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Question 1
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A patient has been diagnosed with multi-drug resistant tuberculosis and is currently bring treated with rifampicin, isoniazid, and pyrazinamide. He is commenced on streptomycin. Which among the following is the most likely neurological side-effect of streptomycin?
Your Answer: Vestibular damage
Explanation:Vestibular damage is a neurological side effect of streptomycin.
Streptomycin is an aminoglycoside bactericidal antibiotic. It is used in the treatment of tularaemia and resistant mycobacterial infections.
The most common neurological side-effect is vestibular damage leading to vertigo and vomiting.
Cochlear damage is less frequent and results in deafness.
Other side-effects include rashes, angioneurotic oedema, and nephrotoxicity. -
This question is part of the following fields:
- Pharmacology
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Question 2
Incorrect
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Which of the following statements is false regarding the bioavailability of a drug?
Your Answer: The bioavailability of a drug given orally may be affected by co-administration of other drugs
Correct Answer: The bioavailability of a drug given orally is often affected by the degree of renal elimination
Explanation:Renal elimination of a drug has no role in altering the bioavailability of a drug.
The bioavailability of a drug is the proportion of the drug which reaches systemic circulation.
Mathematically, bioavailability is the AUCoral/AUCiv x 100%, where AUC = area under the concentration-time curve following a single (oral or iv) dose.Other options are true:
By definition, the bioavailability of a drug given intravenously is 100%.
Drugs given orally that undergo high pre-systemic (first-pass) metabolism in the liver or gut wall have a low bioavailability e.g. lidocaine.
Bioavailability is also affected by the degree of absorption from the gut and this can change depending on gut motility and administration of other drugs. -
This question is part of the following fields:
- Pharmacology
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Question 3
Correct
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A 24-year-old student is brought to A&E having ingested at least 20 tablets of paracetamol 8 hours earlier. She weighs 61kg. What should her immediate management consist of?
Your Answer: Intravenous N-acetylcysteine
Explanation:Activated charcoal is useful if given within one hour of the paracetamol overdose. Liver function tests, INR and prothrombin time will be normal, as liver damage may not manifest until 24 hours or more after ingestion.
The antidote of choice is intravenous N-acetylcysteine, which provides complete protection against toxicity if given within 10 hours of the overdose.
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This question is part of the following fields:
- Pharmacology
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Question 4
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A 74-year-old retired judge who is known to have Alzheimer’s disease is examined in clinic. His latest Mini Mental State Examination (MMSE) score is 18 out of 30. Which of the following is the most appropriate treatment option?
Your Answer: Supportive care + donepezil
Explanation:NICE now recommends the three acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) as options for managing mild to moderate Alzheimer’s disease. Memantine is reserved for patients with moderate to severe Alzheimer’s.
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This question is part of the following fields:
- Neurology
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Question 5
Correct
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A 33-year-old man presents with recurrent episodes of abdominal pain associated with weakness of his arms and legs. Which one of the following urine tests would best indicate lead toxicity?
Your Answer: Coproporphyrin
Explanation:Lead poisoning is characterised by abdominal pain, fatigue, constipation, peripheral neuropathy (mainly motor), and blue lines on gum margin in 20% of the adult patients (very rare in children).
For diagnosis, the level of lead in blood is usually considered with levels greater than 10 mcg/dL being significant. Furthermore, the blood film shows microcytic anaemia and basophilic stippling of red blood cells. Urinary coproporphyrin is increased (urinary porphobilinogen and uroporphyrin levels are normal to slightly increased). Raised serum and urine levels of delta-aminolaevulinic acid may also be seen, making it sometimes difficult to differentiate from acute intermittent porphyria.
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This question is part of the following fields:
- Haematology & Oncology
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Question 6
Incorrect
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Which one of the following statements best describes a type II statistical error?
Your Answer: The p value fails to reach statistical significance
Correct Answer: The null hypothesis is accepted when it is false
Explanation:In statistical hypothesis testing there are 2 types of errors:
– type I: the null hypothesis is rejected when it is true – i.e. Showing a difference between two groups when it doesn’t exist, a false positive.
– type II: the null hypothesis is accepted when it is false – i.e. Failing to spot a difference when one really exists, a false negative. -
This question is part of the following fields:
- Clinical Sciences
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Question 7
Incorrect
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A 50 yr. old male patient was started on amiodarone. Prior to commencement, his blood urea and electrolytes were checked. What is the reason for doing this investigation before starting amiodarone?
Your Answer: To detect a metabolic acidosis
Correct Answer: To detect hypokalaemia
Explanation:Any antiarrhythmic drugs can potentially cause arrhythmias. Before starting amiodarone, any electrolyte imbalance including hypokalaemia, hypomagnesemia, or hypocalcaemia should be corrected to prevent any arrhythmias.
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This question is part of the following fields:
- Cardiology
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Question 8
Incorrect
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You are a ST1 doctor working on a medical ward. You are struggling to cope with the workload and often leave the ward late. Who is the most appropriate action to take?
Your Answer:
Correct Answer: Speak to your consultant
Explanation:Speaking to your consultant is the most appropriate first action to take in this scenario. They are best placed to be able to take action to try and amend the situation. The consultant is also ultimately responsible for patient care and hterefore have a right to know if you are struggling, as this may affect patient care.
Arriving early and taking time off sick do not address the problem. -
This question is part of the following fields:
- Clinical Sciences
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Question 9
Incorrect
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A 20 year old woman presents to the hospital with sharp, left-sided chest pain and shortness of breath. On examination her pulse is 101 beats per minute and blood pressure is 124/61 mmHg. She is seen to be mildly breathless at rest but her oxygen saturation on air was 98%. CXR reveals a left pneumothorax with a 4 cm rim of air visible. Which management strategy is appropriate in this patient?
Your Answer:
Correct Answer: Needle aspiration
Explanation:Pneumothorax is defined as air in the pleural space and may be classified as spontaneous, traumatic or iatrogenic. Primary spontaneous pneumothorax occurs in patients without clinically apparent lung disease.
Primary pneumothorax has an incidence of 18-28 per 100,000 per year for men and 1.2-6 per 100,000 per year for women. Most patients present with ipsilateral pleuritic chest pain and acute shortness of breath. Shortness of breath is largely dependent on the size of the pneumothorax and whether there is underlying chronic lung disease.Young patients may have chest pain only. Most episodes of pneumothorax occur at rest. Symptoms may resolve within 24 hours in patients with primary spontaneous pneumothorax. The diagnosis of a pneumothorax is confirmed by finding a visceral pleural line displaced from the chest wall, without distal lung markings, on a posterior-anterior chest radiograph.
Breathless patients should not be left without intervention regardless of the size of pneumothorax. If there is a rim of air >2cm on the chest X-ray, this should be aspirated.
Aspiration is successful in approximately 70 per cent of patients; the patient may be discharged subsequently. A further attempt at aspiration is recommended if the patient remains symptomatic and a volume of less than 2.5 litres has been aspirated on the first attempt.If unsuccessful, an intercostal drain is inserted. This may be removed after 24 hours after full re-expansion or cessation of air leak without clamping and discharge may be considered.
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This question is part of the following fields:
- Respiratory
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Question 10
Incorrect
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A 42-year-old male patient is admitted with recurrent pancreatitis. He also has a history of parotitis. CT scan is carried out revealing no pancreatic mass, but evidence of widespread lymphadenopathy is seen. Dedicated liver imaging reveals a stricture in the common bile duct but no stones. What is the most likely diagnosis?
Your Answer:
Correct Answer: IgG4 disease
Explanation:IgG4-related disease (IgG4-RD) is a fibro-inflammatory condition that can affect nearly any organ system: the pancreas, biliary tree, salivary glands, periorbital tissues, kidneys, lungs, lymph nodes, meninges, aorta, breast, prostate, thyroid, pericardium, and skin. The histopathological features are similar across organs, regardless of the site. IgG4-RD is analogous to sarcoidosis, in which diverse organ manifestations are linked by similar histopathological characteristics. Raised concentrations of IgG4 in tissue and serum can be helpful in diagnosing IgG4 disease, but neither is a specific diagnostic marker.
Some IgG4-RDs are:
1. Autoimmune pancreatitis
2. Riedel’s Thyroiditis
3. Mediastinal and Retroperitoneal Fibrosis
4. Periaortitis/periarteritis/Inflammatory aortic aneurysm
5. Kuttner Tumour (submandibular glands)
6. IgG4-related Mikulicz disease (lacrimal, parotid, and submandibular glands) -
This question is part of the following fields:
- Haematology & Oncology
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Question 11
Incorrect
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A 70 yr. old male patient presented with chronic congestive heart failure. Which of the following is the most important factor to consider when prescribing drugs for this patient?
Your Answer:
Correct Answer: Administration of a B-blocker reduces the time spent in hospital
Explanation:It is proven that spironolactone has survival benefits and loop diuretics only give symptomatic relief. Beta blockers are however, known to improve exercise tolerance, left ventricular function and reduce symptoms. They also reduce the mortality associated with heart failure. So administration of beta blockers will reduce the time spent in hospital by improving symptoms.
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This question is part of the following fields:
- Cardiology
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Question 12
Incorrect
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A 24 year old female, 28 weeks pregnant presents to the clinic complaining of shortness of breath and right sided pleuritic chest pain. The doctor suspects pulmonary embolism. Which of the following statements is incorrect regarding the management of this case?
Your Answer:
Correct Answer: Ventilation-perfusion scanning exposes the foetus to less radiation than computed tomographic pulmonary angiography
Explanation:V/Q scanning carries a slightly increased risk of childhood cancer compared with CTPA – 1/280,000 versus less than 1/1,000,000 – but carries a lower risk of maternal breast cancer. The rest of the options are true.
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This question is part of the following fields:
- Respiratory
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Question 13
Incorrect
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A 55-year-old female, on warfarin for mitral valve replacement and atrial fibrillation (AF), is due for extensive abdominal surgery. What is the most appropriate step in regards to her anticoagulation therapy?
Your Answer:
Correct Answer:
Explanation:Patients with a VTE within the previous three months, patients with AF and previous stroke or TIA or multiple other risk factors, and patients with a mitral valve replacement should be considered for bridging therapy.
The most appropriate bridging therapy in this case would be low-molecular-weight heparin (LMWH), with the last dose given not less than 24 hours prior to the procedure. Warfarin should be discontinued 5 days prior to the procedure. If the INR is still above 3 on the day prior to the procedure, vitamin K should be administered.
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This question is part of the following fields:
- Haematology & Oncology
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Question 14
Incorrect
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Hepatitis C is what kind of virus?
Your Answer:
Correct Answer: A variable RNA virus
Explanation:Hepatitis C is a single-stranded positive sense RNA virus. It is variable because of the high rate of error of RNA-dependent RNA polymerase and the pressure from the host immune system has caused HCV to evolve and develop seven genetic lineages.
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This question is part of the following fields:
- Gastroenterology
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Question 15
Incorrect
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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:
Correct 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
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Question 16
Incorrect
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Which one of these features is typical of dermatomyositis?
Your Answer:
Correct Answer: Gottron's papules over knuckles of fingers
Explanation:The main symptom of dermatomyositis include skin rash and symmetric proximal muscle weakness (in over 90% of patients) which may be accompanied by pain and tenderness. It occurs more commonly in females. Skin findings include:
Gottron’s sign – an erythematous, scaly eruption occurring in symmetric fashion over the MCP and interphalangeal joints
Heliotrope or lilac rash – a violaceous eruption on the upper eyelids and in rare cases on the lower eyelids as well, often with itching and swelling
Shawl (or V-) sign is a diffuse, flat, erythematous lesion over the back and shoulders or in a V over the posterior neck and back or neck and upper chest, which worsens with UV light.
Erythroderma is a flat, erythematous lesion similar to the shawl sign but located in other areas, such as the malar region and the forehead.
Periungual telangiectasias and erythema occur. -
This question is part of the following fields:
- Dermatology
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Question 17
Incorrect
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Which one of the following statements regarding epidemiological measures is correct?
Your Answer:
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
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Question 18
Incorrect
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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:
Correct 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.
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This question is part of the following fields:
- Respiratory
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Question 19
Incorrect
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A 46-year-old man presents with a swollen, red, and painful left calf. He does not have a history of any recent surgery or a long-haul flight. He is generally fit and well and takes no regular medication other than propranolol for migraine prophylaxis. There is also no history of venous thromboembolism (VTE) in his family. The patient is referred to the deep vein thrombosis (DVT) clinic where he is diagnosed with a proximal DVT in his left calf. Following the diagnosis, he is started on low-molecular-weight heparin (LMWH) whilst awaiting review by the warfarin clinic. Other than commencing warfarin, what further action, if any, is required?
Your Answer:
Correct Answer: Investigate for underlying malignancy + check antiphospholipid antibodies
Explanation:CXR, blood, and urine tests should be carried out initially to exclude an underlying malignancy. If these are normal, a CT scan of abdomen and pelvis should be arranged as the patient’s age is >40 years. Antiphospholipid antibodies should also be checked for the first unprovoked DVT/PE. There is no history, however, to support an inherited thrombophilia.
The National Institute for Health and Care Excellence (NICE) published guidelines in 2012 for the investigation and management of DVT. If a patient is suspected of having DVT, a two-level DVT Wells score should be used:
DVT likely: 2 points or more
DVT unlikely: 1 point or lessThis system of points is based on the following clinical features:
1. Active cancer (treatment ongoing, within six months, or palliative)—1
2. Paralysis, paresis, or recent plaster immobilisation of the lower extremities—1
3. Recently bedridden for three days or more, or major surgery within 12 weeks requiring general or regional anaesthesia—1
4. Localised tenderness along the distribution of the deep venous system—1
5. Entire leg swollen—1
6. Calf swelling at least three cms larger than the asymptomatic side—1
7. Pitting oedema confined to the symptomatic leg—1
8. Collateral superficial veins (non-varicose)—1
9. Previously documented DVT—1
10. An alternative diagnosis is at least as likely as DVT—2If two points or more—DVT is ‘likely’
If one point or less—DVT is ‘unlikely’Management
1. LMWH or fondaparinux should be given initially after a DVT is diagnosed.
2. A vitamin K antagonist such as warfarin should be given within 24 hours of the diagnosis.
3. LMWH or fondaparinux should be continued for at least five days or until the international normalised ratio (INR) is 2.0 or above for at least 24 hours. LMWH or fondaparinux is given at the same time as warfarin until the INR is in the therapeutic range.
4. Warfarin should be continued for at least three months. At three months, clinicians should assess the risks and benefits of extending the treatment.
5. Consider extending warfarin beyond three months for patients with unprovoked proximal DVT if their risk of VTE recurrence is high and there is no additional risk of major bleeding. This essentially means that if there is no obvious cause or provoking factor (surgery, trauma, significant immobility, etc.), it may be implied that the patient has a tendency to thrombose and should be given treatment longer than the normal of three months. In practice, most clinicians give six months of warfarin for patients with an unprovoked DVT/PE.
6. For patients with active cancer, LMWH should be used for six months.As both malignancy and thrombophilia are obvious risk factors for DVT, therefore, all patients with unprovoked DVT/PE who are not already known to have cancer should undergo the following investigations:
1. Physical examination (guided by the patient’s full history)
2. Chest X-ray
3. Blood tests (full blood count, serum calcium, and liver function tests) and urinalysis
4. Testing for antiphospholipid antibodies
5. Testing for hereditary thrombophilia in patients who have had unprovoked DVT/PE and have a first-degree relative who has a history of DVT/PE. -
This question is part of the following fields:
- Haematology & Oncology
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Question 20
Incorrect
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A 48-year-old man is diagnosed with diffuse large B-cell lymphoma and is started on chemotherapy. Two days following his first treatment session, he presents to the A&E with nausea, vomiting, and myalgia. On examination, he appears clinically dehydrated. A diagnosis of tumour lysis syndrome (TLS) is suspected. Which of the following would be consistent with the diagnosis of TLS?
Your Answer:
Correct Answer: Low corrected calcium
Explanation:Out of the aforementioned markers, low corrected calcium is the only biochemistry result consistent with the diagnosis. All of the other markers are elevated in TLS.
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. As phosphate precipitates calcium, the serum concentration of calcium becomes low. 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. Rasburicase is a recombinant version of urate oxidase which is an enzyme that metabolizes uric acid to allantoin. 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
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