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Question 1
Incorrect
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What kind of receptor is the nitric oxide receptor?
Your Answer: Ligand-gated ion channel
Correct Answer: Guanylate cyclase receptor
Explanation:Soluble guanylyl cyclase (GC-1) is the primary receptor of nitric oxide (NO) in smooth muscle cells and maintains vascular function by inducing vasorelaxation in nearby blood vessels. GC-1 converts guanosine 5′-triphosphate (GTP) into cyclic guanosine 3′,5′-monophosphate (cGMP), which acts as a second messenger to improve blood flow.
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This question is part of the following fields:
- Clinical Sciences
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Question 2
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: Gonococcal arthritis
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 3
Correct
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A 29-year-old physiotherapist with a history of bilateral vitreous haemorrhage is referred due to progressive ataxia. Which of the following is the most likely diagnosis?
Your Answer: Von Hippel-Lindau syndrome
Explanation:Retinal and cerebellar haemangiomas are key features of Von Hippel-Lindau syndrome. Retinal haemangiomas are bilateral in 25% of patients and may lead to vitreous haemorrhage. Von Hippel-Lindau (VHL) syndrome is an autosomal dominant condition predisposing to neoplasia. It is due to an abnormality in the VHL gene located on short arm of chromosome 3.
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This question is part of the following fields:
- Neurology
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Question 4
Correct
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A 25 yr. old male presented with acute severe central chest pain which radiated backwards between his scapulae. He didn't have difficulty in breathing and the pain wasn't exacerbated by deep inspiration or a change in position. His father had died due to a heart disease when he was small. He also has a cardiac murmur which was never properly investigated. On examination he was tachycardic with a BP of 165/60 mmHg. There was a diastolic murmur at lower left sternal border which is best heard with the patient sitting forward. Which of the following is the most probable cause for his chest pain?
Your Answer: Aortic dissection
Explanation:The most probable diagnosis is Marfan’s syndrome because of a family history of cardiac death and heart murmurs. A characteristic feature is pain which radiates to the back. A wide pulse pressure and a diastolic heart murmur is suggestive of aortic dissection.
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This question is part of the following fields:
- Cardiology
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Question 5
Correct
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A 27-year-old realtor presented with progressive weakness of both legs over the last 3 years. He complained of being unable to see well at night and having an impaired sense of smell. On examination he had a shortened fourth toe bilaterally with pes cavus. Neurological examination revealed a loss of pinprick sensation to bilateral knees, and weakness of both legs that was more prominent distally. Which of the following would be the best blood test to order to make a diagnosis?
Your Answer: Phytanic acid
Explanation:The diagnosis is Refsum’s disease. This is an autosomal recessive disorder that causes a sensorimotor peripheral neuropathy. It is caused by defective alpha oxidation of phytanic acid leading to its accumulation in tissues. Cardiac conduction abnormalities and cardiomyopathies may also occur.
Epiphyseal dysplasia causes a characteristic shortening of the fourth toe. Serum phytanic acid levels are elevated. Treatment is by dietary restriction of foods containing phytanic acid (dairy products, fish, beef and lamb). -
This question is part of the following fields:
- Neurology
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Question 6
Correct
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A 23-year-old man is being investigated for excessive bleeding following a tooth extraction. His coagulation profile shows: Plts: 173 x 10^9/L, PT: 12.9 secs, APTT: 84 secs. Which clotting factor is he most likely deficient in?
Your Answer: Factor VIII
Explanation:The patient is most likely a case of haemophilia A which is the genetic deficiency of clotting factor VIII in blood.
Haemophilia is an X-linked recessive disorder of coagulation. Up to 30% of patients have no family history of the condition. Haemophilia A is more common than haemophilia B and accounts for 90% of the cases. In haemophilia B (Christmas disease), there is a deficiency of clotting factor IX.
Characteristic features of haemophilia include hemarthrosis, haematomas, and prolonged bleeding following trauma or surgery. Coagulation profile of a haemophiliac person shows prolonged bleeding time, activated partial thromboplastin time (APTT), thrombin time (TT), but a normal prothrombin time (PT).
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This question is part of the following fields:
- Haematology & Oncology
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Question 7
Correct
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A 11-year-old boy is referred to you following his seventh course of antibiotics in the last six years for lower respiratory tract infections. He also has a history of eczema for which he is currently on a topical steroid cream. His full blood count (FBC) report shows: Hb: 13.9 g/dL, Plts: 65 x 10^9/L, WCC: 12.3 x 10^9/L. Which of the following genes should you expect an abnormality in?
Your Answer: WASP
Explanation:The combination of frequent infections, eczema, and thrombocytopaenia are characteristic of Wiskott-Aldrich syndrome, which is due to an abnormality in the WASP gene. It is an X-linked recessive disorder that causes primary immunodeficiency owing to a combined B- and T-cell dysfunction.
The other listed options are:
1. PKD1: polycystic kidney disease
2. CFTR: cystic fibrosis
3. HFE1: haemochromatosis
4. RET: multiple endocrine neoplasia, Hirschsprung’s disease -
This question is part of the following fields:
- Haematology & Oncology
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Question 8
Correct
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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: 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 9
Correct
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In which condition is the sniff test useful in diagnosis?
Your 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 10
Correct
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Raloxifene is used in the treatment of osteoporosis, which of the following best describes it?
Your Answer: A selective oestrogen receptor modulator
Explanation:Raloxifene is a selective oestrogen-receptor modulator (SERM) that has been approved for use in the prevention and treatment of osteoporosis in postmenopausal women.
A SERM interacts with oestrogen receptors, functioning as an agonist in some tissues and an antagonist in other tissues. Because of their unique pharmacologic properties, these agents can achieve the desired effects of oestrogen without the possible stimulatory effects on the breasts or uterus. -
This question is part of the following fields:
- Endocrinology
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Question 11
Correct
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A woman is being seen at the clinic. Her clinic notes are missing and the only results available are lung function tests. Her date of birth is also missing from the report. FEV1 0.4 (1.2–2.9 predicted) Total lung capacity 7.3 (4.4–6.8 predicted) Corrected transfer factor 3.3 (4.2–8.8 predicted) Which disease can be suspected From these results?
Your Answer: Moderate COPD
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 40 which falls within the stage 2 or moderate COP
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This question is part of the following fields:
- Respiratory
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Question 12
Incorrect
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A 52-year-old woman is being reviewed in the oncology clinic following debulking surgery one month ago. She is a known case of primary peritoneal cancer with two liver metastases and has now come in for review prior to adjuvant chemotherapy. During her chemotherapy, which of the following tumour markers would be the most appropriate to monitor her disease progression?
Your Answer: S-100
Correct Answer: CA 125
Explanation:Tumour marker CA 125 is mostly associated with primary peritoneal cancer and ovarian cancer. It can be used to monitor response to chemotherapy, alongside regular CT scans.
Tumour markers can be divided into:
1. Monoclonal antibodies
CA 125: Ovarian cancer, primary peritoneal cancer
CA 19-9: Pancreatic cancer
CA 15-3: Breast cancer2. Tumour specific antigens
Prostate specific antigen (PSA): Prostatic carcinoma
Alpha-feto protein (AFP): Hepatocellular carcinoma, teratoma
Carcinoembryonic antigen (CEA): Colorectal cancer
S-100: Melanoma, schwannomas
Bombesin: Small cell lung carcinoma, gastric cancer3. Enzymes
Alkaline phosphatase (ALP)
Neuron specific enolase (NSE)4. Hormones
Calcitonin
Antidiuretic hormone (ADH)
Human chorionic gonadotropin (hCG) -
This question is part of the following fields:
- Haematology & Oncology
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Question 13
Correct
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A 53-year-old gentleman presents with several months’ history of generalised swelling, fatigue, dyspnoea and several episodes of haemoptysis. There is no significant past medical history and he did not take any regular medication. He smokes 20 cigarettes per day and drinks 14 units of alcohol per week. On examination, he is grossly oedematous and has ascites. Cardiorespiratory examination is unremarkable and there are no neurological signs or rashes. Investigation results are below: Haemoglobin (Hb) 10.2 g/dL, White cell count (WCC) 6.0 × 109/L, Platelets 380 × 109/L, Mean corpuscular volume (MCV) 90fl Na+ 145 mmol/L, K+ 3.7 mmol/L, Urea 8.2 mmol/L, Bilirubin 16 μmol/L, Creatinine 180 μmol/L, Albumin 22 g/l Aspartate transaminase 32 iu/l Alkaline phosphatase 120 iu/l Urinalysis: Protein +++ 24 h urinary protein excretion: 5g Chest radiograph: Enlarged right hilum Echocardiogram: Mild left ventricular impairment, no valve lesion Abdominal ultrasound scan: Normal-sized kidneys, no abnormality seen A renal biopsy was performed. What is it most likely to show?
Your Answer: Thickened glomerular basement membrane with deposits of IgG and C3
Explanation:Renal biopsy in this patient will most likely show thickened glomerular basement membrane with deposits of IgG and C3 as a result of membranous glomerulonephritis that has caused the nephrotic syndrome in this patient. Membranous glomerulonephritis in this case is most likely associated with an underlying bronchial carcinoma, consistent with the patient’s smoking history and physical presentation.
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This question is part of the following fields:
- Nephrology
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Question 14
Correct
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Choose the correct statement regarding endothelin:
Your Answer: Endothelin antagonists are useful in primary pulmonary hypertension
Explanation:Current guidelines recommend the use of ambrisentan, Bosentan (recommendation I, level of evidence A) and macitentan (I, B) in patients with PAH and WHO functional class II and III. In WHO functional class IV, the first-line drug is Epoprostenol and the recommendation for Endothelin receptor antagonists is weaker (IIb, C).
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This question is part of the following fields:
- Clinical Sciences
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Question 15
Correct
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A 55-year-old woman admitted to the hospital with her third urinary tract infection in as many months. She has type-2 diabetes and started Empagliflozin (a sodium glucose co-transporter 2 inhibitor) 4 months ago. You suspect recurrent urinary tract infections secondary to her empagliflozin. Where is the main site of action of the drug?
Your Answer: Early proximal convoluted tubule
Explanation:Selective sodium-glucose transporter-2 (SGLT2) is expressed in the proximal renal tubules and is responsible for the majority of the reabsorption of filtered glucose from the tubular lumen.
Empagliflozin; SGLT2 inhibitors reduce glucose reabsorption and lower the renal threshold for glucose, thereby increasing urinary glucose excretion, thus increasing the risk of urinary tract infections. -
This question is part of the following fields:
- Endocrinology
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Question 16
Incorrect
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A 74-year-old retired judge who is known to have Alzheimer’s disease is examined in clinic. His latest Mini Mental State Examination (MMSE) score is 18 out of 30. Which of the following is the most appropriate treatment option?
Your Answer: Supportive care + memantine
Correct Answer: Supportive care + donepezil
Explanation:NICE now recommends the three acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) as options for managing mild to moderate Alzheimer’s disease. Memantine is reserved for patients with moderate to severe Alzheimer’s.
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This question is part of the following fields:
- Neurology
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Question 17
Correct
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A 14-year-old boy presents with a rash on his buttocks and extensor surfaces following a sore throat. What is the most probable diagnosis?
Your Answer: Henoch-Schönlein purpura (HSP)
Explanation:Henoch-Schönlein purpura (HSP) rashes are commonly found on the legs, feet, and buttocks while Immune thrombocytopenia (ITP) rashes manifest predominantly on the lower legs. HSP happens following a sore throat while ITP usually happens following an URTI or Flu. HSP is an inflammation of a blood vessel (vasculitis) while ITP is immune mediated insufficiency of platelets.
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This question is part of the following fields:
- Dermatology
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Question 18
Incorrect
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A 25-year-old female presents to the emergency department with severe breathlessness and tinnitus. She is under treatment for asthma and depression with albuterol and amitriptyline respectively. On examination, she seems agitated with a BP of 100/44, a pulse rate of 112 bpm, a respiratory rate of 30 cycles/min, and a temperature of 37.8'C. An arterial blood gas performed reveals: pH: 7.48 (7.36 – 7.44) pO2: 11.2 kPa (11.3 – 12.6 kPa) pCO2: 1.9 kPa (4.7 – 6.0 kPa) Bicarbonate: 13 mmol/l (20 – 28 mmol/L) What is the most probable diagnosis?
Your Answer: Pulmonary embolism
Correct Answer: Salicylate poisoning
Explanation:The blood gas analysis provided above is suggestive of a mixed respiratory alkalosis and metabolic acidosis characteristic of salicylate overdose.
Pathophysiology:
The direct stimulation of the cerebral medulla causes hyperventilation and respiratory alkalosis.
As it is metabolized, it causes an uncoupling of oxidative phosphorylation in the mitochondria.
Lactate levels then increase due to the increase in anaerobic metabolism. This, along with a slight contribution from the salicylate metabolites result in metabolic acidosis.Tinnitus is characteristic and salicylate ototoxicity may produce deafness. Other neurological sequelae include encephalopathy and agitation, seizures and CNS depression and coma. Cardiovascular complications include tachycardia, hypotension, and dysrhythmias (VT, VF, and asystole).
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This question is part of the following fields:
- Pharmacology
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Question 19
Correct
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A 80 yr. old male patient with ischaemic heart disease, hypertension and dyslipidaemia presented with productive cough, fever with chills and loss of appetite for 4 days. On examination he was unwell and febrile with a temperature of 38.3. His blood pressure was 130/80mmHg and pulse rate was 140 bpm. Respiratory rate was 18 breaths per minute. On auscultation there were crepitations over the left lower zone of his chest. His abdomen was soft and non-tender. ECG showed an irregular narrow complex tachycardia. Which of the following is the most appropriate acute management to treat his tachycardia?
Your Answer: Antibiotics
Explanation:The most likely diagnosis is acute atrial fibrillation (AF) precipitated by acute pneumonia. History of fever, cough and the auscultation findings support it. So the most appropriate management is treating the pneumonia with antibiotics. Treating the underlying cause will reduce the heart rate. Other responses are helpful in the management of chronic AF.
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This question is part of the following fields:
- Cardiology
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Question 20
Correct
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A 62-year-old software developer with lung cancer is currently taking MST 30mg bd for pain relief. What dose of oral morphine solution should he be prescribed for breakthrough pain?
Your Answer: 10 mg
Explanation:The total daily morphine dose is 30 x 2 = 60 mg. Therefore, the breakthrough dose should be one-sixth of this, 10 mg.
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This question is part of the following fields:
- Pharmacology
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SESSION STATS - PERFORMANCE PER SPECIALTY
