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Question 1
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A 64 year old female presents with sudden onset pain, swelling and stiffness in her right knee. Her medical history is significant for osteoarthritis affecting her hand joints and diet controlled diabetes mellitus. On examination, the right knee is swollen, erythematous and tender. Which of the following tests would be most useful in the diagnosis of this case?
Your Answer: Aspiration and examination of the synovial fluid
Explanation:Arthrocentesis should usually be done when there is a suspicion of pseudogout or septic arthritis as in this case which leads to an early diagnosis and prompt treatment. Polarized microscopy demonstrates weakly positively birefringent rhomboid crystals which are blue when parallel to light and yellow when perpendicular to light. Elevated serum uric acid levels that cause gout are usually found after large consumption of alcohol or meat, or post surgery. Autoimmune diseases like SLE, RA etc require an autoimmune screen.
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This question is part of the following fields:
- Rheumatology
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Question 2
Incorrect
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A 28 year old woman presents with lethargy, arthralgia and cough. Over the past three weeks she has also developed painful erythematous nodules on both shins. Respiratory examination is normal. A chest x-ray is performed which is reported as follows: Bilateral mediastinal nodal enlargement. No evidence of lung parenchymal disease. Normal cardiac size. Given the likely diagnosis, what would be the most appropriate course of action?
Your Answer: Oral corticosteroids
Correct Answer: Observation
Explanation:Sarcoidosis is an inflammatory disease that affects one or more organs but most commonly affects the lungs and lymph glands. The inflammation may change the normal structure and possibly the function of the affected organ(s).
The presentation in sarcoidosis varies with the extent and severity of organ involvement, as follows:
Asymptomatic (incidentally detected on chest imaging): Approximately 5% of cases.
Systemic complaints (fever, anorexia): 45% of cases
Pulmonary complaints (dyspnoea on exertion, cough, chest pain, and haemoptysis [rare]): 50% of casesLöfgren syndrome (fever, bilateral hilar lymphadenopathy, and polyarthralgias): Common in Scandinavian patients, but uncommon in African-American and Japanese patients.
Dermatologic manifestations may include the following:
– Erythema nodosum
– A lower-extremity panniculitis with painful, erythematous nodules (often with Löfgren syndrome)
– Lupus pernio (the most specific associated cutaneous lesion)
– Violaceous rash on the cheeks or nose (common)
– Maculopapular plaques (uncommon)Staging of sarcoidosis is as follows:
Stage 0: Normal chest radiographic findings
Stage I: Bilateral hilar lymphadenopathy
Stage II: Bilateral hilar lymphadenopathy and infiltrates
Stage III: Infiltrates alone
Stage IV: FibrosisNonsteroidal anti-inflammatory drugs (NSAIDs) are indicated for the treatment of arthralgias and other rheumatic complaints. Patients with stage I sarcoidosis often require only occasional treatment with NSAIDs.
Treatment in patients with pulmonary involvement is as follows:
Asymptomatic patients may not require treatment
In patients with minimal symptoms, serial re-evaluation is prudent
Treatment is indicated for patients with significant respiratory symptoms
Corticosteroids can produce small improvements in the functional vital capacity and in the radiographic appearance in patients with more severe stage II and III disease.This patient has Stage 1 Sarcoidosis so observation is the most appropriate action.
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This question is part of the following fields:
- Respiratory
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Question 3
Correct
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A 35-year-old woman is referred to the acute medical unit with a 5 day history of polyarthritis and a low-grade fever. Examination reveals shin lesions which the patient states are painful. Chest x-ray shows a bulky mediastinum. What is the most appropriate diagnosis?
Your Answer: Lofgren's syndrome
Explanation:Lofgren’s syndrome is an acute form of sarcoidosis characterized by erythema nodosum, bilateral hilar lymphadenopathy (BHL), and polyarthralgia or polyarthritis. Other symptoms include anterior uveitis, fever, ankle periarthritis, and pulmonary involvement.
Löfgren syndrome is usually an acute disease with an excellent prognosis, typically resolving spontaneously from 6-8 weeks to up to 2 years after onset. Pulmonologists, ophthalmologists, and rheumatologists often define this syndrome differently, describing varying combinations of arthritis, arthralgia, uveitis, erythema nodosum, hilar adenopathy, and/or other clinical findings.
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This question is part of the following fields:
- Respiratory
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Question 4
Correct
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A 32 year old primigravida, with a history of pulmonary hypertension, presents to the clinic at 36 weeks gestation with worsening shortness of breath. Which of the following is the most accurate statements regarding her condition?
Your Answer: Risk of maternal mortality in patients with pulmonary hypertension is 30%
Explanation:Historically, high rates of maternal and fetal death have been reported for pregnant women with pulmonary hypertension (30–56% and 11–28%, respectively). The causes of poor maternal outcomes are varied and include risk of death from right heart failure and stroke from intracardiac shunting. Furthermore, there is a high peri-/post-partum risk due to haemodynamic stress, bleeding complications and the use of general anaesthesia, which can all lead to right heart failure.
The most common risk to the foetus is death, with premature birth and growth retardation being reported in successfully delivered children.
CXR is not contraindicated in pregnancy. D-dimers are not used as a diagnostic aid as they are almost always elevated in pregnancy. Nifedipine, although contraindicated in pregnant women may be used judiciously if the need arises. -
This question is part of the following fields:
- Respiratory
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Question 5
Correct
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A 43 year old man with hemochromatosis presents with a painful and swollen right knee. X-ray shows extensive chondrocalcinosis but no fracture. Given the most likely diagnosis, which of the following would be present in the joint fluid aspirate?
Your Answer: Positively birefringent rhomboid-shaped crystals
Explanation:Pseudogout is a paroxysmal joint inflammation due to calcium pyrophosphate crystal deposition (calcium pyrophosphate dihydrate). Arthrocentesis should be performed, especially in acute cases.
Polarized light microscopy: detection of rhomboid-shaped, positively birefringent CPPD crystals.
Synovial fluid findings: 10,000-50,000 WBCs/μL with > 90% neutrophils.
X-ray findings: cartilage calcification of the affected joint (chondrocalcinosis).
Fibrocartilage (meniscus, annulus fibrosus of intervertebral disc) and hyaline cartilage (joint cartilage) may be affected. -
This question is part of the following fields:
- Rheumatology
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Question 6
Incorrect
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A 65-year-old gentleman with a history of chronic renal failure due to diabetes comes to the clinic for review. He has reported increasing bone and muscle aches over the past few weeks. Medications include ramipril, amlodipine and indapamide for blood pressure control, atorvastatin for lipid management, and insulin for control of his blood sugar. On examination his BP is 148/80 mmHg, his pulse is 79 and regular. His BMI is 28. Investigations show: Haemoglobin 10.7 g/dl (13.5-17.7) White cell count 8.2 x 10(9)/l (4-11) Platelets 202 x 10(9)/l (150-400) Serum sodium 140 mmol/l (135-146) Serum potassium 5.0 mmol/l (3.5-5) Creatinine 192 μmol/l (79-118) Calcium 2.18 mmol/l (2.2-2.67) Phosphate 1.9 mmol/l (0.7-1.5) He has tried following a low phosphate diet. Which of the following would be the next most appropriate step in controlling his phosphate levels?
Your Answer: Aluminium hydroxide
Correct Answer: Sevelamer
Explanation:Sevelamer is a phosphate-binding drug that can lower raised serum phosphate levels in chronic kidney disease. Because of its aluminium-related side-effects, aluminium hydroxide is no longer the drug of choice.
The other options are calcium-containing salts that may increase risks of tissue calcification. -
This question is part of the following fields:
- Nephrology
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Question 7
Incorrect
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A 23-year-old pregnant woman presents with glycosuria. What is the most likely mechanism?
Your Answer: Increased glucagon secretion
Correct Answer: Reduced renal reabsorption
Explanation:Throughout pregnancy the tubular reabsorption of glucose is less effective than in the non-pregnant state, this leads to glycosuria.
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This question is part of the following fields:
- Nephrology
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Question 8
Incorrect
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What kind of receptor is the nitric oxide receptor?
Your Answer: Tyrosine kinase receptor
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 9
Incorrect
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A 13-year-old girl is brought by her mother to the A&E with breathlessness, fatigue and palpitations. Anamnesis does not reveal any syncope or chest pain in the past. on the other hand, these symptoms were present intermittently for a year. Clinical examination reveals a pan-systolic murmur associated with giant V waves in the jugular venous pulse. Chest auscultation and resting ECG are normal. 24 hour ECG tape shows a short burst of supraventricular tachycardia. What is the most probable diagnosis?
Your Answer: Atrial septal defect
Correct Answer: Ebstein's anomaly
Explanation:Ebstein’s anomaly is characterised by apical displacement and adherence of the septal and posterior leaflets of the tricuspid valve to the underlying myocardium, thereby displacing the functional tricuspid orifice apically and dividing the right ventricle into two portions. The main haemodynamic abnormality leading to symptoms is tricuspid valve incompetence. The clinical spectrum is broad; patients may be asymptomatic or experience right-sided heart failure, cyanosis, arrhythmias and sudden cardiac death (SCD). Many Ebstein’s anomaly patients have an interatrial communication (secundum atrial septal defect (ASD II) or patent foramen ovale). Other structural anomalies may also be present, including a bicuspid aortic valve (BAV), ventricular septal defect (VSD), and pulmonary stenosis. The morphology of the tricuspid valve in Ebstein anomaly, and consequently the clinical presentation, is highly variable. The tricuspid valve leaflets demonstrate variable degrees of failed delamination (separation of the valve tissue from the myocardium) with fibrous attachments to the right ventricular endocardium.
The displacement of annular attachments of septal and posterior (inferior) leaflets into the right ventricle toward the apex and right ventricular outflow tract is the hallmark finding of Ebstein anomaly. -
This question is part of the following fields:
- Clinical Sciences
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Question 10
Incorrect
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A 58-year-old lady was admitted to hospital with increasing thirst and generalised abdominal pain. She was diagnosed with breast carcinoma three years previously and treated with a radical mastectomy. Investigations showed: Serum corrected calcium 3.5 mmol/L (NR 2.2-2.6) Serum alkaline phosphatase 1100 IU/L Her serum calcium was still elevated following 4 litres of 0.9% saline intravenous infusion. Which of the following is the most appropriate next step?
Your Answer: Dexamethasone 8 mg
Correct Answer: Pamidronate 60 mg intravenously
Explanation:This case has hypercalcaemia most likely associated with the bony metastases from her pre-existing breast carcinoma. The most appropriate next step is to give Pamidronate 60mg intravenously, a bisphosphonate, to immediately inhibit bone resorption and formation.
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This question is part of the following fields:
- Nephrology
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Question 11
Incorrect
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A 24-year-old female presents with generalised irritation and erythematous skin after sunbathing on the beach. Which is the most appropriate immediate treatment for this patient?
Your Answer: Ice packs
Correct Answer: Emollient cream
Explanation:Sun burn reactions usually occur after individuals with a light skin tone have prolonged exposure to the sun. The usual symptoms are redness and itching of the skin. The best treatment plan would be further avoidance of sun exposure and the topical application of emollients. These are Ist degree burns and aggressive therapy is not required in such cases.
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This question is part of the following fields:
- Dermatology
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Question 12
Incorrect
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What is correct statement regarding pulsus alternans?
Your Answer: The pulse is irregular
Correct Answer: It is found in association with a third heart sound
Explanation:Pulsus alternans is the alternation of one strong and one weak beat without a change in the cycle length. It occurs most commonly in heart failure due to increased resistance to LV ejection, as occurs in hypertension, aortic stenosis, coronary atherosclerosis, and dilated cardiomyopathy. Pulsus alternans is usually associated with an S3 gallop, which is associated with a poor prognosis. It usually disappears with treatment of the heart failure.
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This question is part of the following fields:
- Cardiology
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Question 13
Incorrect
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A 46-year-old man presents with a swollen, red, and painful left calf. He does not have a history of any recent surgery or a long-haul flight. He is generally fit and well and takes no regular medication other than propranolol for migraine prophylaxis. There is also no history of venous thromboembolism (VTE) in his family. The patient is referred to the deep vein thrombosis (DVT) clinic where he is diagnosed with a proximal DVT in his left calf. Following the diagnosis, he is started on low-molecular-weight heparin (LMWH) whilst awaiting review by the warfarin clinic. Other than commencing warfarin, what further action, if any, is required?
Your Answer: Perform an echocardiogram
Correct Answer: Investigate for underlying malignancy + check antiphospholipid antibodies
Explanation:CXR, blood, and urine tests should be carried out initially to exclude an underlying malignancy. If these are normal, a CT scan of abdomen and pelvis should be arranged as the patient’s age is >40 years. Antiphospholipid antibodies should also be checked for the first unprovoked DVT/PE. There is no history, however, to support an inherited thrombophilia.
The National Institute for Health and Care Excellence (NICE) published guidelines in 2012 for the investigation and management of DVT. If a patient is suspected of having DVT, a two-level DVT Wells score should be used:
DVT likely: 2 points or more
DVT unlikely: 1 point or lessThis system of points is based on the following clinical features:
1. Active cancer (treatment ongoing, within six months, or palliative)—1
2. Paralysis, paresis, or recent plaster immobilisation of the lower extremities—1
3. Recently bedridden for three days or more, or major surgery within 12 weeks requiring general or regional anaesthesia—1
4. Localised tenderness along the distribution of the deep venous system—1
5. Entire leg swollen—1
6. Calf swelling at least three cms larger than the asymptomatic side—1
7. Pitting oedema confined to the symptomatic leg—1
8. Collateral superficial veins (non-varicose)—1
9. Previously documented DVT—1
10. An alternative diagnosis is at least as likely as DVT—2If two points or more—DVT is ‘likely’
If one point or less—DVT is ‘unlikely’Management
1. LMWH or fondaparinux should be given initially after a DVT is diagnosed.
2. A vitamin K antagonist such as warfarin should be given within 24 hours of the diagnosis.
3. LMWH or fondaparinux should be continued for at least five days or until the international normalised ratio (INR) is 2.0 or above for at least 24 hours. LMWH or fondaparinux is given at the same time as warfarin until the INR is in the therapeutic range.
4. Warfarin should be continued for at least three months. At three months, clinicians should assess the risks and benefits of extending the treatment.
5. Consider extending warfarin beyond three months for patients with unprovoked proximal DVT if their risk of VTE recurrence is high and there is no additional risk of major bleeding. This essentially means that if there is no obvious cause or provoking factor (surgery, trauma, significant immobility, etc.), it may be implied that the patient has a tendency to thrombose and should be given treatment longer than the normal of three months. In practice, most clinicians give six months of warfarin for patients with an unprovoked DVT/PE.
6. For patients with active cancer, LMWH should be used for six months.As both malignancy and thrombophilia are obvious risk factors for DVT, therefore, all patients with unprovoked DVT/PE who are not already known to have cancer should undergo the following investigations:
1. Physical examination (guided by the patient’s full history)
2. Chest X-ray
3. Blood tests (full blood count, serum calcium, and liver function tests) and urinalysis
4. Testing for antiphospholipid antibodies
5. Testing for hereditary thrombophilia in patients who have had unprovoked DVT/PE and have a first-degree relative who has a history of DVT/PE. -
This question is part of the following fields:
- Haematology & Oncology
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Question 14
Incorrect
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A 60-year-old woman presents to the oncology clinic with a general feeling of being unwell and temperature of 38.1°C. She is a known case of neuroendocrine cancer of the cervix, treated with carboplatin and etoposide. Her last treatment was eight days ago. Blood cultures are taken and she is started on neutropenic sepsis protocol. What will gram-staining of the blood cultures most likely show?
Your Answer: Gram-negative cocci
Correct Answer: Gram-positive cocci
Explanation:Gram-staining of the blood cultures of this patient will show gram-positive cocci. Gram-negative bacilli used to be the most common pathogen isolated in neutropenic sepsis, but currently, the most common pathogens are gram-positive organisms. Staphylococcus epidermidis is the most frequent causative agent, and following this are other staphylococci and streptococci species.
Neutropenic sepsis is a relatively common complication of cancer therapy—usually chemotherapy. It most commonly occurs 7-14 days after the treatment and is usually defined as a neutrophil count of <0.5 x 10^9/L in a patient undergoing anticancer treatment and who has either a temperature higher than 38°C or has other features consistent with clinically significant sepsis. Management approach includes starting empirical antibiotic therapy (piperacillin with tazobactam—Tazocin) immediately. Following this initial treatment, the patient is usually assessed by a specialist and risk-stratified to see if outpatient treatment may be possible. However, if the patient remains febrile and unwell after 48 hours, an alternative antibiotic such as meropenem is often prescribed with or without vancomycin. If patient is still not responding after 4-6 days, then an antifungal, such as amphotericin B, is started after carrying out investigations (e.g. HRCT and Aspergillus PCR) to determine the likelihood of systemic fungal infection.
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This question is part of the following fields:
- Haematology & Oncology
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Question 15
Incorrect
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A 28 yr. old male was admitted with palpitations and chest discomfort for the past 1 hour. On examination his pulse rate was 200 bpm and blood pressure was 80/50 mmHg. His ECG revealed narrow complex tachycardia with a heart rate of 200 bpm. Which of the following is the most appropriate management of this patient?
Your Answer: Amiodarone iv given centrally through a large vein
Correct Answer: Synchronised DC synchronised cardioversion
Explanation:Narrow complex tachycardia with hypotension is a medical emergency. Immediate synchronized cardioversion is the ideal management.
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This question is part of the following fields:
- Cardiology
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Question 16
Correct
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A 56-year-old male was admitted to the in-patient psychiatric unit last night. He is a poor historian, answering most questions minimally and stating he does not need to be here as he is deceased, and hospitals should be for living patients. What is the type of delusion in this patient and what is it commonly associated with?
Your Answer: Cotard syndrome and Major Depressive Disorder
Explanation:The most probable diagnosis of this patient is Cotard syndrome with major depressive disorder.
Cotard syndrome is a rare mental disorder where the affected patient believes that they (or in some cases just a part of their body) is either dead or non-existent. This delusion is often difficult to treat and can result in significant problems due to patients stopping eating or drinking as they deem it not necessary. Cotard syndrome is often associated with severe depression and psychotic disorders (like schizophrenia).
Other delusional syndromes:
– Othello syndrome is a delusional belief that a patients partner is committing infidelity despite no evidence of this. It can often result in violence and controlling behaviour.
– De Clerambault syndrome (otherwise known as erotomania), is where a patient believes that a person of higher social or professional standing is in love with them. Often this presents with people who believe celebrities are in love with them.
– Capgras syndrome is characterised by a person believing their friend or relative had been replaced by an exact double.
– Couvade syndrome is also known as ‘sympathetic pregnancy’. It affects fathers, particularly during the first and third trimesters of pregnancy, who suffer the somatic features of pregnancy.
– Ekbom syndrome is also known as delusional parasitosis and is the belief that they are infected with parasites or have ‘bugs’ under their skin. This can vary from the classic psychosis symptoms in narcotic use where the user can ‘see’ bugs crawling under their skin or can be a patient who believes that they are infested with snakes. -
This question is part of the following fields:
- Psychiatry
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Question 17
Correct
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Choose the hormone secreted only by the adrenal medulla:
Your Answer: Adrenaline
Explanation:The major endocrine functions of adrenal gland are to produce catecholamines and steroids. Catecholamine, synthesized by the adrenal medulla, is responsible for blood pressure and blood flow regulation whereas steroids produced by the cortex control energy and water homeostasis and immune responses. Glucocorticoids, a major group of adrenal steroids, have a stimulatory effect on catecholamine synthesis in the medulla.
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This question is part of the following fields:
- Clinical Sciences
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Question 18
Correct
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A patient has been diagnosed with multi-drug resistant tuberculosis and is currently bring treated with rifampicin, isoniazid, and pyrazinamide. He is commenced on streptomycin. Which among the following is the most likely neurological side-effect of streptomycin?
Your Answer: Vestibular damage
Explanation:Vestibular damage is a neurological side effect of streptomycin.
Streptomycin is an aminoglycoside bactericidal antibiotic. It is used in the treatment of tularaemia and resistant mycobacterial infections.
The most common neurological side-effect is vestibular damage leading to vertigo and vomiting.
Cochlear damage is less frequent and results in deafness.
Other side-effects include rashes, angioneurotic oedema, and nephrotoxicity. -
This question is part of the following fields:
- Pharmacology
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Question 19
Incorrect
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A 60-year-old lady has been admitted to the stroke ward following a sudden onset of dizziness and visual disturbances, which started yesterday morning. She initially thought she was just dehydrated, however, later realised she was unable to read her own shopping list. On the ward rounds, the consultant examines her and finds she is indeed unable to read. She is, however, able to write. When she writes a sentence it makes perfect sense, although she is again unable to read it out. She has no problems with her speech and is able to converse normally. She has no motor focal neurological deficit. The consultant asks you where the lesion is likely to be?
Your Answer: Wernicke's area
Correct Answer: Corpus callosum
Explanation:The patient presents with sudden onset of alexia (the inability to read) WITHOUT agraphia (inability to write) which is consistent with lesions of the corpus callosum where there is a disconnect syndrome and the patient’s language and visual centres are actually in tact, but are unable to communicate between hemispheres. In this case, the damage due to the stroke is most likely in the left visual cortex, leaving visual processing to the intact right hemisphere which unfortunately cannot communicate the information to the language centres (Broca and Wernicke’s) in the left hemisphere, hence the alexia. Alternatively, the speech and writing are unaffected as the language centres can still communicate with the primary motor cortex.
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This question is part of the following fields:
- Neurology
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Question 20
Incorrect
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An 18 year old prospective medical student is tested for hepatitis B. Her liver tests show alanine transaminase (ALT) 120 U/L and serology shows her to be positive for HBsAg, HBcAb and HBeAg, with a viral load of 105 genome equivalents/mL. A liver biopsy is reported as showing early fibrosis with evidence of moderate inflammation. Which of the following treatments should be offered?
Your Answer: Entecavir
Correct Answer: Interferon alfa 2b
Explanation:Interferon alfa alone, not interferon alfa and ribavirin, has been shown to achieve HBeAg seroconversion for patients with HBeAg-positive chronic hepatitis B.
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This question is part of the following fields:
- Gastroenterology
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