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  • Question 1 - A 52-year-old man presents with numbness and tingling in his left hand. On...

    Incorrect

    • A 52-year-old man presents with numbness and tingling in his left hand. On examination he has weakness of elbow extension, metacarpophalangeal joint flexion and extension and distal interphalangeal joint flexion. All other movements and reflexes are normal. Sensation is normal apart from reduced pin-prick sensation over the medial aspect of the hand. An MRI scan of the cervical spine is performed due to suspicion of a nerve lesion. Which of the following pathologies is most likely to be found on the scan based on the clinical findings?

      Your Answer: Disc herniation between C6 and C7

      Correct Answer: Disc herniation between C7 and T1

      Explanation:

      The C8 nerve forms part of the radial and ulnar nerves via the brachial plexus, and therefore has motor and sensory function in the upper limb. It originates from the spinal column from below the cervical vertebra 7 (C7).
      The C8 nerve receives sensory afferents from the C8 dermatome. This consists of all the skin on the little finger, and continuing up slightly past the wrist on the palmar and dorsal aspects of the hand and forearm.
      The other options available correspond to the C6 or C7 roots and these are unaffected as evidenced by normal elbow flexion and thumb sensation (C6) and normal sensation over the middle finger (C7). Elbow extension is weak as it has roots from both C7 and C8 and so cannot be used alone to decide between the two levels clinically.
      The C8 nerve contributes to the motor innervation of many of the muscles in the trunk and upper limb. Its primary function is the flexion of the fingers, and this is used as the clinical test for C8 integrity, in conjunction with the finger jerk reflex.

      Trunk:
      – Pectoralis major – Medial and lateral pectoral nerves (C5, C6, C7, C8, T1)
      – Pectoralis minor – Medial pectoral nerve (C5, C6, C7,C8, T1)
      – Latissimus dorsi – Thoracodorsal nerve (C6, C7, C8)
      Upper arm:
      – Triceps brachii – Radial nerve (C6, C7,C8)
      Forearm
      – Flexor carpi ulnaris – Ulnar nerve (C7, C8, T1)
      – Palmaris longus – Median nerve (C7,C8)
      – Flexor digitorum superficialis – Median nerve (C8, T1)
      – Flexor digitorum profundus – Median and Ulnar nerves (C8, T1)
      – Flexor pollicis longus – Median nerve (C7,C8)
      – Pronator quadratus – Median nerve (C7,C8)
      – Extensor carpi radialis brevis – Deep branch of the radial nerve (C7,C8)
      – Extensor digitorum – Posterior interosseous nerve (C7,C8)
      – Extensor digiti minimi – Posterior interosseous nerve (C7,C8)
      – Extensor carpi ulnaris – Posterior interosseous nerve (C7,C8)
      – Anconeus – Radial nerve (C6, C7,C8)
      – Abductor pollicis longus – Posterior interosseous nerve (C7,C8)
      – Extensor pollicis brevis – Posterior interosseous nerve (C7,C8)
      – Extensor pollicis longus – Posterior interosseous nerve (C7,C8)
      – Extensor indicis – Posterior interosseous nerve (C7,C8)
      Hand
      – Palmaris brevis – Superficial branch of ulnar nerve (C8, T1)
      – Dorsal interossei – Deep branch of ulnar nerve (C8, T1)
      – Palmar interossei – Deep branch of ulnar nerve (C8, T1)
      – Adductor pollicis – Deep branch of ulnar nerve (C8, T1)
      – Lumbricals – Deep branch of ulnar, Digital branches of median nerve
      – Opponens pollicis – Recurrent branch of median nerve (C8, T1)
      – Abductor pollicis brevis – Recurrent branch of median nerve (C8, T1)
      – Flexor pollicis brevis – Recurrent branch of median nerve (C8, T1)
      – Opponens digiti minimi – Deep branch of ulnar nerve (C8, T1)
      – Abductor digiti minimi – Deep branch of ulnar nerve (C8, T1)
      – Flexor digiti minimi brevis – Deep branch of ulnar nerve (C8, T1)

    • This question is part of the following fields:

      • Clinical Sciences
      31.3
      Seconds
  • Question 2 - Choose the most important stimulator of the central chemoreceptors: ...

    Correct

    • Choose the most important stimulator of the central chemoreceptors:

      Your 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
      10.8
      Seconds
  • Question 3 - Which of the following is correct regarding toxoplasmosis? ...

    Incorrect

    • Which of the following is correct regarding toxoplasmosis?

      Your Answer: Infection in the first trimester of pregnancy is seldom harmful to fetus

      Correct Answer: Can present with fits in patients with AIDS

      Explanation:

      T. gondii infection in immunocompetent people is usually asymptomatic. It can present as fits in patients with AIDs, who are immunosuppressed. Additionally, infection in the first trimester of pregnancy is very harmful. Congenital toxoplasmosis presents with intracranial calcifications, classically. It can also present with hydrocephalus, microcephaly, blindness, petechiae. Siramycin is the drug of choice to try to prevent vertical transmission from mother to baby. It is typically gotten from cat faeces or raw/undercooked meat, not raw eggs (raw eggs: think salmonella).

    • This question is part of the following fields:

      • Infectious Diseases
      21.8
      Seconds
  • Question 4 - Which of the following is associated with heterochromia in congenital disease? ...

    Correct

    • Which of the following is associated with heterochromia in congenital disease?

      Your Answer: Horner's syndrome

      Explanation:

      Heterochromia (difference in iris colour) is seen in congenital Horner’s syndrome, as well as anhidrosis. Other features of non-congenital Horner’s include miosis, ptosis and enophthalmos.

    • This question is part of the following fields:

      • Ophthalmology
      8.1
      Seconds
  • Question 5 - A 32-year-old male who is a known case of sickle cell disease presents...

    Incorrect

    • A 32-year-old male who is a known case of sickle cell disease presents to the Accident and Emergency (A&E) department with fever, tachypnoea, and rib pain. On examination, he has a low-grade fever of 37.9°C, oxygen saturation of 95% on air, and bilateral vesicular breath sounds on chest auscultation. CXR shows opacification in the right middle zone. Which of these statements most accurately describes the initial management of this patient?

      Your Answer: The patient should undergo an exchange transfusion to a target Hb > 8g/dL

      Correct Answer: Incentive spirometry is indicated

      Explanation:

      This is a typical picture of acute chest syndrome (ACS). According to the British Committee for Standards in Haematology (BCSH), ACS is defined as ‘an acute illness characterised by fever and/or respiratory symptoms, accompanied by a new pulmonary infiltrate on chest X-ray’. ACS occurs in sequestration crisis, which is one of the four main types of crises occurring in sickle cell disease.

      The fundamentals of initial management are as follows:
      1. Oxygen therapy to maintain saturation >95%
      2. Intravenous fluids to ensure euvolemia
      3. Adequate pain relief
      4. Incentive spirometry in all patients presenting with rib or chest pain
      5. Antibiotics with cover for atypical organisms
      6. Bronchodilators if asthma co-exists with acute chest syndrome, or if there is an evidence of acute bronchospasm on auscultation
      7. Early consultation with the critical care team and haematology department

      A senior haematologist then makes a decision as to whether a simple or exchange transfusion is necessary in order to achieve a target Hb of 10.0–11.0g/dL in either instance.

      Sickle Cell Crises:
      Sickle cell anaemia is characterised by periods of good health with intervening crises:
      1. Sequestration crisis: acute chest syndrome (i.e. fever, dyspnoea, chest/rib pain, low pO2, and pulmonary infiltrates)

      2. Thrombotic (painful or vaso-occlusive) crisis: precipitated by infection, dehydration, and deoxygenation

      3. Aplastic crisis: sudden fall in haemoglobin without marked reticulocytosis, usually occurring secondary to parvovirus infection

      4. Haemolytic crisis: fall in haemoglobin secondary to haemolysis, rare type of sickle cell crises

    • This question is part of the following fields:

      • Haematology & Oncology
      19.1
      Seconds
  • Question 6 - A young man complains that he feels paralysed and is unable to move...

    Incorrect

    • A young man complains that he feels paralysed and is unable to move when he wakes up and less often when he is falling asleep. He complains of having hallucinations and sees other strangers in the room. His anxiety has also increased with these episodes. What is his likely diagnosis?

      Your Answer: Generalised anxiety disorder

      Correct Answer: Sleep paralysis

      Explanation:

      Sleep paralysis is a temporary inability to move or speak that occurs when you’re waking up or falling asleep. Paralysis is often accompanied by hallucinations

      REM is a stage of sleep when the brain is very active and dreams often occur. The body is unable to move, apart from the eyes and muscles used in breathing, possibly to stop the person from acting out the dreams and hurting himself.

      It’s not clear why REM sleep can sometimes occur while one is awake, but it has been associated with:
      -not getting enough sleep (sleep deprivation or insomnia)
      -irregular sleeping patterns – for example, because of shift work or jet lag
      -narcolepsy – a long-term condition that causes a person to suddenly fall asleep at inappropriate times
      -a family history of sleep paralysis
      -sleeping on one’s back

    • This question is part of the following fields:

      • Psychiatry
      22.3
      Seconds
  • Question 7 - A 73-year-old female is being reviewed in the osteoporosis clinic. She had a...

    Incorrect

    • A 73-year-old female is being reviewed in the osteoporosis clinic. She had a fracture of her left hip 5 years ago and was started on alendronate. Following the development of persistent musculoskeletal pain, alendronate was replaced with risedronate, which was also stopped for similar reasons. Strontium ranelate was therefore started but was also stopped due to the development of deep vein thrombosis in the right leg. Her current T-score is -4.1. A decision is made to start a trial of denosumab. What is the mechanism of action of denosumab?

      Your Answer: Monoclonal antibody against osteoprotegerin

      Correct Answer: Inhibits RANK ligand, which in turn inhibits the maturation of osteoclasts

      Explanation:

      The principal mechanism by which strontium inhibits osteoclast activity is by enhancing the secretion of osteoprotegerin (OPG) and by reducing the expression of the receptor activator of nuclear factor κB ligand (RANKL) in osteoblasts.

      Osteoporosis is defined as low bone mineral density caused by altered bone microstructure ultimately predisposing patients to low-impact, fragility fractures.

      Management:
      Vitamin D and calcium supplementation should be offered to all women unless the clinician is confident they have adequate calcium intake and are vitamin D replete
      Alendronate is the first-line treatment. Around 25% of patients cannot tolerate alendronate, usually due to upper gastrointestinal problems. These patients should be offered risedronate or etidronate.
      Strontium ranelate and raloxifene are recommended if patients cannot tolerate bisphosphonates.
      Other medications that are useful in the treatment of osteoporosis are denosumab, teriparatide, raloxifene, etc.

    • This question is part of the following fields:

      • Pharmacology
      21.5
      Seconds
  • Question 8 - A 52-year-old woman is diagnosed as having acute myeloid leukaemia. What is the...

    Incorrect

    • A 52-year-old woman is diagnosed as having acute myeloid leukaemia. What is the single most important test in determining her prognosis?

      Your Answer: Immunophenotyping

      Correct Answer: Cytogenetics

      Explanation:

      All of the aforementioned options may be important however cytogenetics, for detecting chromosomal abnormalities, is the single most important test to determine her disease prognosis.

      Acute myeloid leukaemia (AML) is the acute expansion of the myeloid stem line, which may occur as a primary disease or follow the secondary transformation of a myeloproliferative disorder. It is more common over the age of 45 and is characterized by signs and symptoms largely related to bone marrow failure such as anaemia (pallor, lethargy), frequent infections due to neutropenia (although the total leucocyte count may be very high), thrombocytopaenia (bleeding), ostealgia, and splenomegaly.

      The disease has a poor prognosis if:
      1. Age of the patient >60 years
      2. >20% blasts seen after the first course of chemotherapy
      3. Chromosomal aberration with deletion of part of chromosome 5 or 7.

      Acute promyelocytic leukaemia (APL) is an aggressive form of AML.

    • This question is part of the following fields:

      • Haematology & Oncology
      15.7
      Seconds
  • Question 9 - A case-control study is being designed to look at the relationship between eczema...

    Incorrect

    • A case-control study is being designed to look at the relationship between eczema and a new vaccine for yellow fever. What is the usual outcome measure in a case-control study?

      Your Answer: Absolute risk increase

      Correct Answer: Odds ratio

      Explanation:

      A case–control study (also known as case–referent study) is a type of observational study in which two existing groups differing in outcome are identified and compared on the basis of some supposed causal attribute. Case–control studies are often used to identify factors that may contribute to a medical condition by comparing subjects who have that condition/disease (the cases) with patients who do not have the condition/disease but are otherwise similar (the controls).
      An odds ratio (OR) is a statistic that quantifies the strength of the association between two events, A and B. The odds ratio is defined as the ratio of the odds of A in the presence of B and the odds of A in the absence of B or vice versa.

    • This question is part of the following fields:

      • Clinical Sciences
      19.4
      Seconds
  • Question 10 - A 45-year-old man who had a liver transplant just over 3 months ago,...

    Incorrect

    • A 45-year-old man who had a liver transplant just over 3 months ago, now has primary sclerosing cholangitis. He complains of fever, abdominal pain and diarrhoea, which has come on over the last week. He has a platelet count of 60 x 109/L and alanine transaminase (ALT) of 300 U/L with a normal bilirubin. He is taking tacrolimus and prednisolone for immunosuppression, and tells you that he recently stopped taking valganciclovir. What is the most likely diagnosis?

      Your Answer: Chronic rejection of liver transplant

      Correct Answer: Donor-acquired cytomegalovirus

      Explanation:

      The fact that he has recently stopped taking his valganciclovir, anti-viral, is key to the answer to this question. This makes the answer quite plainly donor-acquired CMV infection over all of the other answer choices. He needs to stay on prophylaxis against this, particularly in the first 3 months after transplant. Symptoms and presentations of CMV infection can include fever, abdominal pain, diarrhoea, pneumonitis, hepatitis, hematologic abnormalities, retinitis, and esophagitis.

    • This question is part of the following fields:

      • Gastroenterology
      16.8
      Seconds
  • Question 11 - A 27-year-old realtor presented with progressive weakness of both legs over the last...

    Incorrect

    • A 27-year-old realtor presented with progressive weakness of both legs over the last 3 years. He complained of being unable to see well at night and having an impaired sense of smell. On examination he had a shortened fourth toe bilaterally with pes cavus. Neurological examination revealed a loss of pinprick sensation to bilateral knees, and weakness of both legs that was more prominent distally. Which of the following would be the best blood test to order to make a diagnosis?

      Your Answer: ANCA

      Correct Answer: Phytanic acid

      Explanation:

      The diagnosis is Refsum’s disease. This is an autosomal recessive disorder that causes a sensorimotor peripheral neuropathy. It is caused by defective alpha oxidation of phytanic acid leading to its accumulation in tissues. Cardiac conduction abnormalities and cardiomyopathies may also occur.
      Epiphyseal dysplasia causes a characteristic shortening of the fourth toe. Serum phytanic acid levels are elevated. Treatment is by dietary restriction of foods containing phytanic acid (dairy products, fish, beef and lamb).

    • This question is part of the following fields:

      • Neurology
      21.1
      Seconds
  • Question 12 - A 60 year old male presents with thickened patches of skin over his...

    Incorrect

    • A 60 year old male presents with thickened patches of skin over his knuckles and extensor surfaces that are consistent with Gottron's papules. Results reveal an elevated creatine kinase. Diagnosis of dermatomyositis is suspected. Which of the following autoantibody is most specific for this condition?

      Your Answer: Anti-centromere bodies

      Correct Answer: Anti-Mi-2 antibodies

      Explanation:

      Anti–Mi-2 antibodies are highly specific for dermatomyositis, but sensitivity is low; only 25% of patients with dermatomyositis demonstrate these antibodies. A positive antinuclear antibody (ANA) finding is common in patients with dermatomyositis, but is not necessary for diagnosis. Anti-Jo-1 antibodies are mostly associated with polymyositis. Anti Scl-70 antibodies and anti centromere antibodies are most commonly found in systemic scleroderma.

    • This question is part of the following fields:

      • Rheumatology
      8.3
      Seconds
  • Question 13 - A 65 yr. old male presented with acute ST elevation myocardial infarction and...

    Correct

    • A 65 yr. old male presented with acute ST elevation myocardial infarction and thrombolysis was planned. Which of the following is an absolute contraindication for thrombolysis?

      Your Answer: Intracerebral Haemorrhage

      Explanation:

      Absolute contraindications for fibrinolytic use in STEMI

      Prior intracranial haemorrhage (ICH)
      Known structural cerebral vascular lesion
      Known malignant intracranial neoplasm
      Ischemic stroke within 3 months
      Suspected aortic dissection
      Active bleeding or bleeding diathesis (excluding menses)
      Significant closed head trauma or facial trauma within 3 months
      Intracranial or intraspinal surgery within 2 months
      Severe uncontrolled hypertension (unresponsive to emergency therapy)
      For streptokinase, prior treatment within the previous 6 months

    • This question is part of the following fields:

      • Cardiology
      30.5
      Seconds
  • Question 14 - Which is the formula to calculate the number needed to treat? ...

    Incorrect

    • Which is the formula to calculate the number needed to treat?

      Your Answer: 1 / (Hazard ratio)

      Correct Answer: 1 / (Absolute risk reduction)

      Explanation:

      The number needed to treat (NNT) is valuable information in treatment decisions. NNT is the inverse of the absolute risk reduction (1/ARR) between two treatment options.

    • This question is part of the following fields:

      • Clinical Sciences
      61.7
      Seconds
  • Question 15 - A 51 year old smoker was recently diagnosed with non small cell lung...

    Incorrect

    • A 51 year old smoker was recently diagnosed with non small cell lung carcinoma. Investigations show presence of a 3 x 3 x 2 cm tumour on the left side of the lower lung lobe. the mass has invaded the parietal pleura. Ipsilateral hilar node is also involved but there is no metastatic spread. What is the stage of this cancer?

      Your Answer: T3 N1 M0

      Correct Answer: T2 N1 M0

      Explanation:

      The tumour has only invaded the visceral pleura and measures 3cm in the greatest dimension. Hence it is designated at T2. Ipsilateral peribronchial and/or hilar lymph node involvement would make it N1. There is no distal metastasis so M would be 0.

    • This question is part of the following fields:

      • Respiratory
      10.6
      Seconds
  • Question 16 - A 61-year-old female presents to the A&E with malaise and muscle twitching. Her...

    Correct

    • A 61-year-old female presents to the A&E with malaise and muscle twitching. Her blood pressure is 114/78 mmHg and her pulse is 84/min. Blood exam reveals Calcium = 1.94 mmol/l and Albumin = 38 g/l. Which of the following tests is most useful in establishing her diagnosis?

      Your Answer: Parathyroid hormone

      Explanation:

      Hypocalcaemia occurs in patients with impaired function of the parathyroid glands. This is most common after thyroid or parathyroid surgery, but it can be idiopathic—mostly in young adults and less often as part of a genetic syndrome, such as autoimmune polyglandular syndrome type 1. Usually, the first and most useful test to perform in such cases is the measurement of the parathyroid hormone.

    • This question is part of the following fields:

      • Clinical Sciences
      32.2
      Seconds
  • Question 17 - A 56 year old woman taking procainamide develops drug induced erythematosus. Which of...

    Incorrect

    • A 56 year old woman taking procainamide develops drug induced erythematosus. Which of the following features is the most characteristic of this condition?

      Your Answer: It rarely causes pulmonary disease

      Correct Answer: It may occur with chlorpromazine

      Explanation:

      Drug induced lupus is usually positive for antinuclear and antihistone antibodies, typically without renal or neurologic involvement. However, pulmonary involvement is common. Drugs that can induce lupus include isoniazid, hydralazine, procainamide, chlorpromazine, and other anticonvulsants.

    • This question is part of the following fields:

      • Rheumatology
      26.1
      Seconds
  • Question 18 - A 24 year old male, known case of hereditary angioneurotic oedema presents with...

    Incorrect

    • A 24 year old male, known case of hereditary angioneurotic oedema presents with recurrent fever and arthralgia which is accompanied by a rash on face and upper chest. These attacks have been refractory to treatment and have occurred recurrently requiring adrenaline on several occasions. Lab results reveal persistently reduced C4 levels. Which of the following is most likely causing his current symptoms?

      Your Answer: Dermatomyositis

      Correct Answer: Systemic lupus erythematosus

      Explanation:

      Angioedema secondary to C1 inhibitor deficiency has been rarely reported to be associated with systemic lupus erythematosus. A genetic defect of C1 inhibitor produces hereditary angioedema, which is usually presented with cutaneous painless oedema, but oedema of the genital area, gastrointestinal and laryngeal tracts have also been reported. In lupus patients, angioedema may be the result of an acquired type of C1 inhibitor deficiency, most probably due to antibody formation directed against the C1 inhibitor molecule.

    • This question is part of the following fields:

      • Rheumatology
      15.5
      Seconds
  • Question 19 - A 13-year-old girl presents with short stature, webbed neck, cubitus valgus and primary...

    Incorrect

    • A 13-year-old girl presents with short stature, webbed neck, cubitus valgus and primary amenorrhea. Which of the following hormones is most important for long term replacement?

      Your Answer: Growth hormone

      Correct Answer: Oestrogen

      Explanation:

      This girl most probably has Turner’s syndrome, which is caused by the absence of one set of genes from the short arm of one X chromosome.
      Turner syndrome is a lifelong condition and needs lifelong oestrogen replacement therapy. Oestrogen is usually started at age 12-15 years. Treatment can be started with continuous low-dose oestrogens. These can be cycled in a 3-weeks on, 1-week off regimen after 6-18 months; progestin can be added later.

      In childhood, growth hormone therapy is standard to prevent short stature as an adult.

      Fetal ovarian development seems to be normal in Turner syndrome, with degeneration occurring in most cases around the time of birth so pulsatile GnRH and luteinising hormone would be of no use.

    • This question is part of the following fields:

      • Endocrinology
      20.3
      Seconds
  • Question 20 - A 40 year-old lawyer suffered a road traffic accident. MRI reveals that he...

    Incorrect

    • A 40 year-old lawyer suffered a road traffic accident. MRI reveals that he may have hemisection of the spinal cord. Which of the following findings is most likely to occur?

      Your Answer: Contralateral paralysis

      Correct Answer: Ipsilateral hyperreflexia

      Explanation:

      Spinal cord hemisection, also known as Brown-Sequard syndrome, is associated with symptoms affecting one spinothalamic and one corticospinal tract. Symptoms include ipsilateral paralysis, loss of vibration and position sense, and hyperreflexia below the level of the lesion. Contralateral loss of pain and temperature sensation is also seen, usually beginning 2-3 segments below the level of the lesion.

    • This question is part of the following fields:

      • Neurology
      12.5
      Seconds
  • Question 21 - A 25-year-old pregnant mother who is known to have hepatitis B gave birth...

    Incorrect

    • A 25-year-old pregnant mother who is known to have hepatitis B gave birth to a male infant. She is now concerned about her child contracting hep B. Which of the following is the most suitable option for the baby in this case?

      Your Answer: Nothing until immune status checked

      Correct Answer: HepB full vaccine and Ig

      Explanation:

      Hepatitis B full vaccine and Ig should be given to babies born to hepatitis B positive mothers. Hepatitis B vaccine alone or Ig alone is not sufficient to prevent the infection in the new-born baby.

    • This question is part of the following fields:

      • Infectious Diseases
      22.4
      Seconds
  • Question 22 - A 23-year-old designer is requesting the combined oral contraceptive pill. During the history...

    Incorrect

    • 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: Theoretical risk of ischaemic stroke

      Correct 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
      18.4
      Seconds
  • Question 23 - Café-au-lait spots are seen in each of the following, except: ...

    Incorrect

    • Café-au-lait spots are seen in each of the following, except:

      Your Answer:

      Correct Answer: Friedreich's ataxia

      Explanation:

      Café-au-lait spots is hyperpigmented lesions that vary in colour from light brown to dark brown, with borders that may be smooth or irregular. Causes include:
      Neurofibromatosis type I
      McCune–Albright syndrome
      Legius syndrome
      Tuberous sclerosis
      Fanconi anaemia
      Idiopathic
      Ataxia-telangiectasia
      Basal cell nevus syndrome
      Benign congenital skin lesion
      Bloom syndrome
      Chediak-Higashi syndrome
      Congenital nevus
      Gaucher disease
      Hunter syndrome
      Maffucci syndrome
      Multiple mucosal neuroma syndrome
      Noonan syndrome
      Pulmonary Stenosis
      Silver–Russell syndrome
      Watson syndrome
      Wiskott–Aldrich syndrome

    • This question is part of the following fields:

      • Dermatology
      0
      Seconds
  • Question 24 - A 61-year old mechanic recently attended A&E, with a 3 month history of...

    Incorrect

    • A 61-year old mechanic recently attended A&E, with a 3 month history of bilateral paraesthesia's and twitching affecting the thumb, first finger and lateral forearm. He denied any trauma. An MRI scan of his spine was performed and revealed cervical canal stenosis with mild cord compression. He was discharged and advised to see his GP for follow-up. Which of the following is the most appropriate initial step in management?

      Your Answer:

      Correct Answer: Refer to spinal surgery services

      Explanation:

      Bilateral median nerve dysfunction is suggestive of degenerative cervical myelopathy (DCM) rather than bilateral carpal tunnel syndrome. DCM should be suspected in elderly patients presenting with limb neurology. This patient’s twitches are probably fibrillations, a sign of lower motor neuron dysfunction.
      Degenerative cervical myelopathy is associated with a delay in diagnosis. It is most commonly misdiagnosed as carpal tunnel syndrome. In one study, 43% of patients who underwent surgery for degenerative cervical myelopathy had been initially diagnosed with carpal tunnel syndrome.
      Management of these patients should be by specialist spinal services (neurosurgery or orthopaedic spinal surgery). Decompressive surgery is the mainstay of treatment and has been shown to stop disease progression. Physiotherapy and analgesia do not replace surgical opinion, though they may be used alongside. Nerve root injections do not have a role in management.

    • This question is part of the following fields:

      • Neurology
      0
      Seconds
  • Question 25 - A 26-year-old lawyer presents to the gastroenterology clinic with weight loss, intermittent oily...

    Incorrect

    • A 26-year-old lawyer presents to the gastroenterology clinic with weight loss, intermittent oily diarrhoea and malaise. Blood testing reveals folate and iron deficiency. There is also mild hypocalcaemia on biochemistry screening. She has type-1 diabetes of 10 years’ duration and is stable on a basal bolus insulin regime, otherwise her past medical history is unremarkable. Which of these antibody tests is most specific for making a diagnosis?

      Your Answer:

      Correct Answer: Anti-tissue transglutaminase antibodies

      Explanation:

      The prompt is suggestive of celiac disease as an aetiology. The antibody that is used primarily to suggest this diagnosis is anti-tissue transglutaminase antibody. You can also check anti-gliadin and anti-endomyseal antibodies, although anti-TTG antibodies are now the preferred test. To get an official diagnosis you must have a tissue diagnosis (biopsy). Anti-smooth muscle antibodies would be seen in autoimmune hepatitis. Anti-thyroid antibodies are not at all related to this, and are associated with thyroid. Anti-nuclear antibodies are non-specific.

    • This question is part of the following fields:

      • Gastroenterology
      0
      Seconds
  • Question 26 - A 60-year-old male presents with dyspnoea and an urgent chest X-ray is scheduled....

    Incorrect

    • A 60-year-old male presents with dyspnoea and an urgent chest X-ray is scheduled. Sputum cultures reveal pneumonia and he receives treatment with erythromycin. What is the mechanism of action of this drug?

      Your Answer:

      Correct Answer: Inhibit 50S subunit of ribosomes

      Explanation:

      Erythromycin is a bacteriostatic antibiotic. This means it stops the further growth of bacteria rather than directly destroying it. This is achieved by inhibiting protein synthesis. Erythromycin binds to the 23S ribosomal RNA molecule in the 50S subunit of the bacterial ribosome. This causes a blockage in the exiting of the peptide chain that is growing. Given that humans have 40S and 60S subunits, and do not have 50S subunits, erythromycin does not affect protein synthesis in human tissues.

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 27 - A 36 year old female who has been suffering from depression for the...

    Incorrect

    • A 36 year old female who has been suffering from depression for the past 5 years was recently admitted to the psychiatric intensive care unit. She is currently being managed on Sertraline. In clinic she was observed to be sitting in a fixed position for several hours, awake but unable to move. What would be an appropriate treatment for this patient?

      Your Answer:

      Correct Answer: ECT

      Explanation:

      Catatonia is a state of apparent unresponsiveness to external stimuli and apparent inability to move normally in a person who is apparently awake. Catatonia can be acute and occur in severely ill patients with underlying psychiatric or other medical disorders.

      A history of behavioural responses to others usually includes the presence of the following:
      – Mutism (absence of speech)
      – Negativism (performing actions contrary to the commands of the examiner)
      – Echopraxia (repeating the movements of others)
      – Echolalia (repeating the words of others)
      – Waxy flexibility (slight, even resistance to positioning by examiner)
      – Withdrawal (absence of responses to the environment).

      In the presence of a catatonic state, both first and second generation antipsychotics (SGA) may contribute to maintaining or worsening the catatonic state and increase the risk of developing NMS (neuroleptic malignant syndrome).

      Electroconvulsive therapy (ECT) is effective in all forms of catatonia, even after pharmacotherapy with benzodiazepines has failed. Response rate ranges from 80% to 100% and results superior to those of any other therapy in psychiatry. ECT should be considered first-line treatment in patients with malignant catatonia, neuroleptic malignant syndrome, delirious mania or severe catatonic excitement, and in general in all catatonic patients that are refractory or partially responsive to benzodiazepines. Early intervention with ECT is encouraged to avoid undue deterioration of the patient’s medical condition.

      Electroconvulsive therapy (ECT) is a procedure, done under general anaesthesia, in which small electric currents are passed through the brain, intentionally triggering a brief seizure. ECT seems to cause changes in brain chemistry that can quickly reverse symptoms of certain mental health conditions.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 28 - A 57 year old man is reviewed and discovered to be dependent on...

    Incorrect

    • A 57 year old man is reviewed and discovered to be dependent on Temazepam which was prescribed for him as a hypnotic. He wants to end his addiction and requests help. What is the most appropriate strategy?

      Your Answer:

      Correct Answer: Switch to the equivalent diazepam dose then slowly withdraw over the next 2 months

      Explanation:

      Temazepam is a medication that is often prescribed for the treatment of short-term insomnia. It belongs to the benzodiazepine family of drugs and is classed as intermediate-acting, meaning that it can take between six and twenty-four hours for the drug to take effect.

      Although it is known that shorter-acting benzodiazepines are more harmful and more likely to cause addiction, temazepam is, nevertheless, a highly addictive drug. It should not be taken for longer than four weeks.

      -Adverse effects associated with the use of benzodiazepine hypnotics (to which the elderly are most vulnerable) include confusion, over sedation, increased risks of falls and consequent fractures

      -Withdrawal from a benzodiazepine hypnotic must be agreed between the clinician and the patient – patients should never be forced or threatened. The risks of continued benzodiazepine use should be explained. An agreed schedule for reduction of and gradual withdrawal from the benzodiazepine hypnotic should also be agreed. This will involve substitution of the hypnotic with a long-acting benzodiazepine (e.g. diazepam) and a subsequent gradual reduction in dose of the substituted benzodiazepine -the substituted benzodiazepine can then be withdrawn in steps of about one-eighth to one-tenth every fortnight
      Example: withdrawal schedule for patient on temazepam 20mg nocte
      week 1 – temazepam 10mg, diazepam 5mg
      week 2 – stop temazepam, diazepam 10mg
      week 4 – diazepam 9mg
      week 6 – diazepam 8mg
      continue reducing dose of diazepam by 1mg every fortnight – tapering of dose may be slower if necessary

    • This question is part of the following fields:

      • Psychiatry
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  • Question 29 - A 48-year-old male with a history of bipolar disorder presents with acute confusion....

    Incorrect

    • 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:

      Correct 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
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  • Question 30 - A 25 year old female presented with multiple small genital ulcers, which are...

    Incorrect

    • A 25 year old female presented with multiple small genital ulcers, which are painful following a sexual intercourse with an unknown man. Which of the following can be used topically for this presentation?

      Your Answer:

      Correct Answer: Acyclovir

      Explanation:

      The most probable diagnosis is Herpes Simplex infection. Topical Acyclovir can be used in early stages.

    • This question is part of the following fields:

      • Infectious Diseases
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SESSION STATS - PERFORMANCE PER SPECIALTY

Clinical Sciences (1/5) 20%
Infectious Diseases (1/3) 33%
Ophthalmology (1/1) 100%
Psychiatry (0/3) 0%
Gastroenterology (0/2) 0%
Neurology (1/4) 25%
Cardiology (1/1) 100%
Respiratory (0/1) 0%
Dermatology (0/1) 0%
Pharmacology (0/1) 0%
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