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  • Question 1 - A 35-year-old male presented to the ER after being rescued from a house...

    Incorrect

    • A 35-year-old male presented to the ER after being rescued from a house fire. He complained of feeling dizzy and having a worsening headache. On examination, he was dyspnoeic, drowsy and confused. There was no evidence of facial burns and no stridor. He was normotensive, tachycardic (pulse rate: 102 bpm), tachypnoeic (respiratory rate: 35/min) and had O2 saturation of 100% in room air. His venous blood gas results are given below: pH - 7.28 pCO2 - 3.5 kPa pO2 - 15.9 kPa Na+ - 139 mmol/L, K+ - 4.5 mmol/L, Bicarbonate - 11 mmol/L, Chloride - 113 mmol/L, Lactate - 13.6 mmol/L, Keeping in mind the likely diagnosis, which among the following is the most appropriate intervention for this patient?

      Your Answer: Intubate and ventilate

      Correct Answer: Intravenous hydroxocobalamin

      Explanation:

      The most appropriate intervention in this patient is intravenous hydroxocobalamin.
      The clinical scenario provided is suggestive of acute cyanide toxicity secondary to burning plastics in the house fire.
      Cyanide ions inhibit mitochondrial cytochrome oxidase, preventing aerobic respiration. This manifests in normal oxygen saturations, a high pO2 and flushing (or ‘brick red’ skin) brought on by the excess oxygenation of venous blood. In the question above it is important to note that the blood gas sample given is venous rather than arterial. His blood gas also demonstrates an increased anion gap, consistent with his high lactate (generated by anaerobic respiration due to the inability to use available oxygen).

      The recommended treatment for moderate cyanide toxicity in the UK is one of three options: sodium thiosulfate, hydroxocobalamin or dicobalt edetate.

      Among the options given is hydroxocobalamin and this is, therefore, the correct answer. Hydroxocobalamin additionally has the best side-effect profile and speed of onset compared with other treatments for cyanide poisoning.

      Other options:
      – Intubation would be appropriate treatment in the context of airway burns but this patient has no evidence of these, although close monitoring would be advised.
      – High-flow oxygen is the treatment for carbon monoxide poisoning – a sensible differential, but this man’s very high lactate and high venous pO2 fit better with cyanide toxicity. Intravenous dexamethasone would be another treatment for airway oedema once an endotracheal tube had been placed.
      – Intravenous sodium nitroprusside is a treatment for high blood pressure that can cause cyanide poisoning, and would, therefore, be inappropriate.

      Note:

      Cyanide may be used in insecticides, photograph development and the production of certain metals. Toxicity results from reversible inhibition of cellular oxidizing enzymes
      Clinical presentation:
      Classical features: brick-red skin, the smell of bitter almonds
      Acute: hypoxia, hypotension, headache, confusion
      Chronic: ataxia, peripheral neuropathy, dermatitis

      Management:
      Supportive measures: 100% oxygen
      Definitive: hydroxocobalamin (intravenously), also a combination of amyl nitrite (inhaled), sodium nitrite (intravenously), and sodium thiosulfate (intravenously).

    • This question is part of the following fields:

      • Pharmacology
      47.5
      Seconds
  • Question 2 - A 23-year-old designer is requesting the combined oral contraceptive pill. During the history...

    Correct

    • A 23-year-old designer is requesting the combined oral contraceptive pill. During the history taking, she states that in the past she has had migraines with aura. She asks why the combined oral contraceptive pill is contraindicated. Which of the following is the most appropriate response?

      Your Answer: Significantly increased risk of ischaemic stroke

      Explanation:

      SIGN produced guidelines in 2008 on the management of migraines. Key points include that if patients have migraines with aura then the combined oral contraceptive (COC) is absolutely contraindicated due to an increased risk of stroke (relative risk 8.72).

    • This question is part of the following fields:

      • Neurology
      11.8
      Seconds
  • Question 3 - A 50-year-old patient was started on ezetimibe, for his cholesterol a few days...

    Correct

    • A 50-year-old patient was started on ezetimibe, for his cholesterol a few days back. Which among the following statements is true regarding ezetimibe?

      Your Answer: Its principal action is to reduce intestinal cholesterol absorption

      Explanation:

      Ezetimibe is a cholesterol-lowering agent that acts to prevent cholesterol absorption by directly inhibiting cholesterol receptors on enterocytes.
      It does not affect the absorption of drugs (e.g. digoxin, thyroxine) or fat-soluble vitamins (A, D and K) as the anion-exchange resins do. It does not affect the cytochrome P450 enzyme system.
      The increased risk of myositis associated with the statins is not seen with ezetimibe.
      The most common adverse effects include headache, runny nose, and sore throat.
      Less common reactions include body aches, back pain, chest pain, diarrhoea, joint pain, fatigue, and weakness.

    • This question is part of the following fields:

      • Pharmacology
      16.9
      Seconds
  • Question 4 - A 60 yr. old male with no past medical history presented to Casualty...

    Correct

    • A 60 yr. old male with no past medical history presented to Casualty with acute chest pain. ST elevation myocardial infarction (STEMI) is diagnosed following an ECG on arrival. He was subsequently successfully thrombolysed. Which of the following combinations of drugs is the most suitable combination for him to be taking 4 weeks after his STEMI?

      Your Answer: ACE inhibitor + beta-blocker + statin + aspirin + clopidogrel

      Explanation:

      According to NICE guidelines (2013) all people who have had an acute MI, treatment should be offered with ACE inhibitor, dual antiplatelet therapy (aspirin plus a second antiplatelet agent), beta-blocker and a statin.

    • This question is part of the following fields:

      • Cardiology
      6.9
      Seconds
  • Question 5 - An 77-year-old female has been admitted in the psychiatric ward for the past...

    Incorrect

    • An 77-year-old female has been admitted in the psychiatric ward for the past 6 months with a fixed belief that her insides are rotting as she is deceased. Which of the following terms best describe this type of delusion?

      Your Answer: De Clerambault syndrome

      Correct Answer: Cotard delusion

      Explanation:

      The most probable diagnosis of this patient is Cotard syndrome.

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

      Other options:
      – Othello syndrome is a delusional belief that a patients partner is committing infidelity despite no evidence of this. It can often result in violence and controlling behaviour.
      – De Clerambault syndrome (otherwise known as erotomania), is where a patient believes that a person of higher social or professional standing is in love with them. Often this presents with people who believe celebrities are in love with them.
      – Ekbom syndrome is also known as delusional parasitosis and is the belief that they are infected with parasites or have ‘bugs’ under their skin. This can vary from the classic psychosis symptoms in narcotic use where the user can ‘see’ bugs crawling under their skin or can be a patient who believes that they are infested with snakes.
      – Capgras delusion is the belief that friends or family members have been replaced by an identical-looking imposter.

    • This question is part of the following fields:

      • Psychiatry
      10.9
      Seconds
  • Question 6 - A 55-year-old male is admitted with vomiting. He has a long history of...

    Correct

    • A 55-year-old male is admitted with vomiting. He has a long history of alcohol abuse, appears slightly jaundiced and is dishevelled and unkempt. He was started on an intravenous glucose infusion and diazepam and he symptomatically improved. One day later he becomes confused, develops vomiting, diplopia and is unable to stand. What is the most likely diagnosis?

      Your Answer: Vitamin B deficiency

      Explanation:

      The most likely diagnosis is Wernicke’s encephalopathy. This presents in a long time alcoholic from vitamin BI deficiency. Symptoms include confusion and confabulation, oculomotor symptoms/signs, and ataxia.

    • This question is part of the following fields:

      • Gastroenterology
      31.4
      Seconds
  • Question 7 - A 28 year old man presents to the clinic with fatigue, exertional dyspnoea,...

    Correct

    • A 28 year old man presents to the clinic with fatigue, exertional dyspnoea, abdominal discomfort, xerophthalmia and xerostomia. Examination reveals enlargement of the parotid glands bilaterally, hepatomegaly and peripheral motor neuropathy. Lab results are negative for RF, ANA, SS-A and SS-B antibodies. What is the most likely diagnosis?

      Your Answer: Diffuse infiltrative lymphocytic syndrome (DILS)

      Explanation:

      The Diffuse Infiltrative Lymphocytosis Syndrome (DILS) is a rare multisystemic syndrome described in HIV-infected patients. It is characterised by CD8(+) T-cell lymphocytosis associated with a CD8(+) T-cell infiltration of multiple organs. DILS is usually seen in uncontrolled or untreated HIV infection but can also manifest itself independently of CD4(+) T-cell counts. The syndrome may present as a Sjögren-like disease that generally associates sicca signs with bilateral parotiditis, lymphadenopathy, and extra glandular organ involvement. The latter may affect the lungs, nervous system, liver, kidneys, and digestive tract. Anomalies of the respiratory system are often identified as lymphocytic interstitial pneumonia. Facial nerve palsy, aseptic meningitis or polyneuropathy are among the more frequent neurological features. Hepatic lymphocytic infiltration, lymphocytic interstitial nephropathy and digestive tract lymphocytic infiltration account for more rarely noted complications. Sicca syndrome, organomegaly and/or organ dysfunction associated with polyclonal CD8(+) T-cell organ-infiltration are greatly suggestive of DILS in people living with HIV.

    • This question is part of the following fields:

      • Rheumatology
      26.3
      Seconds
  • Question 8 - Choose the best source of folic acid: ...

    Correct

    • Choose the best source of folic acid:

      Your Answer: Liver

      Explanation:

      Beef liver is one of the best sources of folic acid, amongst others like green vegetables and nuts.

    • This question is part of the following fields:

      • Clinical Sciences
      3.5
      Seconds
  • Question 9 - A 40-year-old female is receiving a course of chemotherapy for breast cancer. She...

    Correct

    • A 40-year-old female is receiving a course of chemotherapy for breast cancer. She is, however, experiencing troublesome vomiting which is not responding to domperidone. Which of the following is the most appropriate next step of management?

      Your Answer: Add a 5-HT3 antagonist

      Explanation:

      Nausea and vomiting are the common side effects of chemotherapy. Risk factors for the development of these symptoms include age<50 years, anxiety, concurrent use of opioids, and the type of chemotherapy administered. For patients at low risk of these symptoms, drugs such as metoclopramide may be used. For high-risk patients, however, 5-HT3 receptor antagonists such as ondansetron are often effective, especially if combined with dexamethasone.

    • This question is part of the following fields:

      • Haematology & Oncology
      6.1
      Seconds
  • Question 10 - A study is carried out to assess the efficacy of a new anti-epileptic...

    Incorrect

    • A study is carried out to assess the efficacy of a new anti-epileptic drug for children with absence seizures. The total number of the children selected for the study was 400, from which 150 children were assigned to take the new drug and 250 children were assigned in the control group. After a period of four months, only 15 children taking the new drug had a seizure compared to 100 children from the control group who had seizure. What is the correct value regarding the relative risk reduction?

      Your Answer: 4

      Correct Answer: 75%

      Explanation:

      Relative risk reduction (RRR) tells you by how much the treatment reduced the risk of bad outcomes relative to the control group who did not have the treatment. In the previous example, the relative risk reduction of fever and rash in the group of the children on the intervention was 40 per cent (1 – 0.6 = 0.4 or 40 per cent). RRR = (EER -CER) / CER = (0.1 – 0.4) / 0.4 = -0.75 or 75% reduction.

    • This question is part of the following fields:

      • Clinical Sciences
      186.3
      Seconds
  • Question 11 - A 60-year-old lady has been admitted to the stroke ward following a sudden...

    Correct

    • A 60-year-old lady has been admitted to the stroke ward following a sudden onset of dizziness and visual disturbances, which started yesterday morning. She initially thought she was just dehydrated, however, later realised she was unable to read her own shopping list. On the ward rounds, the consultant examines her and finds she is indeed unable to read. She is, however, able to write. When she writes a sentence it makes perfect sense, although she is again unable to read it out. She has no problems with her speech and is able to converse normally. She has no motor focal neurological deficit. The consultant asks you where the lesion is likely to be?

      Your Answer: Corpus callosum

      Explanation:

      The patient presents with sudden onset of alexia (the inability to read) WITHOUT agraphia (inability to write) which is consistent with lesions of the corpus callosum where there is a disconnect syndrome and the patient’s language and visual centres are actually in tact, but are unable to communicate between hemispheres. In this case, the damage due to the stroke is most likely in the left visual cortex, leaving visual processing to the intact right hemisphere which unfortunately cannot communicate the information to the language centres (Broca and Wernicke’s) in the left hemisphere, hence the alexia. Alternatively, the speech and writing are unaffected as the language centres can still communicate with the primary motor cortex.

    • This question is part of the following fields:

      • Neurology
      10.4
      Seconds
  • Question 12 - A 72-year-old woman presents with a 3 month history of colicky abdominal pain...

    Correct

    • A 72-year-old woman presents with a 3 month history of colicky abdominal pain after eating, and diarrhoea. She has lost 7 kg in weight over the last few months. A recent gastroscopy and colonoscopy were normal. Her past medical history includes angina and a right carotid endarterectomy at the age of 62 years. Her current medication includes aspirin, atenolol, simvastatin and losartan. right carotid endarterectomy at the age of 62 years. Her current medication includes aspirin, atenolol, simvastatin and losartan. Blood tests revealed: Haemoglobin (Hb) 118 g/l, Mean corpuscular volume (MCV) 80 fl, White cell count (WCC) 12.3 x 109/L, Platelets 210 x 109/L, Na+ 133 mmol/L, K+ 5.2 mmol/L, Urea 8.1 mmol/L, Creatinine 134 mmol/L. Select the most appropriate further investigations.

      Your Answer: Contrast-enhanced computed tomography (CT) of the abdomen

      Explanation:

      The patient is 74 years old. She has had a recent gastroscopy and colonoscopy. She has a history of angina and a right CEA. She is having colicky abdominal pain after meals and weight loss, which points to a possible diagnosis of chronic mesenteric ischemia. Thus, you would want to do a contrast-enhanced CT scan of the abdomen to look for this. A 24 hour cardiac monitor would also be helpful to look for any abnormal rhythm that could be a potential aetiology of her disease.

    • This question is part of the following fields:

      • Gastroenterology
      33.7
      Seconds
  • Question 13 - Which one of the following statements regarding epidemiological measures is correct? ...

    Incorrect

    • Which one of the following statements regarding epidemiological measures is correct?

      Your Answer: Incidence = prevalence * duration of condition

      Correct Answer: Cross-sectional surveys can be used to estimate the prevalence of a condition in the population

      Explanation:

      The incidence rate is the number of new cases per population at risk in a given time period. For example, if a population initially contains 1,000 non-diseased persons and 28 develop a condition over two years of observation, the incidence proportion is 28 cases per 1,000 persons per two years, i.e. 2.8% per two years.
      Prevalence is the proportion of a particular population found to be affected by a medical condition (typically a disease or a risk factor such as smoking or seat-belt use). It is derived by comparing the number of people found to have the condition with the total number of people studied, and is usually expressed as a fraction, as a percentage, or as the number of cases per 10,000 or 100,000 people.
      Incidence should not be confused with prevalence, which is the proportion of cases in the population at a given time rather than rate of occurrence of new cases. Thus, incidence conveys information about the risk of contracting the disease, whereas prevalence indicates how widespread the disease is.

    • This question is part of the following fields:

      • Clinical Sciences
      21.5
      Seconds
  • Question 14 - A 40-year-old non-smoker is diagnosed as having emphysema. Further tests reveal that he...

    Correct

    • A 40-year-old non-smoker is diagnosed as having emphysema. Further tests reveal that he has alpha-1 antitrypsin deficiency. What is the main role of alpha-1 antitrypsin in the body?

      Your Answer: Protease inhibitor

      Explanation:

      Alpha-1-antitrypsin (AAT) is a member of the serine proteinase inhibitor (serpin) family of proteins with a broad spectrum of biological functions including inhibition of proteases, immune modulatory functions, and the transport of hormones.

    • This question is part of the following fields:

      • Respiratory
      7.9
      Seconds
  • Question 15 - A 16 year old previously well male presents with a 4 day history...

    Correct

    • A 16 year old previously well male presents with a 4 day history of fever, lethargy and a generalized macular rash. There is no significant previous medical history and the patient has not travelled abroad either. Vitals are as follows: Temp: 38.5 BP: 125/75mmHg Pulse: 100/min On auscultation the chest was clear and no heart murmur was heard. Examination also reveals a non blanching widespread macular rash over the chest and abdomen. There is swelling of interphalangeal joints of both hands and feet associated with mild tenderness. Lymph nodes are palpable over the supraclavicular, axillary and inguinal areas. Abdominal examination reveals palpable mass on both right and left hypochondrium. Lab results are given below: Haemoglobin (Hb) 13.5 g/dL, White cell count (WCC) 14.0 × 109/L, Platelets 380 × 109/L, Sodium 145 mmol/L, Potassium 4.8 mmol/L, Creatinine 89 μmol/L, Rheumatoid factor: Negative, Antinuclear antibody: Negative, Anti-dsDNA: Negative, ASO titre: Not detected. Electrocardiogram (ECG): Sinus rhythm. What is the most likely underlying diagnosis?

      Your Answer: Systemic Still’s disease

      Explanation:

      People with Systemic Juvenile Idiopathic Arthritis (also known as Stills disease) can have recurrent fevers, a macular rash, joint pain, joint deformities, an enlarged liver and/or spleen, and can occasionally have polyserositis, lung involvement or pericardial effusions. Rheumatoid factor and antinuclear antibodies are usually negative. Treatment is with non-steroidal anti-inflammatory drugs (NSAIDs) and the prognosis is better than for adult rheumatoid arthritis.
      In pauciarticular Still’s disease, antinuclear antibodies are present. Large joints are affected and most patients develop classic features of seronegative spondylarthritis.

    • This question is part of the following fields:

      • Rheumatology
      60.8
      Seconds
  • Question 16 - A 50-year-old woman with lung cancer develops deep vein thrombosis (DVT). She is...

    Correct

    • A 50-year-old woman with lung cancer develops deep vein thrombosis (DVT). She is reviewed in the hospital clinic and started on low-molecular-weight heparin (LMWH). Which of the following should be the most appropriate treatment plan?

      Your Answer: Continue on LMWH for 6 months

      Explanation:

      Patients with active cancer are at a continuous risk of having venous thromboembolism (VTE), such as DVT. Therefore, a six-month course of an anticoagulant such as LMWH is recommended. LMWH is the drug of choice since its side effects can be reversed and it can be stopped easily in case of a cancer-related bleed, for example, massive haemoptysis in a patient with lung cancer.

    • This question is part of the following fields:

      • Haematology & Oncology
      6.2
      Seconds
  • Question 17 - A 40-year-old woman presents to her GP with malaise, anorexia, and weight loss....

    Correct

    • A 40-year-old woman presents to her GP with malaise, anorexia, and weight loss. Screening blood samples reveals urea of 50.1 mmol/l and serum creatinine of 690 μmol/l. Her past history includes frequent headaches, but nothing else of note. She has, however, failed to attend her routine ‘well-woman’ appointments.   Ultrasound reveals bilateral hydronephrosis and a suspicion of a central pelvic mass.   What diagnosis is most likely to be responsible for this woman’s hydronephrosis?

      Your Answer: Cervical carcinoma

      Explanation:

      The patient’s history of recent weight loss and malaise, paired with enlarged kidneys and renal failure, as well as a suspected central pelvic mass on ultrasound, gives a suspicion of cervical carcinoma.

    • This question is part of the following fields:

      • Nephrology
      11.9
      Seconds
  • Question 18 - Choose the hormone secreted only by the adrenal medulla: ...

    Correct

    • Choose the hormone secreted only by the adrenal medulla:

      Your 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
      8
      Seconds
  • Question 19 - A 34-year-old woman has had progressive reduction of visual acuity over the past...

    Incorrect

    • A 34-year-old woman has had progressive reduction of visual acuity over the past 3 years. She has now almost lost all of her vision. What is the diagnosis?

      Your Answer: Cataract

      Correct Answer: Retinitis pigmentosa

      Explanation:

      Retinitis pigmentosa is a genetic disorder of the eyes that causes loss of vision. Symptoms include trouble seeing at night and decreased peripheral vision. Onset of symptoms is generally gradual.
      – In keratitis, there will be pain, redness and photophobia but vision is not affected
      – In macular degeneration, near blindness does not occur rather the inability to identify faces or read small print
      – Cataracts are more common in elderly
      – It is not angle closure glaucoma as angle closure glaucoma occurs usually after the age of 50; In open angle glaucoma visual loss is not gradual but rather occurs suddenly following progression

    • This question is part of the following fields:

      • Ophthalmology
      20.3
      Seconds
  • Question 20 - A 52-year-old woman who is a known case of breast cancer is being...

    Correct

    • A 52-year-old woman who is a known case of breast cancer is being reviewed six months after she had a mastectomy following the diagnosis. Which of the following tumour markers is the most useful in monitoring her disease?

      Your Answer: CA 15-3

      Explanation:

      Tumour marker CA 15-3 is mostly associated with breast cancer.

      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
      7.5
      Seconds
  • Question 21 - A 60–year-old woman comes to the hospital for chemotherapy for breast cancer. On...

    Correct

    • A 60–year-old woman comes to the hospital for chemotherapy for breast cancer. On examination, her pulse is 120 bpm and regular and BP is 90/60. Her JVP is not seen, her heart sounds are normal, and her chest is clear. There is evidence of a right mastectomy. Abdominal and neurological examination is normal. Short synacthen test was ordered and the results came as follows: Time (min): 0, 30, 60. Cortisol (nmol/l): 90, 130, 145. Which two of the following would be your immediate management?

      Your Answer: Intravenous normal saline 1l in first hour

      Explanation:

      Synacthen test interpretation:
      – Basal Cortisol level should be greater than 180nmol/L
      – 30min or 60min Cortisol should be greater than 420nmol/L (whatever the basal level)
      – The increment should be at least 170nmol/L, apart from in severely ill patients where adrenal output is already maximal.
      The patient’s results show that she has Acute Adrenal Insufficiency
      The guidelines include the following recommendations for emergency treatment:
      Administer hydrocortisone: Immediate bolus injection of 100 mg hydrocortisone intravenously or intramuscularly followed by continuous intravenous infusion of 200 mg hydrocortisone per 24 hours (alternatively, 50 mg hydrocortisone per intravenous or intramuscular injection every 6 h)
      Rehydrate with rapid intravenous infusion of 1000 mL of isotonic saline infusion within the first hour, followed by further intravenous rehydration as required (usually 4-6 L in 24 h; monitor for fluid overload in case of renal impairment and elderly patients)
      Contact an endocrinologist for urgent review of the patient, advice on further tapering of hydrocortisone, and investigation of the underlying cause of the disease, including the diagnosis of primary versus secondary adrenal insufficiency
      Tapering of hydrocortisone can be started after clinical recovery guided by an endocrinologist; in patients with primary adrenal insufficiency, mineralocorticoid replacement must be initiated (starting dose 100 μg fludrocortisone once daily) as soon as the daily glucocorticoid dose is below 50 mg of hydrocortisone every 24 hours

    • This question is part of the following fields:

      • Endocrinology
      17.4
      Seconds
  • Question 22 - Which of the following involving the scalp may produce alopecia (hair loss)? ...

    Incorrect

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

      Your Answer: Seborrheic dermatitis

      Correct Answer: Discoid lupus erythematosus

      Explanation:

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

    • This question is part of the following fields:

      • Dermatology
      11.3
      Seconds
  • Question 23 - A 53-year-old gentleman presents with several months’ history of generalised swelling, fatigue, dyspnoea...

    Incorrect

    • A 53-year-old gentleman presents with several months’ history of generalised swelling, fatigue, dyspnoea and several episodes of haemoptysis. There is no significant past medical history and he did not take any regular medication. He smokes 20 cigarettes per day and drinks 14 units of alcohol per week. On examination, he is grossly oedematous and has ascites. Cardiorespiratory examination is unremarkable and there are no neurological signs or rashes. Investigation results are below: Haemoglobin (Hb) 10.2 g/dL, White cell count (WCC) 6.0 × 109/L, Platelets 380 × 109/L, Mean corpuscular volume (MCV) 90fl Na+ 145 mmol/L, K+ 3.7 mmol/L, Urea 8.2 mmol/L, Bilirubin 16 μmol/L, Creatinine 180 μmol/L, Albumin 22 g/l Aspartate transaminase 32 iu/l Alkaline phosphatase 120 iu/l Urinalysis: Protein +++ 24 h urinary protein excretion: 5g Chest radiograph: Enlarged right hilum Echocardiogram: Mild left ventricular impairment, no valve lesion Abdominal ultrasound scan: Normal-sized kidneys, no abnormality seen A renal biopsy was performed. What is it most likely to show?

      Your Answer: Fusion of podocyte foot processes on electron microscopy

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

      Explanation:

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

    • This question is part of the following fields:

      • Nephrology
      214
      Seconds
  • Question 24 - A 20 year old heroin addict is admitted following an overdose. She is...

    Correct

    • A 20 year old heroin addict is admitted following an overdose. She is drowsy and has a respiratory rate of 6 bpm. Which of the following arterial blood gas results (taken on room air) are most consistent with this?

      Your Answer: pH = 7.31; pCO2 = 7.4 kPa; pO2 = 8.1 kPa

      Explanation:

      In mild-to-moderate heroin overdoses, arterial blood gas (ABG) analysis reveals respiratory acidosis. In more severe overdoses, tissue hypoxia is common, leading to mixed respiratory and metabolic acidosis.

      The normal range for PaCO2 is 35-45 mmHg (4.67 to 5.99 kPa). Respiratory acidosis can be acute or chronic. In acute respiratory acidosis, the PaCO2 is elevated above the upper limit of the reference range (i.e., >45 mm Hg) with an accompanying academia (i.e., pH < 7.35). In chronic respiratory acidosis, the PaCO2 is elevated above the upper limit of the reference range, with a normal or near-normal pH secondary to renal compensation and an elevated serum bicarbonate levels (i.e., >30 mEq/L).

      Arterial blood gases with pH = 7.31; pCO2 = 7.4 kPa; pO2 = 8.1 kPa would indicate respiratory acidosis.

    • This question is part of the following fields:

      • Respiratory
      11.9
      Seconds
  • Question 25 - A 40-year-old woman presents to the ED with palpitations and shortness of breath....

    Correct

    • A 40-year-old woman presents to the ED with palpitations and shortness of breath. Recent thyroid function tests on the hospital computer reveal thyroid-stimulating hormone (TSH) of <0.05 mU/l and a markedly elevated T4. You arrange blood gas testing. Which of the following findings would be most consistent with Grave’s disease?

      Your Answer: Decreased pa(CO2)

      Explanation:

      Hyperthyroid patients show significantly lower resting arterial CO2 tension, tidal volume and significantly higher mean inspiratory flow and pa(O2) than healthy patients. This may of course lead to misdiagnosis of patients with hyperthyroidism as having hyperventilation syndrome.

    • This question is part of the following fields:

      • Endocrinology
      11.6
      Seconds
  • Question 26 - A 25-year-old man asks to be referred to a plastic surgeon as he...

    Incorrect

    • A 25-year-old man asks to be referred to a plastic surgeon as he claims that his ears are too big in proportion to his face and he seldom leaves the house because of this. His records show that he was treated for anxiety and depression with fluoxetine previously and has been off work with back pain for the past 4 months. On examination, his ears appear to be normal. What is the most appropriate term of this behaviour?

      Your Answer: Somatisation

      Correct Answer: Dysmorphophobia

      Explanation:

      The most probable diagnosis in the given scenario would be body dysmorphic disorder or dysmorphophobia

      It is a mental disorder where patients have a significantly distorted body image.

      Diagnostic and Statistical Manual (DSM) IV criteria:
      Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.
      The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
      The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa).

      Treatment:
      Cognitive-behavioural therapy (CBT) is the most commonly used and most empirically supported intervention to improve body image.
      Several drugs have been targets of study in anorexia nervosa treatment, including selective serotonin reuptake inhibitors, antidepressants, antipsychotics, nutritional supplementation, and hormonal medications.

    • This question is part of the following fields:

      • Psychiatry
      15.9
      Seconds
  • Question 27 - A 65 yr. old woman was referred due to a pulse rate of...

    Correct

    • A 65 yr. old woman was referred due to a pulse rate of 40 bpm. Which of the following answers is associated with the least risk of asystole?

      Your Answer: Complete heart block with a narrow complex QRS

      Explanation:

      From the given answers, complete heart block with a narrow complex QRS complex is associated with the least risk of asystole. Transvenous pacing is indicated by the other given responses.

    • This question is part of the following fields:

      • Cardiology
      7
      Seconds
  • Question 28 - A 19-year-old male presented with a fever and fatigue. On examination, he had...

    Correct

    • A 19-year-old male presented with a fever and fatigue. On examination, he had multiple lesions on his back and abdomen in various forms. Which of the following is the most probable diagnosis?

      Your Answer: Varicella zoster

      Explanation:

      Patients with varicella zoster infection present with general fatigue and fever along with multiple lesions which do not appear to be identical.

    • This question is part of the following fields:

      • Infectious Diseases
      10.5
      Seconds
  • Question 29 - A study was developed to assess a new oral antithrombotic drug on the...

    Correct

    • A study was developed to assess a new oral antithrombotic drug on the chance of stroke in high-risk patients, compared to warfarin. The total number of patients receiving the new drug were 200 compared to 600 who were receiving warfarin. From the ones receiving the new drug, 10 patients had a stroke within 3 years, compared to 12 patients who were receiving warfarin and had a stroke. What is the relative risk of having a stroke within 3 years for patients receiving the new drug?

      Your Answer: 2.5

      Explanation:

      Relative Risk = (Probability of event in exposed group) / (Probability of event in not exposed group)
      Experimental event rate, EER = 10 / 200 = 0.05

      Control event rate, CER = 12 / 600 = 0.02

      Therefore the relative risk = EER / CER = 0.05 / 0.02 = 2.5

    • This question is part of the following fields:

      • Clinical Sciences
      119
      Seconds
  • Question 30 - A patient complaining of nocturnal cough and wheeze is investigated for asthma. Which of...

    Incorrect

    • A patient complaining of nocturnal cough and wheeze is investigated for asthma. Which of the following tests would be most useful in aiding the diagnosis?

      Your Answer: FEV1 and FVC measurements

      Correct Answer: ANCA

      Explanation:

      Churg-Strauss disease (CSD) is one of three important fibrinoid, necrotizing, inflammatory leukocytoclastic systemic small-vessel vasculitides that are associated with antineutrophil cytoplasm antibodies (ANCAs).
      The first (prodromal) phase of Churg-Strauss disease (CSD) consists of asthma usually in association with other typical allergic features, which may include eosinophilia. During the second phase, the eosinophilia is characteristic (see below) and ANCAs with perinuclear staining pattern (pANCAs) are detected. The treatment would therefore be different from asthma. For most patients, especially those patients with evidence of active vasculitis, treatment with corticosteroids and immunosuppressive agents (cyclophosphamide) is considered first-line therapy

    • This question is part of the following fields:

      • Respiratory
      9.3
      Seconds
  • Question 31 - A 27-year-old woman is admitted on the medical intake. She is 10 weeks...

    Correct

    • A 27-year-old woman is admitted on the medical intake. She is 10 weeks postpartum and has been generally unwell for two weeks with malaise, sweating and anxiety. On examination, she is haemodynamically stable and clinically euthyroid. TFTs show the following: Free T4 33 pmol/L (9-23), Free T3 8 nmol/L (3.5-6), TSH <0.02 mU/L (0.5-5). What is the appropriate management?

      Your Answer: Propranolol 20 mg tds

      Explanation:

      The patient is most likely to have Postpartum thyroiditis which goes through 2 phases; hypothyroid and a hyperthyroid phase.
      The hyperthyroid phase of postpartum thyroiditis occurs between 2 and 10 months postpartum. Most commonly, it presents at 3 months. Symptoms more common in women with hyperthyroid postpartum thyroiditis include palpitations, fatigue, heat intolerance, and irritability/nervousness. The frequency of asymptomatic hyperthyroidism is 33%.
      Untreated, the hyperthyroidism resolves spontaneously within 2–3 months. This phase is diagnosed by the combination of a low serum TSH concentration in the presence of thyroid peroxidase antibodies, in women who are TSH receptor antibody-negative. Free T4 levels are typically elevated but may be normal.
      Treatment of hyperthyroidism, when necessary, is based on symptom severity and should be a joint decision of patient and physician. Beta-blockers such as propranolol are given to alleviate palpitations, irritability, and nervousness. The morbidity associated with treatment is the side effects of beta-blockade. The downside of withholding treatment is allowing the woman to remain symptomatic. Antithyroid medicines (thioureas) are not a potential treatment alternative, because the hyperthyroidism is caused by destructive thyroiditis resulting in the release of preformed thyroid hormone.

    • This question is part of the following fields:

      • Endocrinology
      24.8
      Seconds
  • Question 32 - A 51 year old obese female, with a history of smoking, presents to...

    Incorrect

    • A 51 year old obese female, with a history of smoking, presents to the clinic with worsening dyspnoea. She is currently on oestrogen therapy for menopausal symptoms. Clinical examination, ECG and radiological findings correspond to right sided heart failure. There are no signs of left ventricular dysfunction. Which of the following is the most likely cause of cor pulmonale?

      Your Answer: Bronchiectasis

      Correct Answer: Recurrent small pulmonary embolisms

      Explanation:

      Postmenopausal oestrogen therapy and hormone therapy are associated with an increased risk of thromboembolism. The relative risk seems to be even greater if the treated population has pre-existing risk factors for thromboembolism, such as obesity, immobilization, and fracture. Cor pulmonale can occur secondary to small recurrent pulmonary embolisms. Pneumonias and bronchiectasis usually present with purulent sputum, and in case of carcinoma there may be other associated symptoms like weight loss, etc.

    • This question is part of the following fields:

      • Respiratory
      26.9
      Seconds
  • Question 33 - A 35-year-old gentleman presents to the Emergency Department with abdominal pain. This started...

    Correct

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

      Your Answer: IM diclofenac 75 mg

      Explanation:

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

    • This question is part of the following fields:

      • Nephrology
      14.1
      Seconds
  • Question 34 - A 29 year old male visits the clinic and complains of increased anxiety,...

    Incorrect

    • A 29 year old male visits the clinic and complains of increased anxiety, dizziness, and headache which started a week after he crashed his motorcycle. A CT scan of his brain showed no abnormality when it was done. His symptoms resolved four months after he had that episode. What did his original symptoms likely represent?

      Your Answer: Generalised anxiety disorder

      Correct Answer: Post-concussion syndrome

      Explanation:

      Post-concussion syndrome is a complex disorder in which various symptoms, such as headaches and dizziness, last for weeks and sometimes months after the injury that caused the concussion.

      Concussion is a mild traumatic brain injury that usually happens after a blow to the head. It can also occur with violent shaking and movement of the head or body. You don’t have to lose consciousness to get a concussion or post-concussion syndrome. In fact, the risk of post-concussion syndrome doesn’t appear to be associated with the severity of the initial injury.

      Post-concussion symptoms include:
      Headaches
      Dizziness
      Fatigue
      Irritability
      Anxiety
      Insomnia
      Loss of concentration and memory
      Ringing in the ears
      Blurry vision
      Noise and light sensitivity
      Rarely, decreases in taste and smell

    • This question is part of the following fields:

      • Psychiatry
      58
      Seconds
  • Question 35 - Which one of the following statements regarding hepatocellular carcinoma is correct? ...

    Incorrect

    • Which one of the following statements regarding hepatocellular carcinoma is correct?

      Your Answer: Bevacizumab may be used for advanced cases

      Correct Answer: Diabetes mellitus is a risk factor

      Explanation:

      Diabetes is a risk factor for hepatocellular carcinoma. Screening has been shown to be effective. Bevacizumab is not used for advanced cases. The incidence is higher in men. Alcohol is not the most common underlying cause worldwide; this is from cirrhosis from diseases like hepatitis B and C.

    • This question is part of the following fields:

      • Gastroenterology
      9.9
      Seconds
  • Question 36 - Which one of the following is most suggestive of Wilson’s disease? ...

    Correct

    • Which one of the following is most suggestive of Wilson’s disease?

      Your Answer: Reduced serum caeruloplasmin

      Explanation:

      In Wilson’s disease, serum caeruloplasmin is decreased. Skin pigmentation is not increased, but may become jaundiced. 24 hour urine copper excretion is increased. Hepatic copper concentration is increased. Serum copper level is also increased. Key point: high copper. Remember Kayser-Fleisher rings for the eyes in Wilson’s disease.

    • This question is part of the following fields:

      • Gastroenterology
      9.5
      Seconds
  • Question 37 - A 32-year-old woman was referred for endoscopy and found to have a duodenal...

    Correct

    • A 32-year-old woman was referred for endoscopy and found to have a duodenal ulcer and a positive urease test. She was given lansoprazole, amoxicillin and clarithromycin for 7 days. Which of the following is the most appropriate way of determining the successful eradication of H. pylori?

      Your Answer: Urea breath test

      Explanation:

      Urea breath test is the most sensitive test to determine if there has been RESOLUTION/ERADICATION of the infection with H. pylori. The best test for initial diagnosis would be EGD with biopsy.

    • This question is part of the following fields:

      • Gastroenterology
      16
      Seconds
  • Question 38 - A 32 year old man presents with blistering and hyperpigmentation on his face...

    Incorrect

    • A 32 year old man presents with blistering and hyperpigmentation on his face and hands, after a beach holiday with friends. Tests reveal high levels of uroporphyrinogen in the urine. The most likely diagnosis is:

      Your Answer: Acute intermittent porphyria

      Correct Answer: Porphyria cutanea tarda

      Explanation:

      Porphyria cutanea tarda (PCT) is the most common of the porphyries. It is characterised by fragility and blistering of exposed skin. Typically, patients who are ultimately diagnosed with PCT first seek treatment following the development photosensitivities in the form of blisters and erosions on commonly exposed areas of the skin. This is usually observed in the face, hands, forearms, and lower legs. It heals slowly and with scarring. Though blisters are the most common skin manifestations of PCT, other skin manifestations like hyperpigmentation (as if they are getting a tan) and hypertrichosis (mainly on top of the cheeks) also occur. Risk factors for the development of PCT include alcohol and sun.

    • This question is part of the following fields:

      • Dermatology
      12.3
      Seconds
  • Question 39 - A 40-year-old patient under treatment for gout gave a history of progressive weakness...

    Correct

    • A 40-year-old patient under treatment for gout gave a history of progressive weakness of his limbs over 2 months. He noticed that it was particularly difficult for him to get up from the toilet seat and to get out of his car. He also felt some tingling and numbness of his toes at night, which was distressing. He was taking several medications which included Ibuprofen, perindopril, colchicine, vitamin supplements, and indapamide. On examination his pulse was 85/min, blood pressure was 140/90 mmHg and fundi revealed arteriovenous nipping. He had proximal lower limb weakness of 4/5 and absent ankle reflexes. Plantar reflexes were upgoing on both sides. His serum creatinine phosphokinase level was normal. What is the most likely diagnosis?

      Your Answer: Colchicine toxicity

      Explanation:

      The given clinical scenario is suggestive of myo-neuropathy and is most likely to be caused by colchicine toxicity.
      It gives rise to subacute proximal muscle weakness and on occasions can lead to an acute necrotizing myopathy. Creatine phosphokinase may be normal or may be elevated.
      Weakness resolves when the drug is discontinued but the neuropathic features remain.
      Death is usually a result of respiratory depression and cardiovascular collapse.
      Treatment is symptomatic and supportive, and the treatment for colchicine poisoning includes lavage and measures to prevent shock.

    • This question is part of the following fields:

      • Pharmacology
      57
      Seconds
  • Question 40 - A 16-year-old female presents with a two day history of right iliac fossa...

    Correct

    • A 16-year-old female presents with a two day history of right iliac fossa pain, nausea and loss of appetite. You suspect that she has acute appendicitis. Which scoring system could you use to lend support to your diagnosis?

      Your Answer: Alvarado score

      Explanation:

      The prompt is suggestive of acute appendicitis. The Alvarado score is a clinical scoring system used to determine the likelihood of appendicitis, so this is the correct answer. A score greater than 6 is generally considered at risk for having acute appendicitis. It has 8 different criteria included (symptoms, signs, and lab results) and divides patients into appendicitis unlikely, possible, probable, and definite. The Center Score is a score to access the likelihood that pharyngitis is due to Strep. The Child-Pugh score predicts prognosis in liver cirrhosis. The Glasgow score is two different scores– the Glasgow coma score in trauma, which estimates level of consciousness, essentially, and The Glasgow Imrie Criteria which determines the severity of acute pancreatitis based on 8 lab values. The MELD score predicts the severity of end-stage liver disease.

    • This question is part of the following fields:

      • Gastroenterology
      4.4
      Seconds
  • Question 41 - A 28-year-old woman is investigated for bloody diarrhoea which started around six weeks...

    Correct

    • A 28-year-old woman is investigated for bloody diarrhoea which started around six weeks ago. She is currently passing 3-4 loose stools a day which normally contain a small amount of blood. Other than feeling lethargic she remains systemically well with no fever or significant abdominal pain. A colonoscopy is performed which shows inflammatory changes in the ascending colon consistent with ulcerative colitis. Bloods show the following: Hb: 14.2 g/dL, Platelets: 323 * 109/L, WBC: 8.1 * 109/L, CRP: 22 mg/l. What is the most appropriate first-line medication to induce remission?

      Your Answer: Oral aminosalicylate

      Explanation:

      Given she is not showing signs of systemic illness, you do not need to treat for an acute flair (which would be steroids), but you need to put her on maintenance medication. Oral ASA would be the best option for this, it is first line. You cannot give rectal ASA because the location of her disease is in the ascending colon and the enema will not reach.

    • This question is part of the following fields:

      • Gastroenterology
      24.3
      Seconds
  • Question 42 - Randomised control trials offer the following level of evidence: ...

    Correct

    • Randomised control trials offer the following level of evidence:

      Your Answer: Ib

      Explanation:

      1B: Individual Randomised Control Trial (with narrow confidence intervals)

    • This question is part of the following fields:

      • Clinical Sciences
      5.6
      Seconds
  • Question 43 - A 75 yr. old male with rheumatoid arthritis underwent a colectomy 2 days...

    Correct

    • A 75 yr. old male with rheumatoid arthritis underwent a colectomy 2 days ago for colon cancer. He was put on a prophylactic dose of low molecular weight heparin post operatively as well as prednisolone. Now he complains of central chest pain and his ECG revealed an acute ST elevation myocardial infarction. He was given aspirin and oxygen as the initial treatment. Which of the following is the most appropriate management for this patient?

      Your Answer: IV diamorphine + arrange percutaneous coronary intervention

      Explanation:

      There is a high risk of bleeding due to recent surgery and heparin. So thrombolysis is not an option. The most appropriate management is percutaneous coronary intervention.

    • This question is part of the following fields:

      • Cardiology
      13.2
      Seconds
  • Question 44 - A 47-year-old hypertensive man presents with difficulty using his right arm, slow walking...

    Incorrect

    • A 47-year-old hypertensive man presents with difficulty using his right arm, slow walking and occasional loss of balance. He has a broad-based gait with cogwheel rigidity and intention tremor of his right arm. His blood pressure is 140/80 mmHg sitting and 100/60 mmHg standing. Which of the following is the most likely diagnosis?

      Your Answer: Idiopathic Parkinson’s disease

      Correct Answer: Multiple system atrophy

      Explanation:

      This patient presents with a combination of akinetic rigid syndrome, cerebellar signs and the suggestion of autonomic features. This is most indicative of a diagnosis of multiple system atrophy.

      Multiple system atrophy (MSA) is a rare neurodegenerative disorder characterized by autonomic dysfunction, tremors, slow movement, muscle rigidity, and postural instability (collectively known as parkinsonism) and ataxia.

    • This question is part of the following fields:

      • Neurology
      13.2
      Seconds
  • Question 45 - A 52-year-old man presents with numbness and tingling in his left hand. On...

    Correct

    • 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: 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
      100.8
      Seconds
  • Question 46 - A 20-year-old woman presents to casualty with flank pain and a 48 hour...

    Correct

    • A 20-year-old woman presents to casualty with flank pain and a 48 hour history of dysuria. Her past medical history includes polycystic ovarian syndrome. She is not in a steady relationship at present. There is haematuria and proteinuria on urine dipstick testing. Examination reveals a pyrexia of 38.1 °C and flank pain. What diagnosis fits best with this clinical picture?

      Your Answer: Pyelonephritis

      Explanation:

      The patient presents with flank pain and fever with haematuria and proteinuria associated with a social history of not being in a steady relationship. This patient is a young presumably sexually active female, so the diagnosis is most likely pyelonephritis which has an increased incidence in young sexually active women or men of >50 years of age.

    • This question is part of the following fields:

      • Nephrology
      10.4
      Seconds
  • Question 47 - An 83-year-old retired musician is examined for progressive cognitive impairment. Which one of...

    Correct

    • An 83-year-old retired musician is examined for progressive cognitive impairment. Which one of the following features is most suggestive of Lewy body dementia?

      Your Answer: Symptoms worsen with neuroleptics

      Explanation:

      Lewy body dementia is an increasingly recognised cause of dementia, accounting for up to 20% of cases. The characteristic pathological feature is alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas. Neuroleptics should be avoided in Lewy body dementia as patients are extremely sensitive and may develop irreversible parkinsonism. Questions may give a history of a patient who has deteriorated following the introduction of an antipsychotic agent.

    • This question is part of the following fields:

      • Neurology
      6.2
      Seconds
  • Question 48 - A 40-year-old man comes to the endocrine clinic after his second episode of...

    Incorrect

    • A 40-year-old man comes to the endocrine clinic after his second episode of acute pancreatitis. On examination, he has a BP of 125/70 mmHg, his pulse is regular 70 bpm and his BMI is 23. There is evidence of eruptive xanthomas on examination of his skin. It was noted that his fasting triglycerides level is 8.5 mmol/l (0.7-2.1) at his follow up appointment although his LDL level is not particularly raised. Which of the following is the most appropriate therapy for him?

      Your Answer: Omega-3 fatty acids

      Correct Answer: Fenofibrate

      Explanation:

      Three classes of medications are appropriate for the management of major triglyceride elevations: fibric acid derivatives, niacin, and omega-3 fatty acids.

      Fibrate is used as a first-line agent for reduction of triglycerides in patients at risk for triglyceride-induced pancreatitis.

      High-dose niacin (vitamin B-3) (1500 or more mg/d) decreases triglyceride levels by at least 40% and can raise HDL cholesterol levels by 40% or more. Niacin also reliably and significantly lowers LDL cholesterol levels, which the other major triglyceride-lowering medications do not.

      Omega-3 fatty acids are attractive because of their low risk of major adverse effects or interaction with other medications. At high doses (>4 g/d), triglycerides are reduced.

    • This question is part of the following fields:

      • Endocrinology
      16.7
      Seconds
  • Question 49 - A 24-year-old man was hit on the lateral aspect of his head by...

    Correct

    • A 24-year-old man was hit on the lateral aspect of his head by a high velocity cricket ball and lost consciousness immediately. Paramedics found him to have a Glasgow coma score of 15 but take him to the A&E for further investigation. His Glasgow coma score on examination in the A&E is 13 (M5, V4, E4) and he has anterograde and retrograde amnesia to recent events. The doctors arrange an urgent CT scan. Which clinical sign would be most concerning if present?

      Your Answer: Bradycardia

      Explanation:

      Intracranial pressure (ICP) is a complex brain modality that determines cerebral perfusion pressure (CPP), which is the difference between arterial blood pressure (ABP), and ICP. Raised ICP reduces CPP and blood delivery to the brain. This jeopardizes cerebral function and organismal survival in many species. A massive rise in ICP is also known to produce an increase in ABP, bradycardia and respiratory irregularities termed Cushing response. This mechanism is generally considered to be an agonal and terminal event occurring in extreme condition of brainstem ischaemia leading to a sympatho-adrenal response.

    • This question is part of the following fields:

      • Clinical Sciences
      17.2
      Seconds
  • Question 50 - A 57 year old homeless man presents with fever and a productive cough...

    Correct

    • A 57 year old homeless man presents with fever and a productive cough which has green sputum with streaks of blood. A chest x-ray reveals consolidation in the right upper lobe with evidence of cavitation. He is a known alcoholic. What is the most likely causative agent?

      Your Answer: Klebsiella Pneumoniae

      Explanation:

      Infection with Klebsiella organisms occurs in the lungs, where they cause destructive changes. Necrosis, inflammation, and haemorrhage occur within lung tissue, sometimes producing a thick, bloody, mucoid sputum described as currant jelly sputum.
      The illness typically affects middle-aged and older men with debilitating diseases such as alcoholism, diabetes, or chronic bronchopulmonary disease. An increased tendency exists toward abscess formation, cavitation, empyema, and pleural adhesions.

    • This question is part of the following fields:

      • Respiratory
      10.7
      Seconds
  • Question 51 - A 32 year old female is diagnosed with SLE based on her complaints...

    Incorrect

    • A 32 year old female is diagnosed with SLE based on her complaints of polyarthralgia, mouth ulcers and ANA positivity. Labs reveal normal urinalysis, urea and electrolytes. ESR is 90mm in the first hour. How will you manage this patient?

      Your Answer: Prednisolone 30 mg/day

      Correct Answer: Hydroxychloroquine 200 mg/day

      Explanation:

      Hydroxychloroquine is used in the management of SLE as it prevents disease progression and has relatively mild side effects, for instance headache, nausea etc. Its use reduces the usage of corticosteroids. It is particularly effective when the disease is less severe and there is no organ involvement. Cyclophosphamide and prednisolone are indicated in cases of renal, neurological and lung involvement.

    • This question is part of the following fields:

      • Rheumatology
      17.1
      Seconds
  • Question 52 - Choose the correct statement regarding p53 gene: ...

    Incorrect

    • Choose the correct statement regarding p53 gene:

      Your Answer: 50% of families with a strong history of breast cancer have a p53 mutation

      Correct Answer: Li-Fraumeni syndrome predisposes to the development of sarcomas

      Explanation:

      Li-Fraumeni syndrome (LFS) is a cancer predisposition syndrome associated with the development of the following classic tumours: soft tissue sarcoma, osteosarcoma, pre-menopausal breast cancer, brain tumours, adrenocortical carcinoma (ACC), and leukaemia. LFS is diagnosed in individuals meeting established clinical criteria or in those who have a germline pathogenic variant in TP53 regardless of family cancer history.

    • This question is part of the following fields:

      • Clinical Sciences
      7.9
      Seconds
  • Question 53 - A 21-year-old female presents to the emergency department having taken an overdose of...

    Incorrect

    • A 21-year-old female presents to the emergency department having taken an overdose of 40 x 500mg paracetamol tablets and 400ml of vodka. This is her fourth attendance with an overdose over the past 3 years. She is also known to the local police after an episode of reckless driving/road rage. On arrival, she is tearful and upset. Vital signs and general physical examination are normal apart from evidence of cutting on her arms. She is given activated charcoal. Which of the following is the most likely diagnosis?

      Your Answer: Endogenous depression

      Correct Answer: Borderline personality disorder

      Explanation:

      The given clinical scenario is highly suggestive of a borderline personality disorder.

      Borderline personality disorder is marked out by instability in moods, behaviour, and relationships. The diagnosis is confirmed by the presence of at least 5 of the following symptoms;
      1) Extreme reactions including panic, depression, rage, or frantic actions to abandonment, whether real or perceived
      2) A pattern of intense and stormy relationships with family, friends, and loved ones, often veering from extreme closeness and love to extreme dislike or anger
      3) Distorted and unstable self-image or sense of self, which can result in sudden changes in feelings, opinions, values, or plans and goals for the future (such as school or career choices)
      4) Impulsive and often dangerous behaviours, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge eating
      5) Recurring suicidal behaviours or threats or self-harming behaviour, such as cutting, intense and highly changeable moods, with each episode lasting from a few hours to a few days
      6) Chronic feelings of emptiness and/or boredom
      7) Inappropriate, intense anger or problems controlling anger
      8) Having stress-related paranoid thoughts or severe dissociative symptoms, such as feeling cut off from oneself, observing oneself from outside the body, or losing touch with reality.

      Other options:
      There are no features consistent with endogenous depression, such as early morning wakening or loss of appetite.
      There are also no features consistent with hypomania such as pressure of speech, a flight of ideas, or over-exuberant behaviour.
      The lack of history of drug abuse rules out drug-induced psychosis.
      An anti-social personality disorder is characterized by a failure to conform to social norms and repeated lawbreaking. There is consistent irresponsibility, impulsivity, and disregard for both their safety and that of others. This is not the case in the given scenario.

    • This question is part of the following fields:

      • Psychiatry
      36.9
      Seconds
  • Question 54 - Cholecystokinin is secreted from: ...

    Incorrect

    • Cholecystokinin is secreted from:

      Your Answer: K cells in upper small intestine

      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
      5.5
      Seconds
  • Question 55 - A 63-year-old male presents with behavioural disturbances. He has a history of chronic...

    Correct

    • A 63-year-old male presents with behavioural disturbances. He has a history of chronic alcohol intake and previous Wernicke's encephalopathy. He has not consumed alcohol in the past 2 years. Which among the following phenomena is he likely to display on further assessment?

      Your Answer: Confabulation

      Explanation:

      In a patient with chronic alcoholism, one can expect confabulations, which point towards a diagnosis of Korsakoff’s syndrome.

      Korsakoff’s is characterized by confabulation and amnesia, typically occurring in alcoholics secondary to chronic vitamin B1 (thiamine) deficiency.

      Other options:
      Dysthymia refers to mild depression.
      Hydrophobia is a feature of rabies
      Lilliputians may be observed in delirium tremens.
      Perseveration is repetitive speech patterns, commonly seen after traumatic brain injury.

      According to the Caine criteria, the presence of any two among the four following criteria can be used to clinically diagnose Wernicke’s Encephalopathy:
      Dietary deficiency
      Oculomotor abnormalities
      Cerebellar dysfunction
      Either altered mental status or mild memory impairment
      Korsakoff psychosis:
      Altered mental status – disorientation, confabulations
      Oculomotor findings – most often horizontal nystagmus, ophthalmoplegia, cranial nerve IV palsy, conjugate gaze
      Ataxia – wide-based gait

      Treatment:
      The mainstay of treatment in an acute presentation is thiamine replacement.
      Electrolyte abnormalities should be corrected and fluids replaced.
      In particular, magnesium requires replacement, as thiamine-dependent enzymes cannot operate in a magnesium-deficient state.
      After the acute phase of vitamin and electrolyte replacement, memory rehabilitation is beneficial in Korsakoff syndrome.

    • This question is part of the following fields:

      • Psychiatry
      33
      Seconds
  • Question 56 - A 20 year old woman presents to the hospital with sharp, left-sided chest...

    Correct

    • A 20 year old woman presents to the hospital with sharp, left-sided chest pain and shortness of breath. On examination her pulse is 101 beats per minute and blood pressure is 124/61 mmHg. She is seen to be mildly breathless at rest but her oxygen saturation on air was 98%. CXR reveals a left pneumothorax with a 4 cm rim of air visible. Which management strategy is appropriate in this patient?

      Your Answer: Needle aspiration

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Respiratory
      12
      Seconds
  • Question 57 - A 40-year-old man is referred by his general practitioner. He has a family...

    Incorrect

    • A 40-year-old man is referred by his general practitioner. He has a family history of premature cardiovascular disease. Cholesterol testing reveals triglyceride levels of 4.2 mmol/l and a high-density lipoprotein (HDL) level of 0.8 mmol/l. You advise him to start fibrate therapy. Which of the following best describes the mode of action for fibrates?

      Your Answer: They are inhibitors of CETP cholesterol ester transferase protein activity

      Correct Answer: They are inhibitors of lipoprotein lipase activity and increase HDL synthesis

      Explanation:

      Treatment with fibrates, a widely used class of lipid-modifying agents, results in a substantial decrease in plasma triglycerides and is usually associated with a moderate decrease in LDL cholesterol and an increase in HDL cholesterol concentrations.
      Evidence from studies is available to implicate 5 major mechanisms underlying the above-mentioned modulation of lipoprotein phenotypes by fibrates:
      1. Induction of lipoprotein lipolysis.
      2. Induction of hepatic fatty acid (FA) uptake and reduction of hepatic triglyceride production.
      3. Increased removal of LDL particles. Fibrate treatment results in the formation of LDL with a higher affinity for the LDL receptor, which is thus catabolized more rapidly.
      4. Reduction in neutral lipid (cholesteryl ester and triglyceride) exchange between VLDL and HDL may result from decreased plasma levels of TRL.
      5. Increase in HDL production and stimulation of reverse cholesterol transport. Fibrates increase the production of apoA-I and apoA-II in the liver, which may contribute to the increase of plasma HDL concentrations and a more efficient reverse cholesterol transport.

    • This question is part of the following fields:

      • Endocrinology
      14.1
      Seconds
  • Question 58 - A clinical trial is conducted to study the benefits of a new oral...

    Incorrect

    • A clinical trial is conducted to study the benefits of a new oral medication to improve the symptoms of patients with asthma. In the trial 400 patients with asthma, half were given the new medication and half a placebo. Three months later they are asked to rate their symptoms using the following scale: much improved, slight improvement, no change, slight worsening, significantly worse. What is the most appropriate statistical test to see whether the new medication is beneficial?

      Your Answer: Student's t-test (paired)

      Correct Answer: Mann-Whitney U test

      Explanation:

      The type of significance test used depends on whether the data is parametric (can be measured, usually normally distributed) or non-parametric.
      Parametric tests:
      Student’s t-test – paired or unpaired*
      Pearson’s product-moment coefficient – correlation

      Non-parametric tests:
      Mann-Whitney U test – unpaired data
      Wilcoxon signed-rank test – compares two sets of observations on a single sample
      chi-squared test – used to compare proportions or percentages
      Spearman, Kendall rank – correlation.

      The outcome measured is not normally distributed, i.e. it is non-parametric. This excludes the Student’s t-tests. We are not comparing percentages/proportions so the chi-squared test is excluded. The Mann–Whitney U test is a nonparametric test of the null hypothesis that it is equally likely that a randomly selected value from one sample will be less than or greater than a randomly selected value from a second sample.
      This test can be used to investigate whether two independent samples were selected from populations having the same distribution.

    • This question is part of the following fields:

      • Clinical Sciences
      23
      Seconds
  • Question 59 - A 26 year old man with a history of 'brittle' asthma is admitted...

    Correct

    • 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: 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
      30.1
      Seconds
  • Question 60 - A 65 yr. old male patient admitted with myocardial infarction received thrombolysis, which...

    Correct

    • A 65 yr. old male patient admitted with myocardial infarction received thrombolysis, which lead to full resolution of the ST elevations on his ECG. He was on aspirin, clopidogrel, atorvastatin and enalapril. The next day he complained of pain in his legs and there was a diffuse petechial rash over his lower legs, especially in the feet. All his peripheral pulses were palpable. His FBC revealed neutrophilia with eosinophilia. His IgE antibodies were 3 kU/L (<2). What is the most likely reason for this presentation?

      Your Answer: Cholesterol emboli

      Explanation:

      He has a consequence of atherosclerotic disease (MI). The most probable diagnosis is cutaneous cholesterol emboli as it is more common after anticoagulation or thrombolytics, the skin involvement, eosinophilia and raised IgE. It is more common above 60 yrs. of age.

    • This question is part of the following fields:

      • Cardiology
      25.4
      Seconds
  • Question 61 - A 43-year-old man is about to be started on chemotherapy for a high-grade...

    Correct

    • A 43-year-old man is about to be started on chemotherapy for a high-grade lymphoma. He is given intravenous rasburicase to help lower the risk of tumour lysis syndrome (TLS). What is the mechanism of action of this drug?

      Your Answer: Converts uric acid to allantoin

      Explanation:

      Rasburicase is a recombinant version of urate oxidase which is an enzyme that metabolizes uric acid to allantoin.

      TLS is a potentially fatal condition occurring as a complication during the treatment of high-grade lymphomas and leukaemias. It occurs from the simultaneous breakdown (lysis) of the tumour cells and subsequent release of chemicals into the bloodstream. This leads to hyperkalaemia and hyperphosphatemia in the presence of hyponatraemia. TLS can occur in the absence of chemotherapy, but it is usually triggered by the introduction of combination chemotherapy. Awareness of the condition is critical for its prophylactic management.

      Patients at high risk of TLS should be given IV rasburicase or IV allopurinol immediately prior to and during the first few days of chemotherapy. Allantoin is much more water soluble than uric acid and is therefore more easily excreted by the kidneys. Patients in lower-risk groups should be given oral allopurinol during cycles of chemotherapy in an attempt to avoid the condition.

      TLS is graded according to the Cairo-Bishop scoring system as:
      1. Laboratory tumour lysis syndrome
      2. Clinical tumour lysis syndrome

    • This question is part of the following fields:

      • Haematology & Oncology
      4.6
      Seconds
  • Question 62 - Which among the following factors is not associated with a poor prognosis in...

    Incorrect

    • Which among the following factors is not associated with a poor prognosis in patients with schizophrenia?

      Your Answer: Lack of obvious precipitant

      Correct Answer: Acute onset

      Explanation:

      A patient with a gradual onset of schizophrenia is to be associated with a poor prognosis.

      Schizophrenia is a functional psychotic disorder characterized by the presence of delusional beliefs, hallucinations, and disturbances in thought, perception, and behaviour.

      Clinical features:
      Schneider’s first-rank symptoms may be divided into auditory hallucinations, thought disorders, passivity phenomena, and delusional perceptions:

      Auditory hallucinations of a specific type:
      Two or more voices discussing the patient in the third person
      Thought echo
      Voices commenting on the patient’s behaviour

      Thought disorder:
      Thought insertion
      Thought withdrawal
      Thought broadcasting

      Passivity phenomena:
      Bodily sensations being controlled by external influence
      Actions/impulses/feelings – experiences which are imposed on the Individual or influenced by others

      Other features of schizophrenia include
      Impaired insight (a feature of all psychoses)
      Incongruity/blunting of affect (inappropriate emotion for circumstances)
      Decreased speech
      Neologisms: made-up words
      Catatonia
      Negative symptoms: incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), avolition (poor motivation).

      Treatment:
      For the initial treatment of acute psychosis, it is recommended to commence an oral second-generation antipsychotics such as aripiprazole, olanzapine, risperidone, quetiapine, etc.
      Once the acute phase is controlled, switching to a depot preparation like aripiprazole, paliperidone, zuclopenthixol, fluphenazine, haloperidol, pipotiazine, or risperidone is recommended.
      Cognitive-behavioural therapy (CBT) and the use of art and drama therapies help counteract the negative symptoms of the disease, improve insight, and assist relapse prevention.
      Clozapine is used in case of treatment resistance.

    • This question is part of the following fields:

      • Psychiatry
      14.2
      Seconds
  • Question 63 - A 45 year old man presents with fever, malaise, weight loss and myalgias...

    Incorrect

    • A 45 year old man presents with fever, malaise, weight loss and myalgias that have been occurring for a month. You suspect polyarteritis nodosa and arrange for some lab investigations. Which of the following abnormality would most likely be present?

      Your Answer: Positive ANCA

      Correct Answer: Elevated creatinine

      Explanation:

      People with polyarteritis nodosa often exhibit anaemia of chronic disease. Leucocytosis and eosinophilia may also be present. ANCA is only rarely positive. As polyarteritis nodosa affects the kidneys as well, the creatinine is elevated in most cases.

    • This question is part of the following fields:

      • Rheumatology
      9.5
      Seconds
  • Question 64 - A 34-year-old man who is HIV positive has started treatment for Burkitt lymphoma....

    Correct

    • A 34-year-old man who is HIV positive has started treatment for Burkitt lymphoma. His chemotherapy regime includes cyclophosphamide, vincristine, methotrexate, and prednisolone. After one day of starting chemotherapy, he becomes confused and complains of muscle cramps in his legs. Which one of the following is most likely to have occurred?

      Your Answer: Tumour lysis syndrome

      Explanation:

      Tumour lysis syndrome (TLS), triggered by the introduction of chemotherapy, has resulted in the aforementioned symptoms in this patient.

      TLS is a potentially fatal condition occurring as a complication during the treatment of high-grade lymphomas and leukaemias. It occurs from the simultaneous breakdown (lysis) of the tumour cells and subsequent release of chemicals into the bloodstream. This leads to hyperkalaemia and hyperphosphatemia in the presence of hyponatraemia. TLS can occur in the absence of chemotherapy, but it is usually triggered by the introduction of combination chemotherapy. Awareness of the condition is critical for its prophylactic management.

      Rasburicase should be given prior to chemotherapy in order to reduce the risk of tumour lysis syndrome (TLS). Rasburicase is a recombinant version of urate oxidase which is an enzyme that metabolizes uric acid to allantoin. Allantoin is 5–10 times more soluble than uric acid, hence, renal excretion is more effective.

      Burkitt lymphoma is a high-grade B-cell neoplasm. There are two major forms:
      1. Endemic (African) form: typically involves maxilla or mandible.
      2. Sporadic form: abdominal (e.g. ileocaecal) tumours are the most common form. More common in patients with HIV.

      Burkitt lymphoma is associated with the c-myc gene translocation, usually t(8;14). The Epstein-Barr virus (EBV) is strongly implicated in development of the African form of Burkitt lymphoma and to a lesser extent, the sporadic form.

      Management of the lymphoma is with chemotherapy. This tends to produce a rapid response which may cause TLS.

    • This question is part of the following fields:

      • Haematology & Oncology
      13.6
      Seconds
  • Question 65 - A 62-year-old female with a history of COPD and hypertension presents with pain...

    Correct

    • A 62-year-old female with a history of COPD and hypertension presents with pain on swallowing. Current medication includes a salbutamol and becotide inhaler, bendrofluazide and amlodipine. What is the most likely cause of the presentation?

      Your Answer: Oesophageal candidiasis

      Explanation:

      The history gives you a woman who is on inhaled steroid therapy. It is always a good idea for patients to rinse their mouths well after using inhaled steroids. Odynophagia (pain on swallowing) is a symptom of oesophageal candidiasis, which is the most likely answer given the steroids. Typically, you might see this in someone who is immunocompromised (classically, in HIV+ patients).

    • This question is part of the following fields:

      • Gastroenterology
      4.4
      Seconds
  • Question 66 - A 36-year-old man with diabetes is referred with abnormal liver biochemistry. Which of...

    Correct

    • A 36-year-old man with diabetes is referred with abnormal liver biochemistry. Which of the following is in keeping with a diagnosis of haemochromatosis?

      Your Answer: Transferrin saturation 78% (20-50)

      Explanation:

      A high transferrin saturation is seen in hemochromatosis, as well as a high iron level (>30), a high ferritin level, and a LOW TIBC (<20). Think of it like the opposite findings of iron deficiency anaemia which is a low iron, low ferritin, high TIBC.

    • This question is part of the following fields:

      • Gastroenterology
      17.8
      Seconds
  • Question 67 - A 21-year-old patient is referred to the tertiary neurology clinic because of a...

    Correct

    • 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: 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
      17.3
      Seconds
  • Question 68 - An 18-year-old male was diagnosed with meningococcal meningitis, confirmed on lumbar puncture. After...

    Correct

    • An 18-year-old male was diagnosed with meningococcal meningitis, confirmed on lumbar puncture. After 6 months he presents in the infectious clinic with a second episode of meningitis. His past history is clear and he takes no regular medication. Which of the following is most probably deficient?

      Your Answer: C5

      Explanation:

      Pneumococcal meningitis is the most common and severe form of bacterial meningitis. Fatality rates are substantial, and long-term sequelae develop in about half of survivors. Disease outcome has been related to the severity of the proinflammatory response in the subarachnoid space. The complement system, which mediates key inflammatory processes, has been implicated as a modulator of pneumococcal meningitis disease severity in animal studies. C5 fragment levels in cerebrospinal fluid (CSF) of patients with bacterial meningitis correlated with several clinical indicators of poor prognosis.

    • This question is part of the following fields:

      • Clinical Sciences
      5.3
      Seconds
  • Question 69 - Choose the correct formula to calculate the negative predictive value of a screening...

    Incorrect

    • Choose the correct formula to calculate the negative predictive value of a screening test:

      Your Answer: TN / (TN + FP)

      Correct Answer: TN / (TN + FN)

      Explanation:

      NPV = TN / FN+TN

      = TN (true negative) / FN+TN (false negative + true negative)

      = Probability (patient not having disease when test is negative)

    • This question is part of the following fields:

      • Clinical Sciences
      16.6
      Seconds
  • Question 70 - A 50 yr. old male with a history of type II diabetes mellitus...

    Correct

    • A 50 yr. old male with a history of type II diabetes mellitus and hypertension presented with exertional dyspnoea and chest pain for 2 weeks. On examination his blood pressure was 145/80 mmHg. On auscultation reversed splitting of the second heart sound and bibasal crepitations were detected. What would be the most likely finding on his ECG?

      Your Answer: Left bundle branch block

      Explanation:

      When closure of the pulmonary valve occurs before the aortic valve, reversed splitting occurs. The causes of reversed splitting are aortic stenosis, hypertrophic cardiomyopathy, left bundle branch block (LBBB), and a ventricular pacemaker.

    • This question is part of the following fields:

      • Cardiology
      13.9
      Seconds
  • Question 71 - A 42-year-old man presented with bloody diarrhoea and weight loss. Which one of...

    Correct

    • A 42-year-old man presented with bloody diarrhoea and weight loss. Which one of the following would favour the diagnosis of Crohn’s disease on rectal biopsy?

      Your Answer: Patchy inflammation

      Explanation:

      The correct answer is patchy inflammation. Superficial ulceration as well as non-patchy inflammation are seen in ulcerative colitis (UC) in the colon and rectum; you would expect to see transmural inflammation in Crohn’s disease and it can be patchy and located anywhere from mouth to anus. Crypt distortion and crypt abscesses are seen in both UC and Crohn’s, however they are more common in ulcerative colitis.

    • This question is part of the following fields:

      • Gastroenterology
      15.8
      Seconds
  • Question 72 - Which one of the following statements is incorrect with regards to post-partum mental...

    Incorrect

    • Which one of the following statements is incorrect with regards to post-partum mental health problems?

      Your Answer: Post-natal depression usually develops within the first month

      Correct Answer: Post-natal depression is seen in around 2-3% of women

      Explanation:

      Most new moms experience postpartum baby blues after childbirth, which commonly include mood swings, crying spells, anxiety and difficulty sleeping. Baby blues typically begin within the first two to three days after delivery, and may last for up to two weeks.

      Postpartum depression may be mistaken for baby blues at first — but the signs and symptoms are more intense and last longer, and may eventually interfere with your ability to care for your baby and handle other daily tasks. Symptoms usually develop within the first few weeks after giving birth, but may begin earlier, during pregnancy or later, up to a year after birth.

      The period prevalence of postpartum depression among women is a striking 21.9% the first year after birth, which makes it one of the most common medical complications of childbearing. Sertraline has been identified as an antidepressant of choice for breastfeeding women because infants are unlikely to develop quantifiable serum sertraline levels and very few adverse events associated with sertraline have been reported.

      Women with a prior episode of postpartum psychosis have about a 30% risk of having another episode in the next pregnancy.

    • This question is part of the following fields:

      • Psychiatry
      19.3
      Seconds
  • Question 73 - A 60 year old male presents with one month history of generalized headache,...

    Correct

    • A 60 year old male presents with one month history of generalized headache, fever and malaise. He also complains of scalp sensitivity while combing his hair. In order to confirm the diagnosis, which of the following would be the definite test?

      Your Answer: Temporal artery biopsy

      Explanation:

      Temporal arteritis is a chronic large- and medium-sized vessel vasculitis that typically involves the temporal arteries. Classical symptoms include temporal headaches, jaw claudication, amaurosis fugax. Physical exam shows scalp tenderness, palpation of the temporal area may demonstrate an absent pulse, knot-like swelling, and vision loss. Lab results reveal an increased erythematous sedimentation rate and C-reactive protein. Temporal artery biopsy confirms the diagnosis. Management approach: high-dose systemic corticosteroids should be promptly administered even before the diagnosis is established. Temporal artery biopsy confirms the diagnosis. Inability to manage this or administer glucocorticoids might lead to development of blindness.

    • This question is part of the following fields:

      • Rheumatology
      8
      Seconds
  • Question 74 - Intracellular proteins tagged with ubiquitination are destined to which of the following organelles?...

    Correct

    • Intracellular proteins tagged with ubiquitination are destined to which of the following organelles?

      Your Answer: Proteasome

      Explanation:

      Delivery of ubiquitinated substrates to the proteasome.
      Ubiquitinated proteins are delivered to the proteasome by various routes and the complete picture of how these pathways fit together has yet to emerge, reviewed in. Some substrates bind directly to the proteasome by interacting with the 19S regulatory particle subunits Rpn1028 or Rpn1329, and probably Rpt530. Alternatively, ubiquitinated substrates can be brought to the proteasome by adaptors that bind both the proteasome and the ubiquitin chain on the substrate to deliver it for degradation.

    • This question is part of the following fields:

      • Clinical Sciences
      4.8
      Seconds
  • Question 75 - A 6-year-old boy with fever and malaise for 2 days recently developed bloody...

    Correct

    • A 6-year-old boy with fever and malaise for 2 days recently developed bloody diarrhoea. What is the most probable aetiology?

      Your Answer: Escherichia coli 0157

      Explanation:

      The most likely organism is enterohemorrhagic verotoxin-producing E.coli. It usually causes haemolytic uremic syndrome.
      Crohn’s disease rarely manifests in an acute manner.
      Polio and giardiasis usually manifest with non-bloody diarrhoea.

    • This question is part of the following fields:

      • Infectious Diseases
      8
      Seconds
  • Question 76 - A 28 year old female hiker begins complaining of headache and nausea after...

    Correct

    • 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 + 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
      14.8
      Seconds
  • Question 77 - β-blockers are used in the treatment of angina because they have which one...

    Correct

    • β-blockers are used in the treatment of angina because they have which one of the following properties?

      Your Answer: Decrease the heart rate and myocardial contractility

      Explanation:

      The cardiovascular effects of β-adrenoceptor block result from reduction of the sympathetic drive which includes reduced heart rate (automaticity) and reduced myocardial contractility (rate of rise of pressure in the ventricle). This will lead to reduced cardiac output and an overall fall in oxygen consumption.

    • This question is part of the following fields:

      • Pharmacology
      18.1
      Seconds
  • Question 78 - A 19-year-old lady with established anorexia nervosa is admitted with a BMI of...

    Correct

    • A 19-year-old lady with established anorexia nervosa is admitted with a BMI of 16. However, she gives the consent to be fed by a nasogastric tube. Which of the following electrolyte disturbances are you most likely to find?

      Your Answer: Hypophosphataemia

      Explanation:

      Refeeding syndrome can be defined as the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding (whether enterally or parenterally). These shifts result from hormonal and metabolic changes and may cause serious clinical complications. The hallmark biochemical feature of refeeding syndrome is hypophosphatemia. However, the syndrome is complex and may also feature abnormal sodium and fluid balance; changes in glucose, protein, and fat metabolism; thiamine deficiency; hypokalaemia; and hypomagnesaemia.

    • This question is part of the following fields:

      • Clinical Sciences
      10.9
      Seconds
  • Question 79 - A 27-year-old woman presents with recurrent headaches and sweating. On examination, a nodule...

    Correct

    • A 27-year-old woman presents with recurrent headaches and sweating. On examination, a nodule is felt in the region of the thyroid gland. She mentions that her mother had kidney stones and died following a tumour in her neck. A surgeon recommends complete thyroidectomy as her treatment of choice. What is the most important investigation to be done before the surgery?

      Your Answer: 24-hour urinary catecholamines

      Explanation:

      The patient is most likely to have Medullary Thyroid Carcinoma (MTC).
      Sporadic, or isolated MTC accounts for 75% of cases and inherited MTC constitutes the rest.
      Inherited MTC occurs in association with multiple endocrine neoplasia (MEN) type 2A and 2B syndromes, but non-MEN familial MTC also occurs.
      A 24-hour urinalysis for catecholamine metabolites (e.g., vanillylmandelic acid [VMA], metanephrine) has to be done to rule out concomitant pheochromocytoma in patients with MEN type 2A or 2B, as Pheochromocytoma must be treated before MTC.

    • This question is part of the following fields:

      • Endocrinology
      10.9
      Seconds
  • Question 80 - A 35-year-old woman was on a camping holiday in Spain. She awoke at...

    Incorrect

    • A 35-year-old woman was on a camping holiday in Spain. She awoke at three o’clock one morning with severe neck pain radiating down into her left shoulder and down to her forearm. The next day it spread to the dorsal aspect of the forearm. She was otherwise well. Her symptoms resolved after 24 hours. She noticed that after a week she was unable to wind down the car window with her left arm. On examination of the left arm there was wasting of brachioradialis, shoulder, biceps and winging of left scapula. What is the diagnosis?

      Your Answer: Lyme disease

      Correct Answer: Amyotrophic neuralgia

      Explanation:

      This patient present with the classical symptoms of Amyotrophic neuralgia, characterised by sudden onset of pain in the shoulders that radiate down to the forearms and later resolve spontaneously but is followed by muscle wasting.

    • This question is part of the following fields:

      • Neurology
      30.4
      Seconds
  • Question 81 - An 18-year-old woman has been diagnosed with human papillomavirus infection. What is the...

    Correct

    • An 18-year-old woman has been diagnosed with human papillomavirus infection. What is the most significant long-term risk following this infection?

      Your Answer: Cervical cancer

      Explanation:

      Human-papilloma virus (HPV) can lead to cervical cancer. There are many different types, but the types associated with cervical cancer most commonly are 16, 18, 31, 33, and 35. The vaccination against HPV protects against the most common types of HPV that are seen in cervical cancer and is recommended for children/young teens. Cervical cancer has a clear association with HPV, making this the best answer over all of the other answer choices.

    • This question is part of the following fields:

      • Infectious Diseases
      5.4
      Seconds
  • Question 82 - Her parents with a severe headache present a 24-year-old woman. She is afraid...

    Correct

    • Her parents with a severe headache present a 24-year-old woman. She is afraid of light and sun and prefers darker environments. On examination, a generalized rash that does not blanch on pressure is noticed. What is the best action in this case?

      Your Answer: IV benzylpenicillin

      Explanation:

      The rash is a characteristic sign of meningitis. Added to photophobia, headache and neck rigidity, meningitis is highly suggested diagnosis. IV antibiotics should be started immediately.

    • This question is part of the following fields:

      • Infectious Diseases
      14.1
      Seconds
  • Question 83 - Which type of cell is responsible for the production of surfactant? ...

    Correct

    • Which type of cell is responsible for the production of surfactant?

      Your Answer: Type II pneumocyte

      Explanation:

      Type I pneumocyte: The cell responsible for the gas (oxygen and carbon dioxide) exchange that takes place in the alveoli. It is a very thin cell stretched over a very large area. This type of cell is susceptible to a large number of toxic insults and cannot replicate itself.
      Type II pneumocyte: The cell responsible for the production and secretion of surfactant (the molecule that reduces the surface tension of pulmonary fluids and contributes to the elastic properties of the lungs). The type 2 pneumocyte is a smaller cell that can replicate in the alveoli and will replicate to replace damaged type 1 pneumocytes. Alveolar macrophages are the primary phagocytes of the innate immune system, clearing the air spaces of infectious, toxic, or allergic particles that have evaded the mechanical defences of the respiratory tract, such as the nasal passages, the glottis, and the mucociliary transport system. The main role of goblet cells is to secrete mucus in order to protect the mucous membranes where they are found. Goblet cells accomplish this by secreting mucins, large glycoproteins formed mostly by carbohydrates.

    • This question is part of the following fields:

      • Respiratory
      5.8
      Seconds
  • Question 84 - A 56-year-old man, on the acute oncology ward, is a known case of...

    Correct

    • A 56-year-old man, on the acute oncology ward, is a known case of colorectal cancer. He was diagnosed one month ago after participating in a screening test—faecal occult blood test. Following the positive test result, colonoscopy was performed demonstrating a malignant lesion in the descending colon. CT staging showed lymph node involvement but no distant metastases. The patient has undergone a left hemicolectomy and is due to start adjuvant chemotherapy with a combination of fluorouracil (5-FU) and oxaliplatin. During his work-up, his consultant had explained that he would need to be monitored for disease recurrence. Which of the following is important in monitoring the disease activity in colorectal cancer?

      Your Answer: Carcinoembryonic Antigen (CEA)

      Explanation:

      Carcinoembryonic antigen (CEA) is a known tumour marker for colorectal cancer. It is not used diagnostically, but in patients with a known diagnosis of colorectal cancer associated with raised CEA levels, it can be used to monitor disease activity and help with the early identification of disease recurrence.

      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
      7.3
      Seconds
  • Question 85 - A 51-year-old man was admitted with right-sided hemiparesis and right upper motor neurone...

    Correct

    • A 51-year-old man was admitted with right-sided hemiparesis and right upper motor neurone facial nerve palsy. He was known to be on warfarin for a mitral valve replacement and had been adequately anticoagulated. He was also taking furosemide and had recently been started on St John’s wort for low mood. On examination, his pulse was 90 bpm and regular, and his blood pressure was 150/80 mmHg. Cardiac examination demonstrated normal prosthetic valve sounds with an ejection systolic murmur at the left sternal edge. CT scan showed evidence of a left middle cerebral artery infarction. What is the possible explanation for the presentation?

      Your Answer: St John’s wort reduces the activity of warfarin

      Explanation:

      St John’s wort interferes with warfarin by increasing its breakdown and decreasing its effectiveness. This leads to the need for adjustment in the dose of warfarin and careful attention to monitoring if the patient decides to continue with the drug. Ideally, an alternative antidepressant should also be considered.

    • This question is part of the following fields:

      • Haematology & Oncology
      28.8
      Seconds
  • Question 86 - A 26 yr. old male was being investigated further following several hypertensive episodes....

    Correct

    • A 26 yr. old male was being investigated further following several hypertensive episodes. There was a marked difference in his systolic blood pressures between the right brachial and the right femoral arteries. Which of the following is most probable diagnosis?

      Your Answer: Coarctation of the aorta

      Explanation:

      From the given physical findings (the difference in BP between the radial and femoral arteries), the most probable diagnosis is coarctation of the aorta.

    • This question is part of the following fields:

      • Cardiology
      12.3
      Seconds
  • Question 87 - You want to compare a new oral hypoglycaemic drug with an existing treatment,...

    Correct

    • You want to compare a new oral hypoglycaemic drug with an existing treatment, which would also lower HbA1c. Which study design would you choose?

      Your Answer: Superiority trial

      Explanation:

      When the aim of the randomized controlled trial (RCT) is to show that one treatment is superior to another, a statistical test is employed and the trial (test) is called a superiority trial (test).

    • This question is part of the following fields:

      • Clinical Sciences
      8.2
      Seconds
  • Question 88 - Which features may suggest malignant changes in a melanocytic naevi? ...

    Incorrect

    • Which features may suggest malignant changes in a melanocytic naevi?

      Your Answer: Irregularity of surface

      Correct Answer: Decrease in size

      Explanation:

      Melanocytic naevi are skin tumours produced by melanocytes. They usually present in childhood but increase during puberty. The mnemonic A-B-C-D, is used by institutions to assess for suspicion of malignancy. The letters stand for asymmetry, border, colour, and diameter. If a mole starts changing in size, colour, shape or, especially, if the border of a mole develops ragged edges or becomes larger than a pencil eraser, it would be an appropriate time to consult with a physician. Other warning signs include if it begins to crust over, bleed, itch, or become inflamed.

    • This question is part of the following fields:

      • Dermatology
      8.8
      Seconds
  • Question 89 - A 45-year-old female develops profuse watery diarrhoea with lower abdominal pain seven days...

    Correct

    • A 45-year-old female develops profuse watery diarrhoea with lower abdominal pain seven days after undergoing laparoscopic cholecystectomy. What is the most likely diagnosis?

      Your Answer: Pseudomembranous colitis

      Explanation:

      Pseudomembranous colitis is caused by a C. difficile infection that causes membranes to form on the colon wall. It is caused most commonly by broad-spectrum antibiotics. This would include cephalosporins, broad-spectrum penicillin, and clindamycin. Macrolides and quinolones have also been reported as potential aetiologies, but much less commonly. This woman would have received antibiotics prophylactically before her surgery, predisposing her to a possible c difficile infection. This is a much better answer choice than pseudo obstruction, abdominal sepsis, bile acid diarrhoea, and campylobacter gastroenteritis simply based on history of present illness.

    • This question is part of the following fields:

      • Gastroenterology
      6.2
      Seconds
  • Question 90 - A 76 year old female who is admitted to the ward complains that...

    Correct

    • A 76 year old female who is admitted to the ward complains that she is experiencing visual hallucinations. She was admitted following a decline in mobility that was thought to be secondary to a urinary tract infection. Improvements have been seen clinically and biochemically while she has been admitted and she is currently awaiting discharge. Upon review, she states that she has seen wolves walking around her bed. She has a background of hypertension, depression and age-related macular degeneration. What is the most appropriate step in this patient's management?

      Your Answer: Reassure the patient

      Explanation:

      Charles Bonnet syndrome (CBS) involves visual hallucinations due to eye disease, usually associated with a sharp decline in vision. The phenomenon is seen in patients with moderate or severe visual impairment. It can occur spontaneously as the vision declines or it may be precipitated, in predisposed individuals, by concurrent illness such as infections elsewhere in the body.

      It is not clear why CBS develops or why some individuals appear to be predisposed to it. It is particularly noted in patients with advanced macular degeneration. It has been suggested that reduced or absent stimulation of the visual system leads to increased excitability of the visual cortex (deafferentation hypothesis). This release phenomenon is compared to phantom limb symptoms after amputation.

      CBS is much more common in older patients because conditions causing marked visual loss are more common in older people. However, it can occur at any age and has been described in children.
      The prevalence is hard to assess due to considerable under-reporting, perhaps because patients frequently fear that it is a sign of mental illness or dementia. However, it is thought to occur in:
      About 10-15% of patients with moderate visual loss.
      Possibly up to 50% of people with severe visual loss.
      Presentation:
      The nature of the hallucination depends on the part of the brain that is activated. The hallucinations may be black and white or in colour. They may involve grids/brickwork/lattice patterns but are typically much more complex:

      The hallucinations are always outside the body.
      The hallucinations are purely visual – other senses are not involved.
      The hallucinations have no personal meaning to the patient.
      Hallucinations may last seconds, minutes or hours.
      CBS tends to occur in a ‘state of quiet restfulness’. This may be after a meal or when listening to the radio (but not when dozing off).
      Symptoms also have a tendency to occur in dim lighting conditions.
      Patients may report high levels of distress, with some patients reporting anger, anxiety and even fear associated with the hallucinations.

    • This question is part of the following fields:

      • Psychiatry
      27.5
      Seconds
  • Question 91 - A non-cyanosed 1-year-old female patient has a continuous murmur which is loudest at...

    Correct

    • A non-cyanosed 1-year-old female patient has a continuous murmur which is loudest at the left sternal edge. What pulse abnormality is most associated with patent ductus arteriosus if that's her suspected diagnosis?

      Your Answer: Collapsing pulse

      Explanation:

      DIAGNOSIS:
      A consensus definition for hemodynamically significant PDA is lacking. The diagnosis is often suspected clinically, when an infant demonstrates signs of excessive shunting from the arterial to pulmonary circulation. Continuous or a systolic murmur; note, a “silent” PDA may also occur when the ductus shunt is large enough that nonturbulent flow fails to generate a detectible murmur.
      A low diastolic blood pressure (due to runoff into the ductus during diastole, more frequent in the most premature infants).
      A wide pulse pressure (due to ductus runoff or steal)Hypotension (especially in the most premature infants)
      Bounding pulses
      Increased serum creatinine concentration or oliguria
      Hepatomegaly

    • This question is part of the following fields:

      • Clinical Sciences
      36.6
      Seconds
  • Question 92 - A 4-year-old boy is admitted to the hospital after developing hemarthrosis in his...

    Correct

    • A 4-year-old boy is admitted to the hospital after developing hemarthrosis in his right knee whilst playing in the garden. Following blood results are obtained: Plts: 220 x 10^9/L, PT: 11 secs, APTT: 76 secs, Factor VIIIc activity: Normal. What is the most likely diagnosis?

      Your Answer: Haemophilia B

      Explanation:

      A grossly elevated APTT may be caused by heparin therapy, haemophilia, or antiphospholipid syndrome. A normal factor VIIIc activity, however, points towards the diagnosis of haemophilia B, which is the deficiency of factor IX in the blood.

      Haemophilia is an X-linked recessive disorder of coagulation. Up to 30% of patients have no family history of the condition. Haemophilia A is due to the deficiency of clotting factor VIII and is more common than haemophilia B, accounting for 90% of the cases. In haemophilia B (Christmas disease), there is a deficiency of clotting factor IX.

      Characteristic features of haemophilia include hemarthrosis, haematomas, and prolonged bleeding following trauma or surgery. Coagulation profile of a haemophiliac person shows prolonged bleeding time, activated partial thromboplastin time (APTT), thrombin time (TT), but a normal prothrombin time (PT).

    • This question is part of the following fields:

      • Haematology & Oncology
      18
      Seconds
  • Question 93 - A 6-year-old boy is referred by his GP to the neurology clinic with...

    Correct

    • A 6-year-old boy is referred by his GP to the neurology clinic with abnormal movements. His mother noticed that for the last year, the boy has been falling over more and more frequently. He has also been having increasingly slurred speech. These have been getting progressively worse. He has had recurrent chest infections in his childhood. What is the most likely diagnosis?

      Your Answer: Ataxic telangiectasia

      Explanation:

      Ataxic telangiectasia is an inherited combined immunodeficiency disorder that is characterised by cerebellar ataxia and telangiectasia as seen in this child, as well as frequent infections as noted in this child’s history. The other differentials would not present with this clinical picture:

      Friedreich’s ataxia and Infantile-onset spinocerebellar ataxia do not present with immune problems, whereas Cerebral palsy and Di-George Syndrome do not present with ataxia.

    • This question is part of the following fields:

      • Neurology
      12.2
      Seconds
  • Question 94 - A 40-year-old heavy smoker presents with a serum sodium level of 113 mmol/l....

    Correct

    • A 40-year-old heavy smoker presents with a serum sodium level of 113 mmol/l. A diagnosis of SIADH is confirmed. What is the most appropriate initial management for his fluid balance?

      Your Answer: Fluid restriction

      Explanation:

      European guidelines for the treatment of syndrome of inappropriate antidiuresis include the following recommendations for the management of moderate or profound hyponatremia:
      – Restrict fluid intake as first-line treatment.
      – Second-line treatments include increasing solute intake with 0.25–0.50 g/kg per day or a combination of low-dose loop diuretics and oral sodium chloride.
      – Use of lithium, demeclocycline, or vasopressin receptor antagonists is not recommended.
      Recommendations on the treatment of SIADH from an American Expert Panel included the following:
      – If chronic, limit the rate of correction.
      – Fluid restriction should generally be first-line therapy.
      – Consider pharmacologic therapies if serum Na + is not corrected after 24-48 hr of fluid restriction or if the patient has a low urinary electrolyte free water excretion.
      – Patients being treated with vaptans should not be on a fluid restriction initially.
      – Water, 5% dextrose or desmopressin can be used to slow the rate of correction if the water diuresis is profound.

    • This question is part of the following fields:

      • Endocrinology
      3.6
      Seconds
  • Question 95 - 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: Median nerve

      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
      13.8
      Seconds
  • Question 96 - A 73 year old woman attends COPD clinic for review. Her blood gases...

    Incorrect

    • A 73 year old woman attends COPD clinic for review. Her blood gases were checked on her last visit two months back. The test was repeated again today. The paO2 on both occasions was 6.8 kPa. There is no CO2 retention on 28% O2. She stopped smoking around 6 months ago and is maintained on combination inhaled steroids and long acting b2-agonist therapy. What is the next best step in management?

      Your Answer: Offer her oxygen cylinders for use as required

      Correct Answer: Suggest she uses an oxygen concentrator for at least 19 h per day

      Explanation:

      Long-term oxygen therapy (LTOT) ≥ 15 h/day improves survival in hypoxemic chronic obstructive pulmonary disease (COPD). It significantly helps in reducing pulmonary hypertension associated with COPD and treating underlying pathology of future heart failure. There is little to no benefit of oxygen therapy for less than 15 hours.

    • This question is part of the following fields:

      • Respiratory
      50.6
      Seconds
  • Question 97 - A woman with severe renal failure undergoes a kidney transplant. However, after a...

    Incorrect

    • A woman with severe renal failure undergoes a kidney transplant. However, after a few hours, she develops fever and anuria. The doctors are suspecting hyperacute organ rejection. Which are the cells primarily responsible for hyperacute organ rejection?

      Your Answer: Neutrophils

      Correct Answer: B Cells

      Explanation:

      Hyperacute rejection appears in the first minutes following transplantation and occurs only in vascularized grafts. This very fast rejection is characterized by vessel thrombosis leading to graft necrosis. Hyperacute rejection is caused by the presence of antidonor antibodies existing in the recipient before transplantation. These antibodies induce both complement activation and stimulation of endothelial cells to secrete Von Willebrand procoagulant factor, resulting in platelet adhesion and aggregation. The result of these series of reactions is the generation of intravascular thrombosis leading to lesion formation and ultimately to graft loss. Today, this type of rejection is avoided in most cases by checking for ABO compatibility and by excluding the presence of antidonor human leukocyte antigen (HLA) antibodies by cross-match techniques between donor graft cells and recipient sera. This type of rejection is also observed in models of xenotransplantation of vascularized organs between phylogenetically distant species when no immunosuppressive treatment is given to the recipients.

    • This question is part of the following fields:

      • Clinical Sciences
      16.1
      Seconds
  • Question 98 - A 24 year old presents with diarrhoea. She has had a previous ileal...

    Correct

    • A 24 year old presents with diarrhoea. She has had a previous ileal resection for Crohn's Disease. She has also had two recent episodes of loin to groin pain. Her bloods are normal including her inflammatory markers What is the most likely diagnosis?

      Your Answer: Short bowel syndrome

      Explanation:

      Given her history of bowel resections, the most likely answer in this case is short bowel syndrome. IBS is a diagnosis of exclusion and less likely. Bacterial overgrowth does not relate to resection history, so unlikely. Celiac disease or a flare of IBD are also less likely than short bowel syndrome in this case, simply given the history. Also her labs are normal making these unlikely. History, history, history!

    • This question is part of the following fields:

      • Gastroenterology
      12.7
      Seconds
  • Question 99 - A 77-year-old retired engineer presents with a burning sensation around his right eye....

    Incorrect

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

      Your Answer: Ramsay Hunt syndrome

      Correct Answer: Herpes zoster ophthalmicus

      Explanation:

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

    • This question is part of the following fields:

      • Ophthalmology
      13.8
      Seconds
  • Question 100 - A 23 year old man presents with a painful right elbow and left...

    Correct

    • A 23 year old man presents with a painful right elbow and left Achilles tendon. He also gives history of dysuria, fever and conjunctivitis. Examination reveals macules and pustules on his hands. He has returned from a trip to Far East 3 weeks ago and admits to having unprotected sex. Which of the following is the most likely diagnosis?

      Your Answer: Reactive arthritis

      Explanation:

      Reactive arthritis, (formerly known as Reiter’s syndrome), is an autoimmune condition that occurs after a bacterial infection of the gastrointestinal or urinary tract. It is categorized as a seronegative spondylarthritis because of its association with HLA-B27. Reactive arthritis primarily affects young men and usually presents with musculoskeletal or extra‑articular symptoms. The characteristic triad consists of arthritis, conjunctivitis, and urethritis. The diagnosis is based on clinical features such as patient history and physical examination; there are no specific tests for reactive arthritis. Treatment is primarily symptomatic and consists of the administration of NSAIDs, as most patients recover spontaneously. extraarticular dermatologic manifestations include skin lesions of the glans resembling psoriasis (balanitis circinata); hyperkeratinisation of the palms and soles (keratoderma blenorrhagicum), oral ulcers. Other STDs including HIV, syphilis have different presentations. Psoriatic arthritis is not commonly associated with urethritis and conjunctivitis.

    • This question is part of the following fields:

      • Rheumatology
      6.5
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Pharmacology (3/4) 75%
Neurology (5/7) 71%
Cardiology (6/6) 100%
Psychiatry (2/8) 25%
Gastroenterology (11/12) 92%
Rheumatology (4/6) 67%
Clinical Sciences (11/19) 58%
Haematology & Oncology (8/8) 100%
Respiratory (7/10) 70%
Nephrology (3/4) 75%
Ophthalmology (0/2) 0%
Endocrinology (5/7) 71%
Dermatology (0/3) 0%
Infectious Diseases (4/4) 100%
Passmed