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  • Question 1 - A 52-year-old woman is being reviewed in the oncology clinic following debulking surgery...

    Incorrect

    • A 52-year-old woman is being reviewed in the oncology clinic following debulking surgery one month ago. She is a known case of primary peritoneal cancer with two liver metastases and has now come in for review prior to adjuvant chemotherapy. During her chemotherapy, which of the following tumour markers would be the most appropriate to monitor her disease progression?

      Your Answer: CA 15-3

      Correct Answer: CA 125

      Explanation:

      Tumour marker CA 125 is mostly associated with primary peritoneal cancer and ovarian cancer. It can be used to monitor response to chemotherapy, alongside regular CT scans.

      Tumour markers can be divided into:
      1. Monoclonal antibodies
      CA 125: Ovarian cancer, primary peritoneal cancer
      CA 19-9: Pancreatic cancer
      CA 15-3: Breast cancer

      2. Tumour specific antigens
      Prostate specific antigen (PSA): Prostatic carcinoma
      Alpha-feto protein (AFP): Hepatocellular carcinoma, teratoma
      Carcinoembryonic antigen (CEA): Colorectal cancer
      S-100: Melanoma, schwannomas
      Bombesin: Small cell lung carcinoma, gastric cancer

      3. Enzymes
      Alkaline phosphatase (ALP)
      Neuron specific enolase (NSE)

      4. Hormones
      Calcitonin
      Antidiuretic hormone (ADH)
      Human chorionic gonadotropin (hCG)

    • This question is part of the following fields:

      • Haematology & Oncology
      71.2
      Seconds
  • Question 2 - A 32-year-old patient that has just returned from India, complains of dyspnoea. On...

    Incorrect

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

      Your Answer: Infectious mononucleosis

      Correct Answer: Diphtheria

      Explanation:

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

    • This question is part of the following fields:

      • Infectious Diseases
      7.8
      Seconds
  • Question 3 - A young woman is concerned that she has put on weight since she...

    Incorrect

    • A young woman is concerned that she has put on weight since she was a medical student, as she now no longer finds time to exercise. She decides to try various weight loss tablets temporarily. After 2 months, she is successfully losing weight but also has trouble with increased stool frequency, difficulty in climbing stairs and getting up out of chairs. However, she has no problems walking on the flat. She also has difficulty in sleeping at the moment but puts that down to the increased frequency of headaches for the past 2 months. Which one of the following is the most likely cause of her weakness?

      Your Answer: She is abusing metformin

      Correct Answer: She is abusing thyroxine tablets

      Explanation:

      Exogenous thyroid hormone use has been associated with episodes of thyroid storm as well as thyrotoxic periodic paralysis.
      It presents with marked proximal muscle weakness in both upper and lower limbs, hypokalaemia and signs of hyperthyroidism.
      Hyperthyroidism generally presents with tachycardia, hypertension, hyperthermia, and cardiac arrhythmias

      Laxatives and diuretics can result in electrolyte abnormalities.
      Medical complications associated with laxatives include chronic diarrhoea which disrupts the normal stool electrolyte concentrations that then leads to serum electrolyte shifts; acutely, hypokalaemia is most typically seen. The large intestine suffers nerve damage from the chronic laxative use that renders it unable to function properly. The normal peristalsis and conduction are affected; the disorder is thought to be secondary to a degeneration of Auerbach’s Plexi. However, it does not cause muscle weakness.

      Insulin tends to cause weight gain, not weight loss.
      Metformin does not cause muscle weakness but can cause headaches.

    • This question is part of the following fields:

      • Endocrinology
      59.3
      Seconds
  • Question 4 - A 68 year old man presents with acute symptoms of gout on his...

    Incorrect

    • A 68 year old man presents with acute symptoms of gout on his first metatarsophalangeal joint. Which option best explains the underlying mechanism of gout?

      Your Answer: Increased endogenous production of uric acid

      Correct Answer: Decreased renal excretion of uric acid

      Explanation:

      Primary gout is related more often to underexcretion of uric acid or overproduction.

    • This question is part of the following fields:

      • Rheumatology
      50.7
      Seconds
  • Question 5 - The increased risk of oesophageal malignancy in patients with Barrett’s oesophagus is approximately:...

    Correct

    • The increased risk of oesophageal malignancy in patients with Barrett’s oesophagus is approximately:

      Your Answer: 50 - 100 times risk

      Explanation:

      Barrett’s oesophagus is the transformation of the normal squamous epithelium of the oesophagus to columnar, intestinal type epithelium. It is often seen in patients with reflux and there is a 50-100 fold increased risk of oesophageal adenocarcinoma in patients with Barrett’s oesophagus.

    • This question is part of the following fields:

      • Gastroenterology
      10.1
      Seconds
  • Question 6 - A 26-year-old woman presents for her first cervical smear. What is the most...

    Correct

    • A 26-year-old woman presents for her first cervical smear. What is the most important aetiological factor causing cervical cancer?

      Your Answer: Human papilloma virus 16 & 18

      Explanation:

      It has been determined that HPV infection is the most powerful epidemic factor. This virus is needed, but not sufficient for the development of cervical cancer.
      The WHO’s International Agency for Research on Cancer (IARC) classified HPV infection as carcinogenic to humans (HPV types 16 and 18), probably carcinogenic (HPV types 31 and 33) and possibly carcinogenic (other HPV types except 6 and 11).
      Tobacco smoking, the use of contraceptives, and the number of births are factors that showed no statistically significant deviations in the studied population compared to other countries in the region, as well as European countries. They have an equal statistical significance in all age groups.

    • This question is part of the following fields:

      • Endocrinology
      13.3
      Seconds
  • Question 7 - A 20-year-old female has been admitted with an acute infection. She gives a...

    Incorrect

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

      Your Answer:

      Correct Answer: Cefalexin

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Pharmacology
      0
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  • Question 8 - A 21-year-old patient is referred to the tertiary neurology clinic because of a...

    Incorrect

    • A 21-year-old patient is referred to the tertiary neurology clinic because of a possible diagnosis of Juvenile Parkinson’s disease. His symptoms began predominantly with dystonia affecting the lower limbs, but he now has more classical signs of older onset Parkinson’s including tremor, bradykinesia, and rigidity. You map out his family tree and understand that his sister developed Parkinson’s at the age of 16 but that his parents do not have signs of Parkinson’s. Which of the following is the most likely mode of inheritance?

      Your Answer:

      Correct Answer: Autosomal recessive

      Explanation:

      Juvenile Onset Parkinson’s is an autosomal recessive condition that usually presents in late childhood to early adulthood, initially with gait disorders caused by lower limb dystonia that later develops to the more classical signs Parkinson’s.

    • This question is part of the following fields:

      • Neurology
      0
      Seconds
  • Question 9 - Where is secretin secreted from? ...

    Incorrect

    • Where is secretin secreted from?

      Your Answer:

      Correct Answer: S cells in upper small intestine

      Explanation:

      Secretin is a peptide hormone produced in the S cells of the duodenum, which are located in the intestinal glands. In humans, the secretin peptide is encoded by the SCT gene.
      Secretin helps regulate the pH of the duodenum by
      1) inhibiting the secretion of gastric acid from the parietal cells of the stomach and
      (2) stimulating the production of bicarbonate from the ductal cells of the pancreas.
      G cells in the antrum of the stomach release gastrin
      I cells in upper small intestine release CCK
      D cells in the pancreas & stomach secrete somatostatin
      K cells secrete gastric inhibitory peptide, an incretin, which also promotes triglyceride storage.

    • This question is part of the following fields:

      • Clinical Sciences
      0
      Seconds
  • Question 10 - A 20-year-old man presents with a history of sticky greenish discharge, accompanied by...

    Incorrect

    • A 20-year-old man presents with a history of sticky greenish discharge, accompanied by redness of the eyes, and difficulty opening his eyes in the morning. What is the single most likely cause of these symptoms?

      Your Answer:

      Correct Answer: Conjunctivitis

      Explanation:

      Redness of the eyes can present in all of the conditions. However, the green sticky discharge that causes the eyelids to stick together overnight is characteristic of bacterial conjunctivitis. Bacterial conjunctivitis is an inflammatory condition of the conjunctiva in which bacteria commonly Staphylococcus Aureus invade the conjunctiva. The person experiences a foreign body feeling in the eye and mucopurulent or purulent discharge.

    • This question is part of the following fields:

      • Ophthalmology
      0
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  • Question 11 - Which of the following features of the jugular venous waveform indicates the closure...

    Incorrect

    • Which of the following features of the jugular venous waveform indicates the closure of the tricuspid valve?

      Your Answer:

      Correct Answer: c wave

      Explanation:

      The a wave indicates atrial contraction. The c wave indicates ventricular contraction and resulting bulging of the tricuspid valve into the right atrium during isovolumetric systole. The v wave indicates venous filling. The x descent indicates the atrium relaxation and the movement of tricuspid valve downward. The y descent indicates the filling of the ventricle after the opening of the tricuspid valve.

    • This question is part of the following fields:

      • Cardiology
      0
      Seconds
  • Question 12 - Regarding the pathophysiology of diabetes mellitus, which of the following is true? ...

    Incorrect

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

      Your Answer:

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

      Explanation:

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

    • This question is part of the following fields:

      • Endocrinology
      0
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  • Question 13 - Drug-induced lupus erythematosus most often occurs after taking which of the following drugs?...

    Incorrect

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

      Your Answer:

      Correct Answer: Procainamide

      Explanation:

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

    • This question is part of the following fields:

      • Rheumatology
      0
      Seconds
  • Question 14 - A 22-year-old woman has ingested an unknown quantity of paracetamol tablets four hours...

    Incorrect

    • A 22-year-old woman has ingested an unknown quantity of paracetamol tablets four hours ago. She now presents with nausea, vomiting, anorexia and right subchondral pain. Which of the following features suggest that she should be transferred to the liver unit?

      Your Answer:

      Correct Answer: pH 7.25

      Explanation:

      The most widely used prognostic predictors for acetaminophen over-ingestion is King’s College Criteria, which is: arterial PH < 7.3 after fluid resuscitation, Cr level > 3.4, PT > 1.8x control or > 100s, or INR > 6.5, and Grave III or IV encephalopathy.

    • This question is part of the following fields:

      • Gastroenterology
      0
      Seconds
  • Question 15 - Choose the hormone secreted only by the adrenal medulla: ...

    Incorrect

    • Choose the hormone secreted only by the adrenal medulla:

      Your Answer:

      Correct Answer: Adrenaline

      Explanation:

      The major endocrine functions of adrenal gland are to produce catecholamines and steroids. Catecholamine, synthesized by the adrenal medulla, is responsible for blood pressure and blood flow regulation whereas steroids produced by the cortex control energy and water homeostasis and immune responses. Glucocorticoids, a major group of adrenal steroids, have a stimulatory effect on catecholamine synthesis in the medulla.

    • This question is part of the following fields:

      • Clinical Sciences
      0
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  • Question 16 - A 37-year-old social worker is referred to you with a long history of...

    Incorrect

    • A 37-year-old social worker is referred to you with a long history of diarrhoea and abdominal discomfort. She was diagnosed with irritable bowel syndrome 10 years ago and takes mebeverine, peppermint tablets and Gaviscon. She is a vegetarian and rarely drinks or smokes. Examination of all systems is normal. Her blood tests show macrocytic anaemia. An upper gastrointestinal endoscopy reveals oesophagitis, hypertrophy of the gastric body and multiple duodenal ulcers. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Zollinger–Ellison syndrome

      Explanation:

      This case describes Zollinger-Ellison syndrome. It is characterized by refractory peptic ulcer disease, often multiple ulcers. This is typically caused by secretion of gastrin from a gastrinoma, a neuroendocrine tumour. The most common site of ulceration is the duodenum. A symptom of a pancreatic gastrinoma may be steatorrhea from the hypersecretion of gastrin. Serum gastrin levels > 1000 and a pH < 2 are diagnostic of pancreatic gastrinoma. None of the other answer choices are a better answer than this. CT abdomen may potentially show a tumour, but this is not diagnostic for type.

    • This question is part of the following fields:

      • Gastroenterology
      0
      Seconds
  • Question 17 - A 24-year-old female presents with generalised irritation and erythematous skin after sunbathing on...

    Incorrect

    • A 24-year-old female presents with generalised irritation and erythematous skin after sunbathing on the beach. Which is the most appropriate immediate treatment for this patient?

      Your Answer:

      Correct Answer:

      Explanation:

      Sun burn reactions usually occur after individuals with a light skin tone have prolonged exposure to the sun. The usual symptoms are redness and itching of the skin. The best treatment plan would be further avoidance of sun exposure and the topical application of emollients. These are Ist degree burns and aggressive therapy is not required in such cases.

    • This question is part of the following fields:

      • Dermatology
      0
      Seconds
  • Question 18 - A 45-year-old male patient presents with severe pharyngitis and dysphagia. He's found to...

    Incorrect

    • A 45-year-old male patient presents with severe pharyngitis and dysphagia. He's found to be HIV positive and with oesophageal candidiasis. Which of the following regarding HIV virus is correct?

      Your Answer:

      Correct Answer: HIV is an RNA virus

      Explanation:

      The human immunodeficiency virus (HIV) is grouped to the genus Lentivirus within the family of Retroviridae, subfamily Orthoretrovirinae. The HIV genome consists of two identical single-stranded RNA molecules that are enclosed within the core of the virus particle. The genome of the HIV provirus, also known as proviral DNA, is generated by the reverse transcription of the viral RNA genome into DNA, degradation of the RNA and integration of the double-stranded HIV DNA into the human genome.

    • This question is part of the following fields:

      • Clinical Sciences
      0
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  • Question 19 - A 80 yr. old male with hypertension presented with his second episode of...

    Incorrect

    • A 80 yr. old male with hypertension presented with his second episode of atrial fibrillation. He was warfarinised and discharged. Later he was reviewed and found to be in sinus rhythm. Which of the following is the most appropriate next step?

      Your Answer:

      Correct Answer: Continue lifelong warfarin

      Explanation:

      CHA₂DS₂-VASc score is used for atrial fibrillation stroke risk calculation.
      Congestive heart failure – 1 point
      Hypertension – 1 point
      Age ≥75 years – 2 points
      Diabetes mellitus – 1 point
      Stroke/Transient Ischemic Attack/Thromboembolic event – 2 points
      Vascular disease (prior MI, PAD, or aortic plaque) – 1 point
      Age 65 to 74 years – 1 point
      Sex category (i.e., female sex) – 1 point
      A score of 2 or more is considered as high risk and anticoagulation is indicated. This patient’s score is 3, so he needs life long warfarin to prevent stroke.

    • This question is part of the following fields:

      • Cardiology
      0
      Seconds
  • Question 20 - How is the left ventricular ejection fraction calculated? ...

    Incorrect

    • How is the left ventricular ejection fraction calculated?

      Your Answer:

      Correct Answer: Stroke volume / end diastolic LV volume

      Explanation:

      Left ventricular ejection fraction = (stroke volume / end diastolic LV volume ) * 100%

      Stroke volume = end diastolic LV volume – end systolic LV volume

      Pulse pressure = Systolic Pressure – Diastolic Pressure

    • This question is part of the following fields:

      • Clinical Sciences
      0
      Seconds
  • Question 21 - A 25 year old female presented with blisters on the tongue. Some of...

    Incorrect

    • A 25 year old female presented with blisters on the tongue. Some of them secreted pinkish fluid while some were crusted. Which of the following is the most probable diagnosis?

      Your Answer:

      Correct Answer: HSV1

      Explanation:

      The history is suggestive of acute gingivostomatitis, which is a manifestation of primary HSV-1 infection. Patients present with gingivitis and vesicular lesions which develop on the oral mucosa, tongue, and lips and later rupture and coalesce, leaving ulcerated plaques.

    • This question is part of the following fields:

      • Infectious Diseases
      0
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  • Question 22 - A 52-year-old man presents with numbness and tingling in his left hand. On...

    Incorrect

    • A 52-year-old man presents with numbness and tingling in his left hand. On examination he has weakness of elbow extension, metacarpophalangeal joint flexion and extension and distal interphalangeal joint flexion. All other movements and reflexes are normal. Sensation is normal apart from reduced pin-prick sensation over the medial aspect of the hand. An MRI scan of the cervical spine is performed due to suspicion of a nerve lesion. Which of the following pathologies is most likely to be found on the scan based on the clinical findings?

      Your Answer:

      Correct Answer: Disc herniation between C7 and T1

      Explanation:

      The C8 nerve forms part of the radial and ulnar nerves via the brachial plexus, and therefore has motor and sensory function in the upper limb. It originates from the spinal column from below the cervical vertebra 7 (C7).
      The C8 nerve receives sensory afferents from the C8 dermatome. This consists of all the skin on the little finger, and continuing up slightly past the wrist on the palmar and dorsal aspects of the hand and forearm.
      The other options available correspond to the C6 or C7 roots and these are unaffected as evidenced by normal elbow flexion and thumb sensation (C6) and normal sensation over the middle finger (C7). Elbow extension is weak as it has roots from both C7 and C8 and so cannot be used alone to decide between the two levels clinically.
      The C8 nerve contributes to the motor innervation of many of the muscles in the trunk and upper limb. Its primary function is the flexion of the fingers, and this is used as the clinical test for C8 integrity, in conjunction with the finger jerk reflex.

      Trunk:
      – Pectoralis major – Medial and lateral pectoral nerves (C5, C6, C7, C8, T1)
      – Pectoralis minor – Medial pectoral nerve (C5, C6, C7,C8, T1)
      – Latissimus dorsi – Thoracodorsal nerve (C6, C7, C8)
      Upper arm:
      – Triceps brachii – Radial nerve (C6, C7,C8)
      Forearm
      – Flexor carpi ulnaris – Ulnar nerve (C7, C8, T1)
      – Palmaris longus – Median nerve (C7,C8)
      – Flexor digitorum superficialis – Median nerve (C8, T1)
      – Flexor digitorum profundus – Median and Ulnar nerves (C8, T1)
      – Flexor pollicis longus – Median nerve (C7,C8)
      – Pronator quadratus – Median nerve (C7,C8)
      – Extensor carpi radialis brevis – Deep branch of the radial nerve (C7,C8)
      – Extensor digitorum – Posterior interosseous nerve (C7,C8)
      – Extensor digiti minimi – Posterior interosseous nerve (C7,C8)
      – Extensor carpi ulnaris – Posterior interosseous nerve (C7,C8)
      – Anconeus – Radial nerve (C6, C7,C8)
      – Abductor pollicis longus – Posterior interosseous nerve (C7,C8)
      – Extensor pollicis brevis – Posterior interosseous nerve (C7,C8)
      – Extensor pollicis longus – Posterior interosseous nerve (C7,C8)
      – Extensor indicis – Posterior interosseous nerve (C7,C8)
      Hand
      – Palmaris brevis – Superficial branch of ulnar nerve (C8, T1)
      – Dorsal interossei – Deep branch of ulnar nerve (C8, T1)
      – Palmar interossei – Deep branch of ulnar nerve (C8, T1)
      – Adductor pollicis – Deep branch of ulnar nerve (C8, T1)
      – Lumbricals – Deep branch of ulnar, Digital branches of median nerve
      – Opponens pollicis – Recurrent branch of median nerve (C8, T1)
      – Abductor pollicis brevis – Recurrent branch of median nerve (C8, T1)
      – Flexor pollicis brevis – Recurrent branch of median nerve (C8, T1)
      – Opponens digiti minimi – Deep branch of ulnar nerve (C8, T1)
      – Abductor digiti minimi – Deep branch of ulnar nerve (C8, T1)
      – Flexor digiti minimi brevis – Deep branch of ulnar nerve (C8, T1)

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 23 - A 30-year-old female presents with a 4-day history of diarrhoea and vomiting. She...

    Incorrect

    • A 30-year-old female presents with a 4-day history of diarrhoea and vomiting. She has been unable to keep fluids down for 4 days and has been treated with metoclopramide. She develops a dystonic reaction. What is the most appropriate treatment for the woman?

      Your Answer:

      Correct Answer: Benztropine

      Explanation:

      Acute dystonic reactions (extrapyramidal symptoms) such as spasmodic torticollis, trismus, and oculogyric crises can occur following the administration of metoclopramide or stemetil and thus, neither is recommended for the treatment of nausea in young women.

      Such reactions respond well to treatment with benztropine or procyclidine.
      – Benztropine: It is an anticholinergic medication with significant CNS penetration.
      A single dose of benztropine 1 to 2 mg IV followed by 1 to 2 mg p.o twice a day for up to 7 days to prevent a recurrence. Subsequently, both the offending agent and those from the same group should be avoided.
      – Alternatively, diphenhydramine can be used intravenously (up to a dose of 50mg) or intramuscularly followed by p.o therapy every 6 hours for 1 to 2 to prevent a recurrence.
      – Second-line therapy with IV benzodiazepines is reserved for those patients who do not respond to anticholinergics.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 24 - A 14 year-old is brought to the ED after being hit on the...

    Incorrect

    • A 14 year-old is brought to the ED after being hit on the head with a cricket ball during a match. His teacher describes that he initially collapsed on the ground and complained of a sore head. Two minutes later, he got up and said he felt OK and continued playing. However, 30 minutes later he suddenly collapsed and lost consciousness. What injury is he most likely to have sustained?

      Your Answer:

      Correct Answer: Extradural haematoma

      Explanation:

      A lucid interval, in which the patient portrays a temporary improvement in condition after a traumatic brain injury, is especially indicative of an epidural haematoma.

    • This question is part of the following fields:

      • Neurology
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  • Question 25 - A 60 yr. old man with previous history of myocardial infarction and hypertension...

    Incorrect

    • A 60 yr. old man with previous history of myocardial infarction and hypertension presented with severe retrosternal chest pain for the past 2 hours. During initial management he collapsed and pulseless ventricular tachycardia was detected. The external defibrillator arrived in 3 minutes. From the following answers, what is the most appropriate immediate management of this patient?

      Your Answer:

      Correct Answer: He should be given a precordial thump

      Explanation:

      A precordial thumb is not routinely recommended because of its very low success rate for cardioversion of a shockable rhythm. It’s only recommended when there is a delay in getting the defibrillator.

    • This question is part of the following fields:

      • Cardiology
      0
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  • Question 26 - A 30-year-old female presents to the A&E department with epistaxis, which has now...

    Incorrect

    • A 30-year-old female presents to the A&E department with epistaxis, which has now stopped. According to her boyfriend, she has a recent history of mucosal bleeding and has at times been very disorientated. On examination, she has a low-grade fever and appears confused and jaundiced. There is bruising over her legs and arms. A urine pregnancy test is negative. You receive the following blood results from the laboratory: Hb: 8.5 g/dL, Plts: 8 x 10^9/L, WCC: 4.5 x 10^9/L, MCV: 92 fL, Na+: 138 mmol/L, K+: 4.9 mmol/L, Urea: 10.2 mmol/L, Creatinine: 182 mmol/L, Her coagulation profile is normal. Given the likely diagnosis, what is the most appropriate management of this patient?

      Your Answer:

      Correct Answer: Plasma exchange

      Explanation:

      The diagnosis for the aforementioned case is thrombotic thrombocytopenic purpura (TTP). TTP is classically characterised as a pentad of thrombocytopaenia, microvascular haemolysis, fluctuating neurological signs, renal impairment, and fever.

      The differential diagnosis for severe thrombocytopaenia is immune thrombocytopenic purpura (ITP). ITP is more common than TTP. However, a patient of ITP would not present with the range of symptoms seen in this scenario.

      In TTP, there is deficiency of a protease which breaks down large multimers of von Willebrand factor. This leads to abnormally large and sticky multimers of von Willebrand factor which cause platelets to clump within the vessels.

      Untreated TTP has a mortality rate of up to 90%. Therefore, rapid plasma exchange (PEX) may be a life-saving intervention. Platelet transfusion in TTP is only indicated if there is an ongoing life-threatening bleed. Intravenous methylprednisolone is indicated after treatment with PEX has been completed. There is no current role of intravenous immunoglobulin in the routine management of TTP. However, there have been reports of its successful use in PEX- and steroid-refractory cases. Intravenous argatroban is indicated in heparin-induced thrombocytopaenia (HIT), but there is no history of recent heparin administration or hospitalisation in this patient nor are the clinical signs consistent with HIT.

      Management options for TTP include PEX as the treatment of choice. Steroids and immunosuppressants are also given. Antibiotics are not recommended as they may worsen the outcome of the disease. For cases resistant to PEX and pharmacologic therapy, vincristine is given.

    • This question is part of the following fields:

      • Haematology & Oncology
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  • Question 27 - A 75-year-old woman experiences weakness of her left hand. Clinical examination reveals wasting...

    Incorrect

    • A 75-year-old woman experiences weakness of her left hand. Clinical examination reveals wasting of the hypothenar eminence and weakness of finger abduction and thumb adduction. The lesion is most probably located at:

      Your Answer:

      Correct Answer: Ulnar nerve

      Explanation:

      Patients with compressive neuropathy of the ulnar nerve typically describe numbness and tingling of the ulnar-sided digits of the hand, classically in the small finger and ulnar aspect of the ring finger. Among the general population, symptoms usually begin intermittently and are often worse at night, particularly if the elbow is flexed while sleeping. As the disease progresses, paraesthesia may occur more frequently and during the daytime.

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 28 - 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 29 - 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
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  • Question 30 - A 61-year-old female presents to the A&E with malaise and muscle twitching. Her...

    Incorrect

    • A 61-year-old female presents to the A&E with malaise and muscle twitching. Her blood pressure is 114/78 mmHg and her pulse is 84/min. Blood exam reveals Calcium = 1.94 mmol/l and Albumin = 38 g/l. Which of the following tests is most useful in establishing her diagnosis?

      Your Answer:

      Correct Answer: Parathyroid hormone

      Explanation:

      Hypocalcaemia occurs in patients with impaired function of the parathyroid glands. This is most common after thyroid or parathyroid surgery, but it can be idiopathic—mostly in young adults and less often as part of a genetic syndrome, such as autoimmune polyglandular syndrome type 1. Usually, the first and most useful test to perform in such cases is the measurement of the parathyroid hormone.

    • This question is part of the following fields:

      • Clinical Sciences
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Haematology & Oncology (0/1) 0%
Infectious Diseases (0/1) 0%
Endocrinology (1/2) 50%
Rheumatology (0/1) 0%
Gastroenterology (1/1) 100%
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