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A 79-year-old woman, receiving maintenance peritoneal dialysis, presented with sudden onset of shortness of breath and a right-sided pleural effusion. She reported no cough, fever, or chills; she had no oedema. Pleural fluid analysis showed clear yellow fluid with a nucleated cell count of 113 cells per mm3, including 2% neutrophils, 45% lymphocytes. Pleural protein concentration was 5 g/L, glucose 7·9 mmol/L, and creatinine 498 µmol/L. Blood test showed a white blood cell count of 8·67 x 109 per L, C-reactive protein concentration 0·8 mg/L, glucose concentration was 5·4 mmol/L, protein 69 g/L, albumin 32 g/L and creatinine 512 µmol/L. Liver function was normal. Peritonea dialysis fluid showed a glucose concentration of 7·8 g/L and creatinine of 484 µmol/L. Look at the imaging and select the most likely diagnosis? | Pleuro-peritoneal communication | {
"A": "Congestive heart failure",
"B": "Pleuro-peritoneal communication",
"C": "Nephrotic syndrome",
"D": "Malignant pleural effusion"
} | B |
These images are from a 46-year-old woman. Which of these other symptoms would you not expect her to experience? | Seizures | {
"A": "Collapse",
"B": "Hair loss",
"C": "Seizures",
"D": "Dizziness"
} | C |
These leathery-in-texture plaques and nodules were found in a 61-year-old man with Graves’ disease. What is the diagnosis? | Myxoedema | {
"A": "Streptococcus lymphoedema",
"B": "Rheumatoid nodule",
"C": "Myxoedema",
"D": "Erythema elevatum diutinum"
} | C |
A 63-year-old woman with a 3-day history of sudden, painless visual loss in her left eye primarily affecting the inferior part of her visual field, presented to our clinic. The patient had a history of systemic hypertension and was prescribed lisinopril. On examination, she was afebrile; blood pressure was 164/85 mm Hg and pulse was 85 beats per min. Visual acuity was 6/12 with the right eye and 6/60 with the left eye; the visual field of the right eye was full; the left eye visual field had a dense inferior field defect (figure). The right pupil was normally reactive to light; the left pupil was sluggishly reactive, and there was a moderate left relative afferent pupillary defect. On ophthalmoscopy, the right optic disc was slightly small and had no central cup (figure); the left optic disc was swollen and hyperaemic, associated with several peripapillary flame-shaped haemorrhages (figure). She was diagnosed with non-arteritic anterior ischaemic optic neuropathy (NAION). All the following are true except one. Which is it? | Prompt treatment with systemic corticosteroids will result in visual improvement in most patients | {
"A": "Most patients have underlying systemic vascular disease that may not be known at the time they loss vision",
"B": "Patients with NAION in one eye have a 15-20% risk of developing a similar event in the fellow eye",
"C": "Prompt treatment with systemic corticosteroids will result in visual improvement in most patients",
"D": "Patients with NAION have an increased risk of stroke and heart attack"
} | C |
What is the cause of the swelling of the hands that developed gradually over a period of 3 years in a 45-year-old man with newly diagnosed hepatitis C? | Intravenous drug addiction | {
"A": "Angioneurotic oedema",
"B": "Early systemic sclerosis",
"C": "Intravenous drug addiction",
"D": "Milroy’s disease"
} | C |
A 24-year-old man presented with a 5-day history of rapidly progressive shortness of breath, chest pain, and dry cough. 2-months earlier he completed a course of anti-tuberculosis medication. On examination, he had a tachycardia, pulsus paradoxus, jugular venous distension, and muffled heart sounds. Which of the following diagnoses is most likely here? | Cardiac tamponade | {
"A": "Constrictive pericarditis",
"B": "Pulmonary embolism",
"C": "Cardiac tamponade",
"D": "Tension pneumothorax"
} | C |
Which of the following has not been found to be associated with a higher risk of developing hepatocellular carcinoma? | Acute hepatitis A infection | {
"A": "Male sex",
"B": "Liver cirrhosis",
"C": "Acute hepatitis A infection",
"D": "Haemochromatosis"
} | C |
What is the most significant clinical presentation for differential diagnosis of a patient with a huge right upper quadrant tumour? | A fat plane is found between the normal liver and the tumour in abdominal CT scan | {
"A": "An abdominal ultrasound reveals a mixed echoic hepatic tumour",
"B": "The tumour demonstrates arterial enhancement and washout in the portal and delayed phases in triple-phase abdominal CT scan",
"C": "Clinical laboratory data shows elevated liver enzymes and hyperbilirubinaemia, with normal adrenal hormonal workup",
"D": "A fat plane is found between the normal liver and the tumour in abdominal CT scan"
} | D |
A 60-year-old man presented with an abnormality in the oesophagus. He was on no medication, was a former smoker, and sometimes had heartburn. Oesophagogastroduodenoscopy revealed short segment Barrett’s oesophagus and with an adjacent whitish elevated lesion (figure, A). By magnified narrow-band imaging, no vessel structures could be observed because of a whitish plaque (figure, B). Chromoendoscopy with Lugol’s iodine solution demonstrated decreased staining of the lesion (figure, C). What is your diagnosis of this lesion? | Verrucous carcinoma | {
"A": "Adenocarcinoma",
"B": "Squamous cell papilloma",
"C": "Candida oesophagitis",
"D": "Verrucous carcinoma"
} | D |
A previously healthy 20-year-old woman presented with fever, diffuse persistent maculopapular rash, and sore throat. Laboratory findings showed ferritin concentration of 3655 μg/L, C-reactive protein concentration of 229 mg/L, and soluble CD25 concentration of 229 U/mL. The patient was diagnosed with Still’s disease. Which of the following is not a typical feature of Still’s disease? | Presence of strongly positive autoantibodies—including anti-nuclear antibodies and rheumatoid factor | {
"A": "Evanescent skin eruption with occurrence of fever",
"B": "A skin biopsy showing dyskeratotic keratinocytes in the superficial epidermis",
"C": "Presence of strongly positive autoantibodies—including anti-nuclear antibodies and rheumatoid factor",
"D": "Leukocytosis with predominant neutrophilia"
} | C |
A 59-year-old woman was admitted to the emergency hospital department with cardiac failure and tamponade. All except one of the following are eponyms associated with the possible clinical findings, which is it? | Erdheim–Chester | {
"A": "Beck",
"B": "Kussmaul",
"C": "Broadbent",
"D": "Erdheim–Chester"
} | D |
A 63-year-old man attended our hospital reporting a 3-month history of diffuse pain in both hands. He had been investigated for primary hyperparathyroidism with previous episodes of hypercalcaemia, the last episode necessitated hospitalisation. Which of the following options lists all the signs of osteitis fibrosa cystica clearly visible? | Subperiosteal resorption, cystic lesion, and lucent striations | {
"A": "Subperiosteal resorption, cystic lesion, and lucent striations",
"B": "Cystic lesion, cortical tunnelling, and salt-and-pepper degranulation",
"C": "Brown tumour, subperiosteal resorption, and bone tape",
"D": "Lytic lesions, lucent striations, and brown tumour"
} | A |
A 25-year-old woman with no medical history presented with recurrent vomiting and weight loss for 2 weeks. A vague abdominal mass was palpable; her abdominal CT is shown below. Which one of the following courses of management of intussusception would be the best? | Fluid resuscitation followed by immediate laparotomy and bowel resection | {
"A": "Fluid resuscitation, intravenous potassium replacement, and biopsy of the intra-abdominal mass",
"B": "Conservative management with close observation",
"C": "Emergency laparoscopic assessment and biopsy of the lesion",
"D": "Fluid resuscitation followed by immediate laparotomy and bowel resection"
} | D |
A 41-year-old man had sudden-onset neck pain, stiffness, and odynophagia with elevated inflammatory markers which developed over 20 hours. What is the most likely cause? | Acute calcific tendinitis of the longus colli muscle | {
"A": "Retropharyngeal abscess",
"B": "Meningitis",
"C": "Crowned dens syndrome",
"D": "Acute calcific tendinitis of the longus colli muscle"
} | D |
A 70-year-old man presented with fatigue, night sweats, and weight loss of 18 kg. He had been taking nutritional supplements and vitamins. He was diagnosed with chronic lymphocytic leukaemia and started on fludarabine, cyclophosphamide, and rituximab. Investigations showed hepatitis B virus reactivation. What other cause or causes might have led to liver damage in this man? | All the above | {
"A": "Leukemic involvement of the liver",
"B": "Cyclophosphamide or fludarabine-induced liver injury",
"C": "Hepatotoxicity due to nutritional supplements",
"D": "All the above"
} | D |
A 51-year-old man presented with a symptomatic recurrent left groin lump, as shown in the MRI scan done while the patient was straining. What is your likely diagnosis based on this appearance? | Femoral hernia | {
"A": "Indurated lymph nodes",
"B": "Lobulated lipoma",
"C": "Femoral hernia",
"D": "Saphenavarix"
} | C |
The bone marrow examination of a 52-year-old man with osseous lytic lesions and an IgG kappa monoclone is shown. What is the likely diagnosis? | Plasma cell myeloma | {
"A": "Langerhans cell histiocytosis",
"B": "Acute basophilic leukemia",
"C": "Plasma cell myeloma",
"D": "Systemic mastocytosis"
} | C |
An 85-year-old man with a 5-day history of persistent fever and severe neck pain presented to our hospital. No bacteria were identified in the culture test including cerebrospinal fluid. What is the most probable diagnosis? | Spinal gout | {
"A": "Spinal meningitis",
"B": "Spinal gout",
"C": "Crowned dense syndrome",
"D": "Ankylosing spondylitis"
} | B |
A 50-year-old woman with mantle-cell lymphoma reported a 6-month history of a slow-growing mass over the bridge of her nose. The patient had no pain, respiratory symptoms, nasal discharge, double vision, headache, fever, night sweats, or weight loss. She reported no recent infections or recent international travel. On examination, the swelling was firm, fixed, and painless without any pustules or fistulas. What would be the best first step to assess this patient? | Re-staging radiographic imaging | {
"A": "Hospitalization for intravenous antibiotics",
"B": "Attempt to drain the lesion",
"C": "Re-staging radiographic imaging",
"D": "Lumbar puncture"
} | C |
A 16-year-old male patient with a history of precursor B-cell acute lymphoblastic leukaemia presented with 1 week of soft, violaceous, necrotic pubic nodules and new onset of fever. On examination, he was obese with folliculitis on the trunk. What is the most likely diagnosis? | Leukaemia cutis | {
"A": "Furunculosis",
"B": "Ecthyma gangrenosum",
"C": "Leukaemia cutis",
"D": "Sweet’s syndrome"
} | C |
A clinically definite diagnosis of a functional movement disorder requires one of the following. Which is it? | Ascertainment of incongruence and inconsistency of findings on neurological examination | {
"A": "Exclusion of potential organic aetiologies of the movement",
"B": "Ascertainment of substantial psychological stressors",
"C": "Ascertainment of incongruence and inconsistency of findings on neurological examination",
"D": "Electrophysiological confirmation of the movement"
} | C |
A 90-year-old woman presented with a 7-day history of pain in the right upper quadrant, decreased appetite, and post-prandial vomiting. A CT scan of her abdomen showed severe gastric distention due to an obstruction of the gastric outlet. Based on the image, what is the most likely diagnosis? | Bouveret’s syndrome | {
"A": "Duodenal malignancy",
"B": "Bouveret’s syndrome",
"C": "Gastric polyp",
"D": "Peptic stricture"
} | B |
A 30-year-old woman was referred to our urology clinic reporting a 2-year-history of pain in the right flank. The patient said the pain was worse after physical exercise or after standing up for a long time; after these activities, she said a painful abdominal mass would be present, which subsequently disappeared when she rested for a few minutes in a supine decubitus position. Additionally, she reported that her symptoms, which had started without any identified reason, had been getting worse and had begun to affect her ability to carry out her daily routine. The patient had no medical history and said she was otherwise healthy. On examination, she was generally well; we found no masses or organomegaly. However, she showed us pictures of the abdominal mass in her right iliac fossa, which appeared after standing up for 30 min or after doing physical exercise. What is the most likely cause for her abdominal pain? | Obstructive uropathy caused by nephroptosis | {
"A": "Obstructive uropathy caused by lithiasis",
"B": "Vascular compression caused by nephroptosis",
"C": "Obstructive uropathy caused by nephroptosis",
"D": "Complication of a renal cyst"
} | C |
A 69-year-old woman with a 27-year history of rheumatoid arthritis presented to the rheumatology clinic at Kochi Medical School hospital, Japan, with polyarthralgia of both hands and on her right hand painless subcutaneous nodules that had slowly grown over a year. Physical examination revealed arthritis mutilans with ulnar deviation and yellow masses on the metacarpophalangeal joints of the fingers of the right hand. The concentrations of C-reactive protein and rheumatoid factor were 1·78 mg/dL (normal range <0·15 mg/dL) and 1 096·0 IU/mL (<15 IU/mL), respectively. Hyperlipidaemia, cryoglobulinemia, hypocomplementemia, and monoclonal paraproteins were not detected. What is the most likely diagnosis? | Rheumatoid nodule | {
"A": "Lipoma",
"B": "Xanthogranuloma",
"C": "Xanthogranuloma",
"D": "Rheumatoid nodule"
} | D |
A 53-year-old man presented to our emergency department with a 2-week history of increasing dyspnoea. The patient had a history of chronic obstructive pulmonary disease. A chest x-ray showed a right hydropneumothorax (figure). A thoracostomy was done and a right sided chest tube was connected to a negative pressure suction system; 1 h later, a repeat chest x-ray showed complete lung expansion with some right lower lobe consolidation (figure). In the next 24 h, the patient had worsening dyspnoea with hypoxaemia (oxygen saturation 86% on room air). 3 days after admission, an additional chest x-ray showed that the consolidation had resolved, with complete lung expansion (figure). Which of the following is the most likely diagnosis? | Localised re-expansion pulmonary oedema | {
"A": "Community-acquired pneumonia",
"B": "Lung atelectasis",
"C": "Localised re-expansion pulmonary oedema",
"D": "Acute haemorrhage into bullae"
} | C |
A 37-year-old woman presented with a 3-year history of episodic swelling and pain in her left ear. The current episode was accompanied by decreased urine volume, hypertension, oedema of both legs, 1+ proteinuria, and microscopic haematuria. Her creatinine increased from 0.9 mg/dL 1 year ago, to 4.2 mg/dL. What is the most likely diagnosis of her kidney disease? | ANCA-associated glomerulonephritis | {
"A": "Membranous nephropathy",
"B": "Atypical haemolytic-uremic syndrome",
"C": "ANCA-associated glomerulonephritis",
"D": "Post-streptococcal glomerulonephritis"
} | C |
What is the cause of these isolated osteolytic lesions in this 72-year-old man with no suspicion of prostate carcinoma? | Diffuse large B-cell lymphoma | {
"A": "Skeletal angiomas",
"B": "Sudeck’s atrophy",
"C": "Diffuse large B-cell lymphoma",
"D": "Gorham’s disease"
} | C |
A 75-year-old man presented with severe impairment of his general condition and progressive cachexia requiring enteral nutrition via tube. Serum calcium was normal, whereas sodium was low. On physical examination, stiffened ear cartilage compatible with petrified ears was noticed. A 3D reconstruction from a CT scan confirmed calcification of the elastic cartilage of both external ears. What is the most likely diagnosis? | Adrenal insufficiency | {
"A": "Systemic scleroderma",
"B": "Adrenal insufficiency",
"C": "Calciphylaxis",
"D": "Hyperparathyroidism"
} | B |
Hemi-diaphragmatic paralysis can occur with compression of which of the following cervical nerve root or roots? | C4 | {
"A": "C1",
"B": "C4",
"C": "C7",
"D": "C8"
} | B |
A 51-year-old woman attended our emergency department with a 3-day history of dyspnoea, fatigue, and cough; 11 days earlier she had the ChAdOx1 nCoV-19 vaccination. What is the best first step in the management of this patient? | Blood count, including platelet count and D-Dimer | {
"A": "Blood count, including platelet count and D-Dimer",
"B": "Compression ultrasound of both legs",
"C": "SARS-CoV-2 RT-PCR on nasopharyngeal swab",
"D": "CT pulmonary angiography"
} | A |
A 53-year old male presented with fever, abdominal pain, and anasarca. Imaging showed a pleural effusion and ascites. The episodes had recurred since childhood and there was a family history suggestive of an autosomal dominant disorder. What could it be? | Muckle Wells syndrome | {
"A": "Intestinal infection with Taenia solium",
"B": "Protein malnutrition and Kwashiorkor",
"C": "Muckle Wells syndrome",
"D": "Multiple myeloma"
} | C |
An ancient human skeleton was found in the archaeological site in Torre Velha, Portugal. Genetic analysis indicated a possible diagnosis of Klinefelter’s syndrome. What type of morphological and osteological traits might be seen in the skeleton? | Robust morphology, tall stature, and a probable malocclusion | {
"A": "Robust morphology, extremely short stature, and no signs of osteoporosis",
"B": "Robust morphology, tall stature, and a probable malocclusion",
"C": "While most physical traits are variable, signs of osteoporosis are always associated with Klinefelter’s syndrome",
"D": "No physical traits can be observed in the skeleton of an individual with Klinefelter’s syndrome"
} | B |
A 26-year-old woman presented with anaemia and massive splenomegaly at 10 weeks’ gestation. White cell and platelet counts were normal. Blood film showed anisopoikilocytosis with teardrop-shaped red cells. Bone marrow examination demonstrated a hypercellular marrow with relative myeloid hyperplasia, megakaryocytic proliferation with atypia, and minimal fibrosis on reticulin stain. What is the most likely diagnosis? | Myeloproliferative neoplasm | {
"A": "Thalassaemia major",
"B": "Hairy cell leukaemia",
"C": "Myeloproliferative neoplasm",
"D": "Splenic marginal zone lymphoma"
} | C |
Which of the following statements about the management of patients with anorexia nervosa and pancytopenia is correct? | Nutritional refeeding should be optimized to reverse the bone marrow transformation and the potentially impaired immunity | {
"A": "Pancytopenia is irreversible",
"B": "Bone marrow fibrosis is a common issue",
"C": "Nutritional refeeding should be optimized to reverse the bone marrow transformation and the potentially impaired immunity",
"D": "Bone marrow transplantation is commonly needed"
} | C |
This image depicts a chest radiograph in a patient with gastric banding. You would expect this patient to present with: | Vomiting striated with blood | {
"A": "Infection at the site of the port",
"B": "Vomiting striated with blood",
"C": "Typical reflux symptoms",
"D": "Weight regain"
} | B |
A 32-year-old woman, who was 12 weeks’ pregnant, was referred to our emergency department feeling generally unwell after recurrent vomiting. She had no notable medical history. She was mildly confused and reported polyuria. Total serum calcium and phosphorus concentrations were 4·15 mmol/L and 1·02 mmol/L respectively; serum PTH concentration was 992 pg/mL. We made a working diagnosis of primary hyperparathyroidism presenting as a hypercalcaemic crisis. Which of the following is not a recognised complication pre-delivery of hypercalcaemia? | Diplopia and nystagmus | {
"A": "Preeclampsia and hypertension",
"B": "Pancreatitis and nephrolithiasis",
"C": "Diplopia and nystagmus",
"D": "Depression and anxiety"
} | C |
An elderly patient with frontotemporal dementia presented with acute kidney injury. His kidney biopsy revealed calcium oxalate crystals. What is the next most pertinent investigation? | Dietary history | {
"A": "Faecal microbiome testing",
"B": "Genetic testing",
"C": "Dietary history",
"D": "Faecal elastase"
} | C |
A 64-year-old man with a 2-month history of breathlessness, reduced effort tolerance, and a worsening cough, attended our clinic. The patient was a non-smoker, and he had no relevant history of occupational exposures or severe viral infections; he reported that none of his family had lung disease. No consanguinity was noted. Plain chest x-ray showed diffuse sandstorm-like micro-nodular pattern throughout both lung fields obscuring the cardiac border. High resolution chest CT showed a crazy-paving pattern characterised by thickened interlobular septa and punctiform calcifications, distributed diffusely along the interlobular septa. We diagnosed pulmonary alveolar microlithiasis. Which of the following is an effective therapy for this rare condition? | Lung transplantation | {
"A": "Corticosteroids",
"B": "Lung transplantation",
"C": "Whole lung lavage",
"D": "Disodium etidronate"
} | B |
A 45-year-old woman presented with diplopia and vertigo. Brain MRI showed cerebellar bilateral ischemic lesions. Transoesophageal echocardiography showed thickening of the leaflets of the aortic valve and mild aortic regurgitation. CT scan showed a left inferior lung mass and left supraclavicular lymphadenopathy. After lymphadenopathy puncture, the patient was diagnosed with an ALK fusion driven lung adenocarcinoma. Which of the following management options would you recommend? | Treatment with an ALK inhibitor | {
"A": "Aortic valve replacement",
"B": "Systemic anticoagulation and aortic valve replacement",
"C": "Systemic anticoagulation alone",
"D": "Treatment with an ALK inhibitor"
} | D |
A 67-year-old man with a 2-month history of chronic myelomonocytic leukemia and bilateral facial nerve palsy, developed acute onset abdominal pain with hemodynamic instability. Which of the following is not a recognized extrahaematological problem of CMML? | Polyarteritis nodosa with renal micro-aneurysm rupture | {
"A": "Polyarteritis nodosa with renal micro-aneurysm rupture",
"B": "Rheumatoid arthritis",
"C": "Polyneuropathy",
"D": "SLE"
} | A |
A 47-year-old woman came to our institution with a 1-month history of breast erythema, swelling, and a new 1 cm purple skin plaque on her left breast which rapidly increased in size over the following weeks. She had no history of breast trauma. 6 years earlier, she had been treated for luminal A invasive ductal carcinoma in this breast with neoadjuvant chemotherapy followed by breast-conserving surgery, adjuvant radiation therapy, and oral tamoxifen. Which of the following diagnoses should be primarily suspected in this case? | Post radiation angiosarcoma | {
"A": "Chronic radiation dermatitis",
"B": "Mastitis",
"C": "Atypical vascular lesion",
"D": "Post radiation angiosarcoma"
} | D |
A 48-year-old woman presented with asymmetric vision loss. Which of the following is NOT a possible cause for this appearance? | Viral conjunctivitis | {
"A": "Carotid artery narrowing",
"B": "Diabetes mellitus",
"C": "Ocular tumour",
"D": "Viral conjunctivitis"
} | D |
A full-term baby was referred to our care after delivery by emergency caesarean section because of decreased foetal movement. On examination we found the boy to be pale. Foetal-maternal haemorrhage was suspected. Which test cannot confirm the diagnosis? | Apt-Downey test | {
"A": "Rosette screen",
"B": "Kleihauer-Betke test",
"C": "Apt-Downey test",
"D": "Flow cytometry"
} | C |
Which condition is characterised by the association of angiomatous skin lesions and multiple enchondromas? | Maffucci syndrome | {
"A": "Kaposi Sarcoma",
"B": "Ollier disease",
"C": "Klippel-Trenaunay syndrome",
"D": "Maffucci syndrome"
} | D |
A 63-year-old man presented with a 1-month history of an insidious fever with chills, a non-productive cough and 5 kgs loss of weight. CT thorax showed an enhancing mass at the aorto-pulmonary window. He was found to have melioidosis. Which one of the following statements is false? | Diagnosis of melioidosis is straight forward and misdiagnosis is uncommo | {
"A": "Melioidosis is caused by gram-negative bacillus Burkholderia pseudomallei",
"B": "Melioidosis treatment usually requires an initial intensive phase followed by eradication therapy to prevent recrudescence or relapse",
"C": "Diagnosis of melioidosis is straight forward and misdiagnosis is uncommo",
"D": "Melioidosis is endemic to the northern territory of Australia and southeast Asia"
} | C |
A 66-year-old man presented with an ST-elevation myocardial infarction and occluded circumflex artery. After successful coronary stenting, positron emission tomography with 18F-GP1 (a tracer targeting acute thrombus formation) was performed alongside coronary CT angiography. What is the diagnosis? | Type 2 MI due to coronary embolism from a left atrial appendage clot | {
"A": "Type 1 MI due to atherosclerotic plaque rupture",
"B": "Type 1 MI due to atherosclerotic plaque erosion",
"C": "Type 2 MI due to ventricular fibrillation and rate related ischaemia",
"D": "Type 2 MI due to coronary embolism from a left atrial appendage clot"
} | D |
A 13-year-old girl presented with a 2-week history of mild pain in the right knee. On examination, we found tenderness in the proximal right tibia with no swelling, ecchymosis, or any deformity. The range of motion of the knee was normal. What is the most likely diagnosis? | Occult fracture | {
"A": "Ewing’s sarcoma",
"B": "Occult fracture",
"C": "Osteosarcoma",
"D": "Osteomyelitis"
} | B |
A 26-year-old woman presented with history of recurrent superficial thrombophlebitis on all limbs, deep vein thrombosis involving the lower limbs, a fever, and a large non-healing ulcer on the left cubital fossa. There was no history of an oral or genital ulcer, eye involvement, or altered bowel habits. A whole body ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) PET showed ¹⁸F-FDG avid circumferential wall thickening of the aorta and its major branches. The most likely diagnosis is: | Pyoderma gangrenosum with Takayasu arteritis | {
"A": "Behcet’s syndrome",
"B": "Cutaneous tuberculosis with aortitis",
"C": "Pyoderma gangrenosum with Takayasu arteritis",
"D": "Inflammatory bowel disease with Sweet syndrome"
} | C |
A 59-year-old man attended our emergency department reporting a sudden onset of a severe headache and photophobia. A CT scan of the patient’s head showed a diffuse subarachnoid haemorrhage predominantly in the basal cisterns. During three-dimensional rotational angiography, a posterior inferior cerebellar artery aneurysm ruptured. Regarding aneurysm rupture, which of the following statements is correct? | Rebleeding or rupture of cerebral aneurysms occurs in 8-23% of cases within the first 72 h | {
"A": "Rebleeding or rupture of cerebral aneurysms occurs in 8-23% of cases within the first 72 h",
"B": "Between 50-90% of case of rupture or rebleeding of cerebral aneurysms occur after 12 h",
"C": "Risk factors for rebleeding include hypotension and a small aneurysm",
"D": "All cases of rebleeding or rupture occur after administration of antiplatelet drugs"
} | A |
A-25-year old male presented with acute abdominal pain and haematochezia. Multiple café-au-lait macules were seen on his body. An abdominal CT scan showed a 3 cm mass in his jejunum. Histopathologic examination diagnosed a gastrointestinal stromal tumour. What is the most likely diagnosis? | Neurofibromatosis type 1 | {
"A": "McCune-Albright syndrome",
"B": "Neurofibromatosis type 2",
"C": "Neurofibromatosis type 1",
"D": "Legius syndrome"
} | C |
A 19-year-old man presented with acute abdominal pain, fatigue, vomiting and fever of up to 38.8°C. The physical exam revealed dehydration, tachycardia, postural hypotension, and diffuse mucocutaneous darkening. What is the most likely diagnosis? | Adrenal insufficiency | {
"A": "Lead poisoning",
"B": "Acute intermittent porphyria",
"C": "Adrenal insufficiency",
"D": "Hemochromatosis"
} | C |
A 16-year-old girl presented with slowly progressive band-like atrophic grooves located on the forehead and marked facial asymmetry with atrophy of the left side of the face. She had also experienced several episodes of focal seizures and recurrent hemiplegic migraine. What is the most likely diagnosis? | Linear scleroderma with progressive facial hemiatrophy | {
"A": "Acquired partial lipodystrophy (Barraquer–Simons syndrome)",
"B": "Lupus panniculitis",
"C": "Linear scleroderma with progressive facial hemiatrophy",
"D": "Systemic sclerosis"
} | C |
A 26-year-old man patient presented with global aphasia and headache. Symptoms began 1 h before with visual problems on his right side. MRI—including diffusion-weighted imaging—showed no structural abnormalities but hypoperfusion in large areas of the left hemisphere. What is the most likely diagnosis? | Migraine with prolonged aura | {
"A": "Complex-partial seizure",
"B": "Migraine with prolonged aura",
"C": "Ischaemic stroke",
"D": "Cerebral sinus venous thrombosis"
} | B |
A 63-year-old woman with a 6-month history of recurrent vomiting and weight loss of 5 kg, was found to have a distended stomach with atrophic mucosa and subepithelial collagen deposition on gastric biopsy. She had a medical history of dyslipidaemia and hypertension and was prescribed rosuvastatin and olmesartan. The working diagnosis was an olmesartan-induced gastritis. What is the most effective therapy for this condition? | Discontinuation of olmesartan | {
"A": "Administration of steroids",
"B": "Discontinuation of olmesartan",
"C": "Gluten-free diet",
"D": "Administration of proton pump inhibitors"
} | B |
Although elevated parathyroid hormone levels appear to have an expansile effect on calvarial bones, what is the most common skeletal concern in patients with hyperparathyroidism? | Osteoporosis | {
"A": "Osteopetrosis",
"B": "Osteoporosis",
"C": "Osteonecrosis",
"D": "Osteosarcoma"
} | B |
A 24-year-old woman developed sore, painful, bilateral, asymmetrical breast masses over a 3-month period. She had an etonogestrel—progestogen only—contraceptive implant put in 6 months earlier. She has no family history of cancer. The most likely diagnosis is which of the following? | Pseudoangiomatous stromal hyperplasia | {
"A": "Inflammatory breast cancer",
"B": "Fibroadenomas",
"C": "Pseudoangiomatous stromal hyperplasia",
"D": "Fibrocystic disease"
} | C |
A 31-year-old nulliparous woman attended our hospital for treatment of carcinoma of the cervix. She had previously presented with vaginal bleeding when a 28 mm lesion had been found on clinical examination and shown on MRI. The following statements about fertility sparing treatment of carcinoma of the cervix are true except one, which is it? | Removal of the uterus is required after pregnancy | {
"A": "Fertility sparing surgery can be safety offered in adenocarcinoma or squamous cell carcinomas",
"B": "Fertility sparing surgery can be safety offered in patients with stage IBI disease without nodal metastasis",
"C": "Removal of the uterus is required after pregnancy",
"D": "Different approaches can be used to carry out fertility sparing surgery"
} | C |
An 85-year-old woman presented with a 3-week history of fever with auricular chondritis and cervical lymphadenopathy. What is the most probable diagnosis? | Auricular chondritis associated with tuberculous lymphadenopathy | {
"A": "Relapsing polychondritis",
"B": "Granulomatosis with polyangiitis",
"C": "Systemic lupus erythematosus",
"D": "Auricular chondritis associated with tuberculous lymphadenopathy"
} | D |
A 15-year-old boy presented with a 2-week history of decreased vision in his right eye and a painful rash over his toes. On evaluation, he was found to have pancytopenia, a positive test for antinuclear antibodies, and a positive test for anti-double-stranded DNA antibodies, with normal complement concentrations. The image shows fundoscopy of his right eye. What is the most likely diagnosis? | Systemic lupus erythematosus with retinal vasculitis | {
"A": "Systemic lupus erythematosus with retinal vasculitis",
"B": "Behçet's disease with retinal vasculitis",
"C": "Cytomegalovirus retinitis",
"D": "Systemic lupus erythematosus with cytomegalovirus retinitis"
} | A |
A 63-year-old woman attended our clinic with a 10-year history of progressive weakness of the muscles of her forehead, and drooping eyebrows and eyelids that were affecting her field of vision. Notably both her mother and brother had similar symptoms. The clinical presentation was consistent with hereditary gelsolin amyloidosis. Which of the following manifestations are not usually present? | Cognitive and psychiatric disorders | {
"A": "Corneal lattice dystrophy",
"B": "Cardiac and renal complications",
"C": "Cutis laxa",
"D": "Cognitive and psychiatric disorders"
} | D |
A 54-year-old man presented with a history of several weeks of diffuse abdominal pain. On examination his abdomen was soft with slight tenderness. Feet and hands showed diffuse petechia. CT scan showed signs of occult ileocecal perforation and segmented small bowel wall thickening. Explorative laparotomy was performed. Looking at the images, what is the most likely diagnosis? | Granulomatosis with polyangiitis | {
"A": "Lupus enteritis",
"B": "Granulomatosis with polyangiitis",
"C": "Multiple incarcerated hernia",
"D": "Metastatic melanoma"
} | B |
A 38-year-old woman, with trisomy of chromosome 21 (Down syndrome) and a history of ventricular septal defect repaired in infancy, presented with shortness of breath. A large diaphragmatic hernia was found and repaired. Post-operatively she developed respiratory distress. On examination, the patient had a heart murmur, and cardiac CT showed a heart abnormality. Look at the specimen removed during surgery and decide which is the most likely diagnosis. | Congenital unicuspid aortic valve | {
"A": "Atrial septal defect",
"B": "Congenital unicuspid aortic valve",
"C": "Ventricular septal defect",
"D": "Patent ductus arteriosus"
} | B |
A 64-year-old man with well-controlled obstructive sleep apnoea and a low residual apnoea–hypopnoea index presented for a scheduled follow-up appointment. Information downloaded from his continuous positive airway pressure device is shown in the figure. What is the cause of the acute rise in the apnoea–hypopnoea index? | Atrial fibrillation-induced central sleep apnoea | {
"A": "An air leak from his continuous positive airway pressure device",
"B": "Alcohol use",
"C": "High-altitude periodic breathing",
"D": "Atrial fibrillation-induced central sleep apnoea"
} | D |
A 24-week pregnant 18-year-old presented with acute respiratory distress and collapse. Her blood pressure was 222/78 mm Hg, pulse was 39 beats per minute, and she had weak radial pulses and absent pulses in her lower limbs. The following is or are treatment options for severe cases of coarctation of the aorta, select the best answer. A 24-week pregnant 18-year-old presented with acute respiratory distress and collapse. Her blood pressure was 222/78 mm Hg, pulse was 39 beats per minute, and she had weak radial pulses and absent pulses in her lower limbs. The following is or are treatment options for severe cases of coarctation of the aorta, select the best answer. | All the above | {
"A": "Balloon angioplasty alone",
"B": "Trans-catheter stent implantation",
"C": "Surgical coartectomy",
"D": "All the above"
} | D |
A term neonate presented with acral skin lesions of the right foot with partially livid character on the tips of the first, second, and fourth toes 12 h after birth and was referred to our clinic for further investigation. Which one of the following statements is correct? | The condition is mostly benign, related to acrocyanosis | {
"A": "The condition usually resolves within 2-3 h",
"B": "The condition is mostly benign, related to acrocyanosis",
"C": "Surgical removal of the toes is the only therapeutic option",
"D": "The cause is usually thromboembolic events of maternal origin"
} | B |
A 38-year-old woman presented with a spontaneous uterine rupture at 31 weeks of gestation. Tests confirmed a pathogenic mutation in the COL3A1 gene, consistent with vascular Ehlers-Danlos syndrome. The subtypes of Ehlers-Danlos syndrome shown below are autosomal dominant disorders, except for: | Kyphoscoliotic subtype | {
"A": "Vascular subtype",
"B": "Classical subtype",
"C": "Hypermobile subtype",
"D": "Kyphoscoliotic subtype"
} | D |
A 75-year-old man presented with a 12-month history of increasing pain in his right knee; he said that intermittently he had "popping" sensations and episodic locking of the joint that prevented full extension. The patient also reported feeling like objects were moving inside his knee. Looking at the x-ray what is the most likely diagnosis? | Osteochondromatosis | {
"A": "Osteoarthritis",
"B": "Gouty tophi",
"C": "Osteochondromatosis",
"D": "Osteochondral injury"
} | C |
A 69-year-old immunocompetent woman, in apparently good health, has a rapidly growing oral tumour infiltrating the palate. The tumour developed 6 months before the biopsy. Diagnosis was made just based on histological diagnosis. Looking at the photo, what could be the diagnosis? | Non-Hodgkin B-type lymphoma, Epstein–Barr virus positive, sporadic variety | {
"A": "Squamous cell carcinoma",
"B": "Chronic osteomyelitis",
"C": "Papillomatous mucositis / oral lichen planus",
"D": "Non-Hodgkin B-type lymphoma, Epstein–Barr virus positive, sporadic variety"
} | D |
A 37-year-old man presents with sudden unilateral visual impairment, mild neck pain, and headaches. Retinal fundus imaging shows an acute central retinopathy with macular haemorrhage (figure). He received recent double umbilical cord blood transplantation for relapsed Hodgkin lymphoma. What is the most likely diagnosis? | Severe thrombocytopenia | {
"A": "Valsalva retinopathy",
"B": "Hypertensive retinopathy",
"C": "Severe thrombocytopenia",
"D": "Terson’s syndrome"
} | C |
This patient has normal serum calcium, phosphate, and parathyroid hormone concentrations. From who must the abnormal gene responsible for his hand abnormalities must have been inherited? | From his father | {
"A": "From his mother",
"B": "From his father",
"C": "One copy from his father, and one from his mother",
"D": "From his mother and expressed in mosaic fashion"
} | B |
A 50-year-old woman with a sudden onset of chest pain, diaphoresis, and nausea was admitted to our hospital; additionally, she reported a 1-month history of shortness of breath and chest pain brought on by moderate activity for the previous month. She had previously had hypertension, dyslipidaemia, and type 2 diabetes. Coronary angiogram and optical coherence tomography imaging showed a critical stenosis in the distal right coronary artery due to an occlusive atherosclerotic plaque. Which of the following statements is correct? | Drug-coated balloons may be used in patients with in-stent restenosis and de novo coronary lesions | {
"A": "All drug-eluting stents use zotarolimus",
"B": "Some drug-coated balloons use everolimus",
"C": "Bare-metal stents are more effective that drug-coated balloons",
"D": "Drug-coated balloons may be used in patients with in-stent restenosis and de novo coronary lesions"
} | D |
A 66-year-old attended our hospital reporting a 1-year-history of progressively worsening difficulties with walking, falls, a tremor, and erectile dysfunction. Additionally, he believed he had become more impulsive, anxious, and he reported feeling resentment towards others. Genetic testing showed 111 CGG trinucleotide repeats in the fragile X mental retardation 1 protein gene (FMRI), confirming a diagnosis of fragile X-associated tremor or ataxia syndrome (FXTAS). Which of the following statements is false? | Daughters of men with FXTAS have a 50% chance of having the syndrome | {
"A": "All sons of men with FXTAS will have fragile X syndrome",
"B": "All daughters of men with FXTAS are obligate FMRI premutation carriers",
"C": "Daughters of men with FXTAS have a 50% chance of having the syndrome",
"D": "Women with FXTAS have a 50% chance of having a child with the mutation"
} | C |
A 25-year-old man with a recently discovered scrotal mass and elevated tumour markers presented to the emergency room with acute onset, pulsatile headache, and blurred vision. What is the most likely diagnosis? | Metastatic disease from a testis malignancy | {
"A": "Cerebrovascular accident",
"B": "Metastatic disease from a testis malignancy",
"C": "Metastatic disease from a lymphoma",
"D": "Primary CNS malignancy"
} | B |
A 66-year-old man presents with a 6-year history of progressive visual symptoms and difficulties getting dressed. An MRI of his brain showed posterior cortical atrophy. What is the most likely cause? | Alzheimer’s disease | {
"A": "Dementia with Lewy bodies",
"B": "Prion disease",
"C": "Alzheimer’s disease",
"D": "Corticobasal degeneration"
} | C |
An 80-year-old man admitted for planned operation to replace his aortic valve had a cardiac arrest 2 days after the surgery. He was resuscitated and 12 days later was allowed home. Based on the following telemetry strip what is the most likely mechanism for the cardiac arrest? | Under-sensing by pacemaker | {
"A": "Hypokalaemia",
"B": "Prolonged QT interval",
"C": "Under-sensing by pacemaker",
"D": "Myocardial ischemia"
} | C |
A 44-year-old man with a 1-month history of confusion attended our neurology clinic. The patient’s parents reported that their son, who had Down syndrome and socially competent, had shown subtle changes in his behaviour; he was irritable, subject to mood swings, and more demanding of his family’s attention. The patient had no vascular risk factors and was not prescribed any medication. MRI of the head showed multiple lobar cortico-subcortical haemorrhages in both hemispheres and ubiquitous brain microbleeds throughout the cerebral cortex and cerebellum. Which of the following statements is false? | People with Down syndrome have a higher risk of developing vascular dementia | {
"A": "Cerebral amyloid angiopathy can result in intracerebral haemorrhage, cerebral microbleeds and cortical superficial siderosis",
"B": "People with Down syndrome have a higher risk of developing vascular dementia",
"C": "The Boston criteria aid diagnosis of cerebral amyloid angiopathy",
"D": "Cerebral amyloid angiopathy is a major feature of the pathogenesis of Alzheimer’s disease"
} | B |
A 78-year-old man with primary central nervous system lymphoma was started on rituximab, methotrexate, and corticosteroids. Baseline hepatitis B virus (HBV) serologic tests, 2 months before chemotherapy, showed nonreactive hepatitis B surface antigen (HBsAg) and hepatitis B core total antibody (HBcAb total) results. Chemotherapy was discontinued after 5 months due to worsening cognitive function and chemotherapy-related leukoencephalopathy. 1 month after discontinuation of systemic therapy, the patient was readmitted with nausea, anorexia, increased daytime somnolence, and elevated alanine aminotransferase. Further workup confirmed the diagnosis of HBV reactivation with detectable HBV-DNA. Clinical condition resolved with antiviral therapy against HBV. What is the diagnosis in this patient? | Seronegative occult HBV infection | {
"A": "Chronic HBV infection",
"B": "False-reactive HBV",
"C": "Seropositive occult HBV infection",
"D": "Seronegative occult HBV infection"
} | D |
A 45-year-old man presented with cyanosis, dysaesthesia, and paresis of all his fingers and thumbs after a paragliding flight where he encountered a thunderstorm. His hands were exposed to an air temperature of -25°C and wind speeds up to 100 km/h. 2 days later, fluid-filled blisters developed on all the digits of his hands. What is the most likely diagnosis? | Frostbite | {
"A": "Primary Raynaud’s phenomenon",
"B": "Frostbite",
"C": "Bullous pemphigoid",
"D": "Cryoglobulinaemic vasculitis"
} | B |
6 months after initially presenting for weight loss and haemoptysis, a patient returns to the hospital. Though he completed a prescribed antibiotic regimen, he now has the pictured skin lesions on his face, torso, and extremities. MRI of the head shows multiple punctate lesions in the brain. What will be visualised by histopathology of skin biopsy? | Broad-based budding yeasts | {
"A": "Acute angle branching septated hyphae",
"B": "Broad-based budding yeasts",
"C": "Granulomatous inflammation with positive acid fast staining",
"D": "Beaded branching Gram-positive rod organisms, weakly positive on AFB stain"
} | B |
A 48-year-old man with a 12-month history of increasing shortness of breath was admitted to hospital. He was a heavy smoker and had decompensated Child-Pugh class C alcoholic cirrhosis. Physical examination showed the patient had platypnoea, clubbing of his fingers, and clear lung fields. An arterial blood gas breathing room air when lying down was a partial pressure of oxygen (PaO2) of 57 mm Hg with a widened alveolar–arterial oxygen gradient (66 mm Hg). When the patient was sitting upright, the PaO2 dropped to 43 mm Hg. What is the most likely diagnosis? | Hepatopulmonary syndrome | {
"A": "Hepatopulmonary syndrome",
"B": "Portopulmonary hypertension",
"C": "Congestive heart failure",
"D": "Chronic obstructive pulmonary disease"
} | A |
A 48-year-old man presented with multiple episodes of meningitis over a 30 year period. What is the most likely causal organism? | Herpes simplex virus type 2 | {
"A": "Streptococcus pneumoniae",
"B": "Neisseria meningitidis",
"C": "Herpes simplex virus type 2",
"D": "Group B streptococcus"
} | C |
A 40-year-old man presented with abdominal pain after eating sushi. A diagnosis of anisakiasis was made based on this finding at gastroscopy. How many hours after ingestion do the symptoms of gastric anisakiasis typically occur? | 1–12 h | {
"A": "1–12 h",
"B": "12–24 h",
"C": "24–36 h",
"D": "36–48 h"
} | A |
A 36-year-old woman had dyspnoea on exertion, with intermittent chest tightness. Laboratory results were all within the normal range, including serum total cholesterol, low-density lipoprotein, triglycerides, troponin, and c-reactive protein concentrations. A chest radiograph showed no abnormalities. Electrocardiogram during the treadmill test showed ST segment depression in the inferior leads. Coronary angiography showed coronary ectasia and triple vessel disease. What is the most probable diagnosis? | Coronary polyarteritis nodosa | {
"A": "Atherosclerosis",
"B": "Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis",
"C": "Coronary polyarteritis nodosa",
"D": "Antiphospholipid syndrome"
} | C |
Which drug commonly used to treat systemic lupus erythematous is associated with the retinal side-effect shown in the image? | Hydroxychloroquine | {
"A": "Corticosteroids",
"B": "Hydroxychloroquine",
"C": "Methotrexate",
"D": "Azathioprine"
} | B |
A 38-year-old man, presented to our hospital emergency room with sudden onset of severe pain, weakness, and hypoesthesia in both legs. All the toes of his left foot were cyanosed; arterial pulses were detected in the groin but absent in the popliteal fossae. 5 months earlier, he had a protracted acute pneumonia treated with cefuroxime. Anticardiolipin and anti-β2 glycoprotein antibodies were strongly positive. We made a diagnosis of antiphospholipid syndrome. Which of the following statements is correct regarding further tests? | Serology for Coxiella burnettii, the cause of Q fever, is required | {
"A": "A test for cold agglutinin is required",
"B": "A test for cryoglobulins is required",
"C": "Serology for Coxiella burnettii, the cause of Q fever, is required",
"D": "Systemic lupus erythematosus should be tested for"
} | C |
A fetus, on routine growth ultrasound scan, at 36 weeks, was found to have severely enlarged lateral ventricles and a dilated third ventricle, and normal growth. The findings were confirmed by MRI, which also showed signal abnormalities in the caudothalamic grooves, extensive signals in the periventricular white matter indicating possible oedema, macrocephaly, and hepatosplenomegaly. During pregnancy, the mother had ingested cooked venison, and reported feral cats in the backyard—although there was no direct cat exposure. What is the most likely diagnosis? | Toxoplasmosis | {
"A": "Cytomegalovirus",
"B": "Lymphocytic choriomeningitis virus",
"C": "Toxoplasmosis",
"D": "Zika virus syndrome"
} | C |
A 35-year-old woman presented with a 3-day history of dizziness, nausea, and fatigue. Neurological examination was normal. Blood pressure was 83/39 mm Hg. Laboratory investigations indicated a syndrome of inappropriate antidiuretic hormone secretion. CSF showed 8x106 leucocytes per L and a slightly increased CSF:serum albumin ratio without oligoclonal bands or malignant cells. Look at the MRI and choose the most likely diagnosis. | Neuromyelitis optica | {
"A": "High-grade Glioma",
"B": "Neuromyelitis optica",
"C": "Subacute stroke (with disruption of the blood brain barrier)",
"D": "Ependymoma"
} | B |
A previously healthy 37-year-old man presented to our emergency room with sudden onset partial vision loss and diplopia while driving home. Transsphenoidal endoscopic resection showed an extradural mass containing yellow crystalline-like fluid. What is the most likely diagnosis? | Xanthogranuloma | {
"A": "Craniopharyngioma",
"B": "Cystic pituitary adenoma",
"C": "Rathke cleft cyst",
"D": "Xanthogranuloma"
} | D |
A 53-year-old man presented with desaturation, cyanosis, and chocolate-coloured serum. What is the most likely cause? | Methemoglobinemia | {
"A": "Thalassemia",
"B": "Methemoglobinemia",
"C": "Drepanocytosis",
"D": "Carbon monoxide poisoning"
} | B |
A 6-week-old baby boy was seen at the emergency department with severe malnutrition, tachycardia, diarrhoea, and abdominal distention. X-ray showed colonic distension, faeces in the rectum but no air. He had passed faeces 48 h after birth with a glycerine suppository. What test would most definitively confirm the most likely underlying cause of his presentation? | Suction rectal biopsy | {
"A": "Abdominal CT scan without intravenous or oral contrast",
"B": "Sweat chloride test",
"C": "Suction rectal biopsy",
"D": "Clostridium difficile stool assay"
} | C |
A 26-year-old pregnant woman (at 20 weeks’ gestation) presented with a 3-month history of fever, cough, dyspnoea, epistaxis, nasal crusting, haemoptysis, and hearing loss. She had palpable purpura over her legs, and serum inflammatory markers were elevated. Chest x-ray showed cannonball opacities. What is the most likely diagnosis? | Granulomatosis with polyangiitis | {
"A": "Choriocarcinoma",
"B": "Lung carcinoma",
"C": "Granulomatosis with polyangiitis",
"D": "Pulmonary tuberculosis"
} | C |
A 61-year-old woman came to our neurosurgery clinic with a 20-year history of left-sided facial spasms and a 5-year history of severe episodic left facial pain. She had normal corneal reflexes bilaterally. Looking at the two MRIs what is the most likely diagnosis? | Painful tic convulsif | {
"A": "Tourette’s syndrome",
"B": "Multiple sclerosis",
"C": "Painful tic convulsif",
"D": "Trigeminal neuralgia"
} | C |
A 17-year-old boy with paediatric inflammatory multisystem syndrome temporally associated with COVID-19 presented with bilateral mild blurring of vision, bilateral red eyes, photophobia, and aching bilateral eye pain that disturbed his sleep. After instillation of 10% phenylephrine drops to both eyes, the injection remained. Slit lamp examination showed a bilateral anterior chamber grading of 2+ (16–25 cells in a 1 mm × 1 mm field). Look at the images of his eyes and choose the most likely diagnosis. | Anterior uveitis and scleritis | {
"A": "Viral conjunctivitis",
"B": "Acute glaucoma",
"C": "Episcleritis",
"D": "Anterior uveitis and scleritis"
} | D |
A 32-year-old man presented with a 3-week history of fever, cough, and general fatigue; he also reported a 1-month history of night sweats. The patient had no significant medical history; he had been previously fit and well and was prescribed no medications. On examination he was general unwell looking; his temperature was 38·80C, his blood pressure 82/49 mm Hg, and he had a sinus tachycardia of 130 beats per min. CT scans of the patient’s chest and abdomen showed multiple pulmonary nodules and bilateral adrenal masses—in the left adrenal gland the lesion was 61 mm × 36 mm and in the right 90 mm × 63 mm. 18fluorodeoxyglucose PET/CT scan showed an increase in tracer uptake in the multiple pulmonary nodules, the bilateral adrenal masses, and the thyroid gland. What diagnoses should be considered in this patient? Select the least likely. | Sarcoidosis | {
"A": "Malignant lymphoma",
"B": "Granulomatous infectious diseases—including tuberculosis and histoplasmosis",
"C": "Sarcoidosis",
"D": "Lymphomatoid granulomatosis"
} | C |
A 39-year-old woman was transferred to our neurosurgical service following a fall and development of a progressive quadriparesis over the previous 24 h. The patient had a history of uncontrolled type 1 diabetes and chronic pancreatitis associated with alcohol and benzodiazepine dependence. She was diagnosed with meningitis. Which of following statements is false? | The absence of fever, neck stiffness, and altered mental status eliminates meningitis as a likely diagnosis with a sensitivity of about 70% | {
"A": "The classic triad of fever, stiff neck, and alterations in mental status is present in about two-thirds of adults",
"B": "Fever is the most common finding.",
"C": "The absence of fever, neck stiffness, and altered mental status eliminates meningitis as a likely diagnosis with a sensitivity of about 70%",
"D": "Signs and symptoms alone do not provide sufficient information to diagnose meningitis"
} | C |
A 37-year-old woman presented with bone pain affecting her legs. She had no past medical history of these symptoms and she took no regular medications. A bone scan showed widespread increased uptake consistent with osteomalacia. Her serum phosphate was low at 0·3 mmol/L. Serum calcium, parathyroid hormone, and vitamin D were all normal. Urine analysis showed an increased excretion of phosphate (fractional excretion 45%) but normal urinary urate and glucose, with undetectable protein. What is the most likely diagnosis? | Oncogenic osteomalacia | {
"A": "X-linked hypophosphatemic rickets",
"B": "Fanconi syndrome",
"C": "Oncogenic osteomalacia",
"D": "Vitamin D deficiency"
} | C |
A 48-year-old man presented to our eye clinic with painless decline in his vision over the past 3 weeks. He has a history of advanced stage B-cell lymphoma. What is the most likely diagnosis? | Ocular involvement by systemic lymphoma | {
"A": "Bilateral eye infections",
"B": "Ocular involvement by systemic lymphoma",
"C": "Non-neoplastic uveitis",
"D": "Recent ocular steroid injections"
} | B |
A 69-year old man with a history of high blood pressure was admitted to ICU with COVID-19 respiratory distress syndrome, and an ECG showed diffuse inverted T-waves, an elevated troponin. One of the following outlines the recommended course of action. Which is it? | Immediate treatment with antiplatelet and anticoagulation therapy followed by an angiogram within 24 h, and if negative, proceed to cardiovascular magnetic resonance scan | {
"A": "An immediate coronary angiogram followed by anticoagulation and antiplatelet therapy",
"B": "Screen for alternative virus infections—including parvovirus B19, Human Herpes Virus, Epstein-Barr virus, enterovirus, Cytomegalovirus—and if negative, start antiplatelet therapy",
"C": "Cardiovascular magnetic resonance scan followed by coronary angiogram",
"D": "Immediate treatment with antiplatelet and anticoagulation therapy followed by an angiogram within 24 h, and if negative, proceed to cardiovascular magnetic resonance scan"
} | D |
A 19-year-old woman with a 1-month history of increasing bilateral pain and swelling in her lower back, reports recent worsening of her symptoms. She had no fever and had not experienced any recent trauma. She had no medical history of note. Laboratory investigations found no abnormalities. CT scan showed bilateral perinephric hypodense fluid collections sparing renal parenchyma, with left compressive renal injury, consistent with bilateral renal lymphangiomatosis. Which of the following statements about renal lymphangiomatosis is false? | Asymptomatic renal lymphangiomatosis requires treatment | {
"A": "Asymptomatic renal lymphangiomatosis requires treatment",
"B": "Renal lymphangiomatosis is a rare condition caused by lymphatic dysfunction.",
"C": "Renal lymphangiomatosis is a benign pathology.",
"D": "In contrast with autosomal dominant polycystic kidney disease, renal lymphangiomatosis spares the renal parenchyma; cysts are perinephric."
} | A |
A 50-year-old male smoker presented with a 2-year history of mild exertional dyspnoea and a dry cough. Physical examination was unremarkable. Chest x-ray was normal, but lung function testing showed a moderate reduction in diffusion capacity for carbon monoxide. Look at the CT chest and choose the most likely diagnosis. | Pulmonary alveolar proteinosis | {
"A": "Chronic obstructive pulmonary disease",
"B": "Pulmonary alveolar proteinosis",
"C": "Idiopathic pulmonary fibrosis",
"D": "Pulmonary Langerhans cell histiocytosis"
} | B |
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