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  • Question 1 - A 68 year old male, previously diagnosed with osteoarthritis presents to your clinic...

    Correct

    • A 68 year old male, previously diagnosed with osteoarthritis presents to your clinic with acute on chronic pain in his big toe. Past history is significant for hypertension for which he takes Bendroflumethiazide 5mg daily. Examination reveals an erythematous, red hot metatarsophalangeal joint that has a knobbly appearance. X-ray shows punched out bony cysts. Which of the following would be the most appropriate long term management for this patient?

      Your Answer: Stop Bendroflumethiazide and substitute a calcium antagonist

      Explanation:

      The most likely diagnosis is chronic tophaceous gout, which is classically associated with chronic renal impairment or long term diuretic therapy. There is tophus formation due to urate crystal deposition in and around the joint. These tophi can also form in the bones and soft tissues. Renal manifestations with uric acid include nephrolithiasis and uric acid nephropathy. Whenever there is an acute on chronic attack of gout, the inciting cause must be established and in case of diuretic use, they should be immediately replaced with another medication. Allopurinol is never started during an acute episode. it is first allowed to settle before administration of allopurinol. Although dietary restriction must be observed in people with a propensity of gout, this scenario clearly presents diuretics as the cause.

    • This question is part of the following fields:

      • Rheumatology
      142.5
      Seconds
  • Question 2 - A 28 year old male arrives at the clinic complaining of fever, arthralgia...

    Incorrect

    • A 28 year old male arrives at the clinic complaining of fever, arthralgia and urethritis. On examination, the ankle is swollen and there is a pustular rash on the dorsal foot. What is the most likely diagnosis?

      Your Answer: Reactive arthritis

      Correct Answer: Disseminated gonorrhoea

      Explanation:

      DGI presents as two syndromes: 1) a bacteremic form that includes a triad of tenosynovitis, dermatitis, and polyarthralgias without purulent arthritis and 2) a septic arthritis form characterized as a purulent arthritis without associated skin lesions. Many patients will have overlapping features of both syndromes. Time from infection to clinical manifestations may range from 1 day to 3 months. There is no travel history and the rash of Lyme disease is not purulent. Reactive arthritis presents with conjunctivitis, urethritis and arthritis usually with a red hot tender and swollen joint.

    • This question is part of the following fields:

      • Rheumatology
      14.9
      Seconds
  • Question 3 - A 26-year-old office worker presents with a 3 year history of epigastric pain,...

    Incorrect

    • A 26-year-old office worker presents with a 3 year history of epigastric pain, especially 30 minutes after eating. This is associated with nausea and belching. She also describes constipation with occasional explosive diarrhoea. The stools are normally hard with mucus and she needs to strain with every motion. Abdominal pain is relieved after defecation but abdominal bloating persists. She wakes up an hour earlier each morning to finish her breakfast in order to prevent vomiting. She has missed work on a few occasions and feels that her weight has fluctuated. Past medical history includes scarlet fever. She is not on any regular medications except intermittent laxatives over the counter. Abdominal examination is normal. Rectal examination reveals an anal fissure. Investigation results: Haemoglobin (Hb 13.1 g/dL, White blood count (WBC) 6.0 × 109/L, Platelets 180× 109/L, Mean cell volume (MCV) 87 fL, International normalised ratio (INR) 1.0, Na+ 136 mmol/L, K+ 3.9 mmol/L, Urea 3.7 mmol/L, Creatinine 70 μmol/L, Albumin 39 glL. Liver function test normal. Anti-endomysial antibody negative. Thyroid function test normal. Gastroscopy normal. Flexible sigmoidoscopy and biopsy normal. Abdominal and pelvic ultrasound scans are normal. What is the most likely diagnosis to account for her symptoms?

      Your Answer: Diarrhoea pre-dominant irritable bowel syndrome

      Correct Answer: Overlap irritable bowel syndrome and functional dyspepsia

      Explanation:

      This is most likely describing irritable bowel syndrome (IBS). Symptoms are either diarrhoea, constipation, or both, abdominal pain, bloating, of varying duration. It is a functional, not an organic problem, as far as research shows at this point. It is essentially a diagnosis of exclusion. Treatment is a high fibre diet with fluids. Caffeine should be avoided as this can worsen symptoms.

    • This question is part of the following fields:

      • Gastroenterology
      44
      Seconds
  • Question 4 - Briefly state the mechanism of action of salbutamol. ...

    Correct

    • Briefly state the mechanism of action of salbutamol.

      Your Answer: Beta2 receptor agonist which increases cAMP levels and leads to muscle relaxation and bronchodilation

      Explanation:

      Salbutamol stimulates beta-2 adrenergic receptors, which are the predominant receptors in bronchial smooth muscle (beta-2 receptors are also present in the heart in a concentration between 10% and 50%).

      Stimulation of beta-2 receptors leads to the activation of enzyme adenyl cyclase that forms cyclic AMP (adenosine-mono-phosphate) from ATP (adenosine-tri-phosphate). This increase of cyclic AMP relaxes bronchial smooth muscle and decrease airway resistance by lowering intracellular ionic calcium concentrations. Salbutamol relaxes the smooth muscles of airways, from trachea to terminal bronchioles.

      Increased cyclic AMP concentrations also inhibits the release of bronchoconstrictor mediators such as histamine and leukotriene from the mast cells in the airway.

    • This question is part of the following fields:

      • Respiratory
      14
      Seconds
  • Question 5 - Which of the given adverse effects should be anticipated following the administration of...

    Correct

    • Which of the given adverse effects should be anticipated following the administration of an anticholinesterase?

      Your Answer: Bradycardia and miosis

      Explanation:

      Bradycardia and miosis should be anticipated following the administration of anticholinesterases.

      Anticholinesterase agents include the following medications:
      – Pyridostigmine, neostigmine, and edrophonium which play a significant role in the diagnosis and the management of myasthenia gravis.
      – Rivastigmine, galantamine and donepezil are cholinesterase inhibitors found to be significantly useful in the management of Alzheimer’s disease.

      Mechanism of action and pharmacological effects:
      Inhibition of cholinesterase increases the level and the duration of action of acetylcholine within the synaptic cleft.

      Thus, cholinergic effects such as a reduction in heart rate (bradycardia), miosis (pupillary constriction), increased secretions, increased gastrointestinal motility and reduction in BP may occur with anticholinesterases.

      Toxins such as organophosphates and carbamates also are primarily anticholinergic and cause the following typical SLUDGE symptoms:
      – Salivation
      – Lacrimation
      – Urination
      – Diaphoresis
      – Gastrointestinal upset
      – Emesis

    • This question is part of the following fields:

      • Pharmacology
      85.4
      Seconds
  • Question 6 - A 20-year-old talented violinist is brought by her parents as they are concerned...

    Correct

    • A 20-year-old talented violinist is brought by her parents as they are concerned that she had a stroke as she is reporting weakness on her right side. Neurological examination is inconsistent with the provided history, suspecting a non-organic cause for her symptoms her GP provides reassurance. Despite it, the girl remains unable to move her right arm. What is the most probable diagnosis of this patient?

      Your Answer: Conversion disorder

      Explanation:

      The most probable diagnosis in this patient is conversion disorder.

      There may be underlying tension regarding her musical career which could be manifesting as apparent limb weakness.

      Conversion disorder typically involves loss of motor or sensory function. The patient doesn’t consciously feign the symptoms (factitious disorder) or seek material gain (malingering). Patients may be indifferent to their apparent disorder – la belle indifference – although this has not been backed up by studies.

      Other options:
      Unexplained symptoms
      There are a wide variety of psychiatric terms for patients who have symptoms for which no organic cause can be found:

      Somatization disorder
      Multiple physical symptoms present for at least 2 years
      the patient refuses to accept reassurance or negative test results

      Hypochondriacal disorder
      The persistent belief in the presence of an underlying serious disease, e.g. cancer.
      The patient again refuses to accept reassurance or negative test results

      Dissociative disorder
      Dissociation is a process of ‘separating off’ certain memories from normal consciousness
      Unlike conversion disorder, it involves psychiatric symptoms e.g. amnesia, fugue, stupor
      Dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder

      Munchausen’s syndrome
      Also known as factitious disorder
      The intentional production of physical or psychological symptoms

      Malingering
      Fraudulent simulation or exaggeration of symptoms with the intention of financial or another gain.

    • This question is part of the following fields:

      • Psychiatry
      25.3
      Seconds
  • Question 7 - A 14-year-old girl presents with primary amenorrhoea. She is an athlete who is...

    Correct

    • A 14-year-old girl presents with primary amenorrhoea. She is an athlete who is currently training for a national athletics championship. What is the best treatment option for her?

      Your Answer: Adequate diet and observation

      Explanation:

      Intensive physical training and participation in competitive sports during childhood and early adolescence may affect athletes’ pubertal development.
      Female athletes who do not begin secondary sexual development by the age of 14 or menstruation by the age of 16 warrant a comprehensive evaluation and treatment.
      Since she is still 14, adequate diet and observation are enough.

    • This question is part of the following fields:

      • Endocrinology
      5.5
      Seconds
  • Question 8 - A 70-year-old female presented to her ophthalmologist with a complaint of weakening eyesight...

    Incorrect

    • A 70-year-old female presented to her ophthalmologist with a complaint of weakening eyesight despite continued use of her corrective glasses. She also had a history of mild headaches for a few weeks. On fundoscopy, the disc had blurred margins with mild cupping and a sickle shaped scotoma in both eyes. What is the most appropriate treatment in this case?

      Your Answer: Corticosteroids

      Correct Answer: Pilocarpine eye drops

      Explanation:

      Frequent change of eye glasses, scotoma, and mild cupping are suggestive of primary open angle glaucoma. This means that the anterior angle of the eye is normal but there is a problem in the trabecular meshwork, where the Schlemm’s Canal is not allowing the drainage of the aqueous humor. Pilocarpine should be given to the patient because it is a parasympathomimetic agent. It causes the ciliary muscle of the eye to contract, causing the trabecular meshwork to open up, allowing the aqueous humor to drain again.

    • This question is part of the following fields:

      • Ophthalmology
      21.8
      Seconds
  • Question 9 - A 35-year-old woman is referred to the oncology clinic by a general surgeon....

    Correct

    • A 35-year-old woman is referred to the oncology clinic by a general surgeon. She has undergone mastectomy for carcinoma of the right breast. Out of the following, which factor is associated with a poor prognosis in patients with breast cancer?

      Your Answer: Young age

      Explanation:

      Poor prognostic factors for breast cancer include:
      1. Young age (<40 years)
      2. Premenopausal at the time of diagnosis
      3. Increased tumour size
      4. High-grade tumour
      5. Oestrogen and progesterone receptor-negative tumour
      6. Positive lymph node status

    • This question is part of the following fields:

      • Haematology & Oncology
      16.5
      Seconds
  • Question 10 - 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
      13.4
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Rheumatology (1/2) 50%
Gastroenterology (0/1) 0%
Respiratory (1/1) 100%
Pharmacology (1/1) 100%
Psychiatry (1/1) 100%
Endocrinology (1/1) 100%
Ophthalmology (0/1) 0%
Haematology & Oncology (2/2) 100%
Passmed