FRACP Trial Examination

2000

RPAH

 

 

Paper A

Clinical Sciences

 

 

35 MCQs.

Single best answer.

Allow 1 hour.

1.                  Mutations in the RET proto-oncogene are associated with which of the following:

A.                 Medullary carcinoma of the thyroid

B.                 Hirschsprung’s disease

C.                Multiple Endocrine Neoplasia type 1

D.                Neurofibromatosis type 2

E.                 Pheochromocytoma

 

2.                  The commonest gene mutation in non-insulin-dependent diabetes is:

A.                 Insulin receptor

B.                 Glucose transporter

C.                Glucokinase gene

D.                Insulin promoter

E.                 Glucose-6-phosphate

 

 

3.                  The channelopathies are inherited disorders of ion channels. Which of the following clinical conditions are not associated with channelopathies?

A.                 Long QT syndrome

B.                 Myotonic dystrophy

C.                Congenital paramyotonia

D.                Hyperkalemic periodic paralysis

E.                 Hypokalemic periodic paralysis

 

 

4.                  Which of the following statements regarding prion diseases is incorrect:

A.                 Transmissable from one generation to the next

B.                 Transmissable from one species to another

C.                Slow virus infection of the central nervous system

D.                Can be prevented by thoroughly cooking contaminated beef

E.                 Cause a spongioform encephalopathy

 

 

5.                  Which of the following drugs are least likely to decrease IL-2 levels?

A.                 Mycophenolate

B.                 Rapamycin

C.                Cyclosporin A

D.                FK506

E.                 Prednisolone

 

6.                  Severe combined immunodeficiency (SCID) is associated with all of the following except:

A.                 IL-2Rg chain deficiency

B.                 JAK3 deficiency

C.                Adenine deaminase (ADA) deficiency

D.                Purine nucleotide phosphorylase (PNP) deficiency

E.                 CD40L deficiency

 

 

7.                  Viruses may utilise cell surface receptors to gain entry. Which of the following association between the virus and its receptor is incorrect?

A.                 EBV and CD21

B.                 HSV and epidermal growth factor (EGF) receptor

C.                HCV and CD81

D.                HIV and CD4

E.                 Influenza and neuraminidase

 

 

8.                  Disorders of G-coupled proteins occur in all of the following except:

A.                 Familial hypocalciuric hypercalcemia

B.                 Prolactinoma

C.                Neonatal severe hypercalcemia

D.                Pseudohypoparathyroidism

E.                 GH-secreting pituitary adenoma

 

 

9.                  Non-mendelian inheritance is characterised by all of the following features except:

A.                 Unstable DNA repeats

B.                 Genomic imprinting

C.                Anticipation

D.                Maternal inheritance

E.                 Mosaicism

 

 

10.             Apoptosis or programmed cell death is a non-inflammatory form of cell death that is involved in all of the following except:

A.                 Embryogenesis

B.                 Antibody-mediated cellular cytotoxicity

C.                Immunological tolerance

D.                Chemotherapy-induced cell death

E.                 Reperfusion injury

11.             Familial cancer syndromes are associated with all of the following except:

A.                 Mutations in DNA mismatch repair genes

B.                 Loss of heterozygosity

C.                Autosomal dominant inheritance

D.                Somatic mutation in a proto-oncogene

E.                 Germline mutation in a tumour suppressor gene

 

 

12.             Microsatellites are best described as:

A.                 DNA polymorphisms

B.                 Variable number of tandem repeats (VNTRs)

C.                DNA fingerprints

D.                Homeotic genes

E.                 Simple sequence repeats (SSRs)

 

 

13.             Bartter’s syndrome is associated with which of the following:

A.                 Hypercalcemia

B.                 Mutations in the Na/+K+/2Cl- co-transporter

C.                Hypertension

D.                Hyperplasia of the macula densa

E.                 Decreased renin secretion

 

 

14.             The hepatitis B precore mutant is most associated with:

A.                 HBs antigenemia

B.                 HBe antigenemia

C.                Worse prognosis

D.                Lamivudine resistance

E.                 Undetectable HBV viral load

 

 

15.             Which of the following is associated with greatest increase risk of myocardial infarction:

A.                 Factor VIIa

B.                 Factor V Leiden

C.                Homocystinuria

D.                Lupus anticoagulant

E.                 Antithrombin III

 

16.             Which of the following NSAID has most selectivity for COX-2:

A.                 Diclofenac (Voltaren)

B.                 Celefoxib (Celebrex)

C.                Piroxicam

D.                Sulindac (Clinoril)

E.                 Naprosen

 

 

17.             Which of the following gene is least likely to be associated with increased risk of breast cancer:

A.                 BRCA1

B.                 BRCA2

C.                ATM

D.                p53

E.                 H-ras

 

 

18.             Which of the following is asociated with greatest increase in risk of Alzheimers’s disease:

A.                 First degree relative with trisomy 21

B.                 Homozygous ApoE4

C.                Aluminium ingestion

D.                Repeated head injury

E.                 Age

 

 

19.             A 65-year-old man presents with dyspnoea. The arterial blood gas in emergency shows:

 

pH 7.45

pO2 50mmHg

pCO2 45mmg

BE +15

SaO2 85%

 

            Which of the following is correct:

A.                 He has acute metabolic alkalosis

B.                 He has acute metabolic acidosis

C.                He has acute respiratory alkalosis

D.                He has acute respiratory acidosis

E.                 He has chronic carbon dioxide retention

 

 

20.             Which of the following has been shown to most decrease mortality post-myocardial infarction:

A.                 Aspirin

B.                 Beta-blockers

C.                Simvastatin

D.                Smoking cessation

E.                 Enalapril

21.             Which of the following confers the worse prognosis in acute myeloid leukenia:

A.                 Inversion 16

B.                 t(8;21)

C.                t(15;17)

D.                Monosomy 7

E.                 Normal cytogenetics

 

 

22.             Which of the following statements regarding the macrolide antibiotics is true:

A.                 Excellent tissue penetration

B.                 Inhibit bacterial 50S ribosomes

C.                Cross the blood brain barrier

D.                Inhibits bacterial cell wall synthesis

E.                 Inhibits CYP450 IID6

 

 

23.             Which of the following associations is incorrect:

A.                 Sickle cell anemia and salmonella osteomyelitis

B.                 Diabetes mellitus and malignant otitis media

C.                Pregnancy and Listeria monocytogenes

D.                Alcoholism and klebsiella pneumonia

E.                 Thalassemia and Yersinia enterocolitica

 

 

24.             Hereditary haemochromatosis is best diagnosed by:

A.                 Serum ferritin > 1500

B.                 Hepatic iron index >1.9

C.                Detection of the C282Y mutation in the HFE gene

D.                Transferrin saturation >45%

E.                 HLA-typing by PCR

 

 

25.             Watery diarrhoea is a feature of all the following endocrine tumours except:

A.                 Medullary carcinoma of the thyroid

B.                 VIPoma

C.                Zollinger-Ellison syndrome

D.                Somatostatinoma

E.                 Carcinoid tumour

 

26.             Which of the following extraintestinal complications of inflammatory bowel disease is more likely to be associated with Crohn’s disease than ulcerative colitis:

A.                 Pericholangitis

B.                 Pyoderma gangrenosum

C.                Arthritis

D.                Uveitis

E.                 Kidney stones

 

 

27.             Which of the following statements regarding a1-antitrypsin deficiency is correct:

A.                 It is associated with centrilobular emphysema

B.                 It is associated with accumulation of diastase-resistant PAS-positive inclusions in periportal hepatocytes

C.                The PiSS phenotype is more severe than the PiZZ phenotype

D.                It is inherited as an autosomal dominant condition

E.                 Cirrhosis does not occur in the absence of emphysema

 

 

28.             Regarding antibiotic resistance, which of the following is false:

A.                 Methicillin resistance in staphylococci is conferred by the mecA gene which encodes an altered penicillin-binding protein (PBP-2A)

B.                 Pneumococcal meningitis with high-level penicillin resistance (MIC>2.0mg/l) can be adequately treated with vancomycin alone

C.                Vancomycin-resistance in enterococci are encoded by transposons or “jumping genes”

D.                Organisms in the ESCAPPM group rapidly develop resistance when exposed to b-lactams

E.                 Organisms in the ESCAPPM group are best treated by a combination of aminoglycoside and carbapenem

 

 

29.             Which of the following infectious cause of diarrhoea has the longest incubation period:

A.                 Clostridium perfringens

B.                 Staphylococcus aureus

C.                Bacillus cereus

D.                Campylobacter jejuni

E.                 Vibrio parahaemolyticus

 

 

30.             Physiological abnormalities in congestive cardiac failure include all the following except:

A.                 Increased circulating catecholamines

B.                 Decreased secretion of atrial natriuretic peptide

C.                Uncoupling of cardiac b-adrenergic receptors

D.                Activation of the renin-angiotensin-aldosterone system

E.                 Increased expression of the proto-oncogenes c-myc and c-fos

31.             In rheumatoid arthritis the granulation tissue termed pannus is erosive principally because of:

A.                 Production of localised vasculitis

B.                 Production of fibrinoid necrosis

C.                Procoagulant activity and capillary thrombosis

D.                Production of collagenase and other enzymes

E.                 Presence of osteoclasts within the pannus

 

 

32.             Which of the following is least associated with scleroderma:

A.                 Dental caries

B.                 Corneal ulceration

C.                Renal tubular acidosis

D.                Lymphoma

E.                 Cardiac fibrosis

 

 

33.             Homozygous defect in the lipoprotein lipase gene is associated with all of the following except:

A.                 Similar phenotype, but earlier onset of disease, to homozygous apoprotein CII defect

B.                 Recurrent abdominal pain

C.                Increased risk of premature ischemic heart disease

D.                Tubero-eruptive xanthomas

E.                 Accumulation of chylomicrons

 

 

34.             The prevalence of SLE in a population is estimated at 1 in 1 000. The sensitivity of a positive ANA for the diagnosis of SLE is 98% and the specificity is 96%. Which of the following statements is correct?

A.                 The likelihood of having SLE with a positive ANA is 98%

B.                 The negative predictive value of the test is 96%

C.                4% of patients without SLE will have a positive test

D.                A positive test makes the diagnosis of SLE highly likely

E.                 ANA is not a useful screening test for SLE in this population

 

 

35.             With regard to sotalol, which of the following statement is false?

A.                 Sotalol is a competitive, non-selective b-adrenergic receptor antagonist

B.                 Drug interactions resulting in torsades des pointes are commonly seen

C.                Amiodarone and sotalol have approximately equal efficacy in the treatment of ventricular tachycardia and ventricular fibrillation

D.                Quinidine and sotalol have equal efficacy in the control of chronic atrial fibrillation following successful cardioversion

E.                 Sotalol is more effective than digoxin in the rate control of atrial fibrillation

 


 


FRACP Trial Examination

2000

RPAH

 

 

Paper B

Clinical Applications

 

 

30 MCQs.

Single best answer.

Allow 1 hour.

1.                  A woman presents with headache and photophobia. Lumbar puncture shows:

 

CSF pressure 25cm (N: 10-20cm)

WCC 40 ´ 106/ml

85% lymphocytes

Total protein 0.18 g/l (N: 0.15-0.45 g/l)

Glusose 1.0 mmol/l (N: 2.5-4.5 mmol/l)

(Serum glucose 4.9 mmol/l)

 

            Which of the following is the least likely diagnosis:

 

A.                 Partially-treated bacterial meningitis

B.                 Carcinomatosis meningitis

C.                Tuberculous meningitis

D.                Viral meningitis

E.                 Fungal meningitis

 

 

2.                  A 55-year-old woman presents with headache and right-sided weakness. On examination she right-sided pyramidal weakness, right-sided numbness and her left pupil is constricted. The most likely diagnosis is:

 

A.                 Left vertebral artery dissection

B.                 Right vertebral artery dissection

C.                Left carotid artery dissection

D.                Right carotid artery dissection

E.                 Subarachnoid haemorrhage

 

 

3.                  A previously healthy 8-year-old boy presents dyspnoeic at rest with ECG evidence of frequent ventricular ectopic beats. The following biochemical results are obtained: serum sodium 130 mmol/l, potassium 2.8 mmol/l, chloride 128 mmol/l, urea 8 mmol/l, and creatinine 0.11 mmol/l. Arterial blood gas indicate a pH of 7.02.

 

Which of the following is most likely to confirm the diagnosis?

 

A.                 Plain abdominal X-ray

B.                 Failure to produce a urine pH of <5.5

C.                Normalisation of the plasma chloride with loop diuretic therapy

D.                Correction of the metabolic abnormalities with carbonic anhydrase

E.                 Quantitation of urinary glucose and amino acid excretion

 

4.                  For which of the following is there evidence that it retards the progression of Parkinson’s disease:

 

A.                 Slow-release L-dopa/carbidopa combination

B.                 Autologous transplantation of adrenal medulla to the head of the caudate nucleus

C.                Selegeline (Deprenyl)

D.                Bromocriptine

E.                 Vitamin E (a-tocopherol)

 

 

5.                  The following serum results are obtained from a 50-year-old woman who had a mastectomy for breast cancer two years ago:

 

Total calcium             2.85 mmol/l    (N:2.25-2.65)

Ioinised calcium        1.52 mmol/l    (N:1.14-1.28)

Phosphate                 0.90 mmol/l    (N:0.8-1.4)

Albumin                      47 g/l               (N:35-50)

Creatinine                  0.15 mmol/l    (N:<0.12)

SAP                            86 U/l              (N:35-135)

Intact PTH                  5.0 rmol/l       (N1.0-5.5)

 

            Which of the following is the most likely diagnosis?

 

A.                 Sarcoidosis

B.                 Humeral hypercalcemia of malignancy

C.                Vitamin D excess

D.                Primary hyperparathyroidism

E.                 Metastatic bone disease

 

 

6.                  A 24-year-old woman on tetracycline for acne presents with a three month history of headaches and fleeting episodes of blurred vision. On examination she is obese and has severe papilloedema but no other neurological signs. A CT scan is normal.

 

Which of the following is the next most appropriate initial investigation?

 

A.                 MRI brain scan

B.                 Cerebral angiogram

C.                Hypercoaguability screen

D.                Overnight dexamethasone suppression test

E.                 Lumbar puncture

 

7.                  A 35-year-old woman presents with multiple lesions on the hands and sun-exposed areas of the arms. These initially appear as small blisters and heal with scarring. She gives a history of 80 g/day alcohol intake and liver function tests show transaminases raised approximately five times the upper limit of normal. Serum iron is 32 mmol/l, transferrin saturation 70% and ferritin 1 200 ng/ml (N:<300).

 

Which of the following is incorrect?

 

A.                 Her condition has been associated with mutations in the HFE gene

B.                 Her condition is likely to respond to venesection

C.                Exacerbations may be precipitated by estrogens

D.                Neuropsychiatric symptoms are common in this disorder

E.                 HCV infection needs to be excluded

 

 

8.                  A 10-year-old boy presents with 2 days of bloody diarrhoea. Investigations revealed a creatinine of 0.35 mmol/l, urea 35 mmol/l, haemoglobin 91 g/l, white cell count 22 ´ 109/l with 90% neutrophils and platelet count 100 ´ 109/l. The peripheral blood film showed fragmented red blood cells. Renal biopsy revealed thrombotic microangiopathy. With respect to this case, which of the following statements is correct?

 

A.                 The majority of diarrhoea-associated (D+) HUS cases are associated with verocytotoxin-producing E. coli

B.                 Fresh frozen plasma infusions have been shown to improve survival

C.                Antibiotic therapy improves outcome

D.                Atypical HUS without a diarrhoea prodrome (D-) is less likely to result in chronic renal failure than D+ HUS

E.                 Renal pathology in D+ HUS shows severe arteriolar with less marked glomerular lesions of thrombotic microangiopathy

 

9.                  The following are oxygen saturations and pressures obtained at cardiac catheterisation of an 18-year-old man with clubbing, intermittent cyanosis and easy fatigue. Haemoglobin 185 g/l (N: 130-170)

 

Site                             % Oxygen saturation             Pressure

 

IVC                              72

            SVC                            68

            RA                               69                                                        mean = 6

            RV                               73                                                        105/12

            Main PA                     72                                                        30/14

            Pulmonary wedge     95                                                        mean = 13

            LV                               88                                                        105/15

            Femoral artery           88                                                        105/65

 

            Which one of the following is most likely to be present?

 

A.                 Bifascicular block on ECG

B.                 Dextroposition of aorta on chest X-ray

C.                Peripheral pruning of pulmonary vessels on chest X-ray

D.                Systemic arterial desaturation that is decreased by squatting

E.                 Anterior displacement of tricuspid valve on echocardiogram

 

10.             The following results are obtained in a 56-year-old man who presents with fatigue:

 

Haemoglobin                                     190 g/l                        (N:130-170)

White cell count                                 10 ´ 109/l                    (N:4-10)

Platelet                                               480 ´ 109/l                 (N:150-450)

51Cr-labelled red cell volume           39ml/kg body weight(N:<36)

 

Which of the following is the most appropriate next investigation:

 

A.                 Bone marrow examination

B.                 Arterial blood gases

C.                Serum erythropoietin assay

D.                Platelet aggregation studies

E.                 Abdominal ultrasound

 

11.             A 46-year-old man is admitted to emergency with left-sided upper abdominal pain. On exmaination he has splenomegaly and full blood count reveals haemoglobin 100 g/l, white cell count 152 ´ 109/l with 85% neutrophils and platelet count 722 ´ 109/l. Bone marrow aspirate examination showed myeloid hyperplasia and cytogenetic analysis demonstrates the Philadellphia chromosome to be present in 100% of metaphases evaluable.

 

After control of the white cell and platelet count, optimal management would be:

 

A.                 Hydroxyurea

B.                 Busulphan

C.                a-interferon

D.                HLA-identical sibling bone marrow transplant

E.                 Autologous stem cell transplant

 

 

12.             A 24-year-old man presents with three day history of recurrent epistaxis. On examination his BP is 100/60, pulse rate 110/minute and he is febrile at 38.50 C. He is bleeding from both nostrils and has bruising and petechiae on his trunk and legs. Examination of the blood film shows 10% blasts and 30% abnormal promyelocytes. The bone marrow aspirate is hypercellular with 50% blasts containing Auer rods and 30% heavily granulated promyelocytes. His INR is 2.5, APTT 60 seconds, plasma fibrinogen 0.5g/l and D dimers 2,000 mg/ml (N:<250). Which of the following statements is false?

 

A.                 A translocation involving chromosome 15 and 17 is present in >70% of cases

B.                 Disseminated intravascular coagulation may worsen with initiation of therapy

C.                Prognosis with standard chemotherapy is poor with <10% long term survivors reported

D.                Oral all trans-retinoic acid (ATRA) may produce complete remission without addition of standard chemotherapy

E.                 Arsenic may induce remision in patients who are resistant to oral ATRA

 

 

13.             A 72-year-old man is admitted with a five day history of confusion, lethargy and faecal incontinence. He has a dense hemiplegia as a result of a stroke three years earlier and is using hydrochlorothiazide and amiloride for control of hypertension. He stopped smoking five years earlier when he presented with a squamous cell lung cancer which was successfully resected.

 

His supine BP is 155/85. A CT brain scan revealed evidence of past cerebral infarction and chest film revealed no evidence of recurrent malignancy.

 

The initial biochemistry revealed:

 

            Sodium                       115 mmol/l                 (N:134-146)

            Potassium                  3.6 mmol/l                  (N:3.4-5.3)

            Urea                            8 mmol/l                      (N:3.0-8.0)

            Creatinine                  0.11 mmol/l                (N:0.06-O.11)

 

Simultaneous plasma and urine osmolalities measured 256 mOsm/kg and 366 mOsm/kr, respectively. Urinary sodium was 52 mmol/l.

 

Which of the following is correct?

 

A.                 The BP indicates that he is not hypovolemic

B.                 The urinary sodium indicates that he is not hypovolemic

C.                He has SIADH

D.                He has diuretic-induced hyponatremia

E.                 He should have a water deprivation test

 

14.             A 28-year-old woman with no family history of hypertension has an average blood pressure of 155/100 from several measurements. She is currently being treated with frusemide 20mg daily. Renal function is normal and her serum potassium is 2.8 mmol/l (N:3.5-5.0). With regard to the diagnosis of primary hyperaldosteronism, which of the following is incorrect?

 

A.                 Serum potassium should be repeated after potassium supplementation and cessation of all diuretic therapy

B.                 An elevated supine plasma aldosterone and suppressed ambulant plasma renin strongly support the diagnosis

C.                An aldosterone producing adrenal carcinoma is present in more than 65% of cases

D.                Licorice intoxication and Liddle’s syndrome can be distinguished from primary hyperaldosteronisms by suppressed levels of plasma aldosterone

E.                 Suppression of plasma aldosterone with dexamethasone suggests glucocorticoid-remedial aldosteronism (GRA)

 

 

15.             With regards to bee (Apis millifera) envenomation, which of the following statements is corrrect?

 

A.                 In Australia approximately 10 people die per year from anaphylaxis following a bee sting

B.                 In Australia the prevalence of specific IgE to bee venom is 1%

C.                School age children are particularly prone to anaphylaxis but rarely die

D.                Atopy increases the risk of anaphylaxis

E.                 Most systemic reactions to bee stings occur in the months September, October and November

 

 

16.             A 55-year-old man with squamous cell carcinoma of the lung has nausea and constipation with a serum calcium of 3.6 mmol/l. 0.9% sodium chloride is infused at 1 litre per 8 hours. After 36 hours serum calcium is 3.55 mmol/l. Saline infusion is continued. Which of the following is the best choice for further treatment?

 

A.                 Calcitonin

B.                 Frusemide

C.                Hydrocortisone

D.                Disodium pamidronate

E.                 Phosphate

 

 

17.             A 65-year-old man has lost 18 kg in three months. He has also been passing bulky pale foul smelling stools over the same period. There is a history of excessive alcohol intake for over 30 years. On examination he is thin but not anaemic. There is generalised muscle wasting.

 

The following results are obtained:

 

            Haemoglobin                         140 g/l                        (N:130-170)

            MCV                                       102 fl                           (N:81-98)

            Bilirubin                                  26 mmol/l                   (N:<20)

            Alkaline phosphatase           165 U/l                        (N:<135)

            AST                                        62 U/l                          (N:<40)

            ALT                                         47 U/l                          (N:<40)

            Fasting blood glucose          8.9 mmol/l                  (N:3.5-6.0)

 

An avdominal ultrasound and CT scan both show mild hepatomegaly but no other lesion.

 

Which of the following is the most appropriate next investigation?

 

A.                 Small bowel series

B.                 Liver biopsy

C.                Distal duodenal biopsy

D.                Pancreozymin secretin test

E.                 ERCP

 

 

18.             A 56-year-old Greek man presents with lethargy.  He has no other complaints. On examination, he is clinically anameic buth there are no other abnormal findings. Urea, electrolytes and liver fucntion tests are normal. The following additional results are obtained:

 

Haemoglobin             109 g/l            (130 – 170)

Platelet count 520 x 109/L    (150 – 400)

MCV                           78 fl                 (N:81-98)

Leucocytes                7.3 ´ 109/l       (N: 4.0-10.0)

ESR                            26 mm/hr        (N:4-15)

Serum iron                 8 mmol/l          (N:11-32)

Serum transferrin      62 nnol/l          (N:25-50)

Serum ferritin 8 mg/l              (N:30-260)

 

Which is the most appropriate next investigation?

 

A.                 Faecal occult blood test

B.                 Chromium labelled red cell study

C.                Flexible sigmoidoscopy

D.                Haemoglobin electrophoresis

E.                 Colonoscopy

 

 

19.             A 32-year-old man as a history of cough and sputum production for at least ten years. Chest X-ray shows middle lobe consolidation and some increased markings throughout both lung fields. He is infertile and also has a long history of intermittent large joit arthropathy. The most likely diagnosis is:

 

A.                 Allergic bronchopulmonary aspergillosis

B.                 Bronchiectasis secondary to pertussis infection

C.                Immotile cilia syndrome

D.                Cystic fibrosis

E.                 Hypogammaglobulinaemia

 

 

20.             A 35-year-old woman presents with a three week history of pain and swelling involving the metacarpophalangeal and proximal interphalangeal joints of both hands and metatarsophalangeal joints of both feet. She is found to be seronegative for rheumatoid factor.

 

Which of the following alternative diagnoses is least likely?

 

A.                 Psoriatic arthritis

B.                 Rheumatoid arthritis

C.                Viral polyarthritis

D.                Reactive arthritis

E.                 Systemic lupus erythematosus

 

 

21.             Gerstmann’s syndrome resulting from a lesion of the dominant parietal lobe is associated with all of the following except:

 

A.                 Prosopagnosia

B.                 Dysgraphia

C.                Inability to recognise fingers

D.                Inability to distinguish right from left

E.                 Inability to perform simple mental arithmetic

 

 

22.             A 55-year-old man is admitted with ataxia and diplopia. On examination he has complete external and internal ophthalmoplegia and arreflexia but no motor weakness or sensory loss. With regards to this patient which of the following statement is false?

 

A.                 This condition is associated with autoantibodies to a ganglioside (GQ1b)

B.                 This condition is associated with a good prognosis

C.                Autonomic neuropathy is an uncommon but recognised complication

D.                Intravenous corticosteroids is the treatment of choice

E.                 Intravenous immunoglobulin is as effective as plasmapheresis

 

23.             A 36-year-old woman with IDDM since the age of 14 presents with hyperkalaemia. Her BP is 146/96. Laboratory investigations reveal the following:

 

Fasting glucose                     6 mmol/l

Creatinine                              0.19

Sodium                                   135 mmol/l

Potassium                              6.2 mmol/l

Chloride                                 116 mmol/l

Bicarbonate                           14 mmol/l

 

A short synthetic ACTH infusion test is performed and the plasma cortisol increases from 386 to 717 mmol/l. After administration of 80 mg of frusemide and 4 hours of upright posture the plasma renin activity and aldosterone levels remain unchanged from baseline.

 

The best treatment for her hyperkalaemia is:

 

A.                 Fludrocortisone

B.                 Frusemide

C.                Hydrocortisone and frusemide

D.                Haemodialysis

E.                 Potassium-binding anion exhange resin such as resonium A

 

 

24.             A 24-year-old man presents with confusion and headaches. He has widespread purpura and 4cm splenomegaly. There are no focal neurological signs. Distended retinal veins with retinal haemorrhages are noted. Oxygen saturation is 98% on room air by pulse oximetry. Initial results are as follows:

 

Haematocrit               21%

White cell count         500 ´ 109/l

Platelets                     45 ´ 109/l

 

The blood film contains profuse myeloblasts.

 

Sodium                       135 mmol/l

Potassium                  6.8 mmol/l

pH                               7.40

pO2                             45 mmHg

pCO2                          38 mmHg

BE                               +3 mEq

Bicarbonate               22 mmol/l

 

With regard to this patient, which of the following is false?

 

A.                 The white cell count should be lowered urgently with leucapheresis and/or hydroxyurea

B.                 The hypoxemia and hyperkalaemia arelikely to be spurious

C.                The patient should be transfused with packed cells to a haematocrit of >30%

D.                The patient should be treated with intravenous fluids, allopurinol and urinary alkalinisation to prior to commencement of chemotherapy

E.                 The retinal haemorrhages are most likely a consequence of leucostasis and not thrombocytopaenia

 

 

25.             A 43-year-old truck driver presents with a three week history of lethargy and headache and a one day history of left hemiparesis. Chest X-ray reveals a 2cm mass in the left lower zone. CT brain scan shows two contrast –enhancing lesions in the right cerebral hemisphere with surrounding oedema and midline shift.

 

Cryptococcus neoformans var. gattii is cultured from a fine needle aspirate of the pulmonary leion. Which of the following statement is correct?

 

A.                 The patient is unlikely to be immunocompromised

B.                 Dexamethasone is contraindicated

C.                Fluconazole has been shown to be as effective as amphotericin B plus 5-flucytosine

D.                The pulmonary lesion should be resected

E.                 A rise in serum cryptococcal antigen titres after the commencement of therapy indicates a poor prognosis

 

 

26.             A 45-year-old man presents with crushing central chest pain and dysphagia for solids and liquids. ECG and exercise stress testing is normal. The mostlikely diagnosis is:

 

A.                 Achalasia

B.                 Diffuse oesophageal spasm

C.                Lower oesophageal (Schatzki) ring

D.                Oesophageal carcinoma

E.                 Zenker’s diverticulum

 

 

27.             An 18-year-old man presents with weight loss and diarrhoea. On examination he has pedal oedema and a right pleural effusion. Thoracocentesis reveals milky fluid. He is found to have lymphocytopaenia, hypoproteinaemia and hypogammaglobulinaemia. Regarding this patient all the following are correct except:

 

A.                 Abnormal peripheral lymphatics

B.                 Dilated and telangiectatic lymphatic vessels on small bowel biopsy

C.                Increased risk of infection with capsulated bacteria

D.                Response to low-fat diet supplemented with medium-chain triglycerides

E.                 Normal D-xylose absorption test

 

 

28.             A 58-year-old man presents with excessive daytime somnolence and early morning headaches. He is a heavy smoker with an FEV1/VC of 0.6/1.4. On examination he is thin and has normal nasopharyngoscopy.

 

Arterial blood gas on room air:        pH 7.37

pO2 55mmHg

pCO2 60mmHg

BE +14

 

Possible likely mechanisms of REM nocturnal desaturation in this patient include all of the following except:

 

A.                 Upper airway obstruction during sleep

B.                 Hypoventilation due to low tidal volume

C.                Maldistribution of V/Q due to loss of thoracic gas volume

D.                Presence of alveolar hypoventilation while awake

E.                 Effect of sleep on ventilatory drive

 

 

29.             Apreviously healthy 75-year-old man presents with exertional dyspnoea. On examination he has BP 110/70, pulse rate 110, respiratory rate 24 and temperature 370 C. His jugular venous pressure is elevated and he has audible third and fourth heart sounds. His liver is enlarged and he has pedal oedema. ECG shows non-specific ST-T wave changes and occasional premature ventricular ectopics. Chest X-ray shows a mildly enlarged cardiac silhouette and clear lung fields. Echocardiogram reveals normal systolic function and thickened ventricular walls and a “speckled” appearance.

 

Which of the following is the next best test?

 

A.                 Serum and urinary electrophoresis

B.                 Biopsy of subcutaneous abdominal fat

C.                Red cell transketolase

D.                Serum ferritin

E.                 PCR for the C282Y mutation in the HFE gene

 

 

30.             Which of the following statements regarding salicylates is false?

 

A.                 Aspirin is absorbed more rapidly from the stomach than the small bowel

B.                 Salicylate excretion is increased in alkaline urine

C.                Aspirin is of proven benefit in the treatment of unstable coronary syndromes

D.                Aspirin is of proven benefit in the prevention of colorectal cancer

E.                 600mg of aspirin results in greater inhibition of thromboxane A2 synthesis than 100mg of aspirin.