FRACP Trial Examination

2001

RPAH

 

 

Paper A

Clinical Sciences

 

 

35 MCQs.

Single best answer.

Allow 1 hour.

 

1.                  The atherosclerotic plaque most prone to rupture are characterised by all of the following except:

A.                 a thin fibrous cap

B.                 a thick fibrous cap

C.                low-grade vessel stenosis

D.                large lipid core

E.                 eccentric luminal narrowing

 

2.                  Marfanoid body habitus occurs in all of the following conditions except:

A.                 Cystathione-b synthase deficiency

B.                 Mutations in the fibrillin gene

C.                Mutations in the RET proto-oncogene

D.                5,10-methyl tetrahydrofolate reductase deficiency

E.                 Phenylalanine hydroxylase

 

3.                  Morphologic features of apoptosis include all of the following except:

A.                 swelling of intracellular organelles

B.                 nuclear fragmentation

C.                Councilman bodies

D.                chromatin condensation

E.                 cell shrinkage

 

4.                  Heteroplasmy is best described as:

A.                 belonging to another species

B.                 hybrid DNA involving two strands that are different

C.                having only one copy of a genetic locus

D.                presence of more than one type of mitochondrial DNA in a cell

E.                 an individual with two different alleles

 

5.                  Diabetes following total pancreatectomy can be distinguished from IDDM by:

A.                 Increased risk of microvascular complications

B.                 Increase insulin requirements

C.                Increase risk of hypoglycemia

D.                Increase risk of ketoacidosis

E.                 Increase response to sulphonylureas

 

6.                  Prolongation of the QT interval is associated with all of the following except:

A.                 Amiodarone

B.                 Mutations in the voltage-gated outward-rectifying K+ channel

C.                Hypokalemia

D.                Hypomagnesemia

E.                 Hypocalcemia

 

7.         A study performed found the following result:

 

Stroke             No stroke

            Smoker                      50                    25

            Non smoker               10                    20

 

            What is the odds ratio of a smoker having a stroke?

A.                 0.25

B.                 0.67

C.                2.0

D.                2.5

E.                 5.0

 

8.         T-cell receptor excision circles (TRECs) are characterised by all of the following except:

A.        Produced during TCR gene rearrangement

B.                 Absent in elderly people

C.                Found in thymic recent emigrant cells

D.                Markers of thymic function

E.                 Increased following HAART in AIDS-patients

 

9.                  A drug is metabolised 80% by the kidney and 20% by the liver. A patient who is normally maintained on a dose of 100mg daily develops acute renal failure and has a GFR of 30ml/min (normally 120ml/min). What is the new maintenance dose?

A.                 20mg

B.                 25mg

C.                30mg

D.                35mg

E.                 40mg

 

10.             The DF508 mutation in the CFTR gene on chromosome 7 is most specific for:

A.                 bilateral absence of the vas deferens

B.                 cystic bronchiectasis

C.                meconium ileus

D.                pancreatic insufficiency

E.                 sinusitis

 

11.             Which of the following are least associated with hypertriglyceridemia:

A.                 Lipemia retinalis

B.                 Tendon xanthomata

C.                Abdominal pain

D.                Lipoprotein lipase deficiency

E.                 Insulin resistance

 

12.             The oxygen dissociation curve is shifted to the right with all of the following except:

A.                 iron deficiency anaemia

B.                 2,3 BPG deficiency

C.                increase in growth hormone

D.                increase in thyroid hormone

E.                 exercise

 

13.             Which of the following regarding genetic and molecular abnormalities in NHL is correct?

A.                 mutations in BCL-6 are found in 1/3 of patients with diffuse large cell lymphoma

B.                 t(2;5) translocation is characteristic of small cleaved cell lymphoma

C.                abnormalities of c-myc are not found in EBV-associated Burkitt's lymphoma

D.                anaplastic large cell lymphoma is rarely associated with cytogenetic abnormalities

E.                 t(15;17) translocation is associated with a subset of cutaneous T-cell lymphoma

 

14.             In the absence of acquired resistance, cefazolin does not have therapeutic activity against which one of the following bacteria?

A.                 Klebsiella pneumoniae

B.                 Staphylococccus aureus

C.                Enterococcus faecalis

D.                Streptococcus pneumoniae

E.                 Streptococcus pyogenes

 

15.             Features of MEN llb can include all of the following except:

A.                 phaeochromocytoma

B.                 medullary carcinoma of the thyroid

C.                parathyroid hyperplasia

D.                mucosal neuromas

E.                 Marfanoid habitus

 

16.             All of the following are characterised by diffuse glomerulonephritis except:

A.                 thin basement membrane disease

B.                 minimal change nephropathy

C.                membranous glomerulonephritis

D.                mesangiocapillary glomerulonephritis

E.                 crescentic glomerulonephritis

 

17.             Concerning the diffusing capacity of the lung (DLCO), which of the following statements is correct:

A.                 it measures the ability of the lung to transfer carbon dioxide across the alveolar-capillary membrane

B.                 it increases with exercise in normal people

C.                it is usually abnormal in patients with chronic asthma

D.                it is decreased proportionately to the arterial oxygen tension in patients with emphysema

E.                 it is usually reduced in diffuse alveolar haemorrhage

 

18.             Which of the following has resulted in the greatest improvement in outcome for patients with HIV infection:

A.                 primary prophylaxis with bactrim

B.                 early treatment of seroconverters with highly-active anti-retroviral therapy (HAART)

C.                treatment of patients with AIDS with HAART

D.                immunotherapy with interleukin-2

E.                 treatment of HIV-wasting with recombinant human growth hormone (rhuGH)

 

19.             Concerning diabetic amyotrophy, which of the following statements is incorrect:

A.                 signs of sensory involvement are usually minimal

B.                 CSF protein concentration may be moderately elevated

C.                it is usually associated with long-standing IDDM

D.                reduced tendon reflexes are invariably found

E.                 resolution occurs spontaneously over a period of several months

 

20.             Which of the following statements regarding secondary antibody response is incorrect?

A.                 IgG is the dominant isotype

B.                 only occurs with immunisation with thymus-dependent antigens

C.                requires CD40L

D.                affinity maturation occurs in the germinal centre

E.                 the peak antibody response occurs after 7-10days

 

21.             Regarding renal transplantation, which of the following is incorrect?

A.                 recombinant monoclonal antibody to CD25 has been shown to reduce the incidence of acute allograft rejection

B.                 mofetil mycophenolate is superior to azathioprine in the prevention of acute allograft rejection

C.                EBV-associated post-transplant lymphoproliferative may resolve with cessation of cyclosporin

D.                use of OKT3 is associated with increased risk of Pneumocystis carinii pneumonia

E.                 triple immunosuppressive regimes of prednisone, mycophenolate and tacrolimus have been shown to reduce chronic rejection and improve survival

 

22.             Concerning orlistat (Xenical) which of the following is incorrect:

A.                 it inhibits gastrointestinal lipases

B.                 it prevents the absorption of 30% of dietary fat

C.                it is contraindicated in diabetic patients on oral hypoglycemic agents

D.                it interacts with warfarin

E.                 it should not be used in patients with gallstones

 

23.             Calcium oxalate renal stones are associated with all of the following conditions except:

A.                 cystic fibrosis

B.                 ulcerative colitis

C.                Crohn's disease

D.                hereditary hyperoxaluria

E.                 ethylene glycol intoxication

 

24.             In a phase II clinical trial of a new chemotherapeutic drug, which of the following is least likely to influence the result:

A.                 prior chemotherapy

B.                 ECOG status

C.                size of the tumour

D.                number of metastases

E.                 age

 

25.             Which of the following is the major contributing factor in gastroesophageal reflux?

A.                 intermittent relaxation of the lower oesophageal sphincter

B.                 decreased lower oesophageal sphincter tone

C.                H. pylori infection

D.                Increased gastric acid production

E.                 Hiatus hernia

 

26.             Concerning NSAIDs and the gastrointestinal tract, which of the following is correct?

A.                 aspirin may reduce the incidence of colonic neoplasms if taken continuously for more than 5 years

B.                 small intestinal bleeding is a recognised complication

C.                selective serotonin re-uptake inhibitors can be safely used concurrently with NSAIDs

D.                aspirin does not cause colonic ulceration

E.                 gastrointestinal symptoms correlate well with endoscopic findings

 

27.             The commonest cause of bilateral facial nerve palsy is:

A.                 Guillain-Barre syndrome

B.                 Sjogren's syndrome

C.                sarcoidosis

D.                leprosy

E.                 diabetes

 

28.             All of the following infections can cause haemolytic anaemias except:

A.                 human immunodeficiency virus

B.                 plasmodium vivax

C.                syphilis

D.                herpes simplex

E.                 mycoplasma pneumonia

 

29.             Concerning nephrotic syndrome, all of the following are true EXCEPT:

A.                 NSAIDS are a recognised cause

B.                 60% of cases of minimal change nephropathy occur in adults

C.                focal sclerosing glomerulonephritis is associated with increased TGF-b1 gene expression

D.                30-50% of adults with minimal change nephropathy  will relapse within one year

E.                 there is increased risk of thromboembolic disease

 

30.             Sickle cell anaemia is associated with all the following except:

A.                 osteomyelitis

B.                 proliferative retinopathy

C.                the oxygen dissociation curve is shifted to the left

D.                isosthenuria

E.                 severe chest syndrome is the commonest cause of death

 

31.             All of the following neurological disorders are characterised by unstable trinucleotide repeats except:

A.                 Duchenne's muscular dystrophy

B.                 myotonic dystrophy

C.                Huntington disease

D.                fragile X syndrome

E.                 dentatorubralpallidoluysian atrophy

 

32.             Mitochondrial cytopathies are associated with all of the following except:

A.                 lactic acidosis

B.                 periodic paralysis

C.                external opthalmoplegia

D.                retinitis pigmentosa

E.                 encephalopathy

 

33.             All of the following statements regarding secundum atrial septal defect are true EXCEPT:

A.     surgical correction is advisable when pulmonary-to-systemic flow ratio has reached 2.0

B.     affected persons are usually asymptomatic in childhood

C.    electrocardiography shows a leftward axis

D.    echocardiography shows abnormal ventricular septal motion

E.     atrial arrhythmias are common

 

 

34.             All of the following structures have been implicated in the generation of wakefulness EXCEPT:

A.     brainstem reticular formation

B.     midbrain

C.    subthalamus

D.    emboliform nucleus

E.     basal forebrain

 

35.             The primary pathophysiologic problem in idiopathic pulmonary fibrosis is believed to be

A.     microorganism-mediated activation of pulmonary neutrophils

B.     immune complex-mediated activation of alveolar macrophages

C.    direct immune complex-mediated pulmonary interstitial damage

D.    primary fibroblast proliferation

E.     viral-mediated pulmonary epithelial damage  


 


 


FRACP Trial Examination

2001

RPAH

 

 

Paper B

Clinical Applications

 

 

30 MCQs.

Single best answer.

Allow 1 hour.

 

1.                  A male aged 32, with HIV and a CD4+ count of 10 presents with leg weakness and urinary retention. Physical examination reveals brisk tendon jerks and extensor plantar responses. CT scan of the spine reveals no abnormality. CSF examination reveals 800 white cells, mostly polymorphs. The most likely diagnosis is:

A.                 drug-induced peripheral neuropathy

B.                 cytomegalovirus infection

C.                spinal epidural abscess

D.                spinal toxoplasmosis

E.                 HIV-myelopathy

 

 

2.                  A 34 year old woman presents with a three week history of polyuria, polydipsia, weight loss, left loin pain and anorexia. On examination she is dehydrated and confused with a PR of 120 and BP 90/60 and RR 34. Her electrolytes and ABGs are as follows:

Na+=119

K+=6.1

HCO3=4

Cl-=88

Urea = 14.1

Creatinine = 0.14

Glucose = 42.5

 

pH = 7.10

pCO2=10

pO2=127

HCO3- =10

            Which of the following statements is true?

A.                 she is at risk of central pontine myelinolysis with rapid correction of her hyponatremia

B.                 the hyponatremia is due to transcellular movement of water as a result of the elevated plasma glucose

C.                total body potassium is likely to be elevated

D.                total body magnesium is likely to be elevated

E.                 intravenous bicarbonate is indicated in this situation

 

3.                  An otherwise healthy 37 year old man presents with massive splenomegaly and bone marrow examination reveals marked myeloid hyperplasia with prominent myelocytes. Cytogenetic analysis shows he is Philadelphia chromosome negative but molecular analysis by PCR is positive for the bcr-abl oncogene. What is the best treatment?

A.                 induction chemotherapy with idarubicin and high-dose cytosine arabinoside (ara-C)

B.                 outpatient treatment with hydroxurea followed by interferon-alpha for 6 months

C.                outpatient treatment with hydroxyurea followed by HLA-typing of siblings and immediate alleogenic stem cell transplant if a match is found

D.                white cell count control, 12 months treatment with interferon-alpha and autologous stem cell harvest if he achieves a complete molecular remission

E.                 fludaribine containing multiagent chemotherapy followed by allogeneic stem cell transplant from an HLA-identical donor or matched unrelated donor

 

4.                  An 87 year old man with a history of angina treated with metoprolol and isosorbide mononitrate collapses after being stung by a bee. He is brought to hospital and is hypotensive with a rash and chest pain.  Immediate management would not include:

A.                 adrenaline

B.                 haemaccel

C.                hydrocortisone

D.                glucagon

E.                 antihistamines

 

5.                  A 33 year old woman presents in the third trimester with palpitations, dyspnoea at rest and ankle edema. Examination reveal an irregular pulse of 130, blood pressure of 85/55mmHg and a diastolic murmur loudest at the apex. She has coarse crackles in her lung bases and pitting edema to her knees. Fetal heart sounds are present. Which of the following is not indicated:

A.                 digoxin therapy

B.                 heparin therapy

C.                diuretic therapy

D.                open mitral valve surgery

E.                 balloon mitral valvuloplasty

 

6.                  A 40 year old man is investigated for shortness of breath on exertion. The following data were obtained:

 

Pressure                                                        mmHg

Right atrial end-diastolic                              6

Right ventricular end-diastolic                     5

Pulmonary artery                                           54/34

Pulmonary capillary wedge                          18

Left ventricular end-diastolic                        10

 

What is the most likely cause of the patient's breathlessness?

A.                 tricuspid stenosis

B.                 mitral stenosis

C.                left atrial myxoma

D.                atrial thrombus

E.                 aortic stenosis

 

7.                  A 60 year old man with manic depressive psychosis presents with nausea and vomiting. Examination shows he is mildly dehydrated. Investigations are as follows:

 

Na+                  128

K+                    3.1

Cl-                    98

HCO3-             32

pH                   7.50

Ca2+                3.0

Albumin          37g/l

 

            X-ray of the lumbar region shows calcification of the renal pelvis.

 

            The most likely cause of the hypercalcemia is:

 

A.                 hyperparathyroidism

B.                 lithium ingestion

C.                milk-alkali syndrome

D.                thiazide diuretic abuse

E.                 licorice intoxication

 

 

 

 

 

 

 

 

 

 

 

8.                  A 64 year old woman presents with malaise, headaches and earache. She has mild arthralgia, cough and occasional epistaxis. CT scan of her sinuses and CXR are shown.

 

 

 

The next most important investigation is:

A.                 urgent testing for anti-neutrophil cytoplasmic antibodies

B.                 nasal mucosal biopsy

C.                urinalysis for dysmorphic red cells

D.                lung biopsy

E.                 renal biopsy

 

 

 

 

 

 

 

 

 

 

9.                  A 46 year old man presents with weight loss and a skin rash. Blood film is shown. The next most important investigation is:

A.                 bone marrow examination

B.                 EBV serology

C.                iron studies

D.                duodenal biopsy

E.                 skin biopsy

 

 

 

10.             A 32 year old Caucasian woman presents with visual obscuration and pain on eye movement. Examination reveals decreased visual acuity of 6/60 in the left eye; decreased direct response to light in the left eye with a left relative afferent pupillary defect and normal retinal fundoscopy. Which of the following statements is false?

A.                 she is likely to spontaneously recover her vision

B.                 oral prednisone increases the risk of relapse

C.                intravenous methylprednisolone speeds recovery of vision and reduces the risk of developing multiple sclerosis at 2 years follow-up, especially in the presence of unidentified bright objects on magnetic resonance imaging

D.                in the majority (2/3) of cases the optic neuritis is retrobulbar and the initial fundoscopy is normal

E.                 the presence of CSF oligoclonal bands is more predictive of the subsequent development of clinically definite MS than magnetic resonance imaging

 

 

 

 

 

 

 

11.             A 22 year old man presents with jaundice and watery diarrhoea. He has a history of Crohn's disease with extensive ileal involvement and several episodes of small bowel obstruction. He has also had lithotripsy for a renal stone. Examination reveals a thin man with mild jaudice, anemia and right upper quadrant tenderness. What is the most likely cause of this man's jaundice?

A.                 cholelithiasis

B.                 hepatosteatosis

C.                autoimmune hepatitis

D.                sclerosing cholangitis

E.                 pericholangitis

 

12.             A 32 year old abattoir worker presents with fever, fatigue, headache and non-productive cough. CXR is shown below.

 

 

 

 

Investigations reveal he is thrombocytopenic with a normal white cell count. Regarding this patient, which of the following statement is false?

A.                 mycoplasma pneumonia the most likely diagnosis

B.                 he has brucellosis

C.                he has chronic Q fever

D.                isolation of Coxiella burnetti is required for the diagnosis

E.                 phase II antibody titre should be higher than phase I antibody titres in this condition

13.       A 65 year old woman is admitted for management of an acute exacerbation of COPD. She gives you a history of having experienced fleeting visual loss in both eyes for the past week. She has a past history of hypertension and NIDDM. Her visual acuity is found to be normal when you test it. Visual field testing confirms a large blind spot. Fundoscopy was performed.

Her presentation would be in keeping with all of the following EXCEPT:

 

A.                 raised intracranial pressure

B.                 papillitis

C.                CO2 retention

D.                Hypertension

E.                 Retinal vein thrombosis

 

 

 

14. A 42 year old man with a BMI of 43kg/m2 has severe sleep apnoea              and hypertension.

Select the response which is most correct.

 

A.     He is likely to have extremely low serum levels of leptin

B.     His basal metabolic rate will be lower than a man of lesser weight

C.    Serum growth hormone and testosterone levels will both be reduced

D.    A very low calorie diet which results in a 10-12kg weight loss will have minimal effect on his CPAP requirements

E.     The presence of high levels of ob gene mRNA would be predictive of a good response to weight control measures

 

 

 

 

 

 

 

 

15. A 25 year old lady presents with a painless left thyroid swelling measuring 2.5cm in diameter. The most appropriate sequence of investigation and management is:

 

A.     Thyroid function tests; Fine needle biopsy of the nodule. If benign on biopsy then observe and repeat biopsy in 6 months

B.     Thyroid function tests; Nuclear thyroid scan; Thyroid ultrasound. If cool on scan and solid on ultrasound recommend thyroid surgery

C.    Thyroid function tests; Nuclear thyroid scan; CT scan of the neck; Thyroid ultrasound. Reassure patient if nuclear scan shows a functioning nodule

D.    Thyroid function tests; Fine needle biopsy of the nodule. If benign on biopsy then recommend surgery.

E.     Thyroid function tests; Nuclear thyroid scan; Thyroid ultrasound; Fine needle biopsy of the nodule. If benign on biopsy then observe and repeat all investigations in 6 months.

 

 

 

16. A 35 year old woman presented with a two month history of a painless swelling of a left cervical lymph node. She had been well otherwise. A biopsy demonstrated an abnormal lymph node replaced by dense bands of fibrous tissue which surround a pleomorphic infiltrate containing lymphocytes, plasma cells and eosinophils. Cells consistent with Reed-Sternberg cells were present and reacted with an antibody to the CD30antigen. A chest X-ray demonstrated and enlarged anterior mediastinal mass (approximately 15cm). A whole body CT scan confirmed the abnormal lymph nodes masses in the left side of the neck and the anterior mediastinum. The following were all within normal limits; full blood count, biochemical screen, LDH, bone marrow aspirate and trephine.

 

Which of the following best describes the most appropriate management:

 

  1. Radiotherapy using a mantle field
  2. Observation alone
  3. Palliative/symptomatic therapy
  4. Chemotherapy with chlorambucil and prednisone for 6-12months
  5. Combined modality therapy using both multi-agent chemotherapy (MOPP-ABVD or hybrid) and radiotherapy

 

 

17. Which of the following statements is true of Stokes-Adams attacks?

 

A.     Patients almost always have a family history of the disorder

B.     They are caused by high-degree atrioventricular block

C.    They are caused by recurrent paroxysmal tachyarrhythmias

D.    They usually are preceded by an aura

E.     Focal neurologic signs are common after these episodes

18. A 23-year-old woman complains of dyspnoea and substernal chest pain on exertion. Evaluation for this complaint 6 months ago included arterial blood-gas testing, which revealed pH 7.48, PO2 79mmHg, PCO2 31mmHg. Electrocardiography then showed a right axis deviation. Chest x-ray now shows enlarged pulmonary arteries but no parenchymal infiltrates, and a lung perfusion scan reveals subsegmental defects that are thought to have a "low probability for pulmonary thromboembolism." Echocardiography demonstrates right heart strain but no evidence of primary cardiac disease. The most appropriate diagnostic test now would be

 

 

A. open lung biopsy

  1. Holter monitor
  2. right-heart catheterisation
  3. transbronchial lung biopsy
  4. serum alpha1 antitrypsin level

 

19. Which of the following statements concerning the diagnosis of phaeochromocytoma is correct?

 

  1. measurement of plasma catecholamines is the preferred initial screening test
  2. random urine samples are equivalent in diagnostic accuracy to the measurement of catecholamines or catecholamine metabolites in a 24-hr urine collection
  3. after collection, the urine should be treated with dilute sodium hydroxide and refrigerated
  4. the ideal time to collect urine is during a period of clinical stability
  5. strenuous exertion may falsely elevate the level of free urinary catecholamines

 

 

20. After apical scars are found on chest x-ray in a 48 year old postmenopausal woman, chemoprophylaxis with isoniazid is begun. Two months later the woman complains of weakness, nausea, and tingling in the feet. Physical examination is unremarkable, and routine blood and urine tests are normal. Four weeks  later she has a grand mal seizure and is admitted to hospital. Findings on admission include anaemia, seborrhoeic dermatitis, glossitis and absent ankle and knee tendon reflexes. At this point the treating physician should:

 

  1. order immediate electroencephalography
  2. order CT of the brain
  3. discontinue isoniazid and begin treatment with rifampicin
  4. administer IM pyridoxine, 100mg and then give 50mg orally daily
  5. administer IM cyanocobalamin, 100micrograms and then give 100micrograms daily for one week

 

 

 

21. A 35-year old man presents with massively enlarged cervical lymph nodes and an abdominal mass on CT scan involving the terminal ileum and caecum. A biopsy of the cervical mass suggests a diagnosis of non-Hodgkin's lymphoma (Burkitt-like; high grade). His renal function is normal, his serum calcium and electrolytes are normal and a serum LDH is markedly elevated at 2460 IU/l (normal range 40-115). His serum urate is also elevated at 0.84 mmol/l. He is treated initially with IV fluids, allopurinol, urinary alkalinisation followed by combination chemotherapy.

 

Which of the following events would be the earliest indicator that tumour lysis syndrome had occurred?

 

A.     pain in the cervical nodal mass and abdominal pain

B.     hyperkalaemia

C.    hypercalcaemia

D.    increase in serum creatinine and urea

E.     reduction in serum LDH level

 

22. A 26 year old woman presents with a 6 month history of amenorrhoea following several years of decreased menstrual flow and frequency. She has a family history of menstrual irregularity. She is overweight (BMI 28). She does not have significant hirsutism.

 

 Transabdominal ultrasound shows multiple ovarian cysts. Plasma hormone measurements are as follows:

 

Testosterone 4.2 nmol/l (n=0.3-2.5)

DHEAS          8 micmol/l (n<12)

LH                   28 IU/l        (n=2-30)

FSH                7 IU/l          (n=2-30)

Prolactin         620 mIU/l   (n=0-425)

Sex hormone binding globulin 14nmol/l  (n=48-100)

17 alphahydroxyprogesterone         6mg/ml    (n<12)

24 hour urine cortisol            220nmol/day (n=121-518)

 

What is the most likely cause for her amenorrhoea?

 

A.     adrenal androgen overproduction

B.     polycystic ovary syndrome

C.    prolactinoma

D.    premature ovarian failure

E.     non-functioning pituitary tumour

 

23. Concerning asthma and allergy which of the following are true:

A. Exercise asthma may be effectively prevented by treatment with oral and inhaled β2agonists, inhaled nedocromil sodium, long acting β2agonists