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Question 1
Incorrect
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A 65-year-old male was admitted to ED with acute onset left side upper and lower limb weakness and slurred speech. Which of the following is the most appropriate initial investigation?
Your Answer: Lateral cervical spine radiograph
Correct Answer: CT scan of brain
Explanation:The history is suggestive of cerebral stroke and the investigation of choice at most hospitals would be a CT brain. Non-contrast CT scanning is the most commonly used form of neuroimaging in the acute evaluation of patients with apparent acute stroke. MRI scan is more sensitive but availability and cost make this a less likely option.
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Question 2
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A 7-month-old baby girl is admitted with poor feeding and irritability for 2 days. She is lethargic and persistently crying. Urine dipstick showed leucocytes. What is the single most important investigation to arrive at a diagnosis?
Your Answer: Urine for C&S
Explanation:The clinical presentation and leucocytes on the urine dipstick is suggestive of a urinary tract infection. To confirm the diagnosis, urine should be sent for culture and sensitivity.
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Question 3
Incorrect
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A 25 year old female was admitted following the ingestion of 36 paracetamol tablets. On examination she was confused and disoriented. Investigations after 24 hrs showed a normal FBC, pH - 7.2, serum creatinine - 3.7mg/dl and INR 6.5. Which of the following is the most appropriate management for her?
Your Answer: Give N-Acetylcysteine
Correct Answer: Liver transplantation
Explanation:Confusion and disorientation indicate that the patient has grade 3 hepatic encephalopathy. According to King’s College criteria for liver transplantation low pH (< 7.3), features of acute kidney injury (creatinine > 3.4 mg/dL), grade 3-4 hepatic encephalopathy and coagulopathy (INR >6.5 ) are positive criteria for this patient.
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Question 4
Incorrect
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A 45 year old woman has complained of right hypochondrial pain and severe epigastric pain for the past few hours. Upon examination, her CBC is normal, her serum ALP is raided, but she has normal transaminase. She had a cholecystectomy done three months prior. Choose the most appropriate avenue of investigation for this patient.
Your Answer: Upper GI endoscopy
Correct Answer: ERCP
Explanation:MRCP is the most appropriate procedure in this instance. The post-operative US of the abdomen does not give good results for the hepatobiliary system. ERCP is invasive and is linked to complications such as pancreatitis, cholangitis, etc.
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Question 5
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A 55-year-old man was admitted to ED with acute dyspnoea. He was treated for an anterior myocardial infarction a few weeks back. On examination, he is dyspnoeic, peripheral oxygen saturation is 85% on air and he has bibasal crepitations. What is the most suitable investigation to be done at this stage to find the cause for his presentation?
Your Answer: Echo
Explanation:This presentation is compatible with acute pulmonary oedema probably due to sudden papillary muscle rupture or VSD. Echo should be the answer to establish the underlying cause. It will also help to identify other complications associated with MI.
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Question 6
Incorrect
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A 34 year old known alcoholic male has been found unconscious near a pub. The paramedics that attended to him said he was sweating and surrounded by empty cans of cider. Choose the most appropriate initial investigation from the list of options.
Your Answer: ABG
Correct Answer: Capillary blood sugar
Explanation:Capillary blood sugar should be tested as alcohol-induced hypoglycaemia can present itself in cases such as these.
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Question 7
Incorrect
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A 54 year old lady was found unconscious at home and passed away later in the ambulance, due to cardiac arrest. The paramedic's report reveals the woman was a diabetic patient on anti-diabetic medication, lately immobilized due to hip pain. Ulcers were also found on the medial side of her ankle. What is the most likely cause of her death?
Your Answer: Pulmonary embolus
Correct Answer: Acute myocardial infarction
Explanation:The patient was old and had a major cardiovascular risk because she was a diabetic. The ulcers indicate poor glycaemic control and advanced disease which further increased her risk for an ischemic heart attack. Immobilization most probably was the favouring background on which the MI occurred.
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Question 8
Incorrect
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A 15-year-old boy was admitted to the ED with a history of sudden onset chest pain and difficulty in breathing after strenuous exercise. On examination, there was reduced breath sounds on the right side but he was not cyanosed. He maintained oxygen sats of 93% on air. What is the single most appropriate investigation?
Your Answer: Exercise challenge
Correct Answer: CXR
Explanation:The history and examination is suggestive of a spontaneous pneumothorax. The best investigation that can be performed at this stage is a CXR. Spontaneous primary pneumothorax occurs in the absence of a known lung pathology. Proposed risk factors shown to predispose patients to primary spontaneous pneumothorax (PSP) include smoking, family history, Marfan syndrome, homocystinuria, and thoracic endometriosis.
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Question 9
Incorrect
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An 18 year old boy was admitted with severe pain and swelling of his scrotum following a kick to the groin. What is the most appropriate management that can be done at this stage?
Your Answer: USG
Correct Answer: Exploratory surgery
Explanation:The most worrying condition is testicular torsion and to exclude it exploratory surgery is required.
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Question 10
Incorrect
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A 14-year-old male was involved in a bicycle accident. He was brought to the emergency department with abdominal pain. On the CT scan of the abdomen, a hematoma was present beneath the capsule of the spleen. His BP and pulse were normal. What is the next step in his management?
Your Answer: Immediate Laparotomy
Correct Answer: Refer to surgeons for observation
Explanation:A surgeon will observe the patient and will decide which procedure he needs.
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Question 11
Correct
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A 68 year old female underwent surgery for a hysterectomy. 24 hours later, she is complaining of breathlessness. Upon examination, she has bibasal chest crepitations and a raised jugular venous pressure (JVP). From the list of options, which is the most likely electrolyte or fluid abnormality?
Your Answer: Fluid overload
Explanation:The raised JVP and bibasal crepitations in the patient indicate cardiac failure with fluid overload. A chest x-ray and BNP blood level analysis should be performed to confirm this diagnosis. The x-rays should be analysed for alveolar shadowing, Kerly B lines, cardiomegaly, upper lobe diversion, pleural effusion, and fluid in the fissure. If the patient doesn’t have a history of congestive cardiac failure, then this may have been iatrogenic secondary to intravenous fluids.
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Question 12
Correct
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A 2-year-old female presented with symptoms of gastroenteritis. Which of the following signs is the strongest indicator for IV fluid administration?
Your Answer: Capillary refilling time > 4secs
Explanation:Children are very prone to dehydration during an episode of gastroenteritis. Dehydration is detected early by increased capillary filling time.
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Question 13
Incorrect
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A 56 year old male has presented with visual loss on his left side and a history of right sided weakness. Where is the occlusion in this patient?
Your Answer: Ant cerebral artery
Correct Answer: Carotid artery
Explanation:The carotid artery divides itself into two parts: the internal carotid and the external carotid. The internal carotid continues down as the middle cerebral and gives rise to the ophthalmic branch. For this reason, middle cerebral occlusion may give rise to partial visual loss but not complete mono-ocular blindness. Middle cerebral artery occlusion causes paralysis or weakness of contralateral face and arm (faciobracheal). It also causes sensory loss of the contralateral face and arm. Anterior cerebral artery occlusion causes paralysis or weakness of the contralateral foot and leg. Again, sensory loss is experienced at the contralateral foot and leg.
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Question 14
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A 16 year old female has been admitted to hospital after overdosing on paracetamol 4 hours ago. She has also consumed a large amount of alcohol. Her plasma paracetamol concentration is only just below a level which requires treatment. From the list of options, choose the most appropriate treatment option for this patient.
Your Answer: Refer to psychiatry ward
Explanation:As her paracetamol level is under the required treatment threshold, she requires no medical treatment. However, she has taken a simultaneous drug overdose and excessive alcohol consumption. These two factors together require psychiatric evaluation and so she should be referred to the psychiatry ward.
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Question 15
Incorrect
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A prolonged QT interval is linked to which of the following?
Your Answer: Hyperkalaemia
Correct Answer: Hypocalcaemia
Explanation:Prolonged QT interval can be seen in the following conditions: Hypocalcaemia, hypothermia, severe bradycardia, Class 1 and 3 antiarrhythmic drugs, non-sedating antihistamines, tricyclic antidepressants etc.
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Question 16
Incorrect
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A 45 year old male has presented at the hospital with an inoperable carcinoma and pain in his back. His pain has since been controlled well with morphine, but he soon starts vomiting. Morphine administration was ceased, and he was started on both fentanyl patches and metoclopramide. He soon develops stiffness in his neck and a fever. From the list of options, choose the cause of his symptoms.
Your Answer: Fentanyl
Correct Answer: Metoclopramide
Explanation:Metoclopramide side-effects are consistent with the patient’s symptoms: fever and stiffness of the neck. The other medications are not consistent with this symptom.
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Question 17
Incorrect
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A 35-year-old chronic smoker complains of pain in the calf while walking. This symptom has been increasing in severity for 4 months. There is a painful ulcer at the base of left first toe, which despite treatment has not improved. Dorsalis pedis and posterior tibial pulses were absent on the same side. What is the most compatible diagnosis of this presentation?
Your Answer: Embolus
Correct Answer: Thromboangitis Obliterans
Explanation:Thromboangitis obliterans or Buerger’s disease is an inflammatory vasculopathy which is characterized by an inflammatory endarteritis and mainly affects small and medium-sized arteries as well as veins of the upper and lower extremities. It is caused by a prothrombotic state and subsequent obstruction of blood vessels. Ischemic pain, features of inflammation along the vein affected, Raynaud’s phenomenon and painful non-healing ulcers are common presentations.
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Question 18
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A 70-year-old female from a nursing home presented in the emergency department with complaints of headache, blurred vision and confused state for the last 4 to 5 days. On examination, she has several bruises on her head. Which of the following is the most likely cause behind the confused state of this patient?
Your Answer: Subdural hematoma
Explanation:Bruises on her head are suggestive of a head injury. Confused state with a headache and blurred vision are due to a subdural hematoma.
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Question 19
Correct
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A 21-year-old male was brought in unconscious state with high fever, swollen nasal mucosa and constricted pupils. Which of the following substances can cause this presentation?
Your Answer: Cocaine
Explanation:This presentation is suggestive of cocaine toxicity. The major effects of cocaine poisoning include CNS effects such as agitation, seizures and psychosis, and cardiovascular effects such as dysrhythmias, myocardial infarction and cardiovascular collapse. The common route for cocaine ingestion is through the nose, hence the irritated swollen septum.
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Question 20
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A 74-year-old male has received his 3rd cycle of chemotherapy for malignant melanoma 3 days ago. He is presented with a productive cough with greenish sputum. Otherwise he feels well. On examination, he has scattered crepitations, more on the lower right part of the chest. He is afebrile. His labs are: Hb 12.5, TLC 0.9 *10^9 , Plt. 84*10^9. Pan culture was collected and sent. What is the most appropriate next step?
Your Answer: Broad spectrum antibiotic (intravenous)
Explanation:This is a case of hospital acquired infection in an immunocompromised patient. It should be treated vigorously. On the other hand, patients who receive chemotherapy usually have atrophic gastritis and malabsorption syndrome.
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Question 21
Correct
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A 65-year-old male was admitted for surgery 4 days ago. He suddenly became confused and aggressive. His attention span was reduced, and he became very restless. Which single option from the history best explains his condition?
Your Answer: Alcohol consumption
Explanation:Patient was dependent on alcohol. After 4 days of admission he developed signs of alcohol withdrawal.
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Question 22
Correct
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A 40 year old female presented with pain and whitening of the hands on exposure to cold. She has difficulty in swallowing solid foods so she has started swallowing only liquids. She developed shortness of breath on exertion and, subsequently, at rest. Which of the following is the most likely cause for dysphagia in this patient?
Your Answer: Systemic sclerosis
Explanation:Difficulty in swallowing which improves with liquids is mainly due to an obstructive lesion in oesophagus. But pulmonary involvement (breathlessness on exertion and later on rest) and Raynaud’s phenomena can only be described by systemic sclerosis.
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Question 23
Correct
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A 40-year-old male was admitted following 30%, burns sustained from an apartment fire. What is the most appropriate initial treatment of this patient?
Your Answer: Intravenous fluids
Explanation:As this patient has more than a 15% burn area, he needs IV fluids. These patients are more prone to infection and dehydration. Burn area is calculated using the rule of nines and requires fluid replacement over the first 24 hrs, calculated using Parkland’s burn formula.
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Question 24
Correct
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A 34 year old male has been brought to accident and emergency after being involved in a road collision. After his initial evaluation, his score on the Glasgow Coma Scale is 6. What is the most appropriate next step in his treatment?
Your Answer: Secure airway
Explanation:The appropriate next step in this patient’s treatment is to secure his airway.
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Question 25
Incorrect
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A 70 year old male underwent surgery for rectal carcinoma. 10 days after the operation, he presents with a mass in his pelvis and a high-grade fever. Choose the most likely diagnosis from the list of options below.
Your Answer: Septicemia
Correct Answer: Pelvic Abscess
Explanation:Developing a pelvis abscess is one of the most common postoperative surgical complications after rectal operations. The symptoms of a pelvic mass and fever are also consistent with a pelvic abscess.
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Question 26
Correct
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A 55-year-old patient was diagnosed with hepatocellular carcinoma. Tramadol was prescribed to treat the pain. However, the patient is still experiencing intense pain. Which of the following would be the most appropriate treatment for this patient?
Your Answer: Escalate opioid therapy
Explanation:Because the patient’s pain is not responding to Tramadol treatment (already an opioid analgesic), opioid therapy should be escalated until there is pain relief without intolerable side effect.
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Question 27
Correct
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A 30 year male admitted following a stab injury to his left upper chest. He complained of difficulty in breathing. On examination his chest movements were unequal on the left side. Which of the following nerves is most likely to be damaged?
Your Answer: Left phrenic nerve
Explanation:Difficulty in breathing and unequal chest movements are due to paralysis of the diaphragm. So the nerve affected is the left phrenic nerve.
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Question 28
Incorrect
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As the SHO of a hospital, you come across the lab report of a patient. It shows the following: glucose 4mmol/L, K 5.2mmol/L, Na 129mmol/L. How would you manage this patient?
Your Answer: Normal Saline 0.9% + insulin
Correct Answer: Normal Saline 0.9%
Explanation:This patient’s blood glucose levels are within the normal range. From their lab report, they are suffering from milk hyperkalaemia and hypernatremia. Thus, normal saline 0.9 per cent is most appropriate in this case.
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Question 29
Correct
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A 17 year old girl, known to suffer from asthma, was admitted with dyspnoea. Usually her best PEFR is 410 L/min. Which of the following would favour the diagnosis of a severe asthma attack?
Your Answer: PEFR 200 L/min
Explanation:According to the British Thoracic Society, the inability to complete sentences, a HR>110 bpm, a RR>25/min, a PEFR=33-50% of predicted value are all indications of acute severe asthma. Life-threatening asthma would present with hypotension, silent chest, bradycardia and hypoxia.
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Question 30
Correct
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A 55 year old male has complained of severe pain in the right hypochondrium - the pain has been ongoing for the past 24 hours. He describes the pain as coming in waves and it is accompanied by nausea. Nothing he has tried had relieved his pain. His temperature is within the normal range, but he feels hot and is sweating. What is the most appropriate investigation?
Your Answer: US Abdomen
Explanation:A US abdomen would be performed to confirm a diagnosis of biliary colic. A number of symptoms are consistent with this diagnosis: severe right hypochondria pain; pain coming in waves; nausea; no fever; and the absence of jaundice.
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SESSION STATS - PERFORMANCE PER SPECIALTY
