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GENETICS 1.

A 35 year old man presents with an inherited neurological disorder. His father developed the disease in his 60s and his daughter was born 2 years ago with a severe form of the condition. His mother, sister, wife and other child, a son, are unaffected. What is the mode of inheritance?

7.

a. autosomal inheritance b. Mitochondrial inheritance

a. A systemic artery embolus from thrombosis in a peripheral vein.

c. Polygenic inheritance d. Trinucleotide repeat disease

b. A systemic artery embolus from a left atrial mural thrombus.

e. Xlinked inheritance 2.

c. Pulmonary embolism from a left ventricular mural thrombus

Which of the following conditions may be detectable by growth monitoring?

d. A systemic artery embolus from a left ventricular mural thrombus.

a. Hyperthyroidism

e. Pulmonary embolism from thrombosis in a peripheral vein.

b. Hypothyroidism c. Pseudohypoparathyroidism

8.

d. XYY Syndrome

4.

You are asked advice by a young professional couple, Mr and Mrs X. Mrs X is 9 weeks pregnant. Mr X’s brother and his partner had a child with cystic fibrosis. As a result, Mr X was screened and found to carry the DF508 mutation for cystic fibrosis. Mrs X declines to be tested. What are the chances of Mr and Mrs X’s child having cystic fibrosis, given that the gene frequency for this mutation in the general population is 1/20.

b. HDL is assembled in the extracellular space. c. Arterial walls contain cells with LDL receptors. d. VLDL transformation to LDL occurs in adipose tissue. e. Cholesterol is required for the formation of red blood cell membranes. 9.

a. a good response to oestrogen therapy

b. 1/20

b. cerebral arteriovenous malformations

c. 1/40

c. GI haemorrhage as the usual presenting feature

d. 1/80

d. telangiectasia of the mucous membranes, but not the skin

e. 1/160

e. tendency of lesions to become less obvious with age

In meiosis which of the following is true?

10. Genetic anticipation occurs characteristically in all the conditions except

b. At the beginning of meiosis 2, each cell contains 23 single chromosomes.

a. myotonia dystrophica

c. Anaphase lag results in one of the 2 daughter cells receiving an extra part of one chromosome.

c. Marfan’s syndrome

d. Nondisjunction at mitosis (meisois 2) results in mosaicism.

e. Fragile X syndrome

e. The incidence of Down’s Syndrome due to translocation increases with increasing maternal age.

b. spinocerebellar ataxia type 1 d. Huntingdon’s disease 11.

Which ONE of the following have their own self replicating DNA?

b. codon

b. Lysosomes

c. exon

c. mitochondria

d. intron

d. Peroxisome e. Rough Endoplasmic Reticulum A 35 year old male presents with oral and genital mucocutaneous ulcerations associated with polyarthritis affecting the lower limbs. He is currently on warfarin for an recent episode of pulmonary embolism. Which of the genetic association is most commonly associated with his condition: a. HLA A3 b. HLA B5 c. HLA B27 d. HLA DR3 e. HLA DR2

Transcription RNA (tRNA) has three bases specific for a particular amino acid with which it binds tomessenger RNA (mRNA). This specific area of tRNA is called the a. anticodon

a. Golgi body

6.

Which of the following is a feature of hereditary haemorrhagic telangiectasia?

a. 1/4

a. DNA replication occurs during meiosis 1.

5.

With respect to lipoprotein transport and metabolism in the body, the following statements are correct EXCEPT: a. Chylomicrons are synthesized in the liver.

e. Insulin dependent diabetes mellitus 3.

A 62 year old man has experienced substernal chest pain upon exertion with increasing frequency over the past 1 year. An electrocardiogram shows T wave inversion in the anterolateral leads at rest. He has a total serum cholesterol of 7.0 mmol/l. On angiography, he has an 85% narrowing of the left anterior descending artery. Which of the following events is most likely to occur in this patient?

e. transposon 12.

A 44 year old man has had no major medical problems throughout his life, except for arthritis pain involving all extremities for the past couple of years. He has had worsening orthopnoea and ankle oedema in the past six months. He is afebrile. There is no chest pain. A chest Xray shows cardiomegaly with both enlarged left and right heart borders, along with pulmonary oedema. Laboratory test findings include sodium 139 mmol/L, potassium 4.3 mmol/L, urea 7 mmol/L creatinine 95 μmol/L, and glucose 8.6 mmol/L. Which of the following additional laboratory test findings is he most likely to have? a. Anticentromere antibody titer of 1:320 b. Erythrocyte sedimentation rate of 79 mm/Hr


c. Haemoglobin of 10.7 g/dL with MCV of 72 fL

1112

21.

d. Serum ferritin of 3400 pmol/L e. Spherocytes in his peripheral blood smear 13.

Which ONE of the following is associated with Marfan’s syndrome?

a. 0%

a. Autosomal recessive inheritance

c. 50%

b. increased upper : lower body ratio

d. 75%

c. Mental retardation

e. 100%

d. Pulmonary stenosis e. Retinal detachment 14.

b. 25%

22.

b. The amount of DNA required makes it unsuitable for early prenatal diagnosis

MCQ's

b. Congenital Adrenal Hyperplasia

c. Synthetic short DNA primers which flank the sequence of interest are required to initiate the amplification

c. Familial hypercholesterolaemia d. Hereditary Haemorrhagic Telangiectasia e. Huntington’s disease

d. It utilizes the thermostable properties of Taq DNA polymerase

In Down syndrome, which is the commonest congenital heart defect?

e. It can be used to detect the presence of viral DNA in human disease

a. Atrial septal defect b. Atrioventricular septal defect

23.

c. Patent ductus arteriosus d. Tetralogy of Fallot

b. centrifugation

Lipoprotein lipase deficiency is associated with:

c. DNA polymerase

a. Abetalipoproteinaemia

d. heating to nearly 100°C

b. Combined hyperlipidaemia

e. viral reverse transcriptase

c. Familial combined hyperlipidaemia d. Familial Hypercholesterolaemia

24.

e. Marked Hypertriglyceridaemia 17.

Concerning Neurofibromatosis Type 1 (NF1), which one of the following statements is true?

b. ribosomal RNA c. RNA nucleotide

b. Clinical severity in individuals is similar in a given family

d. RNA polymerase

c. New mutations occur rarely

e. transfer RNA

d. Pigmented spots on the iris are a characteristic feature e. The diagnosis is likely if two caféaulait patches are present

25.

The following are features of pseudohypoparathyroidism: a. Increased urinary phosphate and cAMP with PTH infusion b. Low serum PTH c. Low serum calcium and low serum phosphate d. Low serum calcium and high serum phosphate e. Shortened 2nd and 3rd metacarpals

19.

A 17yearold girl is short in stature for her age. She has not shown any changes of puberty. She has a webbed neck. Her vital signs include Temperature 36.6°C Respiratory rate 18/min Pulse 75 bpm and BP 165/85 mmHg. On physical examination, she has a continuous murmur heard over both the front of the chest as well as her back. Her lower extremities are cool with poor capillary filling. A chest radiograph reveals a prominent left heart border, no oedema or effusions, and rib notching. Which of the following pathologic lesions best explains these findings?

Reverse transcriptasePCR is used to ampify:

a. Constriction of the aorta past the ductus arteriosus

a. Antibodies

b. Lack of development of the spiral septum and partial absence of conus musculature

b. DNA

c. Shortening and thickening of chordae tendineae of the mitral valve

c. RNA d. Protein

d. Single large atrioventricular valve

e. Plasmids 20.

Protein synthesis occurs within cells. A particular molecule that is produced in the nucleus initiates protein synthesis. This molecule matures in the cytoplasm and binds to the ribosome. This molecule is a. messenger RNA

a. Bilateral acoustic neuromas are common

18.

The Polymerase Chain Reaction (PCR) is used to amplify small amounts of DNA for further analysis. First the DNA double helix must be split into two strands. This is achieved by a. alkali solution

e. Ventricular septal defect 16.

Which of the following is NOT true regarding the polymerase chain reaction: a. It is used to amplify DNA but not RNA

Autosomal recessive disorders include a. Achondroplasia

15.

The parents of a child with cystic fibrosis consult you wishing to know what is the risk of their next child being a carrier of the condition. Which ONE of the following percentages is the correct risk?

Which of the following is a characteristic feature of familial hypercholesterolaemia? a. Autosomal dominant inheritance b. elevated chylomicrons c. hypertriglyceridaemia d. increased expression of LDL receptors e. Palmar xanthomas

e. Supravalvular narrowing in the aortic root 26.

Autosomal dominant conditions include a. Betathalassaemia b. Cystic fibrosis c. Marfan syndrome d. Wilson’s disease e. Xeroderma Pigmentosa


27.

d. The normal human karyotype consists of 22 pairs of 1113 autosomes e. Telomeres provide the point of attachment to the mitotic spindle 33.

a. Betamyosin

A 36 year old man attends clinic with his wife after failing to conceive after 10 years of marriage. Examination reveals that he his tall, thin and has bilateral gynaecomastia. Investigations show high levels of urinary gonadotrophins. What is the most likely diagnosis?

b. CFTR

a. Andropause

c. FGFR

b. Gaucher’s disease

d. Fibrillin

c. Kleinfelter’s syndrome

e. Spectrin

d. Marfan syndrome e. Noonan’s syndrome

A Plasmid is best described as a. a recombinant section of DNA

34.

a. adult polycystic renal disease is inherited as an autosomal recessive trait

b. a small viral particle c. bacterial DNA separate from the chromosome

b. reflux nephropathy is inherited as an autosomal recessive trait

d. consist of multiple copies of a single gene e. having multiple origins of replication 29. A 59 year old woman has had insulin dependent diabetes mellitus for over two decades. The degree of control of her disease is characterized by the laboratory finding of a HbA1c of 10.1%. She complains of repeated episodes of abdominal pain following meals. These episodes have become more frequent and last for longer periods over the last couple of months. On physical examination, there are no abdominal masses andno organomegaly of the abdomen, and she has no tenderness to palpation. Which of the following findings is most likely to be present:

c. nephrogenic diabetes insipidus is inherited as an autosomal dominant trait d. Alport’s syndrome affects females more severely than males e. medullary sponge kidney is typically not inherited but is a congenital condition. 35.

b. Autosomal Recessive

b. Hepatic infarction

c. Mitochondrial

c. Mesenteric artery occlusion

d. Xlinked Dominant

d. Acute pancreatitis

a. 47, XXY karyotype b. History of antidepressant drug therapy

a. autoimmune haemolytic anaemia

c. Increased risk for breast carcinoma

b. glucose6phosphate dehydrogenase deficiency

d. Increased testosterone levels

c. hereditary spherocytosis

e. Seminoma of the testis

d. pyruvate kinase deficiency

Two strains of Escherichia coli are isolated and both are resistant to ampicillin. Strain A retains its resistance to amplicillin when grown form multiple generations in the absence of ampicillin. However strain B loses its resistance when grown in the absence of ampicillin. Which of the following best explains the loss of antibiotic resistance in strain B? a. Changes in the bacterial DNA gyrase b. Downregulation of the resistance gene c. Loss of a plasmid containing the resistance gene d. Mutations in the resistance gene e. Transposition of another sequence into the resistance gene

32.

e. Xlinked Recessive A 60 year old Chinese man has been started on quinine for leg cramps by his General Practitioner. He presents, a week later, with 5 days of darkened urine and 2 days of increasing breathlessness, back pain and fatigue. Investigations show a haemoglobin of 7.0 g/dl and raised reticulocyte count. Which of the following best explain this drug reaction?

30. A 51yearold healthy man is found to have bilateral breast enlargement. He says that this is normal for him and that he has not noted any change in years. Which of the following is most likely to be present?

31.

A 22 year old lady is affected by an inherited disorder. She has two brothers who are unaffected. She has two sisters both are affected. Her father is affected but not her mother. What is the mode of inheritance? a. Autosomal Dominant

a. Ruptured aortic aneurysm

e. Chronic renal failure

Which one of the following statements is correct?

36.

e. sickle cell disease 37.

Benign Essential Tremor: a. Is present characteristically at rest b. Occur with lesion in sub thalamus c. Occur in liver disease d. Alchohol improves the tremor e. Is autosomal recessive in inheritance

38. In which of the following is mental retardation an expected finding? a. Alkaptonuria b. Cystinuria

Which of the following is true regarding chromosomes?

c. Glycogen storage disease

a. Down’s syndrome is most commonly due to an extra copy of chromosome 21 inherited from the father.

d. Lactose intolerance

b. A Fetus with triploidy will have 47 chromosomes c. Heterochromatin is mostly composed of active genes

e. Maple syrup urine disease

GENETICS

28.

A 19 year old woman is found to have a cardiac murmur characterized by a midsystolic click. An echocardiogram reveals mitral insufficiency with upward displacement of one leaflet. There is also aortic root dilation to 4 cm. She has a dislocated right ocular crystalline lens. She dies suddenly and unexpectedly. The medical examiner finds a prolapsed mitral valve with elongation, thinning, and rupture of chordae tendineae. A mutation involving which of the following genes is most likely have be present in this patient?


1114 39. In X linked recessive inheritance, which of the following is true?

45.

a. Is an autosomal dominant condition.

a. The male to female ratio is 2:1.

b. Is due to mutation of CFTR gene on chromosome 17

b. Each son of a female carrier has a 1:4 risk of being affected.

c. Skin test may be positive for aspergillus

c. Each daughter of a female carrier has a 1:4 risk of being a carrier.

d. Median survival rate is 10 to 15 years. e. Is a cause of mental retardation.

d. Daughters of affected males will all be carriers. e. The family history is often positive since new mutations are rare. 40.

46.

b. 1:800

a. The rate of cell growth

c. 1: 1000

b. Cell death

d. 1:1200

MCQ's

c. The number of cell divisions a cell is capable of undergoing

e. 1:1400

d. Cell survival 41.

47.

Which of the following haematological disorders is inherited as an autosomal recessive condition? a. Antithrombin III deficiency

b. Marfan syndrome

c. Glucose6phosphate dehydrogenase deficiency

c. Maternal folate deficiency

d. Pyruvate kinase deficiency

d. Trisomy 21

e. Acute intermittent porphyria

e. Congenital syphilis

a. It is likely that her mother received stilboestrel in pregnancy

A 40 year old male is diagnosed with Dystrophia myotonica. Which one of the following features would be expected in this patient?

b. It is likely that her mother received Carbimazole for thyrotoxicosis during pregnancy

a. Autosomal recessive inheritance b. Cataracts

c. Low testosterone and oestradiol concentrations would be expected

c. Fasiculations would predominate

d. The diagnosis is likely to be testicular feminisation syndrome

e. Preserved tendon reflexes despite muscle wasting

e. The diagnosis is Noonan’s syndrome 43.

48.

d. Progressive external ophthalmoplegia 49.

b. A Fetus with triploidy will have 47 chromosomes c. Heterochromatin is mostly composed of active genes

b. May be diagnosed radiologically at birth

d. The normal human karyotype consists of 22 pairs of autosomes

c. Increased liability to pathological fractures d. Shortened spine

e. Telomeres provide the point of attachment to the mitotic spindle

e. Subfertility Restriction enzymes a. Cut DNA b. Join two pieces of DNA together c. Synthesize DNA d. Degrade DNA e. Are involved in cell cycle arrest

Which of the following is true regarding chromosomes? a. Down’s syndrome is most commonly due to an extra copy of chromosome 21 inherited from the father.

Which ONE of the following is a recognised feature of achondroplasia? a. Autosomal recessive inheritance

44.

A routine ultrasound at 18 weeks gestation in a diabetic mother reveals a male foetus with an endocardial cushion defect. Other abnormalities include increased nuchal thickening and a “double bubble” sign. Which of the following conditions is most likely to have contributed to this set of findings: a. Maternal use of ACE inhibitor

b. Protein C deficiency

42. A 20 year old female patient is refered with primary amenorrhoea. Investigations reveal a 46 XY karyotype. Which of the following concerning the condition is true?

The incidence of Down syndrome in children born to women aged less than 30 years is a. 1:600

The level of cellular telomerase activity will affect:

e. RNA synthesis

The following is true about Cystic Fibrosis:

50.

A 28 year old lady presents with multiple caféaulait spots. A diagnosis of neurofibromatosis type 1 is made. What is true of the NF1 gene? a. Inherited in a recessive fashion b. Inherited in an Xlinked fashion c. On chromosome 17 d. On mitochondrial genome e. Related to NF2 gene


Genetics - Answers 1. d

26.

2. b

27. d

3. d

28. c

4. d

29. c

5. c

30. a

6. b

31. c

7. d

32. d

8.

a: Chylomicrons are formed in the gut from exogenous triacylglycerols and cholesterol. They are released into the lymph and thereby enter the blood.They are not formed in the liver.

33.

9.

b: In hereditary haemorrhagic telangiectasia there may also be pulmonary AV malformations.Epistaxis, not GI haemorrhage, is the usual presenting feature. Lesions become more obvious with age and affect mucuous membranes as well as skin. Oestrogen therapy is sometimes advocated but the effect, if any, is small.

c: Gaucher’s and Marfan syndrome do not present with infertility. Noonan’s is associated with short stature. Kleinfelter’s is a sex chromosome disorder affecting 1:400 1: 600 male births typically with 47 XXY, XXXYY or XXYY. Andropause is the term for the gradual decrease in serum testosterone concentration with age, but does not occur, usually, until after the age of 50.

34.

e: PKD is usually autosomal dominant although the infantile form is autosomal recessive. Nephrogenic DI is usually Xlinked. Features of Alport syndrome (hereditary nepritis, haematuria, progressive renal failure and highfrequencynerve deafness)are usually more marked in in males. Neither reflux nephropathynor medullary sponge kidneys are hereditary conditions.

11.

c: Anticipation means increased severity/earlier age of onset of disease with successive generations. Other conditions with anticipation include spinocerebellar ataxia type 1 and dentatorubral pallidoluysian atrophy. a: mRNA has codons which are bound by the anticodons on tRNA during translation of protein synthesis. Exons are noncoding sequences in the mRNA and introns are areas of unknown function. Transposons are genetic sequences that have been transposed from one part of DNA to another.

35. d 36. b 37.

12. d 13. e 14.

b: All the others are autosomal dominant of course.

15.

b: 50% of Down syndrome births have congenital heart disease. Defects in order of decreasing frequency are: B, E, C, D and A.

16.

e: Lipoprotein lipase deficiency is autosomal recessive and associated with increased chylomicrons and marked hypertriglyceridaemia.

c: All the others are autosomal recessive of course.

d: There is no tremor at rest, but a rhythmic oscillation develops when the patient holds the arms outstretched. A positive family history is obtained in over half of such patients and the pattern of inheritance in such families indicates an autosomal dominant trait. Alcohol suppresses essential tremor, but the mechanism responsible is unknown

38. e 39. d 40.

3: The telomere is a DNA sequence at the end of each chromosome which becomes progressively shorter with each division the cell undergoes. When it is reduced to a critical length the cell is not capable of dividing, the enzyme telomerase is able to lengthen the telomere thus preventing this occurring.

17. d

41. d

18. d

42. d

19. c

43. b

20. a

44.

c: As both parents are carriers for the CF gene then the chances of another child being affected (homozygote) is 1 in 4 (25%). The chances of their child being free from the CF gene is also 1 in 4 (25%) and the chances of a child being a carrier (heterozygote) is 1in 2 (50%).

a: Restriction enzymes cut DNA at sequences specific for each restriction enzyme, they are vital tools for molecular biology and molecular genetic research.

45.

b: RtPCR is used to amplify RNA rather than PCR specifically. Preimplantation diagnosis uses IVF and genetic analysis of 3 day old embryos, before selective transfer of unaffected embryos to uterus.

c: Cystic fibrosis is an autosomal recessive condition and is due to mutation of CFTR gene on chromosome 7. 20% develop bronchopulmonary aspergillosis. Median survival rate is 25 to 35 years and is currently improving.

46.

d: Maternal age also affects incidence of hydrocephalus, anencephaly and achondroplasia.

21.

22.

23. d 24. a 25. a: She has coarctation of the aorta, and the constriction is postductal, allowing prolonged survival. Her physical characteristics also suggest Turner syndrome (monosomy X).

47. d 48. b 49. d 50. c

GENETICS

10.

1115


CARDIOLOGY 1.

Apreviously well 27 year old woman presents with a history of transient ischaemic attack affecting her right side and speech. On examination there was nothing abnormal to find. An ECG, chest Xray,CT brain scan and routinehaematology and biochemistry were all normal. What is the most likely underlying abnormality? a. atrialmyxoma

b. Central Venous Pressure Monitoring c. Chest XRay d. Echocardiography e. Pulmonary Capillary Wedge Pressure Monitoring 7.

b. carotid artery stenosis

a. reduced plasma lactate levels

c. embolus from paroxysmal atrial fibrillation

b. an increase in serum troponin levels

d. patent foramen ovale

c. an arterial pH less than 7.2

e. subarachnoidhaemorrhage 2.

A 51 year old woman has had several syncopal episodes over the past year. Each episode is characterized by sudden but brief loss of consciousness. She has no chest pain. She has no ankle edema. On brain MRI there is a 1.5 cm cystic area in the left parietal cortex. A chest Xray shows no cardiac enlargement, and her lungfields are normal. Her serum total cholesterol is 6.5 mmol/L. Which of the following cardiac lesions is shemost likely to have?

d. blood gases show increased pCO2 on air e. normalDdimerlevels 8.

b. Aortic dissection

b. Ischemic cardiomyopathy

c. Calcified bicuspid aortic valve

c. Left atrial myxoma

d. Mitral valve annulus calcification

d. Mitral valve prolapse

e. Tricuspid valve endocarditis

e. Tuberculous pericarditis A66yearoldman has developed chronic renal failure with a serum urea of 60 mmol/L and creatinine of 650 micromol/L. Auscultation of the chest reveals a friction rub over the cardiac apex. He is most likley to have a pericarditis that is termed?

a. an uncomplicated ASD b. Fallot’s tetralogy c. aortic stenosis

c. Hemorrhagic

d. Right Bundle Branch Block

d. Purulent

e. constrictive pericarditis

WhichONE of the following is a contraindication to thrombolysis? b. the presence of atrial fibrillation c. asthma

10.

A 62 year old man has experienced substernal chest pain upon exertion with increasing frequency over thepast 1 year. An electrocardiogram shows T wave inversion in the anterolateral leads at rest. He has a totalserum cholesterol of 7.0 mmol/l. On angiography, he has an 85% narrowing of the left anterior descendingartery. Which of the following events is most likely to occur in this patient?

e. background diabetic retinopathy

a. A systemic artery embolus from thrombosis in a peripheral vein.

Whichof the following antimicrobialsis associated with prolongation of the QT interval?

c. Pulmonary embolism from a left ventricular mural thrombus

d. pregnancy

a. Coamoxiclav

b. A systemic artery embolus from a left atrial mural thrombus.

b. Gentamicin

d. A systemic artery embolus from a left ventricular mural thrombus.

c. Cefuroxime

e. Pulmonary embolism from thrombosis in a peripheral vein.

d. Erythromycin e. Isoniazid 6.

Duringauscultation of the heart you discover a wide fixed splitting of the second heart sound. In which of the following conditions does this occur?

b. Fibrinous

a. age over 75 years

5.

9.

a. Constrictive

e. Serous 4.

A 60 year old man has worsening congestive heart failure with increasing pulmonary oedema. His blood pressure is normal. He has been healthy all his life with no major illnesses. A serum glucose is 5.6 mmol/L. His total serum cholesterol is 4.8 mmol/L. The serum creatine kinase is not elevated. The most likely explanation for these findings is? a. Alcoholic cardiomyopathy

a. Cardiac amyloidosis

3.

Whichof the following is a recognised feature of massive pulmonary embolism?

A60yearoldman presents with an inferior MI and receives thrombolysis. 4 hours following initial presentation he becomes acutely breathless. His ECG demonstrates sinus tachycardia (rate 108bpm) with T wave inversion inferiorly. His ST segments are normal. On examination his JVP is elevated at 5 cm. Chest wasclear to auscultation. Following 80 mg of Frusemide he eteriorates. His BP is now 80/60 and his urine outputover the last 2 hours is 5 mls. What is the best investigativeover the last 2 hours is 5 mls. What is the best investigative measure? a. Arterial Blood Gases

11. A17 year old girl was found collapsed and drowsy. Her 12leadECG showed a sinus tachycardia of 120 beats per minute with a corrected QT interval of 500 ms (normal <470). Which of the following is the most likely cause of her presentation? a. Amphetamine b. Diphenhydramine c. Glue sniffing d. Methadone e. Methanol


replaced. Which of the following pathologic findings in the 1117 bioprosthesishas most likely led to the need for replacement?

12. Arandomiseddoubleblindplacebo controlled study of a cholesterollowering drug for the primary prevention of coronary heart disease was conducted. It had a five year follow up period.The results showed an absolute risk of myocardial infarction in the groupreceivingplacebo during was 10 percent. The relative risk of those given the cholesterol lowering medication was 0.8 What number of patientswill need to be treated with the drug for five years to prevent one myocardial infarction? a. 20 b. 40 c. 50 d. 80 13.

Which ONE of the following is true regarding acute pulmonary embolism?

b. Dehiscence c. Infective endocarditis d. Strut failure e. Thrombosis 18. Arandomised, doubleblind, placebo controlled trial of a cholesterol lowering drug in the primary prevention of coronary heart disease is reported. 1000 subjects are treated with the active drug, and 1000 aregiven placebo. They are followed up over a five year period and 100 individuals in the placebo group and 80 inthe treatment group suffer a myocardial infarction. What is the annual percentage risk of myocardial infarction in the group treated with placebo? a. 0.5%

a. a normal ECG excludes the diagnosis

b. 2%

b. embolectomy is more effective than thrombolysis in improving survival

c. 5% d. 8%

c. Heparin is as effective as thrombolytic therapy

e. 10%

d. the presence of hypoxaemia is an indication for thrombolysis e. thrombolysis administered through a peripheral vein is as effective as through a pulmonary artery catheter 14.

19.

A 70 yearoldwoman has a history of dyspnoea and palpitations for six months. An ECG at that time showed atrial fibrillation. She was given digoxin, diuretics and aspirin. She now presents with two shortlived episodes of altered sensation in the left face, left arm and leg. There is poor coordination of the left hand. ECHO was normal as was a CT head scan. What is the most appropriate next step in management? a. anticoagulation

a. ANCA titer of 1:80

b. carotidendarterectomy

b. Antistreptolysin O titer of 1:512

c. clopidogrel

c. Blood culture positive for Streptococcus, viridans group

d. corticosteroid treatment

d. Coxsackie B serologic titer of 1:160

e. no action 15.

A 21 year old man with Hypertrophic Cardiomyopathy presents in clinic with dizzy spells but has not had anysyncopal episodes. Which of the following, if present, would be indicate an increased risk of sudden cardiac death?

e. Total serum cholesterol of 9.6 mmol/l 20.

a. Asymmetric septal hypertrophy with maximum wall thickness of 2.1 cm

a. marantic endocarditis b. paradoxical emboli

c. Left Ventricular Outflow Tract Gradient of 80 mmHg

d. right ventricular thrombi

e. Worsening exertional angina

c. rheumaticendocardialvegetations e. thrombi from an atheromatous aorta 21.

Whilstattending the cardiology clinic, the staff nurse measures the blood pressure of a 61yearold man,and finds that it is 183/100 mmHg sitting and 190/105 standing. He has a heart rate of 81/minute, with anirregularly irregular rhythm. On auscultation of the heart, there are no murmurs, but he has bibasilar crackleson chest examination. Which of the following pathological findings is most likely to be present?

Whichof the following concerning congenital heart disease is correct? a. ASD is the commonest malformation at birth b. congenital complete heart block is usually associated with AntiRoantibodies in the mother c. Ebsteinâ&#x20AC;&#x2122;s anomaly is associated with maternal exposure to lithium carbonate

a. Left ventricular hypertrophy

d. Hypoplastic left heart syndrome is characterised by a large, dilated left ventricle

b. Left atrial myxoma

e. Osteogenesisimperfecta is associated with aortic stenosis

c. Occlusive coronary atherosclerosis d. Corpulmonale e. Mitral regurgitation 17.

A74yearoldman presented with acute pain, pallor and absent pulses in his right leg. Investigations revealed an embolus in his femoral artery. What is the most likely source of this embolus?

b. Blood Pressure drop of 20mmHg during peak exercise tolerance testing d. Systolic Anterior Movement of the mitral valve on echocardiography 16.

A25yearoldpreviously healthy woman has worsening fatigue with dyspnoea, palpitations, and fever over the past one week. Her vital signs on admission to the hospital show Temperature 38.9°C Respiratory rate 30/min Pulse 105 bpm and BP 95/65 mmHg. Her heart rate is irregular. An ECG shows diffuse STT segment changes. A Chest Xray shows mild cardiomegaly. An echocardiogram shows slight mitral and tricuspid regurgitation but no valvularvegetations. Her troponin I is 12 ng/mL. Sherecovers over the next two weeks with no apparent sequelae. Which of the following laboratory test findingsbest explains the underlying etiology for these events?

A 24 year old woman develops infective endocarditis involving the aortic valve. She receives a porcine bioprosthesis because of her desire to have children and not to take anticoagulant medication. After ten years,she must have this prosthetic valve

22.

Which of the following regarding the anatomy of the heart is true? a. The aortic valve is tricuspid. b. The ascending aorta is entirely outside the pericardial sac. c. The left atrial appendage is identified readily by transthoracic echocardiography.

CARDIOLOGY

e. 100

a. Calcification with stenosis


1118 23.

d. The pulmonary trunk lies anterior to the ascending aorta.

b. Headache is the usual presenting feature.

e. The right atrium is posterior to the left atrium.

c. It is defined as systolic blood pressure above the 99th centile for age.

A patient presents with atrial fibrillation and later they revert to sinus rhythm. Under which of the following circumstances is the patient more likely to remain in sinus rhythm? a. age> 75 years old b. been commenced on warfarin

d. Abnormalities are frequently seen on DMSA scan. e. Aortic coarctation is the commonest secondary cause. 28.

c. left atrium size > 6 cm on ECHO d. short history of AF

a. Factor V Leiden mutation

e. ventricular rate on presentation of 130 bpm

MCQ's

24.

A 68 year old man has been very ill for months following the onset of chronic liver disease with hepatitis C infection. He experiences a sudden loss of consciousness and then exhibits paraplegia on the right. A cerebral angiogram reveals lack of perfusion in the left middle cerebral artery istribution. The most likely cardiac lesion to be associated with this finding is?

b. Protein S deficiency c. Protein C deficiency d. Antithrombin deficiency e. Lupus anticoagulant 29.

b. Left atrial myxoma

In a normal heart, the oxygen saturation of a sample of blood taken from a catheter in the pulmonary capillary wedge position should be equal to a sample from which of the following?

c. LibmanSacks endocarditis

a. coronary sinus

d. Nonbacterial thrombotic endocarditis

b. femoral artery

e. Paradoxical thromboembolus

c. pulmonary artery

a. Acute rheumatic fever

25.

A65 year old man presents with severe central crushing chest pain. ECG shows evidence of an inferior myocardial infarction. He receives TPA, Heparin and Aspirin. Four hours after initial presentation, he starts feeling dizzy and breathless. His pulse is 40 bpm regular, BP 80/50. Heart sounds are soft and chest clear to auscultation. ECG shows 2:1 AV block with T wave inversion inferiorly. IV atropine was administered but had no effect. What is the next most important treatment?

d. right atrium e. right ventricle 30.

a. IV Dopamine. b. IV Isoprenaline.

b. aspirin

d. Insert a temporary pacemaker.

c. digoxin

e. Monitor his progress. A70yearoldmale is referred by his GP for management of recently diagnosed congestive heart failure. The patient has a history of poorly controlled hypertension. Over the last three months he has been aware of deteriorating shortness of breath, fatigue, and orthopnea. Over the last month he had been commenced on Digoxin (62.5 micrograms daily), Frusemide (80 mg daily), and amiloride 10 mg. On examination he has a pulse of 96 bpm regular, a blood pressure of 132/88 mmHg. His JVP was not raised, he had some scattered bibasal crackles on auscultation with a displaced apex beat in the anterior axillary line, 6th intercostal space. Auscultation of the heart revealed no murmurs and he had peripheral oedema to the mid tibia. Investigations showed: electrolytes normal serum urea concentration 17 mmol/l (NR 28 mmol/l) creatinine 175 micromol/l (NR 55110). Serum digoxin 0.7 ng/mL {therapeutic: 1.02.0}. One month previously his urea had been 11 mmol/l and creatinine 110 micromol/l. An ECG reveals left ventricular hypertrophy and Chest Xray shows cardiomegaly and calcified aorta. What is the most appropriate next step in management? a. Add an ACE inhibitor to the current regimen

d. dipyridamole e. warfarin 31. Ina patient presenting with aortic stenosis, which of the following findings would be most helpful in establishing a diagnosis of congenital bicuspid valve as the etiology? a. age b. calcified leaflets c. commissural fusion on ECHO d. negative history for rheumatic fever e. systolic ejection click 32. A55yearoldwoman was found to have ++ glycosuria and had a maternal history of Type II diabetes mellitus. She was a smoker of 20 cigarettes per day. Examination reveals no specific abnormalities apart froma BMI of 30. Blood pressure was 132/88 mmHg. Investigations reveal: serumcreatinine 80 μmol/L (60 – 110) plasma glucose (fasting) 11.3 mmol/L (3.0 – 6.0) total serum cholesterol 5.5 mmol/L (<5.2) HDL cholesterol 1.4 mmol/L (>1.55) What is most likely to improve her life expectancy? a. Metformin 500 mg bd

b. Add atenolol at a dose of 25mg daily

b. Ramipril 10 mg daily

c. Increase digoxin to 0.25 mg daily

c. Simvastatin 10 mg daily

d. Increase frusemide to 80 mg twice daily

d. Stopping smoking

e. Maintain on current therapy. 27.

A14yearoldboy presents with hypertension. Which of the following statements concerning hypertension in the young is true? a. Sodium nitroprusside is useful for the longtermtreatment of severe cases.

A60yearoldman with a past history of controlled hypertension presents with acute onset weakness of his left arm, that resolved over 12 hours. He had suffered two similar episodes over the last three months. Examination reveals a blood pressure of 132/82 mmHg and he is in atrial fibrillation with a ventricular rate of 85 per minute. CT brain scan is normal. What is the most appropriate management? a. amiodarone

c. Insert a permanent pacemaker.

26.

A 23 year old male presents with a deep vein thrombosis. He has no past medical history but his mother has suffered from deep vein thromboses. Which of the following is likely to be found on haematological assessment?

e. Weight loss to achieve a BMI of 25 33.

Whichof the following concerning the use of intravenous bicarbonate in cardiorespiratory arrest is correct? a. exacerbates intracellular acidosis


b. has a positive inotropic effect on ischaemic myocardium

c. Chagas Disease

c. improves oxygen release to the tissues

d. Syphillis

d. increases cerebral blood flow

e. Toxoplasmosis

e. reduces preexistent hyperkalemia 34.

40.

Primaryprevention trials for the treatment of hypercholesterolaemia reveal a reduction in all cause mortality following treatment with which of the following? a. Fibrates b. Fish Oils c. Nicotinic acid d. Resins

b. amiodarone

c. intramuscular vitamin B12 alone d. intramuscular vitamin B12 and oral folic acid together e. oral folic acid alone 41.

a. Antidiuretic hormone

c. DC cardioversion

b. Calcitonin

d. flecainide

c. Endothelin

e. verapamil 36. A 56 year old male with left ventricular systolic dysfunction was dyspnoeic on climbing stairs but not at rest. The patient was commenced on ramipril and frusemide. Which one of the following drugs would improvethe patient’s prognosis?

d. Renin e. Somatostatin 42.

b. Barter’s syndrome

b. Amlodipine

c. Diabetic nephropathy

c. Bisoprolol

d. Liddle’s syndrome

d. Digoxin

e. Type IV renal tubular acidosis

e. Nitrate therapy

a. Anticentromereantibody titer of 1:320 b. Erythrocyte sedimentation rate of 79 mm/Hr c. Haemoglobin of 10.7 g/dL with MCV of 72 fL d. Serum ferritin of 3400 pmol/L e. Spherocytes in his peripheral blood smear 38.

Which of the following is a recognised feature of a beta lipoproteinaemia? a. a high serum cholesterol b. palmarxanthomas c. advanced atherosclerotic vascular disease d. abnormal red blood cell morphology e. severe mental retardation

39.

Which of the following infections is least likely to cause myocarditis? a. Coxsackie virus b. Diphtheria

Which of the following may be responsible for a hypokalaemic hypertension ? a. Nonclassical congenital adrenal hyperplasia

a. Amiodarone

37. A 44 year old man has had no major medical problems throughout his life, except for arthritis pain involving all extremities for the past couple of years. He has had worsening orthopnoea and ankle oedema in the past six months. He is afebrile. There is no chest pain. A chest Xray shows cardiomegaly with boththe past six months. He is afebrile. There is no chest pain. A chest Xray shows cardiomegaly with bothenlarged left and right heart borders, along with pulmonary oedema. Laboratory test findings include sodium139 mmol/L, potassium 4.3 mmol/L, urea 7 mmol/L creatinine95 μmol/L, and glucose 8.6 mmol/L. Which ofthe following additional laboratory test findings is he most likely to have?

Which of the following compounds has a vasodilating effect?

43.

A52 year old sales representative is admitted with an inferior myocardial infarction. He receives thrombolysis and makes an uneventful recovery. He is discharged on atenolol, aspirin and orvastatin. He enquires how long after his MI must he wait before he is able to drive? a. One week b. Two weeks c. Four weeks d. Three months e. Six months

44.

A35 year old woman presented with a history of intermittent lightheadedness. Clinical examination and 1 2lead ECG were normal. Which of the following, if present on a 24 hour Holter ECG tracing, would be the most clinically important? a. Atrial premature beats. b. Profound sleepassociatedbradycardia. c. Supraventricular tachycardia. d. Transient Mobitz type 1 atrioventricular block. e. Vertricular premature beats.

45. A 57 year old man develops deep venous thrombosis during a hospitalization for prostatectomy. He exhibits decreased mental status with right hemiplegia, and a CT scan of the head suggests an acute cerebralinfarction in the distribution of the left middle cerebral artery. A chest Xrayreveals cardiac enlargement andprominence of the main pulmonary arteries that suggests pulmonary hypertension. His serum troponin I is<0.4 ng/mL. Which of the following lesions is most likely tobe present on echocardiography? a. Coarctation of the aorta b. Dextrocardia

CARDIOLOGY

b. bone marrow aspiration

A 30 year old man presents with a history of transient loss of consciousness and palpitations. His ECG shows ventricular tachycardia. Which of the following treatments should be avoided? a. adenosine

A 68 year old woman was admitted to hospital with evidence of biventricular cardiac failure. On examination her pulse was 100 beats per minute (sinus rhythm), and her blood pressure was 140/60 mmHg. She had haemorrhages in both fundi. Her condition improved after intravenous diuretics. Investigations revealed: haemoglobin 5.6 g/dl (11.5 – 16.5) haematocrit 0.19 (0.36 – 0.47) MCV 118 fl (80 – 96) MCH 33.0 pg(28 – 32) WCC 3.4 x 109/L (4 – 11) platelet count 95 x 109/L (150 – 400) What is the next most appropriatestep in management? a. blood transfusion

e. Statins 35.

1119


c. Pulmonary stenosis

1120

d. Tetralogy of Fallot e. Ventricular septal defect 46. A 60 year old man had a myocardial infarction 6 weeks ago. He is taking aspirin 75 mg/day and metoprolol 50 mg 2/day. During a routine followup Exercise Test he has a 20 beat run of nonsustained VT. Heachieved stage 4 of the Bruce protocol and 92 % of his target heart rate. The nonsustained VT occurredhalfway through Stage 2. ST segments were normal during the study. What is the definitive investigation?

51. An elderly man with a history of asthma, congestive heart failure, and peptic ulcer disease is admitted with bronchospasm and rapid atrial fibrillation. He recieves frequent nebulised salbutamol and IV digoxin loading, his regular medications are continued. 24 hours after admission his serum potassium is noted to be 2.8 mmol/l.Which of his medications is most likely to have caused this abnormality. a. Digoxin b. ACE inhibitor c. Salbutamol d. Ranitidine

a. Coronary angiography.

e. Spironolactone

b. Echocardiogram. c. Electrophysiological study.

MCQ's

d. Thallium exercise scan. 47.

48.

52. In the diagnosis of rheumatic fever, which of the following may be helpful?

e. 24 hour Holter monitor.

a. A generalisedmacularpapularrash.

A 55 year old woman has had worsening shortness of breath for several years. She now has to sleep sitting up on two pillows. She has difficulty swallowing. There is no history of chest pain. She is afebrile. Recently, she suffered a stroke with left hemiparesis. A chest Xrayreveals a nearnormalleft ventricular size with a prominent left atrial border. Which of the following conditions is most likely to account for these findings?

c. Polyarthritis.

b. ASO titre of less than 1:200. d. Staphylococcus aureus grown on throat culture. e. Splinter haemorrhages. 53. A 55 year old man presents with gynaecomastia while receiving treatment for Heart failure. Which of the following drugs is most likely to be the cause of his gynaecomastia

a. Aortic coarctation

a. Amiloride

b. Cardiomyopathy

b. Carvedilol

c. Essential hypertension

c. Frusemide

d. Left renal artery stenosis

d. Omeprazole

e. Mitral valve stenosis

e. Ramipril

c. Flecainide

A78 year old female is referred by her GP with high blood pressure. Over the last three months her bloodpressure is noted to be around 180/80 mmHg. She has a body mass index of 25.5kg/m2, is a nonsmoker.There are no features to suggest a secondary cause for her hypertension. Which of the following is the mostappropriate treatment for her blood pressure?

d. Propofanone

a. AlphaBlocker

e. Sotalol

b. Angiotensin Converting Enzyme (ACE) Inhibitor

Which of the following antiarrhythmic drugs may be used in the treatment of long QT syndrome?

54.

a. Amiodarone b. Atenolol

49. A70 year old male was receiving amiodarone 200 mg daily for intermittent atrial fibrillation. However, he was aware of tiredness and lethargy. He appeared clinically euthyroid with no palpable goitre. Investigations revealed: Serum free T4 23pmol/L (926)Serum total T3 0.8 nmol/L (0.92.8)Serum TSH 8.2 mU/L (<5) Which of the following statements would explain these results? a. Abnormal thyroxine binding globulin b. Amiodaroneinducedhypothyroidism c. ‘sickeuthyroid’ syndrome d. Spontaneous hypothyroidism e. TSH secreting pituitary adenoma 50.

A 65 year old woman, a heavy smoker for many years, has had worsening dyspnoea for the past 5 years, without a significant cough. A chest Xrayshows increased lung size along with flattening of the diaphragms, consistent with emphysema. Over the next several years she develops worsening peripheral oedema. BP 115/70 mmHg. Which of the following cardiac findings is most likely to be present?

c. Angiotensin Blocker d. Betablocker e. Calcium channel blocker 55. A 17 year old woman loses consciousness while out jogging one afternoon, as she has done for many years. She is taken to where a chest Xray,CT brain scan, FBC, and biochemistry areall normal. Over the next year, she develops mild dyspnea and fatigue. There are several episodes of presyncope.After another syncopal episode, she is referred to a cardiologist who orders and ECG that shows changes of left ventricular hypertrophy and broad Q waves. An echocardiogram reveals left ventricular and septal hypertrophy, small left ventricle, and reduced septal excursion. The septum has a “ground glass” appearance. She then dies suddenly and unexpectedly. The microscopic appearance of the septum with trichrome stain reveals myofiber disarray. Which of the following conditions is she most likely to have had? a. Diabetes mellitus b. Hypertrophic cardiomyopathy c. Rheumatic heart disease

a. Constrictive pericarditis

d. Systemic lupus erythematosus

b. Left ventricular aneurysm c. Mitral valve stenosis d. Nonbacterial thrombotic endocarditis e. Right ventricular hypertrophy

e. Viral myocarditis 56.

Whichof the following is true regarding the coronary circulation? a. Adenosine is the most important mediator of metabolic vasodilation.


b. Coronary blood flow is independent of myocardial oxygen consumption due to autoregulation. c. Coronary blood flow within a normal range of blood pressure is primarily determined by perfusion pressure. d. Increased myocardial O2 demand is met primarily by increasing O2 extraction. e. The vasodilatory reserve of the epicardium and endocardium is equivalent under normal physiologic conditions.

e. Somatization disorder 62. A35yearoldhealthy woman has a faint systolic murmur on physical examination. An echocardiogram is performed, and she is found to have a bicuspid aortic valve. In explaining the meaning of this finding to her, the most appropriate statement is that? a. An aortic valve prosthesis may eventually need to be placed b. Other family members may have the same condition c. She should be treated with a cholesterolloweringagent

57. A54 year old man presents with central crushing chest pain. Examination is normal. 12 lead ECG shows STsegment elevation in leads II, III, aVF and ST depression in V1, V2 and V3. Which coronary artery is occluded?

d. The problem resulted from past injection drug usage e. This is one manifestation of an underlying autoimmune disease process 63.

c. Left Main Stem

a. anakinetic area of LV wall motion on ECHO

d. Obtuse Marginal 58.

e. Right Coronary Artery

b. elevated cardiac enzymes

Whichof the following is true regarding mitral stenosis?

d. history of severe chest pain

c. evolution of Q waves on ECG

a. it is tolerated well in pregnancy b. there is characteristically a low wedge pressure c. in AF, the opening snap disappears

e. ST elevation on ECG 64.

d. The opening snap is not heard when the mitral valve is heavily calcified e. Doppler U/S is usually inaccurate in determining severity 59.

Whichof the following findings is the most specific for a diagnosis of myocardial infarction?

A15 year old female presents following a sore throat with chest pain, fever, and a skin rash. Examinationreveals a diastolic murmur. Her ASO titre is elevated. Which of the following is a major criterion for thediagnosis of Rheumatic fever? a. Fever

A 26 year oldman is noted to have cyanosis of the lower limbs and clubbing of the toes but not the fingers. Which of the following statements is true?

b. Raised ESR

a. He has Eisenmenger’s syndrome.

e. Prolonged PR interval

b. He has coarctation of the aorta. c. He is likely to have a loud continuous ‘machinery’ murmur below the left clavicle.

c. Polyarthritis d. Migratory erythema 65.

d. He is likely to need urgent surgery. e. He has had a Blalock shunt operation. 60. A 74 year old man has had increasingly severe, throbbing headaches for several months, centered on the right. There is a palpable tender cordlikearea over his right temple. His heart rate is regular with no murmurs, gallops, or rubs. Pulses are equal and full in all extremities, BP is 110/85 mmHg. A biopsy of this lesion is obtained, and histologic examination reveals a muscular artery with lumenal narrowing and medial inflammation with lymphocytes, macrophages, and occasional giant cells. He improves with a course of highdosecorticosteroid therapy. Which of the following laboratory test findings is most likely to be present withthis disease?

A 55 year old man with Type 2 Diabetes Mellitus and Ischaemic Heart Disease has been researching the Internet! He asks your opinion on Laser TransmyocardialRevascularisation. Which of the following statementsabout this technique is true? a. avoids the need for major surgery b. damages the endocardium c. involves destruction of coronary stenoses d. is of particular use in severe proximal coronary artery disease e. stimulates collateral vessel formation

66.

Onauscultation of the heart of a 30 year old female a loud first heart sound is heard. Which of the following may be responsible for thsiauscultatory feature? a. a long preceding diastolic interval b. Atrial premature beat

a. Antidoublestranded DNA titer of 1:1024

c. increrased pulmonary arterial pressure

b. Erythrocyte sedimentation rate of 110 mm/hr

d. increased systemic arterial pressure

c. HDL cholesterol of 0.6 mmol/L

e. rupture of a papillary muscle

d. pANCA titer of 1:160 e. Rheumatoid factor titer of 80 IU/mL

67.

61. A 27 year old woman complained of palpitations, breathlessness and chest pain, radiating to the left arm. These symptoms had developed six weeks previously, after she had witnessed her father dying from a myocardial infarction. In the past 10 years she had been investigated for abdominal pain, headaches, joint pains, and dyspareunia, without serious cause being found for these symptoms. What is the most likely diagnosis? a. Depressive episode b. Factitious disorder c. Generalized anxiety disorder d. Hypochondriasis

A 64 year old man is admitted with a right femoral neck fracture following a fall. Also seen in the radiograph of the pelvis are several prominent calcified vessels. What is the most appropriate next step inmanagement of this finding? a. anticoagulate with heparin b. Ignore it c. Order a pulmonary ventilationperfusionscan d. Request a serum troponin test e. Start the patient on a nitrate infusion

68.

A 59 year old man who was active all his life develops sudden severe anterior chest pain that radiates to his back. Within minutes, he is unconscious. He has a history of hypertension, but a recent treadmill test had revealed no evidence for cardiac disease. Which of the following is the most likely diagnosis?

CARDIOLOGY

a. Circumflex b. Left Anterior Descending

1121


1122

69.

a. Acute myocardial infarction

a. Uraemia

b. Group A streptococcal infection

b. Tuberculosis

c. Pulmonary embolus

c. Group B coxsackie virus

d. Right middle cerebral artery embolus

d. Sarcoidosis

e. Tear in the aortic intima

e. Metastatic carcinoma

Which ONE of the following statements is true about the diastolic Austin Flint murmur?

75.

A 60 year old woman is admitted with sudden onset of chest pain and is diagnosed with an acute myocardial infarction. Her acute illness is complicated by low blood pressure and poor tissue perfusion for several days. Her serum lactate becomes elevated. Her serum urea and creatinine are noted to be increasing.

Day 1 Day 2 Day 3

urea (mmol/L) 8 22 30

creatinine (μmol/L) 116 140 200

Granular and hyaline casts are present on microscopic urinalysis. The renal lesion that is most likely to be present in thissituation is?

a. It is associated with a loud first heart sound. b. It is an early sign of aortic regurgitation c. It can be distinguished from the murmur of mitral stenosis by absence of presystolic accentuation

MCQ's

d. It is due to partial closure of the anterior leaflet of the mitral valve e. It does not occur in aortic incompetence secondary to an aortitis 70. A 28 year old man who is known to have Hypertrophic Cardiomyopathy has an out of hospital cardiac arrest and is successfully resuscitated. What is the most appropriate mode of treatment?

a. Acute tubular necrosis

a. Alcohol Septal Ablation

b. Minimal change disease

b. Amiodarone

c. Nodular glomeruloscerosis

c. Beta Blocker

d. Pyelonephritis

d. Implantable Defibrillator e. Myomectomy 71.

A 14 year old boy presents with fever. Which of the following might contribute to a diagnosis of rheumaticfever?

e. Renal vein thrombosis 76.

a. The finding of target lesions on the hands. b. The finding of tender nodules in the fingertips.

a. Cisapride

c. A prolonged PR interval on ECG.

b. Octreotide

d. A CRP of 10. 72.

A 45 year old male type 1 diabetic with a number of complex diabetic gastrointestinal complications is noted to have a PR interval of 0.18s, a QRS duration of 0.1s and a QT interval of 0.48s on routine ECG. Whichof the following drugs may be responsible?

e. Positive Romberg’s sign.

c. Cotrimoxazole

A40yearoldman attending a routing screening has a blood pressure of 166/100 mmHg. Two weeks later his blood pressure was 150/90 mmHg. He does not smoke. He drinks 35 units alcohol / week. His body mass index (BMI) is 30 kg/m2 (20 25). What is the best management strategy?

e. Cimetidine

d. Domperidone 77.

a. amlodipine b. atenolol c. bendrofluazide

a. her cardiac output is decreased

d. enalapril

b. her cardiac output is normal

e. lifestyle advice 73. A 19 year old woman is found to have a cardiac murmur characterized by a midsystolic click. Anechocardiogram reveals mitral insufficiency with upward displacement of one leaflet. There is also aortic rootdilation to 4 cm. She has a dislocated right ocular crystalline lens. She dies suddenly and unexpectedly. Themedical examiner finds a prolapsed mitral valve with elongation, thinning, and rupture of chordae tendineae.A mutation involving which of the following genes is most likely have be present in this patient?

c. her heart is normal d. she has highoutputfailure e. she is in shock due to a noncardiaccause 78.

b. Group A streptococcal infection

b. CFTR

c. Pulmonary embolus

c. FGFR

d. Right middle cerebral artery embolus

d. Fibrillin 74. A 51 year old businessman complains of dyspnoea on exertion. He recently returned from a business trip to the USA. He has distant heart sounds on auscultation of the chest. A chest radiograph reveals that there is athin rim of calcification surrounding the cardiac outline. Which of the following conditions is most likely responsible for these findings?

A 59 year old man who was active all his life develops sudden severe anterior chest pain that radiates to his back. Within minutes, he is unconscious. He has a history of hypertension, but a recent treadmill test had revealed no evidence of cardiac disease. Which of the following do you suspect? a. Acute viral myocarditis

a. Betamyosin

e. Spectrin

Youare asked to see a patient in the Intensive Care Unit who is short of breath and tachycardic to rule outa cardiac cause of her symptoms. A right heart catheter reveals that the mixed venous O2 saturation is 70%;the pulmonary capillary wedge O2 saturation is 97%. The haemoglobin is normal and the patient is afebrile. You are able to state which of the following?

e. Tear in the aortic intima 79.

Concerningcomplete atrioventricularseptal defects which of the following statements is true? a. are seen frequently in patients with trisomy 21 b. frequently have aortic valve insufficiency


c. have a normal mitral valve structure

b. Apparent volume of distribution

d. include a coronary sinus atrial septal defect

c. Lipid solubility

e. include a perimembranous ventricular septal defect

d. Plasma halflife

80. 21 year old woman has a history of palpitations and light headedness. ECG shows short PR interval and inferior Q waves. Her symptoms improve with atenolol 25 mg/day but she has had two short episodes of similar symptoms in the previous 24 hours. What is the longterm management of choice?

e. Renal clearance 87.

e. Radiofrequency ablation.

a. Constriction of the aorta past the ductusarteriosus

a. Anticoagulation. b. Oral amiodarone. c. Oral digoxin.

b. Lack of development of the spiral septum and partial absence of conus musculature

81. A 60 year old man’s echocardiogram shows a dilated left ventricular cavity with the remainder of the other chamber sizes normal. The most likely diagnosis is which of the following?

c. Shortening and thickening of chordae tendineae of the mitral valve d. Single large atrioventricular valve

a. aortic regurgitation

e. Supravalvular narrowing in the aortic root

b. aortic stenosis d. mitral regurgitation

88.

e. mitral stenosis 82.

a. a normal physical exam b. cardiactamponade

Left axis deviation is seen on the ECG in which of the following conditions?

c. constrictive pericarditis d. dilated cardiomyopathy

a. atrioventricular canal defects.

e. myocarditis

b. Ebstein’s anomaly. c. large ventricular septal defect. d. patentductusarteriosus. e. tetralogy of Fallot. 83.

Whichof the following is true regarding the action of Clopidogrel?

89. 75 year old man with a history of anterior MI is taking amiodarone 400 mg/day for history of VT. He has a prolonged QT interval on his ECG.What is the most appropriate management? a. Admit to hospital for monitoring. b. Atenolol.

a. It inhibits cyclooxygenase

c. Change amiodarone to flecainide.

b. It is an ADP receptor antagonist

d. Continue with amiodarone.

c. It is a glycoprotein IIb/IIIa inhibitor d. It is a selective factor Xa inhibitor

e. Discontinue amiodarone immediately.

c. Mental retardation

A58 year old man has had an enlarging abdomen for several months. He has experienced no abdominal orchest pain. On physical examination he has a nontenderabdomen with no masses palpable, but there is a fluid thrill. An abdominal Ultrasound Scan shows a large abdominal fluid collection with a small cirrhotic liver. A chest Xray shows a globally enlarged heart. Which of the following conditions is most likely to be present?

d. Pulmonary stenosis

a. Dilated cardiomyopathy

e. Retinal detachment

b. Lymphocytic myocarditis

e. It is Hydroxymethyl Coenzyme A inhibitor 84.

90.

Which ONE of the following is associated with Marfan’s syndrome? a. Autosomal recessive inheritance b. increased upper : lower body ratio

c. Myocardial amyloid deposition

85. A 30 year old intravenous drug abuser develops acute aortic regurgitation due to infective endocarditis. Which of the following is least likely to be found on clinical examination? a. decreased cardiac output

d. Nonbacterial thrombotic endocarditis e. Severe occlusive coronary atherosclerosis

c. hypotension

Anginadue to an imbalance between O2 supply and demand without atherosclerosis would most likely be seen in which of the following circumstances?

d. mitral valve preclosure

a. aortic regurgitation

e. peripheral vasodilatation

b. cardiactamponade

b. decrescendo diastolic murmur

86.

Elevation of the jugular venous pressure during inspiration is most likely to be found in which of the following situations?

A67 year old man presents with sudden onset atrial fibrillation (ventricular rate of 150/minute). His serumcreatinine concentration was 250 umol/L (70110). What is the main factor that determines the choiceof loading dose of digoxin in this patient? a. Absorption

91.

c. pulmonary regurgitation d. right heart failure e. tricuspid regurgitation

CARDIOLOGY

d. Increase the dose of atenolol.

A 17 year old girl is short in stature for her age. She has not shown any changes of puberty. She has a webbed neck. Her vital signs include Temperature 36.6°C Respiratory rate 18/min Pulse 75 bpm and BP 165/85 mmHg. On physical examination, she has a continuous murmur heard over both the front of the chestas well as her back. Her lower extremities are cool with poor capillary filling. A chest radiograph reveals aprominent left heart border, no oedema or effusions, and rib notching. Which of the following pathologiclesions best explains these findings?

c. hypertensive heart disease

1123


d. Spironolactone

1124 92. An 18 year old man had repeated episodes of breathlessness

and palpitations, lasting about 20 minutes and resolving gradually. There were no abnormal physical signs. What is the most likely cause of these features? a. Drug abuse b. Panic disorder c. Paroxysmal supraventricular tachycardia d. Personality disorder e. Thyrotoxicosis

93.

Apreviously well 60 year old lady is admitted with an Acute Anterior Myocardial Infarction. A random blood glucose concentration was found to be 12.1 mmol/L (<6.7). What is the optimal management of her blood sugar?

e. Valsartan 98. A40yearoldman received an orthotopic cardiac transplant 7 years ago to treat a dilatedcardiomyopathy. Since that time he has been healthy, with no episodes of rejection or infection. Over the nextyear, however, he develops fatigue with exercise. He has worsening pedal edema and orthopnea. On physicalexamination, his vital signs are Temperature 36.3°C, Pulse 78, Respiratory rate 16, and BP 130/70 mm Hg.There are no murmurs, rubs, or gallops audible. Bibasilar crackles in the lungs are audible. Which of thefollowing conditions is most likely to account for these findings? a. Angiosarcoma b. Coronary arteriopathy

MCQ's

a. Diet

c. Mitral valvular stenosis

b. Gliclazide

d. Myocarditis

c. Intravenous insulin plus dextrose d. Metformin e. Subcutaneous insulin 94. A65yearoldwas advised to start oral digoxin at a dose of 250 μg daily. His physician explained that the full effect of this treatment would not be apparent for at least a week. Which one of the following pharmacokinetic variables did the physician use to give this explanation? a. bioavailablity b. halflife c. plasma protein binding d. renal clearance e. volume of distribution 95. A75 yearoldlady presents with sudden breathlessness and palpitations. On examination, she was observed to have an irregular heart beat with rate of 140 bpm, BP 150/84 and normal heart sounds. On auscultation of the chest, Fine basal crepitations are heard. An ECG confirms AF and an old inferior MI. She is anticoagulated with heparin and given diuretics. Her heart rate remains rapid. What is the most appropriate management of the lady’s AF? a. DCCV. b. IV amiodarone. c. IV betablocker. d. IV digoxin. e. Oral quinidine therapy. 96.

A45 year old female presents with a two day history of fever and joint pains. She has a past history of hypertension for which she is receiving antihypertensives.On examination she has a temperature of 38 Celsius, a facial rash and slight swelling with tenderness of the wrist and ankle joints. Which of the following Antihypertensivesmay be responsible for her presentation. a. Minoxidil b. Phenoxybenzamine c. Hydrallazine d. Alphamethyldopa e. Bendrofluazide

97. A70yearoldman with dilated cardiomyopathy remains symptomatic in NYHA class 2 due to chronic heart failure. On examination his pulse is 90 regular, BP 140/90, heart sounds normal, chest auscultation did not reveal any abnormalities. He is currently taking Lisinopril 30 mg OD and Frusemide 80 mg OD. What is the best treatment option? a. Amiodarone b. Carvedilol c. Digoxin

e. Pulmonary hypertension 99.

Whichof the following statements concering the treatment of acute myocardial infarction is correct? a. A pansystolic murmur developing within the first 24 hours does not require further investigation. b. Dipyridamole therapy reduces reinfarction within the first year. c. Heparin is beneficial if given with streptokinase. d. Prophylactic lignocaine given in the first 48 hours is effective in preventing ventricular fibrillation e. Treatment with a dihydropyridine calcium antagonist is associated with increased cardiovascular mortality.

100. A70yearoldman is admitted with an acute Qwaveinferior Myocardial Infarction. On day 5, he suddenly develops pulmonary oedema and a loud systolic murmur. Which of the following would be the most useful in establishing a diagnosis? a. chestXray b. coronary arteriography c. ECG d. right heart catheterisation and oximetry e. serum cardiac enzymes 101. A65yearoldman has longstanding stable heart failure treated with frusemide and enalapril. He complains of swelling in his left knee and his GP treats him with Rofecoxib, a cyclooxygenase2(COX2)inhibitor. Two weeks later the patient has increasing breathlessness and ankle oedema.Which one of the following effects of rofecoxib is the most likely to explain his symptoms? a. decreased absorption of frusemide from the gut b. decreased myocardial contractility c. reduced effective action of enalapril d. the onset of anaemia e. the onset of fluid retention 102. Whichof the following statements are true of coronary artery anatomy? a. Right bundle branch block in acute anterior myocardial infarction suggests obstruction prior to the first septal branch ofthe left anterior descending coronaryartery b. the posterior descending artery is usually a branch of the circumflex artery c. The sinus node is supplied by a branch of the right coronary in over 90% of subjects. d. The AV node is supplied by the left anterior descending coronary artery. e. The left main stem is about 4 cm long


103. A34 year old male presents with episodes of breathlessness on exertion. Examination reveals a loud P2 and fixed splitting of the second sound. Which of the following may be responsible for these signs?

109. A14yearoldboy presents with hypertension. Which of the 1125 following statements concerning hypertension in the young is true?

a. Maternal chicken pox infection

a. Sodium nitroprusside is useful for the longtermtreatment of severe cases.

b. Maternal thalidomide therapy

b. Headache is the usual presenting feature.

c. 47 XXY karyotype

c. It is defined as systolic blood pressure above the 99th centile for age.

d. Homocystinuria e. Excess maternal alcohol consumption

a. acute anterior myocardial infarction b. cerebrocasvular accident c. epileptic seizure d. pulmonary embolism e. ventricular tachycardia 105. Deficiencyof which one of the following trace elements is implicated as a cause of cardiomyopathy?

e. Aortic coarctation is the commonest secondary cause. 110. Anew antihypertensive drug needs to be investigated to establish its relative potency. Which of the following techniques is most appropriate for this purpose? a. bioassay b. casecontrolstudy c. doubleblind,randomized, placebo controlled study d. postmarketing surveillance e. sequential trial 111. A53yearoldman presented with hypertension of 150/110 and is found to have the following results on investigation. Raised serum sodium, raised urinary potassium excretion and normal serum renin. What is the likely diagnosis? a. Adrenocortical adenoma b. Coarctation of aorta c. Malignant hypertension

a. chromium

d. Pheochromocytoma

b. copper

e. Renal tumour

c. manganese d. selenium e. zinc 106. A40yearoldman attending a routing screening has a blood pressure of 166/100 mmHg. Two weeks later his blood pressure was 150/90 mmHg. He does not smoke. He drinks 35 units alcohol / week. His body mass index (BMI) is 30 kg/m2 (20 25). What is the best management strategy? a. amlodipine b. atenolol c. bendrofluazide d. enalapril e. lifestyle advice 107. A78 year old female is referred by her GP with high blood pressure. Over the last three months her blood pressure is noted to be around 180/80 mmHg. She has a body mass index of 25.5kg/m2, is a nonsmoker.There are no features to suggest a secondary cause for her hypertension. Which of the following is the mostappropriate treatment for her blood pressure? a. AlphaBlocker b. Angiotensin Converting Enzyme (ACE) Inhibitor c. Angiotensin Blocker d. Betablocker e. Calcium channel blocker 108. Whichof the following compounds has a vasodilating effect? a. Antidiuretic hormone b. Calcitonin c. Endothelin d. Renin e. Somatostatin

112. A29yearoldfemale who is 22 weeks pregnant is noted to have a blood pressure of 150/90 mmHg on 3 separate occasions. Urine protein is negative. Which of the following would be the first line treatment? a. alpha Methyl Dopa b. Atenolol c. Magnesium Sulphate d. Nifedipine e. Salbutamol 113. A58yearoldman presents with sudden onset chest pain. He has a known history of ischaemic heart disease. ECG shows ST segment elevation in V1V5without reciprocal depression. In which territory is the infarction most likely to have take place? a. Anterior b. Inferior c. Lateral d. Inferiolateral e. Posterior 114. An54yearoldmale redevelops chest pain 72 hours after treatment for an anterior myocardial infarction. Which of the following markers will be the most sensitive in detecting reinfarction? a. CKMB b. LDH c. Myoglobin d. Troponin I e. Troponin T 115. Relationship between arterial blood pressure (BP), cardiac outpur (CO) and peripheral vascular resistance (PVR) can be described as a. BP = COxPVR b. BP = CO/PVR

CARDIOLOGY

104. A72yearoldman presents with an episode of collapse. He has had two similar episodes recently, each lasting about one minute. Four years ago he suffered an anterior myocardial infarction. On examination he was orientated and symptomfreewith a regular pulse rate of 80 bpm, BP 140/80 mmHg and the apex beat was displaced to the left. There was an apical systolic murmur. There were no signs of trauma. ECG showed sinus rhythm, Q waves and ST segment elevation anteriorly without reciprocal depression. What is the diagnosis?

d. Abnormalities are frequently seen on DMSA scan.


1126

c. BP = PVR/CO

a. Diazepam

d. None of the above

b. Fluoxetine

116. If a fibrinolytic drug is used for treatment of acute myocardial infarction, the adverse drug effect that is most likely to occur is a. Acute renal failure b. Development of antiplatelet antibodies c. Encephalitis secondary to liver dysfunction d. Hemorrhagic stroke e. Neutropenia 117. Increased serum levels of which of the following may be associated with a decreased risk of atherosclerosis?

MCQ's

a. Very lowdensitylipoproteins (VLDL) b. Lowdensitylipoproteins (LDL) c. Intermediate – density lipoproteins (IDL) d. Highdensitylipoproteins (HDL) e. Cholesterol 118. If the patient has a history of gout, which of the following drugs is most likely to exacerbate this condition? a. Colestipol b. Gemfibrozil c. Lovastatin d. Niacin e. Simvastatin 119. After being counseled about lifestyle and dietary changes, the patient was started on atorvastatin. During his treatment with atorvastatin, it is important to routinely monitor serum concentrations of a. Blood urea nitrogen (BUN) b. Alanine and aspartate aminotransferase c. Platelets

c. Imipramine d. Lithium e. Potassium 124. A hypertensive patient has been using nifedipine for some time without untoward effects. If he experiences a rapidly developing enhancement of the antihypertensiveeffect of the drug, it is probably due to a. Concomitant use of antacids b. Fods containing tyramine c. Grapefruit juice d. Induction of drug metabolism e. Over – the – counter decongestants 125. A drug lacking vasodilator properties that is useful in angina is a. Isosorbidedinitrate b. Metoprolol c. NIfedipine d. Nitroglycerin e. Verapamil 126. Which one of the following drugs is used in the treatment of male impotence and activates prostaglandin E1 receptors? a. Alprostadil b. Fluoxetine c. Mifepristone d. Sildenafil e. Zafirlukast 127. A treatment of angina that consistently decreases the heart rate and can prevent vasospastic angina attacks is

d. Red blood cells

a. Isosorbidedinitrate

e. Uric acid

b. NIFedipine

120. Six months after beginning atorvastatin, the patient’s total and LDL cholesterol concentrations remained above normal and he continued to have anginal attacks despite good adherence to his antianginal medications. His physician decided for niacin. The major recognized mechanism of action of niacin is a. Decreased lipid synthesis in adipose tissue b. Decreased oxidation of lipids in endothelial cells c. Decreased secretion of VLDL by the liver d. Increased endocytosis of HDL by the liver e. Increased lipid hydrolysis by lipoprotein lipase 121. Following drugs act on imidazoline receptor a. Moxonidine b. Dexmedetomidine c. Tizanidine d. All of the above 122. Which one of the following drugs increase digoxin plasma concentration by a pharmacokinetic mechanism? a. Captopril b. Hydrochorothiazide c. Lidocaine d. Quinidine e. Sulfasalazine 123. A 55yearoldpatient currently receiving other drugs for another condition is to be started on diuretic therapy for mild heart failure. Thiazides are known toreduce the excretion of

c. Nitroglycerin d. Propranolol e. Verapamil 128. In a patient receiving digoxin for congestive heart failure, condition that may facilitate the appearance of toxicity include a. Hyperkalemia b. Hypernatremia c. Hypocalcemia d. Hypomagnesemia e. All of the above 129. Activation of endothelin receptor ETA, leads to a. Vasoconstriction b. Bronchoconstriction c. Aldosterone release d. All of the above 130. Methylxanthine drugs such as aminophylline cause which one of the following? a. Vasoconstriction in many vascular beds b. Decrease in the amount of cAMP in mast cells c. Bronchodilation d. Activation of the enzyme phosphodiesterase e. Sedation


131. Drugs used in asthma that often cause tachycardia and tremor include a. Beclomethasone b. Cromolyn sodium c. Ipratropium d. Metaproterenol e. All of the above 132. Following potassium sparing diuretic inhibits action of aldosterone a. Amiloride b. Triamterene d. All of the above 133. In patients with chronic granulomatous disease which of the following agents increases the synthesis of tumor necrosis factor, leading to activation of phagocytosis?

e. Used in management of supraventricular tachycardias 139. What drug is used to prevent embolism in the lung and during myocardial infarction? a. Alteplase b. Human growth hormone c. Granulocyte–macrophage colony – stimulating factor (GM– CSF) d. EPOGEN (EPO) e. None of the above 140. Which of the following cardiovascular agents is classified chemically as a glycoside? a. Nifedipine b. Digoxin c. Flecainide

a. Aldesleukin

d. Cholestyramine

b. Cyclosporine

e. Warfarin

c. Filgrastim d. Infliximab e. Interferon gamma 134. The mechanism of action of cyclosporine involves a. Activation of calcineurin b. Binding to cyclophilin to cause inhibition of a cytoplasmic phosphatase c. Blockade of interleukin – 2receptors d. Inhibition of phospholipase A2 e. Suppression of bone marrow progenitors 135. Which one of the following drugs predictably prolongs the PR interval and increases cardiac contractility? a. Digoxin b. Lidocaine c. Propranolol d. Quinidine e. Verapamil 136. Which of the following is the drug of choice for management of cardiac arrhythmias that occur in digitalis toxicity? a. Amiodarone b. Lidocaine c. Propranolol

141. Inhibition of carbonic anhydrase results in a. Abolition of NaHCO3 reabsorption in proximal tubule b. Enhanced of NaHCO3 reabsorption in proximal tubule c. Enhanced NAHCO3 secretion in distal tubule d. None of the above 142. Which of the following cyclotron produced radiopharmaceuticals is used for assessing regional myocardial perfusion as part of an exercise stress test? a. Thallous chloride 201TI USP b. Sodium iodide 123I c. Gallium citrate 67Ga USP d. Indium 111In pentetate e. Cobalt 57Co cyanocobalamin 143. Mary has a family history of heart disease and wonders if garlic would be beneficial to her. Which of the following statements is correct about garlic? a. Entericcoatedtablets release their contents in the stomach b. Side effects include heartburn, flatulence, and sweating c. The safety of garlic in pregnancy is unknown d. Garlic does not interact with warfarin 144. Exertion–induced angina, which is nitroglycerin, or both, is referred to as

d. Sotalol

a. Prinzmetal’s angina

e. Prazosin

b. Unstable angina

137. A 54yearoldwoman with severe hypercholesterolemia is to be treated with a combination of niacin and atorvastatin. With this drug combination, it is important that the patient be monitored closely for signs of a. Agranulocytosis b. Gallstones c. Lactic acidosis d. Myopathy e. Thyrotoxicosis 138. Regarding verapamil, which one of the following statements is false? a. Angina pectoris is an important indication for the use of verapamil b. Contraindicated in the asthmatic patient c. Relaxes vascular smooth muscle

relieved

by

rest,

c. Classic angina d. Variant angina e. Preinfarction angina 145. Myocardial oxygen demand is increased by all of the following factors except a. Exercise b. Smoking c. Cold temperatures d. Isoproterenol e. Propranolol 146. Which of the following agents used in prinzmetal’s angina has spasmolytic actions, which increase coronary blood supply? a. Nitroglycerin b. Nifedipine

CARDIOLOGY

c. Spironolactone

d. Slows the depolarization phase of the action potential in AV 1127 nodal cells


1128

c. Timolol

a. Lbutilide

d. Isosorbidemononitrate

b. Mexiletine

e. Propranolol

c. Diltiazem

147. The oral absorption of following osmotic diuretic is negligible a. Glycerin b. Mannitol c. Isosorbide d. All of the above 148. Maximal medical therapy for treating angina pectoris is represented by which of the following choices? a. Diltiazem, verapamil, nitroglycerin

MCQ's

b. Atenolol, isoproterenol, diltiazem c. Verapamil, nifedipine, propranolol d. Isosorbide, atenolol, diltiazem e. Nitroglycerin, isosorbide, atenolol 149. The term ischemic heart disease (IHD) is used to designate all of the following conditions except a. Angina pectoris b. Sudden cardiac death c. Congestive heart failur (CHF) d. Arrhythmias 150. Which of the following thrombolytic agents would be appropriate at this time? a. Anisoylated plasminogen streptokinase activator complex (APSAC) b. Streptokinase (SK) c. Recombinant tissuetypeplasminogen activator (tPA) 151. Strong anticholinergic effects limit the antiarrhythmic use of a. Quinidine b. Procainamide c. Tocainide d. Flecainide e. Disopyramide 152. Following loop diuretic is a phynoxy acetic acid derivative a. Furosemide b. Bumetanide c. Ethacrynic acid d. All of the above 153. Following potassium sparing diuretic is a mineralocorticoid receptor antagonist a. Amiloride b. Triamterene c. Spironolactone d. All of the above 154. A patient receiving a class I antiarrhythmic agent on a chronic basis complains of fatigue, lowgrade fever,and joint pain suggestive of systemic lupus erythematosus (SLE). The patient is most likely receiving

d. Quinidine e. Propranolol 156. Which of the following agents has a direct effect on the AV mode, delaying calciumchannel depolarization? a. Lidocaine b. Diltiazem c. Bretylium d. Quinidine e. Lbutilide 157. Which of the following groups of symptoms is most often associated with a patient who has rightsided heart failure? a. Nocturia, rales, paroxysmal nocturnal dyspnea b. Paroxysmal nocturnal dyspnea, pedal edema, jugular venous distention, hepatojugular reflux c. Jugular venous distention, hepatojugular reflux, pedal edema, shortness of breath d. Hepatojugular reflux, jugular venous distension, pedal edema, abdominal distention e. Paroxysmal nocturnal dyspnea, jugular venous distention, abdominal distention, shortness of breath 158. Which of the following combinations of drugs, when used together, reduce both preload and afterload? a. Nitroglycerin and isosorbidedinitrate b. Hydralazine and isosorbidedinitrate c. Captopril and methyldopa d. Prazosin and angiotension II e. Hydralazine and methyldopa 159. When digoxin is used in a patient with congestive heart failure (CHF), it works by exerting a positive effect on a. Stroke volume b. Total peripheral resistance c. Heart rate d. Blood pressure e. Venous return 160. Because of proven beneficial effects on “cardiac remodeling”, these agents are now indicated as first line therapy in CHF patients. Which of the following isrepresentative of this group of drugs? a. Hydrochlorothiazide b. Enalapril c. Furosemide d. Carvedilol e. Bumetanide 161. For treating the patient with congestive heart failure (CHF), which of the following dosages of dopamine is selected for its positive inotropic effects? a. 2.0 mg/kg/min

a. Lidocaine

b. 5–10 mg/kg/min

b. Procainamide

c. 10–20 mg/kg/min

c. Quinidine

d. 40 mg/kg/min

d. Flecainide

e. 40 mg/kg/min

e. Propranolol 155. Which of the following drugs is a class IV antiarrhythmic that is primarily indicated for the treatment of supraventriculartachyarrhythmias?

162. Milrinone is an example of a. Phosphodiesterase I inhibitor b. Phosphodiesterase II inhibitor


c. Phosphodiesterase III inhibitor

b. Tolerance

d. Phosphodiesterase IV inhibitor

c. Addiction

163. Situations that predispose a digitalistreated patient to toxicity include a. Hypercalcemia b. Hyperkalemia c. Hypermagnesemia 164. Unfractionated heparin binds to antithrombin III and inactivates clotting factor(s) a. Xa b. Ixa d. All of the above e. None of the above 165. A patient to be commenced on oral anticoagulant therapy for DVT would be treated with a. Oral anticoagulant therapy with warfarin for a goal intenational normalized ration (INR) of 2–3 b. Oral anticoagulant therapy with warfarin for a goal INR of 2.5–3.5 c. Oral anticoagulant therapy with aspirin for a goal INR of 2–3 166. A patient on oral anticoagulant therapy is commenced on sulfamethoxazoletrimethoprim, doublestrength twice daily. One may expect to see the international normalized ratio a. Increase b. Decrease c. Remain unchanged 167. When compared to unfractionated heparin, low molecular weight heparins have a. Preferential binding affinity to factor Xa relative to Iia (thrombin)

d. Physical dependence e. Cummulative poisoning 172. The action of digitalis is enhanced by a. Sodium b. Calcium c. Magnesium d. Potassium e. Chloride 173. In case of acute pain of angina pectoris the most effective treatment would be to administer a. Mannitolhexanitrate b. Erythrityltetranitrate c. Sodium nitrate d. Pentaerythritoltetranitrate e. Nitroglycerin 174. Which of the following is used to lower blood lipid levels? a. Trimethadione b. Clofibrate c. Flucytosine d. Coumarin e. Propranolol 175. The chief use of levoarterenol is to treat a. Shock b. Diabetes c. Hypertension d. Cardiac arrhythmias e. Iron deficiencies 176. Tolerance to nitroglycerin may be overcome by

b. Shorter halflives

a. Initially using the largest safe dose of the drug

c. Dose – dependent renal clearance

b. Using other nitrites

168. Acute renal failure (ARF) may be caused by all of the following except a. Acute tubular necrosis (ATN) due to drug therapy (e.g., aminoglycosides, contrast media) b. Severe hypotension or circulatolry collapse c. Decreased cardiac output, as from congestive heart failure d. Hemolysis, myoglobinuria e. Hyperkalemia 169. During Phase 2 of action potential in cardiac cell, depolarizing current through calcium channels is balanced by a. Delayed rectifier potassium current b. outward chloride channel c. Both (a) and (b) d. None of the above 170. The action of quinidine differs from that of digitalis in a. Decreasing irritability of cardiac muscle b. Preventing passage of impulses to the ventricle c. Increasing irritability of heart muscle d. Reducing conductivity e. None of the above 171. Overuse of digitalis may result in a. Habituation

c. Temporarily discontinuing the drug for one or two weeks d. Use of higher doses e. None of the above 177. Quinidine can cause paradoxical tachycardia in a patient of a. Stick sinus syndrome b. Auricular extrasystoles c. Auricular fibrillation d. Ventricular extrasystoles 178. Quinidine is now used primarily for a. Conversion of auricular fibrillation to sinus rhythm b. Control of ventricular rate in atrial flutter c. Termination of ventricular tachycardia d. Prevention of recurrences of atrial and ventricular extrasystoles/tachycardias 179. Procainamide differs from quinidine in the following respect a. It does not cause paradoxical tachycardia b. It has no alfa adrenergic blocking activity c. It has little antivagal action d. Both (b) and (c) 180. In heart, potassium channels determine a. Pacemaker function b. Resting potential

CARDIOLOGY

c. Iia

1129


1130

189. The primary mechanism of beneficial effect of glyceryltrinitrate in classical angina pectoris is

c. Action potential duration d. All of the above

a. Increase in total coronary blood flow

181. Lidocaine is the preferred antiarrhythmic for emergency control of cardiac arrhythmias following acute myocardial infarction because a. It has a rapidly developing and titratable antiarrhythmic action b. It casues little myocardial depression and hypotension

b. Redistribution of coronary blood flow c. Reduction of cardiac preload d. Reduction of cardiac after load 190. Enhanced automaticity in cardiac cells may occur because of a. Ă&#x;adrenergic stimulation

c. It has broad spectrum antiarrhythmic efficacy in atrial as well as ventricular arrhythmias

b. Hypokalemia c. Mechanical stretch of cardiac muscles

MCQ's

d. Both (a) and (b) 182. Hypothyroidism is a possible consequence of prolonged therapy with a. Procainamide

d. All of the above 191. Glyceryltrinitrate is administratered by all of the following routes except a. Oral

b. Mexiletine

b. Sublingual

c. Sotalol

c. Intramuscular

d. Amioiv 183. Which of the following drugs is preferred for termination of paroxysmal supraventricular tachycardia a. Digoxin b. Quinidine c. Propranolol

d. Intravenous 192. A patient of acute myocardial infarction being treated in intensive care unit developed left ventricular failure with raised central venous pressure. It was decided to use glyceryltrinitrate. Which route/method of administration would be most suitable. a. Sublingual

d. Verapamil

b. Oral

184. The following drug is used to reduce the frequency of angina pectoris as well as to terminate an acute attack

c. Intravenous bolus injection d. Slow

a. Digoxin b. Furosemide

193. A patient suffers from spisodic pain diffusely localized over the chest and upper abdomen, which is relieved by sublingual glyceryltrinitrate. He could be suffering from

c. Enalapril d. Amrinone

a. Angina pectoris

185. Antianginal drugs afford the following benefit/benefits

b. Biliary colic

a. Terminate anginal attacks

c. Esophageal spasm

b. Decrease the frequency of anginal attacks

d. All of the above

c. Retard the progression of coronary artery disease

194. The dihydropyridines block the following type of calcium channels.

d. Both (a) and (b) 186. Choose the correct statement about the action of nitrates on coronary vessels

a. Ltypevoltage sensitive channels

a. They mitigate angina pectoris by increasing total coronary flow

c. Ntypevoltage sensitive channels

b. They preferentially dilate conducting arteries without affecting resistance arterioles c. They preferentially dilate autoregulatory arterioles without affecting the larger arteries d. They increase subepicardial blood flow without affecting subendocardial blood flow a. Increasing intracellular cyclic AMP

d. Erythrityltetranitrate

a. Digoxin b. Furosemide c. Enalapril

b. Depolarization

d. Both (b) and (c)

c. Isosorbidemononitrate

Which of the following drugs is most likely to accentuate varient (Prinzmetal) angina ?

a. Causes shortening of action potential duration

c. Decreasing intracellular cyclic AMP

b. Isosorbidedinitrate

195.

196. In cardiac cells, adenosine

b. Increasing intracellular cyclic GMP

a. Glyceryltrinitrate

d. Receptor operated calcium channels

d. Amrinone

187. Organic nitrates relax vascular smooth muscle by

188. Select the organic nitrate which firstpassmetabolism in the liver

b. Ttypevoltage sensitive channels

c. Increase in normal automaticity undergoes

minimal

d. All of the above 197. Which of the following antianginal drugs is most likely to produce tachycardia as a side effect ? a. Amlodipine b. Nifedipine c. Diltiazem d. Verapamil


198. Which of the following is not an attribute of amlodipine ? a. High and consistent oral bioavailability b. Large volume of distribution c. Generation of an active metabolite d. Long elimination halflife 199. Propranolol should not be prescribed for a patient of angina pectoris who is already receiving a. Nifedipine b. Felodipine c. Verapamil d. Isosorbidemononitrate a. Pinacidil b. Hydralazine c. Glibenclamide d. Amiloride 201. Though nitrates and calcium channel blockers are both vasodilators, they are used concurrently in angina pectoris because a. They antagonize each other’s side effects b. Nitrates primarily reduce preload while calcium channel blockers primarily reduce after load c. Nitrates increase coronary flow while calcium d. Both (b) and (c) 202. Coronary steal phenomenon’ has been noted most frequently with a. Glyceryltrinitrate b. Dipyridamole c. Propranolol d. Diltiazem 203. Which of the following drugs is believed to improve microcirculation in peripheral vascular diseases by promoting RBC flexibility ? a. Cyclandelate b. Theophyline c. Pentoxiphyline d. Nicotinic acid 204. Higher incidence of myocardial infarction and increased mortality has been noted with the use of the following antihypertensive drug a. Nifedipine b. Verapamil c. Diltiazem d. Lisinopril 205. Cardiac glycosides are obtained from following plant source. a. Rauwolfiaserpentina b. Strophanthusgratus c. Ricinuscommounts. d. Atropa belladonna 206. Therapeutic dose of digoxin in a normal individual has the following effects, except a. Increase in the speed of myocardial contractility b. No significant change in cardiac output c. Relaxation of peripheral vascular bed d. Increase in the force of myocardial contractility

a. Thyrotoxicosis b. Beriberi c. Corpulmonale d. Atrial fibrillation 208. The agent given sublingually in an acute attack of angina pectoris is a. Glyceryltrinitrate b. Amyl nitrite c. Erythritaltetranitrate d. Pentaerythritoltetranitrate 209. Following statement is true about lidocaine a. Reduce the slope of Phase 4 b. Threshold excitability is not altered c. Action potential is not affected d. All of the above 210. Aspirin in small doses (50 to 150 mg per day) a. Is of benefit in patients of unstable angina b. Has thrombolytic action c. PREFerentially inhibits prostacyclin synthetase enzyme d. MAY Alleviate need for Verapamil in variant angina 211. Major beneficial effect of nitrates in classical angina is due to a. Dilation of veins more than arteries b. Increase in total coronary blood flow c. An increase in the end diastolic size of the heart d. An increase in the heart rate 212. Major lipid class present in chylomicrons is a. Endogenous triglycerides b. Cholesterol esters c. Dietary triglycerides d. All of the above 213. A 65-year-old man presents with central crushing chest pain for the first time. Heis transferred immediately to the closest cardiac unit to undergo a primarypercutaneous coronary intervention. There is thrombosis of the left circumflexartery only. Angioplasty is carried out and a drug-eluding stent is inserted. Whatare the most likely changes to have occurred on ECG during admission? a. ST depression in leads V1–4 b. ST elevation in leads V1–6 c. ST depression in leads II, III and AVF d. ST elevation in leads V5–6 e. ST elevation in leads II, III and AVF 214. A 78-year-old woman is admitted with heart failure. The underlying cause isdetermined to be aortic stenosis. Which sign is most likely to be present? a. Pleural effusion on chest x-ray b. Raised jugular venous pressure (JVP) c. Bilateral pedal oedema d. Bibasalcrepitations e. Atrial fibrillation 215. A patient is admitted with pneumonia. A murmur is heard on examination. Whatfinding points to mitral regurgitation? a. Murmur louder on inspiration b. Murmur louder with patient in left lateral position

CARDIOLOGY

200. Which of the following drugs is a potassium channel opener ?

207. Digoxin given for cardiac failure is extremely valuable in 1131 patients of


1132

c. Murmur louder over the right 2nd intercostal space midclavicular line d. Corrigan’s sign e. Narrow pulse pressure 216. A 79-year-old woman is admitted to the coronary care unit (CCU) with unstableangina. She is started on appropriate medication to reduce her cardiac risk. She ishypertensive, fasting glucose is normal and cholesterol is 5.2. She is found to be inatrial fibrillation. What is the most appropriate treatment? a. Aspirin and clopidogrel b. Digoxin

MCQ's

c. Cardioversion d. Aspirin alone e. Warfarin 217. A 55-year-old man has just arrived in complaining of 20minutes of central crushing chest pain. Which feature is most indicative ofmyocardial infarction at this moment in time?

221. A 49-year-old man is rushed to complaining of a 20-minute history of severe, crushing chest pain. After giving the patient glyceryltrinitrate (GTN) spray, he is able to tell you he suffers from hypertension and type 2 diabetes and is allergic to aspirin. The most appropriate management is: a. Aspirin b. Morphine c. Heparin d. Clopidogrel e. Warfarin 222. While on call you are called by a nurse to a patient on the ward complaining of light headedness and palpitations. When you arrive the patient is not conscious but has a patent airway and is breathing with oxygen saturation at 97 per cent. You try to palpate a pulse but are unable to find the radial or carotid. The registrar arrives and after hearing your report of the patient decides to shock the patient who recovers. What is the patient most likely to have been suffering? a. Torsades de Pointes b. Ventricular fibrillation

a. Inverted T waves

c. Sustained ventricular tachycardia

b. ST depression

d. Non-sustained ventricular tachycardia

c. ST elevation

e. Normal heart ventricular tachycardia

d. Q waves e. Raised troponin 218. A 66-year-old woman presents to with a 2-day history of shortness of breath. The patient notes becoming progressively short of breath as well as a sharp pain in the right side of the chest which is most painful when taking a deep breath. The patient also complains of mild pain in the right leg, though there is nothing significant on full cardiovascular and respiratory examination. Heart rate is 96 and respiratory rate is 12. The patient denies any weight loss or long haul flights but mentions undergoing a nasal polypectomy 3 weeks ago. The most likely diagnosis is: a. Muscular strain b. Heart failure c. Pneumothorax d. Angina e. Pulmonary embolism 219. A 59-year-old man presents for a well person check. A cardiovascular, respiratory, gastrointestinal and neurological examination is performed. No significant findings are found, except during auscultation a mid systolic click followed by a late systolic murmur is heard at the apex. The patient denies any symptoms. The most likely diagnosis is: a. Barlow syndrome b. Austin Flint murmur c. Patent ductusarteriosus d. Graham Steell murmur e. Carey Coombs murmur 220. A 60-year-old man presents to with a 3-day history of increasingly severe chest pain. The patient describes the pain as a sharp, tearing pain starting in the centre of his chest and radiating straight through to his back between his shoulder blades. The patient looks in pain but there is no pallor, heart rate is 95, respiratory rate is 20, temperature 37°C and blood pressure is 155/95 mmHg. The most likely diagnosis is: a. Myocardial infarction b. Myocardial ischaemia c. Aortic dissection d. Pulmonary embolism e. Pneumonia

223. A 67-year-old man presents to with a 3-day history of shortness of breath. On examination you palpate the radial pulse and notice that the patient has an irregular heart beat with an overall rate of 140 bpm. You request an electrocardiogram (ECG) which reveals that the patient is in atrial fibrillation. Which of the following would you expect to see when assessing the JVP? a. Raised JVP with normal waveform b. Large ‘v waves’ c. Cannon ‘a waves’ d. Absent ‘a waves’ e. Large ‘a waves’ 224. A 78-year-old woman is admitted to your ward following a 3-day history of shortness of breath and a productive cough of white frothy sputum. On auscultation of the lungs, you hear bilateral basal coarse inspiratory crackles. You suspect that the patient is in congestive cardiac failure. You request a chest x-ray. Which of the following signs is not typically seen on chest x-ray in patients with congestive cardiac failure? a. Lower lobe diversion b. Cardiomegaly c. Pleural effusions d. Alveolar oedema e. Kerley B lines 225. A 56-year-old man presents to your clinic with symptoms of exertional chest tightness which is relieved by rest. You request an ECG which reveals that the patient has first degree heart block. Which of the following ECG abnormalities is typically seen in first degree heart block? a. PR interval >120 ms b. PR interval <300 ms c. PR interval <200 ms d. PR interval >200 ms e. PR interval <120 ms 226. You see a 57-year-old woman who presents with worsening shortness of breath coupled with decreased exercise tolerance. She had rheumatic fever in her adolescence and suffers from essential hypertension. On examination she has signs which point to a diagnosis of mitral stenosis. Which of the following is not a clinical sign associated with mitral stenosis?


d. Tapping, undisplaced apex beat

hypertensive for about five years and his blood pressure 1133 control had been good on three drugs. However, he had decided to stop all medication two months before this event. Which of the following would be your preferred parenteral medication at this point?

e. Right ventricular heave

a. Glyceryltrinitrate

a. Malar flush b. Atrial fibrillation c. Pan-systolic murmur which radiates to axilla

227. A 48-year-old woman has been diagnosed with essential hypertension and was commenced on treatment three months ago. She presents to you with a dry cough which has not been getting better despite taking cough linctus and antibiotics. You assess the patientâ&#x20AC;&#x2122;s medication history. Which of the following antihypertensive medications is responsible for the patientâ&#x20AC;&#x2122;s symptoms? b. Lisinopril c. Bendroflumethiazide d. Frusemide e. Atenolol 228. A 62-year-old male presents with palpitations, which are shown on ECG to be atrial fibrillation with a ventricular rate of approximately 130/minute. He has mild central chest discomfort but is not acutely distressed. He first noticed these about 3 hours before coming to hospital. As far as is known this is his first episode of this kind. Which of the following would you prefer as first-line therapy? a. Anticoagulate with heparin and start digoxin at standard daily dose b. Attempt DC cardioversion c. Administer bisoprolol and verapamil, and give warfarin d. Attempt cardioversion with IV flecainide e. Wait to see if there is spontaneous reversion to sinus rhythm 229. A 76-year-old male is brought to after collapsing at home. He has recovered within minutes and is fully alert and orientated. He says this is the first such episode that he has experienced, but describes some increasing shortness of breath in the previous six months and brief periods of central chest pain, often at the same time. On examination, blood pressure is 115/88 mmHg and there are a few rales at both bases. On ECG there are borderline criteria for left ventricular hypertrophy. Which of the following might you expect to find on auscultation? a. Mid-diastolic murmur best heard at the apex b. Crescendo systolic murmur best heard at the right sternal edge

c. Labetalol d. Sodium nitroprusside e. Phentolamine 232. A 16-year-old male is referred for assessment of hypertension. On average, his blood pressure is 165/85 mmHg, with radiofemoral delay. There is a mid-systolic murmur maximal at the aortic area, and radiating to the back. Clinical findings and the ECG are compatible with left ventricular hypertrophy. What is the most likely underlying pathology? a. Hypertrophic obstructive cardiomyopathy b. Congenital aortic stenosis c. Coarctation of the aorta d. Patent ductusateriosus e. Atrial septal defect 233. A 16-year-old boy is diagnosed with a small ventricular septal defect, having been screened by echocardiography because of a family history of hypertrophic obstructive cardiomyopathy. He is entirely asymptomatic, plays several sports regularly and has no growth retardation. The echocardiogram also confirms a small left to right shunt, with pulmonary to systemic flow ratio only just above one. Which of the following is the most likely to be a significant complication of his condition? a. Pulmonary hypertension b. Heart failure c. Dysrhythmias d. Endocarditis e. Shunt reversal (right to left flow) 234. A 52 year-old woman has been treated for several years with amlodipine and lisinopril for what has been presumed to be primary hypertension. She is seen by her GP having complained of persistent left loin pain. Her BP is 150/95 mmHg. She is tender in the left loin and both kidneys appear to be enlarged. On urine dipstick testing, there is microscopic haematuria. Which of the following is likely to be the most appropriate investigation at this point? a. Urinary tract ultrasound

c. Diastolic murmur best heard at the left sternal edge

b. Abdominal and pelvic computed tomography (CT) scan

d. Pan-systolic murmur best heard at the apex

c. Microscopy of the urine (microbial and cytological)

e. Pan-systolic murmur best heard at the left sternal edge

d. Renal biopsy

230. A 63-year-old male was admitted to 2 days after discharge following an apparently uncomplicated MI. He complained of rapidly worsening shortness of breath over the previous 48 hours but no further chest pain. He was tachypnoeic and had a regular pulse of 110/minute, which proved to be sinus tachycardia. The jugular venous pressure was raised and a pan-systolic murmur was noted, maximal at the left sternal edge. Which of the following is the most likely diagnosis? a. Mitral incompetence b. Ventricular septal defect c. Aortic stenosis d. Dresslerâ&#x20AC;&#x2122;s syndrome e. Further myocardial infarction 231. A 57-year-old male is admitted complaining of headaches and blurring of vision. His blood pressure is found to be 240/150 mmHg and he has bilateral papilloedema, but is fully orientated and coherent. He had been known to be

e. Intravenous urogram 235. A 61-year-old man presents with a 2-hour history of moderately severe retrosternal chest pain, which does not radiate and is not affected by respiration or posture. He complains of general malaise and nausea, but has not vomited. His ECG shows ST segment depression and T wave inversion in the inferior leads. Troponin levels are not elevated. He has already been given oxygen, aspirin and intravenous GTN; he is an occasional user of sublingual GTN and takes regular bisoprolol for stable angina. What would be the most appropriate next step in his management? a. IV low-molecular weight heparin b. Thrombolysis with alteplase c. IV nicardapine d. Angiography with stenting e. Oral clopidogrel

CARDIOLOGY

a. Amlodipine

b. Hydralazine


1134 236. A 41-year-old woman is referred for assessment after suffering

a second pulmonary embolus within a year. She has not been travelling recently, has not had any surgery, does not smoke and does not take the oral contraceptive pill. She is not currently on any medication as the diagnosis is retrospective and she is now asymptomatic. What should be the next step in her management? a. Initiation of warfarin therapy b. ECG c. Thrombophilia screen d. Insertion of inferior vena cava filter

MCQ's

e. Duplex scan of lower limb veins and pelvic utrasound 237. A 32-year-old woman attends her GP for a routine medical examination and is noted to have a mid-diastolic murmur with an opening snap. Her blood pressure is 118/71 mmHg and the pulse is regular at 66 beats per minute. She is entirely asymptomatic and chest x-ray and ECG are normal. What would be the most appropriate investigation at this point? a. ECG b. Anti-streptolysin O titre c. Cardiac catheterization d. Thallium radionuclide scanning e. Colour Doppler scanning 238. A 46-year-old man develops sudden severe central chest pain after lifting heavy cases while moving house. The pain radiates to the back and both shoulders but not to either arm. His BP is 155/90 mmHg, pulse rate is 92 beats per minute and the ECG is normal. He is distressed and sweaty, but not nauseated. What would you consider the most likely diagnosis? a. Pneumothorax b. MI c. Pulmonary embolism d. Aortic dissection e. Musculoskeletal pain 239. A 49-year-old woman presents with increasing shortness of breath on exertion developing over the past three months. She has no chest pain or cough, and has noticed no ankle swelling. On examination, blood pressure is 158/61 mmHg, pulse is regular at 88 beats per minute and there are crackles at both lung bases. There is a decrescendo diastolic murmur at the left sternal edge. What is the most likely diagnosis? a. Aortic regurgitation b. Aortic stenosis c. Mitral regurgitation d. Mitral stenosis e. Tricuspid regurgitation 240. A 21-year-old man is on his way home from a party when he experiences the sudden onset of rapid palpitations. He feels uncomfortable but not short of breath and has no chest pain. He goes to the nearest department, where he is found to have a supraventricular tachycardia (SVT) at a rate of 170/minute. Carotid sinus massage produced transient reversion to sinus rhythm, after which the tachycardia resumed. What would be the next step in your management? a. Repeat carotid sinus massage b. IV verapamil c. IV propranolol d. IV adenosine e. Synchronized DC cardioversion 241. A 44-year-old woman attends her local department with a history of at least six months of frequent central chest pain in the early morning or during the night. She had no chest pain on exertion. This had been a particularly severe attack,

lasting over 2 hours. Her pulse rate is 84/minute in sinus rhythm, and blood pressure is 134/86 mmHg. The ECG shows anterior ST segment elevation, but troponin levels do not rise. Subsequent coronary angiography is normal. What is the most likely diagnosis? a. MI b. Stable angina c. Unstable angina d. Anxiety e. Variant angina 242. A previously fit 19-year-old man presents with unusual shortness of breath on exertion. At times, this is also associated with central chest pain. On examination there is a loud midsystolic murmur at the left sternal edge. Heart rate and blood pressure are normal and there is no oedema. The ECG shows left axis deviation and the voltage criteria for left ventricular hypertrophy and the echocardiogram reveals a significant thickened interventricular septum, with delayed ventricular filling during diastole. There is a family history of sudden death below the age of 50. Which of the following would be your initial therapy? a. Digoxin b. Long-acting nitrates c. Beta-blockers d. Rate-limiting calcium channel blockers e. Partial excision of the septum 243. A 44-year-old woman presents with episodes of headaches, associated with anxiety, sweating and a slow pulse rate. At the time of her initial consultation, her blood pressure was 150/95 mmHg seated, but 24 hour ambulatory monitoring shows a peak of 215/130 mmHg, associated with the symptoms described above. Which of the following would be your initial diagnostic procedure? a. Magnetic resonance imaging (MRI) scans of the abdomen and pelvis b. Measurement of random plasma catecholamines c. Measurement of urinary metanephrines over several 24 hour periods d. Glucose tolerance test e. Pharmacological provocation using clonidine 244. A 56-year-old man presents to the department with a 2-hour history of central chest pain radiating to the left arm. He is anxious, nauseated and sweaty. His pulse rate is 120/minute in sinus rhythm and the ECG reveals ST elevation in leads II, III and aVF. The troponin level is significantly raised. This is certainly acute MI. Which is the most likely coronary vessel to be occluded? a. Circumflex artery b. Left anterior descending artery c. Right coronary artery d. Left main coronary artery e. Posterior descending artery 245. A 45-year-old woman complains of increasing shortness of breath on exertion, as well as orthopnoea, for the previous 3â&#x20AC;&#x201C;4 months. She had apparently recovered from pericarditis about a year earlier. On ECG there is low voltage, especially in the limb leads, and the chest x-ray shows pericardial calcification. The presumptive diagnosis is constrictive pericarditis. Which of the following physical signs would be consistent with this? a. Increased jugular distention on inspiration b. Third heart sound c. Fourth heart sound d. Rales at both lung bases e. Loud first and second heart sounds


246. A 71-year-old man is being treated for congestive heart failure with a combination of drugs. He complains of nausea and anorexia, and has been puzzled by observing yellow rings around lights. His pulse rate is 53/minute and irregular and blood pressure is 128/61 mmHg. Which of the following medications is likely to be responsible for these symptoms?

atrial fibrillation. Which of the following statements is correct 1135 regarding the management of this patient? a. Digoxin effectively prevents recurrence of the arrhythmia b. Anticoagulation is not necessary c. Sotalol may be effective

a. Lisinopril

d. Amiodarone should be avoided

b. Spironolactone

e. Flecainide orally may be an effective as-needed treatment to abort anAttack

c. Digoxin d. Furosemide e. E. Bisoprolol

a. Arrange for his medication to be given under direct observation b. Add spironolactone to his medication c. Arrange urinary catecholamine assays

a. Thyroid function tests (TSH, free T4)

d. Request an adrenal CT scan

b. ECG

e. Add verapamil to his medication

c. Chest x-ray d. Full blood count e. Fasting blood sugar 248. A 58-year-old man has made an excellent functional recovery after an anterior MI. He is entirely asymptomatic and there is no abnormality on physical examination. His blood pressure is 134/78 mmHg and he is undertaking a cardiac rehabilitation programme. Which of the following would you not recommend as part of his secondary prevention planning? a. Aspirin b. Lisinopril c. Simvastatin d. Bisoprolol e. Omega-3 fatty acids 249. A 25-year-old woman with known mitral valve prolapse develops a low grade fever, malaise and night sweats within a couple of weeks of a major dental procedure. Examination reveals a pulse rate of 10/minute, which is regular, tender vasculitic lesions on the finger pulps and microscopic haematuria. Which investigation is most likely to provide a definitive diagnosis?

253. Cardiac toxicity is seen most in a. Bleomycin b. Adriamycin c. Methotrexate d. Busulphan 254. Cardiospasm is a. Coronary artery stenosis b. Presbyoesophagus c. Esophageal webs d. Cricoid narrowing 255. Carotid sinus massage produces a. Reflex bradypnea b. Reflex bradycardia c. Reflex tachycardia d. Hyperpnea 256. To differentiate between supraventricular tachycardia and ventricular tachycardia of aberrant conduction all the following points support the latter except

a. Full blood count

a. Wide QRS >0.16 secs

b. ECG

b. Carotid massage causes a 2:1 block

c. Autoantibody screen

c. Oesophageal leads show A-V dissociation

d. Blood culture e. Coronary angiography 250. An asymptomatic 31-year-old woman has been referred for cardiological assessment. After her ECG she was told that she had mitral valve prolapse and would like further information on this condition. Which of the following statements is correct? a. Beta-blocker therapy is indicated b. Angiotensin-converting enzyme (ACE) inhibitor therapy is indicated

257. Linked angina means.. a. Tietz syndrome b. Viral pericarditis c. Variant angina d. Angina caused by myocardicalischaemia Gastrointestinal disturbances.

a. 0.5-1kg b. 1-2kg

d. Significant mitral regurgitation will eventually develop

d. 5-7kg

251. A 69-year-old woman complains of intermittent palpitations, lasting several hours, which then stop spontaneously. She also suffers from asthma. Holter monitoring confirms paroxysmal

to

258. Any visible edema of both lower extremetied each preceded by weight gain of

c. One or both leaflets of the mitral valve are pushed back into the leftatrium during systole e. Exercise should be restricted

due

c. 3-5kg 259. In pheochromocytoma there is increased level of a. Serum HMA b. Serum bradykinin

CARDIOLOGY

247. A 29-year-old woman goes to see her GP complaining of fatigue and palpitations. She says she has also lost weight, though without dieting. On examination, her pulse rate is approximately 120/min and irregularly irregular. Her blood pressure is 142/89 mmHg and her body mass index is 19. There are no added cardiac sounds. The ECG confirms the diagnosis of atrial fibrillation. What would you suggest as the most useful next investigation.

252. A 57-year-old man is reviewed in a hypertension clinic, where it is found that his blood pressure is 165/105 mmHg despite standard doses of amlodipine, perindopril, doxazosin and bendroflumethiazide. Electrolytes and physical examination have been, and remain, normal. Which of the following would be your next stage in his management?


1136

c. Urinary VMA d. All of the above 260. Pulsatile exophthalmos is seen in a. Severe AR b. SEVERE TR c. TR d. MR 261. Osteogenesisimperfecta may be associated with all except: a. Aortic dialation b. AR

MCQ's

c. MVP d. PR 262. Kussamaul’s sign is a. Paradoxical rise in height of JVP b. Paradoxical decrease in height of the JVP c. Seen in AS d. Typically occurs in cardiac tamponade 263. W shaped JVP is seen in

270. Diastasis phase accounts for ------% of ventricular filling a. 80% b. 70% c. 60% d. <5% 271. Which are the values of Troponin T that are prognostically significant? a. >/= to 0.05 ng/ml b. >/= to 0.1 ng/ml c. >/= to 0.001 ng/ml d. >/= to 0.01 ng/ml 272. Most consistant phase of pericardial rub is a. Systolic phase b. Presystolic c. Mid diastolic d. All of the above 273. The most common cause of secondary hypertension in children is a. Renal artery stenosis

a. Constrictive pericarditis

b. Adrenal tumors

b. RCM

c. Renal disease

c. DCM

d. Coarctation of aorta

d. HOCM 264. Dicrotic notch in normal pulse indicated a. Opening of mitral valve b. Opening of aortic valve c. Closure of MV d. Closire of AV 265. Pulsustardus means a. Late peaking b. Slow rising c. Reduced peak d. Small amplitude 266. Visible pulsation of the retinal artery is known as a. Hill’s sign b. Duoroziez’s sign c. Traube’s sign d. Beckers sign 267. Urokinase and streptokinase are contraindicated in a. Malignancy b. A-V fistula c. Pulmonary embolism d. Thrombophlebitis 268. Loud S1 is seen in all except a. Short PR interval b. AF c. MS d. Rapid heart rate 269. Reverse splitting of s2 is seen in a. RBBB b. LBBB c. LV Placed beats d. Lv ectopic beats

274. The duration of the depolarisation of the heart from the SA node to the AV node is reflected on the ECG by a. QT interval b. PR interval c. RS interval d. RR interval 275. Digoxin toxicity can be recognized when there is a. QT interval is shortened b. Ventricular bigeminy c. Atrial flutter d. Mobitz II degree heart block 276. Classical S1, Q3, T3 PATTERN occurs in------ % cases of acute PTE a. 5% b. 10% c. 20% d. 30% 277. Preferred antihypertensive in patients of Benign Prostatic Hypertrophy is a. ACE Inhibitors b. Ca channel Blockers c. Alpha Blockers d. Beta Blockers 278. DuctusVenosus is a low resistance bypass between a. Pulmonary vein & IVC b. Portal Vein & IVC c. Hepatic Vein & IVC d. None 279. Fetal cardiac activity can be earliest detected by: a. 4week b. 6 week c. 5 week d. 10 week


280. PulsusParadoxus is commonly seen in:

290. In pheochromocytoma there is increased level of

a. Constrictive pericarditis

a. Serum HMA

b. Cardiac tamponade

b. Serum bradykinin

c. Restrictive cardiomyopathy

c. Urinary VMA

d. Risperidone

d. All of the above

281. Most common congenital heart disease in adults a. ASD b. Tetralogy of fallot c. VSD d. bicuspid Aortic valve

a. stage-1 b. Stage-II c. stage-III d. Stage of pre_Hypertension 283. What does the abbreviation CAVHD stand for? a. Coronary atrioventricular heart disease b. Cavernous atrioventricularhemopoetic disease c. Continuous Arterio Venous Hemo Dialysis d. Calcified aortic venous heterozygous disease 284. The left to right shunt is seen in all of the following except a. PDA b. VSD c. ASD d. TGA 285. Digoxin is used in which of the following conditions a. Atrial ectopics b. Flutter with 2:1 block c. Ventricular tachyarrhythmia d. Ventricular bigeminy 286. The duration of the depolarisation of the heart from the SA node to the AV node is reflected on the ECG by a. QT interval b. PR interval c. RS interval d. RR interval 287. The most common cause of secondary hypertension in children is a. Renal artery stenosis b. Adrenal tumors c. Renal disease d. Coarctation of aorta 288. Which are the values of Troponin T that are prognostically significant? a. >/= to 0.05 ng/ml b. >/= to 0.1 ng/ml c. >/= to 0.001 ng/ml d. >/= to 0.01 ng/ml 289. Urokinase and streptokinase are contraindicated in a. Malignancy b. A-V fistula c. Pulmonary embolism d. Thrombophlebitis

291. An asymptomatic 44 year old male was detected with an abnormality on cardiac examination. His ECG showed a Left Bundle Branch. His 2D Echo showed an Ejection fraction of 55% with no regional wall motion abnormality and no significant valvular pathology. The abnormality detected on cardiac examination was: a. Wide Splitting of the S1 b. Reverse Splitting of the S2 c. Mid diastolic murmur at apex d. Continuous murmur in the infraclavicular area 292. A 64 year old female was diagnosed with Severe Mitral stenosis with moderate mitral regurgitation with LV Systolic dysfunction. Her ECG showed sinus rhythm with a PR Interval of 220 msec. On cardiac examination her first heart sound would be: a. Loud b. Soft c. Variable intensity d. Wide Split 293. A 30 years old female with Primary Pulmonary Hypertension had a 2D Echo with normal LV and RV systolic function and an estimated PA Systolic pressure of 85 mmHg. This would be reflected on clinical examination as which of the following findings? a. Widely Split S2 with Soft P2 b. Narrowly Split S2 with Soft P2 c. Widely Split S2 with loud P2 d. Narrowly split S2 with Loud P2 294. An asymptomatic 11 year old male child was found to have a wide and fixed split of the second heart sound on cardiac examination. He had no murmurs and no other adventitious sounds. His ECG and Chest X Ray were within normal limits. What would be the next most appropriate investigation? a. Reassurance. No further investigations required. b. 2D Echocardiography c. Cardiac MRI d. ASO Titres 295. All the following sounds occur during diastolic phase of the cardiac cycle EXCEPT a. S4 b. Opening Snap c. Aortic Ejection Click d. Pericardial Knock 296. Closure of the Mitral and Tricuspid Valve are following by which phase of the cardiac cycle? a. Iso-volumetric Contraction b. Ejection c. Iso-volumetric Relaxation d. Diasthasis 297. All the following regarding the Third Heart Sound are true EXCEPT a. Occurs 120 â&#x20AC;&#x201C; 200msec after the second heart sound b. Occurs due to early rapid filling phase

CARDIOLOGY

282. 150/100 mm Hg falls in which category of Hypertension as per JNC7

1137


1138

c. Can be heard in VSD and PDA d. Occurs normally in elderly patients 298. The Fourth Heart Sound can be heard in a. Presence of a Non-compliant left ventricle b. Atrial fibrillation c. Severe Mitral Stenosis d. Chronic Mitral Regurgitation 299. Which Heart Sound corresponds with the ‘a’ wave of the JVP? a. S1 b. S2

MCQ's

c. S3 d. S4 300. A 55 year old lady with symptoms of exertional palpitations, insomnia, irritability and heat intolerance was diagnosed with hyperthyroidism. The following would be expected findings on cardiovascular system examination EXCEPT a. Atrial fibrillation b. Wide Pulse Pressure c. Soft S1 d. Means Lerman Scratch 301. A 55 year old male with history of Exertional angina and a single episode of syncope was found to have a Constant Systolic Ejection Click at the Aortic Area, a soft A2, S4 and an Ejection Systolic Murmur with a delayed systolic peak. His diagnosis is

306. A 60 year old Diabetic and hypertensive male presented to the casualty with severe chest pain radiating to the left arm associated with severe breathlessness and orthopnoea. His ECG showed an evolving anterior wall myocardial infarction. All of the following finding on cardiac auscultation would indicate a complication of a Myocardial Infarction EXCEPT a. S3-S4 gallop b. Pericardial Rub c. Early diastolic Murmur at the aortic area d. Pan systolic murmur at the apex 307. Which of the following findings would help to differentiate Hypertrophic Cardiomyopathy from Valvular Aortic Stenosis? a. Bisferians Pulse b. Opening Snap c. Ejection Systolic Murmur with a delayed peak d. S4 308. All of the following findings would help to differentiate an Austin Flint Murmur of Aortic Regurgitation from a Middiastolic Murmur of Mitral Stenosis EXCEPT a. Wide Pulse Pressure b. S3 c. JVP d. Location of the Apex Impulse 309. All the following indicate Severity of Mitral Regurgitation EXCEPT a. Soft S1

a. Bi-cuspid Aortic Valve with Severe Aortic Stenosis

b. S3

b. Degenerative Calcified Severe Aortic Stenosis

c. Mid Diastolic Murmur

c. Hypertrophic Cardiomyopathy with a Severe LV outflow tract obstruction

d. Systolic Thrill

d. Sub Valvular Membrane with severe aortic stenosis 302. A 22 year old patient with Marfans syndrome can have the following findings on cardiac examination EXCEPT

310. A 26 year old male was admitted with Infective Endocarditis with Severe Aortic Regurgitation. His cardiac auscultation revealed all the following murmurs EXCEPT

a. Waterhammer Pulse

a. Ejection systolic murmur at the aortic area radiating to the Carotids

b. S4

b. Short Early Diastolic Murmur at the aortic area

c. Pulsations in the Suprasternal notch

c. Mid Diastolic Murmur at the apex

d. Early diastolic murmur in aortic area

d. Early Systolic murmur at the apex

303. A 46 year old male was diagnosed with Rheumatic Heart disease with Mild Mitral Stenosis 8 years ago. He has gradual worsening of Dypsnea on exertion since 6 months. Which of the following findings indicate increased severity of Mitral Stenosis a. Loud S1 b. Intensity of Opening Snap c. Wide A2-OS interval d. Length of Mid Diastolic Murmur 304. All the following about Opening Snap are false EXCEPT

311. A 26 year old male was diagnosed with Hypertrophic Cardiomyopathy. His cardiac examination revealed one of the following findings: a. Pulsus Alternans b. Aortic Ejection Click c. Mid Systolic Murmur increasing in standing position d. Mid Systolic Murmur decreasing in Phase II of Valsalvas manouver. 312. The following combination of Murmur and Cardiac Pathology is INCORRECT

a. Systolic sound occurring after S1

a. Gibsons Murmur – Patent Ductus Arteriosus

b. Indicates pliability of the mitral valve

b. Rytands Murmur – Severe Aortic Regurgitation

c. A2 – OS interval correlates directly with severity of mitral stenosis

c. Carey Coumbs murmur – Rheumatic Fever

d. Often heard in Calcific Mitral stenosis 305. The following sequence of diastolic sounds according to the timing of their occurrence is CORRECT:

d. Graham Steele’s Murmur – Hypertensive Pulmonary Regurgitation 313. The following are causes of Continuous murmurs except: a. Aortopulmonary Window

a. A2-P2-OS-S3-S4

b. Rupture of Sinus of Valvsalva Aneurysm

b. P2-A2-OS-S3-S4

c. Post Bidirectional Glenns Shunt

c. A2-P2-S3-S4-OS

d. Coronary AV Fistula

d. A2-P2-S3-OS-S4


314. A 7 year old boy presented with fatigue and reduced activity since 1 year. On examination, he had pan-digital clubbing and central cyanosis. He was diagnosed with Tetrology of Fallot. Which of the following findings would correlate with the diagnosis of TOF ? a. Narrowly Split Second Heart Sound b. Loud P2 c. Pan systolic murmur d. Continuous murmurs at the back and axilla 315. Which of the following regarding response to Strain phase of Valvsalva Manouver is INCORRECT ? a. HOCM Murmur – increases in intensity

c. Aortic Stenosis Murmur – decreases in intensity d. Mitral Stenosis Murmur – decreases in intensity 316. The normal apical impulse is characterized by all except a. Lowermost and outermost point of maximal impulse in late systole b. Located in 4th or 5th intercostal space inside the midclavicular line within 10 cm from midsternal line c.

Palpable area of 2-2.5 sq cm and localized to one intercostal space

d. Gentle non sustained tap 317. Left parasternal pulsations are palpable in all except a. Aortic regurgitation b. Tricuspid regurgitation c. Mitral regurgitation d. Pulmonary stenosis

d. ILD with pulmonary artery hypertension. 323. Peripheral edema may be seen in a.

Aortic stenosis

b. Constrictive pericarditis c. Pericardial effusion d. Atrial septal defect 324. Reverse differential cyanosis may be seen in a. PDA with PAH and reversal of shunt b. Coarctation of aorta with interrupted aortic arch with PDA having right to left shunt c. TGA with preductal narrowing, PAH and reverse flow through PDA d. Double outlet right ventricle 325. Central cyanosis may be due to a. TOF with multiple aorto pulmonary collaterals b. Corrected transposition of great arteries c. Congestive heart failure d. Truncus arteriosus 326. The closure of the aortic valve corresponds to which phase of the pulse wave a. Percussion wave b. Anacrotic notch c. Tidal wave d. Dicrotic notch 327. The pulse shown in the figure is characteristic of

318. The following may be associated with a heaving apex beat a. Seen in volume overload states b. Lasts <50% of systole c. There is increased amplitude and duration of LV ejection d. May be seen in thin chest individuals 319. Palpable S4 is seen in all except a. Acute mitral regurgitation b. Acute aortic regurgitation c. Aortic stenosis d. Chronic severe mitral regurgitation 320. Rotch’s sign may be seen in a. Constrictive Pericarditis b. Acute cardiac tamponade c. Massive pericardial effusion d. Restrictive cardiomyopathy 321. All cause clubbing except a. TAPVC b. Bronchogenic carcinoma c. Ulcerative colitis d. ASD 322. A 45 year old man presented with chest discomfort, progressively increasing breathlessness over the past two years which has progressed from NYHA class I to III with episodes of PND. Recently he has noticed bilateral pitting pedal edema. All could be the differential diagnosis except a. Dilated cardiomyopathy with heart failure

1139

c. Coronary artery disease with LV dysfunction

Figure 2 a. Hypertrophic obstructive cardiomyopathy b. Severe aortic stenosis c. Severe aortic regurgitation d. Cardiomyopathy with severe LV dysfunction 328. Pulsus alternans is seen in a. Massive pericardial effusion b. Dilated cardiomyopathy with severe left ventricular dysfunction c. Moderate aortic regurgitation with severe aortic stenosis d. Constrictive pericarditis

CARDIOLOGY

b. Mitral Valve Prolapse – Click occurs later and Murmur is louder

b. Left sided valvular heart disease


1140 329. Pulsus paradoxus may be seen in

a. Isorhythmic AV dissociation

b. Pericardial tamponade

b. Acute pulmonary embolism

c. Primary pulmonary artery hypertension

c. Severe Tricuspid stenosis

d. Hypertrophic obstructive cardiomyopathy

d. Hypertrophic obstructive cardiomyopathy

330. A first year MBBS student has just learnt the art of BP measurement. His professor will give him all the instructions except a. Look for orthostatic hypotension in old age individuals b. If thigh cuff is not available, arm cuff may be tied at the level of ankle for measurement of lower limb BP

MCQ's

335. Cannon A waves may be seen in

a. Restrictive cardiomyopathy

336. A 35 year old female is a known case of rheumatic heart disease with severe mitral stenosis. She has been complaining of progressively increase in breathlessness since the last 2 years. Presently she has noticed symptoms of PND. The reason for the PND may be all except a. Pulmonary arterial hypertension

c. The systolic pressure is estimated by the palpatory method and diastolic pressure by the auscultatory method

b. Pulmonary venous hypertension

d. During BP measurement, the BP apparatus should be at the level of the heart

d. Increased venous return during supine position

331. An intern is posted in the medicine ward. He has been asked to monitor a patient with sepsis. His professor has asked him to inform him if mean pressure is <70 mm Hg or there is urine output <30ml/hour. How will he calculate the mean pressure.

c. Decreased sympathetic drive during sleep 337. A 60 years old gentleman complaints of an episode of syncope. He was diagnosed as bicuspid aortic valve with severe aortic stenosis. He has been advised valve replacement. What could be the probable cause of syncope in him a. Atrial fibrillation

a. Mean BP = Systolic BP - Diastolic BP

b. Exertion induced

b. Mean BP=Diastolic BP + 1/3 pulse pressure

c. Myocardial ischemia

c. Mean BP=Diastolic BP + 1/3 systolic BP d. Mean BP=Systolic BP/2 + Diastolic BP/2 332. A medicine resident is examining the JVP of a patient in his final examination. JVP is best examined in a. Reclining at 45 degree

d. All of the above 338. A 23 year old boy is a known case of Marfan’s syndrome. He presents with sudden onset breathlessness and is suspected of having acute aortic regurgitation. His clinical manifestations may include a. Normal pulse pressure

b. Supine c. Sitting

b. Positive Hill’s sign

d. Any position where the peak of the venous column is well identified

d. Anacrotic pulse

333. The JVP is best timed with cardiac cycle by which of the following a. A wave is visible just before the carotid pulse

c. Water hammer pulse 339. A 19 year old female presents with swelling of the feet. She has atrial fibrillation. Her JVP shows an attenuated X descent. What is her differential diagnosis a. Severe mitral stenosis

b. A wave coincides with S4

b. Severe mitral stenosis with moderate mitral regurgitation

c. X descent is between S1 and S2, X’ is simultaneous with radial pulse

c. Severe pulmonary regurgitation secondary to pulmonary artery hypertension

d. V wave peaks after S2 334. The X’ descent is due to a. Atrial relaxation

d. Severe TR 340.

A prominent X and prominent Y descent may be seen in

b. Downward pull of tricuspid valve by contracting RV

a. Constrictive pericarditis

c. Impact of carotid artery and upward bulging of closed tricuspid valve

b. Restrictive cardiomyopathy c. Dilated cardiomyopathy with heart failure

d. RA emptying when tricuspid valve opens

d. HOCM


Cardiology - Answers 1.

2.

3.

d: This is a typical cause of stroke in a young person due to prolonged immobilty. Deep vein thrombosis with patent foramen ovale will cause paradoxical embolism and stroke.

28. d

c: Atrial myxomas are more often on the left. Though benign, they can occlude the mitral valve and produce sudden loss ofcardiac output. They may embolizesmallportions of themselves or thrombus forned over their surface.

30. e

4. d 5.

e: The macrolides are associated with a prolongation of the QT interval. Other antimicrobials associated with prolonged QT include quinine, levofloxacin.

6. e 7. b 8. c 9.

a: There is a single sound in Fallotâ&#x20AC;&#x2122;s because of an absent P2. Aortic stenosis leads to reversed splitting (also seen with LBBB and ventricular pacemaker). In RBBB there is wide splitting of S2 but it is not fixed.

10.

d: The suggestion here is that this man has coronary artery disease with an impending myocardial infarction. Infarction of the LAD would cause necrosis of the left ventricle. Thrombus may form on an area of dyskinetic ventricle. Therefore he is most at risk of embolus of thrombus from the LV.

11.

b: Many drugs can cause a prolonged QT interval. more

12. c 13. e 14. a 15. b 16. a 17. a: The bioprosthesis has the advantage of not requiring anticoagulation, but it does not wear well with time, and typically mustbe replaced within 5 to 10 years 18. b

29. b

31. e 32. d 33. a 34. e 35. e 36.

c: This patient has NYHA stage II heart failure. Studies such as CIBISII and MERITHF reveal that betablockerssignificantlyreduce morbidity and mortality in heartfailure.

37. d 38. d: Acanthocytes are seen in abetalipoproteinaemia. Retinitis pigmentosa is seen in abetalipoproteinaemia. Mental retardation is not present but motor abnormalities andneurodegenerative are seen. 39. d: Quaternary syphilis involves the cardiovascular system commonly in form of ascending aortic aneurysm and aorticregurgitation. Diphtheria,coxsackievirus,Chagas disease and toxoplasmosis are all associated with myocarditis. 40. b 41. b 42. d 43. c 44. c 45. e 46. c 47. e 48. b 49.

b: The results show normal T4, low T3 with elevated TSH. These results are typical of amiodarone induced hypothyroidismwhich inhibits the peripheral conversion of T4to T3.

50.

e: This lady has Chronic Obstructive Airways disease and subsequent CorPulmonale leading to right heart failure. Nonbacterialthrombotic endocarditis is a conditionseen in frail ill individuals.

19. d 20. e 21. c

51. c

22. a

52. c

23. d

53.

24. d

54. e

25. d

55. b

26. a

56. a

27. d

57. e

d: Omeprazole is associated with gynaecomastia.

CARDIOLOGY

b: The uraemia leads to exudation of fibrin onto the epicardial and pericardial surfaces. Haemorrhagic pericarditis is moretypical of tuberculosis or metastatictumour. Serous pericarditis is more typical of collagen vascular diseases.

1141


85. e

59. a

86. e

60. b

87. a

61. e

88. c

62.

89. e

MCQ's

1142 58. d

a: Bicuspid aortic valve is perhaps the most common form of congenital heart disease in adults. Bicuspid valves have apropensity to wear out and calcify with aging.Bicuspid aortic valve tends to be a sporadic.

90. a: This man has alcoholic liver cirrhosis with ascites. The cardiomyopathy of alcoholism is a dilated or congestive form.

63. c

91. a

64. c

92. b

65. b

93. c

66. b

94. b

67. b

95. d

68.

96. c

69.

70.

e: The history is typical of aortic dissection. All the others could cause sudden collapse but not with acute chest pain radiatingto the back in the presence of arecent normal exercise test. Acute MI is possible but not the most likely. d: The Austin Flint murmur is a low frequency mid/late diastolic murmur which may show presystolic accentuation which isvirtually indistinguishable from that ofmitral stenosis. There is no correlation between presence of murmur and severity of AR, or aetiology. The first heart soundis normal but in severe cases, it may beabsent. d: Patients with HCM are at increased risk of sudden cardiac death due to VF/VT. Implantable Cardio Defibrillators (ICD) aresuperior to Amiodarone or BetaBlockers for preventing this. Reducing outflow tract obstruction with myomectomy or Alcohol Septal Ablation does notreduce the risk of SCD.

97. b 98. b 99. e 100. d 101. e 102. a 103. e 104. e

71. c

105. d: Selenium deficiency is one of the reversible causes of dilated cardiomyopathy.

72. e

106. e

73. d

107. e

74. b

108. b

75.

109. d

a: Ischaemia, typically in hypotensive hospitalized patients, is the most frequent antecedent to acute tubular necrosis. Bloodpressure should be maintained incardiogenic shock with fluids and / or inotropic agents.

76. a: Cisapride has been withdrawn due to the problem of prolonged QT interval and torsades de pointe. Prolonged QT is definedas greater than 0.45s. Other agentsinclude amitriptyline and pheonthiazines yet metoclopramide and dompaeridone are not associated. 77. b 78. e 79. a 80.

e: WPW can be associated with negative delta waves in II, III and aVF. The longterm management of choice is ablation of theaccessory pathway.

81. a 82. a 83. b 84. e

110. a 111. a 112. a 113. a: This MI is likely to be in the LAD and represents an anterior MI. 114. a: Although troponin is highly sensitive and specific it remains elevated for at least one week after infarction. Similarly LDH will be present for approximately oneweek after infarction. After myocardial infarction, CKMB levels become elevated within 3 to 8 hours, peak within 9 to 30hours, and return to normal after 48 to 72 hours. Although my oglobin has a short half life and rises quickly after an MI and is cleared after an MI, it is not specific enough for diagnostic use. 115. a 116. d 117. d 118. d


159. a

199. c

239. a

279. c

120. c

160. b

200. a

240. d

280. b

121. a

161. b

201. b

241. e

281. d

122. d

162. c

202. b

242. c

282. b

123. d

163. a

203. c

243. c

283. c

124. c

164. d

204. a

244. c

284. d

125. b

165. a

205. b

245. a

285. b

126. a

166. a

206. c

246. c

286. a

127. e

167. a

207. d

247. a

287. c

128. d

168. e

208. a

248. e

288. d

129. d

169. a

209. a

249. d

289. a

130. c

170. a

210. a

250. c

290. c

131. d

171. e

211. a

251. e

291. b

132. c

172. b

212. c

252. a

292. b

133. e

173. e

213. d

253. b

293. d

134. b

174. b

214. d

254. b

294. b

135. a

175. a

215. b

255. b

295. c

136. b

176. c

216. e

256. b

296. a

137. d

177. c

217. c

257. d

297. d

138. b

178. d

218. e

258. c

298. d

139. a

179. d

219. a

259. c

299. d

140. b

180. d

220. c

260. b

300. c

141. a

181. d

221. d

261. b

301. a

142. a

182. d

222. b

262. a

302. b

143. b

183. d

223. d

263. a

303. d

144. c

184. a

224. a

264. d

304. b

145. e

185. d

225. d

265. b

305. a

146. b

186. b

226. c

266. d

306. c

147. b

187. b

227. b

267. a

307. a

148. d

188. c

228. b

268. b

308. c

149. c

189. c

229. b

269. b

309. a

150. c

190. d

230. b

270. d

310. d

151. e

191. c

231. d

271. d

311. c

152. c

192. d

232. c

272. a

312. b

153. c

193. d

233 d

273. c

313. c

154. b

194. a

234. a

274. a

314. d

155. c

195. a

235. a

275. b

315. b

156. b

196. a

236. c

276. b

157. d

197. b

237. a

277. c

158. b

198. c

238. d

278. b

1143

CARDIOLOGY

119. d


1144 Explanations:

MCQ's

291 & 292. First Heart Sound

B. Early A2

• MR

• VSD

C. Others:-

• Normal in Children

• Straight back Syndrome

• Pectus Excavation

• Ebsteins anomaly, TAPVC, Common Atrium

Loud S1

Soft S1

Variable S1

Normal in children

Mitral / Tricuspid Regurgitation

Atrial fibrillation

Sinus tachycardia

Mitral valve Prolapse

Complete heart block

Mitral Stenosis

Calcified Mitral stenosis

AV Dissociation

LA Myxoma

Acute Myocardial infarction

Exercise

Cardiomyopathy,

Wide Fixed Split S2:-

Hyperdynamic State

LV Aneurysm

• ASD,

Short PR Interval

Myocarditis

• TAPVC, Common Atruim

LBBB

• Acute Pulmonary Embolism

LOUD T1

Thick chest wall, Obesity

• Severe RV Failure

Tricuspid stenosis

Pericardial effusion

Reverse Split S2 may be due to delayed A2 or early P2

RA Myxoma

Emphysema

A. Delayed A2

Esbteins anomaly

• Electrical:-

Atrial septal defect

o LBBB

o RV Ectopic/RV Pacing

• Mechanical:-

Total anomalous pulmonary venous connection (TAPVC) Wide Split S1 (Delayed T1)

Paradoxical/ Reverse Split S1 (Delayed S1)

o LVOT Obstruction (Aortic Stenosis/Coarctation of Aorta)

o Hypertension

Electrical :

Electrical :

o LV Dysfunction (IHD)

RBBB

LBBB

LV Pacing, LV Ectopics

RV Pacing, RV Ectopics

B. Early P2

• WPW Type IB

Idioventricular Rhythm from LV

Idioventricular Rhythm from RV

• RA Myxoma,

Mechanical

Mechanical

• Tricuspid Regurgitation

Ebsteins anomaly

Mitral Stenosis

Tricuspid stenosis

LA Myxoma

Single S2

a. Absent/Undetectable P2

• Age>60

• Obesity, Thick Chest, Emphysema

• Vascular Pulmonary Stenosis

• Severe Aortic Stenosis (murmur masks P2)

• Tetrology of Fallot

• Pulmonary Atresia

b. Absent / Undetectable A2

• Vascular AS

• Aortic Atresia

• Severe Pulmonary Stenosis (Syst. murmur mask A2)

• Severe Pulmonary Hypertension (retrograde masking )

RA Myxoma 293 & 294. Second Heart Sound

Splitting of S2

Wide Split S2 may be due to delayed P2 or early A2.

A. Delayed P2

• Electrical:-

o RBBB

o LV Pacing/ LV Ectopics

• Mechanical:-

o Pulmonary Stenosis

o Acute PulmonaryEmbolism

• Increased Hangout interval Interval:-

o ASD


Loud A2

Soft A2

Hyperkinetic Stales

Age, Aortic Sclerosis

Systemic Hypertension

Vascular Aortic stenosis

Aortic Aneurysm

Vascular Aortic regurgitation

296. Cardiac Cycle

1145

Aortic Root Pathology (Syphilis) Cong Bicuspid AV Pulmonary Atresia Soft P2

Hyperkinetic States

Vascular Pulmonary stenosis

Pulmonary Hypertension

Dysplastic Pulmonary Valve

ASD (even in absence of PH)

Obesity, Thick Chest, Emphysema

Thin Chest, Straight Back Syndrome

Wide & Fixed S2 in ASD

1. Wide Split S2 Wide split occurs due to delayed P2

Inspiration leads to a increased negative intrathoracic pressure that in turn leads increased venous return and increased RV Filling . This leads to

• Increased RV Ejection Time

• Increased right hangout interval

• Right Bundle Branch Block

2. Fixed Spilt S2

A. Phasic Changes in Venous Return

• Inspiration leads to an increased venous return and no left to right shunt across the ASD.

• Expiration leads to a reduced venous return and a increase in the left to right shunt across the ASD. Therefore there is an increased RV filling in both expiration &inspiration that produces a fixed split.

CARDIOLOGY

Loud P2

Closure of the AV Valves (mitral and tricuspid valves) heralds the end of diastole. At this stage, all the four valves – mitral, tricuspid, aortic and pulmonary valves are closed. The ventricular systole has begun without the change in volume of the ventricles. This is the phase of Isovolumetric Contraction.

297. Third Heart Sound

Characteristics:

• Low Pitched, Mid Diastolic Sound

• Early Rapid Ventricular Filling Phase

• Also called S3 Gallop, Protodialastic Gallop, Ventricular Diastolic Gallop

• Co- insides with- Y Decent of JVP

Timing:

• PATHOLOGICAL: 140-160msec after A2

• PHYSIOLOGICAL: 20-200 msec after A2

Causes of S3

• PHYSIOLOGICAL:

o Children

295. Diastolic Heart Sounds

o Young Adults (40+ <50)

Sequences of Diastolic Events:

o Pregnancy

A2- P2- Opening Snap- Pericardial Knock – Tumour Plop - S3S4

o Anxiety

Timing of Diastolic Sounds in Relation to the Second Heart Sound:

o Exercise

• PATHOLOGICAL:

A2-P2

o Hyperkinetic Status

• Inspiration: 40-50 msec

o MR, TR (RVS3)

• Expiration: <30 msec

o VSD, PDA, ASD (RVS3)

A2-Opening Snap: 30-150 msec

o Ischemic heart disease

A2 – Pericardial Knock: 100-120 msec

o Dilated Cardiomyopathy (DCM)

A2 - S3:

298. Fourth Heart Sound

• Physiological: 120-200 msec

Characteristics:

• Pathological: 140-160 msec

• Low frequency, Late Diastolic Sound

B. Increased Pulmonary Capacitance due to ADS leads to an increased pulmonary blood flow. There is no further increase in pulmonary blood flow during inspiration leading to a fixed split.


1146

• Last Rapid Filling Phase of Diastolic i.e. Atrial Contraction

• Presystolic Gallop, Atrial Diastolic Gallop

• ECG= 70 msec after P wave

• JVP= Just after A wave

MCQ's

Causes:

• Localizes the LVOT obstruction to valvular level; Bicuspid Aortic Valvular Stenosis.

Symptoms of syncope and examination findings of soft A2, S4 and an Ejection Systolic Murmur with a delayed systolic peak are found in any severe left ventricular outflow tract obstruction.

The constant click localizes the LVOT obstruction to the valvular level; to a bicuspid aortic valvular stenosis.

In Degenerative Aortic Stenosis the valve leaflets are not mobile to produce a click. In Hypertrophic cardiomyopathy or subvalvular membrane a aortic click is not heard.

• Physiological:

o Elderly >60 years

• PATHOLOGICAL:

302. Cardiac Manifestations of Marfans Syndrome

o Hyperkinetic States,

Cardiac Manifestations of Marfans syndrome:

o AV Fistula

• Aortic Regurgitation

o Acute MR, TR or AR

• Aortic Aneurysm

o LVOT Obstruction- Aortic Stenosis, HOCM

• Aortic Dissection

o Systemic Hypertension

• Mitral Valve Prolapse

o RVOT Obstruction- P.S.

o Pulmonary Hypertension

o Pulmonary Embolism

In Marfans syndrome, a waterhammer pulse and an early diastolic murmur in aortic area can be seen due to aortic regurgitation. Pulsations in the suprasternal notch can be a sign of an aortic aneurysm.

o Ischemic heart disease

o LV Aneurysm

o Heart blocks

299. See 206 and 208 for explanation 300. HYPERTHYROIDISM AND HEART

Hyperthyroidism can produce the following cardiovascular effects

o Palpitations, Angina, Exercise intolerance, Exertional dyspnoea

o Peripheral edema

o Hyperdynamic precordium, wide pulse pressure

o Atrial fibrillation

o Cardiac Hypertrophy

o Systolic Hypertension

o Congestive cardiac failure

The Means–Lerman scratch is arare murmur found in patients with hyperthyroidism. It is a mid-systolic  scratching  sound best heard over the upper part of the sternum or second left intercostal space at the end of expiration.

301. Aortic Click Characteristics

303. AUSCULTATION IN MITRAL STENOSIS

Characteristic findings on auscultation

• Loud S1

• Absence of S3 or S4

• Opening snap

• Low pitched rumbling presystolic accentuation

In mitral stenosis, the loudness of the S1 and intensity of the opening snap correlate with the mobility and pliability of the mitral valve. Calcific mitral stenosis will usually have a soft S1 and absent opening snap.

The A2-OS interval is inversely proportionate to the severity of mitral stenosis. (Refer to explanation in Q14)

The length of the mid diastolic murmur indicates the duration of time for which the gradient across the mitral valve is maintained.

As the severity increases, the longer is the gradient sustained and the longer is the mid-diastolic murmur.

mid-diastolic

murmur

with

304. OPENING SNAP

Characteristics

• High Frequency Sounds

• Early Diastolic Sound - A2-OS= 30-150 msec

• Indicates pliable mitral valve

• S1-EC= 50 msec

• Intensityof OS parallels Loudness of S1

• Coincides with ANACROTIC NOTCH on the upstroke of aortic pressure Trace

Pre-Requisite:

• Indicated Mobile AV leaflets

• AV Valves Leaflets Thickened But MOBILE

• Heard at apex or base

• LA Pressure high

• Constant click: No respiratory variation

• Velocity across AV Valves High- Rapid excursion of leaflets


Causes:

Austin Flint Murmur of Aortic Regurgitation

Mid-Diastolic Murmur of Mitral Stenosis

6. S1

Normal / Decreased

Loud Absent

• Mitral Stenosis

• Rare Causes

o Tricuspid stenosis

7. S3

Present

o MR, TR

8. Opening Snap

Absent

Present

o VSD,PDA, ASD, Ebsteins

9. Diastolic Thrill Absent

Present

o HOCM

Absent

Present

A2-OS Interval: As the severity of mitral stenosis increases, the opening snap occurs earlier in diastole. As the severity of MS increases, the LA pressure is higher and thus the earlier does the LA pressure increase above the LV diastolic pressure to produce opening of the mitral valve and the opening snap.

10. Presystolic Accentuation of MDM 11. Exercise / Amyl Nitrate

Decreases murmur

Increases murmur

Therefore, the A2-OS interval is inversely proportionate to the severity of the mitral stenosis.

Absent OS in MS:

o Mild MS

o Calcified Immobile MV

o Associated Severe MR

o Associated Severe AR

o Associated Coronary artery disease/ LV Dysfunction

305. Diastolic Heart Sounds: Refer to explanation of Q5

309. Severity of Mitral Regurgitation

Indicators of Severity of MR are :

• Presence of S3 at the apex that indicates increased flow across the MV due to increased regurgitant volume.

• Functional Mid Diastolic Murmur that indicates increased flow across the MV due to increased regurgitant volume.

• Systolic Thrill at the apex

A soft S1 and a pansystolic murmur can be heard in MR of any severity.

310. Murmurs in Aortic Regurgitation

Aortic Regurgitation (AR) produces a Early Diastolic Murmur (EDM) at the aortic area or in the left third of fourth parasternal area. The length of the EDM correlates directly with the severity of AR (more severe AR produces longer diastolic murmur). An exception is in acute AR where the murmur may be short in spite of severe AR due to high left ventricular end-diastolic pressure.

Due to the increased regurgitant volume, an Ejection Systolic Murmur at the aortic area can be heard radiating to the Carotids (flow murmur). Thus radiation to the carotids is not an indicator of organic aortic stenosis.

Severe ‘free’ aortic regurgitation can lead to production of a MidDiastolic Murmur at the apex called the Austin Flint Murmur. It is produced as the regurgitant jet strikes the anterior leaflet of the mitral valve and leads to vibration of the leaflet producing an MDM. Other theories of production of the Austin flint murmur are premature closure of MV due to AR or raised LVEDP in AR producing a diastolic mitral regurgitation producing a MDM.

306. Auscultation during Acute Myocardial Infarction

During an acute myocardial infarction, auscultation can assist in determining certain complications.

a. A S3-S4 gallop indicates Congestive cardiac failure.

b. A Pericardial Rub indicates Pericarditis

c. Pan systolic murmur at the apex indicates a mitral regurgitation due to papillary muscle dysfunction or rupture. A pan systolic murmur in the lower parasternal area indicates a post MI ventricular septal defect.

307. Bisferians Pulse in Hypertrophic Cardiomyopathy

The type of pulse felt in a Hypertrophic cardiomyopathy is a bisferians pulse (twice peaking pulse) with both peaks in systole. The type of pulse felt in valvular aortic stenosis is Pulsus parvus et tardus.

308. Differentiating Austin Flint Murmur of Aortic Regurgitationfrom a Mid-Diastolic Murmur of Mitral Stenosis Austin Flint Murmur of Aortic Regurgitation

Mid-Diastolic Murmur of Mitral Stenosis

1. Etiology

Severe AR (free AR)

Rheumatic

2. Peripheral Run-off signs

Present

Absent

3. Atrial fibrillation

-

Common

4. Pulmonary Hypertension

-

Common

5. Apex beat

Hyperdynamic

Tapping

311. Dynamic Auscultation in Hypertrophic Cardiomyopathy

The LVOT gradient in HOCM can be affected by changes in the myocardial contractility, ventricular volume or arterial pressure.

The Gradient Increases with

• Increase in Contractility (post VPC, post exercise, during dobutamine infusion)

• Reduction in Ventricular Volume (dehydration, blood loss, valsalva manouver, amyl nitrate infusion).

The Gradient Decreases with

• Decrease In Contractility (beta blockers)

• Increase In Ventricular Volume (squatting, isometric hand grip)

CARDIOLOGY

1147


1148

The ejection systolic murmur of dynamic LVOT obstruction in Hypertrophic cardiomyopathy varies with various manouvers of dynamic auscultation as follows:

• Single S2 ( only the aortic component)

• Absent P2

Increases in Intensity

Decreases in Intensity

Valsalva manouver (phase II)

Isometric hand grip

• Aortic Vascular Ejection Click (due to dilated aorta)

Standing (from supine position)

Supine (from standing position)

• Short Ejection systolic murmur (inversely related to the severity of TOF)

Amyl nitrate

Squatting

During or after Exercise

Beta blockers

• Continuous murmurs of bronchopulmonary collaterals in the axilla, back or chest

• Continuous murmur in patient post – Blalock Taussig Shunt

After a Ventricular premature beat

MCQ's

314. Auscultation in Tetrology of Fallot

315. Valsalva Manouver

312. Named Cardiac Murmurs Austin Flints Murmur

Aortic Regurgitation

Mid diastolic murmur at apex

Graham Steell Murmur

Pulmonary Regurgitation secondary to Pulmonary hypertension

Early diastolic murmur at Erbs area

Carey Coumbs Murmur

Acute Rheumatic Valvulitis

Mid diastolic murmur at apex

Rogers Murmur

Ventricular Septal Defect

Pansystolic Murmur

Gibsons Murmur

Patent Ductus Arteriosus

Continuous murmur

Stills Murmur

Innocent Murmur

Children

Rytands Murmur

Complete Heart Block

Mid diastolic murmur at apex

Docks Murmur

Occlusion of Left anterior descending artery

Diastolic murmur

Anemia

Diastolic murmur

Cabot Locke Murmur

Valsalva manouver involves deep inspiration followed by Forced Expiration against a Closed Glottis. There are four phases – initiation, maintenance, release and overshoot. The findings of dynamic auscultation are described in Phase II or Maintenance phase of Valsalva manouver.

During Phase II there is an increase in the thoracic pressure and a decrease in the venous return to the heart. This leads to a decrease in the stroke volume and blood pressure and a reflex increase in the heart rate.

Effects of Phase II of Valsalva Manouver

Decreased Intensity of all heart sounds and heart murmurs except:

a. Hypertrophic Cardiomyopathy: Increase in the intensity of the Ejection systolic murmur

b. Mitral Valve Prolapse: Earlier Click and Longer Systolic murmur

316. a: Lowermost and outermost point of maximal impulse in late systole

As isovolumic intraventricular pressure rises, there is anterior and counter clockwise rotation of the LV during early systole. This produces an early outward thrust. This is a gentle non sustained tap which lasts for 0.08 seconds. Once the aortic valve opens, blood is ejected during systole. There is medial retraction due to counter clockwise rotation of the LV in late systole.

The apex is located in 4th or 5th intercostal space inside the midclavicular line within 10 cm from midsternal line. It is confined to one intercostal space in a palpable area of 2-2.5 sq cm. The RV motion is not palpable. Diastolic events are not palpable.

313. Continuous Murmurs

Causes:

A. High to Low Pressure Shunts

a. Patent ductus arteriosus

b. Aorto pulmonary window

c. Post Blalock Taussig Shunt

d. Bronchopulmonary Collaterals in Tetrology of fallot with pulmonary atresia

317. a: Aortic regurgitation

e. Coronary or Peripheral AV Fistulas

f. Rupture of sinus of valsalva aneurysm

B. Arterial Obstruction (Bruit)

a. Coarctation of aorta

b. Branch Pulmonary Artery stenosis

In normal individuals, RV is neither visible nor palpable. The RV inflow lies behind the left parasternal region of 4th and 5th intercostal space. The infundibular (outflow portion) lies behind the third intercostal space.

Causes of left parasternal pulsations Right Ventricular hypertrophy

Normal Right ventricle

c. Renal, Carotid or Mesentric Artery Stenosis

Pressure overload - PAH, Primary PAH, PS

Moderate to severe MR

C. Increased Flow

a. Venous Hum

Volume overload - Moderate TR, ASD, VSD

Regional wall motion abnormality of LV

b. Mammary Souffle


318. c: There is increased amplitude and duration of LV ejection

The apex beat is examined in supine position and trunk elevated to 30 degree for localization. The character of apex beat is examined in the left lateral position.

Tapping apex beat - It is characterized by a sharp, short tap due to reduced filling of LV. It is equivalent of loud S1.

Hyperdynamic apex - There is an increase in amplitude and duration of excursion of apical impulse. It gives a partial lift to the examining fingers. It is ill sustained, <50% of systole. It is seen in volume overload states and eccentric LVH.

Pulmonary

Differential clubbing

Unilateral clubbing

Unidigital clubbing

PDA with shunt reversal

Aortic aneurysm

Hereditary

Brachial arteriovenous fistula

Median n injury

Pancoast tumor

Tophaceous gout

Erythromelalgia

Sarcoidosis

Lymphangitis

Trauma

Heaving apex - There is an increased amplitude and duration of excursion of the apical impulse. This is due to increased duration of LV ejection. There is a sustained lift of the examining fingers which lasts >50% of systole. It is seen in pressure overload conditions and concentric LVH.

322. d: ILD with pulmonary artery hypertension.

Types of Apex beat Tapping

Hyperdynamic

Heaving

MS

AR, MR

Pressure overload AS, HCM, systemic hypertension

PDA, VSD

Severe LV dysfunction

AV fistula

LV aneurysm

Blalock and Waterson shunt

Severe AR

Anemia, Pregnancy, Thyrotoxicosis

Severe ischemic MR

Progressively increasing breathlessness with episodes of PND suggests a cardiovascular origin of breathlessness.

323. b: Constrictive pericarditis

319. d: Chronic severe mitral regurgitation Palpable S3

Palpable S4

Left ventricular failure, DCM

AS

Chronic severe MR

Hypertrophic Cardiomyopathy (HCM)

Children

Acute MR, Acute AR

Pregnancy

CAD

320. c: Massive pericardial effusion Rotch’s sign - In massive pericardial effusion, the cardio hepatic border becomes obtuse. There may be associated dullness in 2nd ICS also.

321. d: ASD

Causes of peripheral edema Bilateral pitting

Unilateral pitting

Bilateral non pitting

Unilateral non pitting

CHF

Trauma

Myxedema

Lymphatic obstruction - filariasis, radiation, trauma, malignancy

Constrictive pericarditis

Inflammation

Renal Glomerulonephritis, Nephrotic syndrome

Baker’s cyst

Cirrhosis of liver

Varicose veins

Protein losing enteropathy

DVT

Nutritional - anemia, hypoproteinemia

Congenital venous malformation

Milroy’s disease

Pregnancy, pre menstrual edema

Causes of clubbing Cardiovascular

Pulmonary

Gastrointestinal

Cyanotic CHD - TOF, TGA, TAPVC, Tricuspid Atresia

Bronchiectasis

Crohn’s disease

Infective Endocarditis

Emphysema

Myxoid tumor

324. c: TGA with preductal narrowing, PAH and reverse flow through PDA

Differential cyanosis - Cyanosis of lower limbs with no cyanosis of upper limbs

Ulcerative colitis

i. PDA with PAH and reversal of shunt

Empyema

Biliary cirrhosis

Lung abscess

Polyposis of colon

ii. Coarctation of aorta with interrupted aortic arch with PDA having right to left shunt - Oxygenated blood goes to upper parts of the body and desaturated blood goes to lower part of the body via the PDA

Bronchogenic carcinoma Pulmonary tuberculosis

1149

Chronic fibrosing alveolitis

Thin chest, pectus excavatum

Gastrointestinal

CARDIOLOGY

Cardiovascular


1150

Reverse differential cyanosis - Cyanosis of fingers which exceeds that of toes

i. TGA with preductal narrowing (coarctation or interrupted aortic arch), PAH and reverse flow through PDA

ii. DORV with subpulmonary VSD, PAH and reverse flow through PDA

iii. TGA with intact ventricular septum, PAH and reverse flow through PDA

325. d: Truncus arteriosus

MCQ's

Causes of Cyanosis Central cyanosis

Peripheral cyanosis

Mixed cyanosis

TOF

CHF

Chronic cor pulmonale

Eissenmenger syndrome

Septicemia

dTGA, TAPVC, DORV

Cold exposure

Truncus arteriosus

Peripheral vascular disease Raynaud’s phenomenon

326. d: Dicrotic notch

Figure 1

327. a: Hypertrophic obstructive cardiomyopathy

Character and volume of the pulse

a. Hyperkinetic (Bounding) Pulse - It has larger pulse wave amplitude. It is due to increase in left ventricular ejection, stroke volume, arterial pressure, sympathetic activity or decreased arterial compliance. It is seen in i) elderly subjects with arteriosclerosis and systolic hypertension, ii) anxiety, iii) anemia, iv) thyrotoxicosis, v) exercise, vi) hot and humid environment, vii) alcohol intake and viii) high output states with increased distal arterial runoff like aortic regurgitation, patent ductus arteriosus, large A-V fistula, Paget’s disease and severe cirrhosis.

b. Hypokinetic Pulse - A small or diminished pulse is due to low cardiac output with reduced left ventricular stroke volume, shorter left ventricular ejection time or intense vasoconstriction. An unsustained pulse suggests decreased stroke volume without left ventricular outflow obstruction, whereas a slow rising sustained pulse of small volume suggests aortic stenosis. It is seen in i) severe left ventricular dysfunction, ii) congestive cardiac failure, iii) hypotension and iv) left ventricular outflow tract obstruction. c. Pulsus parvus et tardus - It is a slow rising pulse with delayed systolic peak and upstroke. It is best appreciated with simultaneous auscultation and carotid palpation. In aortic stenosis, it is associated with a carotid thrill (carotid shudder). d. Water Hammer (Collapsing pulse) or Corrigan pulse or Pulsus Celer - This term was coined by Thomas Watson after a Victorian toy which comprised of a glass vessel partly filled with water and vacuum. It produces a slapping impact on being turned over. In aortic regurgitation, there is an early, brief peak and a swift descent without dicrotic notch which gives a collapsing sensation. To elicit this, the patient’s arm is suddenly raised above the head and the wrist grasped with the examiner’s hand so that the palm faces the anterior aspect of wrist. The collapsing nature can be felt after each systole. The brief peak is due to rapid ejection of increased stroke volume. The swift descent is due to diastolic run off (back flow into left ventricle), rapid run off to the periphery due to decreased systemic vascular resistance and reflex vasodilatation mediated by carotid baroreceptors. It may also be seen in hyperkinetic circulatory states like patent ductus arteriosus, aortopulmonary window, arteriovenous fistula, rupture of sinus of valsalva into right heart and tetrology of Fallot with bronchopulmonary collaterals. e. Double beating pulse - Simultaneous auscultation and palpation are necessary to delineate the timing of the twice beating pulse. i. Bisferiens pulse - The double peaked pulse occurs in systole and is best detected by light but firm compression of the brachial artery with a single finger. It is seen in pure aortic regurgitation, combined aortic stenosis with predominant aortic regurgitation and high output states with normal heart. It is likely to disappear after onset of congestive cardiac failure. ii. Bifid pulse - A bifid or spike and dome pattern in systole is recorded, but rarely palpable in significant hypertrophic obstructive cardiomyopathy. iii. Dicrotic pulse - The first wave occurs in systole and the second accentuated component is a diastolic reflection wave occurring in diastole. On simultaneous auscultation, S2 separates the two pulse waves. It is better appreciated during inspiration. It is seen in young patients having cardiomyopathy with severe left ventricular dysfunction, low cardiac output, low blood pressure, high systemic vascular resistance, tachycardia, during inspiration in pericardial tamponade, post valve replacement for aortic or mitral regurgitation with left ventricular dysfunction and occasionally with fever in young.

Figure 3


328. b: Dilated cardiomyopathy with severe left ventricular dysfunction

when the radial pulse is no longer palpable. This palpatory 1151 method prevents underestimation of blood pressure due to auscultatory gap. The systolic and diastolic pressures are then estimated by auscultatory method. Cuff should be deflated at <3 mm Hg/sec. The column should be read to the nearest 2 mm Hg. The level of peak systolic pressure is the point at which two consecutive Korotkoff sounds are heard. The disappearance of the Korotkoff sounds is the true diastolic pressure. After every cuff inflation, deflate the cuff completely and allow sufficient time for venous return. There should be no talking between the subject and observer. In severe aortic regurgitation and hyperkinetic circulatory states, the diastolic pressure should be recorded in both phase IV and V. In atrial fibrillation, there is beat to beat variation in blood pressure; hence an average of three readings is taken as a blood pressure. For measurement of lower limb pressure, the patient lies prone; the thigh cuff is wrapped around and auscultate the popliteal fossa. If a thigh cuff is not available, an arm cuff can be wrapped around the lower leg and auscultate the posterior tibial artery or dorsalis pedis artery with a pediatric bell chest piece.

CARDIOLOGY

Pulsus alternans - It is present during sinus rhythm when patient’s peak systolic arterial pressure and pulse volume are alternately strong and weak. It occurs due to beat to beat alteration in left ventricular ejection pressure and signifies severe left ventricular dysfunction. (It is not related to electrical alternans which has a beat to beat variation in the amplitude of QRS complex as seen in massive pericardial effusions). It is best appreciated clinically in the radial or brachial arteries. It may be associated with signs of heart failure like S3 gallop. It can also be detected by slow decompression of the sphygmomanometer cuff while listening to the alteration of Korotkoff sounds. When systolic pressure alternates by >20 mm Hg it can be detected by palpation of the peripheral pulse with patient’s breath held in deep expiration. It is accentuated after a PVC, Valsalva maneuver, abrupt upright posture or deep inspiration.

329. b: Pericardial tamponade

Pulsus paradoxus - This term was coined by Kussmaul. There is marked and exaggerated inspiratory fall in systolic blood pressure in which palpable peripheral arterial pulse and audible Korotkoff sounds disappear in inspiration. The blood pressure cuff is inflated beyond the peak systolic pressure and slowly deflated. The degree of paradoxus is the difference between the systolic pressure at which the Korotkoff sounds are first heard during expiration and the point at which all beats are well heard during both phases of respiration. The word paradoxus is a misnomer because systolic pressure normally falls during inspiration by 4-6 mm Hg. In pulsus paradoxus the difference is >10 mm Hg. The patient must be breathing quietly and not deep breathing or performing Valsalva maneuver. It is seen in pericardial tamponade, constrictive pericarditis, emphysema, asthma, severe congestive cardiac failure and marked obesity.

331. b: Mean BP=Diastolic BP + 1/3 pulse pressure

332. d: Any position where the peak of the venous column is well identified

Mechanism - Cardiac tamponade is a continuum from effusion to full blown circulatory collapse. The hemodynamic effects depend on the amount of effusion and the pericardial pressure volume relationship. As fluid accumulates in pericardial sac, there is increased left and right sided atrial and ventricular pressures which equalize at a pressure similar to intrapericardial pressure. Inspiration increases the venous return to the right side of the heart at a period when the total heart volume is fixed. This increases the right ventricular diastolic dimensions pushing the interventricular septum to the left. This reduces left ventricular dimensions, compliance and filling. Also inspiratory pooling of blood into the pulmonary circulation causes under filling of the left atrium and left ventricle. The under filled left ventricle in tamponade operates on the steep ascending limb of Starling curve, so inspiratory reduction of left ventricle filling causes a marked depression of stroke volume and systolic pressure.

Reverse pulsus paradoxus may be seen in cardiac tamponade with positive pressure ventilation and isorhythmic AV dissociation.

Pulsus paradoxus may be absent in cases of cardiac tamponade with atrial septal defect/ ventricular septal defect/ aortic regurgitation/ pericardial adhesions.

Measurement of blood pressure - The blood pressure is measured with an aneroid or mercury manometer. The bladder length/width should be 80%/40% of the arm circumference. The ratio of cuff width to length should be 1:2. The center of the rubber bladder should be on the brachial artery. The blood pressure cuff is wrapped tightly around the arm. The diaphragm or bell of the stethoscope is firmly placed at the brachial artery, so that the upper edge of the stethoscope is in contact with the distal edge of the cuff. The patient should be seated comfortably, back supported, bared upper arm, legs uncrossed with the arm at level of heart. The cuff is inflated 20 mm Hg above the point

The patient should be reclining comfortably without any tension on neck tissues. The chin is elevated and head rotated to the left. It is preferable to have tangential lighting. Lean over to the left side of the patient while examining the right side of the neck. The sternal angle of Louis is 5 cm above the mid right atrium whether supine, 45 degree or 90 degree position is given. The venous pressure is measured from the angle of Louis. The thorax should be positioned at an angle where the peak of the venous column is well identified. If the venous pressure is too low, place the patient supine with leg elevation and ask him to take deep breaths. If the pressure is too high, the pulsations may be behind the angle of the mandible, so keep the patient at 90 degree and examine. The height of the A and V wave during inspiration is taken as the venous pressure. Two scale method is used. A horizontal scale at the peak of the venous column cuts the vertical scale kept at the angle of Louis. For supine 2 cm is the upper limit of normal and for 45 degree 4.5 cm is the upper limit of normal for venous pulsations. By adding 5 cm, we can obtain the actual venous pressure. If it is not visible, deep inspiration can bring out the waves. The normal level is 4 cm above the angle of Louis which is equal to 9 cm of water or 6 mm Hg.

333. c: X descent is between S1 and S2, X’ is simultaneous with radial pulse

330. c: The systolic pressure is estimated by the palpatory method and diastolic pressure by the auscultatory method

Cardiac output is the product of heart rate and stroke volume (CO=HRxSV). Arterial blood pressure is the product of cardiac output and peripheral resistance (BP=COxPR). The pulse pressure is the difference between systolic and diastolic blood pressure (approximately 40 mm Hg). Mean blood pressure is the sum of diastolic blood pressure and 1/3rd pulse pressure (approximately 95-100 mm Hg).

It is recommended to use the X and Y descent to time the venous pulse. The negative X descent is between S1 and S2 and X’ is simultaneous with radial pulse. The A wave is visible as a flickering pulsation just before the carotid pulse is felt. During auscultation, the A wave coincides with S4 and is almost simultaneous with S1. The V wave peaks just after S2 and Y descent begins after the V wave.

334. b: Downward pull of tricuspid valve by contracting RV

Careful examination of the venous pulse can provide useful information about the right sided cardiac physiology (Figure 4). When the right atrium contracts, its pressure rises pushing the blood from right atrium to the right ventricle at end of ventricular diastole. It also causes blood to flow retrogradely into the superior vena cava and jugular veins. This produces a


positive wave called the A wave. The A wave begins at the peak of the P wave of ECG, immediately prior to S1 and the carotid upstroke. As the right atrium starts relaxing, pressure falls causing the early portion of X descent. Simultaneously, the right ventricular systole commences causing the intraventricular pressure to rise above the atrial pressure. This leads to closure of the tricuspid valve. The upward bulging motion of closed tricuspid valve during isovolumic systole produces a positive wave called C wave. The onset of C wave corresponds to the tricuspid component of S1. It can be confused with transmitted carotid pulsations. It is usually not visible as a separate wave. As the right atrial relaxation continues, right atrial pressure falls during early right ventricular systole. During this phase the tricuspid valve ring is also pulled downwards. The latter part of X descent, Xâ&#x20AC;&#x2122; reaches its lowest point. The X descent begins during systole and ends before S2. The great veins empty into the right atrium during ventricular systole with a closed tricuspid valve. This leads to a rise in the right atrial pressure causing a second positive wave called the V wave. It begins in late systole and ends in early diastole. It is synchronous with the carotid pulse and peaks after S2. At this point of early ventricular diastole, the ventricular pressure falls below the intra atrial pressure causing the tricuspid valve to open and blood flows from right atrium to right ventricle. This causes a negative wave called the Y descent. The H (H from Hirschfelder) wave arises due to passive right heart filling during diastole. In normal individuals, the A wave is larger than the V wave and X descent is more prominent than the Y descent. During inspiration, negative intrathoracic pressure causes increased venous pooling of blood which leads to prominent X and Y descent. During expiration, A wave diminishes and V wave becomes the dominant positive reflection.

MCQ's

1152

Wave

Cause

A wave

RA contraction

X descent

Atrial relaxation

Xâ&#x20AC;&#x2122; descent

RA floor descent and downward pulling of TV by contracting RV

C wave

Impact of carotid artery and upward bulging of TV

V wave

RA filling during RV systole with a closed TV

Y descent

RA emptying when TV opens

H wave

Passive right heart filling during diastole

X descent

V waves

Y descent

Large A waves

Prominent X descent

Prominent V waves

Rapid Y descent

TS, RA myxoma, Tricuspid atresia

Constrictive pericarditis

TR

Constrictive pericarditis

PAH, PS, Acute PE

Cardiac tamponade

Large ASD

Severe TR

RV cardiomyopathy, RV infarction

ASD

Severe CHF, Cor pulmonale

Severe right ventricular failure

AF

ASD with MR

Diminished V waves

Slow Y descent

Severe AS, HCM Cannon waves

Absent X descent

V waves

Y descent

Junctional rhythm, VT, Isorhythmic AV dissociation

TR

Hypovolemia

TS, RA myxoma

Use of nitrates

Pericardial tamponade

Absent A waves AF, Sinus tachycardia 336. a: Pulmonary arterial hypertension

Paroxysmal nocturnal dyspnea - It is occurrence of breathlessness during sleep. Most commonly noticed 2-3 hours after going to sleep and relieved within 15 minutes of sitting upright. It is associated with sweating, wheezing and coughing. These patients are functionally NYHA class III. It is seen in MS, LVF, DCM and CAD

Mechanism of PND

i. Absorption of edema fluid from interstetial compartments of lower limbs during supine position increases venous return to right heart. This leads to pulmonary interstetial edema

ii. Left ventricular failure causes pulmonary interstitial edema and pulmonary venous hypertension.

iii. Decreased sympathetic drive during sleep decreases LV contractility

iv. Nocturnal arrhythmias and dreams

337. d: All of the above

Mechanism of syncope in AS

i. Due to fixed cardiac output, the cardiac output decreases on exertion due to reflex fall in peripheral vascular resistance

ii. Exertion causes marked increase in LV contractility with increased LV systolic pressure without corresponding increase in aortic pressure. This leads to stimulation of LV mechanoreceptors causing sympathetic inhibition and parasympathetic activation via the vagal afferent fibres (Bazold Jarisch reflex). This precipitates syncope.

iii. Myocardial ischemia

iv. Decreased coronary artery perfusion due to hypotension and bradycardia

v. Arrhythmias - AF, Paroxysmal AV block, VT

Abnormalities of the waves A waves

X descent

CHB, Ventricular pacing

335. a: Isorhythmic AV dissociation

A waves

338. a: Normal pulse pressure

Acute aortic regurgitation - In acute aortic regurgitation, there will be sinus tachycardia, slightly low systolic blood pressure with a near normal diastolic blood pressure with pulsus alternans. Peripheral signs may be absent. The mean jugular venous pressure may be elevated.

Peripheral signs of Chronic Aortic regurgitation

i. Bisferiens pulse - A double peaked systolic impulse, best appreciated in brachial artery

ii. Water hammer pulse


iii. Hill’s sign - A difference in systolic blood pressure between the brachial and popliteal arteries is used to assess the severity of aortic regurgitation - 20-40 mm Hg - angiographic 2+ AR, 40-60 mm Hg - angiographic 3+ AR, >60 mm Hg angiographic 4+ AR

iv. Palmar click - A palpable, abrupt flushing of the palms in systole

v. Pulsus magnus - High volume, large amplitude pulse

Eyes

v. Landolfi’s sign - Contraction and dilatation of pupil in systole and diastole respectively vi. Becker’s sign - Prominent retinal artery pulsations

Head and Neck

vii. De Musset’s sign - Visible oscillation or bobbing of the head with each heart beat

viii. Corrigan’s sign - Visible pulsations of carotid artery (dancing carotids)

ix. Muller’s sign - Visible pulsations of the uvula

x. Minervi’s sign - Strong lingual pulsations demonstrated by up and down movement of the tongue depressor

xi. Logue’s sign - Pulsatile sternoclavicular joint when aortic regurgitation is associated with aortic dissection

Upper limb

xii. Locomotor brachialis - Pulsations of the brachial artery

xiii. Quincke’s pulse - Exaggerated sequential reddening and blanching of the fingernail when light pressure is applied to the tip of fingernail. A similar phenomenon can be observed by pressing a glass slide against the lips.

xiv. Palfrey’s sign - Pistol shot sounds over the radial artery

Lower limb

xv. Pistol shot of Traube - A large systolic sound with the stethoscope lightly placed on the femoral artery

xvi. Durozeiz’s sign - Light pressure applied to the femoral artery distal to the edge of the stethoscope produces a to and fro bruit caused by exaggerated reversal of flow in diastole.

A systolic murmur is perceived by pressing the femoral artery proximal to the stethoscope.

340. a: Constrictive pericarditis

Explanation - Refer Q 335

CARDIOLOGY

X descent is attenuated and ultimately disappears. The V wave 1153 is augmented and Y descent is more prominent. In severe tricuspid regurgitation, there is a rounded or plateau like severe regurgitant C-V wave, V wave or S wave. This V wave is a systolic wave which is followed by a sharp, steep trough called the Y descent. In severe cases, prominent eyeballs and pulsatile earlobes have been observed. With inspiration, due to increase in right ventricular inflow, the V wave has a higher peak and a prominent Y descent. In atrial fibrillation, there is disappearance of A wave with presence of a dominant V wave which may simulate the V wave of tricuspid regurgitation.

Figure1

Figure2

Abdomen

xvii. Rosenbach’s sign - Pulsatile liver

xviii. Gerhardts’s sign - Pulsatile spleen

xix. Dennison’s sign - Pulsatile cervix

339. d: Severe TR

Tricuspid regurgitation - Pulse - Hemodynamically significant tricuspid regurgitation may result in low amplitude arterial pulse. Many patients may have associated atrial fibrillation.

Jugular venous pressure - It has more diagnostic importance than auscultation. Sometimes, in severe tricuspid regurgitation, the mean venous pressure is elevated. In such a situation, it may be necessary to examine the patient in a sitting or standing position. Do not conclude that the jugular venous pulse is normal unless the upper level of the wave form is identified in supine, 45 degree or sitting position. As the severity increases,

Figure3


MCQ's

1154

Figure 4

Figure 1: Normal arterial pulse. Note the rapid upstroke of percussion wave, rounded peak of tidal wave and fall off in late systole. The dicrotic notch coincides with S2.

Figure 3: Carotid pulse waveforms and heart sounds. A Normal, B - Severe Aortic stenosis - anacrotic pulse with slow upstroke, C - Severe aortic regurgitation - bifid pulse with two systolic peaks, D - Hypertrophic obstructive cardiomyopathy bifid pulse with spike and dome pattern, E - Dicrotic pulse - one peak in systole, another in diastole.

Figure 4: Normal jugular venous pulse. The large A wave almost coincides with S1 and the V wave coincides with S2. The X descent occurs in systole and Y descent in diastole.


ENDOCRINOLOGY 1.

b. This requires immediate surgery for decompression and fracture repair

Cortisol is secreted from where? a. Adrenal Medulla

c. This is idiopathic and has a high mortality

b. Adrenal Cortex: ZonaFasiculata

d. This is not my problem as trauma service

c. Adrenal Cortex: ZonaReticularis d. Adrenal Cortex: Zona Glomerulus e. Anterior Hypophysis 2.

10.

a. Increases in serum concentration b. Decreases in serum concentration

Which of these is not secreted from the Anterior Hypohysis?

c. Linked to Magnesium

a. Thyroid Stimulating Hormone

d. Linked to albumin

b. Adrenocorticotrophin Hormone c. Oxytocin d. Follicular Stimulating Hormone

11.

b. Hydration c. Calcitonin

Diabetes Insipidus is a deficiency of what hormone?

d. Loop diuretics

a. Atrial Natriuretic Peptide b. Vasopressin c. Aldosterone

12.

d. Insulin e. Progesterone 4.

a. Medication targeted at destroying follicular cells b. Medication that decreases T4 output in the colloid cells

a. Acromegaly

c. Medication that prevents conversion of T4 to T3

b. Gynaecomastia

d. Medication targeted centrally to prevent the release of TSH

d. Anaemia

13.

b. Glucocorticosteriods

Which of the following signs strongly support a diagnosis of pituitary adenoma? a. Carpopedal Spasm b. BitemporalHemianopsia

c. Insulin d. ASA 14.

c. Chvostekâ&#x20AC;&#x2122;s Sign d. Tremor

b. Check a magnesium STAT c. Calcium gluconate 3 gm IV

ADH is secreted by the

d. Oscal with D 4500mg per day

a. Hypothalamus c. Intermediate Lobe of the pituitary

15.

d. Anterior lobe of the pituitary 7.

b. myxedema c. pheochromocytoma

a. Cortex

d. rickets

b. Distal convoluted tubule 16.

d. Proximal convoluted tubule 8.

b. severe hyperglycemia c. too little insulin in the bloodstream

a. Decreased blood flow

d. an allergic reaction to insulin

b. Decrease in gland size d. Increase in colloid 9.

A 16 year old female presents to HMC s/p boating accident and closed head injury with anterior table nondisplacedfrontal sinus fracture. Her urine output on day two is 10 liters a day. You tell the family a. This is self limited and prognosis is good

Insulin shock is characterized by a. severe hypoglycemia caused by an overdose of insulin

TSH stimulation in the thyroid causes

c. Increased in follicular epithelium

Severe hypothyroidism characterized by dry, puffy skin, somnolence, slow mentation, and hoarseness is known as a. hypoparathryroidsim

ADH has it greatest influence on the kidneys at

c. Medulla

A 45 year old man is s/p total thyroidectomy with numbness in cace and hands and a positveChovstek sign. Theserum calcium is 6.9 the appropiate step is a. D/C with close follow up to home

e. Clubbing

b. Posterior lobe of the pituitary

Which medication should be avoided in a thyroid storm a. Bblocker

e. Early Menopause

6.

A 37 year old females is s/p thyroidectomy POD #2 with heart rate of 155, temperature of 102 and altered mentalstatus. Her TSH is 0.01 and T4 is found to be 12.3. First line treatment includes

Excess prolactin causes:

c. Dwarfism

5.

Long term management of hypercalcemia does not include a. Bisphosphonates

e. Lutenising Hormone 3.

In relation to Calcium, phosphorus

17.

Which of the following would be an appropriate medication for someone with hypothyroidism? a. Cymbalta b. Levoxyl c. Zelnorm d. Zithromax


b. Cushing syndrome

1156 18. Chronic excretion of large amounts of urine of low specific gravity is indicative of

c. hyperthyroidism

a. diabetes innocens b. diabetes insipidus c. diabetes intermittens

d. hypothyroidism 28.

a. gastropharesis

d. diabetes mellitus 19.

b. exophthalmos

Potassium, sodium, and chloride are

c. hirsutism

a. catecholamines b. electrolytes c. enzymes

d. moon facies 29.

MCQ's

b. parathymia

Enlargement of the bones of the hands, feet, and face due to overproduction of growth hormone is called

c. hyperinsulinism d. toxic goiter

a. acromegaly b. Cushing syndrome c. polydactyly

30. The â&#x20AC;&#x153;master glandâ&#x20AC;? of the endocrine system, located at the base of the brain, is the a. apical gland

d. Addison disease 21.

b. Bartholin gland

Which of the following is a measure of blood sugar after 4 or more hours of no food?

c. pituitary gland d. thyroid gland

a. fasting glucose b. glucose tolerance test

22.

31.

a. adrenal glands

d. thyroid function test

b. pancreas c. sex organs

Which of the following is transcribed correctly?

b. The patient was diagnosed with type I diabetes at 4 years of age.

d. thyroid gland 32.

a. endocrine gland

d. The patient was diagnosed with type one diabetes at 4 years of age.

c. serous gland

Elevated glucose levels, especially in obese persons, may be due to

b. exocrine gland d. target gland 33.

b. Creactive protein

c. insulin resistance

c. hemoglobin A1c

d. insulin shock Which gland secretes DHEA and cortisol? a. pituitary

d. prolactin 34.

b. goiter

c. parathyroid

c. moon facies

d. pineal a. TFTs

d. thyroiditis 35.

b. BMP

26.

What is a possible diagnosis for a middleage woman with thinning hair, fatigue, irritability, and weight gain? a. hyperthyroidism

c. LFTs

b. hypochondria

d. CMP

c. hypoparathyroidism d. hypothyroidism

Which of the following is a hypoglycemic medication? a. Avandia b. Ceftin

27.

Enlargement of the thyroid gland is called a. bruit

b. adrenal

Measurement of T3, T4 and TSH is collectively known as

Which test is used to evaluate blood glucose levels over the previous 2 months? a. methemoglobin

b. glucose intolerance

25.

Which type of gland secretes hormones directly into the bloodstream rather than into ducts leading to the exterior ofthe body?

c. The patient was diagnosed with type I diabetes at 4years of age.

a. diabetic acidosis

24.

The combining form gonad/o menas

c. microalbumin test

a. The patient was diagnosed with type 1 diabetes at 4 years of age.

23.

Graves disease is also known as a. hypothyroidism

d. steroids 20.

Which of the following is a complication of diabetes mellitus?

36.

Insulin is produced in the a. gallbladder

c. Lipitor

b. kidney

d. Prevacid

c. liver

Overactivity of the thyroid gland is called a. Addison disease

d. pancreas


37.

Which hormone is secreted in the urine of pregnant women? b. oxytocin

b. Hypothyroidism (secondary, ie pituitary disease)

c. growth hormone

c. Hyperthyroidism 48.

b. oxytocin

b. Diiodotyrosine (T2) c. Triiodothyronine (T3) 49.

a. Thyroid

d. prolactin

b. Cellular conversion c. Brain

The class of drugs referred to as glitazones are used to treat 50.

a. Triiodothyronine T3

c. infertility

b. Diiodotyrosine (T2)

d. hypothyroidism

c. Thyroxine (T4)

Which of the following is used to treat diabetes mellitus?

51.

a. Equally from thyroid and tissue conversion of T4

b. Lotrel

b. Small amount from thyroid, and mostly from tissue conversion of T4 c. Mostly from thyroid and small amount from tissue conversion of T4

Which of the following hormones stimulates egg production in the ovaries?

52.

b. Thyroxine T4

b. PSA

c. Reverse T3

c. TSH d. prolactin

53.

b. Same function as T3

a. adrenal glands

c. Inactive

b. pineal glands d. testes

54.

b. Insufficient precursors for production c. Insufficient pituitary production of TSH

a. adrenal gland c. pituitary gland

55.

a. Addison disease

b. Traumatic injury c. Immune mediated 56.

b. Weight gain and PU/PD

c. hirsutism 45.

Growth hormone a. Directly stimulates growth of cartilage and bone b. Levels are subnormal in acromegaly c. Promotes lipolysis in adipose tissue d. Enhance protein breakdown in nonvitalorgans e. Enhance insulinstimulatedglucose uptake by tissue

46.

What test is most useful for Killer? a. TSH concentration b. Skin biopsy c. Total T4 or fT4

What are the most common clinical signs? a. Lethargy and alopecia

b. cretinism d. testoxicosis

How is the gland destroyed? a. Infection

d. thyroid gland 44. An excessive or abnormal hair growth, particularly male pattern hair growth on a woman, is called

What is the mechanism for deficiency of thyroid hormones in majority of cases? a. Bilateral thyroid gland destruction

What is the name of the gland that is composed of a right and left lobe on either side of the trachea? b. parathyroid gland

What is its function? a. Negative feedback to thyroid

Which of the following secrete estrogen and progesterone?

c. ovaries

What other form of thyroid hormone is produced in the cells? a. Diiodotyrosine T2

a. FSH

43.

Where is T3 produced?

a. Humalog

d. Neuronitn

42.

What is the active form of thyroid hormone?

b. noninsulindependent diabetes mellitus

c. Lotensin 41.

Where is it produced?

c. Alopecia and weight gain 57.

Where is the alopecia typically seen? a. Trunk and belly b. Base or tip of tail, base of ears, lateral lumbar region c. Tips of pinnae, base of tail and under chin

58. Other hair coat or skin changes include? a. Dry hair, Short guard hairs, Fading coat colour b. Dry hair, Long guard hairs, Fading coat colour c. Hyperpigmentation, Seborrhea d. A and C e. B and C

ENDOCRINOLOGY

40.

For most dogs, what is the main hormone that is deficient?

c. progesterone

a. diabetes insipidus

1157

a. Thyroxine (T4)

Which of the following is secreted by the posterior lobe of the pituitary gland and stimulates contraction of the uterusduring labor? a. estrogen

39.

What was your diagnosis? a. Hypothyroidism (primary, ie thyroid disease)

d. somatotropin 38.

47.

a. beta hCG


c. Give TRH and measure T4

1158 59. Other common clinical signs include... a. Weight gain, constipation

Hyperthermia,

Bradycardia,

d. All of the above

Infertility, 69.

b. Weight loss, Bradycardia, Constipation

a. Rare

c. Weight gain, Bradycardia, Infertility, Constipation

b. Relatively common

d. Weight loss, Bradycardia, Infertility, Diarrhoea 60.

What nonspecific tests are often abnormal on a haematology and biochemistry profile? a. Anaemia of chronic triglycerides, CK

disease,

increased

MCQ's

c. Anaemia of chronic disease, decreased cholesterol and CK, increased liver enzymes 61.

c. Similar occurrence to other endocrinopathies 70.

b. Most common endocrinopathy c. Similar occurrence to other endocrinopathies 71.

b. Hyperadrenocorticism, Diabetes mellitus

a. Free T4

c. Chronic renal neoplasia

b. TSH concentration d. Total T4 62.

72.

c. Confirm hyperA then differentiate between pituitary and adrenal dependent 73.

b. High dose dexamethasone suppression test c. ACTH concentration

b. Synonymous with hypothyroid

d. ACTH stimulation test

c. Decreased TT3, +/TT3and +/fT4in sick (nonhypothyroid) dog Which of the following may affect the measurement of T4 & T3?

e. Both A and D 74.

What are the causes of HyperA a. Neoplasia + iatrogenic (exogenous steroids)

a. Phenobarbital

b. Neoplasia + iatrogenic + immune mediated

b. Metacam, carprofen

c. Neoplaia + iatrogenic + diet

c. Prednisolone d. General anaesthetic

75.

b. Cortisol

f. All of the above What did you use as hormone replacement therapy? a. Triiodothyroine T3

c. TSH 76.

b. Cortisol

c. Reverse T3 a. Clinical signs of overdosing do not occur with T4 therapy

c. TSH 77.

b. Catabolic + anabolic

c. Lethargy, dullness, inappetance

c. Catabolic + immune stimulation 78.

a. Common

b. High dose dexamethasone suppression test

c. Never occurs

c. Ultrasound &/ or xrayof adrenals d. ACTH concentration

How would you distinguish between primary, secondary and tertiary hypothyroidism? b. Biopsy gland

Which of the following could be used to determine PDH vs AT? a. 4 hour sample in the LDD

b. Rare

a. Measure TSH

What are the major effects of excess cortisol? a. Catbolic + immunosuppression

b. Nervousness, restlessness, panting, tachycardia, PU/PD How common is secondary (pituitary dependent. or tertiary (hypothalamic. hypothyroidism in dogs?

What is the primary hormone in excess in an adrenal tumour a. ACTH

b. Thyroxine T4 Which of the following are signs of overdosing?

What is the primary hormone in excess in a pituitary tumour? a. ACTH

e. Clomipramine

68.

What test/s can be used to confirm/ deny hyperA? a. Low dose dexamethasone suppression test

What does â&#x20AC;&#x2DC;euthyroid sickâ&#x20AC;&#x2122; mean? a. Any form of thyroid abnormality

67.

What are the steps needed to diagnose hyperA?

b. Confirm hyperA but it is not possible to determine whether aetiology is pituitary or adrenal

d. B & C

66.

hepatic

Why not measure T3= active form?

c. Often below normal in euthyroid sick dogs

65.

hypoadrenocorticism,

a. Look for adrenal tumour, if negative look for pituitary tumour

b. Often below normal in hypothyroid dogs

64.

failure,

e. A & D a. Too expensive

63.

What are the most likely diseases for PU/PD & alopecia? a. Diabetes mellitus, Hyperadrenocorticism, GH responsive alopecia

What was the first specific diagnostic test you did?

c. TSH stimulation

How common is hypothyroidism in cats? a. Rare

cholesterol,

b. Anaemia of chronic disease, increased urea, creatinine and CK

How common is hypothyroidism in dogs?

e. All of the above 79.

What is the rationale for using radiography? a. Different adrenal size


b. Identify other abdominal problems c. Mineralisation of the adrenals 80.

90. The main indication for _____ is intravenous calcium 1159 replacement for hypocalcemia. a. Calcium gluconate

What are the implications of a pituitary tumour?

b. Calcium carbonate

a. Most are large tumours that will kill the dog due to space occupation in the brain

c. Calcium citrate d. Raloxifene

b. Most are small tumours, but dog is likely to die from metastasis.

e. Bisphosphonates (“dronate”) f. Calcitonin

c. Most are small tumours; tumour invasion and metastasis rarely cause death 81.

g. Denosumab h. Teriparatide

How would you test for iatrogenic hyperA? b. Low dose dexamethasone suppression test

91. Monoclonal antibody that binds to Her2/neu receptor on breast cancer cells a. Estrogen replacement

c. High dose dexamethasone suppression test 82.

d. ACTH concentration

b. Gonadotropins

What was your final diagnosis for Sheena?

d. Anastrozole

c. Tamoxifen

a. Pituitary dependent hyperadrenocorticism + bacterial cystitis

e. Trastuzumab f. Goserelin

b. Adrenal dependent hyperadrenocorticism + renal failure c. Adrenal dependent hyperadrenocorticism + cystitis 83.

92.

a. Hypoglycemia

What treatment would you recommend?

b. Lactic acidosis

a. Surgery

c. Weight gain

b. Euthanasia

d. Hepatotoxicity

c. No treatment is necessary 84.

e. CV toxicity

What test/s should be performed prior to surgery?

f. Nausea and vomitting

a. Chest radiograph and abdominal ultrasound

g. Pancreatitis

b. Chest radiograph and brain MRI or CT scan

h. EB. Most are small tumours, but dog is likely to die from metastasis.

c. Chest radiograph and cardiac ultrasound 85.

i. C. Most are small tumours; tumour invasion and metastasis rarely cause death

If surgery was not an option? a. Euthanasia b. Drug therapy

93.

c. No treatment necessary 86.

87.

a. Estrogen replacement b. Gonadotropins

a. Mitotane +/prednisoloneor trilostane

c. Tamoxifen

b. Mitotane +/prednisoloneor selegiline/ Ldeprenyl

d. Anastrozole

c. Ketoconazole +/prednisoloneor selegiline/ Ldeprenyl

e. Trastuzumab f. Goserelin

How do you assess the response to treatment? b. ACTH stimulation test

94.

The main mechanism of _____ is to block TH iodination; contraindicated in pregnancy due to possibly teratogenicity.

c. Both of the above

a. Propylthiouracil

Choose the intermediateactinginsulin(s.:

c. Triiodothyronine

a. Lispro b. Aspart c. Regular d. NPH e. Glargine 89.

Partial estrogen agonist (SERM) in breast tissue usedto treat and prevent ERpositivebreast cancer

What drugs?

a. Feed and water intake

88.

Glipizide has the following main sideeffects:

The main mechanism of _____ is to block TH iodination; also prevent peripheral conversion of T4 >T3. a. Propylthiouracil b. Methimazole c. Triiodothyronine d. Iodine e. Potassium thiocyanate f. Betablockers g. Radioactive iodine (I131)

b. Methimazole d. Iodine e. Potassium thiocyanate f. Betablockers g. Radioactive iodine (I131) 95. The main mechanism of _____ is symptomatic relief of hyperthyroidism. a. Propylthiouracil b. Methimazole c. Triiodothyronine d. Iodine e. Potassium thiocyanate f. Betablockers g. Radioactive iodine (I131)

ENDOCRINOLOGY

a. ACTH stimulation


1160 96. The

main indication for _____ is dietary calcium supplementation; need to take with a meal and can take less. a. Calcium gluconate b. Calcium carbonate c. Calcium citrate d. Raloxifene e. Bisphosphonates (“dronate”) f. Calcitonin g. Denosumab h. Teriparatide i. Calcitriol

MCQ's

97.

98.

A 57-year-old woman, presents with dull grey-brown patches in her mouth and the palms of her handwhich she has noticed in the last week. She has also noticed she gets very dizzywhen rising from a seated position and is continually afraid of fainting. The mostlikely diagnosis is:

f. Betablockers g. Radioactive iodine (I131) 103. Metformin has the following main sideeffects: a. Hypoglycemia b. Lactic acidosis c. Weight gain d. Hepatotoxicity e. CV toxicity f. Nausea and vomitting g. Pancreatitis h. Edema 104. _____ is indicated for use in emergent hypercalcemia to quickly reduce serum calcium; given in combnation withbisphosphonates which take ~48 hours to reduce serum calcium.

a. Addison’s disease

a. Calcium gluconate

b. SIADH

b. Calcium carbonate

c. Conn’s syndrome

c. Calcium citrate

d. Waterhouse–Friderichsen syndrome

d. Raloxifene

e. 17-hydroxylase deficiency

e. Bisphosphonates (“dronate”)

The main mechanism of _____ is to replace thyroxine (T4). a. Propylthiouracil b. Methimazole c. Triiodothyronine d. Iodine e. Potassium thiocyanate f. Betablockers g. Radioactive iodine (I131)

99. The main mechanism of _____ is closing K+ membrane channels on beta cells which triggers inulin release. a. Glizipide b. Metformin c. Sitagliptin d. Exenatide e. Pioglitazone/Rosiglitazone 100. Choose the slowactinginsulin(s): a. Lispro b. Aspart c. Regular d. NPH e. Glargine 101. GnRH analog that can suppress fertiltiy if given continuously a. Estrogen replacement b. Gonadotropins c. Tamoxifen d. Anastrozole e. Trastuzumab f. Goserelin 102. The main mechanism of _____ is to block secretion of preformed thyroid hormone. a. Propylthiouracil b. Methimazole c. Triiodothyronine d. Iodine e. Potassium thiocyanate

f. Calcitonin g. Denosumab h. Teriparatide i. Calcitriol 105. This main mechanism of _____ is to act as an analog of incretin (GLP1) which increases glucose dependent insulinsecretion and reduces glucagon release. a. Glizipide b. Metformin c. Sitagliptin d. Exenatide e. Pioglitazone/Rosiglitazone 106. The main mechanism of _____ is to inhibit DPP4. a. Glizipide b. Metformin c. Sitagliptin d. Exenatide e. Pioglitazone/Rosiglitazone 107. The main mechanism of _____ is killing thyroid cells. a. Propylthiouracil b. Methimazole c. Triiodothyronine d. Iodine e. Potassium thiocyanate f. Betablockers g. Radioactive iodine (I131) 108. The main mechanism of _____ is inhibition of gluconeogenesis in the liver. a. Glizipide b. Metformin c. Sitagliptin d. Exenatide e. Pioglitazone/Rosiglitazone 109. The main indication for _____ is vitamin D replacement. a. Calcium gluconate


b. Calcium carbonate

d. Raloxifene

c. Calcium citrate

e. Bisphosphonates (“dronate”)

d. Raloxifene

f. Calcitonin

e. Bisphosphonates (“dronate”)

g. Denosumab

f. Calcitonin

h. Teriparatide

g. Denosumab

i. Calcitriol

h. Teriparatide i. Calcitriol 110. The main mechanism of _____ is to increase insulin sensitivity in peripheral tissue.

116. _____ is a monoclonal antibody that binds RANKL and inhibits osteoclast differentiation. a. Calcium gluconate b. Calcium carbonate c. Calcium citrate

b. Metformin

d. Raloxifene

c. Sitagliptin

e. Bisphosphonates (“dronate”)

d. Exenatide

f. Calcitonin

e. Pioglitazone/Rosiglitazone

g. Denosumab

a. Propylthiouracil b. Methimazole

h. Teriparatide i. Calcitriol 117. T4 is converted to T3 by _____.

c. Triiodothyronine

a. TBG

d. Iodine

b. thyroglobulin

e. Potassium thiocyanate

c. peripheral tissue

f. Betablockers g. Radioactive iodine (I131. 112. Aromatase inhibitor used in postmenopausal women with breast cancer to block peripheral estrogen production.

118. Adrenal hemorrhage and insufficiency due to Neisseria meningitidis is called _____. a. Addison’s b. Cushing’s

a. Estrogen replacement

c. Conn’s

b. Gonadotropins

d. Waterhouse Friderichsen syndrome

c. Tamoxifen d. Anastrozole e. Trastuzumab f. Goserelin 113. _____ is used to treat hypogonadism or ovarian failure, menstrual abnormalities; risk of endometrial cancer, bleeding, vaginal clear cell adenocarcinoma, thrombi formation

119. Subacute thyroiditis causes chronic hyperthyroidism. a. True b. False 120. GnRH, oxytocin, ADH, and TRH signal via... a. cAMP b. cGMP

a. Estrogen replacement

c. IP3

b. Gonadotropins

d. Cytosolic steroid receptor

c. Tamoxifen

e. Nuclear steroid receptor

d. Anastrozole

f. Tyrosine (MAP) kinase pathway

e. Trastuzumab

g. JAK/STAT pathway

f. Goserelin 114. _____ is a selective estrogen receptor modulator and is indicated for treatment of osteoporosis and prevents breastcancer.

121. Insulin and IGF1signal via... a. cAMP b. cGMP

a. Calcium gluconate

c. IP3

b. Calcium carbonate

d. Cytosolic steroid receptor

c. Calcium citrate

e. Nuclear steroid receptor

d. Raloxifene

f. Tyrosine (MAP) kinase pathway

e. Bisphosphonates (“dronate”)

g. JAK/STAT pathway

f. Calcitonin g. Denosumab h. Teriparatide i. Calcitriol 115. The main indication for _____ is dietary calcium supplementation; don’t need to take with a meal but have to takemore. a. Calcium gluconate b. Calcium carbonate c. Calcium citrate

122. Refractory hyperparathyroidism due to chronic renal disease; very elevated PTH and elevated Ca2+ a. Primary hyperparathyroidism b. Secondary hyperparathyroidism c. Tertiary hyperparathyroidism 123. Amylin a neuroendocrine hormone, which is deficient in Type1 DM Type DM in secreated form. a. Pancreatic beta cell b. Brain

ENDOCRINOLOGY

a. Glizipide

111. The main mechanism of _____ is to inhibit iodide transport.

1161


1162

133. In minimal weight gain strategy , the weight neutral pharmacotherapy are all expect-

c. Exocrine Pancrease d. Kidney 124. Average reduction of HbA1C by DPP4 inhibitor isa. .9%

b. Colesevelam c. DPP4 Inhibitor

b. .8%

d. GLP1 Agonist

c. .7%

134. Minimal progressive Beta cell loss strategy best co-prescription with metformin is

d. 1% 125. Colesevolam in addition to glucose lowering action also reduces maximuma. LDL

a. Thaiazolidinediones b. GLP1 Agonist c. DPP4 Inhibitor

b. HDL

d. Sulfunileurea

c. TG

MCQ's

a. AGI

135. Clinical situation to be ruled out in earlier renal failure in Type2 DM is

d. VLDL 126. Up until studies from edmontom the islet cell transplantation the result of Type 1A diabetic patient.

a. Enhanced atherosclerotic and bilaterial renal arterial stenosis.

a. <10% where insulin independent at 1years

b. Renal tubular Acidosis

b. <5% where insulin independent <1years

c. Renal Papillary necrosis

c. >30% where insulin independent at 1years

d. UTI

d. >20% where insulin independent at 1years 127. HIRATA syndrome or insulin autoimmune syndrome is seen mostly in.

136. In overt diabetic nephropathic patients the target BP should be. a. <125/75mmHg

a. Europian Population

b. <135/85 mmHg

b. Asian Population

c. <120/80 mmHg

c. American Population

d. <130/80 mmHg

d. African Population 128. Patient of Type 2 DM should be encouraged to do resistance exercise of all group of muscle at least.

137. Insulin neurities thena. 6 month

a. 2 times a week

b. 3 month

b. 3 times a week

c. 2 month

c. Once a week

d. 1 month

d. 5 days a week 129. The possible mechanism of resistance is

Glucocorticoid induced insulin

a. Activation of PPARα b. Activation of PPAR γ c. Inhibition of PPARα d. Inhibition of PPAR γ 130. Insulin increases the entry of glucose intoa. All tissues b. Renal tubular cells c. The mucosal cell of small intestine d. Skeletal Muscle cell 131. A meal rich in proteins containing amino acids that stimulates insulin secretion but low in carbohydrates does not cause hypoglycaemic becausea. A meal compensatory increase T4 secreation b. Glucagon secreation is also stimulated by meal. c. The amino acid in the meal is converted to glucose. 132. Transient neonatal diabetes resolves between a. 6-12 months of life b. 8-12 months of life c. 10-12 months of life d. 8-1- months of life

by definition should be present for less

138. A 60-year-old man visits his GP complaining of tiredness. He has noticed weightloss over the last six months and irritation of the tip of his penis which appearsinflamed on examination. He mentions he has been visiting the toilet more oftenthan usual and feeling thirsty. The most appropriate investigation would be: a. Oral glucose tolerance test b. Measurement of glycatedhaemoglobin c. Random plasma glucose test d. Water deprivation test e. Measurement of triglyceride levels 139. A 33-year-old obese woman complains of tiredness. She has recently given birthtoa healthy baby boy and is enjoying being a mother. However, she is becoming morereliant on her partner for support as she always feels exhausted and often becomesdepressed. The patient has a poor appetite and often does not finish her meals, despite this she has gained 5 kg in the last 2 weeks. The most likely diagnosis is: a. Postpartum depression b. Eating disorder c. Hyperthyroidism d. Hypothyroidism e. Occult malignancy 140. A 28-year-old woman has noticed a change in her appearance; most notably herclothes do not fit properly and are especially tight around the waist. Her faceappears flushed and more rounded than usual, despite exercising regularly andeating healthily her weight has steadily increased over the last 3 weeks. On visitingher GP, he notices her blood pressure


c. Urinary electrolytes

has increased since her last visit and she hasbruises on her arm. She is especially worried about a brain tumour. The mostappropriate investigation would be:

e. Water deprivation test

a. Low-dose dexamethasone test b. High-dose dexamethasone test c. Urinary catecholamines d. Computed tomography (CT) scan e. Urinary free cortisol measurement

a. Hyperthyroidism b. Cushing’s disease c. Acromegaly

146. A 69-year-old man presents with confusion. His carers state that over the lastmonth he has become increasingly lethargic, irritable and confused. Despitemaintaining a good appetite, he has lost 10 kg in the last month. Blood results areas follows:

Sodium 125 mmol/L

Potassium 4 mmol/L

Urea 3

Glucose (fasting) 6 mmol/L

Urine osmolality 343 mmol/L

The most likely diagnosis is: a. Hypothyroidism

d. Hypothyroidism

b. Dilutionalhyponatraemia

e. Diabetes 142. A 42-year-old woman presents with visual disturbances. She reports having doublevision which was intermittent initially but has now become much more frequent.Inaddition, she becomes breathless very easily and experiences palpitations. Onexamination, raised, painless lesions are observed on the front of her shins and finger clubbing. The most likely diagnosis is: a. De Quervain’s thyroiditis b. Thyroid storm c. Phaeochromocytoma

c. Addison’s disease d. Acute tubulointerstitial nephritis e. Syndrome of inappropriate anti-diuretic hormone (SIADH) 147. A 54-year-old woman presents to her GP complaining of a change in her breathingsound. She first noticed numbness, particularly in her fingers and toes, threemonths ago but attributed this to the cold weather. Her partner now reports hearinga high pitched, harsh sound while she is sleeping. Her BMI is 27. While measuring blood pressure, you notice the patient’s wrist flexing. The most likely diagnosis is: a. Obstructive sleep apnoea

d. Graves’ disease

b. Hypocalcaemia

e. Plummer’s disease

c. DiGeorge syndrome

f. Goitre 143. A 16-year-old girl presents to her GP complaining of a swelling in her neck whichshe has noticed in the last 2 weeks. She has felt more irritable although this is oftentransient. On examination, a diffuse swelling is palpated with no bruit onauscultation. The most likely diagnosis is: a. Hyperthyroidism b. Simple goitre c. Riedel’s thyroiditis

d. Guillain–Barré syndrome e. Raynaud’s syndrome 148. A 39-year-old man presents with a three-month history of depression. The patientrecently lost a family member and around the same period began to feel unwellwith constipation and a depressed mood. He has started taking analgesia for asharp pain in his right lower back that often radiates towards his front. The most appropriate investigation is: a. Serum parathyroid hormone

d. Thyroid carcinoma

b. Serum thyroid stimulating hormone

e. Thyroid cyst 144. A 22-year-old woman complains of dizziness and feeling light-headed. She worksin an office and most frequently experiences this when standing up to visit thetoilet. She has never fainted. The patient has lost 5 kg, but attributes this to eatingmore healthily. She has noticed a recent scar on the back of her hand which has started to turn very dark. The most appropriate investigation is: a. Synacthen test b. Low-dose dexamethasone test

c. Colonoscopy d. Fasting serum calcium e. MRI scan 149. A 47-year-old woman presents to clinic after being referred from her GP forconsistently elevated blood pressure. Her last reading was 147/93. The female doesnot report any symptoms but recently lost her job and attributes the elevatedreading to stress. Her blood tests are as follows:

Sodium 146

d. Urinary free cortisol measurement

Potassium 3.4

e. Abdominal ultrasound (US) scan

Glucose (random) 7.7

Urea 4

The most appropriate investigation is:

c. Cortisol measurement

145. A 29-year-old man presents with a 4-week history of polyuria and extreme thirst.The patient denies difficulty voiding, hesitancy or haematuria, although the urineis very dilute. The patient does not believe he has lost any weight and maintains agood diet. No findings are found on urine dipstick. The most appropriateinvestigation is: a. Serum osmolality b. Fasting plasma glucose

a. CT scan b. 24-hour ambulatory blood pressure c. Abdominal ultrasound scan

ENDOCRINOLOGY

141. A 49-year-old man presents with a history of difficulty sleeping. He reports feelingincreasingly tired and general weakness which he attributes to his poor sleeppattern. Additionally, the patient has noticed he has gained weight and sweats veryeasily. On examination, the patient has coarse facial features. The most likely diagnosis is:

1163

d. Magnetic resonance imaging (MRI) scan of the head


d. Aldosterone–renin ratio

1164

e. Glucose tolerance test 150. A 65-year-old woman complains of panic attacks. She has recently retired as aschool teacher, but 2–3 times a week she suffers extreme anxiety, becomes short ofbreath and sweats excessively. Elevated catecholamines are detected in the urine.

The most appropriate medical treatment is: a. Phenoxybenzamine alone b. Prolopanolol alone c. Phenoxybenzamine followed by propanolol d. Sodium nitroprusside

MCQ's

e. Propanolol followed by phenoxybenzamine 151. A 47-year-old woman complains of weight loss. She has a family history of type 1 and type 2 diabetes but has never been diagnosed herself despite the finding of islet cell antibodies. In the last few months, however, she has noticed progressively increasing polyuria and poydipsia and 5 kg of weight loss. Her fasting plasma glucose is 8 mmol/L and urine dipstick shows the presence of ketones. The most likely diagnosis is: a. Type 1 diabetes b. Non-ketotic hyperosmolar state c. Type 2 diabetes d. Occult malignancy e. Latent autoimmune diabetes of adults (LADA) 152. A 50-year-old Asian man is referred to the diabetes clinic after presenting with polyuria and polydipsia. He has a BMI of 30, a blood pressure measurement of 137/88 and a fasting plasma glucose of 7.7 mmol/L. The most appropriate first-line treatment is: a. Dietary advice and exercise b. Sulphonylurea c. Exenatide d. Thiazolidinediones e. Metformin 153. A 55-year-old diabetic woman presents with altered sensations in her hands and feet. She finds it difficult to turn pages of books and discriminating between different coins. When walking, the floor feels different and she likens the sensation to walking on cotton wool. The most likely diagnosis is:

155. A 15-year-old girl complains of headaches which started 6 weeks ago. Theheadaches initially occurred 1–2 times a week but now occur up to five times aweek, they are not associated with any neurological problems, visual disturbances,nausea or vomiting. The girl also reports a white discharge from both of her nipples. She has not started menstruating. The most appropriate investigation is: a. Lateral skull x-ray b. CT scan c. MRI scan d. Thyroid function tests e. Serum prolactin measurement 156. A 7-year-old girl presents with red striae which her mother noticed around herabdomen. The girl also has plethoric cheeks and, on her back, several faint, irregularbrown macules are observed. The mother is particularly concerned about the earlybreast development that seems apparent on her daughter. Serum phosphate isdecreased. The most likely diagnosis is: a. Paget’s disease of the bone b. McCune–Albright syndrome c. Cushing’s disease d. Hypopituitarism e. Neurofibromatosis 157. An 18-year-old man presents to clinic worried about his scant pubic hairdevelopment. Examination reveals undescended testes and plasma testosterone,luteinizing hormone and follicle stimulating hormone were found to be low. Akarytotype test was 46, XY. The patient was otherwise well, but during neurologicalexamination struggled during the olfactory test. The most likely diagnosis is: a. Hypogonadotropichypogonadism b. Klinefelter’s disease c. Androgen insensitivity syndrome d. 5-alpha reductase deficiency e. Kallman’s syndrome 158. A 47-year-old woman is referred to the endocrine clinic complaining of a twomonthhistory of tiredness. Despite wearing several items of clothing, the patientappears intolerant to the room temperature. She has noticed an increase in weight,particularly around her waist. The most appropriate investigation is:

a. Autonomic neuropathy

a. Radioiodine scan

b. Diabetic amyotrophy

b. Thyroid stimulating hormone (TSH)

c. Acute painful neuropathy

c. Total tetraiodothyronine level (T4)

d. Symmetrical sensory neuropathy

d. Tri-iodothyronine level (T3)

e. Diabetic mononeuropathy

e. Ultrasound scan of the neck

154. A 29-year-old woman is referred to a diabetic clinic for poor diabetes management.She was diagnosed with type 1 diabetes at the age of 12 and prescribed actrapidinsulin injections. Recently, the patient has been suffering fluctuations in herplasma glucose levels and her previously well-controlled glycatedhaemoglobin has risen to 8.1 per cent. The patient admits she has recently been avoiding using herinjections. On examination, the patient has a raised, smooth lump that is firm onpalpation at the lower abdomen. The most likely diagnosis is: a. Worsening of diabetes b. Lipohypertrophy c. Injection scarring d. Lipoma e. Injection abscess

159. A 58-year-old woman presents with an acutely painful neck, the patient has afever, blood pressure is 135/85 mmHg and heart rate 102 bpm. The patient explainsthe pain started 2 weeks ago and has gradually become worse. She also notespalpitations particularly and believes she has lost weight. The symptoms subsideand the patient presents again complaining of intolerance to the cold temperatures.The most likely diagnosis is: a. Thyroid papillary carcinoma b. Plummer’s disease c. De Quervain’s thyroiditis d. Hyperthyroidism e. Thyroid follicular carcinoma 160. A 6-year-old girl presents to accident and emergency with severe abdominal pain,nausea and vomiting. On examination, the patient is tachypnoeic, capillary refill is3 seconds and she has a dry tongue. While listening to the patient’s lungs,


youdetect a sweet odour from her breath. The most likely diagnosis is:

b. Glucose tolerance test

a. Diabetic ketoacidosis

d. Thyroid function tests

b. Non-ketotic hyperosmolar state c. Gastroenteritis d. Pancreatitis e. Adrenal crisis

e. Serum prolactin levels 166. A 19-year-old woman presents with concerns about changes to her facialappearance, in particular her nose and jaw seem quite large, she is also quite sweatyand despite using antiperspirants is finding it difficult to control and is afraid ofembarrassment at university. A glucose tolerance test is performed and found to be raised. The most appropriate management would be: a. Trans-sphenoidal surgery b. Octreotide

a. Ectopic ACTH secreting tumour

c. Bromocriptine

b. Prolactinoma

d. Pituitary radiotherapy

c. Nelson syndrome

e. Pegvisomant

d. Addisonâ&#x20AC;&#x2122;s disease e. Side effects from iatrogenic steroid intake 162. A 29-year-old woman is found unconscious by her partner and rushed to accidentand emergency. She is a type 1 diabetic and has maintained excellent glucosecontrol using insulin injections. Blood biochemistry results demonstrate amoderately raised level of insulin, no detectable C-peptide and very low bloodglucose. Her partner mentions she is a lawyer and has been working particularlyhard in the last week, eating quick meals and occasionally missing meals. The mostlikely diagnosis is:

167. A 29-year-old man presents to his GP complaining of being constantly thirsty, tiredand visiting the toilet more often than usual during the last 4 days. He has noticedhis clothes have become more baggy and he now needs to tighten his belt. Hisparents both have diabetes requiring insulin therapy. A fasting plasma glucose result is most likely to be: a. 9.0 mmol/L b. 6.0 mmol/L c. 16.3 mmol/L d. 5.0 mmol/L e. 3.0 mmol/L

a. Hyperosmolar coma b. Diabetic ketoacidosis c. Insulin overdose d. Hypoglycaemic coma e. Autonomic neuropathy 163. A 49-year-old man has recently been diagnosed with type 2 diabetes and is beingcarefully monitored. He has been advised to maintain a healthier diet and lifestyle,he attends a follow-up clinic and claims to have been following the diet stringentlysince his last appointment three months ago. The most appropriate investigation is: a. Random plasma glucose b. Fasting plasma glucose c. Urine dipstick d. Glycatedhaemoglobin e. Weight measurement 164. A 41-year-old man has been recently diagnosed with type 2 diabetes and has beenfollowing a plan of lifestyle measures to improve his diet and increase his level ofexercise. On returning to clinic, his BMI is 23, fasting plasma glucose 9.0 mmol/L,blood pressure 133/84 mmHg and HbA1c of 7.1 per cent. The most appropriatetreatment option is: a. Metformin b. Sulphonylurea c. Insulin d. Exenatide e. Further diet and exercise 165. A 33-year-old man complains of a tingling sensation in his hands for severalmonths which occasionally awakens him during sleep. The patient has noticed hehas gained weight and no longer wears his wedding ring as it has become too tight. You notice the patient is sweating while speaking to you and has quite a large jaw, furrowed tongue and large hands. His blood pressure reading is 142/91 mmHg. Themost appropriate investigation would be: a. MRI scan of the pituitary

168. A 22-year-old woman is found unconscious in her room by her boyfriend andbrought into accident and emergency. A urine dipstick is positive for glucose andketones and blood analysis shows the following results:

pH 6.9

PCO2 3.0 kPa PO2 13 kPa

Sodium 144 mmol/L

Potassium 5.0 mmol/L

Urea 11

Glucose 20

Chloride 100

Bicarbonate 2.9

The most likely anion gap is: a. 180 b. 118 c. 139.2 d. 46.1 e. 28

169. A 37-year-old man presents with symptoms of an acute headache, vomiting,malaise and visual disturbance. A neurological examination reveals a bitemporalsuperior quadrantanopia. A CT scan shows a hyperdense area within the pituitarygland. The most likely diagnosis is: a. Kallman syndrome b. Septo-optic dysplasia c. Sheehanâ&#x20AC;&#x2122;s syndrome

ENDOCRINOLOGY

161. A 45-year-old Asian man is diagnosed with Cushingâ&#x20AC;&#x2122;s disease in India. He undergoesa bilateral adrenalectomy and recovers well from the operation. On his return to theUK one year later, he complains of a constant dull headache, peripheral visualdisturbances and increasing pigmentation of the skin creases of both hands. Themost likely diagnosis is:

1165

c. Growth hormone levels


1166

d. Empty sella syndrome e. Pituitary apoplexy 170. A 38-year-old woman presents to clinic complaining of changes in her appearanceand weight gain. She has recently been through a divorce and attributed her weightgain to this. However, despite going to the gym her clothes are still tight, especiallyaround her waist, her face seems puffy and flushed. The most likely diagnosis is: a. Hyperthyroidism b. Cushingâ&#x20AC;&#x2122;s disease c. Acromegaly d. Hypothyroidism

MCQ's

e. Diabetes

171. A 60-year-old diabetic man recovering from sepsis after collapsing at home wastreated with appropriate antibiotics after blood culture and aggressive fluidmanagement with 0.9 per cent saline for 2 days for hypotension. Although bloodpressure returned to normal, the patient had the following abnormal biochemical blood results:

pH 7.32

PCO2 5.2

PO2 11.1

Sodium 147 mmol/L

Potassium 3.5 mmol/L

Chloride 119 mmol/L

Bicarbonate 19.5

The most likely diagnosis is: a. Diabetic ketoacidosis b. Lactic acidosis c. Connâ&#x20AC;&#x2122;s syndrome d. Renal tubular acidosis type 1 e. Hyperchloremic acidosis


1167

Endocrinology - Answers 37. a

73. e

109. i

138. c

2. c

38. b

74. a

110. e

139. d

3. b

39. b

75. a

111. e

140. e

4. b

40. a

76. b

112. d

141. c

5. b

41. a

77. a

113. a

142. d

6. b

42. c

78. e

114. d

143. b

7. c

43. d

79. c

115. c

144. a

8. c

44. c

80. c

116. g

145. e

9. c

45. c

81. a

117. c

146. e

10. b

46. c

82. c

118. d

147. b

11. c

47. a

83. a

119. b

148. d

12. c

48. a

84. a

120. c

149. b

13. d

49. a

85. b

121. f

150. c

14. c

50. a

86. a

122. c

151. e

15. b

51. b

87. c

152. a

16. a

52. c

88. d

123. a: williums endo page 1416

17. b

53. c

89. a

18. b

54. a

90. a

19. b

55. c

91. e

20. a

56. a

92. c

21. a

57. b

93. c

22. a

58. e

94. b

23. c

59. c

95. f

24. b

60. a

96. b

25. a

61. e

97. a

26. a

62. d

98. c

27. c

63. c

99. a

28. a

64. f

100. e

29. d

65. b

101. b

30. c

66. b

102. d

31. c

67. b

103. b

32. a

68. d

104. f

33. c

69. b

105. d

34. b

70. a

106. c

35. d

71. b

107. g

36. d

72. c

108. b

124. c: williums endo page 1416 125. a: williums endo page 1416 126. a: williums endo 127. b: williums endo 128. b: williums endo page 1389 129. a: williums endo page 1389 130. d: ganongs physiology 451 131. b: ganongs physiology 451 132. a: williums endo page-1375 133. d: williums endo page-1419 134. a: williums endo page 1419 135. a: williums endo page 1496 136. a: williums endo page 1498 137. a: williums endo page 1504

153. d 154. b 155. e 156. b 157. e 158. b 159. c 160. a 161. c 162. d 163. d 164. b 165. b 166. a 167. a 168. d 169. e 170. c 171. e

ENDOCRINOLOGY

1. d


GASTROENTEROLOGY 1.

Dysphagia to normal solid food is always present if oesphageal diameter is less than ?

10.

a. Steak-house syndrome

a. 1.3 cm

b. Carcinoma oesophagus

b. 2 cm

c. Caustic ingestion

c. 2.5 cm d. 4 cm 2.

Postural dysphagia for liquids is seen in

d. Severe GERD 11.

b. Lifting heavy objects

b. Achalasia

c. Stationery bike riding

c. Diffuse oesophageal spasm 3.

Sitophobia is seen in

d. Running 12.

b. Worsening after meals

b. Viral hepatitis

c. Relieved with bronchodilators

c. Chronic mesenteric vascular ischaemia 4.

In achalasis, basic abnormality is

d. Steroid dependent asthma 13.

b. Oespohageal atresia + distal type of TOF

b. Inhibitory neural degeneration localized to nerve cell bodies

c. Oesophageal stenosis + distal type of TOF

c. Excitatory neural degeneration localized to nerve processes 5.

All are features on oesophageal manometry in scleroderma except

d. Oesophageal stenosis 14.

b. oesophageal rings c. dysphagia lusoria

b. Low amplitude peristalsis

d. oesophageal webs

c. Hypotensive LES 6.

15.

b. Contains only mucosa and submucosa c. This is seen in 40% of patients on routine UGI series

a. Doxorubicin

d. Surgery is the most definitive treatment

b. Bleomycin d. Cisplatin 7.

16.

b. Fat c. peppermint

a. Gastric carcinoma

d. diazepam

b. African trypanosomiasis d. Lymphoma 8.

17.

b. Gastric squamous cell carcinoma c. Gastric adenocarcinoma d. Gastiric lymphoma

a. Cold water c. Edrophonium

18.

d. Ergonovine 9.

b. Pain lasting several hours c. Pain awakens at night d. Provoked by recumbency

Barrett’s epithelium has all the following histological characters except a. Absence of goblet cells b. Lack of intestinal absorptive capacity

In the clinical evaluation of chest pain, the symptom that has no significant statistical difference among cardiac and oesophageal causes is a. Radiation to left arm

The most common neoplasm associated with achalasia a. Oesophageal squamous cell carcinoma

All the following provoke oesophageal contractions in D.O.S. except b. solid food

All the following have effect on LES except a. Truncal vagotomy

All are secondary causes of achalasia except

c. Neuropathic intestinal pseudo- obstruction

True statement regarding schatzki’s ring a. It represents the proximal border of oesophageal vestibule

Severity of radiation oesophagitis is increased by all drugs except

c. Indomethacin

Diet modification is the primary therapeutic approach for a. Hiatal hernia

a. Abnormal sphincter relaxation

d. Low amplitude simultaneous onset contractions

The most common development anomaly of oesophagus is a. Isolated oesophageal atresia

a. Inhibitory neural degeneration localized to nerve processes

d. Excitatory neural degeneration localized to nerve cell bodies

The symptom that does not suggest reflux induced asthma is a. Late age of onset

a. Crohn’s disease

d. A+C

The following manoeuvres aggravate heart burn except a. Straining at stool

a. Scleroderma

d. None

All are causes of odynophagia except

c. Presence of villous structure d. Presence of parietal and chief cells 19.

Regarding tLESRs (Transient lower oesophageal sphincter relaxation), false statement a. Occur in patients with normal LES pressure b. Appear without fixed temporal relation to pharyngeal contractions


20.

c. Persists for shorter duration than swallow induced LESRs

b. Adenocarcinoma

d. Occur physiologically to gastric distension of food/gas.

c. Allergic oesophagitis

“Pseudo-ulcerations” oesophatitis due to

on

oesophagogram

are

seen

d. Parasitic infection

in

a. CMV

30.

b. Oesophagial Carcinoma

c. HSV

c. AIDS

d. Pill induced

d. Post transplant patients 31.

a. CMV

a. Swallowed oropharyngeal debris

b. candida

b. Pill oesophagitis

c. HSV

c. CMV infection

d. Pill induced 22.

Skin condition that is not pre-malignant for oesophageal carcinoma

d. Aspergillus infection 32.

b. Tetanus

b. Bullous perphigoid

c. Hysteria

c. Cicatricial Pemphigoid

d. Achalasia

d. Tylosis et palmaris The incidence and severity of oesophageal damage increase with radiation doses greater than

33.

b. Motilin c. VIP

b. 40 Gy

d. Substance P

c. 50 Gy 24.

34.

b. Carcinoma

a. 3 months

c. Myasthenia gravis

b. 6 months

d. Scleroderma

d. 2 year

35. Hiccups with dysphagia suggest lesion in which part of oesophagus a. Cervical oesophagus

Most common extra pulmonary site for small cell carcinoma

b. Middle part of oesophagus

a. Hypopharynx

c. Lower third of oesophagus

b. Oesophagus

d. No such location can be made

c. Stomach d. Small intestine 26.

36.

b. Schatzki’s ring c. Aberrant subclavian artery

b. Melanoma

d. Diffuse oesophageal spasm

c. Thyroid

e. All the above

d. Beast All the following drugs decrease LES except

37.

a. Progesterone

b. Corrosive stricture

c. Adrenergic agonists

c. Tylosis Palmaris and plantaris

d. Adrenergic antagonists

b. Syncope c. Globus sensation d. Headache 29.

d. Candidiasis e. Radiation stricture

All are extra oesophageal manifestations of GERD except a. Chronic cough

All are premalignant conditions for carcinoma oesophagus except a. Chronic achalasia

b. NSAIDs

28.

Chest pain with dyspagia occurs in a. Leiomyoma of oespophagus

Most frequent primary metastasizing to oesophagus a. Lung

27.

Transfer dysphagia is seen in a. Achalasia

Minimum period from exposure of radiation to oesophageal stricture formation is

c. 1 year 25.

LES pressure is decreased by a. Gastrin

a. 30 Gy

d. 75 Gy

Phagophobia (fear of swallowing) may occur in all except a. Rabies

a. Epidermolysis bullosa

23.

Plaque like lesions resembling candidal infection are seen with all the following except

38.

All are premalignant for squamous cell carcinoma except a. Plummer Vinson syndrome b. Deficiency of zinc, molybdenum, vit A c. Cigarette smoking

Commonest cause of tissue eosinophilia in oesophagus

d. Gastro oesophageal reflux disease

a. GERD

e. Excessive alcohol consumption

GASTROENTEROLOGY

“Volcano lesions” on oesophagogram are seen in oesophagitis due to

Low prevalence of candidal oesophagitis is seen in a. Achalasia

b. Candida

21.

1169


1170 39.

All aggravate heart burn except

a. Cervical oesophagus just below UES b. Near aortic arch

c. Dopamine

c. Above LES

d. Metoclopramide

d. Pharynx 49.

a. Fasting serum gastrin levels are higher by 35-45%

a. Monilial esophagitis

b. Suppression of meal stimulated gastrin release is more than controls c. The plasma gastrin concentration after GRP is high compared to controls

c. Carcinoma with periesophageal involvement

MCQ's

d. Achalasia e. Caustic injury

d. Cure restored fasting and GRP stimulated serum gastrin levels

Water brash is

e. All the statements are correct

a. Effortless appearance of gastic or esophageal contents in mouth

50.

b. Because of incompetence of upper and lower esophageal sphincter

b. Vitiligo c. Porphyria

d. Salivary hyper secreation, which occurs in response to peptic esophagitis e. All the above

d. Pheochromocytoma 51.

b. 2

a. Recumbent position

c. 3

b. Upright position

d. 2.5

c. Right lateral position 43.

52.

b. Serology

a. Dysphagia

c. Urea breath test

b. Nasal regurgitation

d. Histology

c. Chest pain 44.

53.

b. liver

a. Difficulty in swallowing

c. Biliary tract

b. More common in men

d. Colon

c. Barium studies and manometry are abnormal e. Associated with GERD 45.

54.

b. Cushing’s ulcers c. Sepsis

b. Increased gastric emptying

d. Shock

c. Increased oesophageal clearance e. Has action on small intestine and colon

All are associated with increased incidence of peptic ulcer except

Necrotizing oesophagitis is caused by

b. CRF

d. Extrapyramidal effects

55.

a. COPD

a. HSV oesophagitis

c. Systemic sclerosis

b. Varicella zoster oesophagitis c. CMV oesophagitis d. Candidal oesophagitis 47.

Gastric acid hypersecretion is the mechanism in one of the factory related to stress ulcers a. Curling’s ulcers

Metaclopramide has all these effects except a. Increased LES pressure

46.

Duodenal ulcers are least likely to penetrate a. Pancreas

Globus pharyngeus is

d. Treatment is pharyngomyotomy

Confirmation of H. pylori eradication after treatment is by a. Rapid urease test

Orophayngeal paralysis causes all except

d. Tracheobronchial aspiration

Pepsin is maximally active at a pH of a. 1

Oesophageal peristalsis is best studied in

d. Left lateral position

All the following are non GI causes of hypergastrinemia except a. Renal failure

c. Associated with achalasis or diverticulum

42.

H. pylori causes all these effects on gastric secretion except

Odynophagia is characteristic of all except b. Barrett’s ulcer

41.

Commonest site of foreign body impaction

b. Secretin

e. Nicotine 40.

48.

a. CCK

d. Alcoholic cirrhosis 56.

Most common cause of hypergastricnemia

e. All the above

a. Antral G-cell hyperplasia

Oesophagitis in AIDS is caused by

c. Renal failure

a. Cryptosporidium b. Pneumocystis carinii c. Mycobacterium tuberculosis d. All the above.

b. ZE syndrome d. Hypochlorhydria 57.

Medical therapy for ZE syndrome is monitored by a. Clinical symptoms b. BAO


c. Endoscopy

68.

58.

c. Posterior part of antrum

a. Lymphocytic gastritis

d. Posterior part of incisura

b. Eosinophilic gastritis 69.

b. Body

H. pylori is best diagnosed by

c. Cardia

a. Cuture

d. PCR

Most common indication for abdominal surgery within first 6 months of life is

Gastric leiomyomas are best diagnosed by

b. Hypertrophic pyloric stenosis

c. Histology

70.

a. Duodenal atresia

a. Endoscopy

c. Gastric volvulus

b. Endoscopy and biopsy c. Endoscopic ultrasonography d. Chromoendoscopy 61.

a. Duodenal atresia b. Hypertrophic pyloric stenosis

b. 2 cm

c. Gastric atresia

c. 2.5 cm

d. Microgastria a. Antrum b. Fundus

b. Body

c. Midportion of greater curvature

c. Fundus

d. Midpart of lesser curvature 73.

a. I.V. metaclopramide

a. Stomach

b. I.V. erythromycin

b. Jejunum

c. Cisapride

c. Ileum

d. Ondansetron 74.

Torsades â&#x20AC;&#x201C;de-pointes occurs due to drug interaction of

Gastric bicarbonate is stimulated by

a. Cisapride + metaclopramide

a. Alcohol

b. Cisapride + ondansetron

b. Agonists

c. Ondansetron + erythromycin

c. Calcium

d. Cisapride + erythromycin 75.

Gastric bicarbonate is inhibited by

b. Zinc c. Nickel

c. PGE

d. Copper

d. Aspirin Drug that can prevent bleeding from NSAID induced gastropathy is

The metal present in the enzyme urease elaborated by H. pylori is a. Gnotobiotic piglet

b. PGF

76.

Auto vagotomy is seen in a. Scleroderma

a. Misoprostol

b. Diabetes

b. Nizatidine

c. Amyloidosis

c. Lansoprazole

d. Multiple sclerosis

d. None 67.

Drug of choice in acute episodes of gastric stasis

Most common extranodal site for GI lymphoma

a. Calcium

66.

Functional pace maker of stomach is located at

a. Antrum

d. Acetazolamide 65.

72.

Gastric sarcomas are located most commonly at

d. Liver 64.

Congenitalanomaly of stomach that is associated with turnerâ&#x20AC;&#x2122;s syndrome is

a. 1.5 cm

d. Pylorus 63.

71.

Malignant gastric polyps are usually of size

d. 3 cm 62.

d. Diaphragmatic hernia

77.

First line of gastric / duodenal mucosal defense is

Most common cause of gastric outlet obstruction in AIDS

a. Duodenal bicarbonate secretion

a. Cryptosporidium

b. Apical barrier

b. CMV

c. Mucosal blood flow

c. Lymphoma

d. Anti oxidant mechanisms

d. MAC

GASTROENTEROLOGY

d. Incisura angularis

b. RUT

60.

Most fixed portion of stomach is a. Fundus

d. Type D 59.

1171

b. Gastro duodenal junction

Type of gastritis seen with celiac sprue

c. Type A

Bare area of stomach is a. Gastro oesophageal junction

d. Ultrasound


1172 78.

Third line of mucosal defense includes

88.

a. Duodenal bicarbonate secretion

a. Highly selective vagotomy

b. Apical barrier c. Mucosal blood flow

b. Nissen fundoplication

c. Ramsted’s operation

d. Anti oxidant mechanisms 79.

One of the following is not included in the differential diagnosis for post bulbar ulcers

d. Pyloroplasti 89.

a. Carcinoids

b. Undetectable tumor on surgical exploration

c. Gastrinoma

c. Isolated lymphnode tumor

d. Adhesive bands

MCQ's

Poor prognostic factor in carcinoma stomach is a. Upper third tumors

d. Primary duodenal wall tumor 90.

b. Constipation

c. Age of the patient

c. Hypophosphatemia

d. Nodal involvement in EGC

82.

Which of the following surgical option for gastric carcinoma has highest mortality rate?

d. Elevated transaminases 91.

a. 6 hrs

b. Anastomotic leak

b. 12 hrs

c. Palliative resection

c. 18 hrs

d. None

d. 36 hrs

Poor prognostic indicator of gastric lymphomas is

92.

a. Dual therapy is not recommended routinely

b. Diffuse or large cell type

b. Triple therapy for 14 days has greatest efficary

c. Presentation with acute abdomen

c. Eradication of the organism has significant impact on ulcer perforation d. Triple therapy is effective in eradicating the organism in more than 50% of patients infected with resistant strain

CARNEY’s triad includes all except b. Smooth muscle / stromal tumor of stomach

93.

b. 60%

d. Pulmonary chondroma

c. 75%

Pre-malignant gastric polyps are a. Peutz-jegher polyps b. Adenomas

d. 95% 94.

b. Metaclopramide

d. Fundicgland polyps

c. Erythromycin

Commonest site of hyperplastic polyps of stomach is

d. verapamil

a. Body

e. Domperidone

b. Fundus c. Pylorus

95.

Mostfrequent extra nodal location of lymphoma is a. Stomach

d. Antrum

b. Small intestine

Most common cause of death in ZE syndrome is

c. Colon

a. Complications of ulcer disease

d. Liver

b. Malignant tumor invasion

e. Pancreas

c. Malabsorption d. Other comorbid illness 87.

All these drugs are gastric prokinetic agents except a. Cisapride

c. Hyperplastic polyps

86.

Five year survival in ZE syndrome without liver metastases is a. 50%

c. Gastric carcinoid

85.

False statement regarding therapy of H. pylori

a. Tumors < 10 cm

a. Extra adrenal paraganglioma

84.

Duration of action omeprazole is approximately

a. Curative resection

d. Musshoff stage II EI 83.

The following is not a complication of sucralfate a. Gastric Bezoar

b. Early TNM stage

81.

One of the following is a poor prognostic indicator in ZE syndrome a. Presence of cushing’s syndrome

b. Annular pancreas

80.

All the following surgeries can cause dumping syndrome except

96.

a. 30 ml

Most common cause of acute gastric dilatation is

b. 50 ml

a. Diabetes

c. 75 ml

b. Carcinoma stomach

d. 100 ml

c. Idiopathic d. Peptic ulcer

Gastric retention is significant when fasting gastric contents are more than

97.

Gastroscopy is the investigation of choice for all except a. Mallory weiss tear b. Erosive gastritis


c. Gastroparesis

98.

a. Simple and reliable method for identification of H. pylori

e. Alkaline reflux gastritis

b. Positive test increases the pH with phenol red indicator turning from light orange to red

Investigation of choice for leiomyoma and pancreatic rests is a. Barium study b. Endoscopy and biopsy c. Endoscopic ultrasound d. CT Scan abdomen

99.

107. Regarding rapid urease test false statement is

d. Post-operative stomal ulcer

c. Sensitivity and specificity is 100% d. Requires endoscopy 108. One year relapse rate of ulcer in those treated with H2 blockers or those for H. pylori eradication a. Is same in both groups b. Better in H2 receptor blockers group

a. Patients with dysphasia due to head and neck neoplasm’s

d. No comparative studies done

c. Relapse rate is less than 15% in H. pylori treated group 109. Most widely used antacid preparation is

c. Diffuse cerebral injury causing dysphasia

a. Aluminium hydroxide + magnesium hydroxide

d. Gastric malignancy

b. Magnesium hydroxide + magnesium trisilicate

e. Gastroparesis

c. Calcium carbonate + magnesium hydroxide

100. Endoscopic ultrasound can detect staging of all except a. Esophageal malignancy

d. Calcium hydroxide + sodium bicarbonate 110. Duration of therapy for gastric ulcer is

b. Gastric malignancy

a. 4-6 weeks

c. Colonic malignancy

b. 6-8 weeks

d. Pancreatic malignancy

c. 8-12 weeks

101. ‘Back-gut’ syndrome includes all except a. Dysphagia

d. 12-16 weeks 111. Non-healing of gastric ulcer after treatment indicates

b. Localised fibromyalgia

a. Malignant ulcer

c. Peptic or functional GI disorder

b. Gaint ulcer

d. Worsening of epigastirc pain on bending or twisting

c. Associated with duodenal ulcer

102. Major stimulants of gastric acid secretion are a. Carbohydrates

d. Associated gastritis 112. ‘Bull’s eye’ lesion of the stomach on barium study is seen in

b. Proteins

a. Pancreatic rests

c. Fats

b. Gastric leiomyoma

d. All have equal response

c. Malignant melanoma

103. Intrinsic factor is secreted by a. Parietal cells

d. Gastirc Varices 113. Most common symptom of stomal ulcer is

b. chief cells

a. Abdominal pain

c. ECL cells

b. vomiting

d. Mucous cells

c. Hemetemesis

e. Paneth Cells

d. Fatigue, anorexia

104. Artery involved in duodenal ulcer bleeding is a. Common hepatic artery

e. Weight loss 114. Commoncause of stomal ulcer includes all except

b. Spleni Artery

a. Incomplete vagotomy

c. Gastroduodenal Artery

b. H. pylori infection

d. Pancreatica Magna

c. Reflux of bile into stomach

105. Mean maximum acid output in normal males is upto a. 23 mEq/I

115. Anaemia which is common with afferent loop syndrome is

b. 59 mEq/I

a. Iron deficiency anaemia

c. 15 mEq/I

b. Folate deficiency

d. 30 mEq/I

c. B12 deficiency

106. Wrong statement regarding duodenal atresia is a. Poly hydramnious is associated in 50% of patients b. Emesisi is usually non-bilious c. Commonly associated with down’s syndrome d. Double – bubble sign is seen on plain radiographs

d. None of the above

d. All are common 116. Latedumping syndrome includes all these clinical features except a. Dizziness, syncope b. Light headedness c. Palpitation

GASTROENTEROLOGY

Percutaneous endoscopic gastrostomy (PEG) is useful in all except b. Transfer dysphasia secondary to stroke and degenerative diseases

1173


1174

d. Diarrhoea

d. Wall of duodenum

e. Confusion, diaphoresis

e. Stomach, lymph nodes 126. Most common involvement in MEN1 is

117. Dumping syndrome is treated by a. Limitation of simple sugar containing liquids and solid

a. Gastrinoma

b. Elimination of liquids at meal time

b. Insulinoma

c. Eating of frequent small meals

c. Hyperparathyroidism

d. Octreotide (50 ug sc tid) improves severe symptoms

d. Hypopitutarism

e. All the above

e. Hyperthyroidism

MCQ's

118. Vitamin B12 dificiency after peptic ulcer surgery is seen in

127. Diarrhea in gastrinoma is seen in

a. Total gastrectomy

a. 10%

b. Gastritis causing gastric atrophy after surgery

b. 20%

c. Hypochlorohydria and bacterial overgrowth

c. 50%

d. All these conditions can cause vitamin B12 dificiency

d. 75%

119. Iron deficiency anaemia after billroth II is treated by

128. Vit B12 malabsorption in gastrinoma is due to

a. Oral iron preparation

a. Decreased secretion of intrinsic factor

b. Antibiotics

b. Inactivation of pancreatic enzymes at low pH

c. IM preparations of iron

c. Bacterial overgrowth

d. Supply intrinsic factor

d. Impaired absorption in terminal ileum

e. Pancreatic enzyme supplementation

e. All these are involved

120. Massive haemorrhage due to stress ulcers occur after acute insult. a. In first 24 hours

b. in 48 hours c. After 48 hours d. After 1 week e. After 2 weeks 121. Phlegmonous gastritis is caused by all except a. Streptococci b. Staphylococci c. Salmonella d. Proteus species e. E. coli 122. Most common site of involvement of eosinophilic gastritis is a. Fundus b. Body c. Antrum d. Incisura angularis 123. Most common symptom of eosinophilic gastritis is a. Epigastic pain with vomiting b. Loss of appetite c. Distension of abdomen d. Hemetemesis 124. Menetrierâ&#x20AC;&#x2122;s disease show all these features except a. Deep mucosal biopsy and cytology is required for diagnosis b. Anticholinergics and H2 blockers are reported to decrease the protein loss c. Gastric carcinoma is very common complication d. Severe disease with persistent protein loss require total gastrectomy e. All are correct 125. Most of the gastrinomas are located in a. Head of pancreas b. Body of pancreas c. Tail of pancreas

129. A 47-year-old woman presents to your clinic with a threemonth history of dysphagia. There is no history of drastic weight loss and the patient experiences symptoms when swallowing solids but not liquids. Which of the following is not an obstructive cause of dysphagia? a. Pharyngeal carcinoma b. Oesophageal web c. Retrosternal goitre d. Peptic stricture e. Achalasia 130. You see a 47-year-old man in clinic with a three-month history of epigastric dull abdominal pain. He states that the pain is worse in the mornings and is relieved after meals. On direct questioning, there is no history of weight loss and the patientâ&#x20AC;&#x2122;s bowel habits are normal. On examination, his abdomen is soft and experiences moderate discomfort on palpation of the epigastric region. The most likely diagnosis is: a. Gastric ulcer b. Gastro-oesophageal reflux disease (GORD) c. Duodenal ulcer d. Gastric carcinoma e. Gastritis 131. A 55-year-old woman is referred by her GP for upper gastrointestinal (GI) endoscopy following a four-month history of epigastric pain despite treatment with antacids and proton pump inhibitors (PPIs). The results demonstrate a duodenal ulcer coupled with a positive campylobacter-like organism (CLO) test. The patient has no past medical history and has no known drug allergies. The most appropriate treatment is: a. Seven-day course of twice daily omeprazole 20 mg, 1 g amoxicillin and 500 mg clarithromycin b. Seven-day course of twice daily omeprazole 20 mg c. Seven-day course of twice daily omeprazole 20 mg and 1 g amoxicillin d. Seven-day course of twice daily omeprazole 20 mg and 500 mg clarithromycin e. Seven-day course of twice daily 1 g amoxicillin and 500 mg clarithromycin


132. Which of the following is the most common cause of duodenal ulcers? a. NSAIDs b. Helicobacter pylori c. Alcohol abuse d. Chronic corticosteroid therapy e. Zollinger–Ellison syndrome

a. Computer tomography (CT) scan b. Chest x-ray c. Upper GI endoscopy d. Barium meal e. Ultrasound 134. You see a 25-year-old woman who presents with a 24-hour history of watery diarrhoea. She states that she has opened her bowels 11 times since her onset of symptoms. Associated symptoms include nausea and vomiting with abdominal cramps and pain which started in the evening following a barbeque meal in the afternoon that day. The patient is alert and orientated and her observations include a pulse rate of 69, blood pressure of 124/75 and temperature of 37.1°C. On examination, her abdomen is soft, there is marked tenderness in the epigastric region and bowel sounds are hyperactive. The patient is normally fit and well with no past medical history. The most likely diagnosis is: a. Irritable bowel syndrome b. Gastroenteritis c. Ulcerative colitis d. Laxative abuse e. Crohn’s disease 135. A 35-year-old woman presents with a 24-hour history of watery diarrhoea. She has opened her bowels nine times since the onset of her symptoms. You diagnose gastroenteritis after learning that the patient and her family all ate at a new restaurant and the rest of her family have had similar problems. The most appropriate management is: a. Oral rehydration advice, anti-emetics and discharge home b. Oral antibiotic therapy and discharge home c. Admission for intravenous fluid rehydration d. Admission for intravenous antibiotic therapy e. No treatment required 136. A 56-year-old man presents with a 2-week history of diarrhoea which has not settled following an episode of ‘food poisoning’. Which of the following would be the most appropriate investigation? a. Full blood count b. Urea and electrolytes c. Stool sample for microscopy, culture and sensitivities d. Abdominal x-ray e. Liver function tests 137. You are questioned by your registrar regarding bacteria responsible for causing blood-stained diarrhoea. From the list below, select the organism which is not responsible for causing blood-stained diarrhoea. a. Campylobacter spp. b. Salmonella spp. c. Escherichia coli

1175

e. Stapylococcus spp. 138. A 69-year-old man present with a 2-week history of abdominal pain which has worsened over the last few days. On examination, the patient is jaundiced and the abdomen is distended with tenderness in the epigastric region. In addition, there is a smooth hepatomegaly and shifting dullness. Which of the following is a cause of hepatomegaly? a. Iron deficiency anaemia b. Budd–Chiari syndrome c. Ulcerative colitis d. Crohn’s disease e. Left-sided heart failure 139. You see a 19-year-old Caucasian man in your clinic who presents with a history of transient jaundice. On direct questioning, you ascertain that the jaundice is noticeable after periods of increased physical activity and subsides after a few days. The patient has no other symptoms and physical examination is unremarkable. Full blood count is normal (with a normal reticulocyte count) and liver function tests reveal a bilirubin of 37 ìmol/L. The most appropriate management is: a. Reassure and discharge b. Start on a course of oral steroids c. Request abdominal ultrasound d. Request MRCP e. Refer to Haematology 140. You see a 54-year-old woman, referred to accident and emergency through her GP, with a week’s history of jaundice and right upper quadrant abdominal pain. Associated symptoms include dark urine and pale stools. There is no history of weight loss and the patient does not consume alcohol. Her liver function tests reveal a bilirubin of 40 mol/L, ALT of 40 iu/L, AST 50 iu/L and ALP of 350 iu/L. The most likely diagnosis is: a. Gallstones b. Viral hepatitis c. Alcoholic hepatitis d. Carcinoma of the head of the pancreas e. Autoimmune hepatitis 141. You are asked by your registrar to request an imaging investigation for a 49-yearold woman with jaundice and abdominal pain. She has a past medical history of gallstones and you suspect this is a recurrence of the same problem. The most appropriate imaging investigation is: a. Abdominal x-ray b. Abdominal ultrasound c. Abdominal CT d. Magnetic resonance imaging (MRI) e. Endoscopic retrograde cholangiopancreatography (ERCP) 142. You see a 47-year-old woman who presents with a 3-day history of jaundice. You assess her liver function tests (LFTs) and see that the ALP iu/L is raised at 350 iu/L, AST 45 iu/L, ALT 50 iu/L and bilirubin 50 iu/L. The patient feels well in herself, although she has noticed that her urine has become quite dark and her stools quite pale. You assess her medication history. Which of the following drugs from the patient’s medication history may be responsible for the cholestasis? a. Co-amoxiclav b. Bendroflumethiazide c. Ramipril d. Amlodipine e. Aspirin

GASTROENTEROLOGY

133. You see a 48-year-old lorry driver, who presents to you with a three-month history of heartburn after meals which has not been settling with antacids and PPIs. You suspect that the patient has a hiatus hernia. The most appropriate investigation for diagnosing a hiatus hernia is:

d. Shigella spp.


1176 143. During your on-call, you are bleeped to see an 80-year-old

woman on the ward who has not opened her bowels for the last 4 days. She is not known to have a history of constipation. On examination, her observations are within normal range, the abdomen is soft and there is mild discomfort at the left iliac fossa. Bowel sounds are present and on PR examination, the rectum is empty. You consult your registrar who asks you to prescribe an osmotic laxative. What is the most appropriate treatment? a. Ispaghula husk b. Docusate sodium c. Lactulose d. Senna

MCQ's

e. Methylcellulose 144. Which of the following gastroenterological conditions would give rise to finger clubbing? a. Hepatocellular carcinoma b. Ulcerative colitis c. Irritable bowel syndrome d. Hepatocellular carcinoma e. Pancreatic carcinoma 145. You see a 75-year-old man with an acute episode of haematemesis, who was admitted the night before and is awaiting an upper GI endoscopy. You are asked on the ward round about the common causes of upper GI bleeding. From the list below, which of the following is the most common cause of upper GI bleeding? a. Mallory–Weiss tear b. Peptic ulcers c. Oesophageal varices

b. Palmer erythema c. Spider naevia d. Koilonychia e. Jaundice 150. You see a 56-year-old man in your clinic with suspected alcoholic liver disease. Liver function tests reveal a bilirubin of 36 iu/L, AST of 150 iu/L, ALT 75 iu/L and ALP 100 iu/L. Which of the following blood test parameters would support a diagnosis of alcoholic-related liver disease? a. Normal mean cell volume (MCV) b. Low MCV c. Normal mean cell haemoglobin (MCH) d. Low MCH e. Raised MCV 151. You see a 52-year-old woman with rheumatoid arthritis in your clinic. She was referred by her GP after her ALP levels were found to be abnormally high at 300 iu/L. In addition, she was also found to be serum anti-mitochondrial antibody (AMA) positive. The most likely diagnosis is: a. Primary biliary cirrhosis b. Wilson’s disease c. Heriditary haemochromotosis d. Primary sclerosing cholangitis e. Alcoholic liver disease 152. A 47-year-old man presents complaining of weight gain, on examination there is an abdominal distension with a fluid thrill. Which of following is not a cause of ascites secondary to venous hypertension? a. Congestive heart failure

d. Drug induced

b. Cirrhosis

e. Malignancy

c. Constrictive pericarditis

147. A 60-year-old man with alcoholic liver disease was admitted with an upper GI bleed secondary to oesophageal varices. The patient undergoes endoscopic variceal banding and is discharged after 2 weeks in-hospital stay. Which of the following medications would act as prophylaxis in preventing a rebleed from his oesophageal varices? a. Frusemide b. Amlodipine c. Ramipril d. Propranolol e. Irbesartan 148. A 46-year-old woman presents to your clinic with a week’s history of jaundice. Her past medical history includes longstanding atrial fibrillation and hypertension. Physical examination reveals hepatomegaly. You assess her liver function which shows a bilirubin of 41 iu/L, AST 111 iu/L, ALT 55 iu/L and ALP 98 iu/L. There is no history of travel. You have a look at the patient’s medication history. Which of the following drugs below is likely to have caused the derangement in the patient’s liver function? a. Aspirin b. Ramipril c. Amiodarone

d. Budd–Chiari syndrome e. Nephrotic syndrome 153. A 56-year-old man, diagnosed with emphysema, presents with a one-month history of jaundice and ascites. Your registrar suspects that this patient may have liver disease secondary to 1-antitrypsin deficiency. Select the most likely mode of inheritance from the list below: a. Autosomal dominant b. X-linked dominant c. Autosomal recessive d. Polygenic e. None of the above 154. You see a 56-year-old woman who presents with a two-month history of jaundice. Associated symptoms include lethargy and polyarthralgia. Her LFTs reveal a bilirubin of 46 iu/L, AST 200, ALT 175, ALP 104. On examination, the patient is jaundiced and has finger clubbing. There are several spider naevi on the front and back of the trunk. Her abdomen is soft and there is a smooth hepatomegaly. Prior to her onset of symptoms, the patient has been fit and well. Viral serology is normal and anti-soluble liver antigen (SLA) is detected. You decide to start this patient on treatment. The most appropriate treatment is:

d. Bendroflumethiazide

a. Liver transplantation

e. Amlodipine

b. Methotrexate

149. A 67-year-old man presents feeling unwell and complaining of general malaise. He mentions a long history of alcohol abuse and his past medical history shows deranged liver function tests. Which of the following clinical signs does not form part of chronic liver disease? a. Finger clubbing

c. Prednisolone d. Cyclosporin e. Antivirals


155. You are told by your registrar that one of your inpatients has been diagnosed with primary sclerosing cholangitis (PSC). Your registrar suspects that the patient may have an associated condition. Primary sclerosing cholangitis is associated with which of the following diseases? a. Thyroid disease b. Systemic sclerosis c. Rheumatoid arthritis d. Ulcerative colitis e. Irritable bowel syndrome

a. Hepatocellular carcinoma b. Cholangiocarcinoma c. Hepatic fibroma d. Hepatic haemangioma e. Pancreatic carcinoma 157. During a ward round, you are questioned about tumours that may arise from the liver parenchyma. Which of the following liver tumours is considered to be benign?

161. You are told by your registrar that one of the clinic patients has been admitted with a ‘flare up’ of ulcerative colitis (UC. Which he reports as being severe. From the list of answers below, select the parameters which are likely to reflect a severe flare up of ulcerative colitis: a. Fewer than four bowel motions per day with large amounts of rectal bleeding b. Between four and six bowel motions per day with large amounts of rectal bleeding c. More than four bowel motions per day with large amounts of rectal bleeding d. More than five bowel motions per day with large amounts of rectal bleeding e. More than six bowel motions per day with large amounts of rectal bleeding 162. You read a report which was handwritten in a patient’s medical notes who you suspect has inflammatory bowel disease. The report reads, ‘… there is cobblestoning of the terminal ileum with the appearance of rose thorn ulcers. These findings are suggestive of Crohn’s disease’. Select the most likely investigation that this report was derived from: a. Colonoscopy

a. Angiosarcoma

b. Sigmoidoscopy

b. Fibrosarcoma

c. Barium follow through

c. Adenoma

d. Abdominal CT

d. Hepatoblastoma

e. Abdominal ultrasound

e. Leiyomyosarcoma 158. A patient on your ward is diagnosed with hepatocellular carcinoma. You are asked to perform a tumour marker level on this patient. Which of the following tumour markers are elevated in hepatocellular carcinoma? a. fetoprotein b. Carcinoembryonic antigen (CEA) c. CA 15-3 d. HcG e. CA 125 159. A 64-year-old woman attends your clinic with a 2-week history of jaundice. Over the last three months the patient has lost 10 kg. Associated symptoms include decreased appetite, dark urine and pale stools. On examination, the patient is jaundiced, her abdomen is soft and you can palpate a painless mass in the right upper quadrant. From the list of answers below, select the initial most appropriate investigation that you would request for this patient: a. Abdominal x-ray b. Abdominal CT c. MRI of the abdomen d. Abdominal ultrasound e. ERCP 160. A 28-year-old man undergoes a sigmoidoscopy for longstanding diarrhoea and weight loss. On visualization of the rectum, the mucosa appears inflamed and friable. A rectal biopsy is taken and the histology shows mucosal ulcers with inflammatory infiltrate, crypt abscesses with goblet cell depletion. From the list of answers below, which is the most likely diagnosis describing the histology report? a. Crohn’s disease b. Pseudomembranous colitis c. Irritable bowel syndrome

1177

e. No diagnosis – the report is inconclusive

163. You are asked to see a 29-year-old woman diagnosed with ulcerative colitis 18 months ago. Over the last 4 days she has been experiencing slight abdominal cramps, opening her bowels approximately 4–5 times a day and has been passing small amounts of blood per rectum. The patient is alert and orientated and on examination her pulse is 67, blood pressure 127/70, temperature 37.3°C and her abdomen is soft with mild central tenderness. PR examination is nil of note. Blood tests reveal haemoglobin of 13.5 g/dL and a CRP of 9 mg/L. The most appropriate management plan for this patient is: a. Admission to hospital for intravenous fluid therapy and steroids b. Oral steroid therapy + oral 5-ASA + steroid enemas + discharge c. Admission and refer to surgeons for further assessment d. Oral steroid therapy and discharge home e. Reassurance and discharge home with no treatment required 164. A 29-year-old anxious man is diagnosed with mild Crohn’s disease. Due to time constraints, the patient was asked to come back for a follow-up appointment to discuss Crohn’s disease in more detail. The patient returns with a list of complications he researched on the internet. Which of the following are not associated with Crohn’s disease? a. Cigarette smoking reduces incidence b. Fistulae formation c. Abscess formation d. Non-caseating granuloma formation e. Associated with transmural inflammation 165. You see a 40-year-old woman who was diagnosed with Crohn’s disease ten years ago. Due to a severe attack of Crohn’s which failed to respond to medical therapy, she had a small bowel resection. Your registrar tells you that she is at risk of developing vitamin B12 deficiency as a result of her surgery. Which part of the small bowel is responsible for the absorption of vitamin B12?

GASTROENTEROLOGY

156. A 68-year-old man presents to his GP with signs of drastic weight loss. He is known to have PSC. The GP suspects an underlying malignancy. Which of the following tumours would a patient with primary sclerosing cholangitis be more at risk of developing?

d. Ulcerative colitis


1178

a. Jejunum b. Proximal ileum c. Duodenum d. Terminal ileum e. None of the above 166. A 47-year-old woman has been experiencing a four-month history of diarrhea and bloating. Associated symptoms include lethargy and weight loss. Full blood count reveals haemoglobin of 9.3 d/gL and MCV 70 fL. Which of the following investigations would be helpful in the patientâ&#x20AC;&#x2122;s diagnosis? a. Anti-mitochondrial antibodies

MCQ's

b. Anti-smooth muscle antibodies c. Anti-tissue transglutaminase antibodies d. Anti-nuclear antibodies e. Anti-neutrophil cytoplasmic antibodies 167. A 65-year-old man attends your clinic with a three-month history of weight loss of approximately 9 kg despite a normal appetite. A full blood count reveals that his haemoglobin is 9.0 g/dL (previous haemoglobin was 13.5 g/dL one year ago) and the MCV is 71 fL. Abdominal examination is unremarkable and per rectum exam is nil of note. The patient states that he has normal bowel habits and has been feeling quite tired lately. The most appropriate management is: a. Reassure and discharge b. Arrange an upper and lower GI endoscopy c. Prescribe iron tablet supplementation d. Arrange an abdominal ultrasound e. Arrange an abdominal x-ray 168. A 24 year old woman had ulcerative colitis for seven years and was prescribed mesalazine 1.5 g per day.She smoked 20 cigarettes per day and was 10 weeks pregnant. She complained of worsening symptoms withsix bloody stools per day. Which one of the following statements is correct? a. Azathioprine is contraindicated. b. Initiation of an elemental diet risks fetal malnutrition. c. Oral corticosteroids are contraindicated. d. Oral mesalazine therapy should be withdrawn. e. Termination of the pregnancy is advisable. 169. Whichof the following features would be expected on lipid analysis in a 57 year old female with two year history of primary biliary cirrhosis? a. A lipaemic appearance of the serum would be expected. b. is treated with clofibrate therapy c. is characteristically associated with tendon xanthomas

171. Which ONE of the following statements regarding colon cancer is correct: a. In non familial cases, gene mutations in the cancer cells are unusual b. In familial cases the inheritance pattern is typically autosomal recessive c. It occurs most commonly in the ascending colon d. It is a characteristic feature of the PeutzJeghersyndrome e. In familial polyposis coli the increased cancer risk is due to inheritance of a mutated suppressor gene 172. A 40 year old man has a history of leftsidedCrohnâ&#x20AC;&#x2122;s colitis. Though, previously treated with steroids and mesalazine, he has had several relapses in the past year. The last relapse, treated with high doses of steroids,was complicated by gastric bleeding. Investigations show: Haemoglobin 10.8 g/L (13.018.0), MCV 76 fL (8096), MCH 24 pg (2832), White cell count 10 x 109/L (411), Platelets 400 x 109/L (150400), Serum total protein 70 g/L (6176), Serum albumin 30 g/L (3749), Serum CRP 30 mg/L(<10), Abdo XrayNormal. Which of the following is the most appropriate management? a. A trial of oral metronidazole for three months. b. Total colectomy with ileostomy construction. c. Total colectomy with pouch construction. d. Treatment with azathioprine. e. Treatment with oral budesonide. 173. A 45 year old man was receiving phenytoin for longstandingepilepsy. He admitted to heavy alcohol consumption. Examination revealed no focal or neurological signs, 3cm hepatomegaly but no splenomegaly. Investigations showed: Haemoglobin 10.0 g/dL (1318), MCV 122 fL (8096), White cell count 2.2 x 109/L (411), Platelet count 90 x 109/L (150400). What is the most likely planation for these results? a. Alcoholic liver disease. b. Aplastic anaemia. c. Folate deficiency. d. Hypothyroidism. e. Scurvy. 174. A 60 year old woman with known alcoholic liver cirrhosis presents with vague abdominal pains, malaise and nausea. She has been abstinent since she was diagnosed eight months ago. On examination she had moderate ascites and mild, generalised abdominal tenderness. Investigations: Haemoglobin 11.2 g/dL (11.5 16.5), WCC 15 x 10 9/L (4 11), prothrombin time 21 s (<15s), serum albumin 28 g/L (37 49), serum total bilirubin 56 micromol/L (1 22), ascitic fluid protein 26 g/L ascetic fluid amylase normal ascitic fluid white cell count 500 x 109/L What is the most likely reason for her current problem?

d. is characteristically associated with palmar xanthomas

a. hepatic vein thrombosis

e. No evidence of a dyslipidaemia would be expected with this short a duration of disease

b. pancreatic pseudocyst rupture

170. A 55 yearoldman on no current treatment for his quiescent ulcerative colitis is found to have a raised ESR.Investigations show: Haemoglobin 13.2g/L, WCC 4.5, PLT 160, Corrected Calcium 2.58, IgG 25 (613), IgA 1.8 (0.93), IgM 1.6 (0.42.2). What is the most appropriate next investigation? a. Bone marrow trephine and aspiration. b. Isotope bone scan. c. Plasma immunoelectrophoresis. d. Rectal biopsy. e. XRay Skeletal survey.

c. portal vein thrombosis d. primary liver cancer e. spontaneous bacterial peritonitis 175. A 32yearoldman develops profuse diarrhoea with mucus and blood. Biopsies from the flexible sigmiodoscopy shows evidence of ulcerative colitis. Which of the following is true of the condition? a. mesalazine therapy is associated with infertility in males b. pseudopolyps on sigmoidoscopic premalignant potential

examination

have

c. topical 5aminosalicylicacid are less effective than topical steroids in proctitis d. colectomy may produce regression of gall bladder disease e. goblet cells are unaffected in the mucosa


176. Which ONE of the following statements is true of autoimmune hepatitis: a. It usually presents as an acute hepatitis b. It rarely presents before 20 years of age c. It may be associated with keratoconjunctivitis sicca d. It is associated with hypogammaglobulinaemia e. It rarely interferes with menstruation except in later stages 177. Comparedwith bottle feeding, breast feeding is relatively protective against which of the following? a. Late haemorrhagic disease of the newborn c. Late onset diabetes d. Prolonged jaundice e. Underfeeding 178. A 28 year old male presents with a four day history of profuse bloody diarrhoea after returning from a holiday in the Far East. Which of the following regarding his illness is true?

183. Which of the following is NOT true of a patient with ascites due to liver cirhosis: a. Spontaneous bacterial peritonitis is a recognised feature b. The usual source of the ascitic fluid is mainly from the exudation from the surface of the liver c. Hepatic intrasinusoidal pressure is elevated d. Urinary sodium concentration is usually less than 10 mmol/l e. Cardiac output is often elevated 184. A 35 year oldwoman with a history of recurrent anaemia was noted to have target cells and HowellJolly bodies on a blood film examination. Investigations revealed: Haemoglobin 7.0 g/dL (11.316.5), MCV 77 fl (8096), MCH 26.2 pg (2832), Serum B12 140 ug/L (160760), Red cell folate 95 ug/L (160640), Serum ferritin 10 ug/L (15300). What disease specific antibody is most likely to be present? a. Antiendomysial

a. a negative amoebic fluorescent antibody test excludes a diagnosis of acute amoebic dysentry

b. Antigastricparietal cell

b. Cysts to E. histolytica in the stools confirms a diagnosis of acute amoebic dysentry

d. Antiintrinsicfactor

c. cholera is a likely diagnosis d. Giardiasis is a likely diagnosis e. shigellosis is a likely diagnosis 179. A 63 year old patient with known alcohol related cirrhosis presented with ascites, abdominal tenderness and peripheral oedema. A diagnostic tap revealed a neutrophil count of 400/ mm3 (normal <250mm3). Which of the following would be of most immediate benefit? a. fluid restriction and a no added salt diet b. intravenous antibiotics c. oral spironolactone d. therapeutic paracentesis e. transjugularintrahepatic portosystemicshunt 180. A 29 year old man presents with anaemia, bleeding tendency, diarrhoea and abdominal pain. Examinationreveals a palpable mass in the right lower quadrant and anal skin tags. What is the most likely underlyingcondition? a. chronic pancreatitis b. coeliac disease c. crohnâ&#x20AC;&#x2122;s disease d. intestinal lymphoma e. ulcerative colitis 181. Tenindividuals are admitted to casualty with profuse vomiting after attending a retirement dinner in a chinese restaurant. They all ate at roughly 7 pm and became ill at roughly midnight. Nine ate a mixture of dishes except one female who ate vegetarian dishes with her rice. What is the most likely infective organism? a. Salmonella enteriditis b. Staphylococcus aureus c. E. Coli d. Clostridium perfringens e. Bacillus cereus 182. Which of the following is activated by Cholera toxin? a. Adenylate cyclase b. Guanlyate cyclase c. Peroxisome proliferator receptor (PPAR) gamma

1179

e. The glucosesodiumtransporter

c. Antiglutamicacid decarboxylase e. Antimitochondrial 185. Whichone of the following is a feature of the VIPoma syndrome? a. Alkalosis b. Hypoglycaemia c. Hypokalaemia d. Increased gastric acid seceretion e. Provocation of VIP release by somatostatin 186. A 40 year old single man returned from holiday in Europe with mild bloody diarrhoea which had lasted fortwo weeks. He had lost 2.5 kg in weight, had occasional lower abdominal cramping discomfort and a painfulswelling of his left knee. What is the most likely diagnosis? a. amoebiasis b. campylobacter infection c. Crohnâ&#x20AC;&#x2122;s disease d. gonococcal septicaemia e. ulcerative colitis 187. A 43 year old male presents with weight loss and watery diarrhoea. Investigations reveal hypokalaemia with a pancreatic mass. Which of the following would support the diagnosis of a VIPoma? a. Achlorhydria b. Hypoglycaemia c. Increased Pancreatic polypeptide d. Migratory erythema e. Pellagra 188. A 68 year old male presents with alcoholic cirrhosis complicated by mild ascites. Which of the following features is likely in this patient? a. Increased serum sodium b. Increased vascular resistance c. Reduced urinary potassium excretion d. Reduced renin concentrations e. Reduced urinary sodium excretion

GASTROENTEROLOGY

b. Maternal breast cancer

d. Sodium/potassium ATPase


1180 189. A 58 year old man complains of tiredness, fever, weight loss,

arthralgia and diarrhoea. Jejunal biopsy reveals flattened mucosa containing periodic acidSchiff(PAS) positive macrophages. What is the most likely diagnosis? a. coeliac’s disease b. tuberculosis c. tropical sprue d. parasitic infection e. whipple’s disease

MCQ's

190. A 48 year old woman complains of pruritis, steatorrhoea and bruising. On examination, she is jaundiced, pigmented with spider naevi and hepatosplenomegaly. What is the most likely underlying diagnosis? a. autoimmune hepatitis b. primary biliary cirrhosis c. alcoholic liver disease d. alpha1antitrypsin deficiency e. Wilson’s disease 191. Whichof the following concerning the conjugation of bilirubin is correct? a. is catalysed by a glucuronyl transferase b. occurs in the Kupfer cells of the liver c. is increased by valproate

195. A52 year old man with a diagnosis as a child of coeliac disease had been asymptomatic despite poor dietary compliance. He presents with a one month history of intermittent, colicky, central abdominal pain and3 kilogram weight loss and positive faecal occult bloods. What is the most appropriate investigation? a. Antiendomysialantibody. b. Colonoscopy. c. CT scan of abdomen. d. Distal duodenal biopsy. e. Small bowel enema. 196. A44 year old male with Child’s grade C cirrhosis presented with haematemesis. Which one of the following drugs, administered intravenously, would be the most appropriate, immediate, treatment? a. Isosorbide dinitrate. b. Omeprazole. c. Propranolol d. Somatostatin e. Tranexamic acid. 197. A24yearoldman with chronic diarrhoea and malabsorption is suspected of having coeliac disease. A jejunal biopsy is taken. Which of the following findings would be expected in coeliac disease?

d. is inhibited by rifampicin

a. Shows leafshapedvilli

e. is impaired in DubinJohnsonsyndrome

b. Shows flattening of the crypts

192. A 70 year old man was admitted with pallor, lightheadednessand loss of energy. On the day prior to admission he had reported loose dark stools. Examination revealed a pulse of 90 per minute and a blood pressure of 110/70 mmHg. Investigations revealed: Haemoglobin 7.2 g/ dL (1418), MCV 72 fL. (7896), White cell count 11.3 x 109/L (411), Platelet count 480 x 109/L (150400). What is the most appropriate next step in his management? a. Barium meal b. Blood transfusion c. Endoscopy d. Parenteral iron infusion e. Proton pump inhibitor therapy 193. Whichof the following is correct regarding infection with Salmonella typhi a. children are particularly likely to become carriers b. most carriers are female c. faecal culture is almost always positive during the first week of illness d. relapse does not occur if antibiotics are taken for 2 weeks e. vaccinated individuals who develop the disease will have a mild illness 194. A28yearoldlady develops abdominal pain, jaundice and ascites worsening over a week. She drinks ten units of alcohol each week and takes the oral contraceptive pill. Which of the following findings would make adiagnosis of hepatic vein thrombosis (BuddChiarisyndrome) MOST likely? a. alanine aminotransferase of 345 U/L (5 35) b. acute liver failure c. ankle oedema d. ascites fluid protein of 38 g/L e. tender enlarged liver

c. Appearances may resemble severe tropical sprue d. Shows fissures penetrating into the submucosa e. Characteristically shows epithelial cells distended with fat globules 198. Inthe diarrhoea associated with cholera toxin, there is activation of which of the following enzyme systems? a. Adenylate cyclase. b. ATP. c. Guanylate cyclase. d. Naglucosecotransporter. e. Na+/K+ ATPase pump. 199. A36yearoldman presented with a three day history of bloody diarrhoea. He was apyrexial and mildly icteric. Investigations revealed: Haemoglobin 10.5 g/dL (13.018.0), White cell count 19 x 109/L (411), Platelets 70 x 109/L (150400), Serum urea 12.5 mmol/L (2.57.5), Serum aspartate aminotransferase 90 IU/L (131), Prothrombin time 12s (11.515.5), Blood film fragmented red cells. What is the most likely cause of his illness? a. Escherichia coli 0157 colitis b. Ischaemic colitis c. Leptospirosis d. Salmonella enterocolitis e. Ulcerative colitis 200. A52 year old woman presented with history of worsening dysphagia over many years. Recently there hadbeen episodes of illdefinedcentral chest discomfort and nocturnal cough. What is the most likely diagnosis? a. achalasia b. Barrett’s oesophagus c. motor neurone disease d. oesophageal carcinoma e. pharyngeal pouch 201. Whichof the following is true of Gilbert’s syndrome? a. inheritance is autosomal recessive


b. serum conjugated bilirubin levels are elevated

d. The presence of Helicobacter pylori serum antibodies.

c. serum bilirubin levels are decreased by fasting

e. The urease test on gastric biopsy.

d. serum bilirubin levels are decreased by liver enzyme inducers e. there is bilirubinuria 202. A26 year old presents in the first trimester of her first pregnancy (six weeks gestation) for an antenatal check, she feels well. Blood tests show a Bilirubin of 40 µmol/l the other LFT’s are completely normal. The most likely diagnosis is:

208. A32 yearoldwoman with Crohn’s Disease has a history of a right hemicolectomy for ileocolonic disease.Since the operation she has had frequent diarrhoea but no blood in the stools. Investigations show: ESR 10, PLT 240, serum CRP 7 (<10). Which is the best treatment? a. Cholestyramine b. Mesalazine c. Metronidazole

b. Primary biliary cirrhosis

d. Omeprazole

c. Primary sclerosing cholangitis

e. Prednisolone

e. Cholestasis of pregnancy 203. Whichof the following conditions may give a false/positive sweat test? a. Congenital adrenal hyperplasia

209. A24 year old woman was referred with tiredness and intermittent bloody diarrhoea and a past history ofcerebral venous thrombosis. On examination, the sclera of the right eye was inflamed, and multiple mouthulcers were noted. At the colonoscopy, which confirmed colitis, two large vulval ulcers were noted. Which isthe most likely diagnosis?

b. Hyperthyroidism

a. Behcet’s disease.

c. Hyperparathyroidism

b. Crohn’s disease.

d. Obesity

c. HIV infection

e. Glucose6phosphatase deficiency

d. Syphilis

204. Whichof the following statements regarding jejunal biopsy is correct? a. Electron microscopy is necessary to confirm the presence of villous atrophy b. Subtotalvillous atrophy is diagnostic of gluten sensitive enteropathy and is not found in other conditions c. It is contraindicatedover the age of 70 years d. In tropical countries apparently healthy people have a mucosal structure which would be regarded as abnormal in Europe e. It can be used to diagnose Whipple’s disease 205. A54yearoldwoman presented with an eighteen month history of chest pain and dysphagia for both solidsand liquids. She smokes 20 cigarettes per day and drinks 16 units of alcohol per week. Clinical examinationwas normal. What is the most likely diagnosis? a. Achalasia.

e. Ulcerative colitis. 210. Whichof the following is the commonest cause of traveller’s diarrhoea? a. E. Coli b. Entamoeba Histolytica c. Giardia Lamblia d. Shigella Flexneri e. Yersinia enterocolitica 211. A59 year old woman has had insulin dependent diabetes mellitus for over two decades. The degree of control of her disease is characterized by the laboratory finding of a HbA1c of 10.1%. She complains of repeated episodes of abdominal pain following meals. These episodes have become more frequent and last forlonger periods over the last couple of months.On physical examination, there are no abdominal masses or organomegaly and no tenderness to palpation. Which of the following findings is most likely to be present?

b. Bronchial neoplasm.

a. Acute pancreatitis

c. Oesophageal neoplasm.

b. Chronic renal failure

d. Oesophageal web.

c. Hepatic infarction

e. Pharyngeal pouch.

d. Mesenteric artery occlusion

206. A46 year old man with a family history of haemochromatosis presented to outpatients for advice. Investigations revealed. serum ferritin 453ug/L (15 – 300), serum iron 29 umol/L (12 – 30), serum iron binding capacity 46 umol/L (45 – 75), iron saturation 63 per cent (20 – 50), What is the most appropriate next step in management?

e. Ruptured aortic aneurysm 212. Whichof the following is true of Spontaneous bacterial peritonitis? a. A survival rate of over 50% is expected at one year b. Gentamicin is the treatment of choice

a. arrange for DNA analysis

c. is characteristically caused by aerobic bacteria.

b. begin a venesection programme

d. is diagnosed by culture of ascitic fluid.

c. monitor his serum ferritin regularly

e. is due to intestinal perforation

d. take no action unless the iron saturation exceeds 90 per cent e. undertake a liver biopsy 207. A45 year old woman is diagnosed with a duodenal ulcer. Which one of the following is the most sensitivetest for detecting current infection with Helicobacter pylori? a. A gastric fundal biopsy. b. Culture of a gastric biopsy. c. The (13C. urea breath test.

213. A30 year old caucasian male presents with a six month history of weight loss, abdominal pain, and diarrhoea. On examination you note finger clubbing. Which of the following diagnoses is least likely. a. Crohn’s disease b. Ulcerative colitis c. Coeliac disease d. Whipple’s disease e. IleocaecalTB

GASTROENTEROLOGY

a. Gilbert’s syndrome

d. DubinJohnsonsyndrome

1181


1182 214. Refluxoesophagitis of gastric contents

d. Hepatitis D virus

b. can be improved by Helicobacter pylori eradication

e. Hepatitis E virus

c. Occurs during transient relaxation of the lower oesophageal sphincter d. Is neutralised by bicarbonate secreted by the oesophageal mucosa e. Can be excluded by a normal appearance at endoscopy 215. Whichstatement is true concerning iron? a. Iron absorption is mainly in the distal jejunum.

MCQ's

c. Hepatitis C virus

a. is a cause of asthma

221. A58yearoldman has had an enlarging abdomen for several months. He has experienced no abdominal orchest pain. On physical examination he has a nontenderabdomen with no masses palpable, but there is a fluid thrill. An abdominal Ultrasound Scan shows a large abdominal fluid collection with a small cirrhotic liver.A chest Xrayshows a globally enlarged heart. Which of the following conditions is most likely to be present?

b. Parenteral iron is indicated if the haemoglobin level is not raised within 3 days by oral iron.

a. Dilated cardiomyopathy

c. Sustained release preparations are useful if larger doses are required.

c. Myocardial amyloid deposition

d. 200mg iron sulphate has more elemental iron than an equal dose of iron gluconate.

e. Severe occlusive coronary atherosclerosis

e. Absorption is prevented by ascorbic acid. 216. Followingfactors decrease large intestinal motility: a. Parasympathetic activity b. Anticholinergic agents c. Gastric Distension d. CCKPZ e. Laxatives. 217. Whichof the following statements is correct of hepatitis C virus infection?

b. Lymphocytic myocarditis d. Nonbacterial thrombotic endocarditis 222. Whichof the following is true of Spontaneous bacterial peritonitis? a. A survival rate of over 50% is expected at one year b. Gentamicin is the treatment of choice c. is characteristically caused by aerobic bacteria. d. is diagnosed by culture of ascitic fluid. e. is due to intestinal perforation 223. A68 year old male presents with alcoholic cirrhosis complicated by mild ascites. Which of the following features is likely in this patient?

a. Cell cultures of virus are routinely used to assess response to drug therapy

a. Increased serum sodium

b. High antibody titres are an indication for therapy

c. Reduced urinary potassium excretion

c. Less than 5% of cases lead to chronic infection d. More likely to be transmitted by the sexual route than hepatitis B virus e. Treatment with ribavirin and interferon alpha is more effective than interferon alpha alone 218. Which ONE statement is true regarding the treatment of iron deficiency anaemia:

b. Increased vascular resistance d. Reduced renin concentrations e. Reduced urinary sodium excretion 224. A28yearoldlady develops abdominal pain, jaundice and ascites worsening over a week. She drinks ten units of alcohol each week and takes the oral contraceptive pill. Which of the following findings would make adiagnosis of hepatic vein thrombosis (BuddChiarisyndrome) MOST likely?

a. iron is absorbed in the distal jejunum

a. alanine aminotransferase of 345 U/L (5 35)

b. absorption of iron is increased by ascorbic acid

b. acute liver failure

c. sustained release iron is a useful way of giving larger doses

c. ankle oedema

d. ferrous sulphate 200mg has less elemental iron than the same dose of ferrous gluconate

d. ascites fluid protein of 38 g/LS

e. parenteral iron is indicated when the anaemia responds slowly to oral iron 219. A35 year old woman with alcoholic cirrhosis is admitted with deteriorating encephalopathy and abdominaldiscomfort. An ascitic tap revealed a polymorphonuclear cell count of 350 cells per mm3. Which of the following is the most appropriate therapy?

e. tender enlarged liver 225. A45 year old man was receiving phenytoin for longstandingepilepsy. He admitted to heavy alcohol consumption. Examination revealed no focal or neurological signs, 3cm hepatomegaly but no splenomegaly. Investigations showed: Haemoglobin 10.0 g/dL (1318), MCV 122 fL (8096), White cell count 2.2 x 109/L (411), Platelet count 90 x 109/L (150400). What is the most likely explanation for these results?

a. Intravenous amoxicillin

a. Alcoholic liver disease.

b. Intravenous cefotaxime

b. Aplastic anaemia.

c. Intravenous metronidazole

c. Folate deficiency.

d. Oral neomycin

d. Hypothyroidism.

e. Oral norfloxacin

e. Scurvy.

220. A 56 year old man from Thailand presented with abdominal pain and a mass in the right upper quadrant. He reported that he had been diagnosed with viral hepatitis several years previously.Investigations showed: Serum alphafetoprotein13,500 IU/L (< 10). What is the most likely underlying viral infection? a. Hepatitis A virus b. Hepatitis B virus

226. Whichof the following is true concerning a hepatitis E infection? a. It can be transmitted with hepatitis B. b. It is a recognised cause of chronic liver disease. c. CT scan of the liver with contrast shows diagnostic appearances.


d. The incidence of chronic liver disease is reduced by administration of alpha interferon. e. It does not result in a carrier state. 227. Whichof the following statements is correct of hepatitis C virus infection? a. Cell cultures of virus are routinely used to assess response to drug therapy b. High antibody titres are an indication for therapy c. Less than 5% of cases lead to chronic infection

1183

e. Shigella species 233. Half life of albumin is a. 17-21 days

b. 40-50 days c. 3-6 months

d. 1 year 234. Expected weight loss in ascetic patients on adequate diuretic therapy witout pedal oedema is atleast a. 0.1kg

e. Treatment with ribavirin and interferon alpha is more effective than interferon alpha alone

b. 0.2kg

228. A 60 year old woman with known alcoholic liver cirrhosis presents with vague abdominal pains, malaise and nausea. She has been abstinent since she was diagnosed eight months ago. On examination she had moderate ascites and mild, generalised abdominal tenderness. Investigations: Haemoglobin 11.2 g/dL (11.5 16.5), WCC 15 x 10 9/L (4 11), prothrombin time 21 s (<15s), serum albumin 28 g/L (37 49), serum total bilirubin 56 micromol/L (1 22), ascitic fluid protein 26 g/L, ascitic fluid amylase normal, ascitic fluid white cell count 500 x 109/L. What is the most likely reason for her current problem?

d. 0.5kg

c. 0.3kg 235. Vanishing bile duct syndrome is seen in a. Chronic GVHD b. ANDROGENS c. Paracetamol d. Phenytoin 236. All can cause hepatocellular carcinoma except a. HBV

a. hepatic vein thrombosis

b. HCV

b. pancreatic pseudocyst rupture

c. Haemochromatosis

c. portal vein thrombosis

d. Recurrent cholangitis

d. primary liver cancer e. spontaneous bacterial peritonitis 229. A68yearoldman has been very ill for months following the onset of chronic liver disease with hepatitis C infection. He experiences a sudden loss of consciousness and then exhibits paraplegia on the right. A cerebral angiogram reveals lack of perfusion in the left middle cerebral artery distribution. The most likely cardiac lesion to be associated with this finding is? a. Acute rheumatic fever b. Left atrial myxoma c. LibmanSacksendocarditis d. Nonbacterialthrombotic endocarditis e. Paradoxical thromboembolus 230. Whichof the following concerning the conjugation of bilirubin is correct?

237. False statement regarding NCPF a. Presinusoidal b. Dialated portal and splenic vein on ultrasound c. Splenomegaly d. Testicular atropy 238. Which is not a extra hepatic manifestation of HCV?? a. Cryoglobulenemia b. Sialoadenitis c. Porphyria cutanea tarda d. Transverse myelitis 239. Ammonia is metabolized in which major organ a. Brain b. Skeletal muscle

a. is catalysed by a glucuronyl transferase

c. Liver

b. occurs in the Kupfer cells of the liver

d. Spleen

c. is increased by valproate d. is inhibited by rifampicin e. is impaired in DubinJohnsonsyndrome 231. A42yearoldfemale with Ulcerative Colitis is found to have anti219 smooth muscle antibodies. Which is the next most appropriate test for this patient? a. Abdominal Ultrasound b. Colonoscopy c. Full blood count d. Liver biopsy e. Liver function tests 232. Twentyone people are on a Nile boat cruise and present one week into their cruise with diarrhoea. What isthe most likely causative organism? a. Campylobacter b. Cryptosporidium parvum c. Entamoeba histolytica

240. Illeal resuction causes a. Folate malabsorption b. Carbohydrate malabsorption c. B12 malabsorption d. Protein malabsorption 241. Acrodermatitis enteropathica is due to a. Zinc deficiency b. Ca deficiency c. Fe deficiency d. Mn deficiency 242. Pulsion diverticula is seen in a. Mediastinal fibrosis b. Sarcoidosis c. Corrosive strictures d. Motility disorders

GASTROENTEROLOGY

d. More likely to be transmitted by the sexual route than hepatitis B virus

d. Giardia lamblia


1184 243. Which is not a pre malignant polyp a. Tubular adenoma b. FAP c. Gardners polyp d. Juvenile polyp 244. True statement regarding wilsons disease is a. Hepatic involvement is not common is children b. KF ring resolves with treatment c. Cerruloplasmin levels are increased d. Neurological involvement is seen in 50% patients

MCQ's

245. One is the following is not a kings college criteria for Fulminant hepatic failure a. Ph>6.5 b. Ph<7.3

Total bilirubin

c.

HBsAg positivity

d.

Ascites

250. The most common cause of intestinal obstruction in an adult is a. Diverticula b. Adhesions c. Trichobezoar d. Volvulus 251. All of the following drugs are known to cause cholestatic jaundice except

c. O.C.Pills

246. Dose of Omeprazoie to treat a case of Zolinger- Eilison syndrome is

b. 20-40 mg /day

252. As per CDC, 3rd dose of Hepatits B should be given at what interval after 2nd dose? b. After 5 months c. After 4 months

247. â&#x20AC;&#x2DC;Proton Pumpâ&#x20AC;&#x2122; is

d. After 3 months

a. H+ lon b. HCI Acid c. H+K+ ATPase Enzyme

d. HMG CoA Reductase Enzyme 248. Double-bubble appearance is seen in straight X-ray of abdomen in: a. Pyloric Stenosis b. Jejunal Atresia c. Large Gut Obstruction

d. Erythromycin

a. After 6 months

d. 60-80 mg / day

d. Duodenal Atresia

Serum albumin

b.

b. Chlorpromazine

d. GI bleed

c. 40-60 mg / day

a.

a. INH

c. Sr. creatinine >3.5

a. 10-20 mg/ day

249. Which amongst the following is a not criterion used in Child Pugh score for classifying severity of cirrhosis of liver?

253. Which of the following can be found in chronic active hepatitis a. HbsAg positive HbsAb negative b. HbsAg negative HbcAb positive and HbsAb negative c. HbsAg negative HbsAg positive d. HbsAg positive HbcAb negative 254. All of the following are true about ZES except a. Multiple ulcers may be seen b. Ulcers at unusual places may be seen c. Gastrin level is increased d. Urease breath test is positive


1185

Gastroenterology - Answers 38. d

75. c

112. c

150. e

2.

a

39. d

76. b

113. a

151. a

3. d

40. d

77. a

114. d

152. e

4. b

41. d

78. c

115. a

153. c

5. a

42. a

79. a

116. d

154. c

6. c

43. c

80. a

117. e

155. d

7. b

44. e

81. b

118. d

156. b

8. a

45. e

82. c

119. a

157. c

9. a

46. b

83. c

120. c

158. a

10. a

47. d

84. b

121. c

159. d

11. c

48. a

85. d

122. c

160. d

12. c

49. b

86. b

123. a

161. e

13. b

50. c

87. d

124. c

162. c

14. c

51. b

88. c

125. a

163. b

15. b

52. c

89. a

126. c

164. a

16. a

53. d

90. d

127. c

165. d

17. c

54. b

91. c

128. b

166. c

18. a

55. c

92. c

129. e

167. b

19. c

56. d

93. d

130. c

168. b

20. b

57. b

94. d

131. a

169. d

21. c

58. a

95. a

132. b

170. c

22. a

59. c

96. c

133. d

171. e

23. c

60. c

97. c

134. b

172. d

24. a

61. b

98. c

135. a

173. a

25. b

62. c

99. d

136. c

174. e

26. d

63. a

100. c

137. e

175. d

27. b

64. c

101. a

138. b

176. c

28. d

65. d

102. b

139. a

177. b

29. a

66. d

103. a

140. a

178. e

30. d

67. a

104. c

141. a

179. b

31. d

68. a

105. a

142. b

180. c

32. d

69. c

106. b

143. c

181. e

33. c

70. b

107. c

144. b

182. a

34. c

71. b

108. c

145. b

183. b

35. c

72. c

109. a

147. d

184. a

36. d

73. b

110. c

148. c

185. c

37. d

74. d

111. a

149. d

186. b

GASTROENTEROLOGY

1. a


201. d

215. d

229. d

243. d

188. e

202. a

216. b

230. a

244. b

189. e

203. e

217. e

231. e

245. d

190. b

204. e

218. b

232. e

246. d

191. a

205. a

219. b

233. a

247. c

192. b

206. a

220. b

234. d

248. d

193. b

207. b

221. a

235. a

249. c

194. e

208. a

222. c

236. d

250. b

195. b

209. a

223. e

237. d

251. c

196. d

210. a

224. e

238. d

252. b

197. c

211. d

225. a

239. d

253. d

198. a

212. c

226. e

240. c

254. d

199. a

213. e

227. e

241. a

200. a

214. c

228. e

242. d

MCQ's

1186 187. a


HAEMATOLOGY 1.

Causes spurious decrease in MCV

c. Increased Erythrocyte destruction

a. Cryofibrinogen

d. Blood loss

b. hyperglycemia c. autoagglutination

11.

d. high WBC ct

a. Glossitis

e. reduced red cell deformability 2.

b. No neurological symptoms in folic acid c. muscle wasting

When the entire CBC is suppressed due to either anemia, infection, or hemorrhage is called? a. Erythroplasia b. Thrombocytopenia

d. Dizziness 12.

b. False

d. Leukopenia Total RBC count for Women is?

13.

a. 4.4 6

b. Methyldopa

c. 4.05.0 4.

Total RBC for men?

c. Metformin 14.

a. True

b. 4.66.0

b. False

d. 4.06.0

15.

b. Ferritin c. Transferrin

b. increases neutrophil and monocytes c. inhibits DNA synthesis by acting as a ribonucleotide reductase inhibitor 16.

a. Iliac Crest (hip) b. Femur (thigh)

b. False 17. Decitabine increases the fetal hemoglobin production by inducing methylation of DNA and thus prevents the switch from gamma to betaglobinproduction. a. True

c. Distal radius (forearm) d. Tibia (shin) 7.

Laboratory Studies: Red Cell Indices: Determination of relative size of RBC. 8298fl

b. False 18.

b. sprue, cliac disease c. cardiovascular disease, colon cancer

b. MCV

d. A and B

c. MCHC Laboratory Studies: Red Cell Indices: Measurement of average weight of Hb/RBC. 2733pg a. MCH

e. B and C f. All of the above 19.

b. False

c. MCHC

10.

Laboratory Studies: Red Cell Indices: Evaluation of RBC saturation with Hb. 3236%

Wilsons disease can cause liver problems a. True

b. MCV 9.

Hypocupremia is seen in a. osetoporosis, nephrotic disease

a. MCH

8.

Hydroxyurea increases the serum uric acid levels. a. True

d. Hemoglobin The best source of active bone marrow from a 20yearold would be:

Hydroxyurea: a. decreases nitric oxide

What is the major metabolically available storage form of iron in the body? a. Hemosiderin

6.

Hydroxyurea increases hemoglobin production and decreases reticulocyte cells.

a. 4.05.0a. c. 4.26.5 5.

Both vitamin B12 AND iron have drug interactions with which of the following drugs? a. PPI, H2 blockers

b. 4.25 d. 4.25.2

Folic acid therapy can cause sickle cell anemia a. True

c. Pancytopenia 3.

Vitamin B12 and folic have the similar adverse effects, but what separates one form the other?

20.

What are the treatment options for wilsonâ&#x20AC;&#x2122;s disease? a. Pencillamine

a. MCV

b. Riboflavin

b. MCH

c. Trientine

c. MCHC

d. Potassium disulfide

There are 3 classifications of Anemia. What are they? a. In adequate production of Hb b. Decreased RBC production

e. Zinc f. A, B and C


32.

Which drug can be given as a prophylaxis for cadriovascular effects?

Aplasia can occur because of riboflavin deficiency?

1. Ticlopidine

a. True

2. Clopidogrel

3. dipyridamol

g. A, C, and D

1188

h. A, C, D, and E 21.

b. False 22.

Angular stomatitis.cheilosis is a symptom of vitamin B12 deficiency?

a. all b. 1 and 2

a. True

c. 1 and 3

b. False

MCQ's

23.

Antimalarial drugs and high dose birth control will increase riboflavin.

d. 2 and 3 33.

Which drug can increase intracellular levels of cAMP by inhibiting cyclic nucleotide phosphodiesterase?

b. False

1. Sildenafil

Which test can be used to detect hemolytic anemia?

2. Ticlopidine

3. Clopidogrel

4. dipyridamol

a. True 24.

a. Coombs test b. Genetic testing c. Peripheral blood smear (PBS)

a. 1, 3, 4

d. Schilling test 25.

Which anemia is classified as not being able to use iron properly to synthesize hemoglobin because of ainherited cause. a. Iron deficiency anemia

b. 1, 2 , 3 c. 1, 4 34.

a. Alcoholic liver disease

b. hypochromic anemia

b. Gastrointestinal bleeding

c. aplastic anemia 26. Apalstic anemia can be induced by drugs such as Litium, acetazolamide and aspirtin a. True

c. recent neurosugery d. Liver impairment 35.

b. False 36.

a. thromboembolism b. DVT

b. Stage I

d. Pulmonary embolism

c. Stage II

e. All of the above

b. False 29.

d. Stage III e. Stage IV

Homanâ&#x20AC;&#x2122;s sign is classified as pain behind the knee a. True

37.

b. chemotherapy c. Antivirals

a. Sulfinpyrazone

d. rest

b. Clopidogrel d. 1 and 2 e. 2 and 3 30.

38. In patients with low numbers of neoplastic cells, sometimes due to treatment, PCR to amplify DNA can improve sensitivity, and detect signs of relapse. a. True

What is the life span of RBC a. 120 b. 100

b. False 39.

c. 200 This drug can potentiate the effect of prostacyclins to antagonize platelet stickiness and thereforedecreases platelet adhesion to thrombogenic surfaces. a. Sulfinpyrazone b. Dipyridamole c. ticlopidine

Chronic lymphocytic leukemia is most common leukemia in what kind of people? Slide 4 a. young adults

d. 80 31.

Conventional treatment is ______ for Rai stage II a. Antibiotics

Patients that are sensitive to aspirin can take:

c. Ticlopidine

absolute lymphocytosis (>5000/mm^3) without adenopathy, hepatosplenomegaly, anemia,thrombocytopenia is what stage in CLL prognosis ScoringRaiStaging System? a. Stage 0

c. PAD

28.

Isozymes of 2C can greatly effect warfarin a. True

b. False 27. This fatal disorder results from clot/thrombus formation in the blood ciruclation

Warfarin should be used with caution in the following:

b. older adults 40.

absolute lymphocytosis and thrombocytopenia( < 100,000/ mm^3) with or without lymphadenopathy,hepatomegaly, splenomegaly, or anemia is what stage in CLL prognosis ScoringRaiStaging System? a. Stage 0


b. Stage I

49.

c. Stage II

a. True

d. Stage III

b. False

e. Stage IV 41.

Chronic Lymphocytic Leukemia is characterized by peripheral blood and bone marrow _____.

50.

a. lymphocytopenia b. lymphocytosis 42.

a. 0.25 b. 2.5

a. T

d. 10

c. 5 51.

a. Microtubules

Which of the following is the most mature normoblast?

b. Spindle Fibers

a. Orthochromic Normoblast

c. Ribosomes

b. Basophilic Normoblast

d. Centrioles

c. Pronormoblast d. Polychromatic Normoblast

52.

b. Stage I c. Stage II

b. 5th c. End of 6th month d. End of 7th month 53.

d. Stage III

b. Gower 1 and Gower 2 Hgb

45. absolute lymphocytosis without lymphadenopathy without hepatosplenomegaly, anemia, orthrombocytopenia is what stage in CLL prognosis ScoringRaiStaging System?

c. Portland Hgb d. Only Erythroblasts 54.

b. Stage I

b. alpha and epsilon

d. Stage III

c. alpha and delta

e. Stage IV

d. alpha and brotherton 55. Allergic reactions are frequently associated with an increase in the prescence of : a. Lymphocytes

a. soccerball

b. Neutrophils

b. basketball

c. Monocytes

c. football d. tennisball 47.

Which of the following forms of Hb molecule has the lowest affinity for oxygen? a. Tense b. Relaxed c. Arterial d. Venous

48.

What is the recommended cleaner for removing all oil from objective lens? a. 70 % alcohol or lens cleaner b. Xylene c. Water d. Benzene

Normal Adult Hb A contains the following polypeptide chains: a. alpha and beta

c. Stage II

IN Chronic Lymphocytic Leukemia the Lymphocyte appearance: small or slightly larger than normal,hypercondensed(almost ________ appearing. nuclear chromatin patter, bare nuclei called â&#x20AC;&#x153;smudge cellsâ&#x20AC;? arecommon.

Which types of cells develop from yolk sacs (Mesoblastic phase)? a. Hb F, Hg A2, and Hg A

e. Stage IV

a. Stage 0

At which month of fetal development does the bone marrow ecome the primary site of hematopoiesis?? a. 2nd

absolute lymphocytosis with either hepatomegaly or splenomegaly with or without lymphadenopathy is what stage in CLL prognosis ScoringRai Staging System? a. Stage 0

46.

The shape of a cell is maintained by which of the following?

d. Eosinophils 56.

Lipid exchange between the RBC membrane and the plasma occurs: a. To replace lost lipids in the membrane b. To provide a mechanism for excretion of lipidsoluble RBC waste products c. To ensure symmetry between the composition of the interior and exterior lipid layers d. To provide lipidsoluble nutrients to the RBC

57. After the microscope has been adjusted for Kohler illumination, light intensity should never be regulatedby using the... a. Rheostat b. Neutral density filter c. Kohler magnifier d. Condenser

HAEMATOLOGY

c. NK

44.

A 1:20 dilution was made in a unopette, with glacial acetic acid as the diluent. The four corner squares on BOTH sides of the hemacytometer are counted for a total of 100 cells. What is the total WBC (x10^9/L.?

Chronic Lymphocytic Leukemia is characterized by gradual accumulation of small mature ______ cells. b. B

43.

Intravascular hemolysis is the result of trauma to RBCs while 1189 in the circulation


1190 58. Which of the followong types of microscopy is valuable in the identification of crystals that are able torotate light? a. Compound brightfield b. Darkfield c. Polarizing

67. The acceptable range for hemoglobin values on a control sample is 13 + or 0.4g/dL. A hemoglobindetermination is performed five times in succession on the same control sample. The results are (in g/dL. 1212.3, 12, 12.2, and 12.1) These results are: a. Precise, but not accurate

d. Phasecontrast 59.

a. Femur b. Iliac Crest

MCQ's

c. Skull

60.

b. Both accurate and precise c. Accurate, but not precise

During the Medullary Phase of hematopoietic development, which bone is the first to showhematopoietic activity?

d. Neither accurate nor precise 68. The layer of the erythrocyte membrane that is largely responsible for the shape, structure, and deformability of the cell is the:

d. Skull

a. Integral protein

e. Clavicle

b. Exterior lipid c. Peripheral protein

Given the following values, calculate the RPI Observed reticulocyte count 6%Hct30% a. 2 b. 3

d. Interior lipid 69.

a. Bone marrow

c. 4

b. Spleen

d. 5 61.

c. Lymph Nodes d. Liver

The lipids of the RBC membrane are arranged: a. In chains beneath a protein exoskeleton b. So that the hydrophobic portions are facing the plasma

70.

b. Adjacent to megakaryocytes along the adventitial cell lining

d. In two layers that are not symmetric in composition

a. Glucose and lactic acid

c. Surrounding fat cells in apoptotic islands d. Surrounding macrophages near the sinus membrane 71.

b. 2,3BPG and methemoglobin

b. Objective lens

d. ATP and other purine metabolites Which single feature of normal RBCâ&#x20AC;&#x2122;s is most responsible for limiting their life span? a. Loss of mitochondria

c. Condenser d. Optical Tube 72.

b. Increased flexibility of the cell membrane d. Loss of nucleus

b. With a genes and B genes on seperate chromosomes, two a genes on one chromosome and one B gene on a different chromosome

In the Iron cycle, the transferrin receptor carries: a. Iron out of duodenal cells from the intestinal lumen

c. With a genes and B genes on the same chromosome includingfour a genes and four B genes

b. Iron out of duodenal cells into the plasma

d. With a genes and B genes on separate chromosomes foura genes on one chromosome and two B genes on a different chromosome

c. transferrinbound iron in the plasma d. transferrinbound iron into erythrocytes 65.

A multilineage cytokine among the ILs is: a. IL1 b. IL2

73. The maximum number of erythrocytes generated by one Multipotential Stem Cell is: a. 8

c. IL3

b. 1

d. IL4 66.

Which of the following cells may develop in sites other than the bone marrow? a. Monocyte b. Lymphocyte c. Megakaryocyte d. Neutrophil

How are the globin chains genes arranged? Note: a means alpha, B means beta a. With a genes and B genes on the same chromosome including two a genes and two B genes

c. Reduction of Hb iron 64.

Which of the following gathers, organizes, and directs light through the specimen? a. Ocular

c. NADPH and reduced glutathione 63.

In the bone marrow, RBC precursors are located: a. In the center of the hematopoietic cords

c. In a hexagonal lattice 62. The hexose monophosphate pathway activity increases the RBC source of

During midfetal life, the primary source of blood cells is the:

c. 12 a. 16 74.

What is the distribution of normal Hb in adults? a. 8090%

Hb A, 510%

Hb A2, 15%

Hb F

b. >95% Hb A, <3.5 % Hb A2, <12%

Hb F


75.

The most frequent cause of needle punctures is:

83.

a. Patient movement during venipuncture b. Improper disposal of phlebotomy equipment c. Inattention during removal of needle after venipuncture d. Failure to attach needle firmly to tube holder 76. Iron is incorporated into the heme molecule in which of the following forms: a. Ferro

a. Von Willebrand disease

b. Ferrous

b. Liver disease

c. Ferric

c. Disseminated intravascular coagulation

d. Apoferritin

d. Congenital afibrinogenaemia

a. Wearing masks during patient contact

e. Glanzmann’s thrombasthenia 84.

b. Proper handwashing c. Wearing disposable lab coats d. Identifying specimens from known or suspected HIV and HBV patients with a red label

a. Antithrombin deficiency

Which of the following would correlate with an elevated ESR value?

b. Factor V Leiden mutation

a. Osteoarthritis

d. Lupus anticoagulant

b. Polycythemia

e. Protein C deficiency

c. Decreased globulins

c. Protein S deficiency

b. Phosphotriptokinase

A 44-year-old Asian female presents with a two-month history of shortness ofbreath and lethargy. She denies any intolerance to the cold or any changes in herweight and on examination appears slightly pale. She states that she has recentlybecome a vegetarian. A blood film shows the presence of elliptocytes and bloodresults show the following: Haemoglobin 9.9 g/dL, Mean cell volume (MCV) 75 fL, Ferritin Low, The most likely diagnosis is:

c. Pyruvate Kinase

a. Iron deficiency anaemia

d. Glyceraldehyde 3Phosphate

b. Sideroblastic anaemia

d. Inflammation 79.

85.

The enzyme deficiency in the EmbdenMeyerhofpathway that is responsible for most cases ofnonspherocytic hemolytic anemia is: a. Hexokinase

80.

c. Anaemia of chronic disease

The most common type of protein found in the cell membrane is:

d. Thalassaemia trait e. Hereditary elliptocytosis

a. Lipoprotein b. Mucoprotein

86.

c. Glycoprotein d. Nucleoprotein 81.

A woman with BO positive blood and her partner with AB positive blood have achild together. Which of the following cannot be the child’s blood type? a. AB positive b. BB positive

b. Vitamin B12 deficiency

d. AA positive

c. Folic acid deficiency

e. BB negative A 24-year-old man is involved in a road traffic accident and rushed to accident andmergency accompanied by his mother who was unharmed. An examination showssevere abdominal injuries, peripheral cyanosis and cold extremities. The doctor oncall decides a blood transfusion is necessary. The mother thinks the patient is bloodgroup B negative but is unsure. The most appropriate blood group to give thepatient is? a. Group O positive blood b. Group B positive blood c. Group B negative blood d. Group O negative blood e. Group A negative blood

A 47-year-old teacher complains of difficulty maintaining her concentration atwork teaching secondary school children. She states that over the last four monthsshe has become increasingly tired and easily fatigued. She has noticed it hasbecome more difficult for her to lift books, rise from her chair and she has alsonoticed a tingling sensation in her fingers. Examination shows a positive babinskisign and absent reflexes. A blood test reveals the following: Haemoglobin 10 g/dL, MCV 103 fL, The most likely diagnosis is: a. Hypothyroidism

c. AO positive

81.

A 22-year-old Caucasian woman presents with a 1-day history of a painful rightleg which is erythematous on appearance and tender on palpation. She states that she has had this problem many times in the last few years and her family has alsosuffered from similar problems. Her grandmother died of a pulmonary embolism. The most likely diagnosis is:

d. Liver disease e. Alcohol toxicity 87.

A 55-year-old man complains of a 4-week history of general malaise and fatigue,he has also noticed his trousers have become more loose fitting. A blood test showsthe following results: Haemoglobin 12 g/dL, MCV 90 fL, Platelet count 250 × 109/L, WBC 10 109/L, Serum iron 10 mol/L, Total iron-binding capacity 40 ìmol/L, Serum ferritin 160 g/L. The most likely diagnosis is: a. Thalassaemia b. Iron deficiency anaemia c. Anaemia of chronic disease d. Macrocytic anaemia e. Aplastic anaemia

HAEMATOLOGY

77. The most important practice in preventing the spread of disease is:

78.

A 16-year-old boy presents to his GP complaining of 1191 nosebleeds and bleeding afterbrushing his teeth. He is unsure of how long this has been occurring but decided toseek advice after having to continually excuse himself from lessons. On examinationyou notice he has some skin bruises. A blood test shows a prolonged bleeding timeand activated partial thromboplastin time (APTT), while platelet count andprothrombin times are all normal. The most likely diagnosis is:


1192 88. A 43-year-old woman suffers from Crohn’s disease. A blood test shows thefollowing results: Haemoglobin 10.5 g/dL, MCV 120 fL, Platelet count 300× 109/L. The most likely diagnosis is:

93.

a. Vitamin B12 deficiency b. Iron deficiency c. Hypothyroidism d. Folic acid deficiency e. Anaemia of chronic disease

MCQ's

89.

A 45-year-old man collapses at home and is brought to he has a fever at 39.5°C and blood pressure is 90/60 mmHg, although he is in a lucidstate. Bruises can be seen on his skin which he remembers being present before hefell. Blood tests show the patient to have a normocytic anaemia with a low plateletcount and increased fibrin split products. The most likely diagnosis is: a. Warm autoimmune haemolytic anaemia b. Cold autoimmune haemolytic anaemia c. Paroxysmal nocturnal haemoglobinuria d. Disseminated intravascular coagulation e. Thalassaemia minor

90.

A 23-year-old Asian man presents to his GP complaining of shortness of breath following exercise. He has always been a little unfit and decided to start going tothe gym but noticed that even after 4 weeks he is still quite short of breath. He denies any coughing or wheezing and on examination you notice mild pallor but the patient says he has always been slightly pale in colour. Investigation results are given below: Haemoglobin 12 g/dL, MCV 70 fL, Serum iron 14 umol/L, Ferritin 60 ug/L, Transferrin saturation 35 per cent, Mean cell haemoglobin 22 pg, Haemoglobin electrophoresis HbA2 increased. The most likely diagnosis is:

a. Immediate haemolytic transfusion reaction b. Febrile non-haemolytic transfusion reaction c. Delayed haemolytic transfusion reaction d. IgA deficiency e. Transfusion-related lung injury 94. A 52-year-old woman presents complaining of a two-month history of increasing fatigue and numbness in both of her arms and legs. She lives at home with her husband and has found it difficult coping with the daily activities of living. She suffers from hypothyroidism which is well controlled with thyroid replacement medication. A peripheral blood smear shows hypersegmented neutrophils. A blood test reveals the following: Haemoglobin 10 g/dL, Mean corpuscular volume 110 fL, Platelets 150 × 109/L. Liver function tests: ALT 25 IU/L, AST 27 IU/L, GGT 22 IU/L, ALP 100 IU/L, Urea 5 mmol/L, Creatinine 100 ìmol/L. The most likely diagnosis is: a. Thrombotic thrombocytopenic purpura b. Iron deficiency c. Folic acid deficiency d. Liver disease e. Pernicious anaemia 95.

a. á thalassaemia trait b. Anaemia of chronic disease c. â thalassaemia trait d. Haemoglobin H disease e. Iron deficiency anaemia 91. A 29-year-old woman complains of a 1-week history of weakness and malaise, she has recently become a vegetarian and eats mostly green vegetables and drinks lots of tea during the day. She is apyrexial and has a C-reactive protein (CRP) <5. You suspect an abnormality of the patient’s iron stores. What is the most appropriateinvestigation to determine iron store levels? a. Bone marrow biopsy b. Serum ferritin c. Serum transferrin d. Total iron binding capacity e. Serum iron 92.

A 60-year-old man presents with abdominal pain and a cupful of haematemesis.On examination he is noted to have ascites, hepatomegaly and a very enlargedspleen extending to the right iliac fossa. His initial blood tests reveal aleukoerythroblastic picture with a haemoglobin of 8, white cell count (WCC) of 3 and platelets of 120. A diagnosis of myelofibrosis is made. What is most likely tobe seen on the peripheral blood smear? a. Schistocytosis b. Sickle cells c. Spherocytes d. Dacrocytes e. Target cells

A 65-year-old woman suffers significant bleeding during a difficult bowel resectionand is prescribed three units of blood after the operation is completed. It is the firsttime she has required a blood transfusion and her details are checked carefully.Approximately 4 hours after the transfusion the patient feels acutely unwell andcomplains of fever, chills and a dry cough. Blood pressure is 110/80 mmHg, temperature 38°C and oxygen saturation is 94 per cent. The most likely diagnosis is:

During a busy ward round you are asked to visit a patient the consultant has not had an opportunity to see. The only details you are given are that the patient is female and was admitted the previous day with bleeding abnormalities, you are given the results of her blood investigations: Prothrombin time Unaffected, Partial thromboplastin time Prolonged, Bleeding time Prolonged, Platelet count Unaffected. What is the most likely diagnosis? a. Factor V deficiency b. Warfarin therapy c. Glanzmann’s thrombasthenia d. Bernard Soulier syndrome e. Von Willbrand disease

96. A 14-year-old girl is brought to clinic by her parents who have been worried about a fever the patient has had for the last week. The patient looks pale and unwell. Blood tests reveal a neutropenia with normal red blood counts (RBCs) and platelets. A bone marrow exam reveals no abnormalities. The patient has been otherwise fit and well. There is no organomegaly or lymphadenopathy. The most likely diagnosis is: a. Acute myeloid leukaemia b. Aplastic anaemia c. Acute lymphoblastic leukaemia d. Bacterial infection e. Thrombotic thrombocytopenic purpura 97.

A 65-year-old man presents with a chronic history of headaches and occasional dizziness. He hesitantly mentions that he experiences severe pruritus, especially after hot showers and baths. Blood pressure is 160/85 mmHg. A full blood count (FBC) reveals a haemoglobin of 20 g/dL, MCV of 94 fL, platelet count of 470 × 109/L and WBC count of 7.8 × 109/L. The most likely diagnosis is: a. Polycythemia vera b. Idiopathic erythrocytosis


c. Essential thrombocythaemia

c. Tartrate-resistant acid phosphatase stain

d. Myelofibrosis

d. Leukocyte alkaline phosphatase

e. Chronic myeloid leukaemia

e. Auramine O stain

98. A 29-year-old woman complains of tiredness, especially during activity. On examination the patient appears pale. Auer rods and schistocytes can be seen on peripheral blood smear. The patient is referred for a bone marrow biopsy and the extracted cells are sent for cytogenetic analysis. The most likely results are: a. t(8:21) b. t(15;17) c. t(9:22) e. t(8;14) 99.

In which of the following dieases is a massive splenomegaly not a characteristic feature? a. Infectious mononucleosis b. Thalassaemia c. Chronic myeloid leukaemia d. Kala-azar e. Polycythaemia rubra vera

100. A 27-year-old man presents with increasing tiredness and shortness of breath. A macrocytic anaemia with reticulocytes is discovered on blood tests and smear. Genetic analysis reveals the patient has glucose-6-phosphate dehydrogenase deficiency. What cell type is most likely to have been seen on the blood smear? a. Target cells b. Pencil cells c. Spherocytes d. Elliptocytes e. Schistocytes 101. A 33-year-old man travels to South Africa to take part in a safari. On arriving, the patient takes his antimalarial tablets. A few days into his course he becomes ill complaining of shortness of breath, pallor and bloody urine. Blood tests reveal anaemia and reduced haematocrit, while a blood smear shows the presence of Heinz bodies. The most likely diagnosis is: a. Hereditary elliptocytosis b. Glucose-6-phosphate dehydrogenase deficiency c. Hereditary spherocytosis d. Autoimmune haemolytic anaemia e. Microangiopathic haemolytic anaemia 102. An 18-year-old African man presents with worries about his general health stating that hypertension and sickle cell anaemia are present in his family history. The patient denies any shortness of breath, chest pain, digit or limb changes. Blood pressure is 124/77 mmHg. What test would be appropriate to investigate sickle cell anaemia?

104. A 47-year-old woman presents complaining of dark stools and painful fingers on both hands. She appears plethoric and complains of severe itching, often when she is washing. A large liver and spleen is palpable. You suspect features of polycythaemia rubra vera and measure red cell mass and erythropoietin levels among other tests. Which of the following is likely to be most accurate in this patient? a. Low erythropoietin and low red cell mass b. Normal erythropoietin and normal red cell mass c. Raised erythropoietin and low red cell mass d. Raised erythropoietin and raised red cell mass e. Low erythropoietin and raised red cell mass 105. A 29-year-old woman presents complaining of shortness of breath, especially when walking up stairs. She is starting to struggle with yoga classes, which were never a problem before. She does not suffer from any medical conditions and takes no regular medication. On examination there is pallor, heart rate is 90 and blood pressure 119/79 mmHg. The patient mentions that she has recently become a vegetarian and in the morning only has time for tea before heading to work. Which of the following would you expect to be increased in this patient? a. Myoglobin b. Ferritin c. Haemoglobin d. Serum iron e. Transferrin 106. A 65-year-old man presents with a chronic history of malaise, shortness of breath and paraesthesia in his hands. He appears tired and pale while speaking and on examination his heart rate is 115, respiratory rate 16. A Schillings test is positive while blood tests reveal a macrocytic anaemia and a Coombs test is negative. The most likely diagnosis is: a. Iron deficiency anaemia b. Haemorrhage c. Anaemia of chronic disease d. Pernicious anaemia e. Autoimmune haemolytic anaemia 107. A 47-year-old woman presents to clinic concerned about her recent ill health. She has noticed over the last three months that she has been suffering from headaches, fatigue and recurrent infections. She notes she has rarely been to the doctor before and otherwise leads a healthy lifestyle. She decided to see a doctor when she noticed petechial rashes appearing on her arms. On examination there is no organomegaly and blood tests reveal an MCV of 105, a pancytopenia with the bone marrow appearing hypocellular on biopsy.

a. Hamâ&#x20AC;&#x2122;s test

a. Chronic myeloid leukaemia

b. Coombsâ&#x20AC;&#x2122; test

b. Myeloproliferative disorder

c. Schilling test

c. Aplastic anaemia

d. Metabisulfite test

d. Iron deficiency anaemia

e. Osmotic fragility test

e. Acute lymphoblastic anaemia

103. A young patient presents with features of anaemia, neutropenia and thrombocytopenia. A large number of blasts are present on bone marrow biopsy. Which investigation would help differentiate between acute myeloid leukaemia (AML) and acute lymphoblastic leukaemia (ALL)? a. Myeloperoxidase stain b. Sudan black B

108. A 65-year-old man presents to you reporting he has become increasingly worried about his lack of energy in the last 2 weeks. He mentions he has been increasingly tired, sleeping for long periods and has suffered from fevers unresponsive to paracetamol. He became increasingly worried when he noticed bleeding originating from his gums. A blood film shows auer rods, hypogranular neutrophils and stains with

HAEMATOLOGY

d. t(14;18)

1193


1194

Sudan black B. The most likely diagnosis is: a. Acute lymphoblastic leukaemia b. DiGeorge syndrome c. Disseminated intravascular coagulation d. Acute myeloid leukaemia e. Afibrinogenaemia 109. A 70-year-old woman complains of tiredness, fatigue and weight loss. Blood tests reveal an elevated WCC and on examination splenomegaly is palpated. Cytogenetics are positive for the Philadelphia chromosome and the patient is diagnosed with chronic myeloid leukaemia. The most appropriate treatment is:

MCQ's

a. Hydroxycarbamide b. Imatinib c. Venesection

e. Anti-smooth muscle antibodies 114. A 5-year-old girl presents with her parents who have become concerned about the small petechiae and ecchymoses on her skin. An abdominal examination reveals hepatosplenomegaly. You suspect an acute leukaemia. The most appropriate initial investigation for diagnosis is: a. Chromosomal analysis of bone marrow cells b. Cytochemical analysis of bone marrow cells c. Direct microscopy of bone marrow cells d. Electron microscopy e. Flow cytometry 115. A 51-year-old man complains of severe, diffuse back pain. An x-ray finds several lytic lesions in the vertebra alongside hypercalcaemia. Bence–Jones protein is detected in the urine. What is a Bence–Jones protein?

d. Stem cell transplant

a. IgG antibody

e. Dasatinib

b. IgA antibody

110. A 27-year-old woman who suffers from rheumatic mitral stenosis develops atrial fibrillation. She is placed on warfarin therapy. What is the most appropriate target international normalized raio (INR) range? a. <1.0 b. 1.0–2.0 c. 2.0–3.0 d. 3.0–4.0 e. >5.0 111. A 70-year-old woman complains of a dull pain in her lower back, especially when bending forwards to lift things. She presents after a severe episode in the last 2 days. An x-ray reveals a lumbar compression fracture. Blood tests show a normocytic anaemia and urine electrophoresis reveals a monoclonal gammopathy. A diagnosis of multiple myeloma is made. Which of the following is not a recognized cause of multiple myeloma? a. High-dose radiation b. Human herpes virus-8 (HHV-8) c. HIV d. Herbecides and insecticides e. Hereditary 112. A 44-year-old woman presents with recurrent fever, pallor, malaise and shortness of breath. She has noticed a petechial rash on her skin and small bruises on her arms. A blood test reveals a pancytopenia. During examination, you palpate a large spleen. Which investigation would differentiate between hypersplenism and aplastic anaemia? a. Reticulocyte test

c. IgE antibody d. Light chain e. IgM antibody 116. Hand foot Syndrome is related to which of the following? a. Tietz syndrome b. Hypertrophic osteoarthritis c. Sickle cell disease d. Syringomyelia 117. Agranulocytosis occurs due to intake of : a. Olanzapine a. Chloromazine b. Clozapine c. Risperidone 118. Omalizumab is used in the treatment of : a. ITP b. Small cell lung cancer c. Bronchial Asthla d. GLUT 6 119. Packed cells are constructed by a. Filtration b. Centrifugation c. Precipitation d. Sedimentation 120. The phildelphia chromosome is classically associated with which of the following

b. Direct Coombs test

a. CLL

c. Metabisulfite test

b. CML

d. Ham’s test

c. Burkits lymphoma

e. Osmotic fragility test

d. Hairy cell leukaemia

113. A 66-year-old man presents complaining of a three-month history of weakness, tingling in the limbs and a sore tongue. The patient notes an undesired 5 kg weight loss over 2 weeks. A peripheral blood smear shows a macrocytic anaemia, a Schilling test shows impaired vitamin B12 absorption and a diagnosis of pernicious anaemia is made. Which of the following antibodies is most closely associated with pernicious anaemia?

121. The response to iron administration would be earliest seen by a. Increased TIBC b. Increased haemoglobin c. Reticulocytosis d. Increased hematocrit 122. X linked inheritance is seen in all of the following except

a. Anti-mitochondrial antibodies

a. Fabry’s disease

b. Anti-intrinsic factor antibodies

b. G6PD deficiency

c. Anti-gliadin antibodies

c. Myotonic dystrophy

d. Anti-centromere antibodies

d. Heamophilia A


1195

Haematology - Answers 26. a

51. a

76. b

101. b

2. c

27. e

52. c

77. b

102. d

3. c

28. a

53. d

78. d

103. c

4. b

29. e

54. a

79. c

104. e

5. b

30. a

55. d

80. c

105. e

6. a

31. b

56. a

81.

d

106. d

7. b

32. d

57. d

81.

d

107. c

8. b

33. c

58. c

83.

a

108. d

9. c

34. d

59. d

84.

b

109. b

10. a

35. a

60. a

85.

a

110. c

11. b

36. a

61. d

86.

b

111. e

12. b

37. b

62. c

87.

c

112. a

13. a

38. a

63. d

88.

a

113. b

14. a

39. b

64. d

89.

d

114. c

15. c

40. e

65. a

90.

c

115. d

16. a

41. b

66. b

91.

b

116. c

17. b

42. b

67. a

92.

d

117. c

18. f

43. a

68. c

93.

e

118. a

19. a

44. c

69. d

94.

e

119. d

20. h

45. b

70. d

95.

e

120. b

21. a

46. a

71. c

96.

d

121. c

22. b

47. a

72. b

97.

a

122. c

23. b

48. a

73. d

98.

b

24. a

49. a

74. b

99.

a

25. b

50. b

75. b

100. e

HAEMATOLOGY

1. a


DERMATOLOGY 1.

2.

3.

Which of the following would be prescribed for acne?

10.

a. impetigo

b. Actonel

b. melanoma

c. AccuCheck

c. nevus

d. Accutane

d. verruca

An absence of pigment in the skin is called

11.

a. hyperbillirubinemia

b. albinism

b. hyperuricemia

c. melanism

c. hyperkalemia

d. xanthoderma

d. hyporeninemia

A burn which involves 2 layers of the skin and estroys the nerves and blood vessels, but does not go down to muscle or bone is a

12.

b. cutane/o c. pachy/o d. xanth/o

c. thirddegreeburn d. fullthicknessburn

13.

Death of tissue associated with loss of blood supply to the affected area is called

b. atopic dermatitis c. stasis dermatitis

b. eczema

d. seborrheic dermatitis

c. gangrene 14.

b. endodermis c. epidermis

a. acne vulgaris

d. hypodermis

b. pityriasisrosea d. urticaria (hives. 6.

15.

b. epidermis c. epithelium

a. intradermal nevi

d. subcutaneous tissue

b. dysplastic nevi d. verrucae 7.

16.

b. collagen c. keratin

a. papule

d. melanin

b. sebaceous cyst d. vesicle 8.

17.

Excessive hair on the face or body, especially in women, is called:

b. The patient was given metronidazole for roseola and Lamisil for onychomycosis. c. The patient was given metronidazole for roseola and Lamisil for onychomycosis.

b. atrichia c. alopecia

d. The patient was given metroprolol for rosacea and Lamisil for onychomycosis.

d. hirsutism The halfmoonshaped, white area located at the base of a fingernail is called the a. basal layer b. cuticle c. lunula d. stratum

Which of the following is transcribed correctly? a. The patient was given metronidazole for rosacea and Lamisil for onychomycosis.

a. albinism

9.

The brownblackpigment of the skin that is transferred to other epidermal cells and gives the skin its color is called a. albumin

The type of cyst contains yellowish sebum and is commonly found on the scalp, vulva, and scrotum.

c. ulcer

Of the three layers of the skin, which is the thick, fatcontaininglayer? a. dermis

Moles with the potential to develop into malignant melanoma are

c. giant nevi

The outermost layer of skin is the a. dermis

An acute eruption of intensely itchy papules or wheals is called

c. psoriasis

A chronic dermatitis of unknown etiology in patients with a history of allergy is called a. actinic dermatitis

a. cellulitis

d. psoriasis

Which of the following is a combining form meaning skin? a. adip/o

b. seconddegreeburn

5.

Yellowing of the skin is indicative of

a. acanthosisnigricans

a. firstdegreeburn

4.

An epidermal growth caused by a virus (wart.) is called a

a. Actiq

18.

Apocrine glands produce a. mucus b. sebum c. sweat d. keratin


19.

Which of the following infections is also known as ringworm?

a. acne cosmetica

a. folliculitis

b. acne pustulosa

b. herpes simplex

c. acne rosacea

c. impetigo

d. acne vulgaris

d. tineacorporis 20.

29.

Another term for itching is

b. erythema multiforme

b. keratosis

c. hirsutism

c. petechiae

d. keratosis pilaris

d. pruritus

a. dermis b. epidermis

b. lymphatic system

c. stratum corneum unguis

c. musculoskeletal system

d. hypodermis 31.

a. Shallow Epidermal defect

a. topical antifungals

b. Break in epidermis with exposure of dermis

b. antiitch creams

c. Not good for coffee drinkers

c. topical antibiotics

d. A primary problem 32.

b. Difficult for men to deal with c. Only full hair loss d. Never where you want it to be

b. keloid c. keratosis

33.

b. False

In this condition, there is a scaly dermatitis affecting parts of the skin that are supplied by oil glands.

34. Excessive scaling is: a. Gross

a. chronic dermatitis

b. Seborrhea

b. contact dermatitis

c. Dandruff

c. eczema

d. Epidermal Collarette

d. seborrheic dermatitis Which of the following is a fungal infection?

35.

b. False

b. keratosis

36. What is another term for intertrigo?

c. suborrhea

a. Furunculosis

d. tineacapitis

b. Pyotraumatic Dermatitis

A groove or a cracklikesore is called a (an. a. fissure b. nodule

c. Skin Fold Dermatitis 37.

b. Macule

d. ulcer

c. Papule

Which of the following is transcribed correctly? a. This 58yearoldwoman had a biopsy proven melanoma. Clarks level 1, on the left cheek.

d. Pustule 38.

d. This 58yearoldwoman had a biopsyprovenmelanoma.Clark level 1, on the left cheek. 28.

Follicular dilation involving the nose and portions of the cheeks, erythema, papules, and pustules are classic signs of this dermatologic disorder.

Scale is an accumulation of fragments of stratum corneum a. True

b. This 58yearoldwoman had a biopsyprovenmelanoma. Clarkâ&#x20AC;&#x2122;s level 1, on the left cheek. c. This 58yearoldwoman had a biopsy proven melena.Clark level 1, on the left cheek

Circumscribed, developmental skin defect a. Nevus

c. polyp 27.

A vesicle is a sharply circumscribed lesion containing fluid a. True

a. lichen planus

26.

Pyotraumatic Dermatitis is also known as a â&#x20AC;&#x153;hot spotâ&#x20AC;? a. True

d. leukoplakia

25.

Alopecia is: a. Full or partial hair loss

Which skin neoplasm is associated with an increase in the growth of cells in the keratin layer of the epidermis caused by pressure or friction? a. callus

24.

An ulcer is:

Clotrimazole and nystatin are both

d. used to treat eczema 23.

The vascular layer of skin is the

a. integumentary system

d. nervous system 22.

30.

b. False 39.

Inflammation secondary to rupture of a hair follicle a. Furunculosis b. Pustule c. Vesicle d. Plaque

DERMATOLOGY

The skin, hair, nails, and glands all make up this system of the body.

A skin disorder most often caused by the herpes virus and consisting of red lesions that look like targets is a. candidiasis

a. dermatitis

21.

1197


1198 40.

Remnants of a pustule, vesicle, or bulla can be

a. A condition of the ear b. Skin discoloration

c. Plaque

c. Excessive sweating 54.

b. False

b. False 55.

b. red

a. Taunted by a bulla fighta

MCQ's

c. Hives

c. lack of pigmentation 56.

A comedone is a primary problem only a. True

b. False 57.

b. a cold sore or fever blister

44. Actinic means related to chemically active rays of the electromagnetic spectrum.

c. an invasion of pyogenic bacterium 58.

b. an enlarged fever blister

Accumulation of keratin and follicular material that adheres to hair shaft a. Impetigo b. Scales

c. blue colored skin 59.

b. Lichenification

47.

49.

c. yellow skin 60.

a. True

d. Lacking in sensitive people

b. False

Circumscribed, nonpalpablearea characterized by color change

61.

a. Smokers b. A.I.D.S.

b. Papule

c. Sun exposure

A patch is a large macule

62.

a. a pathological change in tissue b. torn skin

b. False

c. laser treatment for skin disease.

“Scratch” is a lay term for excoriation

63.

b. Pustule

b. move or spread through the blood stream or lymph nodes c. abnormal breast condition 64.

a. benign

Benign means noncancerous. a. True

c. Furunculosis A cicatrix is:

Metastasis means to: a. spread infection from one person to another

Dilated hair follicle containing cornified cells and debris a. Comedone

52.

A Laceration is:

a. True

b. False

51.

Kaposi’s Sarcoma is a cancer associated with:

a. Patch

a. True 50.

Impetigo is a contagious bacterial skin infection with pustules that rupture.

c. Scaling

c. Macule 48.

b. blue skin

Thickening of the epidermis and/or dermis a. Callus

Cyanoderma means: a. red skin

c. Follicular Cast 46.

Herpes Zoster is most commonly known as: a. shingles

b. False 45.

Herpes is: a. An S.T.D.

b. False

a. True

Gangrene is necrosis (dead. tissue due to decomposition. a. True

d. A large cyst 43.

Erythema: a. blood condition

What is a bulla? b. A large vesicle

Eczema is an inflammatory condition of the skin. a. True

Circumscribed lesion that is raised and consists of edema is urticaria a. True

42.

Ecchymosis means:

b. Scale d. Cyst 41.

53.

a. Epidermal Collarette

b. False 65.

A 1st degree burn is: a. the most severe type of burn

b. a lesion

b. superficial burn injuring the top layer of skin

c. a scar

c. the first time the patient has been burned.

A cyst is a closed sack of pouch under the skin. a. true b. false

66. ___________ means itching caused by dry skin, parasitic infection or disease. a. Scabies


c. Pruritis

A compressible papule or plaque of dermal oedema, red or 1199 white in colour.

Tinea ________ means ring worm, athleteâ&#x20AC;&#x2122;s foot.

b. Erythema

b. Herpes Zoster 67.

79.

a. Urticaria (Missed.

a. purpura

c. Wheal (Missed.

b. impetigo c. corporis 68.

Scabies is a contagious skin condition caused by parasitic mites.

d. Purpura ,C 80.

a. True

a. True b. False Pediculosis means:

b. False 81.

a. Erythema

a. Inflammatory condition of the skin.

b. Ecchymosis

b. Infestation with lice c. Irritated and peeling feet. 70.

71.

Petechiaeis a small _____________ spot on the skin.

73.

c. Cellulitis 82.

a. Nodule

b. raised

b. Papule

c. discolored

c. Macule

Urticaria means:

83.

a. True

b. thickened skin

b. False 84.

SLE stands for_________________ and is an autoimmune disease.

a. Water (Missed. b. temperature extremes (Missed.

b. systemic lupus erythematosus

c. Frictional abrasives (Missed.

c. septic lymphodic edema

d. Nickel

Similar to a vescle but larger usually more than 5mm in diameter, consisting of clear fluid accumulated within or below the epidermis.

85.

b. False 86.

a. Epidermis

Dried exudate on the surface of the skin.

c. Pilosebaceous unit

b. Dermis d. Subcutaneous fat

b. Crust c. Scale A localised area of colour or textural change in the skin

e. Cutaneous nerves 87.

Cell types of the epidermisWhich of the following cell types are seen in the epidermis?

a. Macule

a. Merkel cells

b. Ecchymosis

b. Langerhans cells

c. Freckle

c. Melanocytes d. Keratinocytes

Alopecia is the absence of hair?

e. None of the above cells are present in the epidermis

a. True b. False Atrophic skin is thin, translucent and wrinkled with easily visable blood vessels a. True b. False 78.

Which one of the following structures is considered a skin appendage?

d. Cyst a. Plaque

77.

Atopic eczema induces lichenification a. True

c. Bulla

76.

Contact dermatitis, which of the following are common irritants?

a. squamous laceration ecchymosis

b. Pustule

75.

Irritants cause more contact dermatitis than allergens do?

a. allergic reaction of the skin

a. Vesicle

74.

A small solid elevation of the skin, generally defined as less than 5mm, maybe flat or domeshaped.

a. hemorragic

c. dead tissue 72.

A purulent inflammation of the skin and subcutaneous tissue

88.

A 56-year-old man, diagnosed with psoriasis three years ago, presents to yourclinic with pruritus. His symptoms are not improving despite being prescribedconventional therapy. On examination, you note the presence of erythematousscaly plaques on the extensor surfaces of the knee and elbows. There is no evidenceof flexural involvement. The most appropriate treatment is:

An acute abcess formation in adjacent hair follicles.

a. Topical retinoid therapy

a. Carbuncle

b. Topical tar preparations

b. Furuncle

c. Topical steroid preparations

c. Folliculitis

DERMATOLOGY

69.

A pustule is a visible collection of pus in a blister. Pustules can be seen in psoriasis


1200 89.

d. Topical vitamin D analogue preparations

b. Testicular carcinoma

e. Antibiotics

c. Breast carcinoma d. Gastrointestinal carcinoma

You are asked by your registrar to see a 45-year-old Caucasian woman withpsoriasis who has presented with suspicious nail changes. Which one of thefollowing nail changes are associated with psoriasis?

e. Prostate carcinoma 95. Contact dermatitis is described as what type of reaction? a. Type I hypersensitivity

a. Koilonychia

b. Type II hypersensitivity

b. Onycholysis

c. Type III hypersensitivity

c. Beau’s lines

d. Type IV hypersensitivity

d. Clubbing e. Paronychia

MCQ's

90.

A 12-year-old boy who has been suffering from atopic dermatitis for the last ten years presents to you with a 3-day history of severe itching and pus discharge from his left elbow. On examination, you observe lichenification of his left elbow with superimposed excoriations which are weeping a viscous yellow fluid. You take aswab of this discharge. Which one of the following organism growths would you likely expect to be isolated from the swab?

e. Non-allergic 96. A 24-year-old woman presents to you with a one-month history of intense burningand itch in her buttock area. On examination, you notice patches of smallerythematouspapulovesicular blisters in the patient’s buttock area. There isobvious evidence of scratching with some areas of bleeding. The signs are typicalof dermatitis herpetiformis. Which one of the following conditions is associatedwith dermatological presentation? a. Inflammatory bowel disease (IBD)

a. Corynebacteriumspp.

b. Irritable bowel syndrome

b. Streptococcus pyogenes

c. Coeliac disease

c. Propionibacterium acnes

d. Varicella zoster virus

d. Staphylococcus aureus e. Pseudomonas aeruginosa 91.

Management of atopic dermatitisA 2-year-old boy who you suspect has atopic dermatitis presents with areas of erythema coupled with itchy blisters on his scalp and cheeks. The most appropriatefirst-line management is:

e. Herpes simplex virus 97. A 33-year-old man with coeliac disease presents with a blistering rash over theelbows and scalp. A diagnosis of dermatitis herpetiformis is made. The mostappropriate treatment is: a. Oral prednisolone

a. Phototherapy

b. Dapsone

b. Immunosuppressant ointment

c. Non-steroidal anti-inflammatory drugs (NSAIDs)

c. Emollient and steroid ointment

d. Aciclovir

d. Oral immunosuppressant therapy e. Wet wraps 92.

e. Fluconazole

c. Penicilliamine

A 26-year-old man presents to you with multiple patches of macularhyperpigmentation which have been present since he was an infant but now areincreasing in number. In addition he has several small, soft, violaceous nodules onhis trunk which tend to catch on clothing causing discomfort. What is the pattern of inheritance in this condition?

d. Psoralens

a. Autosomal recessive

e. Polcystic ovarian disease

b. Autosomal dominant

Which one of the following is a cause of hirsutism?

98.

a. Hypothyroidism b. Anorexia nervosa

93.

A 67-year-old woman presents to you with extensive scalp hair loss which hasbeen getting progressively worse over the last year. You also notice thinning of theeyebrows. The patient’s past medical history includes hypertension, left-sidedpulmonary embolism one year ago and hypercholesterolaemia. You assess thepatient’s medication list. Which one of the following drugs could be responsible forcausing generalized alopecia? a. Aspirin b. Warfarin c. Simvastatin d. Ramipril e. Bendroflumethiazide

94. A 56-year-old man presents in your clinic with a threemonth history of weightloss despite no change in his appetite. The patient has no past medical history andno known drug allergies. On examination, you notice an area of hyperpigmentedskin in his left axilla. On palpation, the texture of the area of hyperpigmentation feels velvety. You suspect that the patient has acanthosisnigricans secondary to apossible malignancy. Which one of the following malignancies is most commonlyassociated with this dermatological presentation? a. Lung carcinoma

c. X-linked dominant d. Polygenic e. No pattern of inheritance 99.

Which one of the following conditions is a cause of generalized cutaneoushypopigmentation? a. Phenylketonuria b. Vitiligo c. Tuberous sclerosis d. Leprosy e. Pityriasisversicolor

100. A 40-year-old woman presents with a 36-hour history of developing erythematousboils on her trunk. Some of them have burst leaving what seems to be painfulwounds on her chest. On examination of the chest you notice three very painfululcerating wounds with undermined edges and surrounding erythema. The lesionsare closely associated with a condition that the patient was diagnosed with 15months ago. Which one of the following conditions is associated with the abovedescribed cutaneous lesions? a. Vasculitis b. Sarcoidosis


c. Tuberculosis d. Crohn’s disease e. Herpes simplex virus 101. Which of the following treatment options would be the most appropriate for apatient with pyodermagangrenosum? a. Oral low-dose prednisolone and dressings b. IV antibiotics and dressings c. Oral antibiotics and dressings d. Oral high-dose prednisolone and dressings e. No treatment required

a. Corynebacteriumminutissimum b. Staphylococcus aureus c. Clostridium perfringens d. Staphylococcus epidermidis e. Streptococcus pneumoniae 108. 68-year-old man is diagnosed with right forearm cellulitis. You are asked to startthe patient on treatment and he has no known drug allergies. Which one of thefollowing antibiotics would be the most appropriate choice in this scenario? a. IV clindamycin b. Oral clindamycin

a. Ulcerative colitis

c. IV flucloxacillin

b. Stevens–Johnson syndrome

d. Oral flucloxacillin

c. Syphilis

e. Oral erythromycin

d. Reiter’s syndrome e. Coeliac disease 103. A 49-year-old woman presents to you in clinic with blue-red nodules on the nosewhich resemble lesions seen in lupus pernio. Which one of the following conditionsis lupus pernio is associated with? a. Rheumatoid arthritis b. Systemic lupus erythematosus (SLE) c. Sarcoidosis d. Tuberculosis e. Herpes simplex infection 104. Which one of the following tumours of the skin is not considered to be benign? a. Seborrhoeic keratosis b. Pyogenic granuloma c. Bowen’s disease d. Epidermal naevi e. Histiocytoma 105. Following genetic profiling and clinical examination, you diagnose an 18-year-oldwoman with tuberous sclerosis. She initially presented with cutaneous lesionswhich were suspicious of this diagnosis. Which one of the following skin lesions isassociated with tuberous sclerosis? a. Pyodermagangrenosum b. Ash-leaf hypopigmentation c. Erythema nodusum d. Café-au-lait spots e. Erythema multiforme 106. Which one of the following nutritional deficiencies is the triad of dermatitis,diarrhoea and dementia associated with?

109. A 56-year-old man presents with two lesions on his neck which have beenincreasing in size over the last three months. On examination you notice two firmbrown-coloured nodular lesions on the anterior aspect of the neck. The nodulesgive an ‘apple-jelly’ appearance on diascopy. The patient is systemically well. The most appropriate treatment is: a. Oral flucloxacillin b. Oral rifampicin, pyrazinamide, isoniazid and ethambutol c. IV vancomycin d. Oral erythromycin e. Oral rifampicin and pyrazinamide 110. A 75-year-old man presents to your clinic with a dark lump on his forehead whichhas been increasing in size over the last 6 weeks. He first noticed the lump,whichinitially appeared as a small pinkish-red patch of skin, over a month ago. Onexamination you observe a 12 cm hyperpigmented nodule with everted edges anda centrally, deep, ulcerated red base. Which one of the following is the most likelydiagnosis? a. Basal cell carcinoma b. Squamous cell carcinoma c. Actinic keratoses d. Keratoacanthoma e. Bowen’s disease 111. A 49-year-old woman is diagnosed with a malignant melanoma which was excisedfrom her right leg. She has been doing some research on the internet regarding thedifferent types of malignant melanoma. Which one of the following variants ofmalignant melanoma is considered to be the most common? a. Nodular melanoma b. Lentigomaligna melanoma c. Acral melanoma

a. Vitamin C deficiency

d. Superficial spreading melanoma

b. Vitamin B1 deficiency

e. Subungual melanoma

c. Protein malnutrition d. Nicotinic acid deficiency e. Vitamin B6 deficiency 107. A 45-year-old woman presents to you with a 3-day history of an ovoid patch oftender erythema, on the posterolateral aspect of her left calf, which has beenincreasing in size. She recalls injuring her left leg a week ago while gardening. Onexamination, the patient is afebrile and on inspection of the left calf, the patch oferythema measures roughly 33 cm with poorly demarcated edges. On palpationthe zone of erythema is warm and very tender. Full blood count reveals a white cellcount of 20.1 with a neutrophil count of 15.0. Which

112. A 40-year-old woman who you referred for excision biopsy of a suspectedmalignant melanoma on her right leg returns for a follow up of her results. Theresults of the biopsy return confirming a superficial spreading melanoma with aBreslow thickness of <1 mm. What five-year survival rate does a Breslow thickness of 1 mm correspond to? a. 50 per cent b. 60–75 per cent c. 75–80 per cent d. 80–96 per cent e. 95–100 per cent

DERMATOLOGY

102. Which of the following answers from the list below is not a cause of orogenitalulceration?

of the following organismsisthe most likely cause of this 1201 condition?


1202 113. A 67-year-old woman presents to you with pruritic plaques over her chest and backwhich are erythematous and resemble psoriatic plaques. From the patient’s historyyou suspect that the lesions are malignant. Which one of the following cutaneousmalignancies resembles psoriasis in the initial stages? a. Merkel cell carcinoma b. Histiocytosis X c. Kaposi’s sarcoma d. Malignant melanoma

MCQ's

e. Cutaneous lymphoma 114. A 63-year-old woman presents to your clinic with a painful wound on her left footwhich has not been healing despite regular application of dressings. The patient hasa history of peripheral vascular disease. On examination, you observe a 21 cmwell-demarcated ulcer on the left heel of the foot. The ulcer has a ‘punched out’appearance and the base appears necrotic. What is the most likely diagnosis? a. Arterial ulcer b. Traumatic ulcer c. Venous ulcer d. Neoplastic ulcer e. Neuropathic ulcer 115. Which one of the following congenital disorders is associated with perioralpigmentation? a. Hereditary haemorrhagic telangiectasia b. Neurofibromatosis c. Ehlers–Danlos syndrome d. Tuberous sclerosis e. Peutz–Jeghers syndrome 116. An 18-year-old man presnts to you with an itchy scalp which has been present for2 weeks following a visit at the barber shop. On examination, you notice a 3 × 3 cmoval area of patchy hair loss in the crown area of the scalp with a ring of erythema.You suspect that the patient has a dermatophytic infection. Which one of thefollowing options would be the most appropriate in treating this condition?

119. A 47-year-old woman presents to clinic with a erythematous, macular, non-tender,‘wing-shaped’ rash over the bridge of the nose and cheeks. Which one of thefollowing conditions is responsible for causing this type of facial rash? a. Rheumatoid arthritis b. Systemic sclerosis c. Systemic lupus erythematosus d. Dermatomyositis e. Psoriatic arthritis 120. A 47-year-old woman patient presents with a facial, macular ‘butterfly rash’. Rheumatological investigations do not reveal that the patient has SLE. You suspectdrug-induced SLE-like syndrome and assess her medication history. Which one ofthe following drugs is most likely to be responsible for this condition? a. Trimethoprim b. Aspirin c. Atenolol d. Diclofenac e. Lansoprazole 121. A patient on the ward has a nodule-like rash and you are asked by your registrarto define the meaning of a nodule. From the list below, select the most appropriatedefinition of a nodule. a. A well-defined flat area of altered pigmentation b. A raised well-defined lesion usually less than 0.5 cm in diameter c. A raised flat-topped lesion which is usually greater than 2 cm in diameter d. A solid lump greater than 0.5 cm in diameter which may besubcutaneous or intradermal e. A well-defined pus-filled lesion 122. Which of the following is not a recognized cause of erythema multiforme? a. Wegener’s granulomatosis b. Herpes simples virus c. Sarcoidosis

a. Oral co-amoxiclav

d. Penicillins

b. Terbinafine cream

e. Idiopathic

c. Fusidic acid cream d. Acyclovir cream e. Oral acyclovir 117. Which one of the following viruses is responsible for causing molluscumcontagiosum?

123. Which of one of the following answers from the list below is a recognized cause oferythema nodosum? a. Diabetes mellitus b. Sarcoidosis c. Venous insufficiency

a. Human papilloma virus (HPV)

d. Pregnancy

b. Herpes simplex virus (HSV)

e. Trauma

c. Pox virus d. Varicella zoster virus (VZV) e. Human immunodeficiency virus (HIV) 118. A 16-year-old male presents to you with multiple comedones on his face and back.On examination you notice the presence of multiple comedones on the patient’sforehead, cheeks and back with peri-lesional erythema. There are no nodules orcysts in these areas. You diagnose the patient with moderate acne. The mostappropriate treatment is: a. Topical benzoyl peroxide

124. Erythema chronicummigransWhich one of the following conditions is erythema chronicummigrans associatedwith? a. Rheumatoid arthritis b. IBD c. Sarcoidosis d. Lyme disease e. SLE 125. Which one of the following skin changes is not typically seen in patients withdiabetes mellitus?

b. Oral erythromycin

a. Neuropathic ulcers

c. Topical clindamycin

b. Necrobiosislipoidica

d. Oral amoxicillin

c. Acanthosisnigricans

e. Oral isotretinoin

d. Lipohypertrophy e. Livedoreticularis


1203

Dermatology - Answers 26. a

51. c

76. a

101. d

2. b

27. d

52.

a

77. a

102. e

3. b

28. c

53. b

78. b

103. c

4. c

29. b

54. a

79. a,c

104. c

5. d

30. a

55. b

80. a

105. b

6. b

31. b

56. a

81. c

106. d

7. b

32. a

57. b

82. b

107. b

8. d

33. a

58. a

83. a

108. c

9. c

34. b

59. b

84. d

109. b

10. d

35. a

60. a

85. a

110. b

11. a

36. c

61. b

86. c

111. d

12. b

37. a

62. b

87. e

112. e

13. b

38. a

63. b

88. a

113. e

14. c

39. a

64. a

89. b

114. a

15. d

40. a

65. b

90. d

115. e

16. d

41. a

66. c

91. c

116. b

17. a

42. b

67. c

92. e

117. c

18. c

43. b

68. a

93. b

118. b

19. d

44. a

69. b

94. d

119. c

20. d

45. c

70. a

95. d

120. a

21. a

46. b

71. a

96. c

121. d

22. a

47. c

72. b

97. b

122. a

23. a

48. a

73. c

98. b

123. b

24. d

49. a

74. b

99. a

124. d

25. d

50. a

75. a

100. d

125. e

DERMATOLOGY

1. d


INFECTION 1.

growth replication determined by environment

a. epidemic b. pandemic

c. viruses

c. endemic 12.

tend to mutate or change during replication making it very difficult for a host to develop adequate immunity

a. bacteria b. fungi

b. fungi

c. viruses

c. viruses

d. protozoa

touching infectious lesion or sexual intercourse a. direct contact b. indirect contact

13. worms, not microorganisms but are parasites and cause infection in humans. they destroy living cells and are common in intestines, heart, worms, hookworms, whipworms, and round worms a. influenza

c. droplet transmission

b. amebic dysentery

d. vectorborne e. noscomial 4.

released after cell death and may cause fever, weakness, or may have serious effects on the circulatory dysfunction

c. helminths 14. drugs derived from organisms such as penicillin from mold. now many drugs are synthetic a. anitmicrobials

a. endotoxins

b. anitibiotics

b. exotoxins 5.

the reservoir is the source of infection (person,animal, water, food)

c. bactericidal 15.

b. streptoccia

b. Fals pathogens are: a. disease causing microbes germs or bugs

c. diplococci 16.

occurring when respiratory of salivary secretions containing pathogens such as influenza or tb are expelled from the body

b. nonpathogenic 17.

b. prodromal period

b. indirect contact

c. acute period

c. droplet transmission e. nosocomial 8.

18.

b. fungi c. viruses d. protozoa

b. exotoxins common signs and symptoms include cysts, abdominal pain, appeteite loss, ulcers, anemia

20.

a. bacteria

b. helminths

c. viruses

c. trichomonasvaginalis

d. protozoa some have an external capsule or slime layer offering additonal protection against human defenses a. bacteria b. fungi c. viruses d. protazoa

protozoa that causes a sexually transmitted infection of the reproductive tracts of men and women, attaching to the mucous membranes and causing inflammation a. amebic dysentery

b. fungi

10.

genetic material takes over control of the host cell, using the hostâ&#x20AC;&#x2122;s capacity for cell metabolism for replication a. bacteria

diffuse through bodily fluid and they stimulate antibodies or antitoxin production a. endotoxins

9.

ends when the host reisitance becomes effective a. incubation period

a. direct contact

d. vectorborne

not causing disease and may be benificial a. pathogenic

b. non disease causing and are benificial 7.

causes skin infections a. staphylococci

a. true 6.

live and grow EVERYWHERE (animals, plants, humans, food, medical equipment)

a. bacteria

d. protozoa 3.

single individuals or localized groups

b. fungi d. protozoa 2.

11.

a. bacteria

21.

worldwide infection a. epidemic b. pandemic c. endemic


22.

AIDS is caused by

32.

a. staphylococci

b. poor personal hygiene

b. streptoccia

c. the HIV virus

c. diplococci

d. contaminated food

33.

c. viruses

b. pandemic

d. protazoa 34.

a. bacteria

a. bacteria

b. fungi

b. fungi

c. viruses

c. viruses

d. protozoa

d. protozoa

Bacteria and viruses can enter the body through:

35.

a. oily skin b. dry skin

b. amebic dysentery

d. moist skin 26. the time between entry of the organism into the body and appearnace of clinical signs symptoms of the disease

c. helminths 36.

a. incubation period

b. candida

c. acute period 37.

b. hep b c. hep c

b. false growth promoted by warmth and moisture a. bacteria

d. hep d 38.

b. fungi

b. fungi

d. protozoa infection occur in health care facilities including hospitals by any method (MRSA, VRE). a. direct contact

c. viruses d. protozoa 39.

b. indirect contact c. droplet transmission

b. antimicrobials

e. nosocomial

31.

involving intermediary such as a contaminated hand or food or inanimate objects

Which are specific to target antifugal, antiviral, antibacterial, these drugs are unique to the type of organism and are NOT interchangeable a. antibiotics

d. vectorborne 30.

can live independently, some live on dead organic matter, and others are parasites living on or in another living host a. bacteria

c. viruses 29.

transmitted by oral fecal route, sex, water, shelfish, a. hep a

a. true 28.

may cause infection in the oral cavity (thrush in infants) or vaginal infection a. tineapedis

b. prodromal period cultures, blood tests, and radiology (x rays) are used to diagnose infection

amebic dysentery of large intestines creating severe diarrhea and live abscesses, is caused by a parasite in the large intestines, vietnam vets, banannas a. STD

c. broken skin

27.

very few are pathogenic, most are considered beneficial since they are important in the production of yogurt, beer, and other foods, as well as serving as a source of antiboitic drugs

c. broad spectrum

a. direct contact

unicellular microorganisms that do NOT require living tissue to survive. they are very simple in structure with a very complex cell wall and they reproduce

b. indirect contact

a. viruses

c. droplet transmission

b. bacteria

d. vectorborne

c. fungi

e. nosocomial

d. protozoa

causes pneumonia

40.

41.

Which exist in many similar forms or strains

a. staphylococci

a. bacteria

b. streptoccia

b. fungi

c. diplococci

c. viruses d. protozoa

INFECTION

24. spread through spores which are reisistant to temp changes and chemicals

require oxygen, carbs, a specific pH, temp b. fungi

a. epidemic c. endemic

1205

a. bacteria

23. infection to a certain area consistently occurring in that popluation

25.

causes respiratory infections

a. the herpes virus


1206 42.

when an insect or animal serves as an intermediary in a disease such as malaria

b. Herpes simplex virus

a. direct contact

d. Mycobacterium tuberculosis

c. Influenza virus

b. indirect contact c. droplet transmission d. vectorborne

e. Neisseria meningitidis 52.

e. nosocomial 43.

a. Cherry red macula

more complex organism, unicellular, mobile, lack a cell wall, and may change shapes

b. Janeway lesions

a. bacteria

d. Retinal artery aneurysms

c. Macular star

b. fungi

MCQ's

c. viruses d. protozoa 44.

hepatitis is a viral infection from liver a. true b. false

45.

e. Roth’s spots 53. A 40 year old single man returned from holiday in Europe with mild bloody diarrhoea which had lasted for two weeks. He had lost 2.5 kg in weight, had occasional lower abdominal cramping discomfort and a painful swelling of his left knee. What is the most likely diagnosis? a. amoebiasis

hard to control, they can hide inside the human cell; they can alter the host cell chromosomes, thus leading to the development of malignant cells or cancer

b. campylobacter infection

a. bacteria

e. ulcerative colitis

b. fungi c. viruses

c. Crohn’s disease d. gonococcalsepticaemia 54.

d. protozoa 46.

a. A bronchopneumonia with abscess formation

a. bacteria

c. An acute respiratory distress syndrome (ARDS) with widespread hyaline membrane formation

b. A haemorrhagic and necrotizing pneumonia

d. An interstitial pneumonitis with foamy intraalveolar exudate

c. viruses d. protozoa Ultrasonic bath cleaners are an effective way to clean tiny crevices in implements only when used with:

e. An organizing bronchopneumonia 55.

a. 70% isopropyl alcohol b. sodium hypochlorite c. an effective disinfectant d. an effective astringent 48. most common nosocomial infection in the world, anaerovic bacterium infection, acquired in hospitals, developcolities following antibiotic intake, 1/3 infected dont have symptoms

b. Haemophilusinfluenzae c. Listeria monocytogenes d. Neisseria meningitidis

b. VRE

e. Streptococcus pneumoniae

c. clostridium difficile some remain latent after invasion; they enter the host cells and replicate very slowly or not at all until some later time a. bacteria b. fungi c. viruses d. protozoa 51.

A 26yearold previously healthy woman has the sudden onset of mental confusion. She has a seizure and is brought to the hospital. Her vital signs show blood pressure 100/60 mm Hg, temperature 37 C., pulse 89, and respirations 22. A lumbar puncture reveals a normal opening pressure, and clear, colorless cerebrospinal fluid is obtained with 1 RBC and 20 WBC’s (all lymphocytes), with normal glucose and protein. An MRI scan reveals swelling of the right temporal lobe with hemorrhagic areas. Which of the following infectious agents is the most likely cause for these findings? a. Haemophilusinfluenzae

A 70yearold man presented to his GP with a twoday history of increasing confusion. He also complained of a headache. He was febrile on examination; nuchal rigidity was noted. A lumbar puncture was performed and CSF microscopy revealed: WBC 800 cells/mL (<5) 90% neutrophils. A few Grampositivediplococci were also noted. What is the cause of his meningitis? a. Cryptococcus neoformans

a. Staph

50.

The morphological appearance of Pneumocystis carinii infection in the lung is best characterised as which one of the following?

a very small parasite that requires a LIVING host cell for replication b. fungi

47.

A 45yearold woman was diagnosed with bacterial endocarditis. What is the characteristic fundoscopic feature of this disease?

56.

A 19yearold man returned to the UK two weeks after working in a refugee camp in subSaharan Africa. On examination he was febrile, dyspnoeic and widespread inspiratory crackles were present. He had an extensive maculopapular rash, conjunctivitis, generalized stomatitis and some bluishgrey spots on the buccal mucosa. What is the most likely diagnosis? a. Epidemic typhus b. Epstein Barr virus infection c. Leptospirosis d. Measles e. Parvovirus infection

57. Twenty of thirty patients in an adult ward develop colicky abdominal pain and diarrhoea without vomiting between 21:00 and 01:00 hrs. Meat stew was served for lunch at noon. Which of the following is the likely diagnosis? a. Bacillus Cereus b. Clostridium perfringens


c. EnterotoxigenicE.Coli

64.

d. Enterovirus 58.

e. Staphylococcus Aureus

a. <1000 cells/mm3

Which of the following is true of tetanus?

c. <350 cells/mm3

b. <500 cells/mm3

a. failure to culture Clostridium tetani from the wound would make the diagnosis doubtful

d. <200 cells/mm3 e. <50 cells/mm3

b. infection confers lifelong immunity c. there is a characteristic EEG

65.

d. Clostridiumspecific intravenous immunoglobulin is of no benefit once spasm has started

b. It is a recognised cause of chronic liver disease. c. CT scan of the liver with contrast shows diagnostic appearances. d. The incidence of chronic liver disease is reduced by administration of alpha interferon. e. It does not result in a carrier state. 66.

a. It is most commonly caused by the fungus microsporumcanis.

b. Penicillinresistant Neisseria gonorrhoeae

b. Its presence should suggest immunological deficiency.

c. Reinfection with Neisseria gonorrhoeae

c. It often results in permanent alopecia.

d. Ureaplasmaurealyticum

d. It causes patches that fluoresce dull green under Wood’s lamp.

e. Urethral stricture 60. A 20 yearoldwoman presented with a solitary, crusted, thickened lesion on her face one month after returning from a holiday in Central America. What is the most likely diagnosis?

e. It is effectively treated with topical Nystatin ointment. 67.

What is the most likely diagnosis? a. HIV infection

a. Cutaneous anthrax

b. Infectious mononucleosis

b. Cutaneous leishmaniasis

c. Malaria

c. Impetigo

d. Miliary tuberculosis

d. Leprosy

e. Visceral leishmaniasis

e. Onchocerciasis 61.

Which statement regarding tineacapitis is correct?

a. Chlamydia trachomatis

A 35yearold man presented with cellulitis of his right leg. On examination he was mildly confused and febrile (40.1°C) with a pulse was 120 / minute and BP 80/55 mmHg. He was treated with intravenous benzylpenicillin and flucloxacillin. Group A Streptococcus was isolated from two sets of blood cultures. There was no significant clinical improvement after 24 hours. What antibiotic should be added? a. Ciprofloxacin b. Clindamycin c. Gentamicin d. Rifampicin e. Vancomycin

68.

A 22yearold female student attended Casualty complaining of fever and rigors for two days. She had returned from a sabbatical in Africa six weeks previously. She was febrile (39.9°C) and a mild petechial rash was also noted. Laboratory investigations showed.

Hb 10.1 g/dL (11.516.5)

WBC 3.0 x 109/L (411)

Platelets 115 x 109/L (150400)

Prothrombin time Normal What is the most likely diagnosis? a. Acute HIV infection (seroconversion illness) b. Cytomegalovirus infection

62. Regarding the epidemiology of infections, which of the following statements is true?

c. Dengue fever

a. Resistant vivax malaria is a major problem in Kenya.

e. Typhoid fever

b. Diphtheria has been eradicated in most parts of the world. c. Polio has been eradicated in most parts of the world. d. Tetanus has been eradicated in most parts of the world. e. The AIDS epidemic seems to be declining worldwide. 63. A 22 year old male presents with generalised pruritus of six weeks duration. Examination reveals little except for erythematous papules between the fingers. Which ofthe following therapies would be most appropriate for this patient? a. Astemizole b. Calamine lotion c. Chlorpromazine d. Ciprofloxacin e. Permethrin cream

d. Plasmodium falciparum malaria 69. A 20yearold caucasian student returns from Ghana with a spiking temperature and nocturnal sweats. She has 0.5% of red blood cells infected with plasmodium falciparum. Select one of the following answers relating to quinine therapy in this case: a. quinine contraindicated in those taking mefloquine prophylactically b. quinine must always be given parenterally initially c. pregnancy is a contraindication for quinine d. glucose level should be monitored in those on treatment with quinine e. dose of quinine should be reduced in liver impairment

INFECTION

A 19yearold male student attends casualty complaining of an urethral discharge. Gram stain shows numerous neutrophils, some of which contain gramnegative intracellular diplococci. The patient is treated with Ceftriaxone, 250 mg as an im injection. Five days later, the patient reattends with persisting discharge. Which of the following is the most likely cause of this discharge?

Which of the following is true concerning a hepatitis E infection? a. It can be transmitted with hepatitis B.

e. cephalic tetanus causes severe dysphagia 59.

In HIV disease, patients first become susceptible to infection 1207 with Pneumocystis carinii when the CD4 cell count falls to:


c. Loss of a plasmid containing the resistance gene

1208 70. Which of the following statements is true about immunological reactions?

d. Mutations in the resistance gene

a. Serum sickness is caused by a type II reaction. b. Grave’s Disease is caused by a type IV reaction. c. Angioneuroticoedema is the most severe form of type I reaction. d. Urticaria usually responds to Cimetidine. e. Deficiencies in the terminal components of complement increase the risk of meningococcal disease.

MCQ's

71.

A 41yearold African man has a history of multiple episodes of sudden onset of severe abdominal pain and back pain lasting for hours. Each time this happens, his peripheral blood smear demonstrates numerous sickled erythrocytes. A haemoglobin electrophoresis shows 94% Hgb S, 5% Hgb F, and 1% Hgb A2. He now has increasing pain in his right groin radiating to the anterior aspect of the thigh and to the knee. His temperature was 38°C and examination of his hip revealed pain on internal rotation. A radiograph reveals irregular bony destruction of the femoral head. The most likely organism to be responsible for these findings is?

e. Transposition of another sequence into the resistance gene 76. A 63 year old patient with known alcohol related cirrhosis presented with ascites, abdominal tendernessand peripheral oedema. A diagnostic tap revealed a neutrophil count of 400/ mm3 (normal <250mm3).Which of the following would be of most immediate benefit? a. fluid restriction and a no added salt diet b. intravenous antibiotics c. oral spironolactone d. therapeuticparacentesis e. transjugular intrahepatic portosystemic shunt 77.

a. children are particularly likely to become carriers b. most carriers are female

a. Candida albicans

c. faecal culture is almost always positive during the first week of illness

b. Clostridium perfringens

d. relapse does not occur if antibiotics are taken for 2 weeks

c. Group B streptococcus

e. vaccinated individuals who develop the disease will have a mild illness

d. Salmonella species e. Yersinia pestis 72.

78.

b. Intravenous cefotaxime c. Intravenous metronidazole

b. lesions are usually painful and tender c. lesions are associated with marked oedema d. Mortality is approximately 20% despite antibiotic therapy e. Is very likely to occur in subjects exposed to anthrax spores 79.

b. infection in the first trimester of pregnancy is seldom harmful to fetus

e. Oral norfloxacin

c. Allergic BronchopulmonaryAspergillosis d. Brucellosis e. Farmers’ lung 74.

c. undercooked meat is an important cause of infection

A 36 year old woman presents with dyspnoea, cough and fever. Crackles are heard on auscultation of the lungs. Circulating precipitans to Micropolysporafaeni are positive.Which of the following is the most likely diagnosis? b. Pigeon fanciers’ lung

d. infection usually by respiration e. prophylacticimmunoglobulins should be given to pregnant women if their IgMantitoxoplasma antibodies detected. 80. A 26yearold man with a history of alcohol and drug abuse was admitted with a 14 day history of fever,cough and fatigue. He was emaciated. His temperature was 39.4°C. Cervical and axillary lymphadenopathywere present. Chest Xray revealed bilateral areas of pulmonary shadowing. Which of the following is themost likely diagnosis? a. alcoholic cardiomyopathy

Which of the following would be indicated in the treatment of a 30 year old HIV positive male withpneumocystis carinii pneumonia? Blood gases reveal a P02 of 55mmHg whilst breathing 28% oxygen.

b. pneumococcal pneumonia c. pneumocystis pneumonia d. pulmonary tuberculosis

a. Atovaquone

e. tricuspid endocarditis

b. Clindamycin c. Leucovirin

81.

d. Pentamidine 75.

Toxoplasmosis a. can cause fits in AIDS

d. Oral neomycin

a. Malt workers’ lung

Which of the following is a true of cutaneous anthrax? a. causes a black eschar which overlies pus

A 35 year old woman with alcoholic cirrhosis is admitted with deteriorating encephalopathy and abdominaldiscomfort. An ascitic tap revealed a polymorphonuclear cell count of 350 cells per mm3. Which of the following is the most appropriate therapy? a. Intravenous amoxicillin

73.

Which of the following is correct regarding infection with Salmonella typhi

Whichof the following is true of Spontaneous bacterial peritonitis?

e. Trimethoprimsulphamethoxazole

a. A survival rate of over 50% is expected at one year

Two strains of Escherichia coli are isolated and both are resistant to ampicillin. Strain A retains its resistance to amplicillin when grown form multiple generations in the absence of ampicillin. However strain B loses its resistance when grown in the absence of ampicillin. Which of the following best explains the loss of antibiotic resistance in strain B?

c. is characteristically caused by aerobic bacteria.

a. Changes in the bacterial DNA gyrase b. Downregulation of the resistance gene

b. Gentamicin is the treatment of choice d. is diagnosed by culture of ascitic fluid. e. is due to intestinal perforation 82.

You are an occupational health physician and have been asked by an anxious employee about contraindications to pertussis immunisation. Which of the following is a contraindication? a. Eczema


b. Cow’s milk protein intolerance. c. Fever to 39.5°C following the first dose. d. Redness of >2.5cm at the injection site after the first dose.

89. Four members of a football team develop diarrhoea due to 1209 Salmonella enteritidis. Eating which food was the most likely source of the infection? a. chicken at a fast food outlet 20 hours earlier

e. Hydrocephalus 83.

b. fried rice at a takeaway 4 hours earlier

The antibiotic combination Quinipristin and Dalfopristin are

c. raw eggs in milk 6 hours earlier

a. effective against resistant mycobacterium TB.

d. raw oysters at a hotel 24 hours earlier

b. indicated in subjects with chronic renal impairment.

e. soft cheeses 48 hours earlier

c. particularly effective in the treatment of pseudomonas infection in Cystic fibrosis. d. administered orally. e. Effective against multiresistant Staph Aureus Which of the following is the commonest cause of traveller’s diarrhoea?

a. Acute rheumatic fever

a. E. Coli

b. Left atrial myxoma

b. EntamoebaHistolytica

c. LibmanSacks endocarditis

c. Giardia Lamblia

d. Nonbacterial thrombotic endocarditis

d. ShigellaFlexneri

e. Paradoxical thromboembolus

e. Yersinia enterocolitica 85.

Which of the following is true concerning Whooping cough (pertussis)?

91.

a. cause resistant infective diarrhoea

a. is a greater threat to children during the second 6 months of life, after maternal antibody has declined, than during the first 6 months

b. produce an enzyme that inactivates vancomycin c. may be found in healthy community volunteers not recently hospitalized

b. may lead to hemiplegia c. is characteristically leucocytosis

associated

with

a

d. high dose ampicillin is the treatment of choice

polymorph

d. is associated with convulsions less frequently than is the case with other febrile conditions

e. are commonly vancomycindependent 92.

e. rapidly resolves with antibiotic treatment 86. A 30 year old renal transplant recipient presented with nonHodgkin’s lymphoma. Which virus is most likely to be of aetiological significance? a. Adenovirus

b. An increased platelet count

c. Epstein Barr virus

c. Cirrhosis of the liver

d. Herpes simplex type 1

d. Generalized atherosclerosis

e. Varicellazoster

e. Poor nutrition 93. A young man from India presents with fever of 4 months duration and splenomegaly. What is the mostlikely diagnosis? a. Coccidiomycosis b. Giardiasis c. Tropical sprue d. Typhoid

a. Aspergillosis b. Pneumocystis carinii pneumonia c. Small cell carcinoma d. Squamous cell carcinoma e. Tuberculosis 88.

Which of the following concerning IgG is correct?

An 85 year old patient from an elderly care home, experiences sudden onset of dyspnea and palpitations. Apulmonary ventilationperfusion scan is performed and indicates a high probability for a perfusion defectinvolving a pulmonary arterial branch. Which of the following findings or conditions is the one that is the most important factor favouring development of her complaint? a. A neutrophilia

b. Cytomegalovirus

87. A 49yearold man with a long history of alcoholism presents with cough, haemoptysis and pleuritic chestpain. He has had night sweats and 10 kg weight loss in the last three months. On chest Xraytgere is a subtle nodular pattern throughout the lung. He underwent a transbronchial biopsy which showed multinucleated giant cells, epithelioid cells and necrotic debris. Which of the following is the most likely diagnosis?

Which of the following is a feature of Vancomycinresistant enterococci?

e. Visceral leishmaniasis 94. A 35yearold man returned from a twoweek holiday complaining of pain in the loins and painful swollenknees. On examination he was afebrile and had significant bilateral knee effusions. Mild penile erythema wasalso noted. Laboratory investigations showed.

a. It has a molecular weight of 50,000 kd.

Hb 15.6 g/dL

b. It is monovalent.

WBC 16.2 x 109/l

Neutrophils 14.1 x 109/l

ESR 65 mm/h

Rheumatoid factor 10 IU/L

Urinalysis No cells, casts or bacteria seen

c. It comprises the majority of circulating antibody in serum. d. It differs from other isotypes in not being able to cross the placental barrier. e. It is the major antibody produced during the primary response.

INFECTION

84.

90. A 68yearold man has been very ill for months following the onset of chronic liver disease with hepatitisC infection. He experiences a sudden loss of consciousness and then exhibits paraplegia on the right. A cerebral angiogram reveals lack of perfusion in the left middle cerebral artery distribution. The most likelycardiac lesion to be associated with this finding is?


1210

b. Intact antigen is presented in association with self MHC molecules.

What is the most likely diagnosis? a. Arthritis due to Neisseria gonorrhoeae infection

c. Cooperation with other cell types is required for T cell recognition of antigen.

b. Lymphogranulomavenereum c. Reactive arthritis

d. gamma/delta + T cells respond to antigen presented in association with MHC class II molecules.

d. Reitter’s syndrome e. Rheumatoid arthritis

MCQ's

95.

A 40yearold man has had decreased mentation with confusion as well as increasing incoordination andloss of movement in his right arm over the past 6 weeks. An MRI scan shows 0.5 to 1.5 cm lesions in cerebralhemispheres in white matter and at the greywhite junction that suggest demyelination. A stereotatic biopsy isperformed, and immunohistochemical staining of the tissue reveals JC papovavirus in oligodendrocytes. Whichof the following laboratory test findings is most likely to be associated with these findings? a. CD4 lymphocyte count of 90/microliter b. HaemoglobinA1c of 9.8%

c. psoralen with ultraviolet light (PUVA) therapy d. topical selenium sulphide e. phototherapy with ultraviolet light (UVB)

e. Serum sodium of 110 mmol/L

b. Absence of erythema surrounding lesions

Which one of the following Tlymphocytes is correct?

c. Are infected by mononucleosis

statements

concerning

EpsteinBarr

virus

in

infectious

d. produceIgG e. T cell lymphoma has a better prognosis

d. Presence of pruritis e. Positive contact history 103. Ten individuals are admitted to casualty with profuse vomiting after attending a retirement dinner in achinese restaurant. They all ate at roughly 7 pm and became ill at roughly midnight. Nine ate a mixture ofdishes except one female who ate vegetarian dishes with her rice. What is the most likely infective organism? a. Salmonella enteriditis

a. It is active against Candida albicans.

d. Clostridium perfringens

c. It should not be used in renal failure. d. It used for a maximum of 2 weeks. e. It is associated with druginduced Stevens Johnson syndrome.

b. Staphylococcus aureus c. E. Coli e. Bacillus cereus 104. A 27 year old man presents with fever, urethritis and arthralgia. He is found to have a swollen ankle witha pustular rash on the dorsal aspect of his foot. What is the most likely diagnosis? a. Gonococcal sepsis

A 14 year old boy presents with fever. Which of the following might contribute to a diagnosis of rheumatic fever?

b. Lyme disease

a. The finding of target lesions on the hands.

d. Staphylococcal arthritis

b. The finding of tender nodules in the fingertips. c. A prolonged PR interval on ECG. d. A CRP of 10. e. Positive Romberg’s sign. A 75 year old man has a history of Chronic Lymphocytic Leukaemia. He has had treatment with severalcourses of chemotherapy and has now been admitted to hospital with pneumonia. His past medical historyrevealed that he had suffered several previous upper respiratory tract infections over the previous six months. Which of the following components of his immune system is likely to be deficient? a. Complement

of

c. Lesions disappearing within a month

You are considering starting a patient on Griseofulvin. Which of the following statements concerning its pharmacology is true? b. It is active against aspergillus.

99.

b. oralterbinafine

a. Presence of macules and papules

b. Compose the majority of lymphocytes in plasma

98.

a. methotrexate

d. Oligoclonal bands in CSF

a. Are the primary host response in bacterial infection

97.

101. A 40yearold man presented with pityriasisversicolor. What is the most appropriate treatment?

102. Which of the following suggests a diagnosis molluscumcontagiosum rather than chickenpox?

c. HDL cholesterol of 0.7 mmol/L

96.

e. Interactions of the TcR with an appropriate Ag/MHC complex activates a resting T cell.

c. Reiter’s syndrome e. Tuberculous arthritis 105. A 63 year old female presents with a one day history of confusion with headaches. On examination she is confused, with a Glasgow ComaScale of 13 and a temperature of 39.5. She has nuchal rigidity and photophobia. CSF examination reveals a glucose of 0.5 mmol/l, a white cell count of 2500 per mm and Gram positive Cocci in pairs. Which of the following is correct? a. The most likely infective organism is Staphylococcus Aureus b. The organism is likely to be penicillin resistant. c. Rifampicin should be given to close contacts.

b. Immunoglobulin G

d. Nerve deafness would be a common complication in this case.

c. Macrophages

e. A characteristic rash would be expected.

d. Mast cells e. T lymphocytes 100. Which of the following is true of the the T cell response to antigen? a. A process of affinity maturation of the T cell receptor occurs.

106. A young teenager presents with fever and headache. He has received oral Amoxycillin for 3 days. Which of the following CSF findings would exclude a partially treated meningitis? a. Negative gram stain b. A CSF glucose of 45% of blood glucose c. A white cell count of 50


d. A negative CSF culture

d. Pneumocystis carinii

e. Negative Kernig’s Sign

e. Toxoplasma gondii

107. Which of the following statments is characteristic of acute hepatitis B infection?

1211

114. In herpes simplex encephalitis which of the following statements is correct?

a. Most patients present with splenomegaly.

a. brain MRI is characteristically normal

b. It confers immunity to hepatitis A.

b. temporal lobe involvement is common

c. It commonly presents with distal joint arthritis.

c. fits are uncommon

d. There is increased infectivity in the presence of the e antigen.

d. cold sores or genital herpes are usually present

e. Pruritis is an important early symptom.

e. viral identification by PCR on cerebrospinal fluid is nonspecific

108. Giardia lambdia infection a. is often symptomatic c. is eradicated by mebendazole d. causessteatorrhoea e. diagnosed by stool culture 109. Which of the following statements is true of psittacosis (ornithosis): a. It is only a risk from contact with psittacines (parrots), not other birds b. It usually causes many polymorphs to be present in the sputem c. It is more of a risk to children than to adults who are exposed to birds

115. A 52yearold woman was admitted with malaise and leg weakness. Her illness started with a sore throat while travelling in Eastern Europe. On examination she was febrile (39.1°C) with several areas of exudates on her pharynx and extensive cervical lymphadenopathy. There was weakness of the legs with absent tendon reflexes. What is the most likely diagnosis? a. Acute myeloid leukaemia b. Cytomegalovirus infection c. Diphtheria d. Glandular fever e. Streptococcal tonsillitis 116. Which of the following Corynebacteriumdiphtheriae is correct?

concerning

d. It does spread from person to person

a. Causes skin infection

e. Infection responds rapidly to penicillin therapy

b. Infection is often complicated by myocardial fibrosis after recovery from severe infection

110. Which of the following is true of Koplik’s spots? a. Are diagnostic of Measles b. Located opposite the incisor teeth.

c. Is most unlikely to cause infection in an individual with a positive Schick test

c. Only appear when fever is over 39°C

d. Mitis strain is generally more virulent than the intermedius strain

d. They appear as red papules on the plamar surface of the hands

e. Toxin is better absorbed through the nasal than the pharyngeal mucosa

e. Typically appear two days after the rash. 111. Which of the following statement is true of infections with Mycobacterium tuberculosis: a. nonsputum producing patients are noninfectious b. a positive tuberculin test indicates active disease c. lymph node positive disease requires longer treatment than pulmonary disease d. in pregnant women treatment should not be given until after delivery e. pyrazinamide has high activity against active extracellular organisms 112. Which of the following statements concerning zoonotic diseases is true? a. Brucellosis is characterised by neutrophil leucocytosis. b. Brucellosis is a recognised cause of spondylitis. c. Toxoplasmosis causes visceral larva migrans. d. Toxoplasmosis causes posterior uveitis. e. Serological evidence of toxoplasmosis is rare in adults. 113. A 42yearold man with advanced HIV disease presented with a tonicclonic seizure. He had been diagnosed with HIV 10 years previously, but had elected not to take antiretroviral therapy. A CT scan of his brain showed a 2 cm ringenhancinglesion in the right parietal lobe. What is the probable causative agent? a. Cryptococcus neoformans b. Mycobacterium aviumintracellulare c. Mycobacterium tuberculosis

117. A 43yearold woman develops a progressive, ascending motor weakness over several days. She is hospitalized and requires intubation with mechanical ventilation. She is afebrile. A lumbar puncture is performed with normal opening pressure and yields clear, colorless CSF with normal glucose, increased protein, and cell count of 5/microliter, all lymphocytes. She gradually recovers over the next month. Which of the following conditions most likely preceded the onset of her illness? a. Ketoacidosis b. Staphylococcus aureus septicemia c. Systemic lupus erythematosus d. Viral pneumonia e. Vitamin B12 deficiency 118. Which of the following is true of anthrax? a. It is caused by an aerobic, gram negative rod. b. It causes trivial disease in the host herbivore population. c. Gastrointestinal anthrax is the most usual form of disease in humans. d. Eshars are usually painless. e. Sputum culture has a high yield in inhalational anthrax. 119. Which of the following forms of encephalitis is caused by a neuroimmunological response? a. Herpes simplex b. Measles c. HIV infection

INFECTION

b. is usually spread faecalorally


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d. Enteral viruses

b. is a killed polysaccharide antigen vaccine

e. Cytomegalovirus

c. should be given to all children who have a strongly positive tuberculin test

MCQ's

120. A 40yearold man with a long history of alcohol abuse is admitted with a subacute illness, comprisingheadache, fever, meningism and ataxia. MRI brain showed patchy high signal abnormality of the brain stem.CSF analysis showed polymphonuclearpleocytosis and low glucose. He had failed to improve after 3 days ofintravenouscefotaxime treatment. The most likely diagnosis of the meningitis is:

d. is presently routinely offered in the UK at age 16 years e. Provides protection against leprosy 127. Which of the following microorganisms is generally sensitive to Benzylpenicillin? a. Bordetella pertussis

a. Mycobacterium tuberculosis

b. Cryptococcus neoformans

b. Cryptococcus neoformans

c. Mycoplasma pneumoniae

c. Nocardiaasteroides

d. Streptococcus Pneumonaie

d. Staphyloccusaureus

e. Streptococcus Viridans

e. Listeria monocytogenes 121. Which of the following is correct regarding human varicella zoster immunoglobulin (VZIG)? a. Is used to treat severe chicken pox infection b. Is recommended for all patients with eczema exposed to chickenpox. c. Is invariably protective against severe varicella. d. Should be given to a 14 day old whose mother has developed chickenpox

128. A 30 year old man developed a febrile illness three days after returning from a holiday in Thailand. He was admitted complaining of severe myalgia. On examination he was febrile (39?C) with a diffuse macular rash on the trunk. There was no lymphadenopathy.

Serum total bilirubin 18 Îźmol/L (122)

Serum alanine aminotransferase 120 U/L (535)

What is the most likely diagnosis?

e. Should be given to a 20 week pregnant nonimmune female who has been exposed to a case of chicken pox.

a. Acute HIV infection (seroconversion illness) b. Dengue fever c. Hepatitis E

122. Which of the following is a contraindication to immunisation?

d. Secondary syphilis

a. Infantile eczema requiring topical steroids.

e. Typhoid

b. Oral poliomyelitis vaccine to a child on oral steroids. c. A history of prolonged jaundice. d. A child with congenital adrenal hyperplasia on oral cortisone.

129. Primary Pulmonary tuberculosis: a. Leads to pleural effusion b. Is highly infective

e. A child with cerebral palsy.

c. Commonly leads to military TB

123. Which of the following statements is correct of hepatitis C virus infection? a. Cell cultures of virus are routinely used to assess response to drug therapy b. High antibody titres are an indication for therapy c. Less than 5% of cases lead to chronic infection d. More likely to be transmitted by the sexual route than hepatitis B virus e. Treatment with ribavirin and interferon alpha is more effective than interferon alpha alone 124. In the diarrhoea associated with cholera toxin, there is activation of which of the following enzyme systems? a. Adenylatecyclase. b. ATP. c. Guanylatecyclase. d. Naglucosecotransporter. e. Na+/K+ ATPase pump. 125. Regarding diphtheria which of the following statments is correct? a. It is predominantly spread from cutaneous lesions. b. It is characterised by an inflammatory exudate forming a greyish membrane on the buccal mucosa. c. It produces a toxin which affects the myocardium, nervous and adrenal tissues. d. 3 doses of toxoid provides 75% protection. e. About 50 cases per year are seen in the UK. 126. Which of the following is true of BCG vaccination? a. is contraindicated in neonates

d. May be totally asymptomatic e. Usually produces cavitation 130. A 54year old woman was admitted with acute breathlessness. On examination she had a temperature of 37.9oC, a respiratory rate of 32 breaths per minute, a pulse of 120 beats per minute, a blood pressure of 100/60 mmHg, and a peak expiratory flow rate of 250 litres per minute.

Auscultation of the heart and chest was normal.

The Chest Xray was normal and blood gases on air showed:

pH 7.35 (7.36 7.44)

Pa02 6.0

kPa (11.3 12.6)

PaC02 3.9

kPa (4.7 6.0)

Serum bicarbonate 20 mmol/l (20 28)

She was started on high flow oxygen. What is the most important next treatment? a. amoxycillin intravenously b. aminophylline intravenously c. intravenous fluids d. low molecular weight heparin e. nebulised salbutamol


131. A 30 year old intravenous drug abuser develops acute aortic regurgitation due to infective endocarditis. Which of the following is least likely to be found on clinical examination? a. decreased cardiac output b. decrescendo diastolic murmur c. hypotension d. mitral valve preclosure e. peripheral vasodilatation 132. Which of the following is correct regarding Herpes simplex encephalitis? a. shows a peak incidence in the Autumn

c. produces a diffuse, evenly distributed inflammation of cerebral tissues d. produces a typical EEG pattern with lateralised periodic discharges at 2 Hz e. should be treated with acyclovir as soon as the diagnosis is confirmed by urgent CSF viral antibody titres 133. Herpes zoster infection : a. Gamma Interferon is an effective treatment. b. produces latent infection within the anterior horn cells c. causes urinary incontinence d. causes congenital limb deformity e. associated pneumonitis is equally common in smokers and nonsmokers 134. A 25 year old male homosexual is admitted with dyspnoea and weight loss of 2 months duration. He isdiagnosed with Pneumocystis pneumoniae due to AIDS. Which of the following concerning Pneumocystispneumonia is true? a. May have an extra pulmonary presentation b. is always associated with Xray changes c. is caused by a bacterium d. elevated serum antibodies to P. carinii helpful diagnostically e. is best treated with intravenous pentamidine 135. A 45yearold man returned from a twoweek trip in Zimbabwe. Fourteen days later he presented with fever, headaches and a widespread rash. On examination there was generalisedymphadenopathy and a widespread maculopapular rash. What is the most likely diagnosis? a. acute HIV infection b. schistomsomiasis c. strongyloidiasis d. tick typhus e. typhoid fever 136. A 50yearold man presented to hospital feeling generally unwell for 3 days. He had returned from a business trip to Thailand six weeks previously and had taken mefloquine as prophylaxis against malaria. On examination he was afebrile, temperature 36.5°C, Pulse was 100/minute and regular, his BP was 85/60 mm Hg.

Investigations showed:

Hb 14.2 g/dL (13.018.0)

WBC 19.0 x 109/L (411)

Neutrophils 18.0 xl09/L (1.57.0)

AST 72 IU/L (131)

Alkaline phosphatase 255 (45105)

What is the most likely diagnosis?

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a. Acute HIV infection (seroconversion illness) b. Dengue fever c. Gramnegativebacteraemia d. Hepatitis B e. Mefloquineinduced hepatitis 137. A 70 year old woman developed herpes zoster ophthalmicus. Which one of the following is most likely to be a complication of this condition? a. Hyphaema b. Keratitis c. Keratoconus d. Posterior subcapsular cataract e. Scleromalacia 138. Which is true regarding Eczema Herpeticum? a. Is invariably fatal if untreated. b. Usually has an indolent onset. c. Only a single crop of vesicles usually appear. d. Is typically associated with a high fever for over a week. e. Is more severe in reactivation disease. 139. A 28 year old male presents with a four day history of profuse bloody diarrhoea after returning from a holiday in the Far East. Which of the following regarding his illness is true? a. a negative amoebic fluorescent antibody test excludes a diagnosis of acute amoebic dysentry b. Cysts to E. histolytica in the stools confirms a diagnosis of acute amoebic dysentry c. cholera is a likely diagnosis d. Giardiasis is a likely diagnosis e. shigellosis is a likely diagnosis 140. Which of the following infections is least likely to cause myocarditis? a. Coxsackie virus b. Diphtheria c. Chagas Disease d. Syphillis e. Toxoplasmosis 141. Chronic Lliver disease is NOT a complication of a. Haemosiderosis b. Hepatitis C c. alpha1 antitrypsin deficiency d. cystic fibrosis e. haemochromatosis 142. A 25yearold previously healthy woman has worsening fatigue with dyspnoea, palpitations, and fever over the past one week. Her vital signs on admission to the hospital show Temperature 38.9°C Respiratory rate 30/min Pulse 105 bpm and BP 95/65 mmHg. Her heart rate is irregular. An ECG shows diffuse STT segment changes. A Chest Xray shows mild cardiomegaly. An echocardiogram shows slight mitral and tricuspid regurgitation but no valvularvegetations. Her troponin I is 12 ng/mL. She recovers over the next two weeks with no apparent sequelae. Which of the following laboratory test findings best explains the underlying etiology for these events? a. ANCA titer of 1:80 b. Antistreptolysin O titer of 1:512 c. Blood culture positive for Streptococcus, viridans group

INFECTION

b. is associated with a polymorphonuclearpleocytosis in the CSF


d. Coxsackie B serologic titer of 1:160

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e. Total serum cholesterol of 9.6 mmol/l 143. A 18 year old homosexual male developed progressive pneumonia not responding to antibiotics. Methenamine silver staining of the sputum showed small circular cyst and Giemsa staining demonstrated the small, punctate nuclei of the trophozoites and intracysticsporozoite. Which is the most likely organism? a. Toxoplasma gondii b. Trypanosomacruzi c. Cryptococcus neoformans d. Leishmaniadonovani

MCQ's

e. Pneumocystis carinii 144. Which is true of herpes simplex encephalitis? a. brain MRI is characteristically normal b. fits are uncommon c. genital herpes is usually present d. temporal lobe involvement is common e. viral identification using polymerase chain reaction on CSF is nonspecific 145. A 38 year old female presents with red target lesions confined to the hands and is diagnosed with erythema multiforme. Which of the following could be the cause? a. Cytomegalovirus infection b. Ureaplasmaurealyticum c. Group B Streptococci d. Langerhanâ&#x20AC;&#x2122;s cells histiocytosis e. Penicillin V 146. In the diagnosis of rheumatic fever, which of the following may be helpful? a. A generalisedmacularpapular rash. b. ASO titre of less than 1:200. c. Polyarthritis.

149. A 19yearold male student attends casualty complaining of an urethral discharge. Gram stainshowsnumerous neutrophils, some of which contain gramnegative intracellular diplococci. The patient is treated with Ceftriaxone, 250 mg as an injection. Five days later, the patient reattends with persisting discharge. Which of the following is the most likely cause of this discharge? a. Chlamydia trachomatis b. Penicillinresistant Neisseria gonorrhoeae c. Reinfection with Neisseria gonorrhoeae d. Ureaplasmaurealyticum e. Urethral stricture 150. A 27 year old man presents with fever, urethritis and arthralgia. He is found to have a swollen ankle with a pustular rash on the dorsal aspect of his foot. What is the most likely diagnosis? a. Gonococcal sepsis b. Lyme disease c. Reiterâ&#x20AC;&#x2122;s syndrome d. Staphylococcal arthritis e. Tuberculous arthritis 151. A 22 year old male presents with generalised pruritus of six weeks duration. Examination reveals little except for erythematous papules between the fingers. Which ofthe following therapies would be most appropriate for this patient? a. Astemizole b. Calamine lotion c. Chlorpromazine d. Ciprofloxacin e. Permethrin cream 152. A 38yearold male with a diagnosis of HIV presents with lethargy, confusion, personality change and a seizure. CT shows multiple uniformly enhancing mass lesions in both cerebral hemispheres What treatment is indicated?

d. Staphylococcus aureus grown on throat culture.

a. ketoconazole

e. Splinter haemorrhages.

b. pyrimethamine and sulfonamide

147. A 56yearold man from Thailand presented with abdominal pain and a mass in the right upper quadrant. He reported that he had been diagnosed with viral hepatitis several years previously. Investigations showed:

Serum alphafetoprotein 13,500 IU/L (< 10)

What is the most likely underlying viral infection? a. Hepatitis A virus b. Hepatitis B virus c. Hepatitis C virus d. Hepatitis D virus e. Hepatitis E virus

148. Regarding pneumonia caused by Legionella pneumophilia, which of the following is true? a. is associated with hyponatremia b. is best treated with intravenous amoxycillin and clavulanic acid c. is common in AIDS patients

c. rifampicin and pyrazinimide d. broad spectrum antibiotics e. corticosteroids 153. Which RBC antigen is involved in the entry of P. vivax into red blood cells? a. AntiD b. AntiS c. Duffy d. Kell e. Kidd 154. A 27-year-old woman, who has recently returned from holiday in Africa, presents with a 7-day history of fevers, sweats, headache, malaise and lethargy. On examination, her temperature is 39°C. Cardio respiratory and gastrointestinal examinations are unremarkable. What is the most likely differential diagnosis? a. Malaria b. Tuberculosis

d. is readily diagnosed by standard aerobic culture of sputum

c. Influenza

e. should be managed on the ward in a respiratory isolation cubicle

e. Dengue fever

d. Typhoid


155. A 25-year-old woman, who has recently returned from holiday in Africa, presents with a 7-day history of fevers, sweats, headache, malaise and lethargy. On examination, her temperature is 39°C. A diagnosis of malaria is suspected. What is the investigation of choice to confirm the diagnosis? a. Blood cultures b. Full blood count c. Thick and thin blood films d. Ziehl–Nielson stain e. Paul–Bunnell test

a. Conservative management b. Acyclovir c. Omeprazole d. Chloroquine e. Quinine 157. A 40-year-old Indian man presents with a one-month history of haemoptysis. He is a non-smoker. On further questioning, he mentions that he has also been having fevers and night sweats. Chest x-ray shows nodular shadowing in the right upper zone. What is the most likely diagnosis? a. Sarcoidosis b. Small cell carcinoma of the lung c. Primary tuberculosis d. Post-primary tuberculosis e. Pneumocystis pneumonia 158. A 54-year-old investment banker presents with a 5-day history of productive cough of green sputum, fevers and feeling generally unwell. On examination, there is bronchial breathing in the left lower zone. Chest x-ray demonstrates left lower zone consolidation. What is the most likely causative organism? a. Mycoplasma pneumoniae b. Klebsiellapneumoniae c. Staphlococcusaureus d. Haemophilusinfluenzae e. Streptococcus pneumonia 159. A 74-year-old woman patient, who is being treated for chest infection following an elective gastrectomy, develops profuse diarrhoea. A stool sample is collected and microscopy, culture and sensitivity reveal Clostridium difficiletoxin. What is the most appropriate treatment? a. Intravenous co-amoxiclav b. Oral metronidazole c. Isolate the patient and treat conservatively with intravenous fluids d. Isolate the patient and treat conservatively with oral rehydration solution e. Prednisolone 160. A 23-year-old woman medical student, who has returned home from a trip to India 1 day ago, presents with profuse watery diarrhoea. This started suddenly and she describes her stool as being profuse and colourless. She is unable to quantify the number of times she has opened her bowels prior to presentation. On examination her pulse is 110 bpm. Cardiorespiratory and gastrointestinal examination are unremarkable. What is the most likely diagnosis? a. Cholera b. Typhoid

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d. Shigella e. EnterotoxigenicEscherichia coli diarrhea 161. A 30-year-old woman aid worker, who has returned from a trip to Haiti 1 day ago, presents with profuse watery diarrhoea. This started suddenly and she describes her stool as being profuse and colourless. On examination her pulse is 120 bpm. What is the most appropriate treatment? a. Rehydration with oral rehydration solutions b. Rehydration with intravenous fluids c. Rehydration with oral rehydration fluids plus metronidazole d. Codeine phosphate e. Oral azithromycin 162. A three-year-old boy presents, with his mother, to his GP with a 2-day history of fevers, vomiting and diarrhoea. His mother mentions that several other children at the nursery have been off sick this week with the same problem. What is the most likely cause? a. EnterotoxigenicE. coli b. Salmonella c. Rotavirus d. Influenza e. Shigella 163. A nine-year-old boy presents to his GP with a 2-day history of sudden onset itchy rash over his face, scalp, neck and trunk, On examination, his temperature is 38°C and there is a widespread vesicular rash. What is the most likely infective organism? a. Epstein–Barr virus b. Cytomegalovirus c. Varicella zoster virus (VZV) d. Staphlococcusaureus e. Herpes-simplex type 1 164. A 70-year-old man presents with a 1-day history of a painful rash across his trunk. He has a past medical history of hypertension and hypercholesterolaemia. On examination, there is a well-demarcated blistering rash on the right side of his trunk. What is the most appropriate treatment? a. Oral acyclovir b. High dose intravenous acyclovir c. Topical steroids d. Paracetamol e. Amitryptiline 165. A 27-year-old investment banker presents with a 4-day history of painful rash on his penis and testicles. He also reports feeling generally run down with a fever and myalgia. He returned from a trip to New York a week ago. On examination, there is a painful vesicular rash over his penis and testicles. What is the most appropriate treatment? a. Oral acyclovir b. High-dose intravenous acyclovir c. Oral flucloxacillin d. Paracetamol e. Glyceryltrinitrate cream 166. A 22-year-old medical student presents to the GUM clinic with large amounts of yellow-coloured penile discharge and discomfort on urinating. He has just arrived home from his summer holiday in Ibiza. What is the most likely diagnosis? a. Chlamydia b. Genital herpes

INFECTION

156. A 30-year-old man, who has recently returned from holiday in Africa, presents with a 7-day history of fever, sweats, malaise and lethargy. Thick and thin blood films detect Plasmodium falciparum. What is the most appropriate treatment?

c. Pseudomembranous colitis


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c. Cystitis d. Gonorrhoea e. Syphilis 167. A 30-year-old man presents to his GP with a lesion on his penis, which appeared a week ago. On further questioning, he reports a change in sexual partner 4 weeks ago. He has otherwise been well. On examination, there is a painless hard ulcer on the shaft of the penis. What is the most likely diagnosis? a. Chancroid b. Genital herpes c. Chlamydia

MCQ's

d. Primary syphilis e. Secondary syphilis 168. A 34-year-old man presents to his GP with a painless hard penile ulcer. Venereal Disease Research Laboratory tests and Treponemapallidumhaemagglutination assay confirm the diagnosis of primary syphilis. What is the most appropriate treatment for this patient? a. Co-amoxiclav b. Acyclovir c. Azithromycin d. Ciprofloxacin e. Procaine penicillin 169. A 45-year-old man presents to accident and emergency, having returned from a holiday to India a week ago. He has subsequently been unwell with nausea and reduced appetite. Over the past 2 days he has become jaundiced. He mentions that his two brothers with whom he went on holiday have also become jaundiced in the last 2 days. On examination, he is apyrexial and there is a palpable liver edge. Liver function tests reveal a raised ALT, AST and bilirubin. All other blood tests are normal. What is the most likely diagnosis? a. Hepatitis A b. Hepatitis B c. Hepatitis C d. Gilbert’s syndrome e. Malaria 170. A 40-year-old man presents having returned from a holiday to India a week ago. He has subsequently been unwell with nausea and reduced appetite. Over the past 2 days he has become jaundiced. On examination, he is apyrexial and there is a palpable liver edge. Liver function tests reveal a raised ALT, AST and bilirubin. A diagnosis of hepatitis A is suspected. What is the most appropriate treatment? a. Intravenous hydrocortisone b. Pegylated interferon alpha plus ribavirin c. Conservative management d. Acyclovir e. Chloroquine 171. A 19-year-old medical student presents with a 1-week history of fever, anorexia and a sore throat. On examination, she is pyrexial at 39°C and cervical, axillary and inguinal lymph nodes are palpable. Palatal petechiae are visible within the mouth and her tonsils appear inflamed. A full blood count reveals a lymphocytosis and a blood film reveals the presence of atypical lymphocytes. What is the most likely diagnosis? a. Toxoplasmosis b. Cytomegalovirus infection c. Infectious mononucleosis d. Streptococcal sore throat e. Influenza

172. A 19-year-old medical student presents to his GP during fresher’s fortnight. He is complaining of neck stiffness, headache and sensitivity to light. On examination, a nonblanching, petechial rash is observed on the trunk. What is the most appropriate immediate management? a. Send the patient immediately b. Send him home with advice to rest and return if the symptoms worsen c. Administer 1.2 g of intramuscular benzylpenicillin d. Give 500 mg of ciprofloxacin e. Take a full set of blood tests 173. A 19-year-old man presents to his GP with a 4-day history of painful facial swelling, fevers and lethargy. On examination, there is bilateral swelling of his parotid glands. What is the most likely diagnosis? a. Measles b. Mumps c. Influenza d. Infectious mononucleosis e. Pertussis 174. A 41-year-old teacher presents to her GP with a 5-day history of fevers, headaches, lethargy and muscle aches. She also mentions that she is developing an expanding red rash on her left thigh. On further questioning, she mentions that she has been on a school camping trip the previous week. She is otherwise fit and well. What is the most likely diagnosis? a. Lyme disease b. Sarcoidosis c. Brucellosis d. Syphilis e. Erythema abigne 175. A 39-year-old Indian man presents to his GP with a 5-week history of haemoptysis, night sweats and weight loss. Which of the following investigations can be used to confirm the diagnosis of tuberculosis? a. Tuberculin skin testing b. Blood cultures c. Chest x-ray d. Ziehl–Nielsen sputum staining e. Computed tomography pulmonary angiogram (CTPA) 176. A 23-year-old man presents with a 1-day history of severe headache, discomfort when looking at the lights and neck stiffness. There is a non-blanching rash observed on his trunk. He has recently recovered from chicken pox. On examination he is pyrexial at 39°C. The most likely causative organism is: a. Streptococcus pneumoniae b. Listeria monocytogenes c. Neisseria gonorrheae d. VZV e. Neisseria menigitidis 177. A 51-year-old man presents with a lesion on his forearm. He mentions that he has spent the past three months travelling around South America and only returned home 3 days ago. While his lesion has been present for a few weeks he was reluctant to see a doctor in South America. On examination, there is a 33 cm erythematous ulcer on the left forearm with a raised edge. What is the most likely diagnosis? a. Leishmaniasis b. African trypanosomiasis c. Herpes zoster


d. Schistosomiasis

a. Manage conservatively

e. Cryptosporidiosis

b. Start intravenous vancomycin

178. Which of the following statements is most accurate regarding leishmaniasis? a. It is transmitted by the anopheles mosquito b. Leishmaniaare bacteria c. Leishmaniaisis is usually a self-limiting condition d. It is transmitted by the tsetse fly e. The presence of Leishman–Donovan bodies confirms the disease

a. Leishmaniasis b. Schistosomiasis c. African trypanosomiasis d. Malaria e. Influenza 180. A 35-year-old man presents to his GP with diarrhoea, abdominal pain and nausea. He says he his stools have been pale and he has felt persistently bloated. His symptoms started 6 weeks ago while on a surfing holiday in Peru. What is the most likely diagnosis? a. Coeliac disease b. Enterotoxigenic E. coli gastroenteritis c. Salmonella d. Giardia e. Cryptosporidiosis 181. A 26-year-old Bangladeshi man presents with a 1-week history of fever, headache, malaise and dry cough. He returned to the UK 2 weeks ago, having spent his summer in Bangladesh. On examination, his temperature is 39°C and a patchy maculopapular rash is seen over his trunk. On examination of the abdomen, there is splenomegaly. Blood tests reveal a low white cell count. What is the most likely diagnosis? a. Tetanus b. Malaria c. Typhoid d. Cholera e. Primary syphilis 182. A 32-year-old man presents with the inability to open his jaw, starting a few hours earlier. His wife mentions that he has ‘had the flu’ since returning from a weekend camping trip. What is the most likely diagnosis? a. Tetanus b. Dislocation of the temporomandibular joint c. Clostridium perfringensinfection d. Influenza e. Clostridium difficileinfection 183. Following a colonic resection, a 72-year-old woman becomes unwell with acute confusion, pyrexia, tachycardia and hypotension. The patient has had a difficult postoperative period, which has included an admission to ITU for the management of a chest infection. Blood cultures are sent and grow methicillin-resistant Staphylococcus aureus (MRSA). The patient is placed in isolation and barrier nursing is implemented. What is the most appropriate management of this patient?

c. Start intravenous co-amoxiclav d. Start intravenous co-amoxiclav and gentamicin e. Start oral metronidazole 184. A 90-year-old man presents with a 2-week history of fevers, lethargy and night sweats. He has recently had crowns fitted at the dentists. He has a past medical history of hypertension, gout and type 2 diabetes mellitus. On examination his temperature is 39°C, his pulse is 120 bpm and splinter haemorrhages are seen in the nails. On auscultation of the heart a pansystolic murmur is audible. A diagnosis of endocarditis is suspected and blood cultures are taken. What organism is most likely to be grown? a. Staphlococcusaureus b. Staphlococcusepidermidis c. Actinobacillus d. Enterococcus faecalis e. Streptococcus viridans 185. A 45-year-old man who lives in a homeless shelter presents with an itchy rash. The itching is particularly bad at night. On examination, there is a papular rash between the web spaces of the fingers and toes, the palms of the hands and soles of the feet, the axilla and on the genitalia. What is the most likely diagnosis? a. Scabies b. Shingles c. Chicken pox d. Molluscumcontagiosum e. Tineacruris 186. A 20-year-old man presents with extreme pain in the right knee. On examination, his temperature is 38.5°C and the knee is hot and swollen. He is unable to move his knee due to pain. The joint is aspirated and blood cultures are taken. The patient is admitted and started on intravenous antibiotics. Gram staining of the joint aspirate shows gram-negative diplococci. What is the most likely responsible organism? a. Chlamydia trachomatis b. Neisseriaegonnorrheae c. Haemophilusinfluenzae d. Streptococcus pneumoniae e. Streptococcus viridians 187. A 74-year-old man presents with extreme pain in theleft knee. On examination, his temperature is 39°C and the knee is swollen and hot.He is unable to move the joint due to pain. The joint is aspirated and the patient isadmitted and started on intravenous antibiotics. What is the most likely causative organism? a. Neisseriaegonorrheae b. Mycobacterium tuberculosis c. Neisseria meningitidis d. Staphlococcusaureus e. Haemophilusinfluenzae 188. A 42-year-old man presents with a 3-week history ofshortness of breath, dry cough, fevers and malaise. He has presented as his exercisetolerance has deteriorated. He mentions that he has been HIV positive for ten years.On examination, there are fine crackles throughout both lung fields. Chest x-ray demonstrates bilateral perihilar interstitial shadowing. What is the most likelycausative organism? a. Pneumocystis jiroveci b. Herpes simples virus type 1

INFECTION

179. A 24-year-old man presents with fevers, lethargy, myalgia and a cough. He has also developed an itchy rash on his feet. He returned home from a charity trip to Malawi last month and is worried he might have malaria. On examination, a papular rash is noted around his feet and there is a palpable liver edge. Initial blood tests show a raised white cell count with an eosinophilia. What is the most likely diagnosis?

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1218

c. Herpes simplex virus type 2

c. Hypercalcemia

d. Streptococcus pneumoniae

d. Rash

e. Mycoplasma pneumonia 189. A 42-year-old man presents with a 3-week history ofretrosternal discomfort after swallowing. He mentions that he has been unable tokeep any food down at all. He has been HIV positive for ten years. He is admittedand endoscopy shows areas of ulceration throughout the oesophagus. What is the most likely causative organism? a. Staphylococcus aureus b. Crytosporidiumparvus c. Candida albicans

MCQ's

d. Pneumocystis jiroveci e. Cryptococcus neoformans 190. A 42-year-old man presents to his GP with ‘blotches’ over his legs. He has been HIVpositive for ten years. On examination, there are multiple purple and brown papulesover his legs and his gums. What is the most likely diagnosis? a. Malignant melanoma b. Squamous cell carcinoma c. Basal cell carcinoma d. Kaposi’s sarcoma e. Toxoplasmosis 191. A 42-year-old man presents to his GP with ‘blotches’ over his legs. He has been HIVpositive for ten years. On examination, there are multiple purple and brown papulesover his legs and his gums. A diagnosis of Kaposi’s sarcoma is suspected. What isthe most likely causative organism? a. Herpes simplex virus type 1 b. Herpes simplex virus type 2 c. Human herpes virus type 3 d. Human herpes virus type 8 e. Pneumocystis jiroveci 192. A 42-year-old man presents to his GP complaining of deterioration in his vision inthe right eye and the presence of floaters. The change in his vision has been causinghim to suffer from headaches. He has been HIV positive for ten years. Fundoscopyreveals haemorrhages and exudates on the retina. What is the most likely diagnosis? a. Retinal detachment b. CMV retinitis c. Kaposi’s sarcoma d. Optic atrophy e. Diabetic retinopathy 193. A 42-year-old man presents with a 1-day history ofheadache and fevers. He presents with his partner who says he has been becomingincreasingly confused and disorientated. On examination, his temperature is 38.5°C.On cranial nerve examination there is a right-sided superior quadrantanopia. Anurgent CT scan of the head is organized which shows multiple ring enhancinglesions. What is the most likely diagnosis? a. Toxoplasmosis b. Meningitis c. Cryptosporidiosis d. CMV encephalitis e. Histoplasmosis 194. In toxic shock syndrome all of the following can be seen except a. Shock b. Fever

195. Aschoff nodules are seen in a. Rheumatoid arthritis b. Rheumatic fever c. SLE d. Sjogren’s syndrome 196. The antibioitic which can be safely used in pregnancy is a. Tetracycline b. Ampicillin c. Streptomycin d. Sulphonomides 197. Ototoxicity is seen in all of the following except a. Ampicillin b. Streptomycin c. Kanamycin d. Gentamycin 198. In the life cycle of anopheles mosquito the humans are a. Accidental hosts b. Intermediate host c. Definitive host d. Obligatory hosts 199. TB cases can be detected in mass populations by which of the following a. Sputum AFB b. Tuberculin c. Sputum culture d. MMR 200. Disc collapse 1st change in TB spine is a. Erosion of pedicle b. Narrowing of disc space c. Abcess with soft tissue swelling d. Disc collapse 201. A 25-year-old man has had type 1 diabetes mellitus for 5 years. His physician is concerned about the possibility of permanent renal damage. Which of the following is the best early indicator for diabetic nephropathy? a. Albuminuria b. Hypertension  c. Rising blood urea nitrogen d. Rising creatinine  e. Urinary tract infection 202. Biphasic saddle back fever is suggestive of: a. Lymes disease b. Relapsing fever c. Typhoid fever d. Dengue fever 203. Epidemic Dropsy is due to a. Sanguinarine b. Aflatoxin c. Pyrrolizidini alkaloids d. Ergotamine


204. Snowman configuration of Heart in Chest X-ray is seen in: a. TAPVC b. TGA c. Ebsteinâ&#x20AC;&#x2122;s Anomaly d. TOF 205. DOC for cholera in pregnant women: a. Doxycycline b. Furazolidone c. Rifampicin d. Cotrimoxazole 206. Melenyâ&#x20AC;&#x2122;s Ulcer is caused by: b. Hemolytic staph. Aureus c. Both a+b d. B- hemolytic streptococci

a. Crimean Congo Haemorrhagic Fever b. H1N3 Influenza c. Ebola d. All of the above 208. What is the international quarantine period also approved by Government of India for yellow fever ? a. 2 weeks b. 10 days c. 6 days d. 2 days 209. The discovery of the small pox vaccination is credited to a. Pasteur b. Jenner c. Lister d. Koch

INFECTION

a. Microaerophilic Non-hemolytic streptococci

207. WHO has set priority for emerging disease research to prevent 1219 severe outbreaks of these diseases.


MCQ's

1220

Infection - Answers 1. a

39. b

77. b

114. 2

151. 5

2. c

40. b

78. c

115. 3

152. 2

3. a

41. c

79. a

116. 1

153. 3

4. a

42. d

80. c

117. 4

154. a

5. a

43. d

81. c

118. 4

155. c

6. a

44. a

82. c

119. 2

156. e

7. c

45. c

83. e

120. 5

157. d

8. b

46. c

84. a

121. 5

158. e

9. d

47. c

85. b

122. 2

159. b

10. a

48. c

86. c

123. 5

160. a

11. a

50. c

87. e

124. 1

161. b

12. b

51. b

88. c

125. 3

162. c

13. c

52. e

89. a

126. 5

163. c

14. b

53. b

90. d

127. 4

164. a

15. a

54. d

91. c

128. 2

165. a

16. b

55. e

92. b

129. 4

166. d

17. c

56. d

93. e

130. 5

167. d

18. c

57. b

94. a

131. 5

168. e

20. c

58. e

95. a

132. 4

169. a

21. b

59. a

96. b

133. 4

170. c

22. c

60. b

97. e

134. 1

171. c

23. c

61. b

98. c

135. 1

172. c

24. b

62. c

99. b

136. 3

173. b

25. c

63. e

100. c

137. 2

174. a

26. a

64. d

101. b

138. 4

175. d

27. a

65. e

102. b

139. 1

176. e

28. b

66. d

103. e

140. 4

177. a

29. e

67. e

104. a

141. 1

178. e

30. b

68. a

105. d

142. 4

179. b

31.

c

69. d

106. c

143. 5

180. d

32. b

70. e

107. 4

144. 4

181. c

33. a

71. d

108. 4

145. 5

182. a

34. b

72. b

109. 4

146. 3

183. b

35. b

73. e

110. 1

147. 2

184. e

36. b

74. e

111. 1

148. 1

185. a

37. a

75. c

112. 2

149. 1

186. b

38. d

76. b

113. 5

150. 1

187. d


188. a

193. a

198. b

203. a

208. c

189. c

194. c

199. a

204. a

209. b

190. d

195. b

200. b

205. b

191. d

196. b

201. aÂ

206. c

192. b

197. a

202. b

207. d

1221

INFECTION


IMMUNOLOGY 1.

The most scientific method to identify which triggers may be causing my nasal allergies is to:

9.

a. Lymph

a. Track the time of year when my symptoms occur

b. Immune

b. Have an allergist perform a skin test

c. Nervous

c. Have an allergist run a blood test

d. Autonomic

d. There is no good way to know what Iâ&#x20AC;&#x2122;m allergic to and/or C 2.

Which is the most effective treatment for nasal allergies? a. Overthecounterantihistamines

3.

10. An allergen is anything that triggers an allergic or hypersensitive response.Which of these could be an allergen? a. Dust

c. Antihistamine decongestant combination pills

b. Food

d. Nasal corticosteroid sprays

c. Nickel jewelry

e. Oral leukotriene receptor antagonists

d. All of the above e. None of the above

Which one of the following is least likely to trigger asthma? 11.

a. Plasma

c. Reading the newspaper

b. Epinephrine

d. Cat dander

c. Histamine

e. Tobacco smoke

d. Red Blood cells

Which of the following factors can predisposeyou to having allergies?

e. Cortisone 12.

a. Blood pressure drops

c. Number and type of Exposures

b. Breathing becomes difficult

d. Emotional factors

c. Runny nose develops

e. All of the above

d. A and B

Hypersensitivity of which system of your body creates an allergic response?

e. B and C 13.

b. Runny nose

c. Circulatory System

c. Diarrhea

d. Pulmonary System

d. Nausea

e. Digestive System Which of the following treatments can be used to reduce allergic reactions to unavoidable substances?

e. Wheezing 14.

b. Wheat

b. Mist inhalation therapy

c. Celery

c. Regularly wearing a face mask

d. A and B

d. Desensitization (Allergy shots)

e. B and C

e. Regularly wearing a garlic necklace

a. Oral antihistamines

8.

Which of these foods are most likely to trigger an allergy? a. Shellfish

a. Milk thistle three times daily

Which of the following is the most commonly prescribed treatment for hives?

Which of these symptoms may indicate a food allergy? a. Skin rash

b. Immune System

7.

The most severe form of allergic reaction is called anaphylaxis. What happens?

b. Environmental Conditions

a. Skin

6.

What does the body release to combat allergens?

b. A common cold

a. A family history of allergies

5.

e. Circulatory

b. Prescription antihistamines

a. Strenuous exercise

4.

Which of these body systems causes allergic reactions?

15. More Americans are developing a sensitivity to the plant proteins in latex materials or the chemical additives used in manufacturing the materials. Whoâ&#x20AC;&#x2122;s most at risk of developing a latex allergy?

b. Oral corticosteroids such as prednisone

a. Patients who undergo numerous medical procedures

c. Epinephrine (adrenaline)

b. Health care workers

d. Aspirin

c. Children

e. Immunotherapy

d. A and B

Which of the following does NOT reduce or delay allergies in children? a. Reducing dustcollecting items b. Limiting exposure early in life to indoor furry pets c. Avoiding smoking in and around the house d. Exclusively wearing cotton clothes e. All actions adequately reduce allergies

e. B and C 16.

Pediatricians who treat children with egg allergies are cautious about using certain vaccines because they may be grown in an egg medium. Which of these vaccines warrant caution? a. MMR b. Flu c. Polio


e. B and C

What can you do to reduce exposure to outdoor asthma 1223 triggers?

Dust mites trigger indoor respiratory allergies. Where are you most likely to find them in the home?

b. Schedule camping trips in May, June or August through October

d. A and B 17.

25.

a. Exercise outdoors on high ozone days

a. Carpet

c. Pursue outdoor sports in cold weather

b. Beds

d. None of the above

c. Drapes d. All of the above e. None of the above 18.

b. Evening primrose herb

b. 500 years ago

c. Yoga

c. 100 years ago

d. Aromatherapy

d. 50 years ago

e. All of the above 27.

a. Bathe the pet weekly

a. Tightness in the chest

b. Keep the pet outside if possible

b. Wheezing

c. Own a dog, not a cat

c. Sneezing

d. All of the above

d. A and B

e. None of the above 28.

a. Asthma

a. Exercise

b. Allergies

b. Aspirin

c. Acne

c. Laughing

d. A and B

d. All of the above

e. B and C 29.

Which of these allergens are most likely to induce asthma?

b. Teenagers c. Adults 20 to 49

c. Feathers

d. Older adults

d. B and C

e. All of the above

e. A and B Which of these foods should children with asthma avoid?

30.

b. It can leave pockmarks on the skin

b. All nuts

c. It cycles through periods of flares and remissions

c. Foods with preservatives

d. It is worse in autumn

d. None of the above

e. There is no correct answer

e. All of the above 31.

Atopic dermatitis is also often called: a. Acne

a. Broccoli

b. Eczema

b. Oranges

c. Psoriasis

c. Apples

d. Pimples

d. Fish

e. Hives

e. Peanut 24.

One characteristic of atopic dermatitis is: a. It affects the face more than the rest of the body

a. Dairy products

Which of these, if eaten on a weekly basis, can help reduce chronic coughing and wheezing in asthmaticchildren?

Which group of people is more likely to develop atopic dermatitis? a. Infants and young children

b. Cockroaches

23.

People who have atopic dermatitis also may have:

Which of these can trigger an asthma attack?

a. Ragweed

22.

What should you do if pet hair triggers your asthma?

What are the symptoms of asthma?

Which sports are best for asthmatics? a. Baseball b. Swimming c. Sprinting d. All of the above e. Sport is dangerous for asthmatics

32. In the past, doctors thought which of these caused atopic dermatitis? a. Too much sun b. An emotional disorder c. Food allergies d. Dust mite allergy e. None of the above

IMMUNOLOGY

a. Nightly massages

e. None of the above 21.

Which of these alternative health treatments have reduced symptoms in children?

a. 1,000 years ago

e. B and C 20.

26.

How long ago was asthma identified as an ailment?

e. 100,000 years ago 19.

e. All of the above


1224 33. Which is a symptom of atopic dermatitis?

41.

a. Blisters on the palms of hands and soles of feet

a. Dust mites

b. Itchy, inflamed skin

34.

c. Scaly patches of skin on the scalp

b. Sagebrush

d. Coinshapedpatches of irritated skin on the arms and lower legs

c. Ragweed d. Perfume

e. All answers are correct

e. Cigarette smoke

Some people with atopic dermatitis develop: a. Thick, leathery skin

42. State one from airborne substances listed below is NonIgEmediated irritant: a. Dust mites

b. Red, scaling skin

b. Cat dander

c. Small raised bumps on the skin

c. Ragweed

MCQ's

d. All of the above

d. Sagebrush

e. None of the above 35.

The skin of a person with atopic dermatitis is more susceptible to: a. Skin infections

e. Cigarette smoke 43. State one from airborne substances listed below is Seasonal allergen: a. Dust mites

b. Warts

b. Cat dander

c. Herpes simplex

c. Ragweed

d. All of the above

d. Perfume

e. None of the above 36.

Match the immune deficiency in WiskottAldrich syndrome with the appropriate lab test:

e. Cigarette smoke 44.

c. NBT test (nitroblue tetrazolium test, oxidated burst)

In June, a 24yearoldfemale presents with angioedema of the face, including eyelids and lips. She has had two previous similar episodes. Her father has also had recurrent angiodema of the face and extremities.Neither has associated pruritis with the angioedema. Which diagnosis is suggested?

d. Serum calcium

a. Hereditary angioedema

e. Platelet count and morphology

b. Food allergy

a. Quantitative immunoglobulins b. CD11 by flow cytometry

37.

c. Enterovirus infection

Match the immune deficiency in Di George anomaly with the appropriate lab test:

d. Idiopathic angioedema e. An ACE inhibitor was prescribed by her internist for hypertension

a. Quantitative immunoglobulins b. CD11 by flow cytometry c. NBT test (nitroblue tetrazolium test, oxidated burst)

45.

d. Serum calcium e. Platelet count and morphology 38.

Match the immune deficiency in Brutonâ&#x20AC;&#x2122;s disease with the appropriate lab test:

b. Food allergy

b. CD11 by flow cytometry

c. Enterovirus infection

c. NBT test (nitroblue tetrazolium test, oxidated burst)

d. Idiopathic angioedema

d. Serum calcium

e. An ACE inhibitor was prescribed by her internist for hypertension

e. Platelet count and morphology Match the immune deficiency in Leukocyte adhesion defect with the appropriate lab test:

46.

a. Quantitative immunoglobulins b. CD11 by flow cytometry c. NBT test (nitroblue tetrazolium test, oxidated burst)

In June, a 24 year old female presents with angioedema of the face, including eyelids and lips. She has had two previous similar episodes. This episode, like the previous ones, occurred during the summer and was accompanied by diarrhea, low grade fever once and classical urticarial lesions. a. Hereditary angioedema

d. Serum calcium 40.

In June, a 24 year old female presents with angioedema of the face, including eyelids and lips. She has had two previous similar episodes. She always has associated gas and diarrhea with the angioedema. She was previously skin tested and found to have sensitivities to milk, ragweed and molds. Which diagnosis is suggested? a. Hereditary angioedema

a. Quantitative immunoglobulins

39.

State one from airborne substances listed below is Perennial allergen:

e. Platelet count and morphology

b. Food allergy

Match the immune deficiency in Chronic Granulomatous disease with the appropriate lab test:

d. Idiopathic angioedema

c. Enterovirus infection e. An ACE inhibitor was prescribed by her internist for hypertension

a. Quantitative immunoglobulins b. CD11 by flow cytometry c. NBT test (nitroblue tetrazolium test, oxidated burst) d. Serum calcium e. Platelet count and morphology

47.

Hereditary angioedema is: a. Inherited as an autosomal recessive disorder b. Usually associated with urticaria c. Usually responsive to antihistamines


d. Can be managed with Danazol (synthetic androgenic steroid) e. All of the above are correct 48.

55. Reasonable recommendations for a patient with moderate 1225 persistent asthma poorly controlled on low doseinhaled corticosteroids include all except: a. Add salmeterol inhaler BID

Which of the following adverse drug reactions is believed to be due to IgEmediated mechanisms?

b. Double the dose of inhaled corticosteroid c. Add a leukotriene modifier

a. Aspirin induced anaphylaxis

d. Add nebulized cromolyn BID

b. Reaction to radiocontrast dye c. StevenJohnsonâ&#x20AC;&#x2122;sSyndrome after a course of trimethoprim/ sulfa d. Wheezing, urticaria after administration of penicillin

e. All answers are correct 56.

Which of the following food allergies is most likely outgrown? a. Milk

b. A 26yearoldpatient with a history of Steven Johnsonâ&#x20AC;&#x2122;s Syndrome after receiving amoxicillin.

b. Peanut c. Walnuts

c. A 65yearoldICU patient receiving penicillin and vancomycin withflushing and hypotension.

d. Shellfish e. All of the abova 50.

d. A 39yearoldfemale who, eleven days after taking penicillin for a streppharyngitis, develops angioedema, arthralgias, urticaria and a low gradefever.

Indications for immunotherapy for hymenoptera allergy: a. Children and adults with a history of a lifethreateningreaction to a hymenoptera sting b. People who have a history of a large local skin reaction that gets worse with each sting

e. All of the above. 57.

a. They do cross the blood brain barrier and help patients to relax

c. Children with a history of generalized urticaria after a sting d. Anyone with a family history of an allergic reaction to a hymenoptera sting

b. They are very long acting c. They cause decongestion as well as decreasing rhinorrhea

e. Patients with allergic rhinitis 51.

d. They minimally cross the blood brain barrier and have a decreased sedationeffect

Eczema in an infant most commonly occurs in/on the:

e. They decrease appetite

a. Antecubitutal and Popliteal fossae b. Perineal region c. Scalp and flexural areas

52.

58.

a. Sinusitis

e. All of the above

b. Otitis media

As part of the work up of adult asthma, which of the following reproducible, pre and post bronchodilatorpulmonary function test results would be interpreted as showing significant reversibility? b. a 15% increase in FEV1 (425 ml improvement)

c. Pneumonia d. Meningitis e. All of the above 59. The most common cause of chronic urticaria, especially in adults, is: a. Food allergy

c. a 20% increase in FEV1 (180 ml improvement)

b. Connective tissue disease

d. a 15% increase in FEV1/FVC ratio

c. Drug allergy

e. a 15% increase in FVC All of the following medications can affect late phase (including by prophylaxis of the immediate allergic response) response in asthma except:

d. Idiopathic e. Viral infections 60.

a. Corticosteroids

b. Recurrent Neisserial infections

c. Cromolyn sodium

c. Lupuslikedisease

d. Albuterol

d. Candidiasis

e. There is no such medication in the list Drug of choice for uncomplicated acute urticaria is: a. Corticosteroid b. Antihistamines (H2 type) c. Antihistamines (H1 type) d. Subcutaneous terbutaline e. All of the above

Congenital absence of the late complement components (C5, C6, C7, C8) is most often associated with: a. Viral infections

b. Leukotriene modifiers

54.

Which of the following types of infection are increased in patients with humoral or B cell Immunedeficiencies?

d. Extensor surface of arm and legs

a. a 15% increase in FEF 2575%

53.

The major advantage of second generation antihistamines is:

e. Delayed separation of the umbilical cord 61.

Congenital complement deficiencies are best screened by which of the following laboratory tests: a. Quantitative immunoglobulins b. NBT c. Total CH50 d. C3, C4 and properdin e. Flow Cytometry

IMMUNOLOGY

a. A 40yearoldpatient with a history of anaphylaxis after ampicillin tenyears ago. The patient now has endocarditis. Culture is positive for astreptococcal organism sensitive only to penicillin.

e. None of the above 49.

Which of the following is a clear indication for penicillin allergy skin testing:


d. Avoiding specific food allergy triggers

A 40 year old male presents to the Emergency Room complaining of hives, wheezing and difficulty breathing following an insect sting. Pulse is 120 beats/min. BP is 100/56. After Epinephrine is administered and quick assessment of the patient is done, you determine that the patient is moving air adequately and isnot in shock. The next medication to give the patient immediately is:

e. Topical therapy with steroid or nonsteroidimmune modulating agent(pimecolimus, tacrolimus)

b. Methylprednisolone 100 mg IV

1226 62. All of the following except one can be useful in managing atopic dermatitis:

69.

a. Skin lubrication/moisturization b. Controlling pruitus to reduce scratching c. Immunotherapy (allergy injections)

a. Diphenhydramine 50 mg IV c. Epinephrine 0.3 ml (1:1000 aqueous) sub Q or IM

63. All of the following regarding aspirin intolerance are true except: a. Patients with asthma are at no greater risk for aspirin intolerance than the general population

MCQ's

b. A proposed mechanism of aspirin intolerance involves aspirin’s effect on arachidonic acid metabolism

d. Cholorpheniramine 8 mg orally e. None of the above 70.

a. Nasal congestion

c. There is cross reactivity between aspirin and NSAID intolerance

64.

b. Cough

d. Aspirin desensitization may be of benefit in a patient with aspirin intolerance who requires the drug

c. Fever

e. Leukotriene modifiers are particularly beneficial in most patients

e. Mucopurulent rhinorrhea

Which of the following tests would be most useful in helping to diagnose asthma:

d. “Postnasal”drip 71.

b. Neonatal tetany

b. Pre and post bronchodilator FEV1

c. Pervasive developmental delay in a 6yearoldfemale

c. Arterial blood gases

d. Recurrent/persistent otitis and diarrhea in a 6monthold

d. Pulmonary functions preandpostmethacholinechallenge e. B and D Conditions which may worsen asthma include (Identify the one incorrect choice):

e. None of the above 72.

d. Family history of swelling

d. Cardiac disease

e. Absence of symptoms before puberty 73.

b. Drug allergy

b. Aspirin sensitivity

c. Viral infection

c. Bronchitis

d. Inhalant allergy

d. Sinusitis 67.

Inhaled corticosteroids (Choose the one incorrect answer):

e. Hymenoptera stings 74. The two most common superinfections in atopic dermatitis are due to:

a. Can be useful in patients who have persistent asthma

a. Staph aureus and Herpes simplex

b. Can be useful in patients who require rescue inhaler 12times per week

b. Staph epidermidis and cutaneous viral infections

c. Can be used in 612yearoldchildren with asthma

d. Staph epidermidis and Candida

c. Staph aureus and Candida

d. Acutely increase peak flow rate, a measure of large airway function e. Reduce airway hyperreactivity 68.

Common causes of acute urticaria include all of the following except: a. Food allergy

a. Beta Blocker sensitivity

e. Inhalant allergies

A 40yearoldmale presents to the Emergency Room complaining of hives,wheezing and difficulty breathing following an insect sting. Pulse is 120 beats/min.BP is 100/56. Immediate therapy should include which one of the following: a. Diphenhydramine 50 mg IV b. Methylprednisolone 100 mg IV c. Epinephrine 0.3 ml (1:1000 aqueous) sub Q or IM d. Cholorpheniramine 8 mg orally e. None of the above

is

c. Low C4 levels during and between attacks

c. Pregnancy

Which of the following is the most common underlying cause of asthma (Choose the one best answer):

deficiency)

b. Urticaria or hives

b. Sinusitis

66.

Hereditary angioedema (C1 inhibitor characterized by all of the following except: a. Frequent abdominal pain

a. Diabetes Mellitus

e. Gastroesophagealreflux

Which of the following would not suggest a FISH (Fluorescence In Situ Hybridization) test to identify DiGeorge syndrome? a. Recurrent otitis media in a 3yearold

a. Diffusing capacity

65.

Which of the following symptoms is least common in patients with sinusitis?

e. Acinetobacter and Herpes simplex 75.

The most common cause of contact dermatitis in general is: a. Latex b. Poison ivy, poison oak and poison sumac c. Nickel d. Darkcoloredpigments in shoes and clothing e. None of the above

76. A 2 year old with wheezing, persistent cough, a history of vomiting with cough, as well as hives and angioedema and increased cough after milk products comes to your office for evaluation. He drinks soy and grandma is not feeding him any milk products. He has been treated with prn albuterol


nebulizer treatments with benefit in the past. On exam he has frequent congested cough, p = 112, r =26, shiners and Dennies lines.On chest exam he has transmitted upper airway rhonchi and coarse breath sounds but no wheezes or rales.Nasal exam reveals swollen pale nasal mucosa without any visible discharge. CXR shows increased bronchovascular markings without infiltrate but with hyperexpansion. What diagnostic lab information do youwant to obtain?

81.

a. CBC and diff, IgE and IgG RAST to milk and soy

a. Start a leukotriene antagonist daily, albuterol inhaler prn and before exercise

b. CBC and diff, total IgE, IgG RAST to milk c. CBC and diff, total IgE, and skin or RAST testing to milk, casein and soy

b. Start an inhaled corticosteroid at low to moderate dose, continue albuterol prn and before exercise

d. CBC, milk precipitins, IgE RAST to milk and casein e. B and D

c. Start the patient on a combined controller inhaler with inhaled steroid and long acting bronchodilator

The one true statement about anaphylaxis is

d. Start the patient on an inhaled steroid and leukotriene antagonist, and albuterol inhaler before exercise and prn

a. There are always skin findings—rash, angioedema, etc. b. People with recurrent anaphylaxis with no identifiable cause (idiopathic)are the most likely to carry adrenalin c. After adrenalin, the most important medication to administer immediatelyis steroids

e. All therapy strategies listed are adequate for this patient 82.

d. After adrenalin, the most important medication to administer promptly isan H2 blocker e. The most likely patient to die of anaphylaxis has underlying asthma 78.

A 5 year old boy lives in a smoking household and has a history of RSV bronchiolitis in infancy. He has been diagnosed with bronchitis at least once, and sometimes twice, every winter. He has sneezing and allergicsalute in spring and fall. When he runs in kindergarten he often coughs but has no obvious shortness of breath.He wakes at night coughing only when he has bronchitis. He is unable to do full pulmonary functions. Thehistorical information most suggestive of asthma in this child is:

a. Mild intermittent b. Mild persistent c. Moderate persistent d. Severe persistent e. Well controlled asthma 83.

a. Cough at night when ill b. His allergic symptoms

b. Anticholinergic

d. Cough with exercise

c. Decongestant

e. He has been living in a smoking household

a. Vernal conjunctivitis b. Allergic conjunctivitis c. Glaucoma d. Dryness from hormone replacement

d. Nasal corticosteroid e. Antileukotrienereceptor antagonist 84. An 18yearoldteenager with a history of asthma as a young child, which she “outgrew” by the time she was in first grade, presents to her primary care physician in November 4 months pregnant, with wheezing and cough for the last month. On questioning, she admits to ragweed hayfever and frequent heartburn. On exam, she is coughing at frequent intervals. Chest is clear to auscultation with fair breath sounds throughout. There is slightly prolonged expiratory phase. What is the most appropriate treatment for this patient: a. Prn albuterol inhaler, loratadine and calcium carbonate antacid.

e. Behcet’s disease 80. An 8yearoldmale has asthma symptoms about three times per month requiring the use of an albuterol inhaler, despite adequate inhaled steroid treatment. These episodes typically occur at night. The child is notallergic to his guinea pig or dust mites, and there is no smoking in the home. He has no problems with exercise and rarely needs albuterol during the day except when he has an upper respiratory tract viral infection. His FEV1 and PEFR are both >80% predicted. Based on this history, the most likely trigger for his nighttime asthma is: a. Allergic rhinitis b. Obstructive sleep apnea c. Gastroesophageal reflux disease (GERD) d. Drop in endrogenous corticosteroid levels at night e. None of the above

In treating allergic rhinitis, which of the following medication or medications control the symptoms of congestion, rhinorrhea and itching. a. Antihistamine

c. RSV bronchiolitis in infancy

79. A 45yearoldwoman with a strong family history of both allergies and glaucoma presents with frequent red eyes that sometimes itch, sometimes feel dry and sometimes water. On exam, bulbar conjunctivae are injected, palpebral conjunctiva are normal in color. Nasal mucosa is moderately swollen and pale. Which of the following is the most likely diagnosis?

A 52yearoldmale with known asthma for 27 years is seen in your office for a follow up of his asthma. Hestates his asthma has been in good control on his low dose of inhaled corticosteroid. But when asked aboutalbuterol use, he says he uses it 23times daily. When asked about nighttime awakening due to asthma, hestates he awakes because of asthma 3 times per month. He also tells you his asthma has been in good controland that he has not missed a day of work. A PFT indicates he has an FEV1 of 81% predicted. You wouldcharacterize his asthma as:

b. Prn albuterol inhaler, beclomethasone inhaled corticosteroid and ranitidine. c. Prn albuterol inhaler, budesonide inhaled corticosteroid, ranitidine and oral steroid burst. d. Prn albuterol inhaler, oral steroid burst and proton pump inhibitor. e. Prn albuterol inhaler, course of erythromycin for possible mycoplasma infection, calcium carbonate antacid. 85.

Complement activation is a part of which type of hypersensitivity reaction? a. Type I b. Type II and Type III c. Type IV

IMMUNOLOGY

77.

A 10yearoldgirl has had asthma for 18 months. She typically 1227 complains of asthma symptoms 3 times perweek on the average, with daily symptoms when she has a URIs. She has never been hospitalized for asthmabut has had 2 ED visits for wheezing with URIs. She complains of cough and shortness of breath withstrenuous exercise. Her FEV1 and PEFR are both >80% predicted. Her treatment to date has been an albuterolinhaler prn. At this point, the one clearly inadequate therapy for this patient is:


d. Type III and IV

1228

93.

e. Type I and IV

a. Converting viral DNA into RNA

86. After playing in the bushes during a camping trip, a 7yearoldgirl complains of intense itching & blistering of the hands, arms, & legs. What is the most likely condition & what type of hypersensitivity reaction is she displaying?

b. Converting viral RNA into DNA c. Converting proteins into viral RNA d. Both A and B e. Both B and C

a. Hives; Type I reaction b. Hives; Type IV reaction c. Contact Dermatitis; Type IV reaction

94.

b. Plasma Cell

MCQ's

e. SLE; Type V reaction

c. Red blood cell d. Virus

87. Skin testing is useful in the diagnosis of which type of hypersensitivity reaction? b. Type II and Type III

e. Both A and D 95.

c. Type IV

a. Peptide

e. Type I and IV

b. MHC II molecule c. Complement

88. Rh disease & Goodpasture’s syndrome are which type of hypersensitivity reaction?

d. Antigen

a. Type I c. Type III

e. Allergen 96.

d. Type IV

b. Antibody

Megakaryocytes are minimally immunoresponsive. What type of cell do megakaryocytes give rise to?

c. Antigen

a. RBC

e. Both B and C

b. Platelets c. Leukocytes

d. Both A and B 97.

d. Monocytes

b. Oxidative activity c. Fright

A latent, measleslikeviral infection &, presumably, a defect in cellular immunity is associated with which of the following diseases?

d. Drowning e. All of the above

a. Hereditary angioedema b. Systemic lupus erythematous (SLE)

98.

c. Subacute sclerosing panencephalitis (SSPE) d. DiGeorge syndrome

b. Chemotaxis

What host cell membrane structures enable the attachment of a virus like human immunodeficiency virus (HIV)?

c. Phagocytosis

a. Ion channels

e. All of the above

b. Nuclear pores c. Ribosomes d. Receptors e. All of the above 92.

What is the term applied to white blood cells squeezing between endothelial cells lining the blood vessel to reach the site of an infection? a. Diapedesis

e. Bruton disease 91.

What is an important mechanism white blood cells use to kill bacteria, fungi and other invading pathogens? a. Asphyxiation

e. Mast cells 90.

What product of the immune system attaches to bacteria, making them easier to eat by white blood cells? a. Hemoglobin

e. Type V 89.

What’s a specific term for a bacterial or other foreign protein that initiates antibody production by the body?

d. Type III and IV

b. Type II

Which of these produces and secretes antibodies in the body? a. Bacteria

d. Contact Dermatitis; Type I reaction

a. Type I

In HIV infection, reverse transcription describes which of the following?

d. Enucleation 99.

What HIV protein helps insert the HIV provirus into the host’s DNA? a. Transcriptase b. Integrase

Name the process a cell such as a neutrophil or a macrophage uses to ingest (eat) its prey.

c. Protease

a. Halitosis

e. Oxydase

b. Chemotaxis c. Botulism d. Phagocytosis e. Pinocytosis

d. Dismutase 100. What main characteristic of HIV makes the virus difficult to treat with a single drug? a. Its ability to destroy drugs b. Impenetrable capsule c. Its ability to mutate


d. Its environmental durability e. RNA containing 101. A 36-year-old woman presents to the rheumatology outpatient clinic with at wo-month history of stiff hands and wrists. She mentions that the pain isparticularly bad for the first few hours after waking up and is affecting her work asa dentist. On examination, the wrists, metacarpophalangeal joints and proximalinterphalangeal joints are swollen and warm. What is the most likely diagnosis? a. Rheumatoid arthritis b. Osteoarthritis c. Septic arthritis e. Reactive arthritis 102. A 45-year-old woman presents to the rheumatology outpatient clinic with a threemonthhistory of stiff hands and wrists. She mentions that the pain is particularlybad first thing in the morning. On examination, the wrists, metacarpophalangealjoints and proximal interphalyngeal joints are swollen and warm. A diagnosis of rheumatoid arthritis is suspected. Which of the following investigations is mostspecific for confirming the diagnosis? a. X-rays b. Rheumatoid factor levels c. Anti-citrullinated peptide antibody (anti-CCP) levels d. C-reactive protein e. Erythrocyte sedimentation rate 103. A 40-year-old woman presents to the rheumatology outpatient clinic with a threemonthhistory of stiff hands and wrists. She mentions that the pain is particularlybad first thing in the morning. On examination, the wrists, metacarpophalangealjoints and proximal interphalangeal joints are swollen and warm. A diagnosis of rheumatoid arthritis is suspected. Blood tests for rheumatoid factor return aspositive. What is the most appropriate management? a. Non-steroidal anti-inflammatory drugs (NSAIDs) b. Intramuscular depot injection of methylprednisolone plus NSAIDs c. Anti-TNF therapy d. Intramuscular depot injection of methylprednisolone plus NSAIDs andmethotrexate and sulfasalazine e. Physiotherapy 104. A 50-year-old woman, who has received a recent diagnosis of rheumatoid arthritis,presents to her GP with ongoing pain and stiffness in her hands and feet. Whichjoints are usually spared at onset of rheumatoid arthritis? a. Proximal interphalangeal joints b. Distal interphalangeal joints c. Metacarpophalangeal joints d. Wrists e. Metatarsophalangeal joints 105. A 55-year-old man presents to his GP with a 2-week history of pain in his hands.The pain is particularly bad in his right hand. On examination, brown discolorationof the nails with onycholysis is noted and the distal interphalangeal joints aretender on palpation. What is the most likely diagnosis? a. Rheumatoid arthritis b. Dermatomyositis c. Reactive arthritis d. Osteoarthritis e. Psoriatic arthritis

a. Rheumatoid arthritis b. Osteoarthritis c. Reactive arthritis d. Polymyalgia rheumatica e. Gout 107. A 79-year-old woman presents to her GP with pain in the left knee. This isparticularly bad in the evenings and is stopping her from sleeping. The GP explainsthat her discomfort is most likely due to osteoarthritis and arranges for her to havean x-ray of the knee. Which of the following descriptions are most likely to describe the x-ray? a. Reduced joint space, subchondral sclerosis, bone cysts and osteophytes b. Increased joint space, subchondral sclerosis, bone cysts and osteophytes c. Reduced joint space, soft tissue swelling and peri-articular osteopenia d. Increased joint space, soft tissue swelling and peri-articular osteopenia e. Normal x-ray 108. A 76-year-old man presents to accident and emergency with pain in his knees.It is worse in the right knee. He describes the pain as being worse in the eveningand after exertion. On examination, bony nodules are palpable on the distalinterphalangeal joints of both his hands. The right knee is swollen and there is areduced range of active movement. X-rays show reduction in the joint space,subchondral sclerosis and osteophyte formation. What is the most appropriatetreatment? a. Anti-TNF therapy b. NSAIDs and urgent orthopaedic follow up c. NSAIDs and GP follow up d. NSAID and intramuscular depot methylprednisolone with GPfollow up

injection

of

e. Admit the patient for orthopaedic assessment 109. A 32-year-old man presents to accident and emergency with a 1-day history ofpain in the right knee. He also mentions that he has had a fever and is feelinggenerally unwell. On examination, the right knee is swollen, warm and extremelypainful to move. What is the most appropriate next step? a. Empirical intravenous antibiotic treatment b. X-rays of the right knee c. Aspiration of the joint and blood cultures d. Referral for physiotherapy e. Immobilize the joint 110. A 30-year-old man presents to his GP with a 1-week history of painful, swollenknees and a painful right heel. Further history reveals that he has been experiencingburning pains while urinating for the past 2 weeks and that his eyes have becomered and itchy. What is the most likely diagnosis? a. Septic arthritis b. Gout c. Ankylosing spondylitis d. Enteropathic arthritis e. Reactive arthritis

IMMUNOLOGY

d. Polymyalgia rheumatica

106. A 75-year-old woman presents to accident and emergency 1229 complaining of pain inher knees. She mentions that this has been troubling her for several months. Painis generally worse in the evenings and after walking. On examination, there arepalpable bony swellings on the distal interphalangeal joints of the fingers on both hands. In addition, there is reduced range of movement and crepitus in the knees. What is the most likely diagnosis?


1230 111. A 70-year-old woman presents to accident and emergency

with sudden onset painand swelling in the right knee. Her past medical history includes hypertension andhypercholesterolaemia. She is currently taking aspirin, ramipril and simvastatin.On examination, she is apyrexial and the right knee is swollen. There is reduced range of movement in the knee due to swelling and pain. X-ray of the right kneeshows chondrocalcinosis. What is the most likely diagnosis? a. Gout b. Pseudo-gout

MCQ's

c. Septic arthritis

b. MRI scan c. Full blood count, bone and liver biochemistry blood tests d. Vitamin D levels e. DEXA scan 116. A 20-year-old man presents to accident and emergency with sudden onset pain inthe right eye, with associated blurred vision and discomfort when gazing at thelights. He has a history of back pain and has recently been diagnosed withankylosing spondylosis. What is the most likely cause of his eye pain? a. Conjunctivitis

d. Reactive arthritis

b. Retinal detachment

e. Osteoarthritis

c. Anterior uveitis

112. A 74-year-old woman presents to accident and emergency with sudden onset painand swelling in the left knee. On examination, she is apyrexial and the left knee isswollen. There is reduced range of movement in the knee due to swelling and pain.X-ray of the right knee shows chondrocalcinosis. Microscopy of the fluid aspiratedfrom the joint is most likely to show: a. Rhomboidal, weakly positively birefringent crystals under polarized lightmicroscopy b. Needle-shaped negatively birefringent crystals under polarized lightmicroscopy c. Atypical mononuclear cells

117. A 70-year-old woman presents to her GP complaining of severe unilateral headacheover the left side of her head. On further questioning, she mentions that she hasbeen having bilateral shoulder and neck pains over the past few weeks. She has alsobeen feeling lethargic. On examination, the left side of her scalp is painful to touch. What is the most likely diagnosis? a. Polyarteritis nodosa b. Polymyositis d. Migraine

e. Tophi

e. Giant cell arteritis

113. A 23-year-old man presents to the rheumatology clinic with lower back and hippain. These have been occurring every day for the past two months. Pain andstiffness are worse in the mornings. He also mentions that his right heel has beenhurting. He is previously fit and well, but had occasions of lower back pain when he was a teenager. His symptoms have stopped him from playing tennis. Recentblood tests organized by his GP have shown a raised C-reactive protein (CRP) anderythrocyte sedimentation rate (ESR). What is the most appropriate treatment? a. NSAID and spinal exercises

a. Steroid therapy and arrange urgent temporal artery biopsy b. NSAID analgesia and arrange urgent temporal artery biopsy c. Paracetamol analgesia and discharge with advice to bed rest e. NSAID analgesia and arrange urgent electromyography

c. Oral prednisolone d. Methotrexate plus sulfasalazine e. Bed rest 114. A 32-year-old man presents to the minor injuries walk-in clinic, complaining ofback pain. This had started suddenly that morning after he had lifted a heavy boxat home. He mentions that the pain has been shooting down his left leg and hecannot walk without the support of his friend. He has not passed urine since the onset of pain. On neurological examination of the lower limbs, tone and powercannot be assessed due to pain but there are decreased ankle reflexes and a sacralanaesthesia. What is the most appropriate next step? analgesia

118. A 77-year-old woman presents to accident and emergency complaining of severeunilateral headache over the left side of her head. On examination, the left side ofher scalp is painful to touch. Blood tests reveal a raised ESR and CRP. What is themost appropriate management?

d. Arrange urgent MRI head

b. NSAID and bed rest

and

complete

neurological

b. Send the patient home with NSAID analgesia and bed rest advice c. Arrange urgent MRI of spine d. Give NSAID analgesia and catheterize the patient e. Send the patient home with NSAID analgesia and advice to avoid heavylifting 115. A 70-year-old woman with a history of vertebral crush fractures presents to theosteoporosis outpatient clinic. Which of the following investigations is most usefulto assess the extent of her osteoporosis? a. Spinal x-rays

e. Acute glaucoma

c. Hypothyroidism

d. Reed Sternberg cells

a. Give NSAID examination

d. Corneal ulceration

119. A 60-year-old woman presents to her GP with a two-month history of lethargy andweakness. She mentions that she is finding it increasingly difficult to climb thestairs and do the housework. On examination, there is wasting and weakness of theproximal muscles in the upper and lower limbs. What is the most likely diagnosis? a. Dermatomyositis b. Polymyositis c. Polymyalgia rheumatica d. Kawasaki’s disease e. Polyarteritis nodosa 120. A 30-year-old Afro-Carribean woman presents to accident and emergency with a1-week history of progressive shortness of breath and fever. On further questioningshe mentions that her hands have been painful and stiff over the past few monthsand she has been having recurrent mouth ulcers. Chest x-ray confirms bilateralpleural effusions and blood tests reveal a raised ESR and a normal CRP. What is themost likely diagnosis? a. Systemic lupus erythematosus b. Systemic sclerosis c. Sjögren’s syndrome d. Discoid lupus e. Beçhet’s disease


121. A 34-year-old Afro-Carribean woman has been admitted for management andinvestigation of increasing shortness of breath. On further questioning, shementions that her hands have been painful and stiff over the past few months andshe has been having recurrent mouth ulcers. Chest x-ray confirms bilateral pleural effusions and blood tests reveal a raised ESR and a normal CRP. A diagnosis ofsystemic lupus erythematosus (SLE) is suspected and a full autoantibody screen issent to the laboratory. Which of the following autoantibodies is most specific tothe suspected diagnosis?

126. A 45-year-old woman presents to the rheumatology clinic with 1231 a three-monthhistory of itchy, dry eyes and a persistently dry mouth. She also mentions that herfingers have been extremely cold, occasionally turning blue after going outside inthe morning. Shirmer’s test is positive. What is the most likely diagnosis? a. Systemic sclerosis b. Raynaud’s disease c. SLE

a. Anti-nuclear antibody

d. Primary Sjögren’s syndrome

b. Rheumatoid factor

e. Secondary Sjögren’s syndrome

c. Anti-double stranded DNA antibody e. Anti-mitochondrial antibody 122. A 55-year-old woman presents to her GP with shortness of breath and dry cough. Thesymptoms began a few months ago and have progressed. She has a past medicalhistory of rheumatoid arthritis, diagnosed ten years earlier. On respiratory examination,there are bibasal fine inspiratory crackles on auscultation. What is the most likelycause of her symptoms? a. Pulmonary oedema b. Consolidation c. Pleural effusions d. Pulmonary fibrosis e. Intrapulmonary nodules 123. A 27-year-old woman presents to accident and emergency complaining of suddenonset shortness of breath and rightsided pleuritic chest pain. She has a past medicalhistory of three miscarriages and a deep venous thrombosis in the right leg. Onexamination, pulse is 110 bpm, respiratory rate is 24 bpm, oxygen saturation is 88per cent on room air. An arterial blood gas shows pH 7.40, PO2 8.0, PCO2 3.1. Whatis the diagnostic investigation of choice? a. Full blood count b. Chest x-ray c. D-dimer d. CT pulmonary angiogram (CTPA) e. ECG 124. A 27-year-old woman presents to accident and emergency complaining of suddenonset shortness of breath, right-sided pleuritic chest pain and haemoptysis. She hasa past medical history of three miscarriages and a deep venous thrombosis in theright leg. CTPA confirms a large pulmonary embolism. What is the most likely underlying diagnosis? a. SLE b. Primary anti-phospholipid syndrome c. Raynaud’s disease d. Systemic sclerosis e. Beçhet’s disease 125. A 27-year-old woman presents to accident and emergency complaining of suddenonset shortness of breath, right-sided pleuritic chest pain and haemoptysis. She has apast medical history of three miscarriages and a deep venous thrombosis in the rightleg. CTPA confirms a large pulmonary embolism. A diagnosis of anti-phospholipid syndrome is suspected and a full autoantibody screen is sent. Which of the followingautoantibodies would confirm the diagnosis if detected?

127. A 24-year-old woman presents to her GP complaining of cold hands and feet. Thishas been ongoing for the past three months and is especially bad when she goes outin the mornings and may last for hours. On further questioning, she mentions thather hands sometimes turn blue or red and that gloves are unhelpful. She has otherwise been feeling well and has no past medical history. What is the mostappropriate treatment? a. Propanolol b. Aspirin c. Nifedipine d. Subcutaneous injection of low molecular weight heparin e. Prednisolone 128. A 42-year-old woman presents to accident and emergency with retrosternaldiscomfort. She was diagnosed with systemic sclerosis a year ago. Which of thefollowing statements is true about systemic sclerosis? a. Microstomia is only seen in diffuse cutaneous systemic sclerosis b. Skin involvement is limited to face, hands and feet in limited cutaneoussystemic sclerosis c. Oesophageal dysmotility is only seen in limited cutaneous systemicsclerosis d. Anti-double stranded DNA antibodies are normally detected in patientswith systemic sclerosis e. Raynaud’s phenomenon occurs as a result of skin fibrosis (scleroderma) 129. A 30-year-old woman presents to accident and emergency with worsening stiffnessin the hands, wrists and feet. She mentions that the pain has been particularly badin the mornings. On examination, there is a palpable spleen. Initial blood tests reveala low neutrophil count and a raised C-reactive protein. The most likely diagnosis is: a. Felty’s syndrome b. Reactive arthritis c. Still’s disease d. Infectious mononucleosis e. Serum sickness 130. A 53-year-old man, who works as a chef, presents to accident and emergency withsudden onset severe pain, tenderness and swelling of the first metatarsophalangealjoint. The pain is making it difficult for him to mobilize. He has had two previoussimilar episodes. Blood tests reveal a raised serum urate level. The most likely diagnosis is: a. Gout b. Pseudo-gout c. Septic arthritis

a. Anti-cardiolipin antibody

d. Reactive arthritis

b. Anti-centromere antibody

e. Osteoarthritis

c. Anti-nuclear antibody d. Anti-mitochondrial antibody e. Anti-histone antibody

IMMUNOLOGY

d. Anti-centromere antibody


1232 131. A 59-year-old man presents to his GP with sudden onset severe

pain, tendernessand swelling of the first metatarsophalangeal joint. He is known to suffer fromacute gout and has had several previous similar episodes. What is the mostappropriate treatment? a. Allopurinol b. NSAIDs c. Conservative measures including reduced alcohol intake and weight loss d. Intra-articular steroid injection

MCQ's

e. Methotrexate 132. A 30-year-old Turkish man presents to accident and emergency with oral ulcers,genital ulcers and painful legs. On examination, there are apthous ulcers in themouth, genital ulceration, erythema nodosum over the shins. He is admitted underthe medical team on call and a skin pathergy test is positive. What is the most likely diagnosis? a. Henoch–Schönlein purpura b. Lyme disease c. Berger’s disease d. Caplan’s syndrome e. Behçet’s disease 133. A 23-year-old woman presents to accident and emergency with a purpuric rashover the buttocks and lower limbs and haematuria. She is finding it difficult tomobilize due to pain in her ankles and knees. What is the most likely diagnosis? a. Henoch–Schönlein purpura b. Perthes’ disease c. Behçet’s disease d. Still’s disease e. Ehlers–Danlos syndrome

134. A 67-year-old man presents to his GP with pain in his pelvis. During the consultation,he mentions that his friends have been commenting that his head appears largerthan before. In addition, he has noticed deterioration in hearing in his left ear. Onneurological examination, a left-sided sensorineural deafness in detected. Closerinspection of the legs reveals bowing of the tibia. What is the most likely diagnosis? a. Osteomalacia b. Osteoporosis c. Acromegaly d. Ricketts e. Paget’s disease 135. In a patient with Paget’s disease of the bone, which of the following blood testresults are most likely to be seen? a. Normal serum calcium, normal serum phosphate, raised serum alkaline phosphatase b. Normal serum calcium, normal serum phosphate, normal serum alkaline phosphatase c. Raised serum calcium, low serum phosphate, normal serum alkaline phosphatase d. Normal serum calcium, low serum phosphate, raised serum alkaline phosphatase e. Low serum calcium, low serum phosphate, low serum alkaline Phosphatase


1233

Immunology - Answers 55. d

82. b

109. c

2. d

29. a

56. a

83. d

110. e

3. c

30. c

57. d

84. a

111. b

4. e

31. b

58. e

85. b

112. a

5. c

32. b

59. a

86. c

113. a

6. d

33. b

60. b

87. e

114. c

7. a

34. d

61. c

88. b

115. e

8. d

35. d

62. c

89. b

116. c

9. b

36. e

63. a

90. c

117. e

10. b

37. d

64. e

91. d

118. a

11. c

38. a

65. a

92. d

119. b

12. d

39. b

66. e

93. b

120. a

13. a

40. c

67. d

94. b

121. c

14. d

41. a

68. c

95. d

122. d

15. d

42. e

69. b

96. b

123. d

16. d

43. c

70. b

97. b

124. b

17. b

44. a

71. c

98. a

125. a

18. a

45. b

72. b

99. b

126. d

19. d

46. d

73. d

100. c

127. c

20. d

47. d

74. a

101. a

128. b

21. d

48. d

75. b

102. c

129. a

22. d

49. a

76. c

103. a

130. a

23. b

50. a

77. c

104. b

131. b

24. d

51. c

78. d

105. e

132. e

25. d

52. b

79. b

106. b

133. a

26. a

53. d

80. c

107. a

134. e

27. d

54. c

81. d

108. c

135. a

b and/or c

IMMUNOLOGY

28. d

1.


METABOLIC DISORDERS 1.

2.

Regarding serratus anterior muscle which is incorrect?

10.

a. Incidence of the disease

b. Lifts arm above the shoulder

b. Incidence is low in the community

c. Supplied by long thoracic nerve

c. Early detection leads to favorable outcome

d. Originates from lower eight ribs

d. The disease has a lead time

The treatment of choice for atticoantral variety of chronic suppurative otitis media is:

11.

b. Median

b. Medical management

c. Axillary

c. Underlay myringoplasty d. Insertion of ventilation tube All of the following are the complications in the new born of a diabetic mother except?

d. Musculocutaneous 12.

b. 15%

b. Hyperglycemia

c. 50%

c. Hypocalcemia 4.

The correct line of management in child who has swallowed a coin is?

d. 80% 13.

b. Block of alpha & beta receptors c. Agonistic action on alpha receptors

b. Rigid endoscopy

d. Adrenaline only

c. Laparotomy 5.

14.

b. Calcarine

a. T cells

c. Superior temporal

b. Macrophages

d. Inferior occipital

c. B cells 6.

15.

b. Methyl testosterone

a. Superior conchae

c. Oestrogens

b. Cymba conchae

d. Osmic acid

c. Middle conchae 7.

16.

b. Avascular necrosis head of humerous c. Brachial plexus injury

a. Enteroinvasive E.coil

d. Chip fracture scapula

b. Enteropathogenic E.coil d. Enteroaggregative E.coil 8.

17.

b. Flavivirus c. Oncovirus d. Arbovirus

a. Phenylketonuria c. Multiple carboxylase deficiency

18.

d. Glutaric aciduria 9.

b. Neurological abnormalities c. Hepatic failure d. Thrombotic angiopathy

a. Urea c. Blood ammonia d. Urinary nitrogen content

In shigella dysentery associated hemolytic uremic syndrome, the false statement is? a. Leucocytosis

For assessing the ability of protein utilisation the best index is? b. Uric acid

HIV is a? a. Retrovirus

With urine turning green on ferric chloride test, the diagnosis is: b. Alkaptonuria

Anterior dislocation of shoulder causes all except? a. Circumflex artery injury

Most common strain of E.coil giving rise to travellerâ&#x20AC;&#x2122;s diarrhoea is?

c. Enterotoxigenic E.coil

Medical treatment for BPH includes? a. Finesteride

Mac Ewenâ&#x20AC;&#x2122;s triangle can be felt through the?

d. Posterior part of auricle

Primary visual field is situated around the ______ sulcus? a. Central

Helper cells belong to?

d. Monocytes

Vasomotor reversal of Dale is because of? a. Block of alpha receptors

a. Fiber optic endoscopy

d. Wait and Watch

What is the percentage of chances of hydatidiform mole to develop choriocarcinoma? a. 5%

a. Hyperbilirubinemia

d. Hypomagnesemia

Nerve not related to humerus is? a. Radial

a. Mastoidectomy

3.

Screening test is not useful when?

a. Multipinnate muscle

19.

Dengue hemorrhagic fever is caused by? a. Type I secrotype b. Reinfection with the same serotype of dengue virus


c. Reinfection with the different serotype of the dengue virus

29.

20.

c. Fracture of first metatarsal d. Fracture of first metacarpal

a. Numerator is increased c. Both numerator and denominator are changed

30.

b. Cellulose acetate electrophoric

Oesophagus receives blood supply from all except?

d. Osmotic fragility test

b. Inferior phrenic artery d. Bronchial artery

Which of the following is not likely in patients taking amiodarone?

All are pencillinase resistant except?

b. Hypothyroidism

c. Internal mammary artery

31.

a. Pulmonary fibrosis

a. Methicillin

c. Hyperthyroidism

b. Nafcillin c. Penicillin d. Dicioxacillin

d. Gynaecomastia 32.

a. High fiber diet

23. Mild hemolyti anaemia is associated with vitamin.. . Deficiency?

b. Selenium c. Antioxidants

a. B6

d. Fatty food

b. E c. A

33.

b. Illeum

Trimethoprim acts by?

c. Jejunum

a. Inhibiting DHFR

d. Duodenum

b. Inhibiting cell metabolism c. Inhibiting DNA

34.

b. Confined to small group of muscles

Paradoxically split second heart sound signifies severe?

c. Occurs only in voluntary muscles

a. Pulmonary stenosis

d. All of the above

b. Mitral stenosis c. aortic stenosis

35.

b. Technetium

Riboflavin nutritional status is assessed by?

c. Gallium

a. Xanthine oxidase levels in RBC’s

d. Pottasium

b. Glutathione reductase activation in RBC’s c. Urine excretion of Riboflavin

36.

b. Carcinoma endometrium

Provision of free medical care to the people at government expense is known as?

c. Krukkenberg tumour d. Carcinoma vulva

a. State medicine b. Social therapy c. Social medicine

37.

b. Upjohn c. Lindsay

Shortest sacrocotyloid diameter causing narrowing of pelvis is a feature of which type of maternal pelvis? a. Android b. Gynaecoid c. Platypelloid d. Anthropoid

Cimetidine was synthesized by? a. Black

d. Social insurance programme 28.

”Signet ring cells” are seen in? a. Carcinoma cervix

d. CytochromeCreductase levels in kidneys 27.

The radionuclide used for ventriculography is a. Thallium

d. tricuspid stenosis 26.

Cadaveric spasm a. Instant in onset

d. Inhibiting RNA 25.

Most common site of obstruction in gallstone ileus is? a. Colon

d. C 24.

Which of the following helps in preventing colon cancer?

d. Lilly 38.

Nutritional status of children between 04 years in a community can be assesed by all except? a. Mortality in 04 years b. Birth weight of less than 2.5 gm c. Maternal Hb<11.5 g/dl/ d. Height and weight of all preschool children

METABOLIC DISORDERS

c. Sickling test

a. Inferior thyroid artery

22.

All the following techniques are helpful in the diagnosis of haemoglobinopathies, except? a. Alkali denaturation test

d. Numerator is decreased 21.

1235

b. Fracture dislocation of base of first metatarsal

When the sample size is less than 30, one of the following modifications is made in the formula of standard deviation? b. Denominator is decreased

What is Bennett’s fracture? a. Fracture dislocation of base of first metacarpal

d. Reinfection in immunocompromised host


1236 39.

40.

MCQ's

41.

Pulmonary fibrosis in Bronchogenic carcinoma of lung may follow exposure to?

49. The most important factor to overcome protein energy malnuntrition in children less than 3yrs is;

a. Coal dust

a. Suply of subsidized food from ration shop

b. Silica

b. Early supplimentation of solids in infants

c. Asbestos

c. immunization to the child

d. Bagasse

d. Treatment of anaemia and pneumonia in infant and toddlers

Ejection fraction increases with?

50.

a. Decrease endsystolic volume

a. Carboxyterminal

b. Decrease enddiastolic volume

b. Amino terminal

c. Decreased peripheral resistance

c. Sulphydryl groups

d. Venodilation

d. None of the above

Which is NOT visualized on posterior rhinoscopy? a. Eustachian tube

51. Dissociate anaesthesia is described with which of the following? a. Propofol

b. Inferior meatus

b. ketamine

c. Middle turbinate

c. Thipental

d. Posterior border of nasal septum 42.

43.

Which one of the following would cause a metabolic acidosis is with a normal anion gap?

d. Halothane 52.

a. Strength of returning echo

b. Acute renal failure

b. Relation of transducer to blood flow

c. Diabetic ketoacidosis

c. Frequency of Doppler used

d. Aspirin overdose

d. Type of Doppler machine used

All of the following organs contain aneurysm in polyarteritis nodosa except?

53.

b. Hydrocephalus c. Placenta praevia

c. Kidney d. Pancreas Diphtheria toxin acts by?

d. Polyhydramnios 54.

a. Actinic keratosis

b. Inhibiting glucose transport

b. Chronic cystitis

c. Increasing levels of Cyclic AMP

c. Chronic bronchitis

d. Inhibiting protein synthesis

d. Ulcerative colitis

Smokeless gun powder is composed of?

55.

a. Generally occurs as dissemination of a miliary tuberculosis

b. HCN

b. The cranial nerves frequently are involved

c. Nitrocellulose

c. The most common affected leptomeninges are at the base of the brain d. Communicating and obstructive hydrocephalus cortical abscesses, and empyemas are very uncommon complications

Cetuximab (an EGFR antagonist) can be used in? b. Anal canal carcinoma

56.

b. Maintenance of electrolyte balance

d. Small cell lung carcinoma The formula showing relations of pressure, thickness and radius? a. Laplace formula

c. Sufficient hydration d. Arrest of bleeding 57.

b. Ohm’s law

b. 510%

d. Poisseulle’s formula

c. 1015%

Dapsone is useful for treating all except? b. Dermatitis Herpetiformis c. Madura Foot d. Lymphoma

The average coronary blood flow in human being at rest is _ % of cardiac output ? a. 4.5%

c. Pascal’s law

a. Leprosy

Haemostasis means? a. Coagulation

c. Gastric cancer

48.

True regarding tubercular meningitis:

a. KMno4

a. Palliation in head and neck cancer

47.

Which of the following pathologic processes in an example of dysplasia?

a. Inhibiting Acetyl Choline release

d. Sulphur 46.

The commonest cause of breech presentation is: a. Prematuarity

b. Lung

45.

In colour Doppler the colour depends upon?

a. Renal tubular acidosis

a. Liver

44.

The binding of 2,3 BPG to Hemoglobin is to?

d. 1520% 58.

Rigor mortis first starts in? a. Upper eyelids b. Lower eyelids


c. Lower limbs

69.

59.

c. E.gingivalis

a. Blastomycosis

d. E.nana

b. Nocardia 70.

b. Toxemia

Population of 10000, birth rate 36 per 1000, 5 maternal deaths, the MMR is?

c. Hemorrhage

c. 20

71.

a. Tympanic branch of glossopharyngeal nerve

d. 5 61.

b. Vagus nerve c. Facial nerve

Which of the following is not in WHO surveillance?

d. mandibular nerve

a. Rabies b. Influenza c. Malaraia

72.

b. Prevents ovulation in lactating women c. In responsible for formation of corpus luteum

The cause of breech presentation are all except?

d. Is responsible for progesterone secretion

a. Previous caesarean section b. Placenta previa c. Contracted pelvis

73.

b. Gasserian ganlion c. Geniculate

True about minoxidil is?

d. Celiac ganglion

a. Increases hair growth b. Antihypertensive c. Both

74.

b. Ventricles

Cold agglutinins are seen in?

c. AV node

a. Mycoplasma pneumonia

d. Purknje fibres

b. Psittacosis c. Legionella pneumonia

75.

b. Renal agenesis

No. of negative stools mandatory to release a case from isolation in typhoid?

c. Esophageal atresia d. Hydronephrosis

a. 3 samples same day b. 2 samples on first day and 1 sample on the second day c. 1 sample of first day and 2 samples on the second day

76.

b. B.complex

The most specific feature of death due to hanging is?

c. cyclosporin

a. Tardieu spots

d. steroid

b. Ligature mark c. Fracture of thyroid cartilage

77.

b. CT scan

Cauliflower ear is due to?

c. MRI

a. Haematoma

d. Xray skull

b. Carcinoma c. Fungal infection d. Herpes 68.

Following agents have effects on the NMJ, EXCEPT a. Curare b. Decamethonium c. Succinylcholine d. Hexamethonium

Subarachnoid Haemorrhage is diagnosed by? a. Lumbar puncture

d. Dribbling of saliva 67.

Following is the adjuvant for the treatment of nephrotic syndrome? a. levamisole as immunomodulant

d. 3 samples on 3 separate days 66.

Polyhydramnios is seen in all the following except: a. Diabetes

d. TB 65.

In wolfparkinson white syndrome, there exist a connection between atria and? a. Bundle of His

d. None 64.

Herpes zoster involves? a. Otic ganglion

d. Oligohydramnios 63.

Prolactin? a. Facilitates

d. Varicella 62.

Tympanic plexus is formed by?

78.

Disturbances of affect include all except? a. Panic b. Apathy c. Phobia d. Obsession

METABOLIC DISORDERS

d. Thrombophlebitis

a. 14.5 b. 13.8

most deaths involving placenta previa result from? a. Infection

d. Tinea versicolor 60.

1237

b. E.histolytica

Madura foot is caused by?

c. Candida albicans

Entamoeba, which is not found in gut? a. E.coli

d. Fingers


1238 79.

80.

Deep transverse arrest is seen in?

89.

a. Gastric dilatation

b. Occipitoanterior position

b. Blood glucose levels

c. Breech delivery

c. Blood insulin levels

d. Face presentation

d. All of the above

Kallu, a 25 yr male pt.presented with a red eye and complains of pain, photophobia, watering and blurred vision. He gives a history of trauma to his eye with a vegetable matter. Corneal examination shows a dendritic ulcer. A corneal scraping was taken and

90.

b. Acanthambea

MCQ's

c. Candida

b. Burns c. Tuberculosis d. Zenker’s degeneration 91.

d. Aeno virus

b. Divident of incidence and mean duration of disease c. Sum of incidence and mean duration of disease

a. Hot air oven

d. Difference of incidence and mean duration of disease

b. Autoclaving 92.

d. Ethylene oxide 82.

b. Cesarean section

a. Immediate evacuation

c. High forceps

b. Evacuation after 24 hrs

d. Low forceps after external rotation

c. Antibiotics 83.

93.

A PostThyroidectomy patient develops signs and symptoms of Tetany. The management is?

b. hyperkalemia c. hypoalbuminemia

b. Bicarbonate

d. hypertension

c. Calcitonin 84.

94.

The most effective treatment in the early stages of trachoma is?

b. diagnsis is possible

b. Choromycetin systemically

c. It is seen in PEM Children

c. Sulphonamides systemically

d. Mntoux test is negative

d. Soframycin locally Ideal treatment of Tinosporidiosis is: a. Rifamipicin

e. Leucocytosis is seen 95.

b. Clear cell

c. Dapsone

c. Adeno carcinoma

d. Laser Epithelium of cornea is? a. Pseudostratified

d. Anaplastic carcinoma 96.

b. Rheumatoid arthritis

c. Stratified squamous keratinized

c. Neutropenia

d. Stratified squamous nonkeratinised Bagasosis can be prevented by spraying Bagasse with? a. 10% acetic acid b. 5% acetic acid

d. Nephropathy 97.

The true statement about Zenker’s diverticulum is; a. It is outpouching of ant.pharyngeal wall above the cricopharyngeus muscle

d. 2% propionic acid

b. Barium swallow lateral view for diagnosis is the best investigation

Mc Ardles disease is due to the deficiency of?

d. it is congenital

c. 1% propionic acid 88.

True regarding Felty’s syndrome is all EXCEPT a. Splenomegaly

b. Transitional

87.

Commonest histology of carcinoma of endometrium is? a. Squamous cell

b. Excision with cautery at base

86.

Which statement is not true regarding Cryptic military Tuberculosis? a. Xray

a. Penicillin locally

85.

Coose among the following the most important lab finding in nephrotic syndrome? a. BJ protine

a. I.v.Calcium gluconate

d. Vitamin D

In twin pregnancy, treatment of choice when first baby is in transverse lie is: a. Home delivery

Management of extradural hemorrhage is:

d. Observation

The relationship between incidence and prevalence can be expressed as the? a. Product of incidence and mean duration of disease

Glass vessels and syringes are best sterilised by

c. Irradiation

Coagulative necrosis is seen in all except? a. Myocardial infarction

a. Herpes simplex

81.

Satiety center in hypothalamus is regulated by?

a. Occipitoposterior position

a. Glu 1 phosphatase b. Gluc1, 6 diphosphatase c. Gluc 6 phosphatase d. Myophosphorylase

c. it is a true diverticulum


98.

Which of the following statements about aging is true? a. Zoo animals have shorter lifespans than animals in their normal habitat

99.

Characteristic features of kwashiorkor include following 1239 EXEPT? a. Anorexia

b. All animal species have approximately the same lifespan

b. Flaky paint dematosis

c. Men are programmed to live longer than women.

c. Hepatomegaly

d. Identical twins have a natural lifespan of approximately similar duration

d. Splenomegaly

METABOLIC DISORDERS


MCQ's

1240

Metabolic Disorders - Answers 1. d

21. c

41.

b

61. d

81.

2. a

22. c

42.

a

62. a

82. a

3. b

23. b

43.

c

63. c

83. a

4. d

24. a

44. d

64. a

84. c

5. a

25. c

45. c

65. d

85. b

6. b

26. b

46. a

66. d

86. d

7. c

27. a

47. a

67. a

87. d

8. a

28. c

48. d

68. d

88. d

9. d

29. b

49. b

69. c

89. b

10. b

30. d

50. b

70. c

90. d

11. d

31. d

51. b

71. a

91. a

12. b

32. a

52. b

72. b

92. b

13. a

33.

b

53. a

73. b

93. c

14. b

34. d

54. a

74. b

94. b

15. a

35. b

55. d

75. b

95. c

16. d

36. c

56. d

76. d

96. d

17. a

37. a

57. a

77. a

97.

18. c

38. c

58. a

78. d

98. d

19. c

39. c

59. b

79. a

99. d

20. b

40.

60. b

80. b

a

a

a


NEPHROLOGY 1.

A25yearoldman developed bilateral loin pain and frank haematuria. His symptoms had started 24 hoursafter developing a sore throat. His blood pressure was 138/88 mmHg. Urinalysis was positive for blood (4+)and protein (2+). What is the most likely diagnosis?

d. Manic depression e. Turner’s syndrome 7.

a. IgA nephropathy b. microscopic polyangiitis c. nephrolithiasis d. poststreptococcal glomerulonephritis

A44yearoldwoman with type 1 diabetes mellitus has not attended the diabetic clinic for 5 years. HerHbA1c is 10.1%. Examination shows no abnormalities. Her hemoglobin level is 9 g/dL, hematocrit is 28%, andmean corpuscular volume is 94 mcm3. A blood smear shows normochromic, normocytic anaemia. Which of thefollowing is the most likely cause? a. acute blood loss

e. septicaemia

b. chronic lymphocytic leukaemia c. erythropoietin deficiency

2.

A70 year old female is admitted 12 hours after taking an overdose of aspirin. Investigations revealed:

Serum sodium 138 mmol/L (137144),

Serum potassium 5.9 mmol/L (3.54.9),

Serum bicarbonate 14 mmol/L (2028), Serum urea 18.1 mmol/L (2.57.5),

Serum creatinine 238 umol/L (60110),

Serum salicylate 1120 mg/L (8 mmol/L).

What is the most appropriate treatment of this patient?

a. Acute tubular necrosis

a. Haemodialysis

b. Minimal change disease

b. Haemofiltration

c. Nodular glomeruloscerosis

c. Intravenous sodium bicarbonate.

d. Pyelonephritis

d. Peritoneal dialysis.

e. Renal vein thrombosis

e. Urine alkalinization. 3.

d. microangiopathic haemolysis e. sideroblastic anaemia 8.

9.

Whichof the following is associated with Hyperuricaemia? a. is usually due to an excess purine consumption b. occurs in association with acute lymphoblastic leukaemia c. in primary gout is inherited in an autosomal dominant manner

b. microscopic polyangiitis c. nephrolithiasis

e. can be treated with uricosuric drugs even in renal failure A67 year old man presents with sudden onset atrial fibrillation (ventricular rate of 150/minute). His serumcreatinine concentration was 250 umol/L (70110). What is the main factor that determines the choice of loading dose of digoxin in this patient?

d. poststreptococcal glomerulonephritis e. septicaemia 10.

b. can be measured using the Fick principle c. is higher in the medulla than the cortex

b. Apparent volume of distribution

d. is increased when renal nerves are stimulated

c. Lipid solubility e. Renal clearance 5.

e. is decreased in response to hypoxia 11.

Thefollowing are complications of nephrotic syndrome with the exception of

b. full renal recovery c. permanent renal impairment

b. accelerated hypertension

d. persistent hypertension

c. hypocalcaemia e. venous thrombosis 6.

Autosomalrecessive conditions include: a. Vitamin D resistant rickets b. Huntingdon’s chorea c. Wilson’s disease

Whatis the most likely outcome of minimal change nephropathy at 16 year of age? a. a tendency to relapse

a. acute renal failure

d. pneumococcal infection

Whichof the following concerning renal blood flow is true? a. is 40% of the cardiac output at rest

a. Absorption

d. Plasma halflife

A25yearoldman developed bilateral loin pain and frank hematuria. His symptoms had started 24 hoursafter developing a sore throat. His blood pressure was 138/88 mmHg. Urinalysis was positive for blood (4+)and protein (2+). What is the most likely diagnosis? a. IgA nephropathy

d. can be reduced with low dose aspirin therapy 4.

A60yearoldwoman is admitted with sudden onset of chest pain and is diagnosed with an acutemyocardial infarction. Her acute illness is complicated by low blood pressure and poor tissue perfusion forseveral days. Her serum lactate becomes elevated. Her serum urea and creatinine are noted to be increasing. Day 1 Day 2 Day 3 urea (mmol/L) 8 22 30 creatinine (μmol/L) 116 140 200. Granular and hyaline casts are present on microscopic urinalysis. The renal lesion that is most likely to be present in this situation is?

e. persistent proteinuria 12.

Whichof the following concerning the pH of urine is correct? a. is a useful indicator of the acid/base balance of the blood b. rises on a vegetarian diet c. is determined by the concentration of ammonium d. is lower than 5.5 in renal tubular acidosis e. would be above 7.0 after prolonged and severe vomiting


1242 13.

MCQ's

14.

A2 week old male child is brought to casualty by his concerned parents with diarrhoea and vomiting. He isthe first child of a young couple. Examination reveals few features besides obvious dehydration. He is noted tohave a penile length of 3.5cms. Which of the following is the most appropriate inital treatment for thispatient?

19.

a. Cowâ&#x20AC;&#x2122;s milk allergy is the most likely diagnosis

a. Cereal, toast, biscuits.

b. glutenenteropathyshould be excluded

b. Filter coffee, tea, boiled potatoes.

c. Requires urgent treatment with oral steroids

c. Milk, butter, plain yoghurt

d. Requires urgent treatment with IV normal saline

d. Milk, ham, chicken.

e. Rota virus gastroenteritis is the most likely diagnosis

e. Tomato, potato crisps, banana.

Whichone of the following statements regarding renal function is correct?

20.

a. Proteinuria on urinalysis

b. The permeability of the distal nephron to water increases in the presence of vasopressin

c. Urine plasma osmolality ratio is more than 1:1

d. A ten minute period of hyperventilation will normally be expected to lead to an increased rate of bicarbonate excretion inurine

b. Red cell casts on urinalysis d. Urinary sodium concentration greater than 30 mmol/l e. Creatinine clearance would be expected to be normal 1 year after the initial insult. 21.

e. Sodium reabsorption in the tubules is mainly controlled by aldosterone

a. Aluminium toxicity b. Folate deficiency c. Hyperkalaemia

a. is unlikely to be due to chronic pyelonephritis unless there is a clear history of an acute attack

e. Iron deficiency

c. is an unusual sequel glomerulonephritis

of

acute

post

streptococcal

d. Infection 22. A66yearoldman has developed chronic renal failure with a serum urea of 60 mmol/L and creatinine of650 micromol/L. Auscultation of the chest reveals a friction rub over the cardiac apex. He is most likley tohave a pericarditis that is termed? a. Constrictive

d. is the most common sequel to the nephrotic syndrome

b. Fibrinous

e. is likely to be benefited by administration of corticosteroids

c. Hemorrhagic

16. Acuterenal failure may be distinguished from chronic renal failure by which of the following? a. an increased urinary Na excretion b. left ventricular hypertrophy on the ECG

d. Purulent e. Serous 23.

b. Hyperkalaemia

d. renal size on ultrasound scan

c. Metabolic acidosis

e. hyperkalaemia

d. Reduced renal concentrating ability

Whichone of the following statements is correct? a. adult polycystic renal disease is inherited as an autosomal recessive trait

Whichof the following is characteristic of Bartterâ&#x20AC;&#x2122;s Syndrome? a. Secondary hyperaldosteronism

c. hypophosphataemia

e. Diarrhoea 24.

b. reflux nephropathy is inherited as an autosomal recessive trait

Whichof the following is NOT a recognised cause of acute tubular necrosis? a. Rhabdomyolysis

c. nephrogenic diabetes insipidus is inherited as an autosomal dominant trait

b. Paracetamol poisoning

d. Alportâ&#x20AC;&#x2122;s syndrome affects females more severely than males

d. Hypertension

c. Hypovolaemia

e. medullary sponge kidney is typically not inherited but is a congenital condition. 18.

Inwhich of the following circumstances would the treatment of anaemia with erythropeitin still beexpected to be effective?

Whichof the following are true of chronic renal failure in childhood?

b. if accompanied by renal osteodystrophy is likely to be associated with severe hypertension

17.

Whichof the following features would be expected in acute tubular necrosis?

a. The daily solute excretion will lie between 75 and 300 mosmol

c. The rate of ammonium excretion in urine is inversely related to the rate of urinary hydrogen ion excretion

15.

A33 year old male is receiving regular haemodialysis is noted to have a plasma potassium of 6.9 mmol/L(3.54.9)before a dialysis session. Although normally his potassium is less than 5.5 mmol/L. Which foodcombination from the dietary history would be most likely to cause the high potassium concentration?

Metastaticcalcification in chronic renal failure: a. unaffected by time on CAPD b. rapidly reversed in all sites after parathyroidectomy c. characteristically caused by calcium oxalate deposition d. increased prevalence with time on haemodialysis e. decreased by Vitamin D

e. Corticosteroid therapy 25.

A49yearoldwoman has been an inpatient for the past 10 days for treatment of a bronchopneumonia. Shehas developed the onset of chills, fever, and skin rash over the past two days. A peripheral blood film revealseosinophilia. On urinalysis she has ++ proteinuria. There is no past history of renal disease. Her hemoglobinA1C is normal. These findings would most strongly suggest which of the following diagnoses? a. Acute serum sickness b. Acute tubular necrosis c. Druginducedinterstitial nephritis


26.

d. IgA nephropathy

d. Renal vein thrombosis

e. Post streptococcal glomerulo nephritis

e. Mesangial IgA disease

Oliguriamore likely to be due to prerenal failure than intrinsic renal failure if:

33.

a. urine free of red blood cells or casts c. urine osmolality <350 mOsm/l

b. Fludrocortisone treatment is effective

d. in the presence of hypertension, raised JVP and good peripheral circulation

c. Increased Glomerular filtration rate is expected. d. Increased urinary bicarbonate would be expected.

e. urinary sodium >10mM

e. Normal renal handling of K+ and H+ 34.

c. polymorphism in Class I genes, but not Class II d. multiple sclerosis associated with HLA DR2

c. Left ventricular hypertrophy criteria on the ECG

e. HLA matching more important in kidney/pancreas transplant than liver transplant

d. The presence of arteriovenous nipping on fundoscopy. Whichof the following statements regarding idiopathic membranous nephropathy is correct?

35.

a. Increased urinary phosphate and cAMP with PTH infusion b. Low serum PTH

a. It characteristically presents in the second decade of life.

c. Low serum calcium and low serum phosphate

b. Progression to endstage renal failure is rapid.

d. Low serum calcium and high serum phosphate

c. immune complex deposits are typically seen in the glomerular mesangium. d. Males are twice as commonly affected as females.

e. Shortened 2nd and 3rd metacarpals

d. increase serum [alkaline phosphotase] mainly due to liver isoenzyme

A60yearoldman was diagnosed last year with adenocarcinoma of the lung, and a 4 cm mass lesion wastreated with a right lower lobectomy. He now has an abdominal CT scan that reveals scattered hepatic masslesions and hilar lymphadenopathy. For several weeks, he has had increasing malaise. A urinalysis revealsmarked proteinuria, and a 24 hour urine protein collection is 2.7 g/24hr. His serum urea is 30 mmol/L (2.5 7.5)with creatinine of 450 μmol/L (60 110).A renalbiopsy is performed, and there is focal deposition of IgG and C3 with a granular pattern. He is most likely tohave which of the following conditions?

e. decrease in blood pressure accompanied by increase in extracellular fluid

b. Membranous glomerulonephritis

e. The nephritic syndrome is a characteristic presentation. 29.

36.

Inasymptomatic chronic renal failure: a. there is increase in tubular excretion of urate b. serum ionised [calcium] is normal c. serum [phosphate] characteristically increased before GFR falls to 30ml/min

30.

Thefollowing are features of pseudohypoparathyroidism:

a. Goodpasture’s syndrome c. Minimal change glomerulonephritis

Antineutrophiliccytoplasmic autoantibodies:

d. Nodular glomerulosclerosis

a. positive only in Wegener’s syndrome associated with renal disease b. cause neutropenia in SLE c. present in inflammatory bowel disease

e. Rapidly progressive glomerulonephritis 37.

a. Benign intracranial hypertension

d. increased in systemic lupus erythematosus

b. Myositis

e. ANCA positive glomerulonephritis characteristically causes nephrotic syndrome 31. Inchronic untreated renal failure which of the following findings is characteristic? a. Metabolic alkalosis

c. Hypotension d. Seizures e. Osteoporosis 38.

Whichof the following is a feature of cystinuria? a. accumulation of cystine in the kidney

b. Hypokalaemia

b. a useful response to acidification of urine

c. Hyperosmolar dehydration

c. autosomal dominant inheritance

d. Hypercalcaemia

d. excessive urinary arginine excretion

e. Hypercalcinuria 32. A46yearoldwoman develops nephrotic syndrome and is awaiting further tests to establish theunderlying aetiology. In which circumstance would corticosteroids be most effective in reversing thenephrotic syndrome?

Erythropoietintherapy causes

e. radiolucent urinary calculi 39.

A19yearoldfemale developed pleural effusions, ascites and ankle swelling. Her blood pressure was112/76 mmHg.

a. Membranous nephropathy

Investigations revealed:

b. Minimal change disease

serum alanine transferase 17 U/L (5 15)

serum total bilirubin 17 umol/L (1 22)

c. Primary amyloidosis

NEPHROLOGY

b. Class II products used to activate CD4

b. A Creatinine clearance of 90 mL/min (70140)

e. Serum potassium of 3.9 mmol/L (3.54.9)

Whichof the following is least likely with the HLA complex? a. Class I products recognised by CD8

a. 24 hour urinary protein excretion of 1.6g (<0.2)

28.

Whichof the following is true concerning a 68 year old male with type 2 diabetes diagnosed with type IVrenal tubal acidosis? a. Aminoaciduria would be expected.

b. urine:plasma urea ratio <3

27. A30 year old man had a blood pressure of 150/100 mmHg. Clinical examination was normal. Which one ofthe following would suggest secondary hypertension?

1243


1244

d. Hyperphosphataemia

serum albumin 21 g/L (34 94)

serum total cholesterol 9.8 mmol/L (<5.2)

What is the next most appropriate investigation? a. Antinuclear antibody b. Pregnancy test c. Prothrombin time d. Serum protein electrophoresis

e. Hypokalemia 44. A35yearoldfemale presents with malaise, thirst and increasing nocturia over the last month. Six monthsago she attended the Emergency Department with an episode of renal colic. One month previously her GP hadnoted an eruptive, painful, erythematous rash on the anterior shins, which was selflimiting. What is the likely cause of her symptoms? a. Hypercalcaemia

e. Urinary protein estimation

b. Hyperglycaemia c. Hypocalcaemia

MCQ's

40. A15yearoldgirl was seen by her family physician because of increasing lethargy. She had a recenthistory of the “flu”. Biochemistry tests show that she has renal impairement.

serum sodium 140 mmol/L (137 144)

serum potassium 4.2 mmol/L (3.5 4.9)

serum urea 28 mmol/L (2.5 7.5)

serum creatinine 280 μmol/L (60 110)

Her condition does not improve after several weeks on corticosteroid therapy, so a renal biopsy is performed.The biopsy demonstrates the presence of segmental sclerosis of 3 of 10 glomeruli identified in the biopsyspecimen. Immunofluorescence studies and electron microscopy do not reveal evidence for immune deposits.

What is the most appropriate advice to give regarding her condition? a. She has an underlying malignancy b. She may require a renal transplant in 10 years c. She will improve if she loses weight

41.

e. Hyperoxaluria 45. A 21-year-old man presents with painless haematuria which he has noticed in thelast 3 days. He suffers from type 1 diabetes which is well controlled, but is otherwisefit and healthy. The patient has recently recovered from a mild throat infection. Urine dipstick analysis reveals blood and protein in the urine. The most likely diagnosis is: a. Henoch–Schonleinpurpura b. Benign prostate hypertrophy c. IgA nephropathy d. Diabetic nephropathy e. Urinary tract infection (UTI) 46. A 74-year-old type 2 diabetic woman undergoes a bowel resection for cancer of thecolon. She is well prior to the operation with well–controlled diabetes and no otherunderlying disease. The operation is successful and the patient is given postoperativeinsulin and IV dextrose. Two days after the operation she becomes very agitated.

d. She will likely develop a restrictive lung disease

Sodium 124 (135–145)

e. She will probably improve with additional corticosteroid therapy

Potassium 3.3 (3.5–5.0)

Urea 3.1 (3.0–7.0)

Glucose 7.2 (2.5–6.0)

Serum osmolality 265 (275–295)

Urine osmolality 150

The most likely cause of the hyponatraemia is:

WhichONE of the following is true concerning Antidiuretic hormone (ADH)? a. Carbamazepine potentiates it’s release b. Ethanol potentiates it’s release c. It circulates in the blood bound to neurohypophysin d. It is a cyclic octapeptide e. It is synthesised in the posterior pituitary

42.

A30yearoldfemale presents with fevers, and a 3 month history of malaise.

Results show:

Creatinine 250micromol/l

Complement C3 23 mg/dL (65 190)

What is the likely diagnosis? a. HIV nephropathy b. Infective endocarditis

43.

d. Hypokalaemia

a. Addison’s disease b. Syndrome of inappropriate anti-diuretic hormone (SIADH) c. Diabetic nephropathy d. Excess insulin e. Water overload 47. A 16-year-old boy presents with a low-grade fever which started 1 week ago. Thepatient also reports feeling fatigued and indicates pain in his joints. His parentsmention that he has been visiting the toilet more often than usual. A urine dipstickshows trace proteins, while a blood test shows raised eosinophils. The most likely diagnosis is:

c. Membranous Nephropathy

a. Acute tubulointerstitial nephritis

d. Microscopic Polyangiitis

b. Renal failure

e. Minimal change nephropathy

c. Diabetes mellitus d. UTI

Whichone of the following biochemical abnormalities would fit with a diagnosis of Bartter’s syndrome? a. Hyperchloraemia b. Hyperkalemia c. Hypernatraemia

e. Reactive arthritis 48.

A 58-year-old African man presents with pitting oedema of his ankles. He suffersfrom recently diagnosed hypertension, but is otherwise healthy. Blood results showlow albumin and a urine dipstick is positive for protein. The most appropriateinitial treatment is:


a. High protein diet

d. Metabolic acidosis with respiratory compensation

b. Diuretics

e. Acute respiratory alkalosis

c. Prophylactic anticoagulation d. ACE inhibitor e. Bed rest 49.

A 33-year-old woman presents with severe right flankpain. The pain started 3 hours ago and is not constant, occasionally moving towardsher right iliac fossa. The patient also feels nauseous and has a low-grade fever. Themost appropriate investigation is: a. Abdominal x-ray b. Magnetic resonance imaging (MRI) scan d. Computed tomography (CT) scan e. Abdominal ultrasound (US) scan

50. A 42-year-old diabetic Asian male complains of dysuria, increased urinary frequencyand general malaise for the past six months. In the last few days, he has noticed bloodin the urine. Examination of the urine shows the presence of neutrophils with noorganisms detected on urine culture. The most likely diagnosis is: a. Tuberculosis b. Renal cell cancer c. Diabetic nephropathy d. Bladder cancer e. Nephritic syndrome 51.

A 17-year-old patient is referred by his GP after presenting with periorbitaloedema.The patient noticed the oedematous eyes 3 days ago, but reports feeling unwellsince a throat infection 3 weeks ago with nausea and vomiting in the last week.A urine dipstick is positive for protein and blood while serum creatinine and urea are mildly deranged. The most likely diagnosis is:

b. Serum calcium c. Parathyroid hormone (PTH) d. Plasma glucose e. Serum potassium 55. A 58-year-old man presents with breathlessness, he reports feeling unwell over thelast three months with nausea, vomiting and difficulty breathing. You notice hisankles are swollen and he has bruises on his arms. The patient mentions he has notbeen urinating as often as normal. The most appropriate investigation is: a. Urine microscopy b. Renal ultrasound c. Serum electrolytes, urea and creatinine d. Renal biopsy e. Chest x-ray 56. A 24-year-old man presents with a four-month history of abdominal pain whichhas been getting worse. The patient describes the pain as generalized, dull incharacter and does not radiate but often occurs alongside loin pain. An irregularmass is palpable in both flanks and a mid-systolic click can be auscultated. Themost appropriate investigation is: a. MRI scan b. Abdominal US scan c. Excretion urography d. CT scan

b. Nephritic syndrome

e. Abdominal x-ray

d. Glomerulonephritis e. Von Grawitztumour 52. 28-year-old woman patient who is 13 weeks pregnant presents for an antenatalclinic appointment. The patient feels embarrassed when asked to provide a urinesample and produces enough for a urine dipstick test only which is positive forleukocytes and nitrites. The patient denies any symptoms. The most appropriate treatment is: a. Trimethoprim b. Quinolone c. Tetracycline d. Cephalexin e. Ampicillin

a. Serum phosphate

a. Nephrotic syndrome c. Renal failure

53.

54. A 21-year-old woman complains of urinary frequency, nocturia, constipation andpolydipsia. Her symptoms started 2 weeks ago and prior to this she would urinatetwice a day and never at night. She has also noticed general malaise and some painin her left flank. A urine dipstick is normal. The most appropriate investigation is:

A 32-year-old builder presents in accident and emergency in a distressed state. Hereports suffering from chest pain for the last 2 weeks, the pain is sharp and onlyoccurs when he moves heavy objects. He has a family history of cardiovasculardisease and is worried about a heart attack. His blood gas findings are as follows:

57. A 55-year-old woman is seen in clinic, she has a ten-year history of type 2diabetes treated with glibenclamide. Her blood pressure is 148/93 with new onsetproteinuria, her serum results show elevated lipid levels, glycatedhaemoglobin of5.5 per cent and fasting glucose of 6.0 mmol/L. A renal biopsy shows the presenceofKimmelstielâ&#x20AC;&#x201C;Wilson lesions. The most appropriate management is: a. Increase oral hypoglycaemic dosage b. ACE II antagonists c. Start cholesterol lowering therapy d. Start ACE inhibitors e. Start renal dialysis 58. A 52-year-old man complains of a 3-week history of malaise and shortness ofbreath. He has lost weight in the last few months but attributes this to a loss ofappetite possibly due to stress at work. On examination, he has a palpable mass inthe right lumbar region. He has no urinary symptoms. However, the urine dipstick detected blood. The most likely diagnosis is: a. Renal abscess b. Renal cyst

pH=7.47; PCO2 =3.3; PO2=15.3; bicarbonate=17.53. The most likely diagnosis is:

c. Renal carcinoma

a. Respiratory acidosis with metabolic compensation

e. Pyelonephritis

b. Acute metabolic acidosis c. Respiratory alkalosis with metabolic compensation

d. Adrenal tumour

NEPHROLOGY

c. Intravenous urography

1245


1246 59.

A 37-year-old man presents with a 5-day history of haematuria. Abdominalexamination is unremarkable. Urine analysis reveals hypercalciuria and excretionurography reveals small calculi within the papilla of the patient’s right kidney. Thepatient has presented several times in the past with UTIs and renal stones, but isotherwise healthy. The most likely diagnosis is: a. Medullary sponge kidney b. Renal cell carcinoma c. Medullary cystic disease d. Horse-shoe kidney e. Tertiary hyperparathyroidism

MCQ's

60.

A 38-year-old woman presents to her GP with a 2-week history of dysuria,haematuria and shortness of breath. She suffers from chronic headaches and hasbeen taking ibuprofen in order to treat them. She has a history of cardiovasculardisease in the family and a friend recommended she use aspirin to keep healthy. The most appropriate investigation is: a. Retrograde pyelography

a. Nephritic syndrome b. UTI c. Acute tubulointerstitial nephritis d. Minimal change glomerulonephritis e. Post streptococcal glomerulonephritis 65. A 21-year-old man complains his urine has turned a faint red in the last week. Hedenies any significant changes in his diet or lifestyle and has no other medicalproblems except for sensorineural deafness diagnosed when he was young. Onexamination, you notice retinal flecks and urine dipstick confirms protein and blood. The most likely diagnosis is: a. Alport’s syndrome b. Benign familial haematuria c. Wolfram syndrome d. IgA nephropathy e. Down’s syndrome 66.

b. Renal biopsy c. Abdominal x-ray d. Antegrade pyelography e. CT scan of the kidney 61. A 64-year-old man is undergoing treatment for polycythaemiavera with chemotherapy, he has no other medical problems. Shortly after starting treatment, the patient becomeslethargic, feels unwell and suffers weight loss. He attributes this is to the chemotherapy. After 2 weeks, the patient becomes oliguric, complains of bilateral flank pain andbecomesoedematous. The most likely diagnosis is: a. Analgesic nephropathy b. Renal infarction

a. Chinese herb nephropathy b. Bladder cancer c. Schistosomiasis d. Acute tubulointerstitial nephritis e. Renal cancer 67.

c. Hyperuricaemic nephropathy d. Acute tubulointerstitial nephritis e. Chronic renal failure 62.

A 67-year-old diabetic female is brought infollowing acollapse at her home. She was found by her daughter who said she saw the patientgoing to the toilet and then hearing her collapse. The patient did not lose consciousnessand appears well. Her supine blood pressure is 100/70 and standing 115/79. Urinedipstick is positive for glucose, nitrates, leukocytes and haematuria. The most likelydiagnosis is: a. Diabetic ketoacidosis b. UTI c. Orthostatic hypotension d. Diabetic nephropathy e. Hypoglycaemia

63. An 18-year-old man presents with general malaise and lethargy for the last 2 weeks,he denies any weight loss and has maintained a good appetite. On examination, thereare no abnormalities except for sacral oedema and a polyphonic wheeze. Urinedipstick is positive for protein only and blood pressure is 140/90. The most likelydiagnosis is: a. Nephritic syndrome b. Nephrotic syndrome c. Goodpasture’s disease d. Thin-basement membrane nephropathy e. Minimal change glomerulonephritis 64.

A 6-year-old has a sore throat and has been given antibiotics. Three weeks later, herepresents feeling feverish with nausea, vomiting and tea-coloured urine. Urinedipstick confirms haematuria and protein. Blood pressure is 100/60 mmHg. The mostlikely diagnosis is:

A 65-year-old overweight man presents with a 2-week history of haematuria.The patient denies any other symptoms and his blood pressure is 128/83 mmHg. Hesuffers from no other medical problems but admits to being a chronic smoker sincethe age of 16. He has tried to lose weight using herbal remedies for three years, buthe has only noticed significant weight loss in the last week despite stopping theremedies months ago. The most likely diagnosis is:

A 53-year-old man with HIV suffers a ruptured aortic aneurysm and is rushed intotheatre, he undergoes a successful operation and is recovering on the wards in astable condition. One day after the operation, he becomes oliguric with mildlyelevated urea and creatinine. After 1 week, he becomes polyuric with a GFR of 30. The most likely diagnosis is: a. Haemolytic–uraemic syndrome b. Acute tubular necrosis c. SIADH d. HIV nephropathy e. Acute renal failure

68.

A 64-year-old woman with type 1 diabetes presents to clinic with several monthsof sinus problem and a 4-day history of oliguria. Her blood pressure is 137/80,serum results show mildly elevated urea and creatinine, absence of antiGBMantibodies, while a C-ANCA assay is positive. Red blood cell (RBC) casts are presentin the urine and her renal biopsy reveals glomerular crescents. The most likelydiagnosis is: a. Post-streptococcal glomerulonephritis b. Goodpasture’s syndrome c. Minimal change glomerulonephritis d. Rapidly progressive glomerulonephritis e. Wegener’s granulomatosis

69. A 68-year-old obese Asian man is seen in the hypertension clinic. His bloodpressure is 151/93 and he suffers from poorly controlled type 2 diabetes. Bloodresults demonstrate elevated serum urea and creatinine. An ultrasound scan showsasymmetry between the two kidneys and on examination audible abdominal bruitsare auscultated. Urine dipstick did not detect any blood or protein. The bestinvestigation is: a. CT angiography b. Doppler ultrasonography c. Abdominal x-ray


d. Renal arteriography

72.

e. Renal biopsy 70. A 63-year-old woman presents in accident and emergency with a 3-day history ofworsening abdominal pain and mild flank pain. Examination reveals pain in thesuprapubic region, but otherwise the abdomen is soft with no masses. The patientdenies any other symptoms, such as dysuria, but mentions she has had difficultypassing urine in the last week and is only able to provide a small urine sample whichis odorous and bloody. She has no other medical problems, but admits to being along-term smoker. An ultrasound scan of renal system is most likely to show: a. Bladder dilation c. Bilateral hydronephrosis d. Renal cysts e. Renal cancer 71.

A 19-year-old man is recently diagnosed with type 1 diabetes and attends yourclinic to ask about possible omplications in the future. He mentions an uncle whohas end-stage renal disease due to poorly controlled diabetes and specificallyenquires about testing for early signs of renal impairment. The most appropriateinvestigation is: a. Blood pressure b. Microalbuminuria c. Serum creatinine d. Serum electrolytes e. Urine dipstick for glucose

a. Cyclosporin b. No treatment c. Probenecid d. Renal transplant e. Oral prednisone 73.

A 49-year-old woman attends your clinic suffering from chronic renal failure due toprogressive glomerular disease. She appears well and her blood pressure is 141/92 mmHg. Blood tests reveal elevated phosphate, serum creatinine and urea, while calcium levels arelow. Her estimated glomerular filtration rate is 35 mL/min/1.73 m2. You also notice thepatientâ&#x20AC;&#x2122;s cholesterol levels are moderately raised. The most appropriate management is: a. Sevelamer b. Parathyroidectomy c. Oral vitamin D d. Cinacalcet e. Renal dialysis

74. A 66-year-old woman with poorly controlled type 2 diabetes presents with a 2-day history of severe pain in the right flank, nausea and feversthat come and go. On examination, the patient appears unwell, sweaty and hasvisible rigors with a temperature of 38°C. The patient denies any recent travel. Urinedipstick is positive for protein, blood, leukocytes and nitrates. A CT scan of theabdomen reveals gas in the renal parenchyma area. The most likely diagnosis is: a. Renal stones b. Renal infarction c. Diabetic nephropathy d. Renal TB e. Pyelonephritis

NEPHROLOGY

b. Ureteral stricture

A 21-year-old man presents with lethargy over the last week, he 1247 has periorbitaloedema and proteinuria. The patient mentions he has been to hospital a number oftimes in the past due to the same symptoms as well as mild eczema. Light microscopyof a renal biopsy showed normal morphology. Electron microscopy of the renalbiopsy reveals the diffuse effacement of the epithelial podocytes. The most appropriatetreatment is:


MCQ's

1248

Nephrology - Answers 1. a

16. d

31. e

46. e

61. c

2. a

17. e

32. b

47. a

62. b

3. b

18. d

33. b

48. b

63. e

4. e

19. e

34. c

49. e

64. e

5. b

20. d

35. d

50. a

65. a

6. c

21. c

36. b

51. d

66. b

7. c

22. b

37. d

52. d

67. b

8. a

23. a

38. d

53. e

68. e

9. a

24. e

39. e

54. b

69. d

10. b

25. c

40. b

55. c

70. c

11. b

26. a

41. a

56. b

71. b

12. b

27. a

42. b

57. d

72. e

13. d

28. d

43. e

58. c

73. a

14. d

29. b

44. a

59. a

74. e

15. c

30. c

45. c

60. e


NEUROLOGY 1.

A 23yearold man presents with visual loss in the right eye, diagnosed as optic neuritis. Which one of the following statements would be seen in an afferent pupillary defect?

8.

a. accommodation response is unaffected b. hypersensitive response to pilocarpine in the affected eye c. irregular pupil of the affected eye d. pupil of affected eye larger than the unaffected eye

a. Advise termination due to drug teratogenicity

e. pupil of affected eye smaller than the unaffected eye 2.

A 75yearold man presents with 12 months history of cognitive impairment, parkinsonism, intermittent confusion and generalised myoclonus. He was started on 62.5 tds of sinemet. In the following 2 months he was started experiencing visual hallucinations. The most likely diagnosis is: a. Idiopathic Parkinsonâ&#x20AC;&#x2122;s disease

b. Continue with carbamazepine c. Stop carbamazepine until the second trimester d. Switch therapy to phenytoin e. Switch therapy to sodium valproate 9.

b. Alzheimerâ&#x20AC;&#x2122;s disease c. Diffuse Lewy body disease d. Multiple system atrophy 3.

a. Polymyositis

Which visual field defect is most likely to occur with multiple sclerosis?

c. Acid Maltase Deficiency

b. Inclusion body myositis d. MillerFisher Syndrome e. LambertEaton Myasthenic Syndrome

b. central scotoma c. homonymous hemianopia d. increased blind spot e. tunnel vision

10. A 75 yearold woman with acute monocular visual loss. Fundoscopy reveals a swollen pale optic disc in the affected eye. What is the mose likely diagnosis? a. Central retinal vein occlusion.

Which is true of herpes simplex encephalitis?

b. Closed angle glaucoma.

a. brain MRI is characteristically normal

c. Giant cell arteritis.

b. fits are uncommon

d. Optic neuritis.

c. genital herpes is usually present d. temporal lobe involvement is common e. viral identification using polymerase chain reaction on CSF is nonspecific 5.

Which of the following investigations best supports a diagnosis of new variant CJD: a. CSF analysis b. CT brain c. EEG d. EMG e. MRI brain

6.

Which of the following is a recognised cause of a phrenic nerve palsy? a. Aortic aneurysm b. Dermoid c. Ganglioneuroma d. Pericardial cyst e. Sarcoidosis

7.

A female patient aged 30 has a 5 years history of difficulty getting upstairs and out of a low chair and mild upper limb weakness but no pain. There is no family history. She presented with severe type 2 respiratory failure. EMG showed evidence of myopathy. The most likely diagnosis is:

e. Progressive supranuclear palsy

a. bitemporal hemianopia

4.

A 19 year old girl presents at the antenatal clinic. She is approximately six weeks pregnant and the pregnancy was unplanned. She has a two year history of grand mal epilepsy for which she takes carbamazepine. She has had no fits for approximately six months. She wants to continue with her pregnancy if it is safe to do so. She is worried about her anticonvulsant therapy and the effects on the baby and enquireshow she should be managed?

A 33 year old epileptic female presents with visual problems. Examination reveals a constriction of visual fields to confrontation. Which of the following may be responsible for her visual deterioration? a. Vigabatrin b. Lamotrigine c. Gabapentin d. Phenytoin e. Sodium Valproate

e. Raised intracranial pressure. 11.

A 45yearold man presents with an insidious onset of binocular horizontal diplopia and left sided facial pain. On examination ha has a left abducens nerve palsy and numbness over the maxillary division of the left trigeminal nerve. The most likely anatomical site of his neurological lesion is: a. Cavernous sinus b. Petrous apex c. Superior orbital fissure d. Cerebellopontine angle e. Midbrain

12. An adloescent boy presents with unexplained neurological illness.Which one of the following would suggest substance abuse? a. A history of low selfesteem. b. A history of social isolation. c. Deposits around the mouth. d. A history of family conflict. e. A history of attention deficit disorder. 13. A 45yearold woman noticed tinnitus in her left ear which progressed over some weeks to hearing loss in that ear. On physical examination she is found to have a marked decrease in hearing on the left, with Rinne test indicating air conduction better than bone conduction. The other cranial nerves I VII and IX XII are intact. A brain MRI scan revealed a solitary, fairly discreet, 3 cm mass located in the region of the left cerebellopontine angle. Which of the following statements is most appropriate to tell the patient regarding these findings?


1250

a. A test for HIV1 is likely to be positive

a. Isotretinoin

b. Other family members should undergo MR imaging of the brain

b. Ampicillin

c. Remissions and exacerbations are likely to occur in coming years

d. Dianette

c. Topical tetracycline e. Erythromycin

d. The lesion can be resected with a good prognosis e. You are unlikely to survive for more than a year 14.

20.

a. myelin sheaths extend across the nodes of Ranvier.

A 22yearold man suffers a deep laceration to the forearm resulting in transection of the median nerve. Following this injury, the nerve will undergo which of the following pathological processes?

b. unmyelinated fibres have faster conduction. c. sodium ion influx occurs during the action potential. d. the action potential increases with increased stimulation.

a. Chronic inflammation

e. increased extracellular calcium leads to increased neuronal excitability.

b. Coagulative necrosis

MCQ's

c. Fibrinoid necrosis d. Segmental demyelination e. Wallerian degeneration 15.

21. A 34 year old male presents with backpain and weakness. Which of the following would support a diagnosis of prolapsed intervertebral disc? a. bilateral symmetrical nerve involvement

Which of the following features is characteristic of myasthenia gravis?

b. Loss of sensation over the left outer upper thigh c. no evidence of nerve compression

a. Diplopia

d. pain which is worse on resting

b. Equal sex incidence

e. pain which is unremitting in character

c. Fasciculation d. Lid lag e. Loss of pupillary reflexes 16.

22.

b. Acts via the GABA receptor c. Is associated with induction of hepatic cytochrome p450 enzymes

a. Some symptoms improved by tricyclic antidepressants b. Third nerve palsy

d. Is well absorbed via the oral route

c. External opthalmoplegia

e. Is associated with increased plasma concentrations of sodium valproate

d. bilateral fortification spectra 17. A 48yearold female patient develops an acute, severe and isolated right C6 radiculopathy affecting both the motor and sensory roots. She is examined in an EMG clinic 3 weeks after the onset of symptoms. Which of the following statements is true? a. Absent sensory nerve potentials would be expected on examination of the thumb and index finger on the right. b. A repeat examination 12 months later is likely to reveal rapidly recruited low amplitude short duration motor units in the clinically involved muscle on EMG.

The anticonvulsant Levetiracetecam a. Is used as monotherapy for the treatment of generalised convulsions

A 25yearold woman presents with a severe migraine. Which of the following is not a recognised feature of migraine?

e. precipitation by oral contraceptives

Which of the following is true of human neurons?

23.

Following factors decrease large intestinal motility: a. Parasympathetic activity b. Anticholinergic agents c. Gastric Distension d. CCKPZ e. Laxatives.

24. A 72 year old female presents with general slowness. Examination reveals a tremor of the hands. What frequency of tremor would you suspect in Parkinson’s disease?

c. Fibrillation potentials would be expected in the right brachioradialis and abductor pollicus brevis.

a. 1 Hz

d. Triceps tendon jerk is likely to be depressed or absent.

c. 5 Hz

e. Voluntary motor unit activity may be absent in the right biceps.

d. 8 Hz

18. A 15 year old boy presents with tremor of both hands. Over the previous months he has eveloped a mild dysarthria. He has a history of behavioural problems, of a depressive/psychotic nature. The most likely diagnosis is:

b. 2 Hz

e. 10 Hz 25.

a. is a potent hepatic enzyme inducer b. side effects typically include visual field defects with longterm use

a. Alzheimer’s disease

c. therapy is best monitored through measuring plasma concentrations

b. Huntington’s disease c. Neuroacanthocytosis

d. is of particular value as monotherapy in absence attacks (petit mal)

d. variant CreutzfeldtJakob disease e. Wilson’s disease 19. A 24 year old female presents with vague frontal headaches and visual disturbance. She has a past history of acne for which she is receiving treatment. Examination reveals her to be obese with a blood pressure of 110/70 mmHg. There is absence of the central retinal vein pulsation on fundoscopic examination. Which of the following drugs account for these findings?

Which statement is true regarding Gabapentin?

e. requires dose adjustment in renal disease 26.

A 62yearold man presented with difficult walking. He had a past history of diabetes mellitus and cervicalspondylosis, which had required surgical decompression eight years previously. He drank 40 units of alcohol weekly. On examination there was fasciculation, wasting and weakness in the left deltoid and biceps, with weakness in the shoulder


c. there is a characteristic EEG

girdle muscles bilaterally. There was fasciculation in the glutei and quadriceps bilaterally, weakness of hip flexion and foot dorsiflexion, brisk reflexes in upper and lower limbs, and extensor plantar responses. There was no sensory impairment. What is the diagnosis? a. alcoholic myopathy b. diabetic amyotrophy

e. cephalic tetanus causes severe dysphagia 33.

c. motor neurone disease d. recurrent cervical cord compression

b. optic tract

Which of the following is least likely to cause choreiform movements?

c. chiasma

a. polyarteritis nodosa

e. occipital lobe

c. Rheumatic fever

d. optic radiation 34.

d. systemic lupus erythematosus e. thyrotoxicosis

a. An alternative anticonvulsant should be used in place of sodium valproate

A 24yearold man presents with a five month history of low back pain, radiating to his buttocks, and back stiffness worse in the morning and worse after periods of inactivity. Which of the following signs is the mostlikely to be present?

b. Interaction of sodium valproate with the oral contraceptive increased the risk of pregnancy c. The dose of sodium valproate should be increased

a. exaggerated lumbar lordosis

d. There is an increased risk of a neural tube defect in her fetus

b. positive femoral stretch test

e. She is at increased risk of anaemia in pregnancy

c. positive Trendelenburg test d. restricted straight leg raising e. sacroiliac joint tenderness 29.

A previously well 27yearold woman presents with a history of transient ischaemic attack affecting her right side and speech. She had returned to the United Kingdom from a holiday in New Zealand two days previously. On examination there was nothing abnormal to find. An ECG, chest Xray, CT brain scan and routine haematology and biochemistry were all normal. What is the most likely underlying abnormality? a. atrial myxoma b. carotid artery stenosis c. embolus from paroxysmal atrial fibrillation d. patent foramen ovale e. subarachnoid haemorrhage

30.

Which of the following factors is the most likely to account for this problem? a. altered volume of distribution b. delayed gastric emptying c. first pass metabolism d. hepatic enzyme induction e. reduced gut blood flow

31. A 25yearold female presents with 2 days history of diplopia and unsteadiness. 2 weeks ago she suffered an upper respiratory tract infection. On examination there is complete opthalmoplegia, areflexia and gait ataxia. Which of the following blood tests is the most likely to confirm the underlying diagnosis? a. Acetylcholine receptors antibodies b. Anti GM1 antibodies c. Anti GQib antibodies d. Anti Hu antibodies e. Anti purkinje cell antibodies 32.

Which of the following is true of tetanus? a. failure to culture Clostridium tetani from the wound would make the diagnosis doubtful b. infection confers lifelong immunity

A 21 year old female with epilepsy is well controlled on sodium valproate 600mg bd and had been taking oral contraceptives for three years. She presented to her general practitioner 12 weeks pregnant. Which of the following is correct?

35.

A 40yearold man has had decreased mentation with confusion as well as increasing incoordination and loss of movement in his right arm over the past 6 weeks. An MRI scan shows 0.5 to 1.5 cm lesions in cerebral hemispheres in white matter and at the greywhite junction that suggest demyelination. A stereotatic biopsy is performed, and immunohistochemical staining of the tissue reveals JC papovavirus in oligodendrocytes. Which of the following laboratory test findings is most likely to be associated with these findings? a. CD4 lymphocyte count of 90/microliter b. Haemoglobin A1c of 9.8% c. HDL cholesterol of 0.7 mmol/L d. Oligoclonal bands in CSF e. Serum sodium of 110 mmol/L

36. A 60yearold man presents with an episode of memory loss. Three days earlier he had become confused. His wife led him into the house he apparently sat down at her request, and had a cup of tea. He then wandered around the house, confused, but remained conscious and able to have some conversation with his wife, though continuing to ask similar questions repeatedly. After three hours, he abruptly returned to normal and had no recollection of the events. What is the most likely diagnosis? a. alcohol related amnesia b. chronic subdural haematoma c. complex partial status epilepticus d. hysterical fugue state e. transient global amnesia 37. A 65yearold man presents with 4 months history of swallowing difficulties (worse with liquids than solids). He also complains of nasal regurgitation, coughing and choking episodes during meals and slight dysarthria. He lost 1 stone over the last 8 weeks. Which of the following investigations is the most appropriate for this case? a. Gastroscopy b. Barium swallow c. CXR

NEUROLOGY

b. polycythaemia rubra vera

28.

A68yearold man presents with progressive visual impairment. On examination there is an incongruous homonymous hemianopia. The most likely anatomical site of the neurological lesion is at: a. optic nerve

e. syringomyelia 27.

1251

d. Clostridiumspecific intravenous immunoglobulin is of no benefit once spasm has started


1252

d. Tumour markers

c. confabulation

e. Acetyl choline receptors antibodies

d. loss of personal identity

38. A complete unilateral facial hemiparesis may be caused by which of the following? a. An intracranial tumour

e. normal perception 46.

a. Acalculia

b. Birth injury

b. Astereogenesis

c. Cerebellar atrophy

c. Constructional apraxia

d. Myasthenia gravis

d. Cortical blindness

e. Phenothiazine toxicity 39.

Regarding pseudotumours cerebri (benign hypercranial hypertension) which is true? a. A mildly increased CSF cell count is typical.

MCQ's

b. May be caused by prolonged steriod therapy. c. Is occasionally associated with focal neurological signs.

e. Visuospatial neglect 47. A 17yearoldman has been diagnosed with schizophrenia 4 weeks ago. He was started on haloperidol. Two weeks later he was found confused and drowsy. On examination he was pyrexial (40.7 C), rigid with blood pressure of 200/100. Which of the following treatment will you initiate? a. phenytoin

d. Frequently presents with ataxia.

b. diazepam

e. Is distinguished from hydrocephalus by the absence of suture separation. 40.

b. Hepatitis B and aplastic anaemia c. Turner’s syndrome and acute myeloid leukaemia d. Basophilia and chronic myeloid leukaemia e. Crohn’s disease and TB 41.

c. cefuroxime d. acyclovir

Which of the following associations is correct? a. Renal transplantation and NonHodgkin’s lymphoma

A demyelinating polyneuropathy is typically caused by:

e. dantrolene 48. A 50 yearold male epileptic presents with paraesthesia of hands and feet. He also has unsteadiness when walking. On examination he has Dupytren’s contracture in his left hand, a peripheral sensory neuropathy and palpable lymph nodes in his neck and axillae. Which of the following drugs is the most likely cause of these features? a. Carbamazepine.

a. Diabetes

b. Clonazepam

b. Excessive alcohol

c. Lamotrigine.

c. Hereditary motorsensory neuropathy

d. Phenytoin.

d. Renal failure e. Vitamin B12 deficiency 42.

e. Sodium valproate. 49.

An 80yearold woman has a three month history of progressive numbness and unsteadiness of her gait. On examination, there is a mild spastic paraparesis, with brisk knee reflexes, ankle reflexes are present with reinforcement, extensor plantars, sensory loss in the legs with a sensory level at T10, impaired joint position sense in the toes, and loss of vibration sense below the iliac crests.

e. Pontine haemorrhage

Investigations were as follows:

Which ONE of the following would be expected in a third nerve palsy?

Haemoglobin 12.0 g/dl

a. Enophthalmos

MCV 99 fl

What is the most likely diagnosis?

Causes of dilated pupils include: a. Argyll Robertson pupil b. Ethylene glycol poisoning c. Myotonic dystrophy d. Organophosphate poisoning

43.

b. Constricted pupil c. Convergent strabismus d. Increased lacrimation e. Unreactive pupil to light 44. A 20yearold female presents with acute onset of left foot drop. Examination reveals weakness of ankle dorsiflexion and eversion. There is a small area of sensory loss in the first web space. Reflexes were all present and plantars flexor. Which of the following nerves is likely to be involved? a. Tibial nerve b. Common peroneal nerve c. Sciatic nerve d. Femoral nerve e. Inferior gluteal nerve 45.

A lesion of the occipital lobe causes:

Which of the following is a characteristic feature of transient global amnesia? a. abnormal behaviour b. apraxia

a. anterior spinal artery occlusion b. dorsal meningioma c. multiple sclerosis d. subacute combined degeneration of the cord e. tabes dorsalis 50. A 16 year old girl presented with a three week history of headache and horizontal diplopia on far right lateral gaze. On two separate occasions she noted dimmed vision whilst bending forwards. Over the last year she had gained 12 kilograms in weight. On examination, her weight was 95 kg, and height 162cms. Neurological examination revealed bilateral papilloedema and a partial right sixth cranial nerve palsy. What is the most likely diagnosis? a. Benign intracranial hypertension. b. Multiple sclerosis. c. Pituitary tumour d. Superior sagittal vein thrombosis. e. Thyroid eye disease.


51.

sodium 144 mmol/l

a. Weakness beginning in the arms

potassium 3.9

b. Asymmetrical involvement of distal muscles

urea 10.4

creatinine 120

glucose 8

dip stick urine blood ++, protein +

What is the most important immediate investigation?

Which of the following clinical manifestations suggests Guillain Barré Syndrome?

c. Bulbar involvement in about 50% of cases d. Brisk tendon reflexes e. Normal CSF protein 52. In herpes simplex encephalitis which of the following statements is correct? a. brain MRI is characteristically normal

a. Chest Xray

b. temporal lobe involvement is common

b. MSU

d. cold sores or genital herpes are usually present

c. prostate specific antigen

e. viral identification by PCR on cerebrospinal fluid is nonspecific

e. serum protein electrophoresis

d. serum calcium 58. A 25yearold old woman presents with 2 hrs of a unilateral temporal headache increasing in severity. The Pain is of a throbbing character and is exacerbated by light. There are no abnormal signs on examination. What is the diagnosis? a. Acute Subarachnoid haemorrhage. b. Cluster headache.

a. Chronic progressive external opthalmoplegia.

c. Intracranial Tumour.

b. GuillainBarre syndrome.

d. Migraine.

c. Multiple sclerosis.

e. Tension headaches.

d. Myasthenia gravis. e. Polymyositis 54.

A 63 year old male is admitted with acute onset unsteadiness of gait, dizziness and dysphagia. Examination revealed a rightsided Horner’s syndrome, nystagmus, loss of pain and temperature sensation on the left side of the trunk and in the left arm and leg, and gait ataxia. What is the most likely diagnosis?

a. Alcohol withdrawal. b. Hepatic encephalopathy. c. Hypoglycaemia. d. Subdural haematoma.

b. left sided acoustic neuroma

e. Wernicke’s encephalopathy.

d. right sided pontine infarct e. spontaneous left sided cerebellar haemorrhage Which of the following features are not compatible with the diagnosis of motor neuron disease? a. Dementia

60. A 70yearold man presents with weight loss, lower limb weakness and dry mouth. He has been a heavy smoker. On examination, he looks cachectic; he has proximal lower limb weakness, areflexia (reflexes normalise with repetitive muscle contraction). There is no wasting or fasciculations. Sensory examination is normal. Which of the following blood test is the most likely to confirm the diagnosis? a. Acetylcholine receptors

b. Dysphagia

b. Voltage gated calcium channels antibodies

c. Muscle cramps

c. Anti GM1 antibody

d. Neck weakness

d. Antinuclear antibody

e. Optic atrophy 56.

50yearold old man is admitted to hospital unconsious, and smelling of alcohol. One hour after admission,he becomes suddenly sweaty with a regular tachycardia of 110 bpm and a BP of 100/50. What is thediagnosis?

a. leaking posterior communicating artery aneurysm c. posterior inferior cerebellar artery occlusion

55.

59.

A 35yearold man has wrist drop of his right hand. Examination reveals a small area of sensory loss on the dorsum of the hand. Which of the following nerves is likely to be involved?

e. Anti Ro/La antibodies 61.

a. Median nerve

a. Autonomic dysfunction

b. Ulnar nerve

b. Elevated protein on CSF examination

c. Long thoracic nerve

c. Evidence of muscle wasting

d. Radial nerve

d. Ophthalmoplegia

e. T1 nerve root 57.

A 92yearold man was admitted in a confused state. He has a history of immobility due to severe lower back pain. He had been losing weight for three months and had complains of weakness, urinary frequency, thirst, poor urinary stream and constipation. Lumbar spine Xrays show severe osteopenia and collapse of the body of the vertebra at L3. Investigations show:

haemoglobin 9.6 g/dl

54 year old female is admitted with progressive weakness following a trivial flulike illness. Which of the following would exclude GuillainBarre Syndrome as the diagnosis?

e. Sensory level below D1 62.

An 18 year old man presented with a history of a sudden onset of a frontal headache and photophobia. He had neck stiffness and a temperature of 38°C. Which one of the following findings would suggest a diagnosis of subarachnoid haemorrhage rather than bacterial meningitis? a. a blood neutrophil leucocytosis b. a family history of polycystic renal disease

NEUROLOGY

c. fits are uncommon

53. A 25 yearold lady recently diagnosed with rheumatoid arthritis. She has developed weakness, double vision and tiredness. Examination reveals bilateral weakness of eye abduction, bilateral ptosis, slightly reduced proximal motor power in the limbs, normal reflexes and sensation. What is the diagnosis?

1253


1254

c. a fluctuating conscious level

b. A family history of major psychiatric illness

d. a history of diabetes mellitus

c. Impaired short term memory

e. a history of opiate abuse

d. No previous history of psychiatric illness

63. A 45yearold man has a history of progressive weakness for 5 weeks. He had particular difficulty getting out of the bath. On examination there was severe truncal and proximal limb weakness, without wasting or fasciculation. Tendon reflexes, plantar and sensation were all normal. The vital capacity was 1.8L. What is the most likely diagnosis?

e. Clouding of conciousness 70.

a. cervical myelitis

a. A central cauda equina lesion.

b. GuillainBarre syndrome

b. A cervical spinal cord lesion.

c. polio

c. A foramen magnum lesion.

MCQ's

d. polymyositis

d. A left sided thoracic spinal cord lesion.

e. syringiobulbia 64.

Which is true regarding cerebral palsy? a. The incidence is 2 per 100 live births.

65.

e. Bilateral cerebral hemisphere lesions. 71.

a. enhance the effect of levodopa on the substantia nigra

c. Hearing loss is present in 5%.

b. reduce the extracerebral complications of Ldopa therapy

d. Epilepsy is present in 40%.

c. have anticholinergic activity

e. Learning impairment is present in 30%.

d. should not be given in combination with dopamine agonists e. prevent Ldopa associated dyskinesias

A right carotid artery stenosis could not account for: 72.

b. Contralateral hemisensory loss

b. Deltoid and C5

d. Dysphasia e. Right amaurosis fugax

c. Gastroenemius and S1

Which of the following statements about the spinal cord is true?

e. Long flexors of fingers and C6

a. A lesion of the left side of the spinal cord at C5 causes pyramidal weakness of the right leg

d. Quadriceps and L3 73.

Which of the following would be expected following distal occlusion of the posterior cerebral artery?

b. Centrally placed spinal cord lesions affect joint position sense before other modalities of sensation

a. cerebellar ataxia

c. Conus medullaris lesions characteristically cause mixed upper and lower motor neurone signs in the legs

c. dysarthria

b. contralateral hemiplegia d. homonymous hemianopia

d. The spinal cord ends at the lower border of the L3 vertebra e. The spinothalamic tracts are supplied principally by the anterior spinal artery 67. A 50yearold man presented with 18 months history of parasthesiae of his feet and hands. On examination there is numbness of glove and stocking distribution with generalised hyporeflexia. Nerve conduction studiesrevealed demyelinative sensory polyneuropathy. Which of the following conditions is the most likely diagnosis?

e. palatal palsy 74. A young teenager presents with fever and headache. He has received oral Amoxycillin for 3 days. Which of the following CSF findings would exclude a partially treated meningitis? a. Negative gram stain b. A CSF glucose of 45% of blood glucose c. A white cell count of 50 d. A negative CSF culture

a. Alcohol abuse b. Diabetes c. Chronic inflammatory demyelinating polyneuropathy

e. Negative Kernigâ&#x20AC;&#x2122;s Sign 75.

d. Vasculitis e. Vitamin B12 deficiency

A 52 year old man has a slurring of his speech. Examination reveals bilateral partial ptosis and frontal balding, and difficulty releasing his grip after shaking hands. What is the most likely diagnosis? a. myasthenia gravis

Which of the following would be the result of a spinal lesion at the level of C8?

b. EatonLambert syndrome

a. a reduced brachioradialis reflex

c. Myotonia dystrophica

b. inability to abduct the shoulder

d. Duchenne muscular dystrophy

c. loss of sensation over the lateral aspect of the arm

e. Myotonia congenita

d. winging of the scapula e. weakness of finger flexion 69.

Which of the following associations of muscles and nerve supply are NOT true: a. Triceps and C7

c. Drop attacks

68.

Which of the following relate to Dopadecarboxylase inhibitors?

b. Visual impairement occurs in 50%.

a. Contralateral hemiplegia

66.

A 27 yearold male presents with 3 months of difficulty walking. Examination reveals motor weakness of left leg in a pyramidal distribution with increase in tone. Impaired pinprick sensation of right leg extending into the groin. What is the cause of these signs?

Psychiatric illness rather than an organic brain disorder is suggested by: a. Onset for the first time at the age of 55 years

76.

A 43yearold woman develops a progressive, ascending motor weakness over several days. She is hospitalized and requires intubation with mechanical ventilation. She is afebrile. A lumbar puncture is performed with normal opening pressure and yields clear, colorless CSF with normal glucose, increased protein, and cell count of 5/microliter, all lymphocytes. She gradually recovers over the next month. Which of the


d. occipital lobe

following conditions most likely preceded the onset of her illness? a. Ketoacidosis

83.

d. Viral pneumonia

A 21 year old man recovered from the immediate effects of a head injury sustained in a motor cycle accident three months previously. Which one of the following is the most likely delayed consequence of severe traumatic brain injury?

e. Vitamin B12 deficiency

a. Episodic hypersomnia

b. Staphylococcus aureus septicemia c. Systemic lupus erythematosus

b. Multiple obsessional symptoms c. Outbursts of aggressive behaviour d. Pathological jealousy e. Persistent anxiety 84.

a. a lesion of the occipital cortex

a. EEG

b. a lesion of the optic chiasma

b. 24 hour ECG recording

c. bilateral diabetic retinopathy

c. CT brain

d. chloroquine poisoning

d. ECHO

e. tobacco amblyopia

e. Tilt table test 78. A 36 yearold man has a 3 month history of pain in feet and lower legs. He was diagnosed as having diabetes at age 14 and treated with insulin. He is a cannabis smoker and drinks 30 units of alcohol per week. On examination he has impaired pain and temperature sensation in feet and lower legs, normal joint position and vibration sense. His reflexes are normal. What is the diagnosis?

85.

inflammatory

demyelinating

b. Craniopharyngioma c. Graves’ Ophthalmopathy

polyneuropathy

d. Optic neuritis e. sagittal sinus thrombosis

c. Diabetic polyneuropathy. d. Syringomyelia. e. Vitamin B12 deficiency. 79.

86.

b. auditory agnosia c. dressing apraxia

a. Bitemporal hemianopia

d. focal epileptic fits

b. Homonymous inferior quadrantanopia

e. perseveration

c. Perseveration e. Wernike’s (receptive) aphasia 80.

87.

b. internuclear ophthalmoplegia c. impaired cognitive function

a. ipsilateral Horner’s syndrome

d. fluctuating level of consciousness

b. wasting of the dorsal interossei

e. bilateral papilloedema

c. pain in the arm radiating to the fourth and fifth fingers e. weakness of abduction at the shoulder 81.

88.

b. basal ganglia lesion c. rightsided cerebral infarction

a. Carbon Monoxide Poisoning

d. phenytoin toxicity

b. Ethylene Glycol Poisoning

e. cerebellar vermis lesion

c. Holme’s Adie pupil e. Third Nerve Palsy 82. A 70yearold female patient presents with 2 months history of apathy, withdrawal, urinary and faecal incontinence and anosmia. The most likely anatomical site of the neurological lesion is at the: a. frontal lobe b. parietal lobe c. temporal lobe

A broadbased ataxic gait occurs characteristically with: a. proximal myopathy

Causes of a small pupil include:

d. Pontine haemorrhage

Chronic subdural haematoma in a 75yearold man is NOT associated with the presence of: a. hemiparesis

The following are recognized features of Pancoast’s tumour except:

d. erosion of the first rib

Frontal lobe brain damage is associated with: a. astereognosis

A lesion of the parietal lobe causes:

d. Primitive reflexes

A 22 year old female presents with a month history of episodic, brief visual loss affecting the right eye. Over the last one year she had gained a considerable amount of weight. Examination reveals a BMI of 35, with bilateral optic disc swelling, worse on the right and small retinal haemorrhages on the right. What is the most likely diagnosis? a. benign intracranial hypertension

a. Alcoholic polyneuropathy. b. Chronic (CIDP)

A patient presented with a quadrantic hemianopia. Which of the following conditions is most likeley to cause such a presentation?

89.

Which ONE of the following is associated with Parkinsonian features? a. Chronic carbon dioxide retention b. Kernicterus c. Lead poisoning d. Mercury poisoning e. Wilson’s disease

90. A 30yearold female presents to the eye clinic with an acute

NEUROLOGY

77. A 19yearold woman presents to the clinic having had 5 blackouts over the last year, all while she is standing up. She gets warnings of blurred vision, nausea, feeling hot. She had been witnessed twice to have jerking of all limbs while she is unconscious. The attacks last 3060 seconds. She recovers quickly after the attacks. She has never bitten her tongue or sustained any injuries. Physical examination and an ECG are normal. Her grandmother and sister suffer from epilepsy. Which of the following investigations is the most appropriate?

1255

e. internal capsule


history of pain and blurring in the right eye. Examination reveals a visual acuity of 6/36 in the right eye but 6/6 in the left eye, a central scotoma in the right eye, with a right swollen optic disc. What is the most likely diagnosis?

1256

a. Compression of the optic nerve b. Cavernous sinus thrombosis

95. A 60yearold woman presents with a 24 hours history of headache and vomiting. She has been on steroids for temporal arteritis for the last 3 years. Examination demonstrates pyrexia, neck stiffness, photophobia, dysarthria, nystagmus and ataxia. CSF shows neutrophilic pleocytosis, low glucose, elevated protein. What is the most likely diagnosis? a. Carcinomatosis meningitis

c. Glaucoma

b. Cryptococcal meningitis

d. Optic neuritis

c. Listeria meningitis

e. Retinal vein occlusion

MCQ's

91. A 47yearold man presents with memory impairment worsening over 9 months. He has jerking movements of his limbs and biphasic highamplitude sharp waves on EEG. Which diagnosis is most likely?

92.

e. Tuberculus meningitis 96. In which of the following is mental retardation an expected finding?

a. Alzheimerâ&#x20AC;&#x2122;s disease

a. Alkaptonuria

b. CreutzfeldJakob disease

b. Cystinuria

c. Multiinfarct dementia

c. Glycogen storage disease

d. Normal Pressure Hydrocephalus

d. Lactose intolerance

e. Pickâ&#x20AC;&#x2122;s disease

e. Maple syrup urine disease

A 72yearold woman has a five year history of worsening mental functioning with trouble remembering things. She has no problems with movement. She is noted on an MRI scan of the brain to have symmetrically increased size of the lateral ventricles along with cerebral cortical atrophy in a mainly frontal and parietal distribution. A lumbar puncture reveals a normal opening pressure, and analysis of the clear, colorless cerebrospinal fluid reveals a glucose and protein which are in normal ranges. Cell count on the CSF shows 3 WBCs (all lymphocytes) and 1 RBC. A fundoscopic examination is normal. Which of the following findings is most likely associated with her underlying disease process? a. Increased numbers of Lewy bodies b. Loss of Betz cells c. Loss of gamma aminobutyric acid (GABA) d. Perivascular mononuclear inflammation e. Presence of the e4 allele of apolipoprotein E

93. A 60yearold man was brought to casualty after a fall in his bathroom. Seen immediately by his family, he was already picking himself up from the floor and said he was not injured. His wife felt that he was transiently dazed. On examination, he was alert, and no abnormalities were noted. His past medical history included a history of hypertension for which he was taking bendrofluazide 2.5 mg daily. He was discharged without any further intervention. Two weeks later his wife brings the patient to see you because the dazed state has returned. Examination reveals a temperature of 36.7C, a pulse rate of 84 bpm regular, a blood pressure of 152/94 mm Hg. On questioning he is slightly slowed, being disoriented to time with some deficit in recent memory. The patient moves slowly, but power is normal. Neurologic examination shows slight hyperactivity of the tendon reflexes on the right with unclear plantar responses because of bilateral withdrawal. Which of the following would you request? a. 24hour ambulatory electrocardiogram b. CSF analysis c. CT of the head d. Electromyography and nerve conduction testing e. EEG 94.

d. Meningococcal meningitis

Which of the following forms of encephalitis is caused by a neuroimmunological response? a. Herpes simplex b. Measles c. HIV infection d. Enteral viruses e. Cytomegalovirus

97.

Which of the following is correct regarding Herpes simplex encephalitis? a. shows a peak incidence in the Autumn b. is associated with a polymorphonuclear pleocytosis in the CSF c. produces a diffuse, evenly distributed inflammation of cerebral tissues d. produces a typical EEG pattern with lateralised periodic discharges at 2 Hz e. should be treated with acyclovir as soon as the diagnosis is confirmed by urgent CSF viral antibody titres

98. A 73yearold man presents with an abrupt onset of double vision and left leg weakness. Examination shows weakness of abduction of the right eye, rightsided facial weakness affecting upper and lower parts of the face. He also has a left hemiparesis. Where is the lesion? a. left frontal lobe b. left lateral medulla c. right corpus striatum d. right midbrain e. right pons 99.

Which of the following statements regarding hiccup is true? a. Is caused by a tonic relaxation of the diaphragm. b. May be caused by local irritation to the vagus nerve. c. Can reliably be treated with theophylline. d. May be caused by a posterior fossa tumour. e. May be caused by a foreign body in the nose.

100. In considering the management of convulsions select the correct statement from the list below. a. If the fit lasts longer than 5 minutes, then PR diazepam should be given. b. Phenobarbitone is a useful therapy in school age children. c. Paraldehyde is best given intramuscularly. d. Hypoglycaemia should always be considered. e. When associated with fever, antibiotics should always be given to cover the possibility of meningitis. 101. The action of noradrenaline released at sympathetic nerve endings is terminated by a. enzymatic decarboxylation b. enzymatic inactivation by catecholOmethyl transferase c. reuptake of noradrenaline by the axonal terminals


d. oxidative deamination by monoamine oxidase

a. Optic neuritis

e. Removal by the circulating blood

b. Nonarteritic ischaemic optic neuropathy

102. A 65 yearold woman with 12 hour history of unsteady gait, sudden onset associated with vomiting and headache. Following this she had increasing drowsiness. What is the diagnosis? a. Acute subdural haemorrhage b. Cerebellar haemorrhage. c. Frontal subdural empyema

c. Arteritic ischaemic optic neuropathy d. Acute angleclosure glaucoma e. Compressive optic neuropathy 108. A 67yearold man has drunk 8 units of alcohol a day for most of his adult life. He has worsening symptoms of poor memory, a widebased gait and urinary incontinence for ten months. What is the most likely diagnosis?

d. Herpes simplex encephalitis.

a. HIV encephalitis

e. Pituitary apoplexy.

b. meningovascular syphilis c. normal pressure hydrocephalus d. syringomyelia e. WernickeKorsakoff syndrome 109. A 40 year old male is diagnosed with Dystrophia myotonica. Which one of the following features would be expected in this patient?

a. Multiple sclerosis

a. Autosomal recessive inheritance

b. Anterior spinal artery occlusion

b. Cataracts

c. Postinfectious transverse myelitis

c. Fasiculations would predominate

d. Thoracic disc prolapse

d. Progressive external ophthalmoplegia

e. Guillain Barre syndrome

e. Preserved tendon reflexes despite muscle wasting

104. A 40yearold man with a long history of alcohol abuse is admitted with a subacute illness, comprising headache, fever, meningism and ataxia. MRI brain showed patchy high signal abnormality of the brain stem. CSF analysis showed polymphonuclear pleocytosis and low glucose. He had failed to improve after 3 days of intravenous cefotaxime treatment. The most likely diagnosis of the meningitis is:

110. A 40yearold man presents with 2 years history of intermittent strictly unilateral headaches. The pain is excruciating severe. It is located around the orbital region. The headache usually lasts 4560 minutes. It usually appears early hours in the morning. There is associated ptosis and lacrimation on the side of the headache. The most likely diagnosis is: a. Cluster headaches

a. Mycobacterium tuberculosis

b. Migraine

b. Cryptococcus neoformans

c. Tension type headache

c. Nocardia asteroides

d. Giant cell arteritis

d. Staphyloccus aureus

e. Trigeminal neuralgia

e. Listeria monocytogenes 105. A 27yearold man presents with a two years history of intermittent tingling sensation involving his left side. It starts in his fingers and spreads in 1020 seconds to affect the whole arm and leg on the same side. The attacks only last for one minute. The most likely diagnosis is:

111. A 50 year old female presents with a 4 month history of progressive distal sensory loss and weakness. On examination positive neurological findings include moderate proximal and distal weakness of arms and legs, glove and stocking sensory loss and areflexia. Planter responses were mute. The following conditions could give a similar picture:

a. Migraine with aura

a. GuillianBarre syndrome

b. Transient ischaemic attacks

b. Chronic inflammatory demyelinating neuropathy(CIDP)

c. Somatosensory seizures

c. Cervical spondylosis

d. Hyperventilation

d. Hereditary motor and sensory neuropathy(HMSN)

e. Multiple sclerosis

e. Myasthenia Gravis

106. A 24yearold man presents with a headache that has been present for nine months. He has headache almost every day, mainly frontal, sometimes with nausea. Current medication includes paracetamol, brufen and codeine with only transient relief of symptoms. He has a history of depression. Examination was normal. What is the most likely diagnosis? a. analgesic misuse headache b. cluster headache c. frontal brain tumour d. headache due to depression e. migraine 107. A 60yearold man awakens with painless loss of vision of his left eye. Three years earlier he had suffered a similar episode involving the right eye. Visual loss in that eye has been stationary. He does not complain of any systemic symptoms. What is the most likely diagnosis?

112. Which one of the following would support a diagnosis of subacute combined degeneration of the cord rather than multiple sclerosis? a. absent ankle jerks b. autonomic symptoms c. cerebellar signs d. extensor plantars e. visual problems 113. A 65yearold woman has a one month history of malaise, weight loss, right sided pain around the eye and headaches. She has also noticed intermittent diplopia. Five years previously she had a mastectomy for carcinoma of the breast. On examination, temperature was 37.5°C, there was tenderness of the scalp on the right forehead and temple, and some minor weakness of abduction of the right eye. ESR 55 mm/hour. What is the most likely diagnosis?

NEUROLOGY

103. A 18yearold female presents with a 3 days history of progressive weakness and numbness of her legs, urinary retention and back pain 2 weeks following an upper respiratory infection. On examination there is spastic paraparesis, sensory level up to T5, extensor plantars. Examination of cranial nerves and upper limbs is normal. MRI of the spine is normal. The most likely diagnosis is:

1257


1258

a. thyroid eye disease b. frontal sinusitis c. giant cell arteritis d. meningeal metastastatic disease e. posterior communicating artery aneurysm 114. A sixty year old male presents with a six month history of a gradually increasing burning sensation in his feet. Examination revealed normal cranial nerves and higher mental function. Normal bulk, tone, power, light touch and pinprick sensation, coordination and reflexes in upper and lower limbs. The clinical findings are consistent with

MCQ's

a. Large fibre sensory neuropathy

of Diabetes Mellitus. Examination reveals a central scotoma. What is the diagnosis? a. Central retinal artery occlusion. b. Diabetic retinopathy. c. Optic neuritis. d. Pituitary tumour. e. Migraine. 121. A 72yearold lady has 4 months of memory loss, urinary incontinence and falls. On examination she has mild memory loss and a broadbased, slow gait. Muscle tone is normal and both plantar reflexes are downgoing. What is the likely diagnosis?

b. Small fibre sensory neuropathy

a. Alzheimer’s disease

c. Diabetic Amyotrophy

b. Frontal lobe dementia

d. Motor neurone disease

c. Mulitinfarct dementia

e. Sjogrens syndrome

d. Normalpressure hydrocephalus

115. Which of the following anatomical considerations is correct: a. optic chiasm lesions characteristically produce a bitemporal hemianopia b. central scotoma occurs early in papilloedema c. in cortical blindness pupillary reactions are abnormal d. optic tract lesions produce an ipsilateral homonymous hemianopia e. opticokinetic nystagmus is found with bilateral infarction of the parietooccipital lobes 116. A 62 year old male is noted to have a broadbased ataxic gait. This is characteristic of which of the following? a. A basal ganglia lesion b. Cerebellar vermis lesion c. Osteomalacia d. phenytoin toxicity e. Rightsided cerebral infarction 117. A lesion of the facial nerve in the internal auditory meatus will NOT affect a. taste b. sweating over the cheek c. lacrimation d. hearing e. blinking 118. Which of the following is a form of generalised seizure? a. Aversive seizures b. Epilepsia partialis continua c. Automatisms d. Lennox Gastaut Syndrome e. Benign rolandic epilepsy 119. A 21yearold female presented with a sudden onset of left sided head and neck pain. 24 hours later she presents with sudden onset of right hemiparesis, facial weakness and homonymous hemianopia and left horner’s syndrome. A CT brain showed a left middle cerebral artery territory infarction. The most likely diagnosis is: a. Cardiac embolism b. Migraine c. Left Carotid artery dissection d. Antiphospholipid syndrome e. Systemic vasculitis 120. A 25 yearold man presents with 24 hours blurred vision in left eye and mild frontal headache. He has a 10 year history

e. Parkinson’s disease 122. Baclofen a. acts directly on skeletal muscle b. causes rhabdomyolysis c. reduces cerebral but not spinal spasticity d. cause hallucinations when withdrawn e. reduce Ca2+ release from sarcoplasmic reticulum 123. A 26yearold previously healthy woman has the sudden onset of mental confusion. She has a seizure and is brought to the hospital. Her vital signs show blood pressure 100/60 mm Hg, temperature 37 C., pulse 89, and respirations 22. A lumbar puncture reveals a normal opening pressure, and clear, colorless cerebrospinal fluid is obtained with 1 RBC and 20 WBC’s (all lymphocytes), with normal glucose and protein. An MRI scan reveals swelling of the right temporal lobe with hemorrhagic areas. Which of the following infectious agents is the most likely cause for these findings? a. Haemophilus influenzae b. Herpes simplex virus c. Influenza virus d. Mycobacterium tuberculosis e. Neisseria meningitidis 124. Which of the following statements regarding central pontine myelinolysis is correct? a. Consciousness is preserved characteristically. b. MR imaging shows diagnostic features in the majority of patients. c. The cause has been linked to overrapid correction of hyponatraemic states. d. The condition is confined to malnourished alcoholic patients. e. The pathological changes are confined to the pons. 125. A 48 year old man presented with a two week history of recurrent severe rightsided. Periorbital headache, frequently nocturnal and occurring at least once daily, usually lasting an hour. He had noticed lacrimation from the right eye and blockage of the right nostril during the headache. At the time of the examination he was free from headache and there were no abnormal physical signs. Which of the following is the most likely diagnosis? a. cluster headache b. intracranial aneurysm c. orbital pseudotumour d. right maxillary sinusitis e. trigeminal neuralgia


126. Which of the following is a true of myasthenia gravis?

132. Which of the following may cause a downbeat nystagmus?

a. there is a strong association with antinoradrenergic receptor antibodies

a. Chiari type I malformation

b. neurotransmitter released at the motor end plate is greatly reduced

c. Central cerebellar lesion

c. repetitive stimulation of a motor nerve produces a reduction in the amplitude of the 5th response compared with the 1st in 98% of cases (electrodecremental test) d. electrical recordings of single motor unit activity commonly reveal variation in the latency of the various mucle fibre responses (jitter) e. subjective improvement in muscle strength following edrophonium is diagnostic of the condition

a. Alzheimer’s disease b. Motor Neurone Disease c. Multiple Cerebral Infarcts d. Multiple Sclerosis e. Syringolmyelia 128. A 25yearold female presented with 6 months history of depression, irritability and painful sensory symptoms in her legs. Over the last 4 weeks she presents a broad base ataxic gait. An MRI brain showed bilateral posterior thalamic nuclei (pulvinar region) high signals. The most likely diagnosis is: a. Sporadic CJD b. New variant CJD c. Wilson disease d. Multiple system atrophy e. Herpes simplex encephalitis 129. A 70yearold woman presented with episodic impairment of consciousness. Which of the following is the most likely cause? a. Alzheimer type dementia b. chronic subdural haematoma c. CreutzfeldtJacob disease d. depressive stupor e. normal pressure hydrocephalus 130. A lesion of the Frontal lobe causes: a. Apraxia b. Broca’s (expressive) aphasia c. Cortical blindness d. Homonymous hemianopia e. Visuospatial neglect 131. A 65yearold man has a monotonous, slurred speech. He has an expressionless face and a festinant gait. There is also impairment of vertical gaze. What is the most likely underlying aetiology? a. ShyDrager syndrome b. idiopathic c. cerebrovascular disease d. Wilson’s disease e. SteeleRichardsonOlszewski syndrome

b. Unilateral medial longitudinal fasciculus lesion d. Wernicke’s encephalopathy e. Aqueduct stenosis 133. A 35 year old female presents with headaches. Examination reveals papilloedema. Which of the following would make the diagnosis of benign intracranial hypertension unlikely? a. Absence of retinal venous pulsations b. Bilateral upgoing plantar responses c. Normal ventricles on CT or MRI scan d. Reduced visual acuity e. VIth cranial nerve palsy 134. A teenage girl presents with GuillainBarre syndrome. Her weakness continues to worsen after admission to hospital. Which of the following should be used to monitor her? a. arterial blood gases b. chest expansion size c. FEV1/FVC ratio d. PEFR e. vital capacity 135. A 60 year old man has Parkinson’s disease. He is started on treatment with Ldopa and dopa decarboxylase inhibitor therapy. However he continues to have troublesome tremor. Which of the following drugs would be most likely to help? a. Amantadine. b. Benzexol. c. Propranolol d. Ropinirole e. Selegiline 136. Which of the following would be expected features of a LEFT Posterior cerebral artery occlusion : a. a right homonymous hemianopia b. internuclear ophthalmoplegia c. Wernicke’s aphasia d. pure aphasia (i.e. without alexia) e. decerebrate state 137. A 70yearold woman has a history of dyspnoea and palpitations for six months. An ECG at that time showed atrial fibrillation. She was given digoxin, diuretics and aspirin. She now presents with two shortlived episodes of altered sensation in the left face, left arm and leg. There is poor coordination of the left hand. ECHO was normal as was a CT head scan. What is the most appropriate next step in management? a. anticoagulation b. carotid endarterectomy c. clopidogrel d. corticosteroid treatment e. no action 138. A patient presented with a quadrantic hemianopia. Which of the following conditions is most likeley to cause such a presentation? a. a lesion of the occipital cortex b. a lesion of the optic chiasma c. bilateral diabetic retinopathy d. chloroquine poisoning e. tobacco amblyopia

NEUROLOGY

127. A 55yearold man has progressive weakness of his hands over a period of 1 year. Examination reveals wasting of the muscles of the hands and forearms and fasciculation. There is hyperreflexia of his lower limbs and upgoing plantars. Sensation is normal. Which of the following is the most likely diagnosis?

1259


1260 139. A 57yearold man develops deep venous thrombosis during

a hospitalization for prostatectomy. He exhibits decreased mental status with right hemiplegia, and a CT scan of the head suggests an acute cerebral infarction in the distribution of the left middle cerebral artery. A chest Xray reveals cardiac enlargement and prominence of the main pulmonary arteries that suggests pulmonary hypertension. His serum troponin I is <0.4 ng/mL. Which of the following lesions is most likely to be present on echocardiography? a. Coarctation of the aorta b. Dextrocardia

145. Which of the following clinical manifestations suggests Guillain Barré Syndrome? a. Weakness beginning in the arms b. Asymmetrical involvement of distal muscles c. Bulbar involvement in about 50% of cases d. Brisk tendon reflexes e. Normal CSF protein 146. A complete unilateral facial hemiparesis may be caused by which of the following? a. An intracranial tumour

c. Pulmonary stenosis

b. Birth injury

d. Tetralogy of Fallot

c. Cerebellar atrophy

MCQ's

e. Ventricular septal defect 140. A 55yearold woman has had worsening shortness of breath for several years. She now has to sleep sitting up on two pillows. She has difficulty swallowing. There is no history of chest pain. She is afebrile. Recently, she suffered a stroke with left hemiparesis. A chest Xray reveals a nearnormal left ventricular size with a prominent left atrial border. Which of the following conditions is most likely to account for these findings?

d. Myasthenia gravis e. Phenothiazine toxicity 147. A 65yearold male presents with bilateral leg pain. There is no relevant past medical history, and no excess alcohol use. Both knee reflexes are reduced. Fasting glucose is 6.5 mmol/L. Which is the next most likely investigation to confirm the diagnosis? a. B12 and folate

a. Aortic coarctation

b. Chest Xray

b. Cardiomyopathy

c. CSF examination

c. Essential hypertension

d. MRI spine

d. Left renal artery stenosis

e. Oral glucose tolerance test

e. Mitral valve stenosis 141. A 63 year old male is admitted with acute onset unsteadiness of gait, dizziness and dysphagia. Examination revealed a rightsided Horner’s syndrome, nystagmus, loss of pain and temperature sensation on the left side of the trunk and in the left arm and leg, and gait ataxia. What is the most likely diagnosis?

148. A 45yearold man presents with headaches and low libido. He is found to be hypopituitary. The CT scan shows a pituitary tumour with suprasellar extension. Which of the following structures is likely to be compressed? a. Abducens nerve b. Hypothalamus

a. leaking posterior communicating artery aneurysm

c. Occulomotor nerve

b. left sided acoustic neuroma

d. 3rd Ventricle

c. posterior inferior cerebellar artery occlusion

e. Optic nerve

d. right sided pontine infarct e. spontaneous left sided cerebellar haemorrhage 142. Which of the following would be expected following distal occlusion of the posterior cerebral artery? a. cerebellar ataxia b. contralateral hemiplegia c. dysarthria d. homonymous hemianopia e. palatal palsy 143. Which of the following would be expected features of a LEFT Posterior cerebral artery occlusion : a. a right homonymous hemianopia b. internuclear ophthalmoplegia c. Wernicke’s aphasia d. pure aphasia (i.e. without alexia) e. decerebrate state 144. Regarding pseudotumours cerebri (benign hypercranial hypertension) which is true? a. A mildly increased CSF cell count is typical. b. May be caused by prolonged steriod therapy. c. Is occasionally associated with focal neurological signs. d. Frequently presents with ataxia. e. Is distinguished from hydrocephalus by the absence of suture separation.

149.

A 66-year-old woman complains of stiffness and weakness climbing stairs. She has a history of hypertension and dietcontrolled type 2 diabetes. On examination, there is mild upper arm weakness, hip flexion is 4−/5 bilaterally, with bilateral wasting and flickers of fasciculations in the right quadriceps. Knee extension is 4/5. Dorsiflexion and plantar flexion are strong. Brisk knee and ankle reflexes are elicited, as well as a positive Hoffman’s and Babinski’s sign. Sensory examination and cranial nerves are normal. Her BM is 8.9, her pulse is regular and her blood pressure is 178/97. What is the most likely diagnosis? a. Myasthenia gravis b. Diabetic neuropathy c. Myositis d. Motor neurone disease e. Multiple sclerosis (MS)

150. A 23-year-old man is stabbed in the neck. Once stabilized, his MRI shows a right hemisection of the cord at C6. What is the expected result of this injury? a. Paralysed diaphragm b. Absent sensation to temperature in the left hand c. Paralysis of the left hand d. Absent sensation to light touch in the left hand e. Brisk right biceps reflex 151. A 23-year-old woman complains that her right leg has become progressively stiff and clumsy over the last couple of weeks. She is worried as she has not been able to go to work for the


last 4 days. On examination, tone is increased and there is a catch at the knee. She has six beats of clonus and an upgoing plantar. Power is reduced to 3-4/5 in the right leg flexors. There is no sensory involvement and the rest of the neurological exam is normal other than a pale disc on opthalmoscopy. On further questioning, she admits that she has had two episodes of blurred vision in her right eye in the last two years. Each lasted a couple of weeks from which she fully recovered. What is the most appropriate initial treatment?

the floor and his arms and legs jerked. After waking, he was 1261 shaken but was ‘back to normal’ a few minutes after the event. His medication includes aspirin, atenolol and frusemide. What is the most likely diagnosis?

a. A non-steroidal anti-inflammatory drug (NSAID)

e. Seizure

b. Interferon-beta c. Bed rest d. Methotrexate 152. A 78 year old right-handed male collapses and is brought into accident and emergency. He seems to follow clear one-step commands but he gets very frustrated as he cannot answer questions. He is unable to lift his right hand or leg. He has an irregularly irregular pulse and his blood pressure is 149/87. He takes only aspirin and frusemide. What is the most likely diagnosis?

b. Orthostatic hypotension c. Cardiogenic syncope d. Transient ischaemic attack (TIA) 157. A 41-year-old man complains of terrible headache. It started an hour ago, without warning, while stressed at work. It affects the right side of his head. He scores it ‘11/10’ in severity. When asked, he agrees that light does bother him a little. He had a similar episode six months ago, experiencing very similar headaches over 2 weeks which resolved spontaneously. On observation, he looks quite distressed and prefers to pace up and down, unable to sit still. What is the diagnosis? a. Subarachnoid haemorrhage b. Tension headache c. Intracerebralhaemorrhage

a. Left cortical infarct

d. Migraine

b. Right internal capsule infarct

e. Cluster headache

c. Left cortical haemorrhage d. Left internal capsule haemorrhage e. Brainstem haemorrhage 153. A 19-year-old woman collapses at a concert and is witnessed to have a tonic-clonic seizure lasting 2 minutes. When the paramedics arrive and ask her questions, she mumbles but no-one can understand what she is saying. Only when the paramedic applies pressure to her nailbed does she open her eyes and reach out with her other hand to rub her nail and then push him away. What is her Glasgow Coma Scale (GCS)?

158. A 49-year-old man complains of sudden onset, painless unilateral visual loss lasting about a minute. He describes ‘a black curtain coming down’. His blood pressure is 158/90, heart rate 73 bpm. There is an audible bruit on auscultation of his neck. His past medical history is insignificant other than deep vein thrombosis of his right leg ten years ago. The most likely diagnosis is: a. Retinal vein thrombosis b. Retinal artery occlusion c. Amaurosisfugax

a. 12

d. Optic neuritis

b. 11

e. Acute angle glaucoma

c. 10 d. 9 e. 8 154. A 79-year-old man is admitted with left hemiparesis. CT reveals a middle cerebral artery infarct. What is his most significant risk factor for stroke? a. Hypertension b. Smoking c. Family history d. Diabetes e. Cholesterol 155. A 42-year-old woman presents with ataxia. Gadoliniumenhanced MRI reveals multiple subcortical white matter lesions as well as enhancing lesions in the cerrebellum and spinal cord. She is diagnosed with MS. Two months later she develops optic neuritis. What feature is associated with a milder disease course? a. Her age of 42 b. Her initial presentation of ataxia c. Her female gender d. The interval between the two episodes of two months e. Her MRI scan appearance 156. A 71-year-old man with atrial fibrillation is seen in clinic following an episode of syncope. He describes getting a poor night’s sleep and, as he got out of bed in the morning, feeling dizzy for a couple of seconds before the lights dimmed around him. He was woken a couple of seconds later by his wife who had witnessed the event. She says he went pale and fell to

159. A 77-year-old woman is admitted to hospital with a urinary tract infection. She receives antibiotics and seems to be responding well. On the fourth day she is eating her lunch when she suddenly drops her fork. She calls for the nurse who notices the left side of her face is drooping. What is the best next course of action? a. CT head b. Thrombolysis c. MRI head d. Aspirin e. Place nil by mouth 160. A 71-year-old right-handed male is brought in by ambulance at 17:50 having suffered a collapse. His wife came home to find him on the floor unable to move his right arm or leg and unable to speak. Her call to the ambulance was logged at 17:30. He has a past medical history of well-controlled hypertension, ischaemic heart disease and atrial fibrillation for which he is on warfarin. He had a hernia repair three months ago and his brother had a ‘bleed in the brain’ at the age of 67. What is the absolute contraindication to thrombolysis in this male? a. Family history of haemorrhagic stroke b. History of recent surgery c. Time of onset d. Current haemorrhagic stroke e. Warfarin treatment 161. A 69-year-old man presents to clinic with a six-month history of progressive lower back pain which radiates down to his buttock. He found the pain was exacerbated while taking his daily morning walk and noticed that it eased going uphill but

NEUROLOGY

e. A course of oral steroids

a. Vasovagal syncope


1262

worsened downhill. He stopped his daily walks as a result and he now walks only slowly to the shops when he needs to, taking breaks to sit down and ease the pain. He has a history of hypertension, diabetes and prostatic hyperplasia. What is the diagnosis? a. Peripheral vascular disease b. Osteoporotic fracture c. Spinal stenosis d. Sciatica

MCQ's

e. Metastatic bone disease 162. A 31-year-old woman presents to accident and emergency with progressive difficulty walking associated with lower back pain. A few days ago she was tripping over things, now she has difficulty climbing stairs. She describes tingling and numbness in both hands which moved up to her elbows, she is unable to write. On examination, cranial nerves are intact but there is absent sensation to vibration and pin prick in her upper limbs to the elbow and lower limbs to the hip. Power is 3/5 in the ankles and 4−/5 at the hip with absent reflexes and mute plantars. Her blood pressure is 124/85, pulse 68 and sats 98 per cent on air. She has a past medical history of type I diabetes and recently recovered from an episode of food poisoning a month or two ago. What is the diagnosis? a. MS b. Guillain–Barré syndrome (GBS) c. Myasthenia gravis d. Diabetic neuropathy e. Infective neuropathy 163. A left-handed 79-year-old man presents with a troublesome resting tremor of his left hand. The tremor is evident in his writing. He has also noticed his writing is smaller than it used to be. He complains he has difficulty turning in bed to get comfortable and his wife complains that he sometimes kicks her in the middle of the night. When he gets out of bed in the morning he feels a little woozy, but this resolves after a while. On examination, he blinks about three times a minute and his face does not show much emotion. Glabelar tap is positive. He has a slow, shuffling gait. He has difficulty stopping, starting and turning. He holds his feet slightly apart to steady himself. When you pull him backwards, he is unable to right himself and stumbles back. Which of the signs and symptoms is not commonly associated with parkinsonism? a. Postural instability b. Rapid eye movement (REM) sleep disturbance c. Hypomimia d. Broad-based gait e. Autonomic instability 164. A 33-year-old woman attends her six-month follow-up appointment for headache. They are migrainous in nature but whereas she used to have them every few months, over the last three months she has experienced a chronic daily headache which varies in location and can be anywhere from 3–7/10 severity. Her last migraine with aura was two months ago. She takes co-codamolqds and ibuprofen tds. What is the best medical management? a. Stop all medication b. Start paracetamol

but she has not stopped fitting. What is the most appropriate management? a. Lorazepam b. Phenobarbital c. Intubation d. Call ITU e. Phenytoin loading 166. A 72-year-old man with known epilepsy and hypertension is admitted with pneumonia. His drug history includes aspirin, phenytoin, bendroflumethiazide and amlodipine. His heart rate is 67, blood pressure 170/93, sats 96 per cent on 2 L of oxygen. Neurological examination is normal. His doctor requests blood tests including phenytoin level. What is the correct indication for this test? a. Routine check b. Ensure levels are not toxic c. Confirm patient compliance d. Ensure therapeutic level reached e. Reassure the patient 167. A 23-year-old woman is seen in clinic for recurrent funny turns. She is not aware of them, but her family and friends have noticed them. They say she looks around blankly, then starts picking at her clothes and sometimes yawns, then she comes back after a minute. She can get drowsy after these episodes. What seizure type does this patient describe? a. Absence b. Tonic clonic c. Simple partial d. Complex partial e. Generalized 168. You are asked to perform a lower limb peripheral neurological examination ona 45-year-old diabetic male. The patient has normal tone, 5/5 power, normalplantars and proprioception. However, you notice that the patient does not respondto any sensory stimulus on the medial side of the right lower leg. Which dermatomeis affected? a. L1 b. L2 c. L3 d. L4 e. L5 169. On examination, a patient has 5/5 power in all muscle groups of his upper limbs, 0/5 power in all the muscle groups of his lower limbs. Cranial nerves are intact. Where is the lesion? a. Muscle b. Neuromuscular junction c. Peripheral nerves d. Spinal cord e. Brain 170. On examination, a patient has 5/5 power in his upper limbs, 0/5 power in his lowerlimbs. Further examination reveals a sensory level at the umbilicus. Cranial nervesare intact. Where is the lesion?

c. Start sumatriptan

a. C4

d. Start propranolol

b. T4

e. Continue current medication

c. T10

165. A 17-year-old girl is brought into accident and emergency with generalized tonicclonic seizure. Her mother had found her fitting in her bedroom about 20 minutes ago. The ambulance crew handover state that her sats are 96 per cent on 15 L of oxygen and they have given her two doses of rectal diazepam

d. L1 e. L 171. A patient is unable to move his right arm or leg. When asked to smile, the left sideof his mouth droops. Where is the lesion?


a. Left motor cortex

a. Chvostek’s

b. Right motor cortex

b. Glabellar

c. Left brainstem

c. Hoffman’s

d. Right brainstem

d. Tinel’s

e. Cervical spine

e. Babinksi’s

172. A light is shone into a patient’s right eye and it constricts. When moved to the lefteye, the left eye constricts. When moved back to the right eye, the right eye dilates. What is the diagnosis? a. Afferent lesion b. Efferent lesion c. Relative afferent lesion e. Normal 173. A 55-year-old woman complains of double vision. She finds that she is more tiredthan usual and has difficulty climbing stairs, especially when they are very long.She has difficulty getting items off high shelves at work and lately even brushingher hair is a problem. During the consultation, her voice fades away duringconversation. Reflexes are present and equal throughout. Which sign or symptomis most indicative of myasthenia gravis? a. Proximal weakness b. Normal reflexes c. Diplopia d. Fatigability e. Bulbar symptoms 174. A 55-year-old woman complains of double vision. She finds that she is tired all thetime and has difficulty climbing stairs. She has difficulty getting items off highshelves at work. Reflexes are absent but elicited after exercise. Shoulder abductionis initially 4−5 but on repeated testing is 4-5. What pathology is associated with this female’s diagnosis? a. Thyrotoxicosis b. Peptic ulcer c. Diabetes d. Stroke e. Lung cancer 175. On observation, a patient has a left facial droop. On closer examination hisnasolabial fold is flattened. When asked to smile, the left corner of his mouthdroops. He is unable to keep his cheeks puffed out. Eye closure is only slightlyweaker compared to the right and his forehead wrinkles when he is asked to lookup high. What is the diagnosis?

a. Depression b. Frontotemporal dementia c. Alzheimer’s disease d. Vascular dementia e. Lewy Body disease 179. Which of the following is not a cause of absent ankle jerks and up-going plantars? a. Freidreich’s ataxia b. B12 deficiency c. MS d. Cord compression e. Motor neurone disease 180. A patient has difficulty walking. His gait is unsteady. He seems to have difficultyraising his right leg and swings it round in an arc as he walks. He holds his rightarm and wrist flexed. What type of gait does this patient exhibit? a. Hemiplegic b. Scissoring c. High stepping d. Spastic e. Stomping 181. A patient is admitted with a stroke. On examination of her visual fields, she isunable to see in the right lower quadrant of her field. Where is the lesion? a. Optic chiasm b. Left parietal lobe c. Right temporal lobe

a. Right middle cerebral artery stroke

d. Right optic radiation

b. Parotid gland tumour

e. Left optic nerve

c. Left internal capsule stroke d. Bell’s palsy e. Cerebellar pontine angle tumour 176. A female presents with diplopia. On closer examination, when asked to look right,her left eye stays in the midline but her right eye moves right and starts jerking. What is the diagnosis? a. Myasthenia gravis (MG) b. Vertigo c. Cerebellar syndrome d. MS e. Peripheral neuropathy 177. A neurologist is examining a patient. She takes the patient’s middle finger and flicksthe distal phalanx, her thumb contracts in response. What sign has been elicited?

182. A 43-year-old woman presents with dizziness to accident and emergency. It startedsuddenly this morning, she awoke with a headache and the dizziness started whenshe sat up in bed. She describes the room spinning for a couple of minutes. It settlesif she keeps still, but returns on movement. There is no tinnitus or deafness, but some nausea and no vomiting. The most likely diagnosis is: a. Brainstem stroke b. Benign paroxysmal positional vertigo c. Ménière’s disease d. Vestibular neuronitis e. Migraine 183. A 40-year-old woman seen in clinic has multiple fleshy nodules and several lightbrown, round macules with a smooth border on her back, arms and legs. There arealso freckles under her arms. What is the underlying disorder?

NEUROLOGY

d. Relative efferent lesion

178. A 69-year-old man is taken to his GP by his concerned wife. She complains that hehas not been himself for the last year. He has slowly become withdrawn and stoppedworking on his hobbies. Now she is concerned that he often forgets to brush histeeth. She has noticed he sometimes struggles to find the right word and this has gradually become more noticeable over the last couple of months. She presentedtoday because she was surprised to come home to find him naked and urinating inthe living room last week. He has a history of hypertension and is an ex-smoker. The most likely diagnosis is:

1263


1264

a. Neurofibromatosis type I

keep her balance. What is the diagnosis?

b. Neurofibromatosis type II

a. Diabetes

c. Tuberous sclerosis

b. Cerebellar problem

d. Hereditary haemorrhagictelangectasia

c. Alcohol abuse

e. Sturge–Weber syndrome

d. Proprioceptive problem

184. A 19-year-old man is admitted with a GCS of 12. He was doing push ups when hecomplained of a sudden-onset, severe headache and collapsed. What would youexpect on his CT? a. Convex haematoma b. Midline shift c. Crescent-shaped haematoma

MCQ's

d. Blood along the sulci and fissures e. Intraventricular blood 185. A 60-year-old man presents with visual problems and dizziness. The dizzinessstarted suddenly, he sees the room spinning around and he has noticed he keepsbumping into things on his right. His blood pressure is 159/91, heart rate 72. Onexamination, there is nystagmus and dysdiadochokinesia. Where is his stroke? a. Temporal lobe b. Left parietal lobe c. Right parietal lobe d. Anterior circulation e. Posterior circulation 186. A 45-year-old man presents with a 5-day history of progressive tingling andnumbness of his hands and feet. He insists that he has never had this problembefore and that he was perfectly fine a week ago. Over the last 2 days he has hadsome difficulty walking but mostly he complains about difficulty rolling upcigarettes. On examination, there is mild symmetrical distal weakness, mild gaitataxia and dysdiadochokinesia. He smokes 30 cigarettes a day and drinks 1–2bottles of wine. He has a family history of hypertension and his 63-year-old motherhas type 2 diabetes, whom over the last year has complained of numbness andburning in her feet. He self-discharges. A week later, his symptoms have peaked. Hedisplays moderate distal weakness and numbness to his knees, after which he turns a corner and his symptoms start to slowly resolve. What is the diagnosis? a. Miller Fisher syndrome b. Alcoholic neuropathy c. Chronic idiopathic demyelinating polyneuropathy d. Charcot Marie Tooth disease e. GBS 187. A 28-year-old junior doctor has been complaining of a headache for the last 24hours. It started gradually, intensifying slowly and involving the entire cranium,but over the last couple of hours she has noticed that turning her head isuncomfortable. She feels generally unwell and prefers to lie in a dark room. Herboyfriend has noticed that she seems irritable. On examination, she exhibitsphotophobia and there is neck stiffness. There is no papilloedema. Close examinationof her skin reveals no rashes. Kernig’s sign is negative. A lumbar puncture (LP) reveals low protein, normal glucose and lymphocytosis. What is the diagnosis? a. Viral meningitis b. Migraine c. Aseptic meningitis d. Bacterial meningitis e. TB meningitis 188. A 36-year-old woman presents to clinic with neurological symptoms. Onexamination, she is able to stand with her feet together. Upon closing her eyes,however, she is unable to

e. Visual problem 189. A 29-year-old man is brought to the emergency department in a comatose state a few hours after complaining of sudden onset of excruciating headache. Neurologic examination reveals dilated pupils poorly responsive to light. A CT scan of the head without contrast demonstrates hyperdensity within the suprasellar cistern, while MRI is unremarkable. Lumbar puncture shows hemorrhagic cerebrospinal fluid. Which of the following is the most likely diagnosis? a. Amyloid angiopathy-related hemorrhage  b. Cavernous sinus thrombosis  c. Hemorrhagic infarction d. Pituitary apoplexy e. Ruptured berry aneurysm 190. A 55-year-old woman complains of double vision. She is tired all the time and has difficulty climbing stairs. She has difficulty getting items off shelves. Reflexes are absent but elicited after exercise. Initial shoulder abduction is 4/5 but on repeated testing is 4 +/5. What is the pathology associated with this female’s diagnosis? a. Thyrotoxicosis b. Myasthenia Gravis c. Diabetes d. Stroke e. Lung cancer 191. The worst score in Glasgow Coma Scale (GCS) representing “none” in all three categories assessed is a. Fifteen b. Zero c. Three d. None 192. Nerve fiber most susceptible to hypoxia isa. A b. C c. B d. D 193. Earliest cranial never to be involved in Acoustic Neuroma: a. 5 th b. 7th c. 6 th d. 8 th 194. Deep peronial nerve supplies all of the following except a. Tibialis anterior b. Extensor Hallusislongus c. Extensor digitorumlongus d. Peroneus brevis 195. Which of the following structures enter through the greater sciatic notch and leave through the lessor notch a. Obturator nerve b. Pudendal artery c. Femoral vessels d. Lesser sciatic nerve


1265

Neurology - Answers 40. b

79. b

118. d

157. e

2. c

41. c

80. e

119. c

158. c

3. b

42. b

81. d

120. c

159. e

4. d

43. e

82. a

121. d

160. c

5. e

44. b

83. e

122. d

161. c

6. a

45. e

84. a

123. b

162. b

7. a

46. d

85. a

124. c

163. d

8. b

47. e

86. e

125. a

164. a

9. c

48. d

87. b

126. d

165. e

10. c

49. b

88. d

127. b

166. c

11. b

50. a

89. e

128. b

167. d

12. c

51. c

90. d

129. b

168. d

13. d

52. b

91. b

130. b

169. d

14. e

53. d

92. e

131. e

170. c

15. a

54. c

93. c

132. a

171. c

16. c

55. e

94. b

133. b

172. c

17. a

56. d

95. c

134. e

173. d

18. e

57. d

96. e

135. b

174. e

19. d

58. d

97. d

136. a

175. a

20. c

59. c

98. e

137. a

176. d

21. b

60. b

99. d

138. a

177. c

22. d

61. e

100. d

139. e

178. b

23. b

62. b

101. c

140. e

179. c

24. c

63. d

102. b

141. c

180. a

25. e

64. d

103. c

142. d

181. b

26. c

65. c

104. e

143. a

182. b

27. a

66. e

105. c

144. b

183. a

28. e

67. c

106. a

145. c

184. d

29. d

68. e

107. b

146. b

185. e

30. b

69. b

108. c

147. e

186. e

31. c

70. d

109. b

148. e

187. a

32. e

71. b

110. a

149. d

188. d

33. b

72. e

111. b

150. b

189. e

34. d

73. d

112. a

151. e

190. e

35. a

74. c

113. c

152. a

191. c

36. e

75. c

114. b

153. d

192. c

37. e

76. d

115. a

154. a

193. d

38. b

77. e

116. d

155. c

194. d

39. b

78. c

117. b

156. b

195. a

NEUROLOGY

1. a


PULMONARY MEDICINE 1.

2.

You see a 68-year-old man in clinic, with a 40 (cigarette) pack year history, who has been experiencing reathlessness on exertion and a productive cough of white sputum over the last four months. You assess his spirometry results which reveal an FEV1/FVC of 51 per cent with minimal reversibility after a 2-week trial of oral steroids. Cardiological investigations are normal. Which of the following is the most likely diagnosis?

6.

a. Asthma

a. Bronchogenic carcinoma

b. Chronic obstructive pulmonary disease (COPD)

b. Congestive cardiac failure

c. Left ventricular failure

c. Liver cirrhosis

d. Chronic bronchitis

d. Nephrotic syndrome

e. Lung fibrosis

e. Meig’s syndrome

A 67-year-old woman is admitted to accident and emergency with pyrexia (38.1°C) and a cough productive of green sputum. The observations show a pulse rate of 101, BP 80/60 and respiratory rate of 32. She is alert and orientated in space and time. Blood results reveal a WCC of 21, urea of 8.5 and chest x-ray shows a patch of consolidation in the lower zone of the right lung. She is treated for severe community-acquired pneumonia. Which of the following is the correct calculated CURB-65 score?

7.

a. Magnetic resonance imaging (MRI) of the chest b. High-resolution CT chest (HRCT) c. Chest x-ray d. Ventilation/perfusion scan (V/Q scan)

b. 8

e. CT pulmonary angiogram (CT-Pa)

d. 0

8.

e. 1 Which of the following organisms would typically be found in a patient with atypical community-acquired pneumonia? a. Staphylococcus aureus

b. Long-acting beta-2 agonist inhaler

c. Streptococcus pneumonia

c. Low-dose steroid inhaler

d. Legionella pneumophilia

d. Leukotriene receptor antagonists

e. Haemophilus influenza You are asked to interpret an arterial blood gas of a 76-yearold patient who was admitted to accident and emergency with an acute onset of breathlessness and low oxygen saturations. The test was taken on room air and read as follows: pH 7.37, PO2 7.8, PCO2 4.1, HCO3 24, SO2 89 per cent. Choose the most likely clinical interpretation from these arterial blood gas results:

e. High-dose steroid inhaler 9.

a. Compensated respiratory acidosis c. Compensated respiratory alkalosis

b. Deep S-wave in lead I, pathological Q-wave in lead III and inverted T-waves in lead III

d. Type 2 respiratory failure e. None of the above A 54-year-old woman is seen in clinic with a history of weight loss, loss of appetite and shortnesss of breath. Her respiratory rate is 19 and oxygen saturations (on room air) range between 93 and 95 per cent. On examination, there is reduced air entry and dullness to percussion on the lower to midzones of the right lung. There is also reduced chest expansion on the right. From the list below, select the most likely diagnosis: a. Right middle lobe pneumonia b. Pulmonary embolism c. Right-sided pleural effusion d. Right-sided bronchial carcinoma e. Right lower lobe pneumonia

You see a 46-year-old man who has presented to accident and emergency with an acute onset of shortness of breath. Your registrar has high clinical suspicion that the patient is suffering from a pulmonary embolism and tells you that the patient’s ECG has changes pointing to the suspected diagnosis. From the list below, which of the following ECG changes are classically seen? a. Inverted T-waves in lead I, tall/tented T-waves in lead III and flattened T-waves in lead III

b. Type 1 respiratory failure

5.

A 28-year-old man has been newly diagnosed with asthma. He has never been admitted to hospital with an asthma exacerbation and experiences symptoms once or twice a week. You discuss the treatment options with him. His peak expiratory flow reading is currently 85 per cent of the normal predicted value expected for his age and height. Which of the following is the most appropriate first step in treatment? a. Short-acting beta-2 agonist inhaler

b. Pseudomonas spp.

4.

You are discussing a patient with your registrar who has become acutely short of breath on the ward. After performing an arterial blood gas, you have high clinical suspicion that the patient has a pulmonary embolism. Which of the following is the investigation of choice for detecting pulmonary embolism?

a. 6 c. 4

3.

A 45-year-old woman with unexpected weight loss, loss of appetite and shortness of breath presents to you in clinic. On examination, there is reduced air entry and dullness to percussion in the right lung. A pleural tap is performed and the aspirate samples sent for analysis. You are told that the results reveal a protein content of 30 g/L. From the list below, select the most likely diagnosis:

c. Flattened T-wave in lead I, inverted T-wave in lead III, and deep S-wave in lead III d. No changes in lead I, deep S-wave in lead III e. Deep S-wave in lead I with no changes in lead III 10.

Which of the following arterial blood gas results, taken on room air, would you expect to see in a 67-year-old patient who has been suffering with COPD for two years and is not on home oxygen? a. pH 7.35, PO2 11, PCO2 5.3, HCO3 24, SO2 98 per cent b. pH 7.47, PO2 12, PCO2 5.1, HCO3 30, SO2 97 per cent c. pH 7.44, PO2 8.3, PCO2 6.7, HCO3 28, SO2 93 per cent d. pH 7.31, PO2 10.2, PCO2 6.8, HCO3 25, SO2 95 per cent e. pH 7.30, PO2 11.5, PCO2 5.2, HCO3 18, SO2 96 per cent


11.

d. Prophylactic dose subcutaneous low molecular weight 1267 heparin loading with warfarin and aim for INR between 2 and 3

You see a 46-year-old woman on your ward who has been diagnosed with bronchiectasis following a three-month history of a mucopurulent cough. Which of the following from the list below is not a cause of ronchiectasis?

e. Treatment dose subcutaneous low molecular weight heparin loading with warfarin and aim for INR between 2 and 3

a. Kartagener’s syndrome b. Cystic fibrosis c. Pneumonia d. Left ventricular failure

17.

e. Bronchogenic carcinoma 12.

a. Hoarse voice b. Miosis

a. Empyema

c. Anhydrosis

b. Mesothelioma

d. Exopthalmos

c. Bronchogenic carcinoma d. Cystic fibrosis e. COPD 13.

e. Ptosis 18.

A 55-year-old woman, who has never smoked, presents to you on the ward with a history of weight loss, decreased appetite and finger clubbing. You are told that her chest x-ray revealed opacity in the hilar region of the right lung suggesting a bronchogenic carcinoma. She is currently awaiting a CT-chest with bronchoscopy to follow. From the list below, select the most likely diagnosis:

a. Rheumatoid arthritis

a. Squamous cell carcinoma of the lung

b. Systemic lupus erythematosus (SLE)

b. Adenocarcinoma of the lung

c. Sarcoidosis

c. Small cell carcinoma of the lung

d. Idiopathic pulmonary fibrosis

d. Large cell carcinoma of lung

e. Bronchogenic carcinoma

e. Carcinoid tumour of the lung 14.

You see a 28-year-old man, with no past medical history, in accident and emergency who developed an acute onset of pleuritic chest pain and shortness of breath while playing football. On examination, oxygen saturations are 93 per cent on room air, respiratory rate 20 and temperature is 37.1°C. There is decreased expansion of the chest on the left side, hyper-resonant to percussion and reduced air entry on the left. The most likely diagnosis is:

19.

b. Primary pulmonary hypertension c. Myasthenia gravis d. COPD

b. Left-sided pneumonia

e. Multiple sclerosis

c. Left-sided pleural effusion 20.

e. Traumatic chest injury 15.

You are asked to request imaging for a patient with a suspected pneumothorax who you have just examined in accident and emergency. Which of the following would be the most appropriate first step imaging modality?

b. Pulmonary fibrosis c. Bronchogenic carcinoma

b. Ultrasound chest

d. Bronchitis

c. Chest x-ray e. CT-PA 16.

A 68-year-old woman has presented with acute onset shortness of breath 24 hours after a long haul flight. Her blood results show a raised D-dimer level and the arterial blood gas shows a PO2 of 8.3 kPa and PCO2 of 5.4 kPa. Your consultant suspects a pulmonary embolism and the patient needs to be started on treatment while a CT-PA is awaited. From the list below, please select the most appropriate treatment regime. a. Commence loading with warfarin and aim for an international normalized ratio (INR) between 2 and 3 b. Thromboembolic deterrent stockings c. Aspirin 75 mg daily

You are told by your registrar that a 69-year-old man has been admitted to the chest ward with dyspnoea, cyanosis and finger clubbing. His chest x-ray shows bilateral lower zone reticulonodular shadowing. From the list below, which is the most likely diagnosis? a. Bronchiectasis

a. CT-chest

d. V/Q scan

A 67-year-old man presents with dyspnoea and fatigue with signs of a raised jugular venous pressure (JVP), hepatomegaly and peripheral oedema. The patient has a longstanding history of COPD. You suspect cor pulmonale. Which of the following is not a cause of cor pulmonale? a. Pulmonary fibrosis

a. Left-sided pneumothorax

d. Lung fibrosis

A 50-year-old Afro-Caribbean man, with no past medical history, presents with a four-month history of dry cough and shortness of breath on exertion. The patient’s GP referred him to the chest clinic after performing blood tests which revealed a raised erythrocyte sedimentation rate (ESR) and serum angiotensin-converting enzyme (ACE) level. You review the patient’s chest x-ray which reveals bilateral hilar lyphadenopathy. From the list below, select the most likely diagnosis:

e. COPD 21.

A 25-year-old woman is admitted to accident and emergency with a severe exacerbation of asthma. On examination, her respiratory rate is 30, oxygen saturations are 95 per cent on 15 L O2 and temperature is 37.2°C. As you feel the peripheral pulse, the volume falls as the patient inspires. Which of the following explains this clinical sign? a. Increased left atrial filling pressures on inspiration b. Decreased right ventricular filling pressures on inspiration c. Peripheral vasodilation d. Decreased right atrial filling pressures on inspiration e. Decreased left atrial filling pressures on inspiration

PULMONARY MEDICINE

A 30-year-old man presents to your clinic with a cough and finger clubbing. From the list below, which of these answers is not a respiratory cause of finger clubbing?

You see a 67-year-old man who has been referred to the chest clinic following a three-month history of weight loss and signs which may suggest a Pancoast’s tumour. Which of the following symptoms from the list below is not associated with a Pancoast’s tumour?


1268 22.

A 55-year-old man, who has never smoked and with no past medical history, has been diagnosed with right basal community-acquired pneumonia. There are minimal changes on his chest x-ray and bloods reveal a neutrophil count of 8.2 and a C-reactive protein (CRP) of 15. He has no drug allergies. Although he has a productive cough of green sputum, his respiratory rate is 16, oxygen saturations are 97 per cent on room air and his temperature is 37.4°C. You are asked to place him on treatment. Which of the following treatment options would be appropriate for this patient?

d. it is associated with Kussmaul’s sign e. the commonest symptom is stridor 28.

a. Coal worker’s lung b. Pigeon fancier’s lung c. Mushroom picker’s lung

a. Oral amoxicillin

d. Farmer’s lung

b. Oral erythromycin

e. Malt worker’s lung

c. Intravenous ertapenem

MCQ's

d. Intravenous ertapenem clarithromycin)

with

a

macrolide

(e.g.

29.

e. Intravenous tazocin 23.

A 56-year-old woman who has recently been discharged from your ward, with oral antibiotics for right basal communityacquired pneumonia, is re-admitted with transient pyrexia and shortness of breath. She is found to have a right-sided pleural effusion which is drained and some pleural aspirate sent for analysis. The results reveal an empyema. Which of the following, from the pleural aspirate analysis, would typically be found in a patient with an empyema? a. pH 7.2, ↑ LDH, ↑ glucose

24.

a. Pseudomonas spp. b. S. pneumoniae

c. pH 7.2, ↓ LDH, ↓ glucose

c. Mycoplasma pneumoniae

d. pH 7.2, ↑ LDH, ↓ glucose

d. L. pneumophilia

e. pH 7.2, ↔ LDH, ↔ glucose

e. S. aureus

You are told that a patient in clinic has been diagnosed with cystic fibrosis using the sodium chloride sweat test. Which of the following results from the latter test would indicate a positive diagnosis of cystic fibrosis?

30.

b. Erythromycin c. Amphotericin B d. Flucloxacillin

c. Sodium chloride 50 mmol/L

e. Fluconazole

d. Sodium chloride 60 mmol/L e. Sodium chloride 30 mmol/L

31.

Which of the following organisms, responsible for causing chronic pneumonia, is most commonly found in patients with longstanding cystic fibrosis? a. L. pneumophilia b. S. pneumonia c. Burkholderia cepacia d. Pseudomonas aeruginosa e. H. influenza

68-year-old woman is admitted to accident and emergency with shortness of breath and cough. She has been a smoker for 25 years, smoking on average 20 cigarettes a day, and is a known COPD patient with home oxygen. The observations read a pulse rate of 101, blood pressure of 100/60, respiratory rate of 20, oxygen saturations of 88 per cent on air and temperature of 37.2°C. On auscultation you hear bilateral expiratory wheeze. She is prescribed nebulizers (salbutamol 5 mg ipratropium 500 g) with oxygen and chest x-ray requested. Intravenous access has been established and bloods sent for analysis. From the list below, select the most appropriate next step in this patient’s management plan.

From, the list below, which of the following carcinomas of the lung is highly associated with exposure to asbestos?

a. Arterial blood gas sampling

a. Adenocarcinoma

c. Urine dip microscopy and sensitivity

b. Peak flow assessment

b. Small cell carcinoma

d. Start non-invasive ventilation (e.g. BIPAP)

c. Squamous cell carcinoma

e. Obtain sputum for microscopy, culture and sensitivity (MC&S)

d. Malignant mesothelioma e. Large cell carcinoma 27.

Which of the drugs below would be the most appropriate to treat pulmonary Aspergillus spp. infection? a. Amoxicillin

b. Sodium chloride 60 mmol/L

26.

A 44-year-old plumber has a 4-day history of fever and generalized myalgia. Two days ago he developed a dry cough coupled with mild dyspnoea and has been feeling very lethargic. On examination his temperature is 38.5°C, respiratory rate 20, oxygen saturations ranging between 93 and 96 per cent on room air and auscultation of the chest reveals bibasal crackles. Bloods show a raised white cell count of 18.2 and neutrophil count of 11.0, CRP of 90 and a raised ALT of 261 and ALP 96. Chest x-ray reveals bibasal consolidation. The patient is treated with antibiotics for bibasal pneumonia. From the list below, select the most likely organism responsible for the pneumonia:

b. pH 7.2, ↑ LDH, ↑ glucose

a. Sodium chloride 40 mmol/L

25.

You see a 70-year-old man diagnosed with hypersensitivity pneumonitis following a four-month history of shortness of breath at rest and cyanosis. Which of the following does not fall under the category of hypersensitivity pneumonitis?

A 45yearold man develops facial swelling and breathlessness. His chest Xray reveals paratracheal lymphadenopathy. Which of the following statements is most accurate regarding the superior vena caval obstruction? a. the most common cause is squamous cell carcinoma b. treatment of choice is radiotherapy c. it may be associated with voice hoarseness

32.

During the consultant ward round, you see a 78-year-old woman who is being investigated for hyponatraemia, weight loss and haemoptysis. A mass lesion was detected on a CTchest scan which has been biopsied and sent for histological analysis. Your consultant has a high suspicion that the patient may have bronchogenic carcinoma. From the list below, select the most likely type of bronchogenic carcinoma that would explain the above patient’s symptoms: a. Large cell carcinoma b. Small cell carcinoma


below, which of the following answers is the most appropriate 1269 and recommended treatment regimen for this patient?

c. Adenocarcinoma d. Squamous cell carcinoma

a. Three months of isoniazid, rifampicin, ethambutol and pyrazinamide, followed by three months of isoniazid and rifamipicin

e. Alveolar cell carcinoma 33.

The severity of COPD is assessed using post bronchodilator spirometery analysis. From the list below, select the values that you would expect to see in a patient with moderate COPD.

b. Four months of isoniazid and rifampicin, followed by two months of isoniazid, rifampicin, ethambutol and pyrazinamide

a. FEV1/FVC 0.7, FEV1 per cent predicted 30–49 per cent

c. Six months of isoniazid, rifampicin, ethambutol and pyrazinamide

b. FEV1/FVC 0.7, FEV1 per cent predicted ≥80 per cent c. FEV1/FVC 0.7, FEV1 per cent predicted 30 per cent

d. Six months of isoniazid and rifampicin

d. FEV1/FVC 0.7, FEV1 per cent predicted 50–79 per cent 34.

A 58-year-old man with known COPD, diagnosed eight months ago, attends your clinic with persistent shortness of breath despite stopping smoking and using his salbutamol inhaler (given to him at the time of diagnosis), which he finds he is using more frequently. You assess the patient’s lung function tests that have been recorded just before he saw you in clinic on this occasion. His FEV1 65 per cent of the predicted value. Oxygen saturations are 95 per cent on room air, respiratory rate in 18, and his temperature is 37.1°C. From the list below, select the next most appropriate step in this patient’s management.

38.

a. Pyrazinamide b. Rifampicin

a. 40 mg daily oral prednisolone for 5 days

c. Ethambutol

b. Start long-term oxygen therapy

d. Isoniazid

c. Start inhaled corticosteroid therapy

e. None of the above

d. Add oral theophylline therapy e. Add a long-acting 2 agonist inhaler 35.

A 58-year-old man is admitted with a mild exacerbation of asthma. He suffers with hypertension which is controlled with medication. He was given 5 mg salbutamol and 500 g ipratropium nebulizers, on route to hospital, by paramedics and has received ‘back to back’ salbutamol 5 mg nebulizers since admission to accident and emergency. The patient was then sent to the acute medical unit where he was given regular nebulizers along with his regular antihypertension medication. Before he was discharged, his serum potassium reading was 2.9. Select, from the list below, the drug which is most likely to have caused the hypokalaemia. a. Ipratropium

39.

b. Acute onset c. Pulmonary capillary wedge pressure 19 d. Refractory hypoxaemia (PaO2:FiO2 200) e. Lack of clinical congestive heart failure 40.

c. Salbutamol d. Amlodipine e. Paracetamol A 56-year-old man attends your clinic with a three-month history of a productive cough with blood-tinged sputum, following his return from India. Associated symptoms include lethargy, night sweats and decreased appetite. He is normally fit and healthy with no past medical history. On examination, the patient’s chest has good air entry bilaterally with no added sounds and his temperature is 37.3°C. A sputum sample sent from the patient’s GP reveals a growth of acid fast bacilli. From the list below, which is the most likely diagnosis?

b. Oral amoxillicin and metronidazole c. Intravenous clarithromycin d. Intravenous cefuroxime e. Oral co-amoxiclav

b. Tuberculosis d. Pneumonia e. Bronchogenic carcinoma 37.

Your clinic patient has been diagnosed with pulmonary tuberculosis (TB) following a three-month history of haemoptysis and fever. The patient is due to start on treatment and you are asked by your registrar which of the following regimes is the most suitable. The patient has no known drug allergies and, in addition, liver function tests and urea and electrolytes results are all within normal ranges. From the list

You see a 76-year-old woman in accident and emergency who has been admitted with a 1-day history of shortness of breath and pyrexia (38.4°C). The patient’s past medical history includes hypertension, stroke and insulin-dependent diabetes. She has no known drug allergies. The nursing staff report that the patient vomited after her lunchtime meal yesterday. On examination the patient’s respiratory rate is 26, oxygen saturations 93 per cent on room air. On auscultation of the chest, you hear right basal crackles. You suspect that this patient is suffering from aspiration pneumonia. From the list below, which is the most appropriate antibiotic regimen for this patient? a. Intravenous cefuroxime and metronidazole

a. Pulmonary embolism c. Bronchitis

A 37-year-old woman is admitted to accident and emergency with severe facial burns. Despite prompt management, she develops acute respiratory distress syndrome (ARDS). Which of the following is not associated with the diagnostic criteria for ARDS? a. Bilateral infiltrates on chest x-ray

b. Ramipril

36.

A 45-year-old man with diabetes, diagnosed with pulmonary TB who started treatment two months ago, presents to you with a week’s history of pins and needles in his hands and feet with associated numbness. He tells you that his symptoms started since he stopped taking the vitamins given to him at the start of his TB treatment. From the list below, which of the following drugs is responsible for the symptoms described by the patient?

41.

A 7 month old boy is presented to a doctor by his parents with symptoms of reccurent upper respiratory tract infections. No other members of the family suffer from any smiliar infections.Physical examination showed mild facial hypoplasia. Biochemistry investigations revealed hypocalcaemia. Microbiological investigations were normal and immunoglobulins were within normal limits. The infants immune function would show the following deficiency: a. Complement Deficieny b. B cell number and function

PULMONARY MEDICINE

e. Two months of isoniazid, rifampicin, ethambutol and pyrazinamide, followed by four months of isoniazid and rifampicin

e. FEV1/FVC 0.7, FEV1 per cent predicted 60–70 per cent


c. T cell number and function

1270

42.

50.

a. Cystic fibrosis

e. Macrophage number and function

a. Pulmonary heamorrage b. Bronchitis

Progressive Massive Fibrosis (PMF) is most likely to be found in which of the following? a. Complicated silicosis b. Extrinsic allergic alveolitis

c. Bronchiectasis 51.

c. Lobar pneumonia d. Sarcoidosis

MCQ's 44.

c. Sarcoidosis d. Pulmonary embolism 52.

a. Consolidation

c. Ceftazidime

b. interstitiall pneumonitis

d. Gentamicin

c. increased eosinophils

e. Amoxicillin

d. hilar lymphadenopathy

A 21yearold gentleman with cystic fibrosis presents with infertility. What is the most likely cause for this?

53.

a. Legionella

b. Failure of development of the vas deferens

b. Neisseria meningitides

c. Increasing alkalinisation of semen

c. strep. Pneumoniae

d. Primary failure of testosterone production

d. H. influenza 54.

b. cotrimoxazole c. penicillin d. fluroquinolones 55.

a. Age

d. increased total IgE

b. CHF

e. resolution of symptoms the day after the exam

c. hypothermia d. hyponatremia

All of following produce exudative “pleural effusion” except 56.

Dose og MgSO4 in asthma is-

b. Pulmonary infarction

a. 8 gm iv over 20 min

c. Acute Pancreatitis

b. 2 gm iv over 40 min

d. Cardiac Failure

c. 2 gm iv over 20 min d. 6 gm iv over 20 min

All of the following can precipitate Asthma except : a. LRTI b. Aspirin

57.

Granulomatous condition showing hypercalcemia are all except

c. GERD

a. TB

d. None

b. sarcoidosis c. berylliosis

Which is not a feature of kartagener syndrome:

d. SLE

a. Dextrocardia b. Situs Inversus

58.

c. Cystic Fibrosis

b. inorganic dust

What does the abbreviation BIPEP stand for?

c. toxic gases eg chlorine , sulphur dioxide

a. Bivalvular positive airway pressure b. Bilateral preventive aerodynamic pressure c. Bidirectional positive airway pressure d. Bilevel positive airway pressure

Which of the following is characteristically not associated with development of interstitial lung disease a. Organic dust

d. Absence of cilia 49.

In “pneumonia severity scale” most important factor is

c. past medical history of hayfever and eczema

a. Rheumatoid Disease

48.

DOC for pneumocystic jiroveci is a. Clotrimazole

A 16yearold girl presents with shortness of breath and insomnia prior to an examination. Clinical examination is normal. CXR and PEFR are normal. Which of the following investigations is most suggestive of asthma? b. positive skin prick test to common allergens

47.

A 28 yr female , has diarrhoea , confusion , high grade fever with b/l pneumonitis. The diagnosis is

a. Chronic prostatic insufficiency

a. diurnal variation in PEFR> 20%

46.

Charcterstic pathological feature of pneumococcal pneumonia

b. Cefotaxime

e. Production of antisperm antibodies 45.

b. Congestive cardiac failure

A 17yearold girl with known cystic fibrosis presents with a chest infection. What antibiotic would be most suitable for her? a. Augmentin

In a 40 year patient there was pleural fluid .Analysis of this fluid showed a protein ratio of 0.38 and a LDH level of 125 U/L and LDH ratio of pleural fluid to serum of 0.48. The most probable diagnosis is a. Ureamia

e. Simple coal workers pneumoconiosis 43.

Unexpectedly increase in diffusing capacity is found in

d. Plasma Cell

d. tobacco smoke 59.

Which of the following collagen disorder is not associated with pulmonary fibrosis a. SLE b. progressive systemic sclerosis


60.

c. dermatomyositis

d. Require 34 months to reach completion

d. RA

e. Be irreversible

A truck driver has chronic cough with fever since one month. Chest x ray showing reticonodular infiltrate in mid and lower zone. Diagnosis is

69.

b. Increased adrenergic responsiveness of the airways

b. ILD

c. Increased vascular permeability of bronchial tissue

c. pneumococcal pneumonia

d. Decreased calcium influx into the mast cells

d. pneumocystis carini pneumonia. a. bronchial asthma

62.

e. Decreased prostaglandin production 70.

b. chronic bronchitis

a. Decreased camp in cardiac muscle

c. bronchogenic carcinoma

b. Increased camp in cardiac muscle

d. pulmonary TB

c. Decreased IP3 in gastric mucosa d. Increased IP3 in gastric mucosa

Charcot leyden crystals are derived from

e. Increased IP3 in smooth muscle

a. eosinophil b. basophil

71.

c. mast cell 63.

a. Blurred vision

To prevent exercise induced asthma drug used is

c. Orthostatic hypotension

b. Diarrhea d. P450 inhibition

b. terbutalin c. epinephrine d. sodium chromoglycate

65.

e. Sleepiness 72.

a. Bromocriptine

a. asbestosis

b. Cimetidine

b. coal worker pneumoconiosis

c. Ketanserin

c. byssinosis

d. Loratadine

d. silicosis

e. Ondansetron

Farmers lung is caused by

73.

b. Cimetidine

c. thermophilic actinomycetes

c. Ergotamine

d. grain dust

d. Ketanserin

Most likely precursor to bronchiectesis is a. TB b. carcinoma

e. LSD 74.

c. bronchial adenoma

68.

b. Terbutaline

Which of the following terms best describes the antagonism of leukotriene’s ronchoconstrictor effect (mediated at leukotriene receptors) by terbutaline (acting a adrenoceptors) in a patient with asthma? b. Partial agonist

Drugs that can dilate bronchi during an acute asthmatic attack include all of the following except a. Epinephrine

d. bronchopneumonia

a. Pharmacologic antagonist

Which of the following is most useful in the treatment of hyperprolactinemia ? a. Bromocriptine

b. asperigullus

67.

A patient undergoing cancer chemotherapy is vomiting frequently. A drug that might help in this situation is

Monday chest tightness is characterstic of

a. cryptostroma corticale

66.

Toxicities of H2 antihistamines include which one of the following?

d. bronchial goblet cells a. ipratropium bromide

64.

Which of the following will result from blockade of H2 receptors?

c. Nedocromil d. Theophyline e. Ipratropium 75.

Which of the following is a nonselective but very potent and efficacious bonchodilator that is not active by the oral route?

c. Physiologic antagonist

a. Aminophyline

d. Chemical antagonist

b. Cromolyn

e. Noncompetitive antagonist

c. Epinephrine d. Ipratropium

If therapy with multiple drugs causes induction of drug metabolism in your asthma patient, it will a. Result in increased smooth endoplasmic reticulum b. Result in increased rough endoplasmic reticulum c. Result in decreased enzymes in the soluble cytoplasmic fraction

e. Metaproterenol 76.

Which of the following is a prophylactic agent that appears to stabilize mast cells? a. Aminophyline b. Cromolyn c. Epinephrine

PULMONARY MEDICINE

“creola bodies “ in sputum pathognomic of

The Symptoms of allergenmediated asthma result from which of the following? a. Increased release of mediators from mast cells

a. TB

61.

1271


1272 77.

78.

d. Ipratropium

c. Microacerophiles

e. Metaproterenol

d. Facultative organisms

Which of the following is a direct bronchodilator that is most often used in asthma by the oral route?

a. Increased release of mediators from mast cells

b. Cromolyn

b. Increased adrenergic responsiveness of the airways

c. Epinephrine

c. Inceased vascular permeability of bronchial tissue

d. Ipratropium

d. Decreased calcium influx into the mast cell

e. Metaproterenol

e. Decreased prostaglandin production

Acute exacerbations of asthma can be triggered by all of the following except

MCQ's

86.

a. Bacterial or viral pneumonia

c. Discontinuation of asthma medication

b. Hypersensitivity reaction to penicillin

d. Hot, dry weather

c. Discontinuation of asthma medication

e. Stressful emotional events

d. Hot, dry weather

Which of the following has overdose toxicity that includes insomnia, arrhythmias, and convulsions?

e. Stressful emotional events 87.

a. Theophyline

c. Epinephrine

b. A ßagonist

d. Ipratropium

c. A corticosteroid

e. Metaproterenol

d. Cromolyn sodium

Which of the following is a very longacting ß2 – selective agonist that is used for asthma prophylaxis?

e. An antihistamine 88.

b. Cromolyn

b. Forced vital capacity (FVC)

d. Ipratropium e. Salmeterol

c. Total lung capacity (TLC)

Which one of the following drugs is most suitable for management of essential tremor in a patient who has pulmonary disease?

e. Residual volume (RV)

a. Diazepam

d. Peak expiratory flow rate (PEFR) 89.

b. Levodopa c. Metoprolol

b. Acetaminophen, 650 mg every 4 hours

e. Terbutaline

c. Gold injections, 25 mg intramuscularly once a week

A drug useful in the treatment of asthma but lacking bronchodilator action, is a. Cromolyn b. Ephedrine

d. Azathioprine, 75 mg daily e. Cyclophosphamide, 100 mg daily 90.

c. Isoproterenol

A drug administered by inhalation of powder as a prophylactic for asthma is a. Ephedrine

d. Metaproterenol

b. Disodium cromolyn

e. Metoprolol

c. Isoproterenol

Relative to fexofenadine, diphenhydramine is more likely to

d. Ocytriphylline

a. Be used for treatment of asthma

e. Epinephrine

b. Be used for treatment of gastroesophageal reflux disease c. Cause cardiac arrhythmias in overdose d. Have efficacy in the prevention of motion sickness e. Increase the serum concentration of warfarin 84.

Which of the following agents and dosage regimens is the best choice of treatment for an asthma patient with rheumatoid arthritis who is considered sensitive to aspirin (experiences bronchospasm with use)? a. Lbuprofen, 800 mg three times daily

d. Propranolol

83.

Which of the following tests is used at home to assess therapy and determine if a patient with asthma should seek emergency care? a. Forced expiratory volume in one second (FEV1)

c. Epinephrine

82.

In the emergency department, the preferred firstline therapy for asthma exacerbation is

b. Cromolyn

a. Aminophyline

81.

Acute exacerbations of asthma can be triggered by all of the following except

b. Hypertsensitivity reaction to penicillin

a. Aminophyline

80.

The symptoms of allergenmediated asthma result from which of the following?

a. Aminophyline

a. Bacterial of viral pneumonia

79.

85.

Bacteria that make either a fementative or respiratory set of enzymes are known as a. Obligate anacerobes b. Obligate aerobes

91.

Which of the following may precipitate an asthma attack? a. Respiratory acidosis b. Viran and bacterial infections c. Respiratory alkalosis d. Cranberry jiuce e. Chocolate or Coca Cola


92.

Terbutaline has a preference for stimulation of which of the following receptors? a. Alpha b. Gamma c. Beta 1 d. Beta 2 e. Dopaminergic

93.

102. The antihistaminc which has calcium channel blocking and labyrinthine suppressant property is

c. Clemastine

d. Severe persistent

d. Cetirizine

e. Hypertension The most likely complication of prolonged use of nasal decongestant drops is a. Atrophic rhinitis b. Hypertrophy of nasal mucosa c. Nasopharyngeal moniliasis d. Blockage of Eustachian tubes Which of the following is a selective H1 receptor agoinist ? a. 4methyl histamine b. Impromidine c. 2Thiazolyl ethylamine d. Mepyramine Fall in blood pressure caused by larger doses of histamine is blocked by a. H1 antihistaminics alone b. H2 ANTAgonists alone c. Combination of H1 and H2 antagonists d. None of the above Histamine is involved as a mediator in the following pathological conditon a. Cocaine b. Dibucaine c. Lidocaine d. Procaine 99.

d. All of the above

b. Cinnarizine

d. Premature labor

98.

c. Strenuous physical exertion

c. Moderate persistent

c. Nasal congestion

97.

b. Consuming processed cheese

a. Cyproheptadine

b. Severe hypotension

96.

a. Driving motor vehicles

b. Mild persistent

a. Asthma

95.

101. While prescribing the conventional H1 antihistaminics the patient should be advised to avoid

a. Mild intermittent

Isoxuprine is used to treat

In the emergency department, the preferred firstline therapy for asthma exacerbation is a. Theophylline b. A Ă&#x;agonist c. A corticosteroid d. Cromolyn sodium e. An antihistamine

100. The capacity of an antihistaminic to produce sedation depends on the following except a. Relative affinity for central versus peripheral H1 receptors b. Ability to penetrate bloodbrain barrier

1273

d. Ratio of H1 : H2 blockade produced by the drug

103. Erythromycin should not be given to patient being treated with terfenadine because a. Erythromycin induces the metabolism of terfenadine b. Dangerous ventricular arrhythmias can occur c. Terfenadine inhibits metabolism of erythromycin d. Terfenadine antagonizes erythromycin

the

antimicrobal

action

of

104. Select the H1 antihistaminic which is used topically in the nose for allergic rhinitis a. Deep intraabdominal operation b. Trachial intubation c. Tetanus d. Diagonosis of myasthenia gravis 105. H1 antihistaminics are beneficial in a. All types of allergic disorders b. Certain type I allergic reactions only c. Anaphylactic shock d. Bronchial asthma 106. The action of 5Hydroxy tryptamine mediated by the 5HT3 receptor is a. Vasoconstriction b. Bradycardia c. EDRF release d. Platelet aggregation 107. Tachyphylaxis to many actions on repeated injection is a feature of the following autocoid a. Histamine b. 5Hydroxytryptamine c. Bradykinin d. Angiotensin 108. The smooth muscle stimulating action of 5HT is most marked in the a. Bronchi b. Intestines c. Ureter d. Billary tract 109. The 5HT antagonist that has antihypertensive property is a. Methysergide b. Cyproheptadine c. Ketanserin d. Ondansetron

PULMONARY MEDICINE

94.

The National Institutes of Health (NIH) guidelines for the treatment of asthma recommended institution of routine inhaled corticosteroids when patients are classified as having greater than or equal to which type of asthma?

c. Individual susceptibility


1274 110. The most important receptor involved in cytotoxic drug induced vomiting is

a. Histamine H1 receptor

a. Inhibits antigenantibody reaction in the lungs

b. Serotonin 5HT3 receptor

b. Causes bronchodilatation

c. Dopamine D2 receptor

c. Reduces bronchial hyperreactivity

d. Opioid μ receptor

d. Both (b) and (c)

111. Which of the following expectorants acts both directly on the airway mucosa as well as reflexly ? a. Potassium iodide b. Guaiphenesin c. Terpin hydrate d. Bromhexine

MCQ's

119. In a patient of bronchial asthma, inhaled salbutamol produces the following effect(s).

112. Bromhexine acts by

120. Select the correct statement about salmeterol. a. It is a long acting selective ß2 agonist bronchodilator b. It is a bronchodilator with anti-inflammatory property c. It is a ß blocker that can be safely given to asthmatics d. It is an antihistaminic with mast cells stabilizing property 121. Caffeine is more powerful than theophylline in exerting the following action

a. Inhibiting cough center

a. Bronchodilatation

b. Irritating gastric mucosa and reflexly increasing bronchial secretion

b. Cardiac stimulation

c. Depolymerizing mucopolysaccharides present

d. Augmentation of skeletal muscle contractility

d. Desensitizing stretch receptors in the lungs 113. The primary goals of asthma therapy include all of the following except a. maintain normal activity levels b. maintain control of symptoms c. avoid adverse effects of asthma medications d. prevent acute exacerbations and chronic symptoms e. prevent destruction of lung tissue 114. Antitussives act by

c. Diuresis 122. Methylxanthines exert the following action (s) at cellular/ molecular level a. Intracellular release of Ca2+ b. Antagonism of adenosine c. Inhibition of phosphodiesterase d. All of the above 123. Relatively higher dose of theophylline is required to attain therapeutics plasma concentration in a. Smokers

a. Liquifying bronchial secretions

b. Congestive heart failure patients

b. Raising the threshold of cough centre

c. Those receiving erythromycin

c. Reducing cough inducing impulses from the lungs

d. Those receiving cimetidine

d. Both (b) and (c) 115. Which of the following antitussive is present in opium but has no analgesic or addicting properties ?

124. The antiasthma drug which cannot be administered by inhalation is a. Theophylline

a. Noscapine

b. Ipratropium bromide

b. Codeine

c. Budesonide

c. Pholcodeine

d. Terbutaline

d. Ethylmorphine 116. Bronchodilators are useful in cough a. Only when cough is nonproductive b. Only when cough is associated with thick sticky secretions c. Only when reflex bronchoconstriction is associated d. Irrespective of nature of cough or associated features 117. The common and dose related side effect of salbutamol is a. Rise in blood pressure b. Muscle tremor

125. A 10 year old child suffers from exercise induced asthma: Which is the most suitable first line drug for regular prophylactic therapy ? a. Oral salbutamol b. Oral theophylline c. Inhaled sodium cromoglycate d. Inhaled beclomethasone dipropionate 126. Which of the following drugs is neither bronchodilator nor antiinflammatory, but has antihistaminic and mast cell stabilizing activity ?

c. Hyperglycaemia

a. Sodium cromoglycate

d. Central nervous system stimulation

b. Ketotifen

118. Which of the following tests is used at home to assess therapy and determine if a patient with asthma should seek emergency care? a. Forced expiratory volume in one second (FEV1) b. Forced vital capacity (FVC) c. Total lung capacity (TLC) d. Peak expiratory flow rate (PEFR) e. Residual volume (RV)

c. Beclomethasone dipropionate d. Mepyramine maleate 127. The most consistent, pronounced and sustained relief of symptoms in chronic bronchial asthma is afforded by a. ß2 sympathomimetics b. Anticholinergics c. Sodium cromoglycate d. Corticosteroids


128. Intransasal spray of budesonide is indicated in a. Common cold b. Acute vasomotor rhinitis c. Perennial vasomotor rhinitis d. Epistaxis 129. In patients of bronchial asthma inhaled corticosteroids achieve the following except a. Reduce the need for bronchodilator medication b. Control an attack of refractory asthma d. Reverse diminished responsiveness to sympathomimetic bronchodilators 130. Budesonide is a a. Nonsteroidal anti-inflammatory drug

137. Which xanthine derivative has no function in asthma ? a. Theophylline b. Pentoxyphyllin c. Enprofylin d. None of the above 138. What is symport ? a. Counter transport b. Contransport c. Carrier mediated diffusion d. Solvent drug 139. Pyridostigmine differs from neostigmine in that

b. High ceiling diuretic

a. More potent orally

c. Inhaled corticosteroid for asthma

b. Longer acting

d. Contraceptive

c. Less muscarinic side effects

131. In an asthma patient treated with systemic corticosteroids, bronchodilator drugs a. Are not needed

d. All of the above 140. The following are recognized features of Pancoast’s tumour except:

b. Are contraindicated

a. ipsilateral Horner’s syndrome

c. May be used on ‘as and when required’ basis

b. wasting of the dorsal interossei

d. Are ineffective

c. pain in the arm radiating to the fourth and fifth fingers

132. To be a useful inhaled glucocorticoid the drug should have a. High oral bioavailability b. Low oral bioavailability c. Additional bronchodilator activity d. Prodrug character 133. Histamine a. May be released from mast cells by a number of therapeutic agents b. Causes sedation c. Decreases the force of contraction of ventricular muscle d. Can cause strong contractions of the gravid human uterus 134. Chronic Bronchitis is characterized by I. the distruction of central and peripheral portions of the acinus II. an increased number of mucous glands and goblet cells

1275

d. Triamcinolone

PULMONARY MEDICINE

c. Reduce bronchial hyperreactivity

c. Dexamethasone

III. edema and inflammation of the bronchioles a. only I is correct b. only III is correct c. I and II are correct d. II and III are correct e. I, II and III are correct

135. Smooth muscle relaxation is due to stimulation of which type of histamine receptors a. H1 b. H2 c. H3 d. All of the above 136. All the following are employed in inhalation therapy of asthma except a. Beclomethasone b. Budesonide

d. erosion of the first rib e. weakness of abduction at the shoulder 141. Which of the following is true concerning Whooping cough (pertussis)? a. is a greater threat to children during the second 6 months of life, after maternal antibody has declined, than during the first 6 months b. may lead to hemiplegia c. is characteristically leucocytosis

associated

with

a

polymorph

d. is associated with convulsions less frequently than is the case with other febrile conditions e. rapidly resolves with antibiotic treatment 142. A 19yearold female developed pleural effusions, ascites and ankle swelling. Her blood pressure was 112/76 mmHg. Investigations revealed: serum alanine transferase 17 U/L (5 15), serum total bilirubin 17 umol/L (1 22), serum albumin 21 g/L (34 94), serum total cholesterol 9.8 mmol/L (<5.2), What is the next most appropriate investigation? a. Antinuclear antibody b. Pregnancy test c. Prothrombin time d. Serum protein electrophoresis e. Urinary protein estimation 143. A 51 year old businessman complains of dyspnoea on exertion. He recently returned from a business trip to the USA. He has distant heart sounds on auscultation of the chest. A chest radiograph reveals that there is a thin rim of calcification surrounding the cardiac outline. Which of the following conditions is most likely responsible for these findings? a. Uraemia b. Tuberculosis c. Group B coxsackie virus d. Sarcoidosis e. Metastatic carcinoma


1276 144. A 48yearold woman presented with shortness of breath, cough with heavy sputum production, and a low grade fever. She has smoked 20 cigarettes per day for 30 years. Her arterial blood gases revealed pH of 7.4, PaCO2 of 45 and a PaO2 of 78. What is the most likely diagnosis? a. Bronchial asthma b. Chronic bronchitis c. Cryptogenic fibrosing alveolitis d. Paraneoplastic syndrome

MCQ's

e. Pulmonary embolism 145. A 49yearold man with a long history of alcoholism presents with cough, haemoptysis and pleuritic chest pain. He has had night sweats and 10 kg weight loss in the last three months. On chest Xray tgere is a subtle nodular pattern throughout the lung. He underwent a transbronchial biopsy which showed multinucleated giant cells, epithelioid cells and necrotic debris. Which of the following is the most likely diagnosis? a. Aspergillosis b. Pneumocystis carinii pneumonia c. Small cell carcinoma d. Squamous cell carcinoma e. Tuberculosis 146. A55 year old man who has a 25 year pack history of smoking presents with productive cough with mucoid sputum of 2 year duration. On examination he has scattered ronchi and wheezing. The likeliest diagnosis is : a. Bronchial Asthma b. Bronchiectasis c. Chronic Bronchitis

b. High resolution CT scan of chest c. Measurement of diffusion capacity d. Serum angiotensinconverting enzyme (ACE) level e. Transbronchial lung biopsy 150. A 20yearold male student is assessed for shortness of breath that occurs whilst running. He has no other symptoms and does not smoke. Examination, full blood count, and chest Xray are normal. Which of the following is most likely to be helpful in confirming the suspected diagnosis? a. Arterial blood gas studies before and after exercise b. Determination of lung volumes and diffusing capacity c. Measurement of venous blood lactate before and after exercise d. Spirometry before bronchodilators

and

after

administration

e. Spirometry before and after exercise 151. A 40yearold worker presents with wheezing and breathlessness which seem to improve over weekends and holiday periods when he is not working. What is he most likely to be exposed to at work? a. Platinum salts b. Avian bloom c. Aspergillus clavatus d. Work in the Silver industry e. Exposure to spores of Actinomyces 152. The pulmonary vascular system is different from the systemic circulation in that the pulmonary system demonstrates which of the following?

d. Pneumonitis

a. High pressures, high flow rates, highly compliant vessels

e. Fibrosing Alveolitis

b. High pressures, high flow rates, low compliance vessels

147. A 67 year old who is known to suffer from severe chronic bronchitis is admitted from home with an acute exacerbation. Which of the following is true? a. An Acidosis with a low bicarbonate would be expected b. Extensor plantar responses feature c. Gentamicin would be a reasonable initial treatment until cultures are available d. Oxygen therapy should aim to increase the pO2 to above 8kPa (60mmHg) e. Peripheral oedema indicates coexisting heart failure 148. A 65yearold woman, has smoked 50 cigarettes a day for 40 years. She has had increasing dyspnoea for the several years, but no cough. A Chest Xray shows increased lung size along with flattening of the diaphragms, consistent with emphysema. Over the next several years she develops worsening peripheral oedema. Her vital signs show T° 36.7 C, P 80, RR 15, and BP 120/80 mm Hg. Which of the following cardiac findings is most likely to be present?

c. Low pressures, high flow rates, high compliance vessels d. Low pressures, low flow rates, high compliance vessels e. Low pressures, low flow rates, low compliance vessels 153. A 60 year old man with ankylosing spondylitis presents with cough, weight loss and tiredness. His CXR shows longstanding upper lobe fibrosis. Three sputum tests stain positive for Acid fast bacilli but are consistently negative for Mycobacterium tuberculosis on culture. Which of the following is the most likely cause? a. Mycobacterium avium intracellulare complex b. Micropolyspora faeni c. Allergic Bronchopulmonary Aspergillosis d. Sarcoidosis e. Tuberculosis 154. Which of the following is a recognised cause of a phrenic nerve palsy? a. Aortic aneurysm

a. Mitral valve stenosis

b. Dermoid

b. Constrictive pericarditis

c. Ganglioneuroma

c. Right ventricular hypertrophy

d. Pericardial cyst

d. Left ventricular aneurysmm

e. Sarcoidosis

e. Nonbacterial thrombotic endocarditis 149. A 55yearold plumber presented with a dry nocturnal cough and increasing exertional breathlessness. On examination he had early finger clubbing, cyanosis and bilateral basal crackles. A chest Xray showed bilateral lower zone shadowing. Investigations revealed: PaO2 (breathing air) 8.2 kPa (11.312.6), FEV1/FVC ratio 85%, Which of the following investigations is most likely to establish the diagnosis? a. Echocardiography.

of

155. Which of the following statements is true of the pulmonary function testâ&#x20AC;&#x2122;s vital capacity (VC)? a. Vital capacity cannot be measured from spirometry alone b. Vital capacity is increased in emphysema and reduced in interstitial fibrosis c. Vital capacity is the maximal amount of air which can be exhaled after maximal inspiration d. Vital capacity is the sum of tidal volume (VT) and inspiratory capacity (IC)


e. Vital capacity, when reduced, is a specific indication of restrictive lung disease 156. A 24 year old asthmatic female is admitted with acute severe asthma. Which of the following statements regarding the diagnosis is correct?

162. A 26yearold man with a history of alcohol and drug abuse was 1277 admitted with a 14 day history of fever, cough and fatigue. He was emaciated. His temperature was 39.4°C. Cervical and axillary lymphadenopathy were present. Chest Xray revealed bilateral areas of pulmonary shadowing. Which of the following is the most likely diagnosis?

a. Agitation should be managed with a benzodiazepine

a. alcoholic cardiomyopathy

b. A high inspired Oxygen concentration should be used routinely

b. pneumococcal pneumonia

c. Inhaled salmeterol is indicated as first line therapy

d. pulmonary tuberculosis

d. Normal arterial pCO2 is reassuring 157. Recognised associations. Which of the following is correct? a. pneumoconiosis and clubbing b. lung carcinoids and pleural effusion c. pulmonary embolus and left bundle branch block d. pulmonary fibrosis and hypercapnia e. bronchopulmonary aspergillosis and wheezing 158. Randomised controlled trials have shown that longterm oxygen therapy (LTOT) reduces mortality in: a. cryptogenic fibrosing alveolitis b. cor pulmonale due to chronic airflow obstruction c. asthma d. cystic fibrosis e. pulmonary sarcoidosis 159. A 65yearold woman, a heavy smoker for many years, has had worsening dyspnoea for the past 5 years, without a significant cough. A chest Xray shows increased lung size along with flattening of the diaphragms, consistent with emphysema. Over the next several years she develops worsening peripheral oedema. BP 115/70 mmHg. Which of the following cardiac findings is most likely to be present? a. Constrictive pericarditis

e. tricuspid endocarditis 163. A 75yearold man with squamous cell carcinoma is thought to have resectable disease. Which of the following would be a contraindication to surgery? a. clubbing b. FEV1 of 0.75 L c. his age of 75 years d. pleural effusion e. Syndrome of Inappropriate ADH 164. A 65yearold female presents with a 3 week history of malaise and blood in her sputum. Bronchoscopy reveals a mass in the right main bronchus, and histology demonstrates it to be a small cell carcinoma. Further investigation fails to show any metastases. What is the most appropriate step in management? a. Chemotherapy b. Endobronchial laser therapy c. Radiotherapy d. Surgery e. Palliative therapy 165. A 41 year old man with a history of nasal congestion, breathlessness, cough and wheeze presents with a left foot drop. Which of the following is the most likely diagnosis?

b. Left ventricular aneurysm

a. Diabetes mellitus

c. Mitral valve stenosis

b. Wegeners Granulomatosis

d. Nonbacterial thrombotic endocarditis

c. Churg Staus Syndrome

e. Right ventricular hypertrophy

d. Pulmonary eosinophilia

160. A 45yearold solicitor had an onset of severe, crushing, substernal chest pain while attending a football match. He collapsed on his way to the car. Bystander Cardiorespiratory Resuscitation was begun immediately and continued until arrival in Casualty where an endotracheal tube was inserted and ventilation was maintained on 100% oxygen. Investigations revealed: pH 7.13, PaO2 560 mmHg, PaCO2 18 mmHg, Bicarbonate 5.8, SaO2 98%, Based on these laboratory values, which of the following statements best describes his current pathophysiology? a. He is demonstrating a primary respiratory alkalosis b. He probably developed a large right to left intracardiac shunt c. His anion gap is probably normal d. His oxyhemoglobin curve is shifted to the left e. His pulmonary artery pressure is probably elevated 161. Obstructive sleep apnoea characteristically associated with:

e. Polyarteritsis Nodosa 166. In asbestos related disorders which of the following statements is correct? a. basal fibrotic shadowing on CXR suggests coincidental idiopathic fibrosing alveolitis b. increased incidence of primary lung cancer c. pleural effusion develops more than 20 years after causative asbestos exposure d. pleural plaques are recognized precursors of mesothelioma e. the risk of malignant mesothelioma is greatly increased in smokers compared with nonsmokers 167. A 60 year old man was admitted with communityacquired pneumonia and deteriorated over the next few hours. Which one of the following indicates a poor prognosis? a. A total white cell count of 17 x 109/L (411) b. Blood pressure of 110/70 mm Hg

a. hypersomnolence

c. Respiratory rate of 35 breaths/min

b. impotence

d. Rigors

c. macrognathia

e. Temperature of 39oC

d. insomnia e. polydipsia

168. Which of the following statements concerning industrial lung disorders is correct? a. pneumoconiosis can be diagnosed in the absence of chest Xray abnormalities

PULMONARY MEDICINE

e. Pulsus paradoxus is a reliable sign of severity

c. pneumocystis pneumonia


b. occupational asthma occurs more frequently in atopic persons

1278

c. silo fillers disease is caused by allergy to grain d. widespread crepitations are typically heard in extrinsic allergic alveolitis e. symptoms occur within minutes if exposure to mouldy hay in Farmerâ&#x20AC;&#x2122;s lung 169. A young child presents with respiratory distress, worsening over 2 days. Blood gases show a pH of 7.25, a PCO2 of 7.5kPa, a PO2 of 8.5kPa, and a base excess of 4. Which of the following interpretations is correct? a. Results are consistent with bronchopulmonary dysplasia.

MCQ's

b. Blood gases suggest type 1 respiratory failure.

a. Argyria b. Cyanotic congenital heart disease c. Haemochromatosis d. Methaemoglobinaemia e. Methylene blue poisoning 176. Which of the following is true of BCG vaccination?

c. Immediate intubation is required.

a. is contraindicated in neonates

d. Results are consistent with late severe asthma.

b. is a killed polysaccharide antigen vaccine

e. Bicarbonate may be necessary to correct the acidosis.

c. should be given to all children who have a strongly positive tuberculin test

170. A 19 year old female presents with acute breathlessness. She has had asthma for approximately 3 years and recently commenced new therapy. Which agent may be responsible for this exacerbation? a. Salmeterol b. Theophylline c. Beclomethasone d. Ipratropium bromide e. Monteleukast 171. A 22 year old lady recently returned from a holiday in Malta was admitted with a 3 day history of fever, generalised lymphadenopathy and a macular rash over the trunk and legs. Which of the following is the most likely diagnosis? a. Sarcoidosis b. Tuberulosis c. Familial Mediterranean Fever d. Infectious Mononucleosis e. Actinomycosis 172. Which of the following is a recognised treatment for complications of cystic fibrosis? a. DNAase to assist in reinflating collapsed lung segments. b. Rectal pullthrough and anastamosis for rectal prolapse. c. Pancreatic transplant for diabetes mellitus.

173.

175. A 24 year old male presents after developing a bluish discolouration of the body, lips and nails. He denies any relevant past medical history. Examination reveals a central cyanosis and a grey complexion. Investigation revealed: Haemoglobin 17.0 g/dL (13.018.0), PaO2 13.0 kPa (11.312.6)m SaO2 (using an oximeter) 85% (>95), What is the most likely diagnosis?

d. is presently routinely offered in the UK at age 16 years e. Provides protection against leprosy 177. Carcinoid tumors of the lung (bronchial adenomas) originate from which of the following cell types? a. Ciliated cell b. Clara cell c. Kulchitsky (K) cell d. Mucus (goblet) cell e. Type 2 Alveolar cell 178. A 55 year old woman on treatment for longstanding rheumatoid arthritis has recently become dyspnoeic on mild exertion and developed a dry cough. The oxygen saturation was found to be 87% on air. The chest xray showed a diffuse bilateral interstitial infiltrate. An extensive infection screen was negative and her symptoms were felt to be druginduced. Which drug is most likely to have caused this adverse effect? a. azathioprine b. cyclosporin c. hydroxychloroquine d. methotrexate e. sulphasalazine 179. The following is true about Cystic Fibrosis:

d. Nebulised tobramycin for pseudomonas colonisation of the lower respiratory tract.

a. Is an autosomal dominant condition.

e. Hypotonic saline drinks for hypernatraemic dehydration.

c. Skin test may be positive for aspergillus

Which of the following is a typical feature of Farmerâ&#x20AC;&#x2122;s lung? a. basal crackles b. Eosinophilia c. Haemoptysis d. Increased pCO2 e. Positive serum paraproteins

174. A 28 year old man who had had tuberculosis of the mediastinal lymph nodes diagnosed two weeks previously and who had been started on chemotherapy with rifampicin, isoniazid and pyrazinamide was admitted because of the increasing dyspnoea and stridor. Chest Xray showed compression of both main bronchi by carinal lymph node enlargement. What is the next step in management? a. Start prednisolone b. Mediastinoscopy and biopsy c. Refer for stent insertion/tracheostomy d. Refer for urgent CT scan of the mediastinum e. The addition of ethambutol

b. Is due to mutation of CFTR gene on chromosome 17 d. Median survival rate is 10 to 15 years. e. Is a cause of mental retardation. 180. A 67yearold man presents with a long history of cough,breathlessness on minimal exertion and ankle swelling. He smokes 3040 cigarettes per day. Investigations are as follows: Haemoglobin 19g/dl, white blood count 7.3, PaO2 (air) 6.2kPa, PaCO2 (air) 8.9kPa, serum [H+] 44 nmol/l, serum [HCO3] 36 mmol/l, What is the most likely explanation of these results? a. acute respiratory acidosis b. chronic respiratory acidosis c. chronic respiratory alkalosis d. metabolic acidosis e. metabolic alkalosis 181. Which of the following statement is true of infections with Mycobacterium tuberculosis: a. nonsputum producing patients are noninfectious b. a positive tuberculin test indicates active disease


c. lymph node positive disease requires longer treatment than pulmonary disease

a. aspirin therapy

d. in pregnant women treatment should not be given until after delivery

c. inferior vena cava filter

e. pyrazinamide has high activity against active extracellular organisms 182. In restrictive lung disease due to respiratory muscle weakness, which of the following statements is true? a. Low FEV1/FVC, high RV/TLC b. Low FEV1/FVC, normal TLC d. Low VC, low RV, low TLC e. Low VC, low TLC, high RV/TLC 183. Which of the following would be the least likely finding in a patient with sarcoidosis? a. Hepatic granulomas b. Restrictive pulmonary function tests c. Skin lesions d. Uveitis e. X bodies on bronchoalveolar lavage (BAL) fluid 184. A 72yearold lifelong smoker presents with progressive dyspnoea on exertion. He has a chronic, nonproductive cough. On examination he is thin, breathing with pursed lips, respiratory rate 25/min, with mild wheezing on chest auscultation. Investigations show FEV1 0.8 L, FVC 1.6 L, pH 7.35, paCO2 45 mmHg, paO2 55 mmHg. What is the predominant mechanism of the airflow limitation in this gentleman? a. Bronchospasm b. Foreign body obstruction c. Increased airways resistance d. Loss of elastic recoil e. Mucus plugging in the small airways 185. Which of the following statements regarding cryptogenic fibrosing alveolitis is correct? a. Active inflammation may be suggested by a CT scan b. peak flow rate is a good guide to severity c. 80 per cent of patients iniiration d. Reduced cardiac output e. Reduced airway resistance 186. A 54year old woman was admitted with acute breathlessness. On examination she had a temperature of 37.9oC, a respiratory rate of 32 breaths per minute, a pulse of 120 beats per minute, a blood pressure of 100/60 mmHg, and a peak expiratory flow rate of 250 litres per minute. Auscultation of the heart and chest was normal. The Chest Xray was normal and blood gases on air showed: pH 7.35 (7.36 7.44), Pa02 6.0, kPa (11.3 12.6), PaC02 3.9, kPa (4.7 6.0), Serum bicarbonate 20 mmol/l (20 28). She was started on high flow oxygen. What is the most important next treatment? a. amoxycillin intravenously b. aminophylline intravenously c. intravenous fluids d. low molecular weight heparin e. nebulised salbutamol 187. A 76yearold with a recent history of cerebral haemorrhage is admitted with a cough, worsening breathlessness and right pleuritic chest pain. He is also mildly pyrexial. His ventilationperfusion scan reveals several areas of ventilation/ perfusion mismatches. What is the most appropriate line of management?

d. low molecular weight heparin treatment e. warfarin treatment 188. Which of the following is a recognised feature of massive pulmonary embolism? a. reduced plasma lactate levels b. an increase in serum troponin levels c. an arterial pH less than 7.2 d. blood gases show increased pCO2 on air e. normal Ddimer levels 189. Which of the following statements is true of the diffusion capacity of carbon monoxide? a. Is a specific measure of lung perfusion. b. Depends on the thickness of the alveolar wall. c. Depends on the surface area available for gas exchange. d. Is increased in cigarette smokers. e. Is increased in emphysema. 190. A 19 year old woman became breathless while travelling on an aeroplane. Which one of the following features most strongly supports a diagnosis of acute hyperventilation related to a panic disorder? a. Carpal spasm. b. Finger paraesthesiae. c. Hypotension. d. Lightheadedness. e. Loss of conciousness 191. A 64 year old man is found to have squamous cell bronchogenic carcinoma. Which of the following statements is true regarding surgical resection? a. An FEV1 of 2 L is a major contraindication to surgical resection. b. Hypercalcaemia makes further assessment for surgery unnecessary. c. Is precluded if a CT scan of the thorax shows enlarged mediastinal lymph nodes. d. Positive sputum cytology excludes the bronchoscopic examination of the airways.

need

for

e. The presence of finger clubbing indicates that liver metastases are already present. 192. A 60yearold man with breathlessness, fever and headache is suspected of having Farmers Lung. A CXR shows diffuse nodular shadowing predominantly in the mid and lower zones. What would be the most useful diagnostic test? a. Blood Culture b. Sputum Culture c. Serum precipitating antibodies to Micropolyspora faeni d. Serum Precipitating antibodies to Aspergillus clavatus e. Serum Precipitating antibodies to Cryptostroma corticale 193. A 43 year old asthmatic develops worsening breathlessness and his full blood count has revealed an eosinophilia. Which of the following statements is true with allergic bronchopulmonary aspergillosis that the patient is likely to suffer from? a. The immediate skin test to an extract of aspergillus fumigatus is negative b. Circulating IgG precipitins to aspergillus fumigatus are positive c. The CO transfer factor is unaffected

PULMONARY MEDICINE

c. Low VC, low FEV1, normal TLC, low RV/TLC

1279

b. antibiotics


1280

d. Recurrent haemoptysis is a characteristic feature

b. A haemorrhagic and necrotizing pneumonia

e. Pleural effusion is a complication

c. An acute respiratory distress syndrome (ARDS) with widespread hyaline membrane formation

194. A 35yearold man presents after 3 months of chronic cough with purulent sputum and shortness of breath on exertion. He gives a history of at least two sinus or bronchial infections per year requiring treatment with antibiotics. He also says he and his wife have been unable to have children. He smokes 15 cigarettes per day. Examination is normal except for some wheezing and an area of focal crackles at the left lung base. Chest Xray shows patchy infiltrates at both bases. Investigations revealed FEV1 2.0 L, FVC 2.7 L, pH 7.38, PaCO2 40 mmHg, PaO2 82 mmHg, What is the most likely diagnosis? a. alpha1Antitrypsin (Antiprotease) deficiency

MCQ's

b. Asthma c. Cystic fibrosis d. Hypogammaglobulinemia e. Immotile cilia syndrome 195. An 18 year old attending the A+E department is noted to have central cyanosis. She is perfectly well but was told to go to A+E by her friends who said she looked blue. What is the most likely cause?

d. An interstitial pneumonitis with foamy intraalveolar exudate e. An organizing bronchopneumonia 200. Which of the following statements is NOT true of primary pulmonary tuberculosis: a. It is characteristically asymptomatic b. Miliary spread is commoner in a younger age group c. The initial immunological lympadenopathy

response

causes

d. pleural effusion occurs before tuberculin skin testing is positive e. A positive tuberculin skin test develops within two weeks of infection 201. In which of the following have randomised controlled trials shown that longterm oxygen therapy (LTOT) reduces mortality? a. Asthma

a. Carbon Monoxide Poisoning

b. Cor pulmonale due to chronic airflow obstruction

b. Lead Poisoning

c. Cryptogenic fibrosing alveolitis

c. Drinking water contaminated with nitrates

d. Cystic fibrosis

d. Anorexia Nervosa

e. Pulmonary sarcoidosis

e. Severe Anaemia 196. A 59 year old female smoker is diagnosed with oat cell carcinoma of the bronchus. Which of the following relating to this diagnosis is true?

hilar

202. Which ONE of the following is true regarding acute pulmonary embolism? a. a normal ECG excludes the diagnosis

a. The tumour is likely to be radiosensitive

b. embolectomy is more effective than thrombolysis in improving survival

b. occurs with equal frequency in smokers and nonsmokers

c. Heparin is as effective as thrombolytic therapy

c. has a 5 year survival greater than 20%

d. the presence of hypoxaemia is an indication for thrombolysis

d. Is associated with the elaboration of ectopic ADH secretion

e. thrombolysis administered through a peripheral vein is as effective as through a pulmonary artery catheter

e. Is typically associated with ectopic parathormone secretion. 197. Which of the following conditions may give a false/positive sweat test? a. Congenital adrenal hyperplasia b. Hyperthyroidism c. Hyperparathyroidism d. Obesity e. Glucose6phosphatase deficiency 198. A 60yearold man was diagnosed last year with adenocarcinoma of the lung, and a 4 cm mass lesion was treated with a right lower lobectomy. He now has an abdominal CT scan that reveals scattered hepatic mass lesions and hilar lymphadenopathy. For several weeks, he has had increasing malaise. A urinalysis reveals marked proteinuria, and a 24 hour urine protein collection is 2.7 g/24hr. His serum urea is 30 mmol/L (2.5 7.5) with creatinine of 450 Îźmol/L (60 110). A renal biopsy is performed, and there is focal deposition of IgG and C3 with a granular pattern. He is most likely to have which of the following conditions? a. Goodpastureâ&#x20AC;&#x2122;s syndrome b. Membranous glomerulonephritis c. Minimal change glomerulonephritis d. Nodular glomerulosclerosis e. Rapidly progressive glomerulonephritis 199. The morphological appearance of Pneumocystis carinii infection in the lung is best characterised as which one of the following? a. A bronchopneumonia with abscess formation

203. A 36 year old man complains of a persistent cough. A CXR shows fibrosis of both upper lobes. What is the most likely diagnosis? a. Systemic Sclerosis b. Primary Pulmonary Hypertension c. Cystic Fibrosis d. Ankylosing Spondylitis e. Allergic bronchopulmonary aspergillosis 204. Which one of the following statements is true of chronic obstructive pulmonary disease? a. patients show at least a 15 per cent improvement in the FEV1 after nebulised bronchodilator b. inhaled corticosteroid usage does not improve longterm prognosis c. breathlessness is uncommon until the FEV1 falls to approximately 50 per cent of predicted d. emphysema is associated with increased transfer factor e. in advanced cases there is reduced pulmonary vascular resistance 205. A 16 year old boy with cystic fibrosis presents with abdominal pain. Which of the following is most likely to be the cause? a. Ulcerative colitis b. Irritable Bowel Syndrome c. Pyelonephritis d. Meconium Ileus Equivalent Syndrome e. Renal Calculi


206. A patients’ arterial blood gases give the following results; pO2 10 kPa (75mmHg), pCO2 7 kPa (52 mmHg), pH 7.47, [HCO3] 37. Which of the following is the most likely cause? a. Chronic Hyperventilation Syndrome b. Acute exacerbation of COPD c. Several days of Pyloric obstruction d. Pulmonary Embolism e. Diabetic Coma

a. Pulmonary Eosinophilia

213. A lifelong nonsmoker is diagnosed with emphysema. Which of the following would be the most likely aetiological agent ? a. Isocyanates b. Cadmium Exposure c. Steel d. Zinc e. Asbestos 214. Which cell type is responsible for the early asthmatic response?

b. Asthma [0]

a. Basophil

c. Pulmonary nodules

b. Eosinophil

d. Fibrosing Alveolitis

c. Mast cell

e. Pulmonary Embolus

d. Neutrophil

208. In the normal adolescent lung which of the following is correct? a. There is an intrapleural pressure of 30 cmH2O (3kPa) at the end of normal expiration. b. There is a resting pulmonary blood flow of 10L/min. c. The V:Q ratio is greater in apical than basal segments of the lung when upright and at rest. d. The majority of airway resistance is from large airways. e. Cartilage is present in all respiratory bronchioles. 209. Sleep Apnoea syndrome is best diagnosed by the following: a. Polygraphic Sleep Studies b. therapeutic trial of amphetamines c. EEG d. Blood gases during apneic episodes e. Presence of HLADR2 and DQw1 210. A 70yearold man presented with weight loss and haemoptysis. He was a heavy smoker. A chest radiograph showed a mass lesion in the left lung bronchoscopic biopsies confirmed a squamous carcinoma. a. Chest wall invasion by primary tumour b. An enlarged mediastinal lymph node on CT scanning c. Forced expiratory volume (FEV1) of 1.2 litres d. Hypercalcaemia e. Malignant pleural effusion 211. Which of the following statements regarding prognosis in lung cancer is true?

e. TH1lymphocyte 215. A 43yearold Caribbean female Comprehensive school teacher complains of slowly increasing breathlessness. She has no smoking history. Investigations reveal she has bilateral enlarged hilar lymph nodes, elevated serum calcium, interstitial lung disease, and enlarged liver and spleen. What is the most likely diagnosis? a. Coccidioidomycosis [0] b. Hyperparathyroidism [0] c. Hypervitaminosis D [0] d. Sarcoidosis [100] e. Tuberculosis [0] 216. A 58yearold man presents with weight loss and haemoptysis. He has smoked most of his life. On examination he is clubbed and has clinical evidence of right pleural effusion. His serum calcium is 3.2mM. Which of the following histological type of lung cancer is he most likely to suffer from? a. mesothelioma b. small cell carcinoma c. large cell carcinoma d. squamous cell carcinoma e. adenocarcinoma 217. A 68yearold man presents with a onemonth history of dyspnoea and a 3kg weight loss. On examination there were signs of a large left pleural effusion, confirmed on Chest Xray. Investigations revealed: Pleural fluid analysis: Protein 38 g/L, Cytology a few lymphocytes and red blood cells. Which one of the following investigations should be considered next?

a. Combined modality therapy (chemotherapy, radiation therapy and surgery) has improved overall lung cancer survival to 40% at 5 years.

a. Bronchoscopy.

b. Overall lung cancer survival is < 15% at 5 years.

d. Thoracoscopic pleural biopsy.

c. Patients undergoing radiation therapy have a 5 year survival of 40%. d. Patients who qualify for surgery have a 50% 5 year survival. e. With chemotherapy, overall survival in small cell (oat cell) carcinomas has risen to 60% at 5 years. 212. A breathless patient undergoes pulmonary Function testing. The following results are obtained; FEV1 = 74% predicted, FVC = 68% predicted, TLC = 77% predicted, Tlco = 46% predicted, Kco = 53% predicted. Which of the following is the most likely cause ? a. COPD b. Asthma c. Cryptogenic Fibrosing Alveolitis

1281

e. kyphoscoliosis

b. CT scan of thorax. c. Repeat pleural aspiration with biopsy. e. Tuberculin test. 218. A 63yearold woman presents a 5 day history of progressive shortness of breath. Her family brought her in because she was increasingly sleepy during the last 24 hours. She was diagnosed with Chronic Obstructive Pulmonary Disease 3 years ago and has a FEV1 less than 50% of predicted. She has an oxygen concentrator at home. Examination revealed depressed consciousness and a respiratory rate of 24 with shallow breaths. There were decreased breath sounds with minimal air movement. If an arterial blood gas on room air were to be performed, which of the following results would you expect? a. pH 7.16 paCO2 70 paO2 50 HCO3 24 b. pH 7.24 paCO2 80 paO2 55 HCO3 30

PULMONARY MEDICINE

207. A patient with Rheumatoid arthritis complains of progressive breathlessness. Which of the following is the most likely cause?

d. Morbid obesity


1282

c. pH 7.32 paCO2 60 paO2 70 HCO3 30 d. pH 7.41 paCO2 40 paO2 50 HCO3 24 e. pH 7.48 paCO2 30 paO2 85 HCO3 24 219. A 47 year old woman presenting with breathlessness has arterial blood gases taken which give the following results: pO2 8.7 kPa (65mmHg), pCO2 4.4 kPa (33mmHg), pH 7.46, {HCO3]24. Which of the following is the most likely diagnosis. a. Hyperventilation syndrome b. Acute severe asthma c. Emphysema d. Kyphoscoliosis

MCQ's

e. Opiate overdose 220. Which of the following forms of pulmonary embolism is the commonest cause of secondary pulmonary hypertension? a. Air embolism (Caissonâ&#x20AC;&#x2122;s disease) b. Fat embolism c. Massive pulmonary embolism (e.g., saddle embolism) d. Multiple small recurrent pulmonary embolism e. Paradoxical embolism 221. Primary Pulmonary tuberculosis: a. Leads to pleural effusion b. Is highly infective c. Commonly leads to military TB d. May be totally asymptomatic e. Usually produces cavitation 222. An elderly man with a history of asthma, congestive heart failure, and peptic ulcer disease is admitted with bronchospasm and rapid atrial fibrillation. He recieves frequent nebulised salbutamol and IV digoxin loading, his regular medications are continued. 24 hours after admission his serum potassium is noted to be 2.8 mmol/l. Which of his medications is most likely to have caused this abnormality. a. Digoxin b. ACE inhibitor c. Salbutamol d. Ranitidine e. Spironolactone 223. The parents of a child with cystic fibrosis consult you wishing to know what is the risk of their next child being a carrier of the condition. Which ONE of the following percentages is the correct risk? a. 0% b. 25% c. 50% d. 75% e. 100% 224. Most of the cells that fill the alveoli in desquamative interstitial pneumonitis (DIP) are which of the following? a. Eosinophils

d. More than 60mmol/L of chloride in sweat is diagnostic of cystic fibrosis. e. False/positive results may be encountered in children with nephrotic syndrome. 226. A 42 year old woman presents with an acute attack of asthma. She is able to speak in short sentences. Her respiratory rate is 28 breaths per minute and the peak expiratory flow rate 120L/min (predicted 480 L/min. What is the most appropriate treatment for this patient? a. Intravenous aminophylline. b. Intravenous salbutamol c. Nebulized salbutamol d. Oral salbutamol e. Oral theophylline 227. A 15 year old boy presented with wheezing when playing football and nocturnal cough. Which is the best test to confirm the underlying condition? a. A trial of oral corticosteroids b. A trial of inhaled corticosteroids c. A trial of inhaled salbutamol d. Serial peak expiratory flow rate measurements e. Spirometry alone 228. Which of the following is NOT true with regard to the radiological appearance of a chest Xray? a. Consolidation of the right middle lobe will obliterate the right atrial shadow in the PA view b. Consolidation of the right apical lobe will extend to the horizontal fissure in the PA view c. Consolidation of the right anterior segment of the right middle lobe will extend to the right transverse fissure and the right hilum in PA view d. A consolidation of the lingular lobe will obliterate the aortic knuckle and pulmonary trunk in the PA view e. A consolidation of the left lower lobe will elevate the left hemidiaphragm 229. Which of the following statements is true of psittacosis (ornithosis): a. It is only a risk from contact with psittacines (parrots), not other birds b. It usually causes many polymorphs to be present in the sputem c. It is more of a risk to children than to adults who are exposed to birds d. It does spread from person to person e. Infection responds rapidly to penicillin therapy 230. Which of the following statements is true regarding smoking in pregnancy? a. Smoking assists in maturation of the fetal lung. b. The reduction in birth weight is related to the number of cigarettes smoked per day.

b. Lymphocytes

c. Maternal smoking may adversely affect testicular function in male children.

c. Macrophages

d. Dysmorphic facies is a recognised complication.

d. Neutrophils

e. The newborn baby may require adjustments in drug dosages because of it.

e. Plasma cells 225. Which of the following statemtns regarding the sweat test is true? a. Sweating is enhanced by application of atropine. b. The filter paper is left on for a total of about 4 hours. c. At least 25mg of sweat is necessary for a reliable result.


231. A 55 year old man presents with ataxia and bilateral gynaecomastia. Which of the following is the most likely diagnosis? a. Kleinfelters Syndrome

233. Which one of the following is correct regarding longacting 1283 beta2 agonists? a. Can be used to prevent activityinduced symptoms without anti-inflammatory therapy.

b. Long term treatment with cyclophosphamide for Wegenerâ&#x20AC;&#x2122;s Granulomatosis

b. Become less effective over time (tolerance).

c. Long term treatment with oral steroids for chronic asthma

d. Protect against allergen challenge for up to 48 hours.

d. Bronchial Carcinoma e. Hypereosinophilic Syndrome

a. Dexamethasone b. Ibuprofen c. nalidixic acid d. penicillamine e. sulphasalazine

e. Should not be used in association with erythromycin.

PULMONARY MEDICINE

232. A 45 year old female presents with a 6 month history of exertional dyspnoea and is diagnosed with pulmonary fibrosis. Over the last one year she has received a variety of medications. Which of the following drugs could be responsible?

c. Are beneficial in acute viral croup.


MCQ's

1284

Pulmonary Medicine - Answers 1. b

38. d

75. c

112. c

149. b

2. c

39. c

76. b

113. e

150. e

3. d

40. a

77. a

114. d

151. a

4. b

41. c

78. d

115. a

152. d

5. c

42. a

79. a

116. c

153. a

6. a

43. c

80. e

117. b

154. a

7. e

44. b

81. c

118. d

155. c

8. a

45. a

82. a

119. b

156. b

9. b

46. d

83. d

120. a

157. e

10. c

47. b

84. d

121. d

158. b

11. d

48. d

85. a

122. d

159. e

12. e

49. b

86. d

123. a

160. e

13. b

50. b

87.

b

124. a

161. a

14. a

51. d

88.

d

125. c

162. c

15. c

52. a

89.

c

126. b

163. b

16. e

53. a

90.

b

127. d

164. a

17. d

54. b

91.

b

128. c

165. c

18. c

55. a

92.

d

129. b

166. c

19. e

56. c

93.

b

130. c

167. c

20. b

57. d

94.

d

131. c

168. b

21. e

58. d

95.

a

132. b

169. d

22. a

59. c

96.

c

133. d

170. a

23. d

60. d

97.

c

134. c

171. d

24. b

61. a

98.

b

135. b

172. d

25. d

62. a

99.

b

136. c

173. a

26. d

63. d

100. d

137. b

174. a

27. c

64.

c

101. a

138. b

175. d

28. a

65. c

102. b

139. b

176. e

29. d

66. a

103. b

140. e

177. c

30. c

67. c

104. d

141. b

178. d

31. a

68. a

105. b

142. e

179. c

32. b

69. a

106. b

143. b

180. b

33. d

70. a

107. b

144. b

181. a

34. e

71. d

108. b

145. e

182. e

35. c

72. e

109. c

146. c

183. e

36. b

73. a

110. b

147. b

184. d

37. e

74. c

111. a

148. c

185. a


196. d

206. c

216. d

226. c

187. c

197. e

207. d

217. d

227. d

188. b

198. b

208. c

218. b

228. e

189. b

199. d

209. a

219. b

229. d

190. a

200. e

210. e

220. d

230. b

191. c

201. b

211. b

221. d

231. d

192. c

202. e

212. c

222. c

232. e

193. b

203. e

213. b

223. c

233. a

194. e

204. b

214. c

224. c

195. c

205. d

215. d

225. d

1285

PULMONARY MEDICINE

186. e


EMERGENCY MEDICINE 1.

A 43-year-old woman presents with epigastric pain thatstarted 4 hours ago. The woman describes the pain as being sharp and radiating toher back. She feels nauseous but has not vomited and is fully alert and orientated. The patient responds well to IV fluids and analgesia. Biochemical blood results show:

Bilirubin 8 μmol/L

ALT 38 IU/L

AST 34 IU/L

ALP 421 IU/L

Amylase 1850 U/L

The most appropriate investigation would be:

5.

a. Mechanical ventilation b. IV naloxone c. IV naloxazone d. IV naltrexone e. Methadone 6.

d. Endoscopic retrograde cholangiopancreatography (ERCP)

An 18-year-old woman presents to her GP. She appears anxious and explains shehas been revising for her exams but suffered an acute severe headache this morningwhich left her unable to work and she has not felt well ever since. She denies anyrecent travelling, fever or neck stiffness. She appears tearful but otherwise well, with no signs following a neurological examination. The most likely diagnosis is:

e. Magnetic resonance imaging (MRI) scan

a. Tension headache

a. Abdominal ultrasound (US) scan b. Computed tomography (CT) scan c. Erect chest x-ray

2.

A 28-year-old woman is rushed in a confused state. Herpartner reports seeing the patient vomiting and breathing very rapidly beforefalling ill, at which point he called the ambulance. Empty aspirin packets werefound close to the patient, the partner estimates it has been approximately 45minutes since the patient may have ingested the pills. The most appropriate firstlinemanagement would be:

b. Migraine c. Subarachnoid haemorrhage d. Meningitis e. Space-occupying lesion in the brain 7.

d. Gastric lavage

A 26-year-old man with a past medical history of asthma presents to accident andemergency with difficulty breathing. He has a respiratory rate of 35 bpm, heart rate120 bpm and difficulty in answering questions. On auscultation, a polyphonicwheeze is heard and SpO2 is 93 per cent. The patient is unable to perform a peak expiratory flow rate (PEFR). The most appropriate treatment is:

e. Intravenous fluids and electrolytes

a. Nebulized adrenaline

a. Haemodialysis b. Activated charcoal c. IV sodium bicarbonate

3.

A 43-year-old man presents with profuse vomiting, abdominal pain and a faintmetallic taste in the mouth. The patient is mildly jaundiced on examination withfaint green discoloration of the gums. The patient denies taking any recreationaldrugs, but mentions he has been away on sabbatical in rural India. The most likely diagnosis is:

b. IV magnesium sulphate c. 100 per cent oxygen d. Salbutamol nebulizer e. Oral prednisolone 8.

c. Iron toxicity

A 65-year-old Asian man with type 2 diabetes complains of central chest painwhich he describes as severe and crushing in nature. On appearance, the patientappears anxious, sweaty and has difficulty breathing. The most appropriate firstlinetreatment is:

d. Liver failure

a. Blocker

e. Organophosphate poisoning

b. Glyceryltrinitrate (GTN) sublingual spray

a. Copper poisoning b. Magnesium poisoning

4.

A 22-year-old unconscious man is brought into accident and emergency. He wasfound lying alone on the street by passersby who called the ambulance and thecrew mention seeing needles on the floor. The patient’s Glasgow Coma Scale is 12, he has a respiratory rate of 10 and blood pressure of 97/65 mmHg. During your examination you notice pinpoint pupils. The most appropriate treatment is:

A 16-year-old boy presents in a confused state. Heappears pale, sweaty and has a heart rate of 110 bpm and temperature of 37°C.Respiratory examination reveals good air entry and a respiratory rate of 12. He isaccompanied by a group of friends who admit they had been drinking alcohol earlier and smoking marijuana. They deny he has any medical problems apartfrommild asthma and deny ingesting any other recreational substances. Urine dipstickis negative for any significant findings. His blood glucose is 2.1 mmol/L. The most likely cause of the patient’s symptoms is:

c. Non-steroidal anti-inflammatory drug (NSAID) d. Aspirin e. Oxygen therapy 9.

A 74-year-old man with a known history of chronic obstructive pulmonary disease(COPD) presents with a 3-day history of worsening shortness of breath, wheeze,non-purulent cough and fever. He appears unwell and the following blood resultswere obtained:

a. Diabetic ketoacidosis

WCC 13.8 × 109/L

b. Ethanol toxicity

CRP 39.2 mg/L

c. Ecstasy ingestion d. Asthma attack e. Cannabis toxicity

PO2 49 mmHg PCO2 33.2 mmHg

SaO2 95 per cent


The most appropriate treatment is:

c. Bacterial meningitis

a. Oxygen therapy

d. Epstein–Barr virus (EBV)

b. Antibiotic treatment

e. Malaria

c. Physiotherapy d. Short-acting bronchodilator therapy e. Intravenous theophylline

15. A 17-year-old male is brought unconscious to accident and emergency. His friendsreport they were at a nightclub while celebrating his birthday, they deny havingany alcohol or recreational drugs. The club has strobe light effects and while thesewere on he suffered a seizure. The friends called an ambulance and while waiting the patient suffered another seizure shortly after the first, he was not consciousduring any of the attacks. The most appropriate treatment is: a. Intravenous lorazepam b. Rectal diazepam c. Intravenous thiamine

a. Tension pneumothorax

d. Intravenous midazolam

b. Pneumonia

e. Intravenous thiopental

c. Pleural effusion d. Aortic dissection

16.

e. Pulmonary embolism 11. A 59-year-old obese woman underwent a coronary artery stent procedure. Sheisa well-controlled type 2 diabetic. The operation was successful. However, after1week during recovery, the patient complained of severe chest pain and shortnessofbreath. Her heart rate was 115 bpm and blood pressure 107/89 mHg. Following resuscitation of the airway, breathing and circulation, an electrocardiogram(ECG) showed sinus tachycardia and right axis deviation. The most appropriatetreatment is: a. Warfarin b. Intravenous adrenaline c. Alteplase d. Salbutamol e. Intravenous heparin 12. A 47-year-old man presents with a 3-day history ofmelaena. The patient appears pale, has a heart rate of 110 bbpm and blood pressureof 105/71 mmHg. The patient reports suffering a sprained ankle 1 week previouslyand has been using NSAIDs to control his symptoms. The most likely diagnosis is:

A 20-year-old woman presents with a 3-day history of diffuse acute abdominalpain. The patient reports feeling generally unwell earlier during the week with astrange sensation in her mouth. She denies any recent travel history or sexualactivity. On examination, skin turgor is reduced and a fruity odour can be smelt.The most likely diagnosis is: a. Pancreatitis b. Diabetic ketoacidosis c. Acute porphyria d. Liver failure e. Maple syrup urine disease

17. A 75-year-old woman presents with confusion to accident and emergency, she wasbrought in by her neighbours who found her outside her house in her nightclothesduring the middle of the day. She appears oedematous in appearance, particularlyof her neck. The patient’s hand is visibly shaking and while coughing a rustcolouredsputum is produced. Blood tests reveal a mild hyponatraemia while bloodpressure is 110/82. The most likely diagnosis is: a. Sepsis b. Pneumonia c. Myxoedema coma

a. Duodenal ulcer

d. Lung cancer

b. Gastric ulcer

e. Schmidt’s syndrome

c. Colon cancer d. Rectal varices e. Diverticular disease 13. A 69-year-old woman presents in a distressed state. Sheis extremely breathless and an audible wheeze can be heard, frothy clear sputum isproduced each time she coughs. A gallop rhythm and widespread wheezes andcrackles are heard on auscultation. The most likely diagnosis is:

18. A 52-year-old man presents after collapsing at home.He appears pale on appearance with cold extremities. Blood pressure is 97/73 mmHg,heart rate 110 bpm, temperature 36.9°C and an ECG shows normal findings. Bloodculture and urine culture are negative for any findings. He reports returning froma weekend break in Wales, but forgot to take his medication for Crohn’sdiseasewith him. The most likely diagnosis is: a. Addisonian crisis

a. Acute asthma attack

b. Sepsis

b. Emphysema

c. Myocardial infarction

c. Pneumonia

d. Abdominal aneurysm rupture

d. Pulmonary oedema e. COPD 14. A 19-year-old woman complains of general malaise and lethargy. She has recentlystarted university after a gap year in the Western Cape of South Africa and is nowreturning home to visit her parents. She felt feverish with a headache which hasbecome considerably worse by the afternoon with nausea and vomiting. Supineflexion of the patient’s neck causes unassisted knee flexion. The most likelydiagnosis is: a. Subarachnoid haemorrhage b. Encephalitis

e. Nelson’s syndrome 19.

A 44-year-old woman is brought after becoming ill atthe airport after a flight from Australia. She presents with mild pain that causes herto catch her breath and has been coughing blood-stained sputum. On examination,her respiratory rate is 25, heart rate 100 bpm and blood pressure is 130/85 mmHg. The most appropriate management is: a. D-dimers b. Chest x-ray c. Start heparin therapy

EMERGENCY MEDICINE

10. A 54-year-old known hypertensive male presented with a 3-day history of shortnessof breath. The patient reported feeling unwell with a sharp pain in the left side ofthe chest and loss of appetite. His clinical findings included a heart rate of 117 bpm,blood pressure of 97/85 mmHg, temperature 37.2°C and a respiratory rate of 22 bpm.Respiratory examination showed reduced air entry and hyper-resonance onpercussion. The most likely diagnosis is:

1287


1288

MCQ's

20.

d. Start warfarin

c. Decubitus angina

e. CT pulmonary angiography

d. Prinzmetal angina

A 27-year-old woman visits her GP complaining of a fever. She returned from Indiaalmost 2 weeks ago and had felt unwell but attributed this to jet lag. After sufferingfrom a fever she rested for 2 days and on recovering returned to work as anaccountant. After another 2 days she now reports waking up at night again with a high fever, feeling drowsy and confused. On presentation she appears unwell, paleand sweaty. The most likely diagnosis is:

e. Nocturnal angina

a. Plasmodium falciparum

A 57-year-old woman complains of a headache and weakness on the right side ofher body. The headache is normally worst first thing in the morning and isparticularly painful on her left hand side. The weakness has occurred very graduallyover several weeks and is most noticeable when lifting objects. On examination, her temperature is 38.5°C, she has recently had a left ear infection which is notcausing any pain now. The most likely diagnosis is:

b. Plasmodium vivax

a. Cerebral abscess

c. Plasmodium malariae

b. Otitis media

d. Plasmodium ovale

c. Subdural haemorrhage

e. Plasmodium knowlesi

d. Mollaret’s meningitis

21. A 35-year-old man complains of a three-month history of intermittent excruciatingheadaches. They are very variable and occur from once a month to three times aweek. The headaches are associated with extreme anxiety and sweating. Onexamination, the patient’s blood pressure is 152/95 mmHg and during palpation of the abdomen the patient’s skin flushes red. The most likely diagnosis is: a. Cluster headache b. Phaeochromocytoma

25.

e. Cerebellar abscess 26. A 42-year-old man presents with a 2-day history of severe chest pain. The patientreports a sudden ripping sensation at the front of the chest that occasionallyradiates to the back. The patient has tried paracetamol and ibuprofen to alleviatethe pain, but has had no success. The patient suffers from poorly controlledhypertension and at the last GP appointment his blood pressure was 167/95 mmHg. The most definitive investigation is: a. ECG

c. Subarachnoid haemorrhage

b. Chest x-ray

d. Migraine

c. MRI scan

e. Temporal arteritis 22. A 47-year-old obese Asian man complains of a sharp pain on the left side of hischest with difficulty breathing. The pain started a few hours ago and does notradiate anywhere, the patient also reports feeling increasingly short of breath andbecame extremely anxious when he started coughing blood-stained sputum. Hestates he has been flying all week on business trips and is getting late for his nextflight. The most likely diagnosis is:

d. Transoesophageal echo e. CT scan with contrast

a. Myocardial infarction

A 53-year-old woman with hypertension presents with muscle weakness andpainful cramping. She admits some confusion with her new medicationspironolactone after a recent dosage change, and may have taken more than thenew prescribed dose. On examination, the patient appears well, an ECG showsabsent p waves and widened QRS complexes. The most appropriate treatment is:

b. Muscular injury

a. Intravenous fluids only

c. Pneumothorax

b. Intravenous 10 per cent calcium gluconate

d. Pulmonary embolism

c. Nebulized salbutamol

e. Pericarditis

d. Intravenous insulin and dextrose

23. A 53-year-old severely distressed and confused woman presents to accident andemergency with her husband. A collateral history reveals she has been sufferingincreasingly severe tremors, sweating and weight loss during the week. Sinceyesterday she has started to suffer from palpitations and increasing confusion.Blood pressure is 157/93 mmHg and there is an irregularly irregular pulse. The mostlikely diagnosis is:

27.

e. Intravenous insulin alone 28.

a. 0.05 mg intravenous adrenaline b. 100 mg intravenous hydrocortisone

a. Phaeochromocytoma

c. 20 mg intravenous chlorphenamine

b. Carcinoid tumour

d. 0.5 mg intramuscular adrenaline

c. Thyroid crisis

e. 0.3 mg intramuscular adrenaline

d. Addisonian crisis e. Serotonin syndrome 24.

A 57-year-old man complains of a two-month history of chest pain which hasrecently become more severe. The patient describes the pain as a tightness occurringin the centre of the chest which he most often notices when reaching the top of thestairs. The pain usually recedes after a short rest. In the last 2 weeks he has noticed the pain is more severe and, unless he is sitting down or sleeping, is present all thetime. The most likely diagnosis is:

A 17-year-old boy is rushed after breathing difficultiesin a restaurant. The parents report the patient feeling unwell after eating a cakecontaining nuts. The patient has swollen lips and tongue and an audible wheeze isheard. The most appropriate first-line treatment is:

29.

A 51-year-old Caucasian male with poorly controlled hypertension presents toaccident and emergency with confusion, nausea and vomiting. His daughter visitshim weekly and called the ambulance on finding him in this state at home. Bloodpressure measurement shows 200/140 mmHg. The most appropriate management is: a. Thiazide diuretic b. Angiotension II receptor antagonist c. Calcium channel blocker

a. Classical angina

d. ACE inhibitor

b. Crescendo angina

e. Beta blocker


30.

A 67-year-old woman suffered a fracture to her hip during a fall and undergoes asuccessful hip replacement. After 2 weeks, the patient complains of pain in her rightleg, particularly on movement. On examination, the leg is swollen below the knee,erythematous and tender on palpation. The most appropriate management is: a. Unfractionated heparin b. Low weight molecular heparin

33. A 49-year-old man is assaulted by a gang and is brought 1289 into accident andemergency. After resuscitation, he regains consciousness with a Glasgow ComaScale (GCS) of 15. He has suffered multiple fractures of the left leg and left arm butremains stable. While in the intensive care unit, he becomes agitated and complainsof difficulty breathing which does not improve despite high flow oxygen. Younotice a widespread petechial rash. The most likely diagnosis is: a. Cardiac tamponade

c. Warfarin

b. Fat embolism

d. Early ambulation

c. Pulmonary embolism

e. Thrombolytic therapy A 29-year-old woman is brought after suffering from aseizure at work witnessed by a colleague. She reports the patient has been unwellfor the past week with headaches and nasal congestion, but refused any sick leave.The patient has a temperature of 38.3°C, a swollen bulging eye and an ipsilateral gaze palsy. The most likely diagnosis is:

d. Disseminated intravascular coagulation e. Pulmonary infarction 34.

a. Cavernous sinus thrombosis b. Giant cell arteritis c. Duane syndrome d. Cerebral abscess

a. Prinzemetal angina

e. Meningitis 32.

A 30-year-old man is brought by his wife in a confusedstate. After an argument at home, the wife had left the patient and on returningfound him unconscious. She suspects he may have made a suicide attempt but hadnot thought to look for any pills or bottles close to the patient. While waiting to be seen, the patient suffers a seizure. On recovery, an examination shows the patient’stemperature is 39°C, pulse is irregular, respiratory rate is 20 and the patient’s pupilsare dilated. An ECG recording reveals tachycardia and widened QRS complexes,while a blood gas is normal. The most likely substance ingested is:

b. Gastro-oesophageal reflux disease (GORD) c. Tension pneumothorax d. Myocardial infarction e. Oesophageal rupture 35. A 19-year-old woman presents with an acute episode of feeling unwell. While inthe middle of moving to a new house, she experienced an extremely severe painnear the back of her head. She denies any recent travelling, fever or neck stiffness. The most definitive investigation is: a. Lumbar puncture

a. Carbamazepine

b. Blood culture

b. Gabapentin

c. CT scan

c. Aspirin

d. Fundoscopy

d. Sodium valproate e. Amitryptiline

A 65-year-old man presents with a 25-minute history of severe chest pain that hedescribes as ‘gripping’ in nature. The pain does not radiate anywhere and is themost severe pain the patient has experienced. The patient is sweaty and anxious inappearance, tachycardic and has a normal blood pressure. An ECG shows hyperacuteT-waves and serum creatinine kinase levels are not raised. The patient has a historyof peptic ulcer disease but is otherwise healthy. The most likely diagnosis is:

e. MRI scan 36.

qSOFA criteria for severe sepsis is all except: a. Respiratory rate > 22 b. BP <100 mm Hg c. Serum Procalcitonin> 3 SD d. Altered sensorium

EMERGENCY MEDICINE

31.


MCQ's

1290

Emergency Medicine - Answers 1.

a

9.

d

17.

c

25.

a

33.

b

2.

e

10.

a

18.

a

26.

e

34.

d

3.

a

11.

e

19.

a

27.

b

35.

c

4.

b

12.

b

20.

a

28.

d

36.

c

5.

b

13.

d

21.

b

29.

d

6.

c

14.

c

22.

d

30.

b

7.

c

15.

b

23.

c

31.

a

8.

b

16.

b

24.

b

32.

e


ONCOLOGY 1.

A 55-year-old man has presented to his GP complaining of several episodes of spontaneous facial blushing. In addition, he mentions he has had several episodes of watery diarrhoea. On examination of the ardiovascular system, giant v waves are noted on observation of the jugular venous pressure. In addition, a pansystolic murmur is heard in the lower sternal edge on inspiration. Examination of the gastrointestinal system reveals an enlarged, irregular, non-tender liver edge. What is the most likely diagnosis?

b. Intravenous saline rehydration and pamidronate c. Pamidronate d. Calcitonin e. Intravenous saline rehydration plus calcitonin 6.

a. Superior vena cava obstruction b. Carcinoid tumour

a. Adjuvant

c. Carcinoid syndrome

b. Neoadjuvant

d. Phaeochromocytoma

c. Palliative

e. Conn’s syndrome 2.

A 62-year-old woman with metastatic breast cancer, including bone metastases, presents to sudden onset back pain and difficulty walking. An urgent MRI of the spine confirms cord compression at the level of L1–L2. What is the most appropriate initial management?

d. Radical e. Brachytherapy 7.

a. Surgical decompression of spinal cord b. Dexamathasone

b. β-human chorionic gonadotrophin (β -hCG)

d. Chemotherapy

c. CA 19-9

e. Physiotherapy A 60-year-old man with metastatic adenocarcinoma of the lung, who has finished two cycles of palliative cisplatin/ pemetrexed chemotherapy, presents with a 2-day history of fever and lethargy. On examination, he is pyrexial with a temperature of 38.8°C. What is the most appropriate next step?

d. CA 125 e. CEA 8.

a. Blood cultures b. Urgent full blood count

b. Lymph node dissection

d. Start empirical broad spectrum antibiotics

c. Radiotherapy to affected lymph nodes

e. Prescribe paracetamol A 50-year-old woman with T2N2M1 squamous cell carcinoma of the tongue has been electively admitted for her third cycle of palliative cisplatin/5-fluorouracil chemotherapy. She has known metastasis to the T3 vertebrae and the ribs. Since her last cycle of chemotherapy she has been very lethargic and constipated. Upon checking her bloods you discover that her corrected calcium levels are 15 Mg %. The most appropriate treatment is:

d. Chemo-radiotherapy e. Surveillance using tumour markers. 9.

a. Administering the chemotherapy b. Intravenous rehydration and pamidronate

b. Small cell carcinoma

d. Delaying the chemotherapy and advising the patient to minimize calcium intake

c. Adenocarcinoma d. Leiomyoma

e. Intravenous rehydration alone A 50-year-old woman presents to complaining of excessive lethargy. In addition, she mentions that she has been constipated. On examination, there are clinical features of dehydration. Blood tests have revealed a corrected calcium of 16mg %. Her chest x-ray shows bilateral streaky shadowing throughout both lung fields. She is given 3 L of saline in 24 hours after admission. The following day her blood tests are repeated and her corrected calcium level is now 14mg%. Results of parathyroid hormone levels and thyroid function tests are still awaited. What is the most appropriate management? a. Intravenous saline rehydration

A 60-year-old man has presented to the gastroenterology outpatient clinic with a four-month history of progressive dysphagia. The patient reports a weight loss of 9 kg in the same time period. He has suffered from gastro-oesophageal reflux disease for the past 10 years. At endoscopy, a 5 cm malignant stricture is seen at the lower end of the oesophagus and biopsies are taken. Histological analysis is most likely to reveal: a. Squamous cell carcinoma

c. Calcitonin

5.

A 22-year-old man with testicular cancer has undergone an inguinal orchidectomy. Histology has confirmed teratoma. A preoperative CT staging scan has shown involvement of the para-aortic lymph nodes. Which of the following treatments is the best post-operative option? a. Chemotherapy (bleomycin, etoposide, cisplatin)

c. Urgent chest x-ray

4.

A 57-year-old woman with adenocarcinoma of the sigmoid colon with liver metastasis is attending for cycle six of her palliative FOLFOX chemotherapy. Which tumour marker can be measured in the blood test to indicate the effect of the chemotherapy? a. α-fetoprotein (AFP)

c. Radiotherapy

3.

A 74-year-old man with T2N0M0 squamous cell carcinoma of the tongue is currently undergoing hyper-fractionated radiotherapy with curative intent. He has had no previous surgery. This type of therapy is best described by which of the following terms:

e. Gastrointestinal stromal tumours 10.

A 70-year-old man presents to his GP having noticed a slowly enlarging ‘spot’ on his left cheek. On examination, there is a well-circumscribed, skin-coloured nodular lesion on the left cheek with some overlying small blood vessels visible. The most likely diagnosis of this lesion is: a. Basal cell carcinoma b. Squamous cell carcinoma c. Nodular malignant melanoma d. Superficial spreading malignant melanoma e. Basal cell papilloma


d. 30 mg of morphine sulphate tablets, twice daily

1292 11. A 62-year-old electrician has presented to a sudden decline

in his exercise tolerance. He mentions that he can only walk 5 yards and that he has had a persistent cough with some haemoptysis over the previous month. A chest x-ray confirms a right-sided pleural effusion, which is then drained. A repeat x-ray shows a round shadow in the right perihilar region. Subsequent bronchoscopy and biopsy confirms small cell carcinoma. Which of the following statements is most true about small cell carcinomas of the lung?

e. 18 mg of diamorphine via a continuous subcutaneous syringe driver 16.

a. They are sensitive to chemotherapy

The most important diagnostic investigation is:

b. Two-year survival of disease confined to the lung is 50 per cent

a. Urea and electrolyte blood tests b. CT head

c. They are more common than non-small cell lung carcinomas

c. CT thorax, abdomen and pelvis

MCQ's

d. They are not associated with cigarette smoking

d. Lumbar puncture

e. They most commonly arise from the periphery of the lung 12.

A 68-year-old man presents to his GP complaining of increasing shortness of breath. He has noticed deterioration in his exercise tolerance, particularly while mowing the lawn. He has a past history of squamous cell carcinoma of the lung for which he finished radiotherapy treatment a year ago. On examination, there are fine inspiratory crackles in the right lung base. The most likely cause of his shortness of breath is: a. Recurrence of the cancer b. Pneumonitis

A 58-year-old male with known small cell lung cancer presents to a 5-day history of severe headache and recurrent vomiting. He has recently commenced chemotherapy for small cell arcinoma of the lung. On examination of the visual fields, there is a left inferior homonymous quadrantinopia.

e. Chest x-ray 17. A 64-year-old man presents to following a collapse. He describes a blackout, subsequently regaining consciousness when on the floor. He presently feels well and describes no other symptoms. However, he mentions that he has unintentionally lost some weight over the past few months. There is no past medical history. Blood tests reveal a haemoglobin level of 9 g/dL with a mean cell volume on 71 fL. The most appropriate next investigation of this patient is: a. Flexible sigmoidoscopy

c. Pulmonary oedema

b. Endoscopy

d. Pulmonary fibrosis

c. Colonoscopy

e. Chronic obstructive pulmonary disease (COPD)

d. Endoscopy and colonoscopy

13. A 39-year-old woman has undergone a wide local excision for a 0.5 cm ductal carcinoma of her right breast. Sentinal node biopsy, histology and staging scans have confirmed the disease as T1N0M0. Histology has confirmed the cancer as oestrogen and progesterone receptor positive. Which of the following statements is most accurate regarding this female’s treatment options?

e. Profile of tumour markers 18. A 57-year-old man with metastatic adenocarcinoma of the lung is attending for cycle three of his palliative pemetrexed/ cisplatin chemotherapy. During his cisplatin infusion, he noticed his arm becoming painful, swollen and red at the cannula site. The most likely cause of this is: a. Cellulitis

a. She should receive radiotherapy

b. Venous thrombosis

b. She is not suitable for radiotherapy

c. Extravasation of chemotherapy

c. She is not suitable for tamoxifen therapy

d. Adverse drug reaction

d. She requires no further treatment

e. Normal chemotherapy reaction

e. She should be considered for cetuximab therapy 14. A 51-year-old man with a recent diagnosis of pancreatic carcinoma with metastases to the liver and omentum is about to commence gemcitabine chemotherapy. Prior to his first cycle he mentions that he is getting increasing severe abdominal pains. He is currently taking paracetemol for this, which eases the pain but is now becoming less effective. The most appropriate analgesia for this patient is:

19.

a. Fentanyl patch b. Oral morphine sulphate solution as required

A 55-year-old woman with metastatic pancreatic cancer attends the oncology clinic prior to her second cycle of chemotherapy. She tolerated her first cycle well but her husband mentions that there have been occasions where she has been confused. Her urea and electrolyte blood tests reveal a serum sodium of 116 mmol/L. All other results were within the normal range. The chemotherapy is delayed and a urine specimen is sent off. This reveals a urine osmolality of 620 mmol/kg. The most likely cause of the hyponatraemia is: a. Water overload

c. Morphine sulphate tablets

b. Diabetes insipidus

d. Codeine phosphate

c. Addison’s disease

e. Codeine phosphate plus paracetamol

d. Syndrome of inappropriate anti-diuretic hormone (ADH)

15. A 48-year-old woman with a recent diagnosis of metastatic cancer of unknown primary, including metastasis to the sacral and thoracic spine, is currently being treated for lower back pain with regular paracetamol, diclofenac and oral morphine solution. She is receiving additional oral morphine solution rescue doses for her breakthrough pain. On review of her drug chart, she has received 60 mg of oral morphine solution over the past 24 hours. Which of the following is the most appropriate escalation for this patient’s pain management? a. 30 mg of morphine sulphate tablets, twice daily with 10 mg oral morphine solution, as required b. 5–10 mg of oral morphine solution, as required c. 10 mg of oral morphine solution, six times a day

e. Renal impairment 20.

A 55-year-old woman with metastatic pancreatic cancer attends the oncology clinic prior to her second cycle of chemotherapy. She tolerated her first cycle well, but her husband mentions that there have been occasions where she has been confused. Her urea and electrolytes on this occasion reveal a serum sodium of 116 mmol/L. All other results were within the normal range. The chemotherapy is delayed and a urine specimen is sent off. This confirms a diagnosis of syndrome of inappropriate ADH (SIADH). The most appropriate treatment is: a. Intravenous infusion of 5 per cent dextrose b. Intravenous infusion of normal saline


c. Intravenous infusion of hypertonic saline

23.

d. Desmopressin e. Fluid restriction to 1 L per day 21. A 60-year-old man with metastatic adenocarcinoma of the lung, who has finished two cycles of palliative cisplatin/ pemetrexed chemotherapy, presents with a 2-day history of nausea and vomiting. On examination, he is tachycardic with a blood pressure of 105/60 mmHg. Blood tests show a urea of 15 mmol/L and a creatinine of 180 mmol/L. Results from a week earlier showed a urea of 4.0 mmol/L and a creatinine of 90 mmol/L. All other blood tests and arterial blood gas results are within the normal range. What is the most appropriate initial management of this patient? b. Intravenous fluid rehydration c. Urgent renal ultrasound scan d. Haemodialysis e. CT scan of kidneys, ureter and bladder 22.

A 65-year-old woman who is currently receiving chemotherapy for acute myeloid leukaemia is found on blood testing to have urea of 10.1 mmol/L, creatinine of 190 mol/L, potassium of 6.1 mmol/L, phosphate of 8.5 mg/dL and corrected calcium of 2.00 mmol/L. The patient is asymptomatic. Her electrolyte levels were normal prior to the start of treatment. What is the most likely cause of this electrolyte disturbance? a. Tumourlysis syndrome b. Hypovolaemia c. Haemolyticuraemic syndrome d. Neutropenic sepsis e. Disease progression

a. Sister Mary Joseph nodule b. Krukenbergtumour c. Acanthosisnigricans d. Peutz–Jeghers syndrome e. Paget’s disease 24.

A 62-year-old man with known metastatic small cell carcinoma of the lung has presented to sudden onset shortness of breath and arm and hand swelling. On examination, his face appears plethoric and Pemberton’s sign is positive. What is the most likely diagnosis? a. Pancoast’s tumour b. Horner’s syndrome c. Superior vena cava obstruction d. Facial oedema e. Malignant pleural effusion

ONCOLOGY

a. Oral fluid rehydration

A 56-year-old man with gastric cancer presents to his GP 1293 complaining of a lump in his belly button. On examination, there is a palpable nodule at his umbilicus. This sign is referred to as:


MCQ's

1294

Oncology - Answers 1. c

6. d

11. a

16. b

21. b

2. b

7. e

12. d

17. d

22. a

3. a

8. a

13. b

18. c

23. a

4. b

9. c

14. e

19. d

24. c

5. a

10. a

15. a

20. e


PHARMACOLOGY 1.

In the autonomic regulation of blood pressure

d. Pilocarpine

a. Cardiac output is maintained constant at the expense of other hemodynamic variables

e. Neostigmine

b. Elevation of blood pressure results in elevated aldosterone secretion

a. Gastrointestinal smooth muscle crampine b. Increased cardiac rate

d. Stroke volume and mean arterial blood pressure are the primary direct determinants of cardiac output

d. Pupillary constriction

c. Increased gastric secretion e. Urinary frequency 9.

b. Lumbar segment only c. Both (a) and (b)

b. Vegetative

d. None of the above

c. Involuntary nervous system d. All of the above

10.

b. Increased blood pressure caused by nicotine c. Increased skeleton muscle strength caused by neostigmine

a. Bronchial relaxation

d. Tachycardia caused by exercise

b. Decreases intestinal motility

e. Tachycardia caused by infusion of acetylcholine

d. Mydriasis

11.

e. Increased heart rate (tachycardia)

b. Irreversible antagonist at muscarinic receptors

Several children at a summer camp were hospitalized with symptoms thought to be due to ingestion of food containingbotulinum toxins. The effects of botulinum toxin are likely to include b. Cycloplegia

c. Physiologic antagonist at muscarinic receptors d. Reversible antagonist at muscarinic receptors e. Reversible antagonist at nicotinic receptors 12.

c. Diarrhea e. Hyperventilation

b. Motion sickness

The neurotransmitter agent that is normally released in the sinoatrial node of the heart in response to a blood pressure increase is

d. Postoperative bladder spasm

a. Acetylcholine b. Dopamine

c. Parkinsonâ&#x20AC;&#x2122;s disease e. Travelerâ&#x20AC;&#x2122;s diarrhea 13.

b. Parasympathetic

d. Glutamate

c. Norepinephrine

e. Norepinephrine A directactingcholinomimetic that is lipidsolubleand often used in the treatment of glaucoma is

In male sex organs _______ system is responsible for erection. a. Sympathetic

c. Epinephrine

7.

Accepted therapeutic indications for the use of antimuscarinic drugs include all of the following except a. Hypertension

d. Skeletal muscle spasms

6.

Which of the following best describes the mechanism of action of scopolamine ? a. Irreversible antagonist at nicotinic receptors

a. Bronchospasm

5.

Which one of the following can be blocked by atropine? a. Decreased blood pressure caused by hexamethonium

Full activation of the sympathetic nervous system, as in maximal exercise, can produce all of the following responses except

c. Increased renal blood flow

4.

The synaptic preganglionicneurons have their cell bodies in the lateral horn of the grey matter of the a. Thoracic segment only

The autonomic nervous system is also known as a. Visceral

3.

Atropine overdose may cause which one of the following

c. Baroreceptor nerve fibers docrease firing rate when arterial pressure increases

e. A condition that reduces the sensitivity of the sensory baroreceptor nerve endings might cause an increase insympathetic discharge 2.

8.

d. None of the above

a. Acetylcholine

A 7yearsoldboy has a significant bedwetting problem. A longactingindirect sympathomimetic agent sometimes used by the oral route for this and otherindications is

b. Bethanechol

a. Dobutamine

c. Physostigmine

b. Ephedrine

d. Pilocarpine

c. Epinephrine

e. Neostigmine

d. Isoproterenol

Which of the following agents is a prodrug that is much less toxic in mammals than in insects ? a. Acetylcholine

14.

e. Phenylephrine 15.

When pupillary dilationbutnot cycloplegiaisdesired, a good choice is

b. Bethanechol

a. Homatropine

c. Physostigmine

b. Isoproterenol c. Phenylephrine


e. Tropicamide

Postural hypotension is a common adverse effect of which one of the following types of drugs ?

‘Fight or flight’ state can be described as

b. Alphareceptorblockers

d. Pilocarpine

1296 16.

24.

a. ACE inhibitors

a. Sympathetic active; parasympatheticquiescent

c. Arteriolar dilators

b. Sympathetic active; parasympatheticactive

d. ß1 – selective receptor blockers

c. Sympathetic quiescent; parasympatheticactive 17.

Your patient is to receive a selective ß2 stimulant drug ß2 selective stimulant are often effective in

e. Nonselective ß blockers 25.

a. Angina due to coronary insufficiency b. Asthma

a. Enalapril

c. Chronic heart failure

b. Losartan

MCQ's

d. Delayed or insufficiently strong labor 18.

e. All of the above

c. Minoxidil

Which of the following drugs is the drug of choice in anaphylaxis associated with bronchospasm and hypotension ?

e. Verapamil

a. Cortisone b. Epinephrine

d. Propranolol 26. Reserprine, an alkaloid Rauwolfiaserpentina

Which of the following effects of epinephrine would be blocked by phentolamine but not by metoprolol ?

e. A spare receptor agonist 27.

b. Decreased venous capacitance c. Increased afterload

e. Relaxation of the uterus

d. Increased cardiac force

Propranolol is useful in all of the following except b. Familial tremor

e. Increased diastolic intramyocardial fiber tension 28.

c. Hypertension

b. Decreased end – diastolic ventricular volume

e. Partial atrioverntricular heart block

c. Dilation of consticted coronary vessels

‘Rest and digest’ state can be described as

d. Increased cardiac force

a. Sympathetic active; parasympatheticquiescent c. Sympathetic quiescent; parasympatheticactive

e. Increased resting heart rate 29. The major common determinant of myocardial oxygen consumption is a. Blood volume

A friend has very severe hypertension and asks about a drug her doctor wishes to prescribe. Her physician has explained that this drug is associated with tachycardia and fluid retention (which may be marked) and increased hair growth. Which of the following is most likely to produce the effects that your friend has described? a. Captopril b. Guanethidine

b. Cardiac output c. Diastolic blood pressure d. Heart rate e. Myocardial fiber tension 30.

b. Sympathetic system causes constriction of coronary arteries

d. Prazosin

c. Sympathetic system causes increased motility of GIT smooth muscles

e. Propranolol

a. Competitively blocks angiotensim II at its receptor b. Decreases angiotensin II concentration in the blood c. Decreases rennin concentration in the blood d. Increases sodium and decreases potassium in the blood e. Decreases sodium and increases potassium in the urine

Choose the incorrect statement from the following a. Sympathetic system increases rate of SA node

c. Minoxidil

Which one of the following is characteristic of captopril and enalapril ?

The antianginal effect of propranolol may be attributed to which one of the following a. Block of exercise – induced tachycardia

d. Idiopathic hypertrophic subaortic cardiomyopathy

b. Sympathetic active; parasympatheticactive

Nitroglycerin, either directly or through reflexes, results in which one of the following effects a. Decreased heart rate

d. Relaxation of bronchial smooth muscle

a. Angina

of

d. Has no cardiac effects

c. Increase of camp in fat

23.

root

c. Can decrease gastrointestinal secretion and motility

b. Contractionof radial smooth muscle in the iris

22.

the

e. Phenylephrine

a. Cardiac stimulation

21.

from

b. Can cause severe depression of mood

d. Norepinephrine

20.

derived

a. Can be used to control hyperglycemia

c. Isoproterenol

19.

A visitor from another city comes to your office complaining of incessant cough. He has diabetes and hypertension and has recently started taking a different antihypertensive medication. The most likely cause of his cough is

d. Sympathetic system causes constriction of sphincter in GIT 31.

Denervation supersensitivityincludes a. Proliferation of receptors b. Loss of mechanism for transmitter removal c. Increased postjunctionalresponsiveness d. All of the above


32.

c. –100

Which of the following is approved for the treatment of hemorrhagic stroke ? a. Amyl nitrite b. Hydralazine

40.

b. Acetyl cholinesterase

d. Nifedipine

c. Both (a) and (b)

e. Nimodipine Which of the following drugs used for the treatment of angina by inhalation has a very rapid onset and a brief duration of effect ?

d. None of the above 41.

a. Amyl nitrite

c. Digoxin

d. Nifedipine

d. Dobutamine

e. Nimodipine

35.

42.

a. Digoxin antibodies

b. Hydralazine

b. Lidocaine

c. Isosorbidemononitrate

c. Magnesium

d. Nifedipine

d. Potassium

e. Nimodipine

e. Quinidine

The biochemical mechanism of action of digitalis is associated with

43.

a. Increases action potential duration b. Increases contractility

b. An increase in ATP synthesis

c. Increses PR interval

c. A modification of the actin molecule

d. Reduces abnormal automaticity

d. An increase in systolic intracellular calcium levels

e. Reduces resting potential

A patient has been taking digoxin for several years for chronic heart failure is about to receive atropine for another condition. A common effect of digoxin (attherapeutic blood levels) that can be almost entirely blocked by atropine is

44.

b. Amiodarone c. Flecainide d. Propranolol

c. Increased PR interval on the ECG d. Headaches e. Tachycardia

e. Quinidine 45.

In a patient given a cardiac glycoside, important effects of the drug on the heart include which of the following?

b. Constipation c. Lupus erythematosus

b. Decreased ejection time

d. Increase in digoxin clearance

c. Increased ectopic automaticity e. All of the above

e. Precipitation of hyperthyroidism 46.

b. abungarotoxin c. Trimethaphan

a. Starting administration of captopril

d. All of the above

b. Starting administration of quinidine d. Hypermagnesemia e. Hypocalcemia 39. At rest, the interior of the typical mammalian neuronal axon potential is approximately ________ mV a. 0 b. –70

Following is an antagonist of ganglion type nicotinic receptors a. Tubercurarine

Which of the following situations constitutes an added risk of digoxin toxicity ?

c. Hyperkalemia

Recognized adverse effects of quinidine include which one of the following? a. Cinchonism

a. Decreased atrioventricular conduction velocity

d. Increased ectopic automaticity

A 16yearoldgirlis found to have paroxysmal attacks of rapid heart rate. The antiarrhythmic of choice in most cases of acute AV nodal tachycardia is a. Adenosine

b. Increased atrial contractility

38.

When used as an antiarrhythmic drug, Lidocaine typically

a. A decrease in calcium uptake by the sarcoplasmic reticulum

a. Decreased appetite

37.

Which of the following is the drug of choice in treating suicidal overdose of digitoxin ?

a. Amyl nitrite

e. A block of sodium/calcium exchange 36.

e. Enalapril

47.

Which of the following is an orally active drug that blocks sodium channels and decreases action potential duration? a. Adenosine b. Amiodarone c. Disopyramide d. Esmolol e. Mexiletine

PHARMACOLOGY

b. Digitoxin

c. Isosorbidemononitrate

Which of the following is a vasodilator drug used for hypertension that lacks a direct effect on autonomic receptors but may provoke anginal attacks?

Which of the following has been shown to prolong life in patient with chronic congestive failure but has a negative inotropic effect on cardiac contractility? a. Carvedilol

b. Hydralazine

34.

Following enzyme is involved in the synthesis of actylcholine a. Choline acetyl transferase

c. Isosorbidemoninitrate

33.

1297

d. –20


1298 48. Which of the following has the longest halflifeof all antiarrhythmic drugs?

49.

56.

a. Adenosine

a. Calcitonin

b. Amiodarone

b. Glucocorticoids

c. Disopyramide

c. Plicamycin

d. Esmolol

d. Parenteral infusion of phosphate

e. Flecainide

e. Thiazide diuretics

Which of the following diuretics would be most useful in a patient with cerebral edema?

57.

a. Act to decrease serum levels of calcium

b. Amiloride

b. Activation of their Vitamin D receptors increases cellular CAMP c. Calcitriol is the major derivative responsible for increasing intestinal absorption of phosphate

MCQ's

d. Furosemide e. Mannitol Which of the following therapies would be most useful in the management of severe hypercalcemia? a. Amiloride plus saline infusion

d. Metabolites of Vitamin D increase renal excretion of calcium e. Vitamin D deficiency results in Pagerâ&#x20AC;&#x2122;s disease 58.

b. Furosemide plus saline infusion

b. Hypoparathyroidism

d. Mannitol plus saline infusion

c. Intestinal osteodystrophy

e. Spironolactone plus saline infusion 51. A 55yearoldpatient with severe posthepatitis cirrhosis is started on a diuretic for another condition. Two days later he is found in a coma. The drug most likely to cause coma in a patient with cirrhosis is

d. Pagerâ&#x20AC;&#x2122;s disease e. Rickets 59.

b. Hyperparathyroidism

b. Amiloride

c. Intestinal osteodystrophy

c. Furosemide

d. Nutritional rickets

d. Hydrochlorothiazide

53.

Oxytremorine is a selective agonist of muscarinic _______ receptors

e. Osteoporosis 60.

a. Calcitonin

b. M2

b. Dihydrotachysterol

c. M3

c. Ergocalciferol

d. M4

d. Etidronate e. Norgestrel

A drug that is useful in glaucoma and highaltitudesickness is 61.

b. Amiloride c. Demeclocycline d. Desmopressin

b. Clonidine c. Hydralazine

Cromolyn has as its major action

d. Neostigmine

a. Block of calcium channels in lymphocytes

e. Propranolol

b. Block of mediator release from mast cells c. Block of phosphodiesterase in mast cells and basophils d. Smooth muscle relaxation in the bronchi

62.

b. Dilution by diffusion and uptake at extraneuronal site c. Metabolic transformation

Following events occur in the cytoplasm and not inside storage vesicles, except b. Conversion of dopa to dopamine c. Conversion of dopamine to norepinephrine d. Conversion of dopamine to 3,4 dihydroxy phenyl acetic acid

Action of norepinephrine and epinephrine are terminated by a. Reuptake into nerve terminal

e. Stimulation of cortisol release by the adrenals

a. Conversion of tyrosine to dopa

A 70yearoldman has severe urinary hesitancy associated with benign prostatic hyperplasia. He has tried alpha blockers with little relief. His physician recommends a drug that blocks 5a reductasein the prostateand writes a prescription for a. Atropine

e. Ethacrynic acid

55.

Which one of the following drugs, when used chronically, is associated with the development of bone pain and mineralization defects such as osteomalacia?

a. M1

a. Acetazolamide

54.

Clinical uses of Vitamin D do not include a. Chronic renal failure

a. Acetazolamide

e. Spironolactone

Which of the following conditions is an indication for the use of calcitonin? a. Chronic renal failure

c. Hydrochlorothiazide plus saline infusion

52.

Characteristics of Vitamin D and its metabolites include which one of the following?

a. Acetazolamide c. Ethacrynic acid

50.

Which one of the following is lest likely to be useful in the therapy of hypercalcemia?

d. All of the above 63.

Typical results of betareceptoractivation include which one of the following? a. Hypoglycemia b. Lipolysis c. Glycogen synthesis


64.

d. Decreased skeletal muscle tremor

c. Is longer acting

e. Decreased rennin secretion

d. Has weaker antimotion sickness activity

A patient is admitted to the emergency room with orthostatic hypotension and evidence of marked GI bleeding. Which of the following most accurately describesthe probable autonomic response to this bleeding?

73.

b. Pipenzolate methyl bromide c. Isopropamide

b. Rapid heart rate, dilated pupils, damp skin

d. Dicyclomine

c. Slow heart rate, dry skin, increased bowel sounds e. Rapid heart rate, constricted pupils, warm skin

74. Glycopyrrolate is the preferred antimuscannic drug for use before and during surgery because a. It is potent and fast acting

Drugs that block the a receptor on effector cells at adrenergic nerve endings

b. It has no central action c. It has antisecretory and vagolytic actions

a. Antagonize the effects of isoproterenol on the heart rate b. Antagonize some of the effects of epinephrine on the blood pressure c. Antagonize the effects of epinephrine on adenylyl cyclase

66.

d. All of the above 75.

d. Cause mydriasis

a. Atropine

e. Decreases blood glucose levels

b. Homatropine c. Tropicamide

Yohimbine is an antagonist of ______ receptors.

d. Cyclopentolate

a. a1 b. a2

67.

76.

a. Atropine sulfate

d. None of the above

b. Homatropine c. Cyclopentolate

Which of the following organs is innervated only by parasympathetic nerves ? b. Ciliary muscle

d. Tropicamide 77.

a. Neostigmine b. Physostigmine

d. Splenic capsule

c. Pilocarpine d. Methacholine

Muscarinic cholinergic receptors 78.

b. Inositol trisphosphate

c. Are present on vascular endothelium which has no cholinergic nerve supply

c. Diacylglycerols d. G protein

d. Predominate in the autonomic ganglia The cardiac muscarinic receptors

79.

a. Are of the M1 subtype

b. Epinephrine > isoproterenol > norepinephrine

c. Are selectively blocked by pirenzepine

c. Isoproterenol = epinephrine = norepinephrine

d. Function through the PIP2 ? IP3/DAG pathway

a. Intestinal b. Ureteric c. Bronchial d. Layngeal 71.

a1 – receptors are coupled with _______ G protein. a. Gs b. Gi

72.

Select the correct statement from the following about a1 – adrenergic receptor agonists a. Isoproterenol > epinephrine = norepinephrine

b. Are of the M2 subtype

Atropine does not exert relaxant/ antispasmodic effect on the following muscle

Atropine is contraindicated in a. Cyclic AMP

b. Mediate responses by opening an instrinsic Na+ ion channel

70.

The most effective antidote for belladonna poisoning is

c. Sweat glands

a. Are located only on parasympathetically innervated effector cells

69.

The most suitable mydratic for a patient of corneal ulcer is

c. both (a) and (b)

a. Iris muscles

68.

Which of the following mydriatics has the fastest and briefest action ?

d. Epinephrine = norepinephrine > isoproterenol 80.

The most efficacious inhibitor of catecholamine synthesis in the body is a. a methyl– p tyrosine b. a methyldopa c. a methylnorepinephrine d. Pyrogallol

81. Tyramine induces release of noradrenaline from adrenergic nerve endings a. By depolarizing the axonal membrane

c. Gq

b. By mobilizing Ca2+

d. Go

c. By a nonexocytotic process

Hyoscine differs from atropine in that it a. Exerts depressant effects on the CNS at relatively low doses b. Exerts more potent effects on the heart than on the eye

d. Only in the presence of MAO inhibitors

PHARMACOLOGY

65.

Which of the following anticholinergic drugs is primarily used in preanaesthetic medication and during surgery a. Glycopyrrolate

a. Slow heart rate, dilated pupils, damp skin

d. Rapid heart rate, constricted pupils, increased bowel sounds

1299


c. Mephentermine

1300 82. Choose the correct statement from the following about a1 – adrenergic receptor agonists

a. Norepinephrine > isoproterenol > epinephrine b. Norepinephrine < epinephrine > isoproterenol

d. Isoxsuprine 92.

a. Neurogenic shock

c. Epinephrine = norepinephrine >> isoproterenol

b. Haemorrhagic shock

d. Epinephrine > isoproterenol > norepinephrine

c. Secondary shock

83. A sympathomimetic amine that acts almost exclusively by releasing noradrenaline from the nerve endings is

MCQ's

a. Ephedrine

84.

d. Hypotension due to spinal anaesthesia 93.

a. Synthesis of transmitter

c. Isoprenaline

b. Metabolism of transmitter

d. Tyramine

c. Release of transmitter d. Displacement of transmitter from axonal terminal

Low doses of adrenaline dilate the following vascular bed 94.

b. Mucosal

b. Ergotamine

d. Skeletal muscle

c. Dihydroergotoxine

a2–adrenergic receptors are associated with following except a. Increase in phospholipase C activity b. Increase in potassium channel conductance

d. Tolazoline 95.

c. Decrease in calcium channel conductance

b. It improves plasma lipid profile c. It does not concurrently enhance noradrenaline release

Adrenaline raises blood glucose level by the following actions except b. Inhibiting insulin secretion from pancreatic ß cells

d. It improves urine flow in males with prostatic hypertrophy 96.

b. It delays ejaculation

d. Inhibiting peripheral glucose utilization Noradrenaline is administered by

c. It is indicated only for treatment of erectile dysfunction in men

a. Subcutaneous injection

d. It blocks cavernosal a2 adrenoceptors

b. Intramuscular injection c. Slow intravenous infusion

97.

d. All of the above routes 88.

b. Atenolol

Dobutamine differs from dopamine in that

c. Acebutolol d. Metoprolol

b. It does not activate adrenergic ß receptors c. It causes pronounced tachycardia d. It has good bloodbrain barrier penetrability

98.

b. Schizopherenia c. Shortterm stressful situation

a. Potency

d. Endogenous depression

b. Inability to penetrate bloodbrainbarrier d. Producing both a and ß adrenergic effects 90.

Continuous exposure of ctecholaminesensitive cells and tissues to adrenergic agonists causes a progressive diminition in their capacity to respond, thisphenomenon is called as a. Refractoriness b. Desensitization c. Tachyphylaxis d. All of the above

91.

While undergoing a surgical procedure a patient develops hypotension. Which of the following drugs can be injected intramuscularly to raise his BP a. Noradrenaline b. Isoprenaline

Propanolol can be used to allay anxiety associated with a. Chronic neurotic disorer

Ephedrine is similar to adrenaline in the following feature

c. Duration of action

The ßadrenergicblocker which possesses both ß1 selectivity as well as intrinsic sympathomimetic activity is a. Alprenolol

a. It does not activate peripheral dopaminergic receptors

89.

Which of the following is true of sildenafil a. It enhances sexul enjoyment in normal men

c. Augmenting glucagons secretion from pancreatic a cells 87.

Prazosin is an effective antihypertensive while nonselective a adrenergic blockers are not because a. It is the only orally active a blocker

d. Increase in adenylyl cyclase activity

a. Inducing hepatic glycogenolysis

The drug which produces vasoconstriction despite being an a adrenergic blocker is a. Phenoxybenzamine

c. Renal

86.

Guanethidine inhibits

b. Dopamine

a. Cutaneous

85.

Vasoconstrictors should not be used in

99.

Propranolol does not block the following action of adrenaline a. Bronchodilation b. Lipolysis c. Muscle tremor d. Mydriasis

100. Phenylephrine a. Mimics the transmitter at postsynapticreceptors b. Displaces transmitter from axonal terminal c. Inhibits synthesis of transmitter d. None of the above


101. Aminoethylimidazole is?

109. Following is an example of paraaminophenol NSAID

a. 2methyl histamine

a. Diclofenac

b. Histamine

b. Acetaminophen

c. 2pyridyl ethylamine

c. Piroxicam

d. 4methyl histamine

d. Celecoxib

102. Agents that often cause vasoconstriction include all of the following except a. Angiotensin II b. Methysergide c. PGF2a e. Thromboxane 103. Inflammation is a complex tissue reaction that includes the release of cytokines, leukotrienes, prostaglandins, and peptides. Prostaglandins involved in inflammatory processes are produced from arachidonic acid by

110. This drug, which does not activate opioid receptors, has been proposed as a maintenance drug in treatment programs for opioid addicts; a singly oral dose will block the effects of injected heroin for up to 48 hours a. Amphetamine b. Buprenorphine c. Naloxone d. Naltrexone e. Propoxyphene 111. Which one of the following dextromethorphan is accurate?

a. Cyclooxygenase 1

a. Activates kappa receptors

b. Cyclooxygenase 2

b. Analgesia equivalent to pentazocine

c. Glutathione – S – transferase

c. Highly effective antiemetic

d. Lipoxygenase

d. Less constipation than codeine

e. Phospholipase A2

e. Use requires a prescription

104. A 60yearold woman has glaucoma following cataract surgery. Which of the following can be used to reduce intraocular pressure? a. Leukotriene LTD4 or its analogs b. Prostaglandin E2 or its analogs c. Prostaglandin F2a or its analogs d. Slowreacting substance of anaplylaxis (SRSA) e. Thromboxane A2 or its analogs 105. Which of the following is a reversible inhibitor of platelet cyclooxygenase? a. Alprostadil b. Aspirin c. Ibuprofen d. LTC4 e. Misoprostol 106. Vasodilation by prostaglandins involves a. Arterioles b. Precapillary sphincters c. Postcapillary venules d. All of the above 107. Fentanyl transdermal patches have been used postoperatively to provide transdermal analgesia. The most dangerous adverse effect of this mode of administration is a. Cutaneous reactions b. Diarrhea c. Hypertension d. Relaxation of skeletal muscle e. Respiratory depression 108. Opioid analgesics are either contraindicated or must be used with extreme caution in several clinical situations. For morphine, such situations do not include a. Aqueous diffusion b. Aqueous hydrolysis c. Lipid diffusion d. Pinocytosis or endocytosis e. Special carrier transport

statements

about

112. Which one of the following effects does not occur in salicylate intoxication ? a. Hyperventilation b. Hypothemia c. Metabolic acidosis d. Respiratory alkalosis e. Tinnitus 113. Which one of the following drugs is not useful in dysmenorrhea? a. Aspirin b. Colchicine c. Ibuprofen d. Rofecoxib e. Naproxen 114. Following gold compound is generally administered orally a. Aurothioglucose b. Auronafin c. Gold sodium thiomalate d. All of the above 115. The main advantage of ketorolac over aspirin is that ketorolac a. Can be combined more safely with an opioid such as codeine b. Can be obtained as an overthecounter agent c. Does not prolong the bleeding time d. Is available in a parenteral formulation that can be injected intramuscularly or intravenously e. Is less likely to cause acute renal failure in patients with some preexisting degree of renal impairment 116. A 45yearold surgeon has developed symmetric early morning stiffness in her hands. She wishes to take a nonsteroidal antiinflammatory drug to relieve these symptoms and wants to avoid gastrointestinal side effects. Which one of the following drugs is most appropriate? a. Aspirin b. Celecoxib c. Ibuprofen

PHARMACOLOGY

d. Prostacyclin

1301


1302

d. Indomethacin

d. Misoprostol

e. Piroxicam

e. Tacrolimus

117. Following is an example of preformed and not lipid derived mast cell mediator of inflammatory process a. LTC4 b. PGD2 c. PAF d. Histamine 118. The toxicity spectrum of aspirin does not include a. Increased risk of encephalopathy in children with viral infections

MCQ's

b. Increased risk of peptic ulcers c. Hyperprothrombinemia d. Metabolic acidosis e. Respiratory alkalosis 119. Accidental poisonings are common with both aspirin and ibuprofen, two OC drugs available in tasty chewable tablets. In cases of overdose, aspirin is more likely than ibuprofen to cause a. Autonomic Instability

125. Acetyl salicylic acid is soluble in a. An aqueous base b. Water c. An aqueous acid 126. Decomposition of the acetyl salicylic acid at room temperature most likely would occur by a. Oxidation of the ester b. Reduction of the carboxylic acid c. Hydrolysis of the ester 127. Diamprit is an agonist of ______ receptors, except a. H1 b. H2 c. H3 d. All of the above 128. Which of the following enzymes is ultimately responsible for the production of prostaglandins associated with inflammatory reactions?

b. Hepatic necrosis

a. Phospholipase

c. Metabolic acidosis

b. Lipoxygenase

d. Thrombocytopenia

c. CyclooxygenaseI

e. Ventricular arrhythmias

d. Cyclooxygenase II

120. A drug that decreases blood pressure and has analgesic and spasmolytic effects when given intrathecally is a. Atenolol b. Clonidine c. Morphine d. Nitroprusside e. Prazosin 121. Cyclooxygenase1 and â&#x20AC;&#x201C;2 are responsible for a. The synthesis of prostaglandins from arachidonate b. The synthesis of leukotrienes from arachidonate c. The conversion of ATP to cAMP d. The metabolic degradation of cAMP e. The conversion of GTP to cGMP 122. Following agent is generally used in allergic rhinitis a. Beclomethasone b. Fluticasone c. Triamcinolone d. All of the above 123. The primary objective for designing drugs that selectively inhibit COX â&#x20AC;&#x201C; 2 is to

e. Xanthine oxidase 129. Which of the following prostaglandin analogs is used specifically for the treatment of NSAID induced gastrointestinal ulcertation? a. Alprostadil b. Misoprostol c. Carboprost d. Dinoprostone e. Epoprostenol 130. Which of the following compounds is most likely to lower circulating levels of leukotrienes? a. Zileuton b. Montelukast c. Carprofen d. Aspirin e. Allopurinol 131. The action of aspirin that results in its greater efficacy as an antithrombotic (antiplatelet) drug is its ability to a. Inhibit lipoxygenase as well as cyclooxygenase b. Selectively inhibit cyclooxygenase I c. Inhibit leukocyte migration

a. Decrease the risk of nephrotoxicity

d. Promote uric acid excretion

b. Improve anti-inflammatory effectiveness

e. Acetylate cyclooxygenase

c. Lower the risk of gastrointestinal toxicity d. Reduce the cost of treatment of rheumatoid arthritis e. Selectively decrease thromboxane A2 without effects on other eicosanoids 124. A newborn was diagnosed as having a congenital abnormality that resulted in transposition of her great arteries. While preparing the infant for surgery, the medical team needed to keep the ductus arteriosus open. They did this by infusing a. Cortisol b. Indomethacin c. Ketorolac

132. Which of the following drugs may be effective in the treatment of gouty arthritis by acting by two separate and distinct mechanisms? a. Allopurinol b. Probenecid c. Colchicine d. Indomethacin e. Sulfinpyrazone


133. Acute or chronic colchicine toxicity may be identified by which of the following signs/symptoms? a. Alopecia b. Blood dyscrasias c. Severe gastrointestinal upset d. All of the above e. None of the above 134. Patients taking chronic doses of nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) should periodically be screened for which of the following toxicities? a. Nephrotoxicity c. Cardiotoxicity d. All of the above e. None of the above 135. Which of the following medications would represent arthritis therapy that is least likely to cause gastric ulceration? a. Aspirin b. Acetaminophen c. Piroxicam d. Meclofenamate e. Rofecoxib 136. In addition to their ability to decrease inflammatory prostaglandin synthesis, some nonsteroidal Antiinflammatory drugs (NSAIDs) may owe part of their effects to their ability to

141. What is the most commom sign/symptom of hemorrhoids? a. Bleeding b. Pain c. Seepage d. Pruritus 142. Which of the following agents is designated as a safe and effective analgesic, anesthetic and antipruritic by the Food and Drug Administration? a. Witch hazel b. Juniper tar c. Hydrocortisone d. Phenylephrine 143. A 65yearold is interested in taking ginkgo. Which of the following statements is correct regarding ginkgo? a. Ginkgo is contraindicated in diabetes and pregnancy b. There is a drugherb interaction between ginkgo and aspirin c. Toxic effects include hypertension and cardiac arrest d. There is a drugherb interaction between ginkgo and phenelzine e. Ginkgo is contraindicated in patients with gallstone pain 144. All of the following medications should not be used routinely in pregnant patients during the third trimester except a. Acetaminophen

a. Inhibit leukocyte migration

b. Nonsteroidal anti-inflammatory drugs

b. Inhibit leukotriene synthesis

c. Warfarin

c. Stabilize lysosmal membranes

d. Lithium

d. All of the above

e. Aspirin

e. None of the above 137. The termination of heparin activity by protamine sulfate is due to a. A chelating action b. The inhibition of gastrointestinal absorption of heparin c. The displacement of heparinplasma protein binding d. An acidbase interaction e. The prothrombinlike activity of protamine 138. In gastrointestinal tract, serotonin causes a. Contraction of gastrointestinal muscles b. Decreased muscle tone c. Decreased peristalsis d. All of the above 139. A FDA â&#x20AC;&#x201C; approved ingredient for protection against painful sensitivity of the teeth due to cold, heat, acids, sweets or contact is a. Dicalcium phosphate b. Sodium lauryl sulfate c. 5% potassium nitrate d. Zinc chloride e. Calcium carbonate 140. Which local anesthetic should be used to treat symptoms of pain, itching, burning, and disconfort in patients with an established lidocaine allergy? a. Tetracaine b. Dibucaine

1303

d. Benzocaine

145. Which of the following statements best describes the usual course of rheumatoid arthritis? a. It is an acute exacerbation of joint pain treated with shortterm anti-inflammatory therapy b. It is a chronic disease characterized by acute changes within nonsynovial joints c. It is an acute disease that is characterized by rapid synovial changes due to inflammation d. It is a chronic disease characterized by acuteexacerbations followed by remissions with consequences associated with chronic inflammatory changes e. It is a joint disease characterized by a marked loss of calcium from the bones and a resultant thinning of the bones 146. All of the following statements concerning an acute gouty arthritis attack are correct except a. The diagonosis of gout is assured by a good therapeutic response to colchicines because no other form of arthritis responds to this drug b. To be assured of the diagnosis, monosodium urate crystals must be identified in the synovial fluid of the affected joint c. Attacks frequently occur in the middle of the night d. An untreated attack may last up to 2 weeks e. The first attack usually involves only one joint, most frequently the big toe (first metatarsophalangeal joint) 147. TNFais an example of eicosanoids a. Interleukins b. Cytotoxic factors c. Interferons d. Colony stimulating factors

PHARMACOLOGY

b. Peripheral neuropathy

c. Pramoxine


1304 148. Potential adverse effects associated with aspirin include all of the following except

a. Gastrointestinal ulceration b. Renal dysfunction c. Enhanced methotrexate toxicity d. Cardiac arrhythmias e. Hypersensitivity asthma 149. All of the following facts are true about nonsteroidal antiinflammatory drugs (NSAIDs) except a. They are antipyretic b. There is a celling effect to their analgesia

MCQ's

c. They can cause tolerance d. They do not cause dependence e. They are antiinflammatory 150. Which of the following narcotics has the longest duration of effect? a. Methadone b. Controlledrelease morphine c. Levorphanol d. Transdermal fentanyl e. Dihydromorphone 151. CylcoocygenaseII specific inhibitors block the following a. Production of cytoprotective prostaglandins b. Tumor necrosis factor a c. Production of prostaglandins responsible for pain and inflammation 152. The emetic action of morphine is due to a. Irritation of gastrointestinal tract b. Stimulation of cerebral cortex c. Stimulation of medullary vomiting center d. Stimulation of emetic chemoreceptor trigger zone e. None of the above 153. Colchicine is used mainly to treat a. Gout b. Arthiritis c. Diabetes

d. Cardiovascular collapse e. None of the above 157. A very common side effect of morphine is a. Allergic response b. Blood dyscrasias c. Constipation d. Liver damage e. Visceral pain 158. Eicosanoids are a group of _____ carbon unsaturated fatty acids a. 20 b. 10 c. 25 d. 35 159. Which of the following durgs is a monamine oxidase inhibitor, but is used to treat hypertension? a. Tranylcypromine (Parnate) b. Reserpine c. Propranolol (Inderal) d. Pargyline (Eutonyl) e. Imipramine (Tofranil) 160. Autacoids differ from hormones in that a. Autacoids are involved only in the causation of pathological states b. Autacoids do not have a specific cell/ tissue of origin c. Autacoids generally act locally at the site of generation and release d. Both (b) and (c) 161. Which of the following eicosanoids is generated through the lipozygenase pathway ? a. Prostaglandin E2 b. Thromboxane A2 c. Prostacyclin d. Leukotriene C4 162. The cyclooxygenase isoenzymes COX1 and COX2 differ from each other in that

d. Carcinomas

a. They catalyse different pathways in prostanoid biosynthesis

e. High blood pressure

b. COX–1 is inhibited by aspirin but not COX–2

154. Which type of patient is most likely to hypersensitive to aspirin? a. Intrinsic asthamatic b. Extrinsic asthamatic

c. COX–2 is inhibited by ibuprofen but not COX–1 d. COX–1 is constitutive while COX–2 is inducible 163. Which of the following is an irreversible inhibitor of cyclooxygenase ?

c. Chronic bronchitic

a. Aspirin

d. Patient with viral injection

b. Phenylbutazone

e. Both (c) and (d)

c. Indomethacin

155. Codeine acts as a cough sedative by a. Producing mild nausea

d. Piroxicam 164. The prostanoid that consistently constricts blood vessels is

b. Depressing bronchiolar secretions

a. Prostaglandin E2

c. Depressing pulmonary action

b. Prostaglandin F2a

d. Depressing cough center

c. Thromboxane A2

e. Paralyzing sensory nerves of bronchi

d. Prostacyclin

156. The greatest threat from morphine poisoning is a. Renal shutdown b. Paralysis of spinal cord c. Respiratory depression

165. The following prostanoid is a potent inducer of platelet aggregation a. Prostacyclin b. Prostaglandin E2


c. Prostaglandin D2 d. Thromboxane A2 166. Aspirin in low doses produces longlasting inhibition a. Platelets contain low quantity of COX b. Platelets cannot synthesize fresh COX molecules c. Platelets bind aspirin with high affinity d. Platelet COX is inducible 167. The early pregnancy uterus is sensitive to the following oxytocic a. Oxytocin c. Prostaglandin F2a d. Both (a) and (b) 168. Cervical priming with prostaglandin results in a. Facilitation of sperm movement through cervical canal b. Increased cervical tone c. Softening of cervix d. Increased cervical secretions 169. Corticosteroids exert anti-inflammatory action by inhibiting the following enzyme a. Cycloxygenase b. Lipozygenase c. Phospholipase A d. Phosphodiesterase 170. Main effect of sulphinpyrazone in hyperuricaemia is a. Suppress the symptoms b. Promote the elimination of urate c. prevent urate synthesis d. All of the above 171. Which of the following glucocorticoids has significant mineralocorticoid activity also ? a. Hydrocortisone b. Triamcinolone c. Dexamethasone d. Betamethasone 172. Corticosteroid therapy is practically mandatory in the following condition. a. Septic shock b. Renal transplant c. Rheumatoid arthritis d. Ulcerative colitis 173. For limiting cerebral edema due to brain tumour, the preferred corticosteroids are betamenthasone/dexamethasone because a. They do not cause Na+ and water retention b. They are more potent c. They can be administered intravenously d. They inhibit brain tumours 174. Systemic corticosteroid therapy is not used routinely and is reserved only for severe cases of a. Exfoliative dermatitis b. Posterior uveitis c. Acute rheumatic fever d. Hodgkinâ&#x20AC;&#x2122;s disease

a. Osteoporosis b. Rise in blood pressure c. Moon face d. Increased susceptibility to infection 176. Which of the following bones is affected more by glucocorticoid induced osteoporosis? a. Femur b. Humerus c. Radius d. Lumber vertebra 177. Morphine produces analgesia by acting at a. Peripheral pain receptors b. A spinal site c. Suspraspinal sites d. Both (b) and (c) 178. In man sedation caused by morphine is characterized by a. Initial excitement b. Little or no motor incoordination c. Rise in seizure threshold d. All of the above 179. Instead of depressing, morphine stimulates a. Vasomotor centre b. Edinger westphal nucleus c. Temperature regulating centre d. Cough centre 180. In a comatose patient suspected of poisoning, which of the following findings would be against the drug being morphine a. Selegiline b. Chlorgiline c. Moclobemide d. Tranylcypromine 181. Instead of being effective in hyperuricaemia following drug is contradictred in the treatment of gout a. Indomethacin b. Diclofenac c. Piroxicam d. Aspirin 182. Morphine dependence is characterized by a. Marked drug seeking behavior b. Physical dependence without psychic dependence c. Physical as well as psychic dependence d. Both (a) and (c) 183. Morphine is contraindicated in head injury because a. It does not relieve the pain of head injury b. It can raise intracranial tension c. It can cause constipation d. It is liable to cause addiction 184. Which of the following opioids is more potent than morphine? a. Pethidine b. Fentanyl c. Dextropropoxyphene d. Tramadol

PHARMACOLOGY

b. Methylergometrine

175. The following adverse effect of corticosteroids is due to their 1305 mineralocorticoid action


1306 185. Which of the following opioid analgesics is similar to codeine in pharmacological profile but is less constipating ? a. Methadone b. Buprenorphine c. Butorphanol d. Dextropropoxyphene 186. Select the analgesic which acts through opioids as well as additional spinal monoaminergic mechanisms. a. Tramadol

MCQ's

b. Ethoheptazine

b. It is inducible c. It generates cytoprotective prostagladins in gastric mucosa d. It is found only in foetal tissues 195. Aspirin produces analgesia by a. Preventing sensitization of peripheral pain receptors b. Affecting gating of pain impulses at spinal level c. Raising pain threshold at subcortical level d. Both (a) and (b) 196. Aspirin reduces fever by

c. Dextropropoxyphene

a. Decreasing heat production in the body

d. Alfentanil

b. Enhancing cutaneous blood flow

187. An opioid analgesic is preferred over aspirin like analgesic in the following condition. a. Acute gout b. Burn

c. Inducing sweating d. Both (b) and (c) 197. In the treatment of chronic inflammatory diseases, the most important limitation of aspirin is

c. Toothache

a. Acid â&#x20AC;&#x201C; base and electrolytc disturbances

d. Neuralgia

b. Hypersensitivity and idiosyncratic reactions

188. Morphine has high affinity for the following opioid receptor(s). a. Îź (Mu) b. k (Kappa)

c. Gastric mucosal damage d. Salicylism 198. Generally the earliest manifestation of salicylism is

c. d (Delta)

a. Visual disturbance

d. All of the above

b. Excitement

189. Which of the following is an agonistantagonist type of opioid analgesic a. Pethidine b. Pentazocine

c. Hyperventillation d. Tinnitus 199. Allergy is immediate hypersensitivity mediated by _____and mast cell degranulation

c. Fentanyl

a. IgG

d. Buprenorphine

b. IgE

190. Pentazocine differs from morphine in that a. It is inactive by the oral route b. It does not produce physical dependence c. It has a lower ceiling of analgesic effect d. Its action is not blocked by naloxone 191. Which action of morphine is incompletely reversed by naloxone ? a. Analgesia b. Respiratory depression c. Sedation d. Miosis 192. Lower dose of naloxone is required to a. Antagonise the actions of nalorphine b. Antagonise the actions of pentazocine c. Precipitate withdrawal in mildly morphine dependent subjects d. Precipitate withdrawal in highly morphine dependent subjects 193. Following mediators are involved in acute inflammation except

c. IgM d. IgA e. IgD 200. Immediate Allergy is what type of hypersensitivity reaction a. Type I Hypersensitivity b. Type II Hypersensitivity c. Type III Hypersensitivity d. Type IV Hypersensitivity e. Type V Hypersensitivity 201. Hypersensitivity refers to undesirable reactions produced by a. circulatory system b. Respiratory system c. Immune System d. Endocrine system e. Autonomic nervous system 202. A mast cell (or mastocyte) is a resident cells of several types of tissues and contains many granules rich in_______. a. Acetylcholine b. Nicotine c. Epinephrine

a. Histamine

d. Histamine

b. Leukotrienes

e. Histadine

c. Interferons d. Bradykinin 194. The distinctive feature of the isoenzyme cyclooxygenase2 is a. It is not inhibited by indomethacin


203. The organ which involve most frequent hypersensitivity reaction is a. Liver b. Kidney c. Skin d. Lungs e. Stomach 204. Penicillin Allergy is usually caused by its chemical degradation to a. Penicillamine b. Penilloic acid d. Penaldic acid e. Penicilloic acid 205. Influenza vaccines can be contraindicated to patients who are allergic to the preservatives of the vaccine, e.g. _____

1307

a. An allergic or immune response that begins within a period lasting from a few minutes to about an hour after exposure to an antigen to which the individual has been sensitized b. An allergic reaction that becomes apparent only hours after contact c. An allergic reaction that results from the formation of antigenantibody complexes between a foreign antigen and IgM or IgG immunoglobulins. d. An allergic reaction that is due to the presence of elevated levels of antigenantibody complexes that cause tissue damage e. It occurs during blood transfusion reactions and in hemolytic disease of the newborn. 211. Immunodeficiency: a. A localized protective reaction of tissue to irritation, injury, or infection, characterized by pain, redness, swelling, and sometimes a loss of function

a. Neomycin

b. A disorder or deficiency of the normal immune response

b. Streptomycin

c. A disease resulting from an immune reaction produced by an individualâ&#x20AC;&#x2122;s white blood cells or antibodies acting on the bodyâ&#x20AC;&#x2122;s own tissues or extracellular proteins

c. Gentamycin d. Doxycycline e. Clavulanic acid 206. Reduction in fever within ___ h withdrawal of drug strongly suggests that suspected drug causing allergy. a. 38 h b. 24h c. 48h d. 16 h e. 20 h 207. If fever is accompanied by ________, drug toxicity is more likely than allergy and is much more serious. a. Granulocytopenia b. Thrombocytopenia c. Histamine d. Leukopenia e. Hypotension 208. A mother comes to the pharmacy with her 3yearold son who has a cough. Which of the following list of symptoms is most likely to indicate an allergy? a. fever b. chesty cough c. rhinorrhoea d. headache e. malaise 209. The primary reason for a physician to prescribe human insulin is that: a. It has a faster onset of action than other insulins b. It has a shorter duration of action than other insulins c. It can be given to patients who have an allergy to animal insulins d. It is more effective in preventing the complications of diabetes than animal insulins e. It is more sterile than other insolines.

d. A disease caused by immune system when the drug passes 1st pass effect and damage the liver. e. It is an immunity disorder which is genetically transferred. 212. Delayed allergy reaction (type IV allergic reaction) is: a. An An allergic or immune response that begins within a period lasting from a few minutes to about an hour after exposure to an antigen to which the individual has been sensitized b. An allergic reaction that becomes apparent only hours after contact c. An allergic reaction that results from the formation of antigenantibody complexes between a foreign antigen and IgM d. allergic reaction that is due to the presence of elevated levels of antigenantibody complexes that cause tissue damage e. An allergic disorder which is transferred genetically. 213. Which one of the following is a false statement about atopic eczema? a. It commonly begins by drug reaction. b. Superadded herpes complication.

simplex

infection

is

a

serious

c. The serum IgE level is normally raised. d. The skin lesions are typically itchy. e. Treatment with systemic steroids is often necessary. 214. Which one of the following statements is false ? Allergic asthma is characterized by: a. Response to cyclosporin therapy in severe disease. b. Is characterised by reversible airways obstruction. c. T2 cells are found in bronchoalveolar lavage fluid. d. Affects 5% of the population. e. Is diagnosed routinely by use of ELISA

PHARMACOLOGY

c. Penicillenic acid

210. Immediate allergy reaction (type I allergic reaction) is:


MCQ's

1308

Pharmacology - Answers 1.

d

38.

b

76.

a

112. b

149. c

2.

c

39.

b

77.

b

113. b

150. d

3.

c

40.

a

78.

d

114. b

151. c

4.

b

41.

a

79.

a

115. d

152. d

5.

a

42.

a

80.

a

116. b

153. a

6.

d

43.

d

81.

c

117. d

154. a

7.

c

44.

a

82.

c

118. c

155. d

8.

b

45.

a

83.

d

119. c

156. c

9.

c

46.

c

84.

d

120. b

157. c

10.

e

47.

e

85.

d

121. a

158. a

11.

d

48.

b

86.

d

122. d

159. d

12.

a

49.

e

87.

c

123. c

160. d

13.

b

50.

b

88.

a

124. d

161. d

14.

b

51.

a

89.

d

125. a

162. d

15.

c

52.

a

89.

d

126. c

163. a

16.

a

53.

a

90.

d

127. a

164. c

17.

b

54.

b

91.

c

128. d

165. d

18.

b

55.

c

92.

c

129. b

166. b

19.

b

57.

c

93.

c

130. a

167. c

20.

e

58.

d

94.

b

131. e

168. c

21.

c

59.

b

95.

c

132. d

169. c

22.

c

60.

d

96.

c

133. d

170. b

23.

b

61.

b

97.

c

134. a

171. a

24.

b

62.

d

98.

c

135. e

172. b

25.

a

63.

b

99.

d

136. d

173. a

26.

b

64.

b

100. a

137. d

174. c

27.

d

65.

b

101. b

138. a

175. b

28.

a

66.

b

102. d

139. c

176. d

29.

e

67.

b

103. b

140. c

177. b

30.

c

68.

c

104. c

141. a

178. b

31.

d

69.

b

105. c

142. b

179. b

32.

e

70.

d

106. d

143. b

180. a

33.

a

71.

c

107. e

144. a

181. d

34.

b

72.

a

108. e

145. d

182. d

35.

d

73.

a

109. b

146. a

183. b

36.

c

74.

d

110. d

147. b

184. b

37.

e

75.

c

111. d

148. e

185. d


186. a

192. d

198. d

204. e

210. a

187. b

193. c

199. b

205. a

211. b

188. a

194. b

200. a

206. c

212. b

189. b

195. d

201. c

207. a

213. e

190. c

196. d

202. d

208. c

214. e

191. c

197. c

203. c

209. c

1309

PHARMACOLOGY


PICTORIAL QUIZ 1.

CT Scan of thorax

Diagnosis ?

5.

Most common cardiac abnormality in this paitent?

6. Diagnosis

2.

Diagnosis ?

3.

CT Scan of Head

7.

8.

Diagnosis ?

4.

Diagnosis


9.

Causative organism is ?

10.

14.

Diagnosis 11.

Diagnosis 15.

Diagnosis

Diagnosis

16.

12.

Diagnosis

Diagnosis

1311

PICTORIAL QUIZ

13.


1312 17.

21.

MCQ's

Diagnosis 18.

Diagnosis 22.

Diagnosis

Diagnosis

19.

23.

Diagnosis 20.

Diagnosis 24.

Diagnosis

Diagnosis


29.

A 55 year male with pain abdomen and weight loss?

a. Pancreatic pseudocyst

Diagnosis

b. Pancreatic carcinoma

26.

c. Cystic tumor of pancreas d. Neuroendocrine tumor 30.

A 40 year chronic alcoholic with pain abdomen?

Diagnosis 27.

a. Pancreatic pesudocyst b. Pancreatic carcinoma c. Cystic tumor of pancreas d. Neuroendocrine tumor 31.

A 35 year male with recurrent ascites?

Diagnosis 28.

a. Cirrhosis of liver b. Abdominal tuberculosis c. budd chiari syndrome d. Constrictive pericarditis. Diagnosis

1313

PICTORIAL QUIZ

25.


1314 32.

A 22 year female with chronic diarrhea

35.

A 30 year old female with sudden onset pain abdomen and jaundice?

a. mirzziâ&#x20AC;&#x2122;s syndrome

MCQ's

b. Choledocholithiasis c. Cholelithiasis

a. Inflammatory bowel disease b. Tuberculosis

d. Periampullary tumor 36.

A 40 year old male with recurrent idiopathic pancreatitis

c. Normal CT eneterography d. Amyloidosis 33.

A 65 year female with painless progressive jaundice with loss of weight and apettite

a. Microlithiasis b. Annular pancreas c. Pancreatic divisum d. Abnormal pancreatico-biliary communication. 37.

A 50 year female post cholecystectomy status with painless jaundice?

a. Primary sclerosing cholangitis b. Hilar cholangiocarcinoma c. Carcinoma gall bladder d. lymphoma 34.

A chronic Hepatitis B related cirrhosis patient with loss of weight

a. Primary sclerosing cholangitis b. Iatrogenic CBD stricture c. Distal cholangiocarcinoma d. Ig4 related cholangitis

a. Regenerative nodule b. Intrahepatic cholangiocarcinoma c. HCC d. Metastasis


38.

What is the ERCP procedure shown here?

41.

A 60 year old male with progressive mechanical dysphagia?

1315

a. Double CBD metal stenting b. Single CBD meal stenting

a. Achalsia cardia

c. Y-stenting 39.

c. Carcinoma esophagus

Which procedure is shown here?

d. GERD 42.

A 24 year old female with vomiting and chronic cough?

a. ERCP guided cystogastrostomy b. EUS guided cystogastrostomy c. Balloon dilatation of peptic stricture d. CBD stenting. 40.

a. Jackhammer esophagus

A 30 year female with pain abdomen and loss of weight for 6 months?

b. Distal esophageal spasm c. Type III achalsia cardia d. Type II achalasia cardia 43. A 55 year old male presented with acute intestihnal obstruction. What s depicted in the X RAY?

a. Crohnâ&#x20AC;&#x2122;s disease b. Tuberculosis c. Either a or b d. lymphoma a. Balloon Dilatation of the stricture b. SEMS c. Plastic stent d. Dilated bowel loops.

PICTORIAL QUIZ

b. Distal esophageal spasm

d. PTBD


1316 44.

What is the treatment of choice?

48.

A patient with hepatitis B related CLD with loss of weight and apettite?

a. Conservative management

MCQ's

b. Endoscopic Removal on urgent basis with roth net

45.

c. Surgery

a. Cirrhotic nodule

d. Either b or c

b. Dysplastic nodule c. Hepatocellular carcinoma

Which advance endoscopy imaging is showed here?

d. Cholangiocarcinoma 49.

A 40 year old male with history of constipation and finger evacuation now having bleeding Per rectum?

a. Chromoendoscopy b. Autoflouresence endoscopy c. Narrow band imaging d. Confocal laser endomicroscopy. 46.

What is this used for?

a. Inflammatory bowel disease b. Polyp c. Solitary rectal ulcer syndrome d. Any of the above 50.

A 34 year old female with pain abdomen, fever and loss of weight

a. Gastrointestinal imaging b. Gastrointestinal p H measurement c. Gastrointestinal Motility d. Both B and C 47.

A 30 year old with bleeding per rectum? a. Adenocarcinoma b. Tuberculosis c. Crohnâ&#x20AC;&#x2122;s disease d. Either b or c

a. Tubolo-villous adenoma b. Serrated adenoma c. Hyperplastic polyp d. adenocarcinoma


51.

A 50 year old male with history of corrosive consumption

54.

A 65 year old female underwent cholecystectomy for pain 1317 abdomen. What does the specimen shows?

b. Gall bladder polyp a. Carcinoma esophagus

c. Gall bladder carcinom

b. Multiple esophageal stricture

d. Gall bladder calculi

c. Normal barium swallow d. Post dilatation barium swallow 52.

55.

a 24 year old HIV positive patient with chronic small bowel diarrhea with steatorhea

A 68 year old male with loss of weight, anorexia, anemia

a. Cryptosporiasis b. Giardiasis c. Entameba histolytica

d. Trichenella infection a. Tuberculosis of stomach b. Early carcinoma of stomach

56.

A 30 year old female with chronic pain abdomen for 6 months

c. Lymphoma d. H.Pylori related gastritis 53.

Surgical specimen from a 60 year old male presenting with history of constipation and mass per abdomen

a. Pancreatic pseudocyst b. Walled off pancreatic nectosis c. Serous cyst adenoma

a. Carcinoma colon b. Tuberculosis of colon c. Amebic colitis d. lymphoma

d. Pancreatic neuroendoscrine tumor

PICTORIAL QUIZ

a. Cholesterosis


1318 57.

A 30 year old male with recurrent jaundice with itching for 5 years

60.

A 28 year old male with dysphasia to solids

MCQ's

a. Esophageal A ring b. Sckatziâ&#x20AC;&#x2122;s ring

a. Sclerosing cholangitis

c. Eosinophilic esophagitis

b. HIV cholangiopathy

d. Peptic stricture

c. Hilar cholangiocarcinoma d. Periampullary carcinoma 58.

61.

What is this used for?

A 33 year old female with inetrmittent chest pain and dysphagia

a. Gastrointestinal PH measurement b. Motility c. Mucosal imaging d. All of the above

a. Nutcracker esophagus b. Jackhammer esophagus

62.

A 54 year old male with asymptomatic transaminesimia

c. Achalasia cardia d. Distal esophageal spasm 59.

A 40 year old female wit dysphagia and regurgitation

a. EJG outflow tract obstruction

a. Microvesicular staetosis

b. Type I achalasia cardia

b. Macrovesicular steatosis

c. Type II achalsia cardia

c. Both a nd b

d. Type III achalasia cardia

d. cirrhosis


63.

A 32 year old female with bleeding per rectum and diarrhea

66.

A 50 year old male with AIDS, fever and chest pain

1319

b. Cytomegalovirus

a. Adenocarcinoma

c. Candidiasis

b. Lymphoma

d. tuberculosis

c. Inflammatory bowel disease d. tuberculosis 64.

67.

A 20 year old with recurrent aspiration pneumonia

A 29 year old male presented with dysphagia and chest pain

a. Treacheo-esophageal fistula b. Esophageal diverticulum c. Esophageal duplication cyst d. Esophageal crohnâ&#x20AC;&#x2122;s disease

a. GERD b. Crohnâ&#x20AC;&#x2122;s disease

68.

c. Esophageal candidiasis

A 55 year old alcoholic male with chronic abdominal pain and weight loss

d. Eosinophilic Esophagitis 65.

A 60 year old male with pulmonary tuberculosis and dysphagia

a. Pancreatic adenocarcinoma b. pancreatic cystic neoplasm c. Chronic calcific pancreatitis d. Pancreatic pseudocyst

a. Carcinoma esophagus b. Mega esophagus c. Crcinoma stomach d. Tuberculous involvement of esophagus.

PICTORIAL QUIZ

a. Herpes simplex


1320 69.

A 55 year old male with painless extrahepatic jaundice for 1 month

72.

A 50 year old male presented with chronic heartburn and regurgitation

MCQ's

a. Carcinoma esophagus a. Periampullary carcinoma

b. Barretts esophagus

b. Hilar cholangiocarcinoma

c. Eosinophilic esophagitis

c. Carcinoma gall bladder

d. Infectious esophagitis

d. Autoimmune pancreatitis 70.

73.

A 45 year female with bloating and pain abdomen

a. Chronic hepatitis

a. Celeac disease

b. Cirrhosis

b. H.pylori related chronic gastritis

c. Hepatocellular carcinoma

c. Autoimmune gastritis d. lymphoma 71.

A 50 year old male chronic alcoholic with following liver biopsy?

What is this gross specimen of a patient with anorexia and weight loss

d. Non alcoholic fatty liver disease 74.

Which advanced endoscopy technique is shown here?

a. Chromoendoscopy b. Autoflouresence endoscopy c. Narrow band imaging d. Confocal laser endomicroscopy. a. Carcinoma stomach b. Carcinoma esophagus c. Carcinoma small intestine d. Carcinoma colon


75.

What is this specimen of a 44 year female with recurrent intestinal obstruction?

a. Moulds in airconditioners b. Isocyanates

c. Ulcerative colitis

c. Micobacterium avium complex

d. Carcinoma colon Which procedure is shown in this image of a 44 year male with acute pancreatitis and massive GI bleed?

d. Cigarette smoking 79.

25 Yr female presented with inability to climb up stairs, joint pain, fever o/e

a. SLE b. RA c. DERMATOMYOSITIS d. POLYMYOSITIS

a. Pseudaneurysm of spleenic artery with coiling

80.

b. BRTO c. TIPSS

A 25 yr male presented with 6 days H/O fever, headache, generalised bodyache,. O/E eschar was found . What is the causative organism?

d. Diagnostic angiography 77.

1321

b. Crohns disease

76.

Hot tub lungs is best related to hypersensitivity to:

Hamman sign is characteristic of:

a. R .tsutsugamusi b. R. Typhi c. R .Prowazaki d. R .rickettsii 81.

40 yr female DM with skin lesion

a. Diaphragmatic paralysis b. Pneumomediastinum c. Tension pneumothorax d. Hydropneumothorax

a. necrobiosis lipoidica diabeticorrum b. acanthosis nigricans c. Bullous diabeticorrum d. Diabetic skin spots

PICTORIAL QUIZ

a. Tuberculosis

78.


MCQ's

1322

Pictorial Quiz - Answers 1.

CT thorax showing bronchiectatic changes

29.

c

56.

b

2.

Adenoma sebaceousum

30.

a

57.

a

3.

Intracerebral haemmorhage, haemorrhage is putamen

31.

d

58.

b

4.

Bow legs seen in rickets

32.

a

59.

c

5.

Simian crease in down syndrome. Most common cardiac abnormality in down syndrome is vsd

33.

b

60.

b

34.

c

61.

d

6.

Bitots spot

35.

b

62.

c

7.

Duputyren contracture, most common finger affected is ring fingure

36.

c

63.

c

8.

Electrical alternance seen in cardiac temponarde.

37.

c

64.

d

9.

C T thorax showing hydatid cyst of liver, causating organism eccinococcus granulossus

38.

c

65.

a

10.

Hair on end appeareance on skull x-ray, seen in sickle cell disease, thalassaemia

39.

b

66.

a

11.

Rheumatoid arthitis

40.

c

67.

a

12.

Increased heel pad thickness seen in acromegaly

41. c

68.

c

42.

d

69.

a

43.

b

70.

b

most

common

site

of

intraparenchymal

13. Herpes zoster opthalmicus, cranial nerve involved trigeminal nerve (ophthalmic) division. 14.

K- F ring seen in wilsons disease

44.

b

71.

a

15.

Large equiphasic QRS complex in v2 v3 v4 (katz watchel phenomenon) seen in biventricular hypertrophy

45.

c

72.

b

46.

b

73.

b

16.

Multiple punched out lesion. Seen in multiple myeloma

47.

a

74.

a

17.

Slapped chick appearance seen in parvovirus infection

48.

c

75.

b

18.

Multiple ring enhancing lesion. Seen in tuberculosis

49.

c

76.

a

19.

Pericardial effusion

50.

b

77. b

20.

Bilateral hilar adenopathy seen in sarcoidosis

51.

b

78. c

21.

Rugger jersey spine X-ray lumbosacral spine showing increased bone density at both ends with tranlucency in middle seen in hyperparathyroidsm

52.

b

79. c

22.

Superior venacaval syndrome

53.

a

80. a

23.

Acute subdural haemorrage

54.

a

81. a

24.

Dermatomyositis- shawl sign

55.

a

25.

Snow storm appeareance on usg. Seen in molar pregnancy

26.

X-ray of lumbosacral spine showing calcification of intervertebral disc. Seen in chondro calcinosis

27.

Fusion of cervical vertebrae seen in klippel feil syndrome

28.

Coin shadow in cheast xray seen in carcinoma laungs


MISCELLANEOUS 1.

2.

Regarding serratus anterior muscle which is incorrect?

10.

a. Incidence of the disease

b. Lifts arm above the shoulder

b. Incidence is low in the community

c. Supplied by long thoracic nerve

c. Early detection leads to favorable outcome

d. Originates from lower eight ribs

d. The disease has a lead time

The treatment of choice for atticoantral variety of chronic suppurative otitis media is:

11.

b. Median

b. Medical management

c. Axillary

c. Underlay myringoplasty d. Insertion of ventilation tube All of the following are the complications in the new born of a diabetic mother except?

d. Musculocutaneous 12.

b. 15%

b. Hyperglycemia

c. 50%

c. Hypocalcemia 4.

The correct line of management in child who has swallowed a coin is?

d. 80% 13.

b. Block of alpha & beta receptors c. Agonistic action on alpha receptors

b. Rigid endoscopy

d. Adrenaline only

c. Laparotomy 5.

14.

b. Calcarine

a. T cells

c. Superior temporal

b. Macrophages

d. Inferior occipital

c. B cells 6.

15.

b. Methyl testosterone

a. Superior conchae

c. Oestrogens

b. Cymba conchae

d. Osmic acid

c. Middle conchae 7.

16.

b. Avascular necrosis head of humerous c. Brachial plexus injury

a. Entero-invasive E.coil

d. Chip fracture scapula

b. Entero-pathogenic E.coil d. Entero-aggregative E.coil 8.

17.

b. Flavivirus c. Oncovirus d. Arbovirus

a. Phenylketonuria c. Multiple carboxylase deficiency

18.

d. Glutaric aciduria 9.

b. Neurological abnormalities c. Hepatic failure d. Thrombotic angiopathy

a. Urea c. Blood ammonia d. Urinary nitrogen content

In shigella dysentery associated hemolytic uremic syndrome, the false statement is? a. Leucocytosis

For assessing the ability of protein utilisation the best index is? b. Uric acid

HIV is a? a. Retrovirus

With urine turning green on ferric chloride test, the diagnosis is: b. Alkaptonuria

Anterior dislocation of shoulder causes all except? a. Circumflex artery injury

Most common strain of E.coil giving rise to travellerâ&#x20AC;&#x2122;s diarrhoea is?

c. Entero-toxigenic E.coil

Medical treatment for BPH includes? a. Finesteride

Mac Ewenâ&#x20AC;&#x2122;s triangle can be felt through the?

d. Posterior part of auricle

Primary visual field is situated around the ______ sulcus? a. Central

Helper cells belong to?

d. Monocytes

Vasomotor reversal of Dale is because of? a. Block of alpha receptors

a. Fiber optic endoscopy

d. Wait and Watch

What is the percentage of chances of hydatidiform mole to develop choriocarcinoma? a. 5%

a. Hyperbilirubinemia

d. Hypomagnesemia

Nerve not related to humerus is? a. Radial

a. Mastoidectomy

3.

Screening test is not useful when?

a. Multipinnate muscle

19.

Dengue hemorrhagic fever is caused by? a. Type I secrotype b. Reinfection with the same serotype of dengue virus


1324 20.

21.

c. Reinfection with the different serotype of the dengue virus

c. Fracture of first metatarsal

d. Reinfectionin immunocompromised host

d. Fracture of first metacarpal

When the sample size is less than 30, one of the following modifications is made in the formula of standard deviation?

30.

a. Numerator is increased

a. Alkali denaturation test

b. Denominator is decreased

b. Cellulose acetate electrophoric

c. Both numerator and denominator are changed

c. Sickling test

d. Numerator is decreased

d. Osmotic fragility test

Oesophagus receives blood supply from all except?

31.

a. Inferior thyroid artery

b. Hypothyroidism

MCQ's

c. Internal mammary artery

c. Hyperthyroidism

d. Bronchial artery All are pencillinase resistant except? a. Methicillin

d. Gynaecomastia 32.

b. Selenium

c. Penicillin

c. Antioxidants

d. Dicioxacillin

24.

25.

26.

27.

d. Fatty food 33.

a. Colon

b. E

b. Illeum

c. A

c. Jejunum

d. C

d. Duodenum

Trimethoprim acts by?

34.

Cadaveric spasm

a. Inhibiting DHFR

a. Instant in onset

b. Inhibiting cell metabolism

b. Confined to small group of muscles

c. Inhibiting DNA

c. Occurs only in voluntary muscles

d. Inhibiting RNA

d. All of the above

Paradoxically split second heart sound signifies severe?

35.

The radionuclide used for ventriculography is

a. Pulmonary stenosis

a. Thallium

b. Mitral stenosis

b. Technetium

c. aortic stenosis

c. Gallium

d. tricuspid stenosis

d. Pottasium

Riboflavin nutritional status is assessed by?

36.

“Signet ring cells” are seen in?

a. Xanthine oxidase levels in RBC’s

a. Carcinoma cervix

b. Glutathione reductase activation in RBC’s

b. Carcinoma endometrium

c. Urine excretion of Riboflavin

c. Krukkenberg tumour

d. CytochromeCreductase levels in kidneys

d. Carcinoma vulva

Provision of free medical care to the people at government expense is known as?

37.

b. Upjohn c. Lindsay

c. Social medicine d. Social insurance programme Shortest sacrocotyloid diameter causing narrowing of pelvis is a feature of which type of maternal pelvis?

d. Lilly 38.

b. Birth weight of less than 2.5 gm

b. Gynaecoid

c. Maternal Hb<11.5 g/dl/

c. Platypelloid What is Bennett’s fracture?

Nutritional status of children between 04 years in a community can be assesed by all except? a. Mortality in 04 years

a. Android

d. Anthropoid

Cimetidine was synthesized by? a. Black

b. Social therapy

29.

Most common site of obstruction in gallstone ileus is?

a. B6

a. State medicine

28.

Which of the following helps in preventing colon cancer? a. High fiber diet

b. Nafcillin

23. Mild hemolyti anaemia is associated with vitamin.. . Deficiency?

Which of the following is not likely in patients taking amiodarone? a. Pulmonary fibrosis

b. Inferior phrenic artery

22.

All the following techniques are helpful in the diagnosis of haemoglobinopathies, except?

d. Height and weight of all preschool children 39.

Pulmonary fibrosis in Bronchogenic carcinoma of lung may follow exposure to?

a. Fracture dislocation of base of first metacarpal

a. Coal dust

b. Fracture dislocation of base of first metatarsal

b. Silica


40.

41.

c. Asbestos

c. immunization to the child

d. Bagasse

d. Treatment of anaemia and pneumonia in infant and toddlers

Ejection fraction increases with?

50.

a. Carboxyterminal

b. Decrease enddiastolic volume

b. Amino terminal

c. Decreased peripheral resistance

c. Sulphydryl groups

d. Venodilation

d. None of the above

a. Eustachian tube

51. Dissociate anaesthesia is described with which of the following? a. Propofol

b. Inferior meatus

c. Thipental

d. Posterior border of nasal septum

43.

Which one of the following would cause a metabolic acidosis is with a normal anion gap?

d. Halothane 52.

a. Strength of returning echo

b. Acute renal failure

b. Relation of transducer to blood flow

c. Diabetic ketoacidosis

c. Frequency of Doppler used

d. Aspirin overdose

d. Type of Doppler machine used

All of the following organs contain aneurysm in polyarteritis nodosa except?

53.

b. Hydrocephalus

b. Lung

c. Placenta praevia

c. Kidney d. Pancreas

45.

Diphtheria toxin acts by?

d. Polyhydramnios 54.

a. Actinic keratosis

b. Inhibiting glucose transport

b. Chronic cystitis

c. Increasing levels of Cyclic AMP

c. Chronic bronchitis

d. Inhibiting protein synthesis

d. Ulcerative colitis

Smokeless gun powder is composed of?

55.

a. Generally occurs as dissemination of a miliary tuberculosis

b. HCN

b. The cranial nerves frequently are involved

c. Nitrocellulose

c. The most common affected leptomeninges are at the base of the brain d. Communicating and obstructive hydrocephalus cortical abscesses, and empyemas are very uncommon complications

Cetuximab (an EGFR antagonist) can be used in? b. Anal canal carcinoma c. Gastric cancer

56.

b. Maintenance of electrolyte balance c. Sufficient hydration

The formula showing relations of pressure, thickness and radius? a. Laplace formula b. Ohm’s law

d. Arrest of bleeding 57.

c. Pascal’s law

b. 510% c. 1015%

Dapsone is useful for treating all except?

d. 1520%

a. Leprosy c. Madura Foot

58.

b. Lower eyelids c. Lower limbs

49. The most important factor to overcome protein energy malnuntrition in children less than 3yrs is; b. Early supplimentation of solids in infants

Rigor mortis first starts in? a. Upper eyelids

d. Lymphoma

a. Suply of subsidized food from ration shop

The average coronary blood flow in human being at rest is _ % of cardiac output ? a. 4.5%

d. Poisseulle’s formula

b. Dermatitis Herpetiformis

Haemostasis means? a. Coagulation

d. Small cell lung carcinoma

48.

True regarding tubercular meningitis:

a. KMno4

a. Palliation in head and neck cancer

47.

Which of the following pathologic processes in an example of dysplasia?

a. Inhibiting Acetyl Choline release

d. Sulphur 46.

The commonest cause of breech presentation is: a. Prematuarity

a. Liver

44.

In colour Doppler the colour depends upon?

a. Renal tubular acidosis

d. Fingers 59.

Madura foot is caused by? a. Blastomycosis

MISCELLANEOUS

b. ketamine

c. Middle turbinate 42.

The binding of 2,3 BPG to Hemoglobin is to?

a. Decrease endsystolic volume

Which is NOT visualized on posterior rhinoscopy?

1325


d. E.nana

b. Nocardia

1326

c. Candida albicans d. Tinea versicolor 60.

70.

a. Infection

Population of 10000, birth rate 36 per 1000, 5 maternal deaths, the MMR is?

b. Toxemia

a. 14.5

d. Thrombophlebitis

b. 13.8 c. 20

c. Hemorrhage 71.

b. Vagus nerve

Which of the following is not in WHO surveillance?

c. Facial nerve

a. Rabies

MCQ's

b. Influenza c. Malaraia

d. mandibular nerve 72.

b. Prevents ovulation in lactating women

The cause of breech presentation are all except?

c. In responsible for formation of corpus luteum

a. Previous caesarean section b. Placenta previa c. Contracted pelvis

d. Is responsible for progesterone secretion 73.

b. Gasserian ganlion

True about minoxidil is?

c. Geniculate

a. Increases hair growth b. Antihypertensive c. Both

d. Celiac ganglion 74.

d. None 64.

a. Bundle of His b. Ventricles

a. Mycoplasma pneumonia

c. AV node

b. Psittacosis

d. Purknje fibres

d. TB

75.

a. Diabetes b. Renal agenesis

a. 3 samples same day

d. Hydronephrosis

c. 1 sample of first day and 2 samples on the second day

c. Esophageal atresia 76.

d. 3 samples on 3 separate days

b. B.complex c. cyclosporin

b. Ligature mark

d. steroid 77.

Subarachnoid Haemorrhage is diagnosed by? a. Lumbar puncture

Cauliflower ear is due to?

b. CT scan

a. Haematoma

c. MRI

b. Carcinoma

d. Xray skull

c. Fungal infection d. Herpes

78.

Disturbances of affect include all except? a. Panic

Following agents have effects on the NMJ, EXCEPT

b. Apathy

a. Curare

c. Phobia

b. Decamethonium

d. Obsession

c. Succinylcholine d. Hexamethonium 69.

a. levamisole as immunomodulant

a. Tardieu spots

d. Dribbling of saliva

68.

Following is the adjuvant for the treatment of nephrotic syndrome?

The most specific feature of death due to hanging is?

c. Fracture of thyroid cartilage 67.

Polyhydramnios is seen in all the following except:

No. of negative stools mandatory to release a case from isolation in typhoid? b. 2 samples on first day and 1 sample on the second day

66.

In wolfparkinson white syndrome, there exist a connection between atria and?

Cold agglutinins are seen in?

c. Legionella pneumonia 65.

Herpes zoster involves? a. Otic ganglion

d. Oligohydramnios 63.

Prolactin? a. Facilitates

d. Varicella 62.

Tympanic plexus is formed by? a. Tympanic branch of glossopharyngeal nerve

d. 5 61.

most deaths involving placenta previa result from?

79.

Deep transverse arrest is seen in? a. Occipitoposterior position

Entamoeba, which is not found in gut?

b. Occipitoanterior position

a. E.coli

c. Breech delivery

b. E.histolytica

d. Face presentation

c. E.gingivalis


80.

Kallu, a 25 yr male pt.presented with a red eye and complains of pain, photophobia ,watering and blurred vision. He gives a history of trauma to his eye with a vegetable matter. Corneal examination shows a dendritic ulcer. A corneal scraping was taken and

90.

c. Candida

b. Burns c. Tuberculosis d. Zenker’s degeneration 91.

d. Aeno virus 81.

b. Divident of incidence and mean duration of disease c. Sum of incidence and mean duration of disease

a. Hot air oven 92.

d. Ethylene oxide

a. Home delivery

Management of extradural hemorrhage is:

b. Cesarean section

a. Immediate evacuation

c. High forceps

b. Evacuation after 24 hrs

d. Low forceps after external rotation

c. Antibiotics d. Observation 83.

93.

A PostThyroidectomy patient develops signs and symptoms of Tetany. The management is?

b. hyperkalemia c. hypoalbuminemia

b. Bicarbonate

d. hypertension

c. Calcitonin 84.

94.

The most effective treatment in the early stages of trachoma is?

b. It is seen in PEM Children

b. Choromycetin systemically

c. Mntoux test is negative

c. Sulphonamides systemically 85.

Ideal treatment of Tinosporidiosis is:

d. Leucocytosis is seen 95.

b. Clear cell

b. Excision with cautery at base

c. Adeno carcinoma

c. Dapsone 86.

Epithelium of cornea is?

d. Anaplastic carcinoma 96.

b. Rheumatoid arthritis

b. Transitional

c. Neutropenia

c. Stratified squamous keratinized 87.

Bagasosis can be prevented by spraying Bagasse with?

d. Nephropathy 97.

b. Barium swallow lateral view for diagnosis is the best investigation

b. 5% acetic acid c. 1% propionic acid

c. it is a true diverticulum

d. 2% propionic acid Mc Ardles disease is due to the deficiency of? a. Glu 1 phosphatase

d. it is congenital 98.

c. Gluc 6 phosphatase

b. All animal species have approximately the same lifespan

d. Myophosphorylase

c. Men are programmed to live longer than women.

Satiety center in hypothalamus is regulated by?

d. Identical twins have a natural lifespan of approximately similar duration

a. Gastric dilatation b. Blood glucose levels c. Blood insulin levels d. All of the above

Which of the following statements about aging is true? a. Zoo animals have shorter lifespans than animals in their normal habitat

b. Gluc1, 6 diphosphatase

89.

The true statement about Zenker’s diverticulum is; a. It is outpouching of ant.pharyngeal wall above the cricopharyngeus muscle

a. 10% acetic acid

88.

True regarding Felty’s syndrome is all EXCEPT a. Splenomegaly

a. Pseudostratified

d. Stratified squamous nonkeratinised

Commonest histology of carcinoma of endometrium is? a. Squamous cell

a. Rifamipicin

d. Laser

Which statement is not true regarding Cryptic military Tuberculosis? a. Xray diagnsis is possible

a. Penicillin locally

d. Soframycin locally

Coose among the following the most important lab finding in nephrotic syndrome? a. BJ protine

a. I.v.Calcium gluconate

d. Vitamin D

In twin pregnancy, treatment of choice when first baby is in transverse lie is:

99.

Characteristic features of kwashiorkor include following EXEPT? a. Anorexia

MISCELLANEOUS

d. Difference of incidence and mean duration of disease

b. Autoclaving

82.

The relationship between incidence and prevalence can be expressed as the? a. Product of incidence and mean duration of disease

Glass vessels and syringes are best sterilised by

c. Irradiation

1327

a. Myocardial infarction

a. Herpes simplex b. Acanthambea

Coagulative necrosis is seen in all except?


1328

b. Flaky paint dematosis c. Hepatomegaly d. Splenomegaly 100. Adrenergic neuron contain which of the following

109. Which of the following is not related to GERD a. Pregnancy b. Post heller myotomy

a. Norepinephrine

c. Prolonged nasogastric tube intubation

b. Acetyl choline

d. Sickle cell disease

c. Neuropeptide Y and somatostatin d. A and C 101. NOD2/ CARD15 polymorphism is associated with which of the following a. UC b. Crohns disease

MCQ's

d. Photophobia

c. Coeliac dis d. Carcinoid 102. 60 year old admitted for hip fracture found to have hyperglycemia. which micronutrient deficiency explains this problem a. Chromium deficiency b. Copper deficiency

110. Which statement about pepsin is false a. It is produced in inactive proenzyme form b. Activation of gastrin require gastric acid c. Pepsin is produced in parietal cell d. It is inactivated at pH 5 111. Which of the following tumour do no metastasizes to stomach a. Melanoma b. Prostate c. Breast ca d. Colon ca 112. Which of the following is most likely to remain asymptomatic a. Annular pancreas

c. Iron deficiency

b. Gastric duplication

d. Selenium deficiency

c. Gastric diverticulum

103. 32 year old women are considering bariatric surgery. Which of the following would usually be recommended as part of her preoperative evaluation? a. CT of abdomen and pelvis b. USG abdomen c. Upper GI endoscopy d. Manometry. 104. What is the most common gastric lesion causing severe protein loss a. Menteriers disease b. H. Pylori gastritis c. Allergic gastroenteropathies d. SLE gastroenteropathies 105. False positive elevations of 5-HIAA levels in urine can result from ingestion of all of the following except a. Melatonin b. Methyldopa c. Rifampicin d. Isoniazid 106. Which of the following is the most common cause of death in celiac disease a. ulcerative jejunitis b. Lymphoma c. Malnutrition d. Sepsis due to immunoglobulin deficiency 107. Which of the following is least harmful to pregnant patients and their fetuses during Endoscopy a. Fluoroscopy b. Mepridine c. Morphine d. Benadryl 108. Imatinib cause all of the following adverse effect except a. Periorbital odema b. Myalgia c. Myelotoxicity

d. Duodenal cyst 113. Which of the following is not usually a site of ectopic pancreatic tissue a. Stomach b. Proximal jejunum c. Meckels diverticulum d. Spleen 114. Which of the following is risk factor for pancreatic cancer a. Alcohol b. Tobacco abuse c. Chronic steroid use d. High dietary diet intake 115. Fatty acid synthesis occurs in which site of liver a. Cytosol b. Nucleus c. Mitochondria d. Membrane bound protein 116. Which of the following aids host in defending against intestinal infection a. Intestinal microflora b. Adherens c. Intestinal acidity d. Cytotoxins 117. Which of the following gastrointestinal signaling agent shown to increase appetite a. Apolipoprotein a b. CCK c. Ghrelin d. Leptin 118. Paraneoplastic visceral neuropathy is associated with a. Gastric ca b. Breast ca c. Ovarian ca d. Small cell lung ca


119. Which is major anion transporter in colon a. Chloride b. Bicarbonate c. Boron d. Small chain fatty acid 120. What is the volume of fluid that gall bladder can accommodate a. A.10 to 30 ml b. B.30 to 50ml c. C.50 to 70 ml d. D.70to 100 ml a. Frequently present in individuals with cholesterol stones b. Highly prevalent in certain ethnic groups c. More common in women d. Often symptomatic 122. Which of the following condition is not important for pathophysiology of gall stone formation-? a. Cholesterol nucleation b. Dietary calcium intake c. Gall bladder hypomotility d. Genetic factors such as LITH gene 123. For which of the following biliary manometry is most necessary before sphincterotomy a. Type I SOD b. Type II SOD c. Type III SOD d. Type IV SOD 124. A hilar tumor that starts below the confluence of hepatic ducts and reaches the confluence has Bismuth corlette classification of a. Type I b. Type II c. Type III a d. Type IV 125. Which hepatic structure allows a difference in concentration of solutes between cytoplasm and bile canaliculi? a. anchoring junction b. gap junction c. lipid raft d. Tight junction 126. Cholestasis and hepatocellular inflammation develop in a 55 yr. old man after aminopenicillin. Which of the following is most specific for diagnosis? a. drug rechallenge. b. in vitro testing c. liver biopsy. d. peripheral eosinophil count 127. Autoimmune thyroiditis Gravesâ&#x20AC;&#x2122; disease ulcerative colitis is most common extra hepatic manifestation of which of the following a. PBC b. Celiac disease c. type 1 AIH d. type II AIH.

a. ACE inhibitor b. Furosemide c. nifedipine d. reduction in dose of immunosuppressant 129. A 56 year old man presented with alcohol related cirrhosis. What is the principle mechanism of liver fibrosis? a. An alcohol mediated free radical injury b. chronic intra hepatic cholestasis. c. Increase in matrix degradation d. increase in stellate cell activation. 130. Diarrhea from cryptosporidiosis is most severe in a. Hiv patients CD4 >700 b. Child bearing woman c. Patient with immunoglobulin deficiency d. Adolescent. 131. Most common symptom of acute mesenteric ischemia a. fever b. abdominal pain c. nausea vomiting. d. Bloody diarrhea 132. Which of following is not a gas produced by enteric bacteria a. CH4 b. CO c. CO2 d. H2 133. Following pair of organisms can reside in biliary treea. chlonorchis and strongyloides b. opisthorchis and enactor c. ascaris and fasciola. d. Fasciolopsis and fasciola 134. What is most common finding on XRAY in bowel ischemia â&#x20AC;&#x201C;? a. Ileus b. thumb printing of right colon c. air in portal vein. d. normal 135. Most common cause of SIBO secondary to neoplasma. carcinoid tumor b. Advanced colorectal carcinoma c. Metastatic breast cancer d. endometrial carcinoma 136. What diameter is considered as threshold for colonic decompression in acute intestinal pseudobstruction-? a. 6 cm b. 9 cm. c. 12 cm. d. 15 cm. 137. What is the initial test of choice for giardiasis? a. Stool ELISA b. Stool for ova parasite. C. duodenal aspirate. d. Stool acid fast stain

MISCELLANEOUS

121. Cholesterosis of gall bladder is-

128. Which of the following is best initial approach to treat 1329 systemic hypertension in the absence of volume overload after liver transplantation?


1330 138. Which of the following is deficient in Cohn’sdisease? a. TNF b. NFk B c. T- regulatory cell d. IL-2 139. Vitamin B 12 malabsorption will not general occur until more than how much of ileum is resected a. 10 cm b. 20 cm c. 30 cm.

MCQ's

d. 40 cm. 140. The best duration of treatment to ensure 90% duodenal ulcer healing with H2 receptor antagonist is a. 1 week b. 2 weeks c. 4 weeks d. 8 weeks 141. dysphagia with frequent chocking and nasal regurgitation occurs in:

c. a+b d. gastric acid and bilirubin 148. You see a 67-year-old man with three month history of weight loss and signs which suggest Pancoast’s tumour. Which of the following symptoms from the list below is not associated with a Pancoast’s tumour? a. Hoarse voice b. Miosis c. Anhydrosis d. Exopthalmos e. Ptosis 149. A 63-year-old male was admitted 2 days after discharge following an apparently uncomplicated MI. He complained rapidly worsening, shortness of breath over the previous 48hrs but no further chest pain. He was tachypnoeic and had a regular pulse of 110/minute, which proved to be sinus tachycardia. The jugular venous pressure was raised and a pan-systolic murmur was noted, maximal at the left sternal edge. diagnosis? a. Mitral incompetence b. Ventricular septal defect

a. Achalasia

c. Aortic stenosis

b. Shatzki’s ring.

d. Dressler’s syndrome

c. Pharyngeal paralysis

e. Further myocardial infarction

d. Diffuse esophageal spasm 142. Chagas’ disease may be suspected if a patient has all except a. Constipation b. Dysphagia c. Heart failure d. Jaundice 143. the double stranded hepatitis B virus can survive outside the body for a. six to twelve hours b. one to two days c. C. two to seven days d. D more than seven days 144. In Achalasia the most appropriate long term therapy is: a. Nifedipine b. Domperidone c. Metoclopramide d. Balloon dilatation 145. What is the most effective treatment for solitary rectal ulcer syndrome?

150. A 30-year-old man presents to your clinic with a cough and finger clubbing. From the list below, which of these answers is not a respiratory cause of finger clubbing: a. Empyema b. Mesothelioma c. Bronchogenic carcinoma d. Cystic fibrosis e. COPD 151. Most common complications of typhoid fever a. Intestinal haemorrhage and perforation b. Orchitis c. Pancreatitis d. Myocarditis 152. Mode of transmission of typhoid fever is a. Mosquito borne b. Faeco-oral c. IV drug abuse d. None of the above 153. Typhoid myocarditis leads to

a. cortisone enemas

a. ECG changes

b. mesalamine suppositories

b. Elevated cardiac enzymes

c. mesalamine enemas

c. Arrhythmias

d. biofeedback

d. All of above

146. Which of the following cranial muscles does not innervate pharyngeal muscles? a. hypoglossal b. accessory c. facial d. trigeminal 147. Thepathogenesis of peptic oesophagitis secondary to GERD is most dependent on which of the following a. gastric acidity b. pepsin

154. Salmonella infects a. Ileum b. Duodenum c. Stomach d. Colon 155. Diagnosis of typhoid fever can be made by a. Widal test b. Salmonella typhi IgM c. Blood culture d. All of above


156. Which of the following clinical condition shows compromised immunity:a. Pregnancy b. Ageing c. HIV infection d. All of the above 157. In general usual treatment protocol of HIV patients with OIs (opportunistic infections) is:a. HIV therapy to initiate before definitive treatment of OIs is made.

c. Glossitis 166. Anemia in pregnancy is defined as hemoglobin a. Less than 9 gm/dl b. Less than 10 gm/dl c. Less than 11 gm/dl d. Les than 12 gm/dl 167. Maternal and fetal morbidity is more when hemoglobin is a. Less than 10 gm/dl b. Les than 11 gm/dl

c. Both are to be treated simultaneously

c. Less than 6 gm/dl

d. No particular norm

d. Less than 9 gm/dl 168. Following are common side effects of oral iron except

a. HHV-8

a. Pain abdomen

b. HPV

b. Diarrhoea

c. EBV

c. Constipation

d. HSV

d. Fever

159. Kaposi’s Sarcoma is found with CD4 count of

169. Postpartum anemia is defined as hemoglobin less than

a. < 500 cells/ml

a. 10

b. < 200 cells/ml

b. 11

c. < 100 cells/ml

c. 13

d. In any CD4 count

d. 8

160. Presence of HIV increase TB infection by a. 10 folds

MISCELLANEOUS

b. Treatment of OIs to initiate first before HIV therapy

158. Kaposi’s Sarcoma – A viral disease, caused by

1331

d. Splenomegaly

170. Correct statement is

b. 50 folds

a. All microcytic hypochromic supplementation.

c. 100 folds

b. IV iron is contraindicated in pregnancy.

d. None of the above

c. Vitamin C deficiency can lead to iron deficiency anemia by reducing absorption of iron.

161. Most common cause of anemia in pregnancy is a. Folate deficiency b. Copper deficiency c. Thalassemia d. Iron deficiency anemia 162. In pregnancy, following parametres are used as iron deficiency a. Serum iron < 60mcg/dl b. Serum UIBC > 300 mcg/dl c. TIBC <400 mcg/dl d. Serum ferritin <30 ng/ml 163. Which of the statement is correct a. Megaloblastic anemia is the commonest cause of anemia in pregnancy b. Physiological anemia in pregnancy is due to disproportionate increase in red cell mass over plasma volume c. IV iron can be used in first trimester d. About 50% of pregnant ladies has iron deficiency anemia in developed countries 164. Following are causes of microcytic hypochromic namia except a. Iron deficiency anemia

a. ACEIs/ARBs b. CCBs c. Diuretics d. Beta blockers 172. Which is an absolute contraindication to ACEI therapy ? a. unilateral RAS b. bilateral RAS c. fluid overload d. hypokalemia 173. Which ACEI has least incidence of hyperkalemia? a. enalapril b. ramipril c. captopril d. fosinopril 174. Which combination of antihypertensives is to be avoided? a. ACEI and amlodipine b. ACEI and diuretics

d. Folate deficiency anemia

c. Diltiazem and atenolol

b. chielitis

iron

171. Which of the following are first line antihypertensive agents for proteinuric CKD patients?

c. Sideroblastic anemia

a. Pica

needs

d. Oral and IV iron should be always used together in pregnant ladies with IDA.

b. Thalassemia

165. Following are common presenting features of iron deficiency anemia except

anemia

d. Metoprolol and prazosin


1332 175. Which of the following diuretic has antiproteinuric action? a. furesemide b. torsemide

184. In which IGH the term HFnEF (Heart Failure with normal Ejection Fraction) has been mentioned and explained for use in clinical practice a. IGH I

c. indapamide

b. IGH II

d. spironolactone

c. IGH III

176. Which of the following is true; SGLT2 Inhibitors cause: a. Increase in insulin secretion b. Retention of Sodium and oedema c. Natriuresis

d. None of the above 185. Which recent Hypertension Guideline recognizes ABPM and HBPM as tool with criteria for diagnosis of Hypertension a. JNC 8

d. Loss of extracellular fluid volume

b. NICE

MCQ's

e. High plasma uric acid levels

c. IGH III d. None of the Above

177. Principal action of SGLT2 inhibitors is: a. Renal glucosuria b. Reduced food intake c. Reduced gastric emptying d. Reduction in LDL levels e. Inhibition of alpha-glucosidase in the gut 178. Significant Cardiovascular Benefit is observed with the following antidiabetic drugs:

186. A 55-year-old man complains of a 4-week history of general malaise and fatigue • Investigation • Haemoglobin 12 g/dL • MCV 90 fL

a. Sulphonylureas

• Platelet count 250 × 109/L

b. Insulin

• WBC 10 × 109/L

c. Alpha-glucosidase inhibitors d. Pioglitazone e. SGLT2 Inhibitor Empagliflozin 179. Cardiovascular benefit with Empagliflozin within 3-6 months of therapy is possibly partly due to:

• Serum iron 10 μmol/L • Total iron-binding capacity 40 μmol/L • Serum ferritin 160 μg/L a. Thalassaemia

a. Reduction of hyperglycemia and HbA1c

b. Iron deficiency anaemia

b. Weight loss of 2 kg

c. Anaemia of chronic disease

c. Increase in HDL cholesterol

d. Macrocytic anaemia

d. Decreased plasma Triglycerides e. Diuresis and decrease in Extracellular fluid volume 180. Cardiovascular benefit with Empagliflozin within 3-6 months of therapy is possibly partly due to: a. Decrease in blood pressure b. Increased plasma ketones c. Glucagon secretion d. Decreased arterial stiffness e. Decreased sympathetic tone 181. Clinical practice Guidelines provides all except

e. Aplastic anaemia

A 55-year-old woman complains of double vision.She is

187.

tired all the time and has difficulty climbing stairs. She has difficulty getting items off shelves. Reflexes are absent but elicited after exercise. Initial shoulder abduction is 4/5 but on repeated testing is 4 +/5. What is the pathology associated with this female’s diagnosis? a. Thyrotoxicosis b. Peptic ulcer c. Diabetes

a. A more rational basis for referral

d. Stroke

b. A focus for continuing education

e. Lung cancer

c.

Inefficient use of resources

d. None of the above 182. IGH III was published in JAPI in year a.

2012

b. 2013 c.

2014

d. 2015 183. JNC 8 states that in the general population aged ≥60 years, initiate pharmacologic treatment if BP is ≥ a. 130/90 b. 140/90 c. 150/90 d. 160/90

188. A neurologist is examining a patient. She takes the patient’s middle finger and flicks the distal phalanx, her thumb contracts in response. What sign has been elicited? a. Chvostek’s b. Glabellar c. Hoffman’s d. Tinel’s e. Babinksi’s 189. Which of the following is not a cause of absent ankle jerks and up-going plantars? a. Fredreich’s ataxia b. B12 deficiency c. Cord compression d. Motor neurone disease


190. Which of the following extra-intestinal signs is not seen in ulcerative colitis: a. Finger clubbing b. Erythema nodosum c. Iritis d. Sacroiliitis e. Granuloma annulare 191. A 60-year-old man presents with signs and symptoms associated with pulmonary sarcoidoisis which was diagnosed nine months ago. From the list below which of the following is not an extrapulmonary manifestation of sarcoidosis? b. Anterior uveitis c. Erythema marginatum d. Hepatic granuloma infiltration 192. Bedaquiline is the drug for a. Enteric fever b. TB c. Filariasis d. IBS 193. A 44-year-old man presents with non-specific symptoms of fever, shortness of breath and syncope. Blood tests show a raised erythrocyte sedimentation rate (ESR) and a transoesophageal echo shows an atrial myxoma. What is characteristically heard on auscultation in atrial myxoma? a. End-diastolic murmur b. Loud first heart sound c. Fourth heart sound d. Pansystolic murmur e. Loud third heart sound 194. Hot potato voice is a feature of:

b. low plasma glucose level c. relief of symptoms when blood glucose is normal d. history of insulin use 200. DKA most commonly occurs in a. Type 1 DM b. Type 2 DM c. MODY d. LADA 201. All of the following viruse can cause diabetes mellitus except a. congenital rubella b. CMV c. EBV d. coxsackie 202. DRUGS THAT CAN CAUSE DIABETES MELLITUS A/E a. phenytoin b. beta blockers c. thyroid hormone d. thiazides 203. Which country has highest incidence of type1 DM a. JAPAN b. CHINA c. SCANDINAVIA d. USA 204. American diabetic association(ADA) recommends screening for DM in which of the following a. more than 40 yrs every 3 yrs b. more than 40 yrs every 1 yr

a. Hypothyroidism

c. more than 45 yrs every 3 yrs

b. Ludwig angina

d. more than 45 yrs every 1 yr

c. Oropharyngeal candidiasis d.

parkinsons disease

195. Blue toe syndrome is best related to:

205. DKA is characterised by A/E a. Hyperglycemia b. Metabolic acidosis PH<7.3

a. Frost bite

c. Serum bicarbonate >24meq/L

b. Raynaudâ&#x20AC;&#x2122;s phenomenon

d. ketonuria

c. Atheroembo d. AV fistula 196. Multiple myeloma is also known as: a. Kahlers disease b. Strohls disease c. Kayles disease d. Migasha disease 197. Normally neutrophils spend how much time in circulation? a. 2-3 hrs b. 6-7 hrs c. 12-24 hrs d. 24-36 hrs 198. Which of the following is an iron regulatory hormone? a. Ferritin b. Transferrin c. Erythropoitin d. Hepcidin

1333

a. hypoglycaemic symptom

206. In women with high risk of GDM screening for glucose intolerance should be done between which weeks of pregnancy a. 3-12 b. 12-24 c. 24-28 d. 28-36 207. If both parents have type 2 DM the risk of developing diabetes is a. 10%-20% b. 20%-30% c. 30%-40% d. 40%-50% 208. Other than insulin beta cells also secrete a. ptyalin b. amylin c. amylase d. lipase

MISCELLANEOUS

a. Lupus pernio

199. Whipple triad include, A/E


1334 209. What proportion of insulin in portal system is degraded by the liver a. 10% b. 25% c. 50% d. 75% 210. When transisioning for insulin infenic to SC insulin regimen in HHS/DKA stop insulin infusion a. immediately on adminstration of subcutaneous insulin b. 5 hrs after adminstration of subcutaneous insulin c. 1 to 2 hr before adminstration of subcutaneous insulin

MCQ's

d. 1 to 2 hr after adminstration of subcutaneous insulin 211. For every 100mg/dl rise in serum glucose serum sodium is reduced by a. 1meq/l b. 1.2 meq/l c. 1.4 meq/l d. 1.6 meq/l 212. Which of the following drug may cause false positive reactions in nitrocrusside test used to detect urine ketones a. captoprill

c. HDL at target d. TG,BP at target 218. Individuals who have DM for more than 20 years what is the probability of detecting nonproliferative retinopathy a. 25% b. 50% c. 75% d. 100% 219. In a spot urine collection microalbuminaria is defined as a. 10-100 microgram/mg creatinine b. 20-200 microgram/mg creatinine c. 30-300microgram/mg creatinine d. 40-400 microgram/mg creatinine 220. Involvement of which of the following cranial nerve is most common in DM a. II b. III c. VI d. VII 221. Most common partner in dyslipidemia in DM is

b. atrovastatin

a. increase LDLc

c. aspirin

b. reduce HDLc

d. azithromycin

c. increase VLDL

213. Diabetic foot infection is commonly due to A/E a. diabetic peripheral neuropathy

d. increase TG 222. Earliest sign of diabetic neuropathy is

b. anaerobic infection

a. erectile dysfunction

c. peripheral vascular disease

b. gastroparesis

d. recurrent trauma

c. anhydrosis of lower extremity

214. 19 yr female with type 1 DM, WHICH OF THE FLLOWING DENOTES AUTOIMMUNE CONDITION ASSOCIATED except

d. distal Periphaeal neuropathy 223. 1% rise in HbA1c translates into how much increase in mean glucose level

a. Vitiligo

a. 15mg/dl

b. Dormatitis herpeti fermis

b. 25mg/dl

c. Necrolytic mygratory erythema

c. 35mg/dl

d. goitre

d. 45mg/dl

215. With insulin therapy in DKA which of the following resolves first a. acidosis b. ketosis c. hyperglycaemia d. hyperchloremia 216. 60 yrs male Type 2 DM on follow up with 1000mg metformin he does SMBG prior to breakfast and prior to dinner HBA1C is 7.4,fasting blood sugar108,pre-dinner 126 average 152 mg%. why there is discrepancy in hba1c and abg a. unrecognized IDA(iron deficiency anaemia) b. inaccurate glucometer c. post prandial blood glucose d. metformin use 217. 50 yr Type2 DM HBA1C 7.0,mild diabetic retinopathy,microa lbuminuria,hypertension O/E bp-138/82mm hg,LDL 110,HDL 42,TG 180 according to IDF guidelines a. glycemic control,hypertension,LDL at target b. bp at target

224. Anti GAD antibody are present in how many % of type1 DM a. 50 b. 60 c. 70 d. 80 225. In hospital mortality of patients with stress hyperglycaemia compared with afe related impatient with normoglycaemia increases by factor a. 3 b. 6 c. 9 d. 18 226. AACE and ADA guidelines for management of inpatient hyperglycaemia(mg%) a. 90-110 b. 110-140 c. 140-180 d. 180-220


227. Exenatide was originally isolated from

1335

a. snake venom b. lizard venom c. spider venom d. scorpion venon

MISCELLANEOUS


MCQ's

1336

Miscellaneous - Answers 1. d

38. c

75. b

112. c

149. d

2. a

39. c

76. d

113. d

150. e

3. b

40. a

77. a

114. b

151. a

4. d

41. b

78. d

115 . a

152. b

5. a

42. a

79. a

116. a

153. d

6. b

43. c

80. b

117. c

154. a

7. c

44. d

81. a

118. d

155. d

8. a

45. c

82. a

119. d

156. 4

9. d

46. a

83. a

120. b

157. 1

10. b

47. a

84. c

121. c

158. 1

11. d

48. d

85. b

122. b

159. 4

12. b

49. b

86. d

123. c

160. 3

13. a

50. b

87. d

124. b

161. d

14. b

51. b

88. d

125. d

162. d

15. a

52. b

89. b

126. a

163. b

16. d

53. a

90. d

127. c

164. d

17. a

54. a

91. a

128. c

165. d

18. c

55. d

92. b

129. d

166. c

19. c

56. d

93. c

130. c

167. c

20. b

57. a

94. b

131. d

168. d

21. c

58. a

95. c

132. d

169. a

22. c

59. b

96. d

133. c

170. c

23. b

60. b

97. a

134. d

171. a

24. a

61. d

98. d

135. b

172. b

25. c

62. a

99. d

136. b

173. d

26. b

63. c

100. d

137. a

174. c

27. a

64. a

101. b

138. d

175. d

28. c

65. d

102. a

139. c

176. c and d

29. b

66. d

103. c

140. d

177. a

30. d

67. a

104. a

141. a

178. d and e

31. d

68. d

105. c

142. d

179. e

32. a

69. c

106. b

143. d

180. a, d and e

33. b

70. c

107. b

144. d

181. c

34. d

71. a

108. d

145. d

182. b

35. b

72. b

109. d

146. b

183. c

36. c

73. b

110. c

147. c

184. c

37. a

74. b

111. b

148. d

185. b


195. c

204. c

213. b

222. d

187. e

196. a

205. c

214. c

223. c

188. c

197. b

206. c

215. c

224. d

189. d

198. d

207. d

216. c

225. d

190. e

199. d

208. b

217. c

226. c

191. c

200. a

209. c

218. d

227. b

192. b

201. c

210. d

219. c

193. b

202. b

211. d

220. b

194. b

203. c

212. a

221. d

1337

MISCELLANEOUS

186. c


IMPORTANT MEDICAL FACTS CARDIOLOGY

Calcium ions in sarcoplasm then bind to troponin C subunit which produces conformational changes in whole troponin complex that inhibits troponin I interaction with actin.

Prominent U wave in ECG is seen in hypokalemia, inverted U wave is a subtle sign of myocardial infarction.

Adults with mild pulmonic stenosis are usually asymptomatic. Unlike congenital aortic stenosis this condition usually does not progress.

This in turn allows tropomyosin to roll back into the grooves of the F-actin superhelix and allows the interaction of actin and myosin to produce a contraction.

Coarctation of aorta usually occurs just distal to origin of left subclavian artery. If it arises above left subclavian, blood pressure is only raised in right arm.

P cells constitute one of four types of cells involved in impulse formation and rapid conduction. These cells are present in sinus node and internodal pathways.

The delay at AV node occurs at a latter time when atria are fully developed. There are minimum of 8 defined currents that contribute to adult cardiac action potential.

Membrane conductance at the end of an action potential is determined primarily by the activities of two sets of potassium channels.

The innerside of a heart cell during diastole is -60 to -90 mV, this negativity maintained by more pumping out of sodium than pumping in of potassium which is 3:2.

Automatic cells of SA node demonstrate spontaneous diastolic depolarisation, responsible to initiate action-potential. This is brought about by decreased outward K+ flux in SA node cells in comparison to Na+ influx.

Acetylcholine increases K+ conductance and thus suppresses SA node. As heart rate increases, Na+ flux inwards also increases.

Adenosine decreases conduction in AV node; 6-12 mg IV dose terminates most SVTs.

Angiotensin II and beta-agonists augment proto-oncogene expression, stimulate protein synthesis and induce synthesis of fetal forms of actin-myosin thereby causing cardiac hypertrophy.

The gene responsible for familial hypertrophic cardiomyopathy is on chromosome-14.

The vast majority of aortic aneurysms are due to atherosclerosis, 75% of them are located below renal arteries.

Acute pericarditis is associated with ST segment elevation, PR segment depression. Reciprocal ST segment depression in opposite leads is characteristically absent.

The AV node lies within triangle of Koch, the base of which is defined by annulus of tricuspid valve and the opening of coronary sinus.

In pulmonary valve 2 cusps are anterior while in aortic valve 2 cusps are posterior. 19. Thebesian veins drain directly into right atrium and right ventricle.

Cardiac dilatation, hypertrophy, anaerobic metabolism and tachycardia are the few mechanisms by which a beating heart meets increased circulatory demands.

RCA supplies AV node, but in 10-15% cases the supply is from circumflex artery. SA node is supplied in 40-50% cases from circumflex and in the rest from RCA.

The four major determinants of myocardial oxygen consumption are—myocardial mass, wall stress (volume x pressure), inotropic state (contractility) and heart rate.

Kugel’s artery is an important collateral from the base of atrial septum to AV node and the posterior circulation. It may arise from LCA or RCA. 22...T.10 circle of Vieussens provides collateral circulation from left anterior descending to anterior right ventricle.

The arterial pressure gradient (aortic-LV diastolic pressure) and duration of diastole are major determinants of coronary blood flow.

During systole left ventricular intramyocardial pressure exceeds aortic root pressure leading to compression of epicardial coronary vessels that prevents forward coronary blood flow.

Three venous drainages are present in heart (1) coronary sinus draining LV (2) anterior cardiac veins draining RV and (3) Thebesian system.

Heart muscle has the highest fractional extraction of 02, to the extent of 70%. Reduced diastolic coronary flow limits 02 availability and leads to myocardial acidemia due to predominant anaerobic metabolism.

50-65% of pulmonary blood volume lies in thin walled capacitance vessels. Pulmonary vessels constrict in response to arterial hypoxemia and hypercapnea while systemic vessels dilate in response to such stimuli.

There are 5 major classes of lipids in plasma—the cholesterol, cholesterol esters, phospholipids, triglycerides, and unesterified fatty acids.

The aorta functions as a reservoir chamber for the rapidly ejecting LV, converting pulsatile to a continuous flow (Windkessel effect). With aging this is reduced, resulting in higher pulse pressure and systolic hypertension.

Myocardial lymphatic vessels are important in maintaining normal myocardial nutrition.

LDL cholesterol is considered the most villian for atherosclerosis. The number of LDL receptors is the major determinant of LDL concentration in blood. In healthy humans 70% of circulating LDL is removed each day by these LDL receptors. A primary endothelial cell dysfunction plays the vital role in genesis of atherosclerosis.

The action potential of cardiac cell membranes is initiated by depolarisation related to sudden influx of sodium ions followed by slower influx of calcium ions.

The pearly early atheromatous lesions are reversible but if fibrous plaque has formed, the lesions can be arrested by lowering of blood lipids but cannot be fully reversed.

The initial transsarcollemal influx of calcium ion triggers the release of calcium from sarcoplasmic reticulum.

The smooth muscle proliferation in atheromatous lesion is secondary to subendothelial accumulation of lipids.

Rise in diastolic pressure on standing indicates vulnerability


for developing hypertension. Obese people with small arm cuff show hypertension due to cuff-arm mismatch.

A third heart sound is normal finding in children and young 1339 adults. It is not synonymous with a gallop which is a pathological condition.

A “cooing dove” sound is indicative of regurgitant murmur due to ruptured or retroverted aortic cusps. The systolic “whoop” or honk is heard in patients of mitral valve prolapse.

Isometric handgrip increases peripheral resistance thus increasing the intensity of murmurs of MR and AR. It increases systolic murmur of HOCM and MVP due to ventricular dilatation.

Complete disappearance of Korotkoff sound is the point of recording for diastolic BP in adults but muffling of sound is taken as end point in pediatric age group.

Mean arterial BP is (systolic BP-diastolic BP)/3 + diastolic BP. Pulse pressure is the difference between systolic and diastolic BP. Pulse pressure is increased when stroke volume is increased or peripheral vascular resistance is decreased.

The post PVC beat in a patient IHSS or hypertrophic obstructive cardiomyopathy has increased pulse pressure due to enhanced contractility. This is called Brockenborugh’s sign.

Pulsus alternans is defined as regular alteration of pulse pressure detected in peripheral artery where the systolic pressure variation exceeds 20 mmHg.

Valsalva maneuver results in increased intrathoracic pressure with decrease in venous return, and left ventricular volume thus accentuating murmur of HOCM and MVP.

The LV is normally palpated at the cardiac apex. The apical impulse is not necessarily the point of maximum cardiac impulse.

Squatting simultaneously increases venous return and peripheral vascular resistance. It decreases cyanosis of TOF by reducing right to Left shunt, and increasing flow across RVOT. It decreases murmur of MVP.

A ‘Q’ wave is indicative of transmural myocardial infarction, but it may also occur in unstable angina, coronary spasm, prinzmetal angina, and HOCM. ‘Q’ wave of myocardial infarction may disappear because of shrinking of zone of infarction, successful reperfusion, development of an intraventricular conduction delay, `contracoup’ LV infarction, or hypertrophy of adjacent myocardial fibers. Diffuse PR segment changes in association with large LV infarction is suggestive of atrial infarction, PR changes are evident in lead I and left chest lead with depression in right chest leads.

LBBB may mask ECG features of myocardial infarction. However, presence of an anteroseptal infarction can be diagnosed from presence of small Q waves in leads I, V5’ V6. Cabrera’s sign refers to the notch in the assending limb of the predominant negative deflection in leads V3, V4.

A figure 3 sign and E sign in X-ray are features of coarctation. Figure 3 sign identifies the level of coarctation and marks the apex of enlarged LV. The E sign is of barium filled esophagus in coarctation.

The heart defect in Noonan’s syndrome is PS, in Turner syndrome is coarctation, pulmonary stenosis and in Marfan’s syndrome is mitral valve prolapse, TR and aortic root dilatation with AR. 76. 50% of patients with coarctation have bicuspid aortic valve. Bicuspid aortic valves take decades to progress to point of severe aortic stenosis to warrant valve replacement.

Atrial myxomas arise from interatrial septum and intermittently prolapse into inflow tracts to produce transient dizziness and dyspnoea mimicking TIA. MR/TR may occur due to repeated trauma to valve leaflets. High ESR and systemic embolisation (in left sided tumors) are frequent. Auscultatory findings may mimic mitral stenosis and the tumor plop occurring in diastole is frequently confused with opening snap or S3.

Acute severe mitral regurgitation results from endocarditis, papillary muscle rupture/infarction and presents as intractable heart failure requiring vasodilator therapy or IABP.

A hyperkinetic pulse is characterised by rapid upstroke, brief summit and rapid downstroke. It is seen in patients with increased cardiac output due to decreased peripheral resistance.

Kussmaul’s sign refers to an increase in JVP on inspiration when there is resistance to right ventricular filling as in restrictive cardiomyopathy, constrictive pericarditis or RV infarctie.n.

‘a’ wave of JVP is produced by right atrial contraction, ‘y’ descent is due to venous inflow into RV.

In tricuspid stenosis ‘y’ descent is shallow but with regurgitation there is ventricularization of ‘c’ and ‘v’ waves resulting in a single positive systolic wave and an exaggerated ‘y’ descent.

A grade 4 or greater murmur is accompanied by thrill. A palpable P2 implies pulmonary hyeprtension and can be plexogenic, thrombogenic or veno-occlusive.

A palpable S4 implies vigorous atrial contraction and is associated with condition that restrict ventricular filling as in hypertension, hypertrophic cardiomyopathy.

In 10% cases dorsalis pedis pulse is congenitally absent but absence of posterior tibial pulse in always abnormal.

The venous filling time is determined by clevation of lower extremity until veins collapse and then promptly bringing the limb into dependent position. The veins normally fill in < 15 seconds. A delay in venous filling indicates arterial ijisufficiency.

A ventricular septal defect is the most common manifestation of congenital heart disease.

The chest pain of pulmonary hypertension is related to right ventricular ischaemia or pulmonary artery dilatation.

Cheyne-Stokes respiration is a normal variation in newborn but in adults it is due to CVA or LV dysfunction.

Osler’s nodes are nonhaemorrhagic and tender lesions on palms and soles. Splinter haemorrhages are vertical, black linear haemorrhages located on distal third of finger nail.

Continuous murmurs that begin in systole and continue into diastole through second heart sound are heard in PDA, coronary a-v fistula, rupture of sinus of valsalva aneurysm.

The centre of right atrium is approximately 5 cm below the sternal angle of Luis regardless of body position. Thus CVP is determined from addition of vertical height of oscillating venous column above sternal angle to 5 cm. It is commonly estimated in right internal jugular vein with 30° of body inclination and oblique lighting. External jugular vein since has valves is not suitable for CVP study.

The earliest abnormalities in dilated cardiomyopathy are ventricular systolic dysfunction and ventricular enlargement. Causes include, alcohol, myocarditis, peripartum cardiomyopathy, anthracycline antibiotics, end stage ischaemic heart disease. Patients with high cardiac gallium 67 uptake have lymphocytic myocarditis.

In hypertrophic cardiomyopathy the primary abnormality is diastolic stiffness with abnormal left ventricular filling. ECHO

IMPORTANT MEDICAL FACTS


features are left ventricular hypertrophy (symmetrical or asymmetrical) premature closure of aortic valve, and systolic anterior motion of anterior leaflet of mitral valve. HCM is the most frequent pathologic finding in young athletes who die suddenly. The development of ventricular arrhythmia in HCM is a poor prognostic sign.

Wenckebach phenomenon is typically due to block proximal to bundle of His, usually within AV node. On the other hand type II, second degree AV block typically occurs at or below bundle of His. It commonly progresses to complete AV block, thus requiring pacemaker implantation.

Complete heart block associated with inferior wall infarction is usually transient without haemodynamic consequence, thus rarely requiring pacing. On the other hand bifascicular block developed acutely during anterior myocardial infarction progresses frequently to complete heart block requiring pacing.

Increased vagal tone leading to bradycardia and asystole are very common during anaesthesia and surgery. Atropine given IV may reverse the bradycardia, else IV epinephrine be given. Blows to sternum can terminate asystole. Temporary pacing should be done if asystole or bradycardia do not respond to above measures.

During CPR, the mitral and tricuspid valves remain open both during compression and relaxation. Thus chest compression is no longer felt to move blood peripherally by simply squeezing blood out of ventricles. The ventricular refil ‘s rather enhanced as ventricles recoil during release phase of chest compression. Thus the heart serves primaril • as a passive conduit during CPR.

About one-third of normal patients develop ventricular ectopics during exercise testing which are usually uniform or unifocal. Multifocal VPBs, couplets or VT are indications of coronary artery disease. Presence of late potentials continuous with QRS complex and persisting into ST segment, thus indicating delayed and fragmented ventricular activation indicate high risk of myocardial infarction and VT.

An elderly patient with decreased cardiac reserve can easily develop CHF in presence of stress like fever, anaemia, or tachycardia. Myocardium in aged has increased lipofuscin or iron pigment.

The combination of LV dysfunction and complex ventricular ectopics is associated with poor prognosis in patients following MI.

LV hypertrophy can be concentric or eccentric. In concefitric hypertrophy ventricular chamber diameter is not increased as seen in pure AS. In eccentric hypertrophy, the internal diameter of ventricle increases proportionately as in athletes and patients of LV volume overload (MR, AR).

First degree AV block may represent normal finding especially in trained athletes. Hyperthyroidism, adreno-cortical deficiency, TOF may often have it.

Fusion beats result from simultaneous activation of atrium and ventricle by a spontaneous impulse or a paced impulse.

Ventricular pacing rather than atrial pacing is generally used in patients of sick sinus syndrome, because of frequent association with disease of distal conduction system and atrial arrhythmias which make atrial pacing ineffective. In elderly patients with LV dysfunction, atrial pacing is helpful in improving CHF by providing atrial kick to ventricular filling.

The autonomic and neural reflex mechanisms called upon to adjust the circulatory system in shock include three major classes of receptors that moderate affarent neural impulses: (1) arterial baroreceptors (aortic arch and carotid body), V Cardiac receptors (posterior left ventricular wall) and (3) Chemoreceptors (aortic body and carotid body). The first two classes are inhibitory receptors, that when stimulated inhibit sympathoadrenal response. In shock their activity is decreased, leading to sympathetic stimulation. Chemoreceptors are excitatory receptors that are stimulated by hypoxia and acidosis and thus increase sympathoadrenal response.

Sick sinus syndrome is associated with following pathologic abnormalities—(1) amyloid deposit in the node, (2) excessive loss for age of nodal cells, (3) atrophy or hypoplasia of the node, (4) no detectable abnormality. Sick sinus syndrome has been with loss of fibers in more distal conduction system as well as after open heart surgery.

Parasystole is a ‘protected’ focus of automatic activity. It exhibits abnormal conduction into and out of the focus. The abnormal conduction into the focus is called- entrance block and that out of the focus is called exit block; coupling intervals may be varying or fixed. ro

The model of re-entry has 3 components—unidirectional block, a finite circuit, and slow conduction within one of the limbs. The limbs of finite circuit are named alpha and beta. The alpha limb conducts antigrade and beta limb conducts retrograde. Alpha pathway has slower conduction and longer refractory period. The mechanism for torsade-de-pointis is probably due to fusion of two colliding cycles of epicardial depolaris tion and early afterdepolarisation (a form of re-entry).

Triggered activity is one of the two potential abnormalities associated with impulse origination that may give rise to arrhythmia formation. The other mechanism is automaticity. Triggered activity requires a stimulus to provoke repetitive

1340

MCQ's

In restrictive cardiomyopathy diastolic ventricular filling in restricted but systolic function is relatively preserved. Maximum ventricular filling occurs in early diastole (the dip and plateau observed in ventricular pressure tracing). The two most common causes of it are—cardiac amyloidosis and endomyocardial fibrosis (nutritional).

In cardiac amyloidosis endomyocardial biopsy is diagnostic. 99m Tc pyrophosphate myocardial uptake is high and patients are likely develop atrial fibrillation and high-grade a-v block.

Patients of constrictive pericarditis typically have some degree of restriction in both ventricles but in restrictive cardiomyopathy left sided pressure exceed right sided pressure by more than 5 mm.

The echocardiographic features of cardiac tamponade are— right atrial and right ventricular early diastolic collapse. Among the malignant tumors, malignant melanoma has the highest propensity to involve pericardium with effusive-constrictive pericarditis.

Digitalis action is mediated by its inhibiting effect on Nalc+ ATPase. Patients of CHF with sinus rhythm with abnormalities in LV diastolic function do not benefit from digoxin. AV node is supplied by posterior descending branch of right coronary artery in 90% cases. Bundle of His is supplied by both AV nodal artery and first septal perforator of LAD. The vascular distribution to left anterior fascicle is same as that of right bundle branch, which accounts for occurence of bifascicular block in acute anteroseptal myocardial infarction.

Ablation of AV node for unmanageable SVT is by alcohol injection into AV nodal artery or electrical RF ablation of AV node.

Torsade de pointis (twisting of points) is a particular form of pleomorphic ventricular tachycardia with alternating polarity of QRS complexes around base line, and QT prolongation. 95. Pacemakers are rarely indicated for first degree AV block. Occasionally H-V prolongation can lead to first degree block and a pacemaker in this situation is indicated.


activity. Triggered activity is effectively suppressed by verapamil but automaticity is not. Triggered activity exhibits warm-up, a term signifying gradual increase in rate. •

The presence of a new right bundle branch block in the setting of acute myocardial infarction has serious consequences. The right bundle receives its vascular supply in one of two ways. In 50%, it is first septal perforator of anterior descending which is the sole supplier and in rest the supply is from AV nodal artery or right coronary and first septal perforator.

PND in the face of worsening systemic venous hypertension 1341 indicates onset of tricuspid stenosis. •

A positive exercise ECG response for CAD in a young woman has predictive accuracy of 50%, while in middle aged man the predictive accuracy is 70-80%.

Diffuse esophageal spasm may produce chest pain that is very similar to angina in quality, location and radiation, but it occurs after meal and is not related to physical exertion.

Complications of cardioversion are related to 3 categories—(1) electrical cardioverter is not synchronised to R wave, thus often delivered within vulnerable period of cardiac cycle producing ventricular fibrillation (2) systemic embolization (3) appearance of postcardioversion arrhythmias.

Patients of unstable angina carry a high risk of sudden death and myocardial infarction within the first 3-months of onset of symptoms. The most powerful predictors of outcome in the early postinfarction period are the degree of LV dysfunction and objective evidence of ischaemia during exercise testing.

Synope with effort is a major symptom of aortic stenosis, hypertrophic obstructive cardiomyopathy and pulmo-nary hypertension secondary to congenital heart disease.

Asymptomatic ischaemia (silent ischaemia) has a prevalence of 2-4% in men over 40 years of age. These patients have lower risk of developing myocardial infarction or sudden death.

Four major characteristics associated with increased risk of sudden cardiac death in patients of coronary artery disease or hypertension are (1) ventricular electrical unstability (2) extensive coronary artery narrowing (3) abnormal LV function and (4) conduction/repolarisation abnormalities.

Even after successful thrombolysis, the incidence of reocclusion of the infarct affected artery is 25%. Hence, coronary angiography after 24-48 hours of thrombolysis with PTCA of the occluded artery is advisable.

Epinephrine is the most crucial drug used during resuscitation effort. It increases arterial and coronary perfusion, stimulates spontaneous contraction during asystole, makes fine ventricular fibrillation more responsive to defibrillation, and acts as inotropic agent. It prevents carotid artery collapse, and enhances responsiveness to external caridac compression.

Patients with exercise induced ischaemia and single vessel disease have approximately 2% annual mortality while those with tripple vessel disease have 6% annual mortality.

In variant angina (coronary spasm) ST depression occurs as commonly as ST elevation. Subendocardial ischaemia causing ST depression may be in part due to subtotal coronary occlusion, involvement of smaller branch vessels or due to presence of major collaterals. Variant angina frequently occurs at same time of the day and there is no increase in heart rate.

The pathophysiology of mild essential hypertension is different from that of moderate or severe hypertension. Increased beta adrenegic activity and reduced parasympathetic activity results in increased myocardial contracility and heart rate in mild hypertension.

Patients of moderate and severe hypertension either have low renin, normal or high plasma renin. Orthostatic hypertension is evidence of increased nor adrenergic activity.

Diagnosis of pheochromocytoma should be considered in patients of episodic hypertension. 10% of these tumor are extraadrenal, 10% are bilateral and 10% are malignant. Failure of plasma norepinephrine to fall with oral clonidine is an indirect indicator. Plasma volume is usually reduced but plasma renin activity is usually increased. Preoperative volume expansion and alpha receptor blockade are essential.

Diastolic dysfunction may be the earliest manifestation of hypertensive heart disease. LV hypertrophy is associated with reduced compliance and imparied LV filling. Prolongation of isovolumetric relaxation correlates positively with LV mass index. The length of pre-ejection period reflects systolic function. Peak velocity of early filling is reduced while that of later filling is increased.

Urinary excretion of metanephrine is the most sensitive test for adrenal pheochromocytoma, A urinary metanephrine-creatinine ratio above 22 is highly predictive. CT and NMR have replaced adrenal venography for diagnosis of pheochromocytomas.

Renovascular hypertension is the most common curable cause of secondary hypertension. It should be considered in patients of abdominal bruit, those below 35 years of age, those with severe resistant hypertension and in whom renal function deteriorates following antihypertensive therapy. The two most common causes of renovascular hypertension are atherosclerosis and fibromuscular dysplasia of renal artery. The former benefit more from surgical revascularisation and the latter from ballon

Amrinone is a noncatecholamine, nonglycoside bipyridine derivative that acts as a phosphodiesterase inhibitor. When used IV it reduces systemic and pulmonary vascular resistance and LV filling pressure unaffecting heart rate (similar to dobutamine). Its vasodilator property predominates over positive inotropic characteristic. Enoximone and piroximone are also phosphodiesterase inhibitors but are imidazolone derivatives. In total anomalous pulmonary venous return, all the pulmonary veins unite to form a common chamber superior to left atrium. An intra atrial communication is necessary to transport partially oxygenated blood to the left side of heart and to sustain life until surgical correction is made.

Postinfarction rupture of septal wall occurs within 24 hours of chest pain in upto 1/3 of patients and presents with a loud, harsh holosystolic murmur.

Aneurysm of sinus of valsalva occurs due to congenital absence of media in the aortic wall. Its rupture most commonly occurs in young males. There is acute onset of chest pain accompanied by continuous murmur as the rupture is commonly to right atrium/ ventricle.

Only 50% cases of mitral stenosis recall a history of acute rheumatic fever. Mitral annulus calcification can rarely cause mitral stenosis but usually causes mitral regurgitation or heart block due to calcific encroachment of conduction system.

Mitral regurgitation after myocardial infarction can be due to ischaemia/infarction of papillary muscle or the adjacent myocardium. The posteromedial set of muscles are more commonly involved than the arterior set by a ratio of 4:1. Severity of mitral regurgitation depends upon whether an entire set or only isolated heads are involved.

Causes of tricuspid stenosis can be due to rheumatic fever, endocardial fibroelastosis, endomyocardial fibrosis, SLE, carcinoid syndrome, right atrial myxma/thrombus and tumor metastasis. In a patient of mitral stenosis relief of dyspnoea,

IMPORTANT MEDICAL FACTS


angioplasty. Complications of balloon angioplasty include acute renal failure, renal infarction and renal artery dissection.

1342

Reduced plasma potassium in a patient of hypertension may indicate hyperaldosteronism. Primary aldosteronism can result from adenoma or bilateral hyperplasia of zona glomerulosa. Patients with bilateral hyperplasia are better treated with spironolactone.

Elevation of serum lipid and potassium may accompany use of betablockers in hypertension and renal failure.

The indications for venous interruption in pulmonary embolism are (1) recurrent emboli on adequate anticoagu-lation (2) contraindication of anticoagulants (3) persistent disease state leading to emboli (4) septic embolization from below heart (4) certain patients with massive emboli in whom a further embolus would be fatal. Thrombolytic therapy does not reduce long-term mortality when compared to heparin anticoagulation alone.

12 MCQs in Medicine

Fat embolization usually occurs following fracture of midfemur or pelvic bones. Patient has acute respiratory distress with altered consciousness, seizure, delirium, coma and development of petechae, Heparin is not beneficial and may even be detrimental in that the lipase activity might increase the toxic fatty acids in the lungs.

MCQ's

The most sensitive indicator of pulmonary hypertension is enlargement of pulmonary arteries. RV enlargement is often difficult to demonstrate when emphysema causes a vertical heart shadow. Patients of sleep apnoea syndrome develop general alveolar hypoventilation and hypoxia leading to pulmonary hypertension. The symptoms of sleep apnoea are morning headache, day time somnolence, loud snoring and periodic apnoea daring sleep and personality disorder. In dilated cardiomyopathy, atrial _fibrillation and left bundle branch block are common rhythm disturbances caused by replacement ofmyocardial cells with fibrosis as well as myocytolysis. Abnormal thallium perision scan is common in long-standing dilated cardiomyopathy. Approximately 55% of the anterior surface of heart is by right ventricle, 20% by left ventricle and 10% by left atrium. Nonpenetrating trauma, hence is more likely to involve right ventricle. ECG in such patients is similar to infarction. The most common site of aortic rupture following blunt chest trauma is at the level of ligamentum ductus arteriosus. Survival is higher in distal aortic rupture and in those forming a false aneurysm initially at the site of rupture. The prevalence of cerebral infarction is 3%. Heart failure, atrial arrhythmias, anterolateral infarction and ven-tricular aneurysm all predispose to cerebral embolism. Cerebral infarction occurs in upto 17% of patients with cyanotic congenital heart disease. TOF and TGA account for most of these patients. Patients with congenital heart disease and right to left shunt are at increased risk of developing brain abscess. Patients of ostium primum atrial septal defect have left axis deviation with mitral regurgitation and enlargement of left atrium. Complete heart block may appear immediately after ASD closure or months later. Banding of pulmonary arteries may be needed in patients of ASD with large Lt to Rt shunt, to prevent pulmonary vascular disease. ASD children with severe MR or increased pulmonary vascular resistance must be repaired early since survival to age 5 without surgical correction occurs in only 4%. The normal aortic valve area is 2-3 cm2. Chest pain, syncope, heart failure, and sudden death occur in critical aortic stenosis. Survival averages 5 years from development of exertional chest pain; 3-4 years from that of syncope and 2 years from

date of CHF. Sudden death occurs in 15-20% of patients with symptomatic aortic stenosis. Elderly patients with calcific aortic stenosis have a faster downhill course. •

The means by which hypertension induces atherosclerosis is not clear. Increased renin levels may induce cellular changes that lead to atherosclerosis. Altered characteristics of flow including eddy currents and back flow of blood at selected anatomic sites within arterial tree may result in focally altered endothelium and the development of atherosclerotic lesion.

Cholesterol is a strong independent predictor of coronary mortality. Patients with serum cholesterol of 250-275 mg% have twice the risk of myocardial infarction as in patients with a serum cholesterol level of < 175 mg%. The incidence of coronary artery disease appear to be inversely related to HDL2 level. The ratio HDL to LDL is a better predictive index for CAD than absolute HDL level.

Glucose intolerance doubles the occurrence of CAD in men and tripples or quadruples the incidence in women particularly prior to 50 years of age. Diabetes may predispose to atherosclerotic CAD by a number of mechanisms including increased lipid levels, hypertension, obesity. Control of hyperglycemia alone does not eliminate coronary risk. However, improved glucose tolerance is associated with increase in HDL value.

Oral contraceptives increase body weight, and blood pressure, elevate triglyceride level, reduce glucose tolerance and reduce HDL levels. Their use is associated with higher risk of myocardial infarction, cerebrovascular and thromboembolic diseases. They are relatively safe for women below 35 years who do not smoke, are normotensive with normal lipid profile and no history of thromboembolic disease.

Aspirin 325 mg daily on long-term intake reduces chances of myocardial infarction in general population by 50% in some studies. Betablockers started before hospital discharge in patients of myocardial infarction also reduces future sudden death by 26-39%.

Exercise thallium scintigraphy is significantly superior to exercise ECG alone in both specificity and sensitivity. Multiple perfusion defects can be seen in 50% of patients with triple vessel disease and in 2/3 of patients with left main disease.

The status of LV function is a more important prognostic variable than the extent of angiographic narrowing. Patients of 3 vessel disease and normal ventricular function have a four-year survival of 80% compared to less than 60% in those with TVD and impaired LV function.

The most important determinants of survival in patients after myocardial infarction are infarct size and degree of LV dysfunction.

Most patients of ischaemic cardiomyopathy die of dysrrythmias rather than of congestive failure or infarction. Fifty per cent of patients with CAD and severe LV dysftinction die within 3-year of presentation and about 80% die within 5-years.

Diltiazem When given within 72 hours of non Q wave infarction, will reduce chances of reinfarction in 50%.

The most common pattern of anomalous aortic origin of a coronary artery is that of left circumflex arising from right sinus of valsalva and courses between aorta and pulmonary artery, there is an increased incidence of exercise induced sudden death. Anomalous origin of LCA from pulmonary artery presents in infancy with angina, infarction or CHF.

Systolic compression of epicardial vessel due to intramyocardial bridging is a relatively rare arteriographic finding occurring in less than 1% cases studied for chest pain. Left arterior descending is commonly involved with systolic lumen < 25% of diastolic diameter of vessel.


The exact etiology of primary pulmonary hypertension is unknown. Atherosclerotic plaques in large elastic pulmonary arteries and medial hypertrophy of small muscular arteries are relatively specific pathologic findings, but fibrinoid medial necrosis is a nonspecific finding.

Cardiac myxoma is the most common benign cardiac tumor. The most frequent location for cardiac myxoma is left atrium (75%), right atrium 18%, right ventricle 4% and left ventricle 4%. They usually arise from fossa ovalis.

In ASD the mean LA pressure is usually less than 3 mm higher than RA pressure. The larger the ASD, less is the resistance and so minimal is the pressure difference between two atria. Atrial distensibility, atrioventricular valve distensibility and ventricular compliance contribute to the flow across the defect. 166. Features of a patient with single atrium are similar to those of a large ASD with fixed split S2, hyperdynamic right ventricular lift and holo systolic murmur of mitral regurtitation. Clubbing and mild cyanosis that increase with crying differentiate it from ASD.

There is higher incidence of PDA among female children, in children with birth asphyxia/respiratory distress syndrome and in children with maternal exposure to rubella. Commonly associated defects include VSD and coarctation of aorta. The magnitude of shunt is determined by cross sectional area and length of ductus. Indications for PDA closure include uncontrollable congestive failure in neonate or growth retardation. Persistence of ductus beyond six months of age is also an indication for closure as endocarditis is a danger.

The mid-diastolic rumble of mitral stenosis can be heard in other conditions like vsrt, PDA, due to increased flow across mitral valve. Austin flint murmur of aortic regurgitation is due to aortic jet impinging upon anterior leaflet of mitral valve. Left atrial myxoma, ball valve thrombus can also cause mitral middiastolic murmur.

Acute mitral regurgitation is more sinister as the receiving left atrim is not dilated with normal compliance. Hence pulmonary edema occurs easily. A holosystolic murmur is more common to chronic mitral regurgitation. Dyspnoea and fatigue occur late in chronic mitral regurgitation. Once LV dysfunction occurs in chronic MR, valve replacement may not bring full relief. 176. Occlusion of circumflex or right coronary branch produces papillary muscle infarction and resultant regurgitation, either due to rupture of the muscle or its malalignment.

Coronary fistula arise more frequently from right coronary than left coronary. History may include recent or remote chest trauma, and chest pain compatible with coronary steal phenomena. Physical examination reveals a continuous murmur. X-ray and ECG are unrewarding.

Kawasaki’s disease is characterised by non-purulent cervical adenopathy, desquamation of extremities, pharyngeal erythema and sterile conjunctivitis. In 20% cases, vasculitis of vasavasorum leads to coronary arteritis, aneurysm, stenosis and occlusion. Syphilis causes coronary osteal stenosis in 25% of patients with tertiary leutic cardio-vascular disease. Other infections that rarely affect coronary arteries are salmonellosis, tuberculosis and leprosy.

Hypertrophic cardiomyopathy may be determined by an aberration of catecholamine function as it is associated with pheochromocytoma, systemic hypertension, Friedreich’s ataxia and neurofibromatosis and LV function improves with betablocker therapy but worsens with isoproterenol. Amyloid heart disease is a form of restrictive cardiomyopathy characterised by normal systolic function, normal cavitary dimensions, and reduced LV diastolic function. Amyloid deposits can be seen in over 50% of patients above 60 years of age and most of the lesions are limited to atria, only one-third involving the valves and ventricles.

In aortic stenosis a measured pulse pressure s’ 30 mmHg suggests severe aortic stenosis. Absence of systolic thrill indicates systollic gradient 5 30 mmHg. Paradoxical splitting of S2 is due to severe aortic obstruction or LV dysfunction. Patients of severe AS show in ECG absence of R wave in V1 V2, loss of Q wave in V6 and ST-T changes anterolaterally.

Aortic stenosis can be valvular, subvalvular or supravalvular. An ejection click in the apex is the hallmark of valvular aortic stenosis. Half of the patients of subvalvular stenosis have aortic regurgitation. In postvalvular stenosis patients .have characteristic facies, hypercalcemia and mental retardation (William’s syndrome). Poststenotic dilatation is common in valvular aortic stenosis but concentric LV hypertrophy is common to all forms.

• Sarcoidosis may cause pericarditis and restrictive cardiomyopathy. Sudden death due to dysarrhythmia or heat block is a common presentation. Thallium study shows myocardial perfusion defects due to sarcoid granulomas.

One-third of patients with supravalvular pulmonic stenosis have unilateral stenosis while 2/3 have bilateral peripheral pulmonic stenosis. 2/3 of these patients have associated anomalies like VSD, coarctation, TOF, supravalvular aortic stenosis.

Patients with Noonan syndrome have a dysplastic pulmonary valve that causes pulmonary stenosis.

4 electrocardiographic stages have been described in acute pericarditis. Stage I-diffuse ST elevation with PR depression. This ST elevation is less than 5 mm and is without monophasic patterns. There is reciprocal ST depression with corresponding PR elevation in aVR and V1 Stage II-phase of normalization; stage Ill-diffuse T wave inversion; Stage IV-abnormal T waves may remain or revert to normal. Absence of Q waves, concavity of ST segment upwards and absence of associated T wave inversion differentiate it from myocardial infarction.

Chronic constrictive pericarditis in developing countries is largely due to tuberculosis. Pericardial involvement occurs in 30% cases of rheumatoid arthritis but it is subacute and seldom calcified.

Syphilitic, aortic aneurysm occurs most commonly in ascending aorta and tends to be saccular or fusiform. Coronary osteal stenosis does not extend distally beyond I cm. Atherosclerosis on the contrary usually spares ascending aorta, except in diabetes.

14 MCQs in Medicine •

In corrected transposition pulmonary artery arises from left sided morphologic right ventricle. In addition to ventricular inversion there is inversion of A-V valves. A VSD is present in most patients and 50% have Ebstein’s anomaly of inverted left sided pulmonary valve.

The most prominent complaint in mitral stenosis is dyspnea due to pulmonary edema. Patient may also present with

IMPORTANT MEDICAL FACTS

The pulmonary circulation must remain as a low pressure, low resistance conduit to preserve the cardiac output. This is maintained because pulmonary arteries are thin walled, with little resting muscle tone, autonomic nervous system has very little effect on pulmonary vessels, and there are many small arteries and capillaries that are not utilized at rest but are perfused with exercise. Hypoxia causes a rise in pulmonary vascular resistance. In COPD. PA pressure is related to level of hypoxemia and is usually decreased by 02 administration.

complications arising from arrhythmia (atrial fibrillation), 1343 embolic manifestation (LA clot), and haemoptysis. Less common presentations are hoarseness, chest pain.


1344 •

The major manifestations of cardiovascular syphilis are aortic regurgitation, aortic aneurysm and coronary osteal stenosis. To begin with there is involvement of vasa vasoruni of aorta.

The term mycotic aneurysm is a misnomer, since the invading organism is not always a fungus but can be bacteria.

In osteogenesis imperfecta, there is aortic root dilatation but no regurgitation. Inheritance is autosomal dominant; bones are fragile and sclera is bluish.

Thaizide diuretics cause a rise in serum triglyceride and LDL cholesterol. It also reduces insulin secretion leading to glucose intolerance. Peaked or tented T waves, which are the earliest electrocardiographic manifestation of hyperkalemia occur when plasma potassium exceeds 5.5 mEq/lit but are only seen in 20% of patients. Subendocardial ischaemia and cerebro-vascular accidents also cause tall peaked T waves.

Depression of intra-atrial conduction at plasma greater than 7 mEq/lit results in broad and low amplitude P waves. When potassium level is greater than 9 mEq/liter the QRS widens. Acidosis, hyponatremia, and hypocalcemia potentiate ECG manifestations and cardiotoxic effects of hyperkalemia.

MCQ's

Hypocalcemia is associated with prolonged QTc interval but there is no correlation between serum calcium level and QTc. Despite primary role of calcium in contraction, heart failure as a complication of hypocalcemia is rare.

ECG manifestation of hypomagnesemia include narrow QRS complex and tall peaked T waves. Patients predisposed to magnesium depletion are those on diuretics, patients of gastrointestinal disease, diabetes mellitus, patients of heart failure and secondary aldosteronism. Hypomagnesemia potentiates digitalis induced arrhythmia.

Severe hypophosphatemia may be associated with depression of myocardial contractility. Prolonged respiratory alkalosis, nutritional recovery from starvation, alcohol withdrawal and recovery phase of diabetic ketoacidosis are associated with hypophosphatemia. The immediate cardiac effects of electric shock include asystole or ventricular fibrillation. Apnoea and hypoxia induced by shock can lead to cardiac arrest which takes longer time to recover. Myocardial infarction can also result from electric shock. Week end ‘angina’ occurs in workers involved in ammunition making that uses nitroglycerol. This compound is 180 times more volatile than nitroglycerin and is thus easily absorbed from lungs and skin. Chest pain and sudden death can occur in these workers on withdrawal from prolonged nitroglycerin or nitrate exposure.

Chronic use of vibrating tools predispose to cardiovascular changes similar to those seen in endurance athletes with increased ejection fraction and left ventricular end diastolic dimension with a decreased resting heart rate.

Betablockers cross placenta, can cause low birth weight and induce premature labor but they still be used cautiously in pregnant ladies with hypertrophic obstructive cardiomyopathy. In young hypertensives betablockers should be tried but in older age group vasodilators because in the latter betablocker induced vasodilatory response is minimal.

SLE can cause pancarditis with involvement of pericardium, endocardium, myocardium and coronary arteries. The pericardium is most frequently involved and pericardial effusion occurs in over 50% cases. Fibrofibrinous sterile vegetations known as Libman-Sacks vegetations occur but do not produce any valve dysfunction.

Aortic root dilatation occurs in rheumatoid arthritis, psoriatic arthritis, Reiter’s syndrome, and ankylosing spondylitis. This aortic root inflammation is clinically silent until aortic regurgitation occurs. While corticosteroids can be useful in iritis associated with these diseases, it is not helpful in aortic root disease.

Tricyclic antidepressants may cause mild tachycardia and also orthostatic hypertension. They also have a quini-dine like property, hence antiarrhythmic. In overdose they cause sinus tachycardia, prolongation of PR, QRS, and QT intervals, bundle branch block.

Doxorubicin may cause cardiomyopathy in dose (total) exceeding 430 mg/m2. Vincrystine is reported to cause myocardial infarction. Among general anesthetics, halothane, enflurane and nitrous oxide are rarely used alone because of dysarrhythmia and cardiac depression. Ketamine may also cause post-operative psychosis and dysphoria. Pancuronium maintains sympathetic tone by inhibition of catecholamines at nerve terminal which leads to tachycardia and hypertension.

Naloxone may reverse the depressant effects of narcotic analgesics, but may be dangerous in a patient of coronary artery disease as it produces sympathetic stimulation.

In younger persons the endsystolic volume diminishes with exercise, reflecting a betasympathomimetic effect that enhances inotropic state and promotes effective arterial vasodilation. Elderly persons however, lack this response.

Atrial natriuretic factor is formed and stored in granules in atrial tissue, to be released under conditions of atrial stretch. It increases GFR and decreases hypertonicity of renal medulla. It inhibits vasopressin and aldosterone.

The earliest haemodynamic response to isotonic exercise is vasodilatation of resistance vessels in exercising muscles with fall in systemic vascular resistance, increase venous return, increase in end diastolic volume and increase in cardiac output.

One MET is the energy expenditure of sitting quietly at rest and is equal to 02 consumption of 3.5 ml/kg/min. In stage I of standard Bruce protocol energy expenditure is 5 MET. The metabolic response to treadmill is relatively independent of body mass, but metabolic response of ergometric exercise is inversely related to body mass.

False negative exercise test commonly occurs in single vessel disease (usually left circumflex) that supplies electrically silent area of myocardium.

The mechanism of action of heparin depends on its simultaneous binding to antithrombin III to coagulation enzymes.

Converting enzyme inhibitors (peptidyl dipeptide hydrolase inhibitors) block production of vasoactive octapeptide angiotensin II from decapeptide angiotensin 1. ACE inhibitors also inhibit aldosterone secretion and promote diuresis. They increase circulating levels of bradykinin by inhibiting it degradation and hence have vasodilator property. They are agents of first choice in mild to moderate hypertension and in congestive heart failure. A dry cough is troublesome in nearly 10% of patients taking enalapril.

Digoxin binds to Na+ ATPase thus directly causing increased calcium influx. Digoxin is unstable in highly acidic solutions and may be inactivated by hydrolysis if gastric emptying is unduly delayed. About 10% of patients demonstrate extensive intestinal metabolism of digoxin which causes high digoxin requirement.

Amrinone is a phosphodiesterase inhibitor and thus leads to increased intracellular eyclic AMP and consequent positive inotropic effect. It has also vasodilator properties. It improves cardiac output and diminishes LV filling pressure in patients of


heart failure without causing tachycardia and change in blood pressure. Urokinase is more clot selective whereas streptokinase is a nonspecific lytic agent. Allergic reactions are more common with streptokinase. Patients of anterior myocardial infarction seem to benefit more from thrombolysis and early reperfusion.

The present treatment of choice for digoxin overdose is digoxin specific Fab fragment antibody which rapidly removes digoxin from cell membrane. Fab fragments have low molecular weight and hence rapid renal clearance. Immunodeficiency is a problem if multiple doses are required.

Dopamine in small doses is renal vasodilator and hence promotes sodium excretion. In a setting of myocardial infarction and hypotension dopamine or norepinephrine infusion is preferred over doubtamine as latter causes vasodilation, tachycardia and decreased LV filling pressure.

Most thiazide diuretics are ineffective when glomercular filtration rate falls to below 20 ml/min and therefore, are not useful in renal failure. However, metolazone is an exception.

Gemfibrozil and clofibrate are fibric acid derivatives that (1) stimulate lipoprotein lipase activity, (2) partially inhibit synthesis of VLDL-triglycerides, (3) increase activity of LDL receptors, (4) decrease conversion of choles-terol and, (5) increase bile secretion of cholesterol. Thus, they reduce LDL and increase HDL.

The value of endomyocardial biopsy is well established in cardiac transplant rejection, amyloidosis. haemo-chromastosis, sarcoidosis, carcinoid heart disease, endocardial fibroelastosis.

Internal mammary artery is an excellent alternative to saphenous vein as a conduit since it is relatively free of atherosclerosis with 95% long-term patency rate. Its use as a free graft does not reduce its effectiveness or long-term patency. ;

The major determinants of pump function are preload, afterload, heart rate and contractility. The determinants of cardiac output are arteriolar vascular resistance, contractility, preload, and heart rate.

Pulsus alternans is the most specific indication of LV failure. Cardiomegaly, MR, S3, LV enlargement on ECG may all exist in absence of heart failure.

ENDOCRINOLOGY AND METABOLISM •

Osteogenesis imperfecta is a series of at least 6 disorders that can be inherited as autosomal dominant or auto-somal recessive. Some but not all of these syndromes have blue sclera.

Fabry’s disease is inherited as an x-linked trait and is caused by deficiency of alpha-galactosidase which causes intra-lysosomal deposition of glycosphingo lipids. Aminocentesis and cell culture for enzyme study is essential.

Phenyl ketonuria is autosomal recessive and is due to deficiency of phenylalanine hydroxylase. A liver biopsy is necessary to demonstrate deficiency of the enzyme since hyperphenylalanenmia can be seen in other conditions. Gene therapy for the disorder is a distinct possibility.

Hereditary haemochromatosis is autosomal recessive and is due 1345 to increased intestinal absorption of iron. Most of these patients have hypogonadism due to failure to secrete gonadotropins. Those who develop cirrhosis carry a risk of developing hepatocellular carcinoma in 30%. Arthropathy is common but not renal involvement.

Hypophosphatasia is a familial disease characterised by a failure to deposit bone mineral. Patients have low level of bone and serum alkaline phosphatase. Presentation is similar to rickets often with multiple fractures.

Refsum disease is an autosomal recessive disorder with accumulation of phytanic acid, manifesting as peripheral neuropathy and night blindness (retinitis pigmentosa).

Neurofibromatosis is one of the most pleiotropic of all genetic disorder that can virtually affect any organ system with variable severity and expressivity.

The gene coding for human G6PD is X-linked. There are more than 80 defined variants of the enzyme. Only older RBCs are the victims of oxidant stress in G6PD deficiency as neocytes have sufficient level of enzyme to avoid drug induced haemolysis.

Orotic aciduria is characterised by megaloblastic anaemia, leukopenia and growth retardation. Deficiency of phosphoribosyl transferase and ornithine carbamoyl transferase can produce this disorder but not carbamoyl synthetase deficiency.

Laurence-Moon-Biedl syndrome is associated with obesity, retinitis pigmentosa, hypogonadism and polydactyly.

Turner’s syndrome can be caused by a variety of chromosomal anomalies-45 XO in 50%, isochromosome X in 20%, mosaicism in 20%.

Defective activity of the enzyme ferrochelatase results in erythropoitic protoporphyria manifesting as pruritic erythema on sun exposure. Acute intermittent porphyria is autosomal dominant and is due to diminished prophobilinogen deaminase activity. Though 90% are asymptomatic, symptomatic patients have abdominal pain, ilieus, vomiting etc. Neurological disturbances include proximal motor weakness, mental disturbances. Porphyria cutanea tarda is the most common form of porphyria with deficiency in hepatic uroporphyrinogen decarboxylase. Patients develop bullous erruptions on exposure to sun.

Xeroderma pigmentosa is an autosomal recessive disorder of DNA synthesis manifesting in children with photo-sensitivity, freckles, zerosis, hypopigmentation etc. These patients have propensity for developing melanoma, basal/squamous cell carcinoma.

Testicular feminization manifests with underdeveloped female genitalia in a genotypic male. Androgen receptors are defective and inheritance is X-linked.

• Palmar xanthomas are characteristic of familial dysbetalipoproteinemia a disorder resulting from abnormalities in the structure of apoprotein E. •

Tendon xanthomas are seen in patients of familial hypercholesterolemia who fail to clear LDL from plasma but have normal triglyceride level.

Hereditary angioedema is due to complement C1 inhibitor deficiency manifesting with intermittent edema of skin, respiratory tract and GI tract, (causes abdominal pain).

Panacinar emphysema is common to those patients of alpha 1 antitrypsin deficiency who are homozygous for Z allele of the gene.

Patients of LCAT deficiency show hyperuricemia and a tendency for self mutilation (Lesch-Nyhan syndrome). Many are mentally retarded, have seizures and ataxia.

C1 esterase inhibitor deficiency causes hereditary angioedema with abdominal pain. Andorgen supplement prevents the edema as well as reverses the biochemical defect.

IMPORTANT MEDICAL FACTS


The major cause of early death in trisomy 21 is cardiovascular malformation. Nonan’s syndrome is often termed `male Turner’s syndrome.

Both adenosine deaminase deficiency and nucleoside phosphorylase deficiency are inherited as autosomal recessive traits. The former leads to severe combined, immune deficiency but the latter leads to T cell deficiency with intact B cell function.

Hunter’s syndrome is X-linked recessive but Hurler’s syndrome is autosomal recessive. Both have mental retardation and coarse facies. Cloudy cornea is characteristic of Hurler’s syndrome but cornea is normal in Hunter’s syndrome.

Hypothalamic failure results in high prolactin level due to loss of hypothalamic dopamine secretion which is prolactin inhibititory factor. Secretion of all other pituitary hormones is decreased.

Malignant otitis externa is common to diabetics over the age of 35 and the infecting organism is P. auroginosa.

MCQ's

1346 •

• Lymphocytic thyroiditis is characterised by clinical hyperthyroidism with low radioiodine uptake. Gradual recovery over period of time is usual. •

The occurrence of diabetes insipidus following pituitary surgery is common and is triphasic. Initially polyuria occurs because of inhibition of ADH release. Next there is period of oliguria and high urine osmolality and finally there is polyuria.

Diabetic amyotr.ophy usually involves proximal muscles i.e., muscles of pelvic girdle and thigh with weakness, atrophy and severe pain but no sensory loss. Spontaneous gradual recovery is usual.

• Gastroparesis diabeticorum refers to reduced gastric emptying and gastrointestinal motility secondary to diabetic neuropathy manifesting with bloating, distension, hicuups etc. Metoclopramide improves symptoms. •

Amiodarone is approximately 40% iodide. It hence induces hypothyroidism. More over it suppresses peripheral conversion of T4 to T3.

Carcinoids are almost always metastatic at the time of diagnosis. Hence diarrhoea of carcinoid syndrome is treated with cyproheptadine, methysergide or pochlorophenylalanine.

Patients of isosexual precocious pseudopuberty have usually congenital adrenal hyperplasia. If there is hypertension in the child 11 hydroxylase deficiency is certain.

Genetics in the most important determinant of obesity. The Ob gene produces leptin? a protein secreted by fat cells in response to fat storage. Leptin acts upon brain to decrease appetite and increase body’s metabolic rate. Obese individuals secrete more leptin but their brain is insensitive to it.

Octreotide in the first line drug for gigantism where transphenoidal surgery is unavailable. When combined with bromocriptine it has additive value.

Paget’s disease is a relatively common bone disease in patients over age of 70. Mithramycin, prednisone. diphosphonates and calcitonin are all helpful.

Abrupt weight loss, anorexia, low BP, small heart and pigmentation imply Addison’s disease, infection may precipitate addisonian crisis.

Bromocriptine 2.5-20 mg/d and pergolide 0.25-2 mg/d are equally effective in treating hyperprolactinemia. Ladies can have transvaginal bromocriptine.

The initial work up in suspected Cushing’s syndrome is dexamethasone overnight suppression test or 24 hour urinary free cortisol measurement. Metyrapone test, CT scans of adrenal and pituitary are done subsequently.

Elevated antithyroglobulin and antithyroperoxidase antibodies indicate Hashimoto’s thyroiditis while elevated antimicrosomal and TSH receptor antibodies indicate Grave’s disease.

Cyproterone acetate, spironolactone and finasteride are all effective in hirsutism so also flutamide.

In a patient of elevated FSH despite normal testis, normal testosterone and LH levels suggests diagnosis of Sertoli cell only tumor. There is azoospermia and patients are infertile. Testicular biopsy is of limited help and infertility is irreversible.

Serum fructosamine level monitoring in diabetes indicates glycemic control over past 2 weeks.

Blood insulin level of 8ng/ml or more in presence of blood sugar below 40 mg/dL is suggestive of insulinoma. Patients of insulinoma have raised proinsulin representing 30-90% of total immunoreactive insulin.

Unresectable or partially resectable insulinoma need treatment with diazoxide, verapamil or somatostatin.

Vit. C, E and A are antioxidants and may retard atherosclerosis. Oxidized LDL is particularly atherogenic. Antibodies to oxidized LDL may promote atherosclerosis.

Marine fish contain n-3 or omega-3 fatty acid which retard platelet aggregation; fatty acids with transisomer have been associated with increased risk of coronary artery disease.

Statins reduce LDL more than triglyceride; the opposite is true of germfibrozil. However over all CHD risk is reduced only by simvastatin and gemfibrozil.

Obesity is genetically determined Mutation in gene for 83 receptor in adipose tissue involved in lipolysis and thermogenesis, markedly increase the risk of obesity.

Acute attacks of abdominal pain that are often precipitated by diet or drug (barbiturate, anticonvulsants sulphonamides, alcohol) may be due to acute intermittent porphyria.

Hormone binding is specific for a single type of receptor but cortisol and estrogens can bind to an array of receptors.

Chronic alcoholics may develop stigmata resembling Cushing’s syndrome and biochemical studies may reveal hypercortisolemia. Hence such patients should be reevaluated after abstinence from alcohol.

In a patient of moderately severe ketoacidosis normokalemia implies severe total body potassium depletion which is likely to be aggravated with fluid replacement. Thus potassium infusion is mandatory.

In a diabetic with moderate hyperkalemia, metabolic acidosis, and mild depression in renal function have usually hyporeninemic hypoaldosteronism.

Acute nonthyroidal disease can cause decrease serum T3 and increased reverse T3 concentration as T4 is preferentially converted to reverse T3.

Klinefelter’s syndrome should be suspected in patients of hypogonadism with small firm testis, gynaecomastia, low testosterone levels and increased plasma FSH and LH. Chromosomal analysis is a must for such patients (XXY pattern).

The sense of smell must be tested in all patients with delayed puberty or eunuchoid features to exclude Kallmann’s syndrome due to reduced pituitary GnRH release.


Membrane receptors for hormones are of 4 major groups (a) GPCR (for LH, FSH, ACTH, PTH etc) (2) tyrosine kinase receptors (insulin) (3) Cytokine receptors (GH) and (4) serine kinase (TGF β) Nuclear receptors (T3T4, cortisol) number around 100, many of which are orphan because their ligands are unidentified. Carney syndrome is characterised by skin pigmentation, myoxmas and endocrine tumors of testis, adrenal, and pituitary-a chromosome 2 disorder.

Cabergoline is a long acting dopamine (D2) agonist, suppressing PRL for over 2 weeks with a single dose 0.5-1 mg twice weekly shrinks 80% microadenomas and is effective in those resistant to bromocriptine. Other D2 receptor agonist are pergoide, lisuride and quinagolide.

Dose of octreotide for growth hormone secreting adenoma is 50 µg tid increased upto 1500 µg/day. Modest regression of tumor occurs in 40% but effect is reversed when treatment is stopped.

Lanreotide is a depot preparation of somatostatin whose effect lasts for 10-14 days after 30 µg IM.

Inferior petrosal venous sampling before and after CRH administration is best to differentiate between pituitary ACTH secreting tumor from ectopic ACTH secreting tumor.

The main mechanism of thyroid tissue destruction in idiopathic hypothyroidism is activation of T4 and T8 cells with increased apoptosis of thyroid follicles by upregulation of FaS. Antibodies present to thyroid tissue have minimal role (Tg,TP0). TPO antibodies fix complement but not Tg anti bodies. These antibodies only amplify the ongoing autoimmune response.

TSH-R blocking antibodies are present in 20% of Asian patients with hypothyroidism and cause thyroid atrophy

Thyroid associated ophthalmopathy is due to cytokine induced synthesis of glycosaminoglycans that trap water. Orbital fibroblasts are uniquely sensitive to cytokines.

Hashimoto’s encephalopathy of hypothyroidism is associated with myoclonus and progresses to confusion and coma but is corticosteroid responsive.

Conversion of angiotensin I to angiotensin II is mainly in pulmonary vasculature, and latter is converted to angiotensin III in liver. Angiotensin II and III act through AT-1 receptor, role of AT-2 receptor is unidentified.

In normal women 90% urinary ketosteroids (DHEA metabolism) is of adrenal origin and in men 60-70% is of adrenal origin .

Statins can reduce progression of diabetic retinopathy, so also strict blood pressure control but not strict glycemic Le. control. Once advanced retinopathy is present, strict glycemic control is of less benefit.

Insulin lispro and aspara are short and quick acting soluble insulins. In the former lysine and proline in 28th and 29th position of betachain are reversed by rDNA technology. Insulin glargine is a long acting biosynthetic insulin which has later onset of action and longer duration of action ies without pronounced peak, hence may replace nocturnal NPH.

Insulin sensitizers rosiglitazone and pioglitazone reduce insulin resistance and improve glucose utilization in ted peripheral tissues and skeletal muscle. They may induce ovulation in PCOD.

Osteoblast is of mesenchymal origin whereas osteoclast has haematopoitic origin. PTH, Vit D help in formation of active osteoblast that secretes collagen I, osteopontin, osteocalcin and alkaline phosphatase. Osteoclast formation is influenced

Jansen’s disease is AD with mutations in PTH/PTHrP receptor. There is short limbed dwarfism with multiple cystic areas in bone, undetectable PTH, hypercalcemia and hypophosphatemia.

Zoledronate is third generation biphosphonate, upto 800 times more potent than pamidronate and normalizes raised serum calcium more quickly.

Raloxifene is selective estrogen receptor modulator, approved for use in postmenopausal osteoporosis. It is antiestrogenic for breast cancer whose risk is reduced by 70%. Unlike tamoxifen it does not increase risk of uterine mer cancer.

GASTROENTEROLOGY •

In liver failure, there is failure of conversion of all amino acids (except for branched chain ones like leucine, isoleucin, valine) taken up from portal circulation to urea. Hence ammonia level rises to cause CNS dysfunction.

Other mechanism for hyperammonemia in liver failure includebacteria deamination of amino acids in gut following bleeding, portal hypertension allowing gut ammonia to bypass the hepatic detoxification and alkalosis which favors NH4, NH3 equilibrium in favour of ammonia.

Carcinoma colon is the most common cause of mechanical obstruction of colon and is followed in frequency by sigmoid diverticulitis and volvulus. Adhesions and hernias cause 75% of small intestinal obstruction.

Gut sterilization with neomycin leads to defective absorption of vit K and this can compound hypoprothrom-binemia.

Interferon-alfa is the only promise for chronic active hepatitis of HBV and HCV. Prednisolone is effective when CAH is of nonviral etiology. 4 month course of interferon achieves 40% seroconversion from HBeAg positivity to detectable levels of anti HBe.

The risk of subsequent complications or symptoms in a patient of silent GB stone is less than 1% per year. Hence diabetics with silent gallstone need not have cholecystectomy as long as there is no cholesterosis, porcelain gallbladder or adenomyomatosis.

The clinical constellation of tender hepatomegaly, a bruit in right upper abdomen, bloody ascites and very high alkaline phosphatase in a stable patient of cirrhosis indicate hepatoma. There is high level of alfa fetoprotein.

Vit B12 malabsorption occurs in chronic pancreatitis and is due to excessive binding of vitamin by non-intrinsic factor binding proteins which are normally destroyed by pancreatic proteases.

The combination of weight loss, anaemia and a bullous akin eruption in a patient with hepatic metastasis and evidence of pancreatic lesion is highly suggestive of glucagonoma.

Presence of HBeAg is linked to infectiousness and the antigen is present during viremic period of HBV. Although HBeAg correlate% well with viral replication, its detection in serum does not predict development of chronic active hepatitis. Disappearance of HBeAg from serum indicates resolution of infection. HBeAg negative persons should be considered infectious till antibody to HBsAg is no longer detected in serum.

Most gastrinomas are found in the pancreas and usually multiple. About two thirds of gastrinomas are malignant. It should be suspected when multiple, fulminant, poorly responding peptic ulcers are present at unusual sites.

IMPORTANT MEDICAL FACTS

by IL-1, IL-6, M-CSF and active osteoclasts secrete 13 integrin, 1347 TRAF, cathepsin and carbonic anhydrase. The RANK signalling pathway links osteoblasts with osteoclasts.


1348 •

Two areas in CNS control the act of vomiting. The vomiting centre in the lateral reticular formation in medulla receives input from GI tract and controls outflow to phrenic, vagus and spinal nerves which innervate musclesinvolved in retching. The CTZ in floor of 4th ventricle is stimulated by drugs and metabolic toxins and abnormalities. CTZ is connected to vomiting center by distinct pathway. Antivomiting drugs, i.e. dopaminergic inhibitors or serotonin antagonists act on CTZ. Risk factors for development of coloncancer in patients of ulcerative colitis include presence of disease for more than 10 years, pancollitis and family history of colon cancer. Neither steroids nor megadblon and pseudopolyps increase risk of colon cancer.

Acute haemorrhage from colonic diverticula is the most common cause lower G1 bleed among elderly. Bleeding usually arises from ascending colon even though diverticular disease is common on the left.

MCQ's

Adenomatous polyps of the colon are very common in general population and the incidence increases with age. An increasing size and flatness correlate with increased risk of malignancy.

Chronic liver disease of any etiology is associated with increased risk of hepatic cancer. Aflatoxin, alcoholic liver disease, hepatitis B, alfal antitrypsin deficiency are main villains.

All dyspeptic patients should undergo test for H. pylori (breath test, IgG serology) because H. pylori erradication will cure dyspepsia. 18. The haematocrit is a poor indicator of severity of acute bleeding because it takes 24-72 hours to equilibrate with extravascular fluid. Somatostatin 250 pg IV bolus followed by 250 pg every hour controls variceal bleed. Continuous IV infusion of octreotide 50100 pg/hour also reduces portal pressure and splanchnic blood flow. Combination of vasopressin and nitroglycerine is another alternative.

In lower G1 bleed embolisation is promising but is associated with infarction in 15% cases.

The serum ascites albumin gradient (SAAG) is the best single test for classifying ascites; the gradient correlates directly with portal pressure. SAAG < 1.1 indicates ascites due to non-portal hypertension.

Transjugular intrahepatic portosystemic shunt can control variceal bleed in 90% cases. Several trials indicate band ligation or sclerotherapy can control acute variceal bleed better than medical management though do not decrease overall mortality.

without dissemination to lymph nodes and hence carry excellent prognosis. •

Whipple’s disease is a multisystem disease caused by Tropheryma Whippeli bacillus producing intestinal malabsorption arthritis and myocardial involvement. Treatment is with trimethoprim-sulfamethoxazole for 1 year.

Octreotide represents a major advance in the treatment of severe carcinoid syndrome and diarrhoea. Carcinoid syndrome is seen only in those with hepatic metastasis. Virtually all patients with carcinoid syndrome have obvious signs of cancer with liver metastasis on imaging.

HCV is responsible for over 90% cases of post-transfusion hepatitis. HCV may be a pathogenic factor in cryoglobulinemia, glomerulonephritis, and sporadic porphyrea cutanea tarda.

Recombinant human interferon alfa 2b, 3 million units 3 times a week for 24 weeks achieves biochemical and histologic improvement in 50% cases of hepatitis C. In addition to interferon lamivudine 100 mg daily is useful in treatment of HBV Ribavirin plus interferon yields better result in HCV but this combination therapy is disappointing in interferon non responders.

HBV vaccine in a dose of 10-20 µg, 3 doses provides protection for upto 10 years and is recommended for all children and high risk groups.

Hepatopulmonary syndrome is the triad of liver disease, increased alveolar-arterial gradient and right to left intrapulmonary shunt. Patients have platypnea.

Altai antitrypsin deficiency frequently presents in the neonatal period with cholestasis and then often progresses to cirrhosis.

In addition to abdominal cramps and diarrhoea patients of whipple disease may have a variety of extra-intestinal symptoms like arthritis, lymphadenopathy and fever. Small bowel obstruction is of course a feature.

Granuloma inguinale is a papulo-vesicular and ulcerating infection of skin, perianal area and anus. Unlike LGV it never causes proctitis.

Pericholangitis associated with ulcerative colitis is usually a benign process consisting of portal tract inflammation and occasionally periductular fibrosis but jaundice is rare.

Celiac sprue typically involves only the mucosa where as eosinophilic gastroenteritis involves deeper layers in addition.

Chronic H. pylori infection is attributed to causing chronic gastritis, duodenal and gastric ulcer, gastric lymphoma and gastric carcinoma H. pylori in erradicated with MOC regime (metronidazole 500 mg bid, omeprazole 20 mg bid and clarithromycin 500 mg twice daily) or AOC regime (amoxycillin 1 gm twice daily, omeprazole and clarithromycin as above) Amoxycillin can replace clarithromycin in MOC regime. These regimes achieve cure rate of 85-90% in 1-2 weeks of therapy.

When a patient has melanin deposit on lips, buccal mucosa, palms, soles and perianal skin, Gl bleed and history of intestinal obstruction the possible diagnosis is Peutz-Jeghers syndrome, an autosomal dominant disorder with benign intestinal polyposis. Since these polyps are benign hamartomas, not adenomas, malignancy potential is only 3% where as polyps of Gardner’s syndrome (familiar polyposis) have a 95% risk of adenocarcinoma.

Omeprazole 20mg/d and lansoprazole 15 mg/d achieve 90% duodenal ulcer healing in 4 weeks. Omeprazole 40 mg/d and lansoprazole 30-60 mg/d heal 90% gastric ulcer after 8 weeks. Patients on long-term proton pump inhibitors should have serum gastrin estimation after 6 months of therapy and if its level is above 500 pg/ml, the dose should be reduced or stopped.

Chronic diverticulitis can present with pneumaturia, left lower abdominal pain, fever, lower Gl bleed. Such colon-vesicular fistula can also occur in Crohn’s disease and carcinoma of colon.

Excessive flatus production results from lactase deficiency because the breakdown of undigested lactose in the colon yields hydrogen and carbon dioxide. The hydrogen breath test is more specific and more sensitive than the traditional lactose tolerance test. ‘Gas pain’ of otherwise normal individual is due to disorder of intestinal motility.

There is no need to treat an asymptomatic patient of chronic active hepatitis with prednisolone and azathioprine since they do not prolong survival. As long as patient remains

Sucralfate is more effective in duodenal than gastric ulcer. Bismuth promotes ulcer healing through stimulation of mucosal bicarbonate and prostaglandin production. It has antibacterial action against H. pylori similar to proton pump inhibitors.

About 10% of gastric lymphomas arise from mucosa associated lymphoid tissue and tend to be lowgrade indolent tumors


Unlike renal insufficiency, there are no practical nomograms for 1349 calculating drug dosage in liver disease. Liver disease offers no protection for drug-drug interaction.

Haemochromatosis, a chromosome 6 disorder can only definitely diagnosed form quantitation of hepatic iron from liver biopsy. Presence of stainable iron in more than 75% of hepatocytes only correlates roughly with quantitative measurement. Chronic alcoholics also have increased hepatic iron.

Aspirin and other NSAID which block production of prostaglandin E2 and I2 are ulcerogenic because they hamper with prostaglandin mediated cytoprotection.

No biochemical values like serum levels of (1) GABA mercaptan and ammonia (2) CSF levels of glutamine and (3) ratio of aromatic to branched chain amiho acids accurately stage hepatic encephalopathy. Hence EEG is the only dependable tool.

Ulcer on the posterior duodenal bulb juxtaposed to the gastroduodenal artery is far more likely to cause massive GI bleed.

Valproic acid has been associated with acute and sometimes fatal hepatic failure, the histological picture resembling acute fatty liver of pregnancy or tetracyline toxicity.

Vit A when taken in amounts exeeding 40,000 IU 8 day for years leads to hepatic damage as well as systemic symptoms of hairloss, fever, pruritus and bone pain.

Androgenic anabolic steroids like oxymetheolone can cause peliosis hepatis, hepatic rupture and haemorrhage as well as hepatocellular carcinoma.

Cimetidine which has an imidazole ring has anti-androgenic effect but ranitidine which has the furan ring is devoid of antiandrogenic effect.

Any mother who is HBEAg +ve is most likely to transmit the infection to her baby. 72. Only side to side portocaval shunt besides reducing portal pressure improves ascites.

Villous adenomas of descending colon, sigmoid colon and rectum can be associated with secretory diarrhoea, and hypokalemia. They carry a more chance of malignancy than a similar sized adenomatous polyp.

Endoscopic US plays an important role in evaluating depth of invasion of upper GI malignancy.

Dieulafoy’s lesion refers to a large caliber arteriole that runs immediately beneath the gastrointestinal mucosa, usually in the proximal lesser curvature that causes occult GI haemorrhage.

Magnetic resonance cholangiopancreatography and helical CT can diagnose bile duct malignant without need for ERC P.

Charcot’s triad of abdominal pain, fever and jaundice is present only in 70% of patients witth ascending cholangitis and biliary sepsis.

All patients with history of heart burn for over 10 years need frequent endoscopic surveillance for Barret’s esophagus, dysplasia and early malignancy.

While prescribing a liquid antacid for peptic ulcer, the principal factor to be taken into consideration is the acid neutralizing capacity not the mere volume of antacid. A bedtime dose is essential to neutralise nocturnal acid production.

Milk has a weak acid neutralizing capacity but its high calcium content is a potent stimulator of gastic acid production. Antacid tablets have only a limited place in treatment of acid peptic disease.

Wilson’s disease can manifest with chronic active hepatitis and fulminant hepatic failure with normal ceruloplasmin. KayserFleischer ring may be absent in very young children with Wilson’s disease and it may be present in any patient with severe and prolonged cholestasis.

Though A. lumbricoides, F. hepatica and C. sinensis can all infest the biliary tree and cause obstruction and infection, only C. sinsensis can live in human host for decades to cause cholangiocarcinoma

Adults of S. mansoni live primarily in rectal submucosal venous channels, deposit eggs that find their way into inferior mesenteric venous plexus to land up in portal venules but not in bile ducts.

Half of the right colonic haemorrhages are due to vascular ectasia. Radionuclide scans are helpful but distal small bowel lesion is difficult to exclude

Pancreatic pseudocysts can compress the gastric outlet or common bile duct. Chronic leakage of cyst contents can result in ascites which is high in digestive enzyme content. Cystadenocarcinomas of pancreas never arise from pseudocysts

Persisting elevation in serum amylase after recovery from acute pancreatitis indicates pseudocyst formation. Amylase elevation occurs in 20% cases of pancreatic cancer but it can also be elevated in acute cholecystitis.

Asymptomatic cholelithiasis is a relatively benign condition and less than 25% of these patients subsequently develop serious complications. The risk of gallbladder cancer in a patient of asymptomatic cholelithiasis is exceedingly small and does not call for prophylactic cholecystectomy.

Colchicine affects intestinal epithelial cell function and can result in mild steatorrhoea and an abnormal D xylose test.

Individuals who are HBSAg +ve are 200 times more prone to develop hepatocellular carcinoma than those who are HBSAg -ve, making hepatitis B virus infection perhaps the strongest known risk factor for any human cancer.

Barret’s esophagus can also lead to chronic peptic ulcer of esophagus with high and long strictures. Endoscopic mucosal resection or photodynamic laser ablation may be curative.

The cause of duodenal ulceration in H.pylori infection is uncertain. There is gastric metaplasia in duodenum, less of duodenal bicarbonate production or increased gastric acid secretion from H.pylori induced gastrin release.

A BAO:MAO ratio >0.6 is highly suggestive of ZES; an increase in gastrin >200 pg/ml within 15 minutes of secretin infusion is also >90% specific for ZES.

Medium chain triglycerides (8-10 carbon atoms) are abundant in coconut oil and are absorbed directly to portal blood without a micellar phase independent of pancreatic lipase.

In celiac disease IgA antigliadin and antiendomysial antibodies are present but the relation of these antibodies to disease is not

Up to 80% of patients of duodenal ulcer suffer a relapse within one year of treatment and many recurrent ulcers are asymptomatic. Midcolon transverse diameter more than 7 cm with loss of haustral details in a patient of ulcerative colitis indicates toxic megacolon. Toxic megacolon can occur in Crohn’s disease, amoebic colitis and shigella infection as well.

IMPORTANT MEDICAL FACTS

asymptomatic and his biomedical studies do not change, there is no need of repeat liver biopsy.


certain. Patients of celiac sprue are at higher risk of developing intestinal lymphoma, GI and non GI neoplasms.

MCQ's

1350 •

Single dose of IV infliximab 5 mg/kg can bring remission in resistant Crohn’s disease upto 3 months and repeated injection can maintain remmission. However IL-10 that decreases TH1, response, has only modest effect in CD.

An AST: ALT ratio > 2:1 is suggestive of alcoholic liver disease. The AST rarely exceeds 300 IU/L but ALT is often low due to alcohol induced pyridoxine deficiency.

GGT is rarely elevated in conditions other than liver disease. 92. HBV mutants exist (precore mutants and escape mutants) and may complicate vaccination strategies and serologic diagnosis. Precore mutants that are unable to secrete HBeAg tend to have severe and resistant liver diseases rapidly progressing to cirrhosis.

WHO recomended regimen for leprosy is questioned since 20-40% relapse in LL and demonstrable activity in 50% cases of tuberculoid leprosy. So present recommendation is that TT patients be given dapsone 100 mg daily for 5 years; LL patients dapsone 100 mg daily for life plus rifampicin 600 mg daily for 3 years.

• Nontuberculous mycobacteria are ubiquitous in the environment. Their isolation from sputum or urine does not constitute proof of disease. •

Live attenuated varicella vaccine is available and is given in 2 doses 4-8 weeks apart to persons of 12 years or older. Duration of immunity in about 10 years.

Influenza vaccination is recommended yearly. It is a chick embryo vaccine like measules, mumps and yellow fever vaccines.

Pneumococcal vaccine, single dose confers life long immunity and is recommended for patients of asplenia, nephrotic syndrome, transplant recipients.

Absolute CD44 lymphocyte count is used as predictor of HIV progression. Risk of progression is high with CD44 count below 200/pl. p2 microglobulin is a cell surface protein indicative of macrophage monocyte stimulation; levels

Cervical cancer and vulval cancer are related to HPV infection

In clostridial myonecrosis, the efficacy of polyvalent gas gangrene antitoxin is questionable so also that of hyperbaric oxygen.

Ehrlichiosis is a tick borne rickettsial disease causing myalgia, fever, headache, severe infection; can cause meningoencephalitis, toxic spetic shock and ARDS, bleeding and neutropenia/ thrombocytopenia. Tetracycline is the drug of choice.

Fomivirsen is antisense oligonucleotide active against CMVwhich is otherwise resistant to gancyclovir, foscarnet, cidofovir.

IFN a 2a, a 2b and alfacon have similar efficacy in HCV but treatment of HDV requires higher doses for 12 months with 50% response rate, only to relapse after stoppage of therapy.

Third generation vaccines use DNA/RNA to induce immunity. A DNA plasmid containing the gene sequence for the immunogenic protein is assembled. A single immunization with plasmid results in DNA uptake into cells where the gene is expressed and the product stimulates the immune response.

Neuraminidase inhibitors like zanamivir and oseltamivir are effective against both influenza A & B; both in treatment and prophylaxis. 21. HTLV-1 causes tropical spastic paraparesis as well as neoplasms, i.e. adult T cell leukemia/lymphoma (ATL) due to proviral integration of T4 cells. Treatment is a combination of antiretroviral drugs plus chemotherapy as for lymphoma but success rate is poor. HTLV II is a virus “searching for a disease”.

HIV infected individuals should receive pneumococcal and other nonlive attenuated vaccines; but measles vaccine is not contraindicated.

Severe measles in small children can be ameliorated by high dose vit A-1-2 lakh units on two consecutive days; ribavirin may be considered for immunocompromised.

Septic shock is due to exaggerated response to cytokines like TNF, IL-1p, INFy and IL-8 and nitric oxide, and phospholipid derived mediators (leukotrienes) promoted by lipid A. However, no antilipid A agent is yet available.

Hantavirus pulmonary syndrome is a fatal condition that needs aggressive treatment for hypoxemia, but has a fatality of 3050%.

Quinine-clindamycin combination is effective for babesiosis; resistant cases may be tried with azithromycin, atovaquone.

Formalin inactivated hepatitis A vaccine is available to be given 1 ml (adult) and 0.5 ml 2 doses for children followed by booster after 6-12 months.

HGV and TT virus are also transmitted by transfusion but do not cause hepatitis.

Interferon therapy in chronic HBV is not advisable if patient has immunosuppression, acquisition of infection in childhood (Asian), decompensated liver disease, or precore mutant. However lamivudine can be safely given in all above situations.

A distinguishing feature of chronic HDV is presence of anti LKM3 (anti LKM1 is present in autoimmune hepatitis and subset of HCV). HDV clearance needs 9 million units of IFNα. Thrice weekly for 12 months with clinical improvement in 50%.

Hepatitis C can be associated with lichen planus, myxed cryoglobulinema and porphyrea cutanea tarda and interferon therapy may cause their regression. Transjugular intrahepatic portosystemic shunt (TIPS) is good to reduce portal pressure for control of variceal bleed. It is also promising in refractory ascites but no way prolongs survival.

INFECTIONS •

Nucleic acid probe technology is used to identify difficult to grow or noncultivable bacterial pathogens like Mycobacteria, Legienella, Ehrlichia, Rickettsia, Babesia, Borrelisa and Trepheryma whippeli.

TTE is 65% sensitive to detect vegetation in endocarditis but TEE is 90% sensitive.

In infective endocarditis moderate to severe refractory heart failure caused by valve dysfunction is the major indication for surgical intervention because 60-90% of them die within 6 months without surgery.

Fluoroquinolone resistance among mycobacteria is a major concern. Hence random use of them in tuberculosis be discouraged.

IMMUNOLOGY AND RHEUMATOLOGY •

Antacids increase urine pH thereby increasing renal excretion of salicylates and hence lower serum salicylate level.


The risk of developing non Hodgkin’s lymphoma in Sjogren’s syndrome is very high. Sjogren’s syndrome hence is not only keratoconjunctivitis sicca with seropositive rheumatoid arthritis but with renal and pulmonary involvement and vasculitis.

XIII and kallikrin. C1 esterage inhibitor deficiency causes 1351 angioedema. •

Null cells (large granular lymphocytes) constitute 5-10% of peripheral blood lymphocytes. They have receptors for Fc portion of IgE and proliferate in response to IL8. A subset of NK cells mediate antibody mediated cytotoxicity and natural killer cell activity. These cells have antitumor activity and play some role in transplant rejection.

A walking stick or cane should be held on the side opposite the arthritic knee. The most common deformity of knee in osteoarthritis is bowleg not knock knee; in rheumatoid arthritis opposite is true.

In older patients renal prostaglandin synthesis maintains renal perfusion. Use of NSAIDs in them can cause olieuric renal failure.

Macrophages secrete IL1, and IL6,8 to clonally amplify the specific T cell and also secrete IL8 and gamma interferon to recruit additional T cells.

Most patients of Still’s disease do not have positive rheumatoid factor. Leukocytosis and quotidian fever are characteristic.

Oral ulcers of Reiter’s syndrome are painless while those of Behcet’s syndrome are painful.

Isolated IgA deficiency is the most common immunodeficiency disorder. Both serum and secretory IgA are reduced. Recurrent sinopulmonary infection is most common. Some patients have antibodies against IgA. Immunoglobulin therapy does not restore IgA level.

Gottron’s patches are erythematous, scaling lesions overlying the proximal and distal interphallangeal joints, the characteristic of dermatomyositis.

Sausage digits are seen primarily in the seronegative spondyloarthropathies.

Sacroilitis of longstanding ankylosing spondylitis is invariably bilateral and symmetric.

• •

Dendritic cells are key initiators both of innate immune responses via cytokine production and of adaptive immune responses via presentation of antigen to T lymphocytes.

Annulus fibrosus calcification is characteristic and also contributes to radiographic appearance of “bamboo spine”.

NK cells kill target cells that do not express HLA class I molecule i.e. malignant cells and virus infected cells.

Pregnancy, particularly in the first trimester and puerperium is associated with increased risk of lupus flareups. Prednisone has little effect on fetus, probably because it is brokendown by placental hydroxylase but dexamethasone can cross placenta and hence is contraindicated.

Ligand for CD28 is CD80, CD86 and for CD 40 is CD 154.

Monocytes macrophages express CD14, CD16, CD32 and CD64 and CD35 (activated complement component). Dendritic/ Largerhans cells are bone marrow derived APCs, derived both from myeloid and lymphoid lineage and lack standard T, B, NK cell and monocyte markers.

LPS of gram-negative bacteria binds to CD14 and TLR4 protein on macrophage initiating an intracellular signalling cascade that leads to expression of immunomodulatory genes, including cytokines and costimulatory molecules. High levels of immune system activation by bacterial LPS may lead to septic shock.

Eosinophils express CD32 and are cytotoxic effector cells for parasites. Basophils and mast cells are reservoirs for IL-4 that produces TH2 response.

Ear inflammation i.e., destruction of cartilage of pinna sparing the ear lobule is a feature of relapsing polycondritis.

Visual loss in atherosclerosis of carotid artery is due to involvement retinal vessels and may be reversible but that in giant cell arteritis it is irreversible as there is ischaemic necrosis of ophthalmic nerve.

Back pain worsening with rest and improving with moderate activity is distinct feature of ankylosing spondylitis.

Chondromalacia patellae is a common cause of pain beneath the patella.

Avascular necrosis is a complication of SLE. Bilateral involvement is common.

Urticaria pigmentosa or systemic mastocytosis results from infiltration of skin by mast cells. The involved areas have freckle-like lesion that produce wheal and flare when stroked (Darier’s sign).

The presence of wrist involvement in a patient thought to have osteoarthritis should prompt for other diagnostic considerations like rheumatoid disease, infection etc.

• Combination of sinusitis, pulmonary disease and glomerulonephritis should arouse suspicion of Wegener’s granulo-matosis. Biopsy shows granulomatous necrotising vasculitis. Steroid and cyclophosphamide are mainstay of treatment.

• T4 helper cells can be subdivided on basis of cytokine production. TH1 cells secrete IL-2, IFNy, IL-3, TNF a, TNF-β and GM-CSF while activated TH2 helper T cells secrets IL-3, 4, 5, 6, 10 and 13 essential for humoral immunity and isotype switching. Excess of TH1 response is linked to Crohn’s disease, rheumatoid arthritis but is basically meant to induce cytotoxic T cells (TNFα) macrophage activation (GM-CSF) and antibody production (TNFβ). •

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Eicosanoids refers to all metabolites of cyclooxygenase and lipooxygenase pathways of arachidonic acid metabolism. Salicylates and NSAIDs inhibit cyclooxygenase pathway with reduced formation of endoperoxides like prostaglandins and thromboxane. Lipooxygenase pathway is for formation of leukotrienes. Complement activity plays an important role in inflammatory response. C1 binds to immune complex with activation mediated by Clq. Activated C1 then activates C4 and C2. Activated Cl is destroyed by C1 esterage inhibitor. Latter also regulates factor

Lymphocyte endothelial cell interactions have 4 stages:

Stage I—attachment and rolling mediated by L-selection

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Stage II—adhesion triggering by IL-8, PAF, LTB4, C5a

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Stage III—Sticking and arrest mediated by integrin and their ligand ICAM-1 and ICAM-2 “.

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Stage IV—Transendothelial migration mediated by CD44 Lps.

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In the immune system apoptosis is a mechanism induced to remove autoreactive T cells in thymus and to remove but autoreactive T and B cells from peripheral lymphoid organs (lymph node and spleen)

Bc12 and Bel XL are two proteins that inhibit apoptosis.

IMPORTANT MEDICAL FACTS


1352 •

MCQ's

Wide variety of stimuli trigger TNF receptor family on cell surface or cytoplasmic receptors that activate FLICE or caspase-8. Caspase activation leads to formation of DEDD that inhibits DNA transcription in nucleolus with fragmentation of DNA. Caspase-8 is inhibited by Bc12 and Bel XL.

decreased serum calcium and increased PTH production. Diseased kidney cannot form active vit. D3. •

Soluble TNF-a R and IL-I ra inhibit TNF-a and IL-I and are useful in RA. IL-12 which induces IFN y and CTLs can be of value in tuberculosis and cancer. IL-2 has been used in treatment of renal cell carcinoma and when used in HIV disease increases T4 cells.

IgA nephropathy is the most common form of acute glomerulonephritis in Asia. It presents with haematuria associated with upper respiratory infection. In comparision to poststreptococcal GMN-hypertension and edema are uncommon.

HLA class I-peptide complex is preferentially recognised by CD8 T cells and class II peptide complex by CD4 T cells. The CD8 recognition site is on α3 domain of MHC class I molecule while CD4 recognition site is on β2 132 domain of class II molecule.

In IgA nephropathy serum IgA is increased in half the patient, serum complement level is normal and dermal capillaries have IgA deposit. In kidney there is diffuse deposit of IgA in mesangium.

A polymorphism in the promoter region of TNF a gene in the HLA class III region is linked to cerebral malaria, LL leprosy, HBV chronicity and fatal meningococcal meningitis.

Recent evidence suggests that daily dose of 12 gm of fish oil (N3-fatty acid) retard rate of loss of renal function in IgA nephropathy.

A diagnosis of Goodpasture’s syndrome is confirmed by finding anti- GBM antibodies in an individual with pulmonary haemorrhage or alveolar infiltrates and glomerulonephritis but over 50% of these patients do not have pulmonary haemorrhage or extrarenal manifestation.

HIV-C subtype is the most common form worldwide and also in India, while subtype B is prevalent in USA and subtype E in South East Asia.

SDF-1 is the lateral ligand for CXCR-4, where as RAN-TES, MIP a and 13 are natural ligands for CCR5.

ACcumulative analgesic intake of 3 kg or 1 gm daily for 3 years strongly supports the diagnosis of analgesic nephropathy.

HIV envelop glycoprotein gp 120 and gp 160 have high affinity for CD4.

80% renal carcinoma are hypervascular, 15% hypovascular and 5% are avascular.

Western blot is only to be taken as positive if antibodies are present to atleast 2 of the 3 major gene products i.e. p24, gp41 and gp 120/160 (gag, pol, and env). Absence of pD 31 band may be indicator of false positivity Faint bands in Western blot with negative PCR, may represent cross reactivity and demands DNA PCR, RNA PCR or (b) DNA assay.

A renal cyst in US can be malignant if has thick walls, calcifications, solid component and mixed echogenicity.

APKD is aptosomal dominant, the defective gene located in short arm of chromosome 16. Patients have aneurysm in circle of Willis aortic aneurysm and abnormalities of mitral valve.

ELISA for P-24 antigen is only positive in 50% of patients and detects only when p24 level is > 15 pg/ml.

The earlier changes in kidneys in diabetes mellitus is increased in kidney size and rise in GFR by 20-50%.

Treatment should be started when CD4 count is < 500/cmm or viral load is >20,000 copies of HIV RNA/ml. End point of treatment is to achieve viral load to < 50 copies/ml.

Altenuated androgens are effective in angioedema of Cl INH deficiency, else alfa aminocaproic acid may be used.

Lupus nephritis can take any of the 5 forms. A patient can progress from one type to another. Serologic evidence of activity includes increased level of antinuclear antibodies, antibodies to double stranded DNA, reduced C3, C4, CHSO.

A number of additional antibodies may be found in RA including antibodies to filaggrin, citrulin, calpastatin and RA33. Some of them appear even before RA is positive and may indicate aggressive disease.

Most prostatic cancers are hypoechoic. Transrectal ultrasound helps in staging prostate cancer and helps in guiding biopsy.

Infliximab and etanercept are the two TNF a neutralizing agents which can bring remission the RA who have otherwise failed to DMARD.

Abnormal PSA (> 4 ng/ml) has a sensitivity of 67% and specificity of 97% in diagnosis of prostate cancer. A rate of change of PSA. greater than 0.75 ng/ml per year is associated with increased likelyhood of cancer detection.

All patients of prostate cancer with PSA level greater than 10 ng/ ml should under go radionuclide bone scan.

90% bladder cancer are transitional cell carcinomas.

Prerenal azotemia is certain when serum BUN to creatinine is > 20:1, urine osmolality is above 500 and fractional excretion of sodium is less than 1.

Renal cell carcinoma originates from proximal tubule cells. Various cell types (acinar, papillary solid) are observed but cell type and histologic pattern do not affect treatment.

Large kidneys in US with renal failure implies amyloidosis, obstructive uropathy, diabetes mellitus, PKD or multiple myeloma.

No effective chemotherapy is available for metastatic renal cell carcinoma. Vinblastine in single most effective agent with shortterm partial response rate of 15%.

Cryptoorchidism is more common on right side and paripassu testicular malignancy is more common on right side.

Hypertension is a complication of erythropoietin therapy. Dose of erythropoietin in CRF is 30-150 units 3 times a week SC.

Orchipexy does not alter the malignant potential of cryptoorchid testis but facilitates examination and tumor detection.

In a patient of multiple myeloma, a negative urine dipstick test but positive sulfosalisylic acid reaction indicates Bence Jones proteinuria.

NEPHROLOGY •

• Platelet dysfunction in uraemia can be tackled desmopresscin 0.03 mg/kg and conjugated estrogen. •

with

Components of renal osteodystrophy are osteomalacia and ostitis fibrosa, mostly caused by hyperphosphatemia with


Progression of CRD to ESRD has individual variability 1353 irrespective of underlying etiology and is probably influenced by inheritable factors like insertion/deletion of ACE gene.

Alport’s syndrome is an autosomal dominant renal disorder characterized by microscopic haematuria, mild proteinuria, nerve deafness, and progression to endstage renal failure by 3rd to 4th decade. Renal histology shows diffuse glomerular and interstitial changes.

Low turnover uremic osteodystrophy is not only due to lack of active vit D3 but due to lack of PTH (PTH is usually Î in ESRD). This PTH lack is accounted for by supraphysiologic Ca++ and vit D3 given to these patients. Aluminium deposition in bone due to its presence in dialyste or given orally to bind phosphates also lowers bone turnover causing osteomalacia.

The diagnosis of antiglomerular basement membrane disease is warrnated only when anti GBM antibodies are present in serum and glomeruli where a characteristic linear immunofluorescent pattern is seen.

Secondary hyperparathyroidism and osteitis fibrosa cystica are best prevented by phosphate restricted diet and CaCO3 and CaSO4 used as binding agents. Suppression of PTH to <120 pg/ ml should not be attempted.

IgA nephropathy is characterized by IgA deposits in mesangium. Gross haematuria may occur but the course is usually benign. Only 25% of adults progress to renal failure gradually.

Dietary protein restriction and effective control of intraglomerular hypertension and/or glomerular hypertrophy can retard progression of CRD.

The EM examination of renal biopsy specimens in membranous glomerulonephritis reveals granular electron dense deposits but complement levels are always normal.

Polysulfone, polymethylmethacrylate and polyacrylonitrile membranes are more biocompatible and do not activate complement. They are reusable too.

In renal histology for GM, lesions are classified as focal when they involve <50% glomeruli and diffuse if they involve >50% glomeruli. The clinical term RPGN and pathologic term crescentic GM are used interchangeably.

“Stary sky” appearance in immunofluorescence microscopy is feature of poststreptococcal GM. Garland pattern bears worse prognosis.

Mild anaemia, enlarged kidney and chronic renal failure indicate polycystic kidney disease.

In medullary sponge kidney there is ectasia and calcification of medullary collecting tubules. Most patients are asymptomatic and renal failure is uncommon but urinary tract infections and renal calculi formation are frequent.

Distal (type 1) renal tubular acidosis is characterised by constant low grade bicarbonate loss and persistently high urinary pH. In children it may be familial or sporadic but in adult it is due to drugs (amphotericin, gentamicin, vit. D intoxication), toxins, cirrhosis, SLE, sickle cell disease etc.

Proximal (type II) renal tubular acidosis is a result of impaired bicarbonate reabsorption in proximal tubule. It can be associated with cystinosis, Wilson’s disease, myeloma, lead poisoniag etc. When associated with aminoaciduria, glycosuria and phosphaturia it is called Fanconi syndrome.

• Fibrillary immunotactoid glomerulopathy presents with nephrotic syndrome and progresses to ESRD in 1-10 years. No treatment is available except for transplantation. •

Essential mixed cryoglobulinemia is complicated by in 50% cases with nephrotic syndrome, and haematuria. C3, C4, CHSO are low and HCV RNA may be present. Hence alfa interferon therapy is warranted.

NEUROLOGY

The key to diagnosis of urinary tract obstruction is the demonstration of a dilated urinary collecting system. The nephrogram will be delayed but quite dense in acute obstruction.

The pontine gaze centre controls ipsilateral horizontal gaze. The rostral interstitial nucleus of MLF controls vertical gaze, MLF connects the gaze centres and oculomotor nuclei.

Nephrogenic diabetes insipidus unresponsive to vasopressin and causing polyuria and pure water loss may be a side effect of drugs like lithium, demeclocyline, and vinblastine.

A lesion of dominant parietal lobe causes Gerstman syndrome. Affected individual is unable to calculate, write and differentiate right from left.

As long as liver function and muscle mass remain constant, plasma urea and creatinine are inversely related to GFR.

Only 20% of filtered IC+ is excreted in urine. A K+ secretory process operates in distal tubule, dependent upon sodium absorption. Hence daily K+ intake is balanced by equal amount of excretion in urine minus the loss in sweat and stool.

Unilateral occlusion of vertebral artery typically causes lateral medullary syndrome with damage to 9th and 10th cranial nerves, inferior cerebellar penduncle, lower vestibular complex, sympathetic tract ipsilaterally and the spino thalamic fibers subserving pain and temperature on opposite side.

Most ARF is due to renal hypoperfusion with intact renal parenchyma. Most ARF is hence reversible, the kidney being unique among major organs in its ability to recover from almost complete loss of function.

Cranial nerves III, IV and VI pass through cavernous sinus, so that complete ophthalmoplegia may occur in cavernous sinus thrombosis. Since mandibular are division of trigeminal does not pass through it, the brow and check may be numb but not the chin.

Angiotensin II preserves GFR by selective constriction of efferent arterioles. ACE inhibitors blunt this response and precipitate ARF.

Bilateral lateral rectus palsies that develop acutely in alcoholics imply Wernicke’s encephalopathy.

Renal biopsy is indicated only when pre- and postrenal failure are excluded and cause of intrinsic renal failure is unclear.

Acute mononeuropathy involving oculomotor or peroneal calls for exclusion of diabetes. Neuropathy that is primarily sensory, distal and progressive is most characteristic of diabetes but may occur with occult neoplasm. Relapsing neuropathy is more typical of idiopathic polyneuritis.

IMPORTANT MEDICAL FACTS

Renal involvement occurs in 50% cases of multiple myeloma. Acute renal failure may result from hypercalcemia, dehydration or tubular dysfunction. When a patient of carcinoma of lung without apparent brain metastasis presents with confusion, hyponatremia and high urine osmolality, the diagnosis is SIADH. Oatcell carcinoma of lung is known to produce ADH.


1354 •

The essential or familial tremor is faster (8 Hz) and responds to alcohol and propranolol. Rest tremor is associated with Parkinsonism but is suppressed by willful activity.

Conventional EMG, muscle biopsy and nerve conduction studies are not useful in evaluation of myasthenia gravis because it is not a disease of muscle or nerve. Single fiber EMG showing “jitter” or repetitive stimulatin of motor nerves showing decrenental response are useful in diagnosis.

MCQ's

Transient ischaemic attacks are caused either by low flow in large vessels, embolism from arterial or cardiac sources or penetrating vessel atherosclerosis.

Radiosensitivity is a well known feature of most primary CNS lymphomas, which are almost always of B cell origin. Its complete disappearance with steroids may mimic multiple sclerosis.

The findings of total hemianaesthesia and loss of all sensory modalities in the face, arm and leg are characteristic of thalamic infarction.

To differentiate between syncope and seizure syncope rarely occurs during recumbency and patient recovers fully once BP returns to normal without any headache, confusion or drowsiness postictally.

More than 75% of myasthenia have circulating antibodies to components of postsynaptic membrane including acetylcholine receptors. Antibody action leads to unfolding or simplification of the membrane. As a result existing acetylcholine in the synapse is less effective.

Patients of Wernicke’s aphasia have damage in posterior temperoparietal regions, supplied by lower division of middle cerebral artery. Speech is effortless and well woven but spoken, written communication, auditory and visual understanding is affected.

A pure motor hemiparesis on one side without aphasia or cortical sensory loss suggest lesion at internal capsule. either lacunar infarct or hypertensive bleed.

In peripheral nerve, small fibers mediate sensations of pain, and temperature, large fibers are involved in touch, joint position and vibration.

Meralgia paresthetica is due to entrapment of lateral cutaneous nerve beneath the inguinal ligament near anterior superior iliac spine causing pain and blunting of sensation in lateral thigh in the obese.

Polymyalgia rheumatica typically occurs in elderly with pain, weakness and stiffness of proximal muscles. ESR is high and there may be associated inflammatory arthritis and temporal arteritis.

Lesions in basal ganglia produce a host of movement disorders like akinesia, bradykinesia, lead pipe rigidity. chorea, dystonia myoclonus, asterixis, hemiballismus, tics. There is no weakness of muscles

Testing of evoked potentials is of greater utility in detecting subclinical spinal cord or optic nerve lesions. Upto two-third of persons who have multiple sclerosis have neurologic deficits in evoked potential testing but not clinical examination.

Isolated lesions of third nerve with pupillary sparing are usually due to microinfarction of third nerve in association with diabetes or hypertension.

The abrupt onset of isolated peripheral facial palsy which may include ipsilateral hyperacusis, and loss of test in anterior twothirds of tongue is most often idiopathic—Bell’s palsy.

Although pathophysiology of migraine is unclear, electrical stimulation of midline dorsal raphe nuclei of brainstem leads to characteristic pain. Sumatriptan and dihydroergotamine provide relief by blocking 5 HT receptor (type I-D subtype).

An anomalous artery or vein impinging upon trigeminal nerve root produces trigeminal neuralgia despite normal GT, MRI and angiogram. Decompression by posterior fossa exploration provides lasting relief.

Gabapentin, felbamate and lamotrigine are approved as adjunctive therapy to partial and secondarily generalized seizure. Felbamate causes fatal bone marrow depression.

Antiphospholipid antibodies (lupus anticoagulants, and anticardiolipin antibodies) promote thrombosis and may cause stroke.

Cerebral infarction following thromboembolic spoke has better prognosis than that after cerebral or subarachnoid haemorrhage.

In subarachnoid haemorrhage ECG may show ischaemia or arrhythymia due to excess sympathetic activity. Leukocytosis and glycosuria are common.

Duchenne’s dystrophy is an X-linked recessive disorder. The responsible gene is 2000 kb that codes for 400 kDa protein, the dystrophin. About 60% of patients have an exon deletion or duplication in dystrophin gene.

Neurofibromatosis type I is an autosomal dominant carried on long arm of chromosome 17. It is characterized by peripheral neurofibromas and cafe-au lait spots. There is mutation in gene encoding protein neurofibromin These patients may have optic glioma, glioblastoma and meningioma. In neurofibromatosis II bilateral acoustic neuromas are seen in addition to peripheral neurofibroma. There is mutation in gene encoding for protien fibrillin. In syringomyelia pain is lost but touch is preserved. Tissue loss in central gray matter of spinal cord where pain fibers cross to contralateral spinothalamic tract are destroyed. Thoracic scoliosis and atrophy of small muscles of hand are usual.

Trigeminal neuralgia is not synonymous with trigeminal neuropathy. Aneurysms, neurofibromas and meningiomas impinging on 5th cranial nerve at any point along its course cause trigeminal neuropathy, with weakness of jaw and sensory loss which are not seen in trigeminal neuralgia.

Antipsychotics in schizophrenia are more useful against positive symptoms like hallucination and agitation but less active against negative symptom like social withdrawal.

The most common tumor of CNS is metastatic in nature; cancer of lung in men and breast cancer in women. Malignant melanoma has predilection for spread to CNS.

Meningioma are most common benign brain tumors and may grow to very large size before dection. They are common in women in 5th or 6th decade. Common sites are around the midline in cerebral hemisphere, olfactory groove, sphenoidal ridge, foramen magnum and tentorium of cerebellum.

Diseases that cause rapid dementia within weeks include metabolic encephalopathy, encephalitis, poisoning. white matter infarction and CZ disease.

basal ganglia which generally produce contralateral hemiplegia with eye deviation away from side of paralysis.

There are 4 major hypertensive haemorrhage syndromes. The most common site of bleeding is internal capsule adjacent to


In subarachnoid haemorrhage vasospasm can be reduced by nimodipine 60 mg every 4 hours for 21 days without serious side effects.

Cerebral venous th