THE UNIVERSITY OF HONG KONG

LKS FACULTY OF MEDICINE

SCHOOL OF CLINICAL MEDICINE

M.B., B.S. Fourth Summative Assessment — July 2022

Paper I: Multiple Choice Questions and Extended Matching Questions

Date July 13, 2022 (Wednesday)

Time 9:30 am — 12:30 pm
Venue Flora Ho Sports Hall

CANDIDATE’S LABEL

INSTRUCTIONS:

1 This paper consists of 120 questions which are divided into Sections A and B. Answer
ALL questions.

Section A: Multiple Choice Questions (One Best Answer Format)

Section B: Extended Matching Questions

Stick your candidate number label in the ““Candidate’s Label” box on this question paper.

You are provided with two answer sheets: one for Section A and one for Section B. Stick
your candidate number label in the “Name Label” box on each of the answer sheets
provided. Mark your answers in pencil on the corresponding answer sheet for each section
Do not write on the question paper.

You are advised to spend around 141 minutes on Section A and 39 minutes on Section B.

Each question carries equal marks. No mark will be deducted for a wrong answer.

The question paper must not be taken away.

SECTION A: MULTIPLE CHOICE QUESTIONS (Q.1 — Q.94)

Question 1

A 65-year-old patient was reviewed at a multidisciplinary board for his locally advanced
hepatocellular carcinoma. Endovascular embolisation was recommended as treatment.
What additional patient characteristic would prompt the radiologist to perform
transarterial radio-embolisation with Yttrium-90 (Y-90) microspheres as opposed to
chemo-embolisation with cisplatin/lipiodol emulsion?

A. Anaphylaxis to contrast
B. Extrahepatic metastases
C. Portal vein tumour thrombus

D. Uncorrectable coagulopathy

Question 2

A 45-year-old man fell on an outstretched hand. On examination, he had tenderness

around the anatomical snuff box of his right hand. What is the BEST initial imaging test
to perform?

A. Hand computed tomography

B. Hand ultrasound

C. Hand X-ray (AP)

D. Hand X-ray with scaphoid views

Question 3

You are a team member of an Emergency Medical Team who responds to a mass casualty
event. It involves an overturn of a double decker bus with more than 100 passengers
extricated. To start, how would you rapidly differentiate those requiring emergency
treatment and those who do not at scene?

A. Check all victims for normal pulsations of limbs

B. Check all victims for the ability to breathe normally
C. Check all victims for the ability to speak their names
D. Check all victims for the ability to walk to another area

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Question 4

Mr. Poon is a 22-year-old male university student who lives in hall. He presents with a 1-
day history of periumbilical, crampy abdominal pain associated with watery diarrhoea.
The symptoms came on suddenly. The pain does not radiate and is temporarily relieved
with each episode of diarrhoea. He has had 5 bowel movements in the past 24 hours. There
is no blood or mucus in the stool. He also complains of nausea and vomiting and has a
body temperature of 37.5°C. Which of the following organisms is the MOST LIKELY
cause of Mr. Poon's condition?

A. Clostridium difficile
B. Norovirus

C. Salmonella

D. SARS-CoV-2 virus

Question 5

A 55-year-old accountant complains of central chest discomfort for the past month. On
further questioning, he also reveals the discomfort comes on after walking uphill for 1 一
2 minutes and settles after resting for 5 minutes. He has been diagnosed to have type II
diabetes mellitus for 5 years. Which of the following is the MOST LIKELY diagnosis?

A. Angina
B. Costochondritis

C. General anxiety disorder

D. Pleuritis

Question 6

Mrs. Yip consulted the doctor because she was worried about not being able to get
pregnant. The couple never had sexual intercourse in their two years of marriage, but
their relationship was very good, and they hugged and kissed every night. It appeared
that Mr. Yip did not have any desire for sexual intercourse. He was also quite introverted
and appeared anxious when he had to speak in weekly meetings at work. An individual
session with Mr. Yip revealed that he never masturbated and never had nocturnal
emissions. Physical examination showed that his testes were slightly smaller than normal,
and that he also had gynaecomastia (increased breast tissue).

What is the MOST LIKELY diagnosis?

A. Mr. Yip had autistic spectrum disorder.

B. Mr. Yip had complete androgen insensitivity syndrome (i.e., the body cannot respond to
the male sex hormone).
C. Mr. Yip had Klinefelter syndrome (i.e., the man has three sex chromosomes, XXY).
D. Mr. Yip had social anxiety disorder which made him avoid interpersonal interactions.
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Question 7

Mrs. Lee was at 12 weeks of pregnancy. She was worried that her husband may have
extramarital affairs/sex if she did not allow sexual intercourse. She asked the doctor
whether she could have sexual intercourse during pregnancy. Which of the following is
the MOST APPROPRIATE answer?

A. If the pregnancy is normal, and that there are no signs of miscarriage, women can have
sexual intercourse during pregnancy.
B. It is best to avoid sexual intercourse during pregnancy because the semen may enter the
cervix and then diffuse across the amniotic membrane to the foetal head.

C. Pregnant women should not have sexual intercourse because the uterus will contract
strongly during orgasm and this may cause a miscarriage.
D. Pregnant women should not have sexual intercourse because this may cause infection of
the cervix and the endometrium (the inner lining of the uterus).

Question 8

A 23-year-old man was admitted to the medical ward following resuscitation and
treatment for possible anaphylaxis. Which of the following investigations would be MOST
USEFUL to help confirm the diagnosis of anaphylaxis?

A. Eosinophil count
B. Inflammatory markers (ESR/CRP)
C. Total IgE
D. Tryptase

Question 9

A 40-year-old woman presented with oligomenorrhoea and progressive weight gain for 2
years. Physical examination revealed the following: blood pressure of 150/90 mmHg, body
mass index of 27.0 kg/m’, moon-like facies, proximal muscle weakness, thin skin, and
purplish abdominal striae. What is the MOST LIKELY diagnosis?

A. Acromegaly
B. Cushing syndrome
C. Hypothyroidism
D. Polycystic ovarian syndrome

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Question 10

Ms. Yuen is a 55-year-old housewife. She noted a rapid onset of numbness over her left
leg 2 years ago. It was followed by numbness of her left arm 2 days later. Weakness of her
left leg was noted 1 year ago. Cranial nerve examination revealed normal smell, normal
visual acuity, normal pupillary reactions to light, full range of eye movements, normal
jaw power, normal facial sensations, symmetrical facial movements, normal shoulder and
neck power, and normal tongue movements. Examination of her limbs revealed mildly
reduced left lower leg muscle bulk, normal muscle tone, mild left leg weakness, normal
arm tendon reflexes, reduced leg tendon reflexes, downgoing plantar responses, normal
coordinations, and reduced touch sensation over left forearm and left lower leg. Where is
the lesion?

A. Brain

B. Muscles

C. Peripheral nerves
D. Spinal cord

Question 11

A 30-year-old woman had been treated for acute leukaemia with bone marrow
transplantation. She remained amenorrhoeic 2 years after oncological treatment. What
would be the expected pattern of her hormonal profile?

A. High follicle-stimulating hormone (FSH), high luteinising hormone (LH), low oestradiol
(E2)
B. Low FSH, high LH, low E2
C. Low FSH, low LH, low E2
D. Low FSH, low LH, normal E2

Question 12

A 20-year-old woman attended antenatal clinic at 14 weeks of gestation. She had a family
history of thalassaemia and her complete blood count showed microcytic anaemia. Which
of the following is the MOST USEFUL screening test for thalassaemia in the antenatal
period?

A. Family history of thalassaemia

B. Haemoglobin level
C. Haemoglobin pattern study
D. Mean corpuscular volume

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Question 13

A 38-year-old, G1IP1, smoker, just delivered her baby via lower segment Caesarean
section (LSCS) 4 days ago. Her antenatal course was uncomplicated except her pre-
pregnant body mass index was 35 kg/m. She underwent medical induction for pre-
eclampsia but had a failed induction with LSCS performed. The operation was
uncomplicated. Urinary catheter was inserted before operation. Clear urine was noted.
She complained of some leg pain, shortness of breath and malaise. Lochia was not heavy,
and uterus was well contracted and non-tender. Chest was clear and mild left calf
tenderness was felt. What is the MOST LIKELY cause of her presentation post-delivery?

A. Deep vein thrombosis

B. Endometritis

C. Urinary tract infection

D. Wound infection

Question 14

A 25-year-old woman attended the Family Planning Clinic for contraceptive advice. She
revealed that she was sometimes engaged in commercial sexual activities, and would like
to consider a contraceptive method for which she can control over the use and which
protect her from pregnancy as well as sexually transmitted infections. Which of the
following is the BEST contraceptive option for her?

A. Combined oral contraceptive pill

B. Male condom

C. Male condom added with spermicide

D. Spermicidal vaginal suppository

Question 15

Tear fluid layer is composed of the mucin, aqueous, and lipid. Dry eye disease can be the
result of abnormality in the production of anyone or combination of the tear composition.
Which of the following structures is responsible for the production of mucin in the tear
fluid layer?

A. Conjunctival goblet cells

B. Lacrimal gland
C. Meibomian gland
D. Tarsal gland

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Question 16

A 45-year-old clerk attended your clinic for a sudden onset of right buttock pain while
lifting heavy objects, with pain radiated from buttock to right posterior thigh and lateral
leg. Physical examination showed numbness over his right lateral leg and foot dorsum,
weakness over extensor hallucis longus and normal ankle jerk. What is the MOST
LIKELY diagnosis?

A. Common peroneal nerve palsy

B. L4 radiculopathy
C. L5 radiculopathy
D. S1 radiculopathy

Question 17

A 90-year-old gentleman slipped and fell in the street. He noted severe left hip pain and
was not able to walk. X-ray showed undisplaced fracture neck of femur. Which of the
following would MOST LIKELY be present?

A. Hypocalcaemia
B. Physical examination revealed shortening of left lower limb
C. T-score of -3 on DEXA scan

D. Vitamin A deficiency

Question 18

A 36-month-old boy received all vaccines as scheduled in the Hong Kong Childhood
Immunisation Programme but was admitted with pneumonia associated with pleural
effusion and empyema. Which of the following pathogens is MOST LIKELY the causative
agent of his pneumonia?

A. Haemophilus influenzae type B

B. Influenza virus
C. Staphylococcus aureus
D. Streptococcus pneumonia serotype 3

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Question 19

A medical technologist extracted RNA from a blood sample and checked the quality of
the extracted RNA by agarose gel electrophoresis. What banding pattern did the medical
technologist expect to observe after electrophoresis for RNA with good quality for
performing molecular tests?

A. A single band with a large molecular weight (larger than 15 kb compared to molecular size
marker)
B. A single band with a size of 5000 bp
C. Multiple bands with size ranging from 100 bp to 1.2 kb
D. Two sharp distinct bands with intensity of the upper band stronger than the lower band

Question 20

BRAF mutation can be used as a biomarker for vemurafenib treatment in melanoma

patients. Which assay can be used to detect the BRAF gene mutation?

A. DNA sequencing
B. FISH
C. Immunohistochemistry
D. Western blot

Question 21

A 40-year-old man was noticed to have hypokalaemia and urine potassium concentration
greater than 40 mmol/L, and a normal anion-gap metabolic acidosis. The urine pH is
greater than 5.5. What is the MOST LIKELY cause of hypokalaemia?

A. Conn syndrome
B. Cushing syndrome
C. Pseudo-Bartter syndrome
D. Sjégren syndrome

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Question 22

Molecular genetic tests are now commonly used to assist diagnostic pathology
particularly in challenging cases. Which of the following gene mutation tests is applied to
assist histopathological diagnosis of ovarian Sertoli-Leydig cell tumour, a sex cord
stromal tumour?

A. BRCA
B. DICER
C. EGFR
D. KRAS

Question 23

A 23-year-old lady was admitted for fever and dizziness. The complete blood count
showed pancytopenia with circulating blasts and a diagnosis of acute leukaemia is
suspected. Bone marrow examination was done and the sample was sent for cytogenetic
testing. Which phase of the cell division cycle is needed for examination of karyotype for
cytogenetic test?

A. Anaphase
B. Metaphase
C. Prophase
D. Telophase

Question 24

Characteristic features of a certain disorder include unpredictable attacks, signs

reminiscent of myocardial infarction, and anticipatory anxiety, in the absence of severe
stress. What is the MOST LIKELY diagnosis?

A. Agoraphobic disorder
B. Conversion disorder

C. Obsessive-compulsive disorder
D. Panic disorder

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Question 25

Normal grief and depression are commonly observed in the terminally ill patients. What
is the difference between normal grief and depression?

A. Active suicidal idea usually exists in both normal grief and depression.
B. Both normal grief and depression are maladaptive responses.
C. Excessive guilt is commonly existed in normal grief but not in depression.
D. Hopelessness is persistent and pervasive in depression. Episodic and focal loss of hope is
in normal grief.

Question 26

A 23-year-old university student presented to the Accident and Emergency Department

with auditory hallucinations, visual hallucinations, persecutory delusion, passivity
experience and disorganised speech. He had a recent history of amphetamine abuse.
Which of the following clinical features indicates substance-induced psychosis, rather
than schizophrenia, is the MOST LIKELY diagnosis?

A. Disorganised speech
B. Passivity experience
C. Persecutory delusion
D. Visual hallucinations

Question 27

A 68-year-old gentleman with poorly-controlled diabetes mellitus presented with

progressively painful perineal swelling for 2 days. On physical examination, body
temperature was 39°C, blood pressure was 98/56 mmHg, pulse was 120 beats per minute.
He was noted to have diffuse erythema involving bilateral scrotum and penile shaft. There
was palpable crepitus. What is the MOST LIKELY diagnosis?

A. Abscess

B. Carbuncle

C. Fournier's gangrene
D. Furuncle

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Question 28

A 50-year-old woman presents to your clinic with a 1 cm cluster of pleomorphic

calcifications in her right breast detected by mammogram during a health check. Which
of the following would be the MOST APPROPRIATE next step of management?

A. History taking and physical examinations

B. MRI of the breast and axilla

C. Stereotactic-guided core biopsy

D. Ultrasound of the breast and axilla

Question 29

A 60-year-old lady presented with difficulty in swallowing. Physical examination showed

a left 7 cm neck mass that moved up with swallowing. The mass could not be gotten below.
The trachea was deviated to the right side. Which of the following is compatible with the
diagnosis of retrosternal goitre?

A. Atrial fibrillation

B. Dilated neck veins in the neck and upper chest wall

C. Enlarged cervical lymph nodes
D. Proptosis

Question 30

A 40-year-old woman presented with malaise and shortness of breath on exertion.

Physical examination showed that she was pale and jaundiced. There was a surgical scar
for cholecystectomy which was done 3 years ago. The abdomen was soft and the spleen
was just palpable below the coastal margin.

Hb 8.0 g/dL (Normal: 12 — 15 g/dL)

Blood film showed the presence of polychromasia and spherocytes.
Direct antiglobulin test was negative.

What is the MOST LIKELY diagnosis?

A. Autoimmune haemolytic anaemia

B. Hereditary spherocytosis
C. Pernicious anaemia

D. Pure red cell aplasia

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Question 31

Ms. Wong completed her university studies 1 year ago. She attended her family physician,
Dr. Lee, for a pre-employment health check. She has been asymptomatic with no specific
complaints. However, noting that her cousin Ms. Chan was recently diagnosed to have
systemic lupus erythematosus complicated by glomerulonephritis, Dr. Lee asked for an
‘autoimmune screen'. Results were as follows:

Test Result
Anti-nuclear antibodies 1/640
Anti-extractable nuclear antibodies Anti-Ro and anti-La positive
Anti-cardiolipin antibodies (IgG) Negative
Anti-cardiolipin antibodies (IgM) Positive 32 [U/L (Normal: < 15 IU/L)
Anti-dsDNA antibodies Negative
Serum C3 102 mg/dL (Normal: 90 — 180 mg/dL)
Serum C4 25 mg/dL (Normal: 10 — 40 mg/dL)
Serum I[gG 1235 mg/dL (Normal: 819 — 1725 mg/dL)
Serum IgA 313 mg/dL (Normal: 70 — 386 mg/dL)
Serum IgM 92 mg/dL (Normal: 55 — 307 mg/dL)

Her complete blood count and renal and liver function tests were reported as normal.

What is the MOST LIKELY clinical diagnosis?

A. Anti-phospholipid antibody syndrome

B. Lupus diathesis
C. Sjogren syndrome
D. Systemic lupus erythematosus

Question 32

A 35-year-old man presented with palpitation and severe hypertension. Investigations

showed a left phaeochromocytoma. Which of the following antihypertensive agents would
you Start first in this patient?

A. Alpha blocker
B. Angiotensin converting enzyme inhibitor
C. Beta blocker

D. Thiazide

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Question 33

A 45-year-old man presents with on-and-off headache and physical examination shows
elevated blood pressure of 145/95 mmHg. Which of the following is the potential
advantage of using ambulatory blood pressure measurement for diagnosis of
hypertension?

A. Cheap and widely available

B. Easily repeated and used over long term to assess blood pressure variability
C. Patient engagement in blood pressure measurement
D. Provide night-time reading

Question 34

A 60-year-old man suffers from ischemic heart diseases with stable angina. He would like
to know the prognosis of his cardiac condition. What is the percentage of patients present
with stable angina progress to acute coronary syndrome within 12 months?

A.<5%
B.
5 一10%
C. 10 一20%
D. > 50%

Question 35

A 65-year-old man was diagnosed to have stable coronary artery disease with chest pain
on exertion. ECG showed sinus rhythm with resting heart rate of 50 beats per minute.
Which of the following agents should be used as first-line treatment of his angina
symptoms?

A. Amlodipine
B. Atenolol

C. Diltiazem

D. Verapamil

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Question 36

A 67-year-old man has been receiving infliximab (anti-TNF-alpha) in the past 6 months
for the treatment of ulcerative colitis. He presented with low grade fever and progressive
shortness of breath for 6 weeks. Chest X-ray revealed a moderate right pleural effusion.
Which of the following investigations will MOST LIKELY provide an early diagnosis?

A. Blood culture

B. Pleural biopsy
C. Pleural fluid culture

D. Pleural fluid cytology

Question 37

A 34-year-old lady with episodic wheezing and shortness of breath for 4 years requires
frequent courses of oral corticosteroid despite inhaled high-dose budesonide and
formoterol. Which of the following may help in selecting further therapeutic options?

A. Exercise-induced bronchospasm
B. FEV1 increased from 0.8 L to 1.2 L with inhaled salbutamol

C. Positive bronchial challenge test

D. Raised peripheral blood eosinophils

Question 38

A 60-year-old man with known alcoholic liver cirrhosis was admitted for increased
confusion. Arterial serum ammonia was noted at 120 pmol/L (Normal: 6 — 47 nmol/L)
Which of the following is MOST LIKELY to precipitate the patient's confusion?

A. Diagnostic paracentesis
B. Duodenal ulcer bleeding
C. Failure of alcohol abstinence

D. Recent diagnosis of hepatocellular carcinoma

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Question 39

A 33-year-old woman of unremarkable past health was noted to be jaundiced and with
increased abdominal distension and mental confusion over the past 2 days. She was
eventually admitted into the intensive care unit. The following were her blood results:

Test Result Normal range

Bilirubin 258 nmol/L <17 pmol/L
Albumin 38 g/L 39 — 50 g/L
AST > 3,000 U/L < 40 U/L
ALT > 3,000 U/L < 538 U/L
INR Led
Hepatitis B surface antigen Negative

She was diagnosed with acute liver failure.

Which of the following is MOST LIKELY to precipitate the patient's acute liver failure?

A. Acute hepatitis E
B. Intake of red wine | day prior to symptoms
C. Recent prescription of atorvastatin for dyslipidaemia
D. Recent prescription of oral corticosteroids for eczema

Question 40

A 40-year-old man complains of heartburn sensation. He is diagnosed with gastro-

oesophageal reflux disease by clinical features and you plan to start him on empirical
proton pump inhibitor trial. He is concerned about the potential side effects of the drug.
Which of the following complications has been shown to be caused by long-term proton
pump inhibitor therapy?

A. Bone fractures

B. Dementia

C. Enteric infections

D. Pneumonia

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Question 41

A 25-year-old lady with type I diabetes mellitus is admitted for recurrent vomiting. The
vomiting started 3 days ago and commenced 30 minutes after each meal. Her glycaemic
control has been satisfactory. She had a mild upper respiratory tract infection 1 week ago.
She does not have abdominal pain or constipation. Abdominal X-ray showed no dilated
bowels but a prominent gastric bubble. Which of the following is the next investigation
for reaching the diagnosis?

A. Amylase level
B. Computed tomography of abdomen
C. Random glucose level
D. Upper endoscopy

Question 42

A 55-year-old female non-smoker has a long-standing diagnosis of rheumatoid arthritis

under good control with disease-modifying anti-rheumatic drugs. She was recently found
to have developed honeycomb appearance on chest imaging. Which of the following drugs
she should avoid?

A. Hydroxychloroquine
B. Ibuprofen
C. Methotrexate

D. Prednisolone

Question 43

A 55-year-old lady with advanced stage lung cancer was admitted for chills and confusion.
She has just received chemotherapy last week. What is the MOST IMPORTANT test to
do at presentation?

A. Clotting profile
B. Complete blood picture
C. Liver function test

D. Renal function test

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Questlon 44

A 75-year-old man has a history of chronic obstructive pulmonary disease and after recent
discharge from hospital he was advised to have home oxygen therapy. What is the MOST
APPROPRIATE therapy for him?

A. Home oxygen therapy at least 16 - 18 hours a day including bedtime

B. Home oxygen therapy during sleep at night
C. Home oxygen therapy during the day except mealtime
D. Home oxygen therapy whenever he has increased dyspnoea or needs exercise

Question 45

A 55-year-old male chronic heavy smoker with a recent diagnosis of severe coronary
artery disease on waitlist for coronary intervention consulted you for smoking cessation.
What is the BEST option to help him quit smoking?

A. Counselling plus Bupropion SR

B. Counselling plus nicotine replacement therapy
C. Counselling plus Varenicline
D. Professional counselling service plus follow up

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Question 46

A 26-year-old man presented to your clinic for health check. He lived an active lifestyle
and had no significant symptoms. He was adopted at the age of 3 months and knew
nothing about his biological family.

Physical examination revealed greyish circumferential deposits around both eyelids.

There were also yellowish papules on the dorsal surface of both hands. His blood pressure
was 118/70 mmHg and pulse was 58 beats per minute.

Investigation results are presented below:

Test Result Normal range

Na 138 136 — 148 mmol/L
K 4.0 3.6 —5.0 mmol/L
eGFR > 90 > 90 ml/min/1.73
m2
Haemoglobin 14.8 13.3 — 17.1 g/dL
HbAtic 5.0 < 6.5%
TSH 1.6 0.35 — 4.8 mIU/L
Cholesterol 8.8 <5.2 mmol/L
Triglycerides 1.0 <1.7 mmol/L
LDL 6.9 < 2.6 mmol/L
HDL 1.4 = 1.6 mmol/L

What would be the MOST APPROPRIATE management for this patient?

A. Calculate 10-year cardiovascular risk

B. Lifestyle modification and repeat lipid profile in 3 months
C. Start ezetimibe

D. Start high dose statin

Question 47

A 68-year-old man presented to the Accident and Emergency Department for fast
palpitation. He had a history of delayed presentation of myocardial infarction 2 years
ago. His current medications include aspirin, rosuvastatin, bisoprolol and entresto.

His blood pressure was 92/50 mmHg, pulse was 188 beats per minute. Physical
examination found a thready pulse and a deviated apex. Cardiac monitor revealed wide
complex tachycardia.

How would you manage this patient?

A. Defibrillation

B. Direct synchronised cardioversion

C. Intravenous adenosine triphosphate
D. Transcutaneous pacing

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Question 48

A 50-year-old obese man was admitted for left calf swelling for 1 day. Ultrasound Doppler
of lower limb venous system confirmed the presence of thrombus in left popliteal vein.

On further questioning, he had a total hip replacement surgery 2 weeks ago and was
discharged from another hospital 3 days earlier. His father also history of deep vein
thrombosis.

Which of the following management is the MOST APPROPRIATE?

A. To arrange reassessment ultrasound Doppler in 1 week and start anticoagulation if there is

progression of thrombus
B. To measure his antithrombin, protein C and protein S levels in view of positive family
history and arrange for long term anticoagulation if he is deficient of any of these proteins
C. To start anticoagulation and for a total of 3 months
D. To start anticoagulation and for a total of 6 months

Question 49

An 80-year-old woman presented with bone pain and anaemic symptoms. Her blood tests
showed her haemoglobin was 8.0 g/dL (Normal: 11.5 — 14.8 g/dL), albumin was 35 g/L
(Normal: 39 — 50 g/L), globulin was 50 g/L (Normal: 26 — 40 g/L). Serum protein
electrophoresis demonstrated the presence of IgG kappa paraprotein of 28 g/L. Bone
marrow examination demonstrated 30% clonal plasma cells. Which of the following is
the MOST IMPORTANT prognosticator in this patient's condition?

A. Beta-2-glycoprotein
B. Beta-2-microglobulin
C. Globulin level

D. Percentage of plasma cells in bone marrow

Question 50

A 25-year-old gentleman with a history of recurrent uveitis, presented to you with

inflammatory back pain for 6 months. Which of the following blood tests is the MOST
SUITABLE investigation for diagnosis?

A. ANA
B. HLA-B27
C. HLA-B5801
D. Rheumatoid factor

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Question 51

A 35-year-old gentleman with spondyloarthritis presented to you with shortness of breath

on exertion and orthopnoea. Physical examination of the cardiovascular system showed
early diastolic murmur, best heard at the left sternal border. Which of the following is the
MOST LIKELY diagnosis?

A. Aortic regurgitation
B. Apical pulmonary fibrosis
C. Mitral stenosis

D. Pulmonary regurgitation

Question 52

A 19-year-old girl was admitted because of polyuria and polydipsia for 2 weeks. Random
blood glucose on admission was 32 mmol/l and urine test for ketone was strongly positive.
Which of the following MUST be included in her management?

A. Saline infusion

B. SGLT2 inhibitor

C. Sodium bicarbonate

D. Subcutaneous insulin injection

Question 53

A 70-year-old woman, who enjoyed good past health, complained of tiredness, bone pain
and constipation for a few weeks. Blood tests revealed the following:

Test Result Normal range

Serum adjusted calcium 3.01 mmol/L 2.11 — 2.55 mmol/L
Serum phosphate 0.98 mmol/L 0.88 — 1.45 mmol/L
eGFR 60 ml/min/1.73m2 > 90 ml/min/1.73m2
Alkaline phosphatase 300 U/L 42 — 110 U/L
Parathyroid hormone < 0.3 pmol/L 1.6 — 6.9 pmol/l

Which of the following is the MOST APPROPRIATE investigation?

A. 1,25OHVit D levels
B. Bone scan

C. MIBG scan

D. Sestamibi scan

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Question 54

A 40-year-old man, chronic smoker, complained of fever, neck pain, bilateral hand tremor
and heat intolerance for 1 week. Physical examination revealed a tender neck swelling
without bruit. Which of the following is the MOST APPROPRIATE investigation to
delineate the cause of his condition?

A. Anti-thyroid peroxidase antibody

B. Anti-TSH receptor antibody
C. Thyroid scan
D. Ultrasound of the thyroid

Question 55

A 35-year-old woman had fever, headache and confusion. Neurological examination was
normal. Computed tomography of the brain was normal. Lumbar puncture and
cerebrospinal fluid analyses revealed the following results: a cell count of 180 per
microlitre (Normal: <5 per microlitre) with a differential count of 25% lymphocytes and
70% neutrophils, total protein ievel of 2.5 g/L (Normal: 0.15 — 0.45 g/L), and glucose level
of 5.2 mmol/L (Normal: 2.5 — 4 mmol/L). Her simultaneous blood glucose level was 14
mmol/L (Normal: 5—7 mmol/L). Which of the following is the MOST LIKELY diagnosis?

A. Bacterial meningitis
B. Cerebral abscess

C. Tuberculous meningitis
D. Viral meningitis

Question 56

Gout is a common cause of acute monoarthritis. To prevent recurrent attacks of acute

gouty arthritis, appropriate long-term management is important. Which of the following
is CORRECT?

A. Daily use of colchicine

B. Daily use of non-steroidal anti-inflammatory drugs (NSAIDs)
C. Give methotrexate

D. Use urate lowering agents

P.21 of 42 SA40722
Question 57

Haemarthrosis is one of the causes of monoarthritis. Which of the following investigations

can confirm the diagnosis?

A. Anti-nuclear antibody
B. Joint aspiration for synovial fluid analysis
C. Serum urate level

D. X-ray of the index joint

Question 58

An isolated prolongation of activated partial thromboplastin time (APTT) was found in

a healthy 25-year-old man during a health check-up. All other blood tests were normal.
He had an uneventful appendectomy 2 years ago. What is the MOST LIKELY cause of
the isolated prolongation of APTT?

A. Factor VII deficiency

B. Factor VIII deficiency
C. Factor X deficiency
D. Factor XII deficiency

Question 59

A 79-year-old woman, a non-smoker and non-drinker, enjoyed good past health and her
life after retirement with her husband until she experienced frequent short-lasting sharp
lightening pain over her right cheek in the past 3 weeks. The pain was very severe and
multiple attacks occurred daily though each attack lasted for 30 — 40 seconds only. She
cried during some attacks because of the severe pain. She consulted a neurologist who
told her that she had some form neuralgia. What investigation should be arranged for
her?

A. Computed tomography (CT) brain scan

B. Magnetic resonance imaging (MRI) brain scan
C. Positron emission tomography (PET) brain scan
D. Single-photon emission computed tomography (SPECT) brain scan

P.22 of 42 SA40722
Question 60

Which of the following is the standard surgical method of removing a bone osteosarcoma
without metastasis?

A. Biopsy
B. Intra-lesional excision

C. Marginal excision
D. Wide local resection

Question 61

Which of the following skin cancers is the MOST PREVALENT in Chinese population?

A. Basal cell carcinoma

B. Dermatifibrosarcoma protuberans
C. Melanoma

D. Microcystic adnexal carcinoma

Question 62

A 40-year-old man sustained a whiplash injury in a car crash. Which of the following
findings suggests a high risk of respiratory compromise?

A. Bilateral hand numbness and clumsiness

B. Loss of cervical lordosis

C. Raised diaphragm on chest radiograph

D. Systemic hypotension and bradycardia

Question 63

An 89-year-old gentleman undergoes laparoscopic cholecystectomy for gallstones. He

develops hypotension right after the surgeon insufflates the peritoneal cavity with CO2.
Which of the following is a physiological effect of pneumoperitoneum?

A. Decrease in airway resistance

B. Decrease in functional residual capacity
C. Increase in renal perfusion
D. Increase in venous return

P.23 of 42 SA40722
Question 64

An 11-year-old boy with a recent history of sore throat presented with fever and right
lower quadrant pain for 2 days. Laparoscopy showed the appendix was not inflamed.
However, there were enlarged lymph nodes at the terminal ileal mesentery. What is the
MOST LIKELY diagnosis?

A. Crohn's ileitis

B. Intestinal tuberculosis

C. Mesenteric adenitis

D. Pyelonephritis

Question 65

A 23-year-old gentleman presented with a 4 cm roundish swelling at the back. The

overlying skin was normal and the swelling was soft on palpation. It was not attached to
the skin or underlying structure. What is the MOST LIKELY diagnosis?

A. Basal cell carcinoma

B. Lipoma
C. Lymph node
D. Sebaceous cyst

Question 66

A 60-year-old Chinese man complained of blood-stained post-nasal drip and left-side

hearing loss. Physical examination showed presence of otitis media with effusion on the
left side. There was a 2 cm left level IL cervical lymph node. Nasoendoscopy showed a
tumour occupying the whole nasopharynx and biopsy showed the presence of
undifferentiated carcinoma. Which of the following is the MOST APPROPRIATE
treatment of his condition?

A. Concurrent chemotherapy and radiotherapy

B. Immunotherapy
C. Intensity modulated radiotherapy
D. Nasopharyngectomy and neck dissection

P.24 of 42 SA40722
Question 67

A head-injured patient could open eyes to painful stimulation, show abnormal flexion of
his upper limbs, and make incomprehensible sound. What was his Glasgow Coma Score?

A.4
B.5
C.6
D.7

Question 68

A 56-year-old man presented with a sudden onset of right hemiplegia and aphasia. Plain
computed tomography of the brain did not show any haemorrhages. Which of the
following statements BEST describes the subsequent management of his condition?

A. Endovascular mechanical thrombectomy is only effective for small vessel occlusion.

B. Intravenous tPA should only be given after observing the patient for 6 hours.
C. The absence of 'dense MCA sign’ does not exclude cerebral ischaemia.
D. Tranexamic acid should be given routinely.

Question 69

A 30-year-old woman complained of a recent onset of amenorrhoea and galactorrhoea.

Imaging studies showed a tumour at the sella turcica. Her serum prolactin level was 10
times above normal limit. Which of the following would be the MOST APPROPRIATE
management option?

A. Bromocriptine
B. Oral contraceptive pills
C. Temozolomide

D. Transsphenoidal tumour resection

P.25 of 42 SA40722
Question 70

An 80-year-old man consults his general practitioner for bed wetting at night for a few
months. He has long-standing lower urinary tract symptoms, including hesitancy,
straining, sense of incomplete emptying. What is the MOST LIKELY cause for his
nocturnal enuresis?

A. Mixed urinary incontinence

B. Overflow incontinence

C. Stress urinary incontinence

D. Urinary tract infection

Question 71

A 45-year-old lady underwent routine health screening before COVID-19 vaccination at

the advice of her family general practitioner. Health screening grew 10° colony-forming
units of Escherichia coli from her mid-stream urine. Urine biochemical analysis revealed
negative nitrites and microscopy showed squamous cells. She is voiding normally with no
symptoms. Which of the following is the MOST APPROPRIATE response to her
screening result?

A. No action required
B. Oral cefuroxime for seven days
C. Oral ciprofloxacin for three days
D. Oral nitrofurantoin for seven days

Question 72

In adult cardiac arrest advanced life support, which of following drugs is reeommended
by intravenous or intraosseous administration?

A. Bupivacaine
B. Calcium chloride

C. Epinephrine (adrenaline)
D. Sodium bicarbonate

P.26 of 42 SA40722
Question 73

A 25-year-old woman was admitted for water deprivation test because of polyuria. At the
end of the test, the urine osmolality was 150 mOsm/kg. However, after given DDAVP
injection (desmopressin acetate injection), the urine osmolality remained the same. Which
of the following is the MOST LIKELY cause of polyuria?

A. A defective arginine vasopressin receptor

B. An anterior pituitary lesion
C. Central diabetes insipidus
D. Nephrogenic diabetes insipidus

Question 74

A 48-year-old woman with metastatic breast cancer complained of back pain. There was
no neurological symptom or sphincter disturbance. Her lower limb power was full.
Magnetic resonance imaging (MRI) scan showed early cord compression at T9-10 level.
Palliative radiotherapy (30 Gy in 10 fractions) done. What is the MOST LIKELY outcome
after 1 month of completion of radiotherapy?

A. Decrease pain, ambulatory, urinary continent

B. Decrease pain, wheelchair bound, urinary continent
C. Decrease pain, wheelchair bound, urinary incontinent
D. Increase pain, ambulatory, urinary continent

Question 75

A 43-year-old lady with breast cancer (stage ID) is now receiving adjuvant chemotherapy.
On day 8 of her second cycle of chemotherapy, she attended the Accident and Emergency
Department (AED) for fever. On physical examination, her temperature was 38.5°C,
blood pressure 120/80 mmHg, pulse 85 beats per minute, SaO2 99% on room air. There
were no chest, gastrointestinal, or urinary symptoms. The doctor thought she might have
neutropenic fever. Which of the following is the MOST APPROPRIATE initial
management at AED after completing the septic workup?

A. Granulocyte colony stimulating factor (G-CSF) injection

B. Intravenous broad-spectrum antibiotics
C. Intravenous fluid resuscitation

D. Paracetamol

P.27 of 42 SA40722
Question 76

A middle-aged woman has a 1 cm lung nodule in the right lower lobe on the computed
tomography (CT) of her chest which has increased in size to 3 cm on the subsequent CT
chest 1 year later. What further investigation can be performed to confirm the
histological diagnosis of primary lung carcinoma?

A. CT-guided lung biopsy

B. Mediastinoscopy
C. PET-CT
D. Whole body CT

Question 77

A middle-aged female with rheumatoid arthritis presents with gradual worsening of

shortness of breath. The chest X-ray shows bilateral reticular opacities in the lower zones
bilaterally and reduced lung volumes bilaterally. What is the MOST LIKELY diagnosis?

A. Bacterial pneumonia
B. Heart failure

C. Interstitial lung disease

D. Metastatic lung carcinoma

Question 78

Your trauma team is taking care of a middle-aged man who is a victim of a traffic collision.
Multiple rib fractures are clinically suspected during primary survey. He complains to
have immense pain and requests immediate pain control. He has no known drug allergy
and chronic illness. Other aspects of primary and secondary surveys are unremarkable.
How would you control his pain during resuscitation for trauma in the Accident and
Emergency Department?

A. Inhalational nitrous oxide and oxygen mixture (Entonox®)

B. Intercostal nerve block with lignocaine
C. Intravenous morphine
D. Rectal diclofenac sodium

P.28 of 42 SA40722
Question 79

You are the leader of an Emergency Medical Team which is responsible for field triage.
There is a young woman who is lying on the ground. She can breathe normally at a rate
of 20 per minute. The radial pulse and capillary refill are normal. She is not able to follow
your commands. What triage category will you assign according to the START criteria?

A. Delayed
B. Expectant
C. Immediate

D. Minor

Question 80

A 35-year-old homemaker has had a low mood for the past 6 weeks. She has little interest
in cooking and playing with her children, which she used to enjoy. Which of the following
standard assessment instruments would be MOST RELEVANT to further explore this
patient's mental health problem?

A. Generalised Anxiety Disorder 7-item scale (GAD7)

B. Mini Mental State Examination (MMSE)
C. Patient Health Questionaire-2 (PHQ2)
D. Patient Health Questionaire-9 (PHQ9)

Question $1

Mrs. Wong, a 55-year-old widow, attends your primary care clinic today complaining of
insomnia. Her only son recently got married and moved out of the family home. She is
working as a cashier in the supermarket. She can cope with her work but she feels lonely
when she returns home with nobody around. Her appetite is normal. Mrs. Wong is
currently in which of the following family life-cycle stages?

A. Family in later life

B. Launching children and moving on (empty nest)
C. Leaving home (single young adult)
D. Marriage (new couple)

P.29 of 42 SA40722
Question 82

Mr. Tsui, a 60-year-old surveyor, presents to your family medicine clinic with a facial
lesion which has been growing slowly for the past 10 months as seen below. There is no
associated pain or itching. He has good past health and enjoys hiking.
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Source: Courtesy of https://www.visualdx.com

What is the MOST LIKELY diagnosis?

A. Basal cell carcinoma

B. Dermatofibroma

C. Keratoacanthoma

D. Molluscum contagiosum

P.30 of 42 SA40722
Question 83

A 3-year-old girl presented with fever for 4 days (peak 39.5°C). She had a seneralised
rash that first appeared on the face on day 3 of illness and spread downward to the neck,
trunk, and limbs. The following figure below showed a close-up view of the rash over the
trunk.

ee

os

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Bs
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Source: https://cluelessmedic.tumblIr.com

What is the MOST LIKELY clinical diagnosis?

A. Chickenpox
B. Measles

C. Parvovirus B19 infection

D. Roseola

Question 84

A young lady complains of a gradual onset of bilateral blurred vision after starting
university. A Snellen acuity test shows that the visual acuity in her right eye is 6/9 and
6/12 in her left eye. After adding the pinhole, her visual acuity improved to 6/6 in both
eyes. Which of the following statements is CORRECT?

A. A visual acuity of 6/12 means that a normal patient can read the letter at 6 meters while the
patient can read the same letter at 12 meters.
B. A visual acuity of 6/12 means that a normal patient can read the letter at 12 meters while
the patient can read the same letter at 6 meters.
C. Myopia and hyperopia can be corrected with a pinhole but astigmatism cannot.
D. Presbyopia can be corrected by a pinhole.

P.31 of 42 SA40722
Question 85

A 12-year-old female patient presented with poor vision. On examination, the patient was
of tall stature, being over the 95" percentile in height. The upper and lower limbs were
characterised as being long and thin. Scoliosis of the thoracic spine was noted, and eye
examination revealed subluxation of the lens bilaterally. Cardiac examination did not
reveal presence of any murmurs over the heart. What first-line genetic test would you
perform to confirm the suspected diagnosis?

A. Array comparative genomic hybridisation (CGH)

B. Karyotyping
C. Sequencing of the FBN/ gene
D. Testing for trinucleotide repeats

Question 86

A 5-year-old boy complained of having headache of 2 weeks duration with intermittent

vomiting for 3 times without any temporal pattern. He was also noted to have polyuria
and polydipsia with secondary nocturnal enuresis. He was less playful than he used to be.
Which of the following blood investigations will be helpful in arriving at the diagnosis?

A. AFP and B-HCG

B. CEA
C. Complete blood picture
D, LDH

Question 87

Mr. Tsang, a 19-month-old boy, was admitted for vomiting and diarrhoea for 3 days with
increasing severity. Prior to admission, he vomited undigested food for 5 times and had
loose watery stool for 4 times today. On examination, he has a body temperature of
37.9°C. He looks tired but is responsive. His peripheries are warm, and capillary refill is
3 seconds. His pulse rate is 120 beats per minute and blood pressure is 101/67 mmHg. His
respiratory rate is 30 breaths per minute. Urine ketone is 3+. Examination of his abdomen
reveals mild peri-umbilical tenderness, but no guarding or rigidity. He just passed a large
amount of watery stool which is greenish yellow with no blood. He vomited twice in the
Accident and Emergency Department. Which of the following is the MOST
APPROPRIATE management?

A. Give intravenous fluid maintenance

B. Give oral rehydration fluid alone and encourage fluid intake

C. Insert orogastric tube for fluid replacement by enteric route
D. Replace fluid deficit and ongoing loss by intravenous route

P.32 of 42 SA40722
Question 88

Mo Mo was referred to the paediatric general clinic for language delay. By the age of 3
years, he could express in single words, and he had a lot of echolalia. He could identify 2
body parts but could not identify colours or shapes. His parents expressed concern of his
easy loss of temper when his needs were not meet. When you met him at the clinic, he
could perform circular scribbles but could not copy straight lines or circles. He could go
up and down stairs holding on to rail. He had brief eye contact and did not response to
your name calling. What is the MOST LIKELY diagnosis?

A. Attention deficit hyperactivity disorder with fine motor delay

B. Autism spectrum disorder with global developmental delay
C. Global developmental delay with temper tantrum
D. Specific language impairment

Question 89

A 10-year-old girl is admitted for shortness of breath during exertion and progressive
ankle swelling over the past 2 weeks. For the past medical history, she received
chemotherapy for acute leukaemia diagnosed at 2 years old. She remained well after
completion of the treatment. On physical examination, she looks tired and has facial
puffiness and bilateral ankle oedema. The pulse is regular with a rate of 110 beats per
minute. The cardiac apex is located at the sixth intercostal space over the left anterior
axillary line. A cardiac murmur is audible at the cardiac apex and left lower sternal
border. The edge of the liver is palpable at 4 cm below the right costal margin. What is
the MOST LIKELY diagnosis?

A. Cardiomyopathy
B. Liver cirrhosis

C. Mitral regurgitation
D. Ventricular septal defect

Question 90

Cervical cancer is one of the most common cancers in women globally but is highly
preventable. Large scale adoption of cervical cytology screening has been found to be
effective in reducing the incidence and mortality of cervical cancer. For a screening
population, which of the following is the MOST COMMON abnormal cervical cytology
diagnosis?

A. Adenocarcinoma in situ

B. Atypical squamous cells of undetermined significance (ASC-US)

C. High-grade squamous intraepithelial lesion (HSIL)
D. Squamous cell carcinoma

P.33 of 42 SA40722
Question 91

According to the American Heart Association, moderate alcohol consumption refers to

having up to 1 standard drink per day for women and up to 2 standard drinks per day
for men. What is the amount of pure alcohol contained in 1 standard drink?

A. 4 grams
B. 14 grams
C. 24 grams
D. 34 grams

Question 92

The Smoking (Public Health) (Amendment) Bill 2019 was approved in the Legislative
Council on October 21, 2021. Under this Bill, which of the following activities regarding
electronic cigarettes and heated tobacco products is still allowed in Hong Kong?

A. Import
B. Manufacture

C. Personal use

D. Sale

Question 93

What is the MOST EFFECTIVE control measure to prevent asbestosis?

A. Install better ventilation system

B. Prohibit the use of asbestos

C. Provide personal protective equipment

D. Replace asbestos by fibrous silicate

Question 94

As part of a mental state examination, an interviewer asks, ''What is the similarity

between a chair and a table?". The interviewee replies, ''They both have legs."". What
kind of thinking is demonstrated in the mental state examination?

A. Abstract thinking
B. Bizarre thinking
C. Concrete thinking
D. Idiosyncratic thinking

P.34 of 42 SA40722
SECTION B: EXTENDED MATCHING QUESTIONS (Q.1 — Q.26)

I EXAMINATION OF THE III, [V AND VI CRANIAL NERVES IS IMPORTANT

A Facial asymmetry on smiling

B Impaired left eye abduction

Impaired left eye vertical gaze
Impaired right eye adduction
Loss of sensation over right face
Nystagmus of both eyes on horizontal gaze
Partial ptosis of left eye with small left pupil
Partial ptosis of right eye with normal pupil size and light reflex
I Weakness of right pterygoid muscle

J Weakness of right temporalis muscle

For each of the following clinical syndromes or neurological disorders, identify the MOST
LIKELY sign that can be detected from the list of options above. Each option may be used
once, more than once, or not at all.

Question |

Right cerebellar infarction

Question 2

Left abducens nerve palsy

Question 3

Left Horner syndrome

Question 4

Right oculomotor nerve palsy

Question 5

Autoimmune myasthenia gravis

P.35 of 42 SA40722
I PANCYTOPENIA
Acute lymphoblastic leukaemia
Acute myeloid leukaemia
Aplastic anaemia
Chronic myeloid leukaemia
Hodgkin lymphoma
Multiple myeloma
Myelodysplastic syndrome
Pernicious anaemia

I Primary myelofibrosis

J Sezary syndrome

For each of the following clinical scenarios, select the MOST LIKELY underlying cause
for the pancytopenia from the list of options above. Each option may be used once, more
than once, or not at all.

Question 6

A 24-year-old woman presented with malaise. Physical examination showed that she was pale.
There was no lymphadenopathy and hepatosplenomegaly. Blood film showed normal red cell
and neutrophil morphology. There were no other circulating abnormal cells. Bone marrow
examination showed a markedly hypocellular marrow.

Question 7

An 80-year-old woman presented with malaise. Physical examination showed that she was
pale. There was no lymphadenopathy and hepatosplenomegaly. Blood film showed the
presence of 5% circulating blasts with some of them containing single Auer rod. Some of the
neutrophils were agranular.

Question 8

A 65-year-old man presented with malaise. Physical examination showed that he was pale and
jaundiced. Glossitis was present. There was no lymphadenopathy and hepatosplenomegaly.
Blood film showed the presence of macro-ovalocytes and hyper-segmented neutrophils.

Question 9

A 52-year-old man presented with malaise. Physical examination showed that he was pale.
Physical examination showed a splenomegaly of 10 cm below the coastal margin. Blood film
showed the presence of occasional nucleated red cells and myelocytes, and tear-drop red blood
cells. No blasts were seen. Bone marrow biopsy was attempted but it was a dry tap.

P.36 of 42 SA40722
II. PANCYTOPENIA (con’t)
Question 10

An 18-year-old woman presented with malaise. Physical examination showed that she was
pale. There was also bilateral cervical lymphadenopathy. Blood film showed the presence of
circulating blasts that were myeloperoxidase and Sudan Black B negative.

P.37 of 42 SA40722
Ul. HEAD AND NECK SURGERY
A Adenocarcinoma

B Adenoid cystic carcinoma

C Ameloblastoma

Basal cell carcinoma

Dermatofibrosarcoma protuberans
Epulis
Multiple myeloma
Osteosarcoma

I Pleomorphic adenoma

J Squamous cell carcinoma

For each of the following clinical scenarios, choose the MOST LIKELY diagnosis from
the list of options above. Each option may be used once, more than once, or not at all.

Question 11

A 30-year-old pregnant woman presents with multiple inflammatory gingival swellings with
contact bleeding. The gingival condition improves after delivery.

Question 12

A 65-year-old man has a history of head and neck cancer operation 5 years ago. He was
diagnosed with lung metastasis for more than 2 years but is still asymptomatic.

Question 13

An 80-year-old man has a pigmented non-healing ulcer at his nose for 1 year. It is not painful
and is getting larger slowly.

Question 14

A 65-year-old man, who is a chronic smoker and chronic drinker, presents with hoarseness, a
right neck mass and infrequent haemoptysis for 2 months.

Question 15

A 30-year-old woman has a right upper neck mass for 3 years. It slowly increases in size
without any other symptoms.

P.38 of 42 SA40722
IV. FATIGUE
A Anaemia

B Cancer

C Depression
Diabetes

Fatigue of unknown origin

HIV/AIDS
Sleep-related disorder

Stress

I Thyroid disease

J Viral infection

For each of the following clinical scenarios, select the MOST LIKELY diagnosis from the
list of options above. Each option may be used once, more than once, or not at all.

Question 16

A 35-year-old mother of 3 young children has been feeling progressively more tired associated
with irregular menstrual cycles, dry skin and feeling cold.

Question 17

A 50-year-old obese taxi driver complains that he is very tired during the day and is worried he
will crash his car. He wakes up in the morning with a dry mouth and sore throat.

Question 18

A 58-year-old woman presents with fatigue for the past 2 months. She thinks it is because she
wakes up at 4:00 am and cannot go back to sleep. She also feels sad and disinterested in her
hobbies.

P.39 of 42 SA40722
Vv OPPORTUNISTIC INFECTION IN IMMUNOCOMPROMISED PATIENTS
Aspergillus fumigatus
Brucella melitensis

Cytomegalovirus
Entamoeba histolytica
Escherichia coli

Staphylococcus aureus
Streptococcus mitis
Streptococcus pneumoniae

I Talaromyces marneffei

J Yersinia pestis

For each of the following clinical scenarios, select the microorganism MOST LIKELY to
have caused the clinical presentation from the list of options above. Each option may be
used once, more than once, or not at all.

Question 19

A 50-year-old man with human immunodeficiency virus (HIV) infection is only recently started
on combined antiretroviral therapy but with poor compliance. His latest CD4 count was 60
cells/uL. He was admitted for high fever for 1 week, disseminated skin papules, and shortness
of breath. Chest X-ray showed bilateral patchy pulmonary infiltrate. There was
hepatosplenomegaly and diffuse lymphadenopathies on physical examination.

Question 20

A 45-year-old man with acute myeloid leukaemia was admitted for the third cycle of
chemotherapy. He developed severe and prolonged neutropenia afterwards. While on
meropenem, he developed breakthrough fever and worsening oral mucositis. The blood culture
was positive.

Question 21

A 60-year-old woman with hepatitis B virus (HBV)-related cirrhosis received living donor liver
transplantation 3 months ago. She is now on prednisolone 5 mg daily, tacrolimus 5 mg BD, and
mycophenolate mofetil (MMF) 500 mg BD. She presented with low-grade fever, abdominal
pain, and diarrhoea for 5 days. There is no recent travel or contact history. Endoscopic biopsy
of the inflamed sigmoid showed the presence of inclusion bodies.

P.40 of 42 SA40722
VI. AMENORRHOEA
A Androgen insensitivity syndrome

B Asherman syndrome

C Congenital adrenal hyperplasia

Hyperprolactinaemia
Hypothalamic amenorrhoea

Mayer-Rokitansky-Kiister-Hauser (MRKH) syndrome

Menopause
Premature ovarian insufficiency

I Transverse vaginal septum

J Tuberculosis endometritis

For each of the following scenarios, select the MOST LIKELY diagnosis from the list of
options above. Each option may be used once, more than once, or not at all.

Question 22

A 28-year-old woman attended the gynaecology clinic for secondary amenorrhoea for 6
months. She had 3 surgical terminations of pregnancies, of which the last one was 6 months
ago and was complicated by pelvic inflammatory disease requiring hospital admission. Her
period did not return after the termination of pregnancy. She did not have any sexual intercourse
postoperatively.

Question 23

A 19-year-old girl attended the gynaecology clinic for primary amenorrhoea. She had normal
breast development but no pubic hair. Her body height was 170 cm, body weight was 54 kg,
and BMI was 18.6 kg/m’.

Question 24

A 16-year-old girl attended the gynaecology clinic for primary amenorrhoea. She had normal
secondary sexual characteristics. She had lower abdominal pain for 2 —3 days around the same
time every month in the past year. Pelvic and perineal ultrasound found a normal-sized uterus
with a haematocolpos of 10 x 10 cm.

Question 25

An 18-year-old girl attended the gynaecology clinic for primary amenorrhoea. Her body height
was 147 cm, body weight was 45 kg, and BMI was 20.8 kg/m*. Breast development was absent
but pubic hair was normal. Karyotype was 45,X.

P.41 of 42 SA40722
VI. AMENORRHOEA (con’t)

Question 26

A 52-year-old woman attended the gynaecology clinic for secondary amenorrhoea. She had her
menarche at 13 years of age and used to have regular menstrual cycles. She had diabetes
mellitus which was well controlled on metformin. In the past year, she noticed lengthening of
menstrual cycles from 30 days to 60 days, which progressed to amenorrhoea during the past 6
months.

- End of Paper -

P.42 of 42 SA40722