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Question 1
Incorrect
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A 47-year-old man presents to the Emergency Department with a history of chronic alcoholism and multiple episodes of upper gastrointestinal bleeding. Physical examination reveals dilated superficial abdominal veins, enlarged breasts, palmar erythema, and numerous small, dilated blood vessels on the face and trunk. Further investigation reveals liver biopsy results showing bridging fibrosis and cells with highly eosinophilic, irregularly shaped hyaline bodies near the nucleus. The presence of these inclusions suggests that the cells originated from which of the following embryonic structures?
Your Answer: Neural crest
Correct Answer: Endoderm
Explanation:The Origin of Hepatocytes: Understanding the Different Germ Layers
Hepatocytes are a type of cell found in the liver that play a crucial role in metabolism and detoxification. Understanding their origin can provide insight into various liver diseases and conditions.
Endoderm is the germ layer from which hepatocytes differentiate during embryonic development. Mallory bodies, intracytoplasmic inclusions seen in injured hepatocytes, are derived from cytokeratin, an intermediate cytoskeletal filament unique to epithelial cells of ectodermal or endodermal origin.
While hepatocytes and bile ducts are endodermal in origin, hepatic blood vessels and Kupffer cells (hepatic macrophages) are mesodermal in origin.
Spider angioma, palmar erythema, gynaecomastia, and dilation of the superficial abdominal veins are signs of cirrhosis or irreversible liver injury. Bridging fibrosis extending between the adjacent portal systems in the liver is the precursor of cirrhosis.
It is important to note that hepatocytes are not derived from ectoderm or neural crest cells. The yolk sac gives rise to primordial germ cells that migrate to the developing gonads.
Understanding the origin of hepatocytes and their relationship to different germ layers can aid in the diagnosis and treatment of liver diseases.
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This question is part of the following fields:
- Gastroenterology
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Question 2
Incorrect
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A 72-year-old man is brought by ambulance to the Accident and Emergency department. He is visibly distressed but gives a history of sudden onset central compressive chest pain radiating to his left upper limb. He is also nauseous and very sweaty. He has had previous myocardial infarctions (MI) in the past and claims the pain is identical to those episodes. ECG reveals an anterior ST elevation MI.
Which of the following is an absolute contraindication to thrombolysis?Your Answer: Pregnancy
Correct Answer: Brain neoplasm
Explanation:Relative and Absolute Contraindications to Thrombolysis
Thrombolysis is a treatment option for patients with ongoing cardiac ischemia and presentation within 12 hours of onset of pain. However, there are both relative and absolute contraindications to this treatment.
Absolute contraindications include internal or heavy PV bleeding, acute pancreatitis or severe liver disease, esophageal varices, active lung disease with cavitation, recent trauma or surgery within the past 2 weeks, severe hypertension (>200/120 mmHg), suspected aortic dissection, recent hemorrhagic stroke, cerebral neoplasm, and previous allergic reaction.
Relative contraindications include prolonged CPR, history of CVA, bleeding diathesis, anticoagulation, blood pressure of 180/100 mmHg, peptic ulcer, and pregnancy or recent delivery.
It is important to consider these contraindications before administering thrombolysis as they can increase the risk of complications. Primary percutaneous coronary intervention is the preferred treatment option, but if not available, thrombolysis can be a viable alternative. The benefit of thrombolysis decreases over time, and a target time of <30 minutes from admission for commencement of thrombolysis is typically recommended.
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This question is part of the following fields:
- Cardiology
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Question 3
Incorrect
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A 30-year-old sexually active, unmarried man comes in with a painful sore on the glans of his penis. He reports experiencing discomfort and swelling in both of his groin areas. Upon examination, a tender ulcer with distinct, undermined borders that bleeds easily is discovered. Additionally, bilateral inguinal lymphadenopathy is observed during the examination, and a small sinus is visible above one of the lymph nodes, with pus easily expressed.
What is the probable diagnosis?Your Answer: Gonorrhea
Correct Answer: Chancroid
Explanation:Sexually Transmitted Diseases: Chancroid, Chlamydia, Syphilis, HIV, and gonorrhoeae
Sexually transmitted diseases (STDs) are infections that are spread through sexual contact. Chancroid, caused by Haemophilus ducreyi, is a common STD that presents with painful genital ulcers and tender lymphadenopathy. Treatment involves a single dose of azithromycin. Chlamydia, caused by Chlamydia trachomatis, may be asymptomatic or present with penile/vaginal discharge or pain. Syphilis, on the other hand, presents with painless genital pustules that eventually ulcerate and does not typically involve lymphadenopathy. HIV, although associated with an increased risk of STDs, does not present with genital ulcers. gonorrhoeae, caused by Neisseria gonorrhoeae, usually presents with penile/vaginal discharge, dysuria, and pelvic pain, but can also be asymptomatic. It is important to practice safe sex and get tested regularly for STDs to prevent their spread.
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This question is part of the following fields:
- Microbiology
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Question 4
Incorrect
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A 65-year-old woman diagnosed with primary breast cancer is considering whether or not to give her consent for an axillary node clearance. What specific complication should she be informed of regarding this procedure?
Your Answer: Brachial plexus injury
Correct Answer: Lymphedema causing functional arm impairment
Explanation:Functional arm impairment is a potential consequence of lymphedema, which carries a risk following axillary lymph node dissection. While other complications are theoretically possible, they are not commonly observed. A study published in the Annals of Plastic Surgery in April 2019 quantified the impact of radiation and a lymphatic microsurgical preventive healing approach on lymphedema incidence.
Breast cancer management varies depending on the stage of the cancer, type of tumor, and patient’s medical history. Treatment options may include surgery, radiotherapy, hormone therapy, biological therapy, and chemotherapy. Surgery is typically the first option for most patients, except for elderly patients with metastatic disease who may benefit more from hormonal therapy. Prior to surgery, an axillary ultrasound is recommended for patients without palpable axillary lymphadenopathy, while those with clinically palpable lymphadenopathy require axillary node clearance. The type of surgery offered depends on various factors, such as tumor size, location, and type. Breast reconstruction is also an option for patients who have undergone a mastectomy.
Radiotherapy is recommended after a wide-local excision to reduce the risk of recurrence, while mastectomy patients may receive radiotherapy for T3-T4 tumors or those with four or more positive axillary nodes. Hormonal therapy is offered if tumors are positive for hormone receptors, with tamoxifen being used in pre- and perimenopausal women and aromatase inhibitors like anastrozole in postmenopausal women. Tamoxifen may increase the risk of endometrial cancer, venous thromboembolism, and menopausal symptoms. Biological therapy, such as trastuzumab, is used for HER2-positive tumors but cannot be used in patients with a history of heart disorders. Chemotherapy may be used before or after surgery, depending on the stage of the tumor and the presence of axillary node disease. FEC-D is commonly used in the latter case.
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This question is part of the following fields:
- Surgery
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Question 5
Incorrect
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You encounter a 36-year-old woman during her antenatal check-up. She has recently undergone an anomaly scan and is undergoing a routine review. During the consultation, she expresses her concern about not feeling any fetal movement yet, despite experiencing it by 18 weeks gestation in her previous pregnancies.
At what point in her gestation would it be appropriate to refer her to the maternal fetal medicine unit for further evaluation?Your Answer: 20 weeks
Correct Answer: 24 weeks
Explanation:Referral to a maternal fetal medicine unit is recommended if fetal movements have not been felt by 24 weeks, as reduced movements can be a sign of fetal distress and hypoxia. While most women feel their babies move around 18-20 weeks, it can happen earlier in some cases. Although singular episodes of reduced movements may not be harmful, they can also indicate stillbirths and restricted growth. The absence of movements is particularly concerning and requires further investigation. The RCOG has set the 24 week cut off as a guideline.
Understanding Reduced Fetal Movements
Introduction:
Reduced fetal movements can indicate fetal distress and are a response to chronic hypoxia in utero. This can lead to stillbirth and fetal growth restriction. It is believed that placental insufficiency may also be linked to reduced fetal movements.Physiology:
Quickening is the first onset of fetal movements, which usually occurs between 18-20 weeks gestation and increases until 32 weeks gestation. Multiparous women may experience fetal movements sooner. Fetal movements should not reduce towards the end of pregnancy. There is no established definition for what constitutes reduced fetal movements, but less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) is an indication for further assessment.Epidemiology:
Reduced fetal movements affect up to 15% of pregnancies, with 3-5% of pregnant women having recurrent presentations with RFM. Fetal movements should be established by 24 weeks gestation.Risk factors for reduced fetal movements:
Posture, distraction, placental position, medication, fetal position, body habitus, amniotic fluid volume, and fetal size can all affect fetal movement awareness.Investigations:
Fetal movements are usually based on maternal perception, but can also be objectively assessed using handheld Doppler or ultrasonography. Investigations are dependent on gestation at onset of RFM. If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used.Prognosis:
Reduced fetal movements can represent fetal distress, but in 70% of pregnancies with a single episode of reduced fetal movement, there is no onward complication. However, between 40-55% of women who suffer from stillbirth experience reduced fetal movements prior to diagnosis. Recurrent RFM requires further investigations to consider structural or genetic fetal abnormalities. -
This question is part of the following fields:
- Obstetrics
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Question 6
Incorrect
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A 22-year-old woman, who is a known type 1 diabetic, visited the GP clinic with a complaint of decreased vision. Her left eye has a vision of 6/6, while her right eye has a vision of 6/18.
Your GP placement supervisor has requested you to conduct a dilated direct fundoscopy on her eyes. During the examination, you observed exudates forming a ring around a dot haemorrhage near the fovea.
What is the initial treatment for this eye condition?Your Answer: Increase daily insulin dose
Correct Answer: Anti-vascular endothelial growth factor (VEGF) intravitreal injection
Explanation:Treatment Options for Diabetic Maculopathy
Diabetic maculopathy is a condition that affects the retina and can lead to vision loss. There are several treatment options available to manage this condition, including anti-vascular endothelial growth factor (VEGF) intravitreal injection, focal laser photocoagulation, community diabetic eye screening, increase daily insulin dose, and pan-retinal photocoagulation.
Anti-VEGF intravitreal injection is a first-line treatment that works by stopping abnormal blood vessels from leaking, growing, and bleeding under the retina. This treatment targets VEGF, a protein that promotes the growth of new blood vessels.
Focal laser photocoagulation is another treatment option, but it is not recommended for lesions near the fovea due to the risk of damaging vision.
Community diabetic eye screening is not appropriate for diabetic maculopathy, as it requires more specialized treatment.
Increasing the daily insulin dose is not recommended unless blood glucose levels are erratic.
Pan-retinal photocoagulation is typically used in cases of proliferative diabetic retinopathy.
Overall, the best treatment option for diabetic maculopathy will depend on the individual patient’s condition and needs. It is important to consult with a healthcare professional to determine the most appropriate course of action.
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This question is part of the following fields:
- Ophthalmology
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Question 7
Incorrect
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A 22-year-old man with a history of hearing voices is brought to the Emergency Department by his family. He describes these voices as telling him to kill himself, ‘as he has a demon in him’. He also reports noting his intelligence being tapped through the television by a higher power. This has been going on for the past 3 months. His family denies either depression or manic episodes. The patient was admitted to the inpatient Psychiatry Unit and, after an evaluation, a diagnosis of schizophreniform disorder was made. He was started on Haldol (haloperidol) for his symptoms. Two days after initiation of therapy, the patient’s temperature rose to 41 °C, blood pressure 150/85 mmHg and pulse 110 bpm. Physical examination revealed muscular rigidity and delirium.
What is the most likely diagnosis?Your Answer: Acute dystonia
Correct Answer: Neuroleptic malignant syndrome
Explanation:Understanding Neurological Disorders Caused by Medications
Neurological disorders can be caused by certain medications, such as high-potency anti-psychotic drugs like haloperidol. One such disorder is neuroleptic malignant syndrome, which can result from the use of these medications to treat conditions like schizophrenia. Symptoms include muscular rigidity, fever, and altered mental status. Treatment involves discontinuing the medication and managing symptoms with cooling measures and medications like dantrolene or bromocriptine.
Another medication-induced neurological disorder is serotonin syndrome, which can occur when a patient takes multiple doses or an overdose of medications like selective serotonin reuptake inhibitors (SSRIs) or serotonin agonists. Symptoms include muscular twitching, agitation, and autonomic instability. Treatment involves discontinuing the medication and managing symptoms with supportive care.
Malignant hyperthermia is a similar disorder that can occur during anesthesia administration and is caused by an inherited genetic disorder. Symptoms include fever, muscle rigidity, and altered mental status. Treatment involves using medications like dantrolene and providing supportive care.
It’s important to note that not all neurological disorders are caused by medications. Meningitis, for example, is not a side effect of haloperidol. Acute dystonia, which presents with spasms of various muscle groups, can also be caused by haloperidol, but the presenting symptoms are more consistent with neuroleptic malignant syndrome. Understanding the different neurological disorders caused by medications can help healthcare providers make accurate diagnoses and provide appropriate treatment.
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This question is part of the following fields:
- Psychiatry
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Question 8
Incorrect
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A 9-year-old boy has been experiencing progressive gait disturbance and falls. He was initially evaluated by a paediatric neurologist at the age of 5 years due to unsteady gait and toe walking. His gait unsteadiness began around the age of 4 years with frequent falls, and he had also developed hand tremors prior to this visit. Upon further examination, he was found to have pes cavus, mild scoliosis, and no cardiac murmur. What is the mode of inheritance for the underlying condition?
Your Answer: X-linked recessive
Correct Answer: Autosomal recessive
Explanation:Friedreich’s ataxia is inherited in an autosomal recessive manner. This is the most common type of hereditary ataxia and typically presents with symptoms before the age of 25, including ataxia, cardiomyopathy, motor weakness, pes cavus foot deformity, and scoliosis. It should be noted that Friedreich’s ataxia is not inherited in an autosomal dominant or X-linked recessive manner, nor is it caused by mitochondrial dysfunction.
Autosomal Recessive Conditions
Autosomal recessive conditions are genetic disorders that occur when an individual inherits two copies of a mutated gene, one from each parent. These conditions are often referred to as ‘metabolic’ as they affect the body’s metabolic processes. However, there are notable exceptions, such as X-linked recessive conditions like Hunter’s and G6PD, and autosomal dominant conditions like hyperlipidemia type II and hypokalemic periodic paralysis.
Some ‘structural’ conditions, like ataxia telangiectasia and Friedreich’s ataxia, are also autosomal recessive. The following conditions are examples of autosomal recessive disorders: albinism, congenital adrenal hyperplasia, cystic fibrosis, cystinuria, familial Mediterranean fever, Fanconi anemia, glycogen storage disease, haemochromatosis, homocystinuria, lipid storage disease (Tay-Sach’s, Gaucher, Niemann-Pick), mucopolysaccharidoses (Hurler’s), PKU, sickle cell anemia, thalassemias, and Wilson’s disease.
It is worth noting that Gilbert’s syndrome is still a matter of debate, and many textbooks list it as autosomal dominant. Nonetheless, understanding the inheritance patterns of these conditions is crucial for genetic counseling and management.
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This question is part of the following fields:
- Paediatrics
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Question 9
Incorrect
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A 93-year-old man is brought into the emergency department after a car accident. He was in the passenger seat and wearing a seatbelt at the time.
His son, who was also in the car, reports hearing a loud 'thud' when his father's knees hit the dashboard. He had a right total hip replacement 12 years ago.
A primary survey shows right-sided dislocation of the hip.
What findings would be anticipated on examination, considering the probable type of dislocation?Your Answer: Hip abduction and internal rotation
Correct Answer: Leg shortening and internal rotation
Explanation:A potential complication of total hip replacement is posterior dislocation, which can present with sudden leg shortening, internal rotation, and a clunk sound. This may occur due to direct impact on a flexed hip, such as when sitting in a car. The hip will be adducted, internally rotated, and flexed in a posterior dislocation. Therefore, options suggesting hip abduction, external rotation, or hyperextension are incorrect.
Osteoarthritis (OA) of the hip is a prevalent condition, with the knee being the only joint more commonly affected. It is particularly prevalent in older individuals, and women are twice as likely to develop it. Obesity and developmental dysplasia of the hip are also risk factors. The condition is characterized by chronic groin pain that is exacerbated by exercise and relieved by rest. However, if the pain is present at rest, at night, or in the morning for more than two hours, it may indicate an alternative cause. The Oxford Hip Score is a widely used tool to assess the severity of the condition.
If the symptoms are typical, a clinical diagnosis can be made. Otherwise, plain x-rays are the first-line investigation. Management of OA of the hip includes oral analgesia and intra-articular injections, which provide short-term relief. However, total hip replacement is the definitive treatment.
Total hip replacement is a common operation in the developed world, but it is not without risks. Perioperative complications include venous thromboembolism, intraoperative fracture, nerve injury, surgical site infection, and leg length discrepancy. Postoperatively, posterior dislocation may occur during extremes of hip flexion, presenting with a clunk, pain, and inability to weight bear. Aseptic loosening is the most common reason for revision, and prosthetic joint infection is also a potential complication.
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This question is part of the following fields:
- Musculoskeletal
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Question 10
Incorrect
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A 21-year-old man experiences sudden right-sided chest pain while exercising. The pain persists in the Emergency Department, but he is not short of breath. There is no past medical history of note. Observations are recorded:
temperature 36.6 °C
heart rate (HR) 90 bpm
blood pressure (BP) 115/80 mmHg
respiratory rate (RR) 18 breaths/minute
oxygen saturation (SaO2) 99%.
A chest X-ray reveals a 1.5 cm sliver of air in the pleural space of the right lung.
Which of the following is the most appropriate course of action?Your Answer: Admit for a trial of nebulised salbutamol and observation
Correct Answer: Consider prescribing analgesia and discharge home with information and advice
Explanation:Management Options for Primary Pneumothorax
Primary pneumothorax is a condition where air accumulates in the pleural space, causing the lung to collapse. The management of primary pneumothorax depends on the severity of the condition and the presence of symptoms. Here are some management options for primary pneumothorax:
Prescribe analgesia and discharge home with information and advice: This option can be considered if the patient is not breathless and has only a small defect. The patient can be discharged with pain relief medication and given information and advice on how to manage the condition at home.
Admit for a trial of nebulised salbutamol and observation: This option is not indicated for a patient with primary pneumothorax, as a trial of salbutamol is not effective in treating this condition.
Aspirate the air with a needle and syringe: This option should only be attempted if the patient has a rim of air of >2 cm on the chest X-ray or is breathless. Aspiration can be attempted twice at a maximum, after which a chest drain should be inserted.
Insert a chest drain: This option should be done if the second attempt of aspiration is unsuccessful. Once air has stopped leaking, the drain should be left in for a further 24 hours prior to removal and discharge.
Insert a 16G cannula into the second intercostal space: This option is used for tension pneumothoraces and is not indicated for primary pneumothorax.
In conclusion, the management of primary pneumothorax depends on the severity of the condition and the presence of symptoms. It is important to choose the appropriate management option to ensure the best outcome for the patient.
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This question is part of the following fields:
- Respiratory
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