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Question 1
Correct
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A baby is born to a mother who is known to have chronic hepatitis B. The mothers latest results are as follows: HBsAg: Positive, HBeAg: Positive. What is the most appropriate strategy for reducing the vertical transmission rate?
Your Answer: Give the newborn hepatitis B vaccine + hepatitis B immunoglobulin
Explanation:The Green Book guidelines report in an active infection (HBeAg+ and HBsAg+) to give the vaccine as well as immunoglobulin. If antibodies are present it is not active infection (anti-Hbe) and then in that case only the vaccine, and no immunoglobulin, would be given. The presence of HBeAg means a person is infectious and can transmit to other people.
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This question is part of the following fields:
- Gastroenterology
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Question 2
Correct
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A 33-year-old man presents with recurrent episodes of abdominal pain associated with weakness of his arms and legs. Which one of the following urine tests would best indicate lead toxicity?
Your Answer: Coproporphyrin
Explanation:Lead poisoning is characterised by abdominal pain, fatigue, constipation, peripheral neuropathy (mainly motor), and blue lines on gum margin in 20% of the adult patients (very rare in children).
For diagnosis, the level of lead in blood is usually considered with levels greater than 10 mcg/dL being significant. Furthermore, the blood film shows microcytic anaemia and basophilic stippling of red blood cells. Urinary coproporphyrin is increased (urinary porphobilinogen and uroporphyrin levels are normal to slightly increased). Raised serum and urine levels of delta-aminolaevulinic acid may also be seen, making it sometimes difficult to differentiate from acute intermittent porphyria.
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This question is part of the following fields:
- Haematology & Oncology
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Question 3
Incorrect
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A 32-year-old male who is a known case of sickle cell disease presents to the Accident and Emergency (A&E) department with fever, tachypnoea, and rib pain. On examination, he has a low-grade fever of 37.9°C, oxygen saturation of 95% on air, and bilateral vesicular breath sounds on chest auscultation. CXR shows opacification in the right middle zone. Which of these statements most accurately describes the initial management of this patient?
Your Answer: Empirical antibiotic therapy is not indicated
Correct Answer: Incentive spirometry is indicated
Explanation:This is a typical picture of acute chest syndrome (ACS). According to the British Committee for Standards in Haematology (BCSH), ACS is defined as ‘an acute illness characterised by fever and/or respiratory symptoms, accompanied by a new pulmonary infiltrate on chest X-ray’. ACS occurs in sequestration crisis, which is one of the four main types of crises occurring in sickle cell disease.
The fundamentals of initial management are as follows:
1. Oxygen therapy to maintain saturation >95%
2. Intravenous fluids to ensure euvolemia
3. Adequate pain relief
4. Incentive spirometry in all patients presenting with rib or chest pain
5. Antibiotics with cover for atypical organisms
6. Bronchodilators if asthma co-exists with acute chest syndrome, or if there is an evidence of acute bronchospasm on auscultation
7. Early consultation with the critical care team and haematology departmentA senior haematologist then makes a decision as to whether a simple or exchange transfusion is necessary in order to achieve a target Hb of 10.0–11.0g/dL in either instance.
Sickle Cell Crises:
Sickle cell anaemia is characterised by periods of good health with intervening crises:
1. Sequestration crisis: acute chest syndrome (i.e. fever, dyspnoea, chest/rib pain, low pO2, and pulmonary infiltrates)2. Thrombotic (painful or vaso-occlusive) crisis: precipitated by infection, dehydration, and deoxygenation
3. Aplastic crisis: sudden fall in haemoglobin without marked reticulocytosis, usually occurring secondary to parvovirus infection
4. Haemolytic crisis: fall in haemoglobin secondary to haemolysis, rare type of sickle cell crises
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This question is part of the following fields:
- Haematology & Oncology
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Question 4
Incorrect
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A 53-year-old woman presents with upper GI haemorrhage. She has a history of rheumatoid arthritis for which she is managed with low dose prednisolone, diclofenac and codeine phosphate. On examination in the Emergency ward her BP is 90/60 mmHg, pulse 100/min. You fluid resuscitate her and her BP improves to 115/80 mmHg, with a pulse of 80/min. Investigations; Hb 10.4 g/dL, WCC 6.1 x109/L, PLT 145 x109/L, Na+ 139 mmol/L, K+ 4.9 mmol/L, Creatinine 180 μmol/L, ECG – Lateral ST depression , Upper GI endoscopy reveals a large bleeding ulcer on the posterior aspect of the duodenum. It cannot be easily reached with the endoscope, and you decide to attempt embolization. Which of the following is the artery that should be targeted?
Your Answer: Gastroduodenal artery
Correct Answer: Posterior superior Pancreaticoduodenal artery
Explanation:The most common location for a duodenal ulcer bleed is the posterior duodenum (remember: posterior bleeds, anterior perforates). The perfusion to this area is most specifically from the posterior superior pancreaticoduodenal artery.
The anterior superior pancreaticoduodenal artery supplies the anterior region. The gastroepiploic artery supplies mostly the stomach. The splenic artery goes, obviously, toward the spleen, in the other direction. The gastroduodenal artery is a branch of the celiac artery, and it’s branches are the anterior superior pancreaticoduodenal artery and posterior superior pancreaticoduodenal artery.
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This question is part of the following fields:
- Gastroenterology
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Question 5
Incorrect
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Which of the following statements regarding the clinical effects of long-term oxygen therapy (LTOT) is the most accurate?
Your Answer: No effect on mortality
Correct Answer: Reduced sympathetic outflow
Explanation:Studies have shown that benefits of Long-tern oxygen therapy (LTOT) include improved exercise tolerance, with improved walking distance, and ability to perform daily activities, reduction of secondary polycythaemia, improved sleep quality and reduced sympathetic outflow, with increased sodium and water excretion, leading to improvement in renal function.
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This question is part of the following fields:
- Respiratory
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Question 6
Correct
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A 40-year-old female patient with a history of rheumatoid arthritis is diagnosed with type 1 renal tubular acidosis. What is the most probable sequela of this condition?
Your Answer: Nephrocalcinosis
Explanation:Distal renal tubular acidosis is due to defective proton secretion from the alpha intercalated cells of the distal tubule caused by dysfunction of the H+/K+ antiporter on the apical membrane. This leads to failure of H+ excretion thereby causing systemic acidosis and potassium depletion. Inability to lower the urine pH below 5.3 in the presence of systemic acidosis is the diagnostic hallmark of type I or distal renal tubular acidosis. Hypercalciuria, hypocitraturia and elevated urinary pH observed in distal renal tubular acidosis can lead to nephrocalcinosis and may cause renal calculi, obstructive uropathy and renal failure necessitating surgical or endoscopic stone extraction.
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This question is part of the following fields:
- Clinical Sciences
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Question 7
Correct
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An elderly woman is referred with worsening chronic pulmonary disease (COPD). She smokes seven cigarettes per day. Her exercise tolerance is only a few yards around the house now. Her FEV1 is 37% of predicted. What is the most appropriate intervention for this patient?
Your Answer: Give regular high-dose inhaled fluticasone and inhaled long-acting β-agonist
Explanation:The Stages of COPD:
Mild COPD or Stage 1—Mild COPD with a FEV1 about 80 percent or more of normal.
Moderate COPD or Stage 2—Moderate COPD with a FEV1 between 50 and 80 percent of normal.
Severe COPD or Stage 3—Severe emphysema with a FEV1 between 30 and 50 percent of normal.
Very Severe COPD or Stage 4—Very severe or End-Stage COPD with a lower FEV1 than Stage 3, or people with low blood oxygen levels and a Stage 3 FEV1.This patient has a FEV1 percent of 37 which falls within the stage 3 or severe COPD.
During stage 3 COPD, you will likely experience significant lung function impairment. Many patients will experience an increase in COPD flare-ups or exacerbations. For some people, the increase in flare-ups means they could need to be hospitalized at times as well.Inhaled corticosteroid (ICS) use in combination with long-acting β2-agonists (LABAs) was shown to provide improved reductions in exacerbations, lung function, and health status. ICS-LABA combination therapy is currently recommended for patients with a history of exacerbations despite treatment with long-acting bronchodilators alone. The presence of eosinophilic bronchial inflammation, detected by high blood eosinophil levels or a history of asthma or asthma–COPD overlap, may define a population of patients in whom ICSs may be of particular benefit.
The Towards a Revolution in COPD Health (TORCH) trial was a pivotal, double-blind, placebo-controlled, randomized study comparing salmeterol plus fluticasone propionate (50 and 500 µg, respectively, taken twice daily) with each component alone and placebo over 3 years.26 Patients with COPD were enrolled if they had at least a 10-pack-year smoking history, FEV1 <60% predicted, and an FEV1:FVC ratio ≤0.70.26 Among 6,184 randomized patients, the risk of death was reduced by 17.5% with the ICS-LABA combination vs placebo (P=0.052). ICS-LABA significantly reduced the rate of exacerbations by 25% compared with placebo (P<0.001) and improved health status and FEV1 compared with either component alone or placebo.
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This question is part of the following fields:
- Respiratory
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Question 8
Incorrect
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A 20-year-old male presents to the emergency department about 4 hours after ingesting 20g of paracetamol. N-acetyl cysteine was started immediately. What is the mechanism of action of N-acetyl cysteine?
Your Answer:
Correct Answer: Replenishes glutathione
Explanation:N-acetylcysteine depletes glutathione reserves by providing cysteine, which is an essential precursor in glutathione production.
Glutathione within the liver can normally detoxify these minuscule quantities of NAPQI and prevent tissue damage.
N-acetylcysteine (NAC) is the mainstay of therapy for acetaminophen toxicity.Paracetamol overdose:
The liver normally conjugates paracetamol with glucuronic acid/sulphate. During an overdose, the conjugation system becomes saturated leading to oxidation by cytochrome P450 (predominately CYP2E1) mixed-function oxidases. This produces a toxic metabolite N-acetyl-p-benzoquinone imine (NAPQI).Normally glutathione acts as a defence mechanism by conjugating with the toxin forming the non-toxic mercapturic acid. If glutathione stores run-out, the toxin forms covalent bonds with cell proteins, denaturing them and leading to cell death.
Other uses: In COPD, cystic fibrosis, and other lung conditions, nebulized NAC has mucolytic, anti-inflammatory, and antioxidant properties.
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This question is part of the following fields:
- Pharmacology
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Question 9
Incorrect
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A 42-year-old male patient is admitted with recurrent pancreatitis. He also has a history of parotitis. CT scan is carried out revealing no pancreatic mass, but evidence of widespread lymphadenopathy is seen. Dedicated liver imaging reveals a stricture in the common bile duct but no stones. What is the most likely diagnosis?
Your Answer:
Correct Answer: IgG4 disease
Explanation:IgG4-related disease (IgG4-RD) is a fibro-inflammatory condition that can affect nearly any organ system: the pancreas, biliary tree, salivary glands, periorbital tissues, kidneys, lungs, lymph nodes, meninges, aorta, breast, prostate, thyroid, pericardium, and skin. The histopathological features are similar across organs, regardless of the site. IgG4-RD is analogous to sarcoidosis, in which diverse organ manifestations are linked by similar histopathological characteristics. Raised concentrations of IgG4 in tissue and serum can be helpful in diagnosing IgG4 disease, but neither is a specific diagnostic marker.
Some IgG4-RDs are:
1. Autoimmune pancreatitis
2. Riedel’s Thyroiditis
3. Mediastinal and Retroperitoneal Fibrosis
4. Periaortitis/periarteritis/Inflammatory aortic aneurysm
5. Kuttner Tumour (submandibular glands)
6. IgG4-related Mikulicz disease (lacrimal, parotid, and submandibular glands) -
This question is part of the following fields:
- Haematology & Oncology
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Question 10
Incorrect
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A 54-year-old female presents with fatigue and xerostomia. Bloods tests reveal the following: Hb 13.9 g/dL, WBC 6.1 *109/L, Platelets 246 *109/L, Bilirubin 33 µmol/L, ALP 292 u/l ALT 47 u/l What is the most likely diagnosis?
Your Answer:
Correct Answer: Primary biliary cirrhosis
Explanation:With a bilirubin of 33, automatically the diagnosis from the choices listed is primary biliary cirrhosis or autoimmune hepatitis, not SLE, mono, or Primary Sjogren’s Syndrome. With autoimmune hepatitis, however, you would not expect such a high bilirubin and would expect very high AST/ALT, which here is just mildly elevated. This makes primary biliary cirrhosis the most likely answer. The classic presentation is itching in a middle-aged woman. The dry mouth is likely due to Sicca Syndrome, which occurs in 70% of cases of PBC, but with these liver function tests, PBC is most the likely answer.
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This question is part of the following fields:
- Gastroenterology
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Question 11
Incorrect
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A 73-year-old gentleman with type 2 diabetes mellitus, complains of difficulty walking and trouble with his hands. It began with a tingling sensation in his soles, which later extended up to his ankles. He now feels unsteady when walking, and more recently, has noticed numbness and tingling in the fingers of both hands. On examination, he has absent ankle reflexes, a high steppage gait, and altered sensation to his mid-calves. What is the underlying pathological process?
Your Answer:
Correct Answer: Axonal degeneration
Explanation:This case presents with sensorimotor neuropathy secondary to his DM. The progression of the neuropathy, known dying-back neuropathy, is a distal axonopathy or axonal degeneration as where the sensorimotor loss begins distally and travels proximally.
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This question is part of the following fields:
- Neurology
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Question 12
Incorrect
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A 45-year-old female develops profuse watery diarrhoea with lower abdominal pain seven days after undergoing laparoscopic cholecystectomy. What is the most likely diagnosis?
Your Answer:
Correct Answer: Pseudomembranous colitis
Explanation:Pseudomembranous colitis is caused by a C. difficile infection that causes membranes to form on the colon wall. It is caused most commonly by broad-spectrum antibiotics. This would include cephalosporins, broad-spectrum penicillin, and clindamycin. Macrolides and quinolones have also been reported as potential aetiologies, but much less commonly. This woman would have received antibiotics prophylactically before her surgery, predisposing her to a possible c difficile infection. This is a much better answer choice than pseudo obstruction, abdominal sepsis, bile acid diarrhoea, and campylobacter gastroenteritis simply based on history of present illness.
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This question is part of the following fields:
- Gastroenterology
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Question 13
Incorrect
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A 23 year old man presents with a painful right elbow and left Achilles tendon. He also gives history of dysuria, fever and conjunctivitis. Examination reveals macules and pustules on his hands. He has returned from a trip to Far East 3 weeks ago and admits to having unprotected sex. Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Reactive arthritis
Explanation:Reactive arthritis, (formerly known as Reiter’s syndrome), is an autoimmune condition that occurs after a bacterial infection of the gastrointestinal or urinary tract. It is categorized as a seronegative spondylarthritis because of its association with HLA-B27. Reactive arthritis primarily affects young men and usually presents with musculoskeletal or extra‑articular symptoms. The characteristic triad consists of arthritis, conjunctivitis, and urethritis. The diagnosis is based on clinical features such as patient history and physical examination; there are no specific tests for reactive arthritis. Treatment is primarily symptomatic and consists of the administration of NSAIDs, as most patients recover spontaneously. extraarticular dermatologic manifestations include skin lesions of the glans resembling psoriasis (balanitis circinata); hyperkeratinisation of the palms and soles (keratoderma blenorrhagicum), oral ulcers. Other STDs including HIV, syphilis have different presentations. Psoriatic arthritis is not commonly associated with urethritis and conjunctivitis.
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This question is part of the following fields:
- Rheumatology
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Question 14
Incorrect
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Double-stranded DNA is found in which of the following cell organelles?
Your Answer:
Correct Answer: Mitochondria
Explanation:Mitochondrial DNA (mtDNA) is a double-stranded molecule of 16.6 kb (Figure 1, lower panel). The two strands of mtDNA differ in their base composition, with one being rich in guanines, making it possible to separate a heavy (H) and a light (L) strand by density centrifugation in alkaline CsCl2 gradients.
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This question is part of the following fields:
- Clinical Sciences
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Question 15
Incorrect
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A 68 year old man who has chronic obstructive pulmonary disease (COPD) is reviewed. On examination, there is evidence of cor pulmonale with a significant degree of pedal oedema. His FEV1 is 44%. During a recent hospital stay his pO2 on room air was 7.4 kPa. Which one of the following interventions is most likely to increase survival in this patient?
Your Answer:
Correct Answer: Long-term oxygen therapy
Explanation:Assess the need for oxygen therapy in people with:
– very severe airflow obstruction (FEV1 below 30% predicted)
– cyanosis (blue tint to skin)
– polycythaemia
– peripheral oedema (swelling)
– a raised jugular venous pressure
– oxygen saturations of 92% or less breathing air.Also consider assessment for people with severe airflow obstruction (FEV1 30–49% predicted).
Consider long-term oxygen therapy for people with COPD who do not smoke and who:
have a partial pressure of oxygen in arterial blood (PaO2) below 7.3 kPa when stable or have a PaO2 above 7.3 and below 8 kPa when stable, if they also have 1 or more of the following:
– secondary polycythaemia
– peripheral oedema
– pulmonary hypertension. -
This question is part of the following fields:
- Respiratory
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Question 16
Incorrect
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A 78-year-old male with long-standing Alzheimer's disease is being reviewed in your clinic. Which among the following is true regarding memantine, a drug which has been approved for the management of dementia in the UK?
Your Answer:
Correct Answer: It is an NMDA-receptor agonist
Explanation:Memantine is an antagonist of the NMDA (N-Methyl-D-Aspartate)-receptor subtype of glutamate receptor. It is used to slow the neurotoxicity thought to be involved in Alzheimer’s disease and other neurodegenerative diseases.
Drug interactions:
When given concomitantly with other NMDA-receptor antagonists (e.g., ketamine, amantadine) increase the risk of psychosis.
Dopamine agonists, L-dopa, and anticholinergics enhance effects of memantine.
Antispasmodics (e.g., baclofen) enhance effects, as memantine has some antispasmodic effects.
Drugs excreted by cationic transporters in the kidney (e.g. quinine, cimetidine, ranitidine) reduce excretion.Common adverse effects include dizziness, headache, confusion, diarrhoea, and constipation.
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This question is part of the following fields:
- Pharmacology
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Question 17
Incorrect
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A 30-year-old lawyer presents with a one-day history of a painful, red left eye. She describes how her eye is continually streaming tears. On examination, she exhibits a degree of photophobia in the affected eye and application of fluorescein demonstrates a dendritic pattern of staining. Visual acuity is 6/6 in both eyes. What is the most appropriate management?
Your Answer:
Correct Answer: Topical acyclovir
Explanation:This patient has a dendritic corneal ulcer. Herpes simplex keratitis most commonly presents with a dendritic corneal ulcer. Topical acyclovir and ophthalmology review is required. Giving a topical steroid in this situation could be disastrous as it may worsen the infection.
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This question is part of the following fields:
- Ophthalmology
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Question 18
Incorrect
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A 50 year old retired coal miner with simple silicosis presented with shortness of breath. He had been short of breath for 3 months. Around 3 months ago he began keeping turtle doves as pets. On auscultation he had basal crepitations and chest x-ray showed fine nodular shadowing in the apices. What is the most likely diagnosis?
Your Answer:
Correct Answer: Extrinsic allergic alveolitis
Explanation:Extrinsic allergic alveolitis (EAA) refers to a group of lung diseases that can develop after exposure to certain substances. The name describes the origin and the nature of these diseases:
‘extrinsic’ – caused by something originating outside the body
‘allergic’ – an abnormally increased (hypersensitive) body reaction to a common substance
‘alveolitis’ – inflammation in the small air sacs of the lungs (alveoli)Symptoms can include: fever, cough, worsening breathlessness and weight loss. The diagnosis of the disease is based on a history of symptoms after exposure to the allergen and a range of clinical tests which usually includes: X-rays or CT scans, lung function and blood tests.
EAA is not a ‘new’ occupational respiratory disease and occupational causes include bacteria, fungi, animal proteins, plants and chemicals.
Examples of EAA include:
Bird fancier’s lung (BFL) is a type of hypersensitivity pneumonitis (HP). It is triggered by exposure to avian proteins present in the dry dust of the droppings and sometimes in the feathers of a variety of birds. The lungs become inflamed, with granuloma formation. Birds such as pigeons, parakeets, cockatiels, shell parakeets (budgerigars), parrots, turtle doves, turkeys and chickens have been implicated.
People who work with birds or own many birds are at risk. Bird hobbyists and pet store workers may also be at risk. This disease is an inflammation of the alveoli in the lungs caused by an immune response to inhaled allergens from birds. Initial symptoms include shortness of breath (dyspnoea), especially after sudden exertion or when exposed to temperature change, which can resemble asthma, hyperventilation syndrome or pulmonary embolism. Chills, fever, non-productive cough and chest discomfort may also occur.
A definitive diagnosis can be difficult without invasive testing, but extensive exposure to birds combined with reduced diffusing capacity are strongly suggestive of this disease. X-ray or CT scans will show physical changes to the lung structure (a ground glass appearance) as the disease progresses. Precise distribution and types of tissue damage differ among similar diseases, as does response to treatment with Prednisone.
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This question is part of the following fields:
- Respiratory
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Question 19
Incorrect
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In which condition is the sniff test useful in diagnosis?
Your Answer:
Correct Answer: Phrenic nerve palsy
Explanation:The phrenic nerve provides the primary motor supply to the diaphragm, the major respiratory muscle.
Phrenic nerve paralysis is a rare cause of exertional dyspnoea that should be included in the differential diagnosis. Fluoroscopy is considered the most reliable way to document diaphragmatic paralysis. During fluoroscopy a patient is asked to sniff and there is a paradoxical rise of the paralysed hemidiaphragm. This is to confirm that the cause is due to paralysis rather than unilateral weakness. -
This question is part of the following fields:
- Respiratory
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Question 20
Incorrect
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A 25-year-old gentleman presents to the hospital feeling unwell and breathless. History reveals that he has chronic renal failure, for which he receives haemodialysis three times per week. Since one week prior to consultation, he has been on vacation and has missed two dialysis sessions. Examination reveals pulmonary oedema. His ECG shows no P waves, broad QRS complexes and peaked T waves. What should you do?
Your Answer:
Correct Answer: Give 10 ml of 10% calcium gluconate intravenously
Explanation:The patient is most likely complaining of the effects of hyperkalaemia, due to missing his dialysis sessions. Additionally, because the patient presents with a risk of cardiac arrest (based on pulmonary oedema and ECG findings), the best intervention is to give calcium gluconate that will address the hyperkalaemia as well as improve the cardiac condition.
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This question is part of the following fields:
- Nephrology
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Question 21
Incorrect
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A 26 year old woman visits the clinic with an acute asthma attack. Which lung function abnormality is she most likely to have?
Your Answer:
Correct Answer: Increased residual volume
Explanation:Asthma is a condition characterized by airway hyperresponsiveness, which results in reversible increases in bronchial smooth muscle tone, and variable amounts of inflammation of the bronchial mucosa.
During an acute asthma attack, the already inflamed airways narrow further due to bronchospasm, which leads to increased airway resistance. Because of the increased smooth muscle tone during an asthma attack, the airways also tend to close at abnormally high lung volumes, trapping air behind occluded or narrowed small airways. Thus the acute asthmatic will breathe at high lung volumes, his functional residual capacity will be elevated, and he will inspire close to total lung capacity. The accessory muscles of respiration are often used to maintain the lungs in a hyperinflated state.During episodes of acute asthma, pulmonary function tests reveal an obstructive pattern. This includes a decrease in the rate of maximal expiratory air flow (a decrease in FEV1 and the FEV1/FVC ratio) due to the increased resistance, and a reduction in forced vital capacity (FVC) correlating with the level of hyperinflation of the lungs. Because these patients breathe at such high lung volumes (near the top of the pressure-volume curve, where lung compliance greatly decreases), they must exert significant effort to create an extremely negative pleural pressure, and consequently fatigue easily. Overinflation also reduces the curvature of the diaphragm, making it less efficient in generating further negative pleural pressure.
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This question is part of the following fields:
- Respiratory
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Question 22
Incorrect
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A 63-year-old gentleman is admitted to the Emergency Department, with a past history of chronic renal failure, who complains of increasing shortness of breath. Bloods reveal a creatinine of 570 μmol/l, urea of 48 mmol/l. He is also anaemic with a haemoglobin (Hb) of 8.9 g/dl. On examination he has a pericardial rub and there are bibasal crackles consistent with heart failure. Which of the following represents the best treatment option for this patient?
Your Answer:
Correct Answer: Urgent haemodialysis
Explanation:This case presents with symptoms and lab results suggestive of uremic pericarditis, which is an indication for immediate haemodialysis. Uremic pericarditis is caused by inflammation of the membranes of the pericardial sac, which usually resolves after a period of intensive dialysis.
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This question is part of the following fields:
- Nephrology
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Question 23
Incorrect
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A 45-year-old man presents with haematemesis. His consumption of alcohol has been estimated to be 120 units per week. Following alcohol withdrawal, when is the peak incidence of seizures expected in this patient?
Your Answer:
Correct Answer: 36 hours
Explanation:The peak incidence of seizures is expected 36 hours following the onset of alcohol withdrawal.
Pathophysiology:
Chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors. Alcohol withdrawal is thought to lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission).Clinical course in alcohol withdrawal:
Symptoms begin 6-12 hours following the onset of alcohol withdrawal
Seizures occur 36 hours following the onset of withdrawal
Delirium tremens (coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia) occurs approximately 72 hours after the onset of alcohol withdrawal.Management
First-line: benzodiazepines e.g. lorazepam, chlordiazepoxide.
Carbamazepine is also effective in the treatment of alcohol withdrawal.
Phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures. -
This question is part of the following fields:
- Psychiatry
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Question 24
Incorrect
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A 18-year-old gentleman is referred to dermatology. He has around 10 hyperpigmented macules on his torso which vary in size from 1.5-5 cm in size. His GP also noted some freckles in the groin region. He is also currently under orthopaedic review due to a worsening scoliosis of the spine. His father suffered from similar problems before having a fatal myocardial infarction two years ago. Which chromosome is most likely to have a gene defect?
Your Answer:
Correct Answer: Chromosome 17
Explanation:The patient’s history and presentation and familial history, meets the diagnostic criteria for Neurofibromatosis type I, presenting with neurofibromas noted in this patient as hyperpigmented macules and freckles, musculoskeletal disorders like the scoliosis in this case, and a familial history. Neurofibromatosis type I is caused by a mutation on Chromosome 17.
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This question is part of the following fields:
- Neurology
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Question 25
Incorrect
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A 25-year-old woman is reviewed in clinic. She was previously treated with omeprazole, amoxicillin and clarithromycin for Helicobacter pylori (H. pylori). She remains on PPI therapy but continues to have epigastric discomfort. You suspect she has ongoing H. pylori infection and request a urea breath test to investigate this. How long would the patient need to stop her PPI therapy before the urea breath test?
Your Answer:
Correct Answer: 14 days
Explanation:PPI will affect the accuracy of the test. In general, most recommend discontinuing PPI therapy for 2 weeks prior to a urea breath test. PPI’s have an anti-H. pylori effect.
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This question is part of the following fields:
- Gastroenterology
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Question 26
Incorrect
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A 19-year-old woman comes to the endocrine clinic with excessive hairiness and acne. She tells you that she has a period only every few months and when she has one it tends to be very heavy. On examination, she has obvious facial acne. Her BP is 142/78 mmHg, her pulse is 72bpm and regular and her BMI is 30. There is facial hair and hair around her upper chest and breasts. Investigations show: Haemoglobin 11.9 g/dl (11.5-16.0), White cell count 6.0 x 10(9)/l (4-11), Platelets 202 x 10(9)/l (150-400), Sodium 137 mmol/l (135-146), Potassium 3.9 mmol/l (3.5-5), Creatinine 90 µmol/l (79-118), Total testosterone normal, Free androgen index elevated, LH / FSH ratio 2.2. Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Polycystic ovarian syndrome
Explanation:Rotterdam criteria for the diagnosis of polycystic ovary syndrome:
Two of the following three criteria are required:
1. Oligo/anovulation
2. Hyperandrogenism
– Clinical (hirsutism or less commonly male pattern alopecia) or
– Biochemical (raised FAI or free testosterone)
3. Polycystic ovaries on ultrasound
Other aetiologies must be excluded such as congenital adrenal hyperplasia, androgen-secreting tumours, Cushing syndrome, thyroid dysfunction and hyperprolactinaemia.
Cushing’s is excluded because there would have been marked obesity, hypertension and other related features. -
This question is part of the following fields:
- Endocrinology
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Question 27
Incorrect
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A 50-year-old woman is investigated for weight loss and anaemia. Clinical examination reveals splenomegaly associated with pale conjunctivae. Her full blood count (FBC) report shows: Hb: 10.9 g/dL, Plts: 702 x 10^9/L, WCC: 56.6 x 10^9/L. Moreover, all stages of granulocyte maturation are seen on her blood film. Given the likely diagnosis, what should be the most appropriate treatment?
Your Answer:
Correct Answer: Imatinib
Explanation:This patient is a case of chronic myeloid leukaemia (CML) and should be started on imatinib as the first-line drug of choice.
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This question is part of the following fields:
- Haematology & Oncology
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Question 28
Incorrect
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A 32 year old male with a history of smoking half a pack of cigarettes per day complains of worsening breathlessness on exertion. He was working as a salesman until a few months ago. His father passed away due to severe respiratory disease at a relatively young age. Routine blood examination reveals mild jaundice with bilirubin level of 90 µmol/l. AST and ALT are also raised. Chest X-ray reveals basal emphysema. Which of the following explanation is most likely the cause of these symptoms?
Your Answer:
Correct Answer: α-1-Antitrypsin deficiency
Explanation:Alpha-1 antitrypsin deficiency is an inherited disorder that may cause lung and liver disease. The signs and symptoms of the condition and the age at which they appear vary among individuals. This would be the most likely option as it is the only disease that can affect both liver and lung functions.
People with alpha-1 antitrypsin deficiency usually develop the first signs and symptoms of lung disease between ages 20 and 50. The earliest symptoms are shortness of breath following mild activity, reduced ability to exercise, and wheezing. Other signs and symptoms can include unintentional weight loss, recurring respiratory infections, fatigue, and rapid heartbeat upon standing. Affected individuals often develop emphysema. Characteristic features of emphysema include difficulty breathing, a hacking cough, and a barrel-shaped chest. Smoking or exposure to tobacco smoke accelerates the appearance of emphysema symptoms and damage to the lungs.
About 10 percent of infants with alpha-1 antitrypsin deficiency develop liver disease, which often causes yellowing of the skin and sclera (jaundice). Approximately 15 percent of adults with alpha-1 antitrypsin deficiency develop liver damage (cirrhosis) due to the formation of scar tissue in the liver. Signs of cirrhosis include a swollen abdomen, swollen feet or legs, and jaundice. Individuals with alpha-1 antitrypsin deficiency are also at risk of developing hepatocellular carcinoma. -
This question is part of the following fields:
- Respiratory
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Question 29
Incorrect
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Choose the correct statement regarding p53 gene:
Your Answer:
Correct Answer: Li-Fraumeni syndrome predisposes to the development of sarcomas
Explanation:Li-Fraumeni syndrome (LFS) is a cancer predisposition syndrome associated with the development of the following classic tumours: soft tissue sarcoma, osteosarcoma, pre-menopausal breast cancer, brain tumours, adrenocortical carcinoma (ACC), and leukaemia. LFS is diagnosed in individuals meeting established clinical criteria or in those who have a germline pathogenic variant in TP53 regardless of family cancer history.
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This question is part of the following fields:
- Clinical Sciences
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Question 30
Incorrect
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A 50-year-old woman under treatment for manic-depressive psychosis presents in an unconscious state after an episode of seizure on the street. Her husband who accompanied her into the ER reported that they argued about 6-7 hours ago. On examination, she is found to be hypertonic with a GCS of 8, BP: 90/60 mmHg and a pulse of 105 bpm. Blood investigations revealed a lithium level of 3.2 mmol/L. She was intubated and ventilated. Which of the following are the TWO interventions which are most appropriate in this case?
Your Answer:
Correct Answer: Gastric lavage should be considered
Explanation:Among the above statements, gastric lavage and normal saline IV infusion are the two appropriate interventions for a patient of acute lithium toxicity.
Activated charcoal is not effective after lithium overdose, although gastric lavage should be considered if patients present within 6–8 h.
Where levels are above 3 mmol/l, the use of normal saline to induce diuresis should be considered, although careful monitoring of fluid balance is necessary.
Where levels of lithium are above 4 mmol/l, dialysis is often required. Haemodialysis is preferred, but in a facility where haemodialysis is not possible, peritoneal dialysis may be considered.
Patients should not be discharged until they are asymptomatic and have a serum lithium level less than 1.5 mEq/L. -
This question is part of the following fields:
- Pharmacology
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