00
Correct
00
Incorrect
00 : 00 : 0 00
Session Time
00 : 00
Average Question Time ( Secs)
  • Question 1 - A 63 year old man presents to the clinic complaining of a 6-month history...

    Correct

    • A 63 year old man presents to the clinic complaining of a 6-month history of shortness of breath on exertion and a non-productive cough.   On examination there is clubbing, and crepitations heard at the lung bases. Lung function tests show a reduced vital capacity and an increased FEV1/FVC ratio.   What is his diagnosis?

      Your Answer: Idiopathic pulmonary fibrosis

      Explanation:

      Idiopathic pulmonary fibrosis (IPF) is a condition in which the lungs become scarred and breathing becomes increasingly difficult.
      The most common signs and symptoms of idiopathic pulmonary fibrosis are shortness of breath and a persistent dry, hacking cough. Many affected individuals also experience a loss of appetite and gradual weight loss.

      The clinical findings of IPF are bibasilar reticular abnormalities, ground glass opacities, or diffuse nodular lesions on high-resolution computed tomography and abnormal pulmonary function studies that include evidence of restriction (reduced VC with an increase in FEV1/FVC ratio) and/or impaired gas exchange (increased P(A-a)O2 with rest or exercise or decreased diffusion capacity of the lung for carbon monoxide [DLCO]).

    • This question is part of the following fields:

      • Respiratory
      17.2
      Seconds
  • Question 2 - A 25-year-old woman with Charcot-Marie-Tooth disease (type 1) asks how likely it is...

    Incorrect

    • A 25-year-old woman with Charcot-Marie-Tooth disease (type 1) asks how likely it is that any future children will have the disease. What is the most accurate answer?

      Your Answer: 25%

      Correct Answer: 50%

      Explanation:

      Because Charcot-Marie-Tooth disease (type 1) is an autosomal dominant condition; therefore, there is a 50% chance that the children of this patient will be affected.

    • This question is part of the following fields:

      • Neurology
      16.5
      Seconds
  • Question 3 - A 25-year-old woman presented to the ED with carbon monoxide poisoning. High-flow oxygen...

    Incorrect

    • A 25-year-old woman presented to the ED with carbon monoxide poisoning. High-flow oxygen was administered immediately. She had a GCS of 15 and her vitals were stable. Which one of the following is not an indication for hyperbaric oxygen therapy in this scenario?

      Your Answer: Pregnancy and a carboxyhaemoglobin concentration of >20%

      Correct Answer: A carboxyhaemoglobin concentration of 16%

      Explanation:

      Carbon monoxide (CO) poisoning, considered as the great imitator of other diseases, as the patients present with a myriad of symptoms. The carbon monoxide diffuses rapidly across the pulmonary capillary membrane binding to the haem molecule with a very high affinity (240 times that of oxygen) forming carboxy-haemoglobin (COHb). Non-smokers have a baseline COHb of ,3% while smokers have a baseline COHb of 10-15%.

      Use of Hyperbaric oxygen therapy (HBOT) for treatment of mild to moderate CO poisoning is not routine.
      The selection criteria for HBOT in cases of CO poisoning include:
      • COHb levels > 20-25%
      • COHb levels > 20% in pregnant patient
      • Loss of consciousness
      • Severe metabolic acidosis (pH <7.1)
      • Evidence of end-organ ischemia (e.g., ECG changes, chest pain, or altered mental status)
      Principle of HBOT:
      Exposing patients to 100 percent oxygen under supra-atmospheric conditions results in a decrease in the half-life (t1/2) of COHb, from , 90 min in atmospheric air to , 30 minutes. The amount of oxygen dissolved in the blood also rises from , 0.3 to 6 mL/dL, increasing the delivery of non-haemoglobin-bound oxygen to the tissues.

    • This question is part of the following fields:

      • Pharmacology
      74
      Seconds
  • Question 4 - A 28-year-old man who is admitted with bright red haematemesis, which occurred after...

    Incorrect

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

      Your Answer: Give one-month course of omeprazole

      Correct Answer: Send home

      Explanation:

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

    • This question is part of the following fields:

      • Gastroenterology
      43
      Seconds
  • Question 5 - Choose the most important stimulator of the central chemoreceptors: ...

    Incorrect

    • Choose the most important stimulator of the central chemoreceptors:

      Your Answer: Decrease in pCO2

      Correct Answer: Decrease in pH

      Explanation:

      Central chemoreception refers to the detection of changes in CO2/H+ within the brain and the associated effects on breathing. In the conscious animal the response of ventilation to changes in the brain’s interstitial fluid (ISF) pH is very sensitive. Note that a small change in cerebrospinal fluid (CSF) pH from 7.30 to 7.25 is associated with a doubling of alveolar ventilation; it is a very sensitive reflex response. Note also that the relationship of alveolar ventilation to ISF pH is essentially the same for both types of stimulation, metabolic acid-base disorders and primary CO2 stimulation.

    • This question is part of the following fields:

      • Clinical Sciences
      12.1
      Seconds
  • Question 6 - A 31-year-old female is admitted to the E.D complaining of severe abdominal pain....

    Incorrect

    • A 31-year-old female is admitted to the E.D complaining of severe abdominal pain. On examination, she is seen trembling and rolling around the trolley. She has previously been investigated for abdominal pain and no cause has been found. She states that she will commit suicide unless she is given morphine for the pain. Which condition is this is an example of?

      Your Answer: Munchausen's syndrome

      Correct Answer: Malingering

      Explanation:

      Malingering is not considered a mental illness. In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), malingering receives a V code as one of the other conditions that may be a focus of clinical attention. The DSM-5 describes malingering as the intentional production of false or grossly exaggerated physical or psychological problems. Motivation for malingering is usually external (e.g., avoiding military duty or work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs).

      Malingering should be strongly suspected if any combination of the following factors is noted to be present: (1) medicolegal context of presentation; (2) marked discrepancy between the person’s claimed stress or disability and the objective findings; (3) lack of cooperation during the diagnostic evaluation and in complying with the prescribed treatment regimen; and (4) the presence in the patient of antisocial personality disorder (ASPD).

      This patient is be pretending to be sick in order to get morphine.

    • This question is part of the following fields:

      • Psychiatry
      19.3
      Seconds
  • Question 7 - A 46 year old woman with a history of depression visits the clinic...

    Correct

    • A 46 year old woman with a history of depression visits the clinic for a review. She was started on Fluoxetine 7 weeks earlier and is requesting that this medication be stopped because she feels well. What recommendation would you give with regards to the treatment?

      Your Answer: It should be continued for at least another 6 months

      Explanation:

      Depressive disorders require long-term treatment with antidepressants, psychotherapy, or both. The goal of antidepressant therapy is complete remission of symptoms and return to normal daily functioning. Studies have shown that achieving remission and continuing antidepressant therapy long after the acute symptoms remit can protect against the relapse or recurrence of the psychiatric episode. Many patients, however, inadvertently or intentionally skip doses of their antidepressant, and even discontinue it, if their symptoms improve or if they experience side effects. Antidepressant discontinuation may increase the risk of relapse or precipitate certain distressing symptoms such as gastrointestinal complaints, dizziness, flu-like symptoms, equilibrium disturbances, and sleep disorders.

      Pharmacologic therapy should be continued long enough to sustain remission and avoid relapses and recurrences. Recurrence refers to a return of depression at a time beyond the expected duration of the index episode (> 9 months after remission). This means that physicians and patients alike should not be too eager to discontinue medication prematurely. An interval of 6 months has been thought to be the usual duration of antidepressant therapy. New recommendations, however, suggest that treatment should continue for up to 9 months after symptoms have resolved (continuation phase) to prevent relapse and for longer to help prevent recurrence (maintenance phase).

      SSRI discontinuation symptoms are similar to those of the TCAs, with dizziness, gastrointestinal symptoms, and sleep disorders common. Anecdotal reports have included complaints of “electric shock–like” sensations, flashes, and “withdrawal buzz.” The type and severity of the symptoms correlate with the relative affinities of the agents for the serotonin reuptake sites and with secondary effects on other neurotransmitters; with SRIs that also affect cholinergic systems, the symptoms possibly correlate with cholinergic rebound.

    • This question is part of the following fields:

      • Psychiatry
      18
      Seconds
  • Question 8 - Which statement is true regarding anorexia nervosa? ...

    Incorrect

    • Which statement is true regarding anorexia nervosa?

      Your Answer: Around 75-80% of the patients are female

      Correct Answer: It is the most common cause of admissions to child and adolescent psychiatric wards

      Explanation:

      Anorexia nervosa is an eating disorder characterized by an abnormally low body weight, an intense fear of gaining weight and a distorted perception of weight. People with anorexia place a high value on controlling their weight and shape, using extreme efforts that tend to significantly interfere with their lives.

      The minimum level of severity is based, for adults, on current body mass index (BMI) (see below) or for
      children and adolescents, on BMI percentile. The ranges below are derived from World Health
      Organization categories for thinness in adults; for children and adolescents, corresponding BMI percentiles
      should be used. The level of severity may be increased to reflect clinical symptoms, the degree of
      functional disability, and the need for supervision.
      Mild: BMI > 17 kg/m2
      Moderate: BMI 16-16.99 kg/m2
      Severe: BMI 15-15.99 kg/m2
      Extreme: BMI < 15 kg/m2 Anorexia nervosa is more common in women than in men, with a female-to-male ratio of 10-20:1 in developed countries. The prognosis of anorexia nervosa is guarded. Morbidity rates range from 10-20%, with only 50% of patients making a complete recovery. Of the remaining 50%, 20% remain emaciated and 25% remain thin. The main change in the diagnosis of Anorexia Nervosa was to remove the criterion of amenorrhea (loss of menstrual cycle). Removing this criterion means that boys and men with Anorexia will finally be able to receive an appropriate diagnosis.
      Similarly, girls and women who continue to have their period despite other symptoms associated with Anorexia, such as weight loss and food restriction, will now be eligible for a diagnosis of Anorexia.

    • This question is part of the following fields:

      • Psychiatry
      31.1
      Seconds
  • Question 9 - An 84-year-old retired police officer presents to the neurology clinic with double vision...

    Incorrect

    • An 84-year-old retired police officer presents to the neurology clinic with double vision and unsteadiness whilst walking. He has a past medical history of hypertension, hypercholesterolemia and type 2 diabetes. On examination, you notice a right partial ptosis and miosis. The patient also has notable right facial loss of pain and temperature sensation with left sided truncal sensory loss contralateral to the face. In the clinic, apraclonidine eye drops are added to the affected eye, which causes a dilatation, whilst in the opposite eye, a pupil constriction occurs. After the eye drops have been eliminated from the body, 1% hydroxyamphetamine eye drops are then instilled. One hour after instillation, both pupils dilate. Which order of neurons is most likely affected in the sympathetic pathway?

      Your Answer: Third order

      Correct Answer: First order

      Explanation:

      Apraclonidine eye drops are initially used to confirm a Horner’s pupil. Apraclonidine stimulates both alpha-1 and alpha-2 receptors. When added to the affected eye, it causes pupil dilation by >2mm because of the relative super sensitivity of this pupil to alpha-1 receptor activity. In a normal pupil, however, it causes constriction due to the more potent activity at the alpha-2 receptor which triggers re-uptake of noradrenaline in the synaptic cleft.

      Hydroxy amphetamine is then used to distinguish between first/second or third order neurones. In other words, it will distinguish either a lesion in the brainstem, cervical cord, chest or neck and one affecting above the superior cervical ganglion at the carotid bifurcation. In a normal pupil or a first/second order Horner’s, the pupil will dilate secondary to increased levels of noradrenaline released from the post-synaptic neurones. In a third order neurone, this will not occur. There is no fourth or fifth order neurone.

    • This question is part of the following fields:

      • Ophthalmology
      95.7
      Seconds
  • Question 10 - A 26 year old male admits to you that he was sexually abused...

    Correct

    • A 26 year old male admits to you that he was sexually abused in his childhood. Which one of the following features is not a characteristic feature of post-traumatic stress disorder?

      Your Answer: Loss of inhibitions

      Explanation:

      Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by stressful, frightening or distressing events.

      PTSD is a lasting consequence of traumatic ordeals that cause intense fear, helplessness, or horror, such as a sexual or physical assault, the unexpected death of a loved one, an accident, war, or natural disaster. Families of victims can also develop PTSD, as can emergency personnel and rescue workers.

      PTSD is diagnosed after a person experiences symptoms for at least one month following a traumatic event. However symptoms may not appear until several months or even years later. The disorder is characterized by three main types of symptoms:
      -Re-experiencing the trauma through intrusive distressing recollections of the event, flashbacks, and nightmares.
      -Emotional numbness and avoidance of places, people, and activities that are reminders of the trauma.
      -Increased arousal such as difficulty sleeping and concentrating, feeling jumpy, and being easily irritated and angered.

      The goal of PTSD treatment is to reduce the emotional and physical symptoms, to improve daily functioning, and to help the person better cope with the event that triggered the disorder. Treatment for PTSD may involve psychotherapy (a type of counselling), medication, or both.

      Certain antidepressant medications are used to treat PTSD and to control the feelings of anxiety and its associated symptoms including selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants. Mood stabilizers such are sometimes used.

    • This question is part of the following fields:

      • Psychiatry
      12.5
      Seconds
  • Question 11 - Regarding the pathophysiology of diabetes mellitus, which of the following is true? ...

    Correct

    • Regarding the pathophysiology of diabetes mellitus, which of the following is true?

      Your Answer: Concordance between identical twins is higher in type 2 diabetes mellitus than type 1

      Explanation:

      Type 1 diabetes is a chronic illness characterized by the body’s inability to produce insulin due to the autoimmune destruction of the beta cells in the pancreas. Approximately 95% of patients with type 1 DM have either HLA-DR3 or HLA-DR4. Although the genetic aspect of type 1 DM is complex, with multiple genes involved, there is a high sibling relative risk. Whereas dizygotic twins have a 5-6% concordance rate for type 1 DM, monozygotic twins will share this diagnosis more than 50% of the time by the age of 40 years.

    • This question is part of the following fields:

      • Endocrinology
      24.5
      Seconds
  • Question 12 - A 42 year old female presents with morning stiffness that usually takes an...

    Correct

    • A 42 year old female presents with morning stiffness that usually takes an hour to settle and a one year history of intermittent pain and swelling of the small joints of her hands. Examination reveals symmetric soft tissue swelling over the PIP and MCP joints and rheumatoid nodules on the elbows. There is also an effusion of both wrists. Lab results are positive for rheumatoid factor. X-ray of the wrists and hands shows erosions and bony decalcification. NSAIDs are started and the patient is referred to a rheumatologist for consideration of DMARD. Previous history is significant for TB. Which of the following should be avoided?

      Your Answer: Infliximab

      Explanation:

      Anti-TNF-α therapy is effective for patients with arthritis but it can oftentimes lead to the reactivation of latent TB. Hence it should be used with great caution in patients with a past history of TB or current infection.

    • This question is part of the following fields:

      • Rheumatology
      24.3
      Seconds
  • Question 13 - A 20-year-old male presented to the clinic with a long term history of...

    Incorrect

    • A 20-year-old male presented to the clinic with a long term history of pins and needles sensation in both hands. He also has prognathism. He also gives a history of recent onset right upper quadrant pain after being started on a new medication for his condition. Which of the following medications acting on his endocrine system can be responsible for this adverse effect?

      Your Answer: Bromocriptine

      Correct Answer: Octreotide

      Explanation:

      The patient (known case of acromegaly) seems to have developed cholelithiasis (presenting with right upper quadrant pain) probably due to octreotide.

      It is a long-acting analogue of somatostatin which is released from D cells of the pancreas and inhibits the release of growth hormone, glucagon, and insulin.

      Uses
      – Acute treatment of variceal haemorrhage
      – Acromegaly
      – Carcinoid syndrome
      – Prevent complications following pancreatic surgery
      – VIPomas
      – Refractory diarrhoea

      Adverse effects
      Gallstones (secondary to biliary stasis)

      Other options:
      – Bromocriptine – a dopamine agonist with side effects arising from its stimulation of the brain vomiting centre.
      – Desmopressin – predominantly used in patients with diabetes insipidus by increasing the presence of aquaporin channels in the distal collecting duct to increase water reabsorption from the kidneys. The main side effects include headache and facial flushing due to hypertension.
      – Metformin – mainly reduces hepatic gluconeogenesis in patients with type 2 diabetes, common side effects include diarrhoea, vomiting, and lactic acidosis
      – Levothyroxine – synthetic thyroxine used in patients with hypothyroidism, common side effects result from incorrect dosing and mimic the symptoms of hyperthyroidism.

    • This question is part of the following fields:

      • Pharmacology
      84.6
      Seconds
  • Question 14 - A 24 year old presents with diarrhoea. She has had a previous ileal...

    Correct

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

      Your Answer: Short bowel syndrome

      Explanation:

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

    • This question is part of the following fields:

      • Gastroenterology
      27.3
      Seconds
  • Question 15 - What is the mechanism of action of sumatriptan? ...

    Incorrect

    • What is the mechanism of action of sumatriptan?

      Your Answer: 5-HT1 antagonist

      Correct Answer: 5-HT1 agonist

      Explanation:

      Triptans are specific 5-HT1 agonists used in the acute treatment of migraine. They are generally used as first-line therapy in combination with an NSAID or paracetamol.

    • This question is part of the following fields:

      • Pharmacology
      7.3
      Seconds
  • Question 16 - A 39 year old woman with a history of rheumatoid arthritis has recently...

    Incorrect

    • A 39 year old woman with a history of rheumatoid arthritis has recently been switched from methotrexate to leflunomide. Monitoring of full blood count and LFTs has been carried out. Which of the following parameters should also be monitored in this case?

      Your Answer: QT interval on ECG

      Correct Answer: Blood pressure

      Explanation:

      Blood pressure should be routinely measured as leflunomide may cause hypertension and thus an increase in BP. It doesn’t cause changes in blood sugar levels, peak expiratory flow rate or haematuria.

    • This question is part of the following fields:

      • Rheumatology
      40
      Seconds
  • Question 17 - A patient who has recently been diagnosed with SLE undergoes serum testing. A...

    Correct

    • A patient who has recently been diagnosed with SLE undergoes serum testing. A rise in which of the following antibodies would indicate severe systemic involvement?

      Your Answer: Anti double-stranded DNA antibodies

      Explanation:

      Anti ds-DNA antibodies are very specific for SLE and their presence most often indicates systemic spread of the disease. These antibodies are present in about 30 percent of the total cases of SLE.

    • This question is part of the following fields:

      • Rheumatology
      9.5
      Seconds
  • Question 18 - A 43-year-old woman is concerned about osteoporosis as she as a strong family...

    Correct

    • A 43-year-old woman is concerned about osteoporosis as she as a strong family history of it. She is one year postmenopausal and aware of hot flushes at night. Which one of the following therapies would be most appropriate?

      Your Answer: Cyclical oestrogen and progestogen

      Explanation:

      As the patient has early menopause, hormone replacement therapy (HT) is considered to be the first line of choice for prevention of bone loss and fracture in the early postmenopausal period for 5 years.

    • This question is part of the following fields:

      • Endocrinology
      32.1
      Seconds
  • Question 19 - A 85 yr. old previously well man was found to have a BP...

    Incorrect

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

      Your Answer: Start a calcium channel blocker

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

      Explanation:

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

    • This question is part of the following fields:

      • Cardiology
      26.7
      Seconds
  • Question 20 - A 35-year-old woman under treatment for long-term epilepsy with valproate presented with complaints...

    Correct

    • A 35-year-old woman under treatment for long-term epilepsy with valproate presented with complaints of excessive weight gain. She is consuming oral contraceptive pills. Which among the following is the best alternative to valproate for treating long-term epilepsy?

      Your Answer: Lamotrigine

      Explanation:

      Among the given anti-epileptics the best drug that can be given in this patient is lamotrigine.
      Topiramate, carbamazepine, phenytoin, and phenobarbital are all hepatic enzyme inducers and are associated with decreased effectiveness of the oral contraceptive (OCP) due to acceleration of the metabolism of oestrogens and progestogens.
      If she is planning on pregnancy then registry studies suggest that lamotrigine would also be the best choice.
      Other hepatic enzyme inducers include rifampicin, spironolactone, griseofulvin, etc.

    • This question is part of the following fields:

      • Pharmacology
      39.9
      Seconds
  • Question 21 - A 19-year-old female is admitted with a headache, photophobia, fever and confusion. She...

    Correct

    • A 19-year-old female is admitted with a headache, photophobia, fever and confusion. She is managed with antibiotics. What is the mechanism of action of the most commonly used first line antibiotic class?

      Your Answer: Inhibition of cell wall synthesis

      Explanation:

      In adults, the most common symptom of meningitis is a severe headache, occurring in almost 90% of cases of bacterial meningitis, followed by nuchal rigidity (the inability to flex the neck forward passively due to increased neck muscle tone and stiffness). Other signs commonly associated with meningitis include photophobia (intolerance to bright light) and phonophobia (intolerance to loud noises).
      In the United Kingdom empirical treatment consists of a third-generation cefalosporin such as cefotaxime or ceftriaxone. In the USA, where resistance to cefalosporins is increasingly found in streptococci, addition of vancomycin to the initial treatment is recommended. Penicillins, cephalosporins, carbapenems and monobactams all act via inhibition of cell wall synthesis.

    • This question is part of the following fields:

      • Clinical Sciences
      13.9
      Seconds
  • Question 22 - A 48-year-old male with a history of bipolar disorder presents with acute confusion....

    Correct

    • A 48-year-old male with a history of bipolar disorder presents with acute confusion. In-transit to hospital he had a generalized seizure which terminated spontaneously after around 30 seconds. On arrival to the emergency department, his GCS is 14/15 and he is noted to have a coarse tremor. Suspecting a diagnosis of lithium toxicity, intravenous access is obtained, a blood sample was drawn for investigations and a saline infusion is started. The blood investigations revealed: Lithium level: 4.2 mmol/L, Na+: 136 mmol/L, K+: 4.6 mmol/L, Urea: 8.1 mmol/L, Creatinine: 99 µmol/L, Bicarbonate: 18 mmol/L, What is the most appropriate management for the patient?

      Your Answer: Arrange haemodialysis

      Explanation:

      The presentation of the patient is typical of chronic lithium toxicity (due to the presence of mainly neurological manifestations). Additional to the blood investigations mentioned, urine analysis, electrolyte levels, and renal function should also be performed. A low urine Anion gap and a low urine specific gravity are highly suggestive of lithium toxicity.
      ECG obtained in this patient is likely to show: nonspecific, diffuse ST segment depression with T wave inversion.
      Acute lithium toxicity presents with more GI manifestations while, the clinical features of chronic lithium toxicity are mainly neurological and can include:
      Coarse tremors (fine tremors are seen in therapeutic levels), hyperreflexia, acute confusion, seizures, and coma.
      The management of lithium toxicity is as follows:
      Immediate GI decontamination with gastric lavage (in case of acute intoxication)
      Saline Administrations: the goal of saline administration is to restore GFR, normalize urine output and enhance lithium clearance.
      Haemodialysis remains the mainstay treatment for lithium toxicity as lithium is readily dialyzed because of water solubility, low volume of distribution, and lack of protein binding.
      The Extracorporeal Treatments in Poisoning Workgroup (EXTRIP Workgroup) recommendations for dialysis (extracorporeal treatment) in lithium toxicity include:
      • Impaired kidney function and lithium levels > 4.0 mEq/L
      • Decreased consciousness, seizures, or life-threatening dysrhythmias, regardless of lithium levels
      • Levels are > 5.0 mEq/L, significant confusion is noted, or the expected time to reduce levels to < 1.0 mEq/L is more than 36 hours
      As post-dialysis rebound elevations in lithium levels have been documented, continuous veno-venous hemofiltration (CVVH) has been advocated.

    • This question is part of the following fields:

      • Pharmacology
      36.5
      Seconds
  • Question 23 - A 67-year-old man who has terminal lung cancer and is taking morphine slow...

    Incorrect

    • A 67-year-old man who has terminal lung cancer and is taking morphine slow release tablet (MST) 60mg bd as an analgesic, is reviewed. Recently, he has been unable to take medications orally and, thus, a decision has been made to set up a syringe driver. Out of the following, what dose of diamorphine should be prescribed for the syringe driver?

      Your Answer: 120mg

      Correct Answer: 40mg

      Explanation:

      The dose is calculated, using the conversion factor, as follows:

      (Conversion factor used to convert oral morphine to subcutaneous diamorphine = Divide the total daily dose of oral morphine by 3)
      Hence,
      60mg*2 = 120mg
      120mg/3 = 40mg

      The side effects of opioids can be transient or persistent, and these include constipation, nausea, and drowsiness. Therefore, all patients taking opioids should also be prescribed a laxative and an anti-emetic (if the nausea is persistent). Dose-adjustment may be necessary in cases of persistent drowsiness. Moreover, strong opioids can also provide quick relief from metastatic bone pain, as compared to NSAIDs, bisphosphonates, and radiotherapy.

    • This question is part of the following fields:

      • Haematology & Oncology
      42.2
      Seconds
  • Question 24 - A 23-year-old designer is requesting the combined oral contraceptive pill. During the history...

    Correct

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

      Your Answer: Significantly increased risk of ischaemic stroke

      Explanation:

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

    • This question is part of the following fields:

      • Neurology
      42.2
      Seconds
  • Question 25 - A 60-year-old man has consistently elevated levels of white blood cells in the...

    Correct

    • A 60-year-old man has consistently elevated levels of white blood cells in the blood, despite several courses of antibiotics. His full blood count done (FBC) today shows: Hb: 9.1 g/dL, Plts: 250 x 10^9/L, WCC: 32.2 x 10^9/L, Neutrophils: 28.1 x 10^9/L. However, he has at no point shown signs of any infection. The consultant suggests contacting the haematology department for ascertaining the leucocyte alkaline phosphatase (LAP) score. Out of the following, which related condition would have a high LAP score?

      Your Answer: Leukemoid reaction

      Explanation:

      Leukemoid reaction has a high LAP score.

      Leukemoid reaction refers to leucocytosis occurring as a physiological response to stress or infection which may be mistaken for leukaemia, especially chronic myeloid leukaemia (CML). Leucocytosis occurs, initially, because of accelerated release of cells from the bone marrow and is associated with increased count of more immature neutrophils in the blood (left-shift). In order to differentiate, LAP score is used. Leukocytic alkaline phosphatase (ALP) activity is high in a leukemoid reaction but low in CML.

      LAP score is high in:
      1. Leukemoid reaction
      2. Infections
      3. Myelofibrosis
      4. Polycythaemia rubra vera
      5. Steroids, Cushing’s syndrome
      6. Pregnancy, oral contraceptive pill

      LAP score is low in:
      1. CML
      2. Pernicious anaemia
      3. Paroxysmal nocturnal haemoglobinuria (PNH)
      4. Infectious mononucleosis

    • This question is part of the following fields:

      • Haematology & Oncology
      102.3
      Seconds
  • Question 26 - A 45-year-old woman is HIV positive. She is very concerned that she is...

    Correct

    • A 45-year-old woman is HIV positive. She is very concerned that she is at increased risk of cancer. Which one of the following cancers is NOT increased in HIV positive people?

      Your Answer: Breast cancer

      Explanation:

      Breast cancer has a lower incidence in HIV positive patients. Seminoma, Hodgkin’s disease, anal cancer, and non-small cell lung cancer are all increased incidence. Memorize this breast cancer fact.

    • This question is part of the following fields:

      • Infectious Diseases
      20.3
      Seconds
  • Question 27 - An 12 year old girl is taken to the clinic for a review....

    Correct

    • An 12 year old girl is taken to the clinic for a review. Despite being normally fit and well and not visiting a doctor for the past four years, her father is concerned about her behaviour in the past week. The girl has expressed plans to run for president, is active with planning all through the night and seems overtly excited. When asked, she admits to smoking cannabis once a few months ago and has drank alcohol a few times in the past year. The last time she had alcohol was a week ago. Prior to her deterioration a few weeks ago her father describes her as a happy, well-adjusted, sociable girl. Which one of the following is the most likely diagnosis?

      Your Answer: Mania

      Explanation:

      Mania is a state of extreme physical and emotional elation. A person experiencing mania or a manic episode may present with the following symptoms:
      -Elevated mood. The person feels extremely ‘high’, happy and full of energy; he or she may describe the experience as feeling on top of the world and invincible. The person may shift rapidly from an elevated,
      happy mood to being angry and irritable if they perceive they have been obstructed.
      -Increased energy and overactivity. The person may have great difficulty remaining still.
      -Reduced need for sleep or food. The person may be too active to eat or sleep.
      -Irritability. The person may become angry and irritated with those who disagree with or dismiss his or her sometimes unrealistic plans or ideas.
      -Rapid thinking and speech. The person’s thoughts and speech are more rapid than usual.
      -Grandiose plans and beliefs. It is quite common for a person in a hypomanic or manic state to believe that he or she is unusually talented or gifted or has special friends in power. For example, the person may believe that he or she is on a special mission from God.
      -Lack of insight. A person in a hypomanic or manic state may understand that other people see his or her ideas and actions as inappropriate, reckless or irrational. However, he or she is unlikely to personally accept that the behaviour is inappropriate, due to a lack of insight.
      – Distractibility. The person has difficulty maintaining attention and may not be able to filter out external stimuli.

      Careful assessment to rule out organic conditions is an important first step in the management of mania. Often hospitalisation is required for someone who is experiencing acute mania. Both mood-stabilising agents such as lithium carbonate or sodium valproate and an antipsychotic may be needed to treat psychotic symptoms, agitation, thought disorder and sleeping difficulties. Benzodiazepines may be useful to reduce hyperactivity. Treatment with lithium alone may have a relatively slow response rate (up to two weeks after a therapeutic blood level is established), so that adjunctive medication such as sodium valproate is usually required. Regular monitoring of blood levels for lithium and valproate is essential because of the potential for toxicity.

      The symptoms of hypomania are similar to those of mania: elevated mood, inflated self-esteem, decreased need for sleep, etc. except that they don’t significantly impact a person’s daily function and never include any psychotic symptoms.

    • This question is part of the following fields:

      • Psychiatry
      37.4
      Seconds
  • Question 28 - A 27-year-old male is admitted after drinking engine coolant in an apparent suicide...

    Correct

    • A 27-year-old male is admitted after drinking engine coolant in an apparent suicide attempt. Lab investigations reveal: pH 7.1 (7.36-7.44) pO2 15.3 kPa (11.3-12.6) pCO2 3.2 kPa (4.7-6.0) Standard bicarbonate 2.2 mmol/L (20-28) Serum calcium 1.82 mmol/L (2.2-2.6) After replacing calcium, which of the following is the most urgent treatment for this man?

      Your Answer: 8.4% bicarbonate infusion

      Explanation:

      Carbon monoxide has high affinity for haemoglobin and myoglobin resulting in a left-shift of the oxygen dissociation curve and tissue hypoxia. There are approximately 50 deaths per year from accidental carbon monoxide poisoning in the UK. In these circumstances, antidotal therapy to block alcohol dehydrogenase with ethanol or 4-MP alone is insufficient to treat the poisoning. Data suggest that a severe lactic acidosis needs initial correction and in this patient the most appropriate treatment would be IV fluids with bicarbonate to correct the metabolic acidosis. Haemodialysis may be required thereafter.

    • This question is part of the following fields:

      • Pharmacology
      81.3
      Seconds
  • Question 29 - What is the rationale concerning the use of sodium cromoglycate in the prophylaxis...

    Correct

    • What is the rationale concerning the use of sodium cromoglycate in the prophylaxis of bronchial asthma?

      Your Answer: Inhibition of mast-cell degranulation

      Explanation:

      Sodium cromoglycate principally acts by inhibiting the degranulation of mast cells triggered by the interaction of antigen and IgE.
      The inhibitory effect on mast cells appears to be cell-type specific since cromoglycate has little inhibitory effect on mediator release from human basophils.
      Thus, it inhibits the release of histamine, leukotrienes, and slow-reacting substance of anaphylaxis from mast cells by inhibiting degranulation following exposure to reactive antigens.

      Adverse effects include cough, flushing, palpitation, chest pain, nasal congestion, nausea, fatigue, migraine, etc.

    • This question is part of the following fields:

      • Pharmacology
      11.5
      Seconds
  • Question 30 - A 63-year-old male presents with behavioural disturbances. He has a history of chronic...

    Correct

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

      Your Answer: Confabulation

      Explanation:

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

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

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

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

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

    • This question is part of the following fields:

      • Psychiatry
      13.2
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Respiratory (1/1) 100%
Neurology (1/2) 50%
Pharmacology (4/7) 57%
Gastroenterology (1/2) 50%
Clinical Sciences (1/2) 50%
Psychiatry (4/6) 67%
Ophthalmology (0/1) 0%
Endocrinology (2/2) 100%
Rheumatology (2/3) 67%
Cardiology (0/1) 0%
Haematology & Oncology (1/2) 50%
Infectious Diseases (1/1) 100%
Passmed