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Question 1
Incorrect
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Which of the statements is most accurate regarding the lung?
Your Answer: The right lung has nine bronchopulmonary segments
Correct Answer: The medial basal segment is absent in the left lower lobe
Explanation:The right and left lung anatomy are similar but asymmetrical. The right lung consists of three lobes: right upper lobe (RUL), right middle lobe (RML), and right lower lobe (RLL). The left lung consists of two lobes: right upper lobe (RUL) and right lower lobe (RLL). The right lobe is divided by an oblique and horizontal fissure, where the horizontal fissure divides the upper and middle lobe, and the oblique fissure divides the middle and lower lobes. In the left lobe there is only an oblique fissure that separates the upper and lower lobe.
The lobes further divide into segments which are associated with specific segmental bronchi. Segmental bronchi are the third-order branches off the second-order branches (lobar bronchi) that come off the main bronchus.
The right lung consists of ten segments. There are three segments in the RUL (apical, anterior and posterior), two in the RML (medial and lateral), and five in the RLL (superior, medial, anterior, lateral, and posterior). The oblique fissure separates the RUL from the RML, and the horizontal fissure separates the RLL from the RML and RUL.
There are eight to nine segments on the left depending on the division of the lobe. In general, there are four segments in the left upper lobe (anterior, apicoposterior, inferior and superior lingula) and four or five in the left lower lobe (lateral, anteromedial, superior and posterior). The medium sized airways offer the maximum airway resistance, not smaller ones.
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This question is part of the following fields:
- Respiratory
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Question 2
Incorrect
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A 20-year-old gentleman presents with drop foot following a sports injury. On examination there is weakness of ankle dorsiflexion and eversion, and weakness of extension of the big toe. He has some sensory loss restricted to the dorsum of his foot surrounding the base of his big toe. Other examination is within normal limits. Where is the most likely site of the lesion?
Your Answer: Common peroneal nerve at the ankle
Correct Answer: Common peroneal nerve at the head of the fibula
Explanation:Peroneal nerve injury is also known as foot drop. The common peroneal nerve supplies the ankle and toe extensor muscle groups as well as sensation over the dorsum of the foot; thus, there is also loss of sensation in these cases.
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This question is part of the following fields:
- Neurology
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Question 3
Correct
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Which one of the following medications is most useful for helping to prevent attacks of Meniere’s disease?
Your Answer: Betahistine
Explanation:Betahistine is a histamine analogue that has been the mainstay treatment drug for Meniere’s disease.
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This question is part of the following fields:
- Neurology
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Question 4
Incorrect
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Which one of the following features is most helpful in distinguishing beta thalassaemia trait from iron deficiency anaemia?
Your Answer: Target cells on peripheral blood film examination
Correct Answer: Haemoglobin A2 levels
Explanation:Elevated haemoglobin A2 level is seen in beta thalassaemia trait, whereas, it is typically low in iron deficiency anaemia unless the patient has received a recent blood transfusion.
Low mean corpuscular volume (MCV) and reduced haematocrit (Ht) are encountered in both conditions. Peripheral blood smear is grossly abnormal in both beta thalassaemia and severe iron deficiency anaemia, showing bizarre morphology, target cells, and a small number of nucleated red blood cells.
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This question is part of the following fields:
- Haematology & Oncology
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Question 5
Incorrect
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Choose the correct statement regarding endothelin:
Your Answer: It acts on target cells by stimulating guanylate cyclase
Correct Answer: Endothelin antagonists are useful in primary pulmonary hypertension
Explanation:Current guidelines recommend the use of ambrisentan, Bosentan (recommendation I, level of evidence A) and macitentan (I, B) in patients with PAH and WHO functional class II and III. In WHO functional class IV, the first-line drug is Epoprostenol and the recommendation for Endothelin receptor antagonists is weaker (IIb, C).
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This question is part of the following fields:
- Clinical Sciences
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Question 6
Incorrect
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A 45-year-old man with diabetes comes to the clinic for his annual review. He has had diabetes for eight years and he is also being treated for hypertension. He is on the following medications: metformin 500 mg tds, gliclazide 80 mg daily, atorvastatin 10 mg/d, Ramipril 10 mg/d and Bendroflumethiazide 2.5 mg/d. He is noted to be obese (130kg). Physical examination is otherwise unremarkable. Investigations reveal: HbA1c 8.1% (3.8-6.4), Fasting glucose 9 mmol/L (3.0-6.0), 24hr Urine free cortisol 354 mmol/d (<250), 9am Plasma ACTH 4 ng/dL (10-50). CT abdomen 3cm right adrenal mass. Which of the following is most likely to be the adrenal mass?
Your Answer: Ectopic CRF producing phaeochromocytoma
Correct Answer: Cortisol secreting adenoma
Explanation:The patient has Cushing syndrome suggested by the elevated 24hr urine free cortisol. Hence, the mass is most probably a cortisol secreting adenoma.
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This question is part of the following fields:
- Endocrinology
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Question 7
Incorrect
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A 74-year-old woman referred by her GP because of increasing weight loss, early satiety and increasing anorexia. She admits to 2 or 3 episodes of vomiting blood. The GP feels an epigastric mass. There is both a microcytic anaemia and abnormal liver enzymes. Her past history, which may be of importance, includes excess consumption of sherry and spirits, and a 30 pack-year smoking history. Which diagnosis fits best with this clinical picture?
Your Answer: Pancreatic carcinoma
Correct Answer: Gastric carcinoma
Explanation:With a clinical history of weight loss, smoking, drinking alcohol, and hematemesis, the most likely answer is gastric carcinoma (also a mass). Based on symptomatology alone this is more likely than gastric lymphoma, as she has many risk factors for adenocarcinoma and/or squamous cell carcinoma. Helicobacter gastritis would not likely present with the severity of symptoms, neither would benign gastric ulcers.
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This question is part of the following fields:
- Gastroenterology
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Question 8
Incorrect
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A 22-year-old, thin drama student presents with weakness and muscle cramps. She has a past medical history of reflux and bronchial asthma, for which she takes lansoprazole 30mg once daily, inhaled salbutamol PRN, and a once-daily inhaled corticosteroid. She reports feeling stressed lately as she has a leading role in a significant stage production due to open in one week. Her heart rate is 87 bpm, blood pressure 103/71mmHg, respiratory rate 13/min. Her blood results are: pH: 7.46 Na+: 138 mmol/L, K+: 2.8 mmol/L, Chloride: 93 mmol/L, Magnesium: 0.61 mmol/L, What is the most likely aetiology for her symptoms?
Your Answer: Gitelman Syndrome
Correct Answer: Bulimia
Explanation:The most probable diagnosis considering hypochloraemia and the mild metabolic alkalosis as well as the history of GERD (requiring a high dose of PPI to control) would be bulimia.
Other options:
Diuretic abuse tends to give a hypochloraemic acidosis.
Gitelman syndrome also fits the diagnosis but, it is very rare compared to bulimia.
Inhaled steroid use and stress would not be responsible for such marked electrolyte derangement.Other potential signs of bulimia nervosa would be parotid gland swelling and dental enamel erosion induced by regular vomiting.
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This question is part of the following fields:
- Psychiatry
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Question 9
Incorrect
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A 29 year-old new mother presented with a headache that was first noticed as she was picking up her 5 week-old baby. On admission, she was unable to tolerate the lights and complained of feeling sick. Fundoscopy showed bilateral papilledema, and she was complaining that she was unable to see on her left side. CT head showed a small right occipital bleed. Which of the following treatments is most appropriate?
Your Answer: Aneurysm coiling
Correct Answer: Heparin
Explanation:This patient has developed a venous sinus thrombosis peri-partum, resulting in her symptoms. Anticoagulation therapy including Heparin improves outcomes.
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This question is part of the following fields:
- Neurology
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Question 10
Incorrect
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A 28 year old female presents to the rheumatology clinic for review. She has a history of adult onset Still's disease and complains of joint pains and persistent skin rash despite undergoing treatment with methotrexate and etanercept. On examination, an erythematous macular rash and active synovitis is noted. CRP is high (95 mg/dl). Which of the following interventions would be most appropriate?
Your Answer: Tocilizumab
Correct Answer: Anakinra
Explanation:Adult onset Still’s disease (AOSD) is an uncommon systemic inflammatory disease on the clinical spectrum of autoinflammatory disorders. Its presentation and clinical course may result in several well-differentiated phenotypes: from a systemic and highly symptomatic pattern to a chronic articular pattern. Overproduction of numerous pro-inflammatory cytokines is observed in AOSD. Anakinra, a human interleukin (IL)-1R antagonist, has recently been approved in the treatment of AOSD. Denosumab is a RANK ligand inhibitor used in the treatment of osteoporosis. Mepolizumab is used in the treatment of severe asthma with elevated eosinophils. There is some evidence to support the use of tocilizumab, an anti-IL6 monoclonal antibody in adult onset Still’s, but there is stronger data favouring the use of tocilizumab in the treatment of rheumatoid arthritis. Rituximab is usually reserved for patients who are unresponsive to anakinra.
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This question is part of the following fields:
- Rheumatology
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Question 11
Incorrect
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A 24 year old female, 28 weeks pregnant presents to the clinic complaining of shortness of breath and right sided pleuritic chest pain. The doctor suspects pulmonary embolism. Which of the following statements is incorrect regarding the management of this case?
Your Answer: Chest x-ray should be performed
Correct Answer: Ventilation-perfusion scanning exposes the foetus to less radiation than computed tomographic pulmonary angiography
Explanation:V/Q scanning carries a slightly increased risk of childhood cancer compared with CTPA – 1/280,000 versus less than 1/1,000,000 – but carries a lower risk of maternal breast cancer. The rest of the options are true.
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This question is part of the following fields:
- Respiratory
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Question 12
Correct
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A 56-year-old female patient is complaining of a swollen upper limb after an insect bite. Although the bite site looks better, the gross oedema is still present. What is the most likely aetiology? Keep in mind that she has a history of breast cancer and radical mastectomy with axillary lymphadenectomy 10 years ago.
Your Answer: Lymphedema
Explanation:Lymphedema is most commonly the result of removal or damage to lymph nodes.
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This question is part of the following fields:
- Dermatology
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Question 13
Incorrect
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A 50-year-old patient was started on ezetimibe, for his cholesterol a few days back. Which among the following statements is true regarding ezetimibe?
Your Answer:
Correct Answer: Its principal action is to reduce intestinal cholesterol absorption
Explanation:Ezetimibe is a cholesterol-lowering agent that acts to prevent cholesterol absorption by directly inhibiting cholesterol receptors on enterocytes.
It does not affect the absorption of drugs (e.g. digoxin, thyroxine) or fat-soluble vitamins (A, D and K) as the anion-exchange resins do. It does not affect the cytochrome P450 enzyme system.
The increased risk of myositis associated with the statins is not seen with ezetimibe.
The most common adverse effects include headache, runny nose, and sore throat.
Less common reactions include body aches, back pain, chest pain, diarrhoea, joint pain, fatigue, and weakness. -
This question is part of the following fields:
- Pharmacology
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Question 14
Incorrect
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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:
Correct 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 15
Incorrect
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Which of the following is most consistent with achondroplasia?
Your Answer:
Correct Answer: May be diagnosed radiologically at birth
Explanation:Achondroplasia is the most common type of short-limb disproportionate dwarfism. A single gene mapped to the short arm of chromosome 4 (band 4p16.3) is responsible for achondroplasia and is transmitted as an autosomal dominant trait. All people with achondroplasia have a short stature.
Characteristic features of achondroplasia include an average-size trunk, short arms and legs with particularly short upper arms and thighs, limited range of motion at the elbows, and an enlarged head (macrocephaly) with a prominent forehead. Fingers are typically short and the ring finger and middle finger may diverge, giving the hand a three-pronged (trident) appearance. People with achondroplasia are generally of normal intelligence.
Examination of the infant after birth shows increased front-to-back head size. There may be signs of hydrocephalus. It may be diagnosed radiographically at birth, or becomes obvious within the first year with disparity between a large skull, normal trunk length and short limbs. -
This question is part of the following fields:
- Endocrinology
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Question 16
Incorrect
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A 60-year-old gentleman is found dead in his apartment. He was known to be suffering from primary systemic amyloidosis. What is the most probable cause for his death?
Your Answer:
Correct Answer: Cardiac involvement
Explanation:Primary amyloidosis is characterised by abnormal protein build-up in the tissues and organ such as the heart, liver, spleen, kidneys, skin, ligaments, and nerves. However, the most common cause of death in patients with primary amyloidosis is heart failure.
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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 48-year-old male with a history of bipolar disorder presents with acute confusion. In-transit to hospital he had a generalized seizure which terminated spontaneously after around 30 seconds. On arrival to the emergency department, his GCS is 14/15 and he is noted to have a coarse tremor. Suspecting a diagnosis of lithium toxicity, intravenous access is obtained, a blood sample was drawn for investigations and a saline infusion is started. The blood investigations revealed: Lithium level: 4.2 mmol/L, Na+: 136 mmol/L, K+: 4.6 mmol/L, Urea: 8.1 mmol/L, Creatinine: 99 µmol/L, Bicarbonate: 18 mmol/L, What is the most appropriate management for the patient?
Your Answer:
Correct Answer: Arrange haemodialysis
Explanation:The presentation of the patient is typical of chronic lithium toxicity (due to the presence of mainly neurological manifestations). Additional to the blood investigations mentioned, urine analysis, electrolyte levels, and renal function should also be performed. A low urine Anion gap and a low urine specific gravity are highly suggestive of lithium toxicity.
ECG obtained in this patient is likely to show: nonspecific, diffuse ST segment depression with T wave inversion.
Acute lithium toxicity presents with more GI manifestations while, the clinical features of chronic lithium toxicity are mainly neurological and can include:
Coarse tremors (fine tremors are seen in therapeutic levels), hyperreflexia, acute confusion, seizures, and coma.
The management of lithium toxicity is as follows:
Immediate GI decontamination with gastric lavage (in case of acute intoxication)
Saline Administrations: the goal of saline administration is to restore GFR, normalize urine output and enhance lithium clearance.
Haemodialysis remains the mainstay treatment for lithium toxicity as lithium is readily dialyzed because of water solubility, low volume of distribution, and lack of protein binding.
The Extracorporeal Treatments in Poisoning Workgroup (EXTRIP Workgroup) recommendations for dialysis (extracorporeal treatment) in lithium toxicity include:
• Impaired kidney function and lithium levels > 4.0 mEq/L
• Decreased consciousness, seizures, or life-threatening dysrhythmias, regardless of lithium levels
• Levels are > 5.0 mEq/L, significant confusion is noted, or the expected time to reduce levels to < 1.0 mEq/L is more than 36 hours
As post-dialysis rebound elevations in lithium levels have been documented, continuous veno-venous hemofiltration (CVVH) has been advocated. -
This question is part of the following fields:
- Pharmacology
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Question 18
Incorrect
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A 36-year-old lady presents to the emergency department with right upper quadrant pain. She has also noticed that her skin seems slightly yellower over the last week or so and you notice a yellow tinge to her sclera. On further questioning, she complains of itching of her arms. Her only past medical history of note includes ulcerative colitis for which she takes mesalazine. Given her presentation, what is the best investigation to diagnose the most likely underlying condition?
Your Answer:
Correct Answer: ERCP (endoscopic retrograde cholangiopancreatography)
Explanation:With biliary obstructive symptoms in a patient with ulcerative colitis, one should immediately think of primary sclerosing cholangitis (PSC). PSC is characterized by inflammation and fibrosis of the intrahepatic and extrahepatic ducts. The best diagnostic test for PSC is ERCP. ANCA antibiotics may be positive, but not the best test to DIAGNOSE THE CONDITION. The same can be said of serum transaminase levels– they will be abnormal but nonspecific. While a liver ultrasound may be helpful, it is not the best test. Liver biopsy would be used to stage the PSC later.
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This question is part of the following fields:
- Gastroenterology
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Question 19
Incorrect
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A 75 yr. old male with rheumatoid arthritis underwent a colectomy 2 days ago for colon cancer. He was put on a prophylactic dose of low molecular weight heparin post operatively as well as prednisolone. Now he complains of central chest pain and his ECG revealed an acute ST elevation myocardial infarction. He was given aspirin and oxygen as the initial treatment. Which of the following is the most appropriate management for this patient?
Your Answer:
Correct Answer: IV diamorphine + arrange percutaneous coronary intervention
Explanation:There is a high risk of bleeding due to recent surgery and heparin. So thrombolysis is not an option. The most appropriate management is percutaneous coronary intervention.
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This question is part of the following fields:
- Cardiology
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Question 20
Incorrect
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A 60-year-old man with type 1 diabetes is brought to the clinic with his wife. He is limping and his wife noticed that his ankle was abnormally-shaped after he stepped out of the shower. Examination of his right ankle reveals a painless warm swollen joint. There is crepitus and what appears to be palpable bone debris. X-ray reveals gross joint destruction and apparent dislocation. Joint aspiration fluid shows no microbes. Investigations: His CRP and white count are of normal values. Historical review of HB A1c reveals that it has rarely been below 9%. What is the most likely diagnosis?
Your Answer:
Correct Answer: Charcot’s ankle
Explanation:Charcot arthropathy is a progressive condition of the musculoskeletal system that is characterized by joint dislocations, pathologic fractures, and debilitating deformities. It results in progressive destruction of bone and soft tissues at weight-bearing joints. In its most severe form, it may cause significant disruption of the bony architecture.
Charcot arthropathy can occur at any joint; however, it occurs most commonly in the lower extremity, at the foot and ankle. Diabetes is now considered to be the most common aetiology of Charcot arthropathy. -
This question is part of the following fields:
- Endocrinology
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Question 21
Incorrect
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A 50-year-old man is referred with impotence. He has a history of angina, hypertension and type 2 diabetes. Which one of the following drugs that he takes is a contraindication to him being able to receive sildenafil?
Your Answer:
Correct Answer: Isosorbide mononitrate
Explanation:Sildenafil administration to patients who are using organic nitrates, either regularly and/or intermittently, in any form is contraindicated.
Organic nitrates and nitric oxide (NO) donors exert their therapeutic effects on blood pressure and vascular smooth muscle by the same mechanism as endogenous NO via increasing cGMP concentrations. -
This question is part of the following fields:
- Endocrinology
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Question 22
Incorrect
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Which of the following stimulates the secretion of gastrin?
Your Answer:
Correct Answer: Amino acids
Explanation:Gastrin is released from G cells in the antrum of the stomach after a meal. It stimulates parietal cells to release HCl. Gastrin is stimulated by a number of things: antrum distention, vagal stimulation, peptides (especially amino acids) in the stomach, hypercalcemia. Gastrin release is inhibited by acid, SST, GIP, VIP, secretin, glucagon, and calcitonin.
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This question is part of the following fields:
- Gastroenterology
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Question 23
Incorrect
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A 34 year old female presents to the clinic with skin tightness. On examination she has sclerodactyly, thickened skin of the shoulders and bi-basal crepitations. Her HRCT chest shows ground glass changes. Raynaud phenomenon is suspected and she is started on a monthly dose of IV cyclophosphamide (1 gm/month) for 6 months and a daily dose of 10 mg of oral prednisolone. However, she returned over a period of few weeks after developing exertional dyspnoea, pedal oedema and feeling unwell. On examination, JVP is raised, there is marked pedal oedema and bi basal crepitations on chest auscultation. Urine dipstick shows haematuria (++) and proteinuria (++). What in your opinion is the most likely cause of her deteriorating renal function?
Your Answer:
Correct Answer: Scleroderma renal crisis
Explanation:Scleroderma renal crisis (SRC) is a rare but severe complication in patients with systemic sclerosis (SSc). It is characterized by malignant hypertension, microangiopathic haemolytic anaemia with schistocytes and oligo/anuric acute renal failure. SRC occurs in 5% of patients with systemic scleroderma, particularly in the first years of disease evolution and in the diffuse form. Patients may develop symptoms of fluid overload.
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This question is part of the following fields:
- Rheumatology
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Question 24
Incorrect
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An 82-year-old man is reviewed in the haematology clinic. He has been referred due to weight loss, lethargy, and a significantly elevated IgM level. His recent blood results show: Hb: 13.8 g/dL, Plts: 127 x 10^9/L, ESR: 45 mm/hr, IgM: 2150 mg/dL (50-330 mg/dL). Given the probable diagnosis, which one of the following complications is he most likely to develop?
Your Answer:
Correct Answer: Hyperviscosity syndrome
Explanation:The patient is most likely suffering from Waldenström’s macroglobulinemia in which IgM paraproteinemia is found. Hyperviscosity syndrome can occur in the patients accounting for 10–15% of the cases.
Waldenström’s macroglobulinemia (also called lymphoplasmacytic lymphoma) is an uncommon type of non-Hodgkin lymphoma seen in older people. It is a lymphoplasmacytoid malignancy characterised by the secretion of a monoclonal IgM paraprotein. Its features include monoclonal IgM paraproteinemia; hyperviscosity syndrome leading to bilateral central retinal vein occlusion (CRVO) and hence, visual disturbances; weight loss and lethargy; hepatosplenomegaly and lymphadenopathy; and cryoglobulinemia. It is not, however, associated with bone pain.
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This question is part of the following fields:
- Haematology & Oncology
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Question 25
Incorrect
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A 45-year-old woman with a history of hypothyroidism, presents with ptosis and muscle weakness. She's noticed that her muscle weakness becomes worse towards the end of the day. Clinical examination reveals fatigable ptosis and proximal limb weakness. Myasthenia gravis is suspected. Which receptor is implicated in the pathophysiology of this condition?
Your Answer:
Correct Answer: Nicotinic acetylcholine receptors
Explanation:Myasthenia gravis (MG) is an organ-specific autoimmune disease caused by an antibody-mediated assault on the muscle nicotinic acetylcholine receptor (AChR) at the neuromuscular junction. Binding of antibodies to the AChR leads to loss of functional AChRs and impairs the neuromuscular signal transmission, resulting in muscular weakness.
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This question is part of the following fields:
- Clinical Sciences
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Question 26
Incorrect
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A 55-year-old man with a three-year history of type 2 diabetes comes to the clinic for review. He is currently managed with metformin 1 g BD and feels that his home blood glucose monitoring has deteriorated over the past few months. There is a history of hypertension and dyslipidaemia for which he takes Ramipril 10 mg daily and atorvastatin 20 mg. On examination, his BP is 155/82 mmHg, his pulse is 71 and regular. His chest is clear. His BMI is 32. Investigations show: Haemoglobin 12.9 g/dl (13.5 – 17.7), White cell count 5.0 x109/l (4 – 11), Platelets 180 x109/l (150 – 400), Sodium 140 mmol/l (135 – 146), Potassium 5.0 mmol/l (3.5 – 5), Creatinine 123 mmol/l (79 – 118), HbA1c 8.0% (<7.0). He would like to start sitagliptin. Which of the following adverse effects would you warn him about?
Your Answer:
Correct Answer: Pancreatitis
Explanation:Sitagliptin-induced pancreatitis can occur at any time after the initiation of therapy, even after several years. Patients taking sitagliptin who present with signs and symptoms of mild or severe pancreatitis should immediately discontinue sitagliptin and use an alternate medication regimen for control of type 2 diabetes.
In response to pancreatitis reported in post-marketing surveillance through the Adverse Event Reporting System (AERS), the FDA has issued revised prescribing information for sitagliptin stating that cases of acute pancreatitis have been reported with use, to monitor closely for signs and symptoms of pancreatitis, and to use sitagliptin with caution in patients with a history of pancreatitis. -
This question is part of the following fields:
- Endocrinology
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Question 27
Incorrect
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A 33-year-old man with a known history of alcoholic liver disease is reviewed following a suspected oesophageal variceal haemorrhage. He has been resuscitated and intravenous terlipressin has been given. His blood pressure is now 104/60 mmHg and his pulse is 84/min. What is the most appropriate intervention?
Your Answer:
Correct Answer: Endoscopic variceal band ligation
Explanation:The correct course of action after giving terlipressin and resuscitating with IV fluids is to perform an EGD with endoscopic variceal band ligation. According to NICE: ‘Offer endoscopic variceal band ligation for the primary prevention of bleeding for people with cirrhosis who have medium to large oesophageal varices. There are serious complications of a TIPS procedure and it is not the first line treatment.
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This question is part of the following fields:
- Gastroenterology
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Question 28
Incorrect
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A 16-year-old girl comes to clinic complaining of primary amenorrhoea, despite having developed secondary sexual characteristics at 11 years of age. On examination, she has well-developed breasts and small bilateral groin swellings. What is the most likely diagnosis?
Your Answer:
Correct Answer: Complete androgen insensitivity syndrome
Explanation:Androgen insensitivity syndrome (AIS), previously referred to as testicular feminization, is an X-linked disorder in which the patients are genotypically male (possessing and X and Y chromosome) and phenotypically female. This disorder is rare, with reported incidences from 1 in 20,000 to 1 in 60,000 live male births, and is the result of a missing gene on the X chromosome that is responsible for the cytoplasmic or nuclear testosterone receptor. In its absence, the gonad, which is a testis, produces normal amounts of testosterone; however, the end tissues are unable to respond due to the deficient receptors leading to the external genitalia developing in a female fashion. Anti-mullerian hormone, which is produced by the testis, is normal in these patients, leading to regression of the Mullerian duct. Wolffian duct development, which depends on testosterone, does not occur as the ducts lack the receptors.
The cumulative effect is a genotypic male with normal external female genitalia (without pubic or axillary hair), no menses, normal breast development, short or absent vagina, no internal sex organs, and the presence of testis. Frequently, these patients have bilateral inguinal hernias in childhood, and their presence should arouse suspicion of the diagnosis. -
This question is part of the following fields:
- Endocrinology
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Question 29
Incorrect
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A 43-year-old man is reviewed in the gastroenterology clinic. He has had troublesome dyspepsia for the past six months which has not settled with proton pump inhibitor (PPI) therapy. During the review of his systems he also reports passing 6-7 watery stools per day. An OGD 3 weeks ago showed gastric erosions and ulcers. Which one of the following investigations is most likely to be diagnostic?
Your Answer:
Correct Answer: Fasting gastrin
Explanation:This case describes Zollinger-Ellison syndrome. It is characterized by refractory peptic ulcer disease, often multiple ulcers. This is typically caused by secretion of gastrin from a gastrinoma, a neuroendocrine tumour. The most common site of ulceration is the duodenum. A symptom of a pancreatic gastrinoma may be steatorrhea from the hypersecretion of gastrin. Serum gastrin levels > 1000 and a pH < 2 are diagnostic of pancreatic gastrinoma. None of the other answer choices are a better answer than this. CT abdomen may potentially show a tumour, but this is not diagnostic for type.
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This question is part of the following fields:
- Gastroenterology
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Question 30
Incorrect
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A literature review of a number of studies was conducted to assess the potential efficacy of a new drug, which may reduce the chance of patients with chronic kidney disease (CKD) developing gout. In one study 120 out of 1,200 patients receiving the new drug developed gout. The total number of the patients were 2,000 and the remaining 800 individuals received a placebo. From the patients that had received the placebo, 200 developed gout. What is the absolute risk reduction of developing gout?
Your Answer:
Correct Answer: 15%
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) = 0.15 = 15%
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This question is part of the following fields:
- Clinical Sciences
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