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Question 1
Incorrect
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A 51 year-old teacher presents complaining of numerous falls. He states he has difficulty walking up stairs, and he thinks it is because of his weak legs rather than blackouts. He is hypertensive and has suffered chronic back pain for many years. He has smoked for many years as well and has a chronic smokers cough. Upon examination, he has weakness of hip flexion and particularly knee extension. He is unable to keep his fingers flexed against force, with the right being weaker than the left. There are no sensory abnormalities and reflexes are preserved bilaterally. Which of the following is the most likely diagnosis?
Your Answer: Limb-girdle muscular dystrophy
Correct Answer: Inclusion body myositis
Explanation:The pattern of muscle involvement seen with quadriceps and long-finger flexors is characteristic of inclusion body myositis, an inflammatory myopathy. Polymyositis is likely to cause a predominantly proximal weakness, associated with muscle pain. The signs and symptoms are not consistent with upper cord compression, as there would likely be sensory signs, reflex changes, and possible urinary symptoms. Motor neuron disease cannot be ruled out, but there are no findings of upper motor neuron or bulbar features.
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This question is part of the following fields:
- Neurology
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Question 2
Correct
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Organophosphates, such as Sarin, have been used as chemical-warfare agents by terrorists. Which of the following statements is true concerning organophosphate poisoning?
Your Answer: Atropine is useful in the management of organophosphate poisoning
Explanation:The principal action of organophosphates is the inhibition of acetylcholinesterase’s, therefore leading to the accumulation of acetylcholine at muscarinic receptors (miosis, hypersalivation, sweating, diarrhoea, excessive bronchial secretions), nicotinic receptors (muscle fasciculations and tremor) and in the central nervous system (anxiety, loss of memory, headache, coma).
Removal from the source of the organophosphate, adequate decontamination, supplemental oxygen and atropine are the initial treatment measures. Pralidoxime, an activator of cholinesterase, should be given to all symptomatic patients.
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This question is part of the following fields:
- Pharmacology
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Question 3
Incorrect
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There are number of diseases that have to be notified to the consultant responsible for communicable disease control. Which of the following conditions does not belong to above category?
Your Answer: Vivax malaria
Correct Answer: Pneumococcal pneumonia
Explanation:There are number of diseases that have to be notified to relevant authorities to prevent or reduce their spread. Those conditions include Cholera, Diphtheria, Food poisoning, Infectious bloody diarrhoea, Malaria, Measles, Meningococcal septicaemia, Mumps, Plague, Rabies and Rubella.
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This question is part of the following fields:
- Infectious Diseases
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Question 4
Correct
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A 21-year-old woman presents with lethargy and confusion. On examination, you note a purpuric rash covering the abdominal wall and thighs, and a fever of 38C. Investigations reveal haemolytic anaemia, thrombocytopenia, and acute kidney injury. Which feature of the presentation makes the diagnosis of thrombotic thrombocytopenic purpura more likely than haemolytic uremic syndrome?
Your Answer: Confusion
Explanation:Confusion in the patient refers to neurological symptoms that are more associated with thrombotic thrombocytopenic purpura than with haemolytic uremic syndrome. All the other symptoms present in both conditions similarly.
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This question is part of the following fields:
- Nephrology
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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 polycythaemia
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
Incorrect
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Supplementation of which one of the following might help a patient diagnosed with homocystinuria?
Your Answer: Niacin
Correct Answer: Pyridoxine
Explanation:In general, the aim is to keep the homocysteine (Hcy) concentration as close to normal as possible. In patients who are fully-responsive to pyridoxine, standard doses can lead to tHcy levels below 50 μmol/L (and sometimes within the normal range). Some patients who are partially-responsive to pyridoxine may be able to achieve a tHcy level below 50 μmol/L if they are also on a low-Met diet; for others it is not a realistic goal.
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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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Which of the following is most commonly associated with the development of pseudomembranous colitis?
Your Answer: Cefuroxime
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.
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This question is part of the following fields:
- Gastroenterology
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Question 8
Correct
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Which of the following may cause a downbeat nystagmus?
Your Answer: Chiari type I malformation
Explanation:Downbeat nystagmus (DBN) suggests a lesion in the lower part of the medulla. Chiari Type I malformation usually presents with symptoms due to brain stem and lower cranial nerve dysfunction, which includes DBN.
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This question is part of the following fields:
- Neurology
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Question 9
Incorrect
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A 28-year-old man is investigated for lethargy. His full blood count (FBC) report shows: Hb: 8.6 g/dL, Plts: 42 x 10^9/L, WCC: 36.4 x 10^9/L. His blood film report reveals 30% myeloblasts with Auer rods. Given the likely diagnosis, which one of the following is associated with a good prognosis?
Your Answer: 25% blasts following first course of chemotherapy
Correct Answer: Translocation between chromosome 15 and 17
Explanation:A translocation between chromosome 15 and 17 is seen in acute promyelocytic leukaemia (APL), which is known to carry a good prognosis.
Acute myeloid leukaemia (AML) is the acute expansion of the myeloid stem line, which may occur as a primary disease or follow the secondary transformation of a myeloproliferative disorder. It is more common over the age of 45 and is characterized by signs and symptoms largely related to bone marrow failure such as anaemia (pallor, lethargy), frequent infections due to neutropenia (although the total leucocyte count may be very high), thrombocytopaenia (bleeding), ostealgia, and splenomegaly. The disease has poor prognosis if:
The disease has poor prognosis if:
1. Age of the patient >60 years
2. >20% blasts seen after the first course of chemotherapy
3. Chromosomal aberration with deletion of part of chromosome 5 or 7.APL is an aggressive form of AML. It is associated with t(15;17) and has a good prognosis. The general age of presentation is less than that in other types of AML (average age is 25 years old). On blood film, abundant Auer rods are seen with myeloperoxidase staining. Thrombocytopaenia or DIC is seen in patients presenting with this disease.
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This question is part of the following fields:
- Haematology & Oncology
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Question 10
Correct
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A 13-year-old boy complains of several episodes of collapse. He describes the majority of these episodes occurring when he is laughing. He states that he loses power in his legs and falls to the ground. He is alert throughout and recovers quickly. He also describes excessive daytime sleepiness with episodes in the morning of being awake but being unable to move his body. Examination is unremarkable. A diagnosis of narcolepsy is made. Which of the following is the first line treatment for excessive daytime sleepiness?
Your Answer: Modafinil
Explanation:Narcolepsy is a rare condition characterised by excessive daytime sleepiness, sleep paralysis, hypnagogic hallucinations, and cataplexy (sudden collapse triggered by emotion such as laughing or crying). There is no cure for narcolepsy. Treatment options include stimulants, such as methylphenidate (Ritalin) or modafinil (Provigil), antidepressants, such as fluoxetine (Prozac), citalopram (Celexa), paroxetine (Paxil), sertraline (Zoloft) and sodium oxybate (Xyrem). Modafinil has replaced methylphenidate and amphetamine as the first-line treatment of excessive daytime sleepiness (EDS).
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This question is part of the following fields:
- Neurology
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Question 11
Incorrect
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A 35-year-old woman under treatment for long-term epilepsy with valproate presented with complaints of excessive weight gain. She is consuming oral contraceptive pills. Which among the following is the best alternative to valproate for treating long-term epilepsy?
Your Answer: Topiramate
Correct Answer: Lamotrigine
Explanation:Among the given anti-epileptics the best drug that can be given in this patient is lamotrigine.
Topiramate, carbamazepine, phenytoin, and phenobarbital are all hepatic enzyme inducers and are associated with decreased effectiveness of the oral contraceptive (OCP) due to acceleration of the metabolism of oestrogens and progestogens.
If she is planning on pregnancy then registry studies suggest that lamotrigine would also be the best choice.
Other hepatic enzyme inducers include rifampicin, spironolactone, griseofulvin, etc. -
This question is part of the following fields:
- Pharmacology
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Question 12
Correct
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A 76-year-old male presents with recurrent episodes of hallucinations. He often sees faces smaller than normal or other objects out of proportion. He says he knows they're not real. His past medical history includes macular degeneration and an episode of depression 15 years ago following the death of his wife. Neurological examination is unremarkable. What is the most probable diagnosis?
Your Answer: Charles-Bonnet syndrome
Explanation:The most probable diagnosis in the given scenario would be Charles-Bonnet syndrome.
Charles-Bonnet syndrome (CBS) is characterized by persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness. This is generally against a background of visual impairment (although visual impairment is not mandatory for a diagnosis). Insight is usually preserved. This must occur in the absence of any other significant neuropsychiatric disturbance.
Risk factors include:
Advanced age
Peripheral visual impairment
Social isolation
Sensory deprivation
Early cognitive impairmentCBS is equally distributed between sexes and does not show any familial predisposition. The most common ophthalmological conditions associated with this syndrome are age-related macular degeneration, followed by glaucoma and cataract.
Well-formed complex visual hallucinations are thought to occur in 10-30 percent of individuals with severe visual impairment. The prevalence of CBS in visually impaired people is thought to be between 11 and 15 percent.
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This question is part of the following fields:
- Psychiatry
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Question 13
Incorrect
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A 72-year-old woman is admitted with general deterioration and ‘off-legs’. On examination in the emergency department, she looks dry and uremic. Investigations reveal:
- K+ 7.2 mmol/L
- Na+ 145 mmol/L
- Creatinine 512 μmol/L
- Urea 36.8 mmol/L
Your Answer: IV Insulin and dextrose infusion
Correct Answer: ECG & IV Calcium gluconate bolus
Explanation:First and foremost, the patient should be put on ECG monitoring to identify the cardiac state, and because of the markedly raised serum potassium, a calcium gluconate bolus will have the immediate effect of moderating the nerve and muscle performance.
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This question is part of the following fields:
- Nephrology
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Question 14
Incorrect
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A 41-year-old female is referred to medical assessment unit by her physician for querying thrombotic thrombocytopenic purpura (TTP) after she presented with a temperature of 38.9C. Her subsequent urea and electrolytes showed deteriorating renal function with a creatinine 3 times greater than her baseline. What is the underlying pathophysiology of TTP?
Your Answer: A deficiency of von Willebrand factor
Correct Answer: Failure to cleave von Willebrand factor normally
Explanation:Thrombotic thrombocytopenic purpura (TTP) is characterised by the von Willebrand factor (vWF) microthrombi within the vessels of multiple organs. In this condition, the ADAMTS13 metalloprotease enzyme which is responsible for the breakdown of vWF multimer, is deficient, causing its build-up and leading to platelet clots that then decreases the circulating platelets, leading to bleeding in the patient.
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This question is part of the following fields:
- Nephrology
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Question 15
Incorrect
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In a patient with Hashimoto's thyroiditis, which of the following is most specific to the disease?
Your Answer: Raised ESR
Correct Answer: Anti-thyroid peroxidase antibodies
Explanation:Hashimoto thyroiditis is part of the spectrum of autoimmune thyroid diseases (AITDs) and is characterized by the destruction of thyroid cells by various cell- and antibody mediated immune processes. It usually presents with hypothyroidism, insidious in onset, with signs and symptoms slowly progressing over months to years.
The diagnosis of Hashimoto thyroiditis relies on the demonstration of circulating antibodies to thyroid antigens (mainly thyroperoxidase and thyroglobulin) and reduced echogenicity on thyroid sonogram in a patient with proper clinical features.
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This question is part of the following fields:
- Endocrinology
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Question 16
Incorrect
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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: Kimmelstiel–Wilson lesions
Correct 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 17
Incorrect
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A 42-year-old man with a 6 month history of progressive weakness of both lower limbs, complains of lethargy and of difficulties climbing stairs. He also claims he's experienced muscle loss in his lower limbs. History reveals type 2 diabetes mellitus and heavy alcohol use for the last 4 years. Clinical examination reveals marked loss of fine touch and proprioception. The distribution is in a stocking manner and bilateral. However, no evidence of ataxia is present. What is the most probable diagnosis?
Your Answer: Pellagra
Correct Answer: Dry beriberi
Explanation:Hypovitaminosis B1, consistent with dry beriberi is crucially a treatable condition, although sometimes with incomplete recovery, but it is probably under-recognized yet increasingly common given increasing levels of alcohol abuse in the western world. Dry beriberi or ‘acute nutritional polyneuropathy’ is considered to be rare in the western world. Rapid deterioration can occur, typically with weakness, paraesthesia and neuropathic pain. Striking motor nerve involvement can occur, mimicking Guillain-Barré syndrome (GBS). In the context of increasing alcohol abuse in the western world, it is possible that alcoholic neuropathy associated with abrupt deterioration due to concomitant nutritional hypovitaminosis B1 may be seen increasingly often.
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This question is part of the following fields:
- Clinical Sciences
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Question 18
Incorrect
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A gentleman arrives at the renal clinic for review. He has longstanding chronic renal failure and is unfortunately suffering from metabolic bone disease. His GP has asked for an explanation of the causes and features of metabolic bone disease. Which of the following best describes the biochemical changes involved?
Your Answer: Phosphate excretion is increased, parathyroid hormone levels are increased and 1,25-OH vitamin D levels are increased
Correct Answer: Phosphate excretion is decreased, parathyroid hormone levels are increased and 1,25-OH vitamin D levels are decreased
Explanation:The patient’s chronic renal failure causes decreased renal hydroxylation of vitamin D which leads to decreased calcium absorption in the gut. Simultaneously, there is also decreased renal excretion of phosphate, and this combination of factors results in increased PTH levels.
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This question is part of the following fields:
- Nephrology
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Question 19
Incorrect
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A 72-year-old with varicose veins complains of swollen, red, itchy legs. Which is the most likely diagnosis?
Your Answer: Cellulitis
Correct Answer: Varicose eczema
Explanation:Varicose eczema is a common problem, particularly in elderly patients due to stasis or blood pooling from insufficient venous return; the alternative name of varicose eczema comes from a common cause of this being varicose veins. It is often mistaken for cellulitis, but cellulitis is rarely bilateral and is painful rather than itchy.
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This question is part of the following fields:
- Dermatology
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Question 20
Incorrect
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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: Collecting duct
Correct 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 21
Correct
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A 21-year-old woman presents with painful vesicles in her right ear and a fever for some time. What is the most probable diagnosis?
Your Answer: Herpes zoster
Explanation:Herpes zoster oticus is a viral infection of the inner, middle, and external ear. It manifests as severe otalgia with associated cutaneous vesicular eruption, usually of the external canal and pinna. When associated with facial paralysis, the infection is called Ramsay Hunt syndrome.
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This question is part of the following fields:
- Dermatology
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Question 22
Correct
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A 31-year-old homosexual male is complaining of recent weight loss and blurred vision. A fundoscope was performed showing retinal haemorrhage. What is the single most appropriate option?
Your Answer: HIV/AIDS
Explanation:Given the symptoms described in a 31-year-old homosexual male, along with the findings of weight loss, blurred vision, and retinal hemorrhage, the single most appropriate option to consider is HIV/AIDS.
HIV/AIDS can manifest with a wide range of symptoms, including unintentional weight loss and blurred vision. Retinal hemorrhage can also occur as a complication of HIV/AIDS, particularly in advanced stages when the immune system is severely compromised.
In this case, it’s important to conduct further diagnostic tests, including HIV testing, to confirm the diagnosis. Additionally, prompt initiation of antiretroviral therapy (ART) is crucial for managing HIV/AIDS and preventing further complications. Referral to an infectious disease specialist for comprehensive management is recommended.
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This question is part of the following fields:
- Infectious Diseases
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Question 23
Incorrect
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A 14 year-old is brought to the ED after being hit on the head with a cricket ball during a match. His teacher describes that he initially collapsed on the ground and complained of a sore head. Two minutes later, he got up and said he felt OK and continued playing. However, 30 minutes later he suddenly collapsed and lost consciousness. What injury is he most likely to have sustained?
Your Answer: Subdural haematoma
Correct Answer: Extradural haematoma
Explanation:A lucid interval, in which the patient portrays a temporary improvement in condition after a traumatic brain injury, is especially indicative of an epidural haematoma.
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This question is part of the following fields:
- Neurology
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Question 24
Incorrect
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Which is the formula to calculate the number needed to treat?
Your Answer: ((Control event rate) - (Experimental event rate)) / (Control event rate)
Correct Answer: 1 / (Absolute risk reduction)
Explanation:The number needed to treat (NNT) is valuable information in treatment decisions. NNT is the inverse of the absolute risk reduction (1/ARR) between two treatment options.
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This question is part of the following fields:
- Clinical Sciences
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Question 25
Correct
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A 29-year-old accountant presents to the emergency department complaining of left eye pain. He has not been able to wear his contact lenses for the past 24 hours due to the pain. He describes the pain as severe and wonders whether he has 'got something stuck in his eye'. On examination, there is diffuse hyperaemia of the left eye. The left cornea appears hazy and pupillary reaction is normal. Visual acuity is reduced on the left side and a degree of photophobia is noted. A hypopyon is also seen. Which of the following is the most likely diagnosis?
Your Answer: Keratitis
Explanation:Hypopyon can be seen in anterior uveitis, however the combination of a normal pupillary reaction and contact lens use make a diagnosis of keratitis more likely. Keratitis describes inflammation of the cornea, and features include red eye with pain and erythema, photophobia, and foreign body/gritty sensation.
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This question is part of the following fields:
- Ophthalmology
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Question 26
Incorrect
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Which of the following would be the most appropriate treatment (leaving out the current NICE guidelines) for a 29 year old man with erythrodermic psoriasis and arthritis mutilans involving several digits of both hands?
Your Answer: Phototherapy
Correct Answer: Etanercept
Explanation:TNF-alpha inhibitors are known to ameliorate the symptoms and disease activity of Arthritis mutilans (a rare and severe form of psoriatic arthritis), by disabling the cytokines that are involved in inflammation and joint destruction. From the mentioned choices, this would be the most effective option. Methotrexate is the most commonly used DMARD, followed by sulfasalazine used in mild to moderate forms of psoriatic arthritis but has not shown much efficacy in arthritis mutilans. Phototherapy, narrowband UVB light therapy can be very effective in clearing skin lesions.
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This question is part of the following fields:
- Rheumatology
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Question 27
Incorrect
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A study is performed to assess a new proton pump inhibitor (PPI) in 120 elderly patients who are receiving aspirin. A control group of 240 elderly patients is given the standard PPI. The final evaluation after five years revealed that 24 individuals receiving the new PPI experienced an upper GI bleed. What is the absolute risk reduction if 60 individuals receiving the standard PPI experienced the same condition?
Your Answer: 10%
Correct Answer: 5%
Explanation:Absolute risk reduction (ARR) – also called risk difference (RD) – is the most useful way of presenting research results to help your decision-making. Absolute risk reduction = (Control event rate) – (Experimental event rate) = 0.05 = 5% reduction
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This question is part of the following fields:
- Clinical Sciences
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Question 28
Incorrect
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A 48-year-old patient with type 1 diabetes and chronic kidney disease attends for review. His blood tests show: Haemoglobin 11.2 g/dl (13.0 – 18.0 g/dL) MCV 87 fl (80 – 96 fL) Sodium 133 mmol/l (137 – 144 mmol/L) Potassium 4.3 mmol/l (3.5 – 4.9 mmol/L) Urea 19.1 mmol/l (2.5 – 7.5 mmol/L) Creatinine 267 μmol/l (60 – 110 μmol/L) Ferritin 150 μg/l (15 – 300 μg/L) C reactive protein <5 mg/l (< 10 mg/L) What is the most appropriate management of his anaemia?
Your Answer: Renal transplantation
Correct Answer: Monitor haemoglobin, no treatment required at present
Explanation:Because the patient has chronic kidney disease, we need to consider the associated adverse effects of trying to maintain normal haemoglobin levels (14-18g/dl in this patient) and instead only instigate therapy when the level falls below 11 g/dl. Thus, in this case we should just monitor the haemoglobin levels and not initiate therapy just yet.
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This question is part of the following fields:
- Nephrology
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Question 29
Incorrect
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A 25-year-old obese woman is diagnosed with polycystic ovarian syndrome (PCOS). Which of the following findings is most consistently seen in PCOS?
Your Answer: Obesity
Correct Answer: Ovarian cysts on ultrasound
Explanation:The diagnosis of polycystic ovarian syndrome (PCOS) is based on hyperandrogenism or chronic anovulation in the absence of specific pituitary and/or adrenal disease.
Pelvic ultrasonography may be very helpful in the evaluation as well, but polycystic ovaries are not specific for PCOS with over 20% of “normal” women having this finding. The number of follicles and ovary volume are both important in the ultrasound evaluation. The criteria for PCOS put forth by Adams et al. are the most often cited: the presence of ≥10 cysts measuring 2–8 mm around a dense core of stroma or scattered within an increased amount of stroma.
A recent proposal to modify these criteria has been put forth by Jonard et al.: “increased ovarian area (>5.5cm2) or volume (>11 mL) and/or presence of ≥12 follicles measuring 2 to 9 mm in diameter (mean of both ovaries)”.
These criteria have a specificity of 99% and a sensitivity of 75% for the diagnosis of PCOS. -
This question is part of the following fields:
- Endocrinology
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Question 30
Incorrect
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A 55-year-old alcoholic is admitted with portal hypertension. The wedged hepatic venous pressure is recorded. This pressure is reflective of which part of the hepatic vascular system?
Your Answer: Portal vein
Correct Answer: Sinusoids
Explanation:The wedged hepatic venous pressure is a reflection of the portal venous pressure in the hepatic sinusoids. This is a fact to remember. Here is a great but concise explanation as to why: https://www.ncbi.nlm.nih.gov/pubmed/18695309
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This question is part of the following fields:
- Gastroenterology
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Question 31
Incorrect
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A 46-year-old woman was referred to the endocrinology department with hypercalcemia and raised parathyroid hormone levels. Her blood tests are highly suggestive of primary hyperparathyroidism. She has type 2 diabetes controlled by metformin alone. Her albumin-adjusted serum calcium level is 3.5 mmol/litre. Which of the following is the most important reason for her referral?
Your Answer: Vitamin D deficiency
Correct Answer: Albumin-adjusted serum calcium level of 3.5 mmol/litre
Explanation:Indications for surgery for the treatment of primary hyperparathyroidism:
1. Symptoms of hypercalcaemia such as thirst, frequent or excessive urination, or constipation
2. End-organ disease (renal stones, fragility fractures or osteoporosis)
3. An albumin-adjusted serum calcium level of 2.85 mmol/litre or above. -
This question is part of the following fields:
- Endocrinology
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Question 32
Incorrect
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A 25-year-old man having sickle cell anaemia presents with headache, lethargy, and pallor. His blood count shows: Haemoglobin: 4.6 g/dL, Reticulocytes: 3%. Infection with parvovirus is suspected. Out of the following, what is the most likely diagnosis?
Your Answer: Sequestration crisis
Correct Answer: Aplastic crisis
Explanation:Sickle cell anaemia is characterised by periods of good health with intervening crises. One of the main types is aplastic crisis characterised by a sudden fall in haemoglobin without marked reticulocytosis (3%—in this case—is just above the normal range). It usually occurs secondary to parvovirus infection.
The other main types of sickle cell crises are thrombotic crisis (painful or vaso-occlusive crisis), sequestration crisis, and haemolytic crisis. Thrombotic crisis is precipitated by infection, dehydration, alcohol, change in temperature, and deoxygenation. Sequestration crisis is characterised by acute chest syndrome (i.e. fever, dyspnoea, chest/rib pain, low pO2, and pulmonary infiltrates). In haemolytic crisis, fall in haemoglobin occurs secondary to haemolysis. It is a 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 33
Correct
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A social worker has been diagnosed with hepatitis C infection. Which test will conclusively establish the presence of this infection?
Your Answer: HCV RNA
Explanation:The most sensitive test for detecting Hepatitis C infection (acute) is HCA RNA; it can be detected 1-2 weeks after infection. Anti-HCV antibodies take at least 6 weeks to develop and be positive.
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This question is part of the following fields:
- Gastroenterology
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Question 34
Incorrect
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A 42 year old male undergoes a routine cranial nerve examination, which reveals the following findings: Rinne's test: Air conduction > bone conduction in both ears Weber's test: Localizes to the right side What do these test results imply?
Your Answer: Right sensorineural deafness
Correct Answer: Left sensorineural deafness
Explanation:Weber’s test – if there is a sensorineural problem, the sound is localized to the unaffected side (right), indicating a problem on the left side.
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This question is part of the following fields:
- Neurology
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Question 35
Correct
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A 50-year-old woman with lung cancer develops deep vein thrombosis (DVT). She is reviewed in the hospital clinic and started on low-molecular-weight heparin (LMWH). Which of the following should be the most appropriate treatment plan?
Your Answer: Continue on LMWH for 6 months
Explanation:Patients with active cancer are at a continuous risk of having venous thromboembolism (VTE), such as DVT. Therefore, a six-month course of an anticoagulant such as LMWH is recommended. LMWH is the drug of choice since its side effects can be reversed and it can be stopped easily in case of a cancer-related bleed, for example, massive haemoptysis in a patient with lung cancer.
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This question is part of the following fields:
- Haematology & Oncology
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Question 36
Incorrect
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A 30 yr. old male patient presented with palpitations that occur randomly at rest. There have however been episodes of fast palpitations and dizziness on exertion. On examination there was a systolic murmur at the apex as well as a prominent apex beat and the chest was clear. Which of the following is LEAST likely to suggest a diagnosis of hypertrophic cardiomyopathy?
Your Answer: Mitral regurgitation on echocardiography
Correct Answer: A history of hypertension for 10 years
Explanation:Hypertrophic cardiomyopathy is an autosomal dominant condition. Patients present with sudden cardiac death, dyspnoea, syncope and presyncope, angina, palpitations, orthopnoea and paroxysmal nocturnal dyspnoea, Congestive heart failure and dizziness. Physical findings include double or triple apical impulse, prominent a wave in the JVP, an ejection systolic crescendo-decrescendo murmur and a holosystolic murmur at the apex and axilla of mitral regurgitation.
ECG shows ST-T wave abnormalities and LVH, axis deviation (right or left), conduction abnormalities (P-R prolongation, bundle-branch block), sinus bradycardia with ectopic atrial rhythm, atrial enlargement, abnormal and prominent Q wave in the anterior precordial and lateral limb leads.
2D echocardiography shows abnormal systolic anterior leaflet motion of the mitral valve, LVH, left atrial enlargement, small ventricular chamber size, septal hypertrophy with septal-to-free wall ratio greater than 1.4:1, mitral valve prolapse and mitral regurgitation, decreased midaortic flow, partial systolic closure of the aortic valve in midsystole -
This question is part of the following fields:
- Cardiology
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Question 37
Correct
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A 61-year-old chef with a known history of Paget's disease is noted to have irregular dark red lines radiating from the optic nerve. Which of the following is the most likely diagnosis?
Your Answer: Angioid retinal streaks
Explanation:Angioid retinal streaks are seen on fundoscopy as irregular dark red streaks radiating from the optic nerve head. They are caused by degeneration, calcification and breaks in Bruch’s membrane. They are typically associated with Paget’s disease.
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This question is part of the following fields:
- Ophthalmology
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Question 38
Incorrect
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A 22-year-old woman has ingested an unknown quantity of paracetamol tablets four hours ago. She now presents with nausea, vomiting, anorexia and right subchondral pain. Which of the following features suggest that she should be transferred to the liver unit?
Your Answer: Heart rate 120 BPM
Correct Answer: pH 7.25
Explanation:The most widely used prognostic predictors for acetaminophen over-ingestion is King’s College Criteria, which is: arterial PH < 7.3 after fluid resuscitation, Cr level > 3.4, PT > 1.8x control or > 100s, or INR > 6.5, and Grave III or IV encephalopathy.
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This question is part of the following fields:
- Gastroenterology
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Question 39
Incorrect
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A 71-year old gentleman presents with a subacute history of intermittent difficulty in walking, dry mouth, and variable slurring of speech. When the latter is severe he also has difficulty in swallowing. He has lost 3 kg in weight in the last 2 months. On examination he has bilateral mild ptosis, dysarthria, and proximal weakness of the upper and lower limbs, and he is areflexic. The degree of weakness is variable. Nerve conduction studies confirm the clinical suspicion of a neuromuscular junction disorder. Which of the following autoantibodies is likely to be the underlying cause of his neurological symptoms?
Your Answer: Antiganglioside antibody GM1
Correct Answer: Anti-voltage-gated, calcium-channel antibody
Explanation:The clinical picture points to Lambert– Eaton myasthenic syndrome (LEMS) which often presents with weakness of the arms and legs. In LEMS, antibodies against voltage-gated calcium channels (VGCC) decrease the amount of calcium that can enter the nerve ending, causing autonomic symptoms like dry mouth and slurring of speech, as seen in this patient.
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This question is part of the following fields:
- Neurology
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Question 40
Incorrect
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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: Decreased bicarbonate reabsorption in the proximal tubule
Correct 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 41
Incorrect
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A 13-year-old boy is brought to your clinic with a complaint of delayed puberty. While examining the patient which of the following features is most likely to indicate that pubertal change may have commenced?
Your Answer: Change in voice
Correct Answer: Increase in testicular volume
Explanation:In boys, the first manifestation of puberty is testicular enlargement; the normal age for initial signs of puberty is 9 to 14 years in males. Pubic hair in boys generally appears 18 to 24 months after the onset of testicular growth and is often conceived as the initial marker of sexual maturation by male adolescents.
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This question is part of the following fields:
- Endocrinology
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Question 42
Incorrect
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A 24-year-old student is brought to A&E having ingested at least 20 tablets of paracetamol 8 hours earlier. She weighs 61kg. What should her immediate management consist of?
Your Answer: Activated charcoal
Correct Answer: Intravenous N-acetylcysteine
Explanation:Activated charcoal is useful if given within one hour of the paracetamol overdose. Liver function tests, INR and prothrombin time will be normal, as liver damage may not manifest until 24 hours or more after ingestion.
The antidote of choice is intravenous N-acetylcysteine, which provides complete protection against toxicity if given within 10 hours of the overdose.
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This question is part of the following fields:
- Pharmacology
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Question 43
Correct
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A 70 yr. old man underwent temporary transvenous pacing. While in the coronary care unit he developed pre-syncope. His pulse rate was 30 bpm. His ECG showed pacing spikes which were not related to QRS complexes. What is the most appropriate action that can be taken?
Your Answer: Increase the pacing voltage to a maximum
Explanation:Pacemaker spikes on the ECG indicate that pacemaker is functioning. The most probable cause for this presentation is the change of the position of the tip of the pacing wire. Increasing the voltage will solve the problem. If it works, repositioning of the pacing wire should be done.
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This question is part of the following fields:
- Cardiology
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Question 44
Incorrect
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A 65-year-old real estate broker presents with a tremor. Which one of the following features would suggest a diagnosis of essential tremor rather than Parkinson's disease?
Your Answer: Tremor is worse following alcohol
Correct Answer: Tremor is worse when the arms are outstretched
Explanation:Difficulty in initiating movement (bradykinesia), postural instability and unilateral symptoms (initially) are typical of Parkinson’s. Essential tremor symptoms are usually worse if arms are outstretched and eased by rest and alcohol.
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This question is part of the following fields:
- Neurology
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Question 45
Incorrect
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A 30-year-old female diagnosed with rapidly progressive glomerulonephritis complains of pain and redness in the right eye. Which part of the eye is causing these symptoms in this case?
Your Answer: Iris
Correct Answer: Sclera
Explanation:Rheumatoid Scleritis is a painful inflammatory condition of the sclera in patients with rheumatoid arthritis. It might be diffuse, nodular, or necrotizing in nature. This occurs mostly in the sixth decade of life and mostly when the rheumatoid disease is in remission. Sclera is the first ocular manifestation in a patient of rheumatoid arthritis. This inflammation might later spread to the adjacent ocular structures like the cornea, causing keratitis, the uveal tract causing uveitis and the lens causing cataracts.
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This question is part of the following fields:
- Ophthalmology
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Question 46
Correct
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Which of the following symptoms are more indicative of mania than hypomania?
Your Answer: Delusions of grandeur
Explanation:The delusion of grandeur is more indicative of mania than hypomania.
While criteria (e.g. ICD-10, DSM-5) vary regarding the diagnosis between hypomania and mania, the consistent difference between mania and hypomania is the presence of psychotic symptoms.Hypomania vs. mania:
The presence of psychotic symptoms such as delusions of grandeur
auditory hallucinations point towards mania rather than hypomania/The following symptoms are common to both hypomania and mania
Mood:
Predominately elevated
IrritableSpeech and thought:
Pressured
Flight of ideas
Poor attentionBehaviour
Insomnia
Loss of inhibitions: sexual promiscuity, overspending, risk-taking
increased appetite -
This question is part of the following fields:
- Psychiatry
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Question 47
Incorrect
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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: iv Reteplase
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.
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This question is part of the following fields:
- Cardiology
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Question 48
Incorrect
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A 73-year-old female is being reviewed in the osteoporosis clinic. She had a fracture of her left hip 5 years ago and was started on alendronate. Following the development of persistent musculoskeletal pain, alendronate was replaced with risedronate, which was also stopped for similar reasons. Strontium ranelate was therefore started but was also stopped due to the development of deep vein thrombosis in the right leg. Her current T-score is -4.1. A decision is made to start a trial of denosumab. What is the mechanism of action of denosumab?
Your Answer: Monoclonal antibody against osteoprotegerin
Correct Answer: Inhibits RANK ligand, which in turn inhibits the maturation of osteoclasts
Explanation:The principal mechanism by which strontium inhibits osteoclast activity is by enhancing the secretion of osteoprotegerin (OPG) and by reducing the expression of the receptor activator of nuclear factor κB ligand (RANKL) in osteoblasts.
Osteoporosis is defined as low bone mineral density caused by altered bone microstructure ultimately predisposing patients to low-impact, fragility fractures.
Management:
Vitamin D and calcium supplementation should be offered to all women unless the clinician is confident they have adequate calcium intake and are vitamin D replete
Alendronate is the first-line treatment. Around 25% of patients cannot tolerate alendronate, usually due to upper gastrointestinal problems. These patients should be offered risedronate or etidronate.
Strontium ranelate and raloxifene are recommended if patients cannot tolerate bisphosphonates.
Other medications that are useful in the treatment of osteoporosis are denosumab, teriparatide, raloxifene, etc. -
This question is part of the following fields:
- Pharmacology
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Question 49
Incorrect
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A 27-year-old man with a history of asthma presents for review. He has recently been discharged from hospital following an acute exacerbation and reports generally poor control with a persistent night time cough and exertional wheeze. His current asthma therapy is: salbutamol inhaler 100mcg prn Clenil (beclomethasone dipropionate) inhaler 800mcg bd salmeterol 50mcg bd He has a history of missing appointments and requests a prescription with as few side-effects as possible. What is the most appropriate next step in management?
Your Answer:
Correct Answer: Leukotriene receptor antagonist
Explanation:The NICE 2019 guidelines states that in patients who are uncontrolled with a SABA (Salbutamol) and ICS (Beclomethasone), LTRA should be added.
If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS as maintenance therapy, offer a leukotriene receptor antagonist (LTRA) in addition to the ICS and review the response to treatment in 4 to 8 weeks. -
This question is part of the following fields:
- Respiratory
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Question 50
Incorrect
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Which of the following is suggestive of co-existence of mitral regurgitation and mitral stenosis?
Your Answer:
Correct Answer: Displaced apex beat
Explanation:Apex beat displacement is caused by mitral regurgitation and because it is not found in mitral stenosis, it is suggestive of mixed mitral disease. The other given responses occur in mitral stenosis.
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This question is part of the following fields:
- Cardiology
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SESSION STATS - PERFORMANCE PER SPECIALTY
