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Question 1
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A 56-year-old male presents to the emergency department with confusion and agitation for the past four hours. He is a known alcoholic who has abstained from drinking for the past three days. On examination, he is sweating, agitated and disorientated. His temperature is 37.7°C, pulse 112 bpm regular and blood pressure is 150/76 mmHg. Blood investigations performed in the emergency department reveal: FBC: Normal U&E: Normal Plasma glucose: 4.6 mmol/l (3.6-6) Which of the following medications would be the most appropriate treatment for this man?
Your Answer: IV haloperidol
Correct Answer: Oral lorazepam
Explanation:The most probable diagnosis for this patient is delirium tremens due to alcohol withdrawal, which should be treated as a medical emergency.
Delirium tremens is a hyperadrenergic state and is often associated with tachycardia, hyperthermia, hypertension, tachypnoea, tremor, and mydriasis.
Treatment:
– The most common and validated treatment for alcohol withdrawal is benzodiazepine: first-line treatment includes oral lorazepam.
– If the symptoms persist, or the medication is refused, parenteral lorazepam, haloperidol or olanzapine should be given.
– Central-acting, alpha-2 agonists such as clonidine and dexmedetomidine should not be used alone for the treatment of alcohol withdrawal.
– It is also recommended to avoid using alcohol, antipsychotics, anticonvulsants, beta-adrenergic receptor blockers, and baclofen for the treatment of alcohol withdrawal as there are not enough studies to support the safety of these. -
This question is part of the following fields:
- Pharmacology
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Question 2
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A 26 year old male presents with right sided elbow and wrist pain and left sided knee and ankle pain that has persisted for about two weeks. He recently returned from a trip to Thailand that last for two weeks. The patient admits to having unprotected sex while on holiday. Examination reveals swelling and tenderness of tendons around joints but no inflammation of the joints. A vesiculopustular skin rash is also observed. What is the most likely cause?
Your Answer: Gonococcal arthritis
Explanation:Patients with disseminated gonococcal arthritis may present with dermatitis-arthritis syndrome (60%) of with localized septic arthritis. (40%). Arthritis-dermatitis syndrome includes the classic triad of dermatitis, tenosynovitis, and migratory polyarthritis. Gout usually involves a singe joint and does not cause vesicopustular skin rash. Reactive arthritis has ocular symptoms (conjunctivitis), urethritis, and arthritis. Fungal arthritis occurs rarely and it may occur after a surgical infection or fungal spread hematogenously. it presents with tender, red, hot and swollen joint with loss of range of motion.
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This question is part of the following fields:
- Rheumatology
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Question 3
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A 77-year-old retired engineer presents with a burning sensation around his right eye. On examination, an erythematous blistering rash can be seen in the right trigeminal distribution. Which of the following is the most likely diagnosis?
Your Answer: Herpes zoster ophthalmicus
Explanation:Herpes zoster ophthalmicus (HZO) describes the reactivation of the varicella zoster virus in the area supplied by the ophthalmic division of the trigeminal nerve. It accounts for around 10% of case of shingles. Features include a vesicular rash around the eye, which may or may not involve the actual eye itself, and Hutchinson’s sign: a rash on the tip or side of the nose, indicating nasociliary involvement and is a strong risk factor for ocular involvement.
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This question is part of the following fields:
- Ophthalmology
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Question 4
Incorrect
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Which one of the following is a contraindication to the use of a triptan in the management of migraine?
Your Answer: Previous intracranial tumour
Correct Answer: A history of ischaemic heart disease
Explanation:A history of ischaemic heart disease in a contraindication for prescribing triptans because they act by constricting cerebral and also coronary vessels, increasing the risk of stroke.
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This question is part of the following fields:
- Neurology
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Question 5
Incorrect
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A 60-year-old male who has been on IV antibiotics for severe pneumonia developed profuse, watery, green coloured diarrhoea on the fifth day of antibiotics. What is the most likely organism responsible for this condition?
Your Answer: Pseudomonas aeruginosa
Correct Answer: Clostridium difficile
Explanation:The most probable cause for diarrhoea is pseudomembranous colitis which is caused by Clostridium difficile. Pseudomembranous colitis is an inflammatory disease of the colon where the antibiotic-induced change in the balance of normal gut flora allows overgrowth of C difficile. Any antibiotic can cause this but the chances are higher with ampicillin, clindamycin, fluoroquinolones, and cephalosporins.
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This question is part of the following fields:
- Infectious Diseases
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Question 6
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A young woman is concerned that she has put on weight since she was a medical student, as she now no longer finds time to exercise. She decides to try various weight loss tablets temporarily. After 2 months, she is successfully losing weight but also has trouble with increased stool frequency, difficulty in climbing stairs and getting up out of chairs. However, she has no problems walking on the flat. She also has difficulty in sleeping at the moment but puts that down to the increased frequency of headaches for the past 2 months. Which one of the following is the most likely cause of her weakness?
Your Answer: She is abusing thyroxine tablets
Explanation:Exogenous thyroid hormone use has been associated with episodes of thyroid storm as well as thyrotoxic periodic paralysis.
It presents with marked proximal muscle weakness in both upper and lower limbs, hypokalaemia and signs of hyperthyroidism.
Hyperthyroidism generally presents with tachycardia, hypertension, hyperthermia, and cardiac arrhythmiasLaxatives and diuretics can result in electrolyte abnormalities.
Medical complications associated with laxatives include chronic diarrhoea which disrupts the normal stool electrolyte concentrations that then leads to serum electrolyte shifts; acutely, hypokalaemia is most typically seen. The large intestine suffers nerve damage from the chronic laxative use that renders it unable to function properly. The normal peristalsis and conduction are affected; the disorder is thought to be secondary to a degeneration of Auerbach’s Plexi. However, it does not cause muscle weakness.Insulin tends to cause weight gain, not weight loss.
Metformin does not cause muscle weakness but can cause headaches. -
This question is part of the following fields:
- Endocrinology
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Question 7
Incorrect
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A 43 year old ex-marine who has a history of post-traumatic stress disorder visits the office for a review. He is reluctant to try cognitive behavioural therapy. Which medication could be useful in this patient?
Your Answer: Citalopram
Correct Answer: Mirtazapine
Explanation:Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by stressful, frightening or distressing events.
PTSD is a lasting consequence of traumatic ordeals that cause intense fear, helplessness, or horror, such as a sexual or physical assault, the unexpected death of a loved one, an accident, war, or natural disaster. Families of victims can also develop PTSD, as can emergency personnel and rescue workers.
PTSD is diagnosed after a person experiences symptoms for at least one month following a traumatic event. However symptoms may not appear until several months or even years later. The disorder is characterized by three main types of symptoms:
-Re-experiencing the trauma through intrusive distressing recollections of the event, flashbacks, and nightmares.
-Emotional numbness and avoidance of places, people, and activities that are reminders of the trauma.
-Increased arousal such as difficulty sleeping and concentrating, feeling jumpy, and being easily irritated and angered.The goal of PTSD treatment is to reduce the emotional and physical symptoms, to improve daily functioning, and to help the person better cope with the event that triggered the disorder. Treatment for PTSD may involve psychotherapy (a type of counselling), medication, or both.
Eye Movement Desensitization and Reprocessing (EMDR) therapy was initially developed in 1987 for the treatment of posttraumatic stress disorder (PTSD) and is guided by the Adaptive Information Processing model. EMDR is an individual therapy typically delivered one to two times per week for a total of 6-12 sessions, although some people benefit from fewer sessions. Sessions can be conducted on consecutive days.
Drug treatments (paroxetine, mirtazapine, amitriptyline or phenelzine) should be considered for the treatment of PTSD when a sufferer expresses a preference to not engage in trauma-focused psychological treatment.
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This question is part of the following fields:
- Psychiatry
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Question 8
Incorrect
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Choose the correct statement regarding interferon:
Your Answer: Interferon-alpha has been shown to reduce the frequency of exacerbations in patients with relapsing-remitting multiple sclerosis
Correct Answer: Interferon-alpha and interferon-beta bind to the same type of receptor
Explanation:Type I interferons (IFNs) form a network of homologous cytokines that bind to a shared, heterodimeric cell surface receptor and engage signalling pathways that activate innate and adaptive immune responses.
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This question is part of the following fields:
- Clinical Sciences
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Question 9
Incorrect
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A 25-year-old woman presents to the clinic with nausea, thirst and dehydration. She mentioned that she has an uncle with previous parathyroid gland excision and a cousin who has recently been diagnosed with insulinoma. On examination, her BP is 135/72 mmHg, her pulse is 70/min and regular, her BMI is 20. Cardiovascular, respiratory and abdominal examinations are unremarkable. Investigations show: Hb 12.6 g/dL, WCC 5.4 x109/L, PLT 299 x109/L, Na+ 139 mmol/L, K+ 4.4 mmol/L, Creatinine 121 ىmol/L, Albumin 37 g/l, Ca++ 2.95 mmol/L, PTH 18 (normal<10). Which of the following is the most likely cause of her raised calcium?
Your Answer: Parathyroid adenoma
Correct Answer: Parathyroid hyperplasia
Explanation:The combination of Insulinoma and Parathyroid diseases is suggestive of MEN 1 syndrome.
Multiple endocrine neoplasia type 1 (MEN1) is a rare hereditary tumour syndrome inherited in an autosomal dominant manner and characterized by a predisposition to a multitude of endocrine neoplasms primarily of parathyroid, entero-pancreatic, and anterior pituitary origin, as well as non-endocrine neoplasms.
Other endocrine tumours in MEN1 include foregut carcinoid tumours, adrenocortical tumours, and rarely pheochromocytoma. Nonendocrine manifestations include meningiomas and ependymomas, lipomas, angiofibromas, collagenomas, and leiomyomas.Primary hyperparathyroidism (PHPT), due to parathyroid hyperplasia is the most frequent and usually the earliest expression of MEN-1, with a typical age of onset at 20–25 years.
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This question is part of the following fields:
- Endocrinology
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Question 10
Incorrect
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A 23 year old girl presented with complaints of diplopia on looking towards her right side. Which of the nerves will be effected?
Your Answer: Left abducens
Correct Answer: Right abducens
Explanation:This patient has complaints of diplopia in the right eye, when looking towards the right. Eyeball movements towards the right side are controlled by right lateral rectus muscle which is supplied by the abducent nerve.
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This question is part of the following fields:
- Ophthalmology
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