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Question 1
Correct
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A 10 month infant was brought in a drowsy condition with a 4 day history of vomiting and diarrhoea. His skin turgor was reduced and skin appeared mottled. Vital signs showed decreased BP, reduced capillary refill and a heart rate of 145/min. The best choice of treatment in this case would be?
Your Answer: IV fluid bolus over 20 minutes
Explanation:According to WHO, the treatment protocol in severely dehydrated children, is to infuse a bolus of isotonic crystalloid over 20-30 min at 30ml/kg to children less than 12 months of age followed by giving the remaining fluid over 5 hours for infants. Reference: World Health Organisation, the treatment of diarrhoea, a manual for physical and senior health workers.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 2
Incorrect
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Question 3
Correct
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A 20-year-old heroin addict is admitted following an overdose. She is drowsy and has a respiratory rate of 6 bpm. Which of the following arterial blood gas results (taken on room air) are most consistent with this?
Your Answer: pH = 7.31; pCO2 = 7.4 kPa; pO2 = 8.1 kPa
Explanation:In mild-to-moderate heroin overdoses, arterial blood gas (ABG) analysis reveals respiratory acidosis. In more severe overdoses, tissue hypoxia is common, leading to mixed respiratory and metabolic acidosis.
The normal range for PaCO2 is 35-45 mmHg (4.67 to 5.99 kPa). Respiratory acidosis can be acute or chronic. In acute respiratory acidosis, the PaCO2 is elevated above the upper limit of the reference range (i.e., >45 mm Hg) with an accompanying academia (i.e., pH < 7.35). In chronic respiratory acidosis, the PaCO2 is elevated above the upper limit of the reference range, with a normal or near-normal pH secondary to renal compensation and an elevated serum bicarbonate levels (i.e., >30 mEq/L).
Arterial blood gases with pH = 7.31; pCO2 = 7.4 kPa; pO2 = 8.1 kPa would indicate respiratory acidosis.
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This question is part of the following fields:
- Respiratory System
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Question 4
Incorrect
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A 54-year-old plumber presents with general deterioration. He drinks approximately 25 units of alcohol each week and is a smoker of five cigarettes daily. Examination reveals that he is jaundiced, has numerous spider naevi on his chest and he has a temperature of 37.2°C. Abdominal examination reveals hepatosplenomegaly.
Investigations reveal:
Bilirubin 100 micromol/L (1-22)
Alkaline phosphatase 310 iu/l (45 - 105)
ALT 198 iu/l (5 - 35)
AST 158 iu/l (1 - 31)
Albumin 25 g/L (37 - 49)
Hepatitis B virus surface antigen positive
Hepatitis B virus e antigen negative
Hepatitis B virus DNA awaited
What is the most likely diagnosis?Your Answer: Carcinoma of the pancreas
Correct Answer: Chronic hepatitis B infection
Explanation:The clinical scenario describes a man in liver failure. Given the serological results, he is most likely to have a chronic hepatitis B infection. In chronic hepatitis B infection, you have +HBsAg, +anti-HBc, (-)IgM antiHBc, and (-) anti-HBs. In acute hepatitis B infection, you have +HBsAg, +anti-HBc, +IgM anti-HBc, and negative anti-HBs. in immunity due to natural infection, you have negative HBsAg, +anti-HBc, and + anti-HBs. In immunity due to vaccination, you have negative HBsAg, negative anti-HBc, and positive anti-HBs. While he could have a superimposed hepatitis D infection on top of hepatitis B, there is no mention of hepatitis D serology, make this an incorrect answer. The other choices do not involve hepatitis serologies.
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This question is part of the following fields:
- Hepatobiliary System
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Question 5
Incorrect
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After examination, a 50-year-old woman was found to have fissuring of the skin of her hands. She has been complaining of fatigue and difficulty in climbing stairs for a couple of months. CXR shows pulmonary fibrosis. Which antibody would you expect to be positive?
Your Answer: Anti Jo 1
Correct Answer: Anti Scl 70
Explanation:Anti-Scl-70 antibodies are associated with pulmonary fibrosis and indicate a poor prognosis when positive. Also, they are a specific marker for the diffuse type of systemic sclerosis. Systemic scleroderma, also called diffuse scleroderma or systemic sclerosis, is an autoimmune disease of the connective tissue. It is characterized by thickening of the skin caused by accumulation of collagen, and by injuries to small arteries.
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This question is part of the following fields:
- Musculoskeletal System
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Question 6
Incorrect
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A 78-year-old male presents to the emergency department with shortness of breath that has developed gradually over the last 4 days. His symptoms include fever and cough productive of greenish sputum. Past history is notable for COPD for which he was once admitted to the ICU, 2 years back. He now takes nebulizers (ipratropium bromide) at home. The patient previously suffered from myocardial infarction 7 years ago. He also has Diabetes Mellitus type II controlled by lifestyle modification.
On examination, the following vitals are obtained.
BP : 159/92 mmHg
Pulse: 91/min (regular)
Temp: Febrile
On auscultation, there are scattered ronchi bilaterally and right sided basal crackles. Cardiovascular and abdominal examinations are unremarkable.
Lab findings are given below:
pH 7.31
pa(O2) 7.6 kPa
pa(CO2) 6.3 kPa
Bicarbonate 30 mmol/l
Sodium 136 mmol/l
Potassium 3.7 mmol/l
Urea 7.0 mmol/l
Creatinine 111 μmol/l
Haemoglobin 11.3 g/dl
Platelets 233 x 109 /l
Mean cell volume (MCV) 83 fl
White blood cells (WBC) 15.2 x 109 /l.
CXR shows an opacity obscuring the right heart border.
Which of the following interventions should be started immediately while managing this patient?Your Answer: Intravenous hydrocortisone
Correct Answer: Salbutamol and ipratropium bromide nebulisers
Explanation:Acute exacerbations of chronic obstructive pulmonary disease (COPD) are immediately treated with inhaled beta2 agonists and inhaled anticholinergics, followed by antibiotics (if indicated) and systemic corticosteroids. Methylxanthine therapy may be considered in patients who do not respond to other bronchodilators.
High flow oxygen would worsen his symptoms. Usually titrated oxygen (88 to 92 %) is given in such patients to avoid the risk of hyperoxic hypercarbia in which increasing oxygen saturation in a chronic carbon dioxide retainer can inadvertently lead to respiratory acidosis and death. -
This question is part of the following fields:
- Geriatric Medicine
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Question 7
Incorrect
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A 31-year-old woman presents with complaints concerning her bowel habits. She claims that occasionally she sees blood in her stools but she's more concerned about having chronic abdominal and pelvic pain, tenesmus and intermittent diarrhoea. What would be the most probable cause of her condition?
Your Answer: Irritable bowel disease
Correct Answer: Inflammatory bowel disease
Explanation:Inflammatory bowel disease (IBD) includes both ulcerative colitis and Crohn’s disease. Both of them present with similar symptomatology including diarrhoea, fatigue, abdominal and pelvic pain, blood in the stools, weight loss and occasional fever. In diverticulosis, symptoms are less profound with alternating diarrhoea and constipation.
UTIs might produce abdominal or pelvic pain but they do not interfere with the quality of the stools.
Adenomyosis affects the uterus and presents with mainly menstrual complaints. -
This question is part of the following fields:
- Gastrointestinal System
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Question 8
Incorrect
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A 35-year-old female, known case of antiphospholipid syndrome, arrives at the clinic due to a swollen and painful left leg. Doppler ultrasonography confirms the diagnosis of a deep vein thrombosis. She was previously diagnosed with DVT 4 months back and was on warfarin therapy (target INR 2-3) when it occurred. How should her anticoagulation be managed?
Your Answer: Life-long warfarin, target INR 2 - 3
Correct Answer: Life-long warfarin, increase target INR to 3 - 4
Explanation:If the INR in the range of 2-3 has still resulted in thrombosis, the target INR is increased to 3-4. However, because the risk of bleeding increases as the INR rises, the INR is closely monitored and adjustments are made as needed to maintain the INR within the target range.
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This question is part of the following fields:
- Musculoskeletal System
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Question 9
Incorrect
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A 55-year-old diabetic male presents with a feeling of generally being unwell. He also has a history of atrial fibrillation and epilepsy. His main complaint is a blue tinge to his vision. Which one of his medications is most likely to be responsible?
Your Answer: Phenytoin
Correct Answer: Sildenafil
Explanation:Blue tinge of vision/cyanopsia is caused due to the intake of sildenafil citrate.
Sildenafil citrate (Viagra) is the first oral drug to be widely approved for the treatment of erectile dysfunction.
It is a potent and selective inhibitor of type-V phosphodiesterase, the primary form of the enzyme found in human penile erectile tissue, thereby preventing the breakdown of cyclic guanosine monophosphate (cGMP), the intracellular second messenger of nitric oxide.Uses:
It is used for the treatment of erectile dysfunction, idiopathic pulmonary hypertension, premature ejaculation, high altitude illness, penile rehabilitation after radical prostatectomy, angina pectoris, and lower urinary tract symptoms.Adverse effects:
Mild headache, flushing, dyspepsia, cyanopsia, back pain, and myalgias – due to a high concentration of PDE11 enzyme in skeletal muscle, which shows significant cross-reactivity with the use of tadalafil.
It can also cause hypotension, dizziness, and rhinitis.Note: Xanthopsia (yellow-green vision) may occur secondary to treatment with digoxin.
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This question is part of the following fields:
- Pharmacology
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Question 10
Incorrect
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A 45-year-old male patient who was initially investigated for having an abdominal mass is diagnosed as having Burkitt lymphoma. He is due to start chemotherapy today.
Which one of the following should be given prior to his chemotherapy in order to reduce the risk of tumour lysis syndrome?Your Answer: Albumin
Correct Answer: Rasburicase
Explanation:Rasburicase should be given prior to chemotherapy in order to reduce the risk of tumour lysis syndrome (TLS). Rasburicase is a recombinant version of urate oxidase which is an enzyme that metabolizes uric acid to allantoin. Allantoin is 5-10 times more soluble than uric acid, hence, renal excretion is more effective.
TLS is a potentially fatal condition occurring as a complication during the treatment of high-grade lymphomas and leukaemias. It occurs from the simultaneous breakdown (lysis) of the tumour cells and subsequent release of chemicals into the bloodstream. This leads to hyperkalaemia and hyperphosphatemia in the presence of hyponatraemia. TLS can occur in the absence of chemotherapy, but it is usually triggered by the introduction of combination chemotherapy. Awareness of the condition is critical for its prophylactic management.
Burkitt lymphoma is a high-grade B-cell neoplasm. There are two major forms:
1. Endemic (African) form: typically involves maxilla or mandible.
2. Sporadic form: abdominal (e.g. ileocaecal) tumours are the most common form. More common in patients with HIV.Burkitt lymphoma is associated with the c-myc gene translocation, usually t(8;14). The Epstein-Barr virus (EBV) is strongly implicated in development of the African form of Burkitt lymphoma and to a lesser extent, the sporadic form.
Management of the lymphoma is with chemotherapy. This tends to produce a rapid response which may cause TLS.
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This question is part of the following fields:
- Haematology & Oncology
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Question 11
Correct
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A 53-year-old male underwent a partial gastrectomy 15 years ago for a complicated peptic ulcer. Which of the following elements may be deficient in this man?
Your Answer: Iron
Explanation:The proper gastric acidity is required to transform iron from ferric to ferrous state in order to be absorbable. Even partial gastrectomy may cause dumping syndrome. Malabsorption is rare.
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This question is part of the following fields:
- Gastrointestinal System
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Question 12
Incorrect
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Which of the following procedures does not require antibiotic prophylaxis?
Your Answer: Cholecystectomy
Correct Answer: Dental procedure for a patient with an atrial septal defect
Explanation:According to latest NICE guidelines, patients with isolated atrial septal defects do not require prophylactic antibiotics originally used in prevention of infective endocarditis in dental procedures.
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This question is part of the following fields:
- Infectious Diseases
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Question 13
Incorrect
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A 20-year-old girl is presented to the OPD with her mother. Her mother reports that she eats very large portions of food most of the time, but takes diet pills and remains depressed because she thinks she is overweight. However, on general physical examination, she appears to be very thin and her blood pressure is lower than normal. Investigations reveal that she has hypokalaemia. What is this girl most likely suffering from?
Your Answer: C1 esterase deficiency
Correct Answer: Bulimia nervosa
Explanation:Bulimia nervosa is a condition in which a person is involved in binge eating and then purging in an attempt to stay thin despite eating a lot of food. Frequent vomiting can cause electrolyte imbalance that manifests as hyperkalaemia and may lead to hypotension.
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This question is part of the following fields:
- Gastrointestinal System
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Question 14
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 15
Incorrect
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A 53-year-old woman presents with a painless lump in the left breast associated with nipple discharge. The skin over the lump has an orange peel skin appearance. According to the patient, the lump has increased in size, with time.
Diagnosis of breast cancer is strongly suspected. Which of the following would be most useful in monitoring the prognosis of breast cancer, in this case?Your Answer: Extent of skin involvement
Correct Answer: Lymph node metastases
Explanation:The prognosis of breast cancer depends chiefly on the extent of nodal metastases.
The breast cancer TNM staging system is the most common way that doctors use to stage breast cancer. TNM stands for Tumour, Node, Metastasis. The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero), which is non-invasive ductal carcinoma in situ (DCIS), and stages I through IV (1 through 4), which are used for invasive breast cancer.
Staging can be clinical or pathological. Clinical staging is based on the results of tests done before surgery, which may include physical examinations, mammogram, ultrasound, and MRI scans. Pathologic staging is based on what is found during surgery to remove breast tissue and lymph nodes. In general, pathological staging provides the most information to determine a patient’s prognosis.
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This question is part of the following fields:
- Haematology & Oncology
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Question 16
Incorrect
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Which of the following statements regarding restless leg syndrome is not true?
Your Answer: Affects approximately 5% of the general population
Correct Answer: It is three times as common in females
Explanation:In restless leg syndrome (RLS), males and females are thought to be equally affected. RLS is a syndrome of spontaneous, continuous lower limb movements that may be associated with paraesthesia. It is extremely common, affecting between 2-10% of the general population and a family history may be present.
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This question is part of the following fields:
- Nervous System
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Question 17
Incorrect
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A case-control study is being designed to look at the relationship between eczema and a new vaccine for yellow fever. What is the usual outcome measure in a case-control study?
Your Answer: Absolute risk increase
Correct Answer: Odds ratio
Explanation:A case-control study (also known as case-referent study) is a type of observational study in which two existing groups differing in outcome are identified and compared on the basis of some supposed causal attribute. Case-control studies are often used to identify factors that may contribute to a medical condition by comparing subjects who have that condition/disease (the cases) with patients who do not have the condition/disease but are otherwise similar (the controls).
An odds ratio (OR) is a statistic that quantifies the strength of the association between two events, A and B. The odds ratio is defined as the ratio of the odds of A in the presence of B and the odds of A in the absence of B or vice versa. -
This question is part of the following fields:
- Evidence Based Medicine
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Question 18
Incorrect
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A 64-year-old woman presents with malaise, ankle swelling and shortness of breath. Her blood pressure is 215/140 mmHg, she has +2 peripheral oedema and the skin over her fingers appears very tight. Fundoscopy discloses bilateral papilledema.
Â
Plasma creatinine concentration is 370 μmol/l, potassium is 4.9 mmol/l, haemoglobin is 8.9 g/dl and her platelet count is 90 x 109 /ml.
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What is the pathological hallmark of this condition?Your Answer: Stenosis of one or both main renal arteries
Correct Answer: Mucoid intimal thickening of vascular endothelium
Explanation:The history is suggestive of scleroderma renal crisis, where we would expect thrombotic microangiopathy process with vascular endothelium involvement manifesting as mucoid intimal thickening or onion skin effect.
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This question is part of the following fields:
- Renal System
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Question 19
Incorrect
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A 69-year-old woman is admitted with confusion. She's known to have a history of multiple myeloma. Blood exam reveals the following: Na+ = 147 mmol/l, K+ = 4.7 mmol/l, Urea = 14.2 mmol/l, Creatinine = 102 μmol/l, Adjusted calcium = 3.9 mmol/l. What is the single most appropriate management?
Your Answer: IV 0.45% saline
Correct Answer: IV 0.9% saline
Explanation:NICE guidelines on hypercalcemia recommend that maintaining good hydration equals drinking 3-4 L of fluid/day, provided there are no contraindications. A low calcium diet is not necessary because intestinal absorption of calcium is reduced. The patient should avoid any other drugs or vitamins that could worsen the hypercalcemia. Mobilization is encouraged and any symptoms of hypercalcemia should be reported.
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This question is part of the following fields:
- Fluids & Electrolytes
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Question 20
Incorrect
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A 73-year-old post-menopausal woman with an ESR of 72mm/hr, complains of pain on chewing and unilateral headache. Which additional treatment would you choose if she is already on oral steroids?
Your Answer: IV steroids
Correct Answer: Bisphosphonates
Explanation:The symptoms in concordance with the elevated ESR and the age of the patient should make you think of temporal arteritis. Temporal arteritis is treated with steroids which predispose the patient to develop osteopenia and finally osteoporosis. Its very important to take into account the sex and the age of the patient because osteoporosis is common in post-menopausal women. Bisphosphonates are protective towards osteoporosis and they should be administered next.
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This question is part of the following fields:
- Nervous System
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Question 21
Correct
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A 75-year-old woman presented with difficulty in climbing the stairs and difficulty in holding her head up, for the past 6 months. She didn't have any significant joint pain. Her creatinine phosphokinase level was very high and ESR was normal. Which of the following is the most probable diagnosis?
Your Answer: Polymyositis
Explanation:Polymyositis is an idiopathic inflammatory myopathy characterized by symmetrical, proximal muscle weakness, elevated skeletal muscle enzyme levels and characteristic electromyography (EMG) and muscle biopsy findings. Weak neck extensors cause difficulty holding the head up. Pain is not a significant symptom, which differentiates it from arthritic conditions. ESR is elevated in only 50% of patients with polymyositis.
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This question is part of the following fields:
- Musculoskeletal System
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Question 22
Incorrect
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A patient has an autosomal recessive disorder, which causes lysine, arginine, ornithine and cystine to appear in his urine. The treatment proposed is the combination of urinary alkalinisation with penicillamine. Choose the most likely type of renal calculus present.
Your Answer: Triple phosphate
Correct Answer: Cystine
Explanation:The presence in the urine of cystine, orthinine, arginine and lysine indicate a tubular reabsorption defect. This condition is a hereditary one, and stone formation is more common in homozygotes. The patient has no other abnormalities that could indicate stone formation.
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This question is part of the following fields:
- Renal System
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Question 23
Incorrect
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A 39-year-old accountant with long-standing gastro-oesophageal reflux disease is reviewed in clinic. He has recently switched from ranitidine to omeprazole.
What is the main benefit of omeprazole compared to ranitidine?Your Answer: More effective histamine receptor antagonism
Correct Answer: Irreversible blockade of H+/K+ ATPase
Explanation:Proton pump inhibitors can reduce gastric acid secretion by up to 99%. Acid production resumes following the normal renewal of gastric parietal cells.
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This question is part of the following fields:
- Pharmacology
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Question 24
Incorrect
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Question 25
Incorrect
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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: Chicken pox
Correct 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:
- The Skin
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Question 26
Incorrect
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A 9-year-old girl complains of perioral blisters and a burning sensation of her face. Some of the blisters are crusted and some are weeping. What is the most likely diagnosis?
Your Answer: Shingles
Correct Answer: Impetigo
Explanation:Impetigo appears more commonly on the face than other exposed areas like the limbs. Its blisters are clustered and may have a fluid discharge.
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This question is part of the following fields:
- The Skin
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Question 27
Incorrect
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A 50-year-old man is admitted with nausea and excessive drowsiness after taking an antihistamine tablet with grapefruit juice. Which of the following liver enzyme systems is affected by grapefruit juice causing the given side effect?
Your Answer: Glycine decarboxylase
Correct Answer: Cytochrome p450 3A4
Explanation:The cytochrome p450 3A4 enzyme system in the liver is affected by grapefruit juice.
Patients taking antihistamines should be advised to avoid drinking grapefruit juice. This is because constituents of grapefruit juice such as naringin and bergamottin inhibit CYP3A4 in the liver, particularly at high doses, leading to decreased drug elimination via hepatic metabolism and can increase potential drug toxicities.
Inhibition of this enzyme system leads to reduced metabolism of antihistamines leading to an increased incidence of side effects like excessive drowsiness and nausea as in this patient.
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This question is part of the following fields:
- Pharmacology
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Question 28
Correct
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Which one of the following statements regarding epidemiological measures is correct?
Your Answer: Cross-sectional surveys can be used to estimate the prevalence of a condition in the population
Explanation:The incidence rate is the number of new cases per population at risk in a given time period. For example, if a population initially contains 1,000 non-diseased persons and 28 develop a condition over two years of observation, the incidence proportion is 28 cases per 1,000 persons per two years, i.e. 2.8% per two years.
Prevalence is the proportion of a particular population found to be affected by a medical condition (typically a disease or a risk factor such as smoking or seat-belt use). It is derived by comparing the number of people found to have the condition with the total number of people studied, and is usually expressed as a fraction, as a percentage, or as the number of cases per 10,000 or 100,000 people.
Incidence should not be confused with prevalence, which is the proportion of cases in the population at a given time rather than rate of occurrence of new cases. Thus, incidence conveys information about the risk of contracting the disease, whereas prevalence indicates how widespread the disease is. -
This question is part of the following fields:
- Evidence Based Medicine
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Question 29
Incorrect
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Which is the most appropriate agent for the prophylaxis of cluster headaches?
Your Answer:
Correct Answer: Verapamil
Explanation:Verapamil, can effectively reduce the number of attacks during a cluster headache period of exacerbation. Oral sumatriptan has not been shown to be effective prophylactically. Verapamil in dosages of 360 to 480 mg daily is one of the few treatments for episodic cluster headache tested in a randomized controlled trial (RCT) and found effective in reducing attack frequency.
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This question is part of the following fields:
- Nervous System
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Question 30
Incorrect
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Regarding bupropion (Zyban), which one of the following statements is true?
Your Answer:
Correct Answer: It has an antidepressant effect
Explanation:The chief role of bupropion is that it acts as an antidepressant agent, which was used extensively to treat war veterans with post traumatic stress disorders. It is also very effective nicotine replacement therapy. Contraindications include epileptic seizures as it decreases the threshold of epilepsy in these patients to 1:1000.
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This question is part of the following fields:
- Pharmacology
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SESSION STATS - PERFORMANCE PER SPECIALTY
