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  • Question 1 - The spinal cord in a neonate terminates at the lower border of: ...

    Correct

    • The spinal cord in a neonate terminates at the lower border of:

      Your Answer: L3

      Explanation:

      The spinal cord and the vertebral canal are as long as each other in early fetal life. The length of the cord increases faster than the growth of the vertebrae during development. By the time of birth, the spinal cord is at the level of the lower border of the 3rd lumbar vertebra, compared to its original position at the level of the 2nd coccygeal vertebra.

    • This question is part of the following fields:

      • Anatomy
      3.5
      Seconds
  • Question 2 - All of the following statements about that parasympathetic nervous system (PNS) are true...

    Incorrect

    • All of the following statements about that parasympathetic nervous system (PNS) are true except:

      Your Answer: Facial nerve supplies the submandibular, sublingual and lacrimal glands via the pterygopalatine and submandibular ganglions

      Correct Answer: The PNS has nicotinic receptors throughout the system

      Explanation:

      With regards to the autonomic nervous system (ANS)

      1. It is not under voluntary control
      2. It uses reflex pathways and different to the somatic nervous system.
      3. The hypothalamus is the central point of integration of the ANS. However, the gut can coordinate some secretions and information from the baroreceptors which are processed in the medulla.

      With regards to the central nervous system (CNS)
      1. There are myelinated preganglionic fibres which lead to the
      ganglion where the nerve cell bodies of the non-myelinated post ganglionic nerves are organised.
      2. From the ganglion, the post ganglionic nerves then lead on to the innervated organ.

      Most organs are under control of both systems although one system normally predominates.

      The nerves of the sympathetic nervous system (SNS) originate from the lateral horns of the spinal cord, pass into the anterior primary rami and then pass via the white rami communicates into the ganglia from T1-L2.

      There are short pre-ganglionic and long post ganglionic fibres.
      Pre-ganglionic synapses use acetylcholine (ACh) as a neurotransmitter on nicotinic receptors.
      Post ganglionic synapses uses adrenoceptors with norepinephrine / epinephrine as the neurotransmitter.
      However, in sweat glands, piloerector muscles and few blood vessels, ACh is still used as a neurotransmitter with nicotinic receptors.

      The ganglia form the sympathetic trunk – this is a collection of nerves that begin at the base of the skull and travel 2-3 cm lateral to the vertebrae, extending to the coccyx.

      There are cervical, thoracic, lumbar and sacral ganglia and visceral sympathetic innervation is by cardiac, coeliac and hypogastric plexi.

      Juxta glomerular apparatus, piloerector muscles and adipose tissue are all organs under sole sympathetic control.

      The PNS has a craniosacral outflow. It causes reduced arousal and cardiovascular stimulation and increases visceral activity.

      The cranial outflow consists of
      1. The oculomotor nerve (CN III) to the eye via the ciliary ganglion,
      2. Facial nerve (CN VII) to the submandibular, sublingual and lacrimal glands via the pterygopalatine and submandibular ganglions
      3. Glossopharyngeal (CN IX) to lungs, larynx and tracheobronchial tree via otic ganglion
      4. The vagus nerve (CN X), the largest contributor and carries ¾ of fibres covering innervation of the heart, lungs, larynx, tracheobronchial tree parotid gland and proximal gut to the splenic flexure, liver and pancreas

      The sacral outflow (S2 to S4) innervates the bladder, distal gut and genitalia.

      The PNS has long preganglionic and short post ganglionic fibres.
      Preganglionic synapses, like in the SNS, use ACh as the neuro transmitter with nicotinic receptors.
      Post ganglionic synapses also use ACh as the neurotransmitter but have muscarinic receptors.

      Different types of these muscarinic receptors are present in different organs:
      There are:
      M1 = pupillary constriction, gastric acid secretion stimulation
      M2 = inhibition of cardiac stimulation
      M3 = visceral vasodilation, coronary artery constriction, increased secretions in salivary, lacrimal glands and pancreas
      M4 = brain and adrenal medulla
      M5 = brain

      The lacrimal glands are solely under parasympathetic control.

    • This question is part of the following fields:

      • Physiology And Biochemistry
      19.6
      Seconds
  • Question 3 - A patient in the post-anaesthesia care unit was put on ephedrine for episodes...

    Correct

    • A patient in the post-anaesthesia care unit was put on ephedrine for episodes of hypotension. Initial bolus doses were effective and the patient became normotensive, until, a few hours later, there was a noticeable drop in the blood pressure despite administration of another dose of ephedrine. Which of the following best explains the situation above?

      Your Answer: Tachyphylaxis

      Explanation:

      When responsiveness diminishes rapidly after administration of a drug, the response is said to be subject to tachyphylaxis. This may be due to frequent or continuous exposure to agonists, which often results in short-term diminution of the receptor response.

      Many mechanisms may be responsible, such as blocking access of G protein to activated receptor, or receptor molecules internalized by endocytosis to prevent exposure to extracellular molecules.

      Tolerance occurs when larger doses are required to produce the same effect. This may be due to changes in receptor number or function due to exposure to the drug.

      Desensitization refers to the common situation where the biological response to a drug diminishes when it is given continuously or repeatedly. It is a chronic loss of response, occurring over a longer period than tachyphylaxis. It may be possible to restore the response by increasing the dose (or concentration) of the drug but, in some cases, the tissues may become completely refractory to its effect.

      Drug dependence is defined as a psychic and physical state of the person characterized by behavioural and other responses resulting in compulsions to take a drug, on a continuous or periodic basis in order to experience its psychic effect and at times to avoid the discomfort of its absence.

    • This question is part of the following fields:

      • Pharmacology
      27.1
      Seconds
  • Question 4 - A 45-year-old man is being operated on for emergency laparotomy as he presented...

    Correct

    • A 45-year-old man is being operated on for emergency laparotomy as he presented with bowel perforation. During the surgery, the marginal artery of Drummond is encountered and preserved. Which of the following two arteries fuse to form the marginal artery of Drummond?

      Your Answer: Superior mesenteric artery and inferior mesenteric artery

      Explanation:

      The arteries of the midgut (superior mesenteric artery) and hindgut (inferior mesenteric artery) give off terminal branches that form an anastomotic vessel called the marginal artery of Drummond. It runs in the inner margins of the colon and gives off short terminal branches to the bowel wall.

      The marginal artery is formed by the main branches and arcades arising from the ileocolic, right colic, middle colic, and left colic arteries. It is most apparent in the ascending, transverse, and descending colons and poorly developed in the sigmoid colon.

    • This question is part of the following fields:

      • Anatomy
      24.9
      Seconds
  • Question 5 - The population incidence of a disease is best described by? ...

    Incorrect

    • The population incidence of a disease is best described by?

      Your Answer:

      Correct Answer: The number of new cases of a disease per population in a defined period

      Explanation:

      The incidence of a disease is the number of new cases of the disease in a population over a defined time period.

      The prevalence of a disease is the number of cases of the disease in a population over a defined time period describes. It is NOT the number of new cases.

      The number of new cases of a disease only, has no denominator (time period or population) from which to derive an incidence.

      The number of new cases of a disease seeking medical treatment is the incidence of patients seeking medical treatment NOT the incidence of the disease in a population.

      The death rate from a disease is the number of patients dying from the disease in a population.

    • This question is part of the following fields:

      • Statistical Methods
      0
      Seconds
  • Question 6 - About low molecular weight (LMW) heparin, Which of these is true? ...

    Incorrect

    • About low molecular weight (LMW) heparin, Which of these is true?

      Your Answer:

      Correct Answer: Is excreted in the urine

      Explanation:

      Low molecular weight heparin (LMWH) creates a complex by binding to antithrombin. This complex binds with and inactivates factor Xa.

      There is less risk of bleeding with LMWH because it binds less to platelets, endothelium and von Willebrand factor.

      LMW binds Xa more readily. The shorter chains are less likely to bind both antithrombin and thrombin.

      There is need for monitoring in renal impairment because LMHW is excreted in the urine (and partly by hepatic metabolism)

      LMWH have been shown to be as efficacious as unfractionated heparin. It is also safer and have improved inpatient stay and reduced hospital cost.

    • This question is part of the following fields:

      • Pharmacology
      0
      Seconds
  • Question 7 - What can an outbreak of flu that has spread globally be termed as?...

    Incorrect

    • What can an outbreak of flu that has spread globally be termed as?

      Your Answer:

      Correct Answer: Pandemic

      Explanation:

      An epidemic is declared when the increase in a give disease is above a certain level in a specific interval of time.

      An endemic is the general, usual level of a disease in a population at a particular time.

      A pandemic is an epidemic that is spread across many countries and continents.

    • This question is part of the following fields:

      • Statistical Methods
      0
      Seconds
  • Question 8 - A 72-year-old female is diagnosed with acute mesenteric ischemia. On CT angiogram, the...

    Incorrect

    • A 72-year-old female is diagnosed with acute mesenteric ischemia. On CT angiogram, the origin of the superior mesenteric artery is stenosed. At which vertebra level does the superior mesenteric artery branch from the aorta?

      Your Answer:

      Correct Answer: L1

      Explanation:

      The superior mesenteric artery branches from the abdominal aorta just 1-2 cm below the origin of the celiac trunk. It lies posterior to the body of the pancreas and splenic vein and is separated from the aorta by the left renal vein. It passes forwards and inferiorly, anterior to the uncinate process of the pancreas and the third part of the duodenum, to enter the root of the small bowel mesentery and supply the midgut.

      The important landmarks of vessels arising from the abdominal aorta at different levels of vertebrae are:

      T10 – oesophageal opening in the diaphragm

      T12 – Coeliac trunk, aortic hiatus in the diaphragm

      L1 – Left renal artery

      L2 – Testicular or ovarian arteries

      L3 – Inferior mesenteric artery

      L4 – Bifurcation of the abdominal aorta.

    • This question is part of the following fields:

      • Anatomy
      0
      Seconds
  • Question 9 - A project is being planned to assess the effects of a new anticoagulant...

    Incorrect

    • A project is being planned to assess the effects of a new anticoagulant on the coagulation cascade. The intrinsic pathway is being studied and the best measurement to be recorded is which of the following?

      Your Answer:

      Correct Answer: aPTT

      Explanation:

      The intrinsic pathway is best assessed by the aPTT time.

      D-dimer is a fibrin degradation product which is raised in the presence of blood clots.

      A 50:50 mixing study is used to assess if a prolonged PT or aPTT is due to factor deficiency or a factor inhibitor.

      The thrombin time is a test used to assess fibrin formation from fibrinogen in plasma. Factors that prolong the thrombin time include heparin, fibrin degradation products, and fibrinogen deficiency.

      Intrinsic pathway – Best assessed by APTT. Factors 8,9,11,12 are involved. Prolonged aPTT can be seen in haemophilia and use of heparin.

      Extrinsic pathway – Best assessed by Increased PT. Factor 7 involved.

      Common pathway – Best assessed by APTT & PT. Factors 2,5,10 involved.

      Vitamin K dependent factors are factors 2,7,9,10

    • This question is part of the following fields:

      • Physiology And Biochemistry
      0
      Seconds
  • Question 10 - A breakthrough lipid-lowering therapy for stroke had a number needed to treat (NNT)...

    Incorrect

    • A breakthrough lipid-lowering therapy for stroke had a number needed to treat (NNT) of 20 for the prevention of the primary end-point. These results can be best described as:

      Your Answer:

      Correct Answer: For 1000 patients treated with active therapy, there would be 50 fewer strokes

      Explanation:

      Number needed to treat (NNT) is a time specific epidemiological measure that indicates how many patients would be require for an intervention to prevent one additional bad outcome. A perfect NNT would be 1, where everyone improves with treatment, thus the higher the NNT, the less effective the treatment.

      Thus if you treat 1000 patients then you will expect to have 50 fewer strokes.

    • This question is part of the following fields:

      • Statistical Methods
      0
      Seconds
  • Question 11 - A 79-year-old female complains of painful legs, especially in her thigh region. The...

    Incorrect

    • A 79-year-old female complains of painful legs, especially in her thigh region. The pain starts after walking and settles with rest. She occasionally has to take paracetamol to relieve the pain. She is a known case of hyperlipidaemia, type 2 diabetes mellitus, hypertension, and depression. Her physician makes a provisional diagnosis of claudication of the femoral artery, which is a continuation of the external iliac artery. Which of the following anatomical landmarks does the external iliac artery cross to become the femoral artery?

      Your Answer:

      Correct Answer: Inguinal ligament

      Explanation:

      The external iliac artery is the larger of the two branches of the common iliac artery. It forms the main blood supply to the lower limbs. The common iliac bifurcates into the internal and external iliac artery anterior to the sacroiliac joint.

      The external iliac artery courses on the medial border of the psoas major muscles and exits the pelvic girdle posterior to the inguinal ligament. Here, midway between the anterior superior iliac spine and the pubic symphysis, the external iliac artery becomes the femoral artery and descends along the anteromedial part of the thigh in the femoral triangle.

      The pectineus forms the posterior border of the femoral canal.
      The femoral vein forms the lateral border of the femoral canal.
      The medial border of the adductor longus muscle forms the medial wall of the femoral triangle.
      The medial border of the sartorius muscle forms the lateral wall of the femoral triangle.

    • This question is part of the following fields:

      • Anatomy
      0
      Seconds
  • Question 12 - General anaesthesia is administered to a patient in a hospital in Lhasa which...

    Incorrect

    • General anaesthesia is administered to a patient in a hospital in Lhasa which is one of the highest cities in the world (at 11,975 feet). An Anaesthetic rotameter is normally calibrated at 20 C and 1 bar pressure and is known to be underread at altitude. The temperature of the theatre was 10 C. Which one of the following physical properties is responsible for the rotameter inaccuracy in these conditions?

      Your Answer:

      Correct Answer: Density of the gas

      Explanation:

      Since the gas is less dense at higher altitudes, the density of a gas influences flows when passing through the orifice. Due to this reason, for a given flow rate, the bobbin will not be forced as far up the rotameter tube.

      At higher altitudes, the volume of a fixed mass of gas increases, and therefore the molecules of gas are widely spaced resulting in a decrease in density with an increase in altitude.

      Viscosity is simply termed as friction of gas. The viscosity of a gas is important only at low flow rates when the flow characteristic of the gas is laminar.

      Charle’s law stated that the volume occupied by a fixed amount of gas is directly proportional to its absolute temperature (T) provided the pressure remains constant.

      Boyle’s law for a fixed amount of gas at constant temperature, the pressure (P) and volume (V) are inversely proportional.

    • This question is part of the following fields:

      • Basic Physics
      0
      Seconds
  • Question 13 - A sevoflurane vaporiser with a 2 percent setting and a 200 kPa ambient...

    Incorrect

    • A sevoflurane vaporiser with a 2 percent setting and a 200 kPa ambient pressure is used. At this pressure, which of the following options best represents vaporiser output?

      Your Answer:

      Correct Answer: The output is 1% because the saturated pressure of sevoflurane is unaffected by ambient pressure

      Explanation:

      Ambient pressure has no effect on a volatile agent’s saturated vapour pressure (SVP). At a temperature of 20°C, the SVP of sevoflurane is approximately 21 kPa, or 21% of atmospheric pressure (100 kPa).

      The SVP of sevoflurane remains the same when the ambient pressure is doubled to 200 kPa, but the output of the vaporiser is halved, now 21 percent of 200 kPa, equalling 10.5 percent. The vaporiser’s output has increased to 1%, but the partial pressure output has remained unchanged. The splitting ratio will not change because it is determined by temperature changes.

      Calculations can be made as follows:

      Vaporizer output % (ambient pressure) = % volatile (calibrated) x 100 kPa calibrated pressure/ambient pressure
      2% = 2% (dialled) × 100/100
      2% of 100 = 2 kPa

      Altitude, pressure 50 kPa
      4% = 2% (dialled) × 100/50
      4% of 50 = 2 kPa

      High pressure at 200 kPa
      1% = 2% (dialled) × 100/200
      1% of 200 = 2 kPa

      Sevoflurane has a boiling point of 58°C and, unlike desflurane (which has a boiling point of 22.8°C), does not need to be heated and pressurised with a Tec 6 vaporiser.

    • This question is part of the following fields:

      • Anaesthesia Related Apparatus
      0
      Seconds
  • Question 14 - The typical fluid compartments in a normal 70kg male are: ...

    Incorrect

    • The typical fluid compartments in a normal 70kg male are:

      Your Answer:

      Correct Answer: intracellular>extracellular

      Explanation:

      Body fluid compartments in a 70kg male:
      Total volume=42L (60% body weight)
      Intracellular fluid compartment (ICF) =28L
      Extracellular fluid compartment (ECF) = 14L

      ECF comprises:
      Intravascular fluid (plasma) = 3L
      Extravascular fluid = 11L

      Extravascular fluids comprises:
      Interstitial fluid = 10.5L
      Transcellular fluid = 0.5L

    • This question is part of the following fields:

      • Physiology
      0
      Seconds
  • Question 15 - Which of the following statement is correct regarding the difference between dabigatran and...

    Incorrect

    • Which of the following statement is correct regarding the difference between dabigatran and other anticoagulants?

      Your Answer:

      Correct Answer: Competitive thrombin inhibitor blocking both free and bound thrombin

      Explanation:

      Dabigatran template is a prodrug and its active metabolite is a direct thrombin inhibitor. It is a synthetic, reversible, non-peptide thrombin inhibitor. This inhibition of thrombin results in a decrease of fibrin and reduces platelet aggregation.

      Drugs like warfarin act by inhibiting the activation of vitamin K-dependent clotting factors. These factors are synthesized by the liver and activated by gamma-carboxylation of glutamate residues with the help of vitamin K. Hydroquinone form of vitamin K is converted to epoxide form in this reaction and regeneration of hydroquinone form by enzyme vitamin K epoxide reductase (VKOR) is required for this activity. Oral anticoagulants prevent this regeneration by inhibiting VKOR, thus vitamin K-dependent factors are not activated. These factors include clotting factors II, VII, IX, and X as well as anti-clotting proteins, protein C and protein S.

    • This question is part of the following fields:

      • Pharmacology
      0
      Seconds
  • Question 16 - Prophylactic antibiotics are required for which of the following procedures? ...

    Incorrect

    • Prophylactic antibiotics are required for which of the following procedures?

      Your Answer:

      Correct Answer: Appendicectomy

      Explanation:

      Staphylococcus aureus infection is the most likely cause.

      Surgical site infections (SSI) occur when there is a breach in tissue surfaces and allow normal commensals and other pathogens to initiate infection. They are a major cause of morbidity and mortality.

      SSI comprise up to 20% of healthcare associated infections and approximately 5% of patients undergoing surgery will develop an SSI as a result.
      The organisms are usually derived from the patient’s own body.

      Measures that may increase the risk of SSI include:
      -Shaving the wound using a single use electrical razor with a disposable head
      -Using a non iodine impregnated surgical drape if one is needed
      -Tissue hypoxia
      -Delayed prophylactic antibiotics administration in tourniquet surgery, patients with a prosthesis or valve, in clean-contaminated surgery of in contaminated surgery.

      Measures that may decrease the risk of SSI include:
      1. Intraoperatively
      – Prepare the skin with alcoholic chlorhexidine (Lowest incidence of SSI)
      -Cover surgical site with dressing

      In contrast to previous individual RCT’s, a recent meta analysis has confirmed that administration of supplementary oxygen does not reduce the risk of wound infection and wound edge protectors do not appear to confer benefit.

      2. Post operatively
      Tissue viability advice for management of surgical wounds healing by secondary intention

      Use of diathermy for skin incisions
      In the NICE guidelines the use of diathermy for skin incisions is not advocated. Several randomised controlled trials have been undertaken and demonstrated no increase in risk of SSI when diathermy is used.

    • This question is part of the following fields:

      • Physiology And Biochemistry
      0
      Seconds
  • Question 17 - Obeying Boyle's law and Charles's law is a characteristic feature of an ideal...

    Incorrect

    • Obeying Boyle's law and Charles's law is a characteristic feature of an ideal gas. The gas which is most ideal out of the following options is?

      Your Answer:

      Correct Answer: Helium

      Explanation:

      The ideal gas equation makes the following assumptions:

      The gas particles have a small volume in comparison to the volume occupied by the gas.
      Between the gas particles, there are no forces of interaction.
      Individual gas particle collisions, as well as gas particle collisions with container walls, are elastic, meaning momentum is conserved.
      PV = nRT
      Where:

      P = pressure
      V = volume
      n = moles of gas
      T = temperature
      R = universal gas constant

      Helium is a monoatomic gas with a small helium atom. The attractive forces between helium atoms are small because the helium atom is spherical and has no dipole moment. Because helium atoms are spherical, collisions between them approach the ideal state of elasticity.

      Most real gases behave qualitatively like ideal gases at standard temperatures and pressures. When intermolecular forces and molecular size become important, the ideal gas model tends to fail at lower temperatures or higher pressures. It also fails to work with the majority of heavy gases.

      Helium, argon, neon, and xenon are noble or inert gases that behave the most like an ideal gas. Xenon is a noble gas with a much larger atomic size than helium.

    • This question is part of the following fields:

      • Pharmacology
      0
      Seconds
  • Question 18 - What statement about endotoxins is true? ...

    Incorrect

    • What statement about endotoxins is true?

      Your Answer:

      Correct Answer: Can often survive autoclaving

      Explanation:

      Endotoxins are the lipopolysaccharides found in the outer cell wall of Gram-negative bacteria. They are responsible for providing the structure and stability of the cell wall.

      They cannot be destroyed by normal sterilisation as they are heat stable molecules. They require the use of certain sterilant such as superoxide, peroxide and hypochlorite to be neutralised.

      They stimulate strong immune responses, but can only be destroyed partially by specific antibodies. Repeat infections occur as memory T cells cannot be formed.

      It can cause septicaemia and associated symptoms such as fever, shock, hypotension and nausea.

      It activates the alternative complement pathway and the coagulation pathway using secreted cytokines.

      It is not involved in botulism as clostridium botulinum, the responsible organism, secretes a neurotoxic exotoxin.

    • This question is part of the following fields:

      • Pathophysiology
      0
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  • Question 19 - You've been summoned to help resuscitate a 6-year-old child who has suffered a...

    Incorrect

    • You've been summoned to help resuscitate a 6-year-old child who has suffered a cardiac arrest. The ECG monitor shows electrical activity that isn't pulsed. Which of the following statements is the most appropriate during resuscitation?

      Your Answer:

      Correct Answer: The dose of intravenous adrenaline is 180 mcg

      Explanation:

      To begin, one must determine the child’s approximate weight. There are a variety of formulas to choose from. It is acceptable to use the advanced paediatric life support formula:

      (Age + 4) 2 = Weight

      A 5-year-old child will weigh around 18 kilogrammes.

      10 mcg/kg (0.1 ml/kg of 1 in 10 000 adrenaline) = 180 mcg is the appropriate dose of intravenous or intraosseous adrenaline.

      The correct energy level to deliver is 4 J/kg, which equals 72 joules.

      The pad size that is appropriate for this patient is 8-12 cm. For an infant, a 4.5 cm pad is appropriate.

      To allow adequate separation in infants and small children, the pads should be placed anteriorly and posteriorly on the chest.

      When using a bag and mask to ventilate, take two breaths for every 15 chest compressions. If chest compressions are being applied intubated and without interruption, a ventilation rate of 10-20 breaths per minute should be given.

      Chest compressions should be done at a rate of 100-120 per minute, the same as an adult.

    • This question is part of the following fields:

      • Pharmacology
      0
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  • Question 20 - The following are results of some pulmonary function tests: (Measurement - Predicted result...

    Incorrect

    • The following are results of some pulmonary function tests: (Measurement - Predicted result - Test result). Forced vital capacity (FVC) (btps): 3.21, - 1.94. Forced expiratory volume in 1 second (FEV1) (btps): 2.77, 1.82. FEV1/FVC ratio % (btps): 81.9, 93.5. Peak expiratory flow (PEF) (L/second): 6.55, 3.62. Maximum voluntary ventilation (MVV) (L/minute): 103, 87.1 Which statement applies to the results?

      Your Answer:

      Correct Answer: The patient has a moderate restrictive pulmonary defect

      Explanation:

      Severity of a reduction in restrictive defect (%FVC) or obstructive defect (V1/FVC) predicted are classified as follows:

      Mild 70-80%
      Moderate 60-69%
      Moderately severe 50-59%
      Severe 35-49%
      Very severe <35%

      This patient has a %FVC predicted of 60.4% and this corresponds to a moderate restrictive deficit. V1/FVC ratio is 93.5%.

      FEV1/FVC ratio 80% < predicted and VC < 80% = mixed picture.

      FEV1/FVC ratio 80% < predicted and VC > 80% = obstructive picture.

      FEV1/FVC ratio 80% > predicted and VC > 80% = normal picture.

      FEV1/FVC ratio 80% > predicted and VC < 80% predicted= restrictive picture.

      The integrity of the alveolar-capillary barrier is measured by carbon monoxide transfer factor (TLCO) and carbon monoxide transfer coefficient (KCO). These values are seen to be reduced in emphysema, interstitial lung diseases and in pulmonary vascular pathology. However, the KCO (as % predicted) is high in extrapulmonary restriction (pleural, chest wall and respiratory neuromuscular disease), and in loss of lung units provided the structure of the lung remaining is normal. The KCO distinguishes extrapulmonary (high KCO) causes of 'restriction' from intrapulmonary causes (low KCO).

    • This question is part of the following fields:

      • Clinical Measurement
      0
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  • Question 21 - All of the following statements are true regarding calcium except: ...

    Incorrect

    • All of the following statements are true regarding calcium except:

      Your Answer:

      Correct Answer: Serum calcium accounts for 10% of total body calcium stores

      Explanation:

      Calcium is a very important ion and is involved in:
      -cell homeostasis
      -coagulation
      -muscle contraction
      -neuronal impulse transmission/membrane stabilization
      -bone formation and skeletal strength
      -secretion processes

      99% is found in bone and 1% in the plasma. Of the 1% that is in the plasma
      -45% is free ionized calcium
      -45% is bound to proteins, mainly Albumin
      -10% is present as an anion complex

      Reduced levels of IONIZED calcium give rise to features of hypocalcaemia , resulting in increased excitability of membranes. This results when the total calcium concentration goes below 2 mmol/L.

      Features of mild to moderate hypocalcaemia are:
      -paraesthesia (peri-oral, fingers)
      -tetany
      -spasm
      -muscle cramps
      -ECG changes (prolonged QT)
      -Trousseau’s sign (inflation of tourniquet induces carpopedal spasm)
      -Chvostek’s sign (tapping the facial nerve – cranial nerve VII – causes facial muscle twitch/spasm)

      Features of severe hypocalcaemia are:
      -cardiogenic shock and congestive cardiac failure due to reduced myocardial contractility
      respiratory distress due to bronchospasm, agitation, confusion, seizures

      Features of hypercalcaemia (remember ‘bones, stones, groans and psychic moans’):
      -Abdominal pain
      -Vomiting
      -Constipation
      -Polyuria
      -Polydipsia
      -Depression
      -Lethargy
      -Anorexia
      -Weight loss
      -Hypertension
      -Confusion
      -Pyrexia
      -Calcification in the cornea
      -Renal stones
      -Renal failure
      -Decreased Q-T interval
      -Cardiac shock/collapse

    • This question is part of the following fields:

      • Physiology And Biochemistry
      0
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  • Question 22 - A new proton pump inhibitor (PPI) is being evaluated in elderly patients who...

    Incorrect

    • A new proton pump inhibitor (PPI) is being evaluated in elderly patients who are taking aspiring. Study designed has 120 patients receiving the PPI, while a control group of 240 individuals is given the standard PPI. Over a span of 6 years, 24 of the group receiving the new PPI had an upper GI bleed compared to 60 individuals who received the standard PPI. How would you calculate the absolute risk reduction?

      Your Answer:

      Correct Answer: 5%

      Explanation:

      Absolute risk reduction = (Control event rate) – (Experimental event rate)

      Experimental event rate = 24 / 120 = 0.2

      Control event rate = 60 / 240 = 0.25

      Absolute risk reduction = 0.25 – 0.2 = 0.05 = 5% reduction

    • This question is part of the following fields:

      • Statistical Methods
      0
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  • Question 23 - A 24-year old female is brought to the emergency room due to urticarial...

    Incorrect

    • A 24-year old female is brought to the emergency room due to urticarial rash and shortness of breath. Her mother reported that, prior to the symptoms, she took Co-amoxiclav (Augmentin) for her present ear infection. She also reported that she had no previous exposure to penicillin or any other related antibiotics. Which of the following can help to differentiate between type 1 and type II hypersensitivity reaction in this case?

      Your Answer:

      Correct Answer: IgE assay specific for amoxycilloyl

      Explanation:

      Serum specific IgE assays against allergen sources/molecules are the most commonly used in vitro diagnostic approach. The measurement of specific IgE recognizing allergenic epitopes can be achieved both through the usage of single reagents (singleplex) or with a pre-defined panel of a number of molecules to be tested simultaneously (multiplex).

      Several clinical entities have been described and those occurring immediately after drug exposure are immunoglobulin E (IgE)-mediated and explored by skin testing and by the in vitro measurement of serum-specific IgE. The sensitivity of these tests is not 100% and even for patients with a clear positive history, a drug provocation test may be required in order to confirm the diagnosis. The advantages of the in vitro determination of specific IgE antibodies when compared with in vivo testing are that the former poses no direct risk to the patient and does not require personnel with expertise. Even though in vitro tests are recommended in immediate hypersensitivity reactions, their exact place in the diagnostic procedure is not clear and certain authors do not use this method in daily practice. In one study, in terms of sensitivity, 11 of 26 patients (42%) with negative skin tests and a positive drug provocation challenge (or repeated clinical history) had specific IgE to benzylpenicilloyl or amoxicilloyl (4). The specificity of the test was 95€“100%. Therefore, IgE measurements can avoid a potentially harmful drug provocation test.

      An elevated serum tryptase does not differentiate between type 1 and type 2 hypersensitivity reaction. It indicates mast cell degranulation.

      RAST is a useful aid to improve the overall diagnosis of drug allergies by using radioactive detection. This, however, is now rarely used.

      Quantification of basophil activation by CD63 expression can be done by flow cytometry, which forms the basis of experimental drug-induced basophil stimulation tests.

    • This question is part of the following fields:

      • Pathophysiology
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  • Question 24 - Very large SI units are easily expressed using mathematical prefixes. One terabyte is...

    Incorrect

    • Very large SI units are easily expressed using mathematical prefixes. One terabyte is equal to which of the following numbers?

      Your Answer:

      Correct Answer: 1,000,000,000,000 bytes

      Explanation:

      To denote large measured units, the following SI mathematical prefixes are used:

      1 deca = 10 bytes (101)
      1 hecto (h) = 100 bytes
      1 kilo (k)= 1,000 bytes
      1 mega (M) = 1,000,000 bytes
      1 giga (G) = 1,000,000,000 bytes
      1 Tera (T) = 1,000,000,000,000 bytes
      1 Peta (P) = 1,000,000,000,000,000 bytes.

    • This question is part of the following fields:

      • Basic Physics
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  • Question 25 - In medical testing, there are true negative, true positive, false positive and false...

    Incorrect

    • In medical testing, there are true negative, true positive, false positive and false negative results for some test. How are the sensitivity of these predictive tests calculated?

      Your Answer:

      Correct Answer: True positives / (true positives + false negatives)

      Explanation:

      The following terms are used in medical testing:

      True negative – The test is negative and the patient does not have the disease.
      True positive – The test is positive and the patient has the disease.
      False positive – The test is positive but the patient does not have the disease.
      False negative – The test is negative but the patient has the disease.

      The sensitivity of a predictive test = true positives / (true positives + false negatives).

      The specificity of a test = true negatives / (false positives + true negatives).

      The negative predictive value of a test = true negatives / (false negatives + true negatives).

    • This question is part of the following fields:

      • Statistical Methods
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  • Question 26 - The Kappa statistic (aka Cohen's kappa coefficient) can be used to measure which...

    Incorrect

    • The Kappa statistic (aka Cohen's kappa coefficient) can be used to measure which of the following?

      Your Answer:

      Correct Answer: Inter-rater reliability

      Explanation:

      The Kappa Statistic or Cohen’s Kappa is a statistical measure of inter-rater reliability for categorical variables. It is used when two raters both apply a criterion based on a tool to assess whether or not some condition occur. A good example can be two doctors rating individuals for diabetes occurrence on the basis of symptoms.

      It gives a quantitative measure of the magnitude of agreement between observers.

      Kappa can take any value between 0 and 1. 0 implies the observers are in complete disagreement and a value of 1 implies complete agreement.

    • This question is part of the following fields:

      • Statistical Methods
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  • Question 27 - The diaphragm is a muscle that is relatively resistant to non-depolarizing neuromuscular blockade's...

    Incorrect

    • The diaphragm is a muscle that is relatively resistant to non-depolarizing neuromuscular blockade's effects. When these muscle relaxants are used, which of the following peripheral nerve stimulator twitch patterns is best for monitoring the return of diaphragmatic function?

      Your Answer:

      Correct Answer: Post-tetanic count stimulation

      Explanation:

      Certain skeletal muscles are more resistant to the effects of neuromuscular blocking agents, both non-depolarizing and depolarizing. The diaphragm is the most resistant. The muscles of the larynx and the corrugator supercilii are less resistant. The abdominal, orbicularis oris, and limb peripheral muscles are the most sensitive muscles.

      Twitch stimulation patterns:

      Supramaximal single stimulus:

      The frequency ranges from 1 Hz to 0.1 Hz (one every second to one every 10 seconds)
      The response is proportional to the frequency of the event.
      It has limited clinical utility because it only tells you whether or not a patient is paralysed (no information on degree of paralysis).

      Over the course of 0.5 seconds (2 Hz), four supramaximal stimulate were applied:

      It is possible to see ‘fade’ and use it as a basis for evaluation.
      This stimulation pattern is used to determine the degree of blockade (1-2 twitches is appropriate for abdominal surgery)
      If the train of four (TOF) count is 1-2, reversal agents can be used in conjunction with medium-acting neuromuscular blocking agents.

      Ratio of TOF:

      This is the ratio of the 4th twitch amplitude to the 1st twitch amplitude.
      The ratio decreases with non-depolarising block and is inversely proportional to the degree of block, allowing objective measurement of residual neuromuscular blockade.
      To achieve adequate reversal, the ratio (as measured by accelerography) must be between 0.7 and 0.9.

      Count of twitches after a tetanic experience(PTC):

      50 Hz for 5 seconds, then a 3 second pause, followed by a single 1 Hz twitch stimulus.
      When the TOF count is zero, this stimulation pattern is used to assess deep blockade (that is, in neurosurgery, microsurgery or ophthalmic surgery when even small movements of a patient will disturb the surgical field)
      It gives an estimate of how long it will take for the response to return to single twitches, allowing assessment of blocks that are too deep for any other technique.
      A palpable post-tetanic count (PTC) of 2 indicates no twitch response for about 20-30 minutes, and a PTC of 5 indicates no twitch response for about 10-15 minutes.

      This is without a doubt the best way to keep track of paralysis in patients who need to avoid diaphragmatic movement. It’s best to use drug infusions and aim for a PTC of 2. After a tetanic stimulus, acetylcholine is mobilised, causing post-tetanic potentiation.

      Stimulation in Two Bursts:

      750 milliseconds between two short bursts of 50 Hz
      This stimulation pattern is used to assess small amounts of residual blockade manually (tactile).

    • This question is part of the following fields:

      • Clinical Measurement
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  • Question 28 - This vertebrae can be easily differentiated from the rest because of its prominent...

    Incorrect

    • This vertebrae can be easily differentiated from the rest because of its prominent spinous process.

      Your Answer:

      Correct Answer: C7

      Explanation:

      The spinous process is the part of a vertebrae that is directed posteriorly.

      Typical cervical vertebra have spinous processes that are small and bifid, except for C7, which has a long and prominent spinous process.

    • This question is part of the following fields:

      • Anatomy
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  • Question 29 - Fixed performance devices like high air flow oxygen enrichment (HAFOE) masks have large...

    Incorrect

    • Fixed performance devices like high air flow oxygen enrichment (HAFOE) masks have large volumes of air entrained into a flow of 100% oxygen. The term that best describes the physics behind air entrainment is?

      Your Answer:

      Correct Answer: Bernoulli's principle

      Explanation:

      Bernoulli’s principle states that as the speed of a moving fluid increases, there is a simultaneously decrease in static pressure or a decrease in the fluid’s potential energy.
      This is seen in the simultaneous increase in speed and kinetic energy and fall in pressure that causes entrainment of large volumes of air into a flow of 100% oxygen in the nozzle of HAFOE masks.

      The reduction in fluid pressure that happens when a fluid flows through a constriction in a tube is the Venturi effect.

      When a flow of gas or liquid attaches itself to a nearby surface and remains attached even when the surface curves away from the initial direction of flow, this is the Coanda effect.

      The branch of engineering and technology that is concerned with the building of devices that use the flow and pressure of a fluid for functions usually performed by electronic devices is Fluidics . Fluidic logic is used to power some ventilators.

      The branch of engineering that utilises pressurised gases is Pneumatics.

    • This question is part of the following fields:

      • Basic Physics
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  • Question 30 - The action potential in a muscle fibre is initiated by which of these...

    Incorrect

    • The action potential in a muscle fibre is initiated by which of these ions?

      Your Answer:

      Correct Answer: Sodium ions

      Explanation:

      The cardiac action potential has several phases which have different mechanisms of action as seen below:
      Phase 0: Rapid depolarisation – caused by a rapid sodium influx.
      These channels automatically deactivate after a few ms

      Phase 1: caused by early repolarisation and an efflux of potassium.

      Phase 2: Plateau – caused by a slow influx of calcium.

      Phase 3 – Final repolarisation – caused by an efflux of potassium.

      Phase 4 – Restoration of ionic concentrations – The resting potential is restored by Na+/K+ATPase.
      There is slow entry of Na+into the cell which decreases the potential difference until the threshold potential is reached. This then triggers a new action potential

      Of note, cardiac muscle remains contracted 10-15 times longer than skeletal muscle.

      Different sites have different conduction velocities:
      1. Atrial conduction – Spreads along ordinary atrial myocardial fibres at 1 m/sec

      2. AV node conduction – 0.05 m/sec

      3. Ventricular conduction – Purkinje fibres are of large diameter and achieve velocities of 2-4 m/sec, the fastest conduction in the heart. This allows a rapid and coordinated contraction of the ventricles

    • This question is part of the following fields:

      • Physiology
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  • Question 31 - An adult and a 7-year-old child are anatomically and physiologically very different. Which...

    Incorrect

    • An adult and a 7-year-old child are anatomically and physiologically very different. Which of the following physiological characteristics of a 5-year-old most closely resembles those of a healthy adult?

      Your Answer:

      Correct Answer: Dead space ratio

      Explanation:

      Whatever the age, the dead space ratio is 0.3. It’s the dead space (Vd) to tidal volume ratio (Vt).

      The glottis is the narrowest point of the upper airway in an adult, while the cricoid ring is the narrowest point in a child.

      A child’s airway resistance is much higher than an adult’s. The resistance to airflow increases as the diameter of a paediatric airway shrinks. The radius (r) to the power of 4 is inversely proportional to airway resistance (r4). As a result, paediatric patients are more susceptible to changes in airflow caused by a small reduction in airway diameter, such as caused by oedema.

      The compliance of a newborn’s lungs is very low (5 mL/cmH2O), but it gradually improves as lung size and elasticity grow. Lung compliance in an adult is 200 mL/cmH2O.

      In children, minute ventilation (mL/kg/minute) is much higher.

    • This question is part of the following fields:

      • Pathophysiology
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  • Question 32 - At 37 weeks' gestation, a 29-year-old parturient is admitted to the labour ward....

    Incorrect

    • At 37 weeks' gestation, a 29-year-old parturient is admitted to the labour ward. Her antenatal period was asymptomatic for her. The haematological values listed below are available: Hb concentration of 100 g/L (115-165), 200x109/L platelets (150-400), MCV 81 fL (80-96). Which of the following is the most likely reason for the problem?

      Your Answer:

      Correct Answer: Iron deficiency

      Explanation:

      This patient’s limited haematological profile includes mild normocytic anaemia and a normal platelet count.

      Iron deficiency is the most common cause of anaemia during pregnancy. It affects 75 to 95 percent of patients. A haemoglobin level of less than 110 g/L in the first trimester and less than 105 g/L in the second and third trimesters is considered anaemia. There will usually be a low mean cell volume (MCV), mean cell haemoglobin (MCH), and mean cell haemoglobin concentration in addition to a low haemoglobin (MCHC). The MCV may be normal in mild cases of iron deficiency or coexisting vitamin B12 and folate deficiency.

      To determine whether you have an iron deficiency, you’ll need to take more tests. Low serum ferritin (15 g/L) and less reliable indices like serum iron and total iron binding capacity are among them.

      A number of factors contribute to iron deficiency in pregnancy, including:

      Insufficient dietary iron to meet the mother’s and foetus’ nutritional needs
      Multiple pregnancies
      Blood loss, as well as
      Absorption of iron from the gut is reduced.

      The volume of plasma increases by about 50% during pregnancy, but the mass of red blood cells (RBCs) increases by only 30%. Dilutional anaemia is the result of this situation. From the first trimester to delivery, the RBC mass increases linearly, while the plasma volume plateaus, stabilises, or falls slightly near term. As a result, between 28 and 34 weeks of pregnancy, haemoglobin concentrations are at their lowest. The effects of haemodilution will be negated in this patient because she is 37 weeks pregnant.

      Vitamin B12 and folate deficiency are less common causes of anaemia in pregnancy. The diagnosis could be ruled out if the MVC is normal.

      During pregnancy, the platelet count drops, especially in the third trimester. Gestational thrombocytopenia is the medical term for this condition. It’s due to a combination of factors, including haemodilution and increased platelet activation and clearance. Pre-eclampsia and HELLP syndrome are common causes of thrombocytopenia. Pre-eclampsia isn’t the only cause of anaemia during pregnancy.

      A typical blood picture of a haemoglobinopathy like sickle cell disease shows quantitative and qualitative defects, with the former leading to a severe anaemia exacerbated by haemodilution and other factors that contribute to iron deficiency. Microcytic cells are the most common type.

    • This question is part of the following fields:

      • Pathophysiology
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  • Question 33 - Typical sigmoid log dose-response curves are seen in agonists and are used to...

    Incorrect

    • Typical sigmoid log dose-response curves are seen in agonists and are used to compare efficacy and potency. Which of the following opioids has a log dose-response curve furthest to the right?

      Your Answer:

      Correct Answer: Tramadol

      Explanation:

      Lesser the potency of the drug, the higher the dose required to produce maximal receptor occupation. So, the least potent drug will have a log dose-response curve furthest to the right on X-axis.

      Based on the option given, tramadol is the least potent drug and thus higher dose is required to produce maximal opioid receptor occupation.

      Thus, Tramadol is the least potent opioid with a log dose-response curve furthest to the right on X-axis.

      Note, Fentanyl is the most potent opioid with a log dose-response curve furthest to the left on the X-axis.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 34 - A man suffers damage to his vagus nerve during surgery on his neck....

    Incorrect

    • A man suffers damage to his vagus nerve during surgery on his neck. The vagus nerve is cut near its exit from the skull. The man loses his parasympathetic tone raising his heart rate and blood pressure. What other feature will be likely present with a vagus nerve injury?

      Your Answer:

      Correct Answer: Hoarse voice

      Explanation:

      The vagus nerve is a mixed nerve with both autonomic and somatic effects. Its most important somatic effect is the motor supply to the larynx via recurrent laryngeal nerves. If one vagus nerve is damaged, the result will be the same as damage to a single recurrent laryngeal nerve, leading to hoarseness of voice.

      The vagus exits the skull via the jugular foramen, accompanied by the accessory nerve.

      Anal tone, erections, and urination are all controlled by the sacral parasympathetic and would not be affected by the loss of the vagus. Parasympathetic controlled pupillary constriction is via the oculomotor nerve and would not be affected by the loss of the vagus.

    • This question is part of the following fields:

      • Anatomy
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  • Question 35 - The thyroid gland: ...

    Incorrect

    • The thyroid gland:

      Your Answer:

      Correct Answer: Internalises iodine through active transport

      Explanation:

      The thyroid gland is a gland shaped like a butterfly which lies at the base of the anterior neck. It controls metabolism using hormone secretion.

      Iodine is extremely important for the synthesis of hormones within the thyroid. It is internalised into the thyroid follicular cells via the sodium/iodide symporter (NIS).

      The parathyroid glands are found posterior to the thyroid gland, with the recurrent laryngeal nerves running posteromedially.

      The expected weight of a normal thyroid gland is about 30 grams.

    • This question is part of the following fields:

      • Pathophysiology
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  • Question 36 - Concerning the intercostal nerves, which one of the following is true? ...

    Incorrect

    • Concerning the intercostal nerves, which one of the following is true?

      Your Answer:

      Correct Answer: Each is connected to a ganglion of the sympathetic trunk

      Explanation:

      The intercostal nerves arise from the ventral rami of the first 11 thoracic spinal nerves. they course along the costal groove on the lower margin of the rib.

      The twelfth intercoastal nerve is called the subcostal nerve. This is because it is below the 12th rib.

      Each intercostal nerve is connected to a ganglion of the sympathetic trunk from which it carries preganglionic and postganglionic fibres that innervate blood vessels, sweat glands, and muscles.

      The lateral and medial pectoral nerves innervates pectoralis major muscle.

    • This question is part of the following fields:

      • Anatomy
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  • Question 37 - A 26-year-old male was diagnosed with hypovolaemic shock following a road traffic accident....

    Incorrect

    • A 26-year-old male was diagnosed with hypovolaemic shock following a road traffic accident. On clinical examination: Heart rate: 125 beats/min, Blood pressure: 120/105 mmHg. On physical examination, his abdomen was found to be tense and tender. Which of the following receptors is responsible for the compensation of blood loss?

      Your Answer:

      Correct Answer: Alpha 1 adrenergic

      Explanation:

      Alpha 1 adrenergic receptor stimulation results in vasoconstriction of peripheral arteries mainly of those of skin, gut and kidney arterioles. This would cause and increase in total peripheral resistance and mean arterial pressure and as a result the perfusion of vital organs i.e. brain, heart and lungs are maintained.

      Muscarinic M2 receptor also known as cholinergic receptor are located in heart, where they act to slow the heart rate down to normal sinus rhythm after negative stimulatory actions of parasympathetic nervous system. They also reduce contractile forces of the atrial cardiac muscle, and reduce conduction velocity of AV node. This could worsen the compensation.

      Stimulation of beta 2 adrenergic receptor result in dilation of smooth muscle as in bronchodilation.

      Beta 3 adrenergic receptors are present on cell surface f both white and brown adipocytes and are responsible for lipolysis, thermogenesis, and relaxation of intestinal smooth muscle.

      Alpha 2 adrenergic receptor stimulation results in inhibition of the release of noradrenaline in a form of negative feedback.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 38 - All of the following are causes of hypalbuminaemia except: ...

    Incorrect

    • All of the following are causes of hypalbuminaemia except:

      Your Answer:

      Correct Answer: Starvation

      Explanation:

      Major surgery induces the systemic inflammatory response and this causes endothelial leakage and a low albumin level.

      Albumin is a single polypeptide which is made but not stored in the liver. Therefore, levels are a reflection of synthetic activity. It is negatively charged and very soluble.

      Only 40% of albumin is intravascular, and the rest in the in interstitial compartment.

      If there was normal liver function during starvation, albumin will be maintained and proteolysis will occur elsewhere.
      It is not catabolised during starvation.
      Starvation and malnutrition may, however, present as part of other disease processes that are associated with hypalbuminaemia.

      Causes of low albumin are

      1. Decreased production (hepatic dysfunction)
      2. Increased loss (renal dysfunction)
      3. Redistribution (endothelial leak/damage)
      4. Increased catabolism (very rare)

    • This question is part of the following fields:

      • Physiology And Biochemistry
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  • Question 39 - Radical prostatectomy is being performed on a 60-year-old man for carcinoma of the...

    Incorrect

    • Radical prostatectomy is being performed on a 60-year-old man for carcinoma of the prostate gland. What is the direct blood supply of the prostate?

      Your Answer:

      Correct Answer: Inferior vesical artery

      Explanation:

      The prostate gland is primarily supplied by the inferior vesical artery, which branches off from the anterior division of the internal iliac artery. The inferior vesical artery supplies the base of the bladder, the distal ureters, and the prostate. The branches to the prostate communicate with the corresponding vessels of the opposite side.

      The inferior vesical artery branches into two main arteries:
      1. Urethral artery – supplies the transition zone and is the main arterial supply for the adenomas in BPH
      2. Capsular artery – supplies the glandular tissue

      The venous drainage of the prostate is from the prostatic venous plexus, which drains into the paravertebral veins.

    • This question is part of the following fields:

      • Anatomy
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  • Question 40 - Clearance techniques are used to assess renal glomerular function. Which of the following...

    Incorrect

    • Clearance techniques are used to assess renal glomerular function. Which of the following is the most accurate marker for glomerular filtration rate measurement?

      Your Answer:

      Correct Answer: Inulin

      Explanation:

      The perfect glomerular filtration marker is:

      The human body is not harmed by it.
      Chemical or physical methods are used to accurately measure
      Extracellular fluid (ECF) compartment is freely and evenly diffusible.
      Inability to access the intracellular fluid (ICF) compartment
      Filtration in the kidney is the only way to remove it from the blood.

      The ideal marker should not be reabsorbed into the bloodstream by the renal tubules or other urinary system components.

      Creatinine is an endogenous substance that is filtered freely by the glomerulus and secreted by the proximal tubule. As a result, creatinine clearance consistently underestimates GFR. In healthy people, this overestimation ranges from 10% to 40%, but it is higher and more unpredictable in patients with chronic kidney disease.

      The gold standard method of inulin clearance necessitates an intravenous infusion and several hours of timed urine collection, making it costly and time-consuming. Inulin is hard to come by and is difficult to mix and keep as a solution.

      Exogenous filtration markers include the following:

      Although plasma clearance of 51chromium EDTA is a widely used method in Europe, tubular reabsorption can occur.
      Because 125I-iothalamate can be excreted by renal tubules in the urine, it cannot be used in patients who have an iodine assay.

      Radioactive substances must be stored, administered, and disposed of according to these methods.

      The glomerulus filters para-aminohippuric acid (PAH) freely, and any that remains in the peritubular capillaries is secreted into the proximal convoluted tubules. This marker is used to determine the amount of blood flowing through the kidneys.

    • This question is part of the following fields:

      • Pathophysiology
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  • Question 41 - A post-operative patient was brought to the recovery room after completion of dilation...

    Incorrect

    • A post-operative patient was brought to the recovery room after completion of dilation and curettage. Her medical history revealed that she was maintained on levodopa for Parkinson's disease. The nurses administered ondansetron 4 mg and dexamethasone 8 mg prior to transfer from the operating room to the recovery room. However, an additional antiemetic agent is warranted. Which of the following agents should be prescribed to the patient?

      Your Answer:

      Correct Answer: Cyclizine 50 mg IV

      Explanation:

      The Beers criteria, a US set of criteria for good prescribing in the older patient, preclude the use of metoclopramide in Parkinson’s disease. The Adverse Reactions Register of the UK Committee on Safety of Medicines (CSM) for the years 1967 to 1982 contained 479 reports of extrapyramidal reactions in which metoclopramide was the suspected drug; 455 were for dystonic-dyskinetic reactions, 20 for parkinsonism and four for tardive dyskinesia. Effects can occur within days of initiation of treatment and may take months to wear off.

      Other antiemetics are available, such as cyclizine (Valoid), domperidone and ondansetron, which would be more appropriate to use in those with Parkinson’s disease.

      Cyclizine is a piperazine derivative with histamine H1 receptor antagonist and anticholinergic activity. It is used for the treatment of nausea, vomiting, (particularly opioid-induced vomiting), vertigo, motion sickness, and labyrinthine disorders.

      Prochlorperazine is an antipsychotic known to cause tardive dyskinesia, tremor and parkinsonian symptoms and is therefore likely to exacerbate Parkinson’s disease. Prochlorperazine is not favoured for older patients because of the increased risk of stroke and transient ischaemic attack (TIA).

      Droperidol and phenothiazine are also potent antagonists on D2 receptors and must also be avoided.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 42 - The production of carbon dioxide and water occurs during cellular respiration, which involves...

    Incorrect

    • The production of carbon dioxide and water occurs during cellular respiration, which involves an energy substrate and oxygen. For a patient, the respiratory quotient is calculated as 0.7. Which of the following energy substrate combinations is the most likely in this patient's diet?

      Your Answer:

      Correct Answer: Low carbohydrate, high fat and low protein

      Explanation:

      The respiratory quotient (RQ) is the proportion of CO2 produced by the body to O2 consumed per unit of time.

      CO2 produced / O2 consumed = RQ

      CO2 is produced at a rate of 200 mL per minute, while O2 is consumed at a rate of 250 mL per minute. An RQ of around 0.8 is typical for a mixed diet.

      The RQ will change depending on the energy substrates consumed in the diet.

      Granulated sugar is a refined carbohydrate that contains 99.999 percent carbohydrate and no lipids, proteins, minerals, or vitamins.

      Glucose and other hexose sugars – RQ = 1
      Fats – RQ = 0.7
      Proteins – RQ is 0.9
      Ethyl alcohol – RQ = 0.67

    • This question is part of the following fields:

      • Pathophysiology
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  • Question 43 - A 89-year old male has hypertension, with a blood pressure of 170/68 mmHg...

    Incorrect

    • A 89-year old male has hypertension, with a blood pressure of 170/68 mmHg and has been admitted to the hospital. He is on no regular medications. His large pulse pressure can be accounted for by which of the following?

      Your Answer:

      Correct Answer: Reduced aortic compliance

      Explanation:

      Cardiac output = stroke volume x heart rate

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

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

      Pulse pressure = Systolic Pressure – Diastolic Pressure

      Systemic vascular resistance = mean arterial pressure / cardiac output
      Factors that increase pulse pressure include:
      -a less compliant aorta (this tends to occur with advancing age)
      -increased stroke volume

    • This question is part of the following fields:

      • Physiology And Biochemistry
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  • Question 44 - Which muscle separates the subclavian artery and the subclavian vein? ...

    Incorrect

    • Which muscle separates the subclavian artery and the subclavian vein?

      Your Answer:

      Correct Answer: Scalenus anterior

      Explanation:

      The subclavian artery and vein have a similar path throughout their course, with the subclavian vein running anterior to the subclavian artery. The artery and vein are separated by the insertion of the scalenus anterior muscle.

      There are three scalene muscles, found on each side of the neck:
      1. Anterior scalene
      2. Middle scalene
      3. Posterior scalene

      The scalenus anterior muscle is the anterior most of the three scalene muscles. It originates from the transverse processes of vertebrae C3-C6 and is inserted in the first rib.

    • This question is part of the following fields:

      • Anatomy
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  • Question 45 - A 62-year-old woman, presents to emergency department with an ischaemic left colon. Multiple...

    Incorrect

    • A 62-year-old woman, presents to emergency department with an ischaemic left colon. Multiple arteries arise from the aorta at the level of the L3 vertebrae, which is most likely to be involved in this pathology?

      Your Answer:

      Correct Answer: Inferior mesenteric artery

      Explanation:

      The inferior mesenteric artery arises from the abdominal aorta at the level of the L3 vertebrae and supplies blood to the final third of the transverse colon, the descending colon, the sigmoid colon and the uppermost part of the rectum.

      It is the artery most likely to affect the left colon.

    • This question is part of the following fields:

      • Anatomy
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  • Question 46 - The child-Pugh scoring system can be used, if risk classifying a patient with...

    Incorrect

    • The child-Pugh scoring system can be used, if risk classifying a patient with chronic liver disorder earlier to anaesthesia. Which one is the best combination of clinical signs and examinations used within the Child-Pugh scoring system?

      Your Answer:

      Correct Answer: Ascites, grade of encephalopathy, albumin, bilirubin and INR

      Explanation:

      In the Child-Pugh classification system, the following 5 components are determined or calculated in order:

      Ascites

      Grade of encephalopathy

      Serum bilirubin (μmol/L)

      Serum Albumin (g/L)

      Prothrombin time or INR

      Raised liver enzymes are not the component of the classification system.

    • This question is part of the following fields:

      • Basic Physics
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  • Question 47 - Which of the following statements is true regarding oxygen? ...

    Incorrect

    • Which of the following statements is true regarding oxygen?

      Your Answer:

      Correct Answer: Forms molecules containing either two or three atoms

      Explanation:

      Oxygen is formed by a molecule of oxygen and two molecules of hydrogen with a molecular formula of H2O

      The critical temperature is defined as a temperature above which the substance cannot be liquefied, no matter how much pressure is applied.
      Water has a critical temperature of -118.6oC. So, it cannot be liquified at room temperature.

      Medical oxygen cylinder is stored in a cylinder with a white shoulder and black body. Meanwhile, medial air is stored in cylinders with a white and black shoulder and a French grey body.

      The partial pressure of air at a high altitude is less but the relative concentration remains constant.

    • This question is part of the following fields:

      • Basic Physics
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  • Question 48 - A paediatric patient was referred to the surgery department after an initial assessment...

    Incorrect

    • A paediatric patient was referred to the surgery department after an initial assessment of acute gastroenteritis was proven otherwise to be a case acute appendicitis. History revealed multiple episodes of non-bloody emesis. In the paediatric ward, the patient had already undergone fluid resuscitation and replacement, and electrolytes were already corrected. Other pertinent laboratory studies were the following: Serum Na: 138 mmol/l, Blood glucose: 6.4 mmol/l. If the patient weighed 25 kg, which intravenous fluid maintenance regimen would be best for the child?

      Your Answer:

      Correct Answer: 65 ml/hr Hartmann's solution with 0% glucose

      Explanation:

      Maintenance therapy aims to replace water and electrolytes lost under ordinary conditions. In the perioperative period, maintenance fluid administration may not sufficiently account for the increased fluid requirements caused by third-space losses into the interstitium and gut. Specific recommendations vary with the patient, the procedure, and the type and amount of fluid administered during the operation. The fluid for maintenance therapy replaces deficits arising primarily from insensible losses and urinary or gastrointestinal (GI) losses.

      The maintenance fluid volume can be computed using the Holliday-Segar method.

      Body weight Fluid volume
      first 10 kg 4 ml/kg/hr
      next 10-20 kg 2 ml/kg/hr
      >20 kg 1 ml/kg/hr

      In the past few years, there has been growing recognition of the increased risk of hyponatremia in hospitalized children in intensive care and postoperative settings who receive hypotonic maintenance fluids. Several studies, including a randomized controlled trial and a Cochrane analysis, found that the use of isotonic fluids is associated with fewer electrolyte derangements and concluded that isotonic maintenance fluids are preferable to hypotonic solutions in hospitalized children.

      A European consensus statement suggests that an intraoperative fluid should have an osmolarity close to the physiologic range in children in order to avoid hyponatremia, an addition of 1-2.5% in order to avoid hypoglycaemia, lipolysis or hyperglycaemia and should also include metabolic anions as bicarbonate precursors to prevent hyperchloremic acidosis.

      A rate of 40 ml/hr is suboptimal.

      If 0.9% NaCl with 0% glucose is given at a rate of 65 ml/hr, despite of the correct infusion rate, large volumes can lead to hyperchloremic acidosis.

      If 0.18% NaCl with 4% glucose is given at a rate of 65 ml/hr, infusion of this fluid regimen can lead to hyponatremia because of its hypotonicity.

    • This question is part of the following fields:

      • Physiology And Biochemistry
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  • Question 49 - Which one of the following factor affects the minimal alveolar concentration (MAC)? ...

    Incorrect

    • Which one of the following factor affects the minimal alveolar concentration (MAC)?

      Your Answer:

      Correct Answer: Hypoxaemia

      Explanation:

      The minimal alveolar concentration (MAC) is the concentration of an inhalation anaesthetic agent in the lung alveoli required to stop a response to the surgical stimulus in 50% of the patient.

      Following factors don’t affect the MAC of the inhaled anaesthetic agents:

      Gender, acidosis, alkalosis, hypothyroidism, hyperthyroidism, body weight, serum potassium level, and the duration of the anaesthesia.

      MAC increase in children, elevated temperature, high metabolic rate, sympathetic increase and chronic alcoholism.

      MAC decrease in low temperature, low oxygen level, old age, hypotension ( 120mmHg is being used in anesthetic-Hinkman as an additive effect to decrease MAC, however, increase concentration of CO2 activates the sympathetic system resulting the MAC increases.

    • This question is part of the following fields:

      • Physiology
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  • Question 50 - Regarding the classification of breathing systems, which of the following is true? ...

    Incorrect

    • Regarding the classification of breathing systems, which of the following is true?

      Your Answer:

      Correct Answer: The Conway classification describes a functional classification based on whether a CO2 absorber is required

      Explanation:

      Breathing system is an assembly of components which connects patient’s airway to anaesthesia machine through which controlled composition of gas mixture is dispensed. It delivers gas to the patient, removes expired gas and controls the temperature and humidity of the inspired mixture. It allows spontaneous, controlled, or assisted respiration. It may also provide ports for gas sampling, airway pressure, flow and volume monitoring.

      Breathing systems have been classified by Conway and Mapleson.
      Conway suggested a functional classification:
      – Circuits requiring a CO2 absorber
      – Circuits not requiring a CO2 absorber

      William Mapleson designated varying arrangements of breathing system components (masks, breathing tubes, fresh gas flow inlets, adjustable pressure-limiting valves, and reservoir bags) as Mapleson A-E circuits.
      Mapleson A: Arranged as FGF inlet, reservoir bag, APL valve, mask.
      In this circuit, because the reservoir bag is between the FGF inlet valve and the APL valve, expired gas from the patient may re-enter the system and fill the reservoir bag during controlled ventilation. This is the most efficient system for spontaneous breathing as the FGF must only be equal to a patient’s minute ventilation to prevent rebreathing.

      Mapleson B: Arranged as reservoir bag, FGF inlet, APL valve, mask.
      In this circuit, the FGF inlet is closer to the APL valve, which helps prevent the rebreathing concern in the Mapleson A circuit as above during controlled ventilation.

      Mapleson C: Arranged as reservoir bag, FGF inlet, APL valve, mask.
      In this circuit, the arrangement is the same as the Mapleson B circuit. However, this circuit is shorter as it does not contain elongated corrugated tubing. This circuit also has the FGF inlet close to the APL valve to aid in preventing rebreathing.

      Mapleson D: Arranged as reservoir bag, APL valve, FGF inlet, and mask.
      In this circuit, the arrangement interchanges the FGF inlet and APL valve of the Mapleson A circuit. This system prevents rebreathing by directing FGF towards the APL valve rather than towards the patient during exhalation.

      Mapleson E: Arranged as corrugated tubing, FGF inlet, and mask.
      In this circuit, there is no reservoir bag and no APL valve. Given the inability to alter the pressure of the circuit, this is ideal for spontaneously ventilating neonates or paediatric patients where low-pressure ventilation is desired. The system prevents rebreathing, similar to the Mapleson D circuit.

      Jackson Rees later modified the Mapleson E by adding an open ended bag, which has since become known as the Mapleson F.
      Mapleson F: Arranged as APL valve directly connected to reservoir bag, corrugated tubing, FGF inlet, and mask.
      The system prevents rebreathing similarly to Mapleson D by directing FGF towards the APL valve.

    • This question is part of the following fields:

      • Anaesthesia Related Apparatus
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  • Question 51 - Among the following which one is not a criterion for the assessment of...

    Incorrect

    • Among the following which one is not a criterion for the assessment of causality?

      Your Answer:

      Correct Answer: Sensitivity

      Explanation:

      For establishing a cause effect relationship, following criteria must be met:

      1. Coherence & Consistency

      2. Temporal Precedence

      3. Specificity

      As can be seen, sensitivity (The probability of a positive test) is not among these deciding factors..

    • This question is part of the following fields:

      • Statistical Methods
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  • Question 52 - Cells use adenosine-5-triphosphate (ATP) as a coenzyme and is a source of energy....

    Incorrect

    • Cells use adenosine-5-triphosphate (ATP) as a coenzyme and is a source of energy. Glucose metabolism produces the most ATP from which of the following biochemical processes?

      Your Answer:

      Correct Answer: Electron transport phosphorylation in the mitochondria

      Explanation:

      Glycolysis occurs in the cytoplasm of the cell. It converts 1 glucose molecule (6-carbon) to pyruvate (two 3-carbon molecules) and produces 4 ATP molecules and 2NADH but uses 2 ATP in the process with an overall net energy production of 2 ATP.

      Pyruvate is then oxidised to acetyl coenzyme A (generating 2 NADH per pyruvate molecule). This takes place in the mitochondria and then enters the Krebs cycle (citric acid cycle). It produces 2 ATP, 8 NADH and 2 FADH2 per glucose molecule.

      Electron transport phosphorylation takes place in the mitochondria. The aim of this process is to break down NADH and FADH2 and also to pump H+ into the outer compartment of the mitochondria. It produces 32 ATP with an overall net production of 36ATP.

      In anaerobic respiration which occurs in the cytoplasm, pyruvate is reduced to NAD producing 2 ATP.

    • This question is part of the following fields:

      • Physiology
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  • Question 53 - A 63-year old male who has heart failure has peripheral oedema and goes...

    Incorrect

    • A 63-year old male who has heart failure has peripheral oedema and goes to the GP's office. The GP notes that he is fluid-overloaded. This causes his atrial myocytes to release atrial natriuretic peptide (ANP). ANP's main action is by which of these mechanisms?

      Your Answer:

      Correct Answer: Antagonist of angiotensin II

      Explanation:

      Atrial natriuretic peptide (ANP) is secreted mainly from myocytes of right atrium and ventricle in response to increased blood volume.
      It is secreted by both the right and left atria (right >> left).

      It is a 28 amino acid peptide hormone, which acts via cGMP
      degraded by endopeptidases.

      It serves to promote the excretion of sodium, lowers blood pressure, and antagonise the actions of angiotensin II and aldosterone.

    • This question is part of the following fields:

      • Physiology And Biochemistry
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  • Question 54 - Which of the following bias is more prone to case-control studies? ...

    Incorrect

    • Which of the following bias is more prone to case-control studies?

      Your Answer:

      Correct Answer: Recall bias

      Explanation:

      Omitted variable bias occurs when a statistician passes over one or more relevant variables from the study.

      Publication bias occurs in publish academic research. it occurs when the results of the study effect the decision whether to publish or not.

      Expectation bias occurs when the expectation of a researcher about the results effect the behaviour of the participants. Expectations may come from communication and experiences.

      Work up bias occurs in the study of diagnostic test validity, whether a gold standard procedure has been used. work up bias can seriously affect the specificity of the test.

      Recall bias introduced when participants in a study are systematically more or less likely to recall and relate information on exposure depending on their outcome status. Recall bias is more potential for Case-control studies.

    • This question is part of the following fields:

      • Statistical Methods
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  • Question 55 - Which of the following statement is true or false regarding to the respiratory...

    Incorrect

    • Which of the following statement is true or false regarding to the respiratory tract?

      Your Answer:

      Correct Answer: The sympathetic innervation of the bronchi is derived from T2 - T4

      Explanation:

      The diaphragm has three opening through which different structures pass from the thoracic cavity to the abdominal cavity:

      Inferior vena cava passes at the level of T8.

      Oesophagus, oesophageal vessels and vagi at T10.

      Aorta, thoracic duct and azygous vein through T12.

      Sympathetic trunk and pulmonary branches of vagus nerve form a posterior pulmonary plexus at the root of the lung. Fibres continue posteriorly from superficial cardiac plexus to form Anterior pulmonary plexus. It contains vagi nerves and superficial cardiac plexus. These fibres then follow the blood vessel and bronchi into the lungs.

      The lower border of the pleura is at the level of:

      8th rib in the midclavicular line

      10th rib in the lower level of midaxillary line

      T12 at its termination.

      Both lungs have oblique fissure while right lung has transverse fissure too.

      The trachea expands from the lower edge of the cricoid cartilage (at the level of the 6th cervical vertebra) to the carina.

    • This question is part of the following fields:

      • Physiology
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  • Question 56 - Which of the following drugs can have significant clinical effects on neonates when...

    Incorrect

    • Which of the following drugs can have significant clinical effects on neonates when used in appropriate doses for a caesarean section?

      Your Answer:

      Correct Answer: Alfentanil

      Explanation:

      Opioid should be avoided in the caesarean section as it crosses the placental membrane and causes respiratory depression.

      Even though inhalational and intravenous anaesthetic agents readily cross the placenta, they do not have significant effects on APGAR score when used in clinical doses.

      Vecuronium and suxamethonium are highly polar molecules and thus do not cross the placenta in significant amounts.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 57 - Regarding the use of soda lime as part of a modern circle system...

    Incorrect

    • Regarding the use of soda lime as part of a modern circle system with a vaporiser outside the circuit (VOC), which of the following is its most deleterious consequence?

      Your Answer:

      Correct Answer: Carbon monoxide formation

      Explanation:

      When using dry soda lime for VOCs, very high amounts of carbon monoxide may be produced, regardless of the inhalational anaesthetic agent used. The carbon monoxide produced is sufficient enough to cause cytotoxic and anaemic hypoxia. To prevent this, soda lime canisters are shaken well to even out the packing of granules. This can help to evenly distribute gas flow for proper CO2 absorption and ventilation.

      Compound A is formed when dry soda lime, or soda lime in high temperature, reacts with the inhalational anaesthetic Sevoflurane. Animal studies have shown renal toxicity in rats, but renal adverse effects in humans are yet to be observed.

      When monitors are not employed with VOCs, deleterious effects are not for certain. However, monitors not employed with vaporiser inside the circuit (VIC) can lead to significant adverse events.

    • This question is part of the following fields:

      • Pathophysiology
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  • Question 58 - Which of the following statements is NOT true regarding the internal jugular vein?...

    Incorrect

    • Which of the following statements is NOT true regarding the internal jugular vein?

      Your Answer:

      Correct Answer: The terminal part of the thoracic duct crosses anterior to it to insert into the right subclavian vein

      Explanation:

      The internal jugular vein is found on both sides of the neck and collects blood from the brain, superficial regions of the face, and neck. It drains into the right atrium.

      It is a continuation of the sigmoid sinus and begins in the posterior cranial fossa and exits the skull via the jugular foramen.
      It runs within the carotid sheath as it descends in the neck and is accompanied by the vagus nerve posteriorly and the common carotid anteromedially.

      The hypoglossal nerve emerges from the hypoglossal canal medial to the internal carotid artery and the internal jugular vein and ninth, tenth, and eleventh cranial nerves.

      The internal jugular vein crosses anterior to the thoracic duct on the left side.

    • This question is part of the following fields:

      • Anatomy
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  • Question 59 - A 60-year-old man is having his central venous pressure (CVP) measured. A long...

    Incorrect

    • A 60-year-old man is having his central venous pressure (CVP) measured. A long venous line was inserted via the femoral vein into the right atrium for this purpose. The catheter is advanced through the IVC. Which level of the vertebra is the site where this vessel enters the thorax?

      Your Answer:

      Correct Answer: T8

      Explanation:

      The diaphragm divides the thoracic cavity from the abdominal cavity. Structures penetrate the diaphragm at different vertebral levels through openings in the diaphragm to communicate between the two cavities. The diaphragm has openings at three vertebral levels:

      T8: vena cava, terminal branches of the right phrenic nerve
      T10: oesophagus, vagal trunks, left anterior phrenic vessels, oesophageal branches of the left gastric vessels
      T12: descending aorta, thoracic duct, azygous and hemi-azygous vein.

    • This question is part of the following fields:

      • Anatomy
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  • Question 60 - The clavipectoral fascia is penetrated by the cephalic vein to terminate in which...

    Incorrect

    • The clavipectoral fascia is penetrated by the cephalic vein to terminate in which of the listed veins?

      Your Answer:

      Correct Answer: Axillary

      Explanation:

      The cephalic vein is a superficial vein that runs through the forearm and the arm, before draining into the axillary vein where it terminates.

    • This question is part of the following fields:

      • Anatomy
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  • Question 61 - A trail has analysed that a new screening test may increase the survival...

    Incorrect

    • A trail has analysed that a new screening test may increase the survival time of ovarian cancer patients. But analyst say that the apparent increase in the patients survival time is just because of earlier detection instead of actual improvement. What kind of bias is in this experiment?

      Your Answer:

      Correct Answer: Lead time bias

      Explanation:

      Observation bias occurs when the behaviour of an individual changes that results from their awareness of being observed.

      Recall bias introduced when participants in a study are systematically more or less likely to recall and relate information on exposure depending on their outcome status.

      Attrition bias is a systematic error caused by unequal loss of participants from a randomized controlled trial (RCT). In clinical trials, participants might dropout due to unsatisfactory treatment or efficacy, intolerable adverse events, or even death.

      Selection bias introduced when the individuals are not chosen randomly to take a part in the study. It usually occurs when the research decides who is going to be studied, they are not the representative of the population.

      Lead-time bias occurs when a disease is detected by a screening test at an earlier time point rather than it would have been diagnosed by its clinical appearance. In this bias, earlier detection improves the survival time in the intervention group.

    • This question is part of the following fields:

      • Statistical Methods
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  • Question 62 - A 60 year old non insulin dependent diabetic on metformin undergoes hip arthroscopy...

    Incorrect

    • A 60 year old non insulin dependent diabetic on metformin undergoes hip arthroscopy under general anaesthesia. Her preoperative blood glucose is 6.5mmol/L. Anaesthesia is induced with 200 mg propofol and 100 mcg fentanyl and maintained with sevoflurane and air/oxygen mixture. she is given 8 mg dexamethasone, 40 mg parecoxib, 1 g paracetamol and 500 mL Hartmann's solution Intraoperatively. The procedure took thirty minutes and her blood glucose in recovery is 14 mmol/L. What is the most likely cause for her rise in blood sugar?

      Your Answer:

      Correct Answer: Stress response

      Explanation:

      A significant early feature of the metabolic response to trauma and surgery is hyperglycaemia. It is due to an increased glucose production and decreased glucose utilisation bought on by neuroendocrine stimulation. Catecholamines, Growth hormone, ACTH and cortisol, and Glucagon are all increased.

      There is also a decreased insulin sensitivity peripherally and an inhibition of insulin production from the beta cells of the pancreas. These changes lead to hyperglycaemia.

      The stress response to endoscopic surgery will only be prevented with use of high dose opioids or central neuraxial block at anaesthesia.
      To reduce the risk of inducing hyperchloremic acidosis, Ringer’s lactate/acetate or Hartmann’s solution is preferred to 0.9% sodium chloride as routine maintenance fluids.

      Though it has been suggested that administration of Hartmann’s solution to patients with type 2 diabetes leads to hyperglycaemia, one Litre of Hartmann’s solution would yield a maximum of 14.5 mmol of glucose. A rapid infusion of this volume would increase the plasma glucose by no more than 1 mmol/L..

      Dexamethasone, a glucocorticoid, produces hyperglycaemia by stimulating gluconeogenesis . Glucocorticoids are agonists of intracellular glucocorticoid receptors. Their effects are mainly mediated via altered protein synthesis via gene transcription and so the onset of action is slow. The onset of action of dexamethasone is about one to four hours and therefore would NOT contribute to the hyperglycaemia in this patient in the time given.

      0.9% Normal saline with or without adrenaline is the usual irrigation fluid. With this type of surgery, systemic absorption is unlikely to occur.

      Fentanyl is not likely the primary cause of hyperglycaemia in this patient. In high doses (50 mcg/Kg) it has been shown to reduce the hyperglycaemic responses to surgery.

    • This question is part of the following fields:

      • Pathophysiology
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  • Question 63 - Buffers are solutions that resist a change in pH when protons are produced...

    Incorrect

    • Buffers are solutions that resist a change in pH when protons are produced or consumed. They consist of weak acids and their conjugate bases. Buffers are also present in our bodies, and they are known as physiologic buffers. Which of these is the most effective buffer in the blood?

      Your Answer:

      Correct Answer: Bicarbonate

      Explanation:

      The first line of defence against acid-base disorder is buffering. The blood mainly utilizes bicarbonate ion (HCO3-) for its buffering capacity (total of 53%, plasma and red blood cells combined).

      Strong acids, when acted upon by a buffer, release H+, which then combines to HCO3- and forms carbonic acid (H2CO3). When acted upon by the enzyme carbonic anhydrase, H2CO3 dissociates into H2O and CO.

      The rest are the percentage of utilization for the following buffers:
      Haemoglobin (by RBCs) – 35%
      Plasma proteins (by plasma) – 7%
      Organic phosphates (by RBCs) – 3%
      Inorganic phosphates (by plasma) – 2%

    • This question is part of the following fields:

      • Pharmacology
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  • Question 64 - A 61-year-old woman, present to her general practitioner. She complains of a severe...

    Incorrect

    • A 61-year-old woman, present to her general practitioner. She complains of a severe lancinating pain in her forehead that only last a few seconds, possibly triggered by washing her face, occurring over the previous six weeks. On examination, she is normal with no other signs or symptoms. Which nerve is the most likely cause of her pain?

      Your Answer:

      Correct Answer: Sensory branches of the ophthalmic division of the trigeminal nerve

      Explanation:

      Her symptoms are suggestive of trigeminal neuralgia which is a short, sudden, severe sharp unilateral pain in the facial region. The pain often follows the sensory distribution of the trigeminal nerve (CN V).

      The trigeminal nerve gives rise to 3 sensory and 1 motor nuclei. Neuralgia can arise from any of the 3 sensory divisions.

      The ophthalmic division gives rise to 3 further sensory branches, which are the frontal, lacrimal and nasociliary.

      The frontal branch of the ophthalmic division of the trigeminal nerve is responsible for the innervation of the area in question.

      The superior alveolar dental, zygomatic and sphenopalatine nerves are all branches arising from the maxillary division of the trigeminal nerve.

      The mandibular division of the trigeminal nerve provides sensory and motor innervation. The sensory innervation is carried out by the auriculotemporal nerve which supplies the lower third of the face, while the motor fibres are responsible for controlling the muscles of mastication.

      The somatic sensory branches of the vagus nerve are responsible for sensory innervation of the external acoustic meatus and tympanic membrane.

    • This question is part of the following fields:

      • Pathophysiology
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  • Question 65 - The cardiac muscle will primarily utilize which metabolic substrate to produce energy when...

    Incorrect

    • The cardiac muscle will primarily utilize which metabolic substrate to produce energy when at rest?

      Your Answer:

      Correct Answer: Fatty acids

      Explanation:

      Approximately 70% of the heart’s ATP requirement is met by cardiac mitochondria through beta-oxidation of fatty acids at rest. The remaining 30% is supplied by glucose.

      Amino acids and ketones, in the presence of ketoacidosis, may supply at most 10% of the ATP requirement. And, when in high levels, lactate may also contribute to the ATP requirement of the heart, particularly during moments of high muscular activity.

    • This question is part of the following fields:

      • Pathophysiology
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  • Question 66 - A 50-year-old woman is brought into the emergency department in an ambulance. She...

    Incorrect

    • A 50-year-old woman is brought into the emergency department in an ambulance. She was found collapsed on the street. She has visual and oculomotor deficits on examination, but her motor function is intact. A digital subtraction angiography is performed that shows occlusion of the basilar artery at the site where the vertebral arteries fuse to form the basilar artery. Which anatomical landmark corresponds to this site of occlusion?

      Your Answer:

      Correct Answer: The base of the pons

      Explanation:

      The basilar artery is a large vessel that is formed by the union of the vertebral arteries at the junction of the medulla and pons. It lies in the pontine cistern and follows a shallow groove on the ventral pontine surface, extending to the upper border of the pons.

      The basilar artery then bifurcates into the two posterior cerebral arteries that form part of the Circle of Willis.

    • This question is part of the following fields:

      • Anatomy
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  • Question 67 - Concerning the physical principles of temperature measurement by a thermocouple, which of the...

    Incorrect

    • Concerning the physical principles of temperature measurement by a thermocouple, which of the following best describes it?

      Your Answer:

      Correct Answer: The bimetallic strip has a junction potential proportional to temperature

      Explanation:

      A thermocouple, or a thermal junction, is temperature measuring device consisting of a pair of dissimilar metal (bimetallic) wires or strips joined together. Typically, copper and constantan (an alloy of 55% copper and 45% nickel) are used. When there is contact between these metals, a small voltage is generated in the order of millivolts. The magnitude of the thermojunction electromotive force (emf) is proportional to applied temperature (the Seebeck effect). This physical principle is applied in the measurement of temperature. The electromotive force at the measuring junction is proportional to temperature.

      Two wires with different coefficients of expansion, joined together, can be used as a switch for thermostatic control.

      Semiconductors are NOT used in thermocouple. The resistance of the measuring junction of a thermocouple is irrelevant.

    • This question is part of the following fields:

      • Anaesthesia Related Apparatus
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  • Question 68 - Transthoracic echocardiogram (TTE) can be used to investigate the function of the heart...

    Incorrect

    • Transthoracic echocardiogram (TTE) can be used to investigate the function of the heart in patients with suspected heart failure. The aim is to measure the ejection fraction, but to do that, the stroke volume must first be measured. How is stroke volume calculated?

      Your Answer:

      Correct Answer: End diastolic volume - end systolic volume

      Explanation:

      Cardiac output = stroke volume x heart rate

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

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

      Pulse pressure = Systolic Pressure – Diastolic Pressure

      Systemic vascular resistance = mean arterial pressure / cardiac output
      Factors that increase pulse pressure include:
      -a less compliant aorta (this tends to occur with advancing age)
      -increased stroke volume

    • This question is part of the following fields:

      • Physiology And Biochemistry
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  • Question 69 - A 25-year -old man, presents with a suspected uretic colic and is placed...

    Incorrect

    • A 25-year -old man, presents with a suspected uretic colic and is placed on admission. An abdominal x-ray of the kidney, ureter and bladder (KUB) is ordered. Where is the stone most likely to be located on x-ray?

      Your Answer:

      Correct Answer: The tips of the transverse processes between L2 and L5

      Explanation:

      The ureter runs anterior to the vertebrae at the level of L2 to L5, and stones are usually seen at these points on x-ray.

      They can also be seen at the level of the sacro-iliac joints.

    • This question is part of the following fields:

      • Anatomy
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  • Question 70 - What is the order of the anatomical components of the tracheobronchial tree from...

    Incorrect

    • What is the order of the anatomical components of the tracheobronchial tree from proximal to distal?

      Your Answer:

      Correct Answer: Bronchioles, terminal bronchioles, respiratory bronchioles, alveolar ducts, alveolar sacs

      Explanation:

      The tracheobronchial tree is subdivided into the conducting and the respiratory zones.

      The zones from proximal to distal are:

      Trachea
      Bronchi
      Bronchioles
      Terminal bronchioles
      Respiratory bronchioles
      Alveolar ducts
      Alveolar sacs

      from the trachea to terminal bronchioles are the conducting zone while the respiratory zone is from the respiratory bronchioles to the alveola sacs.

    • This question is part of the following fields:

      • Anatomy
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  • Question 71 - Which of the following options will cause an artificial increase in pulse oximeter...

    Incorrect

    • Which of the following options will cause an artificial increase in pulse oximeter (SpO2) readings?

      Your Answer:

      Correct Answer: Heavy smoker

      Explanation:

      A pulse oximeter is a piece of medical equipment used as a non-invasive method of measuring the oxygen saturation of blood.

      It works by measuring the ratio of absorption of red and infrared light in a section of blood flow, as red light is largely absorbed by deoxygenated blood, and infrared light is largely absorbed by oxygenated blood.

      Pulse oximetry relies on photoplethysmography (PPG) waveforms. The oximeter has 2 sides, with different functions. One side houses light-emitting diodes which are responsible for transmitting 2 light wavelengths, 660nm for red light and 940nm for near infrared light. The other side is a photodetector. The light emitted travels through the body and the amount that is not absorbed is measured by the photodetector.

      Smokers often have increased levels of carboxy haemoglobin (COHb). This leads to artificial increases in pulse oximeter readings as it is unable to differentiate between COHb and oxyhaemoglobin (O2HB) as they both absorb red light at 660nm. Every 1% increase of circulating carboxyhaemoglobin, results in a correlative 1% increase in oximeter readings.

      Prilocaine toxicity will cause an artificial decrease in oximeter readings. This is because prilocaine metabolites cause methemoglobinemia (MetHB), which are dysfunctional haemoglobins unable to properly transport oxygen. In this case, a laboratory multiwavelength co-oximeter is recommended for a more accurate reading.

      Anaemia will not affect oximeter readings as long as haemoglobins in the blood are normal.

      Sickle cell disease does not affect oximeter readings despite its ability to cause hypoxia and shift the oxygen dissociation curve to the right.

      Brown-red fingernail polish will cause an underestimation of pulse oximeter readings.

    • This question is part of the following fields:

      • Clinical Measurement
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  • Question 72 - A 30-year old lady has a sub total thyroidectomy. On the 5th post-operative...

    Incorrect

    • A 30-year old lady has a sub total thyroidectomy. On the 5th post-operative day, the wound becomes erythematous and there is a purulent discharge. The most likely organism causing this is:

      Your Answer:

      Correct Answer: Staphylococcus aureus

      Explanation:

      Staphylococcus aureus infection is the most likely cause.

      Surgical site infections (SSI) occur when there is a breach in tissue surfaces and allow normal commensals and other pathogens to initiate infection. They are a major cause of morbidity and mortality.

      SSI comprise up to 20% of healthcare associated infections and approximately 5% of patients undergoing surgery will develop an SSI as a result.
      The organisms are usually derived from the patient’s own body.

      Measures that may increase the risk of SSI include:
      -Shaving the wound using a single use electrical razor with a disposable head
      -Using a non iodine impregnated surgical drape if one is needed
      -Tissue hypoxia
      -Delayed prophylactic antibiotics administration in tourniquet surgery, patients with a prosthesis or valve, in clean-contaminated surgery of in contaminated surgery.

      Measures that may decrease the risk of SSI include:
      1. Intraoperatively
      – Prepare the skin with alcoholic chlorhexidine (Lowest incidence of SSI)
      -Cover surgical site with dressing

      In contrast to previous individual RCT’s, a recent meta analysis has confirmed that administration of supplementary oxygen does not reduce the risk of wound infection and wound edge protectors do not appear to confer benefit.

      2. Post operatively
      Tissue viability advice for management of surgical wounds healing by secondary intention

      Use of diathermy for skin incisions
      In the NICE guidelines the use of diathermy for skin incisions is not advocated. Several randomised controlled trials have been undertaken and demonstrated no increase in risk of SSI when diathermy is used.

    • This question is part of the following fields:

      • Physiology And Biochemistry
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  • Question 73 - A 68-year-old man has suffered a myocardial infarction. He has a heart rate...

    Incorrect

    • A 68-year-old man has suffered a myocardial infarction. He has a heart rate of 40 beats per minute currently. Your senior attending explains that the slow heart rate is due to the damage to the conduction pathways between the sinoatrial and atrioventricular nodes. His ventricles are being paced by the AV node alone. What artery supplies the AV node in the majority of patients?

      Your Answer:

      Correct Answer: Right coronary artery

      Explanation:

      The AV node has an intrinsic firing rate of 40-60 beats per minute which is clinically significant in cases of damage to the conducting pathways as patients continue to have a ventricular rate of 40-60. Patients who have an AV node supplied by the right coronary are said to be right dominant. The remaining 10% are left dominant and supplied by the left circumflex.

      The right coronary artery supplies the right atrium, right ventricle, interatrial septum, and the inferior posterior third of the interventricular septum. It also supplies the atrioventricular node + sinoatrial node in most patients. The posterior descending artery supplies the posterior third of the interventricular septum.

      The heart receives blood supply from coronary arteries. The right and left coronary arteries branch off the aorta and supply oxygenated blood to all heart muscle parts.

      The left main coronary artery branches into:
      1. Circumflex artery – supplies the left atrium, side, and back of the left ventricle. The left marginal artery arises from the left circumflex artery. It travels along the obtuse margin of the heart.
      The left marginal artery, a branch of the circumflex artery, supplies the left ventricle.
      2. Left Anterior Descending (LAD) artery – supplies the front and bottom of the left ventricle and front of the interventricular septum

      The right coronary artery branches into:
      1. Right marginal artery
      2. Posterior descending artery.

    • This question is part of the following fields:

      • Anatomy
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  • Question 74 - Regarding anaesthetic breathing circuits, which one would be the best for spontaneous breathing?...

    Incorrect

    • Regarding anaesthetic breathing circuits, which one would be the best for spontaneous breathing?

      Your Answer:

      Correct Answer: Lack circuit

      Explanation:

      Among the breathing circuits, the Lack circuit is the most efficient for spontaneous breathing.

      An outer coaxial tube is present to deliver fresh air; exhaust air is routed to an inner tube, which is then delivered to a scavenging system. An expiratory valve is seen at the patient end, which is an advantage over other circuits. Moreover, the Lack circuit prevents rebreathing slightly greater than the alveolar minute ventilation at 4-5 litres per minute.

      The Bain circuit prevents rebreathing at 160-200ml/kg per minute, and is a co-axial version of the Mapleson D circuit.

      The Mapleson E circuit prevent rebreathing at a fresh gas flow (FGF) of approximately twice the patient’s normal minute volume. A modification of this, the Mapleson F, has a reservoir bag at the opposite end for the FGF. This circuit is appropriate for paediatric patients with a body weight less than 20 kg.

    • This question is part of the following fields:

      • Anaesthesia Related Apparatus
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  • Question 75 - A 50-year-old man is admitted in hospital. Over four hours, he produces 240...

    Incorrect

    • A 50-year-old man is admitted in hospital. Over four hours, he produces 240 mL of urine and has a plasma creatinine concentration is 10 mcg/mL. The normal concentration of creatinine in urine is 1.25 mg/mL. Calculate his approximate creatinine clearance.

      Your Answer:

      Correct Answer: 125 ml/minute

      Explanation:

      Creatinine clearance is a test used to approximate the glomerular filtration rate (GFR) as an assessment of kidney function.

      Creatinine is formed during the breakdown of dietary sources of meat and skeletal muscle. It is secreted at a consistent concentration and pace into the body’s circulation, and is easily filtered across the glomerulus without being reabsorbed or metabolized by the kidney.

      It is represented mathematically as:
      Creatinine clearance (CL) = U x V/P
      where,
      U: Urinary creatinine concentration (mg/mL)
      V: Volume of urine (mL/min)
      P: Plasma creatinine concentration (mg/mL)

      Therefore, in this case:
      CL: 1.25 x 1 = 125mL/min.

    • This question is part of the following fields:

      • Clinical Measurement
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  • Question 76 - Which of the following derived SI units is correctly expressed as their base...

    Incorrect

    • Which of the following derived SI units is correctly expressed as their base units?

      Your Answer:

      Correct Answer: Volt: m2.kg.s-3.A-1

      Explanation:

      The following units are derived SI units of measurement.

      Energy or work: kg.m2.s-2
      The Joule (J) is the energy transferred to an object when a force of one newton acts on that object in the direction of its motion through a distance of one meter or N.m.

      Power: kg.m2.s-3
      The Watt (W) = rate of transfer of energy or Joule per second J/s.

      Force: kg.m.s-2
      One Newton (N) which is the international unit of measure for force = 1 kilogram meter per second squared. 1 Newton of force is the force required to accelerate an object with a mass of 1 kilogram 1 meter per second per second.

      Volt: kg.m2.s-3.A-1
      The volt (V) is defined as the potential difference across a conductor when a current of one ampere dissipates one watt of power or W/A.

      Pressure: kg.m-1.s-2
      A pascal (Pa) is force per unit area or N/m2.

    • This question is part of the following fields:

      • Basic Physics
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  • Question 77 - Which of the following statement regarding Adrenaline (Epinephrine) is not true? ...

    Incorrect

    • Which of the following statement regarding Adrenaline (Epinephrine) is not true?

      Your Answer:

      Correct Answer: Inhibits glycolysis in muscle

      Explanation:

      Adrenaline acts on α1, α2, β1, and β2 receptors and also on dopamine receptors (D1, D2) and have sympathomimetic effects.

      Natural catecholamines are Adrenaline, Noradrenaline, and Dopamine

      Adrenaline is a sympathomimetic amine with both alpha and beta-adrenergic stimulating properties.
      Adrenaline is the drug of choice for anaphylactic shock
      Adrenaline is also used in patients with cardiac arrest. The preferred route is i.v. followed by the intra-osseous and endotracheal route.

      Adrenaline is released by the adrenal glands, acts on α 1 and 2, β 1 and 2 receptors, and is responsible for fight or flight response.

      It acts on β 2 receptors in skeletal muscle vessels-causing vasodilation.

      It acts on α adrenergic receptors to inhibit insulin secretion by the pancreas. It also stimulates glycogenolysis in the liver and muscle, stimulates glycolysis in muscle.

      It acts on β adrenergic receptors to stimulate glucagon secretion in the pancreas
      It also stimulates Adrenocorticotrophic Hormone (ACTH) and stimulates lipolysis by adipose tissue

    • This question is part of the following fields:

      • Pharmacology
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  • Question 78 - A 55-year-old businesswoman presents to the emergency department complaining of shortness of breath...

    Incorrect

    • A 55-year-old businesswoman presents to the emergency department complaining of shortness of breath and pleuritic chest pain. Her work requires her to travel internationally frequently. The consultant makes a diagnosis and treats her. Now, the consultant recommends placing a filter that will prevent future incidents. A needle is placed into the femoral vein and passed up into the abdomen to insert the filter. What is true regarding the organ where the filter is placed for this patient's condition?

      Your Answer:

      Correct Answer: It is located posteriorly to the peritoneum

      Explanation:

      The patient likely suffers from pulmonary embolism due to her history of frequent international travels. A filter is placed in the inferior vena cava to decrease the risk of future episodes of pulmonary embolism. The IVC filter is a small, wiry device that can catch blood clots and stop them from going into the heart and lungs. Your IVC is a major vessel that brings deoxygenated blood from the lower body to the heart, from where it is pumped into the lungs.

      The filter is placed via a thin catheter inserted into the femoral vein in the groin. The catheter is gently moved up into your IVC, and a filter is introduced.

      The IVC is a retroperitoneal organ.

    • This question is part of the following fields:

      • Anatomy
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  • Question 79 - A 70-year-old man presents with bilateral buttock claudication that spreads down the thigh...

    Incorrect

    • A 70-year-old man presents with bilateral buttock claudication that spreads down the thigh and erectile dysfunction in a vascular clinic. The left femoral pulse is not palpable on examination, and the right is weakly palpable. Leriche syndrome is diagnosed as the blood flow at the abdominal aortic bifurcation is blocked due to atherosclerosis. He is prepared for aortoiliac bypass surgery. Which vertebral level will you find the affected artery that requires bypassing?

      Your Answer:

      Correct Answer: L4

      Explanation:

      The bifurcation of the abdominal aorta into common iliac arteries occurs at the level of L4. The bifurcation is a common site for atherosclerotic plaques as it is an area of high turbulence.

      Leriche Syndrome is an aortoiliac occlusive disease and affects the distal abdominal aorta, iliac arteries, and femoropopliteal vessels. It has a triad of symptoms:
      1. Claudication (cramping lower extremities pain that is reproducible by exercise)
      2. Impotence (reduced penile arterial flow)
      3. Absent/weak femoral pulses (hallmark)

      T12 – aorta enters the diaphragm with the thoracic duct and azygous veins

      L2 – testicular or ovarian arteries branch off the aorta

      L3 – inferior mesenteric artery.

    • This question is part of the following fields:

      • Anatomy
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  • Question 80 - The structure most likely to be damaged during cannulation of the subclavian vein...

    Incorrect

    • The structure most likely to be damaged during cannulation of the subclavian vein is?

      Your Answer:

      Correct Answer: Subclavian artery

      Explanation:

      The subclavian artery lies behind and partly above the subclavian vein. 3-4% of the time, it can be inadvertently cannulated during cannulation of the subclavian vein

      Because of its anatomical position, putting pressure on the subclavian artery is impossible so arresting bleeding with pressure when it is punctured is not viable.

      One of the consequences of subclavian vein cannulation (1%) is pleural puncture leading to a pneumothorax. This is because the apical pleura is inferior and caudal to the subclavian vein.

    • This question is part of the following fields:

      • Anatomy
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  • Question 81 - Regarding management of chronic pain, which of the following describes the mode of...

    Incorrect

    • Regarding management of chronic pain, which of the following describes the mode of action of gabapentin?

      Your Answer:

      Correct Answer: Modulation of voltage dependent calcium channels and NMDA receptor transmission

      Explanation:

      Gabapentin is an amino acid-like molecules that was originally synthesized as an analogue of GABA but is now known not to act through GABA mechanisms. It is used in the treatment of focal seizures and various nonepilepsy indications, such as neuropathic pain, restless legs syndrome, and anxiety disorders.

      Despite its close structural resemblance to GABA, gabapentin does not act through effects on GABA receptors or any other mechanism related to GABA-mediated neurotransmission. Rather gabapentin binds avidly to α2δ, a protein that serves as an auxiliary subunit of voltage-gated calcium channels. Moreover, it binds to NMDA receptor to modulate its transmission.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 82 - A 30-year-old woman admitted following a tonsillectomy has developed stridor with a respiratory...

    Incorrect

    • A 30-year-old woman admitted following a tonsillectomy has developed stridor with a respiratory rate of 22 breaths per minute and obstructive movements of the chest and abdomen that is in a see-saw pattern . Her SpO2 is 92% on 60% oxygen with pulse rate 120 beats per minute while her blood pressure is 180/90mmHg. She is repeatedly trying to remove the oxygen mask and appears anxious. Her pharynx is suctioned and CPAP applied with 100% oxygen via a Mapleson C circuit. Which of these is the most appropriate next step in her management?

      Your Answer:

      Correct Answer: Administer intravenous propofol 0.5 mg/kg

      Explanation:

      Continuous closure of the vocal cords resulting in partial or complete airway obstruction is called Laryngospasm. It is a reflex that helps protect against pulmonary aspiration.

      Predisposing factors include: Hyperactive airway disease, Insufficient depth of anaesthesia, Inexperience of the anaesthetist, Airway irritation, Smoking, Shared airway surgery and Paediatric patients

      Its primary treatment includes checking for blood or stomach aspirate in the pharynx, removing any triggering stimulation, relieving any possible supra-glottic component to airway obstruction and application of CPAP with 100% oxygen.

      In this patient, all the above has been done and the next treatment of choice is the administration of a rapidly acting intravenous anaesthetic agent such as propofol (0.5 mg/kg) in increments as it has been reported to relieve laryngospasm in approximately 75% of cases. Administering suxamethonium to an awake patient would be inappropriate at this stage.

      Magnesium and lidocaine are used for prevention rather than acute treatment of laryngospasm. Superior laryngeal nerve blocks have been reported to successfully treat recurrent laryngospasm but it is not the next logical step in index patient.

    • This question is part of the following fields:

      • Pathophysiology
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  • Question 83 - All the following statements are false regarding local anaesthetic except ...

    Incorrect

    • All the following statements are false regarding local anaesthetic except

      Your Answer:

      Correct Answer: Potency is directly related to lipid solubility

      Explanation:

      The potency of local anaesthetics is directly proportional to lipid solubility because they need to penetrate the lipid-soluble membrane to enter the cell.

      Protein binding has a direct relationship with the duration of action because the higher the ability of the drug to bind with membrane protein, the higher is the duration of action.

      Higher the pKa of a drug, slower the onset of action. Because a drug with higher pKa will be more ionized than the one with lower pKa at a given pH. Local anaesthetics are weak bases, and unionized form diffuses more rapidly across the nerve membrane than the protonated form. As a result drugs with higher pKa will be more ionized will diffuse less across the nerve membrane.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 84 - A study designed to examine the benefits of adding a new antiplatelet to...

    Incorrect

    • A study designed to examine the benefits of adding a new antiplatelet to aspirin after a myocardial infraction. The recorded results give us the percentage of patients that reported myocardial infraction within a three month period. The percentage was 4% and 3% for aspirin and the combination of drugs respectively. How many further patients needed to be treated in order for one patient to avoid any more heart attacks during 3 months?

      Your Answer:

      Correct Answer: 100

      Explanation:

      Number needed to treat can be defined as the number of patients who need to be treated to prevent one additional bad outcome.

      It can be found as:

      NNT=1/Absolute Risk Reduction (rounded to the next integer since number of patients can be integer only).

      where ARR= (Risk factor associated with the new drug group) — (Risk factor associated with the currently available drug)

      So,

      ARR= (0.04-0.03)

      ARR= 0.01

      NNT= 1/0.01

      NNT=100

    • This question is part of the following fields:

      • Statistical Methods
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  • Question 85 - An 80-year-old man will be operated on for an arterial bypass procedure to...

    Incorrect

    • An 80-year-old man will be operated on for an arterial bypass procedure to treat claudication and foot ulceration. The anterior tibial artery will be the target for distal arterial anastomosis. Which structure is NOT closely related to the anterior tibial artery?

      Your Answer:

      Correct Answer: Tibialis posterior

      Explanation:

      The anterior tibial artery originates from the distal border of the popliteus. In the posterior compartment, it passes between the heads of the tibialis posterior and the oval aperture of the interosseous membrane to reach the anterior compartment.

      On entry into the anterior compartment, it runs medially along the deep peroneal nerve.
      The upper third of the artery courses between the tibialis anterior and extensor digitorum longus muscles, while the middle third runs between the tibialis anterior and extensor hallucis longus muscles.

      At the ankle, the anterior tibial artery is located approximately midway between the malleoli. It continues on the dorsum of the foot, lateral to extensor hallucis longus, as the dorsalis pedis artery.

    • This question is part of the following fields:

      • Anatomy
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  • Question 86 - A caudal epidural block is planned for a 6-year-old child scheduled for an...

    Incorrect

    • A caudal epidural block is planned for a 6-year-old child scheduled for an inguinoscrotal hernia repair under general anaesthesia. The weight of the child is 20kg. The most important safety aspect the anaesthetist must keep in mind while performing the block is?

      Your Answer:

      Correct Answer: Limiting the bupivacaine dose to no more than 40 mg

      Explanation:

      Choosing an appropriate dose of local anaesthetic to reduce the chance of toxicity is the most important safety aspect in performing a caudal block.

      The caudal will have to be inserted following induction of anaesthesia as performing it in an awake child is not a viable option.

      The patient is placed in the lateral position and the sacral hiatus is identified. Under strict asepsis, a needle ( usually a 21-23FG needle) is advanced at an angle of approximately 55-65° to the coronal plane at the apex of the sacrococcygeal membrane. When there is loss of resistance, thats the endpoint. The needle must first be aspirated before anaesthetic agent is injected because there is a risk (1 in 2000) of perforating the dura or vascular puncture.

      Alternatively, a 22-gauge plastic cannula can be used. Following perforation of the sacrococcygeal membrane, the stilette is removed and only the blunter plastic cannula is advanced. This reduces the risk of intravascular perforation.

      Eliciting an appropriate end motor response at an appropriate current strength when the caudal and epidural spaces are stimulated helps in improving the efficacy and safety of neural blockade. A 22G insulated needle is advanced in the caudal canal until a pop is felt. If the needle is placed correctly, an anal sphincter contractions (S2 to S4) is seen when an electrical stimulation of 1-10 mA is applied.

      The application of ultrasound guidance in identification of the caudal epidural space has been shown to prevent inadvertent dural puncture and to increase the safety and efficacy of the block in children.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 87 - Which of the following statement is not true regarding soda lime? ...

    Incorrect

    • Which of the following statement is not true regarding soda lime?

      Your Answer:

      Correct Answer: Silica is added to prevent disintegration of the granules

      Explanation:

      Soda-lime contains mostly calcium hydroxide (about 94%) and the remaining sodium hydroxide.

      CO2 + Ca(OH)2 †’ CaCO3 + H2O + heat
      Here in this exothermic reaction, we can see that the production of calcium carbonate does not require heat.

      When soda lime is allowed to dry with subsequent use of desflurane, isoflurane, and enflurane, it can lead to the generation of carbon monoxide.

      Silicated hardens the granules and can thus prevent disintegration.

      The size of soda-lime granules is 4-8 mesh because it allows sufficient surface area for chemical reaction to occur without critically increasing the resistance to airflow.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 88 - An inguinal hernia repair under general anaesthesia is scheduled for a fit 36-year-old...

    Incorrect

    • An inguinal hernia repair under general anaesthesia is scheduled for a fit 36-year-old man (75 kg). For perioperative and postoperative analgesia, you decide to perform an inguinal field block. Which of the following local anaesthetic solutions is the most appropriate?

      Your Answer:

      Correct Answer: 30 mL bupivacaine 0.5%

      Explanation:

      Perioperative and postoperative analgesia can both be provided by an inguinal hernia field block. The Iliohypogastric and ilioinguinal nerves, as well as the skin, superficial fascia, and deeper structures, must be blocked for maximum effectiveness. The local anaesthetic should ideally have a long duration of action, be highly concentrated, and have a volume of at least 30 mL.

      Plain bupivacaine has a maximum safe dose of 2 mg/kg body weight.

      Because the patient weighs 75 kg, 150 mg bupivacaine can be safely administered. Both 30 mL 0.5 percent bupivacaine (150 mg) and 60 mL 0.25 percent bupivacaine (150 mg) are acceptable doses, but 30 mL 0.5 percent bupivacaine represents the optimal volume and strength, potentially providing a denser and longer block.

      The maximum safe dose of plain lidocaine has been estimated to be between 3.5 and 5 mg/kg. The patient weighs 75 kg and can receive a maximum of 375 mg using the higher dosage regimen:

      There are 200 mg of lidocaine in 10 mL of 2% lidocaine (and therefore 11 mL contains 220 mg)
      200 mg of lidocaine is contained in 20 mL of 1% lidocaine.

      While alternatives are available, Although the doses of 11 mL lidocaine 2% and 20 mL lidocaine 1% are well within the dose limit, the volumes used are insufficient for effective field block for this surgery.

      With 1 in 200,000 epinephrine, the maximum safe dose of lidocaine is 7 mg/kg. The patient can be given 525 mg in this case. Even with epinephrine, 60 mL of 1% lidocaine is 600 mg, which could be considered an overdose.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 89 - What is the name of the space between the vocal cords? ...

    Incorrect

    • What is the name of the space between the vocal cords?

      Your Answer:

      Correct Answer: Rima glottidis

      Explanation:

      The rima glottidis is a narrow, triangle-shaped opening between the true vocal cords.

      The vocal folds (true vocal cords) control sound production. The apex of each fold projects medially into the laryngeal cavity.

      Each vocal fold includes these vocal ligaments:

      Vocalis muscle (most medial part of thyroarytenoid muscle)

      The glottis is composed of the vocal folds, processes and rima glottidis.

      The rima glottidis is the narrowest potential site within the larynx, as the vocal cords may be completely opposed, forming a complete barrier.

    • This question is part of the following fields:

      • Anatomy
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  • Question 90 - Which of the following statements is true regarding enantiomers? ...

    Incorrect

    • Which of the following statements is true regarding enantiomers?

      Your Answer:

      Correct Answer: Desflurane is a chiral compound

      Explanation:

      A compound that contains an asymmetric centre (chiral atom or chiral centre) and thus can occur in two non-superimposable mirror-image forms (enantiomers) are called chiral compounds.

      Desflurane, Halothane, and isoflurane are chiral compounds but Sevoflurane is not a chiral compound.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 91 - During exercise, muscle blood flow can increase by 20 to 50 times. Which...

    Incorrect

    • During exercise, muscle blood flow can increase by 20 to 50 times. Which mechanism is the most important for increased blood flow?

      Your Answer:

      Correct Answer: Local autoregulation

      Explanation:

      Skeletal muscle blood flow is in the range of 1-4 ml/min per 100 g when at rest. Blood flow can reach 50-100 ml/min per 100 g during exercise. With maximal vasodilation, blood flow can increase 20 to 50 times.

      The adrenal medulla releases catecholamines and increases neural sympathetic activity during exercise. Normally, alpha-1 and alpha-2 would cause vasoconstriction in the muscle groups being used, but vasodilatory metabolites override these effects, resulting in a so-called functional sympathectomy. Local hypoxia and hypercarbia, nitric oxide, K+ ions, adenosine, and lactate are some of the stimuli that cause vasodilation.

      However, the splanchnic and cutaneous circulations, which supply inactive muscles, vasoconstrict.

      Sympathetic cholinergic innervation of skeletal muscle arteries is found in some species (such as cats and dogs, but not humans). Vasodilation is induced by stimulating smooth muscle beta-2 adrenoreceptors, but at rest, the alpha-adrenoreceptor effects of adrenaline and noradrenaline predominate. During exercise, the skeletal muscle pump promotes venous emptying, but it does not necessarily increase blood flow.

    • This question is part of the following fields:

      • Physiology
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  • Question 92 - In a diagnosis of a compensated respiratory acidosis, which of the following arterial...

    Incorrect

    • In a diagnosis of a compensated respiratory acidosis, which of the following arterial blood gas results is likely to be seen?

      Your Answer:

      Correct Answer: pH = 7.34
      PaCO2 = 7.2 kPa
      HCO3 = 29

      Explanation:

      During normal tissue metabolism, there is production of CO2 (acid) which is then expired by the lungs. If metabolism switches from aerobic to anaerobic due to a lack of oxygen, the tissues are unable to completely oxidise sugars to CO2. As a consequence, the sugars can only be partially oxidised to lactic acid. Since lactic acid cannot be expired by the lungs, it remains in the circulation leading to metabolic acidosis.

      Also, normal tissue metabolism leads to the production of some amount of acid from the breakdown of proteins. These acids are excreted from the body by kidney filtration. Renal failure will therefore results in acidosis after several days.

      An increased acidosis stimulates the brain’s respiratory centres to increase the respiratory rate. This lowers the CO2 in the blood, leading to a decrease in its acidity. Renal excretion removes the excess acid, resulting in a normal pH, and a reduced PaCO2 and HCO3.

      pH PaCO2 (kPa) HCO3
      Compensated respiratory acidosis 7.34 7.2 29
      Acute respiratory acidosis 7.25 7.3 22
      Compensated metabolic acidosis 7.34 3.6 14
      Metabolic acidosis 7.21 5.3 15
      Metabolic alkalosis 7.51 5.1 30

    • This question is part of the following fields:

      • Pathophysiology
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  • Question 93 - Which of the following statements is true about monoamine oxidase (MOA) enzymes? ...

    Incorrect

    • Which of the following statements is true about monoamine oxidase (MOA) enzymes?

      Your Answer:

      Correct Answer: Type A and type B are found in the liver and brain

      Explanation:

      Monoamine oxidase (MOA) enzymes are responsible for the catalyses of monoamine oxidative deamination. It assists the degradation of serotonin, norepinephrine (NE) and dopamine.

      They are found in the mitochondria of most central and peripheral nerve tissues.

      There are 2 different types:

      Type A: Whose main function it to inactivate dopamine, tyramine, norepinephrine and 5-hydroxytryptamine. In addition to the nervous system, it is also found in the liver, brain gastrointestinal tract, pulmonary endothelium and placenta
      Type B: Whose main function is to inactivate dopamine, tyramine, tryptamine and phenylethylamine. In addition to the nervous system, it is also found in the liver, brain (especially in the basal ganglia) and blood platelets.

    • This question is part of the following fields:

      • Pathophysiology
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  • Question 94 - Which of the following statements is correct about a characteristic that is normally...

    Incorrect

    • Which of the following statements is correct about a characteristic that is normally distributed in a population?

      Your Answer:

      Correct Answer: There will be approximately equal numbers who have more or less of the characteristic than the mean

      Explanation:

      68% of the population will be found in one standard deviation (SD) above plus one SD below the mean. Two SDs above plus two SDs below the mean will include 95% of the population.

      The median can be greater or less than the mean as it is simply the mid point of the data after the data is arranged. Half the data are above and half below the median .

      The mode is a true score, unlike the mean or the median. It is the most common score or the score obtained from the largest number of subjects in any given data.

    • This question is part of the following fields:

      • Statistical Methods
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  • Question 95 - Health workers are at increased risks of anaesthetic exposure. Therefore, The Control of...

    Incorrect

    • Health workers are at increased risks of anaesthetic exposure. Therefore, The Control of Substances Hazardous to Health (COSHH) regulations require measures implemented to assess and control the risks related to this exposure. Among the following control measures, which one is most likely to limit potentially harmful exposure to anaesthetic agents within an operating theatre?

      Your Answer:

      Correct Answer: Total intravenous anaesthesia (TIVA)

      Explanation:

      Exposure to anaesthetic hazards is one among the occupational exposures in manipulating toxic agents or inhaling toxic gases during anaesthetic practices.

      Toxic gases mainly nitrous oxide, is one of the most gaseous anaesthetic agents that constitutes an important source of pollution. One of the safe and effective technics used in anaesthesia and reducing the amount of pollution is the Total Intravenous Anaesthesia (TIVA) which consists of using opioids in analgesia and propofol for the induction and the maintenance of anaesthesia. It refers to the administration intravenously of an anaesthetic, sedative, and/or tranquilizer. A less polluting but not the best way to get rid of the toxic aesthetic agents is the scavenger system that collects and expels the gas outside the medical environment. Yet, this technique still represents a hazard for the environment and still increase the risk of exposure for the health workers and clinical staff.

      Fume cupboards are also not recommended to use because of their high pollution potency, mainly of the air resulting in a great harm for medical workers.

      Supraglottic airways as well as the Air Changes per Hour technics could be harmful for both patients and health workers, increasing the risks of transmitted diseases, namely nosocomial infections.

      Therefore, the Total Intravenous Anaesthesia technique (TIVA) is most likely to be safe and recommended to use.

    • This question is part of the following fields:

      • Anaesthesia Related Apparatus
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  • Question 96 - A weakly acidic drug with a pKa of 8.4 is injected intravenously into...

    Incorrect

    • A weakly acidic drug with a pKa of 8.4 is injected intravenously into a patient. At a normal physiological pH, the percentage of this drug unionised in the plasma is?

      Your Answer:

      Correct Answer: 90

      Explanation:

      Primary FRCA is concerned with two issues. The first is a working knowledge of the Henderson-Hasselbalch equation, and the second is a working knowledge of logarithms and antilogarithms.

      The pH at which the drug exists in 50 percent ionised and 50 percent unionised forms is known as the pKa.

      To calculate the proportion of ionised to unionised form of a drug, use the Henderson-Hasselbalch equation.

      pH = pKa + log ([A-]/[HA])

      or

      pH = pKa + log [(salt)/(acid)]
      pH = pKa + log ([ionised]/[unionised])

      Hence, if the pKa ˆ’ pH = 0, then 50% of drug is ionised and 50% is unionised.

      In this example:
      7.4 = 8.4 + log ([ionised]/[unionised])
      7.4 ˆ’ 8.4 = log ([ionised]/[unionised])
      log ˆ’1 = log ([ionised]/[unionised])

      Simply put, the antilog is the inverse log calculation. In other words, if you know the logarithm of a number, you can use the antilog to find the value of the number. The antilogarithm’s definition is as follows:

      y = antilog x = 10x

      Antilog to the base 10 of 0 = 1, ˆ’1 = 0.1, ˆ’2 = 0.01, ˆ’3 = 0.001 and, ˆ’4 = 0.0001.

      [A-]/[HA] = 0.1

      Assuming that we can apply the approximation [A-] << [HA} then this means the acid is 0.1 x 100% = 10% ionised

      so the percentage of (non-ionized) acid will be 100% – 10% = 90%

    • This question is part of the following fields:

      • Pharmacology
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  • Question 97 - A 68-year-old man is to be operated.   His past history is significant...

    Incorrect

    • A 68-year-old man is to be operated.   His past history is significant for a stroke, and some residual neurological deficit. The cranial nerves are examined clinically. He is unable to rotate his head to the left side when resistance is applied. Moreover, there is tongue wasting on the right side. There are no unusual sensory signs and symptoms. The most likely reason for these clinical findings is?

      Your Answer:

      Correct Answer: Damage to hypoglossal (XII) and spinal accessory (XI) nerves

      Explanation:

      The upper five cervical segments of the spinal cord give rise to the XI cranial nerve. They connect with a few smaller branches before exiting the skull through the jugular foramen. The sternomastoid and trapezius muscles get their motor supply from the accessory root. Except for the palatoglossus, the hypoglossal nerve supplies motor supply to all tongue muscles.

      The inability to shrug the shoulder on the affected side and rotate the head to the side against resistance is caused by damage to the spinal accessory nerve. This is due to the trapezius and sternomastoid muscles’ weakness.

      The hypoglossal nerve is damaged, resulting in tongue wasting and inability to move from side to side.

      The stylopharyngeus receives motor supply from the glossopharyngeal nerve. It also carries taste sensory fibres from the back third of the tongue, as well as the carotid sinus, carotid body, pharynx, and middle ear.

      Motor supply to the larynx, pharynx, and palate; parasympathetic innervation to the heart, lung, and gut; and sensory fibres from the epiglottis and valleculae are all provided by the vagus nerve.

    • This question is part of the following fields:

      • Pathophysiology
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  • Question 98 - The renal glomerulus is able to filter 180 litres of blood per day,...

    Incorrect

    • The renal glomerulus is able to filter 180 litres of blood per day, as determined by the starling forces present in the glomerulus. Ninety-nine percent of which is reabsorbed thereafter. Water is reabsorbed in the highest proportion in which segment of the nephron?

      Your Answer:

      Correct Answer: Proximal convoluted tubule

      Explanation:

      Sixty-seven percent of filtered water is reabsorbed in the proximal tubule. The driving force for water reabsorption is a transtubular osmotic gradient established by reabsorption of solutes (e.g., NaCl, Na+-glucose).

      Henle’s loop reabsorbs approximately 25% of filtered NaCl and 15% of filtered water. The thin ascending limb reabsorbs NaCl by a passive mechanism, and is impermeable to water. Reabsorption of water, but not NaCl, in the descending thin limb increases the concentration of NaCl in the tubule fluid entering the ascending thin limb. As the NaCl-rich fluid moves toward the cortex, NaCl diffuses out of the tubule lumen across the ascending thin limb and into the medullary interstitial fluid, down a concentration gradient as directed from the tubule fluid to the interstitium. This mechanism is known as the counter current multiplier.

      The distal tubule and collecting duct reabsorb approximately 8% of filtered NaCl, secrete variable amounts of K+ and H+, and reabsorb a variable amount of water (approximately 8%-17%).

    • This question is part of the following fields:

      • Physiology
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  • Question 99 - Regarding adrenocorticotropic hormone (ACTH) one of these is true. ...

    Incorrect

    • Regarding adrenocorticotropic hormone (ACTH) one of these is true.

      Your Answer:

      Correct Answer: Is increased in the maternal plasma in pregnancy

      Explanation:

      ACTH production is stimulated through the secretion of corticotropin-releasing hormone (CRH) from the hypothalamic nuclei.

      ACTH secretion has a circadian rhythm. A high level of cortisol in the body stops its production. ACTH is secreted maximally in the morning and concentrations are lowest at midnight.

      ACTH can be expressed in the placenta, the pituitary and other tissues.

      Conditions where ACTH concentrations rise include: stress, disease and pregnancy.

      Glucocorticoids (not mineralocorticoids – aldosterone) switch off ACTH production through a negative feedback loop .

    • This question is part of the following fields:

      • Pathophysiology
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  • Question 100 - A 5-year old male has ingested a peanut and has developed urticaria, vomiting...

    Incorrect

    • A 5-year old male has ingested a peanut and has developed urticaria, vomiting and hypotension. The pathogenesis of this condition is derived from predominant cells of which cell line?

      Your Answer:

      Correct Answer: Common myeloid progenitor

      Explanation:

      A is correct. Common myeloid progenitor cells are involved in the anaphylaxis reaction.
      B is incorrect. The common lymphoid lineage gives rise to T-cells, B-cell and NK cells.
      C is incorrect as megakaryocytes give rise to platelets.
      D is incorrect – Neural crest cells give rise to various cells throughout the body, including melanocytes, enterochromaffin cells and Schwann cells. However, they do not give rise to mast cells.
      E is incorrect. Reticulocytes give rise to erythrocytes.

      This is a classic case of anaphylaxis. In this situation, IgE previously raised against antigens (in this case peanut antigen) bind to mast cells, and this causes them to degranulate.
      There is release of vasoactive substances like histamine into the blood, and this is responsible for the symptoms seen. Therefore, the main type of cells involved in the pathogenesis of the disease is mast cells.

    • This question is part of the following fields:

      • Physiology And Biochemistry
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SESSION STATS - PERFORMANCE PER SPECIALTY

Anatomy (2/2) 100%
Physiology And Biochemistry (0/1) 0%
Pharmacology (1/1) 100%
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