, V9), Wolff-Parkinson-White (WPW) Type A, Incorrect lead placement (e.g. V1 and V3 reversed), dextrocardia, hypertrophic cardiomyopathy and dystrophy (myotonic dystrophy and Duchenne Muscular dystrophy).
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Question 30
Incorrect
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A 21 year old patient presents with multiple itchy wheals on his skin. The wheals are of all sizes and they are exacerbated by scratching. The symptoms started after a viral infection and can last up to an hour. What is the most likely diagnosis?
Your Answer:
Correct Answer: Urticaria
Explanation:Urticaria is a group of disorders that share a distinct skin reaction pattern, namely the occurrence of itchy wheals anywhere on the skin. Wheals are short-lived elevated erythematous lesions ranging from a few millimetres to several centimetres in diameter and can become confluent. The itching can be prickling or burning and is usually worse in the evening or night time. Triggering of urticaria by infections has been discussed for many years but the exact role and pathogenesis of mast cell activation by infectious processes is unclear.
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Question 31
Incorrect
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A 5 year old girl presented with short stature, primary amenorrhea, puffy arms and a webbed neck. The most likely diagnosis will be?
Your Answer:
Correct Answer: Turner’s syndrome
Explanation:Turner’s syndrome is characterised by a webbed neck, short stature, primary amenorrhea and cardiac, renal and muscular defects. Gene analysis shows a single X chromosome in the patients. Downs syndrome has certain cognitive and physical abnormalities, whereas in Klinefelter syndrome there are widely spaced nipples, long arms and infertility and it only occurs in men.
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Question 32
Incorrect
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A 61 year old male presented to the emergency with renal colicky pain and a subsequent passage of stone the next day. Radiological examination, however, revealed no signs of calculi. The renal calculus was most likely composed of which of the following?
Your Answer:
Correct Answer: Uric acid
Explanation:Calcium-containing stones are relatively radio dense, and they can often be detected by a traditional radiograph of the abdomen that includes the kidneys, ureters, and bladder (KUB film). Some 60% of all renal stones are radiopaque. In general, calcium phosphate stones have the greatest density, followed by calcium oxalate and magnesium ammonium phosphate stones. Cystine calculi are only faintly radio dense, while uric acid stones are usually entirely radiolucent.
Uric acid is the relatively water-insoluble end product of purine nucleotide metabolism. It poses a special problem because of its limited solubility, particularly in the acidic environment of the distal nephron of the kidney. It is problematic because humans do not possess the enzyme uricase, which converts uric acid into the more soluble compound allantoin. Three forms of kidney disease have been attributed to excess uric acid: acute uric acid nephropathy, chronic urate nephropathy, and uric acid nephrolithiasis. These disorders share the common element of excess uric acid or urate deposition, although the clinical features vary.
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Question 33
Incorrect
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A 25-year-old woman with long-term bipolar disorder is experiencing Hypothermia, weight gain, lethargy. Which psychotropic medication would you associate these side effects?
Your Answer:
Correct Answer: Lithium
Explanation:Lithium is the medication used for a wide range of mental illnesses such as schizophrenia, depression, and bipolar disorders. It is famous for its side effects which includes a number of thyroid disorders (hypothyroidism, hyperthyroidism, and thyroiditis).
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Question 34
Incorrect
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A 14-year-old girl came to the emergency room in a bizarre state with altered consciousness, presenting with symptoms of insomnia, logorrhoea, and anxiety, with incoherent discourse and amnesia of recent events. She has started calling herself The Queen, and is refusing to be her parents' daughter. What is the most likely diagnosis?
Your Answer:
Correct Answer: Ganser syndrome
Explanation:Ganser syndrome is a condition in which a person acts as if he is suffering from a specific psychological disorder in order to gain sympathy and relief.
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Question 35
Incorrect
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A 50-year-old Afro-Caribbean male is noted to have a blood pressure of 186/99 mmHg. He also suffers from asthma. Which of the following anti-hypertensive drugs will be ineffective in this specific patient?
Your Answer:
Correct Answer: ACE inhibitor
Explanation:The Afro-Caribbean population is found to have an increased sensitivity of blood pressure to salt intake as well as a reduced tendency to excrete the ingested salt, associated with low renin levels. ACE inhibitors will then be an ineffective group of anti-hypertensive drugs for this specific population.
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Question 36
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An 8-year-old girl presents with a history of a bright red bloodstain in her underpants one day prior to consultation. Her mother reports that the girl started cycling lessons one week ago. How will you proceed with the investigation in this case?
Your Answer:
Correct Answer: Examination under Anaesthesia
Explanation:A local exam might not help in locating the cause of the bleeding because it might be underneath the superficial structures. A thorough examination should be done under GA to accurately locate the source of bleeding.
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Question 37
Incorrect
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Which feature is NOT characteristic of carcinoid syndrome?
Your Answer:
Correct Answer:
Explanation:Carcinoid syndrome is a paraneoplastic syndrome comprising of signs and symptoms that occur secondary to carcinoid tumours. Diarrhoea, dermatitis, bronchospasm and right sided cardiac valve lesions (tricuspid insufficiency and pulmonary stenosis) are characteristic of carcinoid syndrome.
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Question 38
Incorrect
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Question 39
Incorrect
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A 16 year old boy was stabbed in his right upper back and brought to the ED where he underwent an erect CXR. Findings suggest a homogenous opacity on the lower right lung with the trachea centrally placed. What would explain the those findings?
Your Answer:
Correct Answer: Haemothorax
Explanation:Findings suggest a haemothorax which is very likely to happen, in the absence of a haemo-pneumothorax.
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Question 40
Incorrect
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You are asked to fill the first part of a cremation form. Which of the following would need to be removed prior to cremation?
Your Answer:
Correct Answer:
Explanation:Pacemakers have small electrical parts installed in them that can explode when exposed to extreme heat and pressure.
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