QBANK Flashcards
which of the following is an indication for immediate empirical treatment with n acetylcysteine in paracetamol poisoning ?
A. patient presenting six hours or more after ingestion
B. you are working in rural australia where serum paracetamol level would be available within 24 hours
C. you are certain about timing of the dose
D. patient is fully conscious and can give you detailed history
E. age less than 16 years
Answer b
N-Acetylcysteine Should be started Immediately or empirically In the following situation
-patient presents 8 hours or more after ingestion
-when serum paracetamol level is not available within an 8 hour time window
-when there is uncertainty as to the timing of the overdose
-When the patient is unconscious or has a suspected overdose
So while working in remote areas in australia some blood tests are reported within 24 hours so any patient with suspected or proven paracetamol poisoning should be treated with n-acetylcysteine empirically. period age less than 16 does not change the management. Age less than six years does follow different protocol in paracetamol poisoning .
A 57 year old male presents with nausea and vomiting for the last 12 hours . he is found to have sub acute small bowel obstruction and would require surgery is conservative measures fail . he has a background history of percutaneous coronary intervention eight weeks ago when drug-eluting stents were inserted period he is currently on aspirin clopidogrel simvastatin, ramipril and metoprolol what will you do next?
A. Withhold clopidogrel and continue aspirin B. continue both aspirin and clopidogrel C. withhold simvastatin D. give therapeutic heparin E. defer surgery for six months
answer a
any elective surgery requiring cessation of antiplatelet therapy should be postponed for 6 weeks after insertion of bare-metal stents and twelve months after insertion of the drug-eluting stent. in patients requiring urgent surgery associated with high risk of bleeding within recommended time frames, aspirin should be continued and clopidogrel should be discontinued for 5 to 7 days before surgery. as this patient may require surgery so it is recommended to withhold clopidogrel and continue aspirin. You should be coupled with bridging anticoagulation like heparin ( prophylaxis dose , not the therapeutic dose) if the patient is high risk for coronary artery disease .
A 38 year old female with history of smoking comes for contraception advice which of the following is an appropriate option for her? A. Progesterone only pills B. combined oral contraceptive pills C. male condoms D. Diaphragm E. cervical cap
Answer a
Smoking in women aged more than 35 is absolute contraindication to combined oral contraceptive pills. Best option in this patient is progesterone only pills. POP is also an acceptable alternative method of contraception during breastfeeding. Failure rate per year is 3 to 10% compared with 2 to 6% for the combined pill. All the options are associated with high pregnancy rates
What is the most appropriate test To diagnose hemochromatosis?
Liver biopsy
serum ferritin level and transferrin saturation
Hfe genotype
ultrasound of liver and testes
full blood count
Answer b
The most appropriate test to investigate symptomatic or asymptomatic cases of hemochromatosis is to carry on iron studies. Fasting transferrin saturation more than 60% for men or more than 50% for women has been accurate in detecting over 90% of patients with homozygous hereditary hemochromatosis who have clinical symptoms. If iron studies are abnormal, then hfe mutation analysis should be performed. Since the advent of hfe mutation Analysis, liver biopsy has become less important as a clinical tool in the diagnosis Of hemochromatosis. Liver biopsy should be considered only for the purpose of determining the presence or absence of advanced fibrosis or cirrhosis , which does not have prognostic value . ultrasound of liver and testes is not an appropriate test to diagnose hemochromatosis . the full blood count may show raised hematocrit and platelet count, However it is not diagnostic for hemochromatosis.
- A 38 year old woman presented to your clinic for contraception advice . she has a history of epilepsy and has been prescribed carbamazepine by her neurologist period she does not smoke period she is on progesterone only pills for her contraception . what is the best advice for her ?
Stop progesterone only pill
Cease progesterone only pill and start taking combined oral contraceptive pills
Stop carbamazepine
continue with carbamazepine and progesterone only pills as there is no interaction
advise her to get mri done in 12 months
answer b
anti epileptic drugs such as carbon has been or hepatic enzyme inducers
concomitant use of enzyme inducing drugs is an absolute contraindication 2 using the progesterone only pill and it must be discontinued while the patient is on carbamazepine the patient is a non smoker so she would benefit from being on high estrogen containing combined oral contraceptive pills .
6. A young woman presented for your advice on her choice of oral contraceptive pills . she does not want to use any other method past medical history includes hypertension and diet managed type 2 diabetes mellitus. what will you prescribe her ? Biphasic oral contraceptive pills progesterone only pills triphasic oral contraceptive pills estrogen only pills no contraception possible
Answer B
The following are the conditions in which progesterone only methods are suitable: Hypertension superficial thrombophlebitis history of thromboembolism Biliary tract disease Thyroid disease Epilepsy Diabetes without vascular disease
progesterone only methods are contraindicated In suspected pregnancy, breast cancer, and Undiagnosed bleeding. Relative contraindications are active viral hepatitis and severe chronic liver disease.
A 60 year old man presented with left homonymous hemianopia. His family is concerned as he only saves on the right side of his face and thinks he belongs to only the right side of his body which of the following artery is involved in this stroke ?
A. posterior cerebral artery right middle cerebral artery C. left posterior inferior cerebellar artery D. Left middle cerebral artery E. Basilar artery
Answer B
middle cerebral artery lesions presents with contralateral hemiparesis which is worse in the arm and face then in the legs . other symptoms include dysarthria, contralateral homonymous Hemianopia, aphasia and sensory neglect if non dominant hemisphere is affected. this patient has right mca lesion which is causing left sided neglect and left sided contralateral homonymous hemianopia.
Posterior cerebral artery lesion with contralateral homonymous hemianopia . However other symptoms include unilateral cortical blindness , memory loss and unilateral third cranial nerve palsy . hemiballismus is also a feature of pca lesion .
Posterior inferior cerebellar artery syndrome Pica presents with lateral medullary syndrome . Symptoms include Dysphagia ataxia vertigo, diplopia and truncal ataxia. Basilar artery stroke can cause Vertibrobasilar insufficiency
A 48 year old lady was found to have low serum sodium on day 3 after cranial surgery. Her laboratory investigations are given below.
serum sodium 117 mmol/l
plasma osmolality 25 mosm/kg
urine osmolarity 525 mosm/kg
what is the most likely diagnosis?
A. Diabetes insipidus Siadh C. water intoxication D. Dehydration E. renal failure
Answer B
Siadh is defined as less than maximally dilute urine in the presence of plasma hypo-osmolality (hyponatremia) without volume depletion or overload.
findings in siadh
a low serum osmolality
an inappropriately elevated urine osmolality (above 100mosmol/kg and usually above 300)
urine sodium concentration usually above 40meq/L
diabetes insipidus is characterized by polydipsia due to decreased formation of adh. central diabetes insipidus or resistance to adh nephrogenic by urine osmolality is usually below 250
a low plasma sodium concentration less than 137 with a low urine osmolality less than the plasma osmolality is usually indicative of water overload due to primary polydipsia
a normal a high normal plasma sodium concentration greater than 14222 water loss points towards the i particularly if the urine osmolality is less than the plasma osmolality\
dehydration increases put serum as well as urine osmolality
Which of the following antibiotics can produce a clinical disturbance similar to botulism ?
answer a
gentamicin prevents the release of ach from nerve endings like botulism toxin and can cause muscle paralysis in high-risk patients . symptoms subside rapidly as the responsible drug is eliminated. it is contraindicated in patients with pre-existing disturbance of neuromuscular transmission . is it is best avoided in myasthenia gravis
A 30 year old male comes to your clinic after a knee injury while playing football. He reports severe pain, swelling and clicking of the knee. He is unable to bend the knee and it locks in partial flexion. On examination there is a joint effusion, medial joint line tenderness , the joint is held in a flexed position. What is the most likely diagnosis?
A. Anterior cruciate ligament injury Medial meniscus tear C. collateral ligaments injury D. medial collateral ligament and medial meniscus injury E. none of the above
answer b
this patient has developed clinical features of acute meniscal tear. the acute meniscal tear happens from compression with rotational force through the knee. the medial meniscal is more commonly injured than lateral meniscus due to its attached with deep fibers medial collateral ligament injury.
Which one of the following medications can significantly increase the HDL cholesterol?
a. Gemfibrozil
b. Simvastatin
c. Cholestyramine
d. Colestipol
e. Pravastatin
The correct answer is a.
Drugs causing a significant increase in HDL cholesterol include gemfibrozil and nicotinic acid.
Drugs causing a minor increase in HDL cholesterol include simvastatin, pravastatin, cholestyramine and colestipol
A 57-year-old male presents with ongoing vomiting for last 2 days associated with absolute constipation.On examination, there is no abdominal distension. Gastrografin studies confirmed the presence of small bowel obstruction,
Which of the following is the most common cause of small bowel obstruction
a. Postoperative adhesions
b. Bowel cancer
c. Crohn’s disease
d. Hernias
e. Hypokalemia
The correct answer is a.
Postoperative adhesions remain the most common cause of small bowel obstruction.
The risk of developing an obstruction after surgery from postoperative adhesions is 9% within the first year after abdominal surgery, 19% by 4 years and 35% by 10 years.
Malignant tumours, (bowel cancer,ovarian cancer) are the second most common cause of small bowel obstruction involving about 20% of the cases.us
Hernias are the third leading cause of intestinal obstruction and account for approximately 10% of all cases,
Intraluminal strictures can be caused in Crohn’s disease and radiation therapy.
Hypokalemia can cause temporary paralysis of ileum in children however it can rarely cause small bowel obstruction in adults as well.
A 35-year-old morbidly obese woman with BMI 42 has not been able to conceive after 12 months of marriage.Her husband has normal sperm analysis and has no other abnormality.Her fallopian tube appears to be obstructed. What is the most appropriate next step in her management?
a. Suggest her to lose weight
b. Start her on combined oral contraceptive pills
c. Start estrogen
d. Start clomiphene
e. In-vitro fertilization
The correct answer is a.
This patient has presented with inability to conceive over 12 months, and her fallopian tubes are obstructed. She has BMI of 42.
In-vitro fertilisation (IVF) is an alternate option to get pregnant for this patient as she has obstructed Fallopian tubes.
However it takes a woman with a BMI over 35, twice as many IVF cycles to get pregnant as a woman with a healthy weight.So best advice would be to lose weight for successful IVF as the first step in management.IVF success rates are reduced by 25% in obese (BMI less than 40) patients and 50%.
Which of the following is the most common organism seen in spontaneous bacterial peritonitis?
a. Escherichia coli
b. Streptococcus viridans a
c. Staphylococcus aureus
d. Enterococcus species
e. Clostridium difficile
The correct answer is a.
in spontaneous bacterial peritonitis, the most common organism is Escherichia coli.
Gram-positive bacteria, including Streptococcus viridian, Staphylococcus aureus, and Enterococcus species can also be found in the ascitic culture.
- An-overseas economics student is referred to you for further assessment of positive tuberculin skin test. He does not have any signs and symptoms of tuberculosis.An apical opacity is found on chest X-ray. Sputum examination is positive for acid-fast bacilli.
Which of the following is the most appropriate management?
a. Isoniazid
b. Rifampicin, isoniazid, pyrazinamide,ethambutol
C. Isolation
d. Repeat Mantoux test
e. Repeat chest X-ray in 6 weeks
Correct Answer: b. Rifampicin isoniazid, pyrazinamide,ethambutol
Answer Detail:
The correct answer is b.
Investigations for active tuberculosis include chest x-ray, three sputum samples obtained for acid-fast bacilli (AFB), nucleic acid amplification testing (NAAT), FBC, and electrolytes. Stained smears should be made from sputum specimens to identify AFB, as this is the first bacteriological evidence of infection and gives an estimate of how infectious the patient is. If acid-fast bacilli are seen on sputum smear, anti-tuberculous therapy should be started and the patient maintained in isolation. Initial intensive phase treatment involves the first-line drugs isoniazid, rifampicin, pyrazinamide, and ethambutol for 8 weeks. Then the number of drugs is reduced according to response.
