Question 1 Regarding hypertension, which one of the following statements is incorrect? A. Hypertension is a common transient complication of carotid endarterectomy B. populations following a diet low in dietary salt have negligible prevalence of hypertension C. hypertension caused by fibromuscular dysplasia does not usually respond well to single drug antihypertensive therapy D. with hypokalaemia, hyperreninaemia and low serum aldosterone is frequently seen in Cushing’s syndrome E. with >30mM/24hr urinary potassium excretion when serum K is<3.5mM/L is suggestive of primary aldosteronism D Up to 60% of Carotid EA get transient HT In Cushing’s syndrome, K is low but both others are usually normal Question 2 Which one of the following is incorrect with regards to MODY2? A. There is a defect in the glucokinase (GCK) gene on chromosome 7 B. Inheritance is autosomal dominant C. It is associated with 60% reduction of insulin secretion D. There is a low incidence of microvascular complications E. It is often associated with the cluster of risk factors for macrovascular disease E MODY2 patients often have mild diabetes. Macro- and microvascular complications are rare. There are more than 80 mutations on chromosome 7 in the glucokinase gene, and it is an autosomal dominant disease. Question 3 With regard to Cryptococcus neoformans infection in humans, which of the following is least likely to be true? A. The ecological niche of C. neoformans var. neoformans (serotypes D and A) has not been definitively identified B. The incidence in cryptococcosis in Australian aborigines is significantly higher (p< 0.05) than the incidence in the non-aboriginal population C. The incidence in HIV-infected patients has fallen dramatically in the last 5-10 years D. In immunocompetent patients, the infection is nearly always caused by C. neoformans var. gattii (serotypes B or C) E. The cryptococcal latex agglutination antigen test is a sensitive and specific test for infection even in patients with only pulmonary disease. D Although serotypes A and D is classically “associated” with pigeon droppings, the organism is widespread in other organic material including plant matter, insects etc. Although var. gattii infection almost always (<90%) infects immunocompetent hosts, these patients as a group are still most commonly suffer from var. neoformans infection. Question 4 Concerning fluid and electrolyte balance, which one of the following statements is incorrect? A. Thiazide diuretics act in the early distal tubule. B. In diabetic ketoacidosis urinary sodium concentration is typically <20mM/L C. non steroidal anti-infalmmatory drugs are a common cause of hyperkalaemic distal renal tubular acidosis D. respiratory acidosis leads to a net decrease in urinary potassium excretion E. resistant hypokalaemia occurs with magnesium deficiency B there is salt wasting caused by osmotic effects of ketone bodies which drives the hypovolaemia Question 5 Which of the following is most correct regarding Clostridium difficile colitis? A. Culture of C. difficile from the stool is the most appropriate diagnostic test B. It is more common after the use of intravenous antibiotics as compared to oral antibiotics C. Age is not a known risk factor D. Approximately 20% of patients will have relapse of disease after treatment cessation E. Vancomycin is superior to metronidazole in treatment efficacy, but less cost-effective D Culture has a controversial role; culture requires special media. The most appropriate test is the detection of cytotoxin in the stool. Culture can be used to facilitate diagnosis in uncertain cases. More common after oral antibiotics, and can occur with even a single dose of oral cephalosporin. The following are known risk factors: elderly age, being bedridden, underlying infection and use of antibiotics (~70% of cases are associated with clindamycin) Recurrence occurs in 12-24% of cases. Recurrent disease is difficult to treat and is characterised by frequent further recurrences. Oral metronidazole and vancomycin are of equal efficacy, but metronidazole is the recommended first-line treatment as it is more cost-effective, and due to concerns regarding VRE Question 6 Regarding bronchiectasis, which one of the following statements is correct? A. Immunoglobulin deficiency occurs in the majority of cases B. Bronchiectasis first presents in the lingula in cystic fibrosis C. Bronchiectasis is localised to a single lobe in Primary Ciliary Dyskinesia D. Bronchiectasis with dextrocardia suggests reverse beating of the cilia E. Bronchiectasis can be found in patients with normal ciliary beating E Question 7 Regarding Helicobacter pylori, which one of the following statements is correct? A. Eradication of H. pylori alone induces regression of gastric MALT lymphoma in the majority of cases. B. Eradication of H. pylori improves symptoms in the majority of infected patients with non-ulcer dyspepsia. C. Serologic testing is of use in determining the success of eradication of H. pylori in the first 4 weeks after therapy, while the urea test may be falsely positive. D. Intestinal metaplasia is more likely in antral than in corpus-predominant H. pylori gastritis. E. Most antimicrobial agents active against H. pylori are more effective at lower gastric pH. A (reference NEJM 347, 15; Oct 10, 2002) but no long term data to confirm that remission of MALT is maintained only 9% with non-ulcer dyspepsia have improvement of symptoms serology of little use in follow-up, and urea test false negative in first 4 weeks only duodenal ulcer is more common in antral predominant always combine antimicrobials with proton-pump inhibitors or ranitidine to increase pH Question 8 The cytokine released from Th2 (type 2) cells most responsible for production of IgE is: A. IL-4 B. IL-5 C. IL-6 D. TGF-beta E. IL-10 A Question 9 Regarding pregnancy, which one of the following statements is true? A. hypertension noted in the 18th week of gestation is most likely to be caused by preeclampsia B. hyperuricaemia associated with pre-eclampsia results from decreased proximal tubular urate secretion C. renal transplant recipients intending to conceive should be converted from azathioprine to an alternative immunosuppressive agent to avoid tetatogenic effects D. pre-eclampsia is less common in women with pre-existing renal impairment E. pregnancy does not provoke relapses of nephrotic syndrome in minimal change disease E Question 10 Regarding cystic fibrosis, which one of the following statements is correct? A. Is uniformly fatal before the age of 35 years B. Is most common lethal inherited condition affecting Negroes C. Presents as meconium ileus in the majority of cases D. Is associated with an increased risk of pancreatic cancer E. D In women only affects the respiratory tract Question 11 Concerning systematic reviews and meta-analysis, which one of the following statements is incorrect? A. By combining data will increase the statistical power of results B. If combining sufficient studies performed in different settings, will enhance the transferability of the results C. Can allow small biases to become exaggerated into apparent effect D. Can be undertaken only using data from randomised controlled trials E. Do not always provide the highest level of evidence D Question 12 Regarding clinical trials, which one of the following statements is correct? A. A randomised controlled trial is the best design for establishing the burden of illness within a population B. A cross-sectional study is the usual design for establishing aetiology of illness C. Coin tossing and allocation by day of week at presentation are both examples of adequate randomisation methods. D. Clinically important effects have a p value of <0.05 E. Publication bias is when results of a trial are reported and published more than once in different journals D Question 13 In the setting of nosocomial candidaemia, which of the following is most likely to be true? A. Trauma is not a risk factor B. In Australia, infection is usually (>90%) caused by Candida albicans C. Transmission of Candida from health care worker’s hands to patients is an important infection control issue D. Mucosal colonisation by Candida is not a significant predictor of invasive disease E. Antifungal prophylaxis in the ICU setting is an accepted preventative measure C Question 14 Concerning nephrotic syndrome, which one of the following statements is incorrect? A. membranous nephropathy is the most common cause of nephrotic syndrome in adults B. platelet aggregation is enhanced C. increased hepatic synthesis of high density lipoproteins (HDL) results in high circulating levels of HDL D. may occur in HIV infection as a consequence of focal segmental glomerulosclerosis E. may accompany acute interstitial nephritis caused by non-steroidal anti-inflammatory agents C HDL is lost in the urine; it is VLDL, IDL and LDL which rise Question 15 With regard to invasive aspergillosis (IA) in organ transplant recipients, which of the following is most likely to be correct? A. The chest X Ray is a clinically useful test for the diagnosis of pulmonary IA B. The presence of CMV disease is significantly associated with the likelihood of developing IA C. Treatment of IA with lipid amphotericin preparations leads to better patient outcomes than with conventional amphotericin B D. Autologous HSCT recipients experience a similar risk as allogeneic recipients of developing IA E. In general, the isolation of Aspergillus from respiratory secretions is a good predictor of invasive disease. B Question 16 Which one of the following is FALSE regarding absorption in the gut? A. Proteins are degraded to amino acids in the second part of the duodenum B. Lactose is hydrolysed by disaccharidases C. Chylomicrons are formed in the enteric mucosa D. There is a sodium-glucose cotransport pump in the small intestine E. B12 absorption occurs mainly in the terminal ileum A Proteins are acted upon by peptidases in the latter part of the duodenum (pancreatic enzymes) and jejunum Lactose is a disaccharide composed on glucose and galactose. The brush border is abundant in disaccharidases The apolipoproteins that bind to the fatty acids absorbed from the gut are produced in the enterocyte's SER The sodium-glucose pump is the basis for using glucose-salt mixtures in oral rehydration fluids B12 mainly absorbed in terminal ileum Question 17 Regarding Thrombotic Thrombocytopaenic Purpura (TTP), which one of the following statements is correct? A. The platelet thrombi contain fibrinogen (or fibrin). B. In most cases of idiopathic TTP the activity of a von Willebrand factor-cleaving metalloprotease is suppressed. C. Clopidogrel is indicated as prophylaxis in familial cases. D. Plasma exchange is of no additional benefit over plasmapharesis alone in adult idiopathic cases. E. Low-dose aspirin paradoxically reduces haemorrhagic complications. B (reference NEJM 347, 8; Aug 22, 2002) the platelet thrombi contain von Willebrand factor, but not fibrin. In DIC, the platelet thrombi contain fibrin but not vWF. ADAMTS 13 activity < 5% clopidogrel rarely causes TTP must both replace the metalloprotease, and remove the antibodies directed towards it aspirin is contraindicated in TTP because it provokes haemorrhage Question 18 Regarding Inflammatory Bowel Disease, which one of the following statements is correct? A. Patients with ulcerative colitis are more likely than normal individuals to express variant NOD2 (CARD 15) cytoplasmic protein. B. Early appendectomy is associated with a reduced incidence of ulcerative colitis. C. Smoking is protective against Crohn’s disease. D. In ulcerative colitis, Th1 helper-T-cells predominate in the mucosa. E. Cyclosporine is useful in the treatment of Crohn’s disease, even in the absence of severe perianal disease. B (reference NEJM 347, 6; Aug 8 2002) Patients with Crohn’s disease are more likely than normal individuals to express variant NOD2 (CARD 15) cytoplasmic protein Smoking is protective against UC. Increases risk in Crohn’s Th1 in Crohn’s, Th2 in UC Question 19 Which one of the following statements concerning the regulation of parathyroid hormone and vitamin D in chronic renal failure is correct? A. Hyperphosphataemia has no direct effect on parathyroid hormone synthesis and secretion. B. Hypocalcaemia acts on a cytosolic calcium sensing receptor to increase parathyroid hormone synthesis and secretion. C. 1,25 hydroxyvitamin D acts on a cell surface vitamin D receptor to stimulate parathyroid hormone synthesis and secretion. D. Hyperphosphataemia stimulates 1 hydroxylation of 25 hydroxyvitamin D. E. Parathyroid hormone stimulates 1 hydroxylation of 25 hydroxyvitamin D. E Hyperphosphataemia stimulates parathyroid hormone synthesis and secretion directly, and indirectly via its effect to inhibit activation of 25 hydroxyvitamin D, and by complexing with calcium to reduce circulating ionised calcium. The calcium-sensing receptor is membrane-bound and the vitamin D receptor is cytosolic; hypocalcaemia stimulates and vitamin D inhibits parathyroid hormone synthesis and secretion. PTH increases fractional excretion of phosphate (thus reducing hyperphosphataemia) and also activates 25 hydroxyvitamin D. Question 20 The most common intranuclear antigen targeted in the serum of patients with lupus nephritis is: A. Sm B. dsDNA C. SSA D. RNP E. Topoisomerase B Question 21 With regards to prostate cancer, which one of the following statements is true? A. Maximum androgen blockade using an oral anti-androgen and a LHRH agonist improves survival compared to bilateral orchidectomy alone for patients with metastatic disease B. Populations screening using serum prostate specific antigen and digital rectal examination to diagnose localised prostate cancer has reduced mortality. C. A PSA level of 4 ng/ml twelve months after radical prostatectomy indicates the patient has been cured D. Men with BRCA1 gene mutation have a greater than 80% life-long chance of dying prostate cancer. E. Long term LHRH agonist treatment for prostate cancer leads to an increased risk of osteoporosis-associated bone fracture. E A large randomised trial published in N Engl J Med ~1998 showed no survival benefit for MAB. Trials are underway but no reduction in mortality has yet been shown for prostate cancer screening. PSA should fall to zero after prostatectomy and to about 0.5 after radical radiotherapy There is an increased risk of developing prostate cancer with BRCA1 but it is small. Question 22 Which one of the following factors does not significantly affect graft survival rates one year after renal transplant in Australia? A. Donor Age B. Cause of renal disease C. Cold ischaemia time 24 - 48 hours D. Recipient age E. Steroid immunosuppression E Question 23 Regarding corticosteroid therapy in giant cell arteritis, which one of the following is most correct? A. An initial dose of 20mg Prednisolone daily is adequate in biopsy-proven giant cell arteritis in the absence of visual symptoms. B. Even after unilateral visual loss, it is reasonable to delay steroid administration for a matter of hours to maximise the diagnostic yield from urgent temporal artery biopsy. C. In maintaining clinical remision, alternate day oral steroid therapy is as effective as daily administration in suppressing symptoms. D. Elevation of erythrocyte sedimentation after an initial decline should prompt an increase in steroid dose even without symptom recurrence. E. If bone mineral density is not reduced, calcium and Vitamin D supplementation is adequate osteoporosis prophylaxis in a patient commencing steroid therapy. E (reference NEJM 347, 4 July 25, 2002) 40-60mg Prednisolone daily, 1000mg Methylpred in presence of visual symptoms very high incidence of contralateral blindness after unilateral visual loss, and histopath still likely to be positive even after steroids use bisphosphonate if low BMD Question 24 Regarding Hepatitis B therapy, which one of the following statements is correct? A. Lamivudine therapy is associated with the development of genotype resistance in about 7% of patients after 1 year of therapy B. After 4 years of therapy genotypic resistance occurs in about 40% of patients C. Lamivudine cessation after 12 months in eAg negative hepatitis B is associated with recurrence of hepatitis B viremia in 50% of cases. D. In EAg positive HBV, seroconversion on lamivudine therapy is associated with maintenance of a long term response in 50% of patients. E. Lamivudine therapy is indicated in patients with decompensated HBV infection E Lamivudine therapy is associated with the development of genotype resistance in 16-30% after 1 year After 4 years of therapy genotypic resistance occurs in 70% Lamivudine cessation after 12 months in eAg negative hepatitis B is associated with recurrence of hepatitis B viremia in 85% of cases . In EAg positive HBV, seroconversion on lamivudine therapy is associated with maintenance of a long term response in 85% of patients. Lamivudine therapy in patients with decompensated HBV infection improves B/Albumin etc Question 25 The principal cause of lactic acidosis and hepatic steatosis complicating therapy for HIV with nucleoside analogue reverse transcriptase inhibitors (NRTI) is: A. Accumulation of toxic metabolites of the NRTI B. A combination of the NRTI and alcohol abuse. C. Hepatic toxicity from the NRTI D. Secondary to pancreatitis caused by NRTI induced hyperlipidaemia E. NRTI inhibition of mitochondrial DNA polymerase E Question 26 Concerning urolithiasis, which one of the following statements is incorrect? A. stones occur in 40% of patients with primary hyperparathyroidism B. Calcium oxalate stones are more common in patients with small bowel disease or ileal bypass as a consequence of hyperoxaluria C. magnesium ammonium phosphate and calcium phosphate are the constituents of struvite stones which form in response to chronic infection D. Stones in the renal pelvis commonly present with loin pain in the absence of frank haematuria E. stones are more common in populations with higher consumption of animal protein A stones occur in ~10% of patients with primary hyperparathyroidism frank haematuria mainly related to ureteric stones Question 27 Regarding tinnitus, which one of the following statements is incorrect? A. tinnitus may be a complication of Aspirin therapy. B. low-pitched tinnitus is characteristic of Meniere’s disease. C. lateralised tinnitus is suggestive of acoustic neuroma. D. tinnitus associated with unilateral high-frequency hearing loss is suggestive of acoustic neuroma. E. there is an association between tinnitus and tempero-mandibular joint dysfunction. C (reference NEJM 347, 12 Sept 19, 2002) long list of drugs cause tinnitus, including salicylates tinnitus is usually lateralised, but this is not helpful in differential diagnosis Question 28 Dendritic cells provide the link between the innate and the adaptive immune systems predominantly by which one of the following? A. Processing antigens and representing them on MHC class II antigens B. Expressing high concentrations of co-stimulatory molecules C. Secreting pro-inflammatory cytokines D. Secreting lymphocyte-specific chemokines E. Migrating from peripheral sites to lymph nodes upon antigen encounter B Question 29 A patient whose FT4 is recorded as 30 pmol/l and TSH <0.005 mIU/L has a thyroid technetium scan. Uptake in the gland is not increased. Which one of the following could not explain these results? A. Subacute thyroiditis B. Error in the endocrine laboratory C. Thyrotoxicosis factitia D. Iodine-induced thyrotoxicosis E. Follicular carcinoma of the thyroid. E In subacute thyroiditis there is inflammation and therefore no uptake In thyrotoxicosis factitia, thyroid gland will be suppressed uptake of technetium will be blocked by gland full of iodine follicular carcinoma can occasionally cause thyrotoxicosis, in which a focal area of increased uptake will be seen Question 30 Regarding typhoid fever, which one of the following statements is incorrect? A) Is caused by the bacterium Salmonella enterica serotype typhimurium LT2. B) Strains of the causative bacterium which express the polysaccharide capsular antigen Vi are more infectious and more virulent than Vi-negative strains. C) The Ty21a vaccine is taken orally, but should not be given to the immunocompromised, or patients taking antibiotics. D) Chronic carriage is more common in patients with cholelithiasis. E) Fluoroquinolones are more rapidly effective and are associated with lower rates of stool carriage than trimethoprim-sulfamethoxazole. (reference NEJM 347, 22; Nov 28, 2002) Salmonella enterica serotype typhi Question 31 Which one of the following is the most reliable clinical predictor of progression of chronic renal disease? A. Glomerular hypertension. B. Raised circulating renin. C. Proteinuria. D. Raised intrarenal angiotensin II concentration. E. Hyperlipidaemia C Proteinuria is a hallmark of chronic renal disease and the rate of progression tends to correlate with the severity of proteinuria Glomerular hypertension has been demonstrated in experimental animals to contribute to disease progression, and by inference has been shown to exist in some human diseases such as diabetes mellitus. Via a number of different mechanisms, angiotensin II has been shown to accelerate disease progression in animal models, and ACE inhibitors and angiotensin receptors to slow human progressive renal failure. Hyperlipidaemia has been shown to cause progression in various animal models, and there is one meta-analysis and several poorly controlled clinical studies which suggest that it is a factor in humans as well; however it has not been the subject of a properly designed randomised control trial. Question 32 Patients with avocado allergy are more likely than the general population to be allergic to which one of the following? A. House dust mite B. Grass pollens C. Tree pollens D. Soy milk E. Latex E Question 33 Regarding the cystic fibrosis transmembrane receptor protein (CFTR), which one of the following statements is correct? A. The protein functions as a potassium channel in lymphocytes B. There are more than 2,500 known mutations in the CFTR gene C. The incidence of mutations is higher in Australians of Asian descent than in those of Southern European descent D. The protein is involved in Pseudomonas binding and ingestion E. The carrier rate in the northern Europeans is ~ 1: 2,500 D Question 34 Regarding IgA negphropathy, which one of the following statements is incorrect? A. The glomerular deposits of IgA are exclusively of the IgA1 subclass. B. A minority of patients with IgA nephropathy will eventually develop end-stage renal disease. C. Of all the glomerulonephritides, IgA nephropathy is the most common cause of endstage renal disease in Australia. D. Corticosteroids have been shown to reduce levels of proteinuria. E. There is no evidence to suggest that dietary fish oil supplements are of any benefit in preserving renal function. E (reference NEJM 347, 10; Sept 5, 2002) 15-40% will eventually develop end-stage renal disease. Corticosteroids have been shown to reduce levels of proteinuria, although whether they preserve renal function is debated meta-analysis of 4 RCTs of dietary fish oil supplementation suggests 75% probability of benefit Question 35 Which one of the following regarding portal hyptertension in cirrhosis is TRUE? A. Surgical risk in a cirrhotic patients is primarily determined by Child-Pugh classification, type of surgery and type of anaesthesia B. In acute variceal bleeding, the addition of a somatostatin analogue to endoscopic treatment has not been shown to be of additional value in controlling acute bleeding C. Vasopressin analogues such as terlipressin have therapeutic use in their ability to decrease systemic vascular resistance D. Renal impairment in cirrhotic patients can be due to either hepatorenal syndrome or organic renal disease - administration of terlipressin is equally effective in both cases E. Non-alcoholic steatohepatitis does not progress to cirrhosis and portal hypertension A Risk of post-operative hepatic decompensation is determined largely by these 3 factors. The main principles involved here are: degree of hepatic reserve (ChildPugh class), and the degree of impairment to hepatic perfusion (determined by type of surgey [ie worse if laparotomy or large blood loss] and anaesthetic factors [eg- induction hypotension]) addition of somatostatin analogue has benefit in controlling acute bleeding, but no effect on long term outcome (NEJM 344:23-28, Jan 4 2001) vasopressin analogues act by improving renal perfusion: thus an increase in systemic vascular resistance is required. Terlipressin also results in suppression of endogenous vasoconstrictor activity and reduction in portal pressure terlipressin has been shown to only be useful in hepatorenal syndrome; leads to significant improvement in renal function in hepatorenal syndrome only. though uncommon, it does. A significant proportion of people previously labelled as ‘cryptogenic cirrhosis’ are now known to have suffered from NASH Question 36 Regarding test specificity, which one of the following statements is correct? A. Specificity is the probability that a person with a positive test result does have the disease B. Specificity is a measure of the probability of correctly diagnosing a person without the disease with a screening test C. Specificity is the proportion of patients with the target disorder who have a positive test result D. Specificity is the probability that a person with a negative test result does not have the disease E. Specificity is calculated by dividing the false positive results by the sum of the false positive and true negative results. B A is the predictive value of a positive result C is sensitivity D is the predictive value of a negative result Specificity is TN / (FP + TN) Question 37 Regarding abnormal liver tests, which one of the following statements is correct? A. Aminotransferases are reduced in renal failure B. In HCV infection ALT/AST >1 is suggestive of cirrhosis C. In an individual with alcohol consumption of >60 g/day, an ALT>500 is consistent with alcoholic hepatitis D. Paracetamol hepatotoxicity is increased by fasting as this reduces the levels of GSSG E. Valproate acid is associated with peroxisomal hepatotoxiciy and hence the ASTis usually greater than the ALT F. AST/ALT>1 has high sensitivity for cirrhosis in cases where alcohol is not a cofactor A AST/ALT >1 suggestive of cirrhosis alcoholic hepatitis is rarely associated with ALT>300. Consider paracetamol etc Fasting reduces GSH Valproate is associated with mitochondrial hepatotoxicity and hence AST is greater AST/ALT>1 in cases where alcohol is not a cofactor is relatively specific but not sensitive Question 38 The earliest serum abnormality of calcium and phosphate metabolism in chronic renal failure is: A. Reduced 1,25 dihydroxyvitamin D. B. Elevated parathyroid hormone. C. Hyperphosphataemia. D. Hypercalcaemia. E. Hypocalcaemia. B High parathyroid levels are seen at a GFR as high as 70 mls/min, low vitamin D levels from about 50 mls/min, hyperphosphataemia and hypocalcaemia from 25 mls/min and hypercalcaemia (due to treatment, tertiary hyperparathyroidism, or with adynamic bone disese) is generally seen only in dialysis patients. Question 39 With regards to germ cell tumour, which one of the following statements is true? A. A patient with a testicular mass and a serum alpha fetoprotein level of 200ng/ml most likely has a seminoma B. Chemotherapy for good-prognosis germ cell tumour is associated with an 80% chance of infertility. C. A man in whom the serum beta- HCG level falls from 1000ng/ml preoperatively to 200ng/ml two weeks after radical orchidectomy for testicular cancer is unlikely to have metastatic disease. D. A patient with metastatic germ cell tumour to bone, liver and brain has a 40% chance of cure with appropriate therapy. E. Primary mediastinal germ cell tumours have a better prognosis than testicular primary germ cell tumours D If AFP is elevated the tumour must be non-seminoma. B-HCG may be moderately elevated in seminoma (<100). At least 30% of men who have had chemotherapy will sire children. Not all of these try and so the infertility rate is probably less than 50%. The half-life of BHCG is approximately 1 day (AFP is about 1 week). Two weeks after orchidectomy the BHCG should be normal. The prognostic factors for metastatic testicular cancer 1. Level of markers (AFP, BHCG, LDH) 2. Site of primary (mediastinal primary have a worse prognosis) 3. Presence of non-pulmonary visceral metastases. Even the worst prognostic group has a cure rate of greater than 40%. Question 40 Which one of the following is not characteristic of the hyperlipidaemia of chronic renal failure? A. Low HDL cholesterol. B. Raised lipoprotein (a). C. Raised total cholesterol. D. Hyperhomocysteinaemia . E. Hypertriglyceridaemia C Unlike nephrotic syndrome in which hypercholesterolaemia is the major lipid abnormality, total cholesterol levels tend to be normal in patients with chronic renal failure. Each of the other abnormalities is thought to contribute to the atherogenic profile of uraemia. Question 41 Regarding the use of lamivudine in the treatment of chronic hepatitis B, which one of the following statements is NOT correct? A. The chance of HbeAg loss increases progressively with longer duration of therapy B. The greatest chance of response is seen in those with significantly elevated transaminases C. It can be used in patients with decompensated cirrhosis D. The appearance of a resistant mutant is usually not associated with clinical deterioration E. Lamivudine is effective at suppressing viral replication in patients with the pre-core mutant HBV D Explanation: The percentage of patients who seroconvert their e antigen increases with increasing duration of treatment. The relationship approximates a linear curve. If baseline ALT is <2 x normal, the effect of lamivudine is almost similar to placebo. If >5x normal, the percentage of people who seroconvert is approximately 4x placebo Whilst interferon is contraindicated in decompensated cirrhosis (because interferon can cause a flare of disease), lamivudine does not cause a flare and thus can be used in decompensated disease to good effect Monitoring serial LFTs is useful in assessing response to lamivudine- a sudden rise in LFTs after successful control of transaminitis may indicate emergence of a resistant virus. In patients who have had decompensated disease in the past, the emergence of a resistant variant may even lead to rapid hepatic decompensation Whilst interferon is not useful for precore mutant variant (ie- HBV that does not produce e antigen), lamivudine is useful. The problem is that no serological or biochemical end-point can be used reliably to determine whether or not permanent suppression of virus replication has occurred. Cessation of lamivudine in this group invariably leads to reactivations. Thus many must be treated with lamivudine indefinitely Question 42 The most common cause of new cases of endstage renal failure in Australia at present is: A. IgA disease. B. Insulin requiring Type 2 diabetes mellitus. C. Non –insulin requiring Type 2 diabetes mellitus. D. Polycystic kidney disease. E. Reflux nephropathy. B Diabetes mellitus accounted for 22% of new cases of endstage renal failure in Australia in the year 2000; 50% of these were insulin-requiring Type 2 diabetes, 30% non-insulin requiring Type 2 and 20% Type 1. Glomerulonephritis accounted for 30% of new cases, and of these IgA disease for 25% (i.e. 7.5% of the total). Hypertension was the single most common cause (14%) but included in this group are probably a number with other diagnoses. Polycystic kidney disease and reflux nephropathy accounted for 6% and 5% respectively. Question 43 Concerning the reporting of clinical trial results, which one of the following statements is correct about relative risk ? A. Relative risk estimates the magnitude of an association between exposure and disease B. Relative risk is the absolute difference in event rates between 2 intervention or 2 treatment groups C. Relative risk is calculated as (control event rate – experimental event rate)/ experiment event rate D. Relative risk is the most appropriate way to express results from a case control study E. Relative risk is identical to the odds ratio A Question 44 With respect to the management of meningitis, which of the following statements is incorrect? A. steroid therapy has been shown to be of benefit in the management of pneumococcal meningitis B. single-dose ciprofloxacin is an effective post-exposure prophylaxis for health-care workers exposed to N meningitides C. Ceftriaxone 1g IV bd is appropriate initial therapy for meningococcal meningitis. D. penicillin is generally ineffective in eradicatng N menigitidis from the nasopharynx of carriers and infected individuals E. lumbar puncture can be safely performed in the absence of CT in cases of suspected bacterial meningitis without neurological signs or diminished level of consciousness C Ceftriaxone 2g IV bd Question 45 Regarding the incidence of disease, which one of the following statements is incorrrect? A. Type 1 diabetes occurs with higher incidence at increased latitudes. B. Type 1 diabetes occurs with higher incidence in households of lower socio-economic indices. C. Crohn’s disease occurs with higher incidence at increased latitudes. D. British migrants to northern Australia have a similar incidence of multiple sclerosis to Britons in the UK. E. The incidence of Non-Hodgkin’s lymphoma is increasing in developed countries. D (reference NEJM 347, 12; Sept 19, 2002) incidence of MS in British migrants declines towards Australian levels Question 46 Which of the following statements about the anaemia of chronic renal failure is most correct? A. Primarily due to erythropoietin resistance. B. Iron-responsive. C. Worsened by hypoparathyroidism. D. Primarily due to reduced red cell survival. E. Unrelated to CRP and IL6. :B In dialysis and pre-dialysis patients anaemia of chronic renal failure is compounded by reduced iron availability; thus target serum feritin levels are 200-500 µg/L, and transferrin saturation 25-30%. The anaemia is primarily due to erythropoietin deficiency, although erythropoietin resistance and reduced red cell survival may contribute. Hyperparathyroidism and inflammation (as evidenced by raised CRP and IL6 levels, for example) cause erythropoietin resistance. Question 47 With respect to the management of septic shock, which one of the following statements is correct? A. Antithrombin III has been shown to be an effective intervention in meningococcal sepsis B. activated protein C has not been shown to reduce mortality in septic shock C. suboptimal adrenal responses to sepsis are commonly found in shocked patients D. early dialysis (before strictly indicated as renal replacement therapy) has been shown to improve outcome in sepsis E. recombinant von Willebrand factor (rVWF) has been shown to reduce requirements for inotropes in septic shock. C rVWF is complete bull Question 48 Regarding renal sodium handling in chronic renal failure, which one of the folloing statements is incorrect? A. There is increased proximal reabsorption in undamaged nephrons.. B. There is a slow fall in sodium excretion following dietary sodium restriction. C. There is impaired natriuresis following sodium challenge. D. There is decreased fractional excretion of sodium. E. There is reduced distal tubular absorption in undamaged nephrons. D Fractional excretion of sodium (i.e. clearance of sodium in relationship to GFR) actually increases in chronic renal failure, due to distal tubular processes in undamaged nephrons. This occurs even though proximal tubular reabsorption increases in undamaged nephrons (glomerular tubular balance). The kidney is slow to respond to changes (in either direction) in sodium load. Question 49 With respect to ankylosing spondylitis which one of the following statements is incorrect? A. Sacro-iliitis is the pathologic hallmark and usually one of the first earliest manifestations. B. The early lesion consists of subchondral granulation tissue that ultimately erodes the joint C. Romanus lesion is an erosion of vertebral bodies at the disc margin D. Rheumatoid factor is positive in a low percentage (30%-40%) of patients E. The majority of patients express the HLA B27 gene product D Question 50 The acidosis of chronic renal failure is best explained by which one of the following? A. A urinary acidification defect. B. Bicarbonate wasting. C. Reduced titratable acid excretion. D. Excessive dietary loads. E. Reduced ammoniagenesis. E The mild, raised anion gap metabolic acidosis of chronic renal failure is principally due to reduced whole kidney ammonia production, and to a lesser extent reduced titratable acid excretion (the latter giving rise to the high anion gap). This occurs despite an increase ammoniagenesis and a modest increase in titratable acid excretion in undamaged nephrons. In general, distal tubular acidification of urine is maintained (except in specific medullary diseases). Mild increase in fractional excretion of bicarbonate occurs once GFR falls to < 25 mls/min. Question 51 Concerning carriers of the BRCA1 gene mutation, which one of the following statements is correct? A. who are female are at increased risk of breast and ovarian cancer B. who are male are at increased risk of breast cancer C. who are female should be offered Tamoxifen prophylaxis D. who are male are not at increased risk of prostate cancer E. who are male will not pass the mutation on to male offspring A male breast ca assoc with BRCA2 BRCA1 associated breast cancers tend to be ER negative Autosomal dominant, not X-linked Question 52 Which one of the following is not a recognized side effect of Cyclosporine? A. Tremor B. Hypertrichosis C. Leucopaenia D. Hypercholesterolaemia E. Hypertension C Question 53 Regarding the treatment of chronic hepatitis C with Pegylated interferon and Ribavirin, which one of the following statements is correct? A. In genotype 3 infected patients, PEG/R is more efficacious than standard IFN/R B. In genotype 1 infected patients, PEG/R is more efficacious than standard IFN/R C. The cure rate for Genotype 3 HCV with PEG/R is less than 60% D. The cure rate for Genotype 1 HCV with PEG/R is better than 50% E. There is a dose-response relationship between genotype 3 and the cure rate with IFN/R therapy B In genotype 3 infected patients there is no difference in efficacy between PEG/R and IFN/R In genotype 1 infected patients, PEG/R is 10% more efficacious than standard IFN/R The cure rate for Genotype 3 HCV with PEG/R approaches 80% The cure rate for Genotype 1 HCV with PEG/R is ~50% There is only a dose-response relationship between genotype 1 and the cure rate with IFN/R therapy Question 54 In the presence of normal endogenous and exogenous loads, the serum biochemical abnormality which occurs earliest during the course of chronic renal failure is: A. Hyperphosphataemia B. Low serum bicarbonate. C. Hypocalcaemia. D. Hypermagnesaemia. E. Hyperuricaemia. E Mild hyperuricaemia is one of the earliest biochemical abnormalities, occurring with a GFR >25 mls/min; it tends to be of no clinical significance and does not progress due to increased fractional excretion of uric acid. Under normal circumstances, hyperkalaemia is not seen until GFR falls to <5 mls/min. The other biochemical abnormalities are seen once GFR falls below 25 mls/min. Question 55 A 42 year old lady presents with pneumonia. She has had recurrent otitis media for 7 years, and this is her third bout of pneumonia in the last 2 years. High resolution CT scan shows early bronchiectasis. Her IgA and IgM levels are below the limits of detection and the IgG level is 2.4 g/L (NR 7.5 – 15 g/L). The most likely diagnosis is: A. Bence-Jones myeloma B. IgA deficiency C. Common Variable Immunodeficiency D. Bruton’s hypogammagobulinaemia E. Wiskott-Aldrich syndrome C Question 56 A 32 year old man presents to hospital with difficulty walking. He was last well two weeks ago, at which time he developed a diarrhoeal illness that lasted three days. Four days before presentation he developed back pain, which was followed by pins and needles in his feet. In the following two days he developed weakness, at first noticed when going up stairs, then slapping of his feet when he walked. The day before he presented he developed deep aching in his thighs, pins and needles in his hands, and difficulty holding small objects. He feels slightly breathless. On examination there is symmetrical weakness of small hand muscles, wrist flexion, hip extension, knee flexion and all movements at the ankle. All of the deep tendon reflexes except the right triceps jerk are absent. There is reduction in sensation to pinprick below the knee, and in the hands. Nerve conduction studies reveal dispersed compound muscle action potentials with delayed distal latencies in the median and common peroneal nerves. The median nerve SNAP is absent, and F waves cannot be obtained in the ulnar or tibial nerves. Which one of the following alternatives are you most likely to find on cerebrospinal fluid examination? A. Glucose 4.5 mmol/L, protein 2000 mg/L, no red cells, 8 x 106/L mononuclear cells, no polymorphs, cytology unremarkable B. Glucose 4.5 mmol/L, protein 200 mg/ L, no red cells, no mononuclear cells or polymorphs, cytology unremarkable C. Lumbar puncture is unsafe and should not be performed because of the risk of spinal herniation D. Glucose 5.0 mmol/L, protein 2000 mg/L, no red cells, 6x 10 6/L neutrophils, 160 x 106/L mononuclear cells, cytology shows small lymphocytes and monocytes E. Glucose 2.0 mmol/L, protein 4800 mg/L, 13x 106/L neutrophils, 178 x 106/L mononuclear cells, monomorphic population of atypical lymphatoid cells consistent with lymphomatous infiltration A This patient presents with the typical clinical history and examination of GuillainBarre syndrome (acute demyelinating polyneuropathy) following a Campylobacter jejuni infection. The nerve conduction studies show the typical features of demyelinating polyneuropathy: dispersed and delayed CMAPs and absent late responses (ie the F wave). The CSF hallmark of GBS is “albumino-cytologic dissociation”, or an elevation in CSF protein without a raised CSF cell count. Answer b) is normal CSF; answer c) is not correct despite the back pain, because there are no other features of a space occupying lesion in the spinal column that could cause spinal herniation; answer d) is not correct as the cell count is raised- this is more like the CSF that would be seen in HIV related acute demyelinating neuropathy and answer e) is not correct because the situation presented here (ie that of lymphomatous infiltration of the meninges surrounding the spinal cord) would have normal results for the nerve conduction studies presented. Question 57 A 30 year man from the army presents to Emergency after a 10-day history of pyrexia, lethargy, myalgia and most recently dry cough. He has no history of smoking or illicit drug use but he sometimes binge-drinks alcohol. He has no other significant co-morbidities. On examination, he has a respiratory rate of 40 / min and saturation of 90% on 6L of oxygen / min. He has a blood pressure of 90/40 mmHg and a pulse rate of 120 per minute. His ECG reveals only sinus tachycardia. He is pyrexial with a temperature of 39.8ºC. He looks distressed with some diaphoresis. Examination otherwise is unremarkable. Chest X ray shows slight elevation and haziness of the right hemidiaphragm but no other significant abnormalities. Which one of he following investigations would be the LEAST useful in the immediate management of this patient? A. Arterial blood gas B. Urea, creatinine and electrolytes C. Full blood count D. Serology for mycoplasma E. Urinary legionella antigen D Question 58 A 56 year old lady presents with increasing lethargy over 6-12 months. She was previously active, and only recently ceased work as an accountant due to her tiredness. In the past few weeks, she had become increasingly forgetful and even overtly confused at times. She has noted some ankle swelling and abdominal distension, for which her local doctor had commenced frusemide 20mg daily offering mild improvement. She is previously well, on no regular medication s and does not smoke nor drink alcohol. On examination, she had pitting oedema to the ankles and small amount of ascites. A few bruises and scratch marks were also noted. Chest examination revealed a small right pleural effusion. Cardiac examination revealed a normal JVP and normal cardiac auscultation. Her blood tests are as follows: Hb WCC Plt 126 3.9 69 Na K 3.5 Cl Urea Creat 142 ESR BSL 22 4.2 Bili ALP GGT Alb Glob INR 84 435 522 23 46 1.8 97 6.8 68 Which one of the following investigations is the next most appropriate to determine her diagnosis? A. Echocardiogram and abdominal ultrasound B. Head CT and EEG C. ANA, ENA and anti-dsDNA D. Anti-mitochondrial antibody E. Bone marrow biopsy D Right heart failure and hepatic congestion are possible causes of her clinical picture. However, her JVP is normal and her neurological symptoms are not explained by this. The neurological features are vague, and whilst CT might be done at some stage, it would not address her deranged LFTs etc ANA, ENA and anti-dsDNA are not relevant here The features to note in the above picture are: age, gender, protracted history, evidence of pruritis, oedema/ascites with a normal JVP, ‘cholestatic’ LFTs, evidence of cirrhosis with low platelets, low albumin and coagulopathy. The recent confusion etc is likely to be emerging hepatic encephalopathy. Antimitochondrial antibody is a helpful investigation in the initial work-up of suspected PBC- present in 95% of cases. Titre of AMA does not correlate with severity, stage or progression of disease The low platelet count and coagulopathy may suggest a haematological disease, but BMBx would not be helpful in assessing the whole clinical picture in the first instance Question 59 A 21 year-old woman presents for the second time in 48 hours with fever (38.5(C), headache and constipation. She has been previously well until 3 days ago. One month ago she returned from a tiger safari in northern India. Travel was by foot including wading in fresh water. She recalls numerous mosquito, but no other insect bites. She had received vaccinations (including typhoid) and malaria prophylaxis according to current recommendations. Examination reveals a tippable spleen, but no rash or neck stiffness. A full blood count reveals thrombocytopaenia (Plt 90) but no leucocytosis. Routine biochemistry, including liver function tests are normal. Initial thick and thin films reveal no malaria parasites. With regard to this patient, which one of the following statements is most correct? A. Examination of the blood film for malaria parasites should be repeated after 24 hours. B. Pending serologic confirmation of rickettsial infection, empirical tetracycline monotherapy should be commenced. C. The prolonged incubation period makes typhoid unlikely. A fluoroquinolone antibiotic should only be commenced if serologic assay confirms this diagnosis. D. Penicillin alone is the appropriate empiric antibiotic therapy, pending serologic confirmation of leptospirosis. E. Dengue fever is a possible diagnosis, but can only be confirmed by acute and convalescent serology. A (reference NEJM 347, 7; Aug 15, 2002) this is a good story for vivax malaria (recurrent fever, thrombocytopaenia without leukocytosis, splenomegaly) even with appropriate prophylaxis and negative initial film the incubation period is too prolonged for rickettsia, no rash this is a classic history for typhoid, and appropriate incubation period. However, serology is unreliable, diagnose by blood culture leptospirosis is a reasonable consideration, but Penicillin alone not a reasonable choice. Probably no empiric antibiotics are warranted at this stage. The incubation period is too prolonged for Dengue. Thrombocytopaenia and leukopaenia characteristic. Question 60 A 54 year old male suffers an acute anterior myocardial infarction. After treatment with primary angioplasty there is an uneventful initial recovery. Holter monitoring at 5 weeks shows 5 beats in succession of ventricular tachycardia . The left ventricular ejection fraction is 36% on gated heart pool scan. The management of this patient should include which one of the following? A. Further Holter monitoring to assess recurrence of ventricular tachycardia B. Repeat coronary angiogram to assess patency of stent. C. Commencement of amiodarone D. Electrophysiological studies to assess inducibility of ventricular tachycardia E. Implantation of a cardioverter defibrillator D MADIT and MUSTT trials have demonstrted the role of EPS in this situation. ICD needs to be implanted only if there is inducible VT. VT in this situation is not usually related to acute ischaemia and repeat angiogram is not necessary, unless there are ischaemic symptoms. No need for amiodarone therapy. Amiodarone is less effective than ICD if VT is inducible. Question 61 A 24 yo female presents 1.5 hours after the reported ingestion of 60 x 500 mg (30 grams) paracetamol following a fight with her boyfriend. She complains of nausea and epigastric discomfort, and has vomited twice prior to arrival in the emergency department. Physical examination reveals normal vital signs and mild epigastric tenderness. An ED resident asks you for advice as to what to do next. You would suggest (pick the most appropriate answer): A. Give 50 grams of activated charcoal orally and start N-acetylcysteine infusion immediately as this is potentially a lethal ingestion B. Give 50 grams of activated charcoal orally, take blood for a serum pracetamol concentration and start N-acetylcysteine infusion immediately C. Give 50 grams of activated charcoal orally and check serum paracetamol level 4 hours post-ingestion and treat based on serum paracetamol level D. Give 50 grams of activated charcoal orally and check serum paracetamol 4 hours postingestion and urinary beta HCG level and treat based on serum paracetamol level E. Perform oro-gastric lavage followed by 50 grams of activated charcoal, check serum paracetamol 4 hours post-ingestion and urinary beta HCG level and treat based on serum paracetamol level. D There is no indication to treat a patient on history alone for paracetamol poisoning if they present within 8 hours of ingestion as all patients will do well if treatment is commenced within this window. The risk of adverse reactions to NAC is up to 20% and unnecesary treatment of patients may result in preventable morbidity. Also, reported ingested dose is not always the same as true ingested dose. Oro gastric lavage has not been shown to change outcome and may cause more harm than good than charcoal alone. Patients presenting within 2 hours of paracetamol ingestion may benfit from oral activated charcoal as this has been shown to reduce a potentially toxic 4 hour paracetamol level to a subtoxic one, thus resulting in prevention of need for antidotal therapy. Question 62 A 35 year old patient presents with palpitations, sweatiness and is generally unwell. She had a recent URTI followed by neck soreness. On examination she has a small diffuse goitre with slight tenderness. Her FT4 was 32 pmol/l and TSH <0.005 mIU/L. Which one of the following statements is correct? A. An ESR of 97 is against the diagnosis of subacute thyroiditis. B. Undetectable thyroid stimulating immunogloblin levels excludes Graves’ disease. C. The presence of lid lag suggests Graves’ disease, rather than an alternative cause of thyrotoxicosis. D. The presence of pretibial myxoedema suggests Graves disease. E. The presence of thyroid acropachy suggests subacute thyroiditis. D ESR is typically very high with subacute thryoiditis 20% of Graves’ disease patients have negative TSI lid lag can be due to any cause of thyrotoxicosis pretibial myxoedema is associated with Graves’ thyroid acropachy, or clubbing, is associated with Graves’ Question 63 A 38 year old builder presents with a long history of abdominal bloating and weight loss of about 10kg over 12 months. He has also complained of recent onset of lower back pain. He has been well previously, other than complaints of recurrent itchy skin ‘blisters’. Blood tests are as follows: Hb 101 MCV Platelets Blood film Ferritin 102 121 Macrocytes, target cells, Howell-Jolly bodies 105 Na K Urea Creatinine Calcium Phosphate Albumin Bilirubin ALP GGT ALT AST 138 4.1 6.7 112 1.71 0.68 28 18 200 34 28 25 Which one of the following statements about this patient is correct? A. The blood film is unlikely to be related to his presenting illness B. Colonoscopy and biopsy is the diagnostic investigation that should be performed next C. His skin lesions are likely to be photosensitive D. His back pain is most likely to be mechanical related to his occupation, and does not require futher investigation E. Panendoscopy and biopsy is the diagnostic investigation that should be performed next E His blood film shows features consistent with several aspects of coeliac disease: macrocytosis due to B12 malabsorption, target cells due to Fe deficiency and Howell-Jolly bodies due to associated hyposplenism The skin lesions are dermatitis herpetiformis, a pruritic vesicular rash that is not photosensitive Osteoporosis and vertebral crush fractures should be considered, despite his age. His blood profile shows evidence of hypocalcaemia and raised ALP suggesting increased bone turnover in response to poor calcium absorption Villous atrophy in small bowel biopsies is the gold standard of diagnosis for coeliac disease. Even though the clinical suspicion for coeliac disease is high, biopsies are helpful as a baseline to document subsequent response to glutenfree diet Question 64 A 40 yo female presents to hospital by ambulance following ingestion of 50 x 25 mg amitriptylene tablets 45 minutes earleir. She is unconscious with a Glasgow coma score of 4, pulse 126 bpm, BP 80/60, temperature 35 deg C, finger stick blood sugar 6.3 mmol/L. General physical exam is notable only for diminished bowel sounds and neurologic exam is non-focal with 4mm bilateral pupils, generally decreased deep tendon reflexes and no response to pain. She is intubated and ventilated in the emergency department and suffers a self-limiting 20 second clonic generalised seizure post-intubation. A 12-lead ECG reveals sinus tachycardia (rate 130/min), rightward axis, QRS duration 130 msec, and QTc 470 msec. Which one of the following is correct? A. Phenytoin is the drug of choice to prevent seizures in this patient B. The QTc interval is the best indicator of cardiac toxicity in this patient C. A similar clinical picture may be seen after overdose with disopyramide D. Charcoal hemoperfusion will significantly enhance the elimination of cyclic antidepressants in overdose E. The mechanism of cardiac toxicity in cyclic antidepressant poisoning is related to blockade of potassium rectifier currents during the repolarization phase of the cardiac action potential C Intravenous benzodiazepines are the drug of choice for recurrent seizures following cyclic antidepressant overdose. The QRS interval has some utility in predicting acute CAD toxicity. QRS >/= 100 msec predcits 30% risk of seizures and 50% of those with QRS > 160 msec will develop vetricular arrhythmias. A similar picture of toxicity ma be seen with any drug having class 1a antiarrhythmic activity. This includes quinidine, quinine, disopyramide, thioridazine, diphenhydramine. A simiar patter may also be seen with class 1c agents such as flecanide. Charcoal hemoperfucion will not enhance elimination of these agents as they have very large volume of distribution and high protein binding. Cardiac toxicity is related primarily to Na+ channel blockade which may be overcome by boluses of IV sodium bicarbonate. Question 65 A 30 year old woman with newly diagnosed HIV is noted to have abnormal white areas on her tongue and buccal mucosa (as below). They cannot be removed with a swab. Which one of the following is the most likely cause of these lesions? A. Cytomegalovirus B. Human papilloma virus C. Epstein-Barr virus D. Candida albicans E. Treponema pallidum C Question 66 A 20 year-old woman reports that her fingers have turned blue when exposed to cold temperatures since she was a teenager. She takes propranolol as migraine prophylaxis. Which one of the following statements is correct? A. In this patient, the presence of recurrent small, painful digital ulcers would suggest an underlying connective tissue disorder. B. In this patient, Raynaud’s phenomenon is likely to be caused by the non-selective beta blocker. C. If the ANA is positive 1:640, this patient is likely to have secondary Raynaud’s phenomenon. D. The incidence of migraine in those with primary Raynaud’s phenomenon is not significantly different from normal controls. E. Nifedipine has been shown to reduce the frequency of attacks only in secondary Raynaud’s phenomenon. A (reference NEJM 347, 12; Sept 19, 2002) Trials do not support any association between beta-blockers and Raynaud’s 30% positive predictive value of ANA for 2ary Raynaud’s There is an increased incidence of migraine in those with primary Raynaud’s phenomenon. Nifedipine has been shown to be useful in both primary and secondary Question 67 A 22 year old university student from China presents to the hospital emergency with a three week history of headache and fevers. On examination she is febrile and confused with neck stiffness. There are no focal neurologic signs. Physical examination is otherwise unremarkable. She has recently travelled to China and has had a new sexual partner. She keeps a cat. LP reveals pressure 30cm H2O, Glucose 1.8mmol/l, Protein 2883mg/l, Polymorphs 0, Mononuclear cells 94/ul, Red cells 13/ul. Aciclovir and ceftriaxone are commenced. A contrast cerebral CT scan with sinus views and a CXR are normal. CSF culture is negative at 48 hours. She remains unwell with fever, headache and becomes more confused. A repeat LP on day 4 reveals pressure 33cm H2O, Glucose 1.1mmol/l, Protein 4016mg/l, Polys 0, Mononuclear cells 112/ul, Red cells 225/ul. CSF cryptococcal antigen is negative, ZN stain is negative and mycobacterial and fungal cultures are pending. CSF PCR for HSV, Enterovirus and M. tuberculosis are negative. HIV antibody and TPPA are negative. Toxoplasma IgG antibody is positive. The most appropriate next step in management would be: A. HIV PCR on CSF B. Treatment for Mycobacterium tuberculosis C. Treatment for Cryptococcus neoformans D. Serology for Bartonella henselae E. Treatment for Toxoplasma gondii B Question 68 A 28 yo female presents 4 hours after the ingestion of 20 x 240 mg verapamil SR tablets. She is alert and orientated, well perfused with a pulse 66 bpm, BP 105/70. The most appropriate immediate management is: A. give 50 grams of oral activated charcoal and observe for 6 hours. Medically clear the patient if she is well at this time. B. give 50 grams of oral activated charcoal and a further 50 grams 6 hours later. Medically clear the patient if she is well 24 hours post-ingestion. C. give 50 grams of oral activated charcoal and commence whole bowel irrigation with polyethylene glycol-electrolyte solution and observe the patient for 12 hours. Discharge if well at this time. D. give 50 grams of oral activated charcoal and commence whole bowel irrigation with polyethylene glycol-electrolyte solution and observe for 24 hours. Discharge if well at this time. D This is a potentially lethal overdose with patients becoming symptomatic as late as 17 hours post-ingestion with inadequate GIT decontamination. Whole bowel irrigation is rarley indicated in poisoning but this is one situation where it should be attempted early BEFORE the development of an ileus to clear the SR tablets from the gut. Patients should be asymptomatic fot 24 hours prior to being medically cleared from hospital. Question 69 A 60 year old female presents with an 8 week history of diarrhoea. She has a background history of hypertension, asthma and mild rheumatoid arthritis. Her medications are enalapril and indomethacin prn. The diarrhoea is watery and non-bloody, and she passes between 510 motions per day. She has otherwise not had any other symptoms such as abdominal pain, vomiting nor significant weight loss. Stool microscopy and culture have been performed on several occasions: small numbers of both red and white cells occasionally, and 1 of 5 samples yielded growth of Blastocystis hominis. Blood tests show a Hb 108 (normal MCV/MCH), albumin of 32, ESR 25, but otherwise normal LFTs, TFTs, Fe and B12/folate. Colonoscopy was performed which was macroscopically normal, and one random biopsy was normal. Which of the following statements regarding this patient is most correct? A. Irritable bowel syndrome is the most likely diagnosis, as significant pathology on colonoscopy has been excluded B. She should be treated with a prolonged course of metronidazole C. Repeat colonoscopy and biopsies of several areas of colon should be performed D. If admitted to hospital, she needs to be managed in isolation given her stool culture result E. No further investigations are necessary C Diarrhoea-predominant IBS is a possible diagnosis, but some features (such as mild anaemia, positive microscopy), should prompt further investigation before this diagnosis of exclusion is made. Blastocystis hominis is an intestinal protozoan, whose pathogenicity is unclear, but probably does not have any clearly defined pathogenic potential and clinical illness should not be attributed solely to this organism A highly possible diagnosis in this patient is microscopic colitis, which has not been satisfactorily looked for thus far. She has several ‘risk factors’ for a microscopic colitis (either lymphocytic colitis or collagenous colitis), including age, gender and co-existent RA. Prolonged watery diarrhoea in a patient such as this should prompt careful biopsy at several sites if the colonoscopy is macroscopically normal. Right colon and rectum are good sights for biopsies. Question 70 A 62 year old male was resuscitated from a cardiac arrest. Ventricular tachycardia at a rate of 250 beats per minute was documented before cardioversion. Serial cardiac enzymes were not elevated. ECG showed evidence of old anterior myocardial infarction. Coronary angiogram showed a left anterior descending artery totally occluded at its proximal aspect. The other arteries were disease-free. There was moderate left ventricular dysfunction with anterior wall aneurysm. Which one of the following is the optimal management? A. Amiodarone B. Sotalol C. Implantation of cardioverter defibrillator D. Coronary artery bypass surgery E. Percutaneous intervention for the occluded left anterior descending artery C The optimum management of a patient with symptomatic ventricular tachycardia, not related to a reversible cause, is implantation of a cardioverter defibrillator (AVID Trial). Antiarrhythmic drugs are inferior in efficacy to ICD (AVID trial). Revascularisation has no role in this situation. Question 71 A 34 year old man presents to hospital with six hours of weakness of his left side of the face and left arm, and milder weakness of the left leg. Neck pain which developed after a particularly vigorous cutback (ie whilst surfing). He is a non- smoker, and has no personal history of hypertension, hypercholesterolaemia, diabetes mellitus or ischaemic heart disease. He has no family history of stroke to his knowledge. Examination reveals a young man with left facial droop and left arm, and (milder) left arm weakness. The right eyelid is ptosed, and the right pupil constricted and reactive. Extraocular movements are full with no diplopia, and there is no detectable visual field defect. There are no carotid or other bruits. Heart sounds are dual, and there are no added sounds or murmurs. His apex beat is in the fifth intercostal space in the mid- clavicular line, and the chest is clear. Cerebral CT reveals loss of the normal grey / white differentiation in the right frontal lobe. The most appropriate investigation to demonstrate the causative pathology is: A. Duplex ultrasound of the carotids B. Transoesophageal echocardiography C. MRI of the neck with MR angiography D. Angiography of the cerebral circulation E. Holter monitoring C 1 This patient has sustained a stroke from dissection of the right carotid artery, which probably occurred whilst he was surfing. Stroke from carotid dissection is not usually caused by occlusion of the involved artery, but embolisation of thrombus to a more distal artery1. Carotid dissection may be associated with pain in the face, eye or neck ipsilateral to the dissection. A Horner’s syndrome may occur with irritation of the sympathetic fibres around the internal carotid artery. Occasionally ipsilateral palsies of lower cranial nerves may occur, which can cause false localisation of a brainstem stroke. After artery to artery embolism (from atherosclerosis), cardio- embolism, and lacunar infarction, arterial dissection is next most common cause of stroke (the most common of the uncommon causes, so to speak). The best test for cervical arterial dissection is MR angiography, and MRI of the neck to show the blood in the false lumen of the artery. Angiography may not Warlow CP et al. (2001) Stroke: a practical guide to management 2nd ed. show the characteristic elongated and tapering stenosis, ultrasound is too insensitive, and both TOE and Holter monitoring are irrelevant in this case. Question 72 An 11 year-old boy is noted to have a heart murmur and an unusual facial appearance (pictured below). He has mild developmental delay. His attempt (in red) to copy an abstract figure (in green) is illustrated below. There is a history of hypercalcaemia in infancy. He undergoes left heart catheterisation (pictured below). With regard to this patient, which one of the following statements is incorrect? A. He has Williams’ syndrome. B. There is a genetic defect in collagen metabolism C. The inability to copy figures is likely to reflect a specific visuo-spatial cognitive deficit. D. The abnormality in calcium metabolism is likely to have resulted from hypersensitivity to and/or excess of Vitamin D. E. The cardiac catheter reveals supra-valvular aortic stenosis. B Elastin Question 73 A 32 yo man with a history of heavy alcohol consumption presents to hospital complaining of nausea, epigastric discomfort, and vomiting for 12 hours. Examination reveals well perfused, alert and orientated but slightly agitated male patient with P 105 bpm, BP 100/50 mmHg, T 37.5 deg C and mild epigastric tenderness. IV normal saline is commenced and routine bloods are drawn. Serum electrolytes reveal Na 146, K 3.0, Cl 101, Bic 10 mmol/L, Urea 10.2 mmol/L, Creat 160 umol/L, BSL 4.0 mmol/L. Hb 145 g/L WCC 12.3, plt 240,000. Liver function tests, amylase and lipase normal. Serum ethanol 20 mmol/L. Measured serum osmolality 326 mosm/L. Which one of the following statements is correct? A. the patient has a normal anion gap B. the patient has a significant omolar gap C. the patient should be commenced on an intravenous ethanol infusion D. the patient should be urgently haemodialysed E. the patient may complain of tinnitus on further questioning E The patient has an elevated anion gap of 35 with a normal osmolar gap (2Na+Urea+gluc+EtOH level). It is unlikely that he has a toxic alcohol ingestion in view of the normal osmolar gap and the fact that he still has a detectable EtOH level which would inhibit the metabolism of any toxic alcohol until the ethanol was metabolised first. Hence he would not have an acidemia yet. Intravenous ethanol is not indicated and hamodialysis is not required at this stage. The patient may well complain of tinnitus on further questioning suggesting the possibility of salicylate poisoning which can present with a mixed picture of respiratory alkalemia with metabolic acidemia. Hemodialysis may well be indicated after further biocemical assessment and estimation of serum salicylate levels but is not required at this stage. Question 74 A 35 year old female presents with a 2 week history of fever and fatigue and mild arthralgia. Examination is unremarkable with the exception of fever 38C and proteinuria and haematuria on dipstick urinalysis. Serum complement levels are as follows: C3 0.30 (reference range 0.83-1.70g/L); C4 0.15 (reference range 0.10-0.41g/L). Which of the following is the most correct statement? A. Serum sickness is unlikely because the C4 level is normal. B. Repeated measurement of the C3 level is useful in monitoring disease activity. C. Urinary protein loss is the most likely cause of the low C3 level. D. A deficiency of phophatidyl inositol linkages is the cause of the low C3 and haematuria. E. A renal biopsy is the most appropriate next investigation. B Question 75 A 55 year old lady is found to be anaemic with a Hb of 97, MCV 115. Her past history includes diabetes mellitus, partial gastrectomy for refractory peptic ulcer disease at age 20 and hypertension. She was found to be B12 deficient, and the following investigations were performed subsequently. Schilling test Labelled B12 alone Labelled B12 + intrinsic factor 4% of dose excreted at 24 hours 5% of dose excreted at 24 hours C14 breath test Early rise in labelled CO2 Which of the following is the most likely cause of her B12 deficiency? A. Pernicious anaemia B. Terminal ileal disease C. Bacterial overgrowth D. Dietary insufficiency E. Previous gastrectomy C The C14 glycocholic acid breath test is also infrequently performed, but the main principle here is to measure the amount of labelled CO2 in expired air after an oral dose of the labelled glycocholic acid (a bile salt). Bacteria deconjugate the bile salt subsequently releasing labelled CO2 in the breath. An early rise in the breath radioactivity indicates either bacterial overgrowth in the small intestine or rapid transit to colon. Hence, the picture given in the question is that of a bacterial overgrowth syndrome. The Schilling test is rarely performed, but the point of this question is to understand the pathophysiology of disturbed B12 metabolism. Schilling test simplified: 1. Oral load of radioactive cobalamin 2. IM injection of unlabelled cobalamin2 3. Measure proportion of radioactivity excreted in urine over the next 24 hours If due to malabsorption (from any cause), the amount of radioactivity in the urine will be low 4. Oral dose of radioactive cobalamin bound to intrinsic factor 5. Check urine radioactivity again If the deficiency is due to intrinsic factor deficiency (from either pernicious anaemia or surgery), the urine radioactivity will now be high If it is still low, there may be: Blind loop syndrome Terminal ileal disease 2 The IM dose is to saturate the transcobalamin carriers, and FLUSH the radioactive cobalamin from the blood and other tissue sites into the urine 6. Administer antibiotics If it is due to blind loop, the antibiotics should correct the problem, and urine radioactivity will then increase