-
Question 1
Incorrect
-
A 35-year-old woman presents to the Emergency Department (ED) after experiencing palpitations while exercising at the gym. She has a past medical history of heart surgery to repair a congenital defect and an abnormal valve.
Upon examination in the ED, her blood pressure is 120/80 mmHg and her heart rate is 90 bpm and regular. She is not experiencing any signs of heart failure. An ECG shows sinus rhythm with a short PR interval, as well as right bundle branch block (RBBB) and a delta wave.
What is the most likely diagnosis for this patient?Your Answer: WPW syndrome
Correct Answer:
Explanation:Diagnosis and Management of Ebstein’s Anomaly with WPW Syndrome
Ebstein’s anomaly is a rare congenital heart disease that results from abnormal formation of the tricuspid valve, atrialisation of the right ventricle, and associated defects such as ASD. Patients with Ebstein’s anomaly may also present with Wolff–Parkinson–White (WPW) syndrome, as seen in this case with the presence of delta waves and short PR interval on ECG.
Digoxin and verapamil are not recommended for arrhythmias associated with WPW as they may worsen tachycardia. DC cardioversion is the preferred acute management for tachyarrhythmia, but for long-term management, radiofrequency ablation of the accessory pathway is preferable, especially in younger patients like this one.
It is unlikely that the patient’s presentation was due to uncomplicated SVT, as the abnormal resting ECG with short PR interval, delta waves, and RBBB suggests otherwise. Lown–Ganong–Levine syndrome, another pre-excitation syndrome, only presents with a short PR interval without delta waves or abnormal QRS complex.
Amphetamine toxicity and thyrotoxicosis can cause tachyarrhythmia but should not affect PR interval or cause delta waves. Therefore, the diagnosis of Ebstein’s anomaly with WPW syndrome is the most likely explanation for this patient’s presentation, given his past surgical history.
-
This question is part of the following fields:
- Cardiology
-
-
Question 2
Incorrect
-
A 22-year-old female comes to you for counselling regarding the initiation of combined oral contraceptive pill. Which of the following statements is correct?
Your Answer: She is likely to put on 2-3 kilograms of weight per year while using the combined pill
Correct Answer: She will still be protected against pregnancy if she takes amoxicillin for a lower respiratory tract infection while on the combined pill
Explanation:The true statement among the given options is that she will still be protected against pregnancy if she takes amoxicillin for a lower respiratory tract infection while on the combined pill.
Other than enzyme-inducing antibiotics such as rifampicin, antibiotics do not reduce the efficacy of the combined oral contraceptive pill.
It was previously advised that barrier methods of contraception should be used if taking an antibiotic while using the contraceptive pill, due to concerns that antibiotics might reduce the absorption of the pill. This is now known to be untrue. However, if the absorptive ability of the gut is compromised for another reason, such as severe diarrhoea or vomiting, or bowel disease, this may affect the efficacy of the pill.
The exception to the antibiotic rule is that hepatic enzyme-inducing antibiotics such as rifampicin and rifaximin do reduce the efficacy of the pill. Other enzyme-inducing drugs, such as phenytoin, phenobarbital, carbamazepine or St John’s Wort can also reduce the effectiveness of the pill.
Other options:
The combined pill is often prescribed for women with heavy periods as it can make them lighter and less painful.
There is no evidence that women on the combined pill put on any significant weight, although they may experience bloating at certain times in the course.
Women on the pill require monitoring of their blood pressure.
There are multiple different types of combined pills. -
This question is part of the following fields:
- Pharmacology
-
-
Question 3
Incorrect
-
You want to measure the potential benefit of creating a service dedicated to patients with multiple sclerosis in the local area. Which factor would determine how many resources will be required?
Your Answer: P value
Correct Answer: Prevalence
Explanation:To describe how often a disease or another health event occurs in a population, different measures of disease frequency can be used. The prevalence reflects the number of existing cases of a disease. In contrast to the prevalence, the incidence reflects the number of new cases of disease and can be reported as a risk or as an incidence rate. Prevalence and incidence are used for different purposes and to answer different research questions.
-
This question is part of the following fields:
- Clinical Sciences
-
-
Question 4
Incorrect
-
A 76-year-old man with chronic lymphocytic leukaemia (CLL) presents with spontaneous bruising. He denies any recent trauma and is currently taking aspirin, simvastatin, and ramipril for a previous heart attack.
During the examination, the patient appears to be in good health. His conjunctiva is pale, but his chest is clear, and he is well-perfused. Several purpura are visible on his arms, back, and chest. Palpable lymph nodes are present in the left inguinal area, but there is no hepatosplenomegaly.
Hb 104 g/l Na+ 135 mmol/l
Platelets 54 * 109/l K+ 4.0 mmol/l
WBC 10.3 * 109/l Urea 3.4 mmol/l
Neuts 6.7 * 109/l Creatinine 87 µmol/l
Lymphs 3.4 * 109/l CRP 14 mg/l
Eosin 0.1 * 109/l
What is the best course of action for managing this patient?Your Answer:
Correct Answer: Start chlorambucil
Explanation:The presence of thrombocytopenia in a patient with CLL signals the need to initiate treatment. While steroids may provide some relief, chemotherapy, particularly with chlorambucil, is the preferred approach. Discontinuing aspirin may be recommended, but it will not address the underlying issue. Hypersplenism is not suspected as the cause of thrombocytopenia. Platelet transfusion is not an urgent intervention as there is no active bleeding and it does not address the underlying problem.
Managing Chronic Lymphocytic Leukaemia
Chronic lymphocytic leukaemia (CLL) is a type of cancer that affects the blood and bone marrow. Treatment is only necessary when certain indications are present. These include progressive marrow failure, massive or progressive lymphadenopathy or splenomegaly, progressive lymphocytosis, systemic symptoms, and autoimmune cytopaenias. Patients who do not have any of these indications are monitored with regular blood counts.
The initial treatment of choice for the majority of CLL patients is fludarabine, cyclophosphamide, and rituximab (FCR). This combination therapy has shown promising results in managing the disease. However, in cases where previous therapies have failed, ibrutinib may be used as an alternative treatment option.
It is important to note that CLL management should be tailored to each patient’s individual needs and circumstances. Regular monitoring and communication with healthcare professionals are crucial in ensuring the best possible outcomes for patients.
-
This question is part of the following fields:
- Haematology
-
-
Question 5
Incorrect
-
A 72 yr. old male with a history of type II diabetes mellitus and hypertension for 15 years, presented with gradual onset difficulty in breathing on exertion and bilateral ankle swelling for the past 3 months. On examination he had mild ankle oedema. His JVP was not elevated. His heart sounds were normal but he had bibasal crepitations on auscultation. Which of the following clinical signs has the greatest sensitivity in detecting heart failure in this patient?
Your Answer:
Correct Answer: Third heart sound
Explanation:The presence of a third heart sound is the most sensitive indicator of heart failure. All of the other signs can be found in heart failure with varying degrees.
-
This question is part of the following fields:
- Cardiology
-
-
Question 6
Incorrect
-
A 22-year-old female patient visits the clinic for evaluation. She was prescribed bisoprolol by her GP after experiencing palpitations and has now developed a rash on her elbows, knees, navel, and genital area. The rash has been itchy but not painful, and she has not experienced any further palpitations. She had eczema as a young child, but it disappeared before she turned five. She is not aware of any allergies. Upon examination, she has a well-defined erythematous rash on the extensor surfaces of her elbows, knees, umbilicus, and groin. What is the most probable diagnosis?
Your Answer:
Correct Answer: Psoriasis
Explanation:The patient is presenting with a non-painful, well-defined, and erythematous rash on their extensor surfaces, which is indicative of flexural psoriasis. It is likely that the use of beta-blockers triggered the onset of this condition, as this is a known side effect for individuals with psoriasis. This presentation is not consistent with a drug allergy, as the rash is not systemic and poorly defined. Additionally, topical dermatitis typically presents with inflammation in areas of contact with an irritant, which is not the case here. Eczema is also an unlikely explanation, as it typically affects flexural surfaces rather than extensor surfaces.
Psoriasis: A Chronic Skin Disorder with Various Subtypes and Complications
Psoriasis is a prevalent chronic skin disorder that affects around 2% of the population. It is characterized by red, scaly patches on the skin, but it is now known that patients with psoriasis are at an increased risk of arthritis and cardiovascular disease. The pathophysiology of psoriasis is multifactorial and not yet fully understood. It is associated with genetic factors such as HLA-B13, -B17, and -Cw6, and abnormal T cell activity that stimulates keratinocyte proliferation. Environmental factors such as skin trauma, stress, streptococcal infection, and sunlight exposure can worsen, trigger, or improve psoriasis.
There are several recognized subtypes of psoriasis, including plaque psoriasis, flexural psoriasis, guttate psoriasis, and pustular psoriasis. Each subtype has its own unique characteristics and affects different areas of the body. Psoriasis can also cause nail signs such as pitting and onycholysis, as well as arthritis.
Complications of psoriasis include psoriatic arthropathy, metabolic syndrome, cardiovascular disease, venous thromboembolism, and psychological distress. It is important for patients with psoriasis to receive proper management and treatment to prevent these complications and improve their quality of life.
-
This question is part of the following fields:
- Dermatology
-
-
Question 7
Incorrect
-
Which treatment of chronic obstructive pulmonary disease (COPD) increases the long-term prognosis in patients?
Your Answer:
Correct Answer: Long-term domiciliary oxygen therapy
Explanation:COPD is commonly associated with progressive hypoxemia. Oxygen administration reduces mortality rates in patients with advanced COPD because of the favourable effects on pulmonary hemodynamics.
Long-term oxygen therapy improves survival 2-fold or more in hypoxemic patients with COPD, according to 2 landmark trials, the British Medical Research Council (MRC) study and the US National Heart, Lung and Blood Institute’s Nocturnal Oxygen Therapy Trial (NOTT). Hypoxemia is defined as PaO2 (partial pressure of oxygen in arterial blood) of less than 55 mm Hg or oxygen saturation of less than 90%. Oxygen was used for 15-19 hours per day.
Therefore, specialists recommend long-term oxygen therapy for patients with a PaO2 of less than 55 mm Hg, a PaO2 of less than 59 mm Hg with evidence of polycythaemia, or cor pulmonale. Patients should be evaluated after 1-3 months after initiating therapy, because some patients may not require long-term oxygen.
-
This question is part of the following fields:
- Respiratory
-
-
Question 8
Incorrect
-
A middle-aged patient with a history of heavy alcohol consumption presents with a persistent fever, coughing up blood, green phlegm, and a left-sided effusion. The patient reports feeling unwell with fluctuating fevers for the past week and admits to drinking a significant amount of alcohol and not maintaining a proper diet. You suspect the possibility of an empyema. What test would be most helpful in confirming your suspicion?
Your Answer:
Correct Answer: Pleural fluid pH
Explanation:Diagnostic Tests for Empyema: Importance of Pleural Fluid pH
Empyema is a serious condition that requires prompt diagnosis and treatment. Among the various diagnostic tests available, pleural fluid pH is the most useful investigation for confirming the presence of empyema. A pH of less than 7.2 is highly suggestive of empyema and should be considered a red flag.
Other diagnostic tests, such as urinary and serum pneumococcal antigen tests, may be helpful but are not definitive. Pleural fluid microscopy and culture are important for tailoring antimicrobial therapy, but only 60% of cultures are positive. Pleural fluid white cell count and differential may also be elevated in empyema, but a low pH is a more reliable indicator.
Given the patient’s history of alcohol excess, the likelihood of a Klebsiella pneumonia causing the empyema is high, rather than a pneumococcal pneumonia. Therefore, clinicians should prioritize pleural fluid pH as a diagnostic test for empyema.
-
This question is part of the following fields:
- Respiratory Medicine
-
-
Question 9
Incorrect
-
A 27-year-old Lebanese woman presented with left branch retinal artery occlusion (BRAO) one week after an uncomplicated elective caesarean delivery. Two weeks postpartum, she also developed mouth and vulval ulcers. Her left eye's visual acuity was limited to counting fingers. Her full blood count, U&Es, and coagulation screen were all normal. Her CRP level was 28, and her ANA titre was 1:20. What is the most probable cause of her left BRAO?
Your Answer:
Correct Answer: Behcet's disease
Explanation:Behcet’s Disease: An Inflammatory Condition of Blood Vessels
Behcet’s disease is a type of inflammatory condition that affects the blood vessels, but its exact cause is still unknown. This disease is more common in people from the eastern Mediterranean and the Middle East. The inflammation caused by Behcet’s disease can affect various parts of the body, including the eyes, which can lead to retinal artery occlusion and other complications.
If a person from the Mediterranean region presents with mouth and genital ulcers accompanied by an inflammatory condition, it is essential to consider Behcet’s disease as a possible diagnosis.
-
This question is part of the following fields:
- Medical Ophthalmology
-
-
Question 10
Incorrect
-
A 30-year-old female presented in the ophthalmology ward complaining of blurry vision for 4 days. Fundoscopy of both eyes revealed cotton wool spots in both the retinas. What is the most likely cause of this condition?
Your Answer:
Correct Answer: CMV infection
Explanation:Fundoscopy findings of cotton wool spots and retinal tears, accompanied by a history of blurred vision, are characteristic of retinitis. Cytomegalovirus is known to cause retinitis.
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 11
Incorrect
-
A 60-year-old Afro-Caribbean female presents to the Emergency Department with a 4-day history of unusual behavior at home. Her family had noticed that she was very disinhibited and agitated during a dinner party they hosted. She also reported experiencing hallucinations. Over the past 3 weeks, she has had two episodes of generalised seizures lasting up to 5 minutes each, with associated urinary incontinence and tongue biting. She has no history of epilepsy and is not taking any regular medications, but was diagnosed with ovarian teratoma two years ago. On examination, she has no focal neurology but exhibits a dystonic orofacial movement disorder. A CT scan of her head was unremarkable, with no acute infarct, haemorrhage or space occupying lesion demonstrated.
What investigation is the most appropriate for making a diagnosis?Your Answer:
Correct Answer: Anti-NMDA receptor antibodies
Explanation:The symptoms presented strongly indicate the possibility of limbic encephalitis caused by autoimmune activity.
Understanding Anti-NMDA Receptor Encephalitis
Anti-NMDA receptor encephalitis is a condition that is often associated with psychiatric symptoms such as agitation, hallucinations, delusions, and disordered thinking. It can also cause seizures, insomnia, dyskinesias, and autonomic instability. This condition is considered a paraneoplastic syndrome, and ovarian teratomas are often found in up to half of all female adult patients, particularly those of Afro-Caribbean descent. While an MRI of the head may appear normal, abnormalities can be seen on FLAIR sequences in the deep subcortical limbic structures. The cerebrospinal fluid (CSF) may show pleocytosis, but it can also be normal initially.
In contrast to other autoimmune conditions, anti-NMDA receptor encephalitis is not associated with anti-MuSK or anti-GM1 autoantibodies. Treatment for this condition typically involves immunosuppression with intravenous steroids, immunoglobulins, rituximab, cyclophosphamide, or plasma exchange, either alone or in combination. Additionally, resection of the teratoma can also be therapeutic.
Overall, understanding the symptoms and treatment options for anti-NMDA receptor encephalitis is crucial for proper diagnosis and management of this condition.
-
This question is part of the following fields:
- Neurology
-
-
Question 12
Incorrect
-
A 56-year-old man presents to the gastroenterology clinic for follow-up of his alcoholic liver disease. He reports abstaining from alcohol for several months but recently had a relapse after receiving distressing news at work. He now feels very unwell and seeks medical attention.
Upon examination, he appears mildly jaundiced and diaphoretic. His heart rate is 119 beats per minute, and his blood pressure is 105/66 mmHg. He is afebrile, and his cardiovascular and respiratory exams are unremarkable. Abdominal examination reveals a tender 2 cm liver edge and shifting dullness.
The patient's blood tests are as follows:
- Hemoglobin: 105 g/l
- Platelets: 167 * 109/l
- White blood cells: 10.5 * 109/l
- Neutrophils: 5.7 * 109/l
- INR: 1.9
- Bilirubin: 33 µmol/l
- ALP: 220 u/l
- AST: 137 u/l
- γGT: 505 u/l
- Albumin: 29 g/l
- Sodium: 132 mmol/l
- Potassium: 4.4 mmol/l
- Urea: 7 mmol/l
- Creatinine: 105 µmol/l
- CRP: 47 mg/l
The patient is diagnosed with alcoholic hepatitis and admitted to the hospital. What treatment option is most likely to improve his survival?Your Answer:
Correct Answer: Prednisolone
Explanation:Antibiotics are not necessary for this gentleman as there is no evidence of infection.
While the patient reports abstinence before the alcohol binge, it is important to monitor for withdrawal symptoms and administer chlordiazepoxide if necessary.
Although human albumin solution is effective for rehydration in cases of hepatorenal syndrome (HRS) in patients with liver disease, it is not necessary for this patient who does not meet the criteria for HRS. Instead, crystalloid should be used for rehydration initially.
Alcoholic liver disease is a range of conditions that includes alcoholic fatty liver disease, alcoholic hepatitis, and cirrhosis. When investigating this disease, gamma-GT levels are typically elevated, and a ratio of AST:ALT greater than 3 strongly suggests acute alcoholic hepatitis. In terms of management, glucocorticoids like prednisolone are often used during acute episodes of alcoholic hepatitis. Maddrey’s discriminant function is used to determine who would benefit from glucocorticoid therapy, and pentoxyphylline may also be used. The STOPAH study compared the effectiveness of pentoxyphylline and prednisolone and found that prednisolone improved survival at 28 days, while pentoxyphylline did not improve outcomes.
-
This question is part of the following fields:
- Gastroenterology And Hepatology
-
-
Question 13
Incorrect
-
A study is carried out to assess the efficacy of a new anti-epileptic drug for children with absence seizures. The total number of the children selected for the study was 400, from which 150 children were assigned to take the new drug and 250 children were assigned in the control group. After a period of four months, only 15 children taking the new drug had a seizure compared to 100 children from the control group who had seizure. What is the correct value regarding the relative risk reduction?
Your Answer:
Correct Answer: 75%
Explanation:Relative risk reduction (RRR) tells you by how much the treatment reduced the risk of bad outcomes relative to the control group who did not have the treatment. In the previous example, the relative risk reduction of fever and rash in the group of the children on the intervention was 40 per cent (1 – 0.6 = 0.4 or 40 per cent). RRR = (EER -CER) / CER = (0.1 – 0.4) / 0.4 = -0.75 or 75% reduction.
-
This question is part of the following fields:
- Clinical Sciences
-
-
Question 14
Incorrect
-
A 27 year old female from Zimbabwe is seen in December with depression. She has no past medical history of interest but is known to smoke Cannabis. She had similar episodes in the past winter. Which condition does this signify?
Your Answer:
Correct Answer: Seasonal affective disorder
Explanation:Seasonal affective disorder (SAD) is a type of depression that’s related to changes in seasons. SAD begins and ends at about the same time every year. For most people with SAD, the symptoms start in the fall and continue into the winter months, sapping the person’s energy and making him feel moody. Less often, SAD causes depression in the spring or early summer.
Treatment for SAD may include light therapy (phototherapy), medications and psychotherapy.
Signs and symptoms of SAD may include:
Feeling depressed most of the day, nearly every day
Losing interest in activities you once enjoyed
Having low energy
Having problems with sleeping
Experiencing changes in your appetite or weight
Feeling sluggish or agitated
Having difficulty concentrating
Feeling hopeless, worthless or guilty
Having frequent thoughts of death or suicide.Seasonal affective disorder is diagnosed more often in women than in men. And SAD occurs more frequently in younger adults than in older adults.
Factors that may increase your risk of seasonal affective disorder include:
Family history. People with SAD may be more likely to have blood relatives with SAD or another form of depression.
Having major depression or bipolar disorder. Symptoms of depression may worsen seasonally if you have one of these conditions.
Living far from the equator. SAD appears to be more common among people who live far north or south of the equator. This may be due to decreased sunlight during the winter and longer days during the summer months. -
This question is part of the following fields:
- Psychiatry
-
-
Question 15
Incorrect
-
A 65-year-old male with stable congestive heart failure presents to the clinic. He is currently taking furosemide 80 mg once daily, digoxin 125 mcg once daily, enalapril 20 mg once daily, and ibuprofen 600 mg three times daily (taken for the last month). During his last visit three months ago, his renal function was normal, and his furosemide dose was increased from 40 mg to 80 mg per day. His baseline blood pressure is 125/75, and his current blood pressure is measured at 120/70 mmHg. Upon investigation, his serum sodium is 132 mmol/L (137-144), serum potassium is 5.4 mmol/L (3.5-4.9), serum urea is 18 mmol/L (2.5-7.5), and serum creatinine is 270 µmol/L (60-110). What is the most likely cause of the deterioration in his renal function?
Your Answer:
Correct Answer: Interstitial nephritis secondary to NSAIDs
Explanation:The most likely cause of sudden deterioration in renal function is acute interstitial nephritis, which is inflammation of the renal tubulo-interstitium due to a hypersensitivity reaction to drugs, with NSAIDs being the most common cause. Other drugs that can cause this include antibiotics, diuretics, and cimetidine. Symptoms include acute renal failure, fever, arthralgia, and skin rashes, with eosinophilia, raised serum IgE, and eosinophiluria often present. Treatment involves withdrawal of the offending drug and may require dialysis. ACE inhibitors can also cause acute deterioration in renal function, mainly in patients with bilateral renovascular disease, and may increase serum potassium. There is no evidence of urinary tract infection or digoxin as a cause of the deterioration.
-
This question is part of the following fields:
- Renal Medicine
-
-
Question 16
Incorrect
-
A 39-year-old woman presents to the Endocrine Clinic with a complaint of excessive sweating and occasional fever for the past six months. She recently went on a trip to Thailand but had to cut it short due to the unbearable heat. She has also noticed a gradual weight loss over the past year, despite having a good appetite.
Upon examination, she is tachycardic but afebrile. Her palms are sweaty, and there is no palpable goitre or cervical lymphadenopathy. Routine FBC, U&E, and LFT are within normal limits.
What is the most probable diagnosis?Your Answer:
Correct Answer: Thyrotoxicosis
Explanation:Night sweats can be a symptom of various medical conditions. In a female patient, the differential diagnosis includes hypoglycemia, phaeochromocytoma, carcinoid, Hodgkin’s disease, tuberculosis, and thyrotoxicosis. Episodic bouts of sweating may suggest hypoglycemia, phaeochromocytoma, or carcinoid. However, if the patient reports night sweats, Hodgkin’s disease or tuberculosis should be considered. Hodgkin’s disease typically presents with localised lymphadenopathy, weight loss, pruritus, and fever. On the other hand, patients with thyrotoxicosis report constant sweating and heat intolerance, even without enlargement of the thyroid gland. In this case, considering the patient’s age and sex, thyrotoxicosis is the most likely diagnosis. Non-Hodgkin’s lymphoma and infection with an undefined organism are less likely causes, as there is no evidence of lymphadenopathy or abnormal blood tests. Phaeochromocytoma is also unlikely, as the patient does not have severe hypertension or other characteristic symptoms.
-
This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
-
-
Question 17
Incorrect
-
A 44-year-old woman is investigated for hot flushes and night sweats. Her blood tests show a significantly raised FSH level and her symptoms are attributed to menopause. Following discussions with the patient, she elects to have hormone replacement treatment. What is the most significant risk of prescribing an oestrogen-only preparation rather than a combined oestrogen-progestogen preparation?
Your Answer:
Correct Answer: Increased risk of endometrial cancer
Explanation:The use of hormone replacement therapy (HRT) based on unopposed oestrogen increases the risk of endometrial cancer, and uterine hyperplasia or cancer.
Evidence from randomized controlled studies showed a definite association between HRT and uterine hyperplasia and cancer. HRT based on unopposed oestrogen is associated with this observed risk, which is unlike the increased risk of breast cancer linked with combined rather than unopposed HRT. -
This question is part of the following fields:
- Endocrinology
-
-
Question 18
Incorrect
-
Briefly state the mechanism of action of salbutamol.
Your Answer:
Correct Answer: Beta2 receptor agonist which increases cAMP levels and leads to muscle relaxation and bronchodilation
Explanation:Salbutamol stimulates beta-2 adrenergic receptors, which are the predominant receptors in bronchial smooth muscle (beta-2 receptors are also present in the heart in a concentration between 10% and 50%).
Stimulation of beta-2 receptors leads to the activation of enzyme adenyl cyclase that forms cyclic AMP (adenosine-mono-phosphate) from ATP (adenosine-tri-phosphate). This increase of cyclic AMP relaxes bronchial smooth muscle and decrease airway resistance by lowering intracellular ionic calcium concentrations. Salbutamol relaxes the smooth muscles of airways, from trachea to terminal bronchioles.
Increased cyclic AMP concentrations also inhibits the release of bronchoconstrictor mediators such as histamine and leukotriene from the mast cells in the airway.
-
This question is part of the following fields:
- Respiratory
-
-
Question 19
Incorrect
-
A 56-year-old woman presents to the emergency department complaining of sudden shortness of breath and slight pleuritic chest pain. She denies coughing up any blood and feeling hot or cold. Her symptoms started four hours ago while she was at rest. She has a medical history of hypothyroidism and underwent a wide local excision for ductal carcinoma in situ a year ago. The patient has never smoked and was previously healthy. On examination, scattered crepitations are heard over the right lower zone, and her oxygen saturation is at 93%. Blood tests, including a D-dimer, are pending. What is the most appropriate next step?
Your Answer:
Correct Answer: Chest X-ray
Explanation:When investigating a PE, a chest X-ray is a necessary examination. This is because a patient with a typical history of a pulmonary embolism should have alternative pathologies such as a chest infection or pneumothorax excluded before arranging a CT pulmonary angiogram urgently. If a definitive scan is not immediately available, starting treatment with low molecular weight heparin would be appropriate after a chest X-ray is done. This information is based on the ‘Venous thromboembolic diseases: diagnosis, management and thrombophilia testing’ Clinical guideline [CG144] by The National Institute for Health and Care Excellence in June 2012.
Pulmonary embolism can be difficult to diagnose as it can present with a variety of cardiorespiratory symptoms and signs depending on its location and size. The PIOPED study in 2007 found that tachypnea, crackles, tachycardia, and fever were common clinical signs in patients diagnosed with pulmonary embolism. The Well’s criteria for diagnosing a PE use tachycardia rather than tachypnea. All patients with symptoms or signs suggestive of a PE should have a history taken, examination performed, and a chest x-ray to exclude other pathology.
To rule out a PE, the pulmonary embolism rule-out criteria (PERC) can be used. All criteria must be absent to have a negative PERC result, which reduces the probability of PE to less than 2%. If the suspicion of PE is greater than this, a 2-level PE Wells score should be performed. A score of more than 4 points indicates a likely PE, and an immediate computed tomography pulmonary angiogram (CTPA) should be arranged. If the CTPA is negative, patients do not need further investigations or treatment for PE.
CTPA is now the recommended initial lung-imaging modality for non-massive PE. V/Q scanning may be used initially if appropriate facilities exist, the chest x-ray is normal, and there is no significant symptomatic concurrent cardiopulmonary disease. D-dimer levels should be considered for patients over 50 years old. A chest x-ray is recommended for all patients to exclude other pathology, but it is typically normal in PE. The sensitivity of V/Q scanning is around 75%, while the specificity is 97%. Peripheral emboli affecting subsegmental arteries may be missed on CTPA.
-
This question is part of the following fields:
- Cardiology
-
-
Question 20
Incorrect
-
A 25 yr. old previously well male presented with chest discomfort and difficulty in breathing while running to the bus. Symptoms disappeared after resting. But the symptoms reappeared whilst he was climbing the stairs. On examination he was not dyspnoeic at rest. BP was 110/70 mmHg and pulse rate was 72 bpm. His heart sounds were normal. There was an additional clicking noise in the fourth left intercostal space which is heard with each heart beat. Which of the following is the most probable cause for his presentation?
Your Answer:
Correct Answer: Spontaneous pneumothorax
Explanation:The given history is more compatible with spontaneous pneumothorax. Left-sided pneumothoraxes may be associated with a clicking noise, which is heard with each heart-beat and can sometimes be heard by the patient.
-
This question is part of the following fields:
- Cardiology
-
-
Question 21
Incorrect
-
A 32-year-old gentleman presents to his GP with a 2 month history of constant abdominal pain and early satiety. He has hypertension for which he takes enalapril. On examination, he has mild tenderness on both flanks. Well-circumscribed masses are palpable in both the left and right flanks. A soft systolic murmur is heard loudest at the apex. His observations are heart rate 67/min, blood pressure 152/94mmHg, temperature 37.2C, respiratory rate 14/min, saturations 97%. Which additional feature is most likely to be found in this patient?
Your Answer:
Correct Answer: Hepatomegaly
Explanation:This patient shows classic symptoms of autosomal-dominant polycystic kidney disease (ADPKD). The abdominal pain and early satiety is caused by the enlarged kidneys that were apparent from the physical examination. Additionally, hypertension is a common symptom along with the systolic murmur that was heard, suggesting mitral valve involvement. In ADPKD cases, the most common extra-renal manifestation is the development of liver cysts which are associated with hepatomegaly.
-
This question is part of the following fields:
- Nephrology
-
-
Question 22
Incorrect
-
A 39-year-old Mexican man presents to the Emergency Department with a 1-month history of dizziness and unsteady gait. He had been visiting his family, who were concerned about his strange behavior, depression, and fatigue. He also complained of back pain and constipation. He works on a cattle ranch in Mexico, does not smoke, and does not use drugs. On examination, he is febrile, confused, and has hepatosplenomegaly and an unsteady gait. His blood work shows low white cell count, low platelets, high LDH, high ALT, high ALP, high bilirubin, and high ESR. Blood cultures and imaging studies are normal, and he tests negative for HIV. What is the most likely diagnosis?
Your Answer:
Correct Answer: Brucellosis
Explanation:Overview of Possible Diagnoses for a Patient with Chronic Granulomatous Disease
Chronic granulomatous disease can present with a variety of symptoms, including bone pain, neuropsychiatric symptoms, and a pyrexia of unknown origin. Here are some possible diagnoses to consider:
Brucellosis: This zoonotic bacterial infection can cause chronic granulomatous disease and is endemic in Mexico, where the patient had cattle exposure.
Melioidosis: This infection caused by Burkholderia pseudomallei is endemic to South and Southeast Asia and can present with pneumonia, skin abscesses, or sepsis.
Tuberculosis: While TB can cause chronic granulomatous disease, it is not the most likely diagnosis in this case, as the patient does not have respiratory symptoms and has neurological signs.
Nocardiosis: This uncommon infection caused by Nocardia bacteria is unlikely in this patient, as it typically affects those with underlying immunodeficiency.
Histoplasmosis: This fungal infection usually presents as a pneumonia and is most common in North America.
It is important to consider all possible diagnoses and perform appropriate diagnostic tests, such as bone marrow aspiration and culture, to accurately diagnose and treat chronic granulomatous disease.
-
This question is part of the following fields:
- Infectious Diseases
-
-
Question 23
Incorrect
-
A 54-year-old female patient presents with a one week history of bloody diarrhoea, fever and abdominal pain. She has a history of rheumatoid arthritis which she controls with methotrexate. Her stool sample shows Campylobacter jejuni. What is the single most appropriate management?
Your Answer:
Correct Answer: Fluids + clarithromycin
Explanation:This woman is receiving methotrexate, an immunosuppressant, to control her rheumatoid arthritis. In such immunocompromised patients, BNF suggests clarithromycin as first-line management.
-
This question is part of the following fields:
- Clinical Sciences
-
-
Question 24
Incorrect
-
A 60 yr. old male patient with hypertension presented with acute onset retrosternal chest pain for 3 hours. On examination his pulse rate was 68 bpm, BP was 100/60 mmHg and JVP was seen 3mm from the sternal notch. Respiratory examination was normal. His ECG showed narrow QRS complexes, ST segment elevation of 2mm in leads II, III and aVF and a complete heart block. What is the most immediate treatment from the following answers?
Your Answer:
Correct Answer: Chewable aspirin 300 mg
Explanation:The diagnosis is inferior ST elevation myocardial infarction. As the right coronary artery supplies the SA and AV nodes and bundle of His, conduction abnormalities are more common with inferior MIs. The most immediate drug management is high dose Aspirin. Definite treatment is urgent cardiac revascularization.
-
This question is part of the following fields:
- Cardiology
-
-
Question 25
Incorrect
-
An 18 year old boy from Middle East presented with a 1 month history of a yellowish, crusted plaque over his scalp, along with some scarring alopecia. What will the likely diagnosis be?
Your Answer:
Correct Answer: Favus
Explanation:Favus is a fungal infection of the scalp, resulting in the formation of a yellowish crusted plaque over the scalp and leads to scar formation with alopecia. Tinea capitus is a fungal infection of the scalp resulting in scaling and non scarring hair loss. Folliculitis presents with multiple perifollicular papules which can be caused by both bacteria and fungi. Cradle cap usually affects infants where the whole scalp is involved. It can lead to hair loss and responds to topical antifungals and keratolytics.
-
This question is part of the following fields:
- Dermatology
-
-
Question 26
Incorrect
-
A 50-year-old woman presents with hallucinations and a history of alcohol dependency. She is currently being treated for hypothyroidism by her GP. Her husband reports that she has been experiencing diarrhoea, difficulty swallowing, and an itchy rash on her arms for the past 3 months. Prior to this, she had been irritable and vomiting regularly.
On examination, the patient is aggressive, but a pigmented, scaly rash is visible on her arms and neck. Her heart sounds are normal, chest is clear, and abdomen is soft. Neurological examination reveals generalised weakness.
Blood tests show:
- Hb: 142 g/l
- Platelets: 200 * 109/l
- WBC: 5.3 * 109/l
- Na+: 140 mmol/l
- K+: 4.2 mmol/l
- Urea: 6 mmol/l
- Creatinine: 84 µmol/l
- TSH: 4.0 U/mL
- Free T3: 3.1 pg/mL
- Free T4: 1.5 ng/L
What is the most likely diagnosis?Your Answer:
Correct Answer: Pellagra
Explanation:Pellagra, a condition characterized by dermatitis, diarrhea, and dementia, is caused by a deficiency of niacin (vitamin B3). This condition is primarily seen in countries where corn is a staple food, such as India and China. In the UK, it is rare and mostly observed in patients with alcohol dependency or anorexia nervosa. Niacin is obtained from foods like beans and eggs and can also be produced from the amino acid tryptophan. Pellagra may also occur in carcinoid syndrome, where tryptophan is converted to serotonin.
Although an over-treatment or intentional overdose of thyroxine could cause some of the patient’s symptoms, her thyroid function tests are normal. SLE and…
Understanding Pellagra: Symptoms and Causes
Pellagra is a condition that results from a deficiency of nicotinic acid, also known as niacin. The classic symptoms of pellagra are commonly referred to as the 3 D’s: dermatitis, diarrhoea, and dementia. Dermatitis is characterized by a scaly, brown rash that appears on sun-exposed areas of the skin, often forming a necklace-like pattern around the neck known as Casal’s necklace. Diarrhoea and dementia are also common symptoms of pellagra, with patients experiencing chronic diarrhoea and cognitive impairment, including depression and confusion.
Pellagra can occur as a result of isoniazid therapy, which inhibits the conversion of tryptophan to niacin. This condition is also more common in individuals who consume excessive amounts of alcohol. If left untreated, pellagra can be fatal. Therefore, it is important to recognize the symptoms and seek medical attention promptly. With proper treatment, including niacin supplementation and dietary changes, individuals with pellagra can recover and avoid further complications.
-
This question is part of the following fields:
- Dermatology
-
-
Question 27
Incorrect
-
A 32-year-old man of ethnic Indian descent presents to the endocrinology clinic for review of his type 1 diabetes. Despite being on a twice-daily mixed insulin regimen, he has poor diabetic control with elevated HbA1c and high blood glucose levels. He expresses concern about increasing his insulin dose or frequency due to his current overweight status with a BMI of 29 kg/m2. Are there any alternative medical management options available to improve his diabetic control besides increasing insulin?
Your Answer:
Correct Answer: Metformin
Explanation:Metformin is the correct answer. The patient in question has type 1 diabetes that is poorly controlled. Additionally, he is overweight and of Indian ethnicity. Due to the side effects, increasing insulin doses is not a popular option. NICE suggests that metformin may be a viable alternative to increasing insulin in overweight individuals of Indian origin. This is particularly beneficial as it would not result in further weight gain.
Understanding Insulin Therapy
Insulin therapy has been a game-changer in the management of diabetes mellitus since its development in the 1920s. It remains the only available treatment for type 1 diabetes mellitus (T1DM) and is widely used in type 2 diabetes mellitus (T2DM) when oral hypoglycemic agents fail to provide adequate control. However, understanding the different types of insulin can be overwhelming, and it is crucial to have a basic grasp to avoid potential harm to patients.
Insulin can be classified by manufacturing process, duration of action, and type of insulin analogues. Patients often require a combination of preparations to ensure stable glycemic control throughout the day. Rapid-acting insulin analogues act faster and have a shorter duration of action than soluble insulin and may be used as the bolus dose in ‘basal-bolus’ regimes. Short-acting insulins, such as Actrapid and Humulin S, may also be used as the bolus dose in ‘basal-bolus’ regimen. Intermediate-acting insulins, like isophane insulin, are often used in a premixed formulation with long-acting insulins, such as insulin determir and insulin glargine, given once or twice daily. Premixed preparations combine intermediate-acting insulin with either a rapid-acting insulin analogue or soluble insulin.
The vast majority of patients administer insulin subcutaneously, and it is essential to rotate injection sites to prevent lipodystrophy. Insulin pumps are available, which delivers a continuous basal infusion and a patient-activated bolus dose at meal times. Intravenous insulin is used for patients who are acutely unwell, such as those with diabetic ketoacidosis. Inhaled insulin is available but not widely used, and oral insulin analogues are in development but have considerable technical hurdles to clear. Overall, understanding insulin therapy is crucial for healthcare professionals to provide safe and effective care for patients with diabetes mellitus.
-
This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
-
-
Question 28
Incorrect
-
A 46-year-old gentleman diagnosed with type 2 diabetes, hypertension, and proteinuria is started on Ramipril to prevent development of renal disease. He reports to his GP that he has developed a troublesome cough since starting the medication. He has no symptoms of lip swelling, wheeze and has no history of underlying respiratory disease. What increased chemical is thought to be the cause of his cough?
Your Answer:
Correct Answer: Bradykinin
Explanation:Ramipril is an ACE inhibitor that blocks the conversion of angiotensin I to angiotensin II as well as preventing the breakdown of bradykinin, leading to blood vessel dilatation and decreased blood pressure. However, bradykinin also causes smooth muscles in the lungs to contract, so the build-up of bradykinin is thought to cause the dry cough that is a common side-effect in patients that are on ACE inhibitors.
-
This question is part of the following fields:
- Nephrology
-
-
Question 29
Incorrect
-
A 35-year-old woman presents to the Emergency Department (ED) after collapsing at a gym. She cannot recall any detail of the collapse. Collateral history confirmed that she collapsed after exercising and there was no seizure activity after the collapse. A rapid heart rate was detected by the first attender at the scene. She has no past medical history, drug history or history of alcohol or drug abuse. She confirms a family history of unexplained sudden death. An 12-lead electrocardiogram (ECG) shows a sinus rhythm with corrected QT interval of 0.48 s.
What is the most likely cause of her collapse?Your Answer:
Correct Answer: LQT1 mutation
Explanation:Long QT syndrome (LQTS) is a genetic disorder that can be caused by mutations in different genes. The most common types of LQTS are LQT1 and LQT2, which account for about 90% of cases. People with LQT1 and LQT2 mutations may experience fainting spells triggered by emotional or physical stress. Jervell-Lange-Nielsen syndrome (JLNS) is a rare form of LQTS that is associated with deafness. JLNS can be caused by mutations in two different genes, JLN 1 and JLN2. JLN2 is less common than JLN1. LQT3 is another type of LQTS that is characterized by tachyarrhythmia events during sleep. This type of LQTS is less common than LQT1 and LQT2, but it is more likely to be fatal. Anderson syndrome is an extremely rare form of LQTS that is associated with skeletal abnormalities and periodic episodes of muscle weakness.
-
This question is part of the following fields:
- Cardiology
-
-
Question 30
Incorrect
-
A 30-year-old female was brought to the ER in a confused state. The patient works in a photograph development laboratory. On admission, she was hypoxic and hypotensive. A provisional diagnosis of cyanide poisoning was made. What is the definitive treatment?
Your Answer:
Correct Answer: Hydroxocobalamin
Explanation:Cyanide poisoning:
Aetiology:
Smoke inhalation, suicidal ingestion, and industrial exposure (specific industrial processes involving cyanide include metal cleaning, reclaiming, or hardening; fumigation; electroplating; and photo processing) are the most frequent sources of cyanide poisoning. Treatment with sodium nitroprusside or long-term consumption of cyanide-containing foods is a possible source.
Cyanide exposure most often occurs via inhalation or ingestion, but liquid cyanide can be absorbed through the skin or eyes. Once absorbed, cyanide enters the blood stream and is distributed rapidly to all organs and tissues in the body.Pathophysiology:
Inside cells, cyanide attaches itself to ubiquitous metalloenzymes, rendering them inactive. Its principal toxicity results from inactivation of cytochrome oxidase (at cytochrome a3), thus uncoupling mitochondrial oxidative phosphorylation and inhibiting cellular respiration, even in the presence of adequate oxygen stores.Presentation:
• ‘Classical’ features: brick-red skin, smell of bitter almonds
• Acute: hypoxia, hypotension, headache, confusion
• Chronic: ataxia, peripheral neuropathy, dermatitisManagement:
• Supportive measures: 100% oxygen, ventilatory assistance in the form of intubation if required.
• Definitive: Hydroxocobalamin (iv) is considered the drug of choice and is approved by the FDA for treating known or suspected cyanide poisoning.
• Coadministration of sodium thiosulfate (through a separate line or sequentially) has been suggested to have a synergistic effect on detoxification.
Mechanism of action of hydroxocobalamin:
• Hydroxocobalamin combines with cyanide to form cyanocobalamin (vitamin B-12), which is renally cleared.
• Alternatively, cyanocobalamin may dissociate from cyanide at a slow enough rate to allow for cyanide detoxification by the mitochondrial enzyme rhodanese. -
This question is part of the following fields:
- Pharmacology
-
00
Correct
00
Incorrect
00
:
00
:
00
Session Time
00
:
00
Average Question Time (
Mins)