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  • Question 1 - A 42 yr. old man presented with palpitations and shortness of breath on...

    Incorrect

    • A 42 yr. old man presented with palpitations and shortness of breath on exertion. On examination his lungs were clear and heart sounds were normal. There was a left sided parasternal heave. His electrocardiogram (ECG) revealed atrial fibrillation with right axis deviation. Echocardiography showed dilated right heart chambers. Left and right heart catheterisation study revealed the following: Inferior vena cava Oxygen saturations 63 %, Superior vena cava Oxygen saturations 59 %, Right atrium Oxygen saturations 77 %, Right ventricle Oxygen saturations 78 %, Pulmonary artery Oxygen saturations 82 %, Arterial saturation Oxygen saturations 98 %. What is the most likely diagnosis from the following answers?

      Your Answer: Ebstein’s anomaly

      Correct Answer: Atrial septal defect

      Explanation:

      Right ventricular volume overload is indicated by a parasternal heave and right axis deviation. Oxygen saturation in right atrium is higher than oxygen saturation of the inferior and superior vena cavae. So the most probable diagnosis is atrial septal defect.

    • This question is part of the following fields:

      • Cardiology
      57.8
      Seconds
  • Question 2 - Which of the following is caused by vitamin D? ...

    Incorrect

    • Which of the following is caused by vitamin D?

      Your Answer: Decreased plasma calcium

      Correct Answer: Increased plasma phosphate

      Explanation:

      Intestinal phosphate absorption is mediated by both transcellular and paracellular routes. The 1,25(OH)2D increases intestinal transcellular phosphate absorption at least in part by enhancing expression of type 2b sodium–phosphate cotransporter, thus increasing plasma phosphate.

    • This question is part of the following fields:

      • Clinical Sciences
      19.5
      Seconds
  • Question 3 - A 27 year old woman presents with a 4cm bleeding ulcer on her...

    Correct

    • A 27 year old woman presents with a 4cm bleeding ulcer on her labia minora. The woman admits she is sexually active. Which lymph nodes will the ulcer drain to?

      Your Answer: Superficial inguinal

      Explanation:

      The woman seems to have a chancroid, which may or may not drain to the lymph nodes of the groin. These nodes are the superficial inguinal lymph nodes.

    • This question is part of the following fields:

      • Infectious Diseases
      32.6
      Seconds
  • Question 4 - A 35-year-old female presented with complaints of earache and a high-grade fever. During...

    Incorrect

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

      Your Answer: Varicella zoster

      Correct Answer: Herpes zoster

      Explanation:

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

    • This question is part of the following fields:

      • Infectious Diseases
      14.3
      Seconds
  • Question 5 - A 85 yr. old previously well man was found to have a BP...

    Correct

    • A 85 yr. old previously well man was found to have a BP of 155/90 mmHg. His average reading from the monitoring of his ambulatory BP was 147/92 mmHg. His calculated 10 year cardiovascular risk was 15%. Which of the following is the most appropriate management of this patient?

      Your Answer: Give lifestyle advice and repeat blood pressure in 6 months

      Explanation:

      According to different guidelines for patients above 80 years, the targeted systolic blood pressure varies from 140-150 mmHg. As this patient’s BP is within that range, he can be kept under observation.

    • This question is part of the following fields:

      • Cardiology
      23.9
      Seconds
  • Question 6 - A 60 yr. old male patient with NSTEMI was started on low dose...

    Correct

    • 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: 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
      11.4
      Seconds
  • Question 7 - Which is the formula to calculate the number needed to treat? ...

    Incorrect

    • Which is the formula to calculate the number needed to treat?

      Your Answer: (Absolute Risk Reduction) / (Number of people in trial)

      Correct Answer: 1 / (Absolute risk reduction)

      Explanation:

      The number needed to treat (NNT) is valuable information in treatment decisions. NNT is the inverse of the absolute risk reduction (1/ARR) between two treatment options.

    • This question is part of the following fields:

      • Clinical Sciences
      7.3
      Seconds
  • Question 8 - The family of a 10-year-old boy was advised to take the boy to...

    Correct

    • The family of a 10-year-old boy was advised to take the boy to see an oncologist, for suspected lymphoma. The boy had lymphadenopathy on presentation. His mother says that he's had a fever, night sweats and has experienced weight loss. The boy underwent a lymph node biopsy at the oncologist which suggests Burkitt's lymphoma. Which oncogene are you expecting to see after molecular testing?

      Your Answer: c-MYC

      Explanation:

      Burkitt lymphoma is a germinal centre B-cell-derived cancer that was instrumental in the identification of MYC as an important human oncogene more than three decades ago. Recently, new genomics technologies have uncovered several additional oncogenic mechanisms that cooperate with MYC to create this highly aggressive cancer.

    • This question is part of the following fields:

      • Clinical Sciences
      21.3
      Seconds
  • Question 9 - 170 patients are enrolled in a study to assess the addition of a...

    Incorrect

    • 170 patients are enrolled in a study to assess the addition of a new antiplatelet drug to aspirin for those who've had a stroke. Out of 170 patients, 120 received the aspirin in addition to the new drug with the remaining 50 patients receiving just aspirin. After 5 years, 18 out of the 120 patients receiving the new drug in addition to aspirin and 10 out of the 50 patients receiving just aspirin, had had a stroke. What is the number needed to treat?

      Your Answer: 1.8

      Correct Answer: 20

      Explanation:

      The number needed to treat (NNT) is valuable information in treatment decisions. NNT is the inverse of the absolute risk reduction (1/ARR) between two treatment options. Control event rate = 10 / 50 = 0.2
      Experimental event rate = 18 / 120 = 0.15

      Absolute risk reduction = 0.2 – 0.15 = 0.05
      Number needed to treat = 1 / 0.05 = 20

    • This question is part of the following fields:

      • Clinical Sciences
      26.8
      Seconds
  • Question 10 - A 24-year-old student is brought to A&E having ingested at least 20 tablets...

    Correct

    • A 24-year-old student is brought to A&E having ingested at least 20 tablets of paracetamol 8 hours earlier. She weighs 61kg. What should her immediate management consist of?

      Your Answer: Intravenous N-acetylcysteine

      Explanation:

      Activated charcoal is useful if given within one hour of the paracetamol overdose. Liver function tests, INR and prothrombin time will be normal, as liver damage may not manifest until 24 hours or more after ingestion.

      The antidote of choice is intravenous N-acetylcysteine, which provides complete protection against toxicity if given within 10 hours of the overdose.

    • This question is part of the following fields:

      • Pharmacology
      17.6
      Seconds
  • Question 11 - 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: Platelet transfusion

      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
      32
      Seconds
  • Question 12 - Which is NOT true of vitiligo? ...

    Incorrect

    • Which is NOT true of vitiligo?

      Your Answer: There is no known cure

      Correct Answer: A positive family history is not a risk factor

      Explanation:

      The cause of Vitiligo is typically unknown. It is believed to be due to genetic susceptibility that is triggered by an environmental factor such that an autoimmune disease occurs. This results in the destruction of skin pigment cells. Risk factors include a family history of the condition or other autoimmune diseases, such as hyperthyroidism, alopecia areata, and pernicious anaemia. Vitiligo is classified into two main types: segmental and non-segmental. Most cases are non-segmental meaning they affect both sides and typically get worse with time. The prevalence of vitiligo is 0.5-1% of populations worldwide. Typical sites include backs of hands, wrists, knees, neck and around body orifices. The Koebner phenomenon refers to skin lesions appearing on lines of trauma. This occurs in vitiligo secondary to scratching.

    • This question is part of the following fields:

      • Dermatology
      10.4
      Seconds
  • Question 13 - A 36-year-old lady presents to the emergency department with right upper quadrant pain....

    Correct

    • A 36-year-old lady presents to the emergency department with right upper quadrant pain. She has also noticed that her skin seems slightly yellower over the last week or so and you notice a yellow tinge to her sclera. On further questioning, she complains of itching of her arms. Her only past medical history of note includes ulcerative colitis for which she takes mesalazine. Given her presentation, what is the best investigation to diagnose the most likely underlying condition?

      Your Answer: ERCP (endoscopic retrograde cholangiopancreatography)

      Explanation:

      With biliary obstructive symptoms in a patient with ulcerative colitis, one should immediately think of primary sclerosing cholangitis (PSC). PSC is characterized by inflammation and fibrosis of the intrahepatic and extrahepatic ducts. The best diagnostic test for PSC is ERCP. ANCA antibiotics may be positive, but not the best test to DIAGNOSE THE CONDITION. The same can be said of serum transaminase levels– they will be abnormal but nonspecific. While a liver ultrasound may be helpful, it is not the best test. Liver biopsy would be used to stage the PSC later.

    • This question is part of the following fields:

      • Gastroenterology
      59
      Seconds
  • Question 14 - A 15-year-old child with learning difficulties is referred to the endocrine clinic for...

    Incorrect

    • A 15-year-old child with learning difficulties is referred to the endocrine clinic for review. His lab results show hypocalcaemia and increased serum concentration of parathyroid hormone. On examination, there is subcutaneous calcification and a short fifth metacarpal in each hand. What is the treatment of choice in this case?

      Your Answer: Parathyroid hormone administration

      Correct Answer: Calcium and vitamin D supplementation

      Explanation:

      This child has pseudo hypoparathyroidism. It is a heterogeneous group of rare endocrine disorders characterized by normal renal function and resistance to the action of parathyroid hormone (PTH), manifesting with hypocalcaemia, hyperphosphatemia, and increased serum concentration of PTH.
      Patients with pseudo hypoparathyroidism type 1a present with a characteristic phenotype collectively called Albright hereditary osteodystrophy (AHO). The constellation of findings includes the following:
      Short stature
      Stocky habitus
      Obesity
      Developmental delay
      Round face
      Dental hypoplasia
      Brachymetacarpals
      Brachymetatarsals
      Soft tissue calcification/ossification
      The goals of therapy are to maintain serum total and ionized calcium levels within the reference range to avoid hypercalcaemia and to suppress PTH levels to normal. This is important because elevated PTH levels in patients with PHP can cause increased bone remodelling and lead to hyper-parathyroid bone disease.
      The goals of pharmacotherapy are to correct calcium deficiency, to prevent complications, and to reduce morbidity. Intravenous calcium is the initial treatment for all patients with severe symptomatic hypocalcaemia. Administration of oral calcium and 1alpha-hydroxylated vitamin D metabolites, such as calcitriol, remains the mainstay of treatment and should be initiated in every patient with a diagnosis of pseudo hypoparathyroidism.

    • This question is part of the following fields:

      • Endocrinology
      42.4
      Seconds
  • Question 15 - A new study was developed to assess the benefit of omega-3 fish oils...

    Incorrect

    • A new study was developed to assess the benefit of omega-3 fish oils in patients with established ischaemic heart disease. The power of the study is equal to:

      Your Answer: standard deviation / square root of sample size

      Correct Answer: 1 - probability of making a type II error

      Explanation:

      The power of a test is defined as 1 − the probability of Type II error. The Type II error is concluding at no difference (the null is not rejected) when in fact there is a difference, and its probability is named β. Therefore, the power of a study reflects the probability of detecting a difference when this difference exists. It is also very important to medical research that studies are planned with an adequate power so that meaningful conclusions can be issued if no statistical difference has been shown between the treatments compared. More power means less risk for Type II errors and more chances to detect a difference when it exists.

    • This question is part of the following fields:

      • Clinical Sciences
      4.5
      Seconds
  • Question 16 - A 65-year-old man presents to you three weeks after initiating metformin for type...

    Incorrect

    • A 65-year-old man presents to you three weeks after initiating metformin for type 2 diabetes mellitus. His body mass index is 27.5 kg/m^2. At a dose of 500mg TDS the patient has experienced significant diarrhoea. Even on reducing the dose to 500mg BD his symptoms persisted. What is the most appropriate next step in this patient?

      Your Answer: Switch to gliclazide 40mg od

      Correct Answer: Start modified release metformin 500mg od with evening meal

      Explanation:

      Here, the patient seems to be intolerant to standard metformin. In such cases, modified-release preparations is considered as the most appropriate next step.
      There is some evidence that these produce fewer gastrointestinal side-effects in patients intolerant of standard-release metformin.

      Metformin is a biguanide and reduces blood glucose levels by decreasing the production of glucose in the liver, decreasing intestinal absorption and increasing insulin sensitivity.
      Metformin decreases both the basal and postprandial blood glucose.
      Other uses: In Polycystic Ovarian Syndrome (PCOS), Metformin decreases insulin levels, which then decreases luteinizing hormone and androgen levels. Thus acting to normalize the menstruation cycle.

      Note:
      Metformin is contraindicated in patients with severe renal dysfunction, which is defined as a glomerular filtration rate (GFR) less than 30 ml/min/1.732m2.
      Metformin overdose has been associated with hypoglycaemia and lactic acidosis, for this reason, it has a black box warning for lactic acidosis.

    • This question is part of the following fields:

      • Pharmacology
      24.4
      Seconds
  • Question 17 - A 23-year-old woman presents with hirsutism and oligomenorrhea for the last five years....

    Incorrect

    • A 23-year-old woman presents with hirsutism and oligomenorrhea for the last five years. She is very anxious about her irregular menses and worried as her mother was diagnosed with uterine cancer recently. She is a lawyer and does not want to conceive, at least for the next couple of years. The examination is essentially normal except for coarse dark hair being noticed under her chin and over her lower back. Investigations done during the follicular phase: Serum androstenedione 10.1 nmol/l (0.6-8.8), Serum dehydroepiandrosterone sulphate 11.6 ىmol/l (2-10), Serum 17-hydroxyprogesterone 5.6 nmol/l (1-10), Serum oestradiol 220 pmol/l (200-400), Serum testosterone 3.6 nmol/l (0.5-3), Serum sex hormone binding protein 32 nmol/l (40-137), Plasma luteinising hormone 3.3 U/l (2.5-10), Plasma follicle-stimulating hormone 3.6 U/l (2.5-10). What is the most appropriate treatment?

      Your Answer: Spironolactone

      Correct Answer: Combined OCP

      Explanation:

      This patient has polycystic ovarian syndrome (PCOS). Medical management of PCOS is aimed at the treatment of metabolic derangements, anovulation, hirsutism, and menstrual irregularity.
      First-line medical therapy usually consists of an oral contraceptive to induce regular menses. The contraceptive not only inhibits ovarian androgen production but also increases sex hormone-binding globulin (SHBG) production. The American College of Obstetricians and Gynaecologists (ACOG) recommends the use of combination low-dose hormonal contraceptive agents for long-term management of menstrual dysfunction.
      If symptoms such as hirsutism are not sufficiently alleviated, an androgen-blocking agent may be added. Pregnancy should be excluded before therapy with oral contraceptives or androgen-blocking agents are started.
      First-line treatment for ovulation induction when fertility is desired is clomiphene citrate. Second-line strategies may be equally effective in infertile women with clomiphene citrate–resistant PCOS.

    • This question is part of the following fields:

      • Endocrinology
      49.8
      Seconds
  • Question 18 - A 30-year-old man with type-1 diabetes mellitus on insulin presents in the A&E...

    Correct

    • A 30-year-old man with type-1 diabetes mellitus on insulin presents in the A&E with fever, cough, vomiting and abdominal pain. Examination reveals a dry mucosa, decreased skin turgor and a temperature of 37.8 °C. Chest examination reveals bronchial breathing in the right lower lobe, and a chest X-ray shows it to be due to a right lower zone consolidation. Other investigations show: Blood glucose: 35 mmol/L, Na+: 132 mmol/L, K+: 5.5 mmol/L, urea: 8.0 mmol/L, creatinine: 120 μmol/L, pH: 7.15, HCO3: 12 mmol/L, p(CO2): 4.6 kPa, chloride: 106 mmol/l. Urinary ketones are positive (+++). The patient is admitted to the hospital and treated. Which of the following should not be used while treating him?

      Your Answer: Bicarbonate

      Explanation:

      Bicarbonate therapy is not indicated in mild and moderate forms of DKA because metabolic acidosis will correct with insulin therapy. The use of bicarbonate in severe DKA is controversial due to a lack of prospective randomized studies. It is thought that the administration of bicarbonate may actually result in peripheral hypoxemia, worsening of hypokalaemia, paradoxical central nervous system acidosis, cerebral oedema in children and young adults, and an increase in intracellular acidosis. Because severe acidosis is associated with worse clinical outcomes and can lead to impairment in sensorium and deterioration of myocardial contractility, bicarbonate therapy may be indicated if the pH is 6.9 or less.

    • This question is part of the following fields:

      • Endocrinology
      39
      Seconds
  • Question 19 - A 60-year-old librarian presents for review. She has recently been diagnosed with dry...

    Incorrect

    • A 60-year-old librarian presents for review. She has recently been diagnosed with dry age-related macular degeneration. Which of the following is the strongest risk factor for developing this condition?

      Your Answer: Diabetes mellitus

      Correct Answer: Smoking

      Explanation:

      Age-related macular degeneration is the most common cause of blindness in the UK. Degeneration of the central retina (macula) is the key feature with changes usually bilateral. Smoking and genetic factors are risk factors for macular degeneration. The severity is divided into early, intermediate, and late types. The late type is additionally divided into dry and wet forms with the dry form making up 90% of cases.

    • This question is part of the following fields:

      • Ophthalmology
      10.1
      Seconds
  • Question 20 - Where is the site of action of spironolactone? ...

    Incorrect

    • Where is the site of action of spironolactone?

      Your Answer: Descending loop of Henle

      Correct Answer: Distal convoluted tubule

      Explanation:

      Spironolactone is an aldosterone antagonist which acts in the distal convoluted tubule. It is a potassium-sparing diuretic that prevents the body from absorbing too much salt and keeps the potassium levels from getting too low. Spironolactone is used to treat heart failure, high blood pressure (hypertension), or hypokalaemia (low potassium levels in the blood).

    • This question is part of the following fields:

      • Pharmacology
      6.1
      Seconds
  • Question 21 - A 28-year-old man who is admitted with bright red haematemesis, which occurred after...

    Incorrect

    • A 28-year-old man who is admitted with bright red haematemesis, which occurred after a bout of vomiting. He had been out with friends on a stag party and consumed 12 pints of beer. Upper gastrointestinal (GI) endoscopy proves unremarkable and haemoglobin (Hb) is stable at 12.5 g/dl the morning after admission, there is no sign of circulatory compromise. There have been no previous similar episodes. Which of the following stems represents the best course of action for this patient?

      Your Answer: Refer for coeliac axis angiography

      Correct Answer: Send home

      Explanation:

      This is a classic clinical presentation, with alcohol intake and nausea/vomiting that leads to hematemesis, of a Mallory-Weiss tear. In Mallory-Weiss tear, they typically present as a hemodynamically stable patient after a night of binge drinking and excessive resultant vomiting. Given his EGD did not show any other pathology and he is now stable, he can be discharged home.

    • This question is part of the following fields:

      • Gastroenterology
      42.1
      Seconds
  • Question 22 - A 28 year old female hiker begins complaining of headache and nausea after...

    Incorrect

    • A 28 year old female hiker begins complaining of headache and nausea after reaching a height of 5010 metres. Despite having the headache and feeling nauseous, she continues to hike but becomes progressively worse. She is seen staggering, complains of feeling dizzy and has an ataxic gait. Which of the following is the appropriate treatment of this patient?

      Your Answer: Descent + acetazolamide

      Correct Answer: Descent + dexamethasone

      Explanation:

      High Altitude Cerebral Oedema (HACE) is a severe and potentially fatal manifestation of high altitude illness and is often characterized by ataxia, fatigue, and altered mental status. HACE is often thought of as an extreme form/end-stage of Acute Mountain Sickness (AMS). Although HACE represents the least common form of altitude illness, it may progress rapidly to coma and death as a result of brain herniation within 24 hours, if not promptly diagnosed and treated.

      HACE generally occurs after 2 days above 4000m but can occur at lower elevations (2500m) and with faster onset. Some, but not all, individuals will suffer from symptoms of AMS such as headache, insomnia, anorexia, nausea prior to transitioning to HACE. Some may also have concomitant High Altitude Pulmonary Oedema (HAPE). HACE in isolation is rare, but the absence of concomitant HAPE or symptoms of AMS prior to deterioration does not rule-out the presence of HACE.

      Most cases develop as a progression of AMS and will include a history of recent ascent to altitude and prior complaints/findings of AMS including a headache, fatigue, nausea, insomnia, and/or light-headedness. Some may also have signs/symptoms of HAPE. Transition to HACE is heralded by signs of encephalopathy including ataxia (usually the earliest clinical finding) and altered mentation which may range from mild to severe. Other symptoms may include a more severe headache, difficulty speaking, lassitude, a decline in the level of consciousness, and/or focal neurological deficits or seizures.

      The mainstay of treatment is the immediate descent of at least 1000m or until symptoms improve. If descent is not an option, one may use a portable hyperbaric chamber and/or supplemental oxygen to temporize illness, but this should never replace or delay evaluation/descent when possible. If available, dexamethasone 8mg for one dose, followed by 4mg every 6 hours should be given to adults via PO, IM, or IV routes.
      Acetazolamide has proven to be beneficial in only a single clinical study. The suggested dosing regimen for Acetazolamide is 250 mg PO, given twice daily. Though effective in alleviating or temporizing symptoms, none of the adjunct treatment modalities are definitive or a replacement for an immediate descent.

    • This question is part of the following fields:

      • Respiratory
      25.5
      Seconds
  • Question 23 - A 21 year-old software developer undergoes a planned lumbar puncture (LP) as part...

    Incorrect

    • A 21 year-old software developer undergoes a planned lumbar puncture (LP) as part of a neurological investigation for possible multiple sclerosis. During the consent process, she expresses concern about a post-LP headache. What is the mechanism of post-LP headaches?

      Your Answer: Too much cerebrospinal fluid removed

      Correct Answer: Leaking cerebrospinal fluid from the dura

      Explanation:

      Leaking of cerebrospinal fluid from the dura is the most likely explanation for post-lumbar puncture headaches. It is thought that ongoing leak of cerebrospinal fluid (CSF) through the puncture site causes ongoing CSF loss, leading to low pressure. A post-LP headache is typically frontal or occipital and occurs within three days. It is normally associated with worsening on standing and improvement when lying down. Treatment in severe cases includes an epidural blood patch, but most resolve on their own.

    • This question is part of the following fields:

      • Neurology
      20.7
      Seconds
  • Question 24 - Which of the following is associated with heterochromia in congenital disease? ...

    Incorrect

    • Which of the following is associated with heterochromia in congenital disease?

      Your Answer: Holmes-Adie pupil

      Correct Answer: Horner's syndrome

      Explanation:

      Heterochromia (difference in iris colour) is seen in congenital Horner’s syndrome, as well as anhidrosis. Other features of non-congenital Horner’s include miosis, ptosis and enophthalmos.

    • This question is part of the following fields:

      • Ophthalmology
      3.5
      Seconds
  • Question 25 - A 53-year-old man is brought into the emergency department by the paramedics. He...

    Correct

    • A 53-year-old man is brought into the emergency department by the paramedics. He collapsed oat home suffering from a myocardial infarction and was subsequently resuscitated following a cardiac arrest. Blood tests show impaired liver function (ALT 1400 u/l). He is on a statin, and at his appointment last week his LFT was normal. There is nothing to note on examination and he is currently not complaining of any pain. Given this man's presentation, what is the most likely cause of his impaired liver function tests?

      Your Answer: Ischaemic hepatitis

      Explanation:

      When you have abnormal liver function tests after a cardiac arrest, the most likely aetiology, barring history that is known or given excluding this diagnosis, would be ischemia. Chronic alcohol abuse would not see an acute elevation like this. Hepatitis B is just unlikely given the clinical picture, ischemia is much more likely. The same is for Budd-Chiari syndrome (venous thrombosis) and Wilson’s disease.

    • This question is part of the following fields:

      • Gastroenterology
      25.5
      Seconds
  • Question 26 - A 26 year old man with a history of 'brittle' asthma is admitted...

    Incorrect

    • A 26 year old man with a history of 'brittle' asthma is admitted with an asthma attack. High-flow oxygen and nebulised salbutamol have already been administered by the Paramedics. The patient is unable to complete sentences and he has a bilateral expiratory wheeze. He is also unable to perform a peak flow reading. His respiratory rate is 31/minute, sats 93% (on high-flow oxygen) and pulse 119/minute. Intravenous hydrocortisone is immediately administered and nebulised salbutamol given continuously. Intravenous magnesium sulphate is administered after six minutes of no improvement. These are the results from the blood gas sample that was taken after another six minutes: pH 7.32 pCO2 6.8 kPa pO2 8.9 kPa What is the most appropriate therapy in this patient?

      Your Answer: Non-invasive ventilation

      Correct Answer: Intubation

      Explanation:

      The normal partial pressure reference values are: oxygen PaO2 more than 80 mmHg (11 kPa), and carbon dioxide PaCO2 lesser than 45 mmHg (6.0 kPa).
      This patient has an elevated PaCO2 of 6.8kPa which exceeds the normal value of less than 6.0kPa.
      The pH is also lower than 7.35 at 7.32

      In any patient with asthma, an increasing PaCO2 indicates severe airway obstruction that is leading to respiratory muscle fatigue and patient exhaustion.

      According to the British Thoracic Society guidelines:
      Indications for admission to intensive care or high-dependency units include
      patients requiring ventilatory support and those with acute severe or life-threatening asthma who are failing to respond to therapy, as evidenced by:
      • deteriorating PEF
      • persisting or worsening hypoxia
      • hypercapnia
      • arterial blood gas analysis showing fall in pH or rising hydrogen concentration
      • exhaustion, feeble respiration
      • drowsiness, confusion, altered conscious state
      • respiratory arrest

      Transfer to ICU accompanied by a doctor prepared to intubate if:
      • Deteriorating PEF, worsening or persisting hypoxia, or hypercapnia
      • Exhaustion, altered consciousness
      • Poor respiratory effort or respiratory arrest

      A single dose of intravenous magnesium sulphate is safe and may improve lung function and reduce intubation rates in patients with acute severe asthma. Intravenous magnesium sulphate may also reduce hospital admissions in adults with acute asthma who have had little or no response to standard treatment.

      Consider giving a single dose of intravenous magnesium sulphate to
      patients with acute severe asthma (PEF <50% best or predicted) who have not had a good initial response to inhaled bronchodilator therapy.
      Magnesium sulphate (1.2–2 g IV infusion over 20 minutes) should only be used following consultation with senior medical staff.

    • This question is part of the following fields:

      • Respiratory
      60.9
      Seconds
  • Question 27 - A 32 year old male who has recently returned from a trip to...

    Incorrect

    • A 32 year old male who has recently returned from a trip to Thailand presents with congestion of eyes and swelling of the knee joint. He completed a course of antibiotics for dysentery 4 weeks back. He experiences no dysuria and urine examination is normal. Which further information would be most useful in establishing a diagnosis?

      Your Answer: Joint aspiration and culture

      Correct Answer: History and physical examination

      Explanation:

      The patient most likely has reactive arthritis which is usually diagnosed on history and clinical examination. The classic triad of symptoms include conjunctivitis, urethritis and arthritis. Arthritis and conjunctivitis may occur 4-6 weeks after a gastrointestinal or genitourinary infection. Arthritis usually occurs acutely, mostly involving the lower limb and is asymmetrical. Blood culture, urine culture and arthrocentesis (joint aspiration) will not yield positive results.

    • This question is part of the following fields:

      • Rheumatology
      34.9
      Seconds
  • Question 28 - Cholecystokinin is secreted from: ...

    Incorrect

    • Cholecystokinin is secreted from:

      Your Answer: G cells in stomach

      Correct Answer: I cells in upper small intestine

      Explanation:

      Cholecystokinin (CCK) was discovered in 1928 in jejunal extracts as a gallbladder contraction factor. It was later shown to be member of a peptide family, which are all ligands for the CCK1 and CCK2 receptors. CCK peptides are known to be synthetized in the small intestinal endocrine I-cells and cerebral neurons.

    • This question is part of the following fields:

      • Clinical Sciences
      7.3
      Seconds
  • Question 29 - Choose the wrong statement regarding hypocalcaemia: ...

    Incorrect

    • Choose the wrong statement regarding hypocalcaemia:

      Your Answer: Prolonged QT interval is seen

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

      Explanation:

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

    • This question is part of the following fields:

      • Clinical Sciences
      33.2
      Seconds
  • Question 30 - A 54-year-old man is found collapsed in the street and is brought to...

    Correct

    • A 54-year-old man is found collapsed in the street and is brought to the A&E. The results from the blood tests reveal Calcium = 1.62mmol/l and Albumin = 33g/l. The man is known to have a history of alcoholic liver disease. Which of the following is the best management regarding his calcium levels?

      Your Answer: 10ml of 10% calcium gluconate over 10 minutes

      Explanation:

      Acute, symptomatic hypocalcaemia is treated with 10ml of 10% calcium gluconate over 10 minutes.

    • This question is part of the following fields:

      • Clinical Sciences
      33.9
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Cardiology (2/3) 67%
Clinical Sciences (1/7) 14%
Infectious Diseases (1/2) 50%
Pharmacology (1/3) 33%
Haematology & Oncology (0/1) 0%
Dermatology (0/1) 0%
Gastroenterology (2/3) 67%
Endocrinology (1/3) 33%
Ophthalmology (0/2) 0%
Respiratory (0/2) 0%
Neurology (0/1) 0%
Rheumatology (0/1) 0%
Passmed