Qs

Question 1

What are prostaglandins used for in labour?

Answer 1

Used in a pessary intra-vaginally to induce labour

Question 2

What is oxytocin used for in labour?

Answer 2

To augment a slow non-obstructed labour

Question 3

What is used to slow labour by direct action on uterine smooth muscle receptors?

Answer 3

Beta adrenoreceptor agonist

Question 4

What is the likely mode of transmission of dengue fever?

Answer 4

Biting insects

Question 5

What is the likely mode of transmission of rotavirus?

Answer 5

Ingestion

Question 6

What is the likely mode of transmission of papillomavirus?

Answer 6

Skin contact

Question 7

Nearly all cervical cancer is due to 2 types of HPV. Which HPV strains account for 70% of all cases?

Answer 7

HPV16 and HPV18

Question 8

Which HPV strains commonly cause genital warts and laryngeal papillomatosis?

Answer 8

HPV6 and HPV11

Question 9

What does rotavirus cause?

Answer 9

Severe diarrhoea in young children by faecal-oral transmission

Question 10

A 30 year old man with HIV AIDS is found to have a vascular pigmented lesion on his trunk and another on his neck. This is thought to be Kaposi’s sarcoma.

Which microorganism is associated with this cancer?

Answer 10

Human herpesvirus type 8

Question 11

A 57 year old woman presents with a blood-stained vaginal discharge. She is found to have an abnormal mass arising in the region of the cervix.

Which microorganism is associated with this cancer?

Answer 11

Human papilloma virus

Question 12

A 65 year old man presents with weight-loss and epigastric pain he is found to have an ulcer on the greater curve of the stomach which on biopsy is found to be malignant.

Which microorganism is associated with this cancer?

Answer 12

Helicobacter pylori

Question 13

What is the MOA of dacarbazine used in Hodgkin’s disease.

• Bifunctional alkylation of DNA and proteins
• Cytotoxic antibody
• Hormone receptor antagonism
• Ionisation of biological molecules
• Microtubule disruption
• Monofunctional alkylation of DNA and protein
• Structural analogue of a metabolite
• Topoisomerase inhibition
• Tyrosine kinase inhibition

Answer 13

Monofunctional alkylation of DNA and protein

Question 14

What is the MOA of the anthracycline, doxorubicin used to breast cancer.

• Bifunctional alkylation of DNA and proteins
• Cytotoxic antibody
• Hormone receptor antagonism
• Ionisation of biological molecules
• Microtubule disruption
• Monofunctional alkylation of DNA and protein
• Structural analogue of a metabolite
• Topoisomerase inhibition
• Tyrosine kinase inhibition

Answer 14

Topoisomerase inhibition

Question 15

What is the MOA of the nitrogen mustard, cyclophosphamide widely used in solid tumours and leukaemias?

• Bifunctional alkylation of DNA and proteins
• Cytotoxic antibody
• Hormone receptor antagonism
• Ionisation of biological molecules
• Microtubule disruption
• Monofunctional alkylation of DNA and protein
• Structural analogue of a metabolite
• Topoisomerase inhibition
• Tyrosine kinase inhibition

Answer 15

Bifunctional alkylation of DNA and proteins

Question 16

Formation of acute skin abscesses are involved with which cell type.

• Basophils
• Eosinophils
• Giant cells
• Lymphocytes
• Macrophages
• Mast cells
• Monocytes
• Neutrophils
• Plasma cells

Answer 16

Neutrophils

Question 17

Release of histamine in the tissues is involved with which cell type?

• Basophils
• Eosinophils
• Giant cells
• Lymphocytes
• Macrophages
• Mast cells
• Monocytes
• Neutrophils
• Plasma cells

Answer 17

Mast cells

Question 18

Which cell type is associated with the precursor in the blood of tissue mast cells?

• Basophils
• Eosinophils
• Giant cells
• Lymphocytes
• Macrophages
• Mast cells
• Monocytes
• Neutrophils
• Plasma cells

Answer 18

Basophils

Question 19

Release of what is activated by decreased afferent arteriolar pressure and filtered sodium load?

Answer 19

Renin

Question 20

What is angiotensinogen the substrate for?

Answer 20

Renin - they combine to form angiotensin I

Question 21

Where is angiotensinogen and renin released from?

Answer 21

Renin - juxtaglomerular kidney cells

Angiotensinogen - liver

Question 22

The juxtaglomerular cells are stimulated to release renin by signaling from what?

Answer 22

The macula densa (an area closely packed specialized cells lining of the DCT)

Question 23

What is the macula densa?

Answer 23

The macula densa is the thickening where the distal tubule touches the glomerulus.

The cells of the macula densa are sensitive to the concentration of sodium chloride in the distal convoluted tubule.

Question 24

What type of joint is the Glenohumeral joint?

What movements does it permit?

Answer 24

Synovial (ball and socket)

• Flexion and extension
• Adduction and abduction
• Circumduction

Question 25

What type of joints are present at the proximal and distal radio-ulnar joints?

Answer 25

Synovial pivot joints

Allow for supination and pronation

Question 26

What type of joint is in the wrist?

What type of movement does it allow?

Answer 26

Synovial condyloid joint

Flexion, extension, adduction, abduction, circumduction

Question 27

A 45 year old man undergoes gastrectomy for treatment of a benign ulcer, which of the following hormones is likely to be most deficient as a result:

1. Cholecystokinin
2. Gastrin
3. Motilin
4. Secretin
5. Vasoactive intestinal polypeptide

Answer 27

2. Gastrin

Question 28

A 20 year old man consulted his general practitioner complaining of bloating of his stomach after eating. A barium meal showed normal gastric mucosal appearance but delayed gastric emptying. The excess production of which of the following hormones may be responsible:

1. Cholecystokinin
2. Gastrin
3. Motilin
4. Secretin
5. Somatostatin

Answer 28

1. CCK

Question 29

A digestive tract enzyme may be initially released in the inactive form. What is the best term to describe this compound:

1. Enterokinase
2. Enzyme
3. Polypeptide
4. Protease
5. Zymogen

Answer 29

5. Zymogen

Question 30

A 19 year old man ate a large bar of white chocolate. Which of the following digestive processes is most important to promote digestion of the food:

1. Conjugation
2. Emulsification
3. Enterohepatic circulation
4. Glycolysis
5. Phosphorylation

Answer 30

2. Emulsification

Question 31

A 23 year old male with a history of alcohol misuse presented with acute upper-abdominal pain and vomiting. He was found to have a raised serum amylase. What is the most likely diagnosis:

1. Acute appendicitis
2. Acute pancreatitis
3. Cholangitis
4. Dissecting aortic aneurysm
5. Peptic ulcer

Answer 31

2. Acute pancreatitis

Question 32

A 47 year old man was referred for investigation of impaired defecation. Which of the following mechanisms best describes the normal defecation mechanism:

1. Stretch receptors in the rectal wall activate both sympathetic and parasympathetic centers in the spinal cord
2. Stretch receptors in the rectal wall activate parasympathetic centers in the spinal cord
3. Stretch receptors in the rectal wall activate sympathetic centers in the spinal cord
4. The external anal sphincter contracts
5. The internal anal sphincter is consciously relaxed

Answer 32

2. Stretch receptors in the rectal wall activate parasympathetic centers in the spinal cord

Question 33

A 50 year old man presented to the emergency department complaining of a 3 month history of epigastric pain and a 2 day history of a very high volume of vomiting. What is the most likely anatomic site of bowel obstruction to cause this symptom:

1. Distal ileum
2. Gastro-oesophageal junction
3. Mid-oesophagus
4. Sigmoid colon
5. Third part of the duodenum

Answer 33

5. Third part of the duodenum

Question 34

A 45 year old woman has surgical removal of her distal ileum to treat inflammatory bowel disease. Which of the following vitamins is she at risk of becoming deficient in:

1. Vitamin B1
2. Vitamin B5
3. Vitamin B6
4. Vitamin B12
5. Vitamin C

Answer 34

4. Vitamin B12

Question 35

A 24 year old has an inherited defect and is unable to produce intrinsic factor. The absorption of which of the following substances is most likely to be impaired:

1. Bile salts
2. Free amino acids
3. Glucose
4. Vitamin B12
5. Water

Answer 35

4. Vitamin B12

Question 36

A 55 year old man presents with a 6 year history of progressive painless jaundice and weight loss. On inspection, he is jaundiced. Abdominal palpation is normal. What is the most likely diagnosis:

1. Crohn’s disease
2. Diverticular disease
3. Duodenal ulcer
4. Pancreatic cancer
5. Renal carcinoma

Answer 36

4. Pancreatic cancer

Question 37

A 30 year old man presents with jaundice. He has been complaining of intermittent right hypochondrial pain and nausea for several months, but the pain has worsened, his urine is darker than usual and his stools pale. Which imaging is most appropriate in the first instance:

1. Abdominal radiograph
2. Abdominal ultrasound
3. Computed tomography
4. Isotope liver scintigraphy
5. Positron emission tomography

Answer 37

2. Abdominal ultrasound

Question 38

A 45 year old man is stabbed in the lower chest. The knife cuts most of the vagus nerve fibres around the oesophagus. He makes a good recovery. Which of the following is most likely to occur as a result of the nerve injury:

1. Delayed gastric emptying
2. Increased gastrin secretion
3. Increased intestinal peristalsis
4. Increased pancreatic enzyme production
5. Reduced bile production

Answer 38

1. Delayed gastric emptying

Question 39

A 40 year old man has a total colectomy to treat a colonic carcinoma. The operation is curative. Which of the following is most likely to occur as a result of this operation:

1. Constipation
2. Excessive water retention
3. Hyponatremia
4. Reduced absorption of vitamin A
5. Reduced glucose absorption

Answer 39

3. Hyponatremia

One of the major functions of the intact large intestine is to absorb water and electrolytes. After colectomy, as much as 400-1000 ml of nearly isotonic ileostomy fluid may be excreted, resulting in a chronic salt and water depletion.

Question 40

A 70 year old woman presents with jaundice. She has been complaining of right abdominal pain and altered bowel habit for several months. On examination she has a hard craggy mass in her right iliac fossa and hepatomegaly. An abdominal ultrasound is performed. Which of the following is the most likely finding in the liver at ultrasound:

1. Cholecystitis
2. Gallstones impacted in the common bile duct
3. Liver abscess
4. Macronodular cirrhosis
5. Multiple liver metastases

Answer 40

5. Multiple liver metastases

Question 41

A 70 year old man presented with abdominal pain, vomiting and abdominal distension. He reported absolute constipation. An abdominal radiograph shows multiple dilated loops of bowel. Which of the following bowel findings on abdominal x-ray would be in keeping with small bowel obstruction:

1. Central distribution of loops of bowel
2. Haustral mucosal folds
3. Peripheral distribution of loops of bowel
   .4. Relatively few loops
4. Wide angle of curvature of loops of bowel

Answer 41

1. Central distribution of loops of bowel

Question 42

A 45 year old smoker presents with massive haematemesis and melaena. Endoscopy reveals an actively bleeding posterior ulcer in the first part of the duodenum. Which artery is most likely to be bleeding:

1. Aorta
2. Common hepatic
3. Gastroduodenal
4. Right gastric
5. Splenic

Answer 42

3. Gastroduodenal

Question 43

A 20 year old female medical student suffers from severe secretory diarrhoea while backpacking in India. She remembers that oral rehydration therapy (ORT) is an effective way to counter the dehydration caused by intestinal fluid loss. Which of the following ingredients would be required to make up a suitable ORT solution:

1. Potassium chloride + fructose
2. Potassium chloride + glucose
3. Sodium chloride + fructose
4. Sodium chloride + glucose
5. Sodium chloride + monoglyceride

Answer 43

4. Sodium chloride + glucose

Question 44

A patient underwent a cholecystectomy for treatment of chronic cholecystitis. During the operation, the surgeon noticed arterial blood loss from the gallbladder neck. Which artery is most likely to have been injured:

1. Coeliac trunk
2. Cystic artery
3. Inferior pancreaticoduodenal artery
4. Splenic artery
5. Superior mesenteric artery

Answer 44

2. Cystic artery

Question 45

A 50 year old patient has chronic peptic ulcer disease that has not responded to drug therapy and undergoes surgical removal of the gastric antrum to reduce gastric acid production. How does the surgical procedure reduce acid production:

1. Decreases gastrin production
2. Decreases pepsin synthesis
3. Increases bile production
4. Increases cholecystokinin production
5. Increases gastric emptying

Answer 45

1. Decreases gastrin production

Question 46

A 25 year old woman presents with a 6-week history of diarrhoea and oral aphthous ulcers. Her stool contains blood and mucous. What is the most likely diagnosis:

1. Crohn’s disease
2. Diverticulitis
3. Infective diarrhoea
4. Irritable bowel syndrome
5. Ulcerative colitis

Answer 46

1. Crohn’s disease

Question 47

A 25 year old man presents with fever, bloody diarrhoea and cramping for several weeks that does not resolve with antibiotic therapy. Proctosigmoidoscopy reveals red, raw mucous and pseudopolyps. What is the most likely cause:

1. Campylobacter infection
2. Crohn’s disease
3. Irritable bowel disease
4. Ulcerative colitis
5. Viral gastroenteritis

Answer 47

4. Ulcerative colitis

Question 48

A 20 year old man presents with a 12-history of collicky periumbillical pain, which shifts to the right iliac fossa, fever and a loss of appetite. What is the most likely diagnosis:

1. Acute appendicitis
2. Acute pancreatitis
3. Acute viral hepatitis
4. Diverticular disease
5. Perforated peptic ulcer

Answer 48

1. Acute appendicitis

Question 49

A 45 year old man was admitted to hospital after ingesting 25 g of paracetamol 3 days earlier. He had no notable past medical history, took no regular medication and rarely consumed alcohol. Which of the following signs would be consistent with his presentation:

1. Finger clubbing
2. Gynaecomastia
3. Jaundice
4. Palmar erythema
5. Spider naevi

Answer 49

3. Jaundice

Question 50

A researcher is investigating enzymatic digestion of polysaccharides. Which of the following combinations of disaccharides and digested products is correct.

1. Maltose = 3 glucose
2. Maltose = 1 glucose + 1 fructose
3. Sucrose = 1 galactose + 1 glucose
4. Lactose = 1 glucose + 1 galactose
5. Sucrose = 2 glucose

Answer 50

4. Lactose = 1 glucose + 1 galactose

Question 51

A 71 year old man had a malignant tumour of the middle third of the oesophagus. What is the most likely histopathological diagnosis:

1. Adenocarcinoma
2. Adenoma
3. Gastrointestinal stromal tumour
4. Liposarcoma
5. Squamous cell carcinoma

Answer 51

5. Squamous cell carcinoma

Question 52

Name the different skin layers

Answer 52

Epidermis
Dermis
Hypodermis

Question 53

Which of the following skin cells are responsible for immediate type hypersensitivity reactions in the skin

1. Neutrophils
2. Lymphocytes
3. Mast cells
4. Melanocytes

Answer 53

3. Mast cells

Question 54

A small, superficial, circumscribed elevation of the skin, less than 0.5cm, that contains serous fluid is called

1. Papule
2. Macule
3. Nodule
4. Vesicle

Answer 54

4. Vesicle = small fluid filled

Question 55

Acute urticaria is an example of which type of hypersensitivity reaction

1. Type 1 = IgE produced specific to an antigen
2. Type 2 = antibodies bind to antigens on self-surface
3. Type 3 = accumulation of immune complexes that give rise to an inflammatory response
4. Type 4 = delayed (2-3 days) T cell-mediated response

Answer 55

1. Type 1 = IgE produced specific to an antigen

Question 56

All of the following can be used in the treatment of atopic eczema except

1. Topical steroids
2. Antihistamines
3. Emollients
4. Antifungal cream

Answer 56

4. Antifungal cream

Question 57

Impetigo is a skin infection caused by

1. Gram positive cocci
2. Gram negative bacilli
3. Anaerobes
4. Protozoa

Answer 57

1. Gram positive cocci = staphylococcus aureus and streptococcus pyogenes

Question 58

List 4 risk factors for melanoma skin cancer

Answer 58

Previous history of skin cancer
Family history of skin cancer
Fair skin (type 1 + 2 skin)
Living in tropical countries for more than 1 year
Working outdoors
Immunosuppressive diseases or immunosuppressive treatment

Question 59

The cell of origin in a squamous cell carcinoma

1. Melanocytes
2. Basal cells
3. Keratinocytes
4. Endothelial cells

Answer 59

3. Keratinocytes = SCC

Melanocytes = melanoma
Basal cells = BBC

Question 60

Treatment of actinic keratosis involves all of the following except:

1. Topical mupirocin
2. Topical 5 fluorouracil
3. Liquid nitrogen
4. Topical imiquimod

Answer 60

1. Topical mupirocin

Question 61

Acne vulgaris is a common skin condition which is characterised by

1. Comedones, papules, pustules and nodulocysts
2. Vesicles and bullae
3. Scales and crusts
4. Ulceration and erosions

Answer 61

1. Comedones, papules, pustules and nodulocysts

Question 62

What unit of measurement can be used for topical medicines?

Answer 62

Fingertip unit measurement (FTU)

Question 63

List 3 clinical types of psoriasis

Answer 63

Plaque psoriasis 
Guttate psoriasis 
Erythrodermic psoriasis
Pustular psoriasis
Palmoplantar psoriasis
Nail psoriasis
Scalp psoriasis

Question 64

A well-circumscribed, elevated, superficial, solid lesion, greater than 1cm in diameter is termed

1. Papule
2. Nodule
3. Pustule
4. Plaque

Answer 64

4. Plaque = larger raised area

Papule = small raised area 
Nodule = ?
Pustule = small pus filled 
Plaque = larger raised area

Question 65

A 56 y old man presented with multiple, well-defined warty and greasy papules with a ‘stuck on’ appearance on his back; what is the most likely diagnosis

1. Melanocytic nevi
2. Malignant melanoma
3. Seborrheic warts
4. Cherry angioma

Answer 65

3. Seborrheic warts

Question 66

A 19 year old lady presented with red, dry excoriated patches on her face, back, arms, cubital and popliteal fossae; her mother and sister have the same problem; what is the most likely diagnosis

1. Scabies
2. Seborrheic dermatitis
3. Urticaria
4. Atopic dermatitis

Answer 66

4. Atopic dermatitis

Question 67

What are 3 types of medications that can be applied topically?

Answer 67

Topical steroids
Topical antifungals
Topical immunosuppressive
Topical antibiotics

Question 68

Name the 3 types of skin cancer

Answer 68

SCC
BCC
Melanoma

Question 69

What are the functions of the skin (name at least 3)?

Answer 69

Protection
Sensation
Temperature regulation
Immunity
Excretion

Question 70

Name 2 benign skin lesions

Answer 70

Benign melanocytic nevus

Seborrheic keratosis

Question 71

Concerning the motor homunculus. Which of the following structures is represented the most medially:

1. Eye
2. Face
3. Knee
4. Tongue
5. Wrist

Answer 71

3. Knee

Question 72

An 80 year old man presents to his GP with gradual onset of walking difficulties, urinary incontinence and cognitive decline. Heh as no headache. These symptoms are most typical of:

1. Frontal lobe tumour
2. Multiple sclerosis
3. Normal pressure hydrocephalus
4. Parkinson’s disease
5. Vascular dementia

Answer 72

3. Normal pressure hydrocephalus

Question 73

A 51 year old man is noted to have a left trigeminal nerve palsy. Which of the following is the most likely examination finding:

1. He has absent taste sensation to the anterior 2/3 of the left of the tongue
2. He has numbness over the left mandible
3. He has numbness over the right maxilla
4. He has numbness over the right posterior aspect of the scalp
5. He is unable to smile with the left side of his mouth

Answer 73

2. He has numbness over the left mandible

Question 74

A 36 year old woman attends her GP stating that she feels like she can’t cope looking after her 3 month old baby. She says that she worries all the time about her ability to raise her child. Which of the following could not be explained by anxiety:

1. Brisk reflexes with flexor plantar responses
2. Excessive sweating and palpitations
3. Fatigue and feeling of something stuck in the throat
4. Numb legs and extensor plantar responses
5. Poor concentration and forgetfulness

Answer 74

4. Numb legs and extensor plantar responses

Question 75

A 50 year old right handed barman presents with cognitive language dysfunction. He has difficulty expressing what he wishes to say and difficulty reading e-mails. He has been taking dihydrocodeine (oral opiates) for rib pain for the last 6 weeks. Which of the following is the most likely explanation for these findings:

1. Alcohol intoxication
2. Lesion in left temporo-parietal area
3. Lesion in right temporo-parietal area
4. Opiate dependence
5. Right chronic subdural haematoma

Answer 75

2. Lesion in left temporo-parietal area

Question 76

A 69 year old man presented with left-sided neglect. Which of the following structures is most likely to be affected:

1. Left frontal lobe
2. Left parietal lobe
3. Right frontal lobe
4. Right parietal lobe
5. Right temporal lobe

Answer 76

4. Right parietal lobe

Question 77

A 21 year old man is involved in a road traffic accident. On arrival in the accident and emergency department his Glasgow Coma Scale (GCS) is 6 and he is subsequently intubated and ventilated. In order to assess his head injury further, what is the most appropriate investigation:

1. Computerised tomography (CT) brain
2. Functional magnetic resonance imagine (MRI)
3. Magnetic resonance imaging (MRI) brain
4. Positron emission tomography (PET) scan
5. Skull X-rays

Answer 77

1. Computerised tomography (CT) brain

Question 78

A 47 year old woman who is known to have multiple sclerosis (MS), presents to her GP with new onset of diplopia. In MS there is demyelination of axons in the brain and spinal cord. Which of the following glial cells form the myelin sheaths in the central nervous system:

1. Astrocyte
2. Endothelial cells
3. Microglia
4. Oligodendrocyte
5. Schwann cell

Answer 78

4. Oligodendrocyte

Question 79

A 19 year old woman was noted to have decreased vision. Which of the following is an appropriate method of testing the function of the 2nd cranial nerve:

1. Asking the patient to screw her eyes shut
2. Assessing the corneal reflex
3. Assessing the pupil response to light
4. Assessing the vestibulo ocular reflex
5. Looking for nystagmus

Answer 79

3. Assessing the pupil response to light

Asking the patient to screw her eyes shut = CN 7
Assessing the corneal reflex = CN 5
response to light
Assessing the vestibulo ocular reflex = CN 8
Looking for nystagmus = CN 8

Question 80

Which of the following is an appropriate method of testing the function of the 7th cranial nerve:

1. Asking the patient to screw her eyes shut
2. Assessing the corneal reflex
3. Assessing the pupil response to light
4. Assessing the vestibulo ocular reflex
5. Looking for nystagmus

Answer 80

1. Asking the patient to screw her eyes shut

Question 81

Which of the following is an appropriate method of testing the function of the 8th cranial nerve:

1. Asking the patient to screw her eyes shut
2. Assessing the corneal reflex
3. Assessing the pupil response to light
4. Assessing the vestibulo ocular reflex
5. Looking for nystagmus

Answer 81

4. Assessing the vestibulo ocular reflex

5. Looking for nystagmus

Question 82

Which of the following is an appropriate method of testing the function of the 5th cranial nerve:

1. Asking the patient to screw her eyes shut
2. Assessing the corneal reflex
3. Assessing the pupil response to light
4. Assessing the vestibulo ocular reflex
5. Looking for nystagmus

Answer 82

2. Assessing the corneal reflex

Question 83

A 40 year old man is admitted for assessment of suspected syphilis. Which organism is responsible for syphilis:

1. Borrelia burgdorferi
2. Leptospira interrogans
3. Staphylococcus aureus
4. Streptococcus anginosus
5. Treponema pallidum

Answer 83

5. Treponema pallidum

Question 84

A 55 year old man has difficulty walking and attends his GP. Which of the following is the most likely feature of an upper motor neurone lesion:

1. Absent reflexes
2. Dysdiadochokinesia
3. Hypotonia
4. Muscle fasciculations
5. Sustained clonus

Answer 84

5. Sustained clonus

Question 85

A 16 year old boy presented with a spinal cord injury with absent motor response below C7. Which of the following is an example of a descending spinal cord tract:

1. Anterior spinocerebellar tract
2. Dorsal column pathway
3. Lateral corticothalamic tract
4. Lateral spinothalamic tract
5. Posterior spinocerebellar tract

Answer 85

3. Lateral corticothalamic tract

Question 86

Which of the following is an example of an ascending spinal cord tract:

1. Anterior corticospinal tract
2. Lateral corticospinal tract
3. Corticobulbar tracts
4. Medial reticulospinal tract
5. Lateral reticulospinal tract
6. Rubrospinal tract
7. Tectospinal tract
8. Dorsal column pathway

Answer 86

8. Dorsal column pathway

Other examples:

• Anterior spinothalamic tract – carries the sensory modalities of crude touch and pressure.
• Lateral spinothalamic tract – carries the sensory modalities of pain and temperature.
• Posterior spinocerebellar tract – Carries proprioceptive information from the lower limbs to the ipsilateral cerebellum.
• Cuneocerebellar tract – Carries proprioceptive information from the upper limbs to the ipsilateral cerebellum.
• Anterior spinocerebellar tract – Carries proprioceptive information from the lower limbs. The fibres decussate twice – and so terminate in the ipsilateral cerebellum.
• Rostral spinocerebellar tract – Carries proprioceptive information from the upper limbs to the ipsilateral cerebellum.

Question 87

What muscles do the corticobulbar tracts supply?

Answer 87

The corticobulbar tracts arise from the lateral aspect of the primary motor cortex. They receive the same inputs as the corticospinal tracts. The fibres converge and pass through the internal capsule to the brainstem.

The neurones terminate on the motor nuclei of the cranial nerves. Here, they synapse with lower motor neurones, which carry the motor signals to the muscles of the face and neck.

Question 88

List cardinal signs of upper motor neuron lesions.

Answer 88

Hypertonia – an increased muscle tone
Hyperreflexia – increased muscle reflexes
Clonus – involuntary, rhythmic muscle contractions
Babinski sign – extension of the hallux in response to blunt stimulation of the sole of the foot
Muscle weakness

Question 89

A 51 year old man is noted to have poor coordination. Which of the following is an appropriate method of testing coordination of the lower limb:

1. Ask the patient to state if his toe is moved up or down, when his eyes are shut
2. Assessing the patient’s ability to sit up from lying
3. Assessing the plantar response
4. Finger-nose test
5. Heel-shin test

Answer 89

5. Heel-shin test

Question 90

A 30 year old man developed intense burning pain in his arm after spilling concentrated bleach on it by accident. This pain response was mediated by the C class of pain nociceptor. Which of the following properties is most associated with C fibres:

1. Efferent
2. Fast conduction (20m/s)
3. Nucleus located in the thalamus
4. Typical diameter of 1-5um
5. Unmyelinated

Answer 90

5. Unmyelinated

Question 91

A 64 year old man presented with a haemorrhage in his left internal capsule. Which of the following arteries is most likely to supply this area:

1. Left external carotid artery
2. Left middle cerebral artery
3. Left posterior cerebral artery
4. Right anterior cerebral artery
5. Right middle cerebral artery

Answer 91

2. Left middle cerebral artery

Question 92

A 75 year old man presents to his GP with a progressive impairment of his cognitive function. He is diagnosed with dementia. Which of the following is suggestive of a vascular aetiology for his dementia:

1. Abnormal movements
2. Myoclonus
3. Parkinsonism
4. Rapid progression of the dementia
5. Stepwise progression

Answer 92

5. Stepwise progression

Question 93

A 51 year old man was noted to have an upper motor neuron 7th nerve palsy. Which of the following is an appropriate method of testing the function of the 7th cranial nerve:

1. Asking the patient to clench his teeth
2. Asking the patient to smile in order to show you his teeth
3. Assessing the jaw jerk
4. Looking for wasting of the temporalis muscle
5. Testing light touch over the mandible and maxilla

Answer 93

2. Asking the patient to smile in order to show you his teeth

Question 94

A 63 year old woman presents with a gradual onset of a right sided weakness and early morning headaches. She undergoes a computerised tomography (CT) scan of her brain. The report of this suggests that she has a metastatic lesion to her left parietal lobe. Tumours from which of the following primary sites commonly metastasise to the brain:

1. Bone
2. Breast
3. Meninges
4. Schwann cells
5. Tongue squamous cell

Answer 94

2. Breast

Question 95

A 47 year old woman presented to the emergency department with severe back pain and urinary retention. She was numb around her perineum and had absent ankle jerks. Which of the following is the most likely diagnosis:

1. Cauda equina syndrome
2. Gerstmann’s syndrome
3. Guillain-barre syndrome
4. L3 radiculopathy
5. S1 radiculopathy

Answer 95

1. Cauda equina syndrome

A condition due to damage to the bundle of nerves below the end of the spinal cord known as the cauda equina.

Symptoms include: low back pain, pain that radiates down the leg, numbness around the anus, and loss of bowel or bladder control.

Question 96

What is the most effective imaging test for the diagnosis of MS?

Answer 96

MRI

Question 97

A patient has a torn rotator cuff of the shoulder joint as the result of an automobile accident. Which muscle tendon is intact and has normal function?

Answer 97

Teres Major

Question 98

A 35-year-old left-handed baseball pitcher experiences a severe spasm of pain while abducting his left arm in beginning to throw a pitch, and is unable to continue playing. Subsequently, he cannot initiate abduction of the left arm. However, if that arm is passively elevated through the first 15° of abduction, he can complete bringing the arm up to a right angle. The tendon of which of the muscle is most likely torn?

Answer 98

Supraspinatus

Question 99

An 18-year-old boy is cut severely on the lateral wall of his right chest during a knife fight. Following healing, his scapula moves away from the thoracic wall when he leans on his right hand, giving the appearance indicated in the given photo. Which of the nerve is likely damaged?

Answer 99

Long thoracic nerve

Question 100

A 22-year-old woman professional soccer player falls hard onto her outstretched right hand during a game, injuring her wrist. Manipulation of the wrist during postgame physical examination by the team physician elicits deep pain in the anatomical snuffbox. Follow-up radiographs will most likely reveal a fracture of which of the bone?

Answer 100

Scaphoid

Question 101

A 38-year-old baseball pitcher felt a sharp pain in his shoulder when he threw the ball very hard. After a visit by the pitching coach, he threw another pitch but he told the catcher that the pain was unbearable. He left the game and went to the dressing room where he was examined by the team’s orthopedic surgeon, who detected tenderness near the greater tubercle of the humerus. An MRI taken the next day revealed a tear in the pitcher’s rotator cuff. What is the most likely cause of the pitcher’s sore shoulder?

Answer 101

Acute rupture of the supraspinatus part of the rotator cuff.

Question 102

Physical examination of a 40-year-old man injured in an automobile accident indicates that he has suffered nerve damage affecting his left upper limb. The patient exhibits significant weakness when pronating his left forearm and flexing his left wrist. What nerve is most likely damaged?

Answer 102

Median nerve

Question 103

A 45-year-old secretary experienced “pins and needles” sensations (paresthesia) and pain in her right hand during the night. These sensations involved the palmar surface of her thumb and the lateral two and a half fingers. Her colleagues told her that she probably has carpal tunnel syndrome. Her family physician confirmed that this was the condition she was experiencing. She also told the physician that she was having some difficulty typing. On further examination, the physician detected some weakness of her right thenar muscles when compared with the left side. Otherwise motor functions were unimpaired currently.

Answer 103

Distal (carpal) compression of the median nerve

Question 104

A 10-year-old boy was running across a parking lot when he tripped and received lacerations on the base of his thumb from a broken glass bottle. On examination, his thumb was unable to oppose to his fingers, and the thumb also showed weakness when abducting and flexing. No sensory deficits were reported. What nerve was most likely severed?§

Answer 104

Recurrent branch of median nerve

Question 105

The ulnar nerve innervates _______________.

Answer 105

part of flexor digitorum profundus.

Question 106

A 14-year-old boy falls on his outstretched hand and has a fracture of the scaphoid bone. The fracture is most likely accompanied by a rupture of which artery?

Answer 106

Radial artery

Question 107

As part of a physical examination to evaluate muscle function in the hand, a physician holds the four fingers (digits 2 through 5) and asks the patient to spread their fingers, as shown below. What muscle(s) is/are the doctor testing?

Answer 107

Dorsal interosseous muscles

Question 108

A 20-year-old man fell from the parallel bar during the Olympic trial. A neurologic examination reveals that he has a lesion of the lateral cord of the brachial plexus. Which of the muscle is most likely weakened by this injury?

Answer 108

Pectoralis major

Question 109

A 31-year-old patient complains of sensory loss over the anterior and posterior surfaces of the medial third of the hand and the medial one and one-half fingers. He is diagnosed by a physician as having “funny bone” symptoms. Which of the nerve is injured?

Answer 109

Ulnar nerve

Question 110

The first bone in the body to ossify and one of the most commonly fractured bones in the body is the______________.

Answer 110

Clavicle

Question 111

A 12-year-old boy walks into your office. He fell out of a tree and fractured the upper portion of his humerus. Which nerves are intimately related to the humerus and are most likely to be injured by such a fracture?

Answer 111

Radial and axillary

Question 112

A 33-year-old tennis player with a history of biceps tendinitis experienced vague pain in the anterior region of her glenohumeral joint. She said she had the sensation of popping during her third set. During the preliminary examination by her trainer, he noted tenderness over the intertubercular groove in the humerus, flexion and supination weakness of the forearm, and an abnormal bulge in the distal part of the anterior part of her arm. Radiographs of the shoulder and arm did not reveal skeletal abnormalities. Rupture of what is most likely the symptoms and signs in this case?

Answer 112

Rupture of the tendon of the long head of the biceps

Question 113

A secretary comes in to your office complaining of pain in her wrists from typing all day. You determine that she likely has carpal tunnel syndrome. Which condition would help you determine the diagnosis?

Answer 113

Flattened thenar eminence

Question 114

A 3-year-old girl is brought to the emergency room holding her right arm with the elbow flexed and the forearm pronated. She refuses to move her arm and complains her elbow “hurts a lot.” Her mother reports they were holding hands and running in the park when the child tripped. The mother pulled on the child’s hand to prevent her from hitting the ground. Given the nature of this injury and the age of the patient, what structure is most likely damaged?

Answer 114

Annular ligament of radius

Question 115

A 10-year-old boy falls off his bike, has difficulty in moving his shoulder, and is brought to an emergency department. His radiogram and angiogram reveal fracture of the surgical neck of his humerus and bleeding from the point of the fracture. The damaged nerve causes numbness of the lateral side of the arm. Cell bodies of the injured nerve fibers involved in sensory loss are located in which structure?

Answer 115

Dorsal root ganglion

Question 116

A 64-year-old man with a history of liver cirrhosis has been examined for hepatitis A, B, and C viruses. In an attempt to obtain a blood sample from the patient’s median cubital vein, a registered nurse inadvertently procures arterial blood. During the procedure, the needle hits a nerve medial to the artery. Which of the nerve is most likely damaged?

Answer 116

Median

Question 117

A 56-year-old woman was stopped at a light when her car was rear-ended by another car. She had her right arm on the steering wheel, and the impact caused forced flexion at her elbow. Several months later, she comes to her physician complaining of numbness and a “pins and needles” sensation in her right little finger when she talks on the phone, rests her head on her right hand at work, or spends most of her day typing at work. She also notices the quality of her typing and her ability to play the violin have diminished. Which nerve is compressed at what location?

Answer 117

Ulnar nerve in the elbow

Question 118

A 21-year-old woman walks in with a shoulder and arm injury after falling during horseback riding. Examination indicates that she cannot adduct her arm because of paralysis of which muscle?

Answer 118

Latissimus Dorsi

Question 119

A 27-year-old patient presents with an inability to draw the scapula forward and downward because of paralysis of the pectoralis minor. What would most likely be a cause of his condition?

Answer 119

Fracture of coracoid process

Question 120

A 16-year-old boy fell from a motorcycle, and his radial nerve was severely damaged because of a fracture of the midshaft of the humerus. Which conditions would most likely result from this accident?

Answer 120

Loss of wrist extension leading to wrist drop

Question 121

During an attempted suicide, a depressed young woman slashes her wrist with a straight razor. She cuts just proximal to the pisiform bone to the depth of the superficial aspect of the flexor retinaculum before passing out at the sight of her own blood. As a result of this wound, she may suffer what kind of neuromuscular deficit?

Answer 121

Inability to adduct thumb

Question 122

Lateral rotation of the arm is an important mechanical component of “bringing the arm back” when preparing to throw an object. What muscle acts to produce lateral rotation of the arm?

Answer 122

Teres minor

Question 123

A dermatologist performed a biopsy on a suspicious mole on the right side of the posterior neck of a 57-year-old male construction worker. Pathology confirmed a malignant melanoma, so the physician excised a substantial amount of tissue surrounding the mole. After the procedure, the patient experienced difficulty elevating his right shoulder and lifting his right arm over his head. No sensory deficits were seen. What nerve was most likely damaged in this patient?

Answer 123

Accessory nerve

Question 124

A physician tests the myotatic biceps reflex as shown. A normal response of involuntary contraction of the biceps brachii muscle is noted. This reflex confirms the integrity of what nerve?

Answer 124

Musculocutaneous nerve

Question 125

A 58-year-old man who smokes presents with a single episode of moderate intensity chest pain, retrosternal and radiating to his jaw, and some mild sweatiness. The pain lasted 2 hours, and he came to A&E. Examination is normal, as is his ECG, and his troponin is not raised. Which of the following options should be followed?

A He may now be safely discharged home for further outpatient evaluation
B He has an acute coronary syndrome and must start dual antiplatelet therapy and low molecular weight heparin immediately
C He is most likely to have gastro-oesophageal reflux
D An aortic dissection is likely
E The diagnosis is open and he needs continued inpatient evaluation

Answer 125

E The diagnosis is open and he needs continued inpatient evaluation

Question 126

A 67-year-old man presents with bilateral ankle oedema and pitting. Which of the following possible causes is most likely?

A A deep venous thrombosis
B Cellulitis
C A ruptured Baker's cyst
D Amlodipine
E Bisoprolol

Answer 126

D Amlodipine

DVT, cellulitis and a ruptured Baker’s cyst cause unilateral oedema, whereas bisoprolol does not cause bilateral oedema unless it has led to decompensated heart failure, which is possible, but not common.

Question 127

In evaluating bilateral leg oedema, which of the following are important?

A Examining the jugular venous pressure
B Rectal examination
C Determining the presence of inguinal lymph nodes
D A travel history
E All the above

Answer 127

E.

The differential diagnosis of leg oedema is broad and includes heart failure, rectal/pelvic cancer, cellulitis, lymphatic obstruction due to cancer or to filariasis, and other causes. A full careful history and examination is always appropriate.

Question 128

The commonest cause of palpitations seen in the GP surgery is which of the following?

A Non-arrhythmic e.g. due to anxiety
B Related to ectopic beats
C Due to thyrotoxicosis
D Due to severe structural heart disease
E Due to a serious heart rhythm disturbance

Answer 128

A Non-arrhythmic e.g. due to anxiety

Question 129

Which of the following are true in investigating palpitations?

A The history is rarely helpful
B The resting ECG is diagnostic
C A 24-hour ECG is very useful
D A family history is not needed
E An ECG during an attack is diagnostic

Answer 129

E An ECG during an attack is diagnostic

Question 130

A 48-year-old man presents with several months of increasing bilateral leg pain, particularly affecting the distal extremities, and he states that it feels ‘as if he is walking on cotton wool’. Examination shows him to be thin, with normal foot pulses, normal orthopaedic examination, decreased light touch and joint position sense distally, and absent ankle jerks. Which of the following is the diagnosis is likely to be?

A Psychological
B Hyperviscosity syndrome
C Raynoud's phenomona
D Painful peripheral neuropathy
E Referred pain from the back

Answer 130

D Painful peripheral neuropathy

Alcoholic peripheral neuropathy is often painful; the clue is likely to be in the general condition of the patient (thin, recent weight loss), along with the specific clinical findings. The neuropathy should be confirmed (by EMG), and then the full range of possible causes excluded.

Question 131

A man presents with a unilateral, swollen, painful left leg 4 weeks after a left total hip replacement. Which of the following are inappropriate investigations?

A A full blood count
B D-dimer
C Chest X-ray
D Doppler ultrasound of the leg
E ECG

Answer 131

B. D-dimer

The pre-test probability of a deep venous thrombosis is very high; a D-dimer in no way alters this probability and is contraindicated.

Question 132

An 85-year-old man presents with effort breathlessness associated with a retrosternal ache. Examination shows a normal rising carotid upstroke, a loud ejection murmur heard best at the apex, and an absence of the second heart sound. The diagnosis is likely to be which of the following?

A Mitral regurgitation
B Pulmonary stenosis
C Ventricular septal defect
D Aortic stenosis
E Anaemia with a flow murmur

Answer 132

D Aortic stenosis

The demographics, history and exam are all consistent with aortic stenosis. A normal carotid upstroke is very common in elderly patients with aortic stenosis.

Question 133

A 35-year-old woman presents breathless at 35 weeks of pregnancy; she has a body mass index of 40, and a grade III/VI murmur along the mid left sternal edge, with no other cardiorespiratory signs. The likely diagnosis of the murmur is which of the following?

A A benign flow murmur
B Aortic stenosis
C Atrial septal defect
D Aortic regurgitation
E Mitral stenosis

Answer 133

A A benign flow murmur

A flow murmur is almost universal in advanced pregnancy.

Question 134

In which of the following types of shock is giving an intravenous bolus of crystalloid most likely to lead to deterioration in the patient’s condition?

A Septic shock due to line sepsis
B Shock due to an acute myocardial infarction complicated by pulmonary oedema
C Shock due to an acute pulmonary embolus
D Anaphylactic shock
E Shock due to cardiac tamponade

Answer 134

B.

Fluid therapy is an appropriate treatment for most forms of shock when evidence of organ hypoperfusion persists. In cardiogenic shock there is a low COt and the heart will be operating on the flat part of the Frank–Starling curve. Increasing venous return is unlikely to increase cardiac output, which may stay the same or fall. Fluid therapy in these circumstances may make pulmonary oedema and hypoxia worse. Note that synthetic colloids may be a rare cause of anaphylactic shock; therefore one must be cautious about using colloids as fluid therapy in this condition as this may have been the original aetiology of anaphylaxis.

Question 135

Which one of the following statements about common causes of persistent cough with a normal chest X-ray is FALSE?

A Oesophageal reflux
B Pulmonary fibrosis
C Post nasal drip
D Asthma

Answer 135

B.

Cough lasting more that 6 weeks in the context of a normal chest X-ray is commonly due to asthma, postnasal drip or acid reflux. Empirical treatment for these conditions following on from a careful history and examination results in resolution in the majority of patients. In pulmonary fibrosis the chest X-ray may be normal, but usually either clinical or radiological signs are present.

Question 136

Which of the following does NOT typically cause wheeze?

A Chronic obstructive pulmonary disease
B Asthma
C Bronchiectasis
D Tracheal tumour
E Pulmonary oedema

Answer 136

D Tracheal tumour

Large airway obstruction by tracheal tumour results in stridor

Wheeze is result of any condition that causes narrowing of smaller airways

Question 137

Which of the following investigations is NOT useful in the differential diagnosis of wheeze?

A Echocardiogram
B Thoracic ultrasound
C Spirometry
D Chest CT
E Flow volume loop

Answer 137

B Thoracic ultrasound

Wheeze is caused by vibration of the airway wall when airway narrowing occurs. It therefore occurs in conditions that lead to narrowing of the airways. These include obstructive pulmonary diseases, which can be diagnosed using spirometry and flow volume loops. Localized obstruction to airways may be revealed by CT of the chest. Pulmonary oedema leading to diffuse airway oedema and narrowing may present with ‘cardiac wheeze’. Echocardiography may occasionally be useful in making this diagnosis.

Question 138

Which of the following does NOT cause an exudate (high protein content produced by any active process that leads to overproduction of fluid by the pleura)?

A Pancreatitis
B Systemic lupus erythematosis
C Mesothelioma
D Nephrotic syndrome
E Pneumonia

Answer 138

D. Nephrotic syndrome

Conditions such as cardiac failure, nephrotic syndrome and malnutrition typically cause transudates that are low in protein content and are caused by an imbalance between colloid oncotic pressure (which tends to hold fluid in the vascular compartment) and pressure driving fluid into the pleural space.

Question 139

Which of the following statements is true?

A Plain chest X-ray is the most reliable way of diagnosing pneumothorax

B Primary spontaneous pneumothorax is commonly associated with lung disease

C Drainage of a primary spontaneous pneumothorax generally requires a large-bore chest drain

D Air travel is safe a month after pneumothorax

E Most patients with primary spontaneous pneumothorax will not have a recurrence

Answer 139

E. Most patients with primary spontaneous pneumothorax will not have a recurrence

Only 30% of patients with a primary spontaneous pneumothorax will subsequently have a recurrence.

After the second episode the recurrence rate rises above 50%. Pneumothorax is more reliably diagnosed by ultrasound or CT than on plain X-rays. Treatment is usually effective with either simple aspiration or narrow-bore chest drains. Air travel should be avoided for 3 months.

Question 140

Which of the following signs does NOT suggest a TENSION pneumothorax?

A Hypotension
B Tracheal deviation
C Tachycardia
D Dyspnoea
E Subcutaneous emphysema

Answer 140

E Subcutaneous emphysema (felt as a crackling under the skin) is a sign of air leaking into the skin.

It may occur in any pneumothorax and does not necessarily imply tension

Question 141

Weight loss and malabsorption is commonly seen as a feature of which of the following?

A Lactose intolerance
B Pernicious anaemia
C Lymphocytic colitis
D Small bowel bacterial overgrowth

Answer 141

D. Small bowel bacterial overgrowth

• Lactose intolerance causes diarrhoea due to colonic fermentation
• Lymphocytic colitis causes colonic diarrhoea
• Pernicious anaemia results in selective deficiency of vitamin B12

Small bowel bacterial overgrowth can occur secondary to jejunal diverticulosis or small bowel motility problems (e.g. systemic sclerosis) and results in small bowel malabsorption.

Question 142

Selective deficiency of vitamin B12 is a commonly seen feature of which of the following?

A Lactose intolerance
B Pernicious anaemia
C Lymphocytic colitis
D Small bowel bacterial overgrowth

Answer 142

B Pernicious anaemia

Question 143

As a cause for malabsorption coeliac disease might be suggested by which of the following?

A Abdominal pain
B A characteristic rash
C Vomiting
D Steatorrhoea

Answer 143

B A characteristic rash

Dermatitis herpetiformis is a blistering rash present on the elbows and buttocks. It is now considered specific for coeliac disease.

Abdominal pain and vomiting are each unusual in malabsorption, whereas steatorrhoea is non-specific and does not infer one particular cause over any other.

Question 144

Which of the following investigations are useful in suspected acute intestinal obstruction?

A Colonoscopy
B Gastroscopy/upper gastrointestinal endoscopy
C Computed tomography
D Abdominal ultrasound

Answer 144

C. CT with contrast (IV and possibly lumenal)

This will delineate the level of intestinal obstruction and may provide diagnostic clues as to the cause

Question 145

Which one of the following does NOT indicate a significant upper GI bleed?

A A tachycardia of over 100
B Systolic hypotension
C A low red cell mean cell volume
D A raised serum urea

Answer 145

C A low red cell mean cell volume

This is indicative of iron deficiency and is more commonly seen in chronic intestinal blood loss rather than an acute bleed.

Question 146

A mechanical cause for dysphagia (i.e. a stricture) may be suggested by which of the following?

A A feeling of a ‘lump in the throat’
B Food bolus impaction
C Coughing and spluttering when swallowing liquids
D Belching

Answer 146

B Food bolus impaction

Question 147

Pain from a gallstone in the common bile duct can be confidently distinguished from one in the gallbladder by which of the following?

A The presence of jaundice
B Vomiting
C The severity of the pain
D The presence of fever

Answer 147

A.

A bile duct stone (choledocolithiasis) will cause intermittent or persisting biliary obstruction resulting in jaundice. Other features of biliary obstruction may include pale stools, dark urine and pruritis (itching)

Question 148

Pain from the colon can typically be described by which of the following?

A Felt in the middle of the abdomen
B Persistant in quality
C Made worse by eating
D Associated with vomiting

Answer 148

The correct answer is C.

Colonic (hindgut) pain will be felt below the umbilicus. It is due to activation of pressure receptors (baroreceptors) in the wall of the colon, which accounts for its variable intensity (i.e. colicky nature). It will be exacerbated by eating despite activation of the gastro-colic reflex but will only cause vomiting if there is a significant obstruction

Question 149

Cholestatic jaundice can be seen as an adverse reaction to which of the following drugs?

A Paracetamol
B Simvastatin
C Co-amoxiclav

Answer 149

The correct answer is C.

Co-amoxiclav is a recognized cause of an acute intrahepatic cholestasis similar to that seen as a consequence of using chlorpromazine-based major tranquilizers. Simvastatin is associated with an acute hepatitis but will rarely cause symptomatic jaundice. Paracetamol may cause fulminant liver failure if taken in sufficient quantitites as a deliberate act of self-harm.

Question 150

A high protein content in ascitic fluid could indicate which of the following?

A Maligancy
B Advanced cirrhosis
C Heart failure
D Nephrotic syndrome

Answer 150

The correct answer is A.

Exudative ascites is reflected by a high protein content and should always arouse suspicion of maligancy or infection even in the setting of established chronic liver heart or renal disease.

Question 151

Polyuria may be caused by which of the following?

A Increased antidiuretic hormone secretion
B Lithium toxicity
C Reduced serum sodium concentration
D Hypocalcaemia
E Hypoglycaemia

Answer 151

The correct answer is B. Increased ADH will reduce urine output. Reduced serum sodium, hypocalcaemia and hypoglycaemia do not directly affect urine output (though hypercalcaemia and hyperglycaemia can cause polyuria). Lithium toxicity is associated with polyuria due to a nephrogenic diabetes insipidus.

Question 152

In an oliguric patient, which of the following signs point towards fluid depletion?

A A depressed haematocrit
B An elevated jugular venous pressure
C Pulmonary oedema
D Postural hypotension
E Hypertension

Answer 152

The correct answer is D.

Fluid depletion would be suggested by an increased haematocrit, a lowered JVP, postural hypotension and hypotension.

Question 153

Which of the following features are most consistent with a urinary tract infection?

A Pyuria (100 000 white cells/mL of urine) and the presence of nitrite on dipstick
B Proteinuria on dipstick and fever
C Myoglobinuria and muscle pain
D Haematuria and renal impairment

Answer 153

A Pyuria and nitrates

Urinary tract infections are usually associated with pyuria and often by the presence of urinary nitrite which can be detected with dipstick tests.

Question 154

In a patient with microscopic haematuria, which of the following favours a glomerular source?

A Red cell casts and proteinuria
B Blood at the beginning of the urinary stream
C Blood at the end of th eurinary stream
D Suprapubic pain
E Abnormal urine cytology

Answer 154

The correct answer is A.

In a patient red cell casts and proteinuria suggest a glomerular source of bleeding.

Visible blood in the urine (‘macroscopic’ haematuria) only occurs in a limited number of glomerulonephritides such as IgA nephropathy but might indicate a malignancy or other structural lesion of the renal tract.

Question 155

In a patient with obesity which of the following anti-obesity therapies are currently available?

A Pioglitazone
B Orlistat
C Sibutramine
D Rimonabant

Answer 155

The correct answer is B.

Pioglitazone is associated with weight gain and is used in type 2 diabetes mellitus. C and D have both been withdrawn because of adverse risk profiles.

Question 156

In a patient with hirsutism (abnormal hair growth on women’s face/body) which finding would make you question whether a diagnosis of polycystic ovary syndrome is incorrect?

A Hyperinsulinaemia

B Elevated 17-hydroxyprogesterone

C Elevated testosterone

D Increased luteinizing hormone/follicle-stimulating hormone ratio

E Elevated androstenedione

Answer 156

The correct answer is C.

Congenital adrenal hyperplasia due to 21-hydroxylase deficiency is associated with hirsutism and elevated 17-OH progesterone, whereas insulin resistance.

Hyperinsulinaemia is frequently associated with PCOS.

An increased LH/FSH ratio, and mild elevation of serum testosterone and androstenedione is found in patients with PCOS, but a markedly elevated testosterone (>5 mmol/L) is highly suspicious of an adrenal tumour or congenital adrenal hyperplasia.

Question 157

Toxin production plays an important part in the pathogenesis of all the following EXCEPT which one?

A Tetanus
B Clostridium difficile
C Cholera
D Haemophilus influenza
E Escherichia coli O571

Answer 157

D. Haemophilus influenza

Toxin production is just one of the mechanisms through which bacteria can cause damage to host cells.

Question 158

Acute viral infections, such as hepatitis A, are normally diagnosed using which of the following?

A White cell count
B Erythrocyte sedimentation rate
C Specific IgM
D Specific IgG
E Tissue culture

Answer 158

C. IgM is the first antibody type to develop and so indicates current or very recent infection. IgG is produced later and so can be used to check previous exposure or immunization.

Question 159

C-reactive protein may be raised in all of the following EXCEPT which one?

A Acute bacterial infection
B Diabetes
C Autoimmune disease
D Tuberculosis
E Malignancy

Answer 159

B Diabetes

Question 160

Non-infective causes of hyperthermia include which of the following?

A Malaria
B Hypothyroidism
C Alcohol use
D Amphetamines/ecstasy

Answer 160

D Amphetamines/ecstasy

Question 161

Clostridium difficile is a nosocomial infection. Which of the following can be used to treat it?

A Broad spectrum antibiotics
B Proton pump inhibitors
C Probiotics
D Vancomycin or metronidazole

Answer 161

D

Question 162

Staphylococcus aureus can cause a variety of types of pathology EXCEPT which of the following?

A Toxic shock syndrome
B Scarlet fever
C Scalded skin syndrome
D Endocarditis
E Bullous impetigo

Answer 162

The correct answer is B. Scarlet fever is caused by group A streptococci.

Question 163

The articulation of the rib with the vertebrae allows for respiratory movements. At the costovertebral joints the head of the 9th rib articulates with the body of vertebra/e:

1. T8
2. T8 and T9
3. T9
4. T9 and T10
5. T10

Answer 163

2, T8 and T9

Question 164

The lungs are dissimilar in their gross anatomical features. The left is characterised by:

1. A cardiac notch in its posterior border
2. An absence of visceral pleura within its fissures
3. An eparterial bronchus in its hilum
4. Oblique and transverse fissures
5. Upper and lower lobes separated by the oblique fissure

Answer 164

5. Upper and lower lobes separated by the oblique fissure

Whereas the Right lung has 2 fissures (transverse and oblique)

L lung = 2 lobes
R lung = 3 lobes

Question 165

A 47 year old man was referred to a neurosurgeon with a spinal cord tumour. The tumour was compressing his posterior (dorsal) columns on the right hand side. Which of the following statement is most likely to be true:

1. There is likely to be a loss of nociceptive sensation below the level of the lesion on the contralateral side
2. There is likely to be a loss of temperature sensation below the lesion on the contralateral side
3. There is likely to be a loss of temperature sensation below the lesion on the ipsilateral side
4. There is likely to be a loss of vibration and proprioception below the lesion on the contralateral side
5. There is likely to be a loss of vibration and proprioception below the lesion on the ipsilateral side

Answer 165

5. There is likely to be a loss of vibration and proprioception below the lesion on the ipsilateral side

DCML = fine touch (tactile sensation), vibration and proprioception.

Pain and temp is via anterolateral system, specifically the lateral spinothalamic tract which eliminates 1-3.

Question 166

A 55 year old woman presents to her GP with a headache which is associated with scalp tenderness over the right temporal artery. The GP diagnoses giant cell arteritis and commences treatment. Which of the following laboratory results would you expect in this condition:

1. Elevated erythrocyte sedimentation rate (ESR)
2. Elevated urate
3. Elevated white cell count
4. Reduced haemoglobin
5. Reduced erythrocyte sedimentation rate (ESR)

Answer 166

1. Elevated erythrocyte sedimentation rate (ESR)

Question 167

A 75 year old man presented to his general practitioner (GP) with difficulty initiating walking. His GP notices a pill rolling tremor and suspected Parkinson’s disease. Which of the following is the most likely neurotransmitter to be affected:

1. Adrenaline
2. Dopamine
3. Histamine
4. Serotonin
5. Substance P

Answer 167

2. Dopamine

Question 168

A 20 year old man was assaulted whilst watching a football match. On arrival at the local accident Accident and Emergency department he opened his eyes to pain, said inappropriate words and localised to pain. What is his Glasgow Coma Score (GCS):

1. 6
2. 7
3. 8
4. 9
5. 10

Answer 168

5. 10

Question 169

Many structures in the human body receive parasympathetic innervation. Which of these is most likely to occur due to its stimulation:

1. Constriction of pupils
2. Dilation of pupils
3. Increased heart rate
4. Reduced saliva production
5. Relaxation of the bladder wall

Answer 169

1. Constriction of pupils

Question 170

A 44 year old woman is noted to have an 11th nerve palsy. Which of the following is an appropriate method of testing the function of the 11th cranial nerve:

1. Look for fasciculation in the deltoid muscle
2. Look for wasting over the deltoid muscle
3. Look for fasciculation in the platysma muscle
4. Look for hypertrophy in the trapezius muscle
5. Look for wasting of the sternocleidomastoid muscle

Answer 170

5. Look for wasting of the sternocleidomastoid muscle

Question 171

GFR would increase if

1. There is afferent arteriole constriction
2. There is efferent arteriole constriction
3. There is an increase in tissue pressure in Bowman’s capsule
4. There is an increased release of renin from the JG cells
5. There is an obstruction of the ureters

Answer 171

2. There is efferent arteriole constriction

If we constrict the efferent arterioles we increase the pressure in the Bowman’s capsule; filtrate increases

Question 172

How would drinking a large amount of water affect osmolarity and volume of the ECF

1. Decreased osmolarity and increased volume
2. Both would increase
3. No change in osmolarity with increased volume
4. No change in either
5. Greater increase in ECF volume than ICF volume

Answer 172

1. Decreased osmolarity and increased volume

Dilute the electrolytes in the body whilst increasing the volume

Question 173

Antidiuretic hormone (ADH)

1. Is produced by the anterior pituitary
2. Inserts aquaporins into all parts of the kidney tubule
3. Causes the hypertonic medullary gradient to be established
4. Is released in response to cellular dehydration
5. Is released in response to increased plasma urea

Answer 173

4. Is released in response to cellular dehydration

Produced by the hypothalamus and stored in the posterior pituitary gland; it only inserts aquaporins into the collecting duct; it uses the medullary gradient to increase the reabsorption of sodium etc

Question 174

If Drug A’s clearance is greater than inulin clearance, then which of the following would be true of drug A

1. Net reabsorption
2. No reabsorption
3. No secretion
4. Net secretion
5. Reabsorbed and secreted

Answer 174

4. Net secretion

Question 175

A 60 year old man has stage 5 chronic kidney disease with a serum creatinine of 500 umol/L (normal 88-116); which of the following is likely to be present

1. High serum calcium
2. Low serum phosphate
3. High serum phosphate
4. Normal serum calcium
5. Normal serum phosphate

Answer 175

3. High serum phosphate

Question 176

The following acid/base values were obtained pH = 7.25 / [HCO3-] = 12 mmoles/L / PCO2 = 3.3kPa (25 mmHg)

1. They are indicative of a respiratory acidosis
2. The reduction in PCO2 is a result of under-breathing
3. The subject has probably been taking bicarbonate of soda
4. It could be related to impaired renal function
5. The subject may have been vomiting very badly

Answer 176

4. It could be related to impaired renal function

Metabolic acidosis = pH drops; metabolic is indicated by a decrease in bicarbonate / respiratory is indicated by an increase in partial pressure of carbon dioxide

Rule is = in metabolic acidosis / alkalosis, the HCO / PCO drop or rise with it respectively whilst in respiratory types if the pH drops (acidosis) the PCO rises (with the HCO rising too in chronic situations) and if the pH rises (alkalosis) the PCO drops (with the HCO dropping too in chronic situations)

Question 177

The following acid / base values were obtained: pH = 7.28 / [HCO3-] = 36 mmoles/L / PCO2 = 8 kPa (60 mmHg) = chronic respiratory acidosis

1. This is typical of an acute respiratory acidosis
2. The subject will be excreting large amounts of bicarbonate ions
3. The subject will be excreting large amounts of ammonium ions
4. The plasma potassium level is likely to be decreased
5. He has as metabolic alkalosis because of the raised bicarbonate

Answer 177

3. The subject will be excreting large amounts of ammonium ions

Question 178

A patient with lung cancer develops the syndrome of inappropriate ADH secretion; which of the following values for Na+ concentration might be expected to be seen (normal = 135-140 mmol/L)

1. 140 mmol/L
2. 145 mmol/L
3. 150 mmol/L
4. 138 mmol/L
5. 128 mmol/L

Answer 178

5. 128 mmol/L

Question 179

Which of the following are classed as loop diuretics:

1. Furosemide
2. Spironolactone
3. Bendroflumethiazide
4. Mannitol
5. Amiloride

Answer 179

1. Furosemide

Question 180

A 6 year old child presents with swelling of his face and legs; his serum albumin concentration is 18g/L (normal 37-42) and his mother notices that his urine is frothy; what is the most likely diagnosis

1. Ig-A glomerulonephritis
2. Minimal change disease
3. Focal and segmental glomerulonephritis
4. Membranous nephropathy
5. Lupus nephritis

Answer 180

2. Minimal change disease

Question 181

The following acid / base values were obtained: pH = 7.50 / [HCO3-] = 45 mmoles/L / PCO2 = 8 kPa (60 mmHg) = metabolic alkalosis

1. This may be the result of bad diarrhoea
2. The subject will be excreting bicarbonate ions
3. The subject will be excreting ammonium ions
4. The plasma potassium level is likely to be increased
5. The subject has a respiratory acidosis because of the raised PCO2

Answer 181

2. The subject will be excreting bicarbonate ions

Question 182

The following acid / base values were obtained: pH = 7.45 / [HCO3-] = 12 mmoles/L / PCO2 = 2.7 kPa (20 mmHg) = chronic respiratory alkalosis

1. The subject is clearly very unwell
2. The subject is likely to have spent a long time at altitude
3. The subject needs bicarbonate
4. The subject is unlikely to be hypoxic
5. This is typical of a metabolic alkalosis

Answer 182

2. The subject is likely to have spent a long time at altitude

Question 183

The following values were made for an elderly female diabetic patient’s creatinine clearance: 24hr urine volume = 1.44L / serum creatinine concentration = 100 umol/L / urine creatinine concentration = 6.6 mmoles/L

1. Clinical features of renal impairment would be expected
2. Serum creatinine alone indicates impaired renal function
3. Serum potassium should be measured urgently
4. The data suggests there may be renal impairment
5. There is reason to suspect an incomplete renal collection

Answer 183

4. The data suggests there may be renal impairment

Question 184

A 23 year old woman complains of flank pain, dysuria and frequency of micturition; she has taken ibuprofen for the pain; her urinalysis shows protein, nitrites and blood; what is the most likely diagnosis

1. Acute pyelonephritis
2. Cystitis
3. Chronic pyelonephritis
4. Reflux nephropathy
5. Analgesic nephropathy

Answer 184

1. Acute pyelonephritis

Question 185

A 40 year old man was found to have asymptomatic proteinuria and microscopic haematuria during routine employment-related examination; his BP was found to be 160/100 mmHg and serum creatinine 170 micromol/L (normal 86-116); he has no urinary symptoms; what is the next most important symptoms

1. Chest X-ray
2. Echocardiogram
3. Intravenous urogram
4. Ultrasound of the urinary tract
5. Renal biopsy

Answer 185

4. Ultrasound of the urinary tract

Question 186

What are the features of acute urinary retention:

1. Painful inability to void with a palpable or percussible bladder
2. Slow stream of micturition with terminal dribbling and frequency
3. Painless condition with a palpable or percussible bladder
4. Dysuria with frank haematuria
5. Bladder pain which is worse when the bladder is full and relieved by voiding

Answer 186

1. Painful inability to void with a palpable or percussible bladder

Question 187

A 60 year old man has stage 5 chronic kidney disease with a serum creatinine of 500 umol/L (normal 88-116); which of the following is likely to be present:

1. Low serum calcium
2. Normal serum calcium
3. Low serum phosphate
4. Normal serum calcium
5. High serum calcium

Answer 187

1. Low serum calcium

Question 188

Patients with renal failure are often anaemic; what is the best treatment for their anaemia:

1. Oral iron therapy
2. Intravenous iron
3. Vitamin B12
4. Erthryopoietin
5. Blood transfusion

Answer 188

4. Erthryopoietin

Question 189

For an uncomplicated urinary infection which of the following organism is the most likely cause:

1. Staphylococcus aureus
2. Klebsiella sp
3. Pseudomonas aeruginosa
4. Candida albicans
5. Escherichia coli

Answer 189

5. Escherichia coli

Question 190

A 70 year old man complains of poor stream of urine, nocturia and post-micturition dribbling; which of the following is the most likely cause:

1. Diabetic neuropathy
2. Urinary tract infection
3. Chronic kidney disease
4. Prostatic hypertrophy
5. Bladder cancer

Answer 190

4. Prostatic hypertrophy

Question 191

A 60 year old man presents with tiredness and malaise; routine investigations reveal a raised serum creatinine and an estimated GFR of 35 ml/min; which of the following stages of CKD is he in

1. Stage 1
2. Stage 2
3. Stage 3
4. Stage 4
5. Stage 5

Answer 191

3. Stage 3

Question 192

The commonest urological malignancy in patients with painless frank haematuria is:

1. Kidney cancer
2. Testicular cancer
3. Bladder cancer
4. Penile cancer
5. Prostate cancer

Answer 192

3. Bladder cancer

Question 193

What is the commonest type of renal tract stones in adults:

1. Calcium phosphate
2. Calcium oxalate
3. Cystine
4. Magnesium ammonium phosphate
5. Uric acid

Answer 193

2. Calcium oxalate

Question 194

What is the commonest mode of presentation for patients with a renal or ureteric stone:

1. Loin pain radiating to the flank and / or groin
2. Frank haematuria
3. Urinary tract infection
4. Lower urinary tract symptoms
5. Acute urinary retention

Answer 194

1. Loin pain radiating to the flank and / or groin

Question 195

The following antibiotics are generally suitable for empirical treatment of complicated urinary tract infections except:

1. Vancomycin
2. Ciprofloxacin
3. Ceftriaxone
4. Gentamicin
5. Co-amoxiclav

Answer 195

4. Gentamicin

Question 196

A patient with hypothyroidism would demonstrate which of the following symptoms:

1. Exopthalmos
2. Increased heart rate
3. Heat tolerance
4. Increased protein metabolism
5. Lethargy

Answer 196

5. Lethargy

Question 197

Goitre is a common symptom of thyroid dysfunction and can be present in both hypo- and hyperthyroidism. However it would not be present in which of the following thyroid pathologies

1. Primary hypothyroidism
2. Secondary hypothyroidism
3. Primary hyperthyroidism
4. Secondary hyperthyroidism
5. Graves disease

Answer 197

2. Secondary hypothyroidism

Question 198

A decrease in circulating cortisol levels would result in which of the following physiological responses

1. Enhanced gluconeogenesis in the liver
2. Hypotension
3. Decreased ACTH secretion from the anterior pituitary
4. Elevated fatty acid levels in the plasma
5. Suppression of the immune system

Answer 198

2. Hypotension

Question 199

A person with primary hypercortisolism would demonstrate

1. Depressed ACTH
2. Elevated CRH
3. Hypotension
4. Hypoglycaemia
5. Increased bone density

Answer 199

1. Depressed ACTH

Question 200

Chronic glucocorticoid therapy is associated with which of the following

1. Enhanced cortisol release from the adrenal glands
2. Enhanced ACTH release from the anterior pituitary
3. Enhanced CRH release from the hypothalamus
4. Adrenal insufficiency
5. Adrenal hypertrophy

Answer 200

4. Adrenal insufficiency

Question 201

Which of the following will elevate free calcium levels in plasma

1. Alkalosis
2. Activation of osteoblasts
3. Increased phosphate excretion at the kidneys
4. Calcitonin
5. All of the above

Answer 201

3. Increased phosphate excretion at the kidneys

Question 202

Regarding growth hormone which of the following is correct

1. It is also known as somatostatin
2. It is also known as somatomedian
3. It is a steroid hormone
4. Levels in adults are at their highest during REM sleep
5. It is relatively insignificant in terms of foetal and neonatal growth

Answer 202

5.It is relatively insignificant in terms of foetal and neonatal growth

Question 203

The adrenal zona glomerulosa secretes which hormone

1. Testosterone
2. Progesterone
3. Aldosterone
4. Cortisol
5. Epinephrine / adrenaline

Answer 203

3. Aldosterone

Question 204

Which of the following responses would you expect following insulin release

1. Hepatic gluconeogenesis
2. Increased ketone formation
3. Increased uptake of glucose by the brain
4. Adipose lipolysis
5. Stimulation of Na/K ATPase

Answer 204

5. Stimulation of Na/K ATPase

Question 205

Which of the following is not a glucose counter regulatory hormone

1. Thyroid hormone
2. Epinephrine (adrenaline)
3. Glucagon
4. Cortisol
5. Growth hormone

Answer 205

1. Thyroid hormone

Question 206

A 21 year old man is diagnosed with Type 1 DM. He is studying engineering at university and has a part-time job as a delivery driver. He had just got married and his wife is expecting their first child. What information should he receive shortly after diagnosis

1. He should be told he cannot continue his driving job in the future
2. He may be able to work off shore depending on his employer and where he is going
3. He is likely to pass on his diabetes to his child
4. He should be advised to stop drinking any alcohol
5. He should be told he is unlikely to ever have any hypos (hypoglycaemic episodes) if he monitors his blood glucose regularly

Answer 206

2. He may be able to work offshore depending on his employer and where he is going

Question 207

It is advisable for everyone to pursue a healthy lifestyle if he / she wishes the reduce the risks of long term illness. Which of the following would be considered appropriate to tell a sedentary man with an unhealthy diet who is keen to change to a more healthy lifestyle

1. Do a minimum of 30 minutes of vigorous physical activity on most days of the week
2. Aim to eat 5 portions of fruit / vegetables per day
3. Aim to eat 4 portions of oily fish / week
4. It is inadvisable to drink more than 20 units of alcohol per week
5. All of the above

Answer 207

5. All of the above

Question 208

A 53 year old man was diagnosed with T2 DM 6 months ago. He has lost 1 stone in weight, his BMI is 28 and HbA1c is 75 mmol/mol (9%). What is the next appropriate medication in his management?

1. Thiazolidinedione (e.g pioglitazone)
2. Sulphonylurea (e.g metformin)
3. Biguanide (e.g metformin)
4. DPP IV inhibitor (e.g sitagliptin)
5. Insulin

Answer 208

3. Biguanide (e.g metformin)

Question 209

Which symptom below is not typical of hypoglycaemia

1. Headache
2. Itch
3. Poor concentration
4. Sweating
5. Irritability

Answer 209

2. Itch

Question 210

A 32 year old patient with T1DM is reviewed at the diabetes clinic. His blood sugar is 3.2 mmol/L and he tells you he is feeling well. What is the best course of action next.

1. Administer IM glucagon
2. Send him home for lunch
3. Give 200ml fresh orange juice
4. Give digestive biscuit
5. Administer his lunchtime insulin

Answer 210

3. Give 200ml fresh orange juice

Question 211

A 25 year old with T1 DM mellitus presents with vomiting and diarrhoea. BP 80/54, RR 24 per minute. Which test is least important for immediate management

1. Blood glucose
2. pH
3. Urine / blood ketones
4. Electrolytes
5. Liver function tests

Answer 211

5. Liver function tests

Question 212

23 year old man diagnosed with hyperthyroidism and has been commenced on carbimazole. What do you need to counsel him about

1. Neutropenia
2. Fertility
3. Metallic taste in mouth
4. Renal function
5. Discolouration

Answer 212

1. Neutropenia

Question 213

A man with a large prolactinoma complains of impaired vision. What is the most likely pattern of visual field loss to be found on clinical confrontation

1. Homonymous hemianopia
2. Bitemporal hemianopia
3. Total loss of vision in one eye
4. Homonymous quadrantanopia
5. Nasal hemianopia

Answer 213

2. Bitemporal hemianopia

Question 214

A 38 year old lady presents feeling tired and dizzy. She is tanned and her investigations show (Na = 123; low), (K = 5.6; high). Thyroid function tests are normal and calcium is normal. Her cortisol is low, 50. What is her diagnosis

1. Hyperparathyroidism
2. Addison’s disease
3. Cushing’s disease
4. Grave’s disease
5. Conn’s syndrome

Answer 214

2. Addison’s disease

Question 215

All the conditions below are well recognised causes of secondary diabetes except one. Which condition is not a recognised cause of secondary diabetes.

1. Acromegaly
2. Haemochromatosis
3. Addison’s disease
4. Cushing’s disease
5. Chronic pancreatitis

Answer 215

3. Addison’s disease

Question 216

The chambers of the heart possess unique, distinguishing features enabling them to function effectively and efficiently.

The right atrium possesses:

1. A bicuspid valve leading to the right ventricle
2. An opening for the azygos vein
3. An opening for the coronary sinus
4. An opening for the right brachiocephalic vein
5. An oval fossa in its anterior wall

Answer 216

3. An opening for the coronary sinus = drains all the blood supplied to the heart back into the right atrium
4. A bicuspid valve leading to the right ventricle = tricuspid valve found between right atrium + right ventricle
5. An opening for the azygos vein = empties into the SVC
6. An opening for the coronary sinus = drains all the blood supplied to the heart back into the right atrium
7. An opening for the right brachiocephalic vein = stems from the SVC and goes on to form the right subclavian + right internal jugular / right external jugular
8. An oval fossa in its anterior wall = fossa ovalis is found in the right atrium of the heart

Question 217

Which of these is NOT a shared feature of skeletal and cardiac muscle:

1. Myocytes in both are electrically connected via gap-junctions = gap junctions fund in cardiac muscle but not in skeletal muscle (electrically coupling is also a cardiac trait)
2. The duration of the depolarising phase of the action potential in both is less than
3. 5 msec = skeletal muscle action potential is about 5ms but the cardiac one is about 250 ms
4. They both exhibit sustained contraction (tetanus) in response to high frequency
5. Stimulation = skeletal muscle can exhibit tetanus but cardiac muscle cannot due to a long refractory period
6. They both have an unstable resting membrane potential = skeletal muscle has a very stable resting membrane potential whereas some cardiac muscle cells have an unstable resting membrane potential (thus acting as pacemakers)
7. None of the above features are shared in common

Answer 217

7. None of the above features are shared in common

Question 218

During embryological development, which of the following gives rise to the common carotid arteries?

1. 2nd pair of aortic arches
2. 3rd pair of aortic arches
3. 4th pair of aortic arches
4. 5th pair of aortic arches
5. 6th pair of aortic arches

Answer 218

2. 3rd

Comments

• 2nd pair of aortic arches = 1st / 2nd disappear early, a remnant of the 1st forms part of the maxillary artery (a branch of external carotid artery)
• 3rd pair of aortic arches = constitutes the commencement of the internal carotid artery and is therefore named the carotid arch
• 4th pair of aortic arches = the 4th left arch forms the right subclavian / the 4th right arch becomes the aortic arch
• 5th pair of aortic arches = disappears on both sides
• 6th pair of aortic arches = forms the pulmonary arteries

Question 219

The arterioles function as resistance vessels because:

1. They only allow blood flow in one direction
2. They have a relatively narrow lumen and a thin elastic wall
3. They have a relatively
   narrow lumen and strong muscular wall
4. They have a relatively wide lumen and strong muscular wall
5. The statement is wrong - arterioles are not resistance vessels

Answer 219

3. They have a relatively narrow lumen and strong muscular wall = narrow lumen gives them a high resistance and the strong muscular wall means they can contract or relax when the resistance needs to be changed

They have a relatively wide lumen and strong muscular wall
The statement is wrong - arterioles are not resistance vessels = of the arteries, arterioles are the muscular resistance arteries
They only allow blood flow in one direction = all other vessels only allow blood flow in 1 direction and are classed differently

Question 220

In the electrocardiogram, depolarisation of the atria corresponds to the:

1. P-wave
2. QRS complex
3. T-wave
4. U-wave
5. None of these

Answer 220

P-wave = atrial depolarisation

QRS complex = ventricular repolarization (+ atrial repolarization)

T-wave = ventricular repolarisation

U-wave = last bit of the ventricular repolarisation; interventricular septum OR the papillary muscle

Question 221

The second heart sound is heard when

1. Blood enters the aortic
2. The atria contract
3. The atrioventricular valves close
4. The atrioventricular valves open
5. The semilunar valves close

Answer 221

5. The semilunar valves close = second heart sound (S2 = DUB)

Comments:

1. Blood enters the aortic = heart sounds are heard when valves shut
2. The atria contract = heart sounds are heard when valves shut
3. The atrioventricular valves close = first heart sound (S1 = LUB)
4. The atrioventricular valves open = heart sounds are heard when valves shut
5. The semilunar valves close = second heart sound (S2 = DUB)

Question 222

A heart rate in excess of 150 beats per minute is likely to:

1. Decrease afterload and therefore decrease stroke volume
2. Decrease contractility and therefore decrease stroke volume
3. Decrease preload and therefore decrease stroke volume
4. Increase afterload and therefore decrease stroke volume
5. Increase preload and therefore decrease stroke volume

Answer 222

3. Decrease preload and therefore decrease stroke volume = less time for cardiac filling; preload decreases; less stretch on the heart; smaller contractile strength; decreased stroke volume

Question 223

Activation of β1-adrenoceptors on cardiac myocytes will:

1. Increase afterload and therefore decrease stroke volume
2. Increase afterload and therefore increase stroke volume
3. Increase contractility and therefore increase stroke volume
4. Increase preload and therefore decrease stroke volume
5. Increase preload and therefore increase stroke volume

Answer 223

3. Increase contractility and therefore increase stroke volume = beta-1-adrenoceptors are present on the cardiac muscle cells so the sympathetic activation will produce a stronger strength of contraction for any given preload / afterload = ejects more blood so the stroke volume (ml/beat) is increased

Question 224

Which of the following is the most significant feature of the pulmonary circulation?

1. Most pulmonary blood flow occurs during diastole
2. Pulmonary arterioles constrict in response to local hypoxia
3. Pulmonary arterioles express β1-adrenoreceptors
4. The pulmonary circulation shows excellent pressure autoregulation
5. The pulmonary circulation shows good active (metabolic) hyperaemia

Answer 224

2. Pulmonary arterioles constrict in response to local hypoxia

Question 225

During exercise, venous pressure (and hence venous return to the heart) may be increased by:

1. An increase in the systemic filling pressure
2. Contraction of smooth muscle surrounding the veins
3. Increased rate and depth of respiration
4. Rhythmic contraction of skeletal muscle
5. All of the above

Answer 225

5. All of the above

Question 226

A 46-year-old woman is usually well but complains of intermittent rapid regular palpitations that are terminated by the valsalva manoeuvre. The most likely diagnosis is:

1. Atrial fibrillation
2. Supraventricular tachycardia
3. Ventricular ectopics
4. Ventricular fibrillation
5. Ventricular tachycardia

Answer 226

2. Supraventricular tachycardia

Comments:
1. Atrial fibrillation = irregular palpitations

2. Supraventricular tachycardia = valsalva manoeuvre effects AV node, where the supraventricular tachycardias arise from
3. Ventricular ectopics = irregular palpitations
4. Ventricular fibrillation = leads to loss of cardiac output, collapse and death so since she is ‘usually well’
5. Ventricular tachycardia = would be related to ventricles, valsalva manoeuvre affects AV node

Question 227

A 65-year-old woman with a history of hypertension presents to the acute medical admissions unit with sudden onset of severe breathlessness, and paroxysmal nocturnal dyspnoea (PND).

She is tachycardic with an elevated jugular venous pressure (JVP), crackles in both lung fields to the mid zones and significant peripheral oedema.

Select the most appropriate drug treatment:

1. Angiotensin converting enzyme inhibitor
2. Angiotensin II blocker
3. Beta blocker
4. Intravenous diuretic
5. Oral diuretic

Answer 227

4. Intravenous diuretic

Question 228

A 65-year-old man with a blood pressure of 220/90 mmHg complains of breathlessness and fatigue. Select the single most informative investigation that could be used to determine the cause of his hypertension:

1. Chest x-ray
2. Echocardiography
3. Renal arteriography
4. Renal ultrasound
5. Serum potassium

Answer 228

2. Echocardiography

Question 229

A 40-year-old man presents with severe hypertension. You believe he may suffer from “white coat hypertension”. Select the single most informative investigation that could be used to confirm this:

1. 24 hour ambulatory blood pressure recording
2. 24 hour urinary catecholamines
3. Echocardiography
4. Renal arteriography
5. Renal ultrasound

Answer 229

1. 24 hour ambulatory blood pressure recording

need to confirm he suffers from genuine hypertension and not just ‘white coat hypertension’

Question 230

26-year-old lady in the first trimester of pregnancy presents with a deep vein thrombosis (DVT). Select the most appropriate treatment:

1. Aspirin
2. Clopidogrel
3. Low molecular weight heparin
4. Thrombolysis
5. Warfarin

Answer 230

3. Low molecular weight heparin - treatment of choice

Question 231

What is the congenital condition that is associated with coarctation of the aorta, short stature, neck webbing and gonadal dysgenesis?

1. Down syndrome
2. Noonan syndrome
3. Shprintzen syndrome
4. Turner syndrome
5. Williams syndrome

Answer 231

4. Turner syndrome - all features

Down syndrome = atrioventricular septal defects

Noonan syndrome = pulmonary stenosis & septal defects

Shprintzen syndrome = tetralogy of Fallot

Williams syndrome = supravalvular aortic stenosis

Question 232

A 70-year-old male, who routinely walks his dog, presents with pain in the back of his calves after walking 500 metres. What is the most likely cause?

1. Arterial thromboembolism
2. Deep venous thrombosis
3. Distended leg veins
4. Gangrene
5. Intermittent claudication

Answer 232

5. Intermittent claudication = ischaemic pain resulting from the exertion of the calf muscles; increased oxygen demand cannot be met due to atherosclerosis of the supplying arteries

Question 233

A newborn infant with a murmur is found to have an atrioventricular septal defect on echocardiography. The baby is hypotonic. The most likely diagnosis is:

1. 22q11 microdeletion
2. Down syndrome
3. Foetal alcohol syndrome
4. Multifactorial congenital heart disease
5. Turner syndrome

Answer 233

2. Down syndrome = heart atrioventricular septal defects + reduced tone

22q11 microdeletion = tetralogy of Fallot

Foetal alcohol syndrome = neurological / craniofacial defects; septal defects CAN be found

Multifactorial congenital heart disease

Turner syndrome = coarctation of the aortic

Question 234

A 70-year-old man presents with an ulcer of his left leg. His sleep is being interrupted by severe lower limb pain. The most likely cause of the ulcer is:

1. Chronic venous insufficiency
2. Critical limb ischaemia
3. Diabetic neuropathy
4. Postphlebitic syndrome
5. Squamous carcinoma

Answer 234

2. Critical limb ischaemia = elevation of the leg causes pain; sleep

Coments:

Chronic venous insufficiency = venous ulcers tend not to cause severe pain

Diabetic neuropathy = diabetic ulcers tend not to cause severe pain

Postphlebitic syndrome = a secondary condition of deep venous thrombosis

Squamous carcinoma = usually painless

Question 235

A 68-year-old man presents with exertional angina. What is the most appropriate treatment to improve symptoms?

1. Introduce ACE inhibitor
2. Start aspirin 75 mg/day
3. Start beta blocker
4. Start low dose warfarin
5. Start simvastatin

Answer 235

3. Start beta blocker

warfarin has no evidence of benefit

Question 236

The maximum volume of air that can be voluntarily exhaled following a maximum inspiration is called:

1. Expiratory Reserve Volume
2. Functional Residual Capacity
3. Residual Volume
4. Tidal Volume
5. Vital Capacity

Answer 236

5 Vital Capacity (correct answer - 4600 ml; from max (5800 ml to 1200 ml [residual volume])

Comments:

1. Expiratory Reserve Volume = volume of air that can be voluntarily forcibly exhaled after normal expiration
2. Functional Residual Capacity = volume left in lungs after normal expiration (ERV + RV)
3. Residual Volume = volume of air in lungs that cannot be voluntarily expired
4. Tidal Volume = volume of air breathed in or out at rest

Question 237

The upper respiratory tract includes all EXCEPT which of the following?

1. Larynx
2. Lungs
3. Mouth
4. Nasal cavity
5. Pharynx

Answer 237

2. Lungs (correct answer; lower respiratory tract; underneath the vocal cords in the larynx)

Question 238

Air flows into the lungs during inspiration because:-

1. The external intercostal and diaphragm muscles contract and thoracic volume decreases
2. The external intercostal and diaphragm muscles contract and thoracic volume increases
3. The internal intercostal and abdominal muscles contract and thoracic volume decreases
4. The internal intercostal and abdominal muscles contract and thoracic volume increases
5. The internal intercostal and diaphragm muscles contract and thoracic volume increases

Answer 238

2. The external intercostal and diaphragm muscles contract and thoracic volume increases (correct answer)

Question 239

Mr Tickle has a respiratory rate of 10 breaths per minute and a tidal volume of 800ml. If his residual volume measures 1000ml and his dead space volume measures 200ml what is Mr Tickle’s alveolar ventilation?

1. 5800 ml/min
2. 6000 ml/min
3. 6200 ml/min
4. 8000 ml/min
5. 10,000 ml/min

Answer 239

2. 6000 ml/min (correct answer) (tidal volume - dead space) x respiratory rate = alveolar ventilation (800 - 200 = 600 x 10

Question 240

In terms of lung compliance which of the following statements is correct?

1. Compliance is a measurement of lung elasticity
2. Compliance is decreased in the lung disease emphysema
3. Compliance is greatest at the base of the lungs
4. Compliance is increased with the lung disease fibrosis
5. High compliance is always a sign of healthy lungs

Answer 240

3. Compliance is greatest at the base of the lungs (correct answer)

Comments:
Compliance is increased in emphysema due to loss of elastic fibres)

Question 241

The partial pressure of oxygen in mixed venous blood is typically around:

1. 40 mmHg (5.3kPa)
2. 46 mmHg (6.1kPa)
3. 100 mmHg (13.3kPa)
4. 160 mmHg (21.3kPa)
5. 200 mmHg (26.7kPa)

Answer 241

1. 40 mmHg (5.3kPa) (correct answer)

Question 242

Arterial partial pressure of oxygen will be reduced in which of the following conditions?

1. Anaemia resulting from iron deficiency
2. Anaemia resulting from vitamin B12 deficiency
3. Blood loss during childbirth
4. Carbon monoxide poisoning
5. Pulmonary oedema

Answer 242

5. Pulmonary oedema (correct answer) this is the only answer where oxygen concentration in solution (PaO2) will be reduced.

The other conditions may result in significant decreases in total oxygen content (due to lack of oxygen binding to Hb or loss of Hb) but oxygen in solution in plasma will be unaffected.

Question 243

Which of the following statements is NOT true for individuals with chronic lung disease?

1. Arterial PCO2 levels are elevated due to poor alveolar ventilation
2. Nitrous oxide is a safe sedative to use
3. They are said to be on hypoxic drive because chronic elevation of PCO2 has blunted central response to CO2
4. They have decreased sensitivity to PCO2
5. They rely on their peripheral chemoreceptors for stimulating ventilation

Answer 243

2. Nitrous oxide is a safe sedative to use (correct answer) Nitrous oxide blunts the peripheral chemoreceptor response to falling oxygen, and as these patients are on “hypoxic drive” this effectively leaves them with no intrinsic means of controlling their ventilation.

Question 244

“Shunt” is a term that would be associated with which of the following situations:

1. Bulk transport of oxygen via haemoglobin to peripheral tissues
2. Movement of air through the conducting airways to the alveoli during inspiration
3. Pulmonary embolism (blockage of the pulmonary vessels by coagulated blood)
4. When perfusion exceeds ventilation in L/min
5. When ventilation exceeds perfusion in L/min

Answer 244

4. When perfusion exceeds ventilation in L/min (correct answer)

A pulmonary shunt is a pathological condition which results when the alveoli of the lungs are perfused with blood as normal, but ventilation (the supply of air) fails to supply the perfused region. In other words, the ventilation/perfusion ratio (the ratio of air reaching the alveoli to blood perfusing them) is zero.

Question 245

Which of the following is most likely to shift the haemoglobin oxygen binding curve to the right?

1. Hypothermia
2. Presence of foetal haemoglobin
3. Respiratory alkalosis
4. Voluntary hyperventilation
5. Running a marathon

Answer 245

5. Running a marathon (correct answer) increase in body temperature, CO2 and lactic acid production shifts curve to the right making oxygen extraction in peripheral tissues easier and therefore increases oxygen delivery.

Comments:
1. Hypothermia decrease in body temperature shifts curve to the left making it difficult to offload oxygen to peripheral tissues.

2. Presence of foetal haemoglobin higher affinity for oxygen than adult haemoglobin so curve would shift to the left.
3. Respiratory alkalosis decrease in [H+] pulls CO2 equilibrium to the right, reducing PCO2 so shifts haemoglobin binding curve to the left.
4. Voluntary hyperventilation decreases PCO2 so would shift curve to the left.

Question 246

A 59-year-old man with known squamous carcinoma of the lung is admitted to hospital as an emergency with abdominal pain, constipation and confusion. The most appropriate investigation would be:

1. Bronchoscopy Peripheral
2. Chest x-ray
3. Mediastinoscopy Cancer
4. Sputum cytology
5. Serum calcium

Answer 246

5. Serum calcium (correct answer) Squamous cell lung cancer associated with hypercalcaemia due to parathyroid hormone related protein. Symptoms in this case classic for hypercalcaemia.

Comments:
1. Bronchoscopy Peripheral lesion can’t be accessed and tissue diagnosis known already

2. Chest x-ray Known lung cancer and this would add nothing further
3. Mediastinoscopy Cancer diagnosis known
4. Sputum cytology cancer diagnosis known and would add nothing further

Question 247

A 79-year-old woman with a peripheral spiculated opacity on chest x-ray and an enlarged supraclavicular lymph node. The most appropriate investigation would be:

1. Bronchoscopy
2. CT thorax
3. Fine needle aspiration (FNA) lymph node
4. Lung function tests
5. Sputum cytology

Answer 247

3. Fine needle aspiration (FNA) lymph node

Comments:
1. Bronchoscopy Peripheral lesion may not be accessible

2. CT thorax Ultimately a pathological diagnosis is needed
3. Fine needle aspiration (FNA) lymph node (correct answer) A sample is needed for pathology to give a tissue diagnosis for cancer type. This offers an easily accessible option for this
4. Lung function tests Would only be used for suspected airway obstruction
5. Sputum cytology Unlikely to yield a diagnosis

Question 248

A 30-year-old woman is admitted to the emergency department with an acute exacerbation of her chronic asthma. Her PaO2 was 7.8 kPa (normal 11- 15 kPa) and her PaCO2 was 8.6 kPa (normal 4.6 – 6.4 kPa) on air. Her arterial gas on admission confirmed type 2 respiratory failure requiring admission to the intensive care unit for possible ventilation.

What would be the most appropriate immediate treatment?

1. Inhaled beta-2 agonist
2. Inhaled corticosteroids
3. Leukotriene receptor antagonist
4. Nebulised beta-2 agonist
5. Oral beta-2 agonist

Answer 248

4. Nebulised beta-2 agonist (correct answer)

Comments:

Answer isn’t 1. because she needs more aggressive treatment than normal inhaler as she is hypoxic and hypercapnic

Question 249

A 32-year-old man is recovering from a bad attack of pneumonia for which he has been off work for several weeks. He goes on to develop rigors, a persistently poor appetite and increasing shortness of breath on exertion. After a week of oral antibiotic treatment his GP refers him to the local respiratory medicine unit for admission. The most likely diagnosis is:

1. Acute interstitial pneumonitis (Haman-Rich syndrome)
2. Aspiration pneumonia
3. Empyema thoracis
4. Giant pulmonary bulla
5. Tuberculosis

Answer 249

3. Empyema thoracis (correct answer)

Question 250

A 55-year-old business man complains of daytime somnolence. He normally sleeps 5 hours per night except on holiday when he will sleep 9 hours per night. His sleep study shows an Apnoea Hypopnoea Index (AHI) of 5 per hour. The most likely diagnosis is:

1. Depression No other symptoms of depression
2. Narcolepsy No features
3. Obstructive sleep apnoea AHI is within normal range
4. Poor sleep hygiene
5. Respiratory muscle weakness

Answer 250

4. Poor sleep hygiene (correct answer)

Change in sleep pattern indicates a behavioral aspect to his lack of sleep

Question 251

A 35-year-old man has cystic fibrosis. The most likely organism infecting his lungs is:

1. Chlamydia psittaci
2. Haemophilus influenzae
3. Legionella pneumoniae
4. Mycobacterium tuberculosis
5. Pseudomonas aeruginosa

Answer 251

5. Pseudomonas aeruginosa

Question 252

A 50-year-old man has lobar pneumonia. The most likely organism to be involved is:

1. Chlamydia psittaci
2. Haemophilus influenzae
3. Legionella pneumoniae
4. Pseudomonas aeruginosa
5. Streptococcus pneumoniae

Answer 252

5. Streptococcus pneumoniae

Question 253

A 38-year-old with exacerbation of asthma is too tired to do a peak flow. Normal values: pH 7.37 – 7.43, PaO2 11 – 15 kPa, PaCO2 4.6 – 6.4 kPa. His blood gas results are most likely to be:

1. pH 6.91, PaO2 16.7 kPa, PaCO2 2.9 kPa, on air
2. pH 7.5, PaO2 6.6 kPa, PaCO2 11.2 kPa, on air
3. pH 7.15, PaO2 29.6 kPa, PaCO2 10.6 kPa, on air
4. pH 7.22, PaO2 7.8 kPa, PaCO2 8.6 kPa, on air
5. pH 7.41, PaO2 11.5 kPa, PaCO2 4.6 kPa, on air

Answer 253

4. pH 7.22, PaO2 7.8 kPa, PaCO2 8.6 kPa, on air

Exhaustion and decreased ventilation leads to hypercapnia, hypoxia and acidosis

Question 254

The British Thoracic Guidelines for the treatment of chronic asthma recommend that a patient with newly diagnosed asthma who is waking up at night because of asthma should be commenced on:

1. Inhaled beta-2 agonist and leukotriene receptor antagonist
2. Inhaled beta-2-agonist
3. Inhaled corticosteroids and inhaled beta-2-agonist
4. Inhaled leukotriene antagonist
5. Inhaled sodium cromoglycate

Answer 254

3. Inhaled corticosteroids and inhaled beta-2-agonist (correct answer)

Nighttime symptoms indicates need for inhaled corticosteroid

Question 255

A 19-year-old previously healthy woman experiences sudden onset of severe right sided chest pain whilst walking upstairs. The pain is associated with breathlessness. Both symptoms are still prominent when she presents to the Accident and Emergency Department one hour later. The most likely diagnosis is:

1. Acute interstitial pneumonitis (Haman-Rich syndrome) Not so sudden onset
2. Aspiration pneumonia
3. Bronchiectasis
4. Primary pneumothorax
5. Pulmonary sequestration

Answer 255

4. Primary pneumothorax (correct answer) Should always be considered in sudden onset pain with shortness of breath in previously healthy person

Question 256

On going epistaxis after a nasal fracture is most likely to be originating from which artery?

Answer 256

Anterior ethmoid artery

Question 257

An 18 month old boy presents with malaise and a history of a painful ear. A CT scan shows an intracranial abscess. What is the intracranial abscess most likely a complication of?

Answer 257

Acute mastoiditis

Question 258

A 58 year old gentleman presents with hearing loss affecting his left ear. Weber’s test localises to the right side and Rinne’s test is positive on both sides. What is the likely hearing issue

Answer 258

Left sensorineural hearing loss

Question 259

Which of the following contacts the oval window as the last bone in the ossicular chain

Answer 259

Stapes

Question 260

A patient with diabetes presents with necrotising otitis externa having had multiple courses of topical antibiotics. What is the likely causative organism?

Answer 260

Pseudomonas Aeruginosa

Question 261

A patient with a family history of MEN (multiple endocrine neoplasia) presents with an anterior neck swelling and weight loss. She is found to have a high calcitonin on blood tests. What is the likely diagnosis?

Answer 261

Medullary thyroid cancer

Question 262

The corda tympani provides innervation to what?

Answer 262

Taste sensation to the anterior 2/3 of the tongue

Question 263

A patient is diagnosed as having oropharyngeal cancer. After further investigation they are staged as T1N2M0. What does the N2 mean the patient has?

Answer 263

Metastases in their neck

Question 264

A 65 year old male presents with a 3 month history of hoarseness and weight loss. He smokes 20 a day. Examination reveals a suspicious vocal cord lesion which is confirmed on biopsy to be cancer. Which imaging modality is commonly used to help stage the patient?

Answer 264

CT of the neck and chest

Question 265

A post thyroidectomy patient presents with a hoarse voice and is found to have a paralysed left vocal cord. Which nerve has been damaged?

Answer 265

Recurrent laryngeal nerve

Question 266

Presbycusis is often referred to as ‘age related hearing loss’. What is the most common finding on audiogram?

Answer 266

Sloping sensorineural hearing loss with hearing worse in higher frequencies

Question 267

In the heart the fast depolarising phase of the cardiac action potential is caused by?

Answer 267

Influx of Na+ ions

Question 268

What is the resting membrane potential due to in cardiac cells?

Answer 268

Leaky K+ Channels

Question 269

What is the U wave?

Answer 269

Occurs after T wave and is caused by the last part of ventricular repolarising (septum or pap muscles)

Question 270

What is the most significant feature of the pulmonary circulation?

Answer 270

Pulmonary arteries constrict in hypoxic conditions

Question 271

During exercise venous pressure (and hence venous return to the heart) may be increased by?

Answer 271

• Increases in systemic filling pressure
• Contraction of smooth muscle surrounding the veins
• Increased rate and depth of respiration
• Rhytmic contraction of skeletal muscle

Question 272

What medications are NOT used in acute heart failure?

Answer 272

ACEi

Beta-blockers

Question 273

What can the valsalva manoeurve help?

Answer 273

Supraventricular tachycardia

Question 274

Why does the valsalva manoeuvre cure supraventricular tachycardia?

Answer 274

Increases vagal tone and the effect at AV.

Question 275

How do you treat heart failure?

Answer 275

IV Diuretics

Question 276

What are some signs of heart failure?

Answer 276

PND
Elevated JVP
Lung crackles
peripheral oedema

Question 277

What is afterload dependent on?

Answer 277

TPR primarily controlled of noradrenaline on alpha 1 -adrenorecpetors

Question 278

A heart rate in excess of 150 bpm is likely to:

Answer 278

Decrease preload and therefore decrease stroke volume

Question 279

Activation of Beta 1 receptors on cardiac myocytes will have what effect on contractility and SV?

Answer 279

Increase contractility and therefore increase stroke volume

Question 280

What treats symptoms of angina?

Answer 280

GTN
Beta-blockers
CCBs
Ivabradine

Question 281

Pregnant mother with DVT?

Answer 281

Anticoagulation

Warfarin is TERATOGENIC in first trimester = Low molecular weight hep

Question 282

What is associated with the tetralogy of fallot (a type of heart defect present at birth. Symptoms include episodes of bluish color to the skin)?

Answer 282

Shprintzen syndrome

Question 283

How do you treat marfans?

Answer 283

Antihypertensives
(beta blockers)

Prophylactic aortic root surgery

Lifestyle advice

Question 284

What are three causes of systolic murmur?

Answer 284

Aortic stenosis
Mitral regurgitation
Aortic sclerosis

Question 285

How do you find mitral regurgitation in physical?

Answer 285

Heard louest at the apex and radiates to the axilla, pan systolic murmur, maximal on expiration

Question 286

How do you find aortic stenosis?

Answer 286

Pulse waveform

Low output pulse, radiates to carotid

Question 287

Which of the following is associated with an increased incidence of multiple sclerosis?

A. latitude of patients home country
B. high dietary cassava
C. hypercalcaemia
D. fungal toe nail infection
E. exposure to vinyl chloride

Answer 287

A. latitude of patient’s home country

cassava is associated with a multi-nodular goitre as they contain thiocyanate

Question 288

Gabby sustains a hockey stick injury. she is initially dazed but rapidly recovers and continues with the match. 30 minutes later she collapses and the paramedics report her GCS as E2V3M3. what injury has she most likely sustained?

a. acute subdural haemorrhage
b. chronic subdural haemorrage
c. acute extradural haemorrage
d. cerebral contusion
e. ruptured cerebral aneurysm

Answer 288

C. acute extradural haemorrhage

there is a lucid interval

Question 289

‘The other Andy’ (ex-alcoholic) is living in a nursing home and it is noticed he has a steady deterioration in memory over 3 days. CT head shows an isodense convex mass between the right frontotemporal cortex and the skull. what is this lesion?

a. meningioma
b. chronic subdural haematoma
c. Alzheimer’s amyloid plaque
d. Frontotemporal dementia
e. Choroid plexus cyst

Answer 289

B. chronic subdural haematoma

Question 290

Abby is performing poorly in school. the teachers complain of recurring episodes of daydreaming lasting for several seconds, from which he cannot be aroused. the boy denies these. what is the most likely cause?

a. leukaemia
b. attention deficit hyperactivity disorder (ADHD)
c. narcolepsy
d. cataplexy
e. absence seizures

Answer 290

E. absence seizures

Question 291

Niall has a witnessed episode of becoming unresponsive, picking at his clothes and lip smacking. his face started twitching followed by his left arm and leg and then entire body. the whole episode lasts 5 minutes. he can remember picking at his clothes, but feeling dreamlike cannot remember the lip smacking. what is this called?

a. simple partial seizure
b. complex partial seizure
c. complex partial seizure with secondary generalization
d. generalised tonic-clonic seizure
e. dissociative (functional) seizure (pesudoseizure)

Answer 291

C. complex partial seizure with secondary generalization

Question 292

Liam suffers an anterior circulation ischaemic stroke. the biggest modifiable risk factor for ischaemic stroke is:

a. hypertension
b. hypercholesterolaemia
c. smoking
d. obesity
e. diabetic control

Answer 292

A. hypertension

Question 293

Matt presents to his GP with a 1 month history of breast swelling, tenderness and recently, occasional lactation. Pregnancy test is negative, but thyroid function tests show a low TSH and low free T3/T4. which blood test should his GP next undertake?

a. serum LH/FSH
b. serum vasopressin
c. lumbar puncture
d. digital rectal exam for bants
e. urinary catecholamines
f. serum prolactin

Answer 293

F. serum prolactin - may be caused by a prolactinoma

Question 294

Taste sensation for the posterior third of the tongue is transmitted to the brain by which nerve?

a. CN V
b. CN VII
c. CN IX
d. CN X
e. CN XII

Answer 294

C. CN IX - the glossopharyngeal nerve.

Question 295

Eaton-Lambert Myasthenia Syndrome (LEMS) is characterised by what?

a. anti-acetylcholine receptor antibodies
b. Anti-voltage-gated-calcium-channel receptor antibodies (anti VGC)
c. anti-acetylcholinesterase antibodies
d. positive tensilon test
e. sensory disturbance

Answer 295

b. anti-voltage-gated-calcium-channel receptor antibodies

Question 296

Which of the following is not a sign of an upper motor neurone deficit?

a. weakness
b. tremor
c. spasticity
d. hyper-reflexia
e. clasp-knife rigidity

Answer 296

B. Tremor

• This is an extra-pyramidal sign such as in parkinsons which affects the substantia nigra (part of the basal ganglia that is aka the extra-pyramidal system of the body)

Question 297

Which of the following drugs can be used to terminate tonic-clonic seizures?

a. dihydrocodeine
b. duloxetine
c. percacets
d. dantrolene
e. diclofenac
f. diazepam

Answer 297

f. diazepam

Question 298

Which of the following is a sign of cerebellar lesion?

a. shuffling gait
b. high-stepping gait
c. stamping gait
d. wide-based gait
e. antalgic gait

Answer 298

D. wide based gait

Question 299

Which of the following is a sign of parkinson’s?

a. shuffling gait
b. high-stepping gait
c. stamping gait
d. wide-based gait
e. antalgic gait

Answer 299

a shuffling gait is characteristic of parkinson’s

Question 300

Which of the following is a sign of foot drop (peroneal nerve in mononeuritis diabetes)?

a. shuffling gait
b. high-stepping gait
c. stamping gait
d. wide-based gait
e. antalgic gait

Answer 300

b. high-stepping gait

Question 301

Which of the following is a sign of a peripheral proprioceptive defect?

a. shuffling gait
b. high-stepping gait
c. stamping gait
d. wide-based gait
e. antalgic gait

Answer 301

C. stamping gait

Question 302

Horner’s syndrome results from injury to which of the following structures:

a. axillary nerve
b. brachial plexus
c. parotid gland
d. cervical sympathetic ganglion
e. occulo-motor nerve

Answer 302

D. cervical sympathetic ganglion

Question 303

Paul is admitted following a seizure. he opens his eyes to voice but is confused asking nursing staff why they are in his house and pushes you away when you attempt to take blood. he is unable to follow simple instructions.
what is his Glasgow coma score?

a. E2V3M6
b. E3V3M5
c. E3V4M5
d E3V5M5
e. E4V5M4

Answer 303

C. E3V4M5

Question 304

Andy crashes his car at 80mph. he is thrown through the windscreen, not wearing a seatbelt and collides with the road central reservation. at the roadside his airway is obstructed and he does not move, speak or even open his eyes in response to pain. what is his GCS?

a. E0 V0 M0
b. E1 V1 M1
c. E2 V2 M2
d. E2 V1 M1
e. E1 V1 M2

Answer 304

B - E1V1M1

Question 305

Which of the following signs is consistent with a right-sided parietal lobe lesion?

a. Disinhibition
b. Loss of episodic memory
c. Cortical blindness
d. Cognitive regression
e. Hemisensory neglect

Answer 305

E - hemisensory neglect

Question 306

Patients with thiamine deficiency are at risk of which condition?

a. Frontal dementia
b. Idiopathic juvenile seizures
c. Central pontine myelinolysis
d. Vanishing white matter disease
e. Wernicke’s encephalopathy

Answer 306

E - Wernicke’s encephalopathy

Question 307

What percentage of strokes are ischaemic in nature?

a. 25%
b. 45%
c. 65%
d. 85%
e. 95%

Answer 307

d - 85%

Question 308

Which of the following is not a form of cerebral herniation?

a. Sprigelian herniation
b. Cingulate herniation
c. Subfalcine herniation
d. Uncal herniation
e. Tentorial herniation

Answer 308

a. Sprigelian herniation

Question 309

Neurodegeneration in which of the following structures characterises Parkinson’s disease?

a. Putamen
b. Substantia nigra
c. Globus pallidus internus
d. Claustrum
e. Caudate nucleus

Answer 309

B - substantia nigra

Question 310

Which of the following conditions shows genetic anticipation?

a. Amyotrophic lateral sclerosis
b. Huntington’s disease
c. Charcot-Marie-Tooth Disease
d. Alzheimer’s disease
e. Lewy Body Dementia

Answer 310

b. Huntington’s disease

Question 311

The foramen lacerum transmits which structure?

a. Optic nerve
b. Trigeminal nerve
c. Middle meningeal artery
d. Internal Carotid artery
e. Jugular vein

Answer 311

d. Internal Carotid artery

Question 312

Which of the following increases cerebral blood flow?

a. Alkalosis
b. Hyperventilation
c. Hypothermia
d. Hyperglycaemia
e. Hypercapnia

Answer 312

E. Hypercapnia

Question 313

Where is cerebrospinal fluid produced

a. Venous sinuses
b. Arachnoid granulations
c. Choroid plexus
d. Spinal nerve roots
e. Cavernous sinuses

Answer 313

C. choroid plexus

Question 314

Action potential propagation along an axon is dependent on which ion channels?

a. Voltage gated calcium channels
b. Voltage gated sodium channels
c. Voltage gated potassium channels
d. Voltage gated magnesium channels
e. Voltage gated chloride channels

Answer 314

B. voltage gated sodium channels

Question 315

Which of the following is associated with Migraine aura?

a. Blurring of vision
b. Hemiplegia
c. Incontinence
d. Diarrhoea
e. Neck stiffness

Answer 315

A. blurring of vision

Question 316

What are women offered as a routine screening for Down’s syndrome?

A. Amniocentesis
B. CUB (combined Ultrasound/biochemical) Screening
C. Double Test
D. Nuchal Translucency Scan
E. Fetal Blood Sampling

Answer 316

B. CUB (combined Ultrasound/biochemical) screening

Question 317

A 40 year-old, Para 4 with a BMI of 40 presents with a leakage of urine on laughing and coughing. All the following are appropriate management steps except:

A. anticholinergic medication
B. Decrease Caffeine intake
C. Physiotherapy
D. Transvaginal tape
E. Weight Loss

Answer 317

A. Anticholinergic medication

Question 318

A woman attends for induction of labour. Certain conditions need to be met before proceeding with induction.
Which of the following is a contraindication of labour:

A. Cephalic Presentation
B. Obesity
C. Oblique Lie
D. Previous Caesarian Section
E. Rupture of Membranes

Answer 318

C. Oblique Lie

Question 319

Which of the following is contraindicated in pregnancy?

A. Ramipril (ACEI)
B. Labetalol
C. Methyldopa
D. Magnesium Sulphate
E. Nifedipine

Answer 319

A. Ramipril

Question 320

A 31 year old woman presents with severe right sided Upper Abdominal Pain at 34 weeks gestation. She reported normal fetal movements up until now. She has no vaginal bleeding but pain is getting worse. Abdomen is tense and tender. high blood pressure was recorded at her midwife visit. Urine dipstick is normal.
What is the most likely diagnosis?

A. Cholecystitis 
B. Placental abruption
C. Pre-Eclampsia
D. Pre-term labour 
E. Urinary Infection

Answer 320

B. Placental Abruption (concealed)

Question 321

In order to prevent Rhesus disease in the baby, which women are recommended to receive anti-D in their pregnancy?

A. All Rhesus Negative Women
B. All Rhesus Positive Women
C. All Women
D. Rhesus negative women with rhesus positive partner
E. Rhesus positive women with rhesus negative partner

Answer 321

A. All Rhesus negative women

Question 322

A 22 y/o woman is referred to the gynaecological clinic with cyclical pain and dyspareunia. The consultant is concerned that she has endometriosis. What is the best investigation to confirm the diagnosis?

A. Barium Enema
B. CT Scan
C. Diagnostic Laparoscopy
D. MRI scan
E. Transvaginal Ultrasound

Answer 322

C. Diagnostic Laparoscopy

Question 323

During the menstrual cycle the levels of hormones changes throughout the menstrual cycle.
Which Hormone has sudden rise in level just before ovulation?

A. 17 (OH) Progesterone
B. Estrogen 
C. LH (Luteinizing hormone)
D. Progesterone 
E. Testosterone

Answer 323

C. Luteinizing hormone

Question 324

A 62 y/o nulliparous lady presented to the General Practitioner with 3 episodes of unprovoked vaginal bleeding. SHe is menopausal, obese and diabetic. Her smears were up to date till 60 years of age, the limit for the National Screening programme. She was referred to the hospital by the GP.
What is the most probable diagnosis?

A. Cervical Cancer
B. Endometrial Cancer
C. Ovarian Cancer
D. Pelvic Inflammatory Disease
E. Rectal Cancer

Answer 324

B, Endometrial Cancer

Question 325

A 27 y/o primigravid patient has been admitted at 37 weeks with a 6 hour history of contractions. She is having 2 contractions in 10 minutes and each is lasting 50 seconds. She has had no show and her membranes are intact but she thinks she is in labour. Which of the following is the best clinical sign to assess if she is in established labour:

A. Abdominal examination to assess the descent of the fetal head
B. Abdominal examination to assess the strength of the contractions
C. Speculum examination to assess the cervical dilatation
D. Vaginal examination to assess the cervical dilatation
E. Vaginal examination to assess if the membranes are intact

Answer 325

E. Vaginal examination to assess the cervical dilatation

Question 326

A parous patient is in established labour and the head is just visible at the introitus. She has had no analgesia. She is pushing well but is screaming for pain relief. What method of pain relief is best for her?

A. Epidural anaesthetic
B. Entonox
C. Morphine
D. Spinal anaesthetic 
E. Supportive Care

Answer 326

B. Entonox

Question 327

A 26 y/o woman is pregnant with her first baby. She has remained very well during her pregnancy but her haemoglobin has dropped from 13g/dl at 12 weeks to 11g/dl at 28 weeks pregnant.
What is the most likely explanation for this?

A. Concealed Haemorrhage
B. Iron Deficiency anemia 
C. Normal physiological change in pregnancy
D. Pernicious anaemia 
E. Sickle Cell disease

Answer 327

C. Normal physiological change in pregnancy

Question 328

Considering secondary prevention of cervical cancer in the UK, CIN (cervical intraepithelial neoplasia) is diagnosed by:

A. Colposcopy
B. Cytology
C. HPV testing
D. Histology 
E. MRI scan

Answer 328

D. Histology

Question 329

What is true about pregnancy women who are diabetic?

A. They do not suffer from a higher rate of stillbirth
B. They have babies who are at risk from neonatal hypoglycaemia
C. They need good diabetic control before contraception to help prevent anomalies in the baby
D. They only suffer complications in the mother as glucose doesnt cross the placenta and therefore doesnt harm the baby
E. They typically have babies which are smaller than non-diabetic mothers

Answer 329

C. They need good diabetic control before contraception to help prevent anomalies in the baby

Question 330

A 50 y/o woman has irregular periods and suffering from mood swings and night sweats. She is perimenopausal and wishing to commence HRT to help with her symptoms.
What lack of hormone is it that causes menopausal symptoms?

A. FSH
B. LH
C. Oestrogen
D. Progesterone
E. Thyroxin

Answer 330

C. Oestrogen

Question 331

Primary Prevention of cervical cancer in the UK is performed by:

A. High risk HPV immunisation
B. HSV immunisation 
C. HPV 16 and 18 immunisation 
D. HIV immunisation 
E. HPV 6, 11, 16 and 18 immunisation

Answer 331

C. HPV 16 and 18 immunisation

Question 332

In the UK NAtional Breast Screening Programme:

A. The screening target population are women aged between 40 and 70 years old
B. The screening target population are offered primary screening by clinical examination of the breasts
C. The screening target population are offered a mammogram every five year
D. The screening target population are registered with a GP practice and are aged between 50 and 70 years.
E. The screening target population is anyone with a family history if a first degree relative with breast cancer

Answer 332

D. The screening target population are registered with a GP practice and are aged between 50 and 70 years.

Question 333

A 22 y/o woman attends her GP requesting emergency contraception. She has a regular 28 day menstrual cycle and it is day 15. She reports unprotected intercourse 78 hours ago.
Which is the most effective option for this woman?

A. Emergency copper intrauterine device
B. Levonelle
C. Mifepristone
D. Mirena levonorgestrel intrauterine 
E. Ulipristil acetate

Answer 333

A. Emergency Copper Intrauterine Device

Question 334

A 35 y/o primigravid patient at 36 weeks gestation is noted to have a blood pressure of 160/98 at routine antenatal check.
Which of the following additional findings would be diagnostic of pre-eclampsia?

A. Excessive weight gain
B. Oedema
C. Paraesthesia 
D. Proteinuria
E. Visual disturbancE

Answer 334

D. Proteinuria

Question 335

A pregnant patient should always be nursed in a left lateral position because:

A. in the supine position the umbilical cord is compressed by the overlying feotus

B. In the supine position the pressure of the gravid uterus on the IVC causes a reduction in venous return to the heart with a possible 25% reduction in the cardiac output.

C. in the left lateral position, there is an increase in functional residual capacity of the lungs

D. In the supine position the pressure of the gravid uterus on the aorta reduces blood flow to vital organs by 10%

E. Nursing in the left lateral position ensures that blood flow to posterior placenta is not compromised

Answer 335

B. In the supine position the pressure of the gravid uterus on the IVC causes a reduction in the venous return to the heart with a possible 25% reduction in the cardiac output.

Question 336

Iron deficiency anaemia is by far the commonest cause of anaemia and iron deficiency is the commonest haematological problem in pregnancy. In pregnancy, the following is true:

A. A pregnancy causes a 10 fold increase in the requirement for iron not only for haemoglobin synthesis but also for certain enzymes and the fetus.

B. Because the expansion in plasma volume is greater than the increase in red cell mass there is a fall in haemoglobin concentration, haematocrit and red cell count

C. Changes in the coagulation system during pregnancy produce a physiological hypercoagulable state - clotting factors VIII, IX, X decrease and fibrinogen increases

D. A woman will not be iron deficient if she has a normal haemoglobin and MCV (mean cell volume)

Answer 336

All women planning a pregnancy should be advised to take 400mcg folate periconceptually and up until 12 weeks gestation to prevent megaloblastic anaemia.

B.

Because the expansion in plasma volume is greater than the increase in red cell mass there is a fall in haemoglobin concentration, haematocrit and red cell count.

Question 337

A 33 year old para 1+2 presents to the antenatal clinic at 9+ weeks gestation.
From this, what do we know about this woman’s obstetric history?

A. This is her 2nd pregnancy
B. This is her 4th pregnancy and she has one child who is alive and well
C. This is her 4th pregnancy and she has had 2 miscarriages
D. This is her first pregnancy
E. This is her 4th pregnancy and she had 2 previous early pregnancy losses

Answer 337

E. This is her 4th pregnancy and she had 2 previous early pregnancy losses

Question 338

Women are seen by a midwife for a booking appointment when they are offered screening for certain infections.
Which of the following infections are women not routinely offered at booking?

A. Hep B
B. HIV
C. Rubella
D. Syphillis
E. Varicella (chicken pox)

Answer 338

Varicella

Question 339

A woman presents with vainal bleeding and lower crampy abdominal pain at approximately 9 weeks gestation. Her observations are stable. Speculum examination reveals blood and small clots coming through the open cervical os.
Which of the following is the most likely diagnosis?

A. Complete Miscarriage
B. Ectopic Pregnancy
C. Pelvic Infection 
D. Inevitable miscarriage
E. Threatened miscarriage

Answer 339

D. Inevitable miscarriage

Question 340

A 28 y/o woman is seen at the infertility clinic. She has irregular periods and a diagnosis of polycystic ovarian syndrome (PCOS). Her partner’s semen analysis is normal. The decision is made to commence on ovulation stimulation

Which one of the following drugs would be the best option?

A. Clomiphene
B. Danazol
C. Decapeptyl SR
D. Dianette
E. Follicle stimulating hormones

Answer 340

A. Clomiphene

Question 341

A 21 year old nulliparous woman presents to the A and E department with right iliac fossa pain. Her last menstrual period was 6 weeks ago. She gives a history of a small amount of bleeding vaginally.
List 4 possible causes:

Answer 341

Ectopic pregnancy
Miscarriage
Urinary tract infection
Appendicitis
Molar pregnancy
Ovarian cyst

Question 342

A 21 year old nulliparous woman presents to the A and E department with right iliac fossa pain. Her last menstrual period was 6 weeks ago. She gives a history of a small amount of bleeding vaginally.

Urine Dipstick was positive Beta HCG and she has shoulder tip pain. A transvaginal US showed an empty uterus and small free fluid in the Pouch of Douglas.

What is your most likely diagnosis?

Answer 342

Ectopic Pregnancy

Question 343

A 23 year old nulliparous lady attends the antenatal clinic following referral by the community midwife at 36 weeks gestation due to small symphysio-fundal height on examination. She is noted to have ++protein and BP 145/95

List 3 symptoms you would further enquire about?

Answer 343

Headache
Blurring of Vision/Visual disturbances
Epigastric Pain
Reduced fetal movement 
Nausea and vomiting

Question 344

A 23 year old nulliparous lady attends the antenatal clinic following referral by the community midwife at 36 weeks gestation due to small symphysio-fundal height on examination. She is noted to have ++protein and BP 145/95

What initial investigations does she need at this stage?

Answer 344

FBC
U and E’s urate
LFTs
Ultrasound - growth scan

Question 345

A 23-year-old nulliparous lady attends the antenatal clinic following referral by the community midwife at 36 weeks gestation due to small symphysio-fundal height on examination. She is noted to have ++protein and BP 145/95

The BP was rechecked 1 hour later and it was 160/100 and the patient was admitted to the Day Ward for observation. She then developed sudden tonic-clonic convulsions and lost consciousness.]

What is your diagnosis?

Answer 345

Eclampsia

Question 346

A 23-year-old nulliparous lady attends the antenatal clinic following referral by the community midwife at 36 weeks gestation due to small symphysio-fundal height on examination. She is noted to have ++protein and BP 145/95

The BP was rechecked 1 hour later and it was 160/100 and the patient was admitted to the Day Ward for observation. She then developed sudden tonic-clonic convulsions and lost consciousness.

What management steps would you take now?

Answer 346

Call for help - senior obstetrician
Check airway - maintain check breathing 
Check BP, PR PP
IV access
Control seizure, magnesium sulphate 
Treat BP

Question 347

Most likely mode of transmission for Dengue fever?

A. Aerosol
B. Biting insects
C. Ingestion
D. Inhalation
E. Nosocomial
F. Oral mucosal contact
G. Percutaneous
H. Skin contact

Answer 347

B. Biting insects

Question 348

Most likely mode of transmission for Papilloma virus?

A. Aerosol
B. Biting insects
C. Ingestion
D. Inhalation
E. Nosocomial
F. Oral mucosal contact
G. Percutaneous
H. Skin contact

Answer 348

H. Skin contact

Question 349

Most likely mode of transmission for Rotavirus?

A. Aerosol
B. Biting insects
C. Ingestion
D. Inhalation
E. Nosocomial
F. Oral mucosal contact
G. Percutaneous
H. Skin contact

Answer 349

A. Infection

Question 350

For each of the following patient histories which are associated with cancer, select the appropriate associated microorganisms.

A. Ebstien-Barr virus
B. Helicobacter pylori
C. Hepatitis B virus
D. Herpes zoster virus
E. Human herpesvirus type 8
F. Human papilloma virus
G. Mycobacterium tuberculosis
H. Rous sarcoma virus
I. Schistosoma haematobium

A 30 year old man with HIV AIDS is found to have a vascular pigmented lesion on his trunk and another on his neck. This is thought to be Kaposi’s sarcoma.

Answer 350

E. Human herpesvirus type 8

Question 351

For each of the following patient histories which are associated with cancer select the appropriate associated microorganisms.

A. Ebstien-Barr virus
B. Helicobacter pylori
C. Hepatitis B virus
D. Herpes zoster virus
E. Human herpesvirus type 8
F. Human papilloma virus
G. Mycobacterium tuberculosis
H. Rous sarcoma virus
I. Schistosoma haematobium

A 57 year old woman presents with a blood-stained vaginal discharge. She is found to have an abnormal mass arising in the region of the cervix.

Answer 351

F. Human papilloma virus

Question 352

For each of the following patient histories which are associated with cancer select the appropriate associated microorganisms.

A. Ebstien-Barr virus
B. Helicobacter pylori
C. Hepatitis B virus
D. Herpes zoster virus
E. Human herpesvirus type 8
F. Human papilloma virus
G. Mycobacterium tuberculosis
H. Rous sarcoma virus
I. Schistosoma haematobium

A 65 year old man presents with weight-loss and epigastric pain he is found to have an ulcer on the greater curve of the stomach which on biopsy is found to be malignant.

Answer 352

B. Helicobacter pylori

Question 353

What is the most appropriate mechanism of dacarbazine used in Hodgkin’s disease?

A. Bifunctional alkylation of DNA and proteins
B. Cytotoxic antibody
C. Hormone receptor antagonism
D. Ionisation of biological molecules
E. Microtubule disruption
F. Monofunctional alkylation of DNA and protein
G. Structural analogue of a metabolite
H. Topoisomerase inhibition
I. Tyrosine kinase inhibition

Answer 353

F. Monofunctional alkylation of DNA and protein

Question 354

What is the most appropriate mechanism of the anthracycline, doxorubicin used for breast cancer?

A. Bifunctional alkylation of DNA and proteins
B. Cytotoxic antibody
C. Hormone receptor antagonism
D. Ionisation of biological molecules
E. Microtubule disruption
F. Monofunctional alkylation of DNA and protein
G. Structural analogue of a metabolite
H. Topoisomerase inhibition
I. Tyrosine kinase inhibition

Answer 354

H. Topoisomerase inhibition

Question 355

What is the most appropriate mechanism of the nitrogen mustard, cyclophosphamide widely used in solid tumours and leukaemias?

A. Bifunctional alkylation of DNA and proteins
B. Cytotoxic antibody
C. Hormone receptor antagonism
D. Ionisation of biological molecules
E. Microtubule disruption
F. Monofunctional alkylation of DNA and protein
G. Structural analogue of a metabolite
H. Topoisomerase inhibition
I. Tyrosine kinase inhibition

Answer 355

A. Bifunctional alkylation of DNA and proteins

Question 356

Which cell is involved in the formation of an acute skin abscess?

A. Basophils
B. Eosinophils
C. Giant cells
D. Lymphocytes
E. Macrophages
F. Mast cells
G. Monocytes
H. Neutrophils
I. Plasma cells

Answer 356

H. Neutrophils

Question 357

Which cell is involved in the release of histamine in the tissues?

A. Basophils
B. Eosinophils
C. Giant cells
D. Lymphocytes
E. Macrophages
F. Mast cells
G. Monocytes
H. Neutrophils
I. Plasma cells

Answer 357

F. Mast cells

Question 358

Which cell is involved in a candidate for the precursor in the blood of tissue mast cells?

A. Basophils
B. Eosinophils
C. Giant cells
D. Lymphocytes
E. Macrophages
F. Mast cells
G. Monocytes
H. Neutrophils
I. Plasma cells

Answer 358

A. Basophils

Question 359

An 18 year old student presents with fever lassitude and cervical lymphadenopathy. A blood film shows abnormal mononuclear cells.

A. Bovine tubeculosis
B. Brucellosis
C. Cat scratch disease
D. Glandular fever
E. Hodgkin’s disease
F. Lymes disease
G. Pneumonia
H. Rubella
I. Secondary spread
J. Troisier’s sign (Virchow’s node)

Answer 359

D. Glandular fever

Question 360

A 68 year old man has progressive weight loss and epigastric pain. He is found to have enlarged non-tender left supraclavicular lymphadenopathy.

A. Bovine tubeculosis
B. Brucellosis
C. Cat scratch disease
D. Glandular fever
E. Hodgkin’s disease
F. Lymes disease
G. Pneumonia
H. Rubella
I. Secondary spread
J. Troisier’s sign (Virchow’s node)

Answer 360

H. Rubella

Question 361

A 30 year old woman presents with multiple joint pains, a macular rash and enlarged occipital lymph nodes.

A. Bovine tubeculosis
B. Brucellosis
C. Cat scratch disease
D. Glandular fever
E. Hodgkin’s disease
F. Lymes disease
G. Pneumonia
H. Rubella
I. Secondary spread
J. Troisier’s sign (Virchow’s node)

Answer 361

J. Trosier’s sign

Question 362

Causes congenital infection in babies whose mothers acquire infection during pregnancy

A. Cryptosporidium
B. Echinococcus
C. Entamoeba histolytica
D. Enterobius
E. Filaria
F. Leishmania
G. Schistosoma
H. Toxoplasma
I. Trichomonas
J. Trypanosoma

Answer 362

H. Toxoplasma

Question 363

Causes dysentery and liver abscess

A. Cryptosporidium
B. Echinococcus
C. Entamoeba histolytica
D. Enterobius
E. Filaria
F. Leishmania
G. Schistosoma
H. Toxoplasma
I. Trichomonas
J. Trypanosoma

Answer 363

C. Entamoeba histolytica

Question 364

Causes sleeping sickness in Africa

A. Cryptosporidium
B. Echinococcus
C. Entamoeba histolytica
D. Enterobius
E. Filaria
F. Leishmania
G. Schistosoma
H. Toxoplasma
I. Trichomonas
J. Trypanosoma

Answer 364

J. Trypanosoma

Question 365

Offered annually to those aged 70 years or over

A. Cholera vaccine
B. HPV vaccine
C. Influenza vaccine
D. Measles, mumps and rubella (MMR) vaccine
E. Meningitis C vaccine
F. Pertussis vaccine
G. Pneumococcal vaccine
H. Rotavirus vaccine
I. The 4-in-1 vaccine (diphtheria, tetanus, pertussis and polio)
J. The 5-in-1 vaccine (diphtheria, tetanus, pertussis, polio and Haemophilus influenzae type B)
K. Varicella zoster vaccine

Answer 365

C. Influenza vaccine

Question 366

Given from 28 weeks of pregnancy to women ‘at risk’

A. Cholera vaccine
B. HPV vaccine
C. Influenza vaccine
D. Measles, mumps and rubella (MMR) vaccine
E. Meningitis C vaccine
F. Pertussis vaccine
G. Pneumococcal vaccine
H. Rotavirus vaccine
I. The 4-in-1 vaccine (diphtheria, tetanus, pertussis and polio)
J. The 5-in-1 vaccine (diphtheria, tetanus, pertussis, polio and Haemophilus influenzae type B)
K. Varicella zoster vaccine

Answer 366

F. Pertussis vaccine

Question 367

Given to infants on three occasions (at 2, 3 and 4 months of age)

A. Cholera vaccine
B. HPV vaccine
C. Influenza vaccine
D. Measles, mumps and rubella (MMR) vaccine
E. Meningitis C vaccine
F. Pertussis vaccine
G. Pneumococcal vaccine
H. Rotavirus vaccine
I. The 4-in-1 vaccine (diphtheria, tetanus, pertussis and polio)
J. The 5-in-1 vaccine (diphtheria, tetanus, pertussis, polio and Haemophilus influenzae type B)
K. Varicella zoster vaccine

Answer 367

J. The 5-in-1 vaccine (diphtheria, tetanus, pertussis, polio and
Haemophilus influenzae type B)

Question 368

Aim of screening in connection with this disease is to reduce incidence

A. Bladder cancer
B. Breast cancer
C. Cervical cancer
D. Colorectal cancer
E. Oesophageal cancer
F. Ovarian cancer
G. Pancreatic cancer
H. Prostate cancer
I. Testicular cancer

Answer 368

C. Cervical cancer

Question 369

Has a strong link with a number of occupational exposures

A. Bladder cancer
B. Breast cancer
C. Cervical cancer
D. Colorectal cancer
E. Oesophageal cancer
F. Ovarian cancer
G. Pancreatic cancer
H. Prostate cancer
I. Testicular cancer

Answer 369

A. Bladder cancer

Question 370

Use of oral contraceptives is associated with a reduced risk of this cancer

A. Bladder cancer
B. Breast cancer
C. Cervical cancer
D. Colorectal cancer
E. Oesophageal cancer
F. Ovarian cancer
G. Pancreatic cancer
H. Prostate cancer
I. Testicular cancer

Answer 370

F. Ovarian cancer

Question 371

Mr LM has developed an abdominal aortic aneurysm. Which one of the following is an unlikely consequence of this problem?

A. Femoral artery embolism
B. Local thrombosis
C. Pulmonary embolism
D. Rupture
E. Vessel wall calcification

Answer 371

C. Pulmonary embolism

An Abdominal Aortic Aneurysm can rupture due to dilation of the vessel walls and the pressure of the blood passing through, consequently local thrombosis, femoral artery embolism and calcification of the walls are also likely. Pulmonary embolism is a rare result of an AAA.

Question 372

Which one of the following is not a cardinal sign of acute inflammation?

A. Erythema
B. Increased temperature of the affected area
C. Local tissue swelling
D. Necrosis
E. Pain

Answer 372

D. Necrosis

Cardinal signs of acute inflammation are erythema, heat, swelling, pain and loss of function. Necrosis occurs in chronic inflammation.

Question 373

Which one of the following statements is correct about acute inflammation?

A. Giant cells result from the fusion of lymphocytes.
B. It normally follows chronic inflammation.
C. Macrophages are derived from blood basophils.
D. Plasma cells phagocytose bacteria.
E. The resulting exudate is rich in protein.

Answer 373

E. The resulting exudate is rich in protein.

In acute inflammation there is a cellular and vascular response, which causes the cardinal signs of acute inflammation, as a result of the cellular response exudates rich in protein is made from the destruction of microbes.

Question 374

Which one of the following statements is correct about the acute inflammatory response?

A. Cell adhesion molecules are only important in chronic inflammation.
B. Margination of monocytes is an early event.
C. Red cell diapedesis is an active phenomenon.
D. The exuded fibrin is formed by local fibroblasts.
E. Vasodilation is caused by histamine release from mast cells.

Answer 374

E. Vasodilation is caused by histamine release from mast cells.

In acute inflammation vasodilatation is caused by histamine and nitric oxide.

Question 375

A 6 year old boy has been admitted to hospital with a stiff neck and fever. You perform a lumbar puncture. Which one of the following findings in the CSF would support a diagnosis of meningococcal meningitis?

A. Glucose level more than 2/3 above a concomitant blood glucose level
B. Gram positive diplococci
C. Large number of lymphocytes
D. Raised protein
E. The presence of oligoclonal IgG bands

Answer 375

D. Raised protein

Meningococcal meningitis, the CSF would be cloudy, purulent due to increased neutrophils, increased protein levels and decreased glucose.

Question 376

Bacteria can acquire resistance to antimicrobial agents. Which one of the following statements is true?

A. A change in cell wall structure always occurs when a bacterium becomes drug- resistant.

B. An individual bacterium is capable of acquiring resistance to only a few classes of antimicrobial.

C. Drugs that target protein synthesis are not associated with resistance as protein synthesis is an essential feature for cellular function.

D. If the drug targets an enzyme, production of a structurally different enzyme may allow resistance to occur.

E. Resistance to a drug which targets DNA synthesis is not seen in clinical practice as a mutant which develops resistance cannot reproduce itself.

Answer 376

D. If the drug targets an enzyme, production of a structurally different enzyme may allow resistance to occur.

Bacteria can acquire resistance to antimicrobial agents. This mainly occurs from genes that encode for bacterial enzymes that block the effect of the antibiotic; these genes are normally found in the plasmids, allowing resistance to be transferred from bacterium to bacterium. Other methods of resistance include, prevention of the drug entering the bacteria, enzyme inactivation, alteration of the antibiotic target site and efflux resistance where the antibiotic is pumped out of the bacteria.

Question 377

Which one of the following is characteristic of caseous necrosis?

A. Associated with superadded infection
B. Denaturation of intracellular protein
C. Follows brain and spinal cord damage
D. Involves mainly fatty tissues
E. Usually caused by tuberculosis

Answer 377

E. Usually caused by tuberculosis

Caseous necrosis is where there is a complete loss of normal tissue architecture, replaced by amorphous, granular and eosinophilic tissue. There are varying amounts of fat giving a cheese like appearance. It is seen in tuberculosis.

Question 378

Which one of the following is not a recognised cause of embolism?

A. Air
B. Amniotic fluid
C. Collagen
D. Shrapnel
E. Thrombus

Answer 378

C. Collagen

Question 379

Which one of the following statements is not true about the examination for central cyanosis?

A. Associated with around 5g reduced haemoglobin
B. Best seen in the tongue
C. Compatible with a normal pO2
D. Not seen in severe anaemia
E. Not seen in the hands

Answer 379

E. Not seen in the hands

Seen in severe respiratory failure, cardiac causes including shunts, oxygen partial pressure may be normal but most often is not. Someone who has central cyanosis in their hands might look cyanosed as well because their blood is deoxygenated and all of their blood is deoxygenated at all sites

Question 380

Which one of the following terms describes autonomously growing tissues?

A. Dysplasia
B. Hyperplasia
C. Hypertrophy
D. Metaplasia
E. Neoplasia

Answer 380

E. Neoplasia

• Neoplasia describes autonomously growing tissue.
• Dysplasia is disordered cell development.
• Hyperplasia is an increase number of cells.
• Hypertrophy is an increase in tissue or organ size.
• Metaplasia is the change from one cell type to another

Question 381

A 35 years old woman presents with a 2 week history of an upper respiratory tract infection with cough, sore throat and headache. She has started to shiver and the cough has become worse with some blood-stained sputum. On examination there is bronchial breathing at the right base and a chest radiograph shows that the whole of the right lower lobe is consolidated with an ‘air bronchogram’.

What organism is most likely to cause this?

A. Haemophilus influenzae
B. Mycoplasma pneumoniae
C. Staphylococcus aureus
D. Streptococcus pneumoniae
E. Viridans group streptococcus

Answer 381

D. Streptococcus pneumoniae

Question 382

Mrs RA has an acute onset of fever cough and chest pain on deep breathing. Which of the following findings on investigation would cast doubt on a diagnosis of acute pneumococcal pneumonia?

A. A blood polymorph leukocytosis
B. A lobar distribution to the abnormality on the chest radiograph
C. Evidence for the presence of fibrinous pleurisy
D. Finding of Gram-positive diplococci in the sputum
E. Predominantly interstitial changes in the lungs on the CT scan

Answer 382

E. Predominantly interstitial changes in the lungs on the CT scan

Question 383

A breast cancer is described as being oestrogen receptor positive. Which one of the following statements is correct in relation to this description?

A. Does not reflect an intact cellular transcription pathway
B. Is more likely to respond to aromatase inhibitor
C. Is more likely to respond to cytotoxic chemotherapy
D. Tends to be worse differentiated
E. Tends to occur in the younger age group

Answer 383

B. Is more likely to respond to aromatase inhibitor

Question 384

A 60 year old woman presents with a spontaneous fracture of her left humerus. X-rays reveal multiple osteolytic lesions. She also has abnormal bands seen on plasma protein electrophoresis and light-chains in the urine.
What type of cell is responsible for this problem?

A. B cell
B. Eosinophil
C. Monocyte
D. NK cell
E. T Cell

Answer 384

A. B cell

Question 385

A 42 year old diabetic woman develops an abscess on her foot with evidence of cellulitis tracking over the dorsum.
What is the most likely causative organism?

A. Aspergillus Fumigatus
B. Bacteroides spp
C. E Coli
D. Enterococcus faecalis
E. Staphylococcus aureus

Answer 385

E. Staphylococcus aureus

Question 386

Influenza A virus is an enveloped, negative sense, single stranded RNA virus. What is the mechanism for the replication of this virus?

A. mRNA is formed using the host’s own RNA polymerase.
B. RNA can be used directly as mRNA.
C. RNA is transcribed by reverse transcriptase into mRNA.
D. RNA is transcribed by viral polymerase into mRNA.
E. RNA is transcribed using viral polymerase into a positive sense strand.

Answer 386

E. RNA is transcribed using viral polymerase into a positive sense strand.

This conversion is required to generate viral RNA that can be used as an mRNA in order to make viral proteins.

Question 387

A 72 year old man is in hospital recovering from a prostatectomy. Two days after removal of his urinary catheter he complains of a burning sensation when he passes urine and he is pyrexial. The patient has chronic renal insufficiency. A mid-stream specimen of urine yields Candida albicans on culture.

Which drug would be appropriate for systemic antifungal treatment of this patient?

A. Amphotericin B
B. Fluconazole
C. Griseofulvin
D. Metronidazole
E. Nystatin

Answer 387

B. Fluconazole

Question 388

During the cell cycle, in which phase is the DNA content fully duplicated?

A. G0 phase
B. G1 phase
C. G2 phase
D. Interphase
E. S phase

Answer 388

C. G2 phase

Question 389

What is central to the success of active immunisation?

A. An increase in complement levels
B. Providing an immediate protection
C. The action of pre-made antibodies
D. The production of clonal memory cells
E. The use of live vaccines only

Answer 389

D. The production of clonal memory cells

Question 390

For what reason is it preferable to use live vaccines rather than killed vaccines?

A. Live vaccines are safer than killed vaccines
B. Live vaccines do not require an adjuvant to be effective
C. Live vaccines produce higher levels of antibody
D. Live vaccines provide immediate protection
E. There is less need to keep live vaccines cold

Answer 390

C. Live vaccines produce higher levels of antibody

Question 391

A 30 year old patient is referred to the Dermatology department by his GP with scaly plaques on both knees and elbows. There is
a family history of similar rash in his father and brother. He is otherwise well in himself. What is the most likely diagnosis?

A. Eczema
B. Discoid lupus erythematosus
C. Lichen planus
D. Lichenification secondary to kneeling
E. Psoriasis

Answer 391

E. Psoriasis

Question 392

Which of the following is the most frequent route of HIV infection globally?

A. Blood transfusions
B. Heterosexual sex
C. Homosexual sex between men
D. Mosquito bites
E. Use of injected drugs

Answer 392

B. Heterosexual sex

Question 393

Which fungi but is not present in that of animals, making it a useful target for antifungal drugs?

A. Chitin
B. Cholesterol
C. Ergosterol
D. Keratin
E. Peptidoglycan

Answer 393

C. Ergosterol

Question 394

What mechanism best explains cell immortalisation in cancer?

A. Evasion of apoptosis (programmed cell death)

B. Evasion of destruction by cells of the immune system

C. Persistent cell proliferation without control from extracellular growth factors

D. Production of telomerase to prevent chromosome shortening

E. Stimulation of formation of blood vessels to supply the tumour cells

Answer 394

D. Production of telomerase to prevent chromosome shortening

Question 395

A 47 year old woman attends with a two week history of a painless lump in the left breast. Which feature on clinical examination is suggestive of carcinoma?

A. Green nipple discharge
B. Overlying redness
C. Pain
D. Skin tethering
E. Well circumscribed mass

Answer 395

D. Skin tethering

Question 396

In which layer of the skin are melanocytes found?

A. Stratum basale
B. Stratum corneum
C. Stratum granulosum
D. Stratum lucidum
E. Stratum spinosum

Answer 396

A. Stratum basale

Question 397

Which structure is commonly blocked by prostatic hyperplasia?

Answer 397

The prostatic urethra is commonly obstructed by benign hyperplasia

Question 398

Which structure produces 60% of the seminal fluid?

Answer 398

Seminal vesicles

The openings of the ureters are found in the upper two corners of the trigone.

Question 399

Where is the trigone of the bladder found?

Answer 399

At the base, it has a different cell type make up.

Question 400

Cardiac arrest due to ventricular arrhythmia

A. Albuminuria
B. Raised blood renin level
C. Raised blood urea
D. Raised blood uric acid
E. Raised serum creatinine level
F. Raised serum potassium levels
G. Reduced serum calcium levels
H. Reduced serum chloride levels
I. Reduced serum erythropoietin levels
J. Reduced serum pH

Answer 400

F. Raised serum potassium levels

The amount of potassium (K+) in the blood determines the excitability of nerve and muscle cells, including the heart muscle or myocardium. When potassium levels in the blood rise, this reduces the electrical potential and can lead to potentially fatal abnormal heart rhythms.

High serum potassium levels also called hyperkalemia can be life threatening and requires immediate therapy. There are several conditions that can significantly affect serum potassium levels and cause them to rise, but renal failure is the most common.

Question 401

Hypertension

A. Albuminuria
B. Raised blood renin level
C. Raised blood urea
D. Raised blood uric acid
E. Raised serum creatinine level
F. Raised serum potassium levels
G. Reduced serum calcium levels
H. Reduced serum chloride levels
I. Reduced serum erythropoietin levels
J. Reduced serum pH

Answer 401

B. Raised blood renin level

Question 402

Normochromic normocytic anaemia

A. Albuminuria
B. Raised blood renin level
C. Raised blood urea
D. Raised blood uric acid
E. Raised serum creatinine level
F. Raised serum potassium levels
G. Reduced serum calcium levels
H. Reduced serum chloride levels
I. Reduced serum erythropoietin levels
J. Reduced serum pH

Answer 402

I. Reduced serum erythropoietin levels

Question 403

The main vasomotor site of action of angiotensin 2.

Select the part of the nephron that is involved.

A. Afferent arteriole
B. Cortical collecting duct
C. Descending loop of Henle
D. Distal convoluted tubule
E. Efferent arteriole
F. Glomerulus
G. Macula densa
H. Medullary collecting duct
I. Proximal convoluted tubule
J. Thick ascending loop of Henle

Answer 403

E. Efferent arteriole

• Angiotensin II constricts the artery leading to increased BP. In the kidney Angiotensin II constricts both the afferent and efferent arterioles, but preferentially increases efferent resistance. At least 2 factors may contribute to this response:
• The efferent arteriole has a smaller diameter in the basal state; as a result, further constriction at this site will produce a greater increase in resistance than at afferent arteriole.
• Angiotensin II stimulates the release of the vasodilator NO from the afferent arteriole, thereby minimizing constriction at this site.

Question 404

The site of a sodium reabsorption through a channel that is blocked by the diuretic furosemide

Select the part of the nephron that is involved.

A. Afferent arteriole
B. Cortical collecting duct
C. Descending loop of Henle
D. Distal convoluted tubule
E. Efferent arteriole
F. Glomerulus
G. Macula densa
H. Medullary collecting duct
I. Proximal convoluted tubule
J. Thick ascending loop of Henle

Answer 404

J. Thick ascending loop of Henle

Furosemide is a loop diuretic. It inhibits water reabsorption in the nephron by blocking the sodium-potassium-chloride cotransporter in the thick ascending limb of the loop of Henle.

This is achieved through competitive inhibition at the chloride binding site on the cotransporter, thus preventing the transport of sodium from the lumen of the loop of Henle into the basolateral interstitium.

Question 405

The major site of bicarbonate reabsorption

Select the part of the nephron that is involved.

A. Afferent arteriole
B. Cortical collecting duct
C. Descending loop of Henle
D. Distal convoluted tubule
E. Efferent arteriole
F. Glomerulus
G. Macula densa
H. Medullary collecting duct
I. Proximal convoluted tubule
J. Thick ascending loop of Henle

Answer 405

J. Thick ascending loop of Henle

About 85 to 90% of the filtered bicarbonate is reabsorbed in the proximal tubule and the rest is reabsorbed by the intercalated cells of the distal tubule and collecting ducts.

Question 406

After intravenous administration of this highly ionised drug, which has a low therapeutic index, there is very rapid plasma clearance by the kidney

A. Amitriptyline
B. Demeclocycline
C. Gentamicin
D. Ibuprofen
E. Lithium
F. Methyl penicillin
G. Ramipril
H. Simvastatin
I. Warfarin

Answer 406

C. Gentamicin

Question 407

Probenecid can block the proximal tubule secretions of anions. A therapeutically useful increase in plasma concentrations can be achieved when Probenecid is combined with this drug

A. Amitriptyline
B. Demeclocycline
C. Gentamicin
D. Ibuprofen
E. Lithium
F. Methyl penicillin
G. Ramipril
H. Simvastatin
I. Warfarin

Answer 407

F. Methyl penicillin

Question 408

This orally available drug with a low therapeutic index will accumulate rapidly in acute kidney injury

A. Amitriptyline
B. Demeclocycline
C. Gentamicin
D. Ibuprofen
E. Lithium
F. Methyl penicillin
G. Ramipril
H. Simvastatin
I. Warfarin

Answer 408

E. Lithium

Question 409

Which bacterium is most frequently implicated as a cause of acute pyelonephritis?

A. Enterococcus faecalis
B. Escherichia coli
C. Klebsiella oxytoca
D. Proteus mirabilis
E. Pseudomonas aeruginosa

Answer 409

B. Escherichia coli

Question 410

Which of these causes a necrotising inflammation.

A. Enterococcus faecalis
B. Escherichia coli
C. Klebsiella oxytoca
D. Proteus mirabilis
E. Pseudomonas aeruginosa

Answer 410

E. Pseudomonas aeruginosa

Question 411

Which physiological change will lead to an increase in the Glomerular filtration rate?

A. A decrease in renal blood flow
B. A decrease in the concentration of plasma protein
C. Compression of the renal capsule
D. Constriction of the afferent arteriole
E. Decrease in afferent arteriole pressure

Answer 411

B. A decrease in the concentration of plasma protein

As the rate is defined by volume of urine x urine flow/ plasma protein concentration. A decrease in plasma protein will increase GFR.

Question 412

What is the principal site for the reabsorption of glucose within the nephron?

A. Ascending limb of the loop of Henle
B. Collecting duct
C. Descending limb of the Loop of Henle
D. Distal tubule
E. Proximal Convoluted Tubule

Answer 412

E. Proximal Convoluted Tubule

Question 413

What is the term that describes the volume of fluid from which a drug can be completely removed per unit of time (rate of drug removal)?

A. Clearance volume
B. Distribution volume
C. Excretion volume
D. Metabolism volume
E. Removal volume

Answer 413

A. Clearance volume

Question 414

A 45 year old woman presents with oedema of the face and ankles. She is normally fit and well. Urine dipstick testing shows 4+ of protein, but no glucose or blood. What is the likely pathological basis for this presentation?

A. A marked increase in cellularity of the glomerulus
B. A marked increase in mesangial matrix of the glomerulus
C. Abnormal proximal tubules
D. An abnormality of the basement membrane of the glomerulus
E. Interstitial infiltration with inflammatory cells

Answer 414

D. An abnormality of the basement membrane of the glomerulus

An abnormality of the basement membrane of the glomerulus would be found as, oedema of the ankles and face and protein in the urine suggests nephrotic syndrome.

The basement membrane is a key component of the filtration barrier (the endothelial cell layer, the basement membrane and the podocytes (epithelial cells).

Question 415

A 50 year old man has recently noticed ankle swelling. Urine testing reveals non-visible haematuria and 4+ proteinuria. What is likely to be causing the haematuria?

A. A small bladder tumour
B. A ureteric stone
C. Glomerulonephritis
D. Retroperitoneal fibrosis
E. Urinary infection

Answer 415

C. Glomerulonephritis

In Glomerulonephritis there may be haematuria and/or proteinuria. However proteinuria is strongly suggestive of a glomerular pathology.

A bladder tumour typically produces isolated haematuria (often, but not always, visible), stones usually produce pain (colic) if they are in the ureter or present with infection.

Retroperitoneal fibrosis produces renal obstruction at the level of the ureters and progressive renal failure.

Question 416

What might you expect to find as a ‘normal variant’ on inspection of the urine of a dehydrated patient?

A. Glucose
B. Granular casts
C. Hyaline casts
D. More than 10 white cells per cubic millimetre
E. Red cells

Answer 416

C. Hyaline casts

Hyaline Casts are seen in normal urine, these are found in healthy individuals who maybe dehydrated or who do vigorous exercise. They are formed from excess (Tamm-Horsfall) protein in the nephrons.

Question 417

A 35 year old woman presents with her first episode of symptoms of urinary frequency and painful micturition. She is normally fit and well. Her urine is cloudy and blood, protein and nitrites are detected on a dipstick test. Which antibiotic is the most appropriate choice in this situation?

A. Ampicillin
B. Ciprofloxacin
C. Metronidazole
D. Nitrofurantoin
E. Trimethoprim

Answer 417

E. Trimethoprim

Question 418

A 35 year old woman presents with her first episode of symptoms of urinary frequency and painful micturition. What is the most reliable guide to the presence of a bacterial infection in the urine?

A. Blood in the urine
B. Nitrites in the urine
C. Protein in the urine
D. Raised blood leukocyte count
E. Raised C-reactive protein in the blood

Answer 418

B. Nitrites in the urine

Question 419

A 76 year old man presents with severe kidney failure. Examination confirms a suprapubic mass consistent with an enlarged bladder. What pathology is most likely to result in this presentation?

A. Benign hyperplasia of the prostate gland
B. Bladder calculus
C. Bladder cancer
D. Posterior urethral valves
E. Urethral stenosis

Answer 419

A. Benign hyperplasia of the prostate gland

Benign prostatic hyperplasia is the commonest cause of bladder outflow obstruction leading to renal failure in men. Posterior urethral valves are seen in young boys. Bladder cancer is more likely to cause obstruction at the level of the vesico-ureteric junction, in which case the bladder would be empty.

Question 420

An 82 year old woman presents with a history of nocturia and polyuria. Blood tests show severe kidney failure. You suspect a diagnosis of post-renal kidney failure. What imaging technique would you request to demonstrate this pathology?

A. CT scan
B. Intravenous pyelogram (urogram)
C. MRI scan
D. Nuclear medicine scan
E. Ultrasound scan

Answer 420

E. Ultrasound

It will demonstrate hydronephrosis in post renal kidney failure. It is therefore the imaging modality of choice in this situation.

Question 421

What is the term for a synthetic non-biological foreign chemical?

A. An antibiotic
B. A probiotic
C. A prebiotic
D. A Xenobiotic
E. A neurobiotic

Answer 421

D. A Xenobiotic

is a substance, typically a synthetic chemical that is foreign to the body or to an ecological system.

Question 422

How is the renal clearance of a drug affected by the urine pH level?

A. Acidic pH prevents clearance of basic drugs
B. basic pH aids clearance of acidic drugs
C. There is no effect
D. acidic pH aids clearance of acidic drugs
E. Basic pH prevents clearance of acidic drugs

Answer 422

B. basic pH aids clearance of acidic drugs

Urine pH is critical to if a substance is easily passed into it. Acidic pH aids basic drugs to be excreted, and vica versa.

Question 423

Which part of the nephron is the primary site of action of the thiazide diuretics?

A. The cortical collecting duct
B. The distal tubule
C. The ascending limb of the loop of Henle
D. The descending limb of the loop of Henle
E. The proximal tubule

Answer 423

B. The distal tubule

Thiazide diuretics inhibit the sodium-chloride transporter in the distal tubule. This transporter reabsorbs about 5% of filtered sodium, and so thiazides are less powerful than loop diuretics.

Question 424

In which part of the nephron is the majority (90%) of filtered sodium bicarbonate reabsorbed?

A. The cortical collecting duct
B. The distal tubule
C. The medullary collecting duct
D. The loop of Henle
E. The proximal tubule

Answer 424

E. The proximal tubule

Question 425

A 6 year old girl has recurrent episodes of cystitis with burning on micturition. Proteus is isolated on several occasions in the urine. What is the most likely reason for these recurrent infections?

A. Descending infection from the kidney
B. Direct spread from the bowel
C. Immunoglobulin deficiency
D. Re-infection via the blood stream
E. Structural abnormality of the urinary tract

Answer 425

E. Structural abnormality of the urinary tract

Recurrent urinary tract infection in a child suggests an underlying cause. The commonest cause would be a structural abnormality of the urinary tract such as vesicoureteric reflux or a duplex system with incomplete drainage.

Ascending urinary tract infection occurs when a lower urinary tract infection results in an infection of the kidney (not the other way around). Females can get recurrent UTIs from GI organisms due to the close anatomical relation of ureter and anus. Immunoglobulin deficiency is rare. Urinary tract infection is more likely to lead to bloodstream infection rather than the other way round.

Question 426

A pharmaceutical company wishes to undertake a study of a new drug that may alter kidney function. In their initial studies they need to measure glomerular filtration rate as precisely as possible in normal volunteers. Which test would give the most accurate measurement of glomerular filtration rate?

A. Creatinine clearance
B. Glucose excretion
C. Inulin clearance
D. Para aminohippurate (pah) clearance
E. Urea clearance

Answer 426

C. Inulin clearance

Inulin is the most accurate substance to measure because it is a small, inert polysaccharide molecule that readily passes through the glomeruli into the urine without being reabsorbed by the renal tubules. The steps involved in this measurement, however, are quite involved; consequently, inulin is seldom used in clinical testing, although it is used in research. Creatinine clearance is the more common procedure used to assess renal function.

Question 427

The right kidney is related posteriorly to what structure?

A. The diaphragm
B. The genitofemoral nerve
C. The psoas major
D. The quadratus lumbrum
E. The subcostal nerve

Answer 427

B. The genitofemoral nerve (branch of lumbar plexus arising within substance of psoas major from union of L1 and L2 spinal nerves)

Question 428

During development the kidneys ascend, assuming their adult position around the ninth week. In ~1/500 people the poles of the kidneys are fused forming a horseshoe kidney. Which structure typically prevents the normal ascent of a horseshoe kidney?

A. Coeliac trunk
B. Inferior mesenteric artery
C. Left hepatic vein
D. Right hepatic vein
E. Superior mesenteric artery

Answer 428

B. Inferior mesentreic artery

Question 429

What pathophysiological mechanism can lead to a sudden fall in GFR following the commencement of treatment with an ACE Inhibitor?

A. Acute glomerulonephritis
B. Acute interstitial nephritis
C. Acute tubular necrosis
D. Afferent arteriolar vasoconstriction
E. Efferent arteriolar vasodilatation

Answer 429

E. Efferent arteriolar vasodilation

Inhibition of ACE by ACE inhibitors such as captopril, leads to inhibition of the conversion of angiotensin 1 to angiotensin II. However in addition ACE inactivates Bradykinin, which is a potent vasodilator. Therefore inhibition of ACE leads to elevated bradykinin levels, and vasodilatation.

Question 430

What are kidney (renal) stones most commonly composed of?

A. Calcium oxalate
B. Crystine
C. Struvite (magnesium ammonium phosphate)
D. Tamm-Horsfall protein
E. Uric acid

Answer 430

A. Calcium oxalate

Question 431

In the normal adult, the kidneys are located at the level of which vertebral bodies?
A. L1-L4
B. L3-S2
C. T11-L2
D. T12-L3
E. T9-T12

Answer 431

D. T12-L3

Question 432

From which embryonic tissue is the nephron of the adult kidney is derived?
A. Ectoderm
B. Endoderm
C. Intermediate mesoderm
D. Lateral mesoderm
E. Paraxial mesoderm

Answer 432

C. Intermediate mesoderm

Question 433

A process which alters normal structures after their formation (e.g. amniotic bands)

A. Chromosomal abnormalities
B. Deformation
C. Disruption
D. Functional defect
E. Malformation
F. Multiple malformation syndromes
G. Sequence
H. Single gene defect
I. Single primary defect
J. Structural defect
K. Teratogenesis

Answer 433

C. Disruption

Amniotic Bands are an example of disruptive congenital defects. Disruption is a destructive process which alters normal structures after their formation.

Question 434

An environmental agent that causes abnormalities e.g. rubella

A. Chromosomal abnormalities
B. Deformation
C. Disruption
D. Functional defect
E. Malformation
F. Multiple malformation syndromes
G. Sequence
H. Single gene defect
I. Single primary defect
J. Structural defect
K. Teratogenesis

Answer 434

K. Teratogenesis

Rubella is an example of an environmental agent that causes a maternal infection resulting in foetal damage. It is therefore, teratogenesis. A teratogen is an environmental agent that causes abnormalities of form or function in an exposed embryo or foetus. To produce a malformation a teratogen must be present in sufficient amounts at appropriate time in a genetically susceptible individual

Question 435

Multiple abnormalities following a single primary defect. e.g. Pierre Robin syndrome

A. Chromosomal abnormalities
B. Deformation
C. Disruption
D. Functional defect
E. Malformation
F. Multiple malformation syndromes
G. Sequence
H. Single gene defect
I. Single primary defect
J. Structural defect
K. Teratogenesis

Answer 435

G. Sequence

Pierre Robin Syndrome is an example of a sequence defect this when there is a pattern of multiple anomalies that occurs when a single primary defect occurs early and produces a cascade of 2º and 3º errors in morphogenesis.

Question 436

It can be elevated following any intramuscular injection. reflecting muscle damage

A. Cortisol
B. Creatine kinase
C. Glucose
D. Lactate dehydrogenase
E. Potassium
F. Progesterone
G. Prolactin
H. Prostate specific antigen
I. Thyroid stimulating hormone

Answer 436

B. Creatine kinase

Question 437

It is increased in patients on antipsychotic medications

A. Cortisol
B. Creatine kinase
C. Glucose
D. Lactate dehydrogenase
E. Potassium
F. Progesterone
G. Prolactin
H. Prostate specific antigen
I. Thyroid stimulating hormone

Answer 437

G. Prolactin

Question 438

It requires an inhibitor in the collection tube to prevent metabolic degradation after specimen collection

A. Cortisol
B. Creatine kinase
C. Glucose
D. Lactate dehydrogenase
E. Potassium
F. Progesterone
G. Prolactin
H. Prostate specific antigen
I. Thyroid stimulating hormone

Answer 438

D. Glucose

Free glucose on whole blood may be broken down by glycolysis carried out by the cells in the blood. Inclusion of an inhibitor of glycolysis (typically fluoride, to inhibit enolase) prevents breakdown of free glucose.

Question 439

Of the following, which one causes the most maternal deaths in the UK?

A. Accidents
B. Post-partum haemorrhage
C. Puerperal sepsis
D. Suicide
E. Toxaemia

Answer 439

D. Suicide

The leading cause of maternal mortality after birth is suicide and then post-partum haemorrhage. However the commonest cause of direct (i.e. related directly to pregnancy) maternal death is thromboembolism. The most common indirect cause is cardiac disease. Both currently outnumber suicide but in the past suicide has been higher. The list is quite different in developing countries when sepsis, haemorrhage and obstructed labour would be common.

Question 440

Which one of the following is correct about the physiological changes in the body in normal pregnancy?

A. Blood volume is unchanged.
B. Cardiac output increases.
C. Mean systemic blood pressure falls.
D. Peripheral arteriole resistance is unchanged.
E. Red cell mass diminishes.

Answer 440

B. Cardiac output increases.

Blood glucose rises by a process of hypervolemia. In order to satisfy this need, there is cardiac remodelling, thus maintaining blood pressure.

Question 441

Which one of the following is correct about the foetal circulation?

A. Blood flow across the ductus arteriosus is from aorta to pulmonary artery.
B. Blood flow across the foramen ovale is from right to left.
C. Blood returning from the inferior vena cava is preferentially diverted into the right ventricle.
D. Oxygenated blood from the placenta is preferentially diverted into the right ventricle.
E. The system favours delivery of oxygenated blood to the lungs and liver.

Answer 441

B. Blood flow across the foramen ovale is from right to left.

In the developing foetus the blood flows from the right to the left of the heart through the foramen ovale, until changes occur at birth, this is to prevent blood entering the right ventricle and therefore the under developed lungs.

The liver is avoided by the ductus venosus.

The ductus arteriosus diverts blood from the pulmonary artery to the aorta.

Question 442

The ductus arteriosus diverts blood from the _ to _ ?

A. Inferior vena cava to right ventricle
B. Right heart to Left heart 
C. Pulmonary artery to Aorta
D. Left heart to Right heart
E. Aorta to Pulmonary artery

Answer 442

C. Pulmonary artery to Aorta

Ductus arteriosus is a temporary fetal structure that shunts blood from the pulmonary arteries to the aorta, in order to avoid circulating blood through the lungs, which are inactive in the womb.

Question 443

What is the ligamentum arteriosum an remnant of?

A. Ductus venosus
B. Ductus arteriosus
C. Foramen ovale

Answer 443

B. Ductus arteriosus

The ligamentum arteriosum (Latin: arterial ligament) is a small ligament that is the remnant of the ductus arteriosus formed within three weeks after birth.

In conjunction with the other fetal shunts, the foramen ovale and ductus arteriosus, it plays a critical role in preferentially shunting oxygenated blood to the fetal brain. It is a part of fetal circulation.

Question 444

The ductus venosus diverts blood from the _ to _ ?

A. Inferior vena cava to right ventricle
B. Right heart to Left heart 
C. Pulmonary artery to Aorta
D. Placenta to inferior vena cava
E. Aorta to Pulmonary artery
F. Placenta to Liver

Answer 444

D. Placenta to inferior vena cava

The ductus venosus shunts a portion of the left umbilical vein blood flow directly to the inferior vena cava. Thus, it allows oxygenated blood from the placenta to bypass the liver.

In conjunction with the other fetal shunts, the foramen ovale and ductus arteriosus, it plays a critical role in preferentially shunting oxygenated blood to the fetal brain. It is a part of fetal circulation.

Question 445

Blood to which structures are avoided by foetal shunts?

Answer 445

Liver (ductus venosus)

Lungs (ductus arteriosus, foramen ovale)

Question 446

Which one of the following is correct about lung development in the foetus?

A. Most lung development takes place in the first few and last few weeks of pregnancy.

B. Respiratory distress syndrome is caused by an excess of surfactant.

C. Surfactant is produced by Type 1 pneumocytes.

D. Surfactant is produced throughout foetal development.

E. Surfactant works by reducing surface tension within the lung alveoli.

Answer 446

E. Surfactant works by reducing surface tension within the lung alveoli.

Question 447

Which of the following is true about the initiation of labour?

A. A nervous reflex is mediated by sacral segments of the spinal cord.

B. Requires prior stimulation of beta-adrenoreceptors in uterine muscle.

C. The mechanism is not known.

D. Triggered by an abrupt fall in placental secretion of oestrogen.

E. Triggered by an increase in oxytocin released from the posterior pituitary.

Answer 447

C. The mechanism is not known.

Oxytocin is released by positive feedback and key in the events of labour but it is unknown what triggers its release. Naturally, labour does not require the stimulation by the beta-adrenoreceptors in the uterine muscles. During labour there are abrupt falls in the oestrogen but it does not initiate labour

Question 448

Loss of a pregnancy is termed a miscarriage if it occurs in which one of the following time spans?

A. Before 12 weeks
B. Before 24 weeks
C. Before 37 weeks
D. Before 40 weeks
E. Between 24 and 37 weeks

Answer 448

B. Before 24 weeks

Question 449

As a GP, you note extensive bruising on the chest wall and back of a 4 year old boy whom you are examining because of a persistent cough. His mother explains that he ‘bruises easily’ and this bruising is from ‘rough and tumble’ games with his 6 year old brother.

Which of these is the most appropriate immediate course of action?

A. Arrange for the boy to be seen urgently in the Emergency Department of the local hospital.

B. Discuss the findings with a senior officer at the local police station.

C. Discuss the findings with the local social services team.

D. Document the clinical findings and review the boy in 1-2 weeks’ time.

E. Refer to Paediatric outpatients department for tests to exclude haematological or clotting disorders

Answer 449

C. Discuss the findings with the local social services team.

because the history the mum gives does not match the signs a child has.

Question 450

In natural conception, where does fertilisation occur?

A. Ampullary-isthmic junction
B. Fimbriae
C. Ostium
D. Utero-tubule junction
E. Uterus

Answer 450

A. Ampullary-isthmic junction

The UTJ is the junction between the oviduct and uterus, through which the blastocyst passes, signifying end of cleavage development. The AIJ is the region where fertilization typically occurs. The fimbriae are the finger-like projections that pick up the ovulated oocyte, the uterus is the organ which supports post implantation development and the ostium is the opening of the oviduct through which the ovulated oocyte is passed.

Question 451

What process must sperm complete before being able to fertilise an oocyte normally?

A. Binding to ZP proteins
B. Capacitation
C. Decondensation
D. Ejaculation
E. Epithelial binding

Answer 451

B. Capacitation

• Ejaculation is not required as sperm can be collected from manual extraction from the testis.
• However, for normal fertilization a sperm must be capacitated (i.e. have become activated and undergone acrosome reaction) in order to penetrate the cumulus and the zona pellucida. Although binding to the epithelia of the oviduct is observed there is no evidence that this is required for successful fertilization.
• Decondensation describes the process occurring to the sperm nuclear material after fertilization and binding to the ZP proteins on the zona pellucida is a key early event in the fertilization process.

Question 452

What process leads to a slow block and prevention of polyspermy?

A. Acrosome reaction
B. Capacitation
C. Cumulus expansion
D. Sperm selection
E. Zona reaction

Answer 452

E. Zona reaction

• The Acrosome reaction describes a process prior to fertilization when the enzymes responsible for digesting through the cumulus are released.
• The zona reaction, or block to polyspermy (zona hardening) is the process mediated by the cortical granule release, altering the protein structures on the zone responsible for sperm binding.
• Cumulus expansion refers to the mucification and expansion of the granulosa-derived cells that accompany the oocyte after ovulation. While the cumulus plays a role in reducing sperm transit to the egg, it does not specifically prevent polyspermy.
• Sperm selection, mediated by binding to the oviduct, reduces the numbers of sperm in the vicinity of the egg, but again does not directly prevent polyspermy.
• Capacitation describes the process by which sperm become able to fertilise and oocyte.

Question 453

Which of the following describes a process prior to fertilisation when the enzymes responsible for digesting through the cumulus are released?

A. Acrosome reaction
B. Capacitation
C. Cumulus expansion
D. Sperm selection
E. Zona reaction

Answer 453

A. Acrosome reaction

Question 454

Which of the. following refers to the mucification and expansion of the granulosa-derived cells that accompany the oocyte after ovulation.

A. Acrosome reaction
B. Capacitation
C. Cumulus expansion
D. Sperm selection
E. Zona reaction

Answer 454

C. Cumulus expansion

While the cumulus plays a role in reducing sperm transit to the egg, it does not specifically prevent polyspermy.

Question 455

At which stage in development does the first cell differentiation event occur?

A. 2 cell stage
B. 4 cell stage
C. Blastocyst
D. Morula
E. Zygote

Answer 455

C. Blastocyst

Question 456

Which cell population synthesizes embryonic-derived progestogens?
A. Ectoderm
B. Endoderm
C. Hypoblast
D. Inner cell mass
E. Syncytiotrophoblast

Answer 456

A. Ectoderm

• The inner cell mass cells are the cells of the blastocyst that will differentiate into epiblast and hypoblast. In turn, these will differentiate into the 3 key cell types of Endoderm and Ectoderm – both of which contribute to the foetus.
• The syncytiotrophoblast derives from the trophectoderm and is the multinucleated cell population that mediates implantation and production of progestogens.
• The hypoblast is a derivative of the inner cell mass.

Question 457

After 13 months of trying unsuccessfully to conceive, what is the recommended course of action for a 34 year old woman and her 37 year old partner to take?

A. Keep trying for another year
B. Request a semen evaluation
C. Seek advice from a fertility clinic
D. Seek advice from a GP
E. Undertake IVF privately

Answer 457

D. Seek advice from a GP

• Current guidance is that for all couples who are unsuccessful in becoming pregnant after one year of regular unprotected intercourse that they should seek advice from the GP.
• Earlier advice was that for women under 35, they should attempt to become pregnant for two year before seeking advice, but this is no longer accurate. It would be early to seek advice from a fertility clinic directly at this stage, and undertaking IVF with clinical investigation would not be recommended.
• Requesting a semen evaluation would not immediately be necessary as there is little indication of male infertility, although this would likely be undertaken if further investigations are carried out.

Question 458

In general terms, what is the biggest factor in determining fertility success?

A. Endometriosis
B. Maternal age
C. Ovulatory dysfunction
D. Paternal age
E. Sperm count

Answer 458

B. Maternal age

• Although there is evidence for declining fertility with advanced paternal age, functional spermatozoa can be produced throughout the male lifetime. Sperm counts are declining, but still, in the general population, remain sufficiently buoyant for healthy fertility.
• Ovulatory dysfunction and endometriosis are relatively common specific causes of infertility, however the biggest cause of infertility is the decline in fertility with maternal age, which is linked to follicular (oocyte) reserve, and declines rapidly beyond the age of 35.

Question 459

When does histotrophic support of the conceptus cease?

A. Fertilisation
B. Final completion of the villus tree
C. Formation of the primary villi
D. Implantation
E. Reduction of the chorionic villi

Answer 459

C. Formation of the primary villi

• Fertilisation and early preimplantation development is nourished by internal embryonic reserves and oviduct cell secretions.
• The implanted conceptus relies on histotrophic support from surrounding tissue until the formation of the primary villi establishes heamotrophic support.
• Reduction of the chorionic villi and completion of the villus tree describe completion of the development of the villus structure.

Question 460

Which cell lineage is common to the amnion, chorion and yolk sac?

A. Ectoderm
B. Endoderm
C. Hypoblast
D. Mesoderm
E. Trophoblast

Answer 460

D. Mesoderm

• The ectoderm contributes to the amnion
• The endoderm to the yolk sac
• The trophoblast to the chorion
• The hypoblast to the endoderm
• The mesoderm contributes to all structures of the placenta.

Question 461

Which key pregnancy hormone requires the co-operation of the placenta and the foetus?

A. Chorionic gonadotrophin
B. Oestradiol
C. Pregnenolone
D. Progesterone
E. Somatomammotropin

Answer 461

B. Oestradiol

• Progesterone and pregnenolone are produced by the placenta from the precursor cholesterol.
• In order to make oestradiol, progesterone must be converted into 17a-hydroxy-pregnenolone-sulphate which requires the foetal adrenals. Somatomammotropin is synthesized by the placenta directly.

Question 462

How would you best describe the role of ‘Monitor’, the regulator of Foundation Trusts (FTs) in England?

A. To deliver care cost effectively
B. To ensure care is provided that satisfies patients
C. To ensure financial obligations are met in terms of balancing income
and expenditure
D. To ensure population health needs are met
E. To monitor the performance of doctors

Answer 462

C. To ensure financial obligations are met in terms of balancing income

Question 463

Which issue is not considered in the NICE Guidelines on treatment of sub-fertility?

A. Maternal age
B. Number of IVF cycles
C. Resource implications
D. Size of current family
E. Smoking

Answer 463

D. Size of current family

Question 464

During primary biochemical screening for cystic fibrosis, in newborn infants in the UK, what is measured in the dried blood spot?

A. Cystic fibrosis transmembrane conductance regulator

B Delta fibroid mutation (delta-F508)

C. Immuno-reactive trypsin

D. Phenylalanine

E. Sodium chloride

Answer 464

C. Immuno-reactive trypsin

Question 465

Which statement best describes the role of the National Audit Office?

A. Scrutinises public spending on behalf of parliament and reports on the economic, efficient and effective use of public money by government bodies

B. Scrutinises public spending on social services to ensure value for money and reports to the prime minister

C. Scrutinises public spending to ensure patient satisfaction and economy and reports to government

D. Scrutinises public spending to ensure probity and equity in the use of public money in the NHS

E. Scrutinises the efficiency and equity effects of tax collection by government and reports to parliament.

Answer 465

A. Scrutinises public spending on behalf of parliament and reports on the economic, efficient and effective use of public money by government bodies

Question 466

As a new house officer you have made a ‘near miss’ error in prescribing a drug. Your consultant tells you to report it.

Which is the most appropriate action you should take?

A. Fill out a ‘yellow card’ for adverse drug reactions
B. Inform the relatives
C. Telephone your medical defence society
D. Tell the medicines and healthcare products regulatory agency
E. Tell the national reporting and learning system

Answer 466

E. Tell the national reporting and learning system

Question 467

According to the study by Dean et al (2002), with what are more than half of medication errors among hospital in-patients concerned?

A. Choice of dose
B. Choice of drug
C. Illegible handwriting
D. Medicines being prescribed off-licence
E. Route of administration

Answer 467

A. Choice of dose

Question 468

Which of the following has a statutory responsibility to take a lead role if it is suspected that a child is being harmed non-accidentally?
A. The GP
B. The health visitor
C. The local authority
D. The paediatrician
E. The police

Answer 468

C. The local authority

Question 469

Which hormone stimulates the production of milk by the mammary gland?
A. GnRH
B. Oestrogen
C. Oxytocin from the posterior pituitary gland
D. Progesterone
E. Prolactin by the anterior pituitary gland

Answer 469

E. Prolactin by the anterior pituitary gland

Question 470

In normal child development, what would be the expected mean age at which a child can walk up stairs, one step at a time?

A. 12 months
B. 15 months
C. 18 months
D. 2 years
E. 2.5 years

Answer 470

D. 2 years

Question 471

What subsequent adult chronic disease is thought to be related to impaired intrauterine growth as a foetus?

A. Asthma
B. Colon cancer
C. Depression
D. Rheumatoid arthritis
E. Type II diabetes

Answer 471

E. Type II diabetes

Question 472

A term infant is noted to be cyanotic at 4 hours of age. There is minimal respiratory distress. What is the most likely cause?

A. Patent ductus arteriosus
B. Patent foramen ovale
C. Severe aortic stenosis
D. Transposition of the great arteries
E. Ventricular septal defect

Answer 472

D. Transposition of the great arteries

Question 473

Select a drug from the above list which is used for the treatment of epilepsy and is described as:

Highly protein bound with narrow therapeutic index; inhibits use-dependent sodium channels

A. Carbamazepine
B. Clozapine
C. Diazepam
D. Ethosuximide
E. Haloperidol
F. Lamotrigine
G. Phenobarbital
H. Phenytoin
I. Sodium valproate

Answer 473

H. Phenytoin

Question 474

Select a drug from the above list which is used for the treatment of epilepsy and is described as:

Selectively targets neurons that synthesise glutamate and aspartate to inhibit transmitter release.

A. Carbamazepine
B. Clozapine
C. Diazepam
D. Ethosuximide
E. Haloperidol
F. Lamotrigine
G. Phenobarbital
H. Phenytoin
I. Sodium valproate

Answer 474

F. Lamotrigine

Question 475

Select a drug from the above list which is used for the treatment of epilepsy and is described as:

Usually restricted to absence seizures; inhibits T-type calcium channels.

A. Carbamazepine
B. Clozapine
C. Diazepam
D. Ethosuximide
E. Haloperidol
F. Lamotrigine
G. Phenobarbital
H. Phenytoin
I. Sodium valproate

Answer 475

D. Ethosuximide

Question 476

A 40 year old woman presents with a 24 hour history of weakness and drooping of the left side of her face. Examination confirms weakness of the left side of the face and absence of wrinkles of the forehead.

A. Abducens nerve
B. Facial nerve lower motor neurone
C. Facial nerve upper motor neurone
D. Glossopharyngeal nerve
E. Hypoglossal nerve
F. Oculomotor nerve
G. Optic nerve
H. Trigeminal nerve
I. Vagus nerve
J. Vestibular branch of the auditory nerve

Answer 476

B. Facial nerve lower motor neurone

Question 477

A 48 year old smoker presents with a short history of a frontal headache which is worse in the mornings. She is unable to abduct the left eye.

A. Abducens nerve
B. Facial nerve lower motor neurone
C. Facial nerve upper motor neurone
D. Glossopharyngeal nerve
E. Hypoglossal nerve
F. Oculomotor nerve
G. Optic nerve
H. Trigeminal nerve
I. Vagus nerve
J. Vestibular branch of the auditory nerve

Answer 477

A. Abducens nerve

Question 478

A 52 year old woman presents with right sided pain affecting the side of the scalp and cheek. It is made worse by eating, cold conditions and provoked by tapping over the right side of the maxilla.

A. Abducens nerve
B. Facial nerve lower motor neurone
C. Facial nerve upper motor neurone
D. Glossopharyngeal nerve
E. Hypoglossal nerve
F. Oculomotor nerve
G. Optic nerve
H. Trigeminal nerve
I. Vagus nerve
J. Vestibular branch of the auditory nerve

Answer 478

H. Trigeminal nerve

Question 479

What is not important in the maintenance of balance?

A. Cranial nerve VIII
B. Lateral spinothalamic tracts
C. Saccule
D. Semicircular canals
E. Visual cues

Answer 479

B. Lateral spinothalamic tracts

The VIII cranial nerve (vestibulcochlear) is responsible for balance and hearing, the saccule, semicircular canals and visual cues are all important in the maintenance of balance. The lateral spinothalamic tracts transmit pain sensation, they are therefore not required in balance maintenance.

Question 480

A 68 year old woman has a widely dilated pupil on one side. Where is the problem likely to be?

A. The oculomotor nerve
B. The cervical sympathetic chain
C. The upper thoracic dorsal roots
D The carotid sheath
E. The ophthalmic division of the trigeminal nerve

Answer 480

A. The oculomotor nerve

• Pupil dilation is controlled by the oculomotor nerve.
• The ophthalmic division of the trigeminal nerve supplies sensation around the eye.

Question 481

Through which one of the following do nerve fibres conveying the sense of smell from the nose, pass into the skull?

A. Foramen magnum
B. Cribriform plate
C. Foramen ovale
D. Jugular foramen
E. Optic canal

Answer 481

B. Cribriform plate

Question 482

Which one of the following is true of the facial nerve?

A. Supplies the anterior belly of the digastric muscle

B. Contains taste fibres from the posterior third of the tongue

C. Is purely sensory in the face

D. Leaves the skull through the stylomastoid foramen

E. Contains parasympathetic nerve fibres which innervate the dilator
pupillae

Answer 482

D. Leaves the skull through the stylomastoid foramen

The facial nerve supplies the posterior belly of the digastric muscle, contains taste fibres from the anterior two-thirds of the tongue, innervates muscles of the face (motor), and supplies parasympathetic innervation to the submandibular and sublingual glands

Question 483

Which one of the following is correct about the middle ear?

A. The tensor tympani is supplied by the facial nerve.

B. The ossicles are united by means of the synovial joints.

C. The chorda tympani crosses the outer surface of the tympanic
membrane.

D. The base or footplate of the stapes closes the fenestra cochleae (round window).

E. It is drained by the auditory tube which opens into the oropharynx.

Answer 483

B. The ossicles are united by means of the synovial joints.

The middle ear isn’t drained by the auditory tube just communicates with the nasopharynx.

The chorda tympani crosses the inner surface of the tympanic membrane.

The oval window is closed by the stapes and the tensor tympani is supplied by the trigeminal nerve.

Question 484

An 82 year old woman has been admitted with a bed sore on her buttocks. Curiously she seems to have had no pain from this and on testing you find absent sensation on both buttocks and lower limb paresis. Where is the most likely site of the problem?
A. Cauda equina
B. Precentral gyrus
C. Sacral nerves
D. Spinothalamic tracts
E. Thalamus

Answer 484

A. Cauda equina

Cauda equine syndrome involves cord compression and produces bilateral symptoms both sensory sacrum, perineum and motors defect to the lower limbs.

Question 485

A 76 year old man presents with difficulty in speech articulation. On examination the muscles on the right side of the tongue are wasted and he is unable to move the tongue on that side.

Where is the lesion most likely to lie?

A. Right facial nerve
B. Right hypoglossal nerve
C. Right trigeminal nerve
D. Right vagus nerve nucleus
E. The left cerebral cortex

Answer 485

B. Right hypoglossal nerve

Lesions to this nerve are commonly extracranial it is purely motor to the tongue

Question 486

A man presents with resting tremor of the arms and on examination you also note an expressionless face and a monotonous voice. You also find cogwheel rigidity of the arms and legs.

Where is the lesion most likely to lie?

A. Caudate nucleus
B. Putamen
C. Reticular formation
D. Substantia nigra
E. The pyramids

Answer 486

D. Substantia nigra

A lesion in substantia nigra would create Parkindsonian symptoms

Question 487

A 55 year old woman has subacute combined degeneration of the cord, a condition is caused by vitamin B12 deficiency and involving, amongst other parts, the posterior columns of the cord.

What physical findings would you expect as a consequence of this damage?

A. Disturbance of bladder function
B. Impaired vibration sense in the feet
C. Muscle wasting of the legs
D. Postural hypotension
E. Reduced pain sensation in the legs

Answer 487

B. Impaired vibration sense in the feet

Subacute combined degeneration of the cord is caused by a vit B12 deficiency causing degeneration of the posterior columns of the cord, causing an impaired vibration sense in the feet Absent ankle jerks and upgoing plantars combined motor and sensory loss.

Question 488

A 45 year old man and previously well, has had a subarachnoid haemorrhage with severe headache and the finding of blood in the CSF.

Which one of the following findings is most likely on further investigation?

A. Aortic aneurysm
B. Atherosclerotic aneurysm
C. Berry aneurysm
D. Mycotic (infective) aneurysm
E. Traumatic aneurysm

Answer 488

C. Berry aneurysm

A subarachnoid Haemorrhage is primarily caused by berry aneurysm, which occur in relation to the circle of Willis.

There is an association with adult polycystic kidney syndrome but most are idiopathic.

Question 489

A 34 year old patient complains of progressive deafness in the right ear with tinnitus. When asked, the patient reports they have had no symptoms of vertigo. On examination the eardrum appears normal; using a tuning fork you deduce air conduction to be better than bone conduction in both ears.

What is the most likely cause of the problem in this patient?

A. Blocked Eustachian tube
B. Earwax
C. Hair cell damage
D. Otitis media
E. Vestibular nerve damage

Answer 489

E. Vestibular nerve damage

A, B and D Blocked Eustachian tube, earwax and otitis media (middle ear infection) are more likely to cause conductive hearing loss, and bone conduction would be louder than air conduction.

Vestibular nerve damage would cause vertigo (dizziness) as it affects the sense of balance, not hearing.

Hair cells in the cochlea that displace in response to sound are easily damaged by prolonged exposure to loud noise.

Question 490

Following a road traffic collision, a 54 year old patient presents with a basal skull fracture of the anterior cranial fossa, anosmia and CSF rhinorrhoea.

Which cranial nerve is most likely to be damaged?

A. I
B. II
C. III
D. IV
E. V

Answer 490

A. I

Question 491

Which ganglion is involved in mediating the pupillary light reflex?

A. Coeliac
B. Ciliary
C. Geniculate
D. Pterygopalatine
E. Trigeminal

Answer 491

B. Ciliary

Question 492

What type of murmur in mitral stenosis?

Answer 492

Rumbling, mid diastolic, loud S1

Early diastolic opening snap

Question 493

A child of 6 with a sudden onset of severe cough and fever and a finding of B. pertussis on a nasal swab.

A. Acute bronchitis
B. Bronchiecstasis
C. Bronchiolitis
D. Broncho pneumonia
E. Cystic fibrosis
F. Legionnella pneumonia
G. Lobar pneumonia
H. Whooping cough

Answer 493

H. Whooping cough

90% of cases occur in below the age of 5. Incubation period 7-10 days. Symptoms similar to upper respiratory tract infection with a cough & nasal discharge; >90% of cultures from respiratory secretions positive for B. pertussis. Cough becomes acute with paroxysms of coughing-with classic inspiratory whoop; paroxysms often followed by vomiting.

Question 494

A man of 36 presents with an acute onset of fever and pleuritic chest pain. Bronchial breathing is found on auscultation and S. pneumoniae isolated from the sputum.

A. Acute bronchitis
B. Bronchiecstasis
C. Bronchiolitis
D. Broncho pneumonia
E. Cystic fibrosis
F. Legionnella pneumonia
G. Lobar pneumonia
H. Whooping cough

Answer 494

G. Lobar pneumonia

S. pneumonia commonest pathogen causing lower respiratory tract infection (60-75% of cases) in all age groups. Lobar pneumonia affects lung parenchyma causing whole areas of lung consolidation; the consolidation results in bronchial breathing. Chest X-ray shows a distinct area of shadowing. Other features include dry cough and purulent sputum, pleuritic pain, rigors and sometimes pleural effusion.

Question 495

A patient of 84 with a long standing productive cough and wheeze admitted with fever, breathlessness and patchy shadowing on the chest x-ray.

A. Acute bronchitis
B. Bronchiecstasis
C. Bronchiolitis
D. Broncho pneumonia
E. Cystic fibrosis
F. Legionnella pneumonia
G. Lobar pneumonia
H. Whooping cough

Answer 495

D. Broncho pneumonia

Patchy shadowing = broncho rather than lobar pneumonia

Bronco pneumonia affects lung parenchyma (mainly alveoli) in a patchy fashion. Causes breathlessness, chest pain, cough and sputum, with lung crackles; chest X-ray shows patchy shadowing.

Question 496

Blocks inward calcium channels and slow AV conduction (class lV) controls atrial tachycardia

A. Adenosine
B. Adrenalin
C. Amiodarone
D. Atenolol
E. Digoxin
F. Lidocaine (lignocaine)
G. Theophylline
H. Verapamil

Answer 496

H. Verapamil

4. Verapamil belongs to the Class IV antiarrhythmic drugs that are calcium antagonists (they block the voltage-sensitive calcium channels) and slow conduction (action potential upstroke) in the SA and AV nodes.

Question 497

Has a vagally-mediated effect on the AV node to slow AV conduction and control atrial fibrillation

A. Adenosine
B. Adrenalin
C. Amiodarone
D. Atenolol
E. Digoxin
F. Lidocaine (lignocaine)
G. Theophylline
H. Verapamil

Answer 497

E. Digoxin

Digoxin is a cardiac glycoside. It acts to cause a cardiac slowing and reduced rate of conduction through the AV node (by increasing vagal outflow) and increases the force of contraction. Acts via inhibition of the Na+/K+ pump. The increased intracellular Na+ slows extrusion of Ca2+ via the Na+/ Ca2+ exchanger decreasing Ca2+ extrusion and thus increased Ca2+ is stored in the SR and available on release. Digoxin is used to slow the ventricular rate in rapid persistent atrial fibrillation. Also used in patients with heart failure who remain symptomatic despite optimal treatment.

Question 498

Reduces sympathetic activity at the AV node (class ll) controls atrial tachycardia

A. Adenosine
B. Adrenalin
C. Amiodarone
D. Atenolol
E. Digoxin
F. Lidocaine (lignocaine)
G. Theophylline
H. Verapamil

Answer 498

D. Atenolol (betablocker)

Atenolol is a Class II antiarrhythmic β1-selective-Adrenoceptor antagonist. It diminishes the Phase 4 depolarisation, thus suppressing automaticity, prolonging AV conduction and decreasing heart rate and contractility. Class II drugs are useful in the treatment of tachyarrhythmias caused by increased sympathetic activity. It is also used for atrial flutter and fibrillation and for AV-nodal re-entrant tachycardia.

Question 499

A beta 1 selective receptor agonist acting to stimulate the heart

A. Atenolol
B. Captopril
C. Digoxin
D. Dobutamine 
E. Furosemide
F. Losartan
G. Nitrates
H. Spironolactone
I. Verapamil

Answer 499

D. Dobutamine

• Dobutamine is a predominantly β1 adrenoceptor agonist and α1 selective activity with some weak β2 activity. It is used to treat acute but potentially reversible heart failure (cardiogenic shock or septic shock) for its β1 inotropic effect in increasing heart contractility and cardiac output.

Question 500

An aldosterone antagonist acting to increase sodium excretion

A. Atenolol
B. Captopril
C. Digoxin
D. Dobutamine 
E. Furosemide
F. Losartan
G. Nitrates
H. Spironolactone
I. Verapamil

Answer 500

H. Spironolactone

• Spironolactone is an aldosterone antagonist used to treat chronic heart failure acting in the collecting ducts to increase sodium and water excretion. The decrease in fluid volume helps relieve the pulmonary oedema and the symptoms of heart failure.

Question 501

Worsens cardiac failure by negative inotropic effect from blocking calcium channels

A. Atenolol
B. Captopril
C. Digoxin
D. Dobutamine 
E. Furosemide
F. Losartan
G. Nitrates
H. Spironolactone
I. Verapamil

Answer 501

I. Verapamil

• Verapamil worsens cardiac failure by having a negative inotropic effect from blocking calcium channels. It acts on the L-type calcium channels. It is therefore contraindicated in heart failure.

Question 502

Bilateral lung abscesses in an intravenous drug user

A. Chlamydia pneumoniae
B. Haemophilus influenzae
C. Klebsiella pneumoniae
D. Legionella pneumophila
E. Mycoplasma pneumoniae
F. Pneumocystis jirovecii
G. Pseudomonas aeruginosa
H. Staphylococcus aureus
I. Streptococcus pneumoniae

Answer 502

H. Staphylococcus aureus

• In general, Staph. Aureus causes pneumonia only after a preceding influenza viral illness. The infection commences in the bronchi, leading to patchy areas of consolidation in one or more lobes, which break down to form abscesses. Infection with this bacterium is often seen in intravenous drug abusers and patients with central catheters being used for parenteral nutrition. The infected puncture site is the source of the Staph. Aureus.

Question 503

Breathlessness, cough and sputum production in a patient with chronic obstructive pulmonary disease and clear lung fields on chest X-ray.

A. Chlamydia pneumoniae
B. Haemophilus influenzae
C. Klebsiella pneumoniae
D. Legionella pneumophila
E. Mycoplasma pneumoniae
F. Pneumocystis jirovecii
G. Pseudomonas aeruginosa
H. Staphylococcus aureus
I. Streptococcus pneumoniae

Answer 503

B

• Haemophilus influenzae is divided into typeable or nontypeable strains based on the presence or absence of a polysaccharide capsule. Nontypeable Haemophilus influenzae is a bacterium that is present in the nasopharynx of most healthy adults and in this situation it appears to be a commensal. It may also spread down to the lower respiratory tract and in these locations it has been well recognized to be associated with inflammation and disease. In this context it is no longer a commensal and becomes an important respiratory pathogen associated with a range of common conditions including bronchitis, bronchiectasis, pneumonia, and particularly chronic obstructive pulmonary disease.

Question 504

Cough, breathlessness and hypoxaemia with minimal chest X- ray changes in a patient with untreated HIV infection.

A. Chlamydia pneumoniae
B. Haemophilus influenzae
C. Klebsiella pneumoniae
D. Legionella pneumophila
E. Mycoplasma pneumoniae
F. Pneumocystis jirovecii
G. Pseudomonas aeruginosa
H. Staphylococcus aureus
I. Streptococcus pneumoniae

Answer 504

F.

It is an opportunistic infection that accounts for 50% of the cases of pneumonia in these patients. Infection is associated with a high fever, breathlessness and a dry cough.

Question 505

Digoxin is useful in the management of:

A. Atrial flutter
B. Bradycardia
C. Sinus arrhythmia
D. Torsades de pointes
E. Ventricular tachycardia

Answer 505

A. Atrial flutter

Digoxin blocks the exchange of intracellular Na+ for extracellular K+ by inhibiting the Na+/K+-ATPase in the cell membrane; this leads to an increases intracellular Ca2+ and causing positive inotropic effect. In addition, digoxin stimulates the vagus and increases vagal tone, which slows the heart down in atrial fibrillation and flutter.

Question 506

Angiotensin converting enzyme inhibitors are useful in all of the following circumstances except one.

Which one?

A. Cardiac arrhythmias
B. Diabetic nephropathy
C. Hypertension.
D. Left ventricular failure
E. Prophylaxis of ischaemic heart disease

Answer 506

A. Cardiac arrhythmias

Angiotensin converting enzyme inhibitors are useful for diabetic nephropathy, hypertension, left ventricular failure, prophylaxis of ischaemic heart disease as they prevent the formation of angiotensin II which is causes vasoconstriction. They would have no effect in cardiac arrhythmias.

Question 507

What is the principal action of calcium channel blocking drugs?

A. Has a negative inotropic effect on the heart
B. Increases smooth muscle contraction in the bowel
C. Increases transmission in cardiac conducting tissue
D. Is vasoconstrictor
E. Reduces peripheral nerve conduction

Answer 507

A. Has a negative inotropic effect on the heart

The principle action of calcium channel blockers is its negative inotropic effect on the heart. Interfere with inward displacement of calcium ions through slow channels (L-type channels) of active cell membranes. Different preparations have different principal sites of action either cardiac or peripheral (vasculature).

Question 508

A 60 year old woman presents with tiredness and weight loss over 3 months. She has smoked 10 cigarettes a day for 30 years. Chest X- ray shows multiple ‘cannon ball’ lesions in both lung fields.

What is the most likely diagnosis?

A. Bronchial carcinoma
B. Metastatic carcinoma
C. Sarcoidosis
D. Small cell carcinoma
E. Tuberculosis

Answer 508

B. Metastatic carcinoma

Canon ball lesions in all lung fields are indicative of metastatic cancer. Typical sites for the primary tumour includes kidney, prostate, breast, bone GI tract, cervix or ovary. Multiple lesions are characteristic of secondaries. Miliary TB the snow storm pattern is often seen. Sarcoidosis and bronchial carcinoma may show hilar prominence due to hilar lymphadenopathy.

Question 509

A 49 year old woman presents with palpitations and you find an irregular pulse on examination. ECG shows absent P waves and irregularly timed, but normal shaped QRS complexes.

Which one of the following is correct?

A. The atria are fibrillating.
B. The heart is being controlled by the AV node.
C. The heart is being controlled by the SA node.
D. The problem lies in the bundle of His.
E. The ventricles are beating autonomously.

Answer 509

A. The atria are fibrillating

An irregular pulse with absent P waves in indicative of atrial fibrillation.

Nodal rhythms still see P waves but are dissociated. SA node sinus rhythm may not be regular in a number of conditions affecting downstream conduction. Problem with bundle of His heart block; this can give rise to right or left bundle block. Idioventricular rhythm heart block; if there is complete heart block no P waves from the atria are conducted to the ventricles. The rate is 30-45 bpm and the QRS complexes are wide (>0.12sec) with a wide and bizarre configuration. Cells of the His-Purkinje system can take over and act as the heart’s pacemaker.

Question 510

What will be the consequence of increasing cardiac pre-load by increasing blood volume or veno-constriction?

A. Decreased cardiac work
B. Decreased oxygen consumption
C. Decreased stroke volume
D. Decreased systemic blood pressure
E. Increased end-diastolic volume

Answer 510

E. Increased end-diastolic volume

Increasing the cardiac pre-load due to an increased blood volume will cause an increased end-diastolic volume. According to starling’s law this should increase the force of contraction but may not in the failing heart.

Question 511

A 55 year old businessman returns from a European trip where he has stayed in a number of hotels. He presents to the Emergency Department with a three day history of malaise, fever, cough and breathlessness. A chest X-ray shows pulmonary infiltration in both lung fields. Laboratory tests indicate hyponatremia, microscopy and staining of the sputum is negative.

Which one of the following is the likely organism in this situation?

A. Haemophilus influenza
B. Legionella pneumophilia
C. Mycobacterium tuberculosis
D. Mycoplasma pneumoniae
E. Streptococcus pneumoniae

Answer 511

B. Legionella pneumophilia

The symptoms of L. pneumophilia are often vague with malaise, headache, myalgia, fever with rigors and a pyrexia up to 400C. The hyponatraemia distinguishes L. pneumophilia infection from other pneumonias.

Question 512

Mr GH presents with shortness of breath of 2 weeks duration. Examination reveals dullness at the left base but his chest radiograph and ultrasound shows a raised paralysed left hemi-diaphragm.

Which one of the following is the most likely explanation for this finding?

A. A 40% pneumothorax

B. Congenital deformity of the diaphragm

C. Damage to the phrenic nerve

D. Left lower lobe pneumonia

E. Tumour in the anterior mediastinum

Answer 512

C. Damage to the phrenic nerve

Damage to the phrenic nerve can be recognised by its permanent elevation and a paradoxical breathing pattern in which the anterior abdominal wall moves inwardly during inspiration and outwardly with forced expiration. Phrenic nerve palsy has many causes, and can be caused by lesions anywhere along the course of the phrenic nerve, as it travels from the neck, to pierce the diaphragm adjacent to the pericardium.The other options are incorrectA. A pneumonthorax of this size would cause some collapse of the lung and a minimal amount of elevation of the diaphragm in this case, but some diaphragmatic movement on breathing would be seen with the ultrasound.B. A congenital deformity of the diaphragm often leads to rupture of the diaphragm and herniation of the diaphragm which would be clearly evident on the radiograph.D. A consolidation of the lower lobes will reveal dullness on percussion, but will often obscure the crisp contour of the adjacent hemi-diaphragm. So this is unlikely to cause a hemi-diaphragm.E. As the name suggests, it is confined to the anterior mediastinum , that portion of the mediastinum anterior to the pericardium and below the level of the

Question 513

Which one of the following is correct about the thoracic duct?

A. Drains all lymph from both right and left sides of the thorax

B. Empties into the inferior vena cava

C. Enters the thorax through the oesophageal opening of the diaphragm

D. Is found anterior to the oesophagus in the thorax

E. Receives lymph from the pelvis and abdomen

Answer 513

E. Receives lymph from the pelvis and abdomen

Receives lymph from the pelvis and abdomenThe other options are incorrect.The thoracic duct drains lymph from the left side of the head, neck, the upper left limb and from the lower limbs, pelvic cavity and abdominal cavity. The right lymphatic duct collects lymph from the right jugular trunk, which drains the right side of the head and neck; the right subclavian trunk, which drains the upper extremity; and the right bronchomediastinal trunk, which drains the right side of the thorax, right lung, right side of the heart and part of the liver.The thoracic duct usually empties into the venous system near the union of the left internal jugular and subclavian veins; the left venous angle.The thoracic duct enters the thoracic cavity through the aortic hiatus and ascends to the right of the midline in the posterior mediastinum between the aorta and azygos vein, posterior to the oesophagus.The thoracic duct is posterior to the oesophagus.

Question 514

A 67 year old man has chronic obstructive airways disease. He is not responding well to his current therapy and you consider adding theophylline to his treatment.

Which one of the following are important factors in your prescription of this drug?

A. Drug interactions are uncommon.
B. It has a narrow therapeutic index.
C. It is excreted unchanged by the kidney.
D. It is metabolised more slowly in cigarette smokers.
E. Therapeutic monitoring is not possible.

Answer 514

B.

Theophylline has a very narrow therapeutic index

So not much of a range between a therapeutic and toxic dose; thus monitoring of plasma theophylline is required, which is measured after 5 days of starting treatment. Start with low dose.

Question 515

What is an important side effect of angiotensin converting enzyme inhibitors?

A. First dose hypotension
B. Myocardial depression
C. Peripheral neuropathy
D. Wheezy breathlessness
E. Worsening diabetic nephropathy

Answer 515

A. First dose hypotension

ACE inhibitors have an important side effect of first dose hypotension especially in those on high dose diuretics or dehydration or on dialysis.

Question 516

A 70 year old man develops sudden, crushing central chest pain radiating into the neck and jaw. What laboratory tests on the serum would be most useful in these circumstances?

A. Bilirubin
B. Glucose
C. Lactic dehydrogenase
D. Lipase
E. Troponin 1

Answer 516

E. Troponin 1

Cardiac troponins: troponin C (TnC) and troponin I(TnI) ) are biological markers of cardiac muscle necrosis, and are now used for diagnosing MI. Highly sensitive tests now exist for both TnC and TnI, allowing results to be obtained within 4 hours of presentation to A&E. Lactic dehydrogenase (LDH) activity is widespread in the body and an increase in LDH is not specific to diagnose an MI and is no longer used.

Question 517

After intravenous administration of this highly ionised drug, which has a low therapeutic index, there is very rapid plasma clearance by the kidney

A. Amitriptyline
B. Demeclocycline
C. Gentamicin
D. Ibuprofen
E. Lithium
F. Methyl penicillin
G. Ramipril
H. Simvastatin
I. Warfarin

Answer 517

Gentamicin

Gentamicin is an antibiotic that can be given via injection or intravenous. It is part of the aminoglycoside family of antibiotics, which work via either preventing the growth of bacteria, or inducing bacterial death. It therefore does not work to prevent colds, or flu infections. It is typically used for serious gram negative bacterial infections which are difficult to treat with other antibiotics. However, it may also cause some serious side effects, including damage to your kidneys and the cochlea in the inner ear, which controls hearing and balance. The clearance of Gentamicin depends on both your kidney function and body weight.

Question 518

Probenecid can block the proximal tubule secretions of anions. A therapeutically useful increase in plasma concentrations can be achieved when Probenecid is combined with this drug.

A. Amitriptyline
B. Demeclocycline
C. Gentamicin
D. Ibuprofen
E. Lithium
F. Methyl penicillin
G. Ramipril
H. Simvastatin
I. Warfarin

Answer 518

Methyl penicillin

Methyl penicillin is more commonly known as Penicillin V and is less effective than Penicillin G against gram-negative bacteria, but shows similar activity against gram positive bacteria. However it is more acid stable than Penicillin G and therefore can be given orally. Probenecid blocks the proximal tube secretion of penicillin by the kidney and therefore increases the penicillin plasma concentration.

Question 519

Which physiological change will lead to an increase in the Glomerular filtration rate?

A. A decrease in renal blood flow
B. A decrease in the concentration of plasma protein
C. Compression of the renal capsule
D. Constriction of the afferent arteriole
E. Decrease in afferent arteriole pressure

Answer 519

B

Glomerular filtration rate (GFR) is a test used to check how well the kidneys are working. Specifically, it estimates how much blood filtered through the glomeruli into Bowman’s space each minute. As the rate is defined by volume of urine x urine flow/ plasma protein concentration a decrease in plasma protein will increase GFR.

Question 520

Dacarbazine used in Hodgkin’s disease

A. Bifunctional alkylation of DNA and proteins
B. Cytotoxic antibody
C. Hormone receptor antagonism
D. Ionisation of biological molecules
E. Microtubule disruption
F. Monofunctional alkylation of DNA and protein
G. Structural analogue of a metabolite
H. Topoisomerase inhibition
I. Tyrosine kinase inhibition

Answer 520

F. Monofunctional alkylation of DNA and protein

Question 521

The anthracycline, doxorubicin used to breast cancer

A. Bifunctional alkylation of DNA and proteins
B. Cytotoxic antibody
C. Hormone receptor antagonism
D. Ionisation of biological molecules
E. Microtubule disruption
F. Monofunctional alkylation of DNA and protein
G. Structural analogue of a metabolite
H. Topoisomerase inhibition
I. Tyrosine kinase inhibition

Answer 521

H. Topoisomerase inhibition

Question 522

The nitrogen mustard, cyclophosphamide widely used in solid tumours and leukaemias

A. Bifunctional alkylation of DNA and proteins
B. Cytotoxic antibody
C. Hormone receptor antagonism
D. Ionisation of biological molecules
E. Microtubule disruption
F. Monofunctional alkylation of DNA and protein
G. Structural analogue of a metabolite
H. Topoisomerase inhibition
I. Tyrosine kinase inhibition

Answer 522

A. Bifunctional alkylation of DNA and protein

Question 523

A candidate for the precursor in the blood of tissue mast cells

A. Basophils
B. Eosinophils
C. Giant cells
D. Lymphocytes
E. Macrophages
F. Mast cells
G. Monocytes
H. Neutrophils
I. Plasma cells

Answer 523

A. Basophils

Question 524

Formation of an acute skin abscess

A. Basophils
B. Eosinophils
C. Giant cells
D. Lymphocytes
E. Macrophages
F. Mast cells
G. Monocytes
H. Neutrophils
I. Plasma cells

Answer 524

H. Neutrophils

Question 525

A 30 year old woman presents with multiple joint pains, a macular rash and enlarged occipital lymph nodes.

A. Bovine tubeculosis
B. Brucellosis
C. Cat scratch disease
D. Glandular fever
E. Hodgkin’s disease
F. Lymes disease
G. Pneumonia
H. Rubella
I. Secondary spread
J. Troisier’s sign (Virchow’s node)

Answer 525

H. Rubella

Question 526

A 68 year old man has progressive weight loss and epigastric pain.
He is found to have enlarged non-tender left supraclavicular lymphadenopathy.

A. Bovine tubeculosis
B. Brucellosis
C. Cat scratch disease
D. Glandular fever
E. Hodgkin’s disease
F. Lymes disease
G. Pneumonia
H. Rubella
I. Secondary spread
J. Troisier’s sign (Virchow’s node)

Answer 526

J. Troisier’s sign

Question 527

Quinolone

Answer 527

Inhibits nucleuic acid synthesis

Question 528

Tetracycline

Answer 528

Inhibits protein synthesis

Question 529

What diseases does nephrotic syndrome in adults cause?

Answer 529

Membranous glomerulopathy
Focal segmental glomeruloscleoris

Diabetic nephropathy
SLE
Amyloidosis

Question 530

What diseases does nephrotic syndrome in children cause?

Answer 530

Minimal change nephropathy

Focal segmental glomerulosclerosis

Question 531

What does nephritic syndrome cause in children?

Answer 531

Haemolytic uraemic syndrome
Henoch-schonlein purpura (IgA vasculitis)
Post-streptococcal GN

Question 532

What are the causes of nephritic syndrome in adults?

Answer 532

Goodpasture’s
ANCA-associated vasculitis
Primary or secondary mesangiocapillary GN

SLE