MCQs VIA WEB 2005

By A. H.

Medicine MCQS VIA WebCopyright © 2005 Elsevier Limited. All rights reserved. Fleshandbones is a registeredtrademark of Harcourt, Inc. in the United States and other jurisdictions, used under licenseThese mcqs were donloaded By Ahmed Hakim ahmedhakim_227@yahoo.comTESTModule4Question 1. The pulse:(a) In pulsus paradoxus the rate slows during inspiration. (False)(b) Pulsus alternans indicates a poorly functioning left ventricle. (True)(c) A tachycardia of 150 beats per minute in a resting patient usually implies an underlying cardiac arrhythmia. (True)(d) A collapsing pulse may be noticed in thyrotoxicosis. (True)(e) Corrigan's sign supports a diagnosis of aortic stenosis. (False)

Question 2. Heart murmurs:(a) A low rumbling diastolic murmur with presystolic accentuation may be heard in mitral stenosis accompanied by

atrial fibrillation. (False)(b) Causes of a pansystolic murmur include mitral regurgitation and ventricular septal defect. (True)(c) A systolic murmur heard over the whole praecordium associated with a thrill usually indicates aortic stenosis.

(True)(d) Left heart murmurs are best heard during expiration. (True)(e) An early blowing diastolic murmur at the left sternal edge indicates aortic incompetence. (True)

Question 3. Pulsus paradoxus:(a) The volume of the pulse increases in inspiration. (False)(b) Can be confirmed by detecting >10 mmHg difference in systolic pressure during the breathing cycle. (True)(c) Is a sign of severe asthma. (True)(d) Is called paradoxus because it is the opposite of what normally happens to the pulse. (False)(e) Can occur in cardiac tamponade. (True)

Question 4. The jugulovenous pressure:(a) Is raised if it is 2 cm from the sternal angle with the patient seated at 45°. (False)(b) Tall 'a' waves may be seen in pulmonary hypertension. (True)(c) Irregular cannon waves indicate complete heart block. (True)(d) Regular cannon waves may indicate a nodal rhythm. (True)(e) Giant 'v' waves and a pulsatile liver indicate tricuspid stenosis. (False)

Question 5. The physical signs of an uncomplicated large pneumothorax include:(a) The trachea deviated to the opposite side. (False)(b) A clicking sound synchronous with the heart beat. (True)(c) Symmetrical expansion of the chest. (False)(d) Increased breath sounds over the pneumothorax. (False)(e) Increased percussion note over the pneumothorax. (True)

Question 6. The following would help distinguish between a kidney and a spleen in the left upper quadrant:(a) Dull to percussion over the mass. (False)(b) A well-localized notched lower margin. (False)(c) Moves with respiration. (False)(d) A ballottable mass. (True)(e) A family history of renal failure. (True)

Question 7. Nystagmus:(a) Vertical nystagmus usually indicates a lesion of the medulla oblongata. (False)(b) Horizontal nystagmus is usually ipsilateral to an irritative lesion of the labyrinth. (False)(c) Ataxic nystagmus indicates a lesion of the medial longitudinal bundle. (True)(d) May be absent in a lesion of the cerebellar vermis (the central part). (True)

MCQs VIA WEB 2005

By A. H.

(e) Pendular nystagmus may indicate partial blindness. (True)

Question 8. The following would suggest an upper rather than a lower motor neuron lesion:(a) Fasciculation. (False)(b) Increased tone. (True)(c) An absent plantar reflex. (False)(d) Clonus. (True)(e) Relatively little wasting. (True)

Question 9. Hand signs:(a) Clubbing may be caused by uncomplicated chronic bronchitis. (False)(b) Koilonychia usually indicates liver disease. (False)(c) Osler's nodes and Heberden's nodes both occur in osteoarthritis. (False)(d) Splinter haemorrhages are due to embolic rather than immunological phenomena. (False)(e) Psoriatic arthritis affects most joints in the hand but usually spares the distal interphalangeal (DIP) joints. (False)(True)

Question 10. The face:(a) A malar flush may indicate mitral valve disease or hypothyroidism. (True)(b) A butterfly rash in the face is seen in dermatomyositis. (False)(c) Bell's palsy can cause ptosis due to paralysis of orbicularis oculi. (False)(d) Herpes labialis may be associated with pneumococcal pneumonia. (True)(e) An expressionless face and drooling could indicate Parkinson's disease. (True)

Question 11. The electrocardiogram:(a) The PR interval is measured from the peak of the P wave to the start of the QRS complex. (False)(b) Right axis deviation is indicated by a QRS axis of -35°. (False)(c) Q waves in S-II, S-III and aVf indicate a transmural inferior myocardial infarction. (True)(d) Left bundle branch block is suggested by broadening of the QRS complex to 0.10 seconds (two and a half little

squares), and positive RSR' waves in V4-V6. (False)(e) P mitrale is suggested by a P wave taller than 2.5 mm. (False)

Question 12. In the full blood count:(a) A haemoglobin of 10.0 g/dL would be considered normal in a premenopausal woman. (False)(b) Polycythaemia rubra vera is usually indicated by elevation not only of the haemoglobin but also of the white cell

count and platelets. (True)(c) A low platelet count could indicate a flare-up of systemic lupus erythematosus (SLE). (True)(d) High platelets can be seen in gastrointestinal bleeding. (True)(e) A raised mean corpuscular volume is usual in significant alcohol excess. (True)

Question 13. Heart failure:(a) The clinical features of left heart failure include: tachycardia, basal crepitations, pulsus alternans and a raised JVP.

(False)(b) Congestion of the pulmonary veins alone does not result in orthopnoea. (False)(c) Chronic congestive heart failure leads to secondary hyperaldosteronism. (True)(d) Causes of heart failure include ischaemic heart disease, hypertension, and thiamine deficiency. (True)(e) Clinical features of right heart failure include a raised JVP, ankle oedema, and hepatomegaly. (True)

Question 14. Stroke:(a) Cerebral haemorrhage accounts for more than 40% of acute strokes. (False)(b) In supratentorial strokes with homonymous hemianopsia, patients cannot see on the hemiplegic side. (True)(c) Vertigo, vomiting, dysphagia, and Horner's syndrome indicate occlusion of the vertebrobasilar circulation. (True)(d) Pinpoint pupils and bilateral upgoing plantars could signal a brainstem stroke. (True)(e) Carotid endarterectomy should be considered for patients with more than 70% stenosis because this is more

effective than medical treatment. (True)

Question 15. Respiratory failure:

MCQs VIA WEB 2005

By A. H.

(a) Type I failure results in a partial pressure of oxygen (pO2) <8 kPa and a partial pressure of carbon dioxide (pCO2)of >6.5 kPa. (False)(b) In respiratory failure associated with chronic bronchitis, the level of carbon dioxide (CO2) determines the

respiratory rate. (False)(c) Respiratory failure as defined in (a) would be an indication for ventilation in pure asthma. (True)(d) Doxapram is a respiratory stimulant used in respiratory failure associated with chronic obstructive pulmonary

disease. (True)(e) The main aim in type II failure is to keep the pO2 >7.0 kPa without worsening of the acidosis or pCO2. (True)

Question 16. Cushing's syndrome:(a) May give rise to hypertension, diabetes, and truncal obesity. (True)(b) Is usually diagnosed by estimation of the urinary free cortisol followed by an overnight dexamethasone suppression

test. (True)(c) Could be associated with pigmentation. (True)(d) The most common cause is probably iatrogenic. (True)(e) Nelson's syndrome is a complication of bilateral adrenalectomy for pituitary-dependent Cushing's disease. (True)

Question 17. Leukaemia:(a) The common presenting triad is infection, bleeding, and fatigue. (True)(b) Acute myeloid leukaemia (AML) may result spontaneously or follow on from CML, polycythaemia rubra vera or

myelosclerosis. (True)(c) The usual development of chronic lymphocytic leukaemia is a transformation to acute lymphoblastic leukaemia.

(False)(d) A platelet count of 40 × 109/L would not normally give rise to spontaneous bleeding. (True)(e) Bone marrow transplantation is a recognized treatment for AML. (True)

Question 18. Hypertension:(a) An average diastolic blood pressure of >90 mmHg over prolonged observation is an indication for drug treatment in

uncomplicated hypertension. (False)(b) Thiazide diuretics are the least effective antihypertensive drugs. (False)(c) Thiazide diuretics work on the loop of Henle in the kidney. (False)(d) Resistant hypertension is defined as a failure to control the blood pressure adequately with a good three-drug

regimen. (True)(e) Thiazide diuretics are contraindicated in gout and diabetes. (True)

Question 19. Oral corticosteroids:(a) Are an effective treatment for SLE. (True)(b) In the long term may cause cataracts. (True)(c) Should be avoided in sarcoidosis because they induce pulmonary oedema. (False)(d) May be stopped abruptly after 2 weeks of 40 mg prednisolone daily in patients who are not exposed to repeated

courses. (True)(e) May reveal that 15% of patients labelled as having chronic bronchitis, in fact have reversible airways disease.

(True)

Question 20. Paracetamol overdose:(a) Ipecacuana followed by oral methionine is effective for most patients who are just over the treatment line. (False)(b) Can cause renal failure. (True)(c) Intravenous N-acetylcysteine frequently causes anaphylaxis. (False)(d) The serum paracetamol level is of most value between 1 and 4 hours after ingestion. (False)(e) In co-proxamol (distalgesic) overdose, sudden death is likely to be due to hypoglycaemia caused by paracetamol.

(False)

Question 21. Treatment of myocardial infarction:(a) Aspirin and streptokinase are more effective than either alone after myocardial infarction. (True)(b) Thrombolysis improves short-term complications but not mortality after myocardial infarction. (False)

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By A. H.

(c) Tissue plasminogen activator and anistreplase are more effective than streptokinase but not used because they arefar more expensive. (False)(d) ACE inhibitors improve outcome after myocardial infarction for patients with ventricular dysfunction. (True)(e) HMGCo-A reductase inhibitor therapy is contraindicated for patients after myocardial infarction. (False)

Question 22. For self-poisoning:(a) Gastric lavage is recommended for most drugs up to 12 hours after ingestion. (False)(b) Naloxone is the specific antidote for benzodiazepine overdose. (False)(c) Patients with tricyclic antidepressant overdose need cardiac monitoring for up to 48 hours. (True)(d) All patients should be assessed by a qualified psychiatrist. (False)(e) Pinpoint pupils could indicate opiate overdose. (True)

Question 23. Digoxin:(a) Is the treatment of choice for ventricular extrasystoles. (False)(b) May cause xanthopsia. (True)(c) Is excreted by the kidneys. (True)(d) Adverse effects are reduced by hypokalaemia. (False)(e) Must not be coadministered with an ACE inhibitor. (False)

Question 24. Dementia may result from:(a) Parkinson's disease. (True)(b) Huntington's chorea. (True)(c) Hypothyroidism. (True)(d) Acquired immune deficiency syndrome (AIDS). (True)(e) A cerebral tumour. (True)

Question 25. Oxygen:(a) Should be administered with a high inspired concentration (>50%) in the treatment of type II respiratory failure.

(False)(b) Should not be used at high concentration in patients with pulmonary embolism because respiration may be severely

impaired when the hypoxic drive is reduced. (False)(c) Continuous long-term (domiciliary) oxygen improves survival in patients with respiratory failure caused by chronic

bronchitis and emphysema. (True)(d) Is needed when respiratory failure is diagnosed by finding a pO2 of less than 11 kPa in an arterial blood sample.

(False)(e) Comprises 21% of atmospheric air. (True)

Module 5 (Cardiology)Question 2. The differential diagnosis for chest pain includes:(a) Myocardial infarction. (True)(b) Oesophagitis. (True)(c) Pulmonary embolus. (True)(d) Cholecystitis. (True)(e) Aortic dissection. (True)

Question 3. The following are causes of acute life-threatening dyspnoea:(a) Myocardial infarction. (True)(b) Pulmonary embolus. (True)(c) Pneumothorax. (True)(d) Ventricular or supraventricular tachyarrhythmia. (True)(e) Bacterial endocarditis. (True)

Question 4. The following are clinical signs found in infective endocarditis:(a) Clubbing. (True)(b) Haematuria. (True)(c) Pyrexia. (True)(d) Rashes. (True)

MCQs VIA WEB 2005

By A. H.

(e) Focal neurological defect. (True)

Question 5. The following are risk factors for ischaemic heart disease:(a) Hypertension. (True)(b) Moderate alcohol intake. (False)(c) Female sex. (False)(d) Hypercholesterolaemia. (True)(e) Increasing age. (True)

Question 6. The following are classical features of cardiac syncope:(a) Gradual onset. (False)(b) Warning symptoms. (False)(c) Rapid recovery. (True)(d) Residual neurological deficit. (False)(e) Precipitated by sudden turning of the head. (False)

Question 7. The following are causes of a pansystolic murmur:(a) Mitral regurgitation. (True)(b) Aortic regurgitation. (False)(c) Tricuspid regurgitation. (True)(d) Atrial septal defect. (False)(e) Aortic stenosis. (False)

Question 8. The following conditions require antibiotic prophylaxis before dental procedures:(a) Prosthetic aortic valve. (True)(b) Ventricular septal defect. (True)(c) Floppy mitral valve with coexistent mitral regurgitation. (True)(d) Enlarged left ventricle. (False)(e) A history of infective endocarditis in the past. (True)

Question 9. The following should be considered as possible signs of a positive exercise test:(a) ST segment depression. (True)(b) Exercise-induced hypotension. (True)(c) Exercise-induced ventricular tachycardia. (True)(d) Lack of adequate tachycardic response to exercise. (True)(e) Leg pain at peak exercise. (False)

Question 10. The following are indications for anticoagulating a patient who has atrial fibrillation with warfarin:(a) Age under 60 years. (False)(b) Associated mitral stenosis. (True)(c) Atrial fibrillation of more than 24 hours' duration. (True)(d) A history of cerebral thromboembolism. (True)(e) Associated left ventricular failure. (True)

Question 11. The following are true of ventricular tachycardia:(a) It is a life-threatening condition. (True)(b) It may be caused by myocardial ischaemia. (True)(c) It may be caused by hypokalaemia. (True)(d) Amiodarone may be used to prevent recurrent episodes of ventricular tachycardia. (True)(e) Acute ongoing ventricular tachycardia should be treated initially with drugs. (False)

Question 12. The following are signs of coarctation of the aorta:(a) Radiofemoral delay in the pulses. (True)(b) Rib notching. (True)(c) Bruits heard over the scapula. (True)(d) Ankle oedema. (False)

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(e) Atrial fibrillation. (False)

Question 13. Functions of the recovery position include:(a) To prevent the tongue from obstructing the airway. (True)(b) To prevent neck injury. (False)(c) To minimize the risk of aspiration of gastric contents. (True)(d) To maintain a straight airway. (True)(e) To enable cardiopulmonary resuscitation to be carried out. (False)

Question 14. Complications of prosthetic heart valves are as follows:(a) Thromboembolic events. (True)(b) Dehiscence of the valve ring. (True)(c) Increased risk of infective endocarditis. (True)(d) Failure of the valve 5 years after placement. (False)(e) Need for anticoagulation in patients who have porcine valves. (False)

Question 15. The following statements are true of thiazide diuretics:(a) They act at the level of the distal convoluted tubule. (True)(b) They may cause gout. (True)(c) Diabetic control may deteriorate. (True)(d) Hypokalaemia may occur. (True)(e) They cause ototoxicity. (False)

Question 16. The following are classified as high-output states:(a) Hypertension . (False)(b) Sepsis. (True)(c) Hypothyroidism. (False)(d) Pregnancy. (True)(e) Arteriovenous malformations. (True)

Question 18. The following statements are true of the apex beat:(a) It is the lowest and most lateral point at which the cardiac impulse can be felt. (True)(b) It is displaced downwards and laterally if the left ventricle is enlarged. (True)(c) It is thrusting in mitral stenosis. (False)(d) It is thrusting in aortic regurgitation. (True)(e) It is heaving in aortic stenosis. (True)

Question 17. Cardiac causes of clubbing are as follows:(a) Uncomplicated atrial septal defect. (False)(b) Chronic infective endocarditis. (True)(c) Atrial fibrillation. (False)(d) Acute endocarditis. (False)(e) Empyema. (False)

Question 19. The following leads represent the inferior myocardium:(a) I, AVL, and V6. (False)(b) V2, V3, and V4. (False)(c) AVR and V1. (False)(d) V1-V6. (False)(e) II, III, and AVF. (True)

Question 20. The following are possible causes of electromechanical dissociation:(a) Pulmonary embolus. (True)(b) Tension pneumothorax. (True)(c) Hypertension. (False)(d) Dehydration. (True)

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(e) Hypocalcaemia. (True)

Question 21. The following are characteristic of pericarditis:(a) The chest pain is dull in nature. (False)(b) There may be an associated pericardial effusion. (True)(c) The pericardial rub may come and go. (True)(d) The ECG usually shows regional ST elevation. (False)(e) The ST elevation is concave. (True)

Question 22. Secondary hypertension may be due to the following:(a) Renal artery stenosis. (True)(b) Renal cell carcinoma. (False)(c) Cushing's syndrome. (True)(d) Pregnancy. (True)(e) Oral contraceptive pill. (True)

Question 23. ECG changes due to myocardial infarction may include the following:(a) ST elevation. (True)(b) Sinus tachycardia. (True)(c) Ventricular tachycardia. (True)(d) Complete heart block. (True)(e) Q waves. (True)

Question 24. The following drugs are used in the treatment of hypertension:(a) Atenolol. (True)(b) Doxazocin. (True)(c) Enalapril. (True)(d) Bendrofluazide. (True)(e) Nicorandil. (False)

Question 25. Complications of myocardial infarction include:(a) Cardiac failure. (True)(b) Mitral regurgitation. (True)(c) Cerebrovascular event. (True)(d) Myocardial rupture. (True)(e) Gastrointestinal bleed. (False)

Module 6 (Neurology)

Question 1. Concerning neuroanatomy:(a) The corticospinal tract decussates in the pons. (False)(b) The oculomotor nerve runs in close proximity to the posterior communicating artery. (True)(c) The superior colliculus is found in the midbrain. (True)(d) The trochlear (fouth cranial) nerve supplies the lateral rectus muscle. (False)(e) The spinal cord ends at the level of the lower border of L3 in the adult. (False)

Question 2. Subdural haematomas can cause:(a) Dementia. (True)(b) Pupillary change. (True)(c) Bradycardia. (True)(d) Changing level of consciousness. (True)(e) Blood-stained cerebrospinal fluid (CSF). (False)

Question 3. In a young woman with a spastic paraparesis, the following suggest a diagnosis of multiple sclerosis:(a) Delayed visual evoked potentials. (True)(b) Fasciculations. (False)

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(c) Raised CSF protein. (False)(d) Oligoclonal bands in the CSF. (True)(e) Periventricular white matter lesions on magnetic resonance imaging (MRI) of the brain. (True)

Question 4. Unilateral facial weakness is a recognized feature of:(a) Herpes zoster infection. (True)(b) Motor neuron disease. (False)(c) Acoustic neuroma. (True)(d) Cholesteatoma. (True)(e) Syringomyelia. (False)

Question 5. The following are true about headaches:(a) The headache of raised intracranial pressure is worst at the end of the day. (False)(b) A normal CT scan rules out subarachnoid haemorrhage. (False)(c) Amaurosis fugax may be caused by temporal arteritis. (True)(d) Neurological signs on examination rules out migraine as a diagnosis. (False)(e) Cluster headaches are more common in men than in women. (True)

Question 6. The following drugs can produce parkinsonism:(a) Chlorpromazine. (True)(b) Benzhexol. (False)(c) Bromocriptine. (False)(d) Metoclopramide. (True)(e) Haloperidol. (True)

Question 7. Concerning movement disorders:(a) Huntington's chorea presents with progressive dementia and chorea in middle age. (True)(b) Myoclonus is a feature of subacute sclerosing panencephalitis. (True)(c) Infarction of the subthalamic nucleus causes ipsilateral hemiballism. (False)(d) Chorea is commonly found in Cruetzfeldt-Jakob disease. (False)(e) Alcohol reduces benign essential tremor. (True)

Question 8. Concerning papilloedema:(a) There is loss of venous pulsation on funduscopy. (True)(b) There may be enlargement of the blind spot. (True)(c) Intracranial pressure may be normal. (True)(d) Hypocalcaemia is a recognized cause. (True)(e) It is a recognized feature in Guillain-Barré syndrome. (True)

Question 9. Ptosis may be a feature of:(a) Myotonic dystrophy. (True)(b) Horner's syndrome. (True)(c) Abducens nerve (sixth nerve ) palsy. (False)(d) Oculomotor nerve (third nerve) palsy. (True)(e) Myasthenia gravis. (True)

Question 10. Concerning the Brown-Séquard syndrome:(a) There is ipsilateral corticospinal loss below the lesion. (True)(b) There is ipsilateral loss of joint-position sense below the lesion. (True)(c) There is ipsilateral loss of two-point discrimination below the level of the lesion. (True)(d) There is ipsilateral loss of pain and temperature below the level of the lesion. (False)(e) A central disc lesion at L3 would cause a Brown-Séquard syndrome in the legs. (False)

Question 11. Concerning the brachial plexus:(a) In brachial neuritis, severe pain around the shoulder precedes rapid wasting. (True)(b) Klumpke's paralysis causes proximal arm weakness. (False)(c) Erb's palsy is caused by a lesion to C5/C6-derived regions of the brachial plexus. (True)

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(d) A brachial plexus lesion and an ipsilateral Horner's syndrome may indicate a Pancoast tumour. (True)(e) Vaccination may precipitate brachial neuritis. (True)

Question 12. Causes of a polyneuropathy include:(a) Diabetes. (True)(b) Guillain-Barré syndrome. (True)(c) Renal failure. (True)(d) Amyloid. (True)(e) Multiple sclerosis. (False)

Question 13. A lesion to the common peroneal nerve at the fibular head causes:(a) Weakness of eversion of the foot. (True)(b) Decreased sensation over the dorsum of the foot. (True)(c) Weakness of plantar flexion. (False)(d) If long term, wasting of tibialis anterior. (True)(e) Brisk ankle jerk. (False)

Question 14. Brainstem death may be confirmed by:(a) Extensor response of the limbs to painful stimuli. (False)(b) Absent corneal reflexes. (True)(c) Absent tendon reflexes. (False)(d) A flat EEG. (False)(e) Absent 'doll's eye' reflexes. (True)

Question 15. A homonymous hemianopia may arise from a lesion of:(a) The optic tract. (True)(b) The occipital cortex. (True)(c) The optic chiasm. (False)(d) The optic nerve. (False)(e) The optic radiation. (True)

Question 16. Dysarthria may result from a lesion of:(a) The cerebellum. (True)(b) Broca's area. (False)(c) The hypoglossal nerve. (True)(d) The basal ganglia. (True)(e) The accessory nerve. (False)

Question 17. The following are clinical features of cerebellar dysfunction(a) Postural tremor. (False)(b) Hypotonia. (True)(c) Dysphasia. (False)(d) Titubation. (True)(e) Impaired rapid altering movements. (True)

Question 18. The following clinical features may help differentiate between a syncopal attack and a seizure:(a) Upright posture at the onset. (True)(b) Convulsive movements of the limbs. (False)(c) A bitten tongue. (True)(d) Urinary incontinence. (True)(e) Prolonged malaise after the attack. (False)

Question 19. The following are features of a subarachnoid haemorrhage:(a) Fever. (True)(b) Thunderclap headache. (True)(c) Photophobia. (True)(d) Positive Kernig's sign. (True)

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(e) Neck stiffness. (True)

Question 20. A physiological tremor is:(a) Present at rest. (False)(b) Worsened by anxiety. (True)(c) Improved by alcohol. (False)(d) Improved by beta-blockers. (True)(e) Familial. (False)

Question 21. A lesion of the medulla on one side may give rise to :(a) An ipsilateral hemiparesis. (False)(b) A contralateral hemiparesis. (True)(c) Ipsilateral weakness of the palate. (False)(d) Contralateral weakness of the tongue. (True)(e) Contralateral third nerve palsy. (False)

Question 22. The following may be seen in a patient with a lesion of the third nerve or nucleus:(a) A fixed dilated pupil. (True)(b) Ptosis. (True)(c) Diplopia in all positions of gaze. (True)(d) A history of diabetes mellitus. (True)(e) A contralateral hemiplegia. (True)

Question 23. In a patient with a sensory ataxia:(a) Vibration may be impaired. (True)(b) The gait is characterized by 'scissoring' posture of the legs. (False)(c) Romberg's test may be positive. (True)(d) A history of alcohol abuse may be implicated in the aetiology. (True)(e) Clonus may be elicited on examination of the legs. (False)

Question 24. A patient with herpes zoster infection of the geniculate ganglion may present with:(a) An upper motor neuron facial weakness. (False)(b) Diplopia. (False)(c) Hyperacusis. (True)(d) Altered perception of taste. (True)(e) Pain from the auditory meatus. (True)

Question 25. A dissociated sensory loss may be seen in:(a) Syringomyelia. (True)(b) Anterior spinal artery occlusion. (False)(c) A radiculopathy. (False)(d) Occlusion of a middle cerebral artery. (False)(e) Compression of the spinal cord by a prolapsed intervertebral disc. (False)

Module 7 (Gastroeneterology)Question 1. The following statements are true:(a) Tylosis is associated with achalasia. (False)(b) On barium swallow, a 'bird's beak' appearance is suggestive of squamous carcinoma. (False)(c) Pneumatic dilatation is the treatment of choice for achalasia. (True)(d) Reduced lower oesophageal sphincter pressure is a common feature of gastro-oesophageal reflux disease . (True)(e) Oesophageal pH is usually less than 4. (False)

Question 2. The following is true of Barrett's oesophagus:(a) Columnar epithelium is replaced by squamous epithelium. (False)(b) It appears in an antegrade (top to bottom) direction. (False)(c) It is a premalignant condition. (True)(d) Severe dysplasia is an ominous sign. (True)

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(e) It is an indication for surveillance endoscopy. (True)

Question 3. Helicobacter pylori:(a) Causes ulceration in the duodenum. (True)(b) Causes Barrett's metaplasia in the oesophagus. (False)(c) Is associated with hypergastrinaemia. (True)(d) Is often resistant to certain antibiotics. (True)(e) Can convert urea to ammonia and carbon dioxide. (True)

Question 4. Gastric hypomotility (gastroparesis):(a) Is commonly associated with diabetes mellitus. (True)(b) Is a risk factor for gastro-oesophageal reflux disease. (True)(c) Is a feature of generalized scleroderma (systemic sclerosis). (True)(d) Occasionally responds to erythromycin. (True)(e) Is often secondary to duodenal ulcer disease. (False)

Question 5. The following are features of coeliac disease:(a) Hypocalcaemia. (True)(b) Hypercalcaemia. (False)(c) Normocytic anaemia. (False)(d) Hypoalbuminaemia. (True)(e) Positive antiparietal cell antibodies. (False)

Question 6. The following is true of Crohn's disease:(a) The rectum is always affected. (False)(b) Commonly affects the terminal ileum. (True)(c) More commonly occurs in smokers. (True)(d) Can result in vitamin B12 deficiency with a negative Schilling test. (True)(e) Commonly presents with bloody diarrhoea. (False)

Question 7. The following is true of giardiasis:(a) Diarrhoea abates with avoidance of dairy produce. (False)(b) Diarrhoea abates with avoidance of gluten. (False)(c) Diarrhoea requires treatment with metronidazole. (True)(d) Diarrhoea is usually accompanied by vomiting. (False)(e) Diarrhoea commonly results in vitamin B12 deficiency. (False)

Question 8. The following is true of inflammatory bowel disease:(a) Increased liver enzymes in the serum usually indicate the complication of carcinoma. (False)(b) Small bowel barium enema is the best radiological investigation for ulcerative colitis. (False)(c) It is occasionally complicated by carcinoma of the caecum. (True)(d) It is commonly associated with thyroiditis. (False)(e) It is sometimes complicated by iritis. (True)

Question 9. The following is true of viral hepatitis:(a) Hepatitis C commonly presents with jaundice. (False)(b) Hepatitis E is fatal particularly in pregnant women. (True)(c) Hepatitis BeAg is a marker of viral replication. (True)(d) Hepatitis A is a risk factor for hepatoma. (False)(e) Hepatitis D occurs only in association with hepatitis C. (False)

Question 10. The following drugs cause jaundice:(a) Methotrexate. (False)(b) Flucloxacillin. (True)(c) Metronidazole. (False)(d) Isoniazid. (True)

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(e) Phenobarbitone. (False)

Question 11. Haemochromatosis:(a) Is a genetic defect resulting in copper overload in the liver. (False)(b) Is a risk factor for the development of hepatoma. (True)(c) Has an equal sex incidence but presents earlier in males than females. (True)(d) Is treated by avoiding meat products. (False)(e) Can cause hypogonadism in the absence of cirrhosis. (True)

Question 12. Colonic carcinoma:(a) Most commonly occurs in the right side of the colon. (False)(b) May present with iron deficiency anaemia in the absence of any gastrointestinal symptoms. (True)(c) Commonly arises in colonic polyps. (True)(d) Carries a 5-year survival of less than 10%. (False)(e) Is the cause of carcinoid syndrome. (False)

Question 13. The following is true of colon polyps and colon cancer:(a) The larger the polyp, the greater the risk of carcinoma. (True)(b) Malignant polyps can be successfully treated by colonoscopy and polypectomy alone. (True)(c) Hyperplastic polyps have a higher malignant potential than villous polyps. (False)(d) Polyps are most common in the ascending colon. (False)(e) Colonic polyps are often recurrent. (True)

Question 14. The following gastrointestinal diseases are associated with the renal conditions listed:(a) Crohn's disease and renal amyloidosis. (True)(b) Hepatitis B and glomerulonephritis. (True)(c) Gastric ulcer and nephrotic syndrome. (False)(d) Pancreatic neuroendocrine tumours and polycystic kidney disease. (False)(e) Liver cysts and glomerulosclerosis. (False)

Question 15. The following is true of villous atrophy in the small intestine:(a) If due to coeliac disease, it should recover completely on a gluten-free diet. (True)(b) It can be caused by tuberculosis. (True)(c) It can be associated with Giardi lamblia. (True)(d) It can be associated with Tropheryma whippelei. (True)(e) When associated with bacteria, it may cause a rise in serum folate. (True

Question 16. The following skin conditions are associated with the named GI diseases:(a) Dermatitis herpetiformis with coeliac disease. (True)(b) Pruritus with primary biliary cirrhosis. (True)(c) Pyoderma gangrenosum with gastric carcinoma. (False)(d) Bullous pemphigoid with pancreatitis. (False)(e) Erythema nodosum with Crohn's disease. (True)

Question 17. The following statements are true in relation to vomiting:(a) Vomiting occurring 12 hours after a suspicious meal is indicative of Salmonella poisoning. (False)(b) Vomiting in association with headache is a feature of migraine. (True)(c) Vomiting associated with weight loss can be indicative of malignant disease. (True)(d) Vomiting usually precedes the pain of biliary colic. (False)(e) Vomiting can be a feature of myocardial infarction. (True)

Question 18. Scleroderma can produce the gastrointestinal complications listed:(a) Diarrhoea due to bacterial overgrowth. (True)(b) Constipation due to gut hypomotility. (False)(c) Diarrhoea which is unresponsive to a gluten-free diet. (True)(d) Gastric ulcer due to chronic gastritis. (False)

MCQs VIA WEB 2005

By A. H.

(e) Dysphagia due to abnormal peristalsis in the oesophagus. (True)

Question 19. Chronic pancreatitis:(a) Is a cause of diabetes mellitus. (True)(b) Can result from alcohol ingestion in moderate amounts. (True)(c) May be hereditary in a minority of cases. (True)(d) Can be diagnosed by a raised serum amylase. (False)(e) Is a cause of pancreas divisum. (False)

Question 20. The following is true of rectal bleeding:(a) In the absence of haemorrhoids, it is usually due to malignant disease. (False)(b) It occurs more commonly in Crohn's disease than in ulcerative colitis. (False)(c) If it occurs in a patient with ulcerative colitis, it usually indicates that carcinoma has developed. (False)(d) When it is due to diverticular disease, colectomy may be indicated to control it. (True)(e) It may be caused by ingestion of aspirin. (True)

Question 21. The following are risk factors for gastric carcinoma:(a) Pernicious anaemia. (True)(b) Coeliac disease. (False)(c) Partial gastrectomy. (True)(d) Helicobacter pylori infection. (True)(e) Ménétrière's disease. (True)

Question 22. The following statements are true:(a) Solitary rectal ulcers are commonly associated with Crohn's disease. (False)(b) Crypt abscesses are typical of coeliac disease. (False)(c) Fistula formation can be a feature of Whipple's disease. (False)(d) Anal fissure predisposes to faecal incontinence. (False)(e) Right iliac fossa pain is common with diverticular disease. (False)

Question 23. The following are true of hepatitis:(a) Hepatitis B is spread via the faecal-oral route. (False)(b) A vaccine is available for hepatitis C. (False)(c) Incubation time for hepatitis A is approximately 2-3 weeks. (True)(d) Hepatitis B is an RNA virus. (False)(e) Interferon treatment is required for hepatitis E infection. (False)

Question 24. The following is a risk factor for the Budd-Chiari syndrome:(a) Oral contraceptive pill. (True)(b) Malignancy. (True)(c) Ascites. (False)(d) Polycythaemia rubra vera. (True)(e) Constrictive pericarditis. (False)

Question 25. The following are true regarding prognostic factors for acute pancreatitis:(a) A low pAO2 indicates a poor prognosis. (True)(b) A high serum GGT has a poor prognosis. (False)(c) Age of over 55 years usually has a good prognosis. (False)(d) A low serum albumin indicates a poor prognosis. (True)(e) Abnormal clotting time has a poor prognosis. (True)

Module 9 (Gastroenterology)Question 1. The following is true of oesophageal pain:(a) It can occur in the absence of heartburn. (True)(b) It can mimic the pain of a myocardial infarction. (True)(c) It can be relieved by glyceryl trinitrate. (True)

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By A. H.

(d) It is usually precipitated by exercise. (False)(e) It can be caused by candidiasis. (True)

Question 2. The following is true of postgastrectomy syndromes:(a) The anaemia can be corrected with ascorbic acid supplements. (True)(b) The risk of gastric cancer in the long term is increased. (True)(c) Sweating and palpitations can be due to hypoglycaemia. (True)(d) Biliary gastritis in the gastric remnant is common. (True)(e) Diarrhoea is commonly due to bacterial overgrowth. (True)

Question 3. The following is true of neoplastic disease in the stomach:(a) Maltoma can occasionally respond to antibiotic treatment in combination with a proton pump inhibitor. (True)(b) Ménétrière's disease is due to metaplasia of the gastric mucosa. (True)(c) Leiomyoma has a characteristic appearance at endoscopy. (True)(d) Gastric carcinoma produces abdominal pain that is often worse after eating. (True)(e) The most common gastric carcinoma is of squamous cell origin. (False)

Question 4. The following statements are true:(a) Iron absorption is reduced in hypochlorhydric states. (True)(b) Vitamin D absorption is often deficient in the presence of gastritis. (False)(c) Vitamin B12 supplements are often necessary following gastrectomy. (True)(d) Anaemia associated with chronic atrophic gastritis may respond to ascorbic acid supplements. (True)(e) Intestinal metaplasia in the stomach is a risk factor for gastric carcinoma. (True)

Question 5. The following clinical features are associated with coeliac disease:(a) Anaemia. (True)(b) Weight loss. (True)(c) Vomiting. (False)(d) Diarrhoea. (True)(e) Jaundice. (False)

Question 6. The following is true of Crohn's disease:(a) C-reactive protein mimics inflammatory activity. (True)(b) Normal albumin indicates remission. (False)(c) Large bowel barium enema is the most definitive radiological test. (False)(d) A small bowel biopsy can be helpful in making the diagnosis. (True)(e) A low blood urea is common. (True)

Question 7. The following is true of ulcerative colitis:(a) It commonly presents with pain in the right iliac fossa. (False)(b) It can be associated with ankylosing spondylitis. (True)(c) It is a risk factor for toxic dilatation of the colon. (True)(d) The occurrence of abdominal tenderness is an ominous sign. (True)(e) It often causes ischiorectal abscesses. (False)

Question 8. Acholuric jaundice without pain:(a) Is a common presentation of pancreatic carcinoma. (False)(b) Is a feature of Gilbert's disease. (True)(c) Can occur in hereditary spherocytosis. (True)(d) Is associated with pale-coloured stools. (False)(e) Is associated with pruritus. (False)

Question 9. The following is true of risk factors for the development of hepatocellular carcinoma:(a) Females are at greater risk than males. (False)(b) Excess iron is a recognized risk factor. (True)(c) Aflatoxin is a risk factor. (True)(d) Hepatitis A is a risk factor. (False)

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By A. H.

(e) Risk factors generally only operate in the presence of cirrhosis. (True)

Question 10. Alcoholic hepatitis:(a) Recovers rapidly on cessation of drinking. (False)(b) Is a risk factor for hepatorenal syndrome. (True)(c) Ascites is a feature. (True)(d) Coagulopathy is corrected with administration of vitamin K. (False)(e) Encephalopathy occurs only if infection is present. (False)

Question 11. Primary sclerosing cholangitis:(a) Occurs predominantly in middle-aged females. (False)(b) Is a major risk factor for cholangiocarcinoma. (True)(c) Occurs in 50% patients with ulcerative colitis. (False)(d) Has been treated with ursodeoxycholic acid. (True)(e) May require insertion of an endoprosthesis for its treatment. (True)

Question 12. The following GI conditions are associated with microcytic hypochromic anaemia:(a) Acute duodenal ulceration. (False)(b) Ankylostoma duodenale. (True)(c) Terminal ileitis due to Crohn's disease. (True)(d) Partial gastrectomy. (True)(e) Carcinoma of caecum. (True)

Question 13. These gastronomic terms are associated with the following gastroenterological conditions:(a) 'Rice water' diarrhoea with cholera. (True)(b) 'Anchovy sauce' discharge with amoebic dysentry. (False)(c) 'Redcurrent jelly' and intussusception. (True)(d) 'Apple core' lesion and diverticulitis. (False)(e) 'Coffee grounds' and oesophageal varices. (False)

Question 14. The following is true of breath tests used for investigation of the gastrointestinal tract:(a) The 14C urea breath test detects Helicobacter pylori infection. (True)(b) The 14C glycocholic acid breath test is used to detect bacterial overgrowth in the colon. (False)(c) A hydrogen breath test following ingestion of lactulose is used to detect bacterial overgrowth in the small intestine.

(True)(d) A lactose breath test is used to detect disaccharidase deficiency. (True)(e) A 14C bile salt test can be used to identify bile duct obstruction. (False)

Question 15. The following autoantibodies are associated with the diseases listed:(a) Antiendomyseal antibodies are associated with coeliac disease. (True)(b) Anti-LKM antibodies are associated with Goodpasture syndrome. (False)(c) Antimitochondrial antibodies are associated with primary biliary cirrhosis. (True)(d) Antiparietal cell antibodies are associated with Wilson's disease. (False)(e) Antismooth muscle antibodies are associated with autoimmune chronic active hepatitis. (True)

Question 16. The following statements are true of colitis:(a) Granulomas are present in collagenous colitis. (False)(b) Rectal sparing is characteristic of Crohn's colitis. (True)(c) Caseating granulomas in the terminal ileum are diagnostic of Crohn's disease. (False)(d) Colitis in a smoker is more likely to be Crohn's than ulcerative colitis. (True)(e) Pain is a characteristic feature of CMV colitis. (True)

Question 17. The following statements are true of ascites:(a) A high protein content in ascites is usual in alcoholic liver disease. (False)(b) Ascites resistant to diuretics is characteristic of hepatic vein thrombosis. (True)(c) Ascites is sometimes associated with a pleural effusion. (True)

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By A. H.

(d) Ascites is a risk factor for bacterial peritonitis. (True)(e) Ascites due to constrictive pericarditis prevents pulsus paradoxus. (False)

Question 18. The following statements are true of non-steroidal anti-inflammatory drugs:(a) They can be given as suppositories to avoid gastrointestinal complications. (False)(b) They may have a role in the prevention of colon cancer. (True)(c) They can produce gastric erosions in elderly people causing occult blood loss. (True)(d) They cause gastric erosions by stimulating gastric acid secretion. (False)(e) They may exacerbate long-standing ulcerative colitis. (True)

Question 19. The following is true of pancreatic tumours:(a) Jaundice occurs only when carcinoma is present in the tail of pancreas. (False)(b) Presence of diabetes mellitus indicates that the tumour is of neuroendocrine origin. (False)(c) They are generally unresponsive to chemotherapy. (True)(d) They characteristically produce back pain when local invasion is present. (True)(e) They occur with increased frequency in patients with ulcerative colitis. (False)

Question 20. The following is true of haematemesis:(a) When it occurs in a patient with alcoholic liver disease, it is always due to oesophageal varices. (False)(b) A visible vessel seen at gastroscopy is a risk factor for further bleeding. (True)(c) When it occurs in patients over 70 years of age who may have arthritis, usually indicates malignancy. (False)(d) When it occurs after repeated retching, it is suggestive of an oesophageal tear. (True)(e) When it is caused by duodenal ulcer, a partial gastrectomy is usually necessary. (False)

Question 21. The following drugs can be used for treatment of GORD:(a) Metronidazole. (False)(b) Amoxycillin. (False)(c) Erythromycin. (False)(d) Metoclopramide. (True)(e) Omeprazole. (True)

Question 22. Which of the following is dependent on bile salts for its absorption:(a) Vitamin A. (True)(b) Vitamin B. (False)(c) Vitamin C. (False)(d) Vitamin D. (True)(e) Vitamin K. (True)

Question 23. The following are indications for liver biopsy:(a) Unexplained abnormal liver enzymes. (True)(b) Pyrexia of unknown origin with normal liver enzymes. (True)(c) Cirrhosis suspected on an ultrasound scan. (True)(d) Raised alkaline phosphatase in teenagers with acholuric jaundice. (False)(e) Abnormal liver enzymes in a patient with epilepsy on phenytoin. (False)

Question 24. The following precipitate portasystemic encephalopathy:(a) Infection. (True)(b) Diarrhoea. (False)(c) Gastrointestinal bleeding. (True)(d) Use of opioid drugs. (True)(e) Certain antibiotics. (False)

Question 25. The following drugs cause cholestatic jaundice:(a) Rifampicin. (False)(b) Isoniazid. (False)(c) Erythromycin. (True)(d) Halothane. (False)

MCQs VIA WEB 2005

By A. H.

(e) Paracetamol. (False)

Module 10 (Neurology)Question 1. The following cranial nerves carry parasympathetic fibres:(a) Oculomotor. (True)(b) Trigeminal. (False)(c) Facial. (True)(d) Hypoglossal. (False)(e) Vagus. (True)

Question 2. Myasthenia gravis:(a) Is caused by antibodies to the acetylcholine receptor in the majority of cases. (True)(b) Causes muscle wasting. (False)(c) May show diurnal variation in symptoms. (True)(d) Is associated with an improvement in strength after exertion. (False)(e) May present with ophthalmoplegia. (True)

Question 3. The causes of a mixed upper and lower motor neuron picture include:(a) Guillain-Barré syndrome. (False)(b) Multiple sclerosis. (False)(c) Syringomyelia. (True)(d) Motor neuron disease. (True)(e) Taboparesis. (True)

Question 4. Bilateral lower motor neuron facial weakness may occur in:(a) Sarcoidosis. (True)(b) Guillain-Barré syndrome. (True)(c) Lyme disease. (True)(d) Lymphoma. (True)(e) Parasagittal meningioma. (False)

Question 5. In idiopathic Parkinson's disease:(a) There is degeneration primarily of the cells of the globus pallidus. (False)(b) The classical features include tremor, bradykinesia, and spasticity. (False)(c) There is an associated vertical gaze palsy. (False)(d) Anticholinergic drugs are most effective in relieving tremor. (True)(e) Treatment is aimed at reducing dopamine levels. (False)

Question 6. The following features suggest that increased tone is due to rigidity:(a) Tone is increased equally in flexors and extensors. (True)(b) Extensor plantar responses. (False)(c) Associated pill-rolling tremor. (True)(d) Clasp-knife reflex. (False)(e) Tone increases with synkinesis. (True)

Question 7. Causes of a small pupil include:(a) Horner's syndrome. (True)(b) Holmes-Adie syndrome. (False)(c) Tabes dorsalis. (True)(d) Optic neuritis. (False)(e) Pilocarpine eye-drops. (True)

Question 8. Concerning optic neuritis:(a) Visual loss is usually painless. (False)(b) White-matter abnormalities on MR imaging increase the likelihood of developing multiple sclerosis in the future.

(True)

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By A. H.

(c) After recovery, some impairment of red-green colour vision may remain. (True)(d) Over 90% of patients with a history of optic neuritis go on to develop multiple sclerosis. (False)(e) It causes a delay in visual evoked potentials. (True)

Question 9. The following may cause a third nerve palsy:(a) Aneurysm of the posterior communicating artery. (True)(b) Diabetes. (True)(c) Motor neuron disease. (False)(d) Herniation of the uncus of the temporal lobe. (True)(e) Pancoast tumour. (False)

Question 10. The following typically occur within the first 24 hours of complete cervical cord transection:(a) Upgoing plantar responses. (False)(b) Fall in blood pressure. (True)(c) Loss of bladder control. (True)(d) Brisk reflexes. (False)(e) Gastric dilatation. (True)

Question 11. In motor neuron disease:(a) Fasciculations are required to make the diagnosis. (False)(b) There may be atrophy of the Betz cells in the motor cortex. (True)(c) Electromyography shows chronic partial denervation. (True)(d) There should be no signs of sensory loss. (True)(e) Familial cases account for 50%. (False)

Question 12. Causes of a mononeuropathy include:(a) Diabetes. (True)(b) Hereditary motor sensory neuropathy. (False)(c) Polyarteritis nodosa. (True)(d) Guillain-Barré syndrome. (False)(e) Lead poisoning. (True)

Question 13. Charcot joints:(a) May affect the feet in diabetes. (True)(b) Are often painful. (False)(c) May be caused by neurosyphilis. (True)(d) May affect the shoulders in syringomyelia. (True)(e) Are usually hot and swollen. (False)

Question 14. Hyposmia may arise secondary to:(a) A head injury. (True)(b) Migraine. (False)(c) Seizures. (False)(d) Antibiotic therapy. (True)(e) A frontal meningioma. (True)

Question 15. The following are causes of acute transient visual impairment:(a) Retinitis pigmentosa. (False)(b) Amaurosis fugax. (True)(c) Papilloedema. (True)(d) Migrainous aura. (True)(e) Glaucoma. (False)

Question 16. The following may be features of frontal lobe dysfunction:(a) Depression. (True)(b) Social disinhibition. (True)(c) Apraxia of gait. (True)

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By A. H.

(d) A receptive dysphasia. (False)(e) A grasp reflex. (True)

Question 17. The following may give rise to a pseudobulbar palsy(a) Poliomyelitis. (False)(b) Syringobulbia. (False)(c) Huntington's chorea. (False)(d) Occlusion of the anterior cerebral artery. (False)(e) Multiple sclerosis. (True)

Question 18. Facial sensory loss may occur with a lesion of:(a) The cerebellopontine angle. (True)(b) The facial nerve. (False)(c) The Gausserian ganglion. (True)(d) The Geniculate ganglion. (False)(e) The cavernous sinus. (True)

Question 19. Sensorineural deafness may occur secondary to:(a) Loud noise. (True)(b) Gentamicin therapy. (True)(c) Ménière's disease. (True)(d) An acoustic neuroma. (True)(e) Otosclerosis. (False)

Question 20. Choreic movements are:(a) Slow and writhing. (False)(b) Shock-like assymetrical and irregular. (False)(c) Brief, jerky and irregular. (True)(d) A sign of restlessness. (False)(e) Rhythmical and oscillatory. (False)

Question 21. Features of an upper motor neuron lesion are:(a) Brisk abdominal and cremasteric reflexes. (False)(b) Wasted muscles. (False)(c) Weakness of individual muscles. (False)(d) Hypotonia. (False)(e) Fatiguable muscle strength. (False)

Question 22. A small pupil may be seen in:(a) A lesion in the midbrain. (False)(b) Elderly patients. (True)(c) Horner's syndrome. (True)(d) Terminally ill patients taking morphine for analgesia. (True)(e) A pontine lesion. (True)

Question 23. Nystagmus may be seen in:(a) A patient with an internuclear ophthalmoplegia. (True)(b) A lesion of the pons. (True)(c) A patient who is blind. (True)(d) A patient with cerebellar dysfunction. (True)(e) A lesion of the foramen magnum. (True)

Question 24. Clinical features of a unilateral lesion of the cerebellopontine angle may be:(a) Conductive deafness on the same side. (False)(b) An ipsilateral hemiparesis. (False)(c) Ipsilateral weakness of the lower face. (False)(d) A pseudobulbar dysarthria. (False)

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By A. H.

(e) Vertigo as a prominent early symptom. (False)

Question 25. The fibres of the dorsal column pathway:(a) Carry information about temperature perception. (False)(b) Decussate in the midbrain. (False)(c) Are affected in the deficiency of vitamin B12. (True)(d) When damaged may result in a positive Romberg's test. (True)(e) Are spared following occlusion of the anterior spinal artery. (True)

Available from Master MedicineModule 1 (trial1)

Question 1. The ECG:· The T wave corresponds to atrial contraction (False)· If the S wave is greater than the R wave in lead I, there is right axis deviation (True)· If the S wave is greater than the R wave in lead II, there is left axis deviation (True)· ST segment depression may be a sign of cardiac ischaemia (True)

Explanation: It may also be a digoxin effect.· A tall R wave in V1 may be a sign of right ventricular hypertrophy (True)

Explanation: It may also be a digoxin effect.

Question 2. Endocarditis:· It is important to take blood cultures over at least 24 hour period to make the diagnosis (False)· Transthoracic echocardiography is a sensitive means of making or confirming the diagnosis (False)· Most patients with Staphylococcus aureus bacteraemia have endocarditis (False)· Viral endocarditis leads to valvular abnormality (False)· In patients with a new stroke, endocarditis can be ruled out if the patient is afebrile (False)

Question 3. Treatment of endocarditis:· Intravenous antibiotics for 6 weeks are necessary to cure viridans type streptococcal endocarditis (False)· Staphylococcal endocarditis on the tricuspid valve in a drug addict is treated with flucloxacillin and valve

replacement (False)· Large vegetations are an indication for surgery (True)

Explanation: Flucloxacillin (with gentamicin or rifampicin) is the medical treatment of choice but valve replacement isnot appropriate. Insertion of a prosthetic heart valve into a drug addict is very likely to lead to prosthetic valveendocarditis subsequently because of their continuing habit.

· Combination antibiotic therapy is almost always appropriate for endocarditis (True)

Explanation: For two reasons; first, the selected combinations are usually additive or synergistic. Second, to prevent thedevelopment of resistance.

· If gentamicin is used for treatment, it should not be used for more than 2 weeks (False)

Question 4. Hypertension:· Treatment is of no proven benefit in patients over the age of 70 years (False)· The symptoms of phaeochromocytoma include headache, sweating and palpitations (True)

Explanation: There is well-proven benefit, particularly in the prevention of stroke.· Oral treatment producing a fall in diastolic blood pressure of 20 mmHg over 24 hours might be regarded as

successful treatment of accelerated hypertension (True)

Explanation: There is well-proven benefit, particularly in the prevention of stroke.· ACE inhibitors are the drugs of choice for hypertension in pregnancy (False)

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By A. H.

· Addison's disease should be considered a possible cause in a hypertensive patient with hirsutism (False)

Question 5. Cardiac dysrhythmias:· Digoxin toxicity may cause supraventricular tachycardia (True)

Explanation: Typically, paroxysmal atrial tachycardia.· A patient with a completely irregular pulse of 180 beats/min is likely to be in atrial fibrillation (True)

Explanation: Typically, paroxysmal atrial tachycardia.· Complete heart block may be asymptomatic (True)

Explanation: Particularly congenital complete heart block.· Digoxin is effective in preventing paroxysms of atrial fibrillation (False)· A QRS width less than 3 small squares on the ECG indicates that a tachycardia is supraventricular (True)

Explanation: Digoxin slows the ventricular rate during paroxysms of atrial fibrillation but does not prevent them; sotalolor amiodarone may prevent them.

Question 6. Chronic bronchial sepsis:· Is an uncommon feature of cystic fibrosis (False)· Typically is caused by unusual, difficult-to-grow bacteria (False)· May lead to haemoptysis (True)

Explanation: Haemoptysis is also seen with dry bronchiectasis, chronic bronchial sepsis and with aspergillomas.· Can usually be cured with oral antibiotics (False)· May lead to pulmonary fibrosis (True)

Explanation: It produces a fibrotic reaction.

Question 7. In the small intestine:· If there is bile salt deficiency, micellar formation is reduced (True)

Explanation: Bile salts are essential for micelle formation.· Long-chain triglycerides are transported from the gut in the lymph as chylomicrons (False)· There is no lymphatic tissue (False)· The entire mucosa is turned over every 2-3 weeks (False)· Is the site of most nutrient absorption (True)

Question 8. Colorectal cancer:· May arise from a metaplastic polyp (False)· Most often occurs in the rectum and sigmoid (True)

Explanation: Metaplastic polyps have no malignant potential.· There are further polyps in most cases (False)· Involvement of local lymph nodes does not affect prognosis (False)· Obstruction is more common in right compared with left-sided lesions (False)

Question 9. Angiodysplasia of the colon:· Is more common in the caecum and ascending colon (True)

Explanation: It usually occurs in the right side of the colon.· Is associated with a macrocytic anaemia (False)· Is best shown by barium enema (False)· Usually requires surgery (False)· Is a congenital lesion (False)

Question 10. Concerning HIV infection and AIDS:· Pneumocystis pneumonia is common in Africa (False)· Tuberculosis in AIDS presents like that in non-AIDS patients (False)· Oral candidiasis is a late feature of AIDS (False)· Toxoplasmosis is usually a cerebral disease (True)

MCQs VIA WEB 2005

By A. H.

Explanation: Brain and heart. The CT/MR scan usually shows multiple ring-enhancing lesions, which are almostdiagnostic of toxoplasmosis in AIDS. CNS lymphomas are usually single. Cardiac toxoplasmosis is usually diagnosedat postmortem.

· Cytomegalovirus retinitis can be treated with aciclovir (False)

Module 1 (trial2)Question 1. In secondary diabetes:

· A patient can be assumed not to be ketosis-prone (False)· A patient is more than 85% likely to have clinical pancreatic exocrine deficiency (False)· Classical diabetic complications do not occur (False)· Thiazide diuretics and beta-blockers can both impair insulin secretion (True)

Explanation: Secondary diabetes causes all the same complications as idiopathic diabetes.· Most patients with acromegaly are diabetic (False)

Question 2. In hypoglycaemia:· Insulin-dependent patients may recover from hypoglycaemic coma without treatment (True)

Explanation: The anti-insulin hormones can bring the patient round and the insulin which caused the coma can 'wearoff'.

· Sweating and shaking are always late symptoms of insulin-induced hypoglycaemia (False)· Insulin-dependent patients may lose their warning symptoms of hypoglycaemia after many years of diabetes

(True)Explanation: About 50% of patients who have had type 1 DM for 20 years or more develop 'hypoglycaemiaunawareness'.

· Metformin is responsible for as many cases of hypoglycaemia as sulfonylureas (False)· The symptoms characteristically come on over hours rather than minutes (False)

Question 3. In insulin treatment:· Pen injectors are reserved for the small minority who take four or more injections per day (False)· Only patients who cannot be controlled with once-daily insulin should have two or more injections (False)· Insulin should be started without delay in a thin hyperglycaemic patient with ketonuria (True)

Explanation: These are signs of type 1 DM.· Insulin may sometimes be needed during short periods of illness in patients with type 2 DM (True)

Explanation: These are signs of type 1 DM.· All patients on insulin should be discouraged from changing their doses without first checking with the doctor

or nurse (False)

Question 4. Diabetic pregnancy:· Insulin-dependent women should be advised not to contemplate pregnancy (False)· Diabetes increases the risk of neural tube defects (True)

Explanation: Neural tube defects are two to three times more common.· Poor glycaemic control at conception increases the risk of congenital malformations (True)

Explanation: Hyperglycaemia is teratogenic in early pregnancy; major congenital malformations are two to three timesmore common.

· There is a less than 10% chance that an episode of ketoacidosis will cause intrauterine death (False)· Sulfonylureas are the treatment of choice for gestational diabetes (False)

Question 5. Thyroid function tests:· Serum thyroid-stimulating hormone (TSH) is a sensitive test of hyperthyroidism (True)

Explanation: Suppression of TSH is the first biochemical sign of hyperthyroidism.· Serum TSH can distinguish primary from secondary hypothyroidism (True)

Explanation: In primary hypothyroidism, TSH is high; in secondary hypothyroidism, it is low.· Serum triiodothyronine can be an unreliable test for hypothyroidism (True)

Explanation: Low triiodothyronine may result from intercurrent illness, particularly in elderly people, and can bemisleading.

· Hyperthyroid patients may have a raised serum triiodothyronine with a normal thyroxine (True)

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By A. H.

Explanation: The condition of 'T3 toxicosis'.

Question 6. Rheumatoid factor is:· An antibody to sheep erythrocytes (False)· Present when rheumatoid nodules are present (True)

Explanation: Nodules are associated with high titres of rheumatoid factor.· Diagnostic of rheumatoid arthritis (False)· Usually is of the IgA subtype (False)· Is not found in rheumatoid synovial, pleural or pericardial fluid (False)

Question 7. In gout:· Tophi are an early sign (False)· Allopurinol is used to treat the acute attack (False)· Furosemide (frusemide) helps to increase urate excretion (False)· Large joints are not affected (False)· Raised serum urate makes the diagnosis certain (False)

Question 8. Ankylosing spondylitis:· Is more common in females (False)· May present as a severe oligoarthritis (True)

Explanation: Commonly affects several joints and often presents with back pain.· Is associated with the histocompatibility antigen HLA-DW3 (False)· Is associated with pulmonary fibrosis (True)

Explanation: It is associated with upper lobe fibrosis and aortic incompetence.· Involves the proximal interphalangeal (PIP) (False)

Question 9. Concerning osteomyelitis:· Debridement of infected bone is essential for cure in chronic bacterial osteomyelitis (True)

Explanation: It is often difficult to remove all dead infected bone.· It is usually accompanied by a very high ESR (True)

Explanation: Virtually always and it is a useful marker of response to treatment and relapse.· A distinctive feature of chronic osteomyelitis is a discharging sinus (True)

Explanation: Although there are other causes of a sinus including actinomycosis, implanted foreign body (such asshrapnel), mycetoma (fungal soft tissue and bony infection of the leg in the tropics).

· A positive culture from a sinus track is a good indication of the bacterial cause of the chronic osteomyelitis(False)

· Usually 2 or 3 weeks' antibiotic therapy is adequate for cure (False)

Question 10. With regard to reactive arthritis:· It may be caused by both Salmonella and Campylobacter spp. (True)

Explanation: It usually occurs 3-12 weeks after the episode of diarrhoea.· It is usually chronic and unremitting over 3-4 years (False)· Confidence in the diagnosis rests on growing a bacterium from stool or other sites (False)· NSAIDs are appropriate therapy (True)

Explanation: It is helpful if it can be done but failure does not rule out the diagnosis.· Rheumatic fever should be excluded (True)

Module 1 (Master Medicine)Question 1. The anatomy of the heart:If you stand on the patient's right side with your right hand across the sternum and cardiac apex, the left ventricle liesunder the sternum (False)On a postero-anterior (PA) chest radiograph, the left heart border is mostly formed by the left ventricle (True)

Explanation: The right ventricle presses against the sternum; the left ventricle constitutes the apex and is felt under thefingers.In an ECG, disease of the interventricular septum causes changes in chest leads V3-4 (True)

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Explanation: The right ventricle presses against the sternum; the left ventricle constitutes the apex and is felt under thefingers.When examining the heart, the cardiac apex is the point where the heart beat can be felt most strongly (False)Occlusion of the left anterior descending coronary artery causes infarction of the anterior wall of the left ventricle and

interventricular septum (True)Explanation: Anterior myocardial infarction is caused by disease of the left anterior descending artery.

Question 2. The ECG:The T wave corresponds to atrial contraction (False)If the S wave is greater than the R wave in lead I, there is right axis deviation (True)If the S wave is greater than the R wave in lead II, there is left axis deviation (True)ST segment depression may be a sign of cardiac ischaemia (True)

Explanation: It may also be a digoxin effect.A tall R wave in V1 may be a sign of right ventricular hypertrophy (True)

Explanation: It may also be a digoxin effect

Question 3. Endocarditis:It is important to take blood cultures over at least 24 hour period to make the diagnosis (False)Transthoracic echocardiography is a sensitive means of making or confirming the diagnosis (False)Most patients with Staphylococcus aureus bacteraemia have endocarditis (False)Viral endocarditis leads to valvular abnormality (False)In patients with a new stroke, endocarditis can be ruled out if the patient is afebrile (False)

Question 4. Treatment of endocarditis:Intravenous antibiotics for 6 weeks are necessary to cure viridans type streptococcal endocarditis (False)Staphylococcal endocarditis on the tricuspid valve in a drug addict is treated with flucloxacillin and valve replacement

(False)Large vegetations are an indication for surgery (True)

Explanation: Flucloxacillin (with gentamicin or rifampicin) is the medical treatment of choice but valve replacement isnot appropriate. Insertion of a prosthetic heart valve into a drug addict is very likely to lead to prosthetic valveendocarditis subsequently because of their continuing habit.Combination antibiotic therapy is almost always appropriate for endocarditis (True)

Explanation: For two reasons; first, the selected combinations are usually additive or synergistic. Second, to prevent thedevelopment of resistance.If gentamicin is used for treatment, it should not be used for more than 2 weeks (False)

Question 5. In acute myocardial infarction:The diagnosis should be questioned if the jugular venous pressure is not raised (False)Streptokinase should not be given until the diagnosis has been confirmed by two sets of raised cardiac enzymes (False)Dysrhythmias in the early hours after presentation carry a poor prognosis (False)Lidocaine should routinely be given to prevent dysrhythmias (False)Rupture of the interventricular septum is an uncommon but serious complication (True)

Explanation: This is of no proven value.

Question 6. In acute dissection of the thoracic aorta:The operative mortality is about 30% (False)Spinal cord ischaemia may occur (True)

Explanation: It is much higher.Hypertension should be treated aggressively (True)

Explanation: Nitroprusside or labetolol infusion is a recommended treatment.Acute aortic stenosis may occur (False)The patient may develop myocardial ischaemia (True)

Explanation: The coronary ostia may be occluded by the dissection

Question 7. Hypertension:Treatment is of no proven benefit in patients over the age of 70 years (False)The symptoms of phaeochromocytoma include headache, sweating and palpitations (True)

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Explanation: There is well-proven benefit, particularly in the prevention of stroke.Oral treatment producing a fall in diastolic blood pressure of 20 mmHg over 24 hours might be regarded as successful

treatment of accelerated hypertension (True)Explanation: There is well-proven benefit, particularly in the prevention of stroke.ACE inhibitors are the drugs of choice for hypertension in pregnancy (False)Addison's disease should be considered a possible cause in a hypertensive patient with hirsutism (False)

Question 8. In ischaemic heart disease:Prevalence is increased in chronic renal failure (True)Explanation: Cushing's syndrome, not Addison's disease.Untreated hypothyroidism predisposes to it (True)

Explanation: Hypothyroidism causes hypercholesterolaemia and atherosclerosis.Polycythaemia may precipitate myocardial ischaemia (True)

Explanation: By increasing blood viscosity and impairing blood flow.An alcohol intake of 18 units per week in a man increases the risk of ischaemic heart disease (False)A high plasma fibrinogen reduces the risk (False)

Question 9. Cardiac dysrhythmias:Digoxin toxicity may cause supraventricular tachycardia (True)Explanation: Typically, paroxysmal atrial tachycardia.A patient with a completely irregular pulse of 180 beats/min is likely to be in atrial fibrillation (True)

Explanation: Typically, paroxysmal atrial tachycardia.Complete heart block may be asymptomatic (True)

Explanation: Particularly congenital complete heart block.Digoxin is effective in preventing paroxysms of atrial fibrillation (False)A QRS width less than 3 small squares on the ECG indicates that a tachycardia is supraventricular (True)

Explanation: Digoxin slows the ventricular rate during paroxysms of atrial fibrillation but does not prevent them; sotalolor amiodarone may prevent them.

Question 10. Hypoventilation occurs in the following:Central sleep apnoea syndrome (True)Explanation: Alveolar hypoventilation is a key feature.Severe kyphoscoliosis (True)

Explanation: Severe kyphoscoliosis can produce mechanical ventilation problems because of the changed curvature ofthe spine.Anxiety (False)Benzodiazepine overdose (True)

Explanation: Drugs such as benzodiazepines depress the respiratory centre.Exercise (False)

Question 11. Pneumothorax is a recognised complication of:Rib fracture (True)Explanation: Pneumothorax can occur secondary to trauma.A bulla (True)

Explanation: Any cavitating or cystic/bullous lung lesion can cause a pneumothorax. Bullae can be single or multiple.They are particularly common in emphysema including á1-antitrypsin deficiency.Kyphoscoliosis (False)Cystic fibrosis (False)Pneumocystis carinii pneumonia (True)

Explanation: And lung abscesses (e.g. Staph. aureus) can lead to pneumothorax.

Question 12. The following are features of fibrosing alveolitis:Cough (True)Explanation: Patients usually present with cough and breathlessness.Clubbing of the fingers in the majority of cases (True)

Explanation: Clubbing occurs in about 60% of patients but is not essential for the diagnosis.Cyanosis in the early stages (False)

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Circulating antibodies to alveolar tissues (False)Haemoptysis (False)

Question 13. Useful drugs for tuberculosis include:Piperacillin (False)Isoniazid (True)

Explanation: Isoniazid is a major, first-line agent.Ciprofloxacin (True)Explanation: Ciprofloxacin is a useful agent, less active than rifampicin; it may obscure infection in patients treatedbefore diagnosis considered.Ethambutol (True)

Explanation: Ethambutol is another major, but second-line agent.Amikacin (True)

Explanation: Amikacin is a useful i.v. second-line agent

Question 14. Causes of life-threatening pneumonia or pneumonitis in adults include:Pneumocystis carinii (True)Explanation: Pneumocystis carinii infection is usually seen in AIDS, but also in lymphoma, steroid-treated, transplantand hypogammaglobulinaemic patients.Influenza A virus (True)

Explanation: Primary influenzal pneumonia or complicated by bacteria, e.g. Staph. aureus.Respiratory syncytial virus (False)Staphylococcus aureus (True)

Explanation: S. aureus pneumonia is often rapidly fatal, especially following influenza.Legionella pneumophila (True)

Explanation: L. pneumophilia pneumonia carries a high mortality if not treated appropriately.

Question 15. Chronic bronchial sepsis:Is an uncommon feature of cystic fibrosis (False)Typically is caused by unusual, difficult-to-grow bacteria (False)May lead to haemoptysis (True)

Explanation: Haemoptysis is also seen with dry bronchiectasis, chronic bronchial sepsis and with aspergillomas.Can usually be cured with oral antibiotics (False)May lead to pulmonary fibrosis (True)

Explanation: It produces a fibrotic reaction

Question 16. Pleural aspiration is useful in the following situations:In diagnosing mesothelioma (False)Pleural tuberculosis (False)Viral pleurisy (False)Empyema (True)

Explanation: An empyema will require tube or surgical drainage for treatment.Relieving breathlessness in patients with malignant effusions (True)

Explanation: Drainage in malignant effusions is often very helpful if litres of fluid are removed or a shunt can beinserted.

Question 17. In the small intestine:If there is bile salt deficiency, micellar formation is reduced (True)Explanation: Bile salts are essential for micelle formation.Long-chain triglycerides are transported from the gut in the lymph as chylomicrons (False)There is no lymphatic tissue (False)The entire mucosa is turned over every 2-3 weeks (False)Is the site of most nutrient absorption (True)

Explanation: The small intestine is the main area for the breakdown and absorption of nutrients.

Question 18. Colorectal cancer:May arise from a metaplastic polyp (False)

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Most often occurs in the rectum and sigmoid (True)Explanation: Metaplastic polyps have no malignant potential.There are further polyps in most cases (False)Involvement of local lymph nodes does not affect prognosis (False)Obstruction is more common in right compared with left-sided lesions (False)

Question 19. Causes of acute pancreatitis include:Alcohol (True)Explanation: Most cases are associated with gall stones or high alcohol intake.Hypocalcaemia (False)Hyperlipidaemia (True)

Explanation: There is an association with hyperlipidaemia, but it is an uncommon cause.Self poisoning with diazepam (False)Endoscopic retrograde cholangiopancreatography (ERCP) (True)

Explanation: ERCP is used in the diagnosis of pancreatic disease but can precipitate an acute attack.

Question 20. Coeliac disease:The patient will almost always have had symptoms since childhood (False)Is best diagnosed on colonic biopsy (False)Is associated with HLA-B8 (True)

Explanation: It is associated with HLA-B8 and HLA-DRW3 antigens.The diagnosis is incorrect if a patient fails to respond to a gluten-free diet (False)Requires a diet free from wheat, barley and rye (True)

Explanation: All contain gluten

Question 21. In a ward with several patients where two of the nurses have had much vomiting and some diarrhoea overa 48-hour period, you should:Send the patients home (False)Culture stools (and vomitus) for viruses (False)Treat everyone with metronidazole (False)Exclude visitors from the ward (True)

Explanation: To prevent further spread, unless necessary for, say, a dying patient.Prevent the patients (affected or not) leaving the ward for investigations, physiotherapy, etc. (True)

Explanation: Unless the investigation was absolutely vital

Question 22. The differential diagnosis of acute bloody diarrhoea includes:Amoebic dysentery (True)

Explanation: This has much mucus and tenesmus.Campylobacter enteritis (True)

Explanation: The amount of blood is usually small.Haemorrhagic colitis caused by E. coli (True)

Explanation: The classic cause, with mostly blood and little stool and no fever.Traveller's diarrhoea (False)Cholera (False)

Question 23. The following are correct:Hepatitis B can be acquired from serous fluid from a wound (True)Explanation: This is the likely mode of horizontal transmission among siblings in developing countries.Hepatitis C is not a cause of hepatocellular carcinoma (False)Hepatitis A is a cause of chronic liver disease (False)Hepatitis E can be acquired by sharing needles (False)A person with only a hepatitis B core IgG test positive is infectious for hepatitis B (False)

Question 24. A 'fatty liver' may represent:Simply an obese person (False)Alcoholism (True)

Explanation: A common 'early' abnormality.

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Hepatitis C infection (True)Explanation: A common 'early' abnormality.Acute vitamin A poisoning (False)An ultrasound artefact (False)

Question 25. Cushing's syndrome:Causes osteoporosis (True)Explanation: Also cardiorespiratory disease.The diagnosis is made by a high-dose dexamethasone test (False)Serum adrenocorticotrophic hormone (ACTH) is important in diagnosing the underlying cause (True)

Explanation: Patients with primary adrenal Cushing's have unmeasurably low serum ACTH.A neoplasm causing a classical 'lemon-on-sticks' appearance is > 25% likely to be small cell carcinoma of the bronchus

(False)Can only be cured by bilateral adrenalectomy (False)

Module 2 (Master Medicine)Question 1. Acute renal failure is a likely complication of the following:Sepsis (or sepsis syndrome) (True)Explanation: Commonly caused by prerenal factors such as sepsis syndrome.Polycystic kidney disease (False)Major arterial surgery (True)

Explanation: Major arterial surgery can cause renal ischaemia and acute tubular necrosis.Retroperitoneal tumours (False)Cardiogenic shock (True)

Question 2. In patients with acute renal failure:Sodium bicarbonate should be given routinely (False)Most patients with acute renal failure need long-term dialysis (False)Skin turgor is a reliable guide to the need for i.v. fluid therapy (False)Urinary catheterisation is sometimes needed to monitor the response to therapy (True)

Explanation: It is important to measure urine flow in the fluid management of acute renal failure.Intravenous pyelography is the investigation of choice to exclude urinary obstruction (False)

Question 3. The following are causes of chronic renal failure:Gout (True)Explanation: In renal failure, the kidneys are unable to excrete urea so the urinary urea concentration is low. Thisdistinguishes renal failure from, for example, volume depletion, in which plasma urea is high but the kidneys retain thecapacity to concentrate urinary urea.Atherosclerosis (True)

Explanation: As a result of extrarenal or intrarenal obstruction to the renal arterial circulation.Analgesic abuse (True)Explanation: As a result of extrarenal or intrarenal obstruction to the renal arterial circulation.Non-insulin-dependent diabetes (True)

Explanation: Both insulin-dependent and non-insulin-dependent diabetes cause renal failure.Hypothyroidism (False)

Question 4. The following may cause the nephrotic syndrome:Minimal change disease (True)Explanation: This is the characteristic disease associated with nephrotic syndrome, particularly in children.Treatment with beta-blockers (False)Rheumatoid arthritis (True)

Explanation: It may be caused by amyloid associated with rheumatoid arthritis or by drugs used to treat the disease(gold or penicillamine). Rarely it is caused by a glomerulonephritis associated with the disease itself.Diabetes mellitus (True)

Explanation: Although the full-blown nephrotic syndrome is a relatively uncommon presentation of diabeticnephropathy.Renal cell carcinoma (False)

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Question 5. The following are features of urinary infections in elderly people:Patients usually complain of dysuria (False)They may present with falls (True)They may present with constipation (True)

Explanation: Or it may be coexistent, perhaps reflecting anorexia and dehydration.Sterile pyuria is most likely caused by tuberculosis (False)Estrogen supplements may reduce their frequency in postmenopausal women (True)

Explanation: Elasticity of the urethra is reduced postmenopausally and this can lead to infection. Local estrogen therapyhelps.

Question 6. Renal artery stenosis:Is invariably caused by atherosclerosis (False)May cause renal failure in patients given ACE (angiotensin-converting enzyme) inhibitor therapy (True)

Explanation: Fibromuscular hyperplasia and radiation fibrosis are two other pathologies which can cause renal arterystenosis, although atherosclerosis is the most common pathology.Can be reliably diagnosed by auscultating for renal bruits (False)May be seen on ultrasound as a unilateral small kidney (True)

Explanation: Hypoperfusion causes reduction in renal size.Is a cause of hypertension (True)

Explanation: Hypoperfusion causes reduction in renal size.

Question 7. The following are true:There is weakness of elbow extension in a crutch palsy (True)Explanation: The triceps is affected in a crutch palsy.Wasting of the hypothenar eminence occurs in the carpal tunnel syndrome (False)Abduction of the thumb is impaired in an ulnar nerve lesion (False)The index finger is hyperextended at the metacarpophalangeal (MCP) joint in an ulnar nerve lesion (False)Sensation is lost over the whole of the back of the hand in radial nerve damage (False)

Question 8. The following are true:A cerebellar vermis lesion will result in a marked intention tremor (False)Macular sparing is a characteristic of lesions affecting the optic tract (False)In a patient with marked visuo-spatial inattention, the lesion is most likely in the left cerebral hemisphere (False)Agnosia means inability to plan and execute motor tasks (False)Dyscalculia is a feature of Alzheimer's disease (True)

Explanation: Remember other higher cortical functions, e.g. dysphasia, dyslexia.

Question 9. Features of a right sixth nerve palsy include:Convergent strabismus (True)Explanation: Complete paralysis of the lateral rectus leaves the medial rectus unopposed hence producing a convergentstrabismus, though mostly the paralysis is only brought out when the eye is abducted.Diplopia worse on looking to the right (True)

Explanation: Diplopia is maximal on looking in the direction of the primary action of the muscle.False image parallel to the true image (True)

Explanation: Unlike a superior oblique palsy.False image occurs further to the left than the true image (False)Images become increasingly separated on looking to the left (False)

Question 10. Parkinson's disease is associated with:Loss of dopamine transmission (True)Explanation: Although the mechanism is unclear, it does involve loss of dopaminergic neurons.Cogwheel rigidity (True)

Explanation: Cogwheel rigidity is a superimposed tremor on the 'lead pipe' increase in tone.Tardive dyskinesia (False)Intention tremor (False)Festinant gait (True)

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Question 11. In a young female with paraplegia, which of the following would suggest a diagnosis of multiple sclerosis:Periventricular lesions seen on MR scanning (True)

Explanation: Periventricular plaques would imply disease remote from the spinal cord. MR scanning is the preferredimaging technique.Raised protein in cerebrospinal fluid (CSF) (False)Raised CSF globulin (True)

Explanation: CNS immunology is disturbed in multiple sclerosis.Denervation of the muscles of the leg (False)Episode of visual disturbance (True)

Explanation: Disturbances of visual acuity are an early sign.

Question 12. The following are more suggestive of dementia than of depression:Several episodes of antisocial behaviour (True)Explanation: Antisocial behaviour is more in keeping with the personality change of dementia.Mutism (False)Duration of symptoms less than 1 month (False)Worsening of symptoms during the early morning (False)Marked impairment of concentration (False)

Question 13. With respect to lumbar puncture:Coagulopathy is a contraindication (True)Explanation: However, if correctable (e.g. haemophiliac) and the indication for lumbar puncture is strong enough, thenit should be corrected and the lumbar puncture carried out.Papilloedema is an absolute contraindication (False)The procedure may cause meningitis (False)The less CSF is removed, the less likely coning is to occur (False)Postlumbar puncture headache is related to the size of the needle used (False)

Question 14. Outcome from bacterial meningitis relates to:Age of patient (True)

Explanation: Mortality is highest in elderly people.Time to first administration of antibiotic (True)

Explanation: Delays lead to increased mortality and morbidity.CSF concentration of antibiotic (True)

Explanation: The CSF concentration of antibiotic needs to exceed by 20-fold the minimum inhibitory concentration ofthe infecting organism. This is the primary reason why i.v. therapy is necessary in meningitis.Development of antibiotic resistance during therapy (False)The causative organism (True)

Explanation: Neisseria meningitidis has a lower mortality than S. pneumoniae meningitis. Furthermore about 5% ofcommunity-acquired cases are other organisms, such as Listeria monocytogenes. Listeria is intrinsically resistant to allcephalosporins, which are now the most common first line treatment for meningitis

Question 15. The following statements are true:Hypocalcaemia causes prolongation of the prothrombin time (False)The prothrombin time is a sensitive test of hepatocellular dysfunction (True)

Explanation: Because hepatocellular dysfunction impairs the synthesis of vitamin K-dependent clotting factors.The activated partial thromboplastin time (APTT) is prolonged by unfractionated heparin therapy (True)

Explanation: This is used as a measure of heparinisation.The effect of heparin is reversed by vitamin K (False)Deep venous thrombosis can be reliably diagnosed by measuring fibrin degradation products (FDPs) (False)

Question 16. The following may cause a microcytic anaemia:Sickle cell disease (False)The thalassaemias (False)Anaemia of chronic disease (False)Anticonvulsant therapy (False)

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Haemolysis, whatever the cause (False)

Question 17. The following statements are true:A neutrophil count of only 0.8 × 109 cells/l is a major risk for infection (False)A neutrophil count in a febrile patient of 25 × 109 cells/l reflects mostly the production of new neutrophils from the

bone marrow (False)In a patient with less than 0.1 × 109 cells/l neutrophils and a fever, treatment with antibiotics should await the results of

blood culture (False)Neutropenia is common in AIDS (False)Neutropenia can be caused by carbimazole therapy (True)

Explanation: Neutropenia occurs in 1:10000 patients treated with carbimazole for thyrotoxicosis.

Question 18. Prognosis of diabetes:Cardiovascular mortality is higher in diabetic than in non-diabetic people up to the age of 80 (True)Explanation: A threefold increase.Diabetic patients with proteinuria have a higher cardiovascular risk than those without it (True)

Explanation: It is indicative of nephropathy, which increases the risk of cardiovascular disease up to 100-fold.When sulfonylureas became available, there was a noticeable improvement in cardiovascular mortality (False)Good glycaemic control, on the balance of available evidence, can reduce cardiovascular mortality in both type 1 and

type 2 DM (False)Even mildly 'impaired glucose tolerance' increases cardiovascular risk (True)

Question 19. In secondary diabetes:A patient can be assumed not to be ketosis-prone (False)A patient is more than 85% likely to have clinical pancreatic exocrine deficiency (False)Classical diabetic complications do not occur (False)Thiazide diuretics and beta-blockers can both impair insulin secretion (True)

Explanation: Secondary diabetes causes all the same complications as idiopathic diabetes.Most patients with acromegaly are diabetic (False)

Question 20. Diabetic retinopathy:Characteristically causes arterio-venous nipping (False)Should be referred to an ophthalmologist only if the patient has visual symptoms (False)Inevitably causes blindness (False)May cause cotton wool spots (soft exudates) (True)

Explanation: These may also occur in hypertension and other ischaemic retinopathies.Is more likely to cause blindness in type 1 than in type 2 DM (False)

Question 21. In insulin treatment:Pen injectors are reserved for the small minority who take four or more injections per day (False)Only patients who cannot be controlled with once-daily insulin should have two or more injections (False)Insulin should be started without delay in a thin hyperglycaemic patient with ketonuria (True)

Explanation: These are signs of type 1 DM.Insulin may sometimes be needed during short periods of illness in patients with type 2 DM (True)

Explanation: These are signs of type 1 DM.All patients on insulin should be discouraged from changing their doses without first checking with the doctor or nurse

(False)

Question 22. Hypertension in diabetes:Is more prevalent in type 1 than in type 2 (False)Its treatment slows the deterioration of nephropathy in type 1 DM (True)

Explanation: Hypertension is associated with type 2 more strongly than with type 1 DM.Thiazide diuretics should not be used in diabetes (False)Beta-blockers may increase the risk of severe hypoglycaemia in insulin-treated patients (True)

Explanation: This is true primarily of non-cardioselective beta-blockers.Increases the risk of stroke in diabetes (True)

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Explanation: This is true primarily of non-cardioselective beta-blockers

Question 23. The following are seen with NSAIDs:Improvement in renal function (False)Increase in serum potassium (True)

Explanation: The change in renal function results in hyperkalaemia.Increased risk of peptic ulcer complications (True)

Explanation: There is a clear relationship between NSAID use and complications such as perforation, bleeding anddeath particularly in old people.Improved long-term prognosis of rheumatoid arthritis (False)Improvement in coexistent asthma (False)

Question 24. The following are features of systemic lupus erythematosus (SLE)Raynaud's phenomenon (True)Explanation: Pain during mastication is a characteristic feature of temporal arteritis.Mononeuritis multiplex (True)

Explanation: Pain during mastication is a characteristic feature of temporal arteritis.Thrombocytopenia (True)

Explanation: This is one of the typical blood-associated dyscrasias.Lymphopenia (True)

Explanation: As with thrombocytopenia

Question 25. In primary osteoarthritis:The ESR is normal (True)Explanation: There are no haematological abnormalities.PIP joints are not usually affected (False)Radiographs show characteristic erosions of articular margins (False)Morning stiffness usually lasts over 1 hour (False)First carpometacarpal joint involvement is a common finding (True)

Explanation: This is common, resulting in 'squaring' of the hand

Available from Davidson's Principles and Practice of MedicineModule 1 (Chapter 1)Question 1. The following infections may be acquired by the following meanstetanus-respiratory droplets or dust (False)Explanation: Via wounds and abrasionslisteriosis-eating contaminated cheese (True)

Explanation: Can survive refrigerationlegionellosis-water aerosols (True)schistosomiasis-via penetration of the skin (True)leptospirosis-via rat urine (True)

Question 2. Diseases typically acquired from animals includeleptospirosis (True)Explanation: From the urine of rats or dogsMycobacterium tuberculosis (False)

Explanation: Mycobacterium bovistoxoplasmosis (True)

Explanation: From dog faecespsittacosis (True)

Explanation: From birdshepatitis A (False)

Explanation: Faecal-oral spread

Question 3. Live viruses are usually used for active immunisation against

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poliomyelitis (True)Explanation: Inactivated vaccine also availablepertussis (False)typhoid fever (False)mumps, measles and rubella (True)

Explanation: Do not give to immunosuppressed patientshepatitis B (False)

Question 4. Pyrexia of unknown originis defined as a temperature of more than 37.5°C persisting for more than 2 weeks (True)Explanation: Not elucidated by investigation in hospitalis due to infection in 75% of cases (False)

Explanation: In approximately 30% onlymay be factitious (True)

Explanation: Suspect if ESR and CRP normalcan be caused by granulomatous hepatitis (True)

Explanation: And other forms of hepatitismay be elucidated by bone marrow biopsy (True)

Explanation: May diagnose haematological malignancy

Question 5. The following statements about infectious mononucleosis are trueinfection is usually attributable to the Epstein-Barr virus (EBV) (True)presentation is with fever, headache and abdominal pain (True)

Explanation: And malaise and anorexiasore throat suggests cytomegalovirus rather than EBV infection (False)meningoencephalitis and pericarditis are recognised complications (True)severe oropharyngeal swelling requires prednisolone therapy (True)

Explanation: Especially if there is dysphagia or breathing difficulty

Question 6. Typical features of toxoplasmosis include the followinginfection is derived from cats, pigs and sheep (True)Explanation: Immunocompromised patients are most at riskpeak age of onset is over 65 years of age (False)

Explanation: 25-35 yearscongenital infection produces choroidoretinitis (True)

Explanation: And sometimes microcephalythere is a positive heterophil antibody test (False)

Explanation: This is typically negativepyrimethamine and sulfadiazine therapy is useful in immunocompromised patients (True)

Question 7. Recognised features of brucellosis includea characteristically rapid response to penicillins (False)Explanation: Typically doxycycline and streptomycinfever, night sweats and back pain (True)

Explanation: And joint pains and anorexiasplenomegaly (True)

Explanation: But a non-specific findingoligoarthritis and spondylitis (True)

Explanation: Due to localised granulomatous diseasethrombocytopenia (True)

Explanation: Due to hypersplenism

Question 8. The typical features of leptospirosis includeincubation period of 1-3 months (False)Explanation: 7-14 daysexposure risk in abattoirs, farms and inland waterways (True)fever, severe myalgia, headache and conjunctival suffusion (True)

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Explanation: With abrupt onsetmeningitis in Leptospira icterohaemorrhagiae rather than L. canicola infection (False)

Explanation: L. canicola infection is usually associated with aseptic meningitispossible diagnosis by examination of the urine (True)

Explanation: Leptospires appear in the urine in the second week of illness

Question 9. The clinical features of Lyme disease includeinfection with the tick-borne spirochaete Borrelia burgdorferi (True)Explanation: Ixodes species of tickan expanding erythematous rash (erythema chronicum migrans) (True)

Explanation: An annular red lesioncranial nerve palsies (True)

Explanation: Or meningitis or radiculopathyasymmetrical large joint recurrent oligoarthritis (True)

Explanation: Not in acute stagesresponse to tetracycline or penicillin therapy (True)

Explanation: And cephalosporins

Question 10. Features consistent with the diagnosis of Q fever includeexposure to sheep, cattle and unpasteurised milk (True)

Explanation: Especially butchers and abattoir workersmeningoencephalitis (True)pneumonia in the absence of fever, headache or myalgia (False)

Explanation: Acute Q fever is an influenza-like illnessblood culture-negative endocarditis (True)prompt clinical response to sulphonamide therapy (False)

Explanation: Responds to tetracyclines

Question 11. The typical features of erysipelas includegroup A haemolytic streptococcal skin infection (True)

Explanation: Streptococcus pyogenesabsence of constitutional symptoms (False)

Explanation: Systemic upset is commonwell-defined area of cutaneous erythema and oedema (True)

Explanation: The rash has a palpably raised edgepainless swelling (False)

Explanation: Typically painfulprompt response within 48 hours to benzylpenicillin (True)

Question 12. Clinical features of anthrax includeoccupational exposure to animals and animal products (True)Explanation: Farmers, butchers and dealers in wool, hides and bone mealan incubation period of 1-3 weeks (False)

Explanation: 1-3 daysa painless cutaneous papule (True)

Explanation: Painless but itchygastroenteritis and bronchopneumonia (True)multiple antibiotic resistance (False)

Explanation: The organism is widely sensitive

Question 13. The features of herpes simplex (HS) virus infections includerecurrent genital ulcers (True)Explanation: Especially HS type 2acute gingivostomatitis (True)

Explanation: HS type 1encephalitis (True)

Explanation: HS type 1

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By A. H.

shingles (False)Explanation: Varicella zoster virusparonychia (True)

Explanation: HS type 1-'herpetic whitlow'

Question 14. In a schoolchild with measlesinfection is due to a paramyxovirus (True)rhinorrhoea and conjunctivitis occur at the onset (True)

Explanation: The catarrhal phaseKoplik's spots appear at the same time as the skin rash (False)

Explanation: They precede the rashthe skin rash typically desquamates as it disappears (True)infectivity is confined to the prodromal phase (False)

Explanation: Contact should be avoided for 7 days after the onset of the rash

Question 15. In patients with rubella infectionthe RNA virus spreads by the faecal-oral route (False)a prolonged fever is typical (False)

Explanation: Typically only on the first day of the rashinfectivity is present for 7 days before and after the rash (True)sub-occipital lymphadenopathy is typical (True)the risk of serious fetal damage is < 5% after the 16th week of pregnancy (True)

Explanation: Greatest risk is in the first 8 weeks

Question 16. The characteristic features of mumps includeinfection with an RNA paramyxovirus by airborne spread (True)high infectivity for 3 weeks after the onset of parotitis (False)

Explanation: Infectivity is generally lowpresentation with an acute lymphocytic meningitis (True)abdominal pain attributable to mesenteric adenitis (False)

Explanation: Pain suggests pancreatitis or oophoritisorchitis which predominantly occurs prepubertally (False)

Explanation: It is usually unilateral and postpubertal

Question 17. The clinical features of amoebic dysentery includean incubation period of 2-4 weeks (False)Explanation: May develop many months after exposurepresentation with blood and mucus per rectum (True)

Explanation: Acute colitic symptoms often seen in the oldgood response to metronidazole in intestinal disease (True)characteristic appearances of the mucosa on sigmoidoscopy (True)

Explanation: Flask-shaped ulcersantibodies detectable by immunofluorescence in only a small minority of patients (False)

Explanation: In 60-95%

Question 18. The following statements about the life cycle of plasmodia are truesporozoites disappear from the blood within minutes of inoculation (True)Explanation: Sporozoites enter the liver within 30 minutesmerozoites re-entering red blood cells undergo both sexual and asexual development (True)all plasmodia multiply in the liver then subsequently in red blood cells (True)

Explanation: Duration of the pre-patent period variesdormant hypnozoites remain within the liver cells in all species (False)

Explanation: Only P. vivax and P. ovale persist in this formfertilisation of the gametocytes occurs in the human red blood cells (False)

Explanation: Fertilisation occurs in the mosquito

Question 19. Recognised clinical features of malaria include

MCQs VIA WEB 2005

By A. H.

absence of P. vivax infection in subjects lacking the Duffy blood group (True)Explanation: West Africans and African Americans are protectedasymptomatic P. malariae parasitaemia persisting for years (True)

Explanation: With or without symptomsenhanced risk of infection in splenectomised patients (True)presentation with rigors, herpes simplex and haemolytic anaemia (True)

Explanation: Especially in P. vivax and P. ovale infectionexcellent response to chloroquine (False)

Explanation: Widespread resistance-quinine preferred

Question 20. The features of typhoid fever includefaecal-oral spread of Salmonella typhi by food handlers (True)Explanation: Usually asymptomatic carrierspresentation with constipation (True)

Explanation: But diarrhoea more common in childrenonset with fever, headache and myalgia (True)

Explanation: And relative bradycardia'rose spots' on the trunk and splenomegaly 7-10 days after onset (True)development of carrier state in 50% of survivors (False)

Explanation: 5%

Question 21. The following are possible causes of fever and a rash in a traveller returning from the tropicsparatyphoid fever (True)leptospirosis (True)meningococcal infection (True)secondary syphilis (True)

HIV seroconversion (True)

Question 22. In the diagnosis of the enteric feversblood cultures are usually positive 2 weeks after onset (False)Explanation: Bacteraemia in the first weekstool cultures are usually positive within 7 days of onset (False)

Explanation: More likely in the second or third weekperipheral blood neutrophil leucocytosis is typically marked (False)

Explanation: Leucopenia is typicalthe Widal reaction is typically positive within 7 days of onset (False)

Explanation: There are frequent false negativespersistent fever despite antibiotics indicates resistant organisms (False)

Explanation: It may suggest a septicaemic focus

Question 23. Clinical features of dengue includemosquito-borne infection with an incubation period of 2-7 days (True)continuous or 'saddle-back' fever (True)

Explanation: Fever may remit on day 4-5 ('saddle-back')rigors, headache, photophobia and backache (True)

Explanation: But non-specificmorbilliform rash and cervical lymphadenopathy (True)

Explanation: Rash starts peripherallyprotection by vaccination every 10 years in endemic areas (False)

Explanation: No vaccine is available

Question 24. The typical features of African trypanosomiasis includetransmission of the parasite by the tsetse cattle fly (True)an incubation period of 2-3 weeks (True)

Explanation: Occasionally longer in T. gambiense infectionsonset with chancre-like skin lesion and local lymphadenopathy (True)

Explanation: At the site of the bite

MCQs VIA WEB 2005

By A. H.

generalised lymphadenopathy, hepatosplenomegaly and encephalitis (True)good prognosis given prompt pentamidine or suramin therapy (True)

Explanation: Unless cerebral infection has developed

Question 25. Typical features of visceral leishmaniasis (kala-azar) includespread of Leishmania donovani by sandflies from dogs and rodents (True)Explanation: Also spread from infected blood transfusionsan incubation period of 1-2 weeks (False)

Explanation: 1 month to 10 yearsrigors with hepatomegaly but no splenomegaly (False)

Explanation: Splenomegaly is characteristicdiagnosis confirmed on peripheral blood film (False)

Explanation: Diagnosis by examination of stained smears of bone marrow, spleen or liverclinical response to pentavalent antimonials, e.g. stibogluconate (True)

Explanation: Amphotericin B is an alternative

Question 26. In diphtheriaheart block is a recognised complication (True)Explanation: Although cardiac involvement usually causes no long-term problemshigh fever is a typical early sign (False)

Explanation: Fever rarely dominant-insidious onsetisolation is usually unnecessary (False)

Explanation: Isolation is vitalparalysis of the soft palate, accommodation or ocular muscles may occur (True)

Explanation: Occasionally with peripheral polyneuritistreatment is with antibiotics alone (False)

Explanation: Diphtheria antitoxin is also important

Question 27. The typical features of strongyloidiasis includeskin penetration with migration to the gut via the lungs (True)Explanation: Producing an itchy rashlarval penetration of the duodenal and jejunal mucosa (True)

Explanation: With pain, diarrhoea, steatorrhoea and weight lossabdominal pain, diarrhoea and malabsorption (True)penetration of perianal skin producing a migrating linear weal (True)

Explanation: Intensely itchysystemic spread in the immunosuppressed, resulting in pneumonia (True)

Explanation: Seen in HIV infection

Question 28. In infestation with the nematode Enterobius vermicularisadult threadworms occur in great numbers in the small bowel (False)

Explanation: Seen in the colonpresentation with intense pruritus ani is typical (True)

Explanation: Worms may be visibleidentifiable ova are found on the perianal skin (True)malabsorption usually develops following heavy infestations (False)

Explanation: The small bowel is unaffectedall family members should take piperazine or mebendazole therapy (True)

Explanation: Cross-infection and autoinfection are common

Question 29. In onchocerciasislarval infection is transmitted by the Simulium fly (True)Explanation: A painful biteworms mature over 2-4 weeks and persist for up to 1 year (False)

Explanation: Worms can live for over 15 yearscutaneous nodules and eosinophilia commonly develop (True)

Explanation: The nodules contain adult worms

MCQs VIA WEB 2005

By A. H.

conjunctivitis, iritis and keratitis are characteristic (True)ivermectin is the drug therapy of choice (True)

Question 30. In schistosomal infectionpainless haematuria may be the presentation (True)Explanation: Due to bladder mucosal involvementdiagnosis can be made by finding cercariae in the urine and/or stool (False)

Explanation: Eggs are passed in urine and/or stoolthe helminths mature in the portal vein (True)peripheral neuropathy commonly causes lower limb weakness (False)

Explanation: But transverse myelitis maypraziquantel is the therapy of choice (True)

Explanation: Or oxamniquine or metrifonate

Question 31. Echinococcus granulosus infestation is usually associated withcontact with sheep, cattle and dogs (True)Explanation: May be many years before clinical manifestations appearacquisition of hydatid cysts in childhood (True)

Explanation: Usually an asymptomatic eventcysts in the liver, brain and lungs (True)

Explanation: Right lobe of the liver is the commonest siteabsence of dissemination during liver aspiration (False)

Explanation: Care must also be taken during excisionprompt response to albendazole therapy if surgically inoperable (False)

Explanation: But further enlargement may be prevented

Question 32. Typical features of cutaneous leishmaniasis includenasal and oral mucosal ulcers (True)Explanation: Secondary to initial cutaneous ulcerationpainful ulcers in the groins or axillae (False)

Explanation: Typically painless and not involving nodesmarked splenomegaly and lymphadenopathy (False)

Explanation: These occur in visceral leishmaniasisulcers which heal without scarring (False)negative leishmanin skin test (False)

Explanation: Typically positive except in diffuse cutaneous leishmaniasis

Question 33. Characteristic features of leprosy includean incubation period of 2-12 years (True)growth of the organism on Löwenstein-Jensen medium after 2-3 months (False)

Explanation: The organism cannot be grown in artificial mediaspread of the tuberculoid form by prolonged patient contact (False)

Explanation: There is no risk of infection in tuberculoid leprosythickened palpable peripheral nerves (True)a cell-mediated immune response in the lepromatous form (False)

Explanation: Characteristic of the tuberculoid form

Question 34. Typical features of lepromatous leprosy includeearly and marked sensory loss (False)Explanation: Late and limitedunlike the tuberculoid form, organisms are scanty in number (False)

Explanation: Is a multibacillary diseaseblood-borne spread from the dermis throughout the body (True)

Explanation: No cell-mediated immune responsestrongly positive lepromin skin test (False)

Explanation: Suggests tuberculoid diseaseanaesthetic hypopigmented skin macules and plaques (False)

MCQs VIA WEB 2005

By A. H.

Explanation: Macules occur, but sensation is retained

Question 35. The following are likely causes of splenomegaly in a patient with fever returning from the tropicstuberculosis (False)trypanosomiasis (True)brucellosis (True)

visceral leishmaniasis (True)infective endocarditis (True)

Question 36. The following statements about syphilis are trueinfection is usually caused by Treponema pertenue (False)Explanation: Due to infection with Treponema pallidumcardiac murmurs are a typical early feature of infection (False)

Explanation: A feature of late diseasethe primary lesion at the site of infection is initially macular (True)

Explanation: But becomes papular, then chancrousthe incubation period for primary syphilis is typically 2-4 weeks (True)

Explanation: But may be up to 90 daystertiary syphilis usually develops within 1 year of infection (False)

Explanation: Takes at least 2 years to develop

Question 37. Characteristic features of late (tertiary and quaternary) syphilis includenegative specific treponemal antigen tests (False)Explanation: The tests are typically positivedestructive granulomas (gummas) in bones, joints and the liver (True)sensory ataxia (True)

Explanation: Due to dorsal column spinal diseaseaneurysms of the ascending aorta (True)

Explanation: Typically with calcificationpoor response of gummas to antibiotic therapy (False)

Question 38. The typical clinical features of gonorrhoea includean incubation period of 2-3 weeks (False)Explanation: 2-10 daysanterior urethritis and cervicitis (True)

Explanation: Dysuria, discharge or no symptomsright hypochondrial pain due to perihepatitis (True)pharyngitis (True)good response to ciprofloxacin therapy in penicillin allergy (True)

Explanation: Or spectinomycin

Question 39. Anogenital herpes simplex is typically associated withtype 2 herpes simplex infection only (False)Explanation: Type 2 and type 1 equallyprimary attacks more severe and prolonged than recurrent attacks (True)

Explanation: Healing is more rapid in recurrent attacksfever with painful genital ulceration and lymphadenopathy (True)sacral dermatomal pain and urinary retention (True)absence of clinical response to oral aciclovir (False)

Explanation: Shortens first attacks and may prevent recurrence

Question 40. HIV infection is associated withan RNA retrovirus (True)heterosexual transmission in the majority of cases world-wide (True)

Explanation: Superseding homosexual and parenteralinvolvement of CD4 lymphocytes (True)

MCQs VIA WEB 2005

By A. H.

a viral half-life of 1-2 hours in plasma (True)a better prognosis in the presence of Kaposi's sarcoma (False)

Explanation: Prognosis is worse with Kaposi's sarcoma

Question 41. In HIV infection80% of vertically transmitted infections are transplacental (False)

Explanation: Majority occur during parturitiona child born to an infected mother has a 90% chance of acquiring HIV (False)

Explanation: Under 50% chancetransmission can occur via breast milk (True)

Explanation: 10-20% additional risk for breast-fed babiesrisk of fetal transmission is unaffected by pre-partum antiviral agents (False)

Explanation: HAART can reduce transmission rate

Question 42. In the diagnosis of HIV infectionELISA testing has a low false negative rate (True)Explanation: ELISA testing therefore widely used as a screening testseroconversion invariably occurs in under 4 weeks (False)

Explanation: 6-12 weeks or longerantibody detection tests are particularly helpful in neonates (False)

Explanation: May have transplacentally acquired maternal antibodyHIV-RNA can be directly measured as a confirmatory test (True)

Explanation: Sometimes used as a confirmatory testHIV-RNA is typically detected before anti-HIV antibodies (True)

Question 43. In the classification of HIV infectiongroup A = acute seroconversion simulating glandular fever (True)Explanation: Also includes asymptomatic patientsgroup B = persistent generalised lymphadenopathy (False)

Explanation: Classed as group A infectiongroup C = constitutional symptoms and oral candidiasis (False)

Explanation: Group C includes conditions meeting CDC/WHO case definitiongroup A1/B1/C1 all have absolute CD4 count > 500/mm3 (True)group B = asymptomatic infection (False)

Explanation: Group A are asymptomatic

Question 44. Presenting features of HIV infection includehairy leucoplakia (True)Explanation: Affects the tongue and mouthatypical pneumonia (True)

Explanation: Especially Pneumocystis cariniithrombocytopenic purpura (True)pulmonary tuberculosis (True)

Explanation: Sometimes with atypical mycobacteriacandidiasis and cryptosporidiosis (True)

Question 45. Cryptosporidiosis in an HIV-positive patient isan AIDS-defining diagnosis if chronic (True)likely to present with painless profuse diarrhoea (False)

Explanation: Profuse diarrhoea, but usually with abdominal painlikely to be self-limiting if the CD4 count is > 200 cells/mm3 (True)preventable by the use of boiled tap water (True)usually diagnosed on stool microscopy (True)

Question 46. Pneumocystis carinii infection in an HIV-positive patient isthe commonest cause of respiratory infection in African patients (False)Explanation: Tuberculosis is more common

MCQs VIA WEB 2005

By A. H.

characterised by copious sputum production (False)Explanation: Dry cough and dyspnoeacharacterised by widespread fine pulmonary crackles (False)

Explanation: Crackles would be unusualmore likely to occur when the CD4 count is < 200/mm3 (True)

Explanation: In 95% of casesexcluded by the finding of a normal chest X-ray (False)

Explanation: Normal chest radiograph is found in 15-20% of cases

Question 47. In a patient with AIDS, cryptococcal meningitis isthe commonest cause of meningitis (True)Explanation: Also causes pulmonary diseasecharacterised by abrupt onset of the classical features of a bacterial meningitis (False)

Explanation: Indolent onsetdiagnosed by India ink stain of cerebrospinal fluid (CSF) (True)

Explanation: And serum/CSF culturetypically associated with negative CSF culture (False)associated with deafness in survivors (True)

Explanation: And blindness

Question 48. In the treatment of HIV infectionall useful drugs work via inhibition of reverse transcriptase (False)Explanation: Some are protease inhibitorsnucleoside reverse transcriptase inhibitors may cause peripheral neuropathy (True)reverse transcriptase inhibitors prevent spread of infectious virus into uninfected cells (True)

Explanation: But not replicationdrug-resistant strains of virus have not been recognised (False)

Explanation: As with zidovudinemonotherapy is preferred (False)

Explanation: Survival rates improve with combination regimens

Question 49. Antimicrobial therapy acts in the following waysaminoglycosides disrupt bacterial protein synthesis (True)Explanation: Via ribosomal bindingsulphonamides interrupt bacterial folate synthesis (True)

Explanation: And hence nucleic acid synthesispenicillins disrupt bacterial protein synthesis (False)

Explanation: Affect cell wall synthesiscephalosporins disrupt bacterial cell wall synthesis (True)Explanation: As with penicillinstetracyclines disrupt bacterial protein synthesis (True)

Explanation: Via ribosomal binding

Question 50. The following statements about penicillins are trueall penicillins are bactericidal (True)Explanation: By interfering with their cell wall synthesislike the cephalosporins, they contain a â-lactam ring (True)

Explanation: Resistance by â-lactamase-producing organisms is commonclavulanic acid inhibits bacterial â-lactamase (True)

Explanation: Used in combination with amoxicillin as co-amoxiclavthey are all safe in pregnancy (False)

Explanation: Imipenem is notthey are synergistic with aminoglycosides (True)

Question 51. Erythromycin is active against the following microorganismsCampylobacter jejuni (True)Escherichia coli (False)

MCQs VIA WEB 2005

By A. H.

Explanation: Hence less likely to disrupt bowel floraLegionella pneumophila (True)Mycoplasma pneumoniae (True)

Explanation: In appropriate dosageClostridium welchii (True)

Question 52. Aminoglycoside drug therapyis ototoxic and nephrotoxic (True)Explanation: Especially in the elderlyis well absorbed orally (False)

Explanation: Negligible oral absorptionmust be monitored using plasma drug concentrations (True)

Explanation: Serum levels and duration of therapy correlate with risk of toxicityis effective against anaerobes and Streptococcus faecalis (False)

Explanation: No anti-anaerobic activityis very effective against Gram-negative organisms (True)

Question 53. Ciprofloxacin is highly active against the following microorganismsEscherichia coli (True)Haemophilus influenzae (True)Proteus mirabilis (True)

Explanation: Active against most of the enterobacteriaStreptococcus pneumoniae (False)

Explanation: Only moderate activityBacteroides fragilis (False)

Question 54. The following antiviral agents are active against the following virusesganciclovir-cytomegalovirus (True)amantadine-orthomyxovirus (True)

Explanation: Used in prophylaxis of influenza Aribavirin-respiratory syncytial virus (True)

Explanation: Also active in Lassa feverzidovudine-retrovirus (True)

Explanation: Used in AIDSfamciclovir-herpes simplex and herpes zoster viruses (True)

Explanation: Like aciclovir, useful orally or parenterally

Module 2 (Chapter 2)Question 1. 200 patients with hypertension are treated with a new drug to prevent strokes and compared with 200similar patients who are given a placebo in a randomised controlled clinical trial (RCT). After 1 year of treatment 5patients in the treatment group and 10 patients in the control group have suffered a stroke. Which of the followingstatements are true?the absolute risk reduction with treatment is 5% (False)Explanation: 2.5%the relative risk is 0.5 (True)

Explanation: 50% relative risk reductionthe number needed to treat is 200 (False)

Explanation: 40all patients with hypertension will benefit from this treatment (False)

Explanation: Only patients similar to those in the trialbenefit can be expected to be similar in following years of treatment (False)

Explanation: Can only be derived from continuing the RCT

Question 2. Examples of pharmacokinetic interactions include the followingallopurinol inhibits the metabolism of azathioprine (True)Explanation: And 6-mercaptopurine; both are metabolised by xanthine oxidasemetoclopramide delays gastric emptying and the rate of drug absorption (False)

MCQs VIA WEB 2005

By A. H.

Explanation: It increases the rate of gastric emptyingdigoxin and verapamil compete for renal tubular secretion (True)

Explanation: Similarly, quinidine and amiodarone compete with digoxin for renal excretionthe effect of methotrexate is inhibited by NSAID therapy (False)

Explanation: Increased effect due to inhibition of renal tubular secretion of methotrexaterenal lithium excretion is inhibited by diuretics (True)

Explanation: Recommend a barrier method as well for patients on the contraceptive pill and taking antibiotics

Question 3. The following drugs should be avoided in severe renal failuregentamicin (False)Explanation: But reduce dose frequency and measure plasma concentrations dailyoxytetracycline (True)

Explanation: Induces protein catabolism and rapidly increasing uraemiamorphine (False)

Explanation: But reduce both dose and dose frequencymesalazine (True)

Explanation: Like all NSAIDs, reduces renal blood flow by prostaglandin inhibitionmetformin (True)

Explanation: Causes lactic acidosis

Question 4. The following drugs exhibit high rates of hepatic clearancecodeine phosphate (False)Explanation: Similar to paracetamol in this respectdiazepam (False)

Explanation: Low rates of clearance during its first passage through the liversimvastatin (True)

Explanation: Lidocaine (lignocaine) is also rapidly cleared during its first passage through the liver ('first-pass' effect)propranolol (True)warfarin (False)

Question 5. The actions of the following drugs are enhanced in liver diseasewarfarin (True)Explanation: Reduces the synthesis of clotting factorsmetformin (True)

Explanation: Produces lactic acidosischloramphenicol (True)

Explanation: Induces bone marrow suppressionsulphonylureas (True)

Explanation: Increase the risk of hypoglycaemianaproxen (True)

Explanation: Like other NSAIDs, increases the risk of gastrointestinal bleeding

Question 6. The following statements about drug prescribing in elderly patients are truethe error rate in patients taking prescribed drugs is similar to that found in younger adults (False)Explanation: Error rates of up to 60% can be found in patients over the age of 60 yearsadverse drug reactions are more likely to occur than in younger adults (True)

Explanation: Adverse drug reactions are 2-3 times more commonan increased proportion of body fat increases the accumulation of lipid-soluble drugs (True)

Explanation: Propranolol accumulation is also increased by reduced drug metabolismdrug excretion is typically increased due to impaired urinary concentrating ability (False)

Explanation: Impaired renal clearance associated with a reduced glomerular filtration rate is commonmetabolism of paracetamol reduces with advancing age (True)

Explanation: As with other drugs (e.g. theophylline and sedative drugs) doses should be reduced

Question 7. The following are statutory requirements for the prescription of controlled drugsprescriptions must be typewritten not written by hand (False)Explanation: Prescriptions must be written entirely in the prescriber's own handwriting, in ink

MCQs VIA WEB 2005

By A. H.

prescriptions must specify the patient's name and address (True)prescriptions must specify the prescriber's name and address (True)prescriptions must state the dosage in both words and numbers (True)

Explanation: Including the total quantity, number of doses, and form and strength of the drugprescriptions must be signed and dated by the prescriber (True)

Module 3 (Chapter 3)Question 1. The use of oral activated charcoal is indicated following poisoning withparacetamol (True)Explanation: More effective if given earlyacetylsalicylic acid (True)

Explanation: More effective if given early and repeated 4-hourly ('gut dialysis')ferrous sulphate (False)

Explanation: Not absorbed by activated charcoalethylene glycol (False)

Explanation: Not absorbed by activated charcoallithium carbonate (False)

Explanation: Not absorbed by activated charcoal

Question 2. Typical features 6-8 hours after paracetamol poisoning includenausea and vomiting (True)Explanation: Abdominal pain may developcoma and internuclear ophthalmoplegia (False)Explanation: Late features suggesting hepatic encephalopathy (after 3-5 days)prolongation of the prothrombin time (False)

Explanation: Rare before 24 hoursmetabolic acidosis and hypoglycaemia (False)

Explanation: Consequence of hepatic necrosis (after 36 hours)prevention of liver damage with N-acetylcysteine therapy (True)

Explanation: But not useful beyond 15 hours

Question 3. Features of salicylate poisoning in an adult may includemetabolic acidosis (True)Explanation: A poor prognostic signdeafness, tinnitus and blurred vision (True)

Explanation: Common featureshypokalaemia and respiratory alkalosis (True)

Explanation: Due to hyperventilationhyperventilation, sweating and restlessness (True)peripheral vasodilatation (True)

Question 4. The following treatments are clinically useful in poisoning with the following agentsglucagons-â-blockers (True)DMPS (dimercaprol)-heavy metal poisons (True)

Explanation: Useful in arsenic, gold and mercury poisoningflumazenil-opioid analgesics (False)

Explanation: Used in benzodiazepine overdoseN-acetylcysteine-paracetamol (True)

Explanation: As indicated by plasma paracetamol concentrations post-ingestiondesferrioxamine-iron salts (True)

Question 5. Typical features following benzodiazepine poisoning includeataxia, dysarthria, nystagmus and drowsiness (True)severe systemic hypotension and respiratory depression (False)

Explanation: Severe cardiorespiratory depression is rarenausea, vomiting and diarrhoea (False)

MCQs VIA WEB 2005

By A. H.

Explanation: Suspect mixed overdoseconvulsions, muscle spasms and papilloedema (False)

Explanation: Suspect alternative or mixed overdoseresolution of symptoms and signs within < 6 hours of poisoning (False)

Explanation: Usually < 24 hours

Question 6. The following are true of cocaine poisoninghypothermia is a typical feature (False)

Explanation: Hyperthermia or pyrexiacerebellar signs may occur (True)

Explanation: As may convulsionsmyocardial infarction occurs only in the presence of abnormal coronary arteries (False)

Explanation: They may be normalactivated charcoal is of benefit within 1 hour of ingestion (True)a dose of over 10 mg would usually be regarded as potentially fatal (False)

Explanation: Over 1 g

Question 7. Typical features of morphine poisoning includenausea, vomiting and pallor (True)coma with widely dilated pupils (False)

Explanation: Pinpoint pupilshypoventilation and respiratory arrest (True)hypotension and hypothermia (True)

Explanation: Use naloxonenon-cardiac pulmonary oedema (True)

Explanation: Characteristic and the commonest mode of death

Question 8. Typical features of carbon monoxide poisoning includenausea, vomiting (False)Explanation: Common features include agitation, headache and confusionmarked central cyanosis (False)

Explanation: Usually skin pallor; patients may appear 'pink' due to carboxyhaemoglobinhypotension and myocardial ischaemia (True)

Explanation: Especially in patients whose coma is prolongedcognitive impairment and personality changes following recovery (True)

Explanation: Due to the effects of cerebral oedema and cerebral anoxiaparkinsonian features following recovery (True)

Explanation: Neuropsychiatric sequelae occur in 10% 2-4 weeks following recovery

Module 4 (Chapter 4)Question 1. The following statements about pulmonary artery wedge pressure (PAWP) monitoring are correctPAWP provides an indirect measure of left atrial pressure (True)the normal range is 15-20 mmHg (False)

Explanation: 6-12 mmHgthe PAWP is reduced in acute left ventricular failure (False)

Explanation: Increased, often > 35 mmHgcomplications of monitoring include pulmonary artery rupture (True)

Explanation: Also pneumothorax, air embolism, sepsis and arrhythmiasthe optimum PAWP in acute circulatory failure is 12-15 mmHg (True)

Question 2. The following statements about monitoring of pulmonary function are correctoxygen saturation (SaO2) should be maintained in the range 75-85% (False)Explanation: Maintain > 90%the oxygenation index (PaO2/FIO2) is a useful measure of gas exchange (True)

Explanation: As is alveolar arterial oxygen gradientend-tidal alveolar CO2 concentration measures the effectiveness of ventilation (True)

Explanation: As does PaCO2

MCQs VIA WEB 2005

By A. H.

measurement of oxygen saturation requires arterial blood sampling (False)Explanation: Finger or earlobe spectrophotometry is satisfactory in most instancesa decreasing cardiac output is likely to induce an abrupt fall in SaO2 (True)

Question 3. The following statements about oxygen transport in the blood are correctthe amount of oxygen carried by haemoglobin is equal to that dissolved in the plasma (False)Explanation: Hb carriage accounts for the majorityan increase in PaCO2 shifts the oxygen/haemoglobin dissociation curve to the right (True)

Explanation: Bohr effect-facilitates unloading of O2 to tissuesthe optimum haemoglobin concentration in a critically ill adult male is 15 g/dl (False)

Explanation: 7-10 g/dl to minimise hyperviscosity problemsat a PaO2 = 3.5 kPa, approximately 10% of the haemoglobin will be saturated (False)

Explanation: Around 50%increasing the haemoglobin concentration of the blood will increase its oxygen content but not its partial pressure of

oxygen (True)Explanation: Hb concentration and saturation are major determinants of O2 content

Question 4. The following statements about oxygen consumption are correctVO2 (global oxygen consumption) can be calculated from the PaO2 and the PaCO2 (False)Explanation: Calculated from inspiratory/expiratory gas analysismixed venous oxygen saturation (SvO2) is the pulmonary arterial oxygen saturation (True)

Explanation: Equates to DO2 (oxygen delivery) - VO2 (global oxygen consumption)SvO2 reflects the amount of oxygen not consumed by the tissues (True)oxygen saturation of venous blood from differing tissues is identical (False)

Explanation: Varies depending on metabolic rateVO2 rises 10-15% for every 1°C rise in body temperature (True)

Explanation: Sepsis and trauma also increase VO2

Question 5. Diagnostic criteria for the systemic inflammatory response syndrome (SIRS) includetemperature > 38°C or < 36°C (True)Explanation: Sepsis may cause hypothermia as well as feverrespiratory rate > 30/min (False)

Explanation: > 20/minheart rate > 90/min (True)white cell count > 12 000 or < 4000/mm2 (True)PaCO2 < 4.3 kPa (True)

Question 6. The following statements about shock syndromes are correctin severe hypovolaemia, a source of blood/fluid loss is invariably apparent clinically (False)Explanation: Bleeding may be internalin cardiogenic shock, the peripheries are characteristically warm (False)

Explanation: Peripheral cyanosis is characteristicmassive pulmonary embolism typically presents with shock (True)

Explanation: Due to central vessel obstructionanaphylactic shock is associated with profound allergen-induced systemic vasoconstriction (False)

Explanation: Vasodilatation occursarteriovenous shunting is a significant contributory factor in septic shock (True)

Explanation: Capillary damage and vasodilatation also occur

Question 7. Acute circulatory failure with an elevated central venous pressure are typical findings inacute pancreatitis (False)Explanation: Hypovolaemic shock occursmassive pulmonary embolism (True)

Explanation: Acute right ventricular failureruptured ectopic pregnancy (False)acute right ventricular infarction (True)pericardial tamponade (True)

MCQs VIA WEB 2005

By A. H.

Question 8. The acute respiratory distress syndrome (ARDS) is characterised bymaintenance of a normal PaO2 despite profound dyspnoea (False)Explanation: Hypoxaemia is a cardinal featureincreased pulmonary compliance (False)

Explanation: Compliance decreasesa normal chest radiograph (False)

Explanation: Diffuse infiltrates are typicalgreatly elevated pulmonary artery wedge pressure (False)

Explanation: Typically normal or slightly elevatedelevated right heart pressure (True)

Explanation: Pulmonary hypertension is common

Question 9. The expected effects of the following vasoactive drugs includenitroprusside-reduction in systemic vascular resistance (True)Explanation: Blood pressure typically fallsepoprostenol (prostacyclin)-increased pulmonary vascular resistance (False)

Explanation: Reduces PVRisoprenaline-sinus tachycardia (True)

Explanation: And moderate increase in myocardial contractilitydopamine-sinus bradycardia (False)

Explanation: Usually tachycardiaadrenaline (epinephrine)-increased splanchnic blood flow (False)

Explanation: Typically declines

Question 10. The following statements about mechanical respiratory support are correctcardiac output increases with positive end-expiratory pressure (PEEP) (False)Explanation: Cardiac output often fallsPEEP helps correct V/Q mismatch (True)

Explanation: Improves oxygenation in atelectatic areascontinuous positive airways pressure (CPAP) requires intubation (False)

Explanation: A tightly fitting face or nasal mask can be usedthe correct position of an endotracheal tube is 4 cm above the carina (True)intermittent ventilation is useful in the transition to non-assisted ventilation (True)

Question 11. In the management of raised intracranial pressure (ICP)normal ICP is < 15 mmHg (True)Explanation: A sustained pressure > 30 mmHg suggests a poor prognosiscerebral perfusion pressure = mean systemic arterial pressure minus intracranial pressure (True)

Explanation: Should be > 70 mmHgmodest hyperglycaemia facilitates a decrease in ICP (False)

Explanation: Glycaemic control should be stricttemporary hyperventilation reduces ICP (True)

Explanation: Target (PaCO2 of 4 kPa for 24 hoursthe patient should be nursed with 30° head-up tilt (True)

Explanation: And avoid excessive neck flexion

Module 5 (Chapter 5)Question 1. The histological features useful in distinguishing benign from malignant lesions includea lower nuclear to cytoplasmic ratio (False)Explanation: Increasedthe presence of aberrations in nuclear morphology (True)the number of cell mitoses (True)

Explanation: Increases with cell proliferation ratethe presence of cellular invasion into surrounding tissues (True)

Explanation: Evidence of metastatic spreadthe number of mitochondria in the cell cytoplasm (False)

MCQs VIA WEB 2005

By A. H.

Question 2. Useful serum tumour markers associated with the following diseases includehuman chorionic gonadotrophin in testicular seminoma (False)Explanation: Useful in testicular germ cell tumoursalpha fetoprotein in primary hepatocellular carcinoma (True)

Explanation: And testicular germ cell tumourscarcinoembryonic antigen in bronchial adenoma (False)

Explanation: Metastatic colorectal carcinomaplacental alkaline phosphatase in cervical carcinoma (False)

Explanation: There are no useful serum markers for cervical carcinomaCA-125 in breast carcinoma (False)

Explanation: Useful in ovarian carcinoma

Question 3. The paraneoplastic syndromes listed below are typical of the following tumoursinappropriate ADH-adenocarcinoma of lung (False)Explanation: Small-cell carcinomaprothrombotic tendency-pancreatic carcinoma (True)polymyositis-gastric carcinoma (True)

Explanation: And ovarian and nasopharyngeal carcinomamyasthenia-like syndrome-small-cell anaplastic lung carcinoma (True)

Explanation: Lambert-Eaton syndromeacanthosis nigricans-gastric carcinoma (True)

Explanation: And other gastrointestinal malignancy

Question 4. Malignant diseases that are potentially curable using combination chemotherapy includecervical cancer (True)squamous cell bronchial carcinoma (False)

Explanation: Refractory to chemotherapychoriocarcinoma (True)

Explanation: Also testicular teratomaoesophageal carcinoma (False)

Explanation: Resistantsoft tissue sarcoma (False)

Explanation: Resistant

Question 5. The following statements about chemotherapy are truemethotrexate is an antifolate-blocking nucleotide synthesis (True)Explanation: An antimetabolitevincristine is an alkylating agent blocking DNA transcription (False)

Explanation: A mitotic spindle poisondoxorubicin is a plant alkaloid which disrupts mitotic spindles (False)

Explanation: An antibiotic anticancer drug which acts primarily as a topoisomerase antagonisttaxanes act as mitotic spindle poisons (True)

Explanation: E.g. docetaxelmelphalan is an alkylating agent which blocks DNA replication (True)

Explanation: And also blocks DNA transcription

Module 6 (Chapter 6)Question 1. In the management of pain in patients with malignant diseasesanalgesia is best prescribed on an 'as required' basis (False)Explanation: Should be given regularlyNSAID therapy is particularly valuable in bone pain (True)

Explanation: Affects prostaglandin metabolismcontrolled-release morphine has a 4-hour duration of action (False)

Explanation: 12 hoursrespiratory depression is a common feature of prolonged opiate use (False)

Explanation: But can occur in acute dosing

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By A. H.

opiates are of no value in neuropathic pain (False)Explanation: But other agents may be more effective

Question 2. The following drugs have clinically useful antiemetic propertieshaloperidol (True)domperidone (True)

Explanation: Blocks dopaminergic receptorsondansetron (True)

Explanation: 5HT3 receptor antagonistdexamethasone (True)

Explanation: Given parenterally with chemotherapyetoposide (False)

Explanation: Chemotherapeutic agent which causes nausea and vomiting

Question 3. The following treatments may be of benefit in a patient with the following cancer-related symptomsco-danthrusate-constipation (True)gabapentin-nausea (False)

Explanation: Used for neuropathic paintrazodone-insomnia (True)

Explanation: A sedating antidepressanteicosapentanoic acid-anorexia (True)

Explanation: If combined with a high-protein dietamitriptyline-neuropathic pain (True)

Module 7 (Chapter 7)Question 1. Expected physiological changes associated with normal ageing includedecreased calcium phosphate content per 100 g bone (False)Explanation: Bone mass declines (osteoporosis) but mineralisation is normalincreased tissue sensitivity to insulin (False)

Explanation: Reduced insulin sensitivity and glucose tolerance declinesreduced numbers of pacing cells within the sinoatrial node (True)

Explanation: Limits ability to mount a tachycardiaincreased glomerular filtration rate (GFR) (False)

Explanation: Decreased number of nephrons, GFR and medullary functionincreased chest wall rigidity (True)

Question 2. Likely causes of recurrent falls in the elderly includeaccidental slips and trips (True)Explanation: Exacerbated by poor mobilitypostural hypotension (True)

Explanation: Often drug-inducedvasovagal syncope (False)

Explanation: More common in the youngParkinson's disease (True)

Explanation: Multiple factors involvedacute myocardial infarction (False)

Explanation: May present with a single fall but not recurrent falls

Question 3. The following interventions may be of value in a patient with fallsoral fludrocortisone (True)Explanation: May help postural hypotensionoccupational therapy home visit (True)

Explanation: To improve environmental safetyprogramme of exercise training (True)soft cervical collar (False)

Explanation: May help vertebrobasilar insufficiencyoral calcium and vitamin D (True)

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By A. H.

Explanation: Help reduce the risk of fall fractures

Question 4. In the frailty syndrome the following domains are impairedmusculoskeletal function (True)aerobic capacity (True)cognitive function (True)integrative neurological function (True)nutritional status (True)

Module 8 (Chapter 8)Question 1. Aetiological factors in psychiatric illness includefamily history of psychiatric illness (True)

Explanation: Rarely, a single gene disorder is identifiedparental loss or disharmony in childhood (True)

Explanation: Especially physical or sexual abusestressful life events and difficulties (True)

Explanation: E.g. bereavement, redundancy, retirementchronic physical ill health (True)

Explanation: Also acute severe physical illnesssocial isolation (True)

Explanation: Particularly lack of a close relationship

Question 2. Important factors in the assessment of mental state includeappearance and behaviour (True)Explanation: Including motor retardationmood state (True)

Explanation: E.g. suicidal ideationspeech and thought content (True)

Explanation: Paranoid, grandiose or depressiveabnormal perceptions and beliefs (True)

Explanation: Depersonalisation, illusions and hallucinationscognitive function (True)

Explanation: Concentration, memory and orientation

Question 3. The following psychiatric definitions are truedelusions-abnormal perceptions of normal external stimuli (False)Explanation: Illusionsillusions-unreasonably persistent, firmly held, false beliefs (False)

Explanation: Delusionshallucinations-abnormal perceptions without external stimuli (True)

Explanation: Suggest psychosisdepersonalisation-perception of altered reality (True)

Explanation: Often with derealisationphobia-abnormal fear leading to avoidance behaviour (True)

Explanation: Typical pattern in neurosis

Question 4. Diseases mimicking anxiety disorders includealcohol withdrawal (True)Explanation: Delirium may also occurhyperthyroidism (True)

Explanation: Exclude biochemicallyhypoglycaemia (True)

Explanation: Measure blood glucosetemporal lobe epilepsy (True)

Explanation: EEG may be necessaryphaeochromocytoma (True)

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By A. H.

Explanation: Rare-measure urinary catecholamines

Question 5. Factors associated with a higher suicide risk following attempted suicide includefemales aged < 45 years (False)Explanation: Older malesself-poisoning rather than more violent methods of self-harm (False)

Explanation: Self-poisoning is frequently parasuicidalabsence of a suicide note or previous suicide attempts (False)

Explanation: Suicide note often left and usually a history of previous attemptschronic physical or psychiatric illness (True)

Explanation: And drug or alcohol misuseliving alone and/or recently separated from partner (True)

Explanation: Or bereavement

Question 6. Cardinal elements in cognitive therapy includerestructuring psychological conflicts and behaviour (False)Explanation: Undertaken in psychotherapyidentification of negative patterns of automatic thoughts (True)

Explanation: E.g. in depressionawareness of connections between thoughts, mood and behaviour (True)

Explanation: Altering thoughts may alter behaviourreorientation of negative views of the past, present and future (True)

Explanation: And development of positive viewspersonality assessment and transactional analysis (False)

Explanation: Features of psychotherapy

Question 7. The typical features of alcohol dependence includeexpansion of the drinking repertoire (False)Explanation: Narrowing of choices of alcoholic beveragesincreasing tolerance of alcohol (False)

Explanation: Decreasing tolerancesubjective compulsion to drink (True)use of alcohol to relieve withdrawal symptoms (True)

Explanation: Classicalrecurrent withdrawal symptoms (True)

Question 8. The typical features of depression includedepressed mood for most of the day (True)Explanation: But diurnal variation may occurinsomnia or hypersomnia (True)

Explanation: Or early morning wakeningloss of pleasure, self-esteem and hope (True)

Explanation: 'Anhedonia'-loss of sense of enjoymentloss of energy, libido and interest (True)

Explanation: Perhaps with other somatic symptomspsychomotor retardation and suicidal thoughts (True)

Explanation: With delusions of worthlessness

Question 9. Clinical features of generalised anxiety disorders includefeelings of worthlessness and excessive guilt (False)Explanation: Suggest depressiondepersonalisation and derealisation (True)

Explanation: May be seen in affective disordersfeelings of apprehension and impending disaster (True)

Explanation: With irritabilitybreathlessness, dizziness, sweating and palpitation (True)

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By A. H.

Explanation: Typical somatic symptomsclaustrophobia and agoraphobia (False)

Explanation: Features of phobic anxiety states

Question 10. Typical features of anorexia nervosa includeonly adolescent girls are affected (False)

Explanation: Either sex, rarely non-adolescentamenorrhoea or loss of libido > 3 months (True)

Explanation: With avoidance of high-calorie foodsweight loss > 25% or weight < 25% below normal (True)

Explanation: In contrast to bulimia nervosanormal perception of body weight and image (False)

Explanation: Emaciation is unrecognised by the patientprogression to death in 20% (False)

Explanation: In 5%

Module 9 (Chapter 9)Question 1. In a normal 65 kg man, the following statements are truetotal body water is approximately 40 litres (True)Explanation: Relatively constant in health70% of the total body water is intracellular (True)

Explanation: Approximately 28 litres75% of extracellular water is intravascular (False)

Explanation: 25% intravascular, 75% interstitialsodium, bicarbonate and chloride ions are mainly intracellular (False)

Explanation: Extracellularpotassium, magnesium, phosphate and sulphate ions are mainly extracellular (False)

Explanation: Intracellular

Question 2. Typical causes of hyponatraemia includediabetes insipidus (False)Explanation: But may be seen in the syndrome of inappropriate antidiuretic hormone (ADH) secretionhepatocellular failure (True)

Explanation: Water retention exceeds sodium retentionpsychogenic polydipsia (True)

Explanation: Increased total body waterCushing's syndrome (False)

Explanation: But seen in adrenocortical insufficiencydiuretic drug therapy (True)

Explanation: Salt loss exceeds water loss

Question 3. Predominant water depletion is a recognised complication ofprimary hyperparathyroidism (True)Explanation: Renal tubular insensitivity to ADHtoxic confusional states (True)

Explanation: Inadequate intakeoesophageal carcinoma (True)

Explanation: Inadequate intakelithium therapy (True)

Explanation: Renal tubular insensitivity to ADHenteral feeding (True)

Explanation: High solute load

Question 4. The following statements about potassium balance are true85% of the daily potassium intake is excreted in the urine (True)intracellular potassium ion concentrations are about 150 mmol/l (True)

Explanation: Compared with extracellular concentrations of about 4 mmol/l

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By A. H.

cellular uptake of potassium is enhanced by adrenaline and insulin (True)alkalosis predisposes to hyperkalaemia (False)the normal dietary potassium intake is about 100 mmol per day (True)

Question 5. Hyperkalaemia is a recognised finding insevere untreated diabetic ketoacidosis (True)

Explanation: Insulin promotes movement into the cellsprimary hypoadrenalism (True)

Explanation: Impairment of secretion in the distal nephronrhabdomyolysis (True)

Explanation: Increased tissue breakdownprostaglandin inhibitor therapy in renal impairment (True)

Explanation: Especially if given with an ACE inhibitorangiotensin-converting enzyme (ACE) inhibitor therapy (True)

Explanation: Avoid concurrent supplementation

Question 6. The emergency treatment of severe hyperkalaemia should includedietary restriction of coffee and fruit juices (False)Explanation: But may be necessary to prevent recurrenceparenteral dextrose and glucagon therapy (False)

Explanation: Give parenteral dextrose and insulinparenteral calcium gluconate therapy (True)

Explanation: Cardioprotective effectrestoration of sodium and water balance (True)

Explanation: Also correct metabolic acidosis if present with 1.26% sodium bicarbonate i.v.Calcium Resonium orally and/or rectally (True)

Explanation: The resin binds potassium in exchange for calcium

Question 7. Recognised causes of potassium depletion includemetabolic alkalosis (True)

Explanation: Renal tubular cell K+ concentration increased, excretion increasedcardiac failure (True)

Explanation: Secondary hyperaldosteronismcorticosteroid treatment (True)

Explanation: Mineralocorticoid-like effectrenal tubular acidosis (True)

Explanation: Primary or secondary tubular defect; also occurs with activation of renin and angiotensinamiloride diuretic therapy (False)

Explanation: Causes hyperkalaemia by an effect on the distal convoluted tubules

Question 8. Metabolic acidosis would be an expected finding inchronic alveolar hyperventilation (False)Explanation: Chronic respiratory alkalosisacute insulin deficiency (True)

Explanation: Diabetic ketoacidosisacute inflammatory polyneuropathy (Guillain-Barré syndrome) (False)

Explanation: Acute respiratory acidosis due to alveolar hypoventilationfailure of distal renal tubular hydrogen ion secretion (True)

Explanation: Distal (type I) renal tubular acidosismethanol poisoning (True)

Question 9. Metabolic alkalosis may be caused byhyperventilation (False)

Explanation: Respiratory alkalosisaspiration of gastric contents (True)

Explanation: Or vomitingmineralocorticoid deficiency (False)

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By A. H.

Explanation: Can produce mild acidosisexcessive liquorice ingestion (True)

Explanation: Due to excessive mineralocorticoid activitydiuretic therapy (True)

Explanation: And hypokalaemia

Question 10. Magnesium deficiency isa cause of confusion, depression and epilepsy (True)Explanation: And tremor and choreiform movementsusually due to prolonged vomiting and diarrhoea (True)

Explanation: Also from chronic diuretic therapyfound in uncontrolled diabetes mellitus and alcoholism (True)

Explanation: Excess losses in the urinefound in primary hyperparathyroidism and hyperaldosteronism (True)

Explanation: Including secondary hyperaldosteronismbest treated with oral magnesium sulphate (False)

Explanation: Very poorly absorbed orally

Module 10 (Chapter 10)Question 1. A healthy daily diet for a slim man with a physical job should include1500 kcal (8.4 MJ) (False)Explanation: About 11.3 MJ (2700 kcal)60% of total energy requirements as carbohydrate (True)

Explanation: 55-75%no less than 10 g salt per day (False)

Explanation: No more than 6 g/day35 g of dietary fibre (True)

Explanation: 27-40 g/dayno more than 10% of total energy requirements as fat (False)

Explanation: 15-30%

Question 2. Recognised medical complications of weight gain includeosteoporosis (False)

Explanation: Bone density increasesrheumatoid arthritis (False)

Explanation: Osteoarthritisgallstones (True)

Explanation: Often asymptomatictype 2 diabetes mellitus (True)

Explanation: With insulin resistancehyperlipidaemia (True)

Explanation: And coronary artery disease

Question 3. Ideal weight-reducing diets in the treatment of moderate obesity shouldprovide no more than 2.5 MJ (600 kcal) per day (False)Explanation: Aim to reduce intake by no more than 2.5 MJ (600 kcal) per dayachieve a theoretical weight loss of at least 2 kg per week (False)

Explanation: 0.5 kg per week (2.5 MJ or 600 kcal deficit/day = 17.15 MJ or 4200 kcal/week = 0.6 kg human tissue)aim to achieve a weight loss of 10% (True)

Explanation: Sufficient to achieve a significant improvement in healthbe part of a multiple risk factor intervention (True)

Explanation: E.g. cessation of smokingreduce carbohydrate intake much more than total fat intake (False)

Explanation: Fat restriction < 50 g/day (calorific values fat = 38 KJ or 9 kcal/g, CHO = 17 KJ or 4 kcal/g)

Question 4. The benefits of a sustained 10 kg weight reduction in the obese includefall in the blood pressure of 10 mmHg (systolic) and 20 mmHg (diastolic) (True)

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By A. H.

reduction in total mortality of 20-25% (True)reduction in fasting glucose of 15% (False)

Explanation: 50%reduction in total cholesterol of 50% (False)

Explanation: Reduction in total cholesterol of 10%reduction in high-density lipoprotein cholesterol of 8% (False)

Explanation: Increases by 8%

Question 5. Drug therapies known to increase appetite and body weight includeorlistat (False)Explanation: Has a role in promoting weight lossfenfluramine (False)

Explanation: But side-effects preclude useamitriptyline (True)fluoxetine (False)

Explanation: Stimulates satiety and can help some patients lose weightsibutramine (False)

Explanation: Can support weight loss

Question 6. The function of the main lipoproteins include the followingchylomicrons transport mainly cholesterol (False)

Explanation: Mainly triglycerides; not present in the normal fasting plasmavery low-density lipoprotein transports endogenous triglycerides (True)

Explanation: VLDL is synthesised in the liver and is the precursor of LDLlow-density lipoprotein transports cholesterol (True)

Explanation: Generated from VLDL in the blood streamhigh-density lipoprotein transports cholesterol from the peripheral tissues to the liver (True)low-density lipoprotein is important for the excretion of cholesterol and is cardioprotective (False)

Explanation: HDL aids cholesterol excretion and is cardioprotective

Question 7. Common causes of secondary hyperlipidaemia includechronic renal failure (True)Explanation: Increases triglycerides and VLDL but decreases HDLdiabetes mellitus (True)

Explanation: Increases triglycerides and VLDL but decreases HDLhyperthyroidism (False)

Explanation: Hypothyroidism increases cholesterol and LDLalcohol misuse (True)

Explanation: Increases triglycerides, VLDL and HDLthiazide diuretics (True)

Question 8. In the classification of hyperlipidaemias, the following findings are typicalchylomicronaemia in types I and V (True)Explanation: Risk of pancreatitis with both types I and V but no atherogenic riskhypertriglyceridaemia in types III, IV and V (True)

Explanation: Triglycerides variably abnormal in all except type IIahypercholesterolaemia in types II, III and IV (True)

Explanation: And all are associated with increased atherosclerosistendon xanthomata in type IIa hypercholesterolaemia (True)

Explanation: And premature coronary atherosclerosisdefective LDL catabolism and receptor binding in type V hyperlipidaemia (False)

Explanation: Defective LDL receptor gene is typical of type II familial hypercholesterolaemia

Question 9. The actions of the lipid-lowering drugs include the followingthe statins inhibit HMG CoA reductase and reduce cholesterol synthesis (True)Explanation: Increase LDL catabolismthe statins increase plasma LDL and triglycerides (False)

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By A. H.

Explanation: Decrease plasma LDL and cholesterolnicotinic acid increases lipolysis and lowers HDL (False)

Explanation: Decreases lipolysis and plasma triglycerides but increases plasma HDLfibrates increase VLDL lipolysis (True)

Explanation: Decrease plasma triglycerides and plasma LDL and increase plasma HDLcolestipol diverts hepatic cholesterol synthesis into an increased bile acid production (True)

Explanation: Like colestyramine, it blocks bile acid reabsorption in the gut

Question 10. Clinical features of protein-energy malnutrition in adults includea body mass index of between 20 and 22 (False)Explanation: BMI < 16. N.B. BMI is calculated from the formula weight (kg) ÷ height2 (m)oedema in the absence of hypoalbuminaemia (True)

Explanation: 'Famine oedema'nocturia, cold intolerance and diarrhoea (True)

Explanation: And weakness, amenorrhoea or impotenceskin depigmentation, hair loss and covert infection (True)

Explanation: Adolescents may maintain hair growthcerebral atrophy and sinus tachycardia (False)

Explanation: Brain weight is preserved; bradycardia is the rule

Question 11. The clinical features of protein-energy malnutrition in children includemarked muscle-wasting and abdominal distension in marasmus (True)Explanation: And absence of oedemaweight loss more than growth retardation in marasmus (True)

Explanation: Weight < 60% standard for agehepatic steatosis and hypoproteinaemic oedema in kwashiorkor (True)

Explanation: With low plasma lipidsdesquamative dermatosis, stomatitis and anorexia in marasmus (False)

Explanation: Features of kwashiorkorassociated zinc deficiency in kwashiorkor (True)

Explanation: Contributing to dermatosis

Question 12. Vitamin A isa fat-soluble vitamin (True)

Explanation: A, D, E, and K are the fat-soluble vitaminspresent as retinol in carrots and certain green vegetables (False)

Explanation: Occurs as retinol in animal produce and as carotene in plantsthe treatment of choice in xerophthalmia and keratomalacia (True)

Explanation: Both conditions are the result of vitamin A deficiency and lead to blindnessassociated with teratogenicity if administered in pregnancy (True)present in high concentrations in fish liver oils (True)

Explanation: Present as retinol

Question 13. Vitamin Dis present in high concentrations in dairy products (False)Explanation: Some margarines are fortifiedis non-essential in the diet given adequate sunlight exposure (True)

Explanation: But less efficiently produced in old agelike vitamin A is stored mainly in the liver (False)

Explanation: But metabolism partly occurs in the liveris converted from cholecalciferol to 1,25-dihydroxycholecalciferol (True)

Explanation: 1-alpha hydroxylation occurs in the kidney and 25-hydroxylation in the liverenhances calcium absorption by the induction of specific enterocyte transport proteins (True)

Explanation: And stimulates osteoclast proliferation

Question 14. Deficiency of the following B vitamins is associated with the disorders listed belowniacin-pellagra (True)

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By A. H.

Explanation: Dermatitis, diarrhoea and dementiapyridoxine-isoniazid-induced peripheral neuropathy (True)

Explanation: Add to anti-tuberculosis regimens using isoniazidpyridoxine-haemolytic anaemia (False)

Explanation: Sideroblastic anaemia may respondriboflavin-angular stomatitis (True)

Explanation: And also nasolabial seborrhoeariboflavin-cheilosis (True)

Explanation: Also seen in niacin deficiency

Question 15. In the classification of acute and non-acute porphyriasä-aminolaevulinic acid synthetase activity is increased in all porphyrias (True)Explanation: Rate-limiting step in biosynthesis of haemporphobilinogen deaminase activity is reduced in acute porphyrias (True)

Explanation: Porphobilinogen accumulatesneuropsychiatric features are typical of the non-acute porphyrias (False)

Explanation: Typical of acute porphyriaphotosensitivity is typical of the acute porphyrias (False)

Explanation: Typical of the non-acute porphyriasvariegate porphyria and coproporphyria are mixed porphyrias (True)

Explanation: Both are hepatic porphyrias

Question 16. Disorders associated with amyloid deposition includefamilial Mediterranean fever (True)Explanation: Reactive (AA) amyloidosisbronchiectasis (True)chronic haemodialysis (True)Alzheimer's disease (True)

Explanation: Also the spongiform encephalitidesrheumatoid arthritis (True)

Explanation: Reactive AA amyloidosis

Module 11 (Chapter 11)Question 1. In humanssomatic cell nuclei contain 22 pairs of homologous autosomes (True)Explanation: In addition there are 2 X chromosomes in females and 1 X and 1 Y in malesgamete nuclei are haploid with a single X or Y chromosome (True)

Explanation: In contrast to somatic cell nuclei which are diploidthe haploid male cell (sperm) contains 22 autosomes and a Y chromosome (False)

Explanation: The haploid male cell (sperm) may contain an X or a Y chromosomethe long and short arms of a chromosome meet at the telomere (False)

Explanation: Centromereboth X chromosomes in females are genetically active (False)

Explanation: One X chromosome is inactive and appears as the Barr body in the nucleus

Question 2. In the chromosomal disordersaneuploidy is the addition or loss of a chromosome (True)Explanation: The most common form of numerical chromosome aberrationdeletions arise from the loss of a segment of a chromosome (True)the majority of affected conceptions result in miscarriage (True)

Explanation: Liveborn frequency is 0.6%identical deletions produce the same effects whether inherited from father or mother (False)

Explanation: Gene expression can be affected by the parental origin of the abnormal chromosometranslocation is the exchange of segments between chromosomes (True)

Explanation: No genetic material is lost

Question 3. In polycystic kidney disease

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By A. H.

inheritance is commonly autosomal dominant (True)hepatic cysts commonly coexist (True)intracranial aneurysms are present in 70% of patients (False)

Explanation: Incidence = 10%DNA testing is useful in determining the presence of PKD1 mutations (False)renal ultrasound after the age of 18 is the best screening test (True)

Explanation: Detects > 95% of individuals

Question 4. The karyotype of anormal male is 45, XY (False)Explanation: 46, XYfemale with Down's syndrome is 46, XX, -21 (False)

Explanation: 47, XX, +21male with Klinefelter's syndrome is 47, XXY (True)female with Turner's syndrome is 45, XO (True)male with trisomy 18 (Edwards' syndrome) is 47, XX, +18 (False)

Explanation: 47, XY, +18

Question 5. The following conditions arise as a result of the noted genetic abnormalityhaemochromatosis-DNA point mutation (True)

Explanation: HFE genecystic fibrosis-DNA point mutation (False)

Explanation: Three base-pair deletionHuntington's disease-triplet repeat expansions (True)

Explanation: On 4p16Down's syndrome-chromosomal deletion (False)

Explanation: Chromosomal aneuploidy (trisomy 21)DiGeorge syndrome-chromosomal microdeletion (True)

Explanation: The commonest microdeletion syndrome

Question 6. In autosomal dominant inheritanceaffected individuals are usually heterozygotes (True)affected individuals rarely have an affected parent (False)

Explanation: Parent is almost always affectedmale offspring are more likely to be affected than female (False)

Explanation: An equal chanceunaffected children of an affected parent have a 50% chance of transmitting the condition (False)

Explanation: Unaffected children are free of the mutant geneclinical disease is always found in genetically affected individuals (False)

Explanation: Some affected individuals are clinically normal-'non-penetrance'

Question 7. Given a husband with haemophilia and his unaffected wifenone of their sons will be affected (True)Explanation: Absence of male to male transmission is a key feature of all X-linked inheritanceall of their daughters will carry the haemophilic gene (True)a daughter with Turner's syndrome may also have haemophilia (True)

Explanation: If the X chromosome is inherited from the fatherall of his sisters will be carriers (False)

Explanation: 50% of his sisters will be carriers and 50% normalhis maternal grandfather could have had haemophilia (True)

Explanation: All the female children of an affected grandfather would carry the gene

Question 8. The following disorders are caused by single gene disorderscleft lip (False)Explanation: Multifactorial disordersickle-cell anaemia (True)

Explanation: Autosomal recessive

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By A. H.

retinitis pigmentosa (True)cystic fibrosis (True)

Explanation: Autosomal recessivefamilial hypercholesterolaemia (True)

Explanation: Autosomal dominant

Module 12 (Chapter 12)Question 1. In the normal human heartthe atrioventricular (AV) node is usually supplied by the left circumflex coronary artery (False)Explanation: Supplied by the right coronary artery in 90%â1-adrenoceptors mediate chronotropic responses (True)

Explanation: These receptors also mediate inotropic responsespulmonary artery systolic pressure normally varies between 90 and 140 mmHg (False)

Explanation: Varies between 15 and 30 mmHg in healththe annulus fibrosus aids conduction of impulses from the atria to the ventricles (False)

Explanation: Restricts electrical connections between the atria and ventricles to the AV nodecardiac output is the product of heart rate and ventricular end-diastolic volume (False)

Explanation: The product of heart rate and ventricular stroke volume

Question 2. With regard to cardiovascular physiologycardiac output is approximately 10 l/min at rest (False)Explanation: Measured in l/min (70/min × 700 ml = 5 l/min)coronary blood vessels are innervated only by the parasympathetic nerves (False)

Explanation: Also by sympathetic-both have dominant vasodilating effectintracoronary acetylcholine provokes vasoconstriction if atheroma is present (True)

Explanation: But endothelial-derived relaxing factor (EDRF)-mediated vasodilatation occurs in normal vesselsan atheromatous coronary lesion restricts blood flow during exercise if > 40% (False)

Explanation: Must be > 70%bradykinin is an endogenous vasodilator (True)

Explanation: Others include adenosine, prostaglandins and nitric oxide

Question 3. In the normal electrocardiogram (ECG)the PR interval is measured from the end of the P wave to the beginning of the R wave (False)Explanation: Measured from the start of the P wave to the start of the R waveeach small square represents 40 milliseconds at a standard paper speed of 25 mm/sec (True)the heart rate is 75 per minute if the R-R interval measures 4 cm (True)

Explanation: Heart rate = 1500/R-R interval (mm) or 300/R-R interval (cm)R waves become progressively larger from leads V1-V6 (True)

Explanation: Reflecting the electrical dominance of the left ventriclethe P wave represents sinoatrial node depolarisation (False)

Explanation: Represents atrial depolarisation

Question 4. In the normal ECGdepolarisation proceeds from epicardium to endocardium (False)Explanation: Proceeds from endocardium to epicardiumdepolarisation away from the positive electrode produces a positive deflection (False)

Explanation: Produces a negative deflectiondepolarisation of the interventricular septum is recorded by the Q wave in V5 and V6 (True)

Explanation: Absent in left bundle branch block (BBB)the aVR lead = right arm positive with respect to the other limb leads (True)

Explanation: Hence the predominant S wave as depolarisation moves away from aVRvoltage amplitudes vary with the thickness of cardiac muscle (True)

Explanation: An aid to the diagnosis of left ventricular hypertrophy

Question 5. In the investigation of patients with suspected heart diseasethe normal upper limit for the cardiothoracic ratio (CTR) on chest radiograph is 0.75 (False)Explanation: The CTR should not be > 0.5

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By A. H.

a negative exercise ECG excludes the diagnosis of ischaemic heart disease (False)Explanation: False negative tests occur in 15-20%a 'step-up' in oxygen saturation at cardiac catheterisation suggests an intracardiac shunt (True)Doppler echocardiography reliably assesses pressure gradients between cardiac chambers (True)

Explanation: Pressure gradients can be extrapolated from measuring intracardiac flow velocitiesradionuclide blood pool scanning accurately quantifies left ventricular function (True)

Explanation: Ejection fraction is usually measured using this technique

Question 6. The pain of myocardial ischaemiais typically induced by exercise and relieved by rest (True)Explanation: Typical chest pain occurring at rest does not exclude myocardial ischaemiaradiates to the neck but not the jaw (False)

Explanation: May also radiate to the shoulders, arms or backrarely lasts longer than 10 seconds after resting (False)

Explanation: Rapid resolution is atypical-pain usually lasts for minutesis easily distinguished from oesophageal pain (False)

Explanation: Oesophageal pain may mimic angina-precipitation by swallowing may be usefulinvariably worsens as exercise continues (True)

Explanation: Can disappear as exercise continues-'second wind' effect ('walk through' angina)

Question 7. In a patient with central chest pain at restintrascapular radiation suggests the possibility of aortic dissection (True)Explanation: As does a tearing qualitypostural variation in pain suggests the possibility of pericarditis (True)

Explanation: As does variation with respirationchest wall tenderness is a typical feature of Tietze's syndrome (True)

Explanation: The syndrome is a form of costochondritisrelief of pain by nitrates excludes an oesophageal cause (False)

Explanation: And oesophageal pain may also be precipitated by exercisefeatures of autonomic disturbance are specific to cardiac pain (False)

Explanation: May occur in severe pain from any cause

Question 8. In the treatment of cardiac failure associated with acute pulmonary oedemacontrolled oxygen therapy should be restricted to 28% oxygen in patients who smoke (False)Explanation: High-flow oxygen in concentrations > 35% should be administeredmorphine reduces vasoconstriction and dyspnoea (True)furosemide (frusemide) therapy given intravenously reduces preload and afterload (True)nitrates should be avoided if the systolic blood pressure < 140 mmHg (False)

Explanation: Can safely be used with systolic pressures > 110 mmHgACE inhibitors decrease the afterload but increase the preload (False)

Explanation: Both preload and afterload are reduced

Question 9. Recognised features of severe cardiac failure includetiredness (True)Explanation: Due to severe reduction in cardiac outputweight loss (True)

Explanation: 'Cardiac cachexia'-however, weight gain due to oedema is more commonepigastric pain (True)

Explanation: Due to hepatic and gastrointestinal congestionnocturia (True)

Explanation: Diuresis is induced by adopting the supine positionnocturnal cough (True)

Explanation: A manifestation of pulmonary congestion

Question 10. With regard to angiotensin-converting enzyme (ACE) inhibitorsACE inhibitors reduce the conversion of angiotensinogen to angiotensin I (False)Explanation: Angiotensin I to angiotensin II

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By A. H.

enalapril has a longer half-life than lisinopril (False)Explanation: Converted to enalaprilat in the livercough is a less common side-effect of ACE inhibitors than angiotensin II antagonists (False)

Explanation: Cough is a more common side-effect of ACE inhibitors-probably due to bradykinin accumulationfirst-dose hypotension occurs less commonly in patients pretreated with diuretics (False)

Explanation: Omitting diuretics pretreatment minimises risktreatment is of no benefit until symptomatic left ventricular systolic dysfunction has developed (False)

Question 11. In the management of chronic heart failureACE inhibitor therapy reduces subsequent hospitalisation rates (True)Explanation: And reduces mortalitycoagulation is impaired and thromboembolic risk therefore declines (False)

Explanation: Other factors favouring thromboembolism outweigh this effectsalt restriction may be beneficial (True)â-adrenoceptor antagonists (â-blockers) should always be avoided (False)

Explanation: There is evidence that they reduce mortality in some patientsdigoxin is only of benefit if atrial fibrillation coexists (False)

Explanation: Reduces need for hospitalisation

Question 12. Complications of systemic hypertension includeretinal microaneurysms (False)Explanation: Arteriolar thickening, irregularity and tortuosity are detectableaortic dissection (True)renal artery stenosis (True)

Explanation: Hypertension predisposes to atheroma formationlacunar strokes of the internal capsule (True)subdural haemorrhage (False)

Explanation: Hypertension predisposes to intracerebral and subarachnoid haemorrhage

Question 13. Recognised causes of secondary hypertension includepersistent ductus arteriosus (False)Explanation: In contrast to coarctation of the aortaprimary hyperaldosteronism (True)

Explanation: Conn's syndromeacromegaly (True)oestrogen-containing oral contraceptives (True)

Explanation: And pregnancythyrotoxicosis (True)

Question 14. In the treatment of systemic hypertensiontreatment has more effect on the risk of stroke than the risk of coronary heart disease (CHD) (True)Explanation: 30% reduction in stroke, 20% in CHDthresholds for treatment are higher in the elderly (False)

Explanation: Absolute risk is highertreatment is less likely to be of benefit if cardiac or renal disease is present (False)there are no proven benefits of therapy in patients aged over 70 years (False)

Explanation: Good evidence of efficacy in the elderlymoderation of alcohol consumption is likely to improve blood pressure control (True)

Explanation: Excessive consumption of alcohol is a significant factor in 10-15% of hypertensivesQuestion 15. Important explanations for hypertension refractory to medical therapy includepoor compliance with drug therapy (True)inadequate drug therapy (True)

Explanation: Common particularly in asymptomatic patientsphaeochromocytoma (True)

Explanation: But rareprimary hyperaldosteronism (True)

Explanation: Conn's syndrome is suggested by a hypokalaemic alkalosis

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By A. H.

renal artery stenosis (True)Explanation: May also develop during follow-up

Question 16. The auscultatory findings listed below are associated with the following phenomenathird heart sound-opening of mitral valve (False)Explanation: Occurs in mid-diastole due to rapid ventricular fillingvarying intensity of first heart sound-atrioventricular dissociation (True)

Explanation: Due to variations in stroke volumesoft first heart sound-mitral stenosis (False)

Explanation: Typically loud in mitral stenosisreversed splitting of second heart sound-left bundle branch block (True)

Explanation: Due to delayed closure of the aortic valve compared with the pulmonary valvefourth heart sound-atrial fibrillation (False)

Explanation: Coincides with atrial contraction and hence cannot occur in atrial fibrillation

Question 17. Syncopefollowed by facial flushing suggests a tachyarrhythmia (False)Explanation: Suggests episodic bradycardia- Adams-Stokes attackswithout warning suggests a vasovagal episode (False)

Explanation: Nausea and lightheadedness typically precede vasovagal attackson exercise is a typical feature of mitral regurgitation (False)

Explanation: Exertional syncope is a feature of severe aortic stenosiscan sometimes be treated by â-blockers (True)may be a feature of Parkinson's disease (True)

Explanation: Due to severe postural hypotension

Question 18. Atrial fibrillation (AF) ispresent in 10% of the elderly population over the age of 75 years (True)usually readily converted to permanent sinus rhythm using DC cardioversion (False)

Explanation: Underlying structural heart disease is common and promotes the recurrence of AFassociated with an annual stroke risk of 5% if structural heart disease is present (True)

Explanation: Warfarin therapy reduces the annual risk to about 1.5%a common presenting feature of the sick sinus syndrome (True)

Explanation: Episodes of sinus bradycardia or sinus arrest may coexist making drug therapy difficultusually associated with a ventricular rate < 100/min before treatment (False)

Explanation: Indicates concomitant AV nodal disease, a common finding in elderly patients

Question 19. In cardiac arresta sharp blow to the praecordium may be useful (True)Explanation: In witnessed arrest onlyasystole is the commonest finding on ECG (False)

Explanation: Ventricular fibrillation is the commonest underlying arrhythmiaa normal ECG may suggest profound hypovolaemia (True)

Explanation: A cause of 'electromechanical' dissociationif cardioversion fails, intracardiac adrenaline (epinephrine) should be given (False)

Explanation: Adrenaline (epinephrine) should be given intravenouslythe compression to ventilation ratio should be 15:2 (True)

Question 20. Atrial tachycardia is typically associated with1:1 AV conduction (False)Explanation: 2:1, 3:1 or variablean atrial rate of 300/min (False)

Explanation: Atrial rate is 140-220/minpresence of P waves identical to those found during sinus rhythm (False)

Explanation: An ectopic atrial focus with abnormal P wavesdigoxin toxicity and intracellular potassium depletion (True)bizarre broad QRS complexes on ECG (False)

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By A. H.

Explanation: QRS complexes are usually narrow

Question 21. Typical features of the Wolff-Parkinson-White (WPW) syndrome includetachyarrhythmias resulting from re-entry phenomenon (True)Explanation: Re-entrant circuit includes AV node and the accessory bundleventricular pre-excitation via an accessory AV pathway (True)atrial fibrillation with a ventricular response of > 160/min (True)

Explanation: Consider WPW in young patients with episodes of atrial fibrillationECG between bouts showing prolonged PR interval with narrow QRS complexes (False)

Explanation: PR interval is shortened and a delta wave is seen in the QRS complexuseful therapeutic response to verapamil or digoxin (False)

Explanation: Differential effects on the normal and anomalous pathways can increase cardiac rate

Question 22. In ventricular tachycardia (VT)underlying cardiac disease is usually present (True)Explanation: Often ischaemic heart diseaseamiodarone is useful in the prevention of recurrent episodes (True)

Explanation: A class III agenta shortened QT interval on ECG predisposes to recurrent episodes (False)

Explanation: A prolonged QT interval predisposes to recurrent VTcarotid sinus massage usually slows the cardiac rate transiently (False)

Explanation: No effect on cardiac ratecomplicated by acute cardiac failure, cardioversion should be avoided (False)

Explanation: The treatment of choice in acute heart failure with VT

Question 23. The following statements about atrioventricular block are truefirst-degree block is usually asymptomatic (True)the PR interval is fixed in Mobitz type I second-degree block (False)

Explanation: Fixed PR = Mobitz type II; variable PR (Wenckebach's phenomenon) = Mobitz type Idecreasing PR intervals suggest Wenckebach's phenomenon (False)

Explanation: PR intervals gradually increaseirregular cannon waves in the jugular venous pressure suggest complete heart block (True)

Explanation: Due to AV dissociationthe QRS complex in complete heart block is always broad and bizarre (False)

Explanation: Can be narrow if the escape rhythm arises from within the bundle of His

Question 24. In the classification of anti-arrhythmic drugs, the following statements are trueclass I agents inhibit the fast sodium channel (True)Explanation: E.g. lidocaine (lignocaine)-like drugsclass II agents are â-adrenoceptor antagonists (True)class III agents prolong the action potential (True)

Explanation: E.g. amiodaroneclass IV agents inhibit the slow calcium channel (True)

Explanation: E.g. verapamil, nifedipinemany anti-arrhythmic agents have actions in more than one class (True)

Explanation: E.g. sotalol and amiodarone

Question 25. The cardiac drugs listed below are associated with the following adverse effectsdigoxin-acute confusional state (True)Explanation: And lidocaine (lignocaine) therapyverapamil-constipation (True)

Explanation: Calcium channel-blocking effect on smooth muscleamiodarone-photosensitivity (True)propafenone-corneal microdeposits (False)

Explanation: An adverse effect of amiodarone therapy

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By A. H.

lidocaine (lignocaine)-convulsions (True)

Question 26. Amiodarone therapyprolongs the plateau phase of the action potential (True)Explanation: In common with other class III drugspotentiates the effect of warfarin (True)is useful in the prevention of ventricular but not supraventricular tachycardia (False)

Explanation: Effective in bothmay cause corneal deposits (True)

Explanation: But no effect on visionhas a significant negative inotropic action (False)

Explanation: Can be safely used in heart failure

Question 27. Digoxinshortens the refractory period of conducting tissue (False)Explanation: Prolongs the refractory period of conducting tissue; shortens it in cardiac muscleusually converts atrial flutter to sinus rhythm (False)

Explanation: Often converts atrial flutter to atrial fibrillationis excreted primarily by the kidney (True)is a class II anti-arrhythmic (False)is a recognised cause of ventricular arrhythmias (True)

Explanation: Increases myocardial excitability

Question 28. The risk of developing clinical evidence of coronary artery disease isincreased by exogenous oestrogen use in postmenopausal females (False)Explanation: Risk is decreased by oestrogen therapydiminished by stopping smoking (True)

Explanation: Effect is measurable within 6 months of stoppingreduced by the moderate consumption of alcohol (True)

Explanation: Not more than 21 units per weekincreased in hyperfibrinogenaemia (True)increased by hypercholesterolaemia but not hypertriglyceridaemia (False)

Explanation: Both confer increased risk

Question 29. In the investigation of suspected angina pectoristhe resting ECG is usually abnormal (False)Explanation: Usually normalexercise-induced elevation in blood pressure indicates significant ischaemia (False)

Explanation: Fall in blood pressure suggests significant ischaemiaa normal ECG during exercise excludes angina pectoris (False)

Explanation: False negatives may occurcoronary angiography is only indicated if an exercise tolerance test (ETT) is abnormal (False)

Explanation: Useful in patients with convincing history but normal ETTphysical examination is of no clinical value (False)

Explanation: Important to exclude anaemia and valvular stenosis

Question 30. In the treatment of patients with angina pectorisaspirin reduces the frequency of anginal attacks (False)Explanation: But it improves the prognosisglyceryl trinitrate is equally effective when swallowed as when taken sublingually (False)

Explanation: Extensive first-pass hepatic metabolismcalcium antagonists may cause peripheral oedema (True)

Explanation: Common adverse effecttissue levels of nitrates must be consistently high for maximum therapeutic effect (False)

Explanation: A nitrate-free period should be achieved

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By A. H.

â-blockers are more effective than other anti-anginal agents (False)Explanation: Nitrates, calcium antagonists and â-blockers are all equally efficacious

Question 31. The clinical features of acute myocardial infarction includenausea and vomiting (True)Explanation: Due to activation of the autonomic nervous systembreathlessness and angor animi (True)hypotension and peripheral cyanosis (True)

Explanation: Suggest a large infarctsinus tachycardia or sinus bradycardia (True)absence of any symptoms or physical signs (True)

Explanation: 15% of infarcts are believed to be clinically 'silent'

Question 32. In the treatment of acute myocardial infarctionaspirin given within 6 hours of onset reduces the mortality (True)Explanation: 30% reduction in short-term mortalitystreptokinase therapy reduces infarct size and mortality by > 25% (True)

Explanation: The earlier thrombolysis is given, the better the resultsdiamorphine is better given intravenously than by any other route (True)

Explanation: Intramuscular injections predispose to haematomaimmediate calcium channel blocker therapy reduces the early mortality rate (False)

Explanation: Similarly, nitrate therapy has no effect on the early mortality ratemobilisation should be deferred until cardiac enzymes normalise (False)

Explanation: Mobilisation should begin on day 2 in the absence of cardiac failure

Question 33. Drug therapies which improve the long-term prognosis after myocardial infarction includeaspirin (True)Explanation: Vascular events are reduced by 25%nitrates (False)calcium antagonists (False)ACE inhibitors (True)

Explanation: Limit infarct expansionâ-blockers (True)

Explanation: Reduce mortality by 25%

Question 34. The following statements about the prognosis of acute myocardial infarction are true50% of all deaths occur within the first 24 hours (True)Explanation: Of which half occur within the first 20 minutes, often before help arrivesstress and social isolation adversely affect the prognosis (True)

Explanation: Rehabilitation programmes can be helpfulthe 5-year survival is 75% for those who leave hospital (True)late mortality is determined by the extent of myocardial damage (True)

Explanation: Limiting infarct size improves prognosisin hospital mortality for those aged over 75 years is over 25% (True)

Explanation: Five times greater than < 55 years of age

Question 35. In intermittent claudication due to atherosclerosispain is typically relieved by rest and elevation of the leg (False)Explanation: Rest relieves but elevation worsens painthe commonest cause of death is lower limb gangrene (False)

Explanation: Myocardial infarction or strokepedal pulses are often still palpable (False)

Explanation: Anaemia or diabetes may produce claudication without loss of the pulsesexercise which causes pain should be avoided (False)

Explanation: Exercise promotes growth of the collateral circulationthe risk of progression is lessened by warfarin (False)

Explanation: Anticoagulation is unhelpful

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By A. H.

Question 36. Characteristic features of aortic dissection includehaemopericardium (True)Explanation: Type A aneurysmsacute paraparesis (True)

Explanation: Due to infarction of the spinal cordinterscapular back pain (True)

Explanation: The pain is often described as 'tearing'early diastolic murmur (True)

Explanation: Type A aneurysmspleural effusion (True)

Explanation: Haemothorax

Question 37. In patients with significant mitral stenosisthe mitral valve orifice is reduced from 5 cm2 to about 1 cm2 (True)Explanation: First symptoms appear at valve areas of around 2 cm2a history of rheumatic fever or chorea is elicited in over 90% of patients (False)

Explanation: Only in 50% of patientsleft atrial enlargement cannot be detected on the chest radiograph (False)

Explanation: Produces a double right heart border and an enlarged left atrial appendagethe risk of systemic emboli is trivial in sinus rhythm (False)

Explanation: Embolic risk over 10 years is 10% compared with 35% if atrial fibrillation is presentmitral balloon valvuloplasty is not advisable if there is also significant mitral regurgitation (True)

Explanation: Mitral regurgitation is a contraindication

Question 38. Recognised features of chronic mitral regurgitation includesoft first heart sound and loud third heart sound (True)presentation with signs of right ventricular failure (True)

Explanation: Due to pulmonary hypertensionleft ventricular dilatation (True)a pansystolic murmur and hyperdynamic displaced apex beat (True)atrial fibrillation requiring anticoagulation (True)

Question 39. Clinical features suggesting aortic stenosis includelate systolic ejection click (False)Explanation: Early systolic click implies the stenosis is valvularnarrow pulse pressure (True)heaving apex beat (True)

Explanation: Implies left ventricular hypertrophysyncope associated with angina (True)loud second heart sound (False)

Explanation: Quiet S2 if the valve is heavily calcified and immobile

Question 40. Disorders associated with aortic regurgitation includeankylosing spondylitis (True)Explanation: Also Reiter's disease and psoriatic arthritisMarfan's syndrome (True)

Explanation: Due to cystic medial necrosissyphilitic aortitis (True)

Explanation: Typically affects the ascending aortapersistent ductus arteriosus (False)

Explanation: Produces the 'machinery murmur'congenital bicuspid aortic valve (True)

Question 41. In infective endocarditisstreptococci and staphylococci account for over 80% of cases (True)Explanation: Streptococcus viridans alone accounts for 30-40% of cases

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By A. H.

left heart valves are more frequently involved than right heart valves (True)normal cardiac valves are not affected (False)

Explanation: About 30% have no identifiable predisposing cardiac lesionglomerulonephritis usually occurs due to immune complex disease (True)a normal echocardiogram excludes the diagnosis (False)

Explanation: Vegetations may be too small to be detected

Question 42. Central cyanosis in infancy is an expected finding in the following congenital heart diseasespersistent ductus arteriosus (False)Explanation: With a left to right shunttransposition of the great arteries (True)

Explanation: Usually due to a shunt through a ventricular septal defectcoarctation of the aorta (False)

Explanation: No shuntFallot's tetralogy (True)

Explanation: Right to left shunt through a ventricular septal defectatrial septal defect (False)

Explanation: Left to right shunt

Question 43. The following statements about persistent ductus arteriosus are trueblood usually passes from the pulmonary artery to the aorta (False)

Explanation: This only happens if the shunt reversesthe onset of heart failure usually occurs in early infancy (False)

Explanation: Typically presents with a murmur in an otherwise healthy infanta systolic murmur around the scapulae is typical (False)

Explanation: Continuous 'machinery' murmur is typical (systolic and diastolic)shunt reversal is indicated by cyanosis of the lower limbs (True)

Explanation: A rare signprophylactic antibiotic therapy to prevent endocarditis is indicated (True)

Question 44. Typical clinical features of coarctation of the aorta includean association with a bicuspid aortic valve (True)Explanation: Frequently coexistscardiac failure developing in male adolescents (False)

Explanation: Cardiac failure is more likely to develop in infancypalpable collateral arteries around the scapulae (True)

Explanation: A useful but unusual findingrib notching on chest radiograph associated with weak femoral pulses (True)

Explanation: Rib notching is due to enlarged collateral vesselsECG showing right ventricular hypertrophy (False)

Explanation: Left (not right) ventricular hypertrophy develops

Question 45. In atrial septal defectthe lesion is usually of secundum type (True)Explanation: Due to a patent fossa ovalisthe initial shunt is right to left (False)

Explanation: Occurs late, and rarelysplitting of the second heart sound increases in expiration (False)

Explanation: Splitting is fixed and widethe ECG typically shows right bundle branch block (True)

Explanation: In primum defect there may be left axis deviationsurgery should be deferred until shunt reversal occurs (False)

Explanation: Surgery is indicated when the pulmonary/systolic flow ratio is > 3:2

Question 46. In small ventricular septal defectsthe murmur is confined to late systole (False)

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By A. H.

Explanation: It is pansystolicthe heart is usually enlarged (False)

Explanation: No cardiomegalythere is a risk of infective endocarditis (True)

Explanation: Prophylaxis is indicatedsurgical repair before adolescence is usually indicated (False)

Explanation: Surgery is only indicated if right-sided pressures risemost patients are asymptomatic (True)

Explanation: Symptomless murmur is a frequent presentation

Question 47. Dilated (congestive) cardiomyopathy isusually idiopathic (True)associated with pathognomonic ECG changes (False)

Explanation: ECG changes are non-specifica recognised complication of HIV infection (True)associated with chronic alcohol misuse (True)caused by Coxsackie A infection (True)

Explanation: And influenza, HIV and others

Question 48. Clinical features compatible with hypertrophic cardiomyopathy includefamily history of sudden death (True)Explanation: 50% of cases are autosomal dominantangina pectoris and exertional syncope (True)

Explanation: Mimicking aortic stenosisjerky pulse and heaving apex beat (True)murmurs suggesting both aortic stenosis and mitral regurgitation (True)

Explanation: Left ventricular outflow obstruction and secondary mitral regurgitationsoft or absent second heart sound (False)

Explanation: Suggests calcific aortic stenosis

Question 49. Typical features of acute pericarditis includechest pain identical to that of myocardial infarction (False)Explanation: Sharp pain worsened by posture and movementa friction rub that is best heard in the axilla in mid-expiration (False)

Explanation: Localisation and character vary greatlyST elevation on the ECG with upward concavity (True)

Explanation: In contrast to ischaemiaelevation of the serum creatine kinase (False)

Explanation: May occur in pericarditis complicating acute myocardial infarctionECG changes that are only seen in the chest leads (False)

Explanation: Widespread ECG changes

Question 50. In pericardial tamponadehigh amplitude QRS complexes are a typical ECG feature (False)Explanation: Low amplitudethe systemic arterial pressure falls dramatically on inspiration (True)

Explanation: This is pulsus paradoxusechocardiography is the definitive investigation (True)an effusion > 250 ml must be present before detrimental haemodynamic effects ensue (False)

Explanation: As little as 75-100 mla normal chest radiograph excludes the diagnosis (False)

Explanation: But the cardiac shadow usually appears globular

Module 13 (Chapter 13)Question 1. Typical chest findings in a large right pleural effusion includenormal chest expansion (False)Explanation: Expansion is reduced on the affected side

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By A. H.

dull percussion note (False)Explanation: Stony dullabsent breath sounds (True)vocal resonance decreased (True)

Explanation: As is tactile vocal fremituspleural friction rub (False)

Question 2. Hypercapnia is a typical feature ofpulmonary embolism (False)Explanation: Hyperventilation unless embolism is massivesevere chest wall injury (True)

Explanation: With type II respiratory failuresalicylate intoxication (False)

Explanation: Hyperventilationpulmonary fibrosis (False)

Explanation: Hyperventilation and type I failuresevere chronic bronchitis (True)

Explanation: Type II respiratory failure may ensue

Question 3. Typical chest findings in right lower lobe collapse includedecreased chest expansion (True)

Explanation: On the affected sidestony dull percussion note (False)

Explanation: Implies effusionbronchial breath sounds (False)

Explanation: Diminished or absent breath soundsdecreased vocal resonance (True)

Explanation: As for vocal fremituscrepitations (False)

Explanation: No specific added sounds

Question 4. The following statements about pulmonary function tests are trueover 80% of vital capacity can normally be expelled in 1 second (False)Explanation: More than 70% is normalthe transfer factor is measured using inspired oxygen (False)

Explanation: Carbon monoxide is usedresidual volume is increased in chronic bronchitis and emphysema (True)

Explanation: The lungs are hyperinflatedanalysis of flow volume curves is of value in suspected central airflow obstruction (True)peak expiratory flow rates accurately reflect the severity of restrictive lung disorders (False)

Explanation: They measure obstructive ventilatory defects

Question 5. In a patient with severe acute breathlessnessa normal arterial PaO2 invariably suggests psychogenic hyperventilation (False)Explanation: The patient may have a metabolic acidosispulsus paradoxus is pathognomonic of acute asthma (False)

Explanation: Also found in pericardial tamponadea normal chest radiograph excludes pulmonary embolism (False)

Explanation: Although subtle changes are frequently presentthe extremities are typically cool and sweaty in left ventricular failure (True)

Explanation: With basal pulmonary crepitationsleft bundle branch block is strongly suggestive of pulmonary embolism (False)

Explanation: Right bundle branch block or S1Q3T3 pattern

Question 6. The following are recognised causes of haemoptysistuberculosis (True)chronic obstructive pulmonary disease (False)

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By A. H.

Explanation: Another cause should be soughtbronchiectasis (True)

Explanation: May be massiveGoodpasture's syndrome (True)

Explanation: With associated renal diseasemitral stenosis (True)

Explanation: With pulmonary hypertension

Question 7. A pleural effusion with a pleural fluid:serum protein ratio of > 0.5 would be typical ofcongestive cardiac failure (CCF) (False)

Explanation: Transudate in CCFrenal failure (False)subphrenic abscess (True)

Explanation: Most frequently on the rightpneumonia (True)

Explanation: With polymorphonuclear leucocytesnephrotic syndrome (False)

Explanation: Severe hypoalbuminaemia produces transudates

Question 8. The sleep apnoea syndrome is associated withobesity (True)Explanation: Found in two-thirds of patients and may be associated with alcohol misusean increased risk of road traffic accidents (True)

Explanation: Increased threefold due to day-time sleepinessnocturnal restlessness apparent to the patient (False)a good response to inhaled bronchodilator therapy administered at bedtime (False)

Explanation: Ineffective; continuous positive airway pressure (CPAP) may be effectivenocturnal hypotension (False)

Explanation: Typically episodic hypertension

Question 9. The following disorders characteristically produce type I respiratory failurekyphoscoliosis (False)Explanation: Typically type II failureGuillain-Barré polyneuropathy (False)

Explanation: Respiratory muscle paralysis causes type II failureacute respiratory distress syndrome (ARDS) (True)

Explanation: Arterial PCO2 is typically normalextrinsic allergic alveolitis (True)

Explanation: Ventilatory drive is usually maintainedinhaled foreign body in a major airway (False)

Explanation: Causes acute type II failure-asphyxia

Question 10. In the treatment of acute COPD exacerbations associated with type II respiratory failurethe inspired oxygen content should be at least 40% (False)

Explanation: Controlled oxygen therapy at about 24-28% is usualnebulised doxapram improves small airways obstruction (False)

Explanation: A central respiratory stimulantflapping tremor is a sensitive indicator of hypercapnia (False)

Explanation: It may be absent-blood gases are vitalcorticosteroid therapy is usually contraindicated (False)

Explanation: May help relieve bronchospasmBIPAP may be valuable if pH falls (True)

Explanation: But not all patients are candidates for such support

Question 11. The following statements about oxygen are trueat sea level, the pressure of oxygen in inspired air is approximately 20 kPa (True)Explanation: PaO2 declines with altitude

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By A. H.

chronic domiciliary oxygen therapy is indicated only when PaO2 is < 6 kPa (False)Explanation: Indicated when PaO2 < 7.3 breathing airdissolved oxygen contributes to tissue oxygenation in anaemia (True)

Explanation: Also in other situations when Hb is maximally saturatedoxygen toxicity in adults can produce retrolental fibroplasia (False)

Explanation: Occurs only in neonatescentral cyanosis unresponsive to 100% oxygen indicates right-to-left shunting of > 20% (True) Explanation: Such

shunts may be extra- or intrapulmonary

Question 12. In the management of chronic obstructive pulmonary diseaseinfluenza immunisation should only be offered once (False)Explanation: Immunisation should be offered yearlylong-term antibiotic treatment decreases the frequency of exacerbations (False)

Explanation: This encourages drug resistanceregular inhaled steroids are of no proven value (True)supplemental oxygen during air travel is necessary if the resting PaO2 < 9 kPa (True)

Explanation: PaO2 will be < 7 kPa in such a patient at altitudelong-term controlled oxygen therapy improves symptoms but not the prognosis (False)

Explanation: Survival has been demonstrated to improve

Question 13. Typical findings in severe chronic obstructive pulmonary disease includeelevation of the jugular venous pressure (True)Explanation: A feature of right heart failuretracheal descent on inspiration (True)

Explanation: Tracheal 'tug' due to mediastinal descentindrawing of the intercostal muscles (True)

Explanation: A sign of hyperinflationcontraction of the scalene muscles (True)

Explanation: And other accessory respiratory musclespursed lip breathing (True)

Explanation: Decreases air trapping

Question 14. Typical pathological features of asthma includeeosinophilic bronchial infiltrate (True)Explanation: And T lymphocytesincreased airway macrophages (True)mucus gland hyperplasia (True)

Explanation: May contribute to development of fixed airways obstructionepithelial shedding (True)

Explanation: A recognised feature in fatal asthma in particularT lymphocyte activation and cytokine release (True)

Question 15. In the management of chronic persistent asthmainhaled â2-agonist use more than once per day is an indication for inhaled steroid therapy (True)Explanation: Typically low-dose steroidssodium cromoglicate therapy is often useful as an alternative to inhaled steroids in adults (False)

Explanation: But may be valuable in childhoodpatients taking high doses of inhaled steroids should use a large-volume spacer device (True)

Explanation: Reduces oropharyngeal and gastric depositionleukotriene antagonists are valuable substitutes for inhaled steroids (False)

Explanation: Use in addition to steroids and â2-agonistanticholinergic agents should be avoided (False)

Explanation: May be valuable

Question 16. Features compatible with severe acute asthma includepulse rate = 120 per minute (True)Explanation: But bradycardia may occur in life-threatening attacks

MCQs VIA WEB 2005

By A. H.

peak expiratory flow (PEF) rate = < 70% of expected (False)Explanation: Usually < 50% of expected PEFpulsus paradoxus (True)

Explanation: But may diminish in severe attacksarterial PaO2 = 14 kPa while breathing air (False)

Explanation: PaO2 < 8 kPa in life-threatening attacksarterial PaCO2 = 5 kPa (True)

Explanation: PaCO2 may remain normal until the late stages

Question 17. The initial management of severe acute asthma should include24% oxygen delivered by a controlled flow mask (False)Explanation: High concentration, high flow should be usedsalbutamol 5 mg by inhalation (True)

Explanation: Intravenous â2-adrenoceptor agonists can also be usedampicillin 500 mg orally and sodium cromoglicate 10 mg by inhalation (False)

Explanation: Of no proven value in acute attackshydrocortisone 200 mg i.v. or prednisolone 40 mg orally (True)

Explanation: Maintain corticosteroid therapy for at least 7 days in severe attacksarterial blood gas analysis and chest radiograph (True)

Explanation: Exclude pneumothorax and ventilatory failure

Question 18. Typical clinical features of bronchiectasis includechronic cough with scanty sputum volumes (False)Explanation: Copious sputum productionrecurrent pleurisy (True)

Explanation: Recurrent pneumoniahaemoptysis (True)

Explanation: Secondary to inflammatory bronchial changefinger clubbing (True)crepitations on auscultation (True)

Explanation: In the presence of large amounts of secretions

Question 19. Cystic fibrosis is associated withan incidence of 1 in 2500 live births (True)Explanation: The commonest severe autosomal recessive disorder in Caucasiansa decreased sweat sodium concentration (False)

Explanation: Increased sweat sodium concentrationmale infertility (True)

Explanation: Due to failure of development of the vas deferensabnormal lung function at birth (False)

Explanation: It is normal; hence prospect for gene therapyrecurring pneumococcal pulmonary infections (False)

Explanation: Pseudomonas and staphylococcal sepsis

Question 20. In pneumonia, the following features are classically associated with the specific organisms notederythema nodosum and Mycoplasma pneumoniae (True)hyponatraemia and Legionella pneumoniae (True)contact with sick birds and Klebsiella pneumoniae (False)

Explanation: Chlamydia psittaciabscess formation and Staphylococcus aureus (True)haemolytic anaemia and Streptococcus pneumoniae (False)

Explanation: Mycoplasma

Question 21. A non-pneumococcal pneumonia should be considered if the clinical features includerespiratory symptoms preceding systemic upset by several days (False)Explanation: The converse is typical of 'atypical' organismslobar consolidation (False)

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By A. H.

rigors (False)the absence of a neutrophil leucocytosis (True)

Explanation: Leucopenia can occur in severe pneumococcal infectionpalpable splenomegaly (True)

Explanation: Rare in pneumococcal disease

Question 22. The following features suggest a poor prognosis in pneumoniadiastolic blood pressure of 90 mmHg (False)Explanation: < 60 mmHgconfusion (True)respiratory rate of 20 breaths per minute (False)

Explanation: > 30/minblood urea of 9 mmol/l (True)

Explanation: > 7 mmol/lwhite cell count of 3000 × 109/l (True)

Explanation: < 4000 × 109/l

Question 23. Typical features of primary tuberculosis includea sustained pyrexial illness (False)Explanation: Typically symptomlesscaseation within the regional lymph nodes (True)

Explanation: Mediastinal, cervical or mesenteric nodes are most frequently involvedbilateral hilar lymphadenopathy on chest radiograph (False)

Explanation: Suggests sarcoidosiserythema nodosum (True)

Explanation: Can also accompany pulmonary sarcoidpleural effusion with a negative tuberculin skin test (False)

Explanation: A hypersensitivity phenomenon typically associated with positive tuberculin test

Question 24. Recognised complications of post-primary tuberculosis includeaspergilloma (True)Explanation: Superinfection of a cavityamyloidosis (True)

Explanation: Associated with chronic immune stimulationmassive haemoptysis (True)bronchiectasis (True)

Explanation: Suggested by chronic productive coughparaplegia (True)

Explanation: Due to vertebral or paraspinal abscess formation

Question 25. In the treatment of post-primary pulmonary tuberculosiscombination drug therapy is always indicated (True)Explanation: Minimises resistance and reduces duration of treatmentsputum remains infectious for at least 4 weeks after the onset of therapy (False)

Explanation: Patients can be regarded as non-infectious after 2 weeks of therapyat least 12 months' daily therapy is required for 100% effectiveness (False)

Explanation: 6- and 9-month regimes are of proven efficacyisoniazid and pyrazinamide do not cross the blood-brain barrier (False)

Explanation: Hence their great value in the treatment of tuberculous meningitistreatment failure is invariably due to multiple drug resistance (False)

Explanation: More often due to non-compliance

Question 26. Recognised adverse reactions to antituberculous drugs includestreptomycin-renal failure (False)Explanation: Causes vestibular disturbance and deafnessisoniazid-hypothyroidism (False)

Explanation: Polyneuropathy

MCQs VIA WEB 2005

By A. H.

rifampicin-optic neuritis (False)Explanation: Ethambutol causes optic neuritispyrazinamide-hepatitis (True)

Explanation: And rifampicinethambutol-vestibular neuronitis (False)

Explanation: Streptomycin causes this

Question 27. Pulmonary infection with Aspergillus fumigatus is a recognised cause of the followingbullous emphysema (False)Explanation: No associationmycetoma (True)

Explanation: Usually in a tuberculous cavitynecrotising pneumonitis (True)

Explanation: A severe, rapidly progressive illnessbronchopulmonary eosinophilia (True)

Explanation: Typically with wheeze, pulmonary infiltrates and peripheral eosinophiliaextrinsic allergic alveolitis (False)

Explanation: Type III and IV immune responses

Question 28. Bronchial carcinomaaccounts for 10% of all male deaths from cancer (False)Explanation: 50% of all male deaths from malignant diseasetypically presents with massive haemoptysis (False)

Explanation: Streaking of sputum with blood in a smoker is more typicalhistology reveals adenocarcinoma in 50% of patients (False)

Explanation: Squamous 35%, adenocarcinoma 30%is associated with asbestos exposure (True)

Explanation: As is mesotheliomais 40 times more common in smokers than in non-smokers (True)

Explanation: Smoking is the major aetiological factor

Question 29. Non-metastatic manifestations of bronchial carcinoma includecerebellar degeneration (True)Explanation: With ataxia and nystagmusmyasthenia (True)

Explanation: Eaton-Lambert syndromegynaecomastia (True)

Explanation: Usually bilateralpolyneuropathy (True)

Explanation: Usually distal sensorimotordermatomyositis (True)

Explanation: Skin rash and proximal myopathy

Question 30. The following are contraindications to surgical resection in bronchial carcinomadistant metastases (True)malignant pleural effusion (True)FEV1 < 0.8 litres (True)ipsilateral mediastinal lymphadenopathy (False)

Explanation: But contralateral nodes are a contraindicationoesophageal involvement (True)

Question 31. Mediastinal opacification on the chest radiograph is a typical feature ofthymoma (True)Explanation: May be associated with myasthenia gravisretrosternal goitre (True)

Explanation: Anterior superior mediastinumPancoast tumour (False)

MCQs VIA WEB 2005

By A. H.

Explanation: Pulmonary apical masshiatus hernia (True)

Explanation: A retrocardiac opacityneurofibroma (True)

Explanation: Can be multiple

Question 32. The following statements about sarcoidosis are truepulmonary lesions typically cavitate (False)Explanation: Caseating granulomata (e.g. TB) are associated with cavitationthe tuberculin tine test is usually positive (False)

Explanation: Typically negativeerythema marginatum is a characteristic finding (False)

Explanation: Erythema nodosum is the typical skin lesionspontaneous resolution is unusual (False)

Explanation: The normal course in stage I and stage II diseasehypercalcaemia suggests skeletal involvement (False)

Explanation: Due to increased vitamin D sensitivity

Question 33. Typical features of cryptogenic fibrosing alveolitis includehypercapnic respiratory failure (False)Explanation: Typically type I respiratory failurepositive antinuclear and rheumatoid factors (True)

Explanation: With or without evidence of connective tissue diseasefinger clubbing (True)recurrent wheeze and haemoptysis (False)

Explanation: Dyspnoea, dry cough and cracklesincreased carbon monoxide transfer factor (False)

Explanation: Reduced

Question 34. Clinical features compatible with a diagnosis of extrinsic allergic alveolitis includeexpiratory rhonchi and sputum eosinophilia (False)Explanation: Acute dyspnoea without wheeze is characteristicdry cough, dyspnoea and pyrexia (True)

Explanation: Influenza-like symptoms may existend-inspiratory crepitations (True)

Explanation: Typically bilateralFEV1/FVC ratio of 50% (False)

Explanation: Airway obstruction is absentpositive serum precipitin tests (True)

Explanation: May also be positive in healthy subjects

Question 35. The following statements about asbestos-related disease are truepleural plaques usually progress to become mesotheliomas (False)Explanation: Often calcifypleural effusions are always malignant (False)

Explanation: But malignancy should be excludedfinger clubbing and basal crepitations suggest pulmonary asbestosis (True)

Explanation: Although cryptogenic fibrosing alveolitis is possiblethe FEV1/FVC ratio is typically decreased (False)

Explanation: A restrictive not an obstructive ventilatory defectmesothelioma can only be reliably diagnosed at thoracotomy (False)

Explanation: Seldom necessary

Question 36. Characteristic features of pulmonary eosinophilia includean association with ascariasis and microfilariasis (True)Explanation: And Toxocara infestationeosinophilic pneumonia without peripheral blood eosinophilia (False)

MCQs VIA WEB 2005

By A. H.

Explanation: Eosinophilia is necessary for the diagnosisprominent asthmatic features (False)

Explanation: Wheeze may be absentinduction by exposure to drugs (True)

Explanation: Imipramine, phenylbutazone or othersopacities on chest radiograph (True)

Explanation: Pulmonary infiltrates and eosinophilia

Question 37. Clinical features characteristic of massive pulmonary embolism includecentral and peripheral cyanosis (True)Explanation: With profound hypoxaemiapleuritic chest pain and haemoptysis (False)

Explanation: Suggests pulmonary infarctionbreathlessness and syncope (True)

Explanation: Non-specifictachycardia and elevated jugular venous pressure (True)

Explanation: Non-specificQ waves in leads I, II and aVL on ECG (False)

Explanation: Classical ECG pattern is S1, Q3, T3

Question 38. Typical features of an empyema thoracis includebilateral effusions on chest radiograph (False)Explanation: Typically unilaterala fluid level on chest radiograph suggesting a bronchopleural fistula (True)

Explanation: Or a recent diagnostic aspirationpersistent pyrexia despite antibiotic therapy (True)

Explanation: Suggests lung abscess, antibiotic resistance or hypersensitivityrecent abdominal surgery (True)

Explanation: Perhaps complicating subphrenic infectionbacteriological culture of the organism despite preceding antibiotic therapy (False)

Explanation: Frequently sterile post-antibiotic therapy

Question 39. The following statements about spontaneous pneumothorax are truebreathlessness and pleuritic chest pain are often present (True)Explanation: A small pneumothorax may be asymptomaticbronchial breathing is audible over the affected hemithorax (False)

Explanation: Diminished or absent breath soundsabsent peripheral lung markings on chest radiograph suggest tension (False)

Explanation: Mediastinal shift suggests tensionsurgical referral is required if there is a bronchopleural fistula (True)

Explanation: Pleurectomy may also be necessarypleurodesis should be considered for recurrent pneumothoraces (True)

Explanation: Particularly if bilateral

Question 40. The following are causes of an elevated hemidiaphragmrecurrent laryngeal nerve paralysis (False)Explanation: Phrenic nerve paralysissurgical lobectomy (True)subphrenic abscess (True)severe pleuritic pain (True)

Explanation: But underlying pathology should be soughtchronic severe asthma (True)

Module 14 (Chapter 14)Question 1. The following statements about renal physiology in health are correcteach kidney comprises approximately 1 000 000 nephrons (True)the kidneys receive approximately 5% of the cardiac output (False)

MCQs VIA WEB 2005

By A. H.

Explanation: 25% of the cardiac outputvariations in the calibre of afferent and efferent arterioles control the filtration pressure (True)the glomerular capillaries are supplied by the afferent arterioles (True)the kidney produces erythropoietin (True)

Question 2. Microscopic haematuria would be an expected finding inurinary tract infection (True)renal papillary necrosis (True)

Explanation: Risk factors include diabetes mellitus, chronic non-steroidal anti-inflammatory drug (NSAID) misuse andalcoholismmembranous glomerulonephritis (False)

Explanation: Typically proteinuriainfective endocarditis (True)

Explanation: Associated with a mesangiocapillary glomerulonephritisrenal infarction (True)

Explanation: May be frank haematuria

Question 3. Urinary protein excretionin Bence Jones proteinuria is readily detectable by stick tests (False)Explanation: Immunoelectrophoresis required> 3.5 g/day is invariably due to glomerular disease (True)

Explanation: Often with oedema and hypoalbuminaemiais greater in the night than during the day (False)

Explanation: Greater when the person is upright-'orthostatic proteinuria'can be assessed by the albumin/creatinine ratio in a single sample (True)

Explanation: Easier to undertake than 24-hour collectionin early diabetic nephropathy typically comprises albumin predominantly (True)

Explanation: Microalbuminuria is a sensitive predictor

Question 4. Typical features of the nephrotic syndrome includebilateral renal angle pain (False)Explanation: Typically painlessgeneralised oedema and pleural effusions (True)

Explanation: Transudateshypoalbuminaemia and proteinuria > 3.5 g/day (True)

Explanation: Serum albumin concentration < 30 g/l and urinary protein > 3.5 g/dayhypertension and polyuria (False)

Explanation: But may occur in chronic renal failureurinary sodium concentration > 50 mmol/l (False)

Explanation: Marked sodium retention-urinary sodium < 10 mmol/l

Question 5. The following findings would support a diagnosis of pre-renal rather than established acute renal failureoliguria < 700 ml per day (False)Explanation: Pre-renal acute failure is not always oliguricurine/plasma urea ratio > 10:1 (True)

Explanation: Indicating preservation of renal medullary functiona urinary osmolality > 600 mOsm/kg (True)

Explanation: Indicating preservation of renal medullary functiona urinary sodium concentration < 20 mmol/l (True)

Explanation: Indicating preservation of renal medullary functionhypertension rather than hypotension (False)

Explanation: Suggests primary renal disease

Question 6. Typical causes of rapidly progressive glomerulonephritis includepost-infectious glomerulonephritis (True)systemic vasculitis (True)

Explanation: Causes focal necrotising glomerulonephritis

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By A. H.

Goodpasture's disease (True)IgA nephropathy (True)

Explanation: Including Henoch-Schönlein purpuramembranous glomerulonephritis (False)

Question 7. Typical biochemical features of chronic renal failure includepolycythaemia (False)Explanation: Anaemia is atypicalhypophosphataemia (False)

Explanation: Hyperphosph ataemiahypercalcaemia (False)

Explanation: Hypocalcaemiametabolic acidosis (True)

Explanation: Resulting in hyperpnoeaimpaired urinary concentrating ability (True)

Explanation: Hence polyuria; urinary diluting ability also impaired

Question 8. Complications of chronic renal failure includemacrocytic anaemia (False)

Explanation: Typically normocytic or microcyticperipheral neuropathy (True)

Explanation: Can improve with haemodialysisbone pain (True)

Explanation: Renal osteodystrophy with osteomalaciapericarditis (True)

Explanation: Even haemorrhagic pericarditis with tamponademetabolic alkalosis (False)

Explanation: Chronic metabolic acidosis

Question 9. The features of Alport's syndrome includean autosomal dominant mode of inheritance (False)Explanation: Autosomal recessive and X-linked modesdegeneration of the glomerular basement membrane (True)mutation of genes encoding type IV collagen (True)

Explanation: Located at Xq22association with progressive chronic renal failure (True)

Explanation: Second most common inherited form of chronic renal failureassociation with high-tone deafness (True)

Explanation: Characteristic feature preceding severe sensorineural deafness

Question 10. Characteristic features of minimal change nephropathy areoccurrence in adults usually follows an acute infection (False)Explanation: Usually children; accounts for 25% of nephrotic syndrome in adultsmarked mesangial cell proliferation on renal biopsy (False)

Explanation: Minor or absentnephrotic syndrome with unselective proteinuria (False)

Explanation: Selective proteinuriahypertension and microscopic haematuria (False)

Explanation: Suggest an alternative causeprogression to chronic renal failure in patients not responding to corticosteroid therapy (False)

Explanation: Renal function is otherwise unimpaired

Question 11. In the treatment of minimal change nephropathytherapy should be deferred pending renal biopsy in childhood (False)Explanation: Diagnosis in children rarely requires histological confirmationdiuretics should be avoided to minimise the risk of renal impairment (False)

Explanation: Useful in management of oedema

MCQs VIA WEB 2005

By A. H.

high-dose steroids usually control proteinuria (True)immunosuppressant therapy is indicated for frequent relapses (True)

Explanation: E.g. cyclophosphamideimpaired renal function commonly develops in the long term (False)

Explanation: Rarely, even in relapsing disease

Question 12. Typical features of acute post-infectious glomerulonephritis includesubendothelial immune deposits on the glomerular basement membrane (True)bacterial rather than viral infections (True)

Explanation: Especially haemolytic streptococci; rare in the UKdiffuse glomerular involvement (True)recurrent haemoptysis (False)

Explanation: Suggests Goodpasture's diseasea poor prognosis when the disease occurs in childhood (False)

Explanation: Usually resolves spontaneously, especially in children

Question 13. Typical features of acute interstitial nephritis (AIN) includeskin rashes, arthralgia and fever (False)Explanation: Less than 30% of patients with drug-induced AIN have features of generalised hypersensitivityperipheral blood eosinophilia (False)

Explanation: Eosinophilia occurs in 30% in the peripheral blood and 70% in the urinerenal biopsy evidence of an eosinophilic interstitial nephritis (True)

Explanation: And neutrophil or monocytic infiltraterenal impairment typically follows withdrawal of the drug (False)

Explanation: Typically resolvesonset following antibiotic or anti-inflammatory drug therapy (True)

Explanation: E.g. penicillin or naproxen

Question 14. Causes of chronic interstitial nephritis includeSjögren's syndrome (True)Explanation: Also associated with sarcoidosis and systemic lupus erythematosusWilson's disease (True)

Explanation: And other heavy metal poisoningsickle-cell nephropathy (True)chronic transplant rejection (True)analgesic misuse (True)

Explanation: Resulting in medullary ischaemia

Question 15. Chronic pyelonephritis in adultsaccounts for the majority of patients with chronic renal failure (CRF) in the UK (False)Explanation: Diabetes mellitus is the commonest causeis usually attributable to vesicoureteric reflux in childhood (True)

Explanation: Other aetiological factors may also be importanthas pathognomonic histopathological features on renal biopsy (False)

Explanation: Similar to chronic interstitial nephritisis usually associated with demonstrable ureteric reflux (False)

Explanation: Reflux is often no longer demonstrable in adulthoodproducing hypotension should be treated with oral sodium salts (True)

Explanation: As a result of a 'salt-losing' nephropathy

Question 16. The clinical features of adult polycystic renal disease includean autosomal recessive mode of inheritance (False)Explanation: Autosomal dominantcystic disease of the liver and pancreas (True)

Explanation: But liver function tests are normalrenal angle pain and haematuria (True)

Explanation: And hypertension and urinary tract infection

MCQs VIA WEB 2005

By A. H.

aortic and mitral regurgitation (True)Explanation: Common but rarely severeaneurysms of the circle of Willis (True)

Explanation: 10% will have a subarachnoid haemorrhage

Question 17. Characteristic features of renal tubular acidosis (RTA) includenormal anion gap (True)Explanation: Anion gap = plasma (Na+ + K+) - (Cl- + HCO3-) normally < 15 mmol/lhyperchloraemic acidosis (True)

Explanation: increased chloride preserves anion gapinappropriately high urinary pH > 5.4 (True)

Explanation: Even in presence of systemic acidosisdecreased glomerular filtration rate (GFR) (False)

Explanation: GFR is normalnormocytic normochromic anaemia (False)

Explanation: No features of uraemia

Question 18. The typical features of acute pyelonephritis in adult females includenormal anatomy of the urinary tract (True)Explanation: But ureteric obstruction may be a predisposing factorvomiting, rigors and renal angle tenderness (True)

Explanation: With loin or epigastric painpyuria (True)peritubular neutrophil infiltration (True)loin pain and fullness in the flank (False)

Explanation: Suggest perinephric abscess

Question 19. In the treatment of renal calculianuria indicates the need for urgent surgical intervention (True)Explanation: Suggests total obstructionthe urine should be alkalinised if the stone is radio-opaque (False)

Explanation: Acidification with ammonium chloride may benefitbendroflumethiazide (bendrofluazide) increases urinary calcium excretion (False)

Explanation: Decreases urinary calcium excretion by 30% in hypercalciuric patientsallopurinol increases urinary urate excretion in gouty patients (False)

Explanation: Decreases urinary urate and may reduce oxalate stone formationrenal pelvic stones require removal at open surgery (False)

Explanation: Fragmentation by lithotripsy and endoscopic removal is possible

Question 20. Recognised features of renal carcinoma includepersistent fever (True)

Explanation: Occurs in 20% and is due to increased interleukin releasebone metastases (True)

Explanation: Typically osteolytic metastaseshaematuria (True)

Explanation: Due to blood clot or direct tumour obstruction of ureterpolycythaemia (True)

Explanation: Erythropoietin secretionserum alphafetoprotein in high titre (False)

Explanation: Suggests hepatoma

Question 21. The typical features of benign prostatic hypertrophy includepeak incidence in the age-group 40-60 years (False)

Explanation: Aged over 60 yearsacute urinary retention and haematuria (True)

Explanation: Sometimes precipitated by urinary tract infectiona response to á-adrenoceptor blocker therapy in > 50% of patients (True)

MCQs VIA WEB 2005

By A. H.

elevated serum prostate specific antigen (False)Explanation: Suggests prostatic carcinomahard, nodular prostatic enlargement on rectal examination (False)

Explanation: Suggests prostatic carcinoma

Question 22. Typical features of prostatic carcinoma includeslowly progressive obstructive uropathy (True)Explanation: As also benign prostatic diseasepresentation with urinary frequency and nocturia (True)

Explanation: Or haematuriapreservation of the normal anatomy on digital rectal examination (False)

Explanation: Hard with obliteration of median furrowlocal spread along the lumbosacral nerve plexus (True)

Explanation: And may involve uretersosteolytic rather than osteosclerotic bone metastases (False)

Explanation: Osteosclerotic metastases

Question 23. Characteristic features of testicular tumours includetesticular pain in seminoma of the testis (False)

Explanation: Typically painlesssecretion of alphafetoprotein and chorionic gonadotrophin by teratomas (True)

Explanation: Helps in the assessment of treatment responseabsence of distant metastases (False)peak incidence after the age of 60 years (False)

Explanation: Peak incidence aged 25-34 yearsseminomas are both radio- and chemosensitive (True)

Explanation: Chemotherapy is given if disease is widespread

Module 15 (Chapter 15)Question 1. Type 1 insulin-dependent diabetes mellitus (IDDM) is associated with'insulitis'-T lymphocyte infiltrate of the islets of Langerhans (True)Explanation: Patchy distribution in pancreasfeeding of cows' milk in early infancy (True)

Explanation: Cross-reactivity of antibodies to bovine serum albumindestruction of over 70% of pancreatic beta cells (True)

Explanation: Symptoms occur only when 70-90% of beta cells have been destroyedconcordance rates in monozygotic twins of 35% (True)

Explanation: Indicating the importance of environmental factorspossession of HLA antigens DR3 and DR4 (True)

Explanation: Linkage with HLA-DQA1 and DQB1 genes encoded on the short arm of chromosome 6

Question 2. The following statements about type 2 diabetes mellitus (NIDDM) are truethere is clear evidence of disordered autoimmunity in most patients with type 2 diabetes mellitus (False)Explanation: In contrast to type 1 diabetes mellitusmonozygotic twins show almost 100% concordance for type 2 diabetes mellitus (True)

Explanation: Compare 35% concordance in monozygotic twins with type 1 diabetes mellituspatients with type 2 diabetes mellitus typically exhibit hypersensitivity to insulin (False)

Explanation: Variable insulin resistanceobesity predisposes to type 2 diabetes mellitus in genetically susceptible individuals (True)

Explanation: Especially if combined with underactivityhypertension, hypercholesterolaemia and hyperinsulinaemia often coexist (True)

Explanation: Syndrome X (Reaven's syndrome) associated with macrovascular disease

Question 3. Secondary diabetes mellitus is associated withthiazide diuretic therapy (True)Explanation: Hypokalaemic alkalosis impairs insulin secretionhaemochromatosis (True)

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By A. H.

Explanation: Pancreatic fibrosisprimary hyperaldosteronism (True)

Explanation: Conn's syndrome produces a hypokalaemic alkalosispancreatic carcinoma (True)

Explanation: Islet cell destructionthyrotoxicosis (True)

Explanation: Also occurs in phaeochromocytoma and acromegaly

Question 4. The physiological effects of insulin includeincreased glycolysis (True)decreased glycogenolysis (True)increased lipolysis (False)

Explanation: Decreased lipolysis and ketogenesisincreased gluconeogenesis (False)

Explanation: Decreased gluconeogenesisincreased protein catabolism (False)

Explanation: Decreased protein catabolism

Question 5. In decompensated diabetes mellitusthirst results from the increased osmolality of glomerular filtrate (True)Explanation: And produces an increase in plasma osmolalityhyperpnoea is the result of acidosis due to increased lactic and ketoacid production (True)

Explanation: Resulting in a metabolic acidosisnegative nitrogen balance results from the increased protein catabolism (True)

Explanation: Insulin deficiency increases protein degradationlipolysis increases as a result of relative insulin deficiency (True)

Explanation: More profound ketogenesis occurs in type 1 diabetes mellitusinsulin deficiency inhibits the peripheral utilisation of ketoacids (False)

Explanation: Insulin deficiency increases ketoacid production

Question 6. In the diagnosis of diabetes mellitusglycated haemoglobin (HbAlc) is a sensitive screening test (False)Explanation: Too insensitive to detect all casesabsence of glycosuria excludes diabetes (False)

Explanation: Renal threshold may be highglycosuria is usually due to a reduced renal threshold in young patients (True)

Explanation: But it should never be assumed to be so2% of patients have significant diabetic complications at presentation (False)

Explanation: 20% have significant diabetic complicationsrandom plasma glucose concentrations > 11 mmol/l are diagnostic (True)

Explanation: When symptoms suggest diabetes

Question 7. Typical presentations of diabetes mellitus includeweight loss (True)Explanation: Catabolismbalanitis or pruritus vulvae (True)

Explanation: Predisposition to monilial infectionnocturia (True)

Explanation: Osmotic diuresislimb pains with absent ankle reflexes (True)

Explanation: Small vessel disease and neuropathyasymptomatic glycosuria in the elderly (True)

Explanation: Often detected on routine urine testing

Question 8. In the dietary management of diabetes mellitus90% of patients also require hypoglycaemic drug therapy (False)Explanation: 50% of new diabetics can be controlled on diet alone

MCQs VIA WEB 2005

By A. H.

carbohydrate should provide 50% of the total calorie intake (True)Explanation: Higher than that in the average UK diet10 g carbohydrate exchanges provide an ideal method of monitoring intake (False)

Explanation: Not advocated as the method takes no account of glycaemic effects or fat intakefat intake should not exceed 35% of total calorie intake (True)

Explanation: UK national diet tends to higher proportion of fatin obese patients, calorie intake should not exceed 750 kcal/day (False)

Explanation: Calorie restriction of 500 kcal/day is more realistic and sustainable

Question 9. Sulphonylurea drug therapy in diabetes mellituscauses less weight gain than biguanide therapy (False)Explanation: Causes more weight gainincreases hepatic gluconeogenesis (False)

Explanation: Stimulates pancreatic insulin secretiondecreases the number of peripheral insulin receptors (False)

Explanation: Such an action would produce insulin resistancedecreases hepatic glycogenolysis (True)

Explanation: Also decreases hepatic gluconeogenesis to reduce hyperglycaemiacauses alcohol-induced flushing (True)

Explanation: Disulfiram-like reaction

Question 10. Biguanide drug therapy in diabetes mellitusis more likely to cause weight loss than weight gain (True)Explanation: Sometimes a useful adjunct to calorie-restricted dietsIncreases plasma immunoreactive insulin concentration (False)

Explanation: Hence does not cause hypoglycaemia in non-diabeticsDecreases pancreatic glucagon release (False)

Explanation: Increases the sensitivity of peripheral insulin receptorsInhibits hepatic glycogenolysis (True)

Explanation: Thus limiting hyperglycaemiaCauses troublesome constipation (False)

Explanation: Causes diarrhoea which may limit drug compliance

Question 11. The following statements about other drug therapies in diabetes mellitus are trueThiazolidinediones enhance endogenous insulin sensitivity (True)Explanation: Activate peroxisome proliferator-activated receptor ã (PPARã agonists)Thiazolidinediones produce hyperinsulinaemia and hypoglycaemia (False)

Explanation: Insulin sensitivity in adipose tissue is only increased in patients with insulin resistanceThiazolidinediones are best prescribed in combination with biguanides, sulphonylureas or insulin (True)

Explanation: Glitazones promote weight gain and fluid retention similar to sulphonylureas and insulinMeglitinides increase peripheral insulin sensitivity (False)

Explanation: Stimulate postprandial insulin secretionAlpha-glucosidase inhibitors induce carbohydrate malabsorption (True)

Explanation: Selectively inhibit intestinal disaccharidases producing flatulence and diarrhoea

Question 12. The following statements about insulin therapy are trueShort-acting, regular insulin should be injected at least 30 minutes pre-prandially (True)Explanation: Onset of effect at least 30 minutes after injectionthe duration of action of short-acting regular insulin is 4-8 hours (True)intermediate-acting isophane insulin action peaks at 1-3 hours (False)

Explanation: Isophane insulin action has an onset at 1-3 hours and lasts 7-14 hoursThe standard UK solution strength is 100 units/ml (True)

Explanation: Different in other countriesOnce absorbed, insulin has a plasma half-life of 2 hours (False)

Explanation: Plasma insulin has a half-life of 7 minutes

Question 13. Typical symptoms of hypoglycaemia in diabetic patients include

MCQs VIA WEB 2005

By A. H.

Feelings of faintness and hunger (True)Explanation: But 50% of long-term type 1 diabetes mellitus patients have no symptomsTremor, palpitation and dizziness (True)

Explanation: Sympathetic nervous system activationHeadache, diplopia and confusion (True)

Explanation: NeuroglycopeniaAbnormal behaviour despite a normal plasma glucose (False)

Explanation: But plasma glucose concentration does not mirror cerebrospinal fluid glucose perfectlyNocturnal sweating, nightmares and convulsions (True)

Explanation: Nocturnal hypoglycaemia may be difficult to recognise

Question 14. In the treatment of severe hypoglycaemia in a diabetic patientpatients should be taught to self-administer 50 ml of 50% glucose intravenously (False)Explanation: Defined as hypoglycaemia requiring the assistance of another person for recoveryglucagon should be given intramuscularly (True)

Explanation: Diabetics and close family members should be taught the techniquethe patient is more likely to have been taking metformin therapy alone rather than a sulphonylurea (False)

Explanation: Hypoglycaemia does not occur with biguanidesreversal of cognitive impairment is complete within 30 minutes of the restoration of normoglycaemia (False)

Explanation: Can take 60-90 minutes after normoglycaemia is restoredcerebral oedema should be considered if consciousness is not rapidly restored (True)

Explanation: Other possibilities include stroke, hypoglycaemia-induced seizures and alcohol intoxication

Question 15. Factors predisposing to frequent hypoglycaemic episodes in a diabetic patient includeDelayed meals (True)Explanation: Or inadequate size of mealunusual exercise (True)

Explanation: Often unanticipatedExcessive alcohol intake (True)

Explanation: A problem with patients on sulphonylurea drugsDevelopment of hypoadrenalism (True)

Explanation: Increased sensitivity to insulin; weight loss and nocturia should signal the possibilityErrors in drug administration (True)

Explanation: Inadvertent and occasionally even deliberate

Question 16. The typical clinical features of diabetic ketoacidosis includeAbdominal pain and air hunger (True)Explanation: Due to the acidosisRapid, weak pulse and hypotension (True)

Explanation: Due to dehydration and acidosisProfuse sweating with skin pallor (False)

Explanation: Suggests hypoglycaemia-skin is typically dry with loss of turgor in diabetic ketoacidosisVomiting and constipation (True)

Explanation: Due to ketosis and dehydrationcoma with focal neurological signs (False)

Explanation: Suggests severe hypoglycaemia

Question 17. Expected findings in moderately severe diabetic ketoacidosis includewater deficit of at least 6 litres (True)Explanation: Average deficit = 6 l (50% intracellular + 50% extracellular)sodium and potassium deficits of at least 400 mmol (True)

Explanation: Chloride deficit similarplasma bicarbonate less than 12 mmol/l (True)

Explanation: Check the arterial blood pH and PaCO2absence of ketones in the urine (False)

Explanation: Absence of ketonuria suggests another cause for the metabolic acidosisperipheral blood leucocytosis (True)

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Explanation: Even in absence of infection due to acidosis

Question 18. In the management of diabetic ketoacidosisintracellular water deficit is best restored using half-strength saline (0.45% saline) (False)Explanation: Use isotonic solutions; change to 5% dextrose when blood glucose falls below 15 mmol/lpotassium should be given immediately anticipating a low serum potassium concentration (False)

Explanation: Avoid until the serum K+ result is available and do not give if the serum K+ > 5.5 mmol/lbicarbonate infusion is rarely necessary in the absence of renal failure (True)

Explanation: Or in severe acidosis, i.e. pH < 7.0 (H+ concentration > 100 nmol/l)5% dextrose solution should be avoided unless hypoglycaemia supervenes (False)

Explanation: Dextrose is used to correct intracellular fluid depletion and if blood glucose < 15 mmol/lperipheral circulatory failure requires rapid volume replacement initially (True)

Explanation: Give plasma expander if blood pressure does not improve rapidly; monitor urine output and central venouspressure

Question 19. The clinical features of diabetic retinopathy includearteriolar spasm with arteriovenous nipping (False)Explanation: Suggests hypertensive changevenous dilatation and increased venous tortuosity (True)

Explanation: Sausage-like venous 'beading'soft and hard exudates (True)

Explanation: Soft exudates indicate retinal ischaemia; hard exudates indicate plasma leakageretinal haemorrhages (True)

Explanation: Appearance of haemorrhages corresponds with their site in the layers of the retinamicroaneurysms (True)

Explanation: Major risk factor for macrovascular disease

Question 20. The following statements about the long-term complications of diabetes are correctcardiovascular disease accounts for 70% of all deaths associated with diabetes (True)Explanation: Renal failure accounts for 10% of deaths associated with diabetesthe excess mortality associated with diabetes is mainly attributable to microvascular complications (False)

Explanation: Mainly macrovascular complications due to atherosclerosisthe frequency and severity of microvascular complications can be minimised by strict glycaemic control (True)

Explanation: Both in type 1 and type 2 diabetescardiovascular complications can be minimised by strict control of the blood pressure (True)

Explanation: Both in type 1 and type 2 diabetesdiabetic patients with hypercholesterolaemia and cardiovascular disease benefit from statin therapy (True)

Explanation: Both type 1 and type 2 diabetics at high risk from cardiovascular disease also benefit from angiotensin-converting enzyme inhibitor therapy

Module 16 (Chapter 16)Question 1. The hypothalamic releasing factors listed below stimulate the pituitary gland to secrete the followinghormonesdopamine-prolactin (False)Explanation: Dopamine inhibits prolactin release; dopamine antagonists and TRH both stimulate prolactin releasesomatostatin-growth hormone (False)

Explanation: Somatostatin inhibits growth hormone releasethyrotrophin-releasing hormone (TRH)-thyroid-stimulating hormone (TSH) and prolactin (True)

Explanation: In vivo significance of effect on prolactin is uncertaingonadotrophin-releasing hormone (GnRH)-luteinising hormone (LH) and follicle-stimulating hormone (FSH)

independently (True)Explanation: Gonadal steroids and inhibin modify GnRH effectscorticotrophin-releasing hormone (CRH)-â-lipotrophic hormone (LPH) and adrenocorticotrophic hormone (ACTH)

(True)Explanation: Arginine vasopressin also effects ACTH release

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Question 2. Causes of hyperprolactinaemia includeoral contraceptive therapy (True)Explanation: And pregnancychlorpromazine therapy (True)Explanation: Dopamine antagonist like metoclopramideprimary hypothyroidism (True)

Explanation: High plasma TRHhypothalamic disease (True)Cushing's disease (True)

Explanation: High plasma ACTH

Question 3. The clinical features of hyperprolactinaemia includehypogonadism and galactorrhoea (True)Explanation: Unilateral galactorrhoea suggests a breast tumourinfertility associated with secondary amenorrhoea (True)

Explanation: Typicalan increased likelihood of macroadenoma in males (True)bitemporal hemianopia associated with microadenomas (True)

Explanation: Pressure effects are only associated with macroadenomasprompt response to dopamine agonist therapy (True)

Explanation: E.g. cabergoline and quinagolide

Question 4. The clinical features of acromegaly includearthropathy and myopathy (True)Explanation: Also carpal tunnel syndromehypertension and impaired glucose tolerance (True)

Explanation: Both occur in 25%goitre and cardiomegaly (True)

Explanation: Visceromegaly and hepatomegalyincreased sweating and headache (True)

Explanation: The commonest of all the symptomsskin atrophy and decreased sebum secretion (False)

Explanation: The skin is thickened with increased sebum production

Question 5. Typical results of investigations in a patient with acromegaly includefailure of the plasma growth hormone (GH) to rise during a glucose tolerance test (GTT) (False)Explanation: Failure to suppress plasma GH-may even rise; GH normally falls during the GTTdecreased serum prolactin (False)

Explanation: Increased serum prolactin occurs in 30%increased serum insulin-like growth factor (IGF-1) (True)abnormality of the pituitary fossa on plain radiograph (False)

Explanation: Rarely abnormal-MR scanning is used for preoperative assessmenttumour shrinkage in response to octreotide therapy (False)

Explanation: Somatostatin analogues reduce GH secretion but not tumour size

Question 6. Typical features of anterior pituitary hormone deficiency in adults includeloss of growth hormone function before luteinising hormone (True)Explanation: Then loss of ACTH and finally loss of TSHhypertension due to ACTH deficiency (False)

Explanation: Hypotension due to the effects of cortisol deficiency on the vascular bed and kidneysskin pigmentation (False)

Explanation: Striking pallor due to the effects of â-LPH deficiency on melanocytesmyxoedema due to TSH deficiency (False)

Explanation: Unlike primary hypothyroidism, skin changes do not occurdilutional hyponatraemia (True)

Explanation: Due to increased ADH release and ADH sensitivity induced by hypotension and cortisol deficiency-ADHdeficiency occurs if there is posterior pituitary damage

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Question 7. Causes of hypopituitarism includeKallmann's syndrome (True)Explanation: GnRH deficiency associated with hypogonadotrophic hypogonadism and anosmiacraniopharyngioma (True)

Explanation: Any tumour close to the pituitary fossa including meningiomashead injury (True)

Explanation: Including radiotherapySheehan's syndrome (True)

Explanation: Post-partum necrosis of the pituitary glandsarcoidosis (True)

Explanation: Also tuberculosis causing chronic basal meningitis

Question 8. Causes of diabetes insipidus (DI) includecongenital sex-linked recessive disorder (True)Explanation: Nephrogenic DI; also congenital cranial DI-autosomal dominantcraniopharyngioma (True)

Explanation: Any tumour or radiotherapy close to the pituitary fossaDIDMOAD syndrome (True)

Explanation: DI, diabetes mellitus, optic atrophy and deafnesssevere hypocalcaemia (False)

Explanation: Severe hypokalaemia and hypercalcaemiasarcoidosis (True)

Explanation: Also tuberculosis causing chronic basal meningitis

Question 9. The typical features of cranial diabetes insipidus includeserum sodium concentration > 150 mmol/l with urine specific gravity < 1.001 (False)Explanation: Severe hypernatraemia only when water access deniedincreased polyuria following corticosteroid therapy for hypopituitarism (True)

Explanation: Glucocorticoid insufficiency may mask diabetes insipidusonset following basal meningitis or hypothalamic trauma (True)

Explanation: Or secondary to pituitary tumours or sarcoiddecreased renal responsiveness to ADH following carbamazepine therapy (False)

Explanation: Carbamazepine stimulates ADH releaseunlike psychogenic polydipsia, the response to ADH is invariably normal (True)

Explanation: An effect of long-term overhydration in psychogenic polydipsia

Question 10. The insulin tolerance test ismandatory to confirm the diagnosis of hypopituitarism (False)

Explanation: An ACTH stimulation test is often the more appropriate testbest terminated as soon as the plasma glucose falls below 2.4 mmol/l (True)

Explanation: Or if severe hypoglycaemic symptoms developcontraindicated in ischaemic heart disease (True)

Explanation: Needs an adequate hypoglycaemic stimulus and runs the risk of hypoglycaemiacontraindicated in severe hypopituitarism (True)

Explanation: Plasma cortisol at 0800 hrs < 180 nmol/lan unreliable test of hypothalamic function (False)

Explanation: Test of hypothalamic-pituitary-adrenal axis

Question 11. The following statements about thyroid hormones are trueT3 and T4 are both stored in colloid vesicles as thyroglobulin (True)Explanation: Thyroglobulin is synthesised within thyroid cellsT4 is metabolically more active than T3 (False)

Explanation: T4 should be regarded as a prohormoneT3 and T4 are mainly bound to albumin in the serum (False)

Explanation: Bound to thyroxine-binding globulin and also to pre-albumin85% of the circulating T3 arises from extra-thyroidal T4 (True)

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Explanation: T4 is deiodinated in liver, muscle and kidneyconversion of T4 to T3 decreases in acute illness (True)

Explanation: Production of reverse T3 may increase

Question 12. The finding of reduced serum free T4 and thyroid-stimulating hormone (TSH) concentrations iscompatible with the following conditionshypopituitarism (True)Explanation: With secondary hypothyroidismprimary hypothyroidism (False)

Explanation: Serum TSH would be elevatednephrotic syndrome (False)

Explanation: Free T4 is normal but total T4 is often increased (high thyroxine-binding globulin (TBG) concentrations)pneumonia (True)

Explanation: Sick euthyroid syndrome-total and free T4 may be reducedpregnancy (False)

Explanation: Free T4 and TSH are normal; total T4 is often increased (high TBG concentrations)

Question 13. The following statements about thyrotoxicosis are truemost patients have Graves' disease (True)Explanation: 75% of casesmultinodular goitre is more common than uninodular goitre (True)

Explanation: 15% multinodular, 5% single noduleamiodarone treatment should be considered as a possible cause (True)

Explanation: May also cause hypothyroidismthe thyroid gland is diffusely hyperactive in Graves' disease (True)

Explanation: A goitre is therefore usually presentthere is an increased prevalence of HLA-DR3 in Graves' disease (True)

Explanation: And HLA-B8 and DR2

Question 14. The clinical features of thyrotoxicosis includeatrial fibrillation with a collapsing pulse (True)Explanation: Or persisting resting sinus tachycardiaweight loss and oligomenorrhoea (True)

Explanation: Appetite is maintainedperipheral neuropathy (False)

Explanation: Muscular weakness may occurproximal myopathy and exophthalmos (True)

Explanation: Occasionally with ophthalmoplegiadecreased insulin requirements in type 1 diabetes mellitus (False)

Explanation: Insulin requirements may increase

Question 15. In the treatment of thyrotoxicosispropranolol should not be given in atrial fibrillation (False)Explanation: Controls ventricular response ratecarbimazole blocks the secretion of T3 and T4 by the thyroid (False)

Explanation: Inhibits the iodination of tyrosinepersistent suppression of the serum TSH is an indication for surgery (False)

Explanation: TSH measurement alone should not guide therapyserum TSH receptor antibodies usually persist despite carbimazole (False)

Explanation: But titres correlate poorly with disease activitysurgery is more likely to be necessary in young men than in women (True)

Explanation: Especially patients with large goiters

Question 16. The clinical features of primary hypothyroidism includecarpal tunnel syndrome and proximal myopathy (True)

Explanation: Both, however, are non-specificcold sensitivity and menorrhagia (True)

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Explanation: And infertility and impotencedeafness and dizziness (True)

Explanation: Perhaps due to oedema of the middle earpuffy eyelids and malar flush (True)

Explanation: And rarely alopecia, vitiligo and dry hairabsent ankle tendon reflexes (False)

Explanation: Reflexes preserved with delayed relaxation

Question 17. Biochemical findings in primary hypothyroidism includedecreased serum free T4 and decreased serum TSH concentration (False)Explanation: Decreased serum free T4 and increased serum TSH concentrationincreased serum prolactin concentration (True)

Explanation: Rarely causing galactorrhoeainappropriate ADH secretion (True)

Explanation: Producing hyponatraemiaincreased serum alkaline phosphatase concentration (False)

Explanation: Serum lactate dehydrogenase and creatine kinase may be elevatedincreased serum cholesterol concentration (True)

Explanation: And serum triglyceride levels

Question 18. The development of a goitre is associated withCoxsackie B viral infection (False)Explanation: May cause painful thyroiditis with transient hypothyroidismdietary iodine deficiency (True)

Explanation: Hypothyroidism if iodine deficiency is severeexcess dietary calcium intake (False)

Explanation: No associationcranial irradiation (True)

Explanation: Secondary hypothyroidismlithium carbonate therapy (True)

Explanation: Inhibits release of thyroid hormones

Question 19. Thyroid carcinoma oflymphomatous type usually presents as a single 'hot' thyroid nodule (False)Explanation: 'Hot' nodules are almost always benignanaplastic type is usually cured by local radiotherapy (False)

Explanation: Radiotherapy provides brief symptomatic relief onlyfollicular type is best treated by 131I radio-iodine therapy alone (False)

Explanation: Total thyroidectomy, radio-iodine and long-term thyroxinepapillary type should be treated with total thyroidectomy (True)

Explanation: Papillary tumours are the most common cell typemedullary type secretes calcitonin causing severe hypocalcaemia (False)

Explanation: Rare despite high calcitonin levels; carcinoid syndrome can occur

Question 20. The serum calcium concentration is typically increased inhypoalbuminaemia (False)Explanation: 40% of calcium is protein-bound; normal after correction for serum albuminpyloric stenosis (False)

Explanation: But metabolic alkalosis decreases the level of ionised calciumcarcinomatosis (True)

Explanation: Due to bone metastases (often microscopic)hypoparathyroidism (False)

Explanation: Decreases serum calcium levelschronic sarcoidosis (True)

Explanation: Increased vitamin D synthesis with decreased PTH concentration

Question 21. Typical clinical features of primary hyperparathyroidism include

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recurrent acute pancreatitis and renal colic due to calculi (True)Explanation: But 50% of patients are asymptomatichyperplasia of all the parathyroid glands on histology (False)

Explanation: Solitary parathyroid adenoma in 90%osteitis fibrosa on bone radiographs at presentation (False)

Explanation: A relatively late featurethe complications of pseudogout and hypertension (True)

Explanation: And peptic ulceration and myopathynephrogenic diabetes insipidus (True)

Explanation: With characteristic polyuria

Question 22. Typical biochemical findings in primary hyperparathyroidism includeincreased serum calcium and phosphate concentrations (False)Explanation: Phosphate is usually lowdecreased serum 1,25-dihydroxycholecalciferol concentration (False)

Explanation: Increased 1,25-dihydroxycholecalciferol concentrationhypercalciuria and hyperphosphaturia (True)

Explanation: Predisposing to stone formationincreased serum alkaline phosphatase with bony involvement (True)

Explanation: Indicating osteoblastic activityincreased serum calcium and PTH concentrations (True)

Explanation: Serum chloride concentration is usually elevated

Question 23. Causes of hypercalcaemia includebone metastases (True)

Explanation: Often via production of osteoclast-activating factorscarcinomas secreting PTH-like peptides (True)

Explanation: Undetectable using standard PTH assayssevere Addison's disease (True)

Explanation: Increased vitamin D synthesis with low PTH concentrationsevere hypothyroidism (False)

Explanation: Hyperthyroidism is a rare causechronic sarcoidosis (True)

Explanation: Increased vitamin D production with low PTH concentration

Question 24. The following statements about adrenal gland physiology are trueACTH normally controls the adrenal secretion of aldosterone (False)

Explanation: Principally under control of angiotensin IIACTH increases adrenal androgen and cortisol secretion (True)

Explanation: In the zona reticularis and zona fasciculata respectivelythe plasma cortisol concentration normally peaks in the evening (False)

Explanation: Cortisol levels fall to a nadir at around midnighthyperglycaemia increases the rate of cortisol secretion (False)

Explanation: Hypoglycaemia stimulates cortisol releasecortisol enhances gluconeogenesis and lipogenesis (True)

Explanation: Anti-insulin effects

Question 25. The typical clinical features of Cushing's syndrome includegeneralised osteoporosis (True)Explanation: Protein catabolism in bonesystemic hypotension (False)

Explanation: Hypertension may occurhirsutism and amenorrhoea (True)

Explanation: Impotence in menproximal myopathy (True)

Explanation: Muscle protein catabolism

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hypoglycaemic episodes (False)Explanation: Impaired glucose tolerance

Question 26. Adverse effects of oral corticosteroid therapy includepeptic ulceration (True)

Explanation: Decreases mucosal resistancehypertension (True)

Explanation: Increased renal sodium reabsorptionavascular bone necrosis (True)

Explanation: Particularly likely to affect the femoral headspseudogout (False)

Explanation: Sometimes used to treat severe pseudogoutinsomnia (True)

Explanation: Typical; causes day-night reversal of biorhythms

Question 27. In primary hyperaldosteronism (Conn's syndrome)peripheral oedema is usually marked (False)Explanation: Unlike oedema in patients with secondary hyperaldosteronismproximal myopathy is due to hypokalaemia (True)

Explanation: Rarely hypokalaemic paralysispolyuria and polydipsia are characteristic (True)

Explanation: Hypertension and hypokalaemia are also characteristicdiabetes mellitus is often present (False)

Explanation: Type 2 diabetes mellitus is, however, associated with primary hypoadrenalismhypertension is associated with hyperreninaemia (False)

Explanation: Associated with renin suppression

Question 28. Causes of primary adrenocortical insufficiency includehaemochromatosis (True)Explanation: Rare causeautoimmune adrenalitis (True)

Explanation: Commonest causeamyloidosis (True)

Explanation: Raresarcoidosis (False)

Explanation: May cause hypercalcaemiatuberculosis (True)

Explanation: Now a rare cause

Question 29. Typical features of primary adrenocortical insufficiency includeanorexia, weight loss and diarrhoea (True)Explanation: All features of glucocorticoid insufficiencypigmentation of scars from surgery preceding hypoadrenalism (False)

Explanation: Only new scars become pigmentedvitiligo, weakness and hypotension (True)

Explanation: Vitiligo is seen in 10-20% of patientsincreased insulin requirements in diabetic patients (False)

Explanation: Increased insulin sensitivity with hypoglycaemiaamenorrhoea and loss of body hair (True)

Explanation: Loss of adrenal androgen

Question 30. The typical features of phaeochromocytoma includepredominantly adrenaline rather than noradrenaline secretion (False)Explanation: Noradrenaline is a precursor of adrenalineepisodic nausea with sweating and marked skin pallor (True)

Explanation: Catecholamine secretionunderlying malignant tumour in the majority (False)

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Explanation: 90% are benignpresentation with hypertension and hypercalcaemia (True)

Explanation: Occurs in MEN type II syndromecontrol of symptoms following propranolol therapy alone (False)

Explanation: Symptoms worsen due to unopposed á-adrenoceptor activity

Question 31. Causes of gynaecomastia includeandrogen deficiency and/or excessive oestrogen production (True)Explanation: E.g. hypogonadism or chronic liver failuremicroprolactinoma or macroprolactinoma (True)

Explanation: Inhibition of LH/FSH secretion caused by prolactincimetidine therapy (True)

Explanation: Also spironolactone and anti-androgen therapy (e.g. cyproterone + GnRH analogues)haemochromatosis (True)

Explanation: Hypergonadotrophic hypogonadismhuman chorionic gonadotrophin-secreting tumour (True)

Explanation: Rare cause of excessive oestrogen production

Question 32. In cryptorchidism with inguinal testes in a childthe individual is usually otherwise normal (True)Explanation: Chromosomal abnormalities are rarehypogonadotrophic hypogonadism should be excluded (True)

Explanation: Occurs in the minoritythe seminiferous tubules are typically normal (False)

Explanation: Sterility follows if bilateraltesticular interstitial cell function is usually normal (True)

Explanation: Secondary sexual characteristics are preservedtreatment with chorionic gonadotrophin or GnRH is contraindicated (False)

Explanation: Testicular descent ensues in 40%

Question 33. Causes of secondary amenorrhoea includepituitary microprolactinoma (True)Explanation: Suppression of LH and FSH secretion by prolactinanorexia nervosa (True)

Explanation: Failure of gonadotrophin secretionCushing's syndrome (True)

Explanation: Associated with hyperprolactinaemiarenal failure (True)

Explanation: Or other severe systemic diseaseStein-Leventhal syndrome (True)

Explanation: Polycystic ovary disease

Question 34. The typical features of the menopause includedecreased plasma LH and FSH concentrations (False)Explanation: Gonadotrophins elevatedhirsutism and clitoral hypertrophy (False)

Explanation: Features of androgen excessbone fractures due to osteomalacia (False)

Explanation: Osteoporosis develops prematurelysuperficial dyspareunia and dysuria (True)

Explanation: Due to oestrogen deficiencynormal age at onset 40 years (False)

Explanation: Normal menopause occurs at age 50-55 years

Question 35. Causes of hirsutism includeidiopathic familial hirsutism (True)Explanation: Commonest cause and treated with anti-androgens (e.g. cyproterone)

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polycystic ovarian syndrome (PCOS) (True)Explanation: PCOS is associated with obesity and infertility; plasma LH:FSH ratio > 2.5:1Cushing's syndrome (True)

Explanation: Modest increase in adrenal androgen synthesisautoimmune polyglandular syndrome (False)

Explanation: Primary adrenal, thyroid, parathyroid, gastric parietal and gonadal failure syndromesovarian tumour (True)

Explanation: Ectopic androgen production does not suppress with dexamethasone (unlike excessive androgenproduction in congenital adrenal hyperplasia)

Module 17 (Chapter 17)Question 1. Causes of mouth ulcers includegluten enteropathy (True)Explanation: And systemic lupus erythematosus, Beh[sfgr ]et's syndrome, Reiter's syndromeCrohn's disease (True)

Explanation: And ulcerative colitislichen planus (True)

Explanation: And pemphigoid and pemphigusadverse drug reaction (True)Explanation: Stevens-Johnson syndrome due to either drugs or infectionsherpes simplex (True)

Explanation: Aphthous mouth ulcers are usually idiopathic rather than viral-induced

Question 2. Causes of salivary gland enlargement includealcoholic liver disease (True)Explanation: Also associated with malnutrition and autoimmune hepatitisSjögren's syndrome (True)

Explanation: Associated with dry mouth and keratoconjunctivitis sicca (dry eyes)bacterial infection (True)Explanation: May be associated with calculi in the parotid ductsarcoidosis (True)

Explanation: Uveoparotid fever (Heerfordt's syndrome)measles (False)

Explanation: Associated with mumps

Question 3. Recognised causes of dysphagia includeiron deficiency anaemia (True)Explanation: Via formation of an oesophageal web-'sideropenic dysphagia'pharyngeal pouch (True)

Explanation: May also be associated with regurgitation and recurrent aspirationBarrett's oesophagus (False)

Explanation: Asymptomatic unless complicated by malignancymyasthenia gravis (True)

Explanation: More commonly caused by stroke; typically worse with fluids than with solidsachalasia (True)

Explanation: Best diagnosed on oesophageal manometry

Question 4. Typical features of oesophageal achalasia includerecurrent pneumonia (True)Explanation: Due to regurgitation and aspirationspasm of the lower oesophageal sphincter (LOS) (False)

Explanation: Failure to relax the LOS with loss of ganglion cells in Auerbach's plexus on histologyheartburn and acid reflux (False)

Explanation: Acid reflux is prevented by the non-relaxing LOSpredisposition to oesophageal carcinoma (True)

Explanation: Even if the obstruction is treatedsymptomatic response to pneumatic balloon dilatation (True)

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By A. H.

Explanation: If this fails, Heller's myotomy may be indicated

Question 5. Gastro-oesophageal reflux disease is associated with the following factorsdecreased intra-abdominal pressure (False)

Explanation: Associated with increased intra-abdominal pressure (e.g. pregnancy)delayed gastric emptying (True)prolonged oesophageal transit time (True)

Explanation: Delayed oesophageal clearance is more common in the elderlyincreased lower oesophageal sphincter tone (False)

Explanation: Associated with decreased lower oesophageal sphincter tonepresence of a hiatus hernia (True)

Question 6. Oesophageal carcinoma in the UK isassociated with gluten enteropathy (True)

Explanation: Squamous rather than adenocarcinomamore likely to be due to adenocarcinoma than squamous carcinoma (False)

Explanation: 80-90% are squamous cellassociated with Barrett's oesophagus (True)

Explanation: Adenocarcinoma is associated with chronic oesophagitismore likely to arise in the upper third rather than the lower third of the oesophagus (False)

Explanation: 90% are in the lower two-thirdsassociated with alcohol and tobacco consumption (True)

Explanation: And betel nut chewing in the East

Question 7. Typical features of oesophageal carcinoma at presentation includeacid reflux and odynophagia (False)Explanation: More suggestive of reflux with oesophagitis and stricture formationpainless obstruction to the passage of a food bolus (True)

Explanation: Painless due to destruction of the mucosal innervationnausea and weight loss (True)

Explanation: Weight loss relates to poor food intakemetastatic spread in the majority of patients (True)

Explanation: 75% have lymph node, liver and/or mediastinal spreadoverall survival rates at 5 years of approximately 50% (False)

Explanation: 5-year survival is about 5%

Question 8. Factors associated with chronic peptic ulcer disease includeoral contraceptive therapy (False)non-steroidal anti-inflammatory drug therapy (True)

Explanation: Plays a role in gastric ulcerpernicious anaemia (False)

Explanation: Associated with achlorhydria-'no acid, no ulcer'Helicobacter pylori - associated gastritis (True)

Explanation: Implicated in > 90% of instancestobacco consumption (True)

Explanation: Associated with both gastric and duodenal ulcer recurrence rates

Question 9. Typical features of peptic ulcer dyspepsia includepain relieved by eating (True)Explanation: Hunger painwell-localised pain relieved by vomiting (True)

Explanation: Perhaps with the 'pointing sign'pain-free remissions lasting many weeks (True)

Explanation: Pain is characteristically periodicnausea and epigastric pain (False)

Explanation: More suggestive of biliary colic; pain rarely lasts > 2 hours

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absence of symptoms prior to acute perforation (True

Question 10. In the investigation and treatment of chronic dyspepsiamost patients aged < 55 years have an underlying peptic ulcer (False)Explanation: Only about 20%; most have reflux dyspepsia or functional dyspepsia25% of duodenal ulcers relapse unless H. pylori has been eradicated (False)

Explanation: 85% relapse if H. pylori has not been eradicatedmagnesium-containing antacids produce constipation (False)

Explanation: Cause diarrhoea; aluminium-containing antacids cause constipationbismuth compounds should not be used for maintenance therapy (True)

Explanation: Due to potential accumulation of bismuth, acid-lowering drugs are preferablegastric ulcers associated with NSAID therapy are less likely to be associated with H. pylori gastritis than gastric ulcers

occurring in patients not taking NSAIDs (True)Explanation: 30% of gastric ulcers are not associated with H. pylori (NSAID-induced ulcers)

Question 11. Gastroduodenal haemorrhage in the UK ismore often due to peptic ulcer than to oesophageal varices (True)Explanation: Peptic ulcer 35-50%, varices < 5%associated with a 5% mortality when due to chronic peptic ulceration (True)

Explanation: Higher mortality in the elderly and especially in patients who rebleeda recognised complication of severe head injury (True)

Explanation: Cushing's stress ulcersbest investigated by endoscopy (True)

Explanation: Diagnostic yield reduces with time post-admissionsignificantly associated with anti-inflammatory drug therapy (True)

Explanation: 75% of patients with gastrointestinal bleed have recently taken NSAIDs (only 50% of 'controls')

Question 12. Typical features of major acute gastroduodenal haemorrhage includesevere abdominal pain (False)Explanation: Typically pain-freeangor animi and restlessness (True)

Explanation: Sympathetic activationsyncope preceding other evidence of bleeding (True)

Explanation: Particularly in older patientselevated blood urea and creatinine concentrations (False)

Explanation: Blood urea but not creatinine rises due to digestion of the blood in the gutperipheral blood microcytosis (False)

Explanation: Only present if preceding iron deficiency

Question 13. When acute gastroduodenal haemorrhage is suspecteda pulse rate > 100/min is most likely to be due to anxiety (False)Explanation: A sign of hypovolaemiahypotension without a tachycardia suggests an alternative diagnosis (False)

Explanation: Bradycardia may occur in profound blood loss or in the elderlythe absence of anaemia suggests the volume of blood loss is modest (False)

Explanation: Haemoglobin concentration remains unaltered until haemodilution occursnasogastric aspiration provides an accurate estimate of blood loss (False)

Explanation: Monitoring the urine output as a measure of perfusion is importantendoscopy is best deferred pending blood volume replacement (True)

Explanation: Patients should first be haemodynamically stable if possible

Question 14. In resuscitating a patient with an acute gastrointestinal bleedoxygen should be administered if there are signs of hypovolaemia (True)

Explanation: Especially in patients with shocktransfusion requires whole blood rather than packed red cells (False)

Explanation: Colloid infusion and packed red cells are adequate for volume replacement

MCQs VIA WEB 2005

By A. H.

volume replacement with colloids is preferable to crystalloids (True)Explanation: Crystalloids rapidly redistribute to the extravascular spacemonitoring central venous pressure and/or urine output is advisable (True)

Explanation: Facilitates restoration of optimal circulating volumesurgical intervention should be considered if rebleeding occurs despite ulcer sclerotherapy (True)

Explanation: Consider surgical options in all patients with continuing bleeding

Question 15. Perforation of a peptic ulcer is typically associated withacute rather than chronic ulcers (False)Explanation: 25% occur in acute ulcersduodenal more often than gastric ulcers (True)

Explanation: Especially anterior wall ulcersabdominal pain radiating to the shoulder tip (True)

Explanation: Diaphragmatic pain referred to one or both shoulder tipsthe absence of nausea and vomiting (False)

Explanation: Vomiting is commonsymptomatic improvement several hours following onset (True)

Explanation: But abdominal rigidity typically persists

Question 16. Characteristic features of gastric outlet obstruction includemetabolic acidosis (False)Explanation: Hypokalaemic metabolic alkalosisbile vomiting (False)

Explanation: Suggests more distal obstructionurinary pH < 5 (True)

Explanation: Paradoxical aciduria due to renal tubular mechanismssymptomatic relief after vomiting (True)

Explanation: Unusually, patients may feel like eating immediately after vomitingabsent gastric peristalsis (False)

Explanation: Often prominent gastric peristalsis and a succussion splash

Question 17. Complications of partial gastrectomy includeearly satiety (True)Explanation: Smaller stomach and loss of vagally mediated gastric relaxationiron deficiency anaemia (True)

Explanation: Malabsorption is common and can produce folate, B12 and vitamin D deficiencyweight loss (True)

Explanation: Most patients will lose at least 5 kgreactive hypoglycaemia (True)

Explanation: Late dumping syndrome with exaggerated insulin releasevomiting and diarrhoea soon after meals (True)

Explanation: Early dumping syndrome with the exaggerated release of upper gastrointestinal hormones

Question 18. The typical features of non-ulcer dyspepsia includeonset under the age of 40 years (True)

Explanation: Women are more commonly affected than mennausea and bloating (True)Explanation: Dysmotility stateweight loss and anaemia (False)

Explanation: Features suggesting serious underlying diseaseconstipation with pellety stools (True)

Explanation: Often associated with an irritable bowel syndromesymptoms of anxiety and depression (True)

Explanation: Often associated with stressful life events and difficulties

Question 19. Carcinoma of the stomach is associated withadenomatous gastric polyps (True)

MCQs VIA WEB 2005

By A. H.

chronic hypochlorhydria (True)Explanation: Pernicious anaemia and partial gastrectomyHelicobacter pylori infection (True)

Explanation: H. pylori may account for 60% of gastric carcinomaMénétrier's disease (True)

Explanation: Hypertrophic gastritis with protein-losing enteropathyalcohol and tobacco consumption (True)

Question 20. Typical features of gastric carcinoma in the UK includeprogression to involve the duodenum (False)Explanation: Extraordinary but trueorigin within a chronic peptic ulcer (False)

Explanation: But may present as a malignant ulceroverall 5-year survival rate of 50% (False)

Explanation: 10% 5-year survivalfolate deficiency anaemia on presentation (False)

Explanation: Iron deficiency anaemia is typicalsupraclavicular lymphadenopathy (True)

Explanation: Virchow's node

Question 21. In gluten enteropathy (coeliac disease)the peak at onset is 11-19 years (False)Explanation: Peak incidence in the age groups 1-5 years and 40-59 yearsthere is a predisposition to gut lymphoma and carcinoma (True)

Explanation: Symptoms return without dietary indiscretionthe toxic agent is the polypeptide á-gliadin (True)

Explanation: A component of the gluten proteingluten-free diets improve absorption but not the villous atrophy (False)

Explanation: Villous atrophy should resolveserum anti-endomysium IgA antibody titres are characteristically elevated (True)

Explanation: Also antigliadin IgA antibody titres

Question 22. Causes of small bowel bacterial overgrowth (blind loop syndrome) includediabetic autonomic neuropathy (True)Explanation: Reduced small intestinal motilitychronic hypochlorhydria (True)

Explanation: E.g. long-term proton pump inhibitor therapy and pernicious anaemiajejunal diverticulosis (True)

Explanation: Best demonstrated by barium mealprogressive systemic sclerosis (True)

Explanation: Reduced small intestinal motilityenterocolic fistula (True)

Explanation: E.g. Crohn's disease

Question 23. Clinical features suggesting the carcinoid syndrome includefacial blanching and sweating (False)Explanation: Facial telangiectasia, flushing and wheezingconstipation (False)

Explanation: Diarrhoea is characteristicintestinal ischaemia (True)

Explanation: Due to mesenteric infiltration and/or vasospasmtricuspid valve dysfunction (True)

Explanation: And pulmonary stenosislate occurrence of metastatic disease (False)

Explanation: Typically associated with widespread liver metastases

Question 24. Causes of acute pancreatitis include

MCQs VIA WEB 2005

By A. H.

measles (False)Explanation: Mumps and Coxsackie B viral infectionshypothermia (True)

Explanation: And hyperlipidaemiacholedocholithiasis (True)

Explanation: 50% of cases are associated with biliary tract diseaseazathioprine therapy (True)

Explanation: And thiazides and corticosteroidsalcohol misuse (True)

Explanation: Common cause in the UK

Question 25. The following are characteristic of acute pancreatitisabdominal guarding develops soon after the onset of pain (False)Explanation: Guarding occurs relatively latenormal serum amylase concentration in the first 4 hours after onset (False)

Explanation: Serum amylase rises and falls rapidlypersistent serum hyperamylasaemia suggests a developing pseudocyst (True)

Explanation: Or pancreatic abscess or non-pancreatic causehypercalcaemia 5-7 days after onset (False)

Explanation: Hypocalcaemiahyperactive loud bowel sounds (False)

Explanation: Bowel sounds usually absent or diminished due to paralytic ileus

Question 26. Adverse prognostic factors in acute pancreatitis includearterial hypoxaemia with a PaO2 < 8 kPa (True)Explanation: Administer high-flow oxygen therapyleucopenia with white blood cell count < 5 × 109/l (False)

Explanation: Poorer prognosis indicated by white blood cell count > 15 × 109/lserum albumin < 30 g/l and serum calcium < 2 mmol/l (True)

Explanation: Reflect extent of peritoneal reactionhypoglycaemia < 2.3 mmol/l (False)

Explanation: Hyperglycaemia > 10 mmol/lblood urea > 16 mmol/l after rehydration (True)

Question 27. In the management of acute pancreatitisearly laparotomy is advisable to exclude alternative diagnoses (False)

Explanation: Diagnostic laparotomy is rarely requiredopiates should be avoided because of spasm of the sphincter of Oddi (False)

Explanation: Effective pain relief is importantintravenous fluids are unnecessary in the absence of a tachycardia (False)

Explanation: Heart rate alone is a poor guide to volume lossesthe urine output and PaO2 should be monitored (True)

Explanation: Shock and respiratory failure are serious complicationspersistent elevation in the serum amylase suggests pancreatic duct obstruction (True)

Explanation: Resulting in pancreatic pseudocyst

Question 28. In the investigation of chronic pancreatic diseaseglucose tolerance is typically normal in pancreatic carcinoma (False)Explanation: Typically impaired glucose tolerance test (GTT)duodenal ileus is a characteristic feature of chronic pancreatitis (False)

Explanation: Occurs in acute pancreatitistransabdominal ultrasound scanning is more sensitive than CT (False)

Explanation: Pancreatic visualisation is superior with CTendoscopic retrograde cholangiopancreatography (ERCP) can reliably distinguish carcinoma from chronic pancreatitis

(False)Explanation: Surgery may be necessarypancreatic calcification suggests alcohol as the cause (True)

MCQs VIA WEB 2005

By A. H.

Explanation: Biliary tract disease is rarely the cause

Question 29. Features consistent with the diagnosis of chronic pancreatitis includeabdominal or back pain persisting for days (True)Explanation: Sometimes relieved by crouching or leaning forwardchronic opiate dependency (True)

Explanation: In 20%increased sodium concentration in the sweat (False)

Explanation: Occasionally in cystic fibrosisabdominal pain induced and relieved by alcohol intake (True)pancreatic calcification on plain radiograph or ultrasound (True)

Explanation: But insensitive diagnostic tests

Question 30. Typical causes of chronic pancreatitis includeannular pancreas (False)Explanation: Associated with pancreas divisumalcoholism (True)

Explanation: Accounts for 70-80% of instancesgallstones (False)

Explanation: Common but not the cause of chronic pancreatitiscystic fibrosis (True)mumps (False)

Question 31. Typical complications of chronic pancreatitis includepancreatic pseudocyst formation (True)Explanation: Also associated with acute pancreatitisobstructive jaundice (True)

Explanation: Due to stricture of the common bile duct as it passes the head of the pancreasportal vein thrombosis (True)

Explanation: And splenic vein thrombosis leading to gastric varicesdiabetes mellitus (True)

Explanation: Occurs in 30% overallopiate drug dependence (True)

Explanation: May occur in up to 20% of patients

Question 32. The typical features of pancreatic carcinoma includeadenocarcinomatous histology (True)Explanation: The vast majorityorigin in the body of the pancreas in 60% of patients (False)

Explanation: Head of pancreas is the origin in 60% of patientspresentation with diabetes mellitus (True)Explanation: Indicating advanced diseaseback pain and weight loss indicate a poor prognosis (True)

Explanation: Even in the absence of metastatic spreadpresentation with painless jaundice (True)

Explanation: Usually due to a tumour in the head of pancreas

Question 33. Characteristic features of ulcerative colitis includeinvariable involvement of the rectal mucosa (True)Explanation: Proctitis is a typical findingsegmental involvement of the colon and rectum (False)

Explanation: Suggests Crohn's diseasepseudopolyposis following healing of mucosal damage (True)

Explanation: Due to oedema and hyperplasiainflammation extending from the mucosa to the serosa (False)

Explanation: Affects mucosa and submucosa only

MCQs VIA WEB 2005

By A. H.

enterocutaneous and enteroenteric fistulae (False)Explanation: Suggest Crohn's disease

Question 34. Ulcerative colitis (UC) differs from Crohn's colitis in thatUC occurs at any age (False)Explanation: Both have a peak incidence at the age of about 20 yearscessation of smoking is likely to reduce activity of Crohn's disease (True)

Explanation: Smoking exacerbates Crohn's disease but not ulcerative colitistoxic dilatation only occurs in ulcerative colitis (False)

Explanation: Also occurs in severe Crohn's colitisthere is no association with aphthous mouth ulcers in UC (unlike Crohn's disease) (False)

Explanation: Occur in boththere is no involvement of the small bowel in UC (True)

Question 35. Recognised complications of ulcerative colitis includepyoderma gangrenosum (True)Explanation: Also occurs in Crohn's disease and rheumatoid arthritispericholangitis (True)

Explanation: Suggested by abnormal liver function testsamyloidosis (True)

Explanation: Induced by many chronic inflammatory diseasescolonic carcinoma (True)

Explanation: Long-standing disease (> 10 years)enteropathic arthritis (True)

Question 36. Characteristic features of Crohn's disease includefamilial association with ulcerative colitis (True)

Explanation: And vice versaonset after the age of 70 years (False)

Explanation: Early adult life most commonlydisease confined to the terminal ileum and colon (False)

Explanation: Affects any part of the alimentary tractpredisposition to biliary and renal calculi (True)

Explanation: Bile acid malabsorption and hyperoxaluriagiant cell granulomata on histopathology (True)

Explanation: Crohn's granulomata are non-caseating unlike those of tuberculosis Explanation: Large joints especially,or spondyloarthritis

Question 37. The typical clinical features of ileal Crohn's disease includeassociation with tobacco consumption (True)Explanation: In contrast to ulcerative colitispresentation with bloody diarrhoea (False)

Explanation: Usually pain rather than diarrhoea unless there is rectal involvement alsopresentation with subacute intestinal obstruction (True)

Explanation: With episodes of colicky painsegmental involvement of the colon and rectum (True)

Explanation: In contrast to ulcerative colitisinflammatory changes confined to the mucosa on histopathology (False)

Explanation: Inflammation is transmural

Question 38. The typical features of the irritable bowel syndrome includenocturnal diarrhoea and weight loss (False)Explanation: Such symptoms suggest organic pathologyonset after the age of 45 years (False)

Explanation: Typically affects females aged 16-45 yearshistory of childhood abdominal pain (True)

Explanation: Many also have dyspeptic and urinary symptoms

MCQs VIA WEB 2005

By A. H.

right iliac fossa pain and urinary frequency (True)Explanation: Pain may be relieved by defaecationabdominal distension, flatulence and pellety stools (True)

Explanation: May be tenesmus, mucus PR and diarrhoea

Question 39. The management of the irritable bowel syndrome should includeexplanation and reassurance after a detailed clinical examination (True)Explanation: Probably the most important therapeutic toolsbarium enema and barium follow-through examinations in all patients (False)

Explanation: Investigations are important in older patientsevaluation of social and emotional factors (True)

Explanation: Anxiety and/or depression are often associated with refractory symptomsreferral for psychiatric assessment and therapy (False)

Explanation: Although occasionally psychiatric intervention may be necessarydihydrocodeine for abdominal pain and diarrhoea (False)

Explanation: Use loperamide, a safer opioid that does not cross the blood-brain barrier

Question 40. Typical features of colonic diverticulosis includepredominant involvement of the right hemicolon (False)Explanation: Sigmoid colon is most commonly involvedpredisposition to the development of colonic carcinoma (False)

Explanation: No causative associationcomplications are more common in patients receiving NSAID therapy (True)

Explanation: Especially bleeding and perforationreduction in the number of diverticula with a high-fibre diet (False)

Explanation: But symptoms may be improvedthe absence of symptoms in the absence of complications (True)

Explanation: Such as acute diverticulitis

Question 41. Typical features of colonic diverticulitis includesevere rectal bleeding (True)Explanation: Exclusion of malignancy may be necessarychronic iron deficiency anaemia (False)

Explanation: But this may be a feature of chronic diverticulosissepticaemia and paralytic ileus (True)

Explanation: With or without perforationright iliac fossa pain (False)

Explanation: Left iliac fossa or hypogastric pain is typicalvesicocolic fistula (True)

Explanation: Or enterocolic or colovaginal

Question 42. Typical features of pseudomembranous colitis includeonset within two weeks of antibiotic therapy (True)Explanation: Occurs from 4 days to 6 weeks post-antibioticsnormal appearance of the rectal mucosa (False)

Explanation: Usually appears as a non-specific proctitisClostridium difficile toxin in the stool (True)presentation with abdominal pain and diarrhoea (True)

Explanation: And even bloody diarrhoeaclinical relapse despite prompt treatment (True)

Explanation: Treated with metronidazole or vancomycin

Question 43. Familial adenomatous polyposis isinherited as an autosomal recessive trait (False)Explanation: Autosomal dominant with a prevalence of 1 in 14 000usually clinically apparent before the age of 10 years (False)

Explanation: Typically presents in the age group 20-40 years

MCQs VIA WEB 2005

By A. H.

likely to progress to carcinoma before the age of 40 years (True)Explanation: Carcinoma is usually present when symptoms commenceassociated with gastric and small bowel polyps (True)

Explanation: Also with lipomas, epidermoid cysts, osteomas and desmoid tumoursbest treated with immunosuppressant therapy in patients aged < 20 years (False)

Explanation: Immunosuppressives have no role; prophylactic colectomy is warranted

Module 18 (Chapter 18)Question 1. Bilirubin isderived exclusively from the breakdown of haemoglobin (False)Explanation: Also from catabolism of other haem-containing proteins (e.g. myoglobin)bound in the unconjugated form to plasma â-globulin (False)

Explanation: Bound to albuminconjugated in the microsomes of the hepatocytes (True)

Explanation: By enzymes of the smooth endoplasmic reticulumreabsorbed in the small bowel as bilirubin diglucuronide (False)

Explanation: Only reabsorbed after metabolism to stercobilinogennormally excreted as stercobilinogen in the faeces and as urobilinogen in the urine (True)

Explanation: And as the oxidation products stercobilin and urobilin

Question 2. The concentration of conjugated bilirubin in theserum in haemolytic anaemia is typically increased (False)Explanation: Unconjugated hyperbilirubinaemiaurine of healthy subjects is typically undetectable (True)

Explanation: As almost all bilirubin is unconjugated and albumin-boundserum normally constitutes most of the total serum bilirubin (False)

Explanation: Most of the serum bilirubin is unconjugatedserum in Gilbert's syndrome is typically increased (False)

Explanation: Unconjugated bilirubin is increasedurine in viral hepatitis parallels that of urobilinogen (False)

Explanation: Urobilinogen is an unreliable indicator of hepatobiliary disease

Question 3. The serum alanine aminotransferase (ALT) concentration isderived from a microsomal enzyme specific to hepatocytes (False)Explanation: Neither ALT nor AST is specific to the livertypically more than six times normal in alcoholic hepatitis (False)

Explanation: Not usually > three times normalusually normal in both obstructive and haemolytic jaundice (False)

Explanation: May be elevated in eitherlikely to rise and fall in parallel with the serum bilirubin in viral hepatitis (False)

Explanation: Changes in serum ALT precede changes in the serum bilirubinlikely to increase in response to enzyme-inducing drug therapy (False)

Explanation: Only the gamma-glutamyl transferase levels increase

Question 4. The serum alkaline phosphatase concentration isderived from the liver, bone, small bowel and placenta (True)Explanation: Therefore not specific to liver diseasetypically increased to more than six times normal in viral hepatitis (False)

Explanation: Not usually > 2.5 times normalderived mainly from hepatic sinusoidal and canalicular membranes (True)

Explanation: Excess synthesis in cholestasisof particular prognostic value in chronic liver disease (False)

Explanation: No prognostic valueincreased more in extrahepatic than in intrahepatic cholestasis (False)

Explanation: No site-specific pattern

MCQs VIA WEB 2005

By A. H.

Question 5. In the investigation of suspected liver diseaseultrasonography reliably distinguishes solid from cystic masses (True)ultrasonography reliably excludes liver disease (False)

Explanation: May appear normal in diseasenormal liver function values exclude significant liver disease (False)

Explanation: May be normal in 10-15% of patients with cirrhosisthe mortality rate of percutaneous liver biopsy is about 5% (False)

Explanation: Approximately 0.05%ascitic protein concentrations > 25 g/l are compatible with a diagnosis of carcinomatosis (True)

Explanation: And tuberculosis and hepatic vein obstruction; protein concentration < 30 g/l = transudate

Question 6. Characteristic features of Gilbert's syndrome includean autosomal recessive mode of inheritance (False)Explanation: Typically autosomal dominantdecreased hepatic glucuronyl transferase activity (True)

Explanation: Causing failure of bilirubin conjugationunconjugated hyperbilirubinaemia < 100 µmol/l (True)

Explanation: And no abnormality of other liver function testsserum bilirubin concentration increased by fasting (True)

Explanation: Sometimes used as a diagnostic testincreased serum bile acid concentrations (False)

Explanation: Unconjugated hyperbilirubinaemia is the sole abnormality

Question 7. Characteristic features of cholestatic jaundice includedark green stools (False)Explanation: Typically pale stools-steatorrhoeadark brown urine (True)

Explanation: Due to conjugated bilirubinuriaunconjugated hyperbilirubinaemia (False)

Explanation: Conjugated hyperbilirubinaemiaserum alkaline phosphatase concentration > 2.5 times normal (True)

Explanation: Diagnostic featureincreased serum bile acid concentrations (True)

Question 8. Typical causes of extrahepatic cholestatic jaundice includesclerosing cholangitis (False)Explanation: Intrahepaticprimary biliary cirrhosis (False)

Explanation: Intrahepaticcystic fibrosis (True)

Explanation: Common bile duct obstruction from chronic pancreatitisalcoholic cirrhosis (False)

Explanation: Intrahepaticnon-alcoholic steatohepatitis (False)

Explanation: Rarely causes jaundice

Question 9. The following features suggest extrahepatic cholestasis rather than viral hepatitisa palpable gallbladder (True)Explanation: E.g. pancreatic carcinomaright hypochondrial tenderness (False)

Explanation: Also common in acute hepatitisserum alkaline phosphatase concentration > 2.5 times normal (True)pruritus and rigors (True)

Explanation: Suggests obstruction with cholangitisperipheral blood polymorph leucocytosis (True)

Explanation: Sometimes relative lymphocytosis in viral hepatitis

MCQs VIA WEB 2005

By A. H.

Question 10. The typical causes of macrovesicular steatosis includealcohol misuse (True)

Explanation: Often asymptomaticpregnancy (False)

Explanation: Microvesicular steatosisReye's syndrome (False)

Explanation: Microvesicular steatosissevere malnutrition (True)

Explanation: Steatohepatitis (macrovesicular steatosis with hepatocyte necrosis) can be seriousdiabetes mellitus (True)

Explanation: Common and benign

Question 11. The typical features of type A viral hepatitis (HAV) includepicornavirus infection spread by the faecal-oral route (True)an incubation period of 3 months (False)

Explanation: 2-4 weeksa greater risk of acute liver failure in the young than in the old (False)

Explanation: But children are more frequently infectedright hypochondrial pain and tenderness (True)

Explanation: Non-specific findings of acute hepatitisprogression to cirrhosis if cholestasis is prolonged (False)

Explanation: Chronic hepatitis does not occur

Question 12. The following statements about type A viral hepatitis are truepersistent viraemia produces the post-hepatitis syndrome (False)Explanation: Viraemia is only transient in hepatitis Arelapsing hepatitis usually indicates a poorer prognosis (False)

Explanation: Spontaneous recovery is the typical outcomethe virus is not usually transmitted via infected blood (True)

Explanation: But a recognised raritydrug-induced acute hepatitis produces similar liver histology (True)

Explanation: Serological investigations should help distinguishtravellers given immune serum globulin are protected for 3 months (True)

Explanation: Some will have natural endogenous protection

Question 13. Circulating hepatitis B surface antigen (HBsAg) isdetectable during the prodrome of acute type B hepatitis (True)Explanation: A reliable marker of hepatitis B infectiona DNA viral particle transmissible in all body fluids (True)

Explanation: A DNA hepadna viruslikely to persist in about 50% of adults following acute type B hepatitis (False)

Explanation: Chronic carriage occurs in 5-10% of adultsinvariably present in a patient with jaundice attributable to type B hepatitis infection (False)

Explanation: Alternative serological evidence of infection should be soughtcommoner in asymptomatic subjects in the Western rather than the Eastern hemisphere (False)

Explanation: Carriage rates are highest in the Middle East and Far East

Question 14. The typical features of type B viral hepatitis (HBV) includean incubation period of 1 month (False)Explanation: Average incubation 3 monthshistory of exposure to unsafe sex or drug misuse (True)

Explanation: Or other exposure to blood or blood productsprodromal illness with polyrtharalgia (True)

Explanation: May cause serum sicknesshepatitic illness more severe than with type A virus (True)

Explanation: Hepatitis A is usually a mild illness

MCQs VIA WEB 2005

By A. H.

absence of progression to chronic hepatitis (False)Explanation: And hepatic cirrhosis also occurs

Question 15. In hepatitis C (HCV)a chronic carriage rate of > 50% is the rule (True)Explanation: With varying degrees of severitythe infecting agent is an RNA flavivirus (True)the disease does not progress to chronic hepatitis (False)

Explanation: Hepatitis C may progress to chronic diseasemost patients experience the symptoms of acute hepatitis (False)

Explanation: Most patients are asymptomatic; incubation period is 2-26 weeksthe virus is responsible for 90% of all post-transfusion hepatitis (True)

Explanation: Although serological screening methods have greatly reduced this

Question 16. The typical features of acute (fulminant) hepatic failure includeonset within 8 weeks of the initial illness (True)Explanation: Without evidence of pre-existing liver diseasehepatosplenomegaly and ascites (False)

Explanation: Suggest chronic liver diseaseencephalopathy and fetor hepaticus (True)

Explanation: With confusion and asterixis (liver flap)nausea, vomiting and renal failure (True)

Explanation: Renal failure is an ominous developmentcerebral oedema without papilloedema (True)

Explanation: Occurs late, if at all

Question 17. Typical liver function values in acute hepatic failure includehypoalbuminaemia (False)Explanation: Serum albumin has a long half-lifehypoglycaemia (True)

Explanation: Impaired hepatic gluconeogenesisprolonged prothrombin time (True)

Explanation: Useful in determining prognosisserum alkaline phosphatase > 6 times normal (False)

Explanation: Typically not so elevated, unlike the serum transaminasesperipheral blood lymphocytosis (False)

Explanation: May be a polymorphonuclear leucocytosis

Question 18. The clinical features of autoimmune hepatitis includean association with autoimmune thyroiditis (True)

Explanation: Type I autoimmune liver disease is associated with Graves' disease and Hashimoto's thyroiditisacute onset simulating viral hepatitis in 25% of patients (True)

Explanation: Occurs in 25% of patients but symptoms and signs then persistarthralgia, fever and amenorrhoea (True)

Explanation: And fatigue, anorexia and jaundicespider telangiectasia and hepatosplenomegaly (True)

Explanation: And other signs of chronic liver diseaseCushingoid facies, hirsutism and acne (True)

Explanation: Altered steroid hormone metabolism

Question 19. The typical features of hepatic cirrhosis includea small shrunken liver (True)Explanation: Liver size reduces as disease progressespainful splenomegaly (False)

Explanation: Painless splenomegaly due to portal hypertensionperipheral blood macrocytosis (True)

Explanation: Particularly in alcoholic liver disease

MCQs VIA WEB 2005

By A. H.

parotid gland enlargement (True)Explanation: Particularly in alcoholic cirrhosiscentral cyanosis (True)

Explanation: Hepatopulmonary syndrome associated with pulmonary telangiectasia

Question 20. Typical features of hepatic encephalopathy includedisordered sleep and loss of concentration (True)Explanation: Grade 1aggressive behaviour and personality change (True)

Explanation: Grade 2yawning and hiccuping (True)

Explanation: And asterixis (hepatic flap)drowsiness and disorientation (True)

Explanation: Grade 3confusion progressing to coma (True)

Explanation: Grade 4

Question 21. Causes of ascites in the absence of intrahepatic liver disease includecongestive cardiac failure (True)Explanation: Also constrictive pericarditis-transudatenephrotic syndrome (True)

Explanation: Also protein-losing enteropathy-transudateperitoneal tuberculosis (True)

Explanation: Also carcinomatosis-exudatelymphatic obstruction (True)

Explanation: Chylous effusionBudd-Chiari syndrome (True)

Explanation: Transudate associated with hepatic vein occlusion

Question 22. In the management of ascites due to hepatic cirrhosisthe dietary sodium intake should be restricted to 140 mmol/day (False)Explanation: Restriction < 40 mmol/day is usually requiredparacentesis and parenteral albumin replacement improve the survival rate (False)

Explanation: A palliative, symptomatic measure with no prognostic valuethe daily calorie intake should be restricted to 1500 calories (False)

Explanation: Calorie restriction is neither required nor desirablediuretic therapy should achieve a daily weight loss of at least 2.5 kg (False)

Explanation: Daily weight loss > 1 kg may precipitate renal impairment and/or encephalopathythe protein intake should be at least 40 g/day unless encephalopathy is suspected (True)

Explanation: Restriction may be necessary to control encephalopathy

Question 23. Causes of portal hypertension includealcoholic cirrhosis (True)Explanation: Intrahepatic parenchymalmyeloproliferative disease (True)

Explanation: Intrahepatic pre-sinusoidalhepatic schistosomiasis (True)

Explanation: Intrahepatic pre-sinusoidal; also sarcoidosisabdominal trauma (True)

Explanation: Extrahepatic pre-sinusoidal (portal vein thrombosis)hepatic vein obstruction (Budd-Chiari syndrome) (True)

Explanation: Extrahepatic post-sinusoidal

Question 24. Complications of portal hypertension includevariceal haemorrhage (True)Explanation: Oesophageal, gastric, stomal and rectal varicescongestive gastropathy (True)

MCQs VIA WEB 2005

By A. H.

Explanation: Associated with hypergastrinaemiahepatorenal failure (True)

Explanation: Associated with reduced renal blood flowhepatic encephalopathy (True)ascites (True)

Explanation: And hypersplenism

Question 25. In the management of acute variceal bleeding due to hepatic cirrhosisthe priority is to restore normovolaemia (True)Explanation: Untreated, shock dramatically reduces liver blood flow and liver functionpharmacological therapy is more effective than variceal banding or sclerotherapy (False)

Explanation: Local measures stop bleeding in 80% of patientssomatostatin (octreotide) and vasopressin both reduce portal venous pressure (True)

Explanation: Constrict splanchnic arterioles; glyceryl trinitrate is given to reduce vasoconstrictionballoon tamponade is best undertaken after endoscopic confirmation of bleeding varices (True)

Explanation: Unless the patient is exsanguinating; 20% of patients are bleeding from non-variceal causestransjugular intrahepatic portosystemic stent shunting (TIPSS) is contraindicated in hepatic failure (False)

Explanation: TIPSS is used when local measures fail and has replaced emergency shunt surgery

Question 26. Prevention of recurrent variceal bleeding is achievable usingsomatostatin (octreotide) therapy (False)Explanation: Somatostatin may be useful in acute bleedsTIPSS (True)

Explanation: Also used in acute variceal bleedingâ-adrenoceptor antagonist (â-blocker) treatment (True)

Explanation: â-blockers reduce portal pressurevariceal banding (True)

Explanation: Better than sclerotherapy in the elective situationsclerotherapy (True)

Explanation: Easier than banding in the emergency situation

Question 27. In primary biliary cirrhosismiddle-aged males are affected predominantly (False)

Explanation: Middle-aged femalespruritus is invariably accompanied by jaundice (False)

Explanation: May precede jaundice by months or yearsosteomalacia and osteoporosis both occur as the disease progresses (True)

Explanation: Vitamin D malabsorption and hepatic osteodystrophyrigors and abdominal pain are presenting features (False)

Explanation: Suggests obstruction of large bile ductsmooth muscle antibodies are present in high titres in the serum (False)

Explanation: High titres of antimitochondrial antibody

Question 28. The typical features of primary haemochromatosis includeassociation with an autosomal dominant pattern of inheritance (False)Explanation: Inherited as an autosomal recessive gene located on chromosome 6male predominance (True)

Explanation: 90% are males; females may be protected by menstruation and pregnancyhepatic cirrhosis and diabetes mellitus (True)

Explanation: 'Bronzed diabetes'congestive cardiomyopathy (True)

Explanation: May be a congestive cardiomyopathygrey skin pigmentation due to ferritin deposition (False)

Explanation: Melanin not iron deposition

Question 29. The typical features of Wilson's disease includehaemolytic anaemia (True)

MCQs VIA WEB 2005

By A. H.

Explanation: Sometimes accompanying an acute hepatitis in childrenacute hepatitis and chronic hepatitis (True)

Explanation: Or acute hepatic failure or cirrhosisparkinsonian syndrome and hepatic cirrhosis (True)

Explanation: A variety of extrapyramidal syndromes may be seenKayser-Fleischer rings (True)

Explanation: Kayser-Fleischer rings are an important diagnostic cluerenal tubular acidosis (True)

Explanation: Copper is deposited in the liver and kidneys

Question 30. The typical features of alcoholic liver disease includemicrovesicular steatosis (False)Explanation: Macrovesicular steatosis is the earliest stage when abstinence will achieve a good prognosisacute hepatitis and chronic hepatitis (True)

Explanation: 33% mortality if liver dysfunction is severehepatic cirrhosis (True)

Explanation: 50% 5-year survival after the initial presentation if abstinentcholestatic jaundice (True)

Explanation: Often associated with tender hepatomegaly and abdominal painalcohol intake > 30 g/day for > 5 years (True)

Explanation: Usually associated with at least 50 g/day for at least 10 years

Question 31. The typical features of hepatocellular carcinoma includefever, weight loss and abdominal pain (True)Explanation: Abdominal pain and a cirrhotic liver suggest hepatomaascites and intra-abdominal bleeding (True)

Explanation: Tumours are vascular and spread locallyarterial bruit over the liver (True)

Explanation: There may also be a hepatic rubrising serum á-fetoprotein titre (True)

Explanation: Rises in 90% of casessurgically resectable disease in 50% of patients (False)

Explanation: Only 10% are suitable for surgery

Question 32. Pyogenic liver abscess is a recognised complication ofascending cholangitis (True)Explanation: Secondary to biliary obstructionCrohn's disease (True)

Explanation: Secondary to portal pyaemiapancreatitis (True)

Explanation: Acute pancreatitissepticaemia (True)

Explanation: Infection via hepatic arterysubphrenic abscess (True)

Explanation: Direct local spread

Question 33. The typical features of pyogenic liver abscess includeobstructive jaundice and pruritus (False)Explanation: Jaundice is usually mild and not often obstructivetender hepatomegaly without splenomegaly (True)

Explanation: Splenomegaly suggests coexistent pathologypleuritic pain and pleural effusion (True)

Explanation: May be right shoulder tip painmultiple abscesses, especially in ascending cholangitis (True)

Explanation: Single lesions are more common in the right liverEscherichia coli, anaerobes and streptococci present in pus (True)

Explanation: Multiple organisms in one-third of cases

MCQs VIA WEB 2005

By A. H.

Question 34. Gallstones are a recognised complication ofobesity (True)Explanation: Increased hepatic cholesterol secretionpregnancy (True)

Explanation: Increased hepatic cholesterol secretion and impaired gallbladder motilitychronic haemolytic anaemia (True)

Explanation: Pigment stonesterminal ileal disease (True)

Explanation: Pigment stonesrapid weight loss (True)

Explanation: Increased hepatic cholesterol secretion

Question 35. The typical clinical features of acute cholecystitis includejaundice, nausea and vomiting (False)Explanation: Jaundice occurs in less than 20% even in the absence of stones (Mirizzi's syndrome)colicky abdominal pain in spasms lasting about 5 minutes (False)

Explanation: Pain is typically continuous for up to 6 hoursright hypochondrial tenderness worse on inspiration (True)

Explanation: Murphy's signair in the biliary tree on plain radiograph (False)

Explanation: May follow passage of a gallstone into intestine or biliary surgeryperipheral blood leucocytosis (True)

Explanation: May be absent in the elderly

Question 36. The post-cholecystectomy syndrome is characteristically associated withpatients with previous acalculous cholecystitis (True)Explanation: Less common in patients with previous typical biliary colic and gallstonesfemales with a history of abdominal pain > 5 years in duration (True)

Explanation: Associated with the irritable bowel syndrome and functional dyspepsiaretained stones in the common bile duct (True)

Explanation: Hence the need to investigate this possibilitydysfunction of the sphincter of Oddi (False)

Explanation: This abnormality may not be causal and may in fact result from cholecystectomyearly postoperative complications (True)

Explanation: Suggest the possibility of a biliary stricture

Module 19 (Chapter 19)Question 1. Peripheral blood lymphocytosis would be an expected finding inbrucellosis (True)Explanation: Often with neutropeniapneumococcal pneumonia (False)

Explanation: Polymorphonuclear leucocytosismeasles and rubella (True)

Explanation: Non-specific feature of many viral infectionsHodgkin's disease (False)

Explanation: Non-Hodgkin's lymphomachronic lymphatic leukaemia (True)

Explanation: Predominantly small lymphocytes

Question 2. Peripheral blood neutrophil leucocytosis would be an expected finding inconnective tissue disease (True)Explanation: Or may be neutropenia in systemic lupus erythematosuscorticosteroid therapy (True)

Explanation: And lithium therapypregnancy (True)

Explanation: Variable, increases at delivery

MCQs VIA WEB 2005

By A. H.

whooping cough (False)Explanation: Typically lymphocytosismesenteric infarction (True)

Explanation: And myocardial infarction

Question 3. Plateletshave a circulation lifespan of 10 hours in healthy subjects (False)Explanation: 10-day lifespanare produced and regulated under the control of thrombopoietins (True)

Explanation: By the megakaryocytescontain small nuclear remnants called Howell-Jolly bodies (False)

Explanation: Found in red blood cellsdecrease in number in response to aspirin therapy (False)

Explanation: May increaserelease 5-hydroxytryptamine (5-HT, serotonin) and von Willebrand factor (vWF) (True)

Explanation: 5-HT (delta granules), and vWF and fibrinogen (alpha granules)

Question 4. The following statements about red blood cell morphology are truehypochromia is pathognomonic of iron deficiency (False)Explanation: Seen in other disorders of haemoglobin synthesis (e.g. thalassaemia)polychromasia indicates active production of new red blood cells (True)

Explanation: Residual ribosomal material is stained faintlypoikilocytosis is invariably associated with anisocytosis (True)

Explanation: Sign of dyserythropoiesispunctate basophilia is a typical feature of beta-thalassaemia (True)

Explanation: And lead poisoningtarget cells are associated with hyposplenism and liver disease (True)

Explanation: And haemoglobinopathies

Question 5. Peripheral blood findings in dietary iron deficiency includemicrocytosis (True)Explanation: Microcytosis is the first signovalocytosis (True)

Explanation: Sometimes poikilocytosismean corpuscular haemoglobin concentration < 50% of normal (False)

Explanation: Only in severe anaemia; hypochromia is due to microcytosisHowell-Jolly bodies (False)

Explanation: Suggests hyposplenismthrombocytosis (True)

Explanation: Thrombocytosis occurs even in the absence of bleeding

Question 6. In the treatment of iron deficiency anaemia with ironfolic acid should also be given if the anaemia is severe (False)Explanation: Only if coexistent deficiency demonstratedtreatment is stopped as soon as haemoglobin normalises (False)

Explanation: Continue for 3 months to replenish storeshaemoglobin should rise by 1 g/l every 7-10 days (False)

Explanation: 10 g/l every 10 days unless there is malabsorption, bleeding or poor compliancemaximal reticulocyte count usually develops within 1-2 days (False)

Explanation: Peak reticulocyte count at 7-10 daysparenteral iron is usually more effective than oral iron (False)

Explanation: Oral iron is usually effective

Question 7. Hypochromic microcytic anaemia is a recognised finding inhaemolytic anaemia (False)Explanation: Macrocytic with polychromasiamyelodysplastic syndrome (True)

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By A. H.

Explanation: Typically a dimorphic red cell populationhypothyroidism (False)

Explanation: Typically macrocyticbeta-thalasaemia (True)

Explanation: And other thalassaemiasrheumatoid arthritis (True)

Explanation: Or a normochromic normocytic picture

Question 8. Normocytic normochromic anaemia is an expected feature ofalcoholic liver disease (False)Explanation: Typically macrocyticchronic renal failure (True)

Explanation: Erythropoietin deficiencyrheumatoid arthritis (True)

Explanation: Typically macrocytickwashiorkor (True)

Explanation: Protein-energy malnutritionstrict vegetarianism (False)

Explanation: Anaemia is rare in modest reductions of dietary vitamin B12 intake

Question 9. Macrocytic anaemia is a typical finding infolic acid deficiency (True)Explanation: With megaloblastic marrowhaemolytic anaemia (True)

Explanation: With polychromasiaalcohol misuse (True)

Explanation: With or without cirrhosisprimary sideroblastic anaemia (False)

Explanation: Dimorphic, with microcytic populationmyelodysplastic syndrome (True)

Explanation: But variable red cell morphology

Question 10. Typical haematological findings in megaloblastic anaemia includepancytopenia and oval macrocytosis (True)Explanation: Commonly due to vitamin B12 deficiencyneutrophil leucocyte hypersegmentation (True)

Explanation: Shift to the right in the nuclear segmentation count (Arneth count)anisocytosis and poikilocytosis (True)

Explanation: And red cell fragmentationreticulocytosis and polychromasia (False)

Explanation: Features of bleeding or haemolysisexcess urinary urobilinogen and bilirubinuria (False)

Explanation: Bilirubinuria is not a feature of any anaemia

Question 11. Folate and vitamin B12 deficiency both typically producesubacute combined degeneration of the spinal cord (False)Explanation: Feature of vitamin B12 deficiency onlyintermittent glossitis and diarrhoea (True)

Explanation: Glossitis less common in folate deficiencymild jaundice and splenomegaly (True)

Explanation: Mild haemolysisperipheral neuropathy (True)marked weight loss (True)

Explanation: Partially dependent on underlying cause

Question 12. Characteristic features of Addisonian pernicious anaemia includeonset before the age of 20 years (False)

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By A. H.

Explanation: Typically 45-65 yearsgastric parietal cell and intrinsic factor antibodies in the serum (True)

Explanation: Found in 90% and < 50% respectivelyincreased serum bilirubin and lactate dehydrogenase concentrations (True)

Explanation: Mild haemolysis occursfour-fold increase in the risk of developing gastric carcinoma (True)

Explanation: Associated gastric atrophySchilling test usually reverts to normal with intrinsic factor (True)

Explanation: Failure to correct suggests terminal ileal disease

Question 13. Causes of folic acid deficiency includevegetarian diet (False)Explanation: Caused by inadequate vegetable intakegluten enteropathy (True)

Explanation: Characteristic findingpregnancy (True)

Explanation: Increased requirementshaemolytic anaemia (True)

Explanation: Increased requirementsantibiotic therapy (False)

Explanation: Methotrexate and phenytoin may cause folate deficiency

Question 14. Characteristic features of primary aplastic anaemia includepeak incidence in the elderly (False)Explanation: Peaks about 30 years of agenormocytic normochromic anaemia with thrombocytosis (False)

Explanation: Thrombocytopeniabone marrow trephine is required to confirm the diagnosis (True)

Explanation: Diagnosis cannot be made on peripheral blood film alonesplenomegaly indicating extramedullary erythropoiesis (False)

Explanation: Splenomegaly occurs in under 10% of casespancytopenia (True)

Explanation: Typical

Question 15. Typical features suggesting intravascular haemolysis includebilirubinuria and haemoglobinuria (False)Explanation: Bilirubin is unconjugated therefore not found in urinemethaemalbuminaemia and haemosiderinuria (True)

Explanation: The latter always indicating intravascular haemolysisincreased serum haptoglobin concentration (False)

Explanation: Decreased serum haptoglobinincreased plasma haemoglobin concentration (True)

Explanation: Most is bound to serum haptoglobinsplenomegaly (True)

Explanation: Often with reticulocytosis

Question 16. Laboratory features suggesting haemolytic anaemia includeincreased serum lactate dehydrogenase (LDH) concentration (True)Explanation: Red cells are rich in LDHconjugated hyperbilirubinaemia and bilirubinuria (False)

Explanation: Unconjugated hyperbilirubinaemia and excess urobilinogen in the urineperipheral blood neutrophil leucocytosis (True)

Explanation: Also red cell abnormalities (e.g. spherocytes)peripheral blood polychromasia and macrocytosis (True)

Explanation: Reflects reticulocytosisbone marrow erythroid hyperplasia (True)

Explanation: With megaloblastic change if folate deficiency is also present

MCQs VIA WEB 2005

By A. H.

Question 17. Typical features of hereditary spherocytosis includesplenomegaly (True)Explanation: Also pigment gallstonesintravascular haemolysis (False)

Explanation: Red blood cell destruction occurs in the spleendecreased red blood cell osmotic fragility (False)

Explanation: Osmotic fragility is increasedtransient aplastic anaemia (True)

Explanation: Often in association with parvovirus infectiondeficiency of red cell spectrin (True)

Explanation: Red blood cell membrane protein

Question 18. The typical clinical features of sickle-cell anaemia includehaemolytic and aplastic crises (True)Explanation: Often precipitated by viral infectionneonatal spherocytic haemolytic anaemia (False)

Explanation: Not until HbF levels fall after the age of 3 monthspulmonary, splenic and mesenteric infarcts (True)

Explanation: Causing pleuritic pain and also renal infarctssplenomegaly with hypersplenism (False)

Explanation: Splenic atrophy and functional hyposplenismbone necrosis and osteomyelitis (True)

Explanation: Painful bone infarcts

Question 19 In patients with sickle-cell disease, acute painful crises are likely to be precipitated byhigh altitude (True)Explanation: Decreased PaO2pregnancy (True)

Explanation: May present as pseudo-toxaemia syndromedehydration (True)

Explanation: Rehydration is an essential component of therapysystemic infection (True)

Explanation: Treat promptly to prevent sickle-cell criseshypoxia (True)

Question 20. The typical features of the beta-thalassaemias includemacrocytic anaemia (False)Explanation: Typically hypochromic microcytic anaemiahepatosplenomegaly (True)

Explanation: In the 'major' (homozygous) formpigment gallstones (True)

Explanation: Pigment gallstones can be associated with chronic haemolysisneonatal haemolytic anaemia (False)

Explanation: Not until HbF synthesis declinesbone infarcts (False)

Explanation: Unlike sickle cell disease

Question 21. The typical features of autoimmune haemolytic anaemia includeperipheral blood spherocytosis and splenomegaly (True)Explanation: Characteristichaemoglobinuria and haemosiderinuria (True)

Explanation: Suggesting intravascular haemolysisincreased serum haptoglobin concentration (False)

Explanation: Decreased serum haptoglobin concentrationpositive Coombs test (True)

Explanation: Warm usually IgG, cold usually IgMassociation with lymphoproliferative disease (True)

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By A. H.

Explanation: Chronic lymphatic leukaemia, lymphoma and also systemic lupus erythematosus

Question 22. The typical features of polycythaemia rubra vera includepeak prevalence aged > 40 years (True)splenomegaly, leucocytosis and thrombocytosis (True)

Explanation: And elevated red cell massheadaches, pruritus and peptic ulcer dyspepsia (True)

Explanation: But may be asymptomaticdecreased leucocyte alkaline phosphatase score (False)

Explanation: A feature of chronic myeloid leukaemiaincreased blood viscosity associated with vascular disease (True)

Explanation: E.g. increased risk of stroke

Question 23. Acute lymphoblastic leukaemia (ALL)has a peak prevalence in patients aged 20-30 years (False)Explanation: Peaks in childhoodtypically produces cytoplasmic Auer rods in blast cells (False)

Explanation: Acute myeloblastic leukaemia (AML)has a median survival of 30 months with chemotherapy (True)

Explanation: AML has a 40% 5-year survival with chemotherapyis the most common of all acute leukaemias (False)

Explanation: AML is four times more common than ALLis a typical complication of multiple myeloma (False)

Explanation: May complicate myelofibrosis

Question 24. Clinical features of chronic myeloid leukaemia (CML) includepainful splenomegaly (True)Explanation: Splenomegaly in 90% of casesgout and arthralgia (True)

Explanation: Hyperuricaemia is often asymptomaticgeneralised lymphadenopathy (False)

Explanation: Atypical featuretendency to bleeding and bruising (True)

Explanation: Variable platelet dysfunctionmedian survival of 15 years with chemotherapy (False)

Explanation: Median survival 5 years

Question 25. The typical laboratory findings in chronic myeloid leukaemia includeleucoerythroblastic anaemia and thrombocytosis (True)Explanation: Platelet count falls after blast transformationperipheral blood neutrophilia, eosinophilia and basophilia (True)chromosomal translocation q-22/q+9 (True)

Explanation: Philadelphia chromosomeincreased neutrophil leucocyte alkaline phosphatase (LAP) score (False)

Explanation: Usually decreased LAP scoretransformation to acute leukaemia (True)

Explanation: Transformation results to either ALL (30%) or acute myeloid leukaemia (AML) (70%)

Question 26. Typical features of chronic lymphocytic leukaemia includeonset in younger patients than in chronic myeloid leukaemia (False)Explanation: Peak age 65 yearsdevelopment of autoimmune haemolytic anaemia (True)

Explanation: Typically warm antibodypresentation with massive hepatosplenomegaly (False)

Explanation: Mild organomegaly onlylymphadenopathy associated with recurrent infections (True)

Explanation: Bacterial more than viral

MCQs VIA WEB 2005

By A. H.

median survival of 15 years following chemotherapy (False)Explanation: Overall median survival 6 years

Question 27. The typical laboratory features in chronic lymphocytic leukaemia includehyperuricaemia and thrombocytosis (False)Explanation: Mild thrombocytopenia with urate usually normalhypogammaglobulinaemia (True)

Explanation: Associated with a paraproteinaemia in 5%peripheral blood lymphocytosis in the absence of lymphoblasts (True)

Explanation: Total WCC typically 50-200 × 109/lpositive Coombs test (True)

Explanation: May be associated with haemolysistransformation to acute leukaemia (False)

Explanation: Transformation is rare

Question 28. Allogeneic bone marrow transplantation is particularly useful in the treatment ofmultiple myeloma (True)Explanation: Also useful in acute myelofibrosissevere aplastic anaemia (True)alpha-thalassaemia (True)

Explanation: All severe thalassaemiassevere combined immunodeficiency disorder (True)chronic lymphocytic leukaemia (False)

Explanation: But useful in most other acute and chronic leukaemias

Question 29. Complications of allogeneic bone marrow transplantation includeacute graft-versus-host disease (True)Explanation: Usually occurs 2-3 weeks after the graft and is associated with infectionsevere infection (True)

Explanation: A major problem, especially with viruses and atypical microorganismsinfertility (True)

Explanation: Important given the age of many of the patientspneumonitis (True)malignant disease during long-term follow-up (True)

Question 30. The presence of lymphadenopathy and splenomegaly would be expected findings inmultiple myeloma (False)Explanation: Neither is characteristicchronic lymphocytic leukaemia (True)

Explanation: Mild splenomegaly, generalised lymphadenopathychronic myeloid leukaemia (False)

Explanation: Moderate to massive splenomegaly, no lymphadenopathyinfectious mononucleosis (True)

Explanation: Usually both mildmyelofibrosis (False)

Explanation: Splenomegaly without lymphadenopathy

Question 31. Recognised clinical features of multiple myeloma includepeak incidence between the ages of 30 and 50 years (False)Explanation: Peak prevalence in males aged 60-70 yearssecondary amyloidosis (True)

Explanation: Amyloidosis occurs in 10% of casesmedian survival > 10 years with chemotherapy (False)

Explanation: Median survival of 40 monthsrecurrent infections and pancytopenia (True)

Explanation: Reduction of normal plasma cells causes immunodeficiency

MCQs VIA WEB 2005

By A. H.

increased serum calcium, urate and blood urea (True)Explanation: All of which may be asymptomatic

Question 32. In differentiating multiple myeloma from a benign monoclonal gammopathy, the following findingswould favour the diagnosis of multiple myelomamonoclonal gammopathy with normal serum immunoglobulin levels (False)Explanation: Myeloma produces suppression of the other serum immunoglobulinsbone marrow plasmacytosis of > 20% (True)

Explanation: A diagnostic prerequisitebilateral carpal tunnel syndrome (True)

Explanation: Amyloidosis also causes a restrictive cardiomyopathyBence Jones proteinuria (True)

Explanation: But the serum paraprotein may be undetectablemultiple osteolytic lesions on radiograph (True)

Explanation: Malignant infiltration is typically associated with a normal isotope bone scan

Question 33. The clinical features of Hodgkin's disease includepainless cervical lymphadenopathy (True)Explanation: Usually painlessanaemia due to bone marrow involvement (False)

Explanation: Unlike non-Hodgkin's lymphomaimpaired T-cell function in the absence of lymphopenia (True)

Explanation: Lymphopenia suggests poor prognosisfever and weight loss (True)

Explanation: Stage Bmedian survival > 10 years (True)

Explanation: Dependent on staging at presentation

Question 34. Typical characteristics of non-Hodgkin's lymphoma includelow-grade lymphomas rapidly produce symptoms due to high cell proliferation rates (False)Explanation: Indolent and often asymptomatic course with low cell proliferation ratesbone marrow and splenic involvement are present from the onset (True)

Explanation: Typically extranodal at diagnosisisolated involvement of gastric mucosa associated with Helicobacter pylori infection (True)

Explanation: MALToma may be cured by H. pylori eradicationthe majority are T-cell rather than B-cell in origin (False)

Explanation: 70% are B-cell tumoursbetter prognosis in high-grade rather than low-grade lymphomas (True)

Explanation: Prognosis is also stage- and age-dependent

Question 35. Recognised causes of thrombocytopenia includemegaloblastic anaemia (True)Explanation: Often with leucopeniaacquired immunodeficiency syndrome (True)

Explanation: Primary, or secondary to superimposed infectionsdisseminated intravascular coagulation (True)

Explanation: Increased peripheral consumption of plateletsvon Willebrand's disease (False)

Explanation: The platelet count is normalaspirin therapy (True)

Explanation: Also many commonly used drugs including heparin and â-blockers

Question 36. Typical features of idiopathic thrombocytopenic purpura includeIgG-mediated thrombocytopenia (True)Explanation: Can therefore be transmitted transplacentallypeak prevalence in patients aged > 60 years old (False)

Explanation: Usually the young and commoner in females

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By A. H.

prolongation of the bleeding time (True)Explanation: Other clotting tests normalsplenomegaly (False)

Explanation: Suggests other causes of thrombocytopeniaprompt response to corticosteroid therapy (True)

Explanation: Particularly in children

Question 37. The prothrombin time is typically prolonged indisorders of the intrinsic pathway (False)Explanation: The extrinsic pathwayfactor X deficiency (True)

Explanation: The Stuart-Prower factorfactor VII deficiency (True)

Explanation: First factor in extrinsic pathwayfactor V deficiency (True)

Explanation: Also affects the activated partial thromboplastin timefactor XII deficiency (False)

Explanation: Disorder of the intrinsic pathway

Question 38. The activated partial thromboplastin time (APTT) is typically prolonged indisorders of the extrinsic pathway (False)

Explanation: The intrinsic pathwayfactor VII deficiency (False)

Explanation: Detected by prothrombin timefactor VIII or X deficiency (True)

Explanation: Factor X also influences prothrombin timefactor XIII deficiency (False)

Explanation: Specific assay to measurefactor IX, XI or XII deficiency (True)

Explanation: Initial factors in the intrinsic system

Question 39. Disseminated intravascular coagulation is a complication ofamniotic fluid embolism (True)Explanation: Initiated by thromboplastinincompatible blood transfusion (True)

Explanation: An unusual complicationhypovolaemic and anaphylactic shock (True)

Explanation: Endothelial injurysepticaemic shock (True)

Explanation: Exogenous endotoxinscarcinomatosis (True)

Explanation: Commonly bronchial carcinoma

Question 40. The bleeding time is characteristically prolonged inascorbic acid deficiency (False)Explanation: Bleeding time is normal but petechial haemorrhages may occurthrombocytopenia (True)

Explanation: Irrespective of its causehaemophilia (False)

Explanation: No vessel wall or platelet defectwarfarin therapy (False)von Willebrand's disease (True)

Explanation: Secondary decrease in factor VIII level with a qualitative platelet defect

Question 41. The following statements about severe haemophilia A are truethe disorder is inherited in an X-linked recessive mode (True)Explanation: Prenatal diagnosis is possible

MCQs VIA WEB 2005

By A. H.

recurrent haemarthroses and haematuria are typical (True)Explanation: Usually not apparent until the age of 6 monthsactivated partial thromboplastin time and prothrombin time are both prolonged (False)

Explanation: Only the activated partial thromboplastin time is prolongedfactor VIII has a biological half-life of about 12 days (False)

Explanation: Half-life is 12 hoursdesmopressin therapy increases factor VIII concentrations (True)

Explanation: Desmopressin (DDAVP) therapy is useful to limit exposure to blood products

Question 42. The following statements about von Willebrand's disease are truethe disorder is inherited in an X-linked recessive mode (False)Explanation: Autosomal dominant-gene locus on chromosome 12it is characterised by a prolonged bleeding time (True)

Explanation: And secondary reduction in factor VIII levelsthe von Willebrand factor (vWF) is synthesised by both platelets and endothelial cells (True)vWF is a carrier protein which is bound to factor VIII (True)deficiency of vWF is best treated by desmopressin (True)

Explanation: Desmopressin (DDAVP) therapy increases vWF concentrations

Question 43. Thrombophilia with a predisposition to recurrent venous thromboses is associated withthe antiphospholipid antibody syndrome (True)Explanation: May present with recurrent spontaneous abortionantithrombin deficiency (True)

Explanation: Decreased inactivation of factors IIa, VIIa, IXa, Xa, XIa, causing heparin resistancefactor V Leiden (True)

Explanation: Prolonged factor V activation; factor II Leiden increases plasma prothrombin levelspolycythaemia rubra vera (True)

Explanation: And chronic myeloid leukaemia-both are associated with thrombocytosisprotein C deficiency (True)

Explanation: And protein S deficiency-reduced inactivation of factors Va and VIIIa

Question 44. Indications for warfarin anticoagulation includevenous thromboembolism (True)Explanation: Maintain the prothrombin ratio in the range 2.0-4.0arterial embolism (True)

Explanation: Less effective in non-embolic peripheral vascular diseasemyocardial infarction (False)

Explanation: Unless associated with mural thrombusatrial fibrillation (True)

Explanation: Reduces the risk of arterial embolismmechanical prosthetic heart valves (True)

Explanation: Reduces the risk of embolic clots and possibly endocarditis

Question 45. The hazards of blood transfusion includeurticaria (True)Explanation: Allergic reactioncardiac failure (True)

Explanation: Volume overload-in patients with previous CCF, give prophylactic diuretic therapydevelopment of Rhesus antibodies in a Rhesus-negative patient (True)

Explanation: Particularly important in women of child-bearing agefever (True)

Explanation: Allergic reaction to one or more of the constituents of the transfusionacute intravascular haemolysis (True)

Explanation: Major ABO incompatibility is the likeliest cause

Question 46. Clinical features suggesting an acute transfusion reaction includeonset within an hour of starting the transfusion (True)

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By A. H.

Explanation: Delayed haemolytic transfusion reaction occurs 5-7 days after the transfusionrigors and fever (True)

Explanation: Stop the transfusion immediatelychest and back pain (True)sudden loss of consciousness (False)

Explanation: Unlikely in the absence of other premonitory changesdevelopment of hypotension and shock (True)

Explanation: May be problematic in anaesthetised patients

Module 20 (Chapter 20)Question 1. The following diseases are associated with antinuclear and/or rheumatoid factor antibodiesinfective endocarditis (True)Explanation: Chronic infections (e.g. tuberculosis, leishmaniasis and schistosomiasis)autoimmune thyroiditis (True)

Explanation: Also found in myasthenia gravisSjögren's syndrome (True)

Explanation: And systemic lupus erythematosus, dermatomyositis and progressive systemic sclerosisfibrosing alveolitis (True)

Explanation: And autoimmune hepatitis and sarcoidosisankylosing spondylitis (False)

Explanation: And, by definition, all the seronegative spondyloarthritides

Question 2. The biochemical features listed below characterise the following metabolic bone disordersincreased serum calcium, serum phosphate and serum alkaline phosphatase-osteoporosis (False)Explanation: All three are normal in osteoporosisnormal serum calcium and serum phosphate but increased serum alkaline phosphatase-Paget's disease (True)

Explanation: Occasionally the serum calcium may be elevated if immobilisation is prolongednormal serum calcium and serum alkaline phosphatase but decreased serum phosphate-osteomalacia (False)

Explanation: All three may be normal (see E)decreased serum calcium, serum phosphate and serum alkaline phosphatase-metastatic bone disease (False)

Explanation: Increased calcium, normal or low phosphate, and high serum alkaline phosphatasedecreased serum calcium and serum phosphate but increased serum alkaline phosphatase-osteomalacia (True)

Explanation: But all three may be normal

Question 3. Presentation with acute monoarthritis suggests the possibility ofcrystal arthritis (True)Explanation: Gout and pseudogouttrauma (True)

Explanation: Trauma usually obviousbacterial infection (True)rheumatoid arthritis (False)

Explanation: Usually polyarticular in onsetenteropathic arthritis (True)

Explanation: Reactive arthritis following enterically or sexually acquired infection

Question 4. The following statements about infective arthritis are truethe onset is typically insidious (False)Explanation: Onset usually acute, but less so in the elderly or the immunocompromisedpre-existing arthritis is a recognised predisposing factor (True)

Explanation: Also occurs after trauma or surgerysmall peripheral joints are involved more often than larger joints (False)

Explanation: Large joints are most frequently affectedHaemophilus influenzae is the commonest causative organism in adults (False)

Explanation: H. influenzae is the main cause in children, streptococci and staphylococci in adultsjoint aspiration should be avoided given the risk of septicaemia (False)

Explanation: Early joint aspiration is vital if the diagnosis is not to be delayed

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By A. H.

Question 5. The following features of backache suggest mechanical or radicular pain rather than inflammatory painradiation of pain down the back of one leg to the ankle (True)Explanation: Suggests lumbar nerve root compressionan elevated C-reactive protein (CRP) (False)

Explanation: Suggests an active inflammatory pathologylocalised tenderness over the greater sciatic notch (True)

Explanation: Suggests lumbar nerve root compressiongradual mode of onset in an elderly patient (False)

Explanation: Suggests significant pathology even if there are no physical signsback pain and stiffness exacerbated by resting (False)

Explanation: Suggests inflammatory disease

Question 6. The typical findings in fibromyalgia includeelevation of the ESR (False)Explanation: A high ESR suggests another diagnosissymptoms of fatigue and an irritable bowel (True)

Explanation: Typical of most psychosomatic disorderscoexistent anxiety and depression (True)rapid, spontaneous resolution (False)

Explanation: Often very chronicmusculoskeletal pain without local tenderness (False)

Explanation: Multiple tender points are characteristic

Question 7. Shoulder pain is a recognised feature ofmyocardial ischaemia (True)Explanation: Either alone or associated with central chest painsupraspinatus tendonitis (True)

Explanation: With characteristic painful arc on shoulder abductionbronchial carcinoma (True)

Explanation: Suggests extra-pleural spread or bony metastasespneumococcal pneumonia (True)

Explanation: Classically due to diaphragmatic irritation secondary to pleurisycervical spondylosis (True)

Explanation: Due to cervical nerve root compression

Question 8. In a patient with neck painaggravation by sneezing suggests cervical disc prolapse (True)Explanation: Disc prolapse may also produce upper or lower limb neurological signsradiation to the occiput suggests disease affecting the upper cervical vertebrae (True)

Explanation: Common in tension headacheassociated bilateral arm paraesthesiae suggest angina pectoris as the most likely diagnosis (False)

Explanation: Suggest cervical radiculopathyand otherwise normal joints, rheumatoid arthritis is excluded as a possible diagnosis (False)

Explanation: Rheumatoid arthritis typically involves atlantoaxial articulations

Question 9. The clinical features of primary (nodal) osteoarthrosis includejoint pain aggravated by rest and relieved by activity (False)Explanation: More suggestive of an inflammatory arthritis such as rheumatoid arthritisproximal interphalangeal and metacarpal-phalangeal joint involvement (False)

Explanation: Typically distal interphalangeal joint involvementinvolvement of the hip, knee and spinal apophyseal joints (True)a strong family history of Heberden's nodes (True)microfractures of subchondral bone (True)

Question 10. Causes of secondary osteoarthritis includeacromegaly (True)

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By A. H.

septic arthritis (True)Explanation: And any joint previously traumatisedhaemochromatosis (True)

Explanation: Also chondrocalcinosis and Wilson's diseasePerthes' disease (True)

Explanation: And most hip dysplasiasEhlers-Danlos syndrome (True)

Explanation: Also other causes of hypermobility

Question 11. Criteria for the diagnosis of rheumatoid arthritis includemorning stiffness lasting more than 1 hour (True)Explanation: American Rheumatism Association criteria (1998)arthritis in both hip joints (False)

Explanation: Arthritis affecting three or more joint areasthe presence of rheumatoid nodules (True)

Explanation: Pathognomonicsymmetrical polyarthritis (True)

Explanation: Diagnosis of RA requires four or more of the criteriaradiological changes (True)

Explanation: In significant titres

Question 12. Common extra-articular manifestations of rheumatological disorders includeepiscleritis and keratoconjunctivitis sicca in rheumatoid arthritis (True)erythema nodosum in enteropathic arthritis (True)enthesitis in ankylosing spondylitis (True)

Explanation: And Reiter's diseasealopecia in systemic lupus erythematosus (True)

Explanation: Also photosensitive skin rashesretinitis pigmentosa in psoriatic arthritis (False)

Question 13. Typical features of active rheumatoid arthritis includefever and weight loss (True)Explanation: These also occur with minimal joint symptoms, making diagnosis difficultmacrocytic anaemia (False)

Explanation: Anaemia is classically normochromic and normocyticanterior uveitis (False)

Explanation: Anterior uveitis is specifically associated with the seronegative spondyloarthritidesthrombocytopenia (False)

Explanation: Modest elevation in platelet count is commongeneralised lymphadenopathy (True)

Explanation: Most obvious in nodes draining actively inflamed joints

Question 14. The typical pattern of synovial disease in rheumatoid arthritis includesearly involvement of the sacroiliac joints (False)Explanation: More suggestive of a seronegative spondyloarthritis such as ankylosing spondylitissymmetrical peripheral joint involvement (True)

Explanation: Characteristic pattern of onsetspindling of the fingers and broadening of the forefeet (True)

Explanation: Involvement of the proximal interphalangeal and metatarsophalangeal joints respectivelydistal interphalangeal joint involvement of fingers and toes (False)

Explanation: More suggestive of osteoarthrosis or psoriatic arthritisatlantoaxial joint involvement (True)

Explanation: Often not obvious clinically but can produce cord compression

Question 15. The following statements about rheumatoid arthritis are truejoint pain and stiffness are typically aggravated by rest (True)Explanation: Early morning stiffness is a characteristic feature of all inflammatory arthritides

MCQs VIA WEB 2005

By A. H.

the rheumatoid factor test is positive in about 70% of patients (True)Explanation: May be absent at disease onset and is not specific to rheumatoid arthritisjoint involvement is additive rather than flitting (True)

Explanation: The usual pattern; in palindromic arthritis flitting episodes are typicalassociated scleromalacia typically produces painful red eyes (False)

Explanation: Scleromalacia is a painless wasting of the sclera unlike the rarer scleritissicca syndrome suggests the presence of an alternative diagnosis (False)

Explanation: Common in rheumatoid arthritis

Question 16. The clinical features of Felty&apos;s syndrome includepeak prevalence in the age group 20-30 years (False)Explanation: Peak prevalence in the age group 50-70 yearsprevious long-standing rheumatoid arthritis (True)negative rheumatoid factor test (False)

Explanation: Positive rheumatoid factor testlymphadenopathy and splenomegaly (True)

Explanation: Characteristicrecurrent infections and leg ulcers (True)

Explanation: Characteristic

Question 17. In the treatment of rheumatoid arthritisbed rest should be avoided because of bony ankylosis (False)Explanation: Bed rest is of great value and without risk of bony ankylosissplinting of the affected joints reduces pain and swelling (True)

Explanation: Reduces joint pain and may reduce contracturesassociated anaemia responds promptly to oral iron therapy (False)

Explanation: Not usually iron-deficient and reflects disease activitysystemic corticosteroids are contraindicated (False)

Explanation: Low-dose steroids may lessen disease progression with only a small risk of side-effectsnon-steroidal anti-inflammatory drugs retard disease progression (False)

Explanation: Not disease-modifying drugs, unlike gold, penicillamine and immunosuppressants

Question 18. Disease-modifying antirheumatic drugs (DMARD) in rheumatoid arthritis includesulfasalazine (True)Explanation: 50% of patients respond in 3-6 monthsnaproxen (False)

Explanation: None of the NSAIDs are DMARDsD-penicillamine (True)

Explanation: Benefit may not be apparent for 3 monthssodium aurothiomalate (True)

Explanation: Adverse effects are common (e.g. proteinuria and marrow suppression)azathioprine (True)

Explanation: Reserved for life-threatening or unresponsive disease

Question 19. A poorer prognosis in rheumatoid arthritis is associated withinsidious onset of rheumatoid arthritis (True)Explanation: An explosive onset confers a relatively better prognosishigh titres of rheumatoid factor early in the course of the disease (True)

Explanation: Especially within 12 months of onsetearly development of subcutaneous nodules and erosive arthritis (True)

Explanation: Indicates seropositive diseaseextra-articular manifestations (True)onset with palindromic rheumatism (False)

Explanation: The presence of periods of remission is a favourable sign

Question 20. Typical features of seronegative spondyloarthritis includeasymmetrical oligoarthritis (True)

MCQs VIA WEB 2005

By A. H.

Explanation: Axial joints are involved initially; only 10% of cases present with a peripheral arthritisinvolvement of cartilaginous joints (True)

Explanation: E.g. the sacroiliac joints; involvement is rare in seropositive arthritidesenthesitis of tendinous insertions (True)

Explanation: Achilles tendonitisscleritis and episcleritis (False)

Explanation: Typical ocular problem is acute anterior uveitismitral valve disease (False)

Explanation: An aortitis usually causing aortic regurgitation

Question 21. Features associated with ankylosing spondylitis includepeak onset in the second and third decades (True)subcutaneous nodules (False)

Explanation: Nodules suggest seropositive arthritis, especially rheumatoid arthritisHLA-B27 in at least 90% of affected patients (True)

Explanation: Identical twins homozygous for HLA-B27 may, however, be discordant for the diseasefaecal carriage of specific Klebsiella species (True)

Explanation: Klebsiella carry an antigen similar to HLA-B27, suggesting a possible aetiologyfamily history of psoriatic arthritis and Reiter's syndrome (True)

Explanation: Familial aggregation of overlapping seronegative spondyloarthritides

Question 22. Features suggesting ankylosing spondylitis includeearly morning low back pain radiating to the buttocks (True)Explanation: Due to sacroiliitis and sometimes mistaken for lumbar disc diseasepersistence of lumbar lordosis on spinal flexion (True)

Explanation: Lumbar lordosis may be lost in advanced diseasechest pain aggravated by breathing (True)

Explanation: Due to involvement of the costovertebral joints'squaring' of the lumbar vertebrae on radiograph (True)

Explanation: Leading to the 'bamboo' spine appearanceerosions of the symphysis pubis on radiograph (True)

Explanation: Involvement of cartilaginous joints is a hallmark of the disease

Question 23. In the treatment of ankylosing spondylitissystemic corticosteroid therapy is contraindicated (False)

Explanation: Can be invaluable in acute iritisprolonged bed rest accelerates functional recovery (False)

Explanation: In contrast to rheumatoid arthritis, the patient with ankylosing spondylitis stiffens with bed restspinal radiotherapy modifies the course of the disease (False)

Explanation: Only to improve symptomsspinal deformity is minimised with physiotherapy (True)

Explanation: Education regarding appropriate back exercises is vitalhip joint involvement augurs a poorer prognosis (True)

Explanation: As does extra-articular disease

Question 24. The typical features of reactive arthritis includethe development of anterior uveitis more often than conjunctivitis (False)Explanation: Conjunctivitis is the classical ocular manifestationnon-specific urethritis and prostatitis (True)

Explanation: Cause dysuria, frequency and suprapubic discomfortsymmetrical small joint polyarthritis (False)

Explanation: Arthritis is asymmetrical, involving large or small jointsonset 1-3 weeks following bacterial dysentery (True)

Explanation: Similar delay following sexually acquired infectionskeratoderma blenorrhagica and nail dystrophy (True)

Explanation: Similar to psoriatic skin and nail disease

MCQs VIA WEB 2005

By A. H.

Question 25. In Reiter's diseasea peripheral blood monocytosis is commonly found (False)Explanation: Polymorphonuclear leucocytosis is typical in the acute phasesacroiliitis and spondylitis develop in most patients (False)

Explanation: Occur in only 15% of patientsSalmonella or Shigella species can be cultured from joint aspirates (False)

Explanation: Organisms cause the preceding dysenteric illnesscalcaneal spurs are not apparent radiologically (False)

Explanation: Appear on radiograph as a periostitisarthritis resolves within 3-6 months of onset (False)

Explanation: 10% of patients have chronic active arthritis 20 years after onset

Question 26. Psoriatic arthritis isusually preceded by the development of psoriasis (True)Explanation: Occasionally there is no evidence of skin disease at onsetlikely to develop in 25% of patients with psoriasis (False)

Explanation: Occurs in around 7% of patientscommoner in patients with psoriatic nail changes (True)

Explanation: Such as pitting and onycholysisassociated with a poorer prognosis than rheumatoid arthritis (False)

Explanation: Except for patients with arthritis mutilanslikely to respond to hydroxychloroquine (False)

Explanation: Should be avoided due to precipitation of an exfoliative dermatitis

Question 27. Recognised patterns of psoriatic arthritis includeasymmetrical oligoarthritis of the fingers and toes (True)Explanation: Occurs in 40% of patientsdistal interphalangeal joint involvement with nail dystrophy (True)

Explanation: Occurs in 15% of patientssacroiliitis and spondylitis (True)

Explanation: Develops in 15% of patients-may be indistinguishable from ankylosing spondylitisrheumatoid-like symmetrical small joint arthritis (True)

Explanation: Occurs in 25% of patientsarthritis mutilans with telescoping of the digits (True)

Explanation: Occurs in 5% of patients

Question 28. Diseases associated with seronegative spondyloarthritis includeSjögren's syndrome (False)

Explanation: Either as a primary disorder or in association with some connective tissue diseasesWhipple's disease (True)

Explanation: Rare conditioncoeliac disease (False)

Explanation: An association between coeliac disease and HLA-B8, DR17 and OQ2 but not HLA-B27ulcerative colitis (True)

Explanation: Arthritis may precede evidence of ulcerative colitis or Crohn's diseaseBehçet's disease (True)

Explanation: Suggested by orogenital ulceration and iritis (more common in Japan)

Question 29. Factors predisposing to hyperuricaemia and gout includehypothyroidism (True)Explanation: Diminished renal excretion of uric acidsevere exfoliative psoriasis (True)

Explanation: Increased purine turnoverchronic renal failure (True)

Explanation: Diminished renal excretion of uric acidpolycythaemia rubra vera (True)

MCQs VIA WEB 2005

By A. H.

Explanation: Increased purine turnovertherapy with loop diuretic agents (True)

Explanation: Diminished renal excretion of uric acid

Question 30. The clinical features of gout includeprecipitation of an acute attack by allopurinol (True)Explanation: Enzyme induction induces an acute attackcellulitis, tenosynovitis and bursitis (True)

Explanation: Non-articular signs may predominatethe abrupt onset of severe joint pain and tenderness (True)

Explanation: Onset may be explosively suddenserum urate levels fall during an acute attack (False)

Explanation: Serum urate is usually elevated but may be normalloin pain and haematuria (True)

Explanation: Urate urolithiasis

Question 31. In the treatment of goutNSAID therapy increases urinary urate excretion (False)Explanation: Uricosuric drugs include probenecid, sulfinpyrazone and the NSAID azapropazonesalicylates control symptoms and accelerate resolution of the acute attack (False)

Explanation: Aspirin may worsen an acute attack by reducing renal urate excretionallopurinol inhibits xanthine oxidase and hence urate production (True)tophi should resolve with control of hyperuricaemia (True)allopurinol or probenecid should be given within 24 hours of onset of the acute attack (False)

Explanation: Delay hypouricaemic therapy unless concomitant colchicine therapy is given

Question 32. In pyrophosphate arthropathycalcium pyrophosphate dihydrate crystals are deposited in the synovial cells (False)Explanation: Crystals are deposited in articular cartilage then shed into the joint spacehaemochromatosis is a recognised predisposing factor (True)the clinical appearances are similar to acute gout (True)

Explanation: Hence 'pseudogout'the findings on synovial aspiration are indistinguishable from acute gout (False)

Explanation: Characteristic appearances of calcium pyrophosphate dihydrate (CPPD) crystals under polarising lightmicroscopyintra-articular corticosteroid injections are contraindicated (False)

Explanation: Such injections are often highly effective

Question 33. Osteoporosis isusually associated with normal serum calcium, phosphate and alkaline phosphatase (True)

Explanation: Serum alkaline phosphatase may rise if fractures occurmore likely to occur if menopause is early (True)

Explanation: Accelerated bone loss occurs with oestrogen withdrawalcommonly asymptomatic (True)

Explanation: Pain only occurs after fracturea typical complication of untreated Addison's disease (False)

Explanation: Occurs in states of corticosteroid excessmore common in patients with chronic high alcohol intake (True)

Explanation: Also associated with cigarette smoking

Question 34. Risk factors for osteoporosis includegluten enteropathy (True)Explanation: All causes of malabsorption including liver diseaserheumatoid arthritis (True)

Explanation: And ankylosing spondylitishyperparathyroidism (True)

Explanation: Multifactorial

MCQs VIA WEB 2005

By A. H.

anorexia nervosa (True)Explanation: Multifactorialhypogonadism (True)

Explanation: Improved by androgen replacement therapy

Question 35. Therapies useful in preventing recurrent vertebral fractures in osteoporosis includeregular exercise (True)Explanation: Excessive exercise may be associated with low body weight and osteoporosisoral phosphate supplementation (False)

Explanation: Unless the patient is hypophosphataemic from severe malnutritionetidronate (True)

Explanation: Bisphosphonate therapy is the most effective and best evaluatedvitamin D and calcium supplementation (True)

Explanation: But this is less effective than bisphosphonate therapycorticosteroid (False)

Explanation: Causes osteoporosis; androgen and oestrogen therapy are both effective

Question 36. In osteomalaciathe finding of a proximal myopathy suggests an alternative diagnosis (False)Explanation: Characteristic; patients may have difficulty in standing up or in climbing stairsbone involvement is characteristically painless (False)

Explanation: Pain may be generalised and severeChvostek's sign indicates that the underlying diagnosis may be hyperparathyroidism (False)

Explanation: Hypocalcaemia increases neuromuscular excitability (latent tetany)due to renal disease, 25-hydroxycholecalciferol therapy is recommended (False)

Explanation: Give 1-á-hydroxycholecalciferol; renal 1-á-hydroxylation is impairedpseudofractures on radiograph are pathognomonic (True)

Explanation: Looser's zones are translucent bands seen on radiograph

Question 37. Typical features of Paget's disease of bone includeonset before the age of 40 years (False)Explanation: Onset usually over the age of 60 yearsincreased serum alkaline phosphatase and urinary hydroxyproline excretion (True)

Explanation: Increased bone turnover and osteoblast activitypresentation with severe bone pain, especially in elderly patients (False)

Explanation: Insidious asymptomatic progression; with nerve root and spinal cord compressiondelayed healing of fractures (False)

Explanation: Fractures occur more commonly but usually heal normallyrisk of development of osteogenic sarcoma (True)

Explanation: Rare complication suggested by bony expansion and localised pain

Question 38. In a male patient with prostate cancer and widespread metastatic bone diseaseosteolytic deposits are characteristic (False)Explanation: Prostatic secondaries are typically osteoscleroticthe plasma parathyroid hormone (PTH) concentration is typically elevated (False)

Explanation: Serum PTH is usually normal even when the serum calcium is highbone pain is invariably present (False)

Explanation: Asymptomatic disease may be detected coincidentally on radiographthe alkaline phosphatase is only elevated if pathological fracture occurs (False)

Explanation: Serum alkaline phosphatase is frequently elevated due to osteoblast activationcyproterone acetate retards progress of the disease (True)

Explanation: Androgen deprivation therapy is of proven value in prostatic cancer

Question 39. Typical features of systemic lupus erythematosus (SLE) includea higher prevalence in Caucasian than in African women (False)Explanation: Afro-Caribbean females are particularly susceptibleonset usually in the fourth and fifth decades (False)

MCQs VIA WEB 2005

By A. H.

Explanation: Most commonly in the second and third decadesimpaired function of suppressor T lymphocytes (True)

Explanation: Associated with polyclonal B lymphocyte activationincreased prevalence in women compared with men (True)

Explanation: Genetic factors appear to be of importance in aetiologypresentation with Raynaud's phenomenon in young men rather than young women (True)

Explanation: And in women aged > 30 years

Question 40. Characteristic clinical features of SLE includeRaynaud's phenomenon (True)Explanation: Not, however, specific to SLEalopecia (True)

Explanation: Occurs in at least 50% of patientsan erythematous photosensitive facial rash (True)

Explanation: Characteristicabsence of renal complications (False)

Explanation: Renal involvement is not infrequent and heralds a poor prognosisneuropsychiatric symptoms (True)

Explanation: Especially depression and organic psychosis

Question 41. In the management of systemic lupus erythematosus, the following are of proven valueNSAIDs for renal involvement (False)Explanation: NSAIDs may worsen renal functioncorticosteroid therapy for cerebral involvement (True)

Explanation: High doses are often used initially, then reduced to as low a dose as possible on remission of diseaseplasmapheresis for immune complex disease (True)

Explanation: Especially when combined with immunosuppressant drugshydroxychloroquine for skin and joint involvement (True)

Explanation: Beware retinal complicationslong-term corticosteroid therapy during periods of remission to prevent relapse (False)

Explanation: Little evidence to suggest that this improves the long-term prognosis

Question 42. Recognised features of primary Sjögren's syndrome includean increased incidence of lymphoma (True)dryness of the eyes, mouth and vagina (True)reduced lacrimal secretion rate (True)

Explanation: Demonstrable with the Shirmer testmore males affected than females (False)

Explanation: More females than malesa positive IgM rheumatoid factor in over 80% of patients (True)

Explanation: Not diagnostic of primary Sjögren's (sicca) syndrome

Question 43. The clinical features of progressive systemic sclerosis includepresentation with Raynaud's phenomenon (True)Explanation: Raynaud's may precede other features by yearsreflux oesophagitis and dysphagia (True)

Explanation: Gastrointestinal tract is involved in most patientsfibrosing alveolitis (True)

Explanation: Occurs in the majority of casesulceration, atrophy and subcutaneous calcification of the fingertips (True)

Explanation: 'Sausaging' of the fingers and sclerodactyly are also seenanti-DNA antibodies and decreased serum complement levels (False)

Explanation: ANA only in 50%; anti-DNA antibodies are not seen and complement is normal

Question 44. In polymyositisa normal serum creatine kinase does not exclude the diagnosis (True)Explanation: Especially common in juvenile myositis

MCQs VIA WEB 2005

By A. H.

antinuclear (DNA) antibodies are characteristically absent (True)Explanation: Similarly in polyarteritis nodosaelectromyography is helpful in differentiation from peripheral neuropathy (True)underlying malignancy is usually present if weight loss is marked (False)

Explanation: Weight loss may occur in the absence of malignancyan erythematous rash on the knuckles, elbows, knees and face is typical (True)

Explanation: Cutaneous features suggest dermatomyositis (Gottron's papules)

Question 45. Features of giant cell arteritis includea predominance in females > 60 years of age (True)pain in the jaw during eating (True)

Explanation: Due to claudication of the massetersconfluent involvement of affected arteries (False)

Explanation: Histological involvement is characteristically patchydifficulty in rising from the seated position (False)

Explanation: Suggests proximal myopathyweight loss with normochromic anaemia and high ESR (True)

Question 46. In polymyalgia rheumaticaantinuclear and rheumatoid factor antibodies are present in high titre (False)

Explanation: This finding would suggest an alternative diagnosistemporal artery biopsy usually confirms the diagnosis (False)

Explanation: Biopsy is positive in < 40% of patientsresponse to oral corticosteroids typically occurs within 7 days (True)

Explanation: No such response should prompt a review of the diagnosiscorticosteroid therapy should be

Question 47. The features of classical polyarteritis nodosa includeincreased prevalence in males (True)Explanation: Male to female ratio is 2:1an association with circulating immune complexes containing hepatitis B virus (True)

Explanation: HBV markers may only become apparent on follow-upinvolvement of small arteries and arterioles (False)

Explanation: Systemic vasculitis affecting medium-sized arteriesmultiple peripheral nerve palsies (True)

Explanation: Due to arteritis of the vasa nervorumsevere hypertension (True)

Explanation: Especially in association with renal involvement

Module 21 (Chapter 21)Question 1. The following statements about the skin are true

the surface area of an adult is approximately 2 m2 (True)Explanation: Comprising the epidermis, dermis and subcutis layersthe predominant cell of the dermis is the fibroblast (True)keratinocytes comprise 10% of the epidermal cell mass (False)

Explanation: They comprise 95% of epidermal cellsLangerhans cells synthesise vitamin D in the epidermis (False)

Explanation: These are modified macrophages; keratinocytes synthesise vitamin Deccrine sweat glands are innervated by the parasympathetic nervous system (False)

Explanation: They are innervated by cholinergic fibres of the sympathetic system

Question 2. In the terminology of skin lesionspapules are solid skin elevations > 20 mm in diameter (False)Explanation: Papules < 5 mm in diameternodules are solid skin masses > 5 mm in diameter (True)

Explanation: Larger than papulesvesicles are fluid-containing skin elevations > 5 mm in diameter (False)

MCQs VIA WEB 2005

By A. H.

Explanation: Vesicles < 5 mm in diameterpetechiae are pinhead-sized macules of blood within the skin (True)

Explanation: They are not palpablemacules are small raised areas of skin of altered colour (False)

Explanation: Macules are flat, with altered skin colour or texture

Question 3. Typical features of melanocytic naevi include the followingusually present from birth (False)Explanation: Most appear in early childhooddevelopment after the age of 40 years (False)

Explanation: Should raise suspicion of malignancyjunctional naevi are smooth, papillomatous, hairy nodules (False)

Explanation: Not hairy and are macularintradermal naevi are circular brown macules < 10 mm in diameter (False)

Explanation: They are nodular30% life-time risk of malignant transformation (False)

Explanation: 6% in congenital melanocytic naevi

Question 4. Typical features of malignant melanoma includechanging appearance of a preceding melanocytic naevus (True)Explanation: 30-50% develop in this waydiameter of the lesion > 5 mm (True)

Explanation: But smaller lesions may be malignantirregular colour, border and elevation (True)

Explanation: Typically asymmetricalpersonal or family history of melanoma (True)

Explanation: Risk is also increased with fair skin and blonde hairpainless, expanding, subungual area of pigmentation (True)

Explanation: Characteristically painless

Question 5. Characteristic features of eczema includeepidermal oedema and intra-epidermal vesicles (True)Explanation: Epidermal oedema (spongiosis) and epidermal thickening (acanthosis)delayed hypersensitivity reaction in seborrhoeic eczema (False)

Explanation: This is a feature of allergic contact eczemaincreased serum IgA concentration in discoid eczema (False)

Explanation: Serum IgE concentrations are elevatedeyelid and scrotal oedema in allergic contact eczema (True)

Explanation: The initial eruption occurs at the contact siteoccurrence in the flexures of the elbows and knees in pompholyx (False)

Explanation: Occurs on palms and plantar surfaces of hands and feet

Question 6. The following blistering eruptions are typically associated with mucosal involvementdermatitis herpetiformis (False)Explanation: An intensely itchy rash without oral mucosal involvementbullous pemphigoid (False)pemphigus (True)

Explanation: Often erosive and with mucosal involvementtoxic epidermal necrolysis (True)porphyria cutanea tarda (False)

Question 7. The following are recognised causes of leg ulcersleprosy (True)Explanation: Typically painlesssickle-cell disease (True)

Explanation: And also cryoglobulinaemiadiabetes mellitus (True)

MCQs VIA WEB 2005

By A. H.

Explanation: Arterial and neuropathic aetiologypyoderma gangrenosum (True)

Explanation: Associated with inflammatory bowel diseasesyphilis (True)

Question 8. The following cause alopecia with scarringtinea capitis (False)alopecia areata (False)discoid lupus erythematosus (True)

Explanation: Typically patchytelogen effluvium (False)androgenetic alopecia (False)

Explanation: Male-pattern baldness

Question 9. With regard to psoriasisa child with one affected parent has a 50% chance of developing the disease (False)Explanation: 15% if there is one affected parentthe cellular infiltrate is typically lymphocytic (True)

Explanation: Of helper type in the dermisguttate psoriasis may be preceded by â-haemolytic streptococcal infection (True)

Explanation: Typically throat infectionnail pitting is associated with distal interphalangeal arthropathy (True)

Explanation: And onycholysisabout 5% of patients develop arthropathy (True)

Question 10. Typical features of psoriasis includewell-defined erythematous plaques with adherent silvery scales (True)Explanation: Typically on the elbows, knees and lower backepidermal thickening and nucleated horny layer cells (parakeratosis) (True)

Explanation: Also a dermal T lymphocyte infiltrateinduction of plaques by local trauma (True)

Explanation: Including surgical wounds (Köbner phenomenon)an association with HLA Cw6 (True)

Explanation: Inheritance is probably polygenicexacerbation by propranolol and lithium carbonate therapy (True)

Explanation: Also antimalarial drugs

Question 11. The characteristic clinical features of psoriasis includesparing of the skin over the head, face and neck (False)Explanation: The scalp is frequently involvedguttate psoriasis usually affects the elderly (False)

Explanation: Usually seen in childrennail changes with pitting and onycholysis (True)

Explanation: Also subungual hyperkeratosisoligoarthritis particularly associated with nail changes occurring in 5% of cases (True)

Explanation: Perhaps mimicking rheumatoid arthritisred non-scaly skin areas in the natal cleft and submammary folds (True)

Explanation: Axillary folds may be similarly affected

Question 12. The typical features of acne vulgaris includeinvolvement of pilosebaceous glands and their ducts (True)Explanation: Ducts may be obstructeddistribution over the face and upper torso (True)

Explanation: Lesions elsewhere suggest an alternative diagnosisinfection with the skin commensal Propionibacterium acnes (True)

Explanation: Antibiotics are helpfulincreased sebum production containing excess free fatty acids (True)

MCQs VIA WEB 2005

By A. H.

Explanation: Largely hormonally mediatedopen and closed comedones, inflammatory papules, nodules and cysts (True)

Explanation: Seborrhoea (greasy skin) is often present also

Question 13. Therapies of proven value in acne vulgaris includeoral tetracycline or erythromycin therapy (True)Explanation: For a minimum of 3 monthstopical preparations of benzoyl peroxide and retinoic acid (True)

Explanation: Antibacterials such as chlorhexidine may also helporal contraceptive pill (False)

Explanation: Unless given with cyproterone acetatecyproterone acetate (True)

Explanation: Anti-androgen therapy often in combination with an oestrogenoral isotretinoin (True)

Explanation: Reduces sebum secretion; highly teratogenic

Question 14. The characteristic features of rosacea includepredominantly affects adolescents (False)Explanation: Commonest in middle ageincreased secretion of sebum (False)

Explanation: Sebum secretion is normalfacial erythema, telangiectasia, pustules and papules (True)rhinophyma, conjunctivitis and keratitis (True)non-responsive to oral tetracycline therapy (False)

Explanation: Repeated courses may be necessary

Question 15. Medical conditions that cause pruritus includeoral contraceptives and pregnancy (True)hypothyroidism and hyperthyroidism (True)

Explanation: Also caused by biliary obstructionlymphoproliferative and myeloproliferative diseases (True)iron deficiency anaemia (True)

Explanation: Also caused by chronic renal failureopiate and antidepressant drug therapy (True)

Question 16. Skin diseases associated with marked pruritus includecutaneous vasculitis (False)Explanation: The rash is non-pruriticlichen planus (True)

Explanation: Usually intensely itchyatopic eczema (True)

Explanation: Classically pruriticseborrhoeic keratosis (False)

Explanation: Non-pruriticdermatitis herpetiformis (True)

Explanation: Associated with coeliac disease

Question 17. Skin diseases associated with blistering eruptions includeerythema multiforme (True)Explanation: Perhaps with target lesionsdermatitis herpetiformis (True)

Explanation: Typically on extensor surfacespemphigoid (True)

Explanation: Tense blood-filled lesionspemphigus vulgaris (True)

Explanation: Superficial flaccid lesionsguttate psoriasis (False)

MCQs VIA WEB 2005

By A. H.

Explanation: Small scaly raised lesions

Question 18. Skin diseases associated with photosensitivity includevariegate and hepatic porphyrias (True)Explanation: Disordered haem metabolismatopic eczema (True)

Explanation: Perhaps progressing to chronic actinic dermatitisdrug reactions to phenothiazine, thiazide and tetracycline (True)

Explanation: And also to amiodarone and enalapril therapypyoderma gangrenosum (False)

Explanation: Associated with inflammatory bowel diseasepityriasis rosea (False)

Explanation: Unaffected by sunlight

Question 19. Recognised causes of erythema multiforme includeherpes simplex infection (True)Explanation: Also orf and other virusesmycoplasmal pneumonia (True)

Explanation: Classicalsulphonamide therapy (True)

Explanation: Also penicillins and barbituratessystemic lupus erythematosus (True)

Explanation: And other connective tissue disordersbronchogenic carcinoma (True)

Explanation: And especially post-radiotherapy

Question 20. Recognised causes of erythema nodosum includesarcoidosis (True)Explanation: Also brucellosisâ-haemolytic streptococcal infection (True)

Explanation: Also mycoplasmal and chlamydial infectionsinflammatory bowel disease (True)

Explanation: Also leukaemias and Hodgkin's diseasetuberculosis (True)

Explanation: Also leprosycontraceptive drug therapy (True)

Explanation: Erythema nodosum can also be caused by some other drugs, e.g. iodides and sulphonamides

Question 21. The typical features of basal cell carcinoma include the followingpredominantly affects the elderly (True)Explanation: Rare in young adultsmetastatic spread to the lungs if untreated (False)

Explanation: Spread by local invasionoccurrence in areas exposed to light or X-irradiation (True)

Explanation: Typically on the face or headpapule with surface telangiectasia or ulcerated nodule (True)

Explanation: With a rolled, pearly edgeunresponsive to radiotherapy (False)Explanation: Radiosensitive but surgery is preferred

Question 22. The typical features of squamous cell carcinoma includeoccurrence in areas exposed to light or X-irradiation (True)Explanation: Typically in Caucasians living in equatorial regionsassociation with chronic immunosuppressant drug therapy (True)

Explanation: E.g. following organ transplantationpreceded by leucoplakia on the lips, mouth or genitalia (True)

Explanation: Or actinic keratosis on the skin

MCQs VIA WEB 2005

By A. H.

metastatic spread to the liver and lungs (False)Explanation: Haematogenous dissemination is rareunresponsive to radiotherapy (False)

Explanation: Radiosensitive but surgery is preferred

Module 22 (Chapter 22)Question 1. The predominant segmental innervation of the following tendon reflexes isbiceps jerk-C5 (True)supinator jerk-C6 (True)

Explanation: Same as the biceps jerktriceps jerk-C7 (True)

Explanation: Finger flexion jerk-C8knee jerk-L4 (True)ankle jerk-S1 (True)

Question 2. A right homonymous hemianopia would be an expected finding in disorders of theleft optic tract (True)Explanation: The optic tract runs between optic chiasm and lateral geniculate bodyleft optic radiation (True)

Explanation: Upper fibre damage causes lower field defectoptic chiasm (False)

Explanation: Midline lesions cause bitemporal hemianopiaright lateral geniculate body (False)

Explanation: Left lateral geniculate bodyleft optic nerve (False)

Explanation: Left monocular visual loss

Question 3. Features suggesting a 3rd cranial nerve palsy includeparalysis of abduction (False)Explanation: Suggests 6th cranial nerve palsyabsence of facial sweating (False)

Explanation: Occurs in Horner's syndromecomplete ptosis (True)

Explanation: Paralysis of levator palpebrae superiorispupillary dilatation (True)

Explanation: Impaired parasympathetic flowabsence of the accommodation reflex (True)

Explanation: And direct light response impaired

Question 4. Paralysis of the 4th cranial nerve producesweakness of the inferior oblique muscle (False)Explanation: Superior obliquepupillary dilatation (False)

Explanation: No pupillary changeimpaired downward gaze in adduction (True)

Explanation: May be difficult to detect clinicallyelevation and abduction of the eye (True)

Explanation: Head may tilt towards normal sidenystagmus more marked in the abducted eye (False)

Explanation: Suggests internuclear ophthalmoplegia

Question 5. Paralysis of the 6th cranial nerveproduces impaired adduction of the eye (False)Explanation: Impaired abductionproduces enophthalmos (False)

Explanation: May be a feature of Horner's syndromeis a characteristic feature of Wernicke's encephalopathy (True)

MCQs VIA WEB 2005

By A. H.

Explanation: Usually bilateral, perhaps other ocular nerves also involvedresults from disease of the upper pons (True)

Explanation: Infarction, haemorrhage or demyelination typicallyis a recognised feature of posterior fossa tumour (True)

Explanation: May be 'false localising sign' in raised intracranial pressure

Question 6. Drooping of the upper eyelid results from a lesion of thelevator palpebrae superioris (True)Explanation: Partial or complete ptosis3rd cranial nerve (True)

Explanation: With pupillary dilatationcervical sympathetic outflow (True)

Explanation: With pupillary constriction7th cranial nerve (False)

Explanation: Orbicularis oculi may be affectedabducens nucleus (False)

Explanation: No ptosis, just a lateral rectus palsy

Question 7. Absence of pupillary constriction in either eye on shining a light into the right pupil suggestsbilateral Argyll Robertson pupils (True)Explanation: Accommodation preservedbilateral Holmes-Adie pupils (True)

Explanation: Defect is probably in the ciliary gangliaright optic nerve lesion (True)

Explanation: An afferent defectright oculomotor nerve lesion (False)

Explanation: Reaction in right eye only is impairedbilateral Horner's syndrome (True)

Explanation: Both pupils may be small but response preserved

Question 8. Features of an intracranial lower motor neuron lesion of the facial nerve includeinability to wrinkle the forehead (True)Explanation: Frontalis weaknessincreased lacrimation on the affected side (False)

Explanation: Decreased due to involvement of nervus intermediusupward deviation of the eye on attempted eyelid closure (True)

Explanation: Bell's signdeafness due to loss of the nerve to the stapedius muscle (False)

Explanation: Produces hyperacusisloss of taste over the anterior two-thirds of the tongue (True)

Explanation: Involvement of the chorda tympani

Question 9. Characteristic features of pseudobulbar palsy includedysarthria (True)Explanation: With dysphoniadysphagia (True)

Explanation: Often with aspirationemotional lability (True)

Explanation: Particularly in cerebrovascular diseasewasting and fasciculation of the tongue (False)

Explanation: Suggest lower motor neuron lesion, 12th nerveabsence of the jaw jerk (False)

Explanation: Jaw jerk is typically brisk

Question 10. The following statements about bladder innervation are correctsacral cord lesions usually produce urinary retention (True)Explanation: Parasympathetic innervation impaired

MCQs VIA WEB 2005

By A. H.

thoracic cord lesions produce urinary urge incontinence (True)Explanation: And incomplete bladder emptyingpelvic nerve parasympathetic stimulation causes bladder emptying (True)

Explanation: Internal sphincter relaxation and detrusor contractionpudendal nerve lesions produce automatic bladder emptying (False)

Explanation: Feature of spinal cord lesionsthe L1-L2 segment sympathetic outflow mediates bladder relaxation (True)

Explanation: And internal sphincter contraction

Question 11. The following statements about the Glasgow coma scale are correctthe best response to an arousal stimulus should be measured (True)

Explanation: Test at least twiceappropriate motor responses to verbal commands = score 6 (True)

Explanation: No response to pain = 1spontaneous eye opening = score 4 (True)

Explanation: No eye opening = 1verbal responses with normal speech and orientation = score 5 (True)

Explanation: No speech = 1the minimum total score = 3 (True)

Explanation: Maximum score = 15

Question 12. The diagnosis of brain death is supported bypin-point pupils (False)Explanation: Dilated and unreactive to lightabsent corneal reflexes (True)

Explanation: A brain-stem reflexabsent vestibulo-ocular responses to caloric testing (True)

Explanation: 20 ml ice-cold water into each ear in turnabsence of spontaneous respiration (True)

Explanation: With PaCO2 > 6.7 kPapreservation of the cough and gag reflexes (False)

Explanation: All brain-stem reflexes absent

Question 13. Typical features of prefrontal lobe lesions includepositive grasp reflex (True)Explanation: And other 'primitive' reflexesastereognosis (False)

Explanation: Suggests a parietal lobe lesionsensory dysphasia (False)

Explanation: Posterior temporo-parietal lesion (Wernicke's area)olfactory hallucinations (False)

Explanation: Temporal lobe signsocial disinhibition (True)

Explanation: Perhaps with antisocial behaviour

Question 14. Typical features of posterior parietal lobe lesions includelower homonymous quadrantanopia (False)Explanation: Contralateral to lesionconstructional apraxia (False)

Explanation: Non-dominant hemispheresensory inattention (False)

Explanation: Perhaps with sensory neglectmotor dysphasia (True)

Explanation: Broca's area in the inferior frontal lobeagnosia and acalculia (False)

Explanation: Gerstmann's syndrome of the dominant angular gyral region

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By A. H.

Question 15. In the evaluation of a patient with headachethunderclap headache is invariably associated with subarachnoid haemorrhage (False)Explanation: Only associated in 1 in 8 patientspatients with viral meningitis invariably display meningism (False)

Explanation: Meningism less common than in bacterial infectionthe presence of concurrent focal limb weakness excludes migraine (False)

Explanation: Migrainous hemiparesis is well recognisedimprovement with simple analgesia suggests tension headache (False)

Explanation: Tension headaches are typically poorly responsiveheadache on waking suggests raised intracranial pressure (True)

Explanation: As does morning vomiting

Question 16. Migrainous neuralgia (cluster headache) ismore common in females than in males (False)Explanation: Male to female ratio is 5:1the commonest form of migraine (False)

Explanation: 10-50 times less commonassociated with Horner's syndrome in some patients (True)

Explanation: And unilateral lacrimationlikely to be cured by prophylactic propranolol treatment (False)

Explanation: Prophylaxis may not be helpfullikely to respond well to sumatriptan therapy (True)

Question 17. In the evaluation of a patient with true vertigoshort-lived symptoms favour a labyrinthine cause (True)Explanation: Persistent vertigo is more often centralthe presence of nystagmus excludes viral labyrinthitis (False)

Explanation: Often present although transientassociated paroxysmal tinnitus suggests Ménière's disease (True)

Explanation: Exclude acoustic neuromapositional vertigo fatigues rapidly when due to central cause (False)

Explanation: Tends to persisttemporal lobe epilepsy should be considered (True)

Explanation: But a rare cause

Question 18. Features suggesting vasovagal faint rather than epilepsy in a patient with a blackout includean olfactory aura (False)Explanation: But many patients are aware that something is about to happenconfusion following the event (False)headache following the event (False)

Explanation: Also absence of injury or tongue-bitingmemory loss surrounding the event (False)tongue-biting (False)

Explanation: Also pallor rather than central cyanosis suggests fainting

Question 19. In the analysis of gaitcircumduction of a leg suggests pyramidal weakness (True)Explanation: Often with dragging of the affected foota high-stepping gait suggests foot drop (True)Explanation: Perhaps with slapping stepsinability to walk heel-to-toe suggests cerebellar disease (True)

Explanation: Classically of the vermisdifficulty negotiating doorways suggests parkinsonism (True)

Explanation: Associated with festinationa waddling gait suggests proximal muscle weakness (True)

Explanation: Usually myopathic in nature

MCQs VIA WEB 2005

By A. H.

Question 20. Jerking nystagmus that changes in direction with the direction of gaze iscompatible with cerebellar hemisphere disease (True)Explanation: Maximal on gaze towards lesion if cerebellar disease is unilateralindicative of a brain-stem disorder (True)

Explanation: May be more marked in the abducting eye (ataxic nystagmus)compatible with a vestibular nerve lesion (False)

Explanation: Typically present only when looking away from side of lesiontypically accompanied by vertigo and tinnitus (False)

Explanation: Suggests vestibulocochlear diseaselikely to continue following closure of the eyes (True)

Explanation: Demonstrable using electronystagmography

Question 21. The characteristic features of trigeminal neuralgia includepain lasting several hours at a time (False)Explanation: Lancinating paroxysms lasting a few secondspain precipitated by touching the face and/or chewing (True)

Explanation: 'Trigger areas' may existabsence of the corneal reflex (False)

Explanation: No abnormal signspredominance in young females (False)

Explanation: Occurs in elderly subjectsresponse to anticonvulsants (True)

Explanation: E.g. carbamazepine

Question 22. The typical features of Ménière's disease includesudden onset of vertigo, nausea and vomiting (True)Explanation: May be disablingprogressive sensorineural deafness and tinnitus (True)

Explanation: Usually unilateraljerking nystagmus and ataxic gait (True)

Explanation: Typically during attacksnystagmus usually persists between attacks (False)

Explanation: Suggests benign positional vertigorestoration of hearing following effective treatment (False)

Explanation: May delay progression but cannot restore auditory loss

Question 23. Typical causes of vertigo includecardiac arrhythmia (False)Explanation: Postural instability and syncopal symptomsacoustic neuroma (True)

Explanation: Or other pathology of the 8th nervevestibular neuronitis (True)

Explanation: Usually associated with vertebral artery ischaemiagentamicin drug therapy (True)

Explanation: And other ototoxic drugsotitis media (True)

Explanation: With secondary labyrinthine inflammation

Question 24. Typical features of generalised epilepsy includeloss of consciousness accompanied by symmetrical EEG discharge (True)Explanation: May follow focal EEG abnormality and symptoms-partial seizuresinvariable presence of an aura (False)

Explanation: Often absentlesion demonstrable on CT of the brain (False)

Explanation: Usually no obvious abnormalityinduction by photic stimulation (True)

Explanation: TV or computer games may induce fits

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By A. H.

induction by hyperventilation (True)Explanation: Often used during the recording of an EEG

Question 25. The clinical features of tonic clonic seizures includeprodromal phase lasting hours or days (True)

Explanation: With vague irritability or lethargyonset with an audible cry due to the aura (False)

Explanation: Audible cry may occur at the onset of the tonic phasesustained spasm of all muscles lasting 30 seconds (True)

Explanation: Tonic phaseinterrupted jerking movements lasting 1-5 minutes (True)

Explanation: Clonic phaseflaccid post-ictal state with bilateral extensor plantars (True)

Explanation: Variable duration

Question 26. The typical features of absence (petit mal) seizures includeloss of consciousness lasting up to 10 seconds (True)Explanation: Sometimes with loss of postureonset around age 25-30 years (False)

Explanation: Typically in childhoodsynchronous three per second spike and wave activity on EEG (True)

Explanation: May be detected inter-ictallylater development of tonic clonic seizures in 40% of patients (True)

Explanation: May not occur until adulthoodsleepiness lasting several hours post-ictally (False)

Explanation: Rapid recovery although may occur very frequently

Question 27. The following statements about epilepsy are correcttreatment should be started following a single witnessed seizure (False)Explanation: Await evidence of recurrent seizures25% of patients will have a further seizure within 1 year of a first seizure (False)

Explanation: 70%, mostly in first 2 monthstrigger factors for epilepsy include sleep deprivation and physical exhaustion (True)

Explanation: Also febrile illnesses and metabolic disturbancesthe lifetime risk of a single seizure is 20% (False)

Explanation: 5%sharp waves on EEG are highly specific for epilepsy (True)

Explanation: Only one in 1000 are false positives

Question 28. A patient with seizures in the UK candrive a private car following a single seizure after 1 year free of recurrence (True)hold a heavy goods vehicle licence if all seizures occurred before the age of 5 years (True)

Explanation: Providing no potentially epileptogenic brain lesion identifieddrive a private car during the withdrawal of anticonvulsant therapy (False)

Explanation: Should stop driving for 6 months after their withdrawaldrive a heavy goods vehicle only if seizure-free for 5 years (False)

Explanation: 10 yearsdrive a private car if seizures have only occurred during sleep in the previous 3 years (True)

Question 29. The following statements about anticonvulsants are correctplasma level monitoring is particularly useful in sodium valproate therapy (False)Explanation: Phenytoin and carbamazepineprimidone is likely to cause sideroblastic anaemia (False)

Explanation: Megaloblastic anaemiaclonazepam is the first-line treatment of absence seizures (False)

Explanation: Ethosuximidesodium valproate is the first-line treatment in primary generalised tonic clonic seizures (True)

MCQs VIA WEB 2005

By A. H.

carbamazepine is a recognised cause of hyponatraemia (True)Explanation: Particularly in older patients

Question 30. Features suggesting epilepsy rather than a simple faint as the cause of blackouts includeimpairment of vision heralding the attack (False)Explanation: Suggests syncopal episodetongue-biting during the attack (True)

Explanation: Not specific, especially in the elderlyeye-witness account of sustained jerking movements during the attack (True)

Explanation: Some jerking movements are common in simple faintsattacks aborted by lying supine (False)

Explanation: Suggests vasovagal syncopeattacks confined to the sleeping hours (True)

Explanation: May occur in blackouts due to bradycardias

Question 31. Clinical features of raised intracranial pressure includetachycardia and hypotension (False)Explanation: Bradycardia and hypertensiondizziness and lightheadedness (True)

Explanation: And vomitingheadache aggravated by bending and straining (True)

Explanation: And coughingbehavioural and personality changes (True)

Explanation: And impairment of conscious level6th or 3rd cranial nerve palsies (True)

Explanation: 'False localising signs'

Question 32. The following statements about primary brain tumours are correctmeningiomas are the most common type in the middle-aged (True)Explanation: 20% of all cerebral tumoursgliomas are the most common type in childhood (False)

Explanation: 40% of all cerebral tumoursmost childhood brain tumours arise within the posterior fossa (True)

Explanation: They are usually cerebellar tumourspresentation with adult-onset partial seizures is typical (True)

Explanation: Indication for CTacoustic neuromas usually present in the 6th and 7th decades (False)

Explanation: Fourth and fifth decades

Question 33. Typical causes of transient cerebral ischaemic attacks includecarotid artery stenosis (True)Explanation: Usually contralateral motor, sensory, speech disturbanceatrial fibrillation (True)

Explanation: Bilateral events may occurhypotension (True)

Explanation: Associated with standingintracerebellar haemorrhage (False)Explanation: Fixed deficit strokeintracerebral tumour (False)

Explanation: Slowly progressive typically

Question 34. Clinical features suggesting lacunar stroke includehomonymous hemianopia (False)Explanation: The optic pathway is only affected by larger lesionsmotor or sensory dysphasia (False)

Explanation: Suggests cortical damagefacial weakness and arm monoparesis (True)

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By A. H.

Explanation: Internal capsule lacunaisolated hemiparesis or hemianaesthesia (True)

Explanation: Internal capsule lacunahistory of hypertension or diabetes mellitus (True)

Explanation: Account for > 80% of lacunar strokes

Question 35. The following statements about stroke are correct65% of completed strokes are due to cerebral infarction (False)Explanation: 85%most strokes are complete in < 6 hours (True)

Explanation: Minority 'stutter' over a longer period20% of cerebral infarcts are secondary to cardiogenic embolism (True)

Explanation: Another 20% are lacunar infarctsfollowing an ischaemic stroke, aspirin reduces the risk of death or further stroke by 25% (True)

Explanation: 75-150 mg daily20% of patients with carotid territory symptoms have a major (> 70%) stenosis (True)

Explanation: Carotid endarterectomy may then be beneficial

Question 36. Clinical features suggesting intracerebral haemorrhage includeabrupt onset of severe headache followed by coma (True)Explanation: Headache is not specific to haemorrhage3rd cranial nerve palsy (True)

Explanation: In midbrain haemorrhageretinal haemorrhages and/or papilloedema (True)

Explanation: With subhyaloid retinal haemorrhagevomiting and neck stiffness (True)

Explanation: Raised ICPtinnitus, deafness and vertigo (False)

Explanation: Suggest peripheral 8th nerve lesion

Question 37. Intracerebral abscess is a typical complication ofinfective endocarditis (True)Explanation: Often streptococcal in originbronchiectasis (True)

Explanation: Usually staphylococcal in originfrontal sinusitis (True)

Explanation: Typically affects the frontal lobeotitis media (True)

Explanation: Cerebellar or temporalhead injury (True)

Explanation: Typically staphylococcal in origin

Question 38. The typical features of an intracerebral abscess includehigh fever, weight loss and peripheral blood leucocytosis (False)Explanation: Usually there is no suggestion of infectionepilepsy persisting after successful treatment of the abscess (True)

Explanation: Prophylactic anticonvulsants should be consideredbradycardia and papilloedema (True)

Explanation: Raised intracranial pressureheadache, vomiting and confusion (True)

Explanation: With focal hemispheric signspositive blood and CSF cultures (False)

Explanation: Lumbar puncture may be hazardous

Question 39. The typical features of adult tuberculous meningitis includeheadache and vomiting (True)Explanation: And general malaise

MCQs VIA WEB 2005

By A. H.

fever associated with neck stiffness (True)Explanation: Fever often low-gradecranial nerve palsies associated with coma (True)

Explanation: Cranial nerve lesions in 25% of casesmiliary tuberculosis is often present (True)

Explanation: Usual source of infectionCSF cell count > 400 neutrophil leucocytes per ml (False)

Explanation: Lymphocytic meningitis

Question 40. In the treatment of adult pyogenic meningitispenicillin therapy should be given intrathecally initially (False)Explanation: Intrathecal penicillin is both unnecessary and dangerouschloramphenicol therapy should be considered for penicillin-allergic patients (True)

Explanation: Covers meningococci, pneumococci and Haemophilusantibiotic therapy should not be given before CSF analysis has been undertaken (False)

Explanation: Start therapy if the diagnosis is likely, given the mortality and morbidityparenteral fluid therapy should be instituted immediately (True)

Explanation: Septicaemic shock often complicates the diseasethe onset of a purpuric rash suggests drug allergy is likely (False)

Explanation: Suggests meningococcaemia

Question 41. Recognised causes of viral meningitis includeherpes simplex (True)Explanation: Sometimes with encephalitispoliomyelitis (True)

Explanation: With subsequent anterior horn cell infectionarenavirus (True)

Explanation: Lymphocytic choriomeningitisCoxsackie viruses (True)

Explanation: Common cause in UKmumps virus (True)

Explanation: Usually self-limiting

Question 42. Typical features of adult viral encephalitis includeacute onset of headache and fever (True)

Explanation: Usually no prodromepartial epilepsy and coma rapidly ensue (True)

Explanation: Occasionally a mild impairment of consciousnessdecreased CSF glucose concentration (False)

Explanation: Suggests pyogenic infectiontemporal lobe EEG abnormalities are pathognomonic of herpes simplex infection (False)

Explanation: Other viruses may cause thismeningism (True)

Explanation: In 75% of patients

Question 43. The typical features of multiple sclerosis includeinvariable progression with relapses and remission (False)Explanation: Only 25% of cases have a chronically progressive courseonset often occurs before the age of puberty (False)

Explanation: Rare in childhoodchoreoathetosis and parkinsonism (False)

Explanation: No extrapyramidal featuresurinary urgency, frequency and incontinence (True)

Explanation: In spinal involvementepilepsy, dysphasia or hemiplegia (False)

Explanation: Epilepsy and hemiplegia are unusual

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By A. H.

Question 44. Useful investigations in diagnosing multiple sclerosis includevisual and somatosensory evoked potentials (True)Explanation: Can detect clinically silent lesions in 75% of patientsmagnetic resonance brain scanning (True)

Explanation: MRI more sensitive than CTCSF analysis for oligoclonal IgG bands (True)

Explanation: Occurs in 70-90% of patients between attackselectroencephalography (False)

Explanation: Non-specific abnormalitieselectromyography (False)

Explanation: Test of lower motor neuronal disease

Question 45. The typical features of idiopathic parkinsonism includehypokinesia (True)Explanation: Impaired fine finger movementsearly-onset dementia (False)

Explanation: Cognitive impairment develops in about 30% of patients as the disease progressesintention tremor (False)

Explanation: Resting tremor'leadpipe' rigidity (True)

Explanation: Also 'cogwheel' rigidity if a tremor is prominentnormal eye movements (True)

Question 46. Clinical findings consistent with the diagnosis of idiopathic Parkinson's disease includeunilateral onset of the disorder (True)Explanation: Typically arm tremoremotional lability (False)

Explanation: Suggests underlying cerebrovascular diseaseoculogyric crises (False)

Explanation: Suggests drug-induced extrapyramidal diseaseextensor plantar responses (False)

Explanation: Suggests multisystems atrophy (MSA)impaired voluntary eye movements (False)

Explanation: Impairment of conjugate eye movements suggests progressive supranuclear palsy

Question 47. In the management of Parkinson's diseaseanticholinergic therapy is the best first-line therapy for hypokinesis (False)Explanation: Principally useful for tremorlevodopa should be introduced as soon as the diagnosis is made (False)

Explanation: Early introduction means earlier waning of effecthypersalivation invariably indicates overuse of levodopa (False)

Explanation: May be a sign of undertreatment causing hypokinesisdopamine receptor agonists, unlike anticholinergics, do not cause confusion (False)

Explanation: Neuropsychiatric problems occur with both types of therapydyskinesia is a frequent dose-limiting side-effect of levodopa (True)

Explanation: Sustained-release preparations sometimes help

Question 48. The characteristic features of Huntington's disease includeautosomal recessive inheritance (False)Explanation: Autosomal dominant transmissionclinical onset before the age of puberty (False)

Explanation: Onset in middle-aged subjectsprogress of dementia arrested with tetrabenazine therapy (False)

Explanation: May help choreachoreiform movements of the face and arms particularly (True)

Explanation: But become generalisedcardiomyopathic changes on echocardiography (False)

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By A. H.

Explanation: Suggests Friedreich's ataxia

Question 49. The clinical features of motor neuron disease (MND) includeinsidious onset in elderly males (True)

Explanation: Prevalence of 4 per 100 000progressive distal muscular atrophy (True)

Explanation: Typically with absent reflexesprogressive bulbar palsy (True)

Explanation: Particularly tongue fasciculationupper motor neuron signs in the lower limbs (True)

Explanation: Or in the upper limbslower motor neuron signs in the upper limbs (True)

Explanation: Or in the lower limbs

Question 50. The differential diagnosis in MND includessyringomyelia (True)Explanation: But no sensory signs in MNDdiabetic amyotrophy (True)

Explanation: Look for evidence of diabetes mellituscervical myelopathy (True)

Explanation: Treatment may limit progressionparaneoplastic syndrome (True)

Explanation: Protean manifestations of a number of tumoursmeningovascular syphilis (True)

Explanation: Check syphilis serology

Question 51. Typical features of cervical radiculopathy includepathognomonic radiograph abnormalities of the cervical spine (False)Explanation: Changes are usually degenerative and non-specificradicular pain in the arm and shoulder (True)

Explanation: Follows the distribution of nerve root(s)painful limitation of movements of the cervical spine (True)

Explanation: Only if due to disc prolapse or destructive pathologyC5-C7 sensory and/or motor loss in the upper limb (True)

Explanation: C5-C7 involvement with appropriate reflex lossneurosurgical intervention is often required (False)

Explanation: Conservative management is usually adequate

Question 52. The following statements about spinal cord compression are correctmetastatic disease is a more common cause than primary tumour (True)

Explanation: Usually extradural depositsthe CSF protein concentration is likely to be normal (False)

Explanation: Typically elevated with xanthochromia (Froin's syndrome)local spinal pain and tenderness usually precede motor weakness (True)

Explanation: Pain may follow nerve root distributionurinary urgency is commonly the presenting feature (False)

Explanation: A late featuremyelography is the best and most appropriate investigation (True)

Explanation: MRI is now invaluable

Question 53. Recognised causes of paraplegia includeintracranial parasagittal meningioma (True)Explanation: Important to remember if spinal investigations are normalvitamin B12 deficiency (True)

Explanation: Rare in UK in this severitytuberculosis of the thoracic spine (True)

Explanation: Associated with vertebral collapse (Pott's disease)

MCQs VIA WEB 2005

By A. H.

anterior spinal artery thrombosis (True)Explanation: Sudden onset typicallyspinal neurofibromas and gliomas (True)

Explanation: Intradural pathology accounts for 20% of cases of cord compression

Question 54. The typical features of syringomyelia includeslow insidious progression of the disease (True)Explanation: Onset in third or fourth decadedissociate sensory loss with normal touch and position sense (True)

Explanation: Leading to trophic ulcerationloss of one or more upper limb tendon reflexes is invariable (True)

Explanation: Damage to anterior horn cellswasting of the small muscles of the hands (True)

Explanation: A common early featurehyperreflexia of the lower limbs and extensor plantar responses (True)

Explanation: Pyramidal tract damage

Question 55. Recognised features of neurofibromatosis includeautosomal dominant inheritance (True)Explanation: Central and peripheral forms occurcafé-au-lait spots (True)

Explanation: And axillary skin frecklingassociation with multiple endocrine neoplasias (True)

Explanation: E.g. phaeochromocytomaintraspinal and intracranial neuromas and meningiomas (True)

Explanation: At almost any sitenerve deafness (True)

Explanation: Acoustic neuroma

Question 56. The following statements about dementia are correct20% of the population aged over 80 years suffer a dementing illness (True)Explanation: Most commonly Alzheimer's diseaseinheritance of the apolipoprotein å4 allele is associated with multi-infarct dementia (False)

Explanation: Risk of Alzheimer's increased four-foldcerebral acetylcholinesterase inhibitors arrest progression of the disease (True)

Explanation: Particularly in Alzheimer'sAlzheimer's disease is characterised by the presence of neurofibrillary tangles (True)

Explanation: And amyloid-rich plaquesassociated parkinsonism suggests possible Lewy body disease (True)

Explanation: Patients often made worse by levodopa therapy

Question 57. Recognised causes of a generalised polyneuropathy includebronchial carcinoma (True)Explanation: Typically sensoryrheumatoid arthritis (True)

Explanation: And systemic lupus erythematosus; also cause mononeuritis multiplexvitamin B12 deficiency and folate deficiency (True)

Explanation: Also vitamin B1, B2, B6, A and E deficiencyamiodarone therapy (True)

Explanation: And numerous drugsdiabetes mellitus (True)

Explanation: And myxoedema

Question 58. Clinical features typical of the following polyneuropathies includepredominantly motor loss-lead poisoning (True)Explanation: Look for haematological cluespredominantly sensory loss-post-inflammatory polyneuropathy (False)

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By A. H.

Explanation: Motor weakness predominatespainful sensory impairment-alcohol misuse (True)

Explanation: Also autonomic neuropathy with local sympathetic neural dysfunctionsparing of the cranial nerves-sarcoidosis (False)

Explanation: The 7th nerve especially is commonly involved in neurosarcoidprominent postural hypotension-diabetes mellitus (True)

Explanation: Suggests autonomic involvement

Question 59. The typical features of Guillain-Barré polyneuropathy includeonset within 4 weeks of an acute infective illness (True)Explanation: 1-4 weeks, usually after viral infectionperipheral paraesthesiae (True)

Explanation: Paraesthesiae spread proximallyascending flaccid paralysis with areflexia (True)

Explanation: Muscle wasting is usually absentsparing of the respiratory and facial nerves (False)

Explanation: Cranial nerves involved in 30-40%normal CSF protein concentration and cell count (False)

Explanation: CSF protein is elevated, cell count is normal

Question 60. Typical causes of proximal myopathy includehypothyroidism (True)Explanation: And also hyperthyroidism; both resolve with treatmenttype 1 diabetes mellitus (False)

Explanation: Causes a variety of different peripheral nerve disordersCushing's syndrome (True)

Explanation: And also acromegalypernicious anaemia (False)

Explanation: Causes a peripheral neuropathy and spinal cord degenerationchronic alcohol misuse (True)

Explanation: Often with a peripheral neuropathy

Question 61. Acute confusion in the elderly is likely to be the result ofan adverse drug reaction (True)Explanation: E.g. opiates, levodopahypothermia (True)

Explanation: Check core temperature with a low-reading thermometerbronchopneumonia (True)

Explanation: Consider the possibility of meningitismyocardial infarction (True)

Explanation: More often asymptomatic in the elderlycerebral infarction (True)

Explanation: CT to exclude subdural haematoma or tumour

Question 62. Recurrent dizziness in the elderly is likely to be the result ofan adverse drug reaction (True)Explanation: Especially if associated with postural hypotensionpostural hypotension (True)

Explanation: Absence of attacks when lying in bed is suggestiveMénière's disease (True)

Explanation: Rare in the absence of hearing lossvertebrobasilar insufficiency (True)

Explanation: Common and may be reproduced by head movementssick sinus syndrome (True)

Explanation: Dizziness is more likely to occur with bradycardias than tachycardiasDownloaded By Ahmed Hakim