can only be diagnosed if psoriasis is present (F) also if fhx of psoriasis ref K&C



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Question 24


  1. F

  2. T?

  3. F

  4. T

  5. F

Postpartum thyrodititis usually self limiting? Carbimazole can’t be used while breast feeding and isn’t used anyway. In the first phase of this condition, you experience signs and symptoms of overactive thyroid (hyperthyroidism). This usually lasts two to four months. Treatment may include beta blockers to reduce symptoms of overactive thyroid. In the second phase, you have signs and symptoms of underactive thyroid (hypothyroidism). This also lasts two to four months. Treatment may include thyroid replacement hormone.

Stop lithium if possible – if not can give thyroxine

Treatment for hirsutism is eflornithine.

Chlorpormazine not listed as treatment for hyperprolactinaemia in BNF. Treatment is bromocripine, cabergoline.

Question 25


  1. T

  2. T

  3. T

  4. T

  5. F

Presentations of Coeliac Disease: steatorrhoe/offensive stools, bloating, nausea, vomiting, aphthous ulcers, angular stomatitis, weight loss, fatigue, weakness, iron-deficiency anaemia, osteomalacia, failure to thrive (children).1/3 may be asymptomatic.

Dermatitis herpetiformis is associated with celiac disease (itchy blisters in groups eg on knees, elbows and scalp)

Howell Jolly bodies are nuclear remnants seen in RBCs post splenectomy, rarely leukaemis, megaloblastic anaemia, iron-deficiency anaemia, hyposplenism (eg celiac disease, neonates, thalassaemia, SLE, lymphoma, leukaemia, amyloid)

The mucosal of the proximal small bowel is predominantly affected, the mucosal damage decreasing in severity towards the ileum as the gluten is digested into smaller non-toxic fragments.

Question 26


  1. F

  2. T

  3. T

  4. F

  5. T

A Fib has absent x descent/a wave in JVP

Pulsus alternans occurs in LVF

Pulsus paradoxus is found in pericardial effusion, constrictive pericarditis and asthma.

Plauteau pulse is found in aortic stenosis.

Question 27


  1. T

  2. T

  3. F?

  4. F

  5. T

Plasmapharesis can be used as treatment in hyperviscosity syndrome due to myeloma, waldenstroms macroglobulinaemia, polycythaemia, leukaemia.

Plasmapheresis is a process in which the fluid part of the blood, called plasma, is removed from blood cells by a device known as a cell separator. The separator works either by spinning the blood at high speed to separate the cells from the fluid or by passing the blood through a membrane with pores so small that only the fluid part of the blood can pass through. The cells are returned to the person undergoing treatment, while the plasma, which contains the antibodies, is discarded and replaced with other fluids. Medication to keep the blood from clotting (an anticoagulant) is given through a vein during the procedure. Today, plasmapheresis is widely accepted for the treatment of myasthenia gravis, Lambert-Eaton syndrome, Guillain-Barré syndrome and chronic demyelinating polyneuropathy. Its effectiveness in other conditions, such as multiple sclerosis, polymyositis and dermatomyositis, is not as well established.

An important use of plasmapheresis is in the therapy of autoimmune disorders, where the rapid removal of disease causing autoantibodies from the circulation is required in addition to slower medical therapy.Other uses are the removal of blood proteins where these are overly abundant and cause hyperviscosity syndrome.

Examples of diseases that can be treated with plasmapheresis:


  • Guillain-Barré syndrome

  • Chronic inflammatory demyelinating polyneuropathy

  • Goodpasture's syndrome

  • Hyperviscosity syndromes:

    • Cryoglobulinemia

    • Paraproteinemia

    • Waldenström macroglobulinemia

  • Myasthenia gravis

  • Thrombotic thrombocytopenic purpura (TTP)

  • Wegener's granulomatosis

  • Lambert-Eaton Syndrome

Plasmapheresis is a plasma donation not platelets

Question 28


Repeat – see q18

Question 29


  1. T

  2. T

  3. F

  4. F

  5. F

Management of obstructive sleep apnoea:



  • weight reduction

  • avoidance of tobacco and alcohol

  • CPAP via nasal mask at night is effective

  • Surgical procedures include tonsillectomy, uvulopalatopharyngoplasty – UPPP, tracheostomy



Question 30


  1. F

  2. T

  3. F

  4. ??

  5. F

eosinophilic granuloma of lung (histiocytosis X) - Neither inspiratory rales (crackles) nor clubbing is common.

Clubbing is a feature of CFA, not EAA.

Idiopathic pulmonary haemosiderosis is a disease mainly of children.

Lympohangiomyomatosis – couldn’t find it.



  1. A 32 year old former IV drug user presents with a several week old history of low grade fever, night sweats and shortness of breath. The following diagnoses are likely

    1. pneumocystis carinii pneumonia

    2. crytospiridosis

    3. pneumococcal pneumonia

    4. toxoplasmosis

    5. pulmonary TB

TFTFT

Assuming that an IV drug abuser is now either immunosuppressed, or carrying a blood borne disease such as hep B/C. The question seems to be asking which of the following can cause respiratory complications of HIV/immunosuppression.


Pneumocystis carinii causes pneumonia in the immunosuppressed. It presents with a dry cough, fever and bilateral crepitations. Treat with co-trimoxazole. Prophylaxis is required if CD4 count is under 200.

Cryptospiridium is a protozoa that can cause outbreaks of diarrhoea and abdominal pain from contaminated water supplies. It is self limiting in immunocompetent hosts but can be life threatening in the immunosuppressed (up to 20 litres of stool per day!).

Pneumococcal pneumonia can also affect the immunocompromised and, presumably, it’s much worse.

Toxoplasma gondi is the chief CNS pathogen in AIDS and it presents with focal neurological signs. Treat with primethamine (+folinic acid) and sulfadiazine or clindamycin for 6 months, with lifelong secondary prophylaxis.

Pulmonary TB: see Oxford Handbook pp564-567.. TB will probably make an appearance on the MCQ is some form or another.

32. A 24 year old student present with jaundice three weeks after returning from a holiday in Mexico. The following make a diagnosis of Hepatitis A likely:



    1. sharing needles

    2. foreign travel

    3. Incubation period

    4. Recent blood transfusion

    5. Extrahepatic manifestation

FTTFF

Hepatitis A is picornavirus which is transmitted via the faeco-oral route.

Incubation period is 2-6 weeks. Prodromal features include fever, malaise, arthralgia.

A patient with active infection will have anti-HAV IgM. IgG indicates old infection with no active disease. Once infection is established, treatment is supportive.

1-4% of patients will develop fulminany hepatitis and death from Hep A is rare (<1%). Chronic hepatitis does not occur.

I have no idea what (e) means in this question.


33. A 61 year old male patient presents with renal colic and the following biochemistry results: Na+ 135 mmol/L, K+ 3.7 mmol/L, Urea 10 mmol/L, Ca++ 2.9 mmol/L, Total protein 95 g/L, albumin 28 g/L. The following are the most likely diagnoses:



    1. Hypercalcemia of malignancy

    2. Nephritic syndrome

    3. Multiple myeloma

    4. Sarcoidosis

    5. Hyperparathyroidism

TFTFT


Increased: Urea, Calcium, Total Protein.

Decreased: Albumin.


Increased Urea:

Drugs (cytotoxics, thiazides, pyrazinamide)

Increased cell turnover

Decreased excretion (primary gout, chronic renal failure, lead nephropathy,

hyperparathyroidism, pre-eclampsia)

Increased Calcium

Malignancy, Hyperparathyroidism, Sarcoid, Vit D intox, Benign hypocalciuric

hypercalcaemia (very rare)

(Treat hypercalcaemia with rehydration and furosemide)



Decreased Albumin

Liver disease, Nephrotic synd, Burns, Protein losing enteropathy, malabsorption,

malnutrition, late pregnancy, posture, genetic variations, malignancy.


I am unsure of these answers but here is my reasoning. Renal colic suggests stones and can occur with hypercalcaemia.

a, c) Malignancy is consistent with all findings. Myeloma is definitely consistent with the raised total protein.

b) Nephritic synd: Proteinuria and haematuria. Not renal colic and not hypercalcaemia.

e) Hyperparathyroidism will cause the hypercalcaemia, hyperuricaemia and renal stones.

34 A 72 year old woman presents with recent chest pain, an uninformative ECG and an elevated troponin level. This indicates


    1. unstable angina

    2. dermatomyositis

    3. crush injury

    4. induction by exercise

    5. myocardial infarct

FFFFT


Unstable angina will not cause a raised troponin.
From http://www.emedicine.com/emerg/topic932.htm

The troponins are regulatory proteins found in skeletal and cardiac muscle. The 3 subunits that have been identified include troponin I (TnI), troponin T (TnT), and troponin C (TnC). The genes that code for the skeletal and cardiac isoforms of TnC are identical; thus, no structural difference exists between them. However, the skeletal and cardiac subforms for TnI and TnT are distinct, and immunoassays have been designed to differentiate between them. This explains the unique cardiospecificity of the cardiac troponins. Skeletal TnI and TnT are structurally different. No cross-reactivity occurs between skeletal and cardiac TnI and TnT with the current assays.


Elevated troponin levels have been documented in other disease states and situations that are not associated with atherosclerotic coronary artery disease, including the following:

• Pacing, automated implantable cardioverter-defibrillator

• Tachyarrhythmias

• Hypertension

• Myocarditis

• Myocardial contusion

• Acute and chronic congestive heart failure

• Cardiac surgery

• Renal failure

• Pulmonary embolism

• Subarachnoid hemorrhage

• Sepsis


• Hypothyroidism

• Shock


  1. Tuberculous cavitation on CXR:

    1. Is usually multiple

    2. Is usually thick walled

    3. May contain Nocardia

    4. Is usually in the mid/lower lobes

    5. Is low in bacteria count

FTFFT

Cavitation occurs in TB when the caseous material liquefies, is extruded out of the bronchi, and eventually liquefies. This is more common in secondary TB. Primary TB is classically charicterised by a calcified tubercle in the middle or lower zone (Ghon Focus) with a calcified perihilar lymph node (Ghon Complex).

Secondary TB tends to involve the apices due to the higher O2 tension.

Nocardia is an acid-fast gram positive rod. Infections are frequently misdiagnosed as TB as it is acid-fast and it causes the same disease process. Nocardia is inhaled and grows in the lungs to produce lung abscesses and cavitations. Treatment is with trimethoprim and sulfamethoxazole.


  1. A 55 year old black US male has radicular chest pain. Serum Na+ is 122 mmol/L and ESR is 96 mm/hr. Which of the following are the likely diagnosis?

    1. dissecting aneurysm

    2. bony metastatic manifestation

    3. multiple myeloma

    4. spinal plasmacytoma

    5. sickle cell crisis

FFTFF
The raised ESR would be consistent with myeloma, and renal insufficiency may cause hyponatraemia in that case. As for the others, I have no idea. Please email any corrections to this question to Ben because I can’t make sense of what’s going on.


  1. In a patient presenting with dermatitis of the face and a previous history of atopic dermatitis, the appropriate therapy would include:

    1. dermovate

    2. emollients

    3. synalar

    4. betnovate

    5. hydrocortisone

FTFFT

Atopic dermatitis is treated with steroids and emollients. Low potency steroids are used on the face, ie hydrocortisone.





  1. The following conditions should be treated with topical steroids

    1. Contact dermatitis

    2. Rosacea

    3. Acne

    4. Lichen planus

    5. Eczema herpeticum

TFFTF

Contact Dermatitis is treated the same as atopic dermatitis except there is the additional avoidance of the precipitant. Topical steroids and emollients are appropriate.

Rosacea: Steroids are contra-indicated. Use metronidazole or tetracyclines.

Acne: Treatment options: TOPICAL (benzoyl peroxide, retinoids, astringents, antibiotics) or SYSTEMIC (antibiotics, cyproterone acetate, isotretinoin, steroids).

Lichen Planus: Potent topical steroids usually suppress irritation.

Eczema Herpeticum: Widespread herpes simplex infection which occurs in atopic eczema. Lymphadenopathy and constitutional symptoms may occur. Steroids (used for atopic eczema) should be stopped until the eczema herpeticum has resolved. Treatment is with iv acyclovir.



  1. In a 47 year old lady with disseminated breast carcinoma, dyspnea may be caused by:

    1. Lymphangitis carcinomatosa

    2. Pericardial effusion

    3. Massive ascites

    4. Superior vena cava obstruction

    5. Tamoxifen therapy

TTTTF

Lymphangitis carcinomatosa: LC occurs as a result of the initial hematogenous spread of tumor to the lungs, with subsequent malignant invasion through the vessel wall into the pulmonary interstitium and lymphatics. Tumor then proliferates and easily spreads through these low-resistance channels. Less commonly, direct infiltration occurs as a result of contiguous mediastinal or hilar lymphadenopathy or an adjacent primary bronchogenic carcinoma.

The usual presenting complaint is of breathlessness in a patient with known malignancy. Occasionally, patients may have a dry cough or hemoptysis. Symptoms often precede the development of any radiographic abnormality.



Pericardial Effusion:

Causes – Bacteria, Fungi, MI, Dressler’s, Uraemia, RA, Myxoedema, Trauma, Surgery, MALIGNANCY, Radiotherapy, Procainamide, Hydralazine.

Clinical Features – Dyspnoea, raised JVP.

Massive ascites: This is unlikely to present with dyspnoea but it may be a cause of dyspnoea.

SVC obstruction: Superior vena cava syndrome (SVCS) is characterized by gradual, insidious compression/obstruction of the superior vena cava (SVC). Although the syndrome can be life threatening, its presentation is often associated with a gradual increase in symptomatology. Dyspnoea is the most common symptom, followed by trunk or extremity swelling.

Tamoxifen does not cause dyspnoea. Its main side effects are hot flushes and nausea.


  1. A 48 year old dentist complains of fatigue for three months, and is found to have markedly elevated serum transaminase and bilirubin levels. Serum alkaline phosphatase is marginally elevated. The differential diagnosis includes:

    1. Gilbert’s syndrome

    2. Hepatitis C

    3. Drug induced hemolysis

    4. Primary biliary cirrhosis

    5. Biliary cholelithiasis

FTFFF

Gilbert’s: Asymptomatic isolated hyperbilirubinaemia which can be precipitated by fasting.

Hepatitis C: Probably the most likely given the occupation that was given in the stem.

Drug induced haemolysis: Would not raise AST and ALT, although it may be associated with gallstones.

Primary Biliary Cirrhosis: Increased Alk Phos and GGT, mildly increased AST and ALT. Late disease will have and increased bili and PT with a decreased PT. Lethargy and pruritis may precede jaundice by months to years. 9 times more common in women, but I guess women can also be dentists. Alk Phos only being marginally increased make this unlikely.

Biliary Cholelithiasis: Increased Alk Phos and GGT.



  1. The following associations are correct:

    1. Primary hyperparathyroidism and high phosphate

    2. Primary hyperparathyroidism and MEN

    3. Secondary hyperparathyroidism and hypocalcemia

    4. Secondary hyperparathyroidism and hypophosphatemia

    5. Tertiary hyperparathyroidism and anemia

FTTTF

PTH increases Ca reabsorption and PO4 excretion.


MEN1: Parathyroid hyperplasia, Pituitary adenoma, Pancreatic tumours

MEN2a: Medullary Thyroid Ca, Pheochromocytoma, Parathyroid hyperplasia

MEN2b: Men2a + neurocutaneous signs –parathyroid hyperplasia.
Secondary hyperparathyroidism is secondary to hypercalcaemia.

Chronic Renal failure is associated with anaemia and causes secondary (not tertiary, although may eventually) hyperparathyroidism.





  1. Alport’s syndrome

    1. Is the most common hereditary nephritis

    2. Is due to a defect in the alpha-7 chain of type IV collagen

    3. Is a Y-linked disease

    4. Is associated with anterior lenticonus

    5. Is a contraindication to renal transplantation

TTFTF

Alport’s syndrome is X-linked dominant, aut dom, or rarely aut rec. Genes code for type IV collagen.

Signs include progressive haematuric nephritis, sensorineural deafness and lenticonus (bulging of the lens capsule).

Renal transplantation is the treatment of choice for ESRD in individuals with Alport syndrome. The results of renal transplantation for patients with Alport syndrome compare favorably with results in persons with other diagnoses.





  1. The following are features of mitral stenosis

    1. A loud first heart sound

    2. Prominently displaced apex beat

    3. An opening snap soon after the heart sound suggests severe disease

    4. Graham-Steell murmur

    5. Giant v waves

TFTTF
Palpation of the precordium reveals a quiet apical impulse. In pulmonary hypertension and RV hypertrophy, a RV parasternal lift may be encountered.
On auscultation, a loud S1 is present because the transmitral gradient holds the mitral valve open throughout diastole until ventricular systole closes the fully opened valve with a loud closing sound (S1). In advanced mitral stenosis, as the mitral leaflets become so damaged that they neither open nor close well, S1 eventually quiets.
S2 is physiologically split with a loud pulmonic component (P2) in the presence of pulmonary hypertension. S2 is usually followed by another early diastolic sound, called the opening snap (OS). The interval between S2 and the OS provides a good estimate of LA pressure and thus the severity of the mitral stenosis. When LA pressure is high, the OS closely follows S2 (0.06 s), but when it is normal, the OS occurs later (0.12 s), and it may mimic the S3 gallop. As mitral stenosis worsens, the S2-OS interval shortens.
The OS is followed by the characteristic low-pitched early-diastolic murmur. This murmur can be soft in patients with low cardiac output. In such patients, modest exercise, such as isometric handgrip, may increase the intensity of the murmur. A presystolic accentuation of the mitral stenosis murmur is also heard coincident with the atrial contraction. In the presence of pulmonary arterial hypertension, another diastolic murmur of blowing quality due to resultant pulmonary regurgitation (Graham Steell murmur) often becomes audible.



  1. Cystic Fibrosis

    1. Results from a mutation in the CF transmembrane regulator

    2. Is characterized by a reduced transepithelial potential difference

    3. Shows significant clinical response to N-acetyl-cysteine

    4. Causes death prematurely principally from gastrointestinal complications

    5. In managed with aerosolized tobramycin to delay pulmonary exacerbations

TFFFT
(b) This is all that I could find on potential differences:

Potential difference (PD) (voltage) measured from nasal mucosa and the reading obtained by a reference electrode inserted into the forearm correlates with the movement of sodium across cell membranes, which is a physiologic function rendered abnormal by a CFTR mutation. The nasal potential difference (NPD) is a sensitive test of electrolyte transport that can be used to support or refute a diagnosis of CF. A normal mean value standard error (SE) is 0.9-24.7 mV; an abnormal value is 1.8-53 mV. When measurements are repeated after mucosal perfusion with amiloride to block an epithelial sodium channel, the drop in PD is greater in patients with CF (73%) than in control subjects (53%). Normally, subsequent perfusion with chloride-free solution and isoproterenol produces a sharp increase in the PD but has little effect when CFTR function is abnormal.

As a result of the lack of commercially available equipment and the practical difficulties with NPD measurement, this test is performed in only a few research centers to diagnose CF in patients in whom making a diagnosis is difficult or a sweat test is not technically possible because of skin problems.
(c) While some patients benefit from mucolytics such as N-acetylcysteine, a universal benefit does not exist (http://www.emedicine.com/med/topic246.htm).

(d) Premature death is primarily from respiratory complications.

(e) Nebulised anti-pseudomonal antibiotics are thought to prevent recurrent exacerbations, reduce antibiotic usage and maintain lung function. (http://www.cysticfibrosismedicine.com/htmldocs/CFText/tobi.htm)


  1. In Ulcerative Colitis

    1. Men and women are equally affected

    2. The rectum is generally spared

    3. The presence of pyoderma gangrenosum relates to disease activity

    4. There is an increased incidence of both large bowel and biliary carcinoma

    5. Elemental diets have a significant therapeutic benefit in acute relapse

FFFTF
(a) No sex predominance

(b) UC is generally considered to always affect the rectum, with contiguous involvement that can include the entire large intestine.

(c) Pyoderma gangrenosum occurs in 1% of patients with UC. An indolent chronic ulcer may occur even when disease is in remission. Intralesional therapy with steroids is useful, and colectomy results in healing in approximately one half of patients.

(d) UC is assoc with Primary Sclerosing Cholangitis, which has an increased risk of biliary carcinoma. UC also has a significant risk of bowel ca.


46. Renal artery stenosis:

(a) False: Not sure, couldn’t find any literature to support either way, however, I would imagine that a relatively high percentage of those going for a peripheral angiography would have renal artery stenosis(arteriopathy), but not 50%.

(b) True: The affected kidney often atrophies

(c)False: Non cardiogenic flash pulmonary oedema is generally associated with severe B/L renal artery stenosis. Flash pulmonary oedema is acute onset pulmonary oedema of any cause. The treatment consist of management of the underlying condition(revascularisation of the kidneys) and direct treatment of the pulmonary oedema(O2, loop diuretic, nitrates, morphine)

(d)True: The renin –angiotensin system is activated in the underperfused kidney which in turn leads to increased aldosterone. The aldosterone is responsible for decreased serum potassium.

(e) False: Similar to coronary arteries – A stenosed coronary artery does not “always” progress to complete occlusion.

47. Heart sounds:


  1. False: A loud S1 actually indicates a pliable valve therefore a soft S1 in mitral stenosis indicates severe disease. Other factors involved in assessing the severity of mitral stenosis are (a)early opening snap, (b) low volume pulse, (c) Signs of pulmonary hypertension eg, loud P2

  2. True: Splitting occurs in inspiration due to delay of closure of the pulmonary valve (P2). This is due to the increased volume load in the right ventricle from the negative intrathoracic pressure created.

  3. True: LBBB will lead to reversed splitting of the Second heart sounds, ie, A2 occuring after P2 on full expiration. Incidentally, LBBB occasionally develops into complete heart block and/or sudden death, however more important factors are cardiovascular and systemic disease

  4. True: Larger pressure gradients exist in the systemic circulation.

  5. False: S3 occurs due to very rapid diastolic filling. Commonly described as a gallop rhythm it is heard loudest at the apex and on full expiration. Causes: Normal in children and young adults, High output states eg, pregnancy and thyrotoxicosis, Left ventricular failure, aortic regurg, mitral regurg.

48. Ulcerative Colitis:



  1. True: Occurs more commonly than in Crohn’s disease

  2. True

  3. False: Associated with rheumatic fever

  4. True: Also seen in Crohn’s disease, autoimmune hepatitis, Wegener’s and myeloma

  5. The major cancer associated with UC is adenocarcinoma, however it is increasingly ackknowledged that lymphoma very rarely complicates UC. Make up your own mind

49. Chronic Liver Disease:



  1. False: Although there is an increased total body sodium, there is a proportionately greater increase in the Extracellular fluid volume

  2. False: Hepatoma aka hepatocellular carcinoma

  3. True: TIPS (Transjugular Intrahepatic portosystemic Shunt) procedure is indicated in refractory variceal haemorrhage. It works by bypassing the diseased liver, thereby dramatically reducing the portal pressure. However, as the portal blood bypasses the liver, many toxic metabolites accumulate, thereby precipitating encephalopathy

  4. True: As blood is digested, many toxic metabolites(eg, ammonia) overwhelm the diseased liver => encephalopathy

  5. False: Quite the reverse

50. The following drugs are paired with common indications for their use:



  1. True: The other main indications for ACE inhibitors are: Hypertension and diabetic nephropathy

  2. False: Beta blockers may precipitate status asthmaticus. Several studies are examining the use of Beta blockers in asthmatics. Other C/I: 2nd and 3rd degree heart block, severe peripheral arterial diseasecardiogenic shock and prinzmetal’s angina

  3. False: Indicated in paracetamol overdose. The treatment of TCA overdose involves Diazepam to prevent convulsions and correction of acidosis and hypoxia(IVI sodium bicarbonate)

  4. False: Verapamil is indicated for arrhytmias whose origin is supraventicular. The treatment of VT involves amiodarone/lignocaine or if compromised – DC shock

  5. True: Best treatment is control of the underlying malignancy, however bisphosphonates are often used. Calcitonin is used for refractory cases.

51. The following may cause falls in the elderly



  1. True

  2. True

  3. True: postural hypotension

  4. True: Medications are the most common cause of falls in the elderly

  5. False: Increase the likelihood of fractures, not falls

52. On examination of the chest



  1. False: If dull, consider; cosolidation(which may co-exist with hyperinflation), Collapse or pleural effusion.

  2. False: Wheeze is due to airways narrowing. (1) polyphinic: suggests diffuse airways disease, eg, COPD, Asthma. (2) Fixed monophonic: Localized narrowing eg, bronchial carcinoma (3) Sequential inspiratory wheeze: Reopening of a collapsed airway eg extrinsic allergic alveolitis

  3. True: Due to compression of the overlying lung. Features; the expiratory sound is louder, classically there is a gap between inspiration and expiration, hollow, blowing quality. Heard when turbulence from large airways are transmitted to the peripheries eg consolidation(Common), pleural effusion, collapsed lung.

  4. False: Extrathoracic; During inspiration there is a relatively positive pressure acting on the trachea, therefore it is being “Squeezed” by the surrounding atmospheric pressure.

  5. True: Provided it is a tension pneumothorax. Other causes; large pleural effusion, mediastinal mass

53. Immediately following an ischaemic stroke



  1. False: However there are two instances when one should consider aggressive blood pressure management in a stroke patient, 1) Malignant hypertension, 2) Dissection of an artery eg, aorta, carotid

  2. True: Rigidity develops over weeks o months.

  3. True: Look for a cardiac cause eg, Atrial fibrillation, myocardial infarction

  4. False: This is a controversial topic due to conflicting studies, however, a significant proportion of normal individuals have poor gag reflex. Conclusion: Absent gag alone would not be an indication, but would form part of the swallowing assessment.

  5. True: Caveat; Exclude a haemorrhagic stroke

54. The following associations are correct



  1. True: Battles sign consists of bruising behind the ears +/- CSF ottorhoea. From fracture of the petrous temporal bone. Associated with a dural tear.

  2. True: Raccoon eyes +/- CSF rhinorhoea

  3. False: Hydrocephalus can be loosely defined increased CSF in the cranium; resulting in enlarged ventricles and/sulci. This would not be consistent with a mass effect on the brain ieexternal pressure on the brain will actually decrease the space occupied by CSF. However, with resolution of a SOL, a space may remain due to cerebral atrophy – Hydrocephalus ex vacuo

  4. True

55. Ulcerative Colitis



  1. False: It is more common In non-smokers and in those with appendices(ie those who have not received appendectomies)

  2. True: About 15% of those with pancolitis will develop colorectal carcinoma within 20 years. Also 20% of those who develop primary sclerosing cholangitis will develop cholangiocarcinoma

  3. True: Backwash ileitis in the terminal ileum

  4. False: Mucosal inflammation(mainly neutrophil), goblet cell depletion and crypt abscesses are histological features of UC

  5. True

56. Breast carcinoma



  1. True: provided it is part of the triple assessment for breast cancer: 1) Clinical assessment 2) Radiology; mammagraphy(women > 35 y/o), US(both diagnostic[women both > and < 35y/o] and to aid biopsy), MRI(useful in symptomatic patients with implants and also to detect local recurrence. 3) Histology; Fine needle aspirate or core biopsy. If there is any disparity between these three, an open biopsy is considered.

  2. False: About 80% of Breast cancers are Ductule. Other types include invasive lobular, tubular, cribriform, mucinous and medullary.

  3. False: Never ignore eczema of the nipple. Paget’s disease of the nipple is associated with invasive ductule carcinoma

  4. True: Therefore assess Calcium and perform a skeletal survey.

57. Abdominal pain may be caused by



  1. True: An atypical presentation

  2. Mesenteric infarction: Classic triad of severe abdominal pain, no abdominal signs and rapid hypovolaemia. Exclude atrial fibrillation as a source of embolus

  3. True: Especially acute intermittant porphyria( no cutaeneous manifestations).An acute attack can present with colicky abdominal pain, nausea and vomiting, thereby mimicking an acute abdomen. Cavé anaesthetics, as they can worsen the attack

  4. True: Referred pain from pleural involvement

  5. True: Pain in the loin radiating to the groin +/- fever and nausea.

58. Groin Lymphadenopathy



  1. True: However the rectal lymphatics drain into the inferior mesenteric nodes

  2. False: Cercix drains into iliac nodes while the body drains into the inguinal nodes.

  3. False

  4. True

  5. True

59. Pulsus alternans



  1. False

  2. False: Likely to cause arrhythmias

  3. True

  4. True

  5. False

This is characterized by regular alternate beats that are both weak and strong. It is seen in severe myocardial failure and is due to prolonged recovery time of the myocardium. It also occurs with abnormal tachycardia – in this case it is a compensatory mechanism


60. Pericardial rub

  1. False: A rub only occurs with inflammation of the pericardium

  2. True

  3. True

  4. True

  5. False

A pericardial friction rub is a scratching sound which may be heard in both diastole and systole. It’s intensity is altered by the posture of the patient, eg, it is often heard loudest when the patient is sitting up and breathing out.

Cause: usually idiopathic(query viral infection?). Less common causes of pericarditis are a heart attack, a bacterial infection, an injury to the chest, radiation treatments for cancer, kidney failure, HIV infection, tuberculosis, autoimmune diseases such as lupus, or certain drugs.

61. (a) F-exam may be normal in pulmonary TB even if radiological abnormalities are present. Primary pulmonary TB infection is classically silent.

(b) F-clubbing occurs due to complications of TB,e.g. bronchiectasis,not primarily due to the disease itself.

(c) ?T-I can’t find a reference for this anywhere but TB is an inflammatory process so I assume it would be raised

(d) T-Pulmonary TB, especially postprimary disease, nearly always causes abnormalities on the chest radiograph. Typically, the disease is parenchymal without nodal enlargement, and it manifests as cavitary lesions. Upper-lobe involvement with cavitation and the absence of lymphadenopathy are helpful in distinguishing postprimary from primary TB. Anterior or basal segments may be involved in as many as 75% of cases, in addition to the usually involved pulmonary segments, namely, the apical or posterior segments of the upper lobe or the superior segment of a lower lobe.

(e) Pneumothorax may occur as a complication of TB infection. However, I can’t find any percentages for this


62(a) ?

(b) ?


(c) ?

(d) ?


(e) T
63(a) T- decreased production of gastric intrinsic factor,needed to bind B12 to facilitate absorbtion

(b) T- causes decreased absorbtion of B12 in terminal ileum due to atrophy of intestinal mucosa

(c) T- B12 deficiency causes a macrocytic anaemia with an increased MCV (usually >100fl)

(d) T-similar mechanism to celiac disease

(e) F-proximal small bowel resection should not affect B12 absobtion,terminal ileal resection, however, will greatly decrease the amount of B12 absorbed.
**I’m assuming this question was supposed to read vitamin B12 MALabsorbtion. If not, then just reverse my answers.

64(a) F-pupil is dilated due to failure of parasympathetic innervation. Pupil constriction occurs with ptosis as part of horner’s syndrome (partial ptosis ,miosis, anhidrosis & enopthalmos) due to failure of sympathetic innervation

(b) T-due to the failure of the medial rectus muscle and the unopposed action of the lateral rectus muscle

(c) T-ipsilateral ptosis due to damaged innervation to levator palpebrae

(d) F-corneal reflx is mediated by CN5 (sensory/afferent) and CN7 (motor/efferent)

(e)F-obviously

65(a) F- this occurs in subarachnoid haemorrhage

(b) T-also alcoholics & patients on anticaogulants

(c) T- very slight injury may precipitate a subdural haemorrhage

(d) F-usually a venous bleed so HTN has little or no aetiological role

(e) F-evacuation via a burr hole usually leads to full recovery (OHCM pp.366)
66. (a) T

(b) T (pp.629 K&C)

(c) F- there are elevated urea & creatinine levels

(d) T


(e) F
67 (a) F-sweating is common in hypoglycemia and the patient is usually warm & clammy

(b) T


(c) F

(d) F-deep,irregular respiration (Kussmaul’s breathing) occurs in DKA

(e) T
68 (a) T

(b) ?


(c) ?

(d) T-sedatives & antidepressants may be causative factors in hypothermia

(e) T- arrythmias & cardiac arrest in particular
69(a) T

(b) T


(c) F- the neutrophil count is decreased in brucella infection

(d) T


(e) T
70(a) T- pain may be referred and/or radiate from hip to knee and vice versa

(b) ? T


(c) ?

(d) F-patellar tap is used to demonstrate the presence of a join effusion. A patello-femoral lesion can be examined for by sliding the patella sideways over the underlying femoral condyles.

(e) F-usually worsens or first becomes symptomatic during pregnancy
71(a) F- incubation period of typhoid fever varies with the size of the infecting dose and averages 7-14 (range, 3-60) days

(b) F- Most patients are moderately anemic, have an elevated erythrocyte sedimentation rate, thrombocytopenia, and relative lymphopenia.

(c) T- At approximately the end of the first week of illness, about a third of patients develop bacterial emboli to the skin known as rose spots. These are considered a classic symptom in typhoid fever, but they occasionally appear in shigellosis and nontyphoidal salmonellosis. Rose spots constitute a subtle, extremely sparse (often <5 spots), salmon-colored, blanching, truncal, maculopapular rash with 1- to 4-cm lesions that generally resolve within 2-5 days. Relative bradycardia and a dicrotic pulse are also common during this stage of illness.

(d) F- Constipation often develops early and is likely due to obstruction at the ileocecal valve by swollen Peyer patches. It may last for the entire duration of illness. In the third week, the patient commonly has pronounced abdominal distension & some individuals may produce liquid, foul, green-yellow diarrhea (pea soup diarrhea). During the incubation period, 10-20% of patients have transient diarrhea (enterocolitis) that usually resolves before the onset of the full-fledged disease. Young children and individuals with AIDS are more likely to have diarrhea that is probably due to blunted secondary immunity. The incidence of constipation versus diarrhea varies geographically, perhaps because of local differences in diet or S typhi strains or genetic variation.

(e) T- Produces rapid improvement in patient's general condition, followed by defervescence in 3-5 d. Cures approximately 90% of patients. By the 1970s, widespread resistance to the drug developed. Ampicillin and co-trimoxazole became treatments of choice. However, in the late 1980s, some S typhi strains developed simultaneous plasmid-mediated resistance to all 3 drugs. Fluoroquinolones and third-generation cephalosporins have filled the breach, but some resistance exists to both.
72(a) F

(b) F


(c) T

(d) T


(e) ? BNF says KCl supplements can cause oesophageal or small bowel ulceration,but I don’t know if this applies to enteric coated preparations. I assume not but I can’t find a reference anywhere.

73(a) T-exposure may cause asbestosis and/or mesothelioma

(b) F-I’ve never heard of painter&decorator’s lung!

(c) T-exposure may cause berylliosis

(d) ?T-Strongyloidiasis: Patients may report skin contact with sand or soil, abdominal pain or distension, and/or diarrhea, with or without immunocompromise. Marked wheezing and/or respiratory distress may occur

(e) ?T- dust is a risk factor for occupational asthma but I can’t find a specific reference to cotton dust


74(a) T-low fibre diet and disordered colonic peristalsis are implicated in diverticular disease

(b) F-pathophysiology of IBD is unknown,believed to be genetic or immunological in nature

(c) F-I can’t find a link between these.

(d) T- a high fat,low fibre diet is implicated in the development of colorectal ca.

(e) F-contributing factors include exposure to nitrosamines in the environment or food, chronic ingestion of hot liquids or foods,cigarette smoking and chronic alcohol exposure, Plummer-Vinson syndrome, caustic injury to the esophagus, vitamin or nutritional deficiencies
75(a) T- The most frequent transfusion reactions are fever, chills, urticaria, or shortness of breath, which resolve promptly without specific treatment or complications

(b) T-Nonimmune hemolytic transfusion reactions occur when RBCs are damaged prior to transfusion, resulting in hemoglobinemia and hemoglobinuria without significant clinical symptoms.

(c) F

(d) ? T -ARF is a rare complication of hemolysis and hemoglobinuria. Most often, it is associated with transfusion reactions



(e)
76FTTFT

Infectious mononucleosis=Glandular fever



Kataloq: archive -> pub -> medstud
archive -> SIĞorta sġNFĠ
archive -> • Rəsmi Salamlama
archive -> MÜNDƏRĠcat
archive -> Сборник статей по материалам XXVI международной научно-практической конференции №12 (26)
archive -> Cilt: 3, Sayı: 3-4/Ağustos-Eylül 1995
archive -> Голосование за аборты есть одновременно голосование за эвтаназию, убийство пожилых людей, калек и больных, за генетические эксперименты – это первый шаг по наклонной, внизу которой находится полная дегуманизация жизни, долина смерти
archive -> Empire State College
medstud -> Objectives Describe basic intracranial physiology
medstud -> Is there a rectal lesion? Is prostate benign or malignant?

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