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Medicine MCQS VIA Web

Copyright © 2005 Elsevier Limited. All rights reserved. Fleshandbones is a registered
trademark of Harcourt, Inc. in the United States and other jurisdictions, used under license

These mcqs were donloaded By Ahmed Hakim

Question 1. The pulse:
(a) In pulsus paradoxus the rate slows during inspiration. (False)
(b) Pulsus alternans indicates a poorly functioning left ventricle. (True)
(c) A tachycardia of 150 beats per minute in a resting patient usually implies an underlying cardiac arrhythmia. (True)
(d) A collapsing pulse may be noticed in thyrotoxicosis. (True)
(e) Corrigan's sign supports a diagnosis of aortic stenosis. (False)

Question 2. Heart murmurs:

(a) A low rumbling diastolic murmur with presystolic accentuation may be heard in mitral stenosis accompanied by
atrial fibrillation. (False)
(b) Causes of a pansystolic murmur include mitral regurgitation and ventricular septal defect. (True)
(c) A systolic murmur heard over the whole praecordium associated with a thrill usually indicates aortic stenosis.
(d) Left heart murmurs are best heard during expiration. (True)
(e) An early blowing diastolic murmur at the left sternal edge indicates aortic incompetence. (True)

Question 3. Pulsus paradoxus:

(a) The volume of the pulse increases in inspiration. (False)
(b) Can be confirmed by detecting >10 mmHg difference in systolic pressure during the breathing cycle. (True)
(c) Is a sign of severe asthma. (True)
(d) Is called paradoxus because it is the opposite of what normally happens to the pulse. (False)
(e) Can occur in cardiac tamponade. (True)

Question 4. The jugulovenous pressure:

(a) Is raised if it is 2 cm from the sternal angle with the patient seated at 45°. (False)
(b) Tall 'a' waves may be seen in pulmonary hypertension. (True)
(c) Irregular cannon waves indicate complete heart block. (True)
(d) Regular cannon waves may indicate a nodal rhythm. (True)
(e) Giant 'v' waves and a pulsatile liver indicate tricuspid stenosis. (False)

Question 5. The physical signs of an uncomplicated large pneumothorax include:

(a) The trachea deviated to the opposite side. (False)
(b) A clicking sound synchronous with the heart beat. (True)
(c) Symmetrical expansion of the chest. (False)
(d) Increased breath sounds over the pneumothorax. (False)
(e) Increased percussion note over the pneumothorax. (True)

Question 6. The following would help distinguish between a kidney and a spleen in the left upper quadrant:
(a) Dull to percussion over the mass. (False)
(b) A well-localized notched lower margin. (False)
(c) Moves with respiration. (False)
(d) A ballottable mass. (True)
(e) A family history of renal failure. (True)

Question 7. Nystagmus:
(a) Vertical nystagmus usually indicates a lesion of the medulla oblongata. (False)
(b) Horizontal nystagmus is usually ipsilateral to an irritative lesion of the labyrinth. (False)
(c) Ataxic nystagmus indicates a lesion of the medial longitudinal bundle. (True)
(d) May be absent in a lesion of the cerebellar vermis (the central part). (True)

By A. H.
(e) Pendular nystagmus may indicate partial blindness. (True)

Question 8. The following would suggest an upper rather than a lower motor neuron lesion:
(a) Fasciculation. (False)
(b) Increased tone. (True)
(c) An absent plantar reflex. (False)
(d) Clonus. (True)
(e) Relatively little wasting. (True)

Question 9. Hand signs:

(a) Clubbing may be caused by uncomplicated chronic bronchitis. (False)
(b) Koilonychia usually indicates liver disease. (False)
(c) Osler's nodes and Heberden's nodes both occur in osteoarthritis. (False)
(d) Splinter haemorrhages are due to embolic rather than immunological phenomena. (False)
(e) Psoriatic arthritis affects most joints in the hand but usually spares the distal interphalangeal (DIP) joints. (False)

Question 10. The face:

(a) A malar flush may indicate mitral valve disease or hypothyroidism. (True)
(b) A butterfly rash in the face is seen in dermatomyositis. (False)
(c) Bell's palsy can cause ptosis due to paralysis of orbicularis oculi. (False)
(d) Herpes labialis may be associated with pneumococcal pneumonia. (True)
(e) An expressionless face and drooling could indicate Parkinson's disease. (True)

Question 11. The electrocardiogram:

(a) The PR interval is measured from the peak of the P wave to the start of the QRS complex. (False)
(b) Right axis deviation is indicated by a QRS axis of -35°. (False)
(c) Q waves in S-II, S-III and aVf indicate a transmural inferior myocardial infarction. (True)
(d) Left bundle branch block is suggested by broadening of the QRS complex to 0.10 seconds (two and a half little
squares), and positive RSR' waves in V4-V6. (False)
(e) P mitrale is suggested by a P wave taller than 2.5 mm. (False)

Question 12. In the full blood count:

(a) A haemoglobin of 10.0 g/dL would be considered normal in a premenopausal woman. (False)
(b) Polycythaemia rubra vera is usually indicated by elevation not only of the haemoglobin but also of the white cell
count and platelets. (True)
(c) A low platelet count could indicate a flare-up of systemic lupus erythematosus (SLE). (True)
(d) High platelets can be seen in gastrointestinal bleeding. (True)
(e) A raised mean corpuscular volume is usual in significant alcohol excess. (True)

Question 13. Heart failure:

(a) The clinical features of left heart failure include: tachycardia, basal crepitations, pulsus alternans and a raised JVP.
(b) Congestion of the pulmonary veins alone does not result in orthopnoea. (False)
(c) Chronic congestive heart failure leads to secondary hyperaldosteronism. (True)
(d) Causes of heart failure include ischaemic heart disease, hypertension, and thiamine deficiency. (True)
(e) Clinical features of right heart failure include a raised JVP, ankle oedema, and hepatomegaly. (True)

Question 14. Stroke:

(a) Cerebral haemorrhage accounts for more than 40% of acute strokes. (False)
(b) In supratentorial strokes with homonymous hemianopsia, patients cannot see on the hemiplegic side. (True)
(c) Vertigo, vomiting, dysphagia, and Horner's syndrome indicate occlusion of the vertebrobasilar circulation. (True)
(d) Pinpoint pupils and bilateral upgoing plantars could signal a brainstem stroke. (True)
(e) Carotid endarterectomy should be considered for patients with more than 70% stenosis because this is more
effective than medical treatment. (True)

Question 15. Respiratory failure:

By A. H.
(a) Type I failure results in a partial pressure of oxygen (pO2) <8 kPa and a partial pressure of carbon dioxide (pCO2)
of >6.5 kPa. (False)
(b) In respiratory failure associated with chronic bronchitis, the level of carbon dioxide (CO2) determines the
respiratory rate. (False)
(c) Respiratory failure as defined in (a) would be an indication for ventilation in pure asthma. (True)
(d) Doxapram is a respiratory stimulant used in respiratory failure associated with chronic obstructive pulmonary
disease. (True)
(e) The main aim in type II failure is to keep the pO2 >7.0 kPa without worsening of the acidosis or pCO2. (True)

Question 16. Cushing's syndrome:

(a) May give rise to hypertension, diabetes, and truncal obesity. (True)
(b) Is usually diagnosed by estimation of the urinary free cortisol followed by an overnight dexamethasone suppression
test. (True)
(c) Could be associated with pigmentation. (True)
(d) The most common cause is probably iatrogenic. (True)
(e) Nelson's syndrome is a complication of bilateral adrenalectomy for pituitary-dependent Cushing's disease. (True)

Question 17. Leukaemia:

(a) The common presenting triad is infection, bleeding, and fatigue. (True)
(b) Acute myeloid leukaemia (AML) may result spontaneously or follow on from CML, polycythaemia rubra vera or
myelosclerosis. (True)
(c) The usual development of chronic lymphocytic leukaemia is a transformation to acute lymphoblastic leukaemia.
(d) A platelet count of 40 × 109/L would not normally give rise to spontaneous bleeding. (True)
(e) Bone marrow transplantation is a recognized treatment for AML. (True)

Question 18. Hypertension:

(a) An average diastolic blood pressure of >90 mmHg over prolonged observation is an indication for drug treatment in
uncomplicated hypertension. (False)
(b) Thiazide diuretics are the least effective antihypertensive drugs. (False)
(c) Thiazide diuretics work on the loop of Henle in the kidney. (False)
(d) Resistant hypertension is defined as a failure to control the blood pressure adequately with a good three-drug
regimen. (True)
(e) Thiazide diuretics are contraindicated in gout and diabetes. (True)

Question 19. Oral corticosteroids:

(a) Are an effective treatment for SLE. (True)
(b) In the long term may cause cataracts. (True)
(c) Should be avoided in sarcoidosis because they induce pulmonary oedema. (False)
(d) May be stopped abruptly after 2 weeks of 40 mg prednisolone daily in patients who are not exposed to repeated
courses. (True)
(e) May reveal that 15% of patients labelled as having chronic bronchitis, in fact have reversible airways disease.

Question 20. Paracetamol overdose:

(a) Ipecacuana followed by oral methionine is effective for most patients who are just over the treatment line. (False)
(b) Can cause renal failure. (True)
(c) Intravenous N-acetylcysteine frequently causes anaphylaxis. (False)
(d) The serum paracetamol level is of most value between 1 and 4 hours after ingestion. (False)
(e) In co-proxamol (distalgesic) overdose, sudden death is likely to be due to hypoglycaemia caused by paracetamol.

Question 21. Treatment of myocardial infarction:

(a) Aspirin and streptokinase are more effective than either alone after myocardial infarction. (True)
(b) Thrombolysis improves short-term complications but not mortality after myocardial infarction. (False)

By A. H.
(c) Tissue plasminogen activator and anistreplase are more effective than streptokinase but not used because they are
far more expensive. (False)
(d) ACE inhibitors improve outcome after myocardial infarction for patients with ventricular dysfunction. (True)
(e) HMGCo-A reductase inhibitor therapy is contraindicated for patients after myocardial infarction. (False)

Question 22. For self-poisoning:

(a) Gastric lavage is recommended for most drugs up to 12 hours after ingestion. (False)
(b) Naloxone is the specific antidote for benzodiazepine overdose. (False)
(c) Patients with tricyclic antidepressant overdose need cardiac monitoring for up to 48 hours. (True)
(d) All patients should be assessed by a qualified psychiatrist. (False)
(e) Pinpoint pupils could indicate opiate overdose. (True)

Question 23. Digoxin:

(a) Is the treatment of choice for ventricular extrasystoles. (False)
(b) May cause xanthopsia. (True)
(c) Is excreted by the kidneys. (True)
(d) Adverse effects are reduced by hypokalaemia. (False)
(e) Must not be coadministered with an ACE inhibitor. (False)

Question 24. Dementia may result from:

(a) Parkinson's disease. (True)
(b) Huntington's chorea. (True)
(c) Hypothyroidism. (True)
(d) Acquired immune deficiency syndrome (AIDS). (True)
(e) A cerebral tumour. (True)

Question 25. Oxygen:

(a) Should be administered with a high inspired concentration (>50%) in the treatment of type II respiratory failure.
(b) Should not be used at high concentration in patients with pulmonary embolism because respiration may be severely
impaired when the hypoxic drive is reduced. (False)
(c) Continuous long-term (domiciliary) oxygen improves survival in patients with respiratory failure caused by chronic
bronchitis and emphysema. (True)
(d) Is needed when respiratory failure is diagnosed by finding a pO2 of less than 11 kPa in an arterial blood sample.
(e) Comprises 21% of atmospheric air. (True)

Module 5 (Cardiology)
Question 2. The differential diagnosis for chest pain includes:
(a) Myocardial infarction. (True)
(b) Oesophagitis. (True)
(c) Pulmonary embolus. (True)
(d) Cholecystitis. (True)
(e) Aortic dissection. (True)

Question 3. The following are causes of acute life-threatening dyspnoea:

(a) Myocardial infarction. (True)
(b) Pulmonary embolus. (True)
(c) Pneumothorax. (True)
(d) Ventricular or supraventricular tachyarrhythmia. (True)
(e) Bacterial endocarditis. (True)

Question 4. The following are clinical signs found in infective endocarditis:

(a) Clubbing. (True)
(b) Haematuria. (True)
(c) Pyrexia. (True)
(d) Rashes. (True)

By A. H.
(e) Focal neurological defect. (True)

Question 5. The following are risk factors for ischaemic heart disease:
(a) Hypertension. (True)
(b) Moderate alcohol intake. (False)
(c) Female sex. (False)
(d) Hypercholesterolaemia. (True)
(e) Increasing age. (True)

Question 6. The following are classical features of cardiac syncope:

(a) Gradual onset. (False)
(b) Warning symptoms. (False)
(c) Rapid recovery. (True)
(d) Residual neurological deficit. (False)
(e) Precipitated by sudden turning of the head. (False)

Question 7. The following are causes of a pansystolic murmur:

(a) Mitral regurgitation. (True)
(b) Aortic regurgitation. (False)
(c) Tricuspid regurgitation. (True)
(d) Atrial septal defect. (False)
(e) Aortic stenosis. (False)

Question 8. The following conditions require antibiotic prophylaxis before dental procedures:
(a) Prosthetic aortic valve. (True)
(b) Ventricular septal defect. (True)
(c) Floppy mitral valve with coexistent mitral regurgitation. (True)
(d) Enlarged left ventricle. (False)
(e) A history of infective endocarditis in the past. (True)

Question 9. The following should be considered as possible signs of a positive exercise test:
(a) ST segment depression. (True)
(b) Exercise-induced hypotension. (True)
(c) Exercise-induced ventricular tachycardia. (True)
(d) Lack of adequate tachycardic response to exercise. (True)
(e) Leg pain at peak exercise. (False)

Question 10. The following are indications for anticoagulating a patient who has atrial fibrillation with warfarin:
(a) Age under 60 years. (False)
(b) Associated mitral stenosis. (True)
(c) Atrial fibrillation of more than 24 hours' duration. (True)
(d) A history of cerebral thromboembolism. (True)
(e) Associated left ventricular failure. (True)

Question 11. The following are true of ventricular tachycardia:

(a) It is a life-threatening condition. (True)
(b) It may be caused by myocardial ischaemia. (True)
(c) It may be caused by hypokalaemia. (True)
(d) Amiodarone may be used to prevent recurrent episodes of ventricular tachycardia. (True)
(e) Acute ongoing ventricular tachycardia should be treated initially with drugs. (False)

Question 12. The following are signs of coarctation of the aorta:

(a) Radiofemoral delay in the pulses. (True)
(b) Rib notching. (True)
(c) Bruits heard over the scapula. (True)
(d) Ankle oedema. (False)

By A. H.
(e) Atrial fibrillation. (False)

Question 13. Functions of the recovery position include:

(a) To prevent the tongue from obstructing the airway. (True)
(b) To prevent neck injury. (False)
(c) To minimize the risk of aspiration of gastric contents. (True)
(d) To maintain a straight airway. (True)
(e) To enable cardiopulmonary resuscitation to be carried out. (False)

Question 14. Complications of prosthetic heart valves are as follows:

(a) Thromboembolic events. (True)
(b) Dehiscence of the valve ring. (True)
(c) Increased risk of infective endocarditis. (True)
(d) Failure of the valve 5 years after placement. (False)
(e) Need for anticoagulation in patients who have porcine valves. (False)

Question 15. The following statements are true of thiazide diuretics:

(a) They act at the level of the distal convoluted tubule. (True)
(b) They may cause gout. (True)
(c) Diabetic control may deteriorate. (True)
(d) Hypokalaemia may occur. (True)
(e) They cause ototoxicity. (False)

Question 16. The following are classified as high-output states:

(a) Hypertension . (False)
(b) Sepsis. (True)
(c) Hypothyroidism. (False)
(d) Pregnancy. (True)
(e) Arteriovenous malformations. (True)

Question 18. The following statements are true of the apex beat:
(a) It is the lowest and most lateral point at which the cardiac impulse can be felt. (True)
(b) It is displaced downwards and laterally if the left ventricle is enlarged. (True)
(c) It is thrusting in mitral stenosis. (False)
(d) It is thrusting in aortic regurgitation. (True)
(e) It is heaving in aortic stenosis. (True)

Question 17. Cardiac causes of clubbing are as follows:

(a) Uncomplicated atrial septal defect. (False)
(b) Chronic infective endocarditis. (True)
(c) Atrial fibrillation. (False)
(d) Acute endocarditis. (False)
(e) Empyema. (False)

Question 19. The following leads represent the inferior myocardium:

(a) I, AVL, and V6. (False)
(b) V2, V3, and V4. (False)
(c) AVR and V1. (False)
(d) V1-V6. (False)
(e) II, III, and AVF. (True)

Question 20. The following are possible causes of electromechanical dissociation:

(a) Pulmonary embolus. (True)
(b) Tension pneumothorax. (True)
(c) Hypertension. (False)
(d) Dehydration. (True)

By A. H.
(e) Hypocalcaemia. (True)

Question 21. The following are characteristic of pericarditis:

(a) The chest pain is dull in nature. (False)
(b) There may be an associated pericardial effusion. (True)
(c) The pericardial rub may come and go. (True)
(d) The ECG usually shows regional ST elevation. (False)
(e) The ST elevation is concave. (True)

Question 22. Secondary hypertension may be due to the following:

(a) Renal artery stenosis. (True)
(b) Renal cell carcinoma. (False)
(c) Cushing's syndrome. (True)
(d) Pregnancy. (True)
(e) Oral contraceptive pill. (True)

Question 23. ECG changes due to myocardial infarction may include the following:
(a) ST elevation. (True)
(b) Sinus tachycardia. (True)
(c) Ventricular tachycardia. (True)
(d) Complete heart block. (True)
(e) Q waves. (True)

Question 24. The following drugs are used in the treatment of hypertension:
(a) Atenolol. (True)
(b) Doxazocin. (True)
(c) Enalapril. (True)
(d) Bendrofluazide. (True)
(e) Nicorandil. (False)

Question 25. Complications of myocardial infarction include:

(a) Cardiac failure. (True)
(b) Mitral regurgitation. (True)
(c) Cerebrovascular event. (True)
(d) Myocardial rupture. (True)
(e) Gastrointestinal bleed. (False)

Module 6 (Neurology)

Question 1. Concerning neuroanatomy:

(a) The corticospinal tract decussates in the pons. (False)
(b) The oculomotor nerve runs in close proximity to the posterior communicating artery. (True)
(c) The superior colliculus is found in the midbrain. (True)
(d) The trochlear (fouth cranial) nerve supplies the lateral rectus muscle. (False)
(e) The spinal cord ends at the level of the lower border of L3 in the adult. (False)

Question 2. Subdural haematomas can cause:

(a) Dementia. (True)
(b) Pupillary change. (True)
(c) Bradycardia. (True)
(d) Changing level of consciousness. (True)
(e) Blood-stained cerebrospinal fluid (CSF). (False)

Question 3. In a young woman with a spastic paraparesis, the following suggest a diagnosis of multiple sclerosis:
(a) Delayed visual evoked potentials. (True)
(b) Fasciculations. (False)

By A. H.
(c) Raised CSF protein. (False)
(d) Oligoclonal bands in the CSF. (True)
(e) Periventricular white matter lesions on magnetic resonance imaging (MRI) of the brain. (True)

Question 4. Unilateral facial weakness is a recognized feature of:

(a) Herpes zoster infection. (True)
(b) Motor neuron disease. (False)
(c) Acoustic neuroma. (True)
(d) Cholesteatoma. (True)
(e) Syringomyelia. (False)

Question 5. The following are true about headaches:

(a) The headache of raised intracranial pressure is worst at the end of the day. (False)
(b) A normal CT scan rules out subarachnoid haemorrhage. (False)
(c) Amaurosis fugax may be caused by temporal arteritis. (True)
(d) Neurological signs on examination rules out migraine as a diagnosis. (False)
(e) Cluster headaches are more common in men than in women. (True)

Question 6. The following drugs can produce parkinsonism:

(a) Chlorpromazine. (True)
(b) Benzhexol. (False)
(c) Bromocriptine. (False)
(d) Metoclopramide. (True)
(e) Haloperidol. (True)

Question 7. Concerning movement disorders:

(a) Huntington's chorea presents with progressive dementia and chorea in middle age. (True)
(b) Myoclonus is a feature of subacute sclerosing panencephalitis. (True)
(c) Infarction of the subthalamic nucleus causes ipsilateral hemiballism. (False)
(d) Chorea is commonly found in Cruetzfeldt-Jakob disease. (False)
(e) Alcohol reduces benign essential tremor. (True)

Question 8. Concerning papilloedema:

(a) There is loss of venous pulsation on funduscopy. (True)
(b) There may be enlargement of the blind spot. (True)
(c) Intracranial pressure may be normal. (True)
(d) Hypocalcaemia is a recognized cause. (True)
(e) It is a recognized feature in Guillain-Barré syndrome. (True)

Question 9. Ptosis may be a feature of:

(a) Myotonic dystrophy. (True)
(b) Horner's syndrome. (True)
(c) Abducens nerve (sixth nerve ) palsy. (False)
(d) Oculomotor nerve (third nerve) palsy. (True)
(e) Myasthenia gravis. (True)

Question 10. Concerning the Brown-Séquard syndrome:

(a) There is ipsilateral corticospinal loss below the lesion. (True)
(b) There is ipsilateral loss of joint-position sense below the lesion. (True)
(c) There is ipsilateral loss of two-point discrimination below the level of the lesion. (True)
(d) There is ipsilateral loss of pain and temperature below the level of the lesion. (False)
(e) A central disc lesion at L3 would cause a Brown-Séquard syndrome in the legs. (False)

Question 11. Concerning the brachial plexus:

(a) In brachial neuritis, severe pain around the shoulder precedes rapid wasting. (True)
(b) Klumpke's paralysis causes proximal arm weakness. (False)
(c) Erb's palsy is caused by a lesion to C5/C6-derived regions of the brachial plexus. (True)

By A. H.
(d) A brachial plexus lesion and an ipsilateral Horner's syndrome may indicate a Pancoast tumour. (True)
(e) Vaccination may precipitate brachial neuritis. (True)

Question 12. Causes of a polyneuropathy include:

(a) Diabetes. (True)
(b) Guillain-Barré syndrome. (True)
(c) Renal failure. (True)
(d) Amyloid. (True)
(e) Multiple sclerosis. (False)

Question 13. A lesion to the common peroneal nerve at the fibular head causes:
(a) Weakness of eversion of the foot. (True)
(b) Decreased sensation over the dorsum of the foot. (True)
(c) Weakness of plantar flexion. (False)
(d) If long term, wasting of tibialis anterior. (True)
(e) Brisk ankle jerk. (False)

Question 14. Brainstem death may be confirmed by:

(a) Extensor response of the limbs to painful stimuli. (False)
(b) Absent corneal reflexes. (True)
(c) Absent tendon reflexes. (False)
(d) A flat EEG. (False)
(e) Absent 'doll's eye' reflexes. (True)

Question 15. A homonymous hemianopia may arise from a lesion of:

(a) The optic tract. (True)
(b) The occipital cortex. (True)
(c) The optic chiasm. (False)
(d) The optic nerve. (False)
(e) The optic radiation. (True)

Question 16. Dysarthria may result from a lesion of:

(a) The cerebellum. (True)
(b) Broca's area. (False)
(c) The hypoglossal nerve. (True)
(d) The basal ganglia. (True)
(e) The accessory nerve. (False)

Question 17. The following are clinical features of cerebellar dysfunction

(a) Postural tremor. (False)
(b) Hypotonia. (True)
(c) Dysphasia. (False)
(d) Titubation. (True)
(e) Impaired rapid altering movements. (True)

Question 18. The following clinical features may help differentiate between a syncopal attack and a seizure:
(a) Upright posture at the onset. (True)
(b) Convulsive movements of the limbs. (False)
(c) A bitten tongue. (True)
(d) Urinary incontinence. (True)
(e) Prolonged malaise after the attack. (False)

Question 19. The following are features of a subarachnoid haemorrhage:

(a) Fever. (True)
(b) Thunderclap headache. (True)
(c) Photophobia. (True)
(d) Positive Kernig's sign. (True)

By A. H.
(e) Neck stiffness. (True)

Question 20. A physiological tremor is:

(a) Present at rest. (False)
(b) Worsened by anxiety. (True)
(c) Improved by alcohol. (False)
(d) Improved by beta-blockers. (True)
(e) Familial. (False)

Question 21. A lesion of the medulla on one side may give rise to :
(a) An ipsilateral hemiparesis. (False)
(b) A contralateral hemiparesis. (True)
(c) Ipsilateral weakness of the palate. (False)
(d) Contralateral weakness of the tongue. (True)
(e) Contralateral third nerve palsy. (False)

Question 22. The following may be seen in a patient with a lesion of the third nerve or nucleus:
(a) A fixed dilated pupil. (True)
(b) Ptosis. (True)
(c) Diplopia in all positions of gaze. (True)
(d) A history of diabetes mellitus. (True)
(e) A contralateral hemiplegia. (True)

Question 23. In a patient with a sensory ataxia:

(a) Vibration may be impaired. (True)
(b) The gait is characterized by 'scissoring' posture of the legs. (False)
(c) Romberg's test may be positive. (True)
(d) A history of alcohol abuse may be implicated in the aetiology. (True)
(e) Clonus may be elicited on examination of the legs. (False)

Question 24. A patient with herpes zoster infection of the geniculate ganglion may present with:
(a) An upper motor neuron facial weakness. (False)
(b) Diplopia. (False)
(c) Hyperacusis. (True)
(d) Altered perception of taste. (True)
(e) Pain from the auditory meatus. (True)

Question 25. A dissociated sensory loss may be seen in:

(a) Syringomyelia. (True)
(b) Anterior spinal artery occlusion. (False)
(c) A radiculopathy. (False)
(d) Occlusion of a middle cerebral artery. (False)
(e) Compression of the spinal cord by a prolapsed intervertebral disc. (False)

Module 7 (Gastroeneterology)
Question 1. The following statements are true:
(a) Tylosis is associated with achalasia. (False)
(b) On barium swallow, a 'bird's beak' appearance is suggestive of squamous carcinoma. (False)
(c) Pneumatic dilatation is the treatment of choice for achalasia. (True)
(d) Reduced lower oesophageal sphincter pressure is a common feature of gastro-oesophageal reflux disease . (True)
(e) Oesophageal pH is usually less than 4. (False)

Question 2. The following is true of Barrett's oesophagus:

(a) Columnar epithelium is replaced by squamous epithelium. (False)
(b) It appears in an antegrade (top to bottom) direction. (False)
(c) It is a premalignant condition. (True)
(d) Severe dysplasia is an ominous sign. (True)

By A. H.
(e) It is an indication for surveillance endoscopy. (True)

Question 3. Helicobacter pylori:

(a) Causes ulceration in the duodenum. (True)
(b) Causes Barrett's metaplasia in the oesophagus. (False)
(c) Is associated with hypergastrinaemia. (True)
(d) Is often resistant to certain antibiotics. (True)
(e) Can convert urea to ammonia and carbon dioxide. (True)

Question 4. Gastric hypomotility (gastroparesis):

(a) Is commonly associated with diabetes mellitus. (True)
(b) Is a risk factor for gastro-oesophageal reflux disease. (True)
(c) Is a feature of generalized scleroderma (systemic sclerosis). (True)
(d) Occasionally responds to erythromycin. (True)
(e) Is often secondary to duodenal ulcer disease. (False)

Question 5. The following are features of coeliac disease:

(a) Hypocalcaemia. (True)
(b) Hypercalcaemia. (False)
(c) Normocytic anaemia. (False)
(d) Hypoalbuminaemia. (True)
(e) Positive antiparietal cell antibodies. (False)

Question 6. The following is true of Crohn's disease:

(a) The rectum is always affected. (False)
(b) Commonly affects the terminal ileum. (True)
(c) More commonly occurs in smokers. (True)
(d) Can result in vitamin B12 deficiency with a negative Schilling test. (True)
(e) Commonly presents with bloody diarrhoea. (False)

Question 7. The following is true of giardiasis:

(a) Diarrhoea abates with avoidance of dairy produce. (False)
(b) Diarrhoea abates with avoidance of gluten. (False)
(c) Diarrhoea requires treatment with metronidazole. (True)
(d) Diarrhoea is usually accompanied by vomiting. (False)
(e) Diarrhoea commonly results in vitamin B12 deficiency. (False)

Question 8. The following is true of inflammatory bowel disease:

(a) Increased liver enzymes in the serum usually indicate the complication of carcinoma. (False)
(b) Small bowel barium enema is the best radiological investigation for ulcerative colitis. (False)
(c) It is occasionally complicated by carcinoma of the caecum. (True)
(d) It is commonly associated with thyroiditis. (False)
(e) It is sometimes complicated by iritis. (True)

Question 9. The following is true of viral hepatitis:

(a) Hepatitis C commonly presents with jaundice. (False)
(b) Hepatitis E is fatal particularly in pregnant women. (True)
(c) Hepatitis BeAg is a marker of viral replication. (True)
(d) Hepatitis A is a risk factor for hepatoma. (False)
(e) Hepatitis D occurs only in association with hepatitis C. (False)

Question 10. The following drugs cause jaundice:

(a) Methotrexate. (False)
(b) Flucloxacillin. (True)
(c) Metronidazole. (False)
(d) Isoniazid. (True)

By A. H.
(e) Phenobarbitone. (False)

Question 11. Haemochromatosis:

(a) Is a genetic defect resulting in copper overload in the liver. (False)
(b) Is a risk factor for the development of hepatoma. (True)
(c) Has an equal sex incidence but presents earlier in males than females. (True)
(d) Is treated by avoiding meat products. (False)
(e) Can cause hypogonadism in the absence of cirrhosis. (True)

Question 12. Colonic carcinoma:

(a) Most commonly occurs in the right side of the colon. (False)
(b) May present with iron deficiency anaemia in the absence of any gastrointestinal symptoms. (True)
(c) Commonly arises in colonic polyps. (True)
(d) Carries a 5-year survival of less than 10%. (False)
(e) Is the cause of carcinoid syndrome. (False)

Question 13. The following is true of colon polyps and colon cancer:
(a) The larger the polyp, the greater the risk of carcinoma. (True)
(b) Malignant polyps can be successfully treated by colonoscopy and polypectomy alone. (True)
(c) Hyperplastic polyps have a higher malignant potential than villous polyps. (False)
(d) Polyps are most common in the ascending colon. (False)
(e) Colonic polyps are often recurrent. (True)

Question 14. The following gastrointestinal diseases are associated with the renal conditions listed:
(a) Crohn's disease and renal amyloidosis. (True)
(b) Hepatitis B and glomerulonephritis. (True)
(c) Gastric ulcer and nephrotic syndrome. (False)
(d) Pancreatic neuroendocrine tumours and polycystic kidney disease. (False)
(e) Liver cysts and glomerulosclerosis. (False)

Question 15. The following is true of villous atrophy in the small intestine:
(a) If due to coeliac disease, it should recover completely on a gluten-free diet. (True)
(b) It can be caused by tuberculosis. (True)
(c) It can be associated with Giardi lamblia. (True)
(d) It can be associated with Tropheryma whippelei. (True)
(e) When associated with bacteria, it may cause a rise in serum folate. (True

Question 16. The following skin conditions are associated with the named GI diseases:
(a) Dermatitis herpetiformis with coeliac disease. (True)
(b) Pruritus with primary biliary cirrhosis. (True)
(c) Pyoderma gangrenosum with gastric carcinoma. (False)
(d) Bullous pemphigoid with pancreatitis. (False)
(e) Erythema nodosum with Crohn's disease. (True)

Question 17. The following statements are true in relation to vomiting:

(a) Vomiting occurring 12 hours after a suspicious meal is indicative of Salmonella poisoning. (False)
(b) Vomiting in association with headache is a feature of migraine. (True)
(c) Vomiting associated with weight loss can be indicative of malignant disease. (True)
(d) Vomiting usually precedes the pain of biliary colic. (False)
(e) Vomiting can be a feature of myocardial infarction. (True)

Question 18. Scleroderma can produce the gastrointestinal complications listed:

(a) Diarrhoea due to bacterial overgrowth. (True)
(b) Constipation due to gut hypomotility. (False)
(c) Diarrhoea which is unresponsive to a gluten-free diet. (True)
(d) Gastric ulcer due to chronic gastritis. (False)

By A. H.
(e) Dysphagia due to abnormal peristalsis in the oesophagus. (True)

Question 19. Chronic pancreatitis:

(a) Is a cause of diabetes mellitus. (True)
(b) Can result from alcohol ingestion in moderate amounts. (True)
(c) May be hereditary in a minority of cases. (True)
(d) Can be diagnosed by a raised serum amylase. (False)
(e) Is a cause of pancreas divisum. (False)

Question 20. The following is true of rectal bleeding:

(a) In the absence of haemorrhoids, it is usually due to malignant disease. (False)
(b) It occurs more commonly in Crohn's disease than in ulcerative colitis. (False)
(c) If it occurs in a patient with ulcerative colitis, it usually indicates that carcinoma has developed. (False)
(d) When it is due to diverticular disease, colectomy may be indicated to control it. (True)
(e) It may be caused by ingestion of aspirin. (True)

Question 21. The following are risk factors for gastric carcinoma:
(a) Pernicious anaemia. (True)
(b) Coeliac disease. (False)
(c) Partial gastrectomy. (True)
(d) Helicobacter pylori infection. (True)
(e) Ménétrière's disease. (True)

Question 22. The following statements are true:

(a) Solitary rectal ulcers are commonly associated with Crohn's disease. (False)
(b) Crypt abscesses are typical of coeliac disease. (False)
(c) Fistula formation can be a feature of Whipple's disease. (False)
(d) Anal fissure predisposes to faecal incontinence. (False)
(e) Right iliac fossa pain is common with diverticular disease. (False)

Question 23. The following are true of hepatitis:

(a) Hepatitis B is spread via the faecal-oral route. (False)
(b) A vaccine is available for hepatitis C. (False)
(c) Incubation time for hepatitis A is approximately 2-3 weeks. (True)
(d) Hepatitis B is an RNA virus. (False)
(e) Interferon treatment is required for hepatitis E infection. (False)

Question 24. The following is a risk factor for the Budd-Chiari syndrome:
(a) Oral contraceptive pill. (True)
(b) Malignancy. (True)
(c) Ascites. (False)
(d) Polycythaemia rubra vera. (True)
(e) Constrictive pericarditis. (False)

Question 25. The following are true regarding prognostic factors for acute pancreatitis:
(a) A low pAO2 indicates a poor prognosis. (True)
(b) A high serum GGT has a poor prognosis. (False)
(c) Age of over 55 years usually has a good prognosis. (False)
(d) A low serum albumin indicates a poor prognosis. (True)
(e) Abnormal clotting time has a poor prognosis. (True)

Module 9 (Gastroenterology)
Question 1. The following is true of oesophageal pain:
(a) It can occur in the absence of heartburn. (True)
(b) It can mimic the pain of a myocardial infarction. (True)
(c) It can be relieved by glyceryl trinitrate. (True)

By A. H.
(d) It is usually precipitated by exercise. (False)
(e) It can be caused by candidiasis. (True)

Question 2. The following is true of postgastrectomy syndromes:

(a) The anaemia can be corrected with ascorbic acid supplements. (True)
(b) The risk of gastric cancer in the long term is increased. (True)
(c) Sweating and palpitations can be due to hypoglycaemia. (True)
(d) Biliary gastritis in the gastric remnant is common. (True)
(e) Diarrhoea is commonly due to bacterial overgrowth. (True)

Question 3. The following is true of neoplastic disease in the stomach:

(a) Maltoma can occasionally respond to antibiotic treatment in combination with a proton pump inhibitor. (True)
(b) Ménétrière's disease is due to metaplasia of the gastric mucosa. (True)
(c) Leiomyoma has a characteristic appearance at endoscopy. (True)
(d) Gastric carcinoma produces abdominal pain that is often worse after eating. (True)
(e) The most common gastric carcinoma is of squamous cell origin. (False)

Question 4. The following statements are true:

(a) Iron absorption is reduced in hypochlorhydric states. (True)
(b) Vitamin D absorption is often deficient in the presence of gastritis. (False)
(c) Vitamin B12 supplements are often necessary following gastrectomy. (True)
(d) Anaemia associated with chronic atrophic gastritis may respond to ascorbic acid supplements. (True)
(e) Intestinal metaplasia in the stomach is a risk factor for gastric carcinoma. (True)

Question 5. The following clinical features are associated with coeliac disease:
(a) Anaemia. (True)
(b) Weight loss. (True)
(c) Vomiting. (False)
(d) Diarrhoea. (True)
(e) Jaundice. (False)

Question 6. The following is true of Crohn's disease:

(a) C-reactive protein mimics inflammatory activity. (True)
(b) Normal albumin indicates remission. (False)
(c) Large bowel barium enema is the most definitive radiological test. (False)
(d) A small bowel biopsy can be helpful in making the diagnosis. (True)
(e) A low blood urea is common. (True)

Question 7. The following is true of ulcerative colitis:

(a) It commonly presents with pain in the right iliac fossa. (False)
(b) It can be associated with ankylosing spondylitis. (True)
(c) It is a risk factor for toxic dilatation of the colon. (True)
(d) The occurrence of abdominal tenderness is an ominous sign. (True)
(e) It often causes ischiorectal abscesses. (False)

Question 8. Acholuric jaundice without pain:

(a) Is a common presentation of pancreatic carcinoma. (False)
(b) Is a feature of Gilbert's disease. (True)
(c) Can occur in hereditary spherocytosis. (True)
(d) Is associated with pale-coloured stools. (False)
(e) Is associated with pruritus. (False)

Question 9. The following is true of risk factors for the development of hepatocellular carcinoma:
(a) Females are at greater risk than males. (False)
(b) Excess iron is a recognized risk factor. (True)
(c) Aflatoxin is a risk factor. (True)
(d) Hepatitis A is a risk factor. (False)

By A. H.
(e) Risk factors generally only operate in the presence of cirrhosis. (True)

Question 10. Alcoholic hepatitis:

(a) Recovers rapidly on cessation of drinking. (False)
(b) Is a risk factor for hepatorenal syndrome. (True)
(c) Ascites is a feature. (True)
(d) Coagulopathy is corrected with administration of vitamin K. (False)
(e) Encephalopathy occurs only if infection is present. (False)

Question 11. Primary sclerosing cholangitis:

(a) Occurs predominantly in middle-aged females. (False)
(b) Is a major risk factor for cholangiocarcinoma. (True)
(c) Occurs in 50% patients with ulcerative colitis. (False)
(d) Has been treated with ursodeoxycholic acid. (True)
(e) May require insertion of an endoprosthesis for its treatment. (True)

Question 12. The following GI conditions are associated with microcytic hypochromic anaemia:
(a) Acute duodenal ulceration. (False)
(b) Ankylostoma duodenale. (True)
(c) Terminal ileitis due to Crohn's disease. (True)
(d) Partial gastrectomy. (True)
(e) Carcinoma of caecum. (True)

Question 13. These gastronomic terms are associated with the following gastroenterological conditions:
(a) 'Rice water' diarrhoea with cholera. (True)
(b) 'Anchovy sauce' discharge with amoebic dysentry. (False)
(c) 'Redcurrent jelly' and intussusception. (True)
(d) 'Apple core' lesion and diverticulitis. (False)
(e) 'Coffee grounds' and oesophageal varices. (False)

Question 14. The following is true of breath tests used for investigation of the gastrointestinal tract:
(a) The 14C urea breath test detects Helicobacter pylori infection. (True)
(b) The 14C glycocholic acid breath test is used to detect bacterial overgrowth in the colon. (False)
(c) A hydrogen breath test following ingestion of lactulose is used to detect bacterial overgrowth in the small intestine.
(d) A lactose breath test is used to detect disaccharidase deficiency. (True)
(e) A 14C bile salt test can be used to identify bile duct obstruction. (False)

Question 15. The following autoantibodies are associated with the diseases listed:
(a) Antiendomyseal antibodies are associated with coeliac disease. (True)
(b) Anti-LKM antibodies are associated with Goodpasture syndrome. (False)
(c) Antimitochondrial antibodies are associated with primary biliary cirrhosis. (True)
(d) Antiparietal cell antibodies are associated with Wilson's disease. (False)
(e) Antismooth muscle antibodies are associated with autoimmune chronic active hepatitis. (True)

Question 16. The following statements are true of colitis:

(a) Granulomas are present in collagenous colitis. (False)
(b) Rectal sparing is characteristic of Crohn's colitis. (True)
(c) Caseating granulomas in the terminal ileum are diagnostic of Crohn's disease. (False)
(d) Colitis in a smoker is more likely to be Crohn's than ulcerative colitis. (True)
(e) Pain is a characteristic feature of CMV colitis. (True)

Question 17. The following statements are true of ascites:

(a) A high protein content in ascites is usual in alcoholic liver disease. (False)
(b) Ascites resistant to diuretics is characteristic of hepatic vein thrombosis. (True)
(c) Ascites is sometimes associated with a pleural effusion. (True)

By A. H.
(d) Ascites is a risk factor for bacterial peritonitis. (True)
(e) Ascites due to constrictive pericarditis prevents pulsus paradoxus. (False)

Question 18. The following statements are true of non-steroidal anti-inflammatory drugs:
(a) They can be given as suppositories to avoid gastrointestinal complications. (False)
(b) They may have a role in the prevention of colon cancer. (True)
(c) They can produce gastric erosions in elderly people causing occult blood loss. (True)
(d) They cause gastric erosions by stimulating gastric acid secretion. (False)
(e) They may exacerbate long-standing ulcerative colitis. (True)

Question 19. The following is true of pancreatic tumours:

(a) Jaundice occurs only when carcinoma is present in the tail of pancreas. (False)
(b) Presence of diabetes mellitus indicates that the tumour is of neuroendocrine origin. (False)
(c) They are generally unresponsive to chemotherapy. (True)
(d) They characteristically produce back pain when local invasion is present. (True)
(e) They occur with increased frequency in patients with ulcerative colitis. (False)

Question 20. The following is true of haematemesis:

(a) When it occurs in a patient with alcoholic liver disease, it is always due to oesophageal varices. (False)
(b) A visible vessel seen at gastroscopy is a risk factor for further bleeding. (True)
(c) When it occurs in patients over 70 years of age who may have arthritis, usually indicates malignancy. (False)
(d) When it occurs after repeated retching, it is suggestive of an oesophageal tear. (True)
(e) When it is caused by duodenal ulcer, a partial gastrectomy is usually necessary. (False)

Question 21. The following drugs can be used for treatment of GORD:
(a) Metronidazole. (False)
(b) Amoxycillin. (False)
(c) Erythromycin. (False)
(d) Metoclopramide. (True)
(e) Omeprazole. (True)

Question 22. Which of the following is dependent on bile salts for its absorption:
(a) Vitamin A. (True)
(b) Vitamin B. (False)
(c) Vitamin C. (False)
(d) Vitamin D. (True)
(e) Vitamin K. (True)

Question 23. The following are indications for liver biopsy:

(a) Unexplained abnormal liver enzymes. (True)
(b) Pyrexia of unknown origin with normal liver enzymes. (True)
(c) Cirrhosis suspected on an ultrasound scan. (True)
(d) Raised alkaline phosphatase in teenagers with acholuric jaundice. (False)
(e) Abnormal liver enzymes in a patient with epilepsy on phenytoin. (False)

Question 24. The following precipitate portasystemic encephalopathy:

(a) Infection. (True)
(b) Diarrhoea. (False)
(c) Gastrointestinal bleeding. (True)
(d) Use of opioid drugs. (True)
(e) Certain antibiotics. (False)

Question 25. The following drugs cause cholestatic jaundice:

(a) Rifampicin. (False)
(b) Isoniazid. (False)
(c) Erythromycin. (True)
(d) Halothane. (False)

By A. H.
(e) Paracetamol. (False)

Module 10 (Neurology)
Question 1. The following cranial nerves carry parasympathetic fibres:
(a) Oculomotor. (True)
(b) Trigeminal. (False)
(c) Facial. (True)
(d) Hypoglossal. (False)
(e) Vagus. (True)

Question 2. Myasthenia gravis:

(a) Is caused by antibodies to the acetylcholine receptor in the majority of cases. (True)
(b) Causes muscle wasting. (False)
(c) May show diurnal variation in symptoms. (True)
(d) Is associated with an improvement in strength after exertion. (False)
(e) May present with ophthalmoplegia. (True)

Question 3. The causes of a mixed upper and lower motor neuron picture include:
(a) Guillain-Barré syndrome. (False)
(b) Multiple sclerosis. (False)
(c) Syringomyelia. (True)
(d) Motor neuron disease. (True)
(e) Taboparesis. (True)

Question 4. Bilateral lower motor neuron facial weakness may occur in:
(a) Sarcoidosis. (True)
(b) Guillain-Barré syndrome. (True)
(c) Lyme disease. (True)
(d) Lymphoma. (True)
(e) Parasagittal meningioma. (False)

Question 5. In idiopathic Parkinson's disease:

(a) There is degeneration primarily of the cells of the globus pallidus. (False)
(b) The classical features include tremor, bradykinesia, and spasticity. (False)
(c) There is an associated vertical gaze palsy. (False)
(d) Anticholinergic drugs are most effective in relieving tremor. (True)
(e) Treatment is aimed at reducing dopamine levels. (False)

Question 6. The following features suggest that increased tone is due to rigidity:
(a) Tone is increased equally in flexors and extensors. (True)
(b) Extensor plantar responses. (False)
(c) Associated pill-rolling tremor. (True)
(d) Clasp-knife reflex. (False)
(e) Tone increases with synkinesis. (True)

Question 7. Causes of a small pupil include:

(a) Horner's syndrome. (True)
(b) Holmes-Adie syndrome. (False)
(c) Tabes dorsalis. (True)
(d) Optic neuritis. (False)
(e) Pilocarpine eye-drops. (True)

Question 8. Concerning optic neuritis:

(a) Visual loss is usually painless. (False)
(b) White-matter abnormalities on MR imaging increase the likelihood of developing multiple sclerosis in the future.

By A. H.
(c) After recovery, some impairment of red-green colour vision may remain. (True)
(d) Over 90% of patients with a history of optic neuritis go on to develop multiple sclerosis. (False)
(e) It causes a delay in visual evoked potentials. (True)

Question 9. The following may cause a third nerve palsy:

(a) Aneurysm of the posterior communicating artery. (True)
(b) Diabetes. (True)
(c) Motor neuron disease. (False)
(d) Herniation of the uncus of the temporal lobe. (True)
(e) Pancoast tumour. (False)

Question 10. The following typically occur within the first 24 hours of complete cervical cord transection:
(a) Upgoing plantar responses. (False)
(b) Fall in blood pressure. (True)
(c) Loss of bladder control. (True)
(d) Brisk reflexes. (False)
(e) Gastric dilatation. (True)

Question 11. In motor neuron disease:

(a) Fasciculations are required to make the diagnosis. (False)
(b) There may be atrophy of the Betz cells in the motor cortex. (True)
(c) Electromyography shows chronic partial denervation. (True)
(d) There should be no signs of sensory loss. (True)
(e) Familial cases account for 50%. (False)

Question 12. Causes of a mononeuropathy include:

(a) Diabetes. (True)
(b) Hereditary motor sensory neuropathy. (False)
(c) Polyarteritis nodosa. (True)
(d) Guillain-Barré syndrome. (False)
(e) Lead poisoning. (True)

Question 13. Charcot joints:

(a) May affect the feet in diabetes. (True)
(b) Are often painful. (False)
(c) May be caused by neurosyphilis. (True)
(d) May affect the shoulders in syringomyelia. (True)
(e) Are usually hot and swollen. (False)

Question 14. Hyposmia may arise secondary to:

(a) A head injury. (True)
(b) Migraine. (False)
(c) Seizures. (False)
(d) Antibiotic therapy. (True)
(e) A frontal meningioma. (True)

Question 15. The following are causes of acute transient visual impairment:
(a) Retinitis pigmentosa. (False)
(b) Amaurosis fugax. (True)
(c) Papilloedema. (True)
(d) Migrainous aura. (True)
(e) Glaucoma. (False)

Question 16. The following may be features of frontal lobe dysfunction:

(a) Depression. (True)
(b) Social disinhibition. (True)
(c) Apraxia of gait. (True)

By A. H.
(d) A receptive dysphasia. (False)
(e) A grasp reflex. (True)

Question 17. The following may give rise to a pseudobulbar palsy

(a) Poliomyelitis. (False)
(b) Syringobulbia. (False)
(c) Huntington's chorea. (False)
(d) Occlusion of the anterior cerebral artery. (False)
(e) Multiple sclerosis. (True)

Question 18. Facial sensory loss may occur with a lesion of:
(a) The cerebellopontine angle. (True)
(b) The facial nerve. (False)
(c) The Gausserian ganglion. (True)
(d) The Geniculate ganglion. (False)
(e) The cavernous sinus. (True)

Question 19. Sensorineural deafness may occur secondary to:

(a) Loud noise. (True)
(b) Gentamicin therapy. (True)
(c) Ménière's disease. (True)
(d) An acoustic neuroma. (True)
(e) Otosclerosis. (False)

Question 20. Choreic movements are:

(a) Slow and writhing. (False)
(b) Shock-like assymetrical and irregular. (False)
(c) Brief, jerky and irregular. (True)
(d) A sign of restlessness. (False)
(e) Rhythmical and oscillatory. (False)

Question 21. Features of an upper motor neuron lesion are:

(a) Brisk abdominal and cremasteric reflexes. (False)
(b) Wasted muscles. (False)
(c) Weakness of individual muscles. (False)
(d) Hypotonia. (False)
(e) Fatiguable muscle strength. (False)

Question 22. A small pupil may be seen in:

(a) A lesion in the midbrain. (False)
(b) Elderly patients. (True)
(c) Horner's syndrome. (True)
(d) Terminally ill patients taking morphine for analgesia. (True)
(e) A pontine lesion. (True)

Question 23. Nystagmus may be seen in:

(a) A patient with an internuclear ophthalmoplegia. (True)
(b) A lesion of the pons. (True)
(c) A patient who is blind. (True)
(d) A patient with cerebellar dysfunction. (True)
(e) A lesion of the foramen magnum. (True)

Question 24. Clinical features of a unilateral lesion of the cerebellopontine angle may be:
(a) Conductive deafness on the same side. (False)
(b) An ipsilateral hemiparesis. (False)
(c) Ipsilateral weakness of the lower face. (False)
(d) A pseudobulbar dysarthria. (False)

By A. H.
(e) Vertigo as a prominent early symptom. (False)

Question 25. The fibres of the dorsal column pathway:

(a) Carry information about temperature perception. (False)
(b) Decussate in the midbrain. (False)
(c) Are affected in the deficiency of vitamin B12. (True)
(d) When damaged may result in a positive Romberg's test. (True)
(e) Are spared following occlusion of the anterior spinal artery. (True)

Available from Master Medicine

Module 1 (trial1)

Question 1. The ECG:

· The T wave corresponds to atrial contraction (False)
· If the S wave is greater than the R wave in lead I, there is right axis deviation (True)
· If the S wave is greater than the R wave in lead II, there is left axis deviation (True)
· ST segment depression may be a sign of cardiac ischaemia (True)

Explanation: It may also be a digoxin effect.

· A tall R wave in V1 may be a sign of right ventricular hypertrophy (True)

Explanation: It may also be a digoxin effect.

Question 2. Endocarditis:
· It is important to take blood cultures over at least 24 hour period to make the diagnosis (False)
· Transthoracic echocardiography is a sensitive means of making or confirming the diagnosis (False)
· Most patients with Staphylococcus aureus bacteraemia have endocarditis (False)
· Viral endocarditis leads to valvular abnormality (False)
· In patients with a new stroke, endocarditis can be ruled out if the patient is afebrile (False)

Question 3. Treatment of endocarditis:

· Intravenous antibiotics for 6 weeks are necessary to cure viridans type streptococcal endocarditis (False)
· Staphylococcal endocarditis on the tricuspid valve in a drug addict is treated with flucloxacillin and valve
replacement (False)
· Large vegetations are an indication for surgery (True)

Explanation: Flucloxacillin (with gentamicin or rifampicin) is the medical treatment of choice but valve replacement is
not appropriate. Insertion of a prosthetic heart valve into a drug addict is very likely to lead to prosthetic valve
endocarditis subsequently because of their continuing habit.
· Combination antibiotic therapy is almost always appropriate for endocarditis (True)

Explanation: For two reasons; first, the selected combinations are usually additive or synergistic. Second, to prevent the
development of resistance.
· If gentamicin is used for treatment, it should not be used for more than 2 weeks (False)

Question 4. Hypertension:
· Treatment is of no proven benefit in patients over the age of 70 years (False)
· The symptoms of phaeochromocytoma include headache, sweating and palpitations (True)

Explanation: There is well-proven benefit, particularly in the prevention of stroke.

· Oral treatment producing a fall in diastolic blood pressure of 20 mmHg over 24 hours might be regarded as
successful treatment of accelerated hypertension (True)

Explanation: There is well-proven benefit, particularly in the prevention of stroke.

· ACE inhibitors are the drugs of choice for hypertension in pregnancy (False)

By A. H.
· Addison's disease should be considered a possible cause in a hypertensive patient with hirsutism (False)

Question 5. Cardiac dysrhythmias:

· Digoxin toxicity may cause supraventricular tachycardia (True)
Explanation: Typically, paroxysmal atrial tachycardia.
· A patient with a completely irregular pulse of 180 beats/min is likely to be in atrial fibrillation (True)
Explanation: Typically, paroxysmal atrial tachycardia.
· Complete heart block may be asymptomatic (True)
Explanation: Particularly congenital complete heart block.
· Digoxin is effective in preventing paroxysms of atrial fibrillation (False)
· A QRS width less than 3 small squares on the ECG indicates that a tachycardia is supraventricular (True)
Explanation: Digoxin slows the ventricular rate during paroxysms of atrial fibrillation but does not prevent them; sotalol
or amiodarone may prevent them.

Question 6. Chronic bronchial sepsis:

· Is an uncommon feature of cystic fibrosis (False)
· Typically is caused by unusual, difficult-to-grow bacteria (False)
· May lead to haemoptysis (True)

Explanation: Haemoptysis is also seen with dry bronchiectasis, chronic bronchial sepsis and with aspergillomas.
· Can usually be cured with oral antibiotics (False)
· May lead to pulmonary fibrosis (True)

Explanation: It produces a fibrotic reaction.

Question 7. In the small intestine:

· If there is bile salt deficiency, micellar formation is reduced (True)
Explanation: Bile salts are essential for micelle formation.
· Long-chain triglycerides are transported from the gut in the lymph as chylomicrons (False)
· There is no lymphatic tissue (False)
· The entire mucosa is turned over every 2-3 weeks (False)
· Is the site of most nutrient absorption (True)

Question 8. Colorectal cancer:

· May arise from a metaplastic polyp (False)
· Most often occurs in the rectum and sigmoid (True)
Explanation: Metaplastic polyps have no malignant potential.
· There are further polyps in most cases (False)
· Involvement of local lymph nodes does not affect prognosis (False)
· Obstruction is more common in right compared with left-sided lesions (False)

Question 9. Angiodysplasia of the colon:

· Is more common in the caecum and ascending colon (True)
Explanation: It usually occurs in the right side of the colon.
· Is associated with a macrocytic anaemia (False)
· Is best shown by barium enema (False)
· Usually requires surgery (False)
· Is a congenital lesion (False)

Question 10. Concerning HIV infection and AIDS:

· Pneumocystis pneumonia is common in Africa (False)
· Tuberculosis in AIDS presents like that in non-AIDS patients (False)
· Oral candidiasis is a late feature of AIDS (False)
· Toxoplasmosis is usually a cerebral disease (True)

By A. H.
Explanation: Brain and heart. The CT/MR scan usually shows multiple ring-enhancing lesions, which are almost
diagnostic of toxoplasmosis in AIDS. CNS lymphomas are usually single. Cardiac toxoplasmosis is usually diagnosed
at postmortem.
· Cytomegalovirus retinitis can be treated with aciclovir (False)

Module 1 (trial2)
Question 1. In secondary diabetes:
· A patient can be assumed not to be ketosis-prone (False)
· A patient is more than 85% likely to have clinical pancreatic exocrine deficiency (False)
· Classical diabetic complications do not occur (False)
· Thiazide diuretics and beta-blockers can both impair insulin secretion (True)
Explanation: Secondary diabetes causes all the same complications as idiopathic diabetes.
· Most patients with acromegaly are diabetic (False)

Question 2. In hypoglycaemia:
· Insulin-dependent patients may recover from hypoglycaemic coma without treatment (True)
Explanation: The anti-insulin hormones can bring the patient round and the insulin which caused the coma can 'wear
· Sweating and shaking are always late symptoms of insulin-induced hypoglycaemia (False)
· Insulin-dependent patients may lose their warning symptoms of hypoglycaemia after many years of diabetes
Explanation: About 50% of patients who have had type 1 DM for 20 years or more develop 'hypoglycaemia
· Metformin is responsible for as many cases of hypoglycaemia as sulfonylureas (False)
· The symptoms characteristically come on over hours rather than minutes (False)

Question 3. In insulin treatment:

· Pen injectors are reserved for the small minority who take four or more injections per day (False)
· Only patients who cannot be controlled with once-daily insulin should have two or more injections (False)
· Insulin should be started without delay in a thin hyperglycaemic patient with ketonuria (True)
Explanation: These are signs of type 1 DM.
· Insulin may sometimes be needed during short periods of illness in patients with type 2 DM (True)
Explanation: These are signs of type 1 DM.
· All patients on insulin should be discouraged from changing their doses without first checking with the doctor
or nurse (False)

Question 4. Diabetic pregnancy:

· Insulin-dependent women should be advised not to contemplate pregnancy (False)
· Diabetes increases the risk of neural tube defects (True)
Explanation: Neural tube defects are two to three times more common.
· Poor glycaemic control at conception increases the risk of congenital malformations (True)
Explanation: Hyperglycaemia is teratogenic in early pregnancy; major congenital malformations are two to three times
more common.
· There is a less than 10% chance that an episode of ketoacidosis will cause intrauterine death (False)
· Sulfonylureas are the treatment of choice for gestational diabetes (False)

Question 5. Thyroid function tests:

· Serum thyroid-stimulating hormone (TSH) is a sensitive test of hyperthyroidism (True)
Explanation: Suppression of TSH is the first biochemical sign of hyperthyroidism.
· Serum TSH can distinguish primary from secondary hypothyroidism (True)
Explanation: In primary hypothyroidism, TSH is high; in secondary hypothyroidism, it is low.
· Serum triiodothyronine can be an unreliable test for hypothyroidism (True)
Explanation: Low triiodothyronine may result from intercurrent illness, particularly in elderly people, and can be
· Hyperthyroid patients may have a raised serum triiodothyronine with a normal thyroxine (True)

By A. H.
Explanation: The condition of 'T3 toxicosis'.

Question 6. Rheumatoid factor is:

· An antibody to sheep erythrocytes (False)
· Present when rheumatoid nodules are present (True)
Explanation: Nodules are associated with high titres of rheumatoid factor.
· Diagnostic of rheumatoid arthritis (False)
· Usually is of the IgA subtype (False)
· Is not found in rheumatoid synovial, pleural or pericardial fluid (False)

Question 7. In gout:
· Tophi are an early sign (False)
· Allopurinol is used to treat the acute attack (False)
· Furosemide (frusemide) helps to increase urate excretion (False)
· Large joints are not affected (False)
· Raised serum urate makes the diagnosis certain (False)

Question 8. Ankylosing spondylitis:

· Is more common in females (False)
· May present as a severe oligoarthritis (True)
Explanation: Commonly affects several joints and often presents with back pain.
· Is associated with the histocompatibility antigen HLA-DW3 (False)
· Is associated with pulmonary fibrosis (True)
Explanation: It is associated with upper lobe fibrosis and aortic incompetence.
· Involves the proximal interphalangeal (PIP) (False)

Question 9. Concerning osteomyelitis:

· Debridement of infected bone is essential for cure in chronic bacterial osteomyelitis (True)
Explanation: It is often difficult to remove all dead infected bone.
· It is usually accompanied by a very high ESR (True)
Explanation: Virtually always and it is a useful marker of response to treatment and relapse.
· A distinctive feature of chronic osteomyelitis is a discharging sinus (True)
Explanation: Although there are other causes of a sinus including actinomycosis, implanted foreign body (such as
shrapnel), mycetoma (fungal soft tissue and bony infection of the leg in the tropics).
· A positive culture from a sinus track is a good indication of the bacterial cause of the chronic osteomyelitis
· Usually 2 or 3 weeks' antibiotic therapy is adequate for cure (False)

Question 10. With regard to reactive arthritis:

· It may be caused by both Salmonella and Campylobacter spp. (True)
Explanation: It usually occurs 3-12 weeks after the episode of diarrhoea.
· It is usually chronic and unremitting over 3-4 years (False)
· Confidence in the diagnosis rests on growing a bacterium from stool or other sites (False)
· NSAIDs are appropriate therapy (True)
Explanation: It is helpful if it can be done but failure does not rule out the diagnosis.
· Rheumatic fever should be excluded (True)

Module 1 (Master Medicine)

Question 1. The anatomy of the heart:
If you stand on the patient's right side with your right hand across the sternum and cardiac apex, the left ventricle lies
under the sternum (False)
On a postero-anterior (PA) chest radiograph, the left heart border is mostly formed by the left ventricle (True)
Explanation: The right ventricle presses against the sternum; the left ventricle constitutes the apex and is felt under the
In an ECG, disease of the interventricular septum causes changes in chest leads V3-4 (True)

By A. H.
Explanation: The right ventricle presses against the sternum; the left ventricle constitutes the apex and is felt under the
When examining the heart, the cardiac apex is the point where the heart beat can be felt most strongly (False)
Occlusion of the left anterior descending coronary artery causes infarction of the anterior wall of the left ventricle and
interventricular septum (True)
Explanation: Anterior myocardial infarction is caused by disease of the left anterior descending artery.

Question 2. The ECG:

The T wave corresponds to atrial contraction (False)
If the S wave is greater than the R wave in lead I, there is right axis deviation (True)
If the S wave is greater than the R wave in lead II, there is left axis deviation (True)
ST segment depression may be a sign of cardiac ischaemia (True)
Explanation: It may also be a digoxin effect.
A tall R wave in V1 may be a sign of right ventricular hypertrophy (True)
Explanation: It may also be a digoxin effect

Question 3. Endocarditis:
It is important to take blood cultures over at least 24 hour period to make the diagnosis (False)
Transthoracic echocardiography is a sensitive means of making or confirming the diagnosis (False)
Most patients with Staphylococcus aureus bacteraemia have endocarditis (False)
Viral endocarditis leads to valvular abnormality (False)
In patients with a new stroke, endocarditis can be ruled out if the patient is afebrile (False)

Question 4. Treatment of endocarditis:

Intravenous antibiotics for 6 weeks are necessary to cure viridans type streptococcal endocarditis (False)
Staphylococcal endocarditis on the tricuspid valve in a drug addict is treated with flucloxacillin and valve replacement
Large vegetations are an indication for surgery (True)
Explanation: Flucloxacillin (with gentamicin or rifampicin) is the medical treatment of choice but valve replacement is
not appropriate. Insertion of a prosthetic heart valve into a drug addict is very likely to lead to prosthetic valve
endocarditis subsequently because of their continuing habit.
Combination antibiotic therapy is almost always appropriate for endocarditis (True)
Explanation: For two reasons; first, the selected combinations are usually additive or synergistic. Second, to prevent the
development of resistance.
If gentamicin is used for treatment, it should not be used for more than 2 weeks (False)

Question 5. In acute myocardial infarction:

The diagnosis should be questioned if the jugular venous pressure is not raised (False)
Streptokinase should not be given until the diagnosis has been confirmed by two sets of raised cardiac enzymes (False)
Dysrhythmias in the early hours after presentation carry a poor prognosis (False)
Lidocaine should routinely be given to prevent dysrhythmias (False)
Rupture of the interventricular septum is an uncommon but serious complication (True)
Explanation: This is of no proven value.

Question 6. In acute dissection of the thoracic aorta:

The operative mortality is about 30% (False)
Spinal cord ischaemia may occur (True)
Explanation: It is much higher.
Hypertension should be treated aggressively (True)
Explanation: Nitroprusside or labetolol infusion is a recommended treatment.
Acute aortic stenosis may occur (False)
The patient may develop myocardial ischaemia (True)
Explanation: The coronary ostia may be occluded by the dissection

Question 7. Hypertension:
Treatment is of no proven benefit in patients over the age of 70 years (False)
The symptoms of phaeochromocytoma include headache, sweating and palpitations (True)

By A. H.
Explanation: There is well-proven benefit, particularly in the prevention of stroke.
Oral treatment producing a fall in diastolic blood pressure of 20 mmHg over 24 hours might be regarded as successful
treatment of accelerated hypertension (True)
Explanation: There is well-proven benefit, particularly in the prevention of stroke.
ACE inhibitors are the drugs of choice for hypertension in pregnancy (False)
Addison's disease should be considered a possible cause in a hypertensive patient with hirsutism (False)

Question 8. In ischaemic heart disease:

Prevalence is increased in chronic renal failure (True)
Explanation: Cushing's syndrome, not Addison's disease.
Untreated hypothyroidism predisposes to it (True)
Explanation: Hypothyroidism causes hypercholesterolaemia and atherosclerosis.
Polycythaemia may precipitate myocardial ischaemia (True)
Explanation: By increasing blood viscosity and impairing blood flow.
An alcohol intake of 18 units per week in a man increases the risk of ischaemic heart disease (False)
A high plasma fibrinogen reduces the risk (False)

Question 9. Cardiac dysrhythmias:

Digoxin toxicity may cause supraventricular tachycardia (True)
Explanation: Typically, paroxysmal atrial tachycardia.
A patient with a completely irregular pulse of 180 beats/min is likely to be in atrial fibrillation (True)
Explanation: Typically, paroxysmal atrial tachycardia.
Complete heart block may be asymptomatic (True)
Explanation: Particularly congenital complete heart block.
Digoxin is effective in preventing paroxysms of atrial fibrillation (False)
A QRS width less than 3 small squares on the ECG indicates that a tachycardia is supraventricular (True)
Explanation: Digoxin slows the ventricular rate during paroxysms of atrial fibrillation but does not prevent them; sotalol
or amiodarone may prevent them.

Question 10. Hypoventilation occurs in the following:

Central sleep apnoea syndrome (True)
Explanation: Alveolar hypoventilation is a key feature.
Severe kyphoscoliosis (True)
Explanation: Severe kyphoscoliosis can produce mechanical ventilation problems because of the changed curvature of
the spine.
Anxiety (False)
Benzodiazepine overdose (True)
Explanation: Drugs such as benzodiazepines depress the respiratory centre.
Exercise (False)

Question 11. Pneumothorax is a recognised complication of:

Rib fracture (True)
Explanation: Pneumothorax can occur secondary to trauma.
A bulla (True)
Explanation: Any cavitating or cystic/bullous lung lesion can cause a pneumothorax. Bullae can be single or multiple.
They are particularly common in emphysema including á1-antitrypsin deficiency.
Kyphoscoliosis (False)
Cystic fibrosis (False)
Pneumocystis carinii pneumonia (True)
Explanation: And lung abscesses (e.g. Staph. aureus) can lead to pneumothorax.

Question 12. The following are features of fibrosing alveolitis:

Cough (True)
Explanation: Patients usually present with cough and breathlessness.
Clubbing of the fingers in the majority of cases (True)
Explanation: Clubbing occurs in about 60% of patients but is not essential for the diagnosis.
Cyanosis in the early stages (False)

By A. H.
Circulating antibodies to alveolar tissues (False)
Haemoptysis (False)

Question 13. Useful drugs for tuberculosis include:

Piperacillin (False)
Isoniazid (True)
Explanation: Isoniazid is a major, first-line agent.
Ciprofloxacin (True)
Explanation: Ciprofloxacin is a useful agent, less active than rifampicin; it may obscure infection in patients treated
before diagnosis considered.
Ethambutol (True)
Explanation: Ethambutol is another major, but second-line agent.
Amikacin (True)
Explanation: Amikacin is a useful i.v. second-line agent

Question 14. Causes of life-threatening pneumonia or pneumonitis in adults include:

Pneumocystis carinii (True)
Explanation: Pneumocystis carinii infection is usually seen in AIDS, but also in lymphoma, steroid-treated, transplant
and hypogammaglobulinaemic patients.
Influenza A virus (True)
Explanation: Primary influenzal pneumonia or complicated by bacteria, e.g. Staph. aureus.
Respiratory syncytial virus (False)
Staphylococcus aureus (True)
Explanation: S. aureus pneumonia is often rapidly fatal, especially following influenza.
Legionella pneumophila (True)
Explanation: L. pneumophilia pneumonia carries a high mortality if not treated appropriately.

Question 15. Chronic bronchial sepsis:

Is an uncommon feature of cystic fibrosis (False)
Typically is caused by unusual, difficult-to-grow bacteria (False)
May lead to haemoptysis (True)
Explanation: Haemoptysis is also seen with dry bronchiectasis, chronic bronchial sepsis and with aspergillomas.
Can usually be cured with oral antibiotics (False)
May lead to pulmonary fibrosis (True)
Explanation: It produces a fibrotic reaction

Question 16. Pleural aspiration is useful in the following situations:

In diagnosing mesothelioma (False)
Pleural tuberculosis (False)
Viral pleurisy (False)
Empyema (True)
Explanation: An empyema will require tube or surgical drainage for treatment.
Relieving breathlessness in patients with malignant effusions (True)
Explanation: Drainage in malignant effusions is often very helpful if litres of fluid are removed or a shunt can be

Question 17. In the small intestine:

If there is bile salt deficiency, micellar formation is reduced (True)
Explanation: Bile salts are essential for micelle formation.
Long-chain triglycerides are transported from the gut in the lymph as chylomicrons (False)
There is no lymphatic tissue (False)
The entire mucosa is turned over every 2-3 weeks (False)
Is the site of most nutrient absorption (True)
Explanation: The small intestine is the main area for the breakdown and absorption of nutrients.

Question 18. Colorectal cancer:

May arise from a metaplastic polyp (False)

By A. H.
Most often occurs in the rectum and sigmoid (True)
Explanation: Metaplastic polyps have no malignant potential.
There are further polyps in most cases (False)
Involvement of local lymph nodes does not affect prognosis (False)
Obstruction is more common in right compared with left-sided lesions (False)

Question 19. Causes of acute pancreatitis include:

Alcohol (True)
Explanation: Most cases are associated with gall stones or high alcohol intake.
Hypocalcaemia (False)
Hyperlipidaemia (True)
Explanation: There is an association with hyperlipidaemia, but it is an uncommon cause.
Self poisoning with diazepam (False)
Endoscopic retrograde cholangiopancreatography (ERCP) (True)
Explanation: ERCP is used in the diagnosis of pancreatic disease but can precipitate an acute attack.

Question 20. Coeliac disease:

The patient will almost always have had symptoms since childhood (False)
Is best diagnosed on colonic biopsy (False)
Is associated with HLA-B8 (True)
Explanation: It is associated with HLA-B8 and HLA-DRW3 antigens.
The diagnosis is incorrect if a patient fails to respond to a gluten-free diet (False)
Requires a diet free from wheat, barley and rye (True)
Explanation: All contain gluten

Question 21. In a ward with several patients where two of the nurses have had much vomiting and some diarrhoea over
a 48-hour period, you should:
Send the patients home (False)
Culture stools (and vomitus) for viruses (False)
Treat everyone with metronidazole (False)
Exclude visitors from the ward (True)
Explanation: To prevent further spread, unless necessary for, say, a dying patient.
Prevent the patients (affected or not) leaving the ward for investigations, physiotherapy, etc. (True)
Explanation: Unless the investigation was absolutely vital

Question 22. The differential diagnosis of acute bloody diarrhoea includes:

Amoebic dysentery (True)
Explanation: This has much mucus and tenesmus.
Campylobacter enteritis (True)
Explanation: The amount of blood is usually small.
Haemorrhagic colitis caused by E. coli (True)
Explanation: The classic cause, with mostly blood and little stool and no fever.
Traveller's diarrhoea (False)
Cholera (False)

Question 23. The following are correct:

Hepatitis B can be acquired from serous fluid from a wound (True)
Explanation: This is the likely mode of horizontal transmission among siblings in developing countries.
Hepatitis C is not a cause of hepatocellular carcinoma (False)
Hepatitis A is a cause of chronic liver disease (False)
Hepatitis E can be acquired by sharing needles (False)
A person with only a hepatitis B core IgG test positive is infectious for hepatitis B (False)

Question 24. A 'fatty liver' may represent:

Simply an obese person (False)
Alcoholism (True)
Explanation: A common 'early' abnormality.

By A. H.
Hepatitis C infection (True)
Explanation: A common 'early' abnormality.
Acute vitamin A poisoning (False)
An ultrasound artefact (False)

Question 25. Cushing's syndrome:

Causes osteoporosis (True)
Explanation: Also cardiorespiratory disease.
The diagnosis is made by a high-dose dexamethasone test (False)
Serum adrenocorticotrophic hormone (ACTH) is important in diagnosing the underlying cause (True)
Explanation: Patients with primary adrenal Cushing's have unmeasurably low serum ACTH.
A neoplasm causing a classical 'lemon-on-sticks' appearance is > 25% likely to be small cell carcinoma of the bronchus
Can only be cured by bilateral adrenalectomy (False)

Module 2 (Master Medicine)

Question 1. Acute renal failure is a likely complication of the following:
Sepsis (or sepsis syndrome) (True)
Explanation: Commonly caused by prerenal factors such as sepsis syndrome.
Polycystic kidney disease (False)
Major arterial surgery (True)
Explanation: Major arterial surgery can cause renal ischaemia and acute tubular necrosis.
Retroperitoneal tumours (False)
Cardiogenic shock (True)

Question 2. In patients with acute renal failure:

Sodium bicarbonate should be given routinely (False)
Most patients with acute renal failure need long-term dialysis (False)
Skin turgor is a reliable guide to the need for i.v. fluid therapy (False)
Urinary catheterisation is sometimes needed to monitor the response to therapy (True)
Explanation: It is important to measure urine flow in the fluid management of acute renal failure.
Intravenous pyelography is the investigation of choice to exclude urinary obstruction (False)

Question 3. The following are causes of chronic renal failure:

Gout (True)
Explanation: In renal failure, the kidneys are unable to excrete urea so the urinary urea concentration is low. This
distinguishes renal failure from, for example, volume depletion, in which plasma urea is high but the kidneys retain the
capacity to concentrate urinary urea.
Atherosclerosis (True)
Explanation: As a result of extrarenal or intrarenal obstruction to the renal arterial circulation.
Analgesic abuse (True)
Explanation: As a result of extrarenal or intrarenal obstruction to the renal arterial circulation.
Non-insulin-dependent diabetes (True)
Explanation: Both insulin-dependent and non-insulin-dependent diabetes cause renal failure.
Hypothyroidism (False)

Question 4. The following may cause the nephrotic syndrome:

Minimal change disease (True)
Explanation: This is the characteristic disease associated with nephrotic syndrome, particularly in children.
Treatment with beta-blockers (False)
Rheumatoid arthritis (True)
Explanation: It may be caused by amyloid associated with rheumatoid arthritis or by drugs used to treat the disease
(gold or penicillamine). Rarely it is caused by a glomerulonephritis associated with the disease itself.
Diabetes mellitus (True)
Explanation: Although the full-blown nephrotic syndrome is a relatively uncommon presentation of diabetic
Renal cell carcinoma (False)

By A. H.

Question 5. The following are features of urinary infections in elderly people:

Patients usually complain of dysuria (False)
They may present with falls (True)
They may present with constipation (True)
Explanation: Or it may be coexistent, perhaps reflecting anorexia and dehydration.
Sterile pyuria is most likely caused by tuberculosis (False)
Estrogen supplements may reduce their frequency in postmenopausal women (True)
Explanation: Elasticity of the urethra is reduced postmenopausally and this can lead to infection. Local estrogen therapy

Question 6. Renal artery stenosis:

Is invariably caused by atherosclerosis (False)
May cause renal failure in patients given ACE (angiotensin-converting enzyme) inhibitor therapy (True)
Explanation: Fibromuscular hyperplasia and radiation fibrosis are two other pathologies which can cause renal artery
stenosis, although atherosclerosis is the most common pathology.
Can be reliably diagnosed by auscultating for renal bruits (False)
May be seen on ultrasound as a unilateral small kidney (True)
Explanation: Hypoperfusion causes reduction in renal size.
Is a cause of hypertension (True)
Explanation: Hypoperfusion causes reduction in renal size.

Question 7. The following are true:

There is weakness of elbow extension in a crutch palsy (True)
Explanation: The triceps is affected in a crutch palsy.
Wasting of the hypothenar eminence occurs in the carpal tunnel syndrome (False)
Abduction of the thumb is impaired in an ulnar nerve lesion (False)
The index finger is hyperextended at the metacarpophalangeal (MCP) joint in an ulnar nerve lesion (False)
Sensation is lost over the whole of the back of the hand in radial nerve damage (False)

Question 8. The following are true:

A cerebellar vermis lesion will result in a marked intention tremor (False)
Macular sparing is a characteristic of lesions affecting the optic tract (False)
In a patient with marked visuo-spatial inattention, the lesion is most likely in the left cerebral hemisphere (False)
Agnosia means inability to plan and execute motor tasks (False)
Dyscalculia is a feature of Alzheimer's disease (True)
Explanation: Remember other higher cortical functions, e.g. dysphasia, dyslexia.

Question 9. Features of a right sixth nerve palsy include:

Convergent strabismus (True)
Explanation: Complete paralysis of the lateral rectus leaves the medial rectus unopposed hence producing a convergent
strabismus, though mostly the paralysis is only brought out when the eye is abducted.
Diplopia worse on looking to the right (True)
Explanation: Diplopia is maximal on looking in the direction of the primary action of the muscle.
False image parallel to the true image (True)
Explanation: Unlike a superior oblique palsy.
False image occurs further to the left than the true image (False)
Images become increasingly separated on looking to the left (False)

Question 10. Parkinson's disease is associated with:

Loss of dopamine transmission (True)
Explanation: Although the mechanism is unclear, it does involve loss of dopaminergic neurons.
Cogwheel rigidity (True)
Explanation: Cogwheel rigidity is a superimposed tremor on the 'lead pipe' increase in tone.
Tardive dyskinesia (False)
Intention tremor (False)
Festinant gait (True)

By A. H.

Question 11. In a young female with paraplegia, which of the following would suggest a diagnosis of multiple sclerosis:
Periventricular lesions seen on MR scanning (True)
Explanation: Periventricular plaques would imply disease remote from the spinal cord. MR scanning is the preferred
imaging technique.
Raised protein in cerebrospinal fluid (CSF) (False)
Raised CSF globulin (True)
Explanation: CNS immunology is disturbed in multiple sclerosis.
Denervation of the muscles of the leg (False)
Episode of visual disturbance (True)
Explanation: Disturbances of visual acuity are an early sign.

Question 12. The following are more suggestive of dementia than of depression:
Several episodes of antisocial behaviour (True)
Explanation: Antisocial behaviour is more in keeping with the personality change of dementia.
Mutism (False)
Duration of symptoms less than 1 month (False)
Worsening of symptoms during the early morning (False)
Marked impairment of concentration (False)

Question 13. With respect to lumbar puncture:

Coagulopathy is a contraindication (True)
Explanation: However, if correctable (e.g. haemophiliac) and the indication for lumbar puncture is strong enough, then
it should be corrected and the lumbar puncture carried out.
Papilloedema is an absolute contraindication (False)
The procedure may cause meningitis (False)
The less CSF is removed, the less likely coning is to occur (False)
Postlumbar puncture headache is related to the size of the needle used (False)

Question 14. Outcome from bacterial meningitis relates to:

Age of patient (True)
Explanation: Mortality is highest in elderly people.
Time to first administration of antibiotic (True)
Explanation: Delays lead to increased mortality and morbidity.
CSF concentration of antibiotic (True)
Explanation: The CSF concentration of antibiotic needs to exceed by 20-fold the minimum inhibitory concentration of
the infecting organism. This is the primary reason why i.v. therapy is necessary in meningitis.
Development of antibiotic resistance during therapy (False)
The causative organism (True)
Explanation: Neisseria meningitidis has a lower mortality than S. pneumoniae meningitis. Furthermore about 5% of
community-acquired cases are other organisms, such as Listeria monocytogenes. Listeria is intrinsically resistant to all
cephalosporins, which are now the most common first line treatment for meningitis

Question 15. The following statements are true:

Hypocalcaemia causes prolongation of the prothrombin time (False)
The prothrombin time is a sensitive test of hepatocellular dysfunction (True)
Explanation: Because hepatocellular dysfunction impairs the synthesis of vitamin K-dependent clotting factors.
The activated partial thromboplastin time (APTT) is prolonged by unfractionated heparin therapy (True)
Explanation: This is used as a measure of heparinisation.
The effect of heparin is reversed by vitamin K (False)
Deep venous thrombosis can be reliably diagnosed by measuring fibrin degradation products (FDPs) (False)

Question 16. The following may cause a microcytic anaemia:

Sickle cell disease (False)
The thalassaemias (False)
Anaemia of chronic disease (False)
Anticonvulsant therapy (False)

By A. H.
Haemolysis, whatever the cause (False)

Question 17. The following statements are true:

A neutrophil count of only 0.8 × 109 cells/l is a major risk for infection (False)
A neutrophil count in a febrile patient of 25 × 109 cells/l reflects mostly the production of new neutrophils from the
bone marrow (False)
In a patient with less than 0.1 × 109 cells/l neutrophils and a fever, treatment with antibiotics should await the results of
blood culture (False)
Neutropenia is common in AIDS (False)
Neutropenia can be caused by carbimazole therapy (True)
Explanation: Neutropenia occurs in 1:10000 patients treated with carbimazole for thyrotoxicosis.

Question 18. Prognosis of diabetes:

Cardiovascular mortality is higher in diabetic than in non-diabetic people up to the age of 80 (True)
Explanation: A threefold increase.
Diabetic patients with proteinuria have a higher cardiovascular risk than those without it (True)
Explanation: It is indicative of nephropathy, which increases the risk of cardiovascular disease up to 100-fold.
When sulfonylureas became available, there was a noticeable improvement in cardiovascular mortality (False)
Good glycaemic control, on the balance of available evidence, can reduce cardiovascular mortality in both type 1 and
type 2 DM (False)
Even mildly 'impaired glucose tolerance' increases cardiovascular risk (True)

Question 19. In secondary diabetes:

A patient can be assumed not to be ketosis-prone (False)
A patient is more than 85% likely to have clinical pancreatic exocrine deficiency (False)
Classical diabetic complications do not occur (False)
Thiazide diuretics and beta-blockers can both impair insulin secretion (True)
Explanation: Secondary diabetes causes all the same complications as idiopathic diabetes.
Most patients with acromegaly are diabetic (False)

Question 20. Diabetic retinopathy:

Characteristically causes arterio-venous nipping (False)
Should be referred to an ophthalmologist only if the patient has visual symptoms (False)
Inevitably causes blindness (False)
May cause cotton wool spots (soft exudates) (True)
Explanation: These may also occur in hypertension and other ischaemic retinopathies.
Is more likely to cause blindness in type 1 than in type 2 DM (False)

Question 21. In insulin treatment:

Pen injectors are reserved for the small minority who take four or more injections per day (False)
Only patients who cannot be controlled with once-daily insulin should have two or more injections (False)
Insulin should be started without delay in a thin hyperglycaemic patient with ketonuria (True)
Explanation: These are signs of type 1 DM.
Insulin may sometimes be needed during short periods of illness in patients with type 2 DM (True)
Explanation: These are signs of type 1 DM.
All patients on insulin should be discouraged from changing their doses without first checking with the doctor or nurse

Question 22. Hypertension in diabetes:

Is more prevalent in type 1 than in type 2 (False)
Its treatment slows the deterioration of nephropathy in type 1 DM (True)
Explanation: Hypertension is associated with type 2 more strongly than with type 1 DM.
Thiazide diuretics should not be used in diabetes (False)
Beta-blockers may increase the risk of severe hypoglycaemia in insulin-treated patients (True)
Explanation: This is true primarily of non-cardioselective beta-blockers.
Increases the risk of stroke in diabetes (True)

By A. H.
Explanation: This is true primarily of non-cardioselective beta-blockers

Question 23. The following are seen with NSAIDs:

Improvement in renal function (False)
Increase in serum potassium (True)
Explanation: The change in renal function results in hyperkalaemia.
Increased risk of peptic ulcer complications (True)
Explanation: There is a clear relationship between NSAID use and complications such as perforation, bleeding and
death particularly in old people.
Improved long-term prognosis of rheumatoid arthritis (False)
Improvement in coexistent asthma (False)

Question 24. The following are features of systemic lupus erythematosus (SLE)
Raynaud's phenomenon (True)
Explanation: Pain during mastication is a characteristic feature of temporal arteritis.
Mononeuritis multiplex (True)
Explanation: Pain during mastication is a characteristic feature of temporal arteritis.
Thrombocytopenia (True)
Explanation: This is one of the typical blood-associated dyscrasias.
Lymphopenia (True)
Explanation: As with thrombocytopenia

Question 25. In primary osteoarthritis:

The ESR is normal (True)
Explanation: There are no haematological abnormalities.
PIP joints are not usually affected (False)
Radiographs show characteristic erosions of articular margins (False)
Morning stiffness usually lasts over 1 hour (False)
First carpometacarpal joint involvement is a common finding (True)
Explanation: This is common, resulting in 'squaring' of the hand

Available from Davidson's Principles and Practice of Medicine

Module 1 (Chapter 1)
Question 1. The following infections may be acquired by the following means
tetanus-respiratory droplets or dust (False)
Explanation: Via wounds and abrasions
listeriosis-eating contaminated cheese (True)
Explanation: Can survive refrigeration
legionellosis-water aerosols (True)
schistosomiasis-via penetration of the skin (True)
leptospirosis-via rat urine (True)

Question 2. Diseases typically acquired from animals include

leptospirosis (True)
Explanation: From the urine of rats or dogs
Mycobacterium tuberculosis (False)
Explanation: Mycobacterium bovis
toxoplasmosis (True)
Explanation: From dog faeces
psittacosis (True)
Explanation: From birds
hepatitis A (False)
Explanation: Faecal-oral spread

Question 3. Live viruses are usually used for active immunisation against

By A. H.
poliomyelitis (True)
Explanation: Inactivated vaccine also available
pertussis (False)
typhoid fever (False)
mumps, measles and rubella (True)
Explanation: Do not give to immunosuppressed patients
hepatitis B (False)

Question 4. Pyrexia of unknown origin

is defined as a temperature of more than 37.5°C persisting for more than 2 weeks (True)
Explanation: Not elucidated by investigation in hospital
is due to infection in 75% of cases (False)
Explanation: In approximately 30% only
may be factitious (True)
Explanation: Suspect if ESR and CRP normal
can be caused by granulomatous hepatitis (True)
Explanation: And other forms of hepatitis
may be elucidated by bone marrow biopsy (True)
Explanation: May diagnose haematological malignancy

Question 5. The following statements about infectious mononucleosis are true

infection is usually attributable to the Epstein-Barr virus (EBV) (True)
presentation is with fever, headache and abdominal pain (True)
Explanation: And malaise and anorexia
sore throat suggests cytomegalovirus rather than EBV infection (False)
meningoencephalitis and pericarditis are recognised complications (True)
severe oropharyngeal swelling requires prednisolone therapy (True)
Explanation: Especially if there is dysphagia or breathing difficulty

Question 6. Typical features of toxoplasmosis include the following

infection is derived from cats, pigs and sheep (True)
Explanation: Immunocompromised patients are most at risk
peak age of onset is over 65 years of age (False)
Explanation: 25-35 years
congenital infection produces choroidoretinitis (True)
Explanation: And sometimes microcephaly
there is a positive heterophil antibody test (False)
Explanation: This is typically negative
pyrimethamine and sulfadiazine therapy is useful in immunocompromised patients (True)

Question 7. Recognised features of brucellosis include

a characteristically rapid response to penicillins (False)
Explanation: Typically doxycycline and streptomycin
fever, night sweats and back pain (True)
Explanation: And joint pains and anorexia
splenomegaly (True)
Explanation: But a non-specific finding
oligoarthritis and spondylitis (True)
Explanation: Due to localised granulomatous disease
thrombocytopenia (True)
Explanation: Due to hypersplenism

Question 8. The typical features of leptospirosis include

incubation period of 1-3 months (False)
Explanation: 7-14 days
exposure risk in abattoirs, farms and inland waterways (True)
fever, severe myalgia, headache and conjunctival suffusion (True)

By A. H.
Explanation: With abrupt onset
meningitis in Leptospira icterohaemorrhagiae rather than L. canicola infection (False)
Explanation: L. canicola infection is usually associated with aseptic meningitis
possible diagnosis by examination of the urine (True)
Explanation: Leptospires appear in the urine in the second week of illness

Question 9. The clinical features of Lyme disease include

infection with the tick-borne spirochaete Borrelia burgdorferi (True)
Explanation: Ixodes species of tick
an expanding erythematous rash (erythema chronicum migrans) (True)
Explanation: An annular red lesion
cranial nerve palsies (True)
Explanation: Or meningitis or radiculopathy
asymmetrical large joint recurrent oligoarthritis (True)
Explanation: Not in acute stages
response to tetracycline or penicillin therapy (True)
Explanation: And cephalosporins

Question 10. Features consistent with the diagnosis of Q fever include

exposure to sheep, cattle and unpasteurised milk (True)
Explanation: Especially butchers and abattoir workers
meningoencephalitis (True)
pneumonia in the absence of fever, headache or myalgia (False)
Explanation: Acute Q fever is an influenza-like illness
blood culture-negative endocarditis (True)
prompt clinical response to sulphonamide therapy (False)
Explanation: Responds to tetracyclines

Question 11. The typical features of erysipelas include

group A haemolytic streptococcal skin infection (True)
Explanation: Streptococcus pyogenes
absence of constitutional symptoms (False)
Explanation: Systemic upset is common
well-defined area of cutaneous erythema and oedema (True)
Explanation: The rash has a palpably raised edge
painless swelling (False)
Explanation: Typically painful
prompt response within 48 hours to benzylpenicillin (True)

Question 12. Clinical features of anthrax include

occupational exposure to animals and animal products (True)
Explanation: Farmers, butchers and dealers in wool, hides and bone meal
an incubation period of 1-3 weeks (False)
Explanation: 1-3 days
a painless cutaneous papule (True)
Explanation: Painless but itchy
gastroenteritis and bronchopneumonia (True)
multiple antibiotic resistance (False)
Explanation: The organism is widely sensitive

Question 13. The features of herpes simplex (HS) virus infections include
recurrent genital ulcers (True)
Explanation: Especially HS type 2
acute gingivostomatitis (True)
Explanation: HS type 1
encephalitis (True)
Explanation: HS type 1

By A. H.
shingles (False)
Explanation: Varicella zoster virus
paronychia (True)
Explanation: HS type 1-'herpetic whitlow'

Question 14. In a schoolchild with measles

infection is due to a paramyxovirus (True)
rhinorrhoea and conjunctivitis occur at the onset (True)
Explanation: The catarrhal phase
Koplik's spots appear at the same time as the skin rash (False)
Explanation: They precede the rash
the skin rash typically desquamates as it disappears (True)
infectivity is confined to the prodromal phase (False)
Explanation: Contact should be avoided for 7 days after the onset of the rash

Question 15. In patients with rubella infection

the RNA virus spreads by the faecal-oral route (False)
a prolonged fever is typical (False)
Explanation: Typically only on the first day of the rash
infectivity is present for 7 days before and after the rash (True)
sub-occipital lymphadenopathy is typical (True)
the risk of serious fetal damage is < 5% after the 16th week of pregnancy (True)
Explanation: Greatest risk is in the first 8 weeks

Question 16. The characteristic features of mumps include

infection with an RNA paramyxovirus by airborne spread (True)
high infectivity for 3 weeks after the onset of parotitis (False)
Explanation: Infectivity is generally low
presentation with an acute lymphocytic meningitis (True)
abdominal pain attributable to mesenteric adenitis (False)
Explanation: Pain suggests pancreatitis or oophoritis
orchitis which predominantly occurs prepubertally (False)
Explanation: It is usually unilateral and postpubertal

Question 17. The clinical features of amoebic dysentery include

an incubation period of 2-4 weeks (False)
Explanation: May develop many months after exposure
presentation with blood and mucus per rectum (True)
Explanation: Acute colitic symptoms often seen in the old
good response to metronidazole in intestinal disease (True)
characteristic appearances of the mucosa on sigmoidoscopy (True)
Explanation: Flask-shaped ulcers
antibodies detectable by immunofluorescence in only a small minority of patients (False)
Explanation: In 60-95%

Question 18. The following statements about the life cycle of plasmodia are true
sporozoites disappear from the blood within minutes of inoculation (True)
Explanation: Sporozoites enter the liver within 30 minutes
merozoites re-entering red blood cells undergo both sexual and asexual development (True)
all plasmodia multiply in the liver then subsequently in red blood cells (True)
Explanation: Duration of the pre-patent period varies
dormant hypnozoites remain within the liver cells in all species (False)
Explanation: Only P. vivax and P. ovale persist in this form
fertilisation of the gametocytes occurs in the human red blood cells (False)
Explanation: Fertilisation occurs in the mosquito

Question 19. Recognised clinical features of malaria include

By A. H.
absence of P. vivax infection in subjects lacking the Duffy blood group (True)
Explanation: West Africans and African Americans are protected
asymptomatic P. malariae parasitaemia persisting for years (True)
Explanation: With or without symptoms
enhanced risk of infection in splenectomised patients (True)
presentation with rigors, herpes simplex and haemolytic anaemia (True)
Explanation: Especially in P. vivax and P. ovale infection
excellent response to chloroquine (False)
Explanation: Widespread resistance-quinine preferred

Question 20. The features of typhoid fever include

faecal-oral spread of Salmonella typhi by food handlers (True)
Explanation: Usually asymptomatic carriers
presentation with constipation (True)
Explanation: But diarrhoea more common in children
onset with fever, headache and myalgia (True)
Explanation: And relative bradycardia
'rose spots' on the trunk and splenomegaly 7-10 days after onset (True)
development of carrier state in 50% of survivors (False)
Explanation: 5%

Question 21. The following are possible causes of fever and a rash in a traveller returning from the tropics
paratyphoid fever (True)
leptospirosis (True)
meningococcal infection (True)
secondary syphilis (True)
HIV seroconversion (True)

Question 22. In the diagnosis of the enteric fevers

blood cultures are usually positive 2 weeks after onset (False)
Explanation: Bacteraemia in the first week
stool cultures are usually positive within 7 days of onset (False)
Explanation: More likely in the second or third week
peripheral blood neutrophil leucocytosis is typically marked (False)
Explanation: Leucopenia is typical
the Widal reaction is typically positive within 7 days of onset (False)
Explanation: There are frequent false negatives
persistent fever despite antibiotics indicates resistant organisms (False)
Explanation: It may suggest a septicaemic focus

Question 23. Clinical features of dengue include

mosquito-borne infection with an incubation period of 2-7 days (True)
continuous or 'saddle-back' fever (True)
Explanation: Fever may remit on day 4-5 ('saddle-back')
rigors, headache, photophobia and backache (True)
Explanation: But non-specific
morbilliform rash and cervical lymphadenopathy (True)
Explanation: Rash starts peripherally
protection by vaccination every 10 years in endemic areas (False)
Explanation: No vaccine is available

Question 24. The typical features of African trypanosomiasis include

transmission of the parasite by the tsetse cattle fly (True)
an incubation period of 2-3 weeks (True)
Explanation: Occasionally longer in T. gambiense infections
onset with chancre-like skin lesion and local lymphadenopathy (True)
Explanation: At the site of the bite

By A. H.
generalised lymphadenopathy, hepatosplenomegaly and encephalitis (True)
good prognosis given prompt pentamidine or suramin therapy (True)
Explanation: Unless cerebral infection has developed

Question 25. Typical features of visceral leishmaniasis (kala-azar) include

spread of Leishmania donovani by sandflies from dogs and rodents (True)
Explanation: Also spread from infected blood transfusions
an incubation period of 1-2 weeks (False)
Explanation: 1 month to 10 years
rigors with hepatomegaly but no splenomegaly (False)
Explanation: Splenomegaly is characteristic
diagnosis confirmed on peripheral blood film (False)
Explanation: Diagnosis by examination of stained smears of bone marrow, spleen or liver
clinical response to pentavalent antimonials, e.g. stibogluconate (True)
Explanation: Amphotericin B is an alternative

Question 26. In diphtheria

heart block is a recognised complication (True)
Explanation: Although cardiac involvement usually causes no long-term problems
high fever is a typical early sign (False)
Explanation: Fever rarely dominant-insidious onset
isolation is usually unnecessary (False)
Explanation: Isolation is vital
paralysis of the soft palate, accommodation or ocular muscles may occur (True)
Explanation: Occasionally with peripheral polyneuritis
treatment is with antibiotics alone (False)
Explanation: Diphtheria antitoxin is also important

Question 27. The typical features of strongyloidiasis include

skin penetration with migration to the gut via the lungs (True)
Explanation: Producing an itchy rash
larval penetration of the duodenal and jejunal mucosa (True)
Explanation: With pain, diarrhoea, steatorrhoea and weight loss
abdominal pain, diarrhoea and malabsorption (True)
penetration of perianal skin producing a migrating linear weal (True)
Explanation: Intensely itchy
systemic spread in the immunosuppressed, resulting in pneumonia (True)
Explanation: Seen in HIV infection

Question 28. In infestation with the nematode Enterobius vermicularis

adult threadworms occur in great numbers in the small bowel (False)
Explanation: Seen in the colon
presentation with intense pruritus ani is typical (True)
Explanation: Worms may be visible
identifiable ova are found on the perianal skin (True)
malabsorption usually develops following heavy infestations (False)
Explanation: The small bowel is unaffected
all family members should take piperazine or mebendazole therapy (True)
Explanation: Cross-infection and autoinfection are common

Question 29. In onchocerciasis

larval infection is transmitted by the Simulium fly (True)
Explanation: A painful bite
worms mature over 2-4 weeks and persist for up to 1 year (False)
Explanation: Worms can live for over 15 years
cutaneous nodules and eosinophilia commonly develop (True)
Explanation: The nodules contain adult worms

By A. H.
conjunctivitis, iritis and keratitis are characteristic (True)
ivermectin is the drug therapy of choice (True)

Question 30. In schistosomal infection

painless haematuria may be the presentation (True)
Explanation: Due to bladder mucosal involvement
diagnosis can be made by finding cercariae in the urine and/or stool (False)
Explanation: Eggs are passed in urine and/or stool
the helminths mature in the portal vein (True)
peripheral neuropathy commonly causes lower limb weakness (False)
Explanation: But transverse myelitis may
praziquantel is the therapy of choice (True)
Explanation: Or oxamniquine or metrifonate

Question 31. Echinococcus granulosus infestation is usually associated with

contact with sheep, cattle and dogs (True)
Explanation: May be many years before clinical manifestations appear
acquisition of hydatid cysts in childhood (True)
Explanation: Usually an asymptomatic event
cysts in the liver, brain and lungs (True)
Explanation: Right lobe of the liver is the commonest site
absence of dissemination during liver aspiration (False)
Explanation: Care must also be taken during excision
prompt response to albendazole therapy if surgically inoperable (False)
Explanation: But further enlargement may be prevented

Question 32. Typical features of cutaneous leishmaniasis include

nasal and oral mucosal ulcers (True)
Explanation: Secondary to initial cutaneous ulceration
painful ulcers in the groins or axillae (False)
Explanation: Typically painless and not involving nodes
marked splenomegaly and lymphadenopathy (False)
Explanation: These occur in visceral leishmaniasis
ulcers which heal without scarring (False)
negative leishmanin skin test (False)
Explanation: Typically positive except in diffuse cutaneous leishmaniasis

Question 33. Characteristic features of leprosy include

an incubation period of 2-12 years (True)
growth of the organism on Löwenstein-Jensen medium after 2-3 months (False)
Explanation: The organism cannot be grown in artificial media
spread of the tuberculoid form by prolonged patient contact (False)
Explanation: There is no risk of infection in tuberculoid leprosy
thickened palpable peripheral nerves (True)
a cell-mediated immune response in the lepromatous form (False)
Explanation: Characteristic of the tuberculoid form

Question 34. Typical features of lepromatous leprosy include

early and marked sensory loss (False)
Explanation: Late and limited
unlike the tuberculoid form, organisms are scanty in number (False)
Explanation: Is a multibacillary disease
blood-borne spread from the dermis throughout the body (True)
Explanation: No cell-mediated immune response
strongly positive lepromin skin test (False)
Explanation: Suggests tuberculoid disease
anaesthetic hypopigmented skin macules and plaques (False)

By A. H.
Explanation: Macules occur, but sensation is retained

Question 35. The following are likely causes of splenomegaly in a patient with fever returning from the tropics
tuberculosis (False)
trypanosomiasis (True)
brucellosis (True)
visceral leishmaniasis (True)
infective endocarditis (True)

Question 36. The following statements about syphilis are true

infection is usually caused by Treponema pertenue (False)
Explanation: Due to infection with Treponema pallidum
cardiac murmurs are a typical early feature of infection (False)
Explanation: A feature of late disease
the primary lesion at the site of infection is initially macular (True)
Explanation: But becomes papular, then chancrous
the incubation period for primary syphilis is typically 2-4 weeks (True)
Explanation: But may be up to 90 days
tertiary syphilis usually develops within 1 year of infection (False)
Explanation: Takes at least 2 years to develop

Question 37. Characteristic features of late (tertiary and quaternary) syphilis include
negative specific treponemal antigen tests (False)
Explanation: The tests are typically positive
destructive granulomas (gummas) in bones, joints and the liver (True)
sensory ataxia (True)
Explanation: Due to dorsal column spinal disease
aneurysms of the ascending aorta (True)
Explanation: Typically with calcification
poor response of gummas to antibiotic therapy (False)

Question 38. The typical clinical features of gonorrhoea include

an incubation period of 2-3 weeks (False)
Explanation: 2-10 days
anterior urethritis and cervicitis (True)
Explanation: Dysuria, discharge or no symptoms
right hypochondrial pain due to perihepatitis (True)
pharyngitis (True)
good response to ciprofloxacin therapy in penicillin allergy (True)
Explanation: Or spectinomycin

Question 39. Anogenital herpes simplex is typically associated with

type 2 herpes simplex infection only (False)
Explanation: Type 2 and type 1 equally
primary attacks more severe and prolonged than recurrent attacks (True)
Explanation: Healing is more rapid in recurrent attacks
fever with painful genital ulceration and lymphadenopathy (True)
sacral dermatomal pain and urinary retention (True)
absence of clinical response to oral aciclovir (False)
Explanation: Shortens first attacks and may prevent recurrence

Question 40. HIV infection is associated with

an RNA retrovirus (True)
heterosexual transmission in the majority of cases world-wide (True)
Explanation: Superseding homosexual and parenteral
involvement of CD4 lymphocytes (True)

By A. H.
a viral half-life of 1-2 hours in plasma (True)
a better prognosis in the presence of Kaposi's sarcoma (False)
Explanation: Prognosis is worse with Kaposi's sarcoma

Question 41. In HIV infection

80% of vertically transmitted infections are transplacental (False)
Explanation: Majority occur during parturition
a child born to an infected mother has a 90% chance of acquiring HIV (False)
Explanation: Under 50% chance
transmission can occur via breast milk (True)
Explanation: 10-20% additional risk for breast-fed babies
risk of fetal transmission is unaffected by pre-partum antiviral agents (False)
Explanation: HAART can reduce transmission rate

Question 42. In the diagnosis of HIV infection

ELISA testing has a low false negative rate (True)
Explanation: ELISA testing therefore widely used as a screening test
seroconversion invariably occurs in under 4 weeks (False)
Explanation: 6-12 weeks or longer
antibody detection tests are particularly helpful in neonates (False)
Explanation: May have transplacentally acquired maternal antibody
HIV-RNA can be directly measured as a confirmatory test (True)
Explanation: Sometimes used as a confirmatory test
HIV-RNA is typically detected before anti-HIV antibodies (True)

Question 43. In the classification of HIV infection

group A = acute seroconversion simulating glandular fever (True)
Explanation: Also includes asymptomatic patients
group B = persistent generalised lymphadenopathy (False)
Explanation: Classed as group A infection
group C = constitutional symptoms and oral candidiasis (False)
Explanation: Group C includes conditions meeting CDC/WHO case definition
group A1/B1/C1 all have absolute CD4 count > 500/mm3 (True)
group B = asymptomatic infection (False)
Explanation: Group A are asymptomatic

Question 44. Presenting features of HIV infection include

hairy leucoplakia (True)
Explanation: Affects the tongue and mouth
atypical pneumonia (True)
Explanation: Especially Pneumocystis carinii
thrombocytopenic purpura (True)
pulmonary tuberculosis (True)
Explanation: Sometimes with atypical mycobacteria
candidiasis and cryptosporidiosis (True)

Question 45. Cryptosporidiosis in an HIV-positive patient is

an AIDS-defining diagnosis if chronic (True)
likely to present with painless profuse diarrhoea (False)
Explanation: Profuse diarrhoea, but usually with abdominal pain
likely to be self-limiting if the CD4 count is > 200 cells/mm3 (True)
preventable by the use of boiled tap water (True)
usually diagnosed on stool microscopy (True)

Question 46. Pneumocystis carinii infection in an HIV-positive patient is

the commonest cause of respiratory infection in African patients (False)
Explanation: Tuberculosis is more common

By A. H.
characterised by copious sputum production (False)
Explanation: Dry cough and dyspnoea
characterised by widespread fine pulmonary crackles (False)
Explanation: Crackles would be unusual
more likely to occur when the CD4 count is < 200/mm3 (True)
Explanation: In 95% of cases
excluded by the finding of a normal chest X-ray (False)
Explanation: Normal chest radiograph is found in 15-20% of cases

Question 47. In a patient with AIDS, cryptococcal meningitis is

the commonest cause of meningitis (True)
Explanation: Also causes pulmonary disease
characterised by abrupt onset of the classical features of a bacterial meningitis (False)
Explanation: Indolent onset
diagnosed by India ink stain of cerebrospinal fluid (CSF) (True)
Explanation: And serum/CSF culture
typically associated with negative CSF culture (False)
associated with deafness in survivors (True)
Explanation: And blindness

Question 48. In the treatment of HIV infection

all useful drugs work via inhibition of reverse transcriptase (False)
Explanation: Some are protease inhibitors
nucleoside reverse transcriptase inhibitors may cause peripheral neuropathy (True)
reverse transcriptase inhibitors prevent spread of infectious virus into uninfected cells (True)
Explanation: But not replication
drug-resistant strains of virus have not been recognised (False)
Explanation: As with zidovudine
monotherapy is preferred (False)
Explanation: Survival rates improve with combination regimens

Question 49. Antimicrobial therapy acts in the following ways

aminoglycosides disrupt bacterial protein synthesis (True)
Explanation: Via ribosomal binding
sulphonamides interrupt bacterial folate synthesis (True)
Explanation: And hence nucleic acid synthesis
penicillins disrupt bacterial protein synthesis (False)
Explanation: Affect cell wall synthesis
cephalosporins disrupt bacterial cell wall synthesis (True)
Explanation: As with penicillins
tetracyclines disrupt bacterial protein synthesis (True)
Explanation: Via ribosomal binding

Question 50. The following statements about penicillins are true

all penicillins are bactericidal (True)
Explanation: By interfering with their cell wall synthesis
like the cephalosporins, they contain a â-lactam ring (True)
Explanation: Resistance by â-lactamase-producing organisms is common
clavulanic acid inhibits bacterial â-lactamase (True)
Explanation: Used in combination with amoxicillin as co-amoxiclav
they are all safe in pregnancy (False)
Explanation: Imipenem is not
they are synergistic with aminoglycosides (True)

Question 51. Erythromycin is active against the following microorganisms

Campylobacter jejuni (True)
Escherichia coli (False)

By A. H.
Explanation: Hence less likely to disrupt bowel flora
Legionella pneumophila (True)
Mycoplasma pneumoniae (True)
Explanation: In appropriate dosage
Clostridium welchii (True)

Question 52. Aminoglycoside drug therapy

is ototoxic and nephrotoxic (True)
Explanation: Especially in the elderly
is well absorbed orally (False)
Explanation: Negligible oral absorption
must be monitored using plasma drug concentrations (True)
Explanation: Serum levels and duration of therapy correlate with risk of toxicity
is effective against anaerobes and Streptococcus faecalis (False)
Explanation: No anti-anaerobic activity
is very effective against Gram-negative organisms (True)

Question 53. Ciprofloxacin is highly active against the following microorganisms

Escherichia coli (True)
Haemophilus influenzae (True)
Proteus mirabilis (True)
Explanation: Active against most of the enterobacteria
Streptococcus pneumoniae (False)
Explanation: Only moderate activity
Bacteroides fragilis (False)

Question 54. The following antiviral agents are active against the following viruses
ganciclovir-cytomegalovirus (True)
amantadine-orthomyxovirus (True)
Explanation: Used in prophylaxis of influenza A
ribavirin-respiratory syncytial virus (True)
Explanation: Also active in Lassa fever
zidovudine-retrovirus (True)
Explanation: Used in AIDS
famciclovir-herpes simplex and herpes zoster viruses (True)
Explanation: Like aciclovir, useful orally or parenterally

Module 2 (Chapter 2)
Question 1. 200 patients with hypertension are treated with a new drug to prevent strokes and compared with 200
similar patients who are given a placebo in a randomised controlled clinical trial (RCT). After 1 year of treatment 5
patients in the treatment group and 10 patients in the control group have suffered a stroke. Which of the following
statements are true?
the absolute risk reduction with treatment is 5% (False)
Explanation: 2.5%
the relative risk is 0.5 (True)
Explanation: 50% relative risk reduction
the number needed to treat is 200 (False)
Explanation: 40
all patients with hypertension will benefit from this treatment (False)
Explanation: Only patients similar to those in the trial
benefit can be expected to be similar in following years of treatment (False)
Explanation: Can only be derived from continuing the RCT

Question 2. Examples of pharmacokinetic interactions include the following

allopurinol inhibits the metabolism of azathioprine (True)
Explanation: And 6-mercaptopurine; both are metabolised by xanthine oxidase
metoclopramide delays gastric emptying and the rate of drug absorption (False)

By A. H.
Explanation: It increases the rate of gastric emptying
digoxin and verapamil compete for renal tubular secretion (True)
Explanation: Similarly, quinidine and amiodarone compete with digoxin for renal excretion
the effect of methotrexate is inhibited by NSAID therapy (False)
Explanation: Increased effect due to inhibition of renal tubular secretion of methotrexate
renal lithium excretion is inhibited by diuretics (True)
Explanation: Recommend a barrier method as well for patients on the contraceptive pill and taking antibiotics

Question 3. The following drugs should be avoided in severe renal failure

gentamicin (False)
Explanation: But reduce dose frequency and measure plasma concentrations daily
oxytetracycline (True)
Explanation: Induces protein catabolism and rapidly increasing uraemia
morphine (False)
Explanation: But reduce both dose and dose frequency
mesalazine (True)
Explanation: Like all NSAIDs, reduces renal blood flow by prostaglandin inhibition
metformin (True)
Explanation: Causes lactic acidosis

Question 4. The following drugs exhibit high rates of hepatic clearance

codeine phosphate (False)
Explanation: Similar to paracetamol in this respect
diazepam (False)
Explanation: Low rates of clearance during its first passage through the liver
simvastatin (True)
Explanation: Lidocaine (lignocaine) is also rapidly cleared during its first passage through the liver ('first-pass' effect)
propranolol (True)
warfarin (False)

Question 5. The actions of the following drugs are enhanced in liver disease
warfarin (True)
Explanation: Reduces the synthesis of clotting factors
metformin (True)
Explanation: Produces lactic acidosis
chloramphenicol (True)
Explanation: Induces bone marrow suppression
sulphonylureas (True)
Explanation: Increase the risk of hypoglycaemia
naproxen (True)
Explanation: Like other NSAIDs, increases the risk of gastrointestinal bleeding

Question 6. The following statements about drug prescribing in elderly patients are true
the error rate in patients taking prescribed drugs is similar to that found in younger adults (False)
Explanation: Error rates of up to 60% can be found in patients over the age of 60 years
adverse drug reactions are more likely to occur than in younger adults (True)
Explanation: Adverse drug reactions are 2-3 times more common
an increased proportion of body fat increases the accumulation of lipid-soluble drugs (True)
Explanation: Propranolol accumulation is also increased by reduced drug metabolism
drug excretion is typically increased due to impaired urinary concentrating ability (False)
Explanation: Impaired renal clearance associated with a reduced glomerular filtration rate is common
metabolism of paracetamol reduces with advancing age (True)
Explanation: As with other drugs (e.g. theophylline and sedative drugs) doses should be reduced

Question 7. The following are statutory requirements for the prescription of controlled drugs
prescriptions must be typewritten not written by hand (False)
Explanation: Prescriptions must be written entirely in the prescriber's own handwriting, in ink

By A. H.
prescriptions must specify the patient's name and address (True)
prescriptions must specify the prescriber's name and address (True)
prescriptions must state the dosage in both words and numbers (True)
Explanation: Including the total quantity, number of doses, and form and strength of the drug
prescriptions must be signed and dated by the prescriber (True)

Module 3 (Chapter 3)
Question 1. The use of oral activated charcoal is indicated following poisoning with
paracetamol (True)
Explanation: More effective if given early
acetylsalicylic acid (True)
Explanation: More effective if given early and repeated 4-hourly ('gut dialysis')
ferrous sulphate (False)
Explanation: Not absorbed by activated charcoal
ethylene glycol (False)
Explanation: Not absorbed by activated charcoal
lithium carbonate (False)
Explanation: Not absorbed by activated charcoal

Question 2. Typical features 6-8 hours after paracetamol poisoning include

nausea and vomiting (True)
Explanation: Abdominal pain may develop
coma and internuclear ophthalmoplegia (False)
Explanation: Late features suggesting hepatic encephalopathy (after 3-5 days)
prolongation of the prothrombin time (False)
Explanation: Rare before 24 hours
metabolic acidosis and hypoglycaemia (False)
Explanation: Consequence of hepatic necrosis (after 36 hours)
prevention of liver damage with N-acetylcysteine therapy (True)
Explanation: But not useful beyond 15 hours

Question 3. Features of salicylate poisoning in an adult may include

metabolic acidosis (True)
Explanation: A poor prognostic sign
deafness, tinnitus and blurred vision (True)
Explanation: Common features
hypokalaemia and respiratory alkalosis (True)
Explanation: Due to hyperventilation
hyperventilation, sweating and restlessness (True)
peripheral vasodilatation (True)

Question 4. The following treatments are clinically useful in poisoning with the following agents
glucagons-â-blockers (True)
DMPS (dimercaprol)-heavy metal poisons (True)
Explanation: Useful in arsenic, gold and mercury poisoning
flumazenil-opioid analgesics (False)
Explanation: Used in benzodiazepine overdose
N-acetylcysteine-paracetamol (True)
Explanation: As indicated by plasma paracetamol concentrations post-ingestion
desferrioxamine-iron salts (True)

Question 5. Typical features following benzodiazepine poisoning include

ataxia, dysarthria, nystagmus and drowsiness (True)
severe systemic hypotension and respiratory depression (False)
Explanation: Severe cardiorespiratory depression is rare
nausea, vomiting and diarrhoea (False)

By A. H.
Explanation: Suspect mixed overdose
convulsions, muscle spasms and papilloedema (False)
Explanation: Suspect alternative or mixed overdose
resolution of symptoms and signs within < 6 hours of poisoning (False)
Explanation: Usually < 24 hours

Question 6. The following are true of cocaine poisoning

hypothermia is a typical feature (False)
Explanation: Hyperthermia or pyrexia
cerebellar signs may occur (True)
Explanation: As may convulsions
myocardial infarction occurs only in the presence of abnormal coronary arteries (False)
Explanation: They may be normal
activated charcoal is of benefit within 1 hour of ingestion (True)
a dose of over 10 mg would usually be regarded as potentially fatal (False)
Explanation: Over 1 g

Question 7. Typical features of morphine poisoning include

nausea, vomiting and pallor (True)
coma with widely dilated pupils (False)
Explanation: Pinpoint pupils
hypoventilation and respiratory arrest (True)
hypotension and hypothermia (True)
Explanation: Use naloxone
non-cardiac pulmonary oedema (True)
Explanation: Characteristic and the commonest mode of death

Question 8. Typical features of carbon monoxide poisoning include

nausea, vomiting (False)
Explanation: Common features include agitation, headache and confusion
marked central cyanosis (False)
Explanation: Usually skin pallor; patients may appear 'pink' due to carboxyhaemoglobin
hypotension and myocardial ischaemia (True)
Explanation: Especially in patients whose coma is prolonged
cognitive impairment and personality changes following recovery (True)
Explanation: Due to the effects of cerebral oedema and cerebral anoxia
parkinsonian features following recovery (True)
Explanation: Neuropsychiatric sequelae occur in 10% 2-4 weeks following recovery

Module 4 (Chapter 4)
Question 1. The following statements about pulmonary artery wedge pressure (PAWP) monitoring are correct
PAWP provides an indirect measure of left atrial pressure (True)
the normal range is 15-20 mmHg (False)
Explanation: 6-12 mmHg
the PAWP is reduced in acute left ventricular failure (False)
Explanation: Increased, often > 35 mmHg
complications of monitoring include pulmonary artery rupture (True)
Explanation: Also pneumothorax, air embolism, sepsis and arrhythmias
the optimum PAWP in acute circulatory failure is 12-15 mmHg (True)

Question 2. The following statements about monitoring of pulmonary function are correct
oxygen saturation (SaO2) should be maintained in the range 75-85% (False)
Explanation: Maintain > 90%
the oxygenation index (PaO2/FIO2) is a useful measure of gas exchange (True)
Explanation: As is alveolar arterial oxygen gradient
end-tidal alveolar CO2 concentration measures the effectiveness of ventilation (True)
Explanation: As does PaCO2

By A. H.
measurement of oxygen saturation requires arterial blood sampling (False)
Explanation: Finger or earlobe spectrophotometry is satisfactory in most instances
a decreasing cardiac output is likely to induce an abrupt fall in SaO2 (True)

Question 3. The following statements about oxygen transport in the blood are correct
the amount of oxygen carried by haemoglobin is equal to that dissolved in the plasma (False)
Explanation: Hb carriage accounts for the majority
an increase in PaCO2 shifts the oxygen/haemoglobin dissociation curve to the right (True)
Explanation: Bohr effect-facilitates unloading of O2 to tissues
the optimum haemoglobin concentration in a critically ill adult male is 15 g/dl (False)
Explanation: 7-10 g/dl to minimise hyperviscosity problems
at a PaO2 = 3.5 kPa, approximately 10% of the haemoglobin will be saturated (False)
Explanation: Around 50%
increasing the haemoglobin concentration of the blood will increase its oxygen content but not its partial pressure of
oxygen (True)
Explanation: Hb concentration and saturation are major determinants of O2 content

Question 4. The following statements about oxygen consumption are correct

VO2 (global oxygen consumption) can be calculated from the PaO2 and the PaCO2 (False)
Explanation: Calculated from inspiratory/expiratory gas analysis
mixed venous oxygen saturation (SvO2) is the pulmonary arterial oxygen saturation (True)
Explanation: Equates to DO2 (oxygen delivery) - VO2 (global oxygen consumption)
SvO2 reflects the amount of oxygen not consumed by the tissues (True)
oxygen saturation of venous blood from differing tissues is identical (False)
Explanation: Varies depending on metabolic rate
VO2 rises 10-15% for every 1°C rise in body temperature (True)
Explanation: Sepsis and trauma also increase VO2

Question 5. Diagnostic criteria for the systemic inflammatory response syndrome (SIRS) include
temperature > 38°C or < 36°C (True)
Explanation: Sepsis may cause hypothermia as well as fever
respiratory rate > 30/min (False)
Explanation: > 20/min
heart rate > 90/min (True)
white cell count > 12 000 or < 4000/mm2 (True)
PaCO2 < 4.3 kPa (True)

Question 6. The following statements about shock syndromes are correct

in severe hypovolaemia, a source of blood/fluid loss is invariably apparent clinically (False)
Explanation: Bleeding may be internal
in cardiogenic shock, the peripheries are characteristically warm (False)
Explanation: Peripheral cyanosis is characteristic
massive pulmonary embolism typically presents with shock (True)
Explanation: Due to central vessel obstruction
anaphylactic shock is associated with profound allergen-induced systemic vasoconstriction (False)
Explanation: Vasodilatation occurs
arteriovenous shunting is a significant contributory factor in septic shock (True)
Explanation: Capillary damage and vasodilatation also occur

Question 7. Acute circulatory failure with an elevated central venous pressure are typical findings in
acute pancreatitis (False)
Explanation: Hypovolaemic shock occurs
massive pulmonary embolism (True)
Explanation: Acute right ventricular failure
ruptured ectopic pregnancy (False)
acute right ventricular infarction (True)
pericardial tamponade (True)

By A. H.

Question 8. The acute respiratory distress syndrome (ARDS) is characterised by

maintenance of a normal PaO2 despite profound dyspnoea (False)
Explanation: Hypoxaemia is a cardinal feature
increased pulmonary compliance (False)
Explanation: Compliance decreases
a normal chest radiograph (False)
Explanation: Diffuse infiltrates are typical
greatly elevated pulmonary artery wedge pressure (False)
Explanation: Typically normal or slightly elevated
elevated right heart pressure (True)
Explanation: Pulmonary hypertension is common

Question 9. The expected effects of the following vasoactive drugs include

nitroprusside-reduction in systemic vascular resistance (True)
Explanation: Blood pressure typically falls
epoprostenol (prostacyclin)-increased pulmonary vascular resistance (False)
Explanation: Reduces PVR
isoprenaline-sinus tachycardia (True)
Explanation: And moderate increase in myocardial contractility
dopamine-sinus bradycardia (False)
Explanation: Usually tachycardia
adrenaline (epinephrine)-increased splanchnic blood flow (False)
Explanation: Typically declines

Question 10. The following statements about mechanical respiratory support are correct
cardiac output increases with positive end-expiratory pressure (PEEP) (False)
Explanation: Cardiac output often falls
PEEP helps correct V/Q mismatch (True)
Explanation: Improves oxygenation in atelectatic areas
continuous positive airways pressure (CPAP) requires intubation (False)
Explanation: A tightly fitting face or nasal mask can be used
the correct position of an endotracheal tube is 4 cm above the carina (True)
intermittent ventilation is useful in the transition to non-assisted ventilation (True)

Question 11. In the management of raised intracranial pressure (ICP)

normal ICP is < 15 mmHg (True)
Explanation: A sustained pressure > 30 mmHg suggests a poor prognosis
cerebral perfusion pressure = mean systemic arterial pressure minus intracranial pressure (True)
Explanation: Should be > 70 mmHg
modest hyperglycaemia facilitates a decrease in ICP (False)
Explanation: Glycaemic control should be strict
temporary hyperventilation reduces ICP (True)
Explanation: Target (PaCO2 of 4 kPa for 24 hours
the patient should be nursed with 30° head-up tilt (True)
Explanation: And avoid excessive neck flexion

Module 5 (Chapter 5)
Question 1. The histological features useful in distinguishing benign from malignant lesions include
a lower nuclear to cytoplasmic ratio (False)
Explanation: Increased
the presence of aberrations in nuclear morphology (True)
the number of cell mitoses (True)
Explanation: Increases with cell proliferation rate
the presence of cellular invasion into surrounding tissues (True)
Explanation: Evidence of metastatic spread
the number of mitochondria in the cell cytoplasm (False)

By A. H.

Question 2. Useful serum tumour markers associated with the following diseases include
human chorionic gonadotrophin in testicular seminoma (False)
Explanation: Useful in testicular germ cell tumours
alpha fetoprotein in primary hepatocellular carcinoma (True)
Explanation: And testicular germ cell tumours
carcinoembryonic antigen in bronchial adenoma (False)
Explanation: Metastatic colorectal carcinoma
placental alkaline phosphatase in cervical carcinoma (False)
Explanation: There are no useful serum markers for cervical carcinoma
CA-125 in breast carcinoma (False)
Explanation: Useful in ovarian carcinoma

Question 3. The paraneoplastic syndromes listed below are typical of the following tumours
inappropriate ADH-adenocarcinoma of lung (False)
Explanation: Small-cell carcinoma
prothrombotic tendency-pancreatic carcinoma (True)
polymyositis-gastric carcinoma (True)
Explanation: And ovarian and nasopharyngeal carcinoma
myasthenia-like syndrome-small-cell anaplastic lung carcinoma (True)
Explanation: Lambert-Eaton syndrome
acanthosis nigricans-gastric carcinoma (True)
Explanation: And other gastrointestinal malignancy

Question 4. Malignant diseases that are potentially curable using combination chemotherapy include
cervical cancer (True)
squamous cell bronchial carcinoma (False)
Explanation: Refractory to chemotherapy
choriocarcinoma (True)
Explanation: Also testicular teratoma
oesophageal carcinoma (False)
Explanation: Resistant
soft tissue sarcoma (False)
Explanation: Resistant

Question 5. The following statements about chemotherapy are true

methotrexate is an antifolate-blocking nucleotide synthesis (True)
Explanation: An antimetabolite
vincristine is an alkylating agent blocking DNA transcription (False)
Explanation: A mitotic spindle poison
doxorubicin is a plant alkaloid which disrupts mitotic spindles (False)
Explanation: An antibiotic anticancer drug which acts primarily as a topoisomerase antagonist
taxanes act as mitotic spindle poisons (True)
Explanation: E.g. docetaxel
melphalan is an alkylating agent which blocks DNA replication (True)
Explanation: And also blocks DNA transcription

Module 6 (Chapter 6)
Question 1. In the management of pain in patients with malignant diseases
analgesia is best prescribed on an 'as required' basis (False)
Explanation: Should be given regularly
NSAID therapy is particularly valuable in bone pain (True)
Explanation: Affects prostaglandin metabolism
controlled-release morphine has a 4-hour duration of action (False)
Explanation: 12 hours
respiratory depression is a common feature of prolonged opiate use (False)
Explanation: But can occur in acute dosing

By A. H.
opiates are of no value in neuropathic pain (False)
Explanation: But other agents may be more effective

Question 2. The following drugs have clinically useful antiemetic properties

haloperidol (True)
domperidone (True)
Explanation: Blocks dopaminergic receptors
ondansetron (True)
Explanation: 5HT3 receptor antagonist
dexamethasone (True)
Explanation: Given parenterally with chemotherapy
etoposide (False)
Explanation: Chemotherapeutic agent which causes nausea and vomiting

Question 3. The following treatments may be of benefit in a patient with the following cancer-related symptoms
co-danthrusate-constipation (True)
gabapentin-nausea (False)
Explanation: Used for neuropathic pain
trazodone-insomnia (True)
Explanation: A sedating antidepressant
eicosapentanoic acid-anorexia (True)
Explanation: If combined with a high-protein diet
amitriptyline-neuropathic pain (True)

Module 7 (Chapter 7)
Question 1. Expected physiological changes associated with normal ageing include
decreased calcium phosphate content per 100 g bone (False)
Explanation: Bone mass declines (osteoporosis) but mineralisation is normal
increased tissue sensitivity to insulin (False)
Explanation: Reduced insulin sensitivity and glucose tolerance declines
reduced numbers of pacing cells within the sinoatrial node (True)
Explanation: Limits ability to mount a tachycardia
increased glomerular filtration rate (GFR) (False)
Explanation: Decreased number of nephrons, GFR and medullary function
increased chest wall rigidity (True)

Question 2. Likely causes of recurrent falls in the elderly include

accidental slips and trips (True)
Explanation: Exacerbated by poor mobility
postural hypotension (True)
Explanation: Often drug-induced
vasovagal syncope (False)
Explanation: More common in the young
Parkinson's disease (True)
Explanation: Multiple factors involved
acute myocardial infarction (False)
Explanation: May present with a single fall but not recurrent falls

Question 3. The following interventions may be of value in a patient with falls

oral fludrocortisone (True)
Explanation: May help postural hypotension
occupational therapy home visit (True)
Explanation: To improve environmental safety
programme of exercise training (True)
soft cervical collar (False)
Explanation: May help vertebrobasilar insufficiency
oral calcium and vitamin D (True)

By A. H.
Explanation: Help reduce the risk of fall fractures

Question 4. In the frailty syndrome the following domains are impaired

musculoskeletal function (True)
aerobic capacity (True)
cognitive function (True)
integrative neurological function (True)
nutritional status (True)

Module 8 (Chapter 8)
Question 1. Aetiological factors in psychiatric illness include
family history of psychiatric illness (True)
Explanation: Rarely, a single gene disorder is identified
parental loss or disharmony in childhood (True)
Explanation: Especially physical or sexual abuse
stressful life events and difficulties (True)
Explanation: E.g. bereavement, redundancy, retirement
chronic physical ill health (True)
Explanation: Also acute severe physical illness
social isolation (True)
Explanation: Particularly lack of a close relationship

Question 2. Important factors in the assessment of mental state include

appearance and behaviour (True)
Explanation: Including motor retardation
mood state (True)
Explanation: E.g. suicidal ideation
speech and thought content (True)
Explanation: Paranoid, grandiose or depressive
abnormal perceptions and beliefs (True)
Explanation: Depersonalisation, illusions and hallucinations
cognitive function (True)
Explanation: Concentration, memory and orientation

Question 3. The following psychiatric definitions are true

delusions-abnormal perceptions of normal external stimuli (False)
Explanation: Illusions
illusions-unreasonably persistent, firmly held, false beliefs (False)
Explanation: Delusions
hallucinations-abnormal perceptions without external stimuli (True)
Explanation: Suggest psychosis
depersonalisation-perception of altered reality (True)
Explanation: Often with derealisation
phobia-abnormal fear leading to avoidance behaviour (True)
Explanation: Typical pattern in neurosis

Question 4. Diseases mimicking anxiety disorders include

alcohol withdrawal (True)
Explanation: Delirium may also occur
hyperthyroidism (True)
Explanation: Exclude biochemically
hypoglycaemia (True)
Explanation: Measure blood glucose
temporal lobe epilepsy (True)
Explanation: EEG may be necessary
phaeochromocytoma (True)

By A. H.
Explanation: Rare-measure urinary catecholamines

Question 5. Factors associated with a higher suicide risk following attempted suicide include
females aged < 45 years (False)
Explanation: Older males
self-poisoning rather than more violent methods of self-harm (False)
Explanation: Self-poisoning is frequently parasuicidal
absence of a suicide note or previous suicide attempts (False)
Explanation: Suicide note often left and usually a history of previous attempts
chronic physical or psychiatric illness (True)
Explanation: And drug or alcohol misuse
living alone and/or recently separated from partner (True)
Explanation: Or bereavement

Question 6. Cardinal elements in cognitive therapy include

restructuring psychological conflicts and behaviour (False)
Explanation: Undertaken in psychotherapy
identification of negative patterns of automatic thoughts (True)
Explanation: E.g. in depression
awareness of connections between thoughts, mood and behaviour (True)
Explanation: Altering thoughts may alter behaviour
reorientation of negative views of the past, present and future (True)
Explanation: And development of positive views
personality assessment and transactional analysis (False)
Explanation: Features of psychotherapy

Question 7. The typical features of alcohol dependence include

expansion of the drinking repertoire (False)
Explanation: Narrowing of choices of alcoholic beverages
increasing tolerance of alcohol (False)
Explanation: Decreasing tolerance
subjective compulsion to drink (True)
use of alcohol to relieve withdrawal symptoms (True)
Explanation: Classical
recurrent withdrawal symptoms (True)

Question 8. The typical features of depression include

depressed mood for most of the day (True)
Explanation: But diurnal variation may occur
insomnia or hypersomnia (True)
Explanation: Or early morning wakening
loss of pleasure, self-esteem and hope (True)
Explanation: 'Anhedonia'-loss of sense of enjoyment
loss of energy, libido and interest (True)
Explanation: Perhaps with other somatic symptoms
psychomotor retardation and suicidal thoughts (True)
Explanation: With delusions of worthlessness

Question 9. Clinical features of generalised anxiety disorders include

feelings of worthlessness and excessive guilt (False)
Explanation: Suggest depression
depersonalisation and derealisation (True)
Explanation: May be seen in affective disorders
feelings of apprehension and impending disaster (True)
Explanation: With irritability
breathlessness, dizziness, sweating and palpitation (True)

By A. H.
Explanation: Typical somatic symptoms
claustrophobia and agoraphobia (False)
Explanation: Features of phobic anxiety states

Question 10. Typical features of anorexia nervosa include

only adolescent girls are affected (False)
Explanation: Either sex, rarely non-adolescent
amenorrhoea or loss of libido > 3 months (True)
Explanation: With avoidance of high-calorie foods
weight loss > 25% or weight < 25% below normal (True)
Explanation: In contrast to bulimia nervosa
normal perception of body weight and image (False)
Explanation: Emaciation is unrecognised by the patient
progression to death in 20% (False)
Explanation: In 5%

Module 9 (Chapter 9)
Question 1. In a normal 65 kg man, the following statements are true
total body water is approximately 40 litres (True)
Explanation: Relatively constant in health
70% of the total body water is intracellular (True)
Explanation: Approximately 28 litres
75% of extracellular water is intravascular (False)
Explanation: 25% intravascular, 75% interstitial
sodium, bicarbonate and chloride ions are mainly intracellular (False)
Explanation: Extracellular
potassium, magnesium, phosphate and sulphate ions are mainly extracellular (False)
Explanation: Intracellular

Question 2. Typical causes of hyponatraemia include

diabetes insipidus (False)
Explanation: But may be seen in the syndrome of inappropriate antidiuretic hormone (ADH) secretion
hepatocellular failure (True)
Explanation: Water retention exceeds sodium retention
psychogenic polydipsia (True)
Explanation: Increased total body water
Cushing's syndrome (False)
Explanation: But seen in adrenocortical insufficiency
diuretic drug therapy (True)
Explanation: Salt loss exceeds water loss

Question 3. Predominant water depletion is a recognised complication of

primary hyperparathyroidism (True)
Explanation: Renal tubular insensitivity to ADH
toxic confusional states (True)
Explanation: Inadequate intake
oesophageal carcinoma (True)
Explanation: Inadequate intake
lithium therapy (True)
Explanation: Renal tubular insensitivity to ADH
enteral feeding (True)
Explanation: High solute load

Question 4. The following statements about potassium balance are true

85% of the daily potassium intake is excreted in the urine (True)
intracellular potassium ion concentrations are about 150 mmol/l (True)
Explanation: Compared with extracellular concentrations of about 4 mmol/l

By A. H.
cellular uptake of potassium is enhanced by adrenaline and insulin (True)
alkalosis predisposes to hyperkalaemia (False)
the normal dietary potassium intake is about 100 mmol per day (True)

Question 5. Hyperkalaemia is a recognised finding in

severe untreated diabetic ketoacidosis (True)
Explanation: Insulin promotes movement into the cells
primary hypoadrenalism (True)
Explanation: Impairment of secretion in the distal nephron
rhabdomyolysis (True)
Explanation: Increased tissue breakdown
prostaglandin inhibitor therapy in renal impairment (True)
Explanation: Especially if given with an ACE inhibitor
angiotensin-converting enzyme (ACE) inhibitor therapy (True)
Explanation: Avoid concurrent supplementation

Question 6. The emergency treatment of severe hyperkalaemia should include

dietary restriction of coffee and fruit juices (False)
Explanation: But may be necessary to prevent recurrence
parenteral dextrose and glucagon therapy (False)
Explanation: Give parenteral dextrose and insulin
parenteral calcium gluconate therapy (True)
Explanation: Cardioprotective effect
restoration of sodium and water balance (True)
Explanation: Also correct metabolic acidosis if present with 1.26% sodium bicarbonate i.v.
Calcium Resonium orally and/or rectally (True)
Explanation: The resin binds potassium in exchange for calcium

Question 7. Recognised causes of potassium depletion include

metabolic alkalosis (True)
Explanation: Renal tubular cell K+ concentration increased, excretion increased
cardiac failure (True)
Explanation: Secondary hyperaldosteronism
corticosteroid treatment (True)
Explanation: Mineralocorticoid-like effect
renal tubular acidosis (True)
Explanation: Primary or secondary tubular defect; also occurs with activation of renin and angiotensin
amiloride diuretic therapy (False)
Explanation: Causes hyperkalaemia by an effect on the distal convoluted tubules

Question 8. Metabolic acidosis would be an expected finding in

chronic alveolar hyperventilation (False)
Explanation: Chronic respiratory alkalosis
acute insulin deficiency (True)
Explanation: Diabetic ketoacidosis
acute inflammatory polyneuropathy (Guillain-Barré syndrome) (False)
Explanation: Acute respiratory acidosis due to alveolar hypoventilation
failure of distal renal tubular hydrogen ion secretion (True)
Explanation: Distal (type I) renal tubular acidosis
methanol poisoning (True)

Question 9. Metabolic alkalosis may be caused by

hyperventilation (False)
Explanation: Respiratory alkalosis
aspiration of gastric contents (True)
Explanation: Or vomiting
mineralocorticoid deficiency (False)

By A. H.
Explanation: Can produce mild acidosis
excessive liquorice ingestion (True)
Explanation: Due to excessive mineralocorticoid activity
diuretic therapy (True)
Explanation: And hypokalaemia

Question 10. Magnesium deficiency is

a cause of confusion, depression and epilepsy (True)
Explanation: And tremor and choreiform movements
usually due to prolonged vomiting and diarrhoea (True)
Explanation: Also from chronic diuretic therapy
found in uncontrolled diabetes mellitus and alcoholism (True)
Explanation: Excess losses in the urine
found in primary hyperparathyroidism and hyperaldosteronism (True)
Explanation: Including secondary hyperaldosteronism
best treated with oral magnesium sulphate (False)
Explanation: Very poorly absorbed orally

Module 10 (Chapter 10)

Question 1. A healthy daily diet for a slim man with a physical job should include
1500 kcal (8.4 MJ) (False)
Explanation: About 11.3 MJ (2700 kcal)
60% of total energy requirements as carbohydrate (True)
Explanation: 55-75%
no less than 10 g salt per day (False)
Explanation: No more than 6 g/day
35 g of dietary fibre (True)
Explanation: 27-40 g/day
no more than 10% of total energy requirements as fat (False)
Explanation: 15-30%

Question 2. Recognised medical complications of weight gain include

osteoporosis (False)
Explanation: Bone density increases
rheumatoid arthritis (False)
Explanation: Osteoarthritis
gallstones (True)
Explanation: Often asymptomatic
type 2 diabetes mellitus (True)
Explanation: With insulin resistance
hyperlipidaemia (True)
Explanation: And coronary artery disease

Question 3. Ideal weight-reducing diets in the treatment of moderate obesity should

provide no more than 2.5 MJ (600 kcal) per day (False)
Explanation: Aim to reduce intake by no more than 2.5 MJ (600 kcal) per day
achieve a theoretical weight loss of at least 2 kg per week (False)
Explanation: 0.5 kg per week (2.5 MJ or 600 kcal deficit/day = 17.15 MJ or 4200 kcal/week = 0.6 kg human tissue)
aim to achieve a weight loss of 10% (True)
Explanation: Sufficient to achieve a significant improvement in health
be part of a multiple risk factor intervention (True)
Explanation: E.g. cessation of smoking
reduce carbohydrate intake much more than total fat intake (False)
Explanation: Fat restriction < 50 g/day (calorific values fat = 38 KJ or 9 kcal/g, CHO = 17 KJ or 4 kcal/g)

Question 4. The benefits of a sustained 10 kg weight reduction in the obese include

fall in the blood pressure of 10 mmHg (systolic) and 20 mmHg (diastolic) (True)

By A. H.
reduction in total mortality of 20-25% (True)
reduction in fasting glucose of 15% (False)
Explanation: 50%
reduction in total cholesterol of 50% (False)
Explanation: Reduction in total cholesterol of 10%
reduction in high-density lipoprotein cholesterol of 8% (False)
Explanation: Increases by 8%

Question 5. Drug therapies known to increase appetite and body weight include
orlistat (False)
Explanation: Has a role in promoting weight loss
fenfluramine (False)
Explanation: But side-effects preclude use
amitriptyline (True)
fluoxetine (False)
Explanation: Stimulates satiety and can help some patients lose weight
sibutramine (False)
Explanation: Can support weight loss

Question 6. The function of the main lipoproteins include the following

chylomicrons transport mainly cholesterol (False)
Explanation: Mainly triglycerides; not present in the normal fasting plasma
very low-density lipoprotein transports endogenous triglycerides (True)
Explanation: VLDL is synthesised in the liver and is the precursor of LDL
low-density lipoprotein transports cholesterol (True)
Explanation: Generated from VLDL in the blood stream
high-density lipoprotein transports cholesterol from the peripheral tissues to the liver (True)
low-density lipoprotein is important for the excretion of cholesterol and is cardioprotective (False)
Explanation: HDL aids cholesterol excretion and is cardioprotective

Question 7. Common causes of secondary hyperlipidaemia include

chronic renal failure (True)
Explanation: Increases triglycerides and VLDL but decreases HDL
diabetes mellitus (True)
Explanation: Increases triglycerides and VLDL but decreases HDL
hyperthyroidism (False)
Explanation: Hypothyroidism increases cholesterol and LDL
alcohol misuse (True)
Explanation: Increases triglycerides, VLDL and HDL
thiazide diuretics (True)

Question 8. In the classification of hyperlipidaemias, the following findings are typical

chylomicronaemia in types I and V (True)
Explanation: Risk of pancreatitis with both types I and V but no atherogenic risk
hypertriglyceridaemia in types III, IV and V (True)
Explanation: Triglycerides variably abnormal in all except type IIa
hypercholesterolaemia in types II, III and IV (True)
Explanation: And all are associated with increased atherosclerosis
tendon xanthomata in type IIa hypercholesterolaemia (True)
Explanation: And premature coronary atherosclerosis
defective LDL catabolism and receptor binding in type V hyperlipidaemia (False)
Explanation: Defective LDL receptor gene is typical of type II familial hypercholesterolaemia

Question 9. The actions of the lipid-lowering drugs include the following

the statins inhibit HMG CoA reductase and reduce cholesterol synthesis (True)
Explanation: Increase LDL catabolism
the statins increase plasma LDL and triglycerides (False)

By A. H.
Explanation: Decrease plasma LDL and cholesterol
nicotinic acid increases lipolysis and lowers HDL (False)
Explanation: Decreases lipolysis and plasma triglycerides but increases plasma HDL
fibrates increase VLDL lipolysis (True)
Explanation: Decrease plasma triglycerides and plasma LDL and increase plasma HDL
colestipol diverts hepatic cholesterol synthesis into an increased bile acid production (True)
Explanation: Like colestyramine, it blocks bile acid reabsorption in the gut

Question 10. Clinical features of protein-energy malnutrition in adults include

a body mass index of between 20 and 22 (False)
Explanation: BMI < 16. N.B. BMI is calculated from the formula weight (kg) ÷ height2 (m)
oedema in the absence of hypoalbuminaemia (True)
Explanation: 'Famine oedema'
nocturia, cold intolerance and diarrhoea (True)
Explanation: And weakness, amenorrhoea or impotence
skin depigmentation, hair loss and covert infection (True)
Explanation: Adolescents may maintain hair growth
cerebral atrophy and sinus tachycardia (False)
Explanation: Brain weight is preserved; bradycardia is the rule

Question 11. The clinical features of protein-energy malnutrition in children include

marked muscle-wasting and abdominal distension in marasmus (True)
Explanation: And absence of oedema
weight loss more than growth retardation in marasmus (True)
Explanation: Weight < 60% standard for age
hepatic steatosis and hypoproteinaemic oedema in kwashiorkor (True)
Explanation: With low plasma lipids
desquamative dermatosis, stomatitis and anorexia in marasmus (False)
Explanation: Features of kwashiorkor
associated zinc deficiency in kwashiorkor (True)
Explanation: Contributing to dermatosis

Question 12. Vitamin A is

a fat-soluble vitamin (True)
Explanation: A, D, E, and K are the fat-soluble vitamins
present as retinol in carrots and certain green vegetables (False)
Explanation: Occurs as retinol in animal produce and as carotene in plants
the treatment of choice in xerophthalmia and keratomalacia (True)
Explanation: Both conditions are the result of vitamin A deficiency and lead to blindness
associated with teratogenicity if administered in pregnancy (True)
present in high concentrations in fish liver oils (True)
Explanation: Present as retinol

Question 13. Vitamin D

is present in high concentrations in dairy products (False)
Explanation: Some margarines are fortified
is non-essential in the diet given adequate sunlight exposure (True)
Explanation: But less efficiently produced in old age
like vitamin A is stored mainly in the liver (False)
Explanation: But metabolism partly occurs in the liver
is converted from cholecalciferol to 1,25-dihydroxycholecalciferol (True)
Explanation: 1-alpha hydroxylation occurs in the kidney and 25-hydroxylation in the liver
enhances calcium absorption by the induction of specific enterocyte transport proteins (True)
Explanation: And stimulates osteoclast proliferation

Question 14. Deficiency of the following B vitamins is associated with the disorders listed below
niacin-pellagra (True)

By A. H.
Explanation: Dermatitis, diarrhoea and dementia
pyridoxine-isoniazid-induced peripheral neuropathy (True)
Explanation: Add to anti-tuberculosis regimens using isoniazid
pyridoxine-haemolytic anaemia (False)
Explanation: Sideroblastic anaemia may respond
riboflavin-angular stomatitis (True)
Explanation: And also nasolabial seborrhoea
riboflavin-cheilosis (True)
Explanation: Also seen in niacin deficiency

Question 15. In the classification of acute and non-acute porphyrias

ä-aminolaevulinic acid synthetase activity is increased in all porphyrias (True)
Explanation: Rate-limiting step in biosynthesis of haem
porphobilinogen deaminase activity is reduced in acute porphyrias (True)
Explanation: Porphobilinogen accumulates
neuropsychiatric features are typical of the non-acute porphyrias (False)
Explanation: Typical of acute porphyria
photosensitivity is typical of the acute porphyrias (False)
Explanation: Typical of the non-acute porphyrias
variegate porphyria and coproporphyria are mixed porphyrias (True)
Explanation: Both are hepatic porphyrias

Question 16. Disorders associated with amyloid deposition include

familial Mediterranean fever (True)
Explanation: Reactive (AA) amyloidosis
bronchiectasis (True)
chronic haemodialysis (True)
Alzheimer's disease (True)
Explanation: Also the spongiform encephalitides
rheumatoid arthritis (True)
Explanation: Reactive AA amyloidosis

Module 11 (Chapter 11)

Question 1. In humans
somatic cell nuclei contain 22 pairs of homologous autosomes (True)
Explanation: In addition there are 2 X chromosomes in females and 1 X and 1 Y in males
gamete nuclei are haploid with a single X or Y chromosome (True)
Explanation: In contrast to somatic cell nuclei which are diploid
the haploid male cell (sperm) contains 22 autosomes and a Y chromosome (False)
Explanation: The haploid male cell (sperm) may contain an X or a Y chromosome
the long and short arms of a chromosome meet at the telomere (False)
Explanation: Centromere
both X chromosomes in females are genetically active (False)
Explanation: One X chromosome is inactive and appears as the Barr body in the nucleus

Question 2. In the chromosomal disorders

aneuploidy is the addition or loss of a chromosome (True)
Explanation: The most common form of numerical chromosome aberration
deletions arise from the loss of a segment of a chromosome (True)
the majority of affected conceptions result in miscarriage (True)
Explanation: Liveborn frequency is 0.6%
identical deletions produce the same effects whether inherited from father or mother (False)
Explanation: Gene expression can be affected by the parental origin of the abnormal chromosome
translocation is the exchange of segments between chromosomes (True)
Explanation: No genetic material is lost

Question 3. In polycystic kidney disease

By A. H.
inheritance is commonly autosomal dominant (True)
hepatic cysts commonly coexist (True)
intracranial aneurysms are present in 70% of patients (False)
Explanation: Incidence = 10%
DNA testing is useful in determining the presence of PKD1 mutations (False)
renal ultrasound after the age of 18 is the best screening test (True)
Explanation: Detects > 95% of individuals

Question 4. The karyotype of a

normal male is 45, XY (False)
Explanation: 46, XY
female with Down's syndrome is 46, XX, -21 (False)
Explanation: 47, XX, +21
male with Klinefelter's syndrome is 47, XXY (True)
female with Turner's syndrome is 45, XO (True)
male with trisomy 18 (Edwards' syndrome) is 47, XX, +18 (False)
Explanation: 47, XY, +18

Question 5. The following conditions arise as a result of the noted genetic abnormality
haemochromatosis-DNA point mutation (True)
Explanation: HFE gene
cystic fibrosis-DNA point mutation (False)
Explanation: Three base-pair deletion
Huntington's disease-triplet repeat expansions (True)
Explanation: On 4p16
Down's syndrome-chromosomal deletion (False)
Explanation: Chromosomal aneuploidy (trisomy 21)
DiGeorge syndrome-chromosomal microdeletion (True)
Explanation: The commonest microdeletion syndrome

Question 6. In autosomal dominant inheritance

affected individuals are usually heterozygotes (True)
affected individuals rarely have an affected parent (False)
Explanation: Parent is almost always affected
male offspring are more likely to be affected than female (False)
Explanation: An equal chance
unaffected children of an affected parent have a 50% chance of transmitting the condition (False)
Explanation: Unaffected children are free of the mutant gene
clinical disease is always found in genetically affected individuals (False)
Explanation: Some affected individuals are clinically normal-'non-penetrance'

Question 7. Given a husband with haemophilia and his unaffected wife

none of their sons will be affected (True)
Explanation: Absence of male to male transmission is a key feature of all X-linked inheritance
all of their daughters will carry the haemophilic gene (True)
a daughter with Turner's syndrome may also have haemophilia (True)
Explanation: If the X chromosome is inherited from the father
all of his sisters will be carriers (False)
Explanation: 50% of his sisters will be carriers and 50% normal
his maternal grandfather could have had haemophilia (True)
Explanation: All the female children of an affected grandfather would carry the gene

Question 8. The following disorders are caused by single gene disorders

cleft lip (False)
Explanation: Multifactorial disorder
sickle-cell anaemia (True)
Explanation: Autosomal recessive

By A. H.
retinitis pigmentosa (True)
cystic fibrosis (True)
Explanation: Autosomal recessive
familial hypercholesterolaemia (True)
Explanation: Autosomal dominant

Module 12 (Chapter 12)

Question 1. In the normal human heart
the atrioventricular (AV) node is usually supplied by the left circumflex coronary artery (False)
Explanation: Supplied by the right coronary artery in 90%
â1-adrenoceptors mediate chronotropic responses (True)
Explanation: These receptors also mediate inotropic responses
pulmonary artery systolic pressure normally varies between 90 and 140 mmHg (False)
Explanation: Varies between 15 and 30 mmHg in health
the annulus fibrosus aids conduction of impulses from the atria to the ventricles (False)
Explanation: Restricts electrical connections between the atria and ventricles to the AV node
cardiac output is the product of heart rate and ventricular end-diastolic volume (False)
Explanation: The product of heart rate and ventricular stroke volume

Question 2. With regard to cardiovascular physiology

cardiac output is approximately 10 l/min at rest (False)
Explanation: Measured in l/min (70/min × 700 ml = 5 l/min)
coronary blood vessels are innervated only by the parasympathetic nerves (False)
Explanation: Also by sympathetic-both have dominant vasodilating effect
intracoronary acetylcholine provokes vasoconstriction if atheroma is present (True)
Explanation: But endothelial-derived relaxing factor (EDRF)-mediated vasodilatation occurs in normal vessels
an atheromatous coronary lesion restricts blood flow during exercise if > 40% (False)
Explanation: Must be > 70%
bradykinin is an endogenous vasodilator (True)
Explanation: Others include adenosine, prostaglandins and nitric oxide

Question 3. In the normal electrocardiogram (ECG)

the PR interval is measured from the end of the P wave to the beginning of the R wave (False)
Explanation: Measured from the start of the P wave to the start of the R wave
each small square represents 40 milliseconds at a standard paper speed of 25 mm/sec (True)
the heart rate is 75 per minute if the R-R interval measures 4 cm (True)
Explanation: Heart rate = 1500/R-R interval (mm) or 300/R-R interval (cm)
R waves become progressively larger from leads V1-V6 (True)
Explanation: Reflecting the electrical dominance of the left ventricle
the P wave represents sinoatrial node depolarisation (False)
Explanation: Represents atrial depolarisation

Question 4. In the normal ECG

depolarisation proceeds from epicardium to endocardium (False)
Explanation: Proceeds from endocardium to epicardium
depolarisation away from the positive electrode produces a positive deflection (False)
Explanation: Produces a negative deflection
depolarisation of the interventricular septum is recorded by the Q wave in V5 and V6 (True)
Explanation: Absent in left bundle branch block (BBB)
the aVR lead = right arm positive with respect to the other limb leads (True)
Explanation: Hence the predominant S wave as depolarisation moves away from aVR
voltage amplitudes vary with the thickness of cardiac muscle (True)
Explanation: An aid to the diagnosis of left ventricular hypertrophy

Question 5. In the investigation of patients with suspected heart disease

the normal upper limit for the cardiothoracic ratio (CTR) on chest radiograph is 0.75 (False)
Explanation: The CTR should not be > 0.5

By A. H.
a negative exercise ECG excludes the diagnosis of ischaemic heart disease (False)
Explanation: False negative tests occur in 15-20%
a 'step-up' in oxygen saturation at cardiac catheterisation suggests an intracardiac shunt (True)
Doppler echocardiography reliably assesses pressure gradients between cardiac chambers (True)
Explanation: Pressure gradients can be extrapolated from measuring intracardiac flow velocities
radionuclide blood pool scanning accurately quantifies left ventricular function (True)
Explanation: Ejection fraction is usually measured using this technique

Question 6. The pain of myocardial ischaemia

is typically induced by exercise and relieved by rest (True)
Explanation: Typical chest pain occurring at rest does not exclude myocardial ischaemia
radiates to the neck but not the jaw (False)
Explanation: May also radiate to the shoulders, arms or back
rarely lasts longer than 10 seconds after resting (False)
Explanation: Rapid resolution is atypical-pain usually lasts for minutes
is easily distinguished from oesophageal pain (False)
Explanation: Oesophageal pain may mimic angina-precipitation by swallowing may be useful
invariably worsens as exercise continues (True)
Explanation: Can disappear as exercise continues-'second wind' effect ('walk through' angina)

Question 7. In a patient with central chest pain at rest

intrascapular radiation suggests the possibility of aortic dissection (True)
Explanation: As does a tearing quality
postural variation in pain suggests the possibility of pericarditis (True)
Explanation: As does variation with respiration
chest wall tenderness is a typical feature of Tietze's syndrome (True)
Explanation: The syndrome is a form of costochondritis
relief of pain by nitrates excludes an oesophageal cause (False)
Explanation: And oesophageal pain may also be precipitated by exercise
features of autonomic disturbance are specific to cardiac pain (False)
Explanation: May occur in severe pain from any cause

Question 8. In the treatment of cardiac failure associated with acute pulmonary oedema
controlled oxygen therapy should be restricted to 28% oxygen in patients who smoke (False)
Explanation: High-flow oxygen in concentrations > 35% should be administered
morphine reduces vasoconstriction and dyspnoea (True)
furosemide (frusemide) therapy given intravenously reduces preload and afterload (True)
nitrates should be avoided if the systolic blood pressure < 140 mmHg (False)
Explanation: Can safely be used with systolic pressures > 110 mmHg
ACE inhibitors decrease the afterload but increase the preload (False)
Explanation: Both preload and afterload are reduced

Question 9. Recognised features of severe cardiac failure include

tiredness (True)
Explanation: Due to severe reduction in cardiac output
weight loss (True)
Explanation: 'Cardiac cachexia'-however, weight gain due to oedema is more common
epigastric pain (True)
Explanation: Due to hepatic and gastrointestinal congestion
nocturia (True)
Explanation: Diuresis is induced by adopting the supine position
nocturnal cough (True)
Explanation: A manifestation of pulmonary congestion

Question 10. With regard to angiotensin-converting enzyme (ACE) inhibitors

ACE inhibitors reduce the conversion of angiotensinogen to angiotensin I (False)
Explanation: Angiotensin I to angiotensin II

By A. H.
enalapril has a longer half-life than lisinopril (False)
Explanation: Converted to enalaprilat in the liver
cough is a less common side-effect of ACE inhibitors than angiotensin II antagonists (False)
Explanation: Cough is a more common side-effect of ACE inhibitors-probably due to bradykinin accumulation
first-dose hypotension occurs less commonly in patients pretreated with diuretics (False)
Explanation: Omitting diuretics pretreatment minimises risk
treatment is of no benefit until symptomatic left ventricular systolic dysfunction has developed (False)

Question 11. In the management of chronic heart failure

ACE inhibitor therapy reduces subsequent hospitalisation rates (True)
Explanation: And reduces mortality
coagulation is impaired and thromboembolic risk therefore declines (False)
Explanation: Other factors favouring thromboembolism outweigh this effect
salt restriction may be beneficial (True)
â-adrenoceptor antagonists (â-blockers) should always be avoided (False)
Explanation: There is evidence that they reduce mortality in some patients
digoxin is only of benefit if atrial fibrillation coexists (False)
Explanation: Reduces need for hospitalisation

Question 12. Complications of systemic hypertension include

retinal microaneurysms (False)
Explanation: Arteriolar thickening, irregularity and tortuosity are detectable
aortic dissection (True)
renal artery stenosis (True)
Explanation: Hypertension predisposes to atheroma formation
lacunar strokes of the internal capsule (True)
subdural haemorrhage (False)
Explanation: Hypertension predisposes to intracerebral and subarachnoid haemorrhage

Question 13. Recognised causes of secondary hypertension include

persistent ductus arteriosus (False)
Explanation: In contrast to coarctation of the aorta
primary hyperaldosteronism (True)
Explanation: Conn's syndrome
acromegaly (True)
oestrogen-containing oral contraceptives (True)
Explanation: And pregnancy
thyrotoxicosis (True)

Question 14. In the treatment of systemic hypertension

treatment has more effect on the risk of stroke than the risk of coronary heart disease (CHD) (True)
Explanation: 30% reduction in stroke, 20% in CHD
thresholds for treatment are higher in the elderly (False)
Explanation: Absolute risk is higher
treatment is less likely to be of benefit if cardiac or renal disease is present (False)
there are no proven benefits of therapy in patients aged over 70 years (False)
Explanation: Good evidence of efficacy in the elderly
moderation of alcohol consumption is likely to improve blood pressure control (True)
Explanation: Excessive consumption of alcohol is a significant factor in 10-15% of hypertensives
Question 15. Important explanations for hypertension refractory to medical therapy include
poor compliance with drug therapy (True)
inadequate drug therapy (True)
Explanation: Common particularly in asymptomatic patients
phaeochromocytoma (True)
Explanation: But rare
primary hyperaldosteronism (True)
Explanation: Conn's syndrome is suggested by a hypokalaemic alkalosis

By A. H.
renal artery stenosis (True)
Explanation: May also develop during follow-up

Question 16. The auscultatory findings listed below are associated with the following phenomena
third heart sound-opening of mitral valve (False)
Explanation: Occurs in mid-diastole due to rapid ventricular filling
varying intensity of first heart sound-atrioventricular dissociation (True)
Explanation: Due to variations in stroke volume
soft first heart sound-mitral stenosis (False)
Explanation: Typically loud in mitral stenosis
reversed splitting of second heart sound-left bundle branch block (True)
Explanation: Due to delayed closure of the aortic valve compared with the pulmonary valve
fourth heart sound-atrial fibrillation (False)
Explanation: Coincides with atrial contraction and hence cannot occur in atrial fibrillation

Question 17. Syncope

followed by facial flushing suggests a tachyarrhythmia (False)
Explanation: Suggests episodic bradycardia- Adams-Stokes attacks
without warning suggests a vasovagal episode (False)
Explanation: Nausea and lightheadedness typically precede vasovagal attacks
on exercise is a typical feature of mitral regurgitation (False)
Explanation: Exertional syncope is a feature of severe aortic stenosis
can sometimes be treated by â-blockers (True)
may be a feature of Parkinson's disease (True)
Explanation: Due to severe postural hypotension

Question 18. Atrial fibrillation (AF) is

present in 10% of the elderly population over the age of 75 years (True)
usually readily converted to permanent sinus rhythm using DC cardioversion (False)
Explanation: Underlying structural heart disease is common and promotes the recurrence of AF
associated with an annual stroke risk of 5% if structural heart disease is present (True)
Explanation: Warfarin therapy reduces the annual risk to about 1.5%
a common presenting feature of the sick sinus syndrome (True)
Explanation: Episodes of sinus bradycardia or sinus arrest may coexist making drug therapy difficult
usually associated with a ventricular rate < 100/min before treatment (False)
Explanation: Indicates concomitant AV nodal disease, a common finding in elderly patients

Question 19. In cardiac arrest

a sharp blow to the praecordium may be useful (True)
Explanation: In witnessed arrest only
asystole is the commonest finding on ECG (False)
Explanation: Ventricular fibrillation is the commonest underlying arrhythmia
a normal ECG may suggest profound hypovolaemia (True)
Explanation: A cause of 'electromechanical' dissociation
if cardioversion fails, intracardiac adrenaline (epinephrine) should be given (False)
Explanation: Adrenaline (epinephrine) should be given intravenously
the compression to ventilation ratio should be 15:2 (True)

Question 20. Atrial tachycardia is typically associated with

1:1 AV conduction (False)
Explanation: 2:1, 3:1 or variable
an atrial rate of 300/min (False)
Explanation: Atrial rate is 140-220/min
presence of P waves identical to those found during sinus rhythm (False)
Explanation: An ectopic atrial focus with abnormal P waves
digoxin toxicity and intracellular potassium depletion (True)
bizarre broad QRS complexes on ECG (False)

By A. H.
Explanation: QRS complexes are usually narrow

Question 21. Typical features of the Wolff-Parkinson-White (WPW) syndrome include

tachyarrhythmias resulting from re-entry phenomenon (True)
Explanation: Re-entrant circuit includes AV node and the accessory bundle
ventricular pre-excitation via an accessory AV pathway (True)
atrial fibrillation with a ventricular response of > 160/min (True)
Explanation: Consider WPW in young patients with episodes of atrial fibrillation
ECG between bouts showing prolonged PR interval with narrow QRS complexes (False)
Explanation: PR interval is shortened and a delta wave is seen in the QRS complex
useful therapeutic response to verapamil or digoxin (False)
Explanation: Differential effects on the normal and anomalous pathways can increase cardiac rate

Question 22. In ventricular tachycardia (VT)

underlying cardiac disease is usually present (True)
Explanation: Often ischaemic heart disease
amiodarone is useful in the prevention of recurrent episodes (True)
Explanation: A class III agent
a shortened QT interval on ECG predisposes to recurrent episodes (False)
Explanation: A prolonged QT interval predisposes to recurrent VT
carotid sinus massage usually slows the cardiac rate transiently (False)
Explanation: No effect on cardiac rate
complicated by acute cardiac failure, cardioversion should be avoided (False)
Explanation: The treatment of choice in acute heart failure with VT

Question 23. The following statements about atrioventricular block are true
first-degree block is usually asymptomatic (True)
the PR interval is fixed in Mobitz type I second-degree block (False)
Explanation: Fixed PR = Mobitz type II; variable PR (Wenckebach's phenomenon) = Mobitz type I
decreasing PR intervals suggest Wenckebach's phenomenon (False)
Explanation: PR intervals gradually increase
irregular cannon waves in the jugular venous pressure suggest complete heart block (True)
Explanation: Due to AV dissociation
the QRS complex in complete heart block is always broad and bizarre (False)
Explanation: Can be narrow if the escape rhythm arises from within the bundle of His

Question 24. In the classification of anti-arrhythmic drugs, the following statements are true
class I agents inhibit the fast sodium channel (True)
Explanation: E.g. lidocaine (lignocaine)-like drugs
class II agents are â-adrenoceptor antagonists (True)
class III agents prolong the action potential (True)

Explanation: E.g. amiodarone

class IV agents inhibit the slow calcium channel (True)
Explanation: E.g. verapamil, nifedipine
many anti-arrhythmic agents have actions in more than one class (True)
Explanation: E.g. sotalol and amiodarone

Question 25. The cardiac drugs listed below are associated with the following adverse effects
digoxin-acute confusional state (True)
Explanation: And lidocaine (lignocaine) therapy
verapamil-constipation (True)
Explanation: Calcium channel-blocking effect on smooth muscle
amiodarone-photosensitivity (True)
propafenone-corneal microdeposits (False)
Explanation: An adverse effect of amiodarone therapy

By A. H.
lidocaine (lignocaine)-convulsions (True)

Question 26. Amiodarone therapy

prolongs the plateau phase of the action potential (True)
Explanation: In common with other class III drugs
potentiates the effect of warfarin (True)
is useful in the prevention of ventricular but not supraventricular tachycardia (False)
Explanation: Effective in both
may cause corneal deposits (True)
Explanation: But no effect on vision
has a significant negative inotropic action (False)
Explanation: Can be safely used in heart failure

Question 27. Digoxin

shortens the refractory period of conducting tissue (False)
Explanation: Prolongs the refractory period of conducting tissue; shortens it in cardiac muscle
usually converts atrial flutter to sinus rhythm (False)
Explanation: Often converts atrial flutter to atrial fibrillation
is excreted primarily by the kidney (True)
is a class II anti-arrhythmic (False)
is a recognised cause of ventricular arrhythmias (True)
Explanation: Increases myocardial excitability

Question 28. The risk of developing clinical evidence of coronary artery disease is
increased by exogenous oestrogen use in postmenopausal females (False)
Explanation: Risk is decreased by oestrogen therapy
diminished by stopping smoking (True)
Explanation: Effect is measurable within 6 months of stopping
reduced by the moderate consumption of alcohol (True)
Explanation: Not more than 21 units per week
increased in hyperfibrinogenaemia (True)
increased by hypercholesterolaemia but not hypertriglyceridaemia (False)
Explanation: Both confer increased risk

Question 29. In the investigation of suspected angina pectoris

the resting ECG is usually abnormal (False)
Explanation: Usually normal
exercise-induced elevation in blood pressure indicates significant ischaemia (False)
Explanation: Fall in blood pressure suggests significant ischaemia
a normal ECG during exercise excludes angina pectoris (False)
Explanation: False negatives may occur
coronary angiography is only indicated if an exercise tolerance test (ETT) is abnormal (False)
Explanation: Useful in patients with convincing history but normal ETT
physical examination is of no clinical value (False)
Explanation: Important to exclude anaemia and valvular stenosis

Question 30. In the treatment of patients with angina pectoris

aspirin reduces the frequency of anginal attacks (False)
Explanation: But it improves the prognosis
glyceryl trinitrate is equally effective when swallowed as when taken sublingually (False)
Explanation: Extensive first-pass hepatic metabolism
calcium antagonists may cause peripheral oedema (True)
Explanation: Common adverse effect
tissue levels of nitrates must be consistently high for maximum therapeutic effect (False)
Explanation: A nitrate-free period should be achieved

By A. H.
â-blockers are more effective than other anti-anginal agents (False)
Explanation: Nitrates, calcium antagonists and â-blockers are all equally efficacious

Question 31. The clinical features of acute myocardial infarction include

nausea and vomiting (True)
Explanation: Due to activation of the autonomic nervous system
breathlessness and angor animi (True)
hypotension and peripheral cyanosis (True)
Explanation: Suggest a large infarct
sinus tachycardia or sinus bradycardia (True)
absence of any symptoms or physical signs (True)
Explanation: 15% of infarcts are believed to be clinically 'silent'

Question 32. In the treatment of acute myocardial infarction

aspirin given within 6 hours of onset reduces the mortality (True)
Explanation: 30% reduction in short-term mortality
streptokinase therapy reduces infarct size and mortality by > 25% (True)
Explanation: The earlier thrombolysis is given, the better the results
diamorphine is better given intravenously than by any other route (True)
Explanation: Intramuscular injections predispose to haematoma
immediate calcium channel blocker therapy reduces the early mortality rate (False)
Explanation: Similarly, nitrate therapy has no effect on the early mortality rate
mobilisation should be deferred until cardiac enzymes normalise (False)
Explanation: Mobilisation should begin on day 2 in the absence of cardiac failure

Question 33. Drug therapies which improve the long-term prognosis after myocardial infarction include
aspirin (True)
Explanation: Vascular events are reduced by 25%
nitrates (False)
calcium antagonists (False)
ACE inhibitors (True)
Explanation: Limit infarct expansion
â-blockers (True)
Explanation: Reduce mortality by 25%

Question 34. The following statements about the prognosis of acute myocardial infarction are true
50% of all deaths occur within the first 24 hours (True)
Explanation: Of which half occur within the first 20 minutes, often before help arrives
stress and social isolation adversely affect the prognosis (True)
Explanation: Rehabilitation programmes can be helpful
the 5-year survival is 75% for those who leave hospital (True)
late mortality is determined by the extent of myocardial damage (True)
Explanation: Limiting infarct size improves prognosis
in hospital mortality for those aged over 75 years is over 25% (True)
Explanation: Five times greater than < 55 years of age

Question 35. In intermittent claudication due to atherosclerosis

pain is typically relieved by rest and elevation of the leg (False)
Explanation: Rest relieves but elevation worsens pain
the commonest cause of death is lower limb gangrene (False)
Explanation: Myocardial infarction or stroke
pedal pulses are often still palpable (False)
Explanation: Anaemia or diabetes may produce claudication without loss of the pulses
exercise which causes pain should be avoided (False)
Explanation: Exercise promotes growth of the collateral circulation
the risk of progression is lessened by warfarin (False)
Explanation: Anticoagulation is unhelpful

By A. H.

Question 36. Characteristic features of aortic dissection include

haemopericardium (True)
Explanation: Type A aneurysms
acute paraparesis (True)
Explanation: Due to infarction of the spinal cord
interscapular back pain (True)
Explanation: The pain is often described as 'tearing'
early diastolic murmur (True)
Explanation: Type A aneurysms
pleural effusion (True)
Explanation: Haemothorax

Question 37. In patients with significant mitral stenosis

the mitral valve orifice is reduced from 5 cm2 to about 1 cm2 (True)
Explanation: First symptoms appear at valve areas of around 2 cm2
a history of rheumatic fever or chorea is elicited in over 90% of patients (False)
Explanation: Only in 50% of patients
left atrial enlargement cannot be detected on the chest radiograph (False)
Explanation: Produces a double right heart border and an enlarged left atrial appendage
the risk of systemic emboli is trivial in sinus rhythm (False)
Explanation: Embolic risk over 10 years is 10% compared with 35% if atrial fibrillation is present
mitral balloon valvuloplasty is not advisable if there is also significant mitral regurgitation (True)
Explanation: Mitral regurgitation is a contraindication

Question 38. Recognised features of chronic mitral regurgitation include

soft first heart sound and loud third heart sound (True)
presentation with signs of right ventricular failure (True)
Explanation: Due to pulmonary hypertension
left ventricular dilatation (True)
a pansystolic murmur and hyperdynamic displaced apex beat (True)
atrial fibrillation requiring anticoagulation (True)

Question 39. Clinical features suggesting aortic stenosis include

late systolic ejection click (False)
Explanation: Early systolic click implies the stenosis is valvular
narrow pulse pressure (True)
heaving apex beat (True)
Explanation: Implies left ventricular hypertrophy
syncope associated with angina (True)
loud second heart sound (False)
Explanation: Quiet S2 if the valve is heavily calcified and immobile

Question 40. Disorders associated with aortic regurgitation include

ankylosing spondylitis (True)
Explanation: Also Reiter's disease and psoriatic arthritis
Marfan's syndrome (True)
Explanation: Due to cystic medial necrosis
syphilitic aortitis (True)
Explanation: Typically affects the ascending aorta
persistent ductus arteriosus (False)
Explanation: Produces the 'machinery murmur'
congenital bicuspid aortic valve (True)

Question 41. In infective endocarditis

streptococci and staphylococci account for over 80% of cases (True)
Explanation: Streptococcus viridans alone accounts for 30-40% of cases

By A. H.
left heart valves are more frequently involved than right heart valves (True)
normal cardiac valves are not affected (False)
Explanation: About 30% have no identifiable predisposing cardiac lesion
glomerulonephritis usually occurs due to immune complex disease (True)
a normal echocardiogram excludes the diagnosis (False)
Explanation: Vegetations may be too small to be detected

Question 42. Central cyanosis in infancy is an expected finding in the following congenital heart diseases
persistent ductus arteriosus (False)
Explanation: With a left to right shunt
transposition of the great arteries (True)
Explanation: Usually due to a shunt through a ventricular septal defect
coarctation of the aorta (False)
Explanation: No shunt
Fallot's tetralogy (True)
Explanation: Right to left shunt through a ventricular septal defect
atrial septal defect (False)
Explanation: Left to right shunt

Question 43. The following statements about persistent ductus arteriosus are true
blood usually passes from the pulmonary artery to the aorta (False)

Explanation: This only happens if the shunt reverses

the onset of heart failure usually occurs in early infancy (False)
Explanation: Typically presents with a murmur in an otherwise healthy infant
a systolic murmur around the scapulae is typical (False)
Explanation: Continuous 'machinery' murmur is typical (systolic and diastolic)
shunt reversal is indicated by cyanosis of the lower limbs (True)
Explanation: A rare sign
prophylactic antibiotic therapy to prevent endocarditis is indicated (True)

Question 44. Typical clinical features of coarctation of the aorta include

an association with a bicuspid aortic valve (True)
Explanation: Frequently coexists
cardiac failure developing in male adolescents (False)
Explanation: Cardiac failure is more likely to develop in infancy
palpable collateral arteries around the scapulae (True)
Explanation: A useful but unusual finding
rib notching on chest radiograph associated with weak femoral pulses (True)
Explanation: Rib notching is due to enlarged collateral vessels
ECG showing right ventricular hypertrophy (False)
Explanation: Left (not right) ventricular hypertrophy develops

Question 45. In atrial septal defect

the lesion is usually of secundum type (True)
Explanation: Due to a patent fossa ovalis
the initial shunt is right to left (False)
Explanation: Occurs late, and rarely
splitting of the second heart sound increases in expiration (False)
Explanation: Splitting is fixed and wide
the ECG typically shows right bundle branch block (True)
Explanation: In primum defect there may be left axis deviation
surgery should be deferred until shunt reversal occurs (False)
Explanation: Surgery is indicated when the pulmonary/systolic flow ratio is > 3:2

Question 46. In small ventricular septal defects

the murmur is confined to late systole (False)

By A. H.
Explanation: It is pansystolic
the heart is usually enlarged (False)
Explanation: No cardiomegaly
there is a risk of infective endocarditis (True)
Explanation: Prophylaxis is indicated
surgical repair before adolescence is usually indicated (False)
Explanation: Surgery is only indicated if right-sided pressures rise
most patients are asymptomatic (True)
Explanation: Symptomless murmur is a frequent presentation

Question 47. Dilated (congestive) cardiomyopathy is

usually idiopathic (True)
associated with pathognomonic ECG changes (False)
Explanation: ECG changes are non-specific
a recognised complication of HIV infection (True)
associated with chronic alcohol misuse (True)
caused by Coxsackie A infection (True)
Explanation: And influenza, HIV and others

Question 48. Clinical features compatible with hypertrophic cardiomyopathy include

family history of sudden death (True)
Explanation: 50% of cases are autosomal dominant
angina pectoris and exertional syncope (True)
Explanation: Mimicking aortic stenosis
jerky pulse and heaving apex beat (True)
murmurs suggesting both aortic stenosis and mitral regurgitation (True)
Explanation: Left ventricular outflow obstruction and secondary mitral regurgitation
soft or absent second heart sound (False)
Explanation: Suggests calcific aortic stenosis

Question 49. Typical features of acute pericarditis include

chest pain identical to that of myocardial infarction (False)
Explanation: Sharp pain worsened by posture and movement
a friction rub that is best heard in the axilla in mid-expiration (False)
Explanation: Localisation and character vary greatly
ST elevation on the ECG with upward concavity (True)
Explanation: In contrast to ischaemia
elevation of the serum creatine kinase (False)
Explanation: May occur in pericarditis complicating acute myocardial infarction
ECG changes that are only seen in the chest leads (False)
Explanation: Widespread ECG changes

Question 50. In pericardial tamponade

high amplitude QRS complexes are a typical ECG feature (False)
Explanation: Low amplitude
the systemic arterial pressure falls dramatically on inspiration (True)
Explanation: This is pulsus paradoxus
echocardiography is the definitive investigation (True)
an effusion > 250 ml must be present before detrimental haemodynamic effects ensue (False)
Explanation: As little as 75-100 ml
a normal chest radiograph excludes the diagnosis (False)
Explanation: But the cardiac shadow usually appears globular

Module 13 (Chapter 13)

Question 1. Typical chest findings in a large right pleural effusion include
normal chest expansion (False)
Explanation: Expansion is reduced on the affected side

By A. H.
dull percussion note (False)
Explanation: Stony dull
absent breath sounds (True)
vocal resonance decreased (True)
Explanation: As is tactile vocal fremitus
pleural friction rub (False)

Question 2. Hypercapnia is a typical feature of

pulmonary embolism (False)
Explanation: Hyperventilation unless embolism is massive
severe chest wall injury (True)
Explanation: With type II respiratory failure
salicylate intoxication (False)
Explanation: Hyperventilation
pulmonary fibrosis (False)
Explanation: Hyperventilation and type I failure
severe chronic bronchitis (True)
Explanation: Type II respiratory failure may ensue

Question 3. Typical chest findings in right lower lobe collapse include

decreased chest expansion (True)
Explanation: On the affected side
stony dull percussion note (False)
Explanation: Implies effusion
bronchial breath sounds (False)
Explanation: Diminished or absent breath sounds
decreased vocal resonance (True)
Explanation: As for vocal fremitus
crepitations (False)
Explanation: No specific added sounds

Question 4. The following statements about pulmonary function tests are true
over 80% of vital capacity can normally be expelled in 1 second (False)
Explanation: More than 70% is normal
the transfer factor is measured using inspired oxygen (False)
Explanation: Carbon monoxide is used
residual volume is increased in chronic bronchitis and emphysema (True)
Explanation: The lungs are hyperinflated
analysis of flow volume curves is of value in suspected central airflow obstruction (True)
peak expiratory flow rates accurately reflect the severity of restrictive lung disorders (False)
Explanation: They measure obstructive ventilatory defects

Question 5. In a patient with severe acute breathlessness

a normal arterial PaO2 invariably suggests psychogenic hyperventilation (False)
Explanation: The patient may have a metabolic acidosis
pulsus paradoxus is pathognomonic of acute asthma (False)
Explanation: Also found in pericardial tamponade
a normal chest radiograph excludes pulmonary embolism (False)
Explanation: Although subtle changes are frequently present
the extremities are typically cool and sweaty in left ventricular failure (True)
Explanation: With basal pulmonary crepitations
left bundle branch block is strongly suggestive of pulmonary embolism (False)
Explanation: Right bundle branch block or S1Q3T3 pattern

Question 6. The following are recognised causes of haemoptysis

tuberculosis (True)
chronic obstructive pulmonary disease (False)

By A. H.
Explanation: Another cause should be sought
bronchiectasis (True)
Explanation: May be massive
Goodpasture's syndrome (True)
Explanation: With associated renal disease
mitral stenosis (True)
Explanation: With pulmonary hypertension

Question 7. A pleural effusion with a pleural fluid:serum protein ratio of > 0.5 would be typical of
congestive cardiac failure (CCF) (False)
Explanation: Transudate in CCF
renal failure (False)
subphrenic abscess (True)
Explanation: Most frequently on the right
pneumonia (True)
Explanation: With polymorphonuclear leucocytes
nephrotic syndrome (False)
Explanation: Severe hypoalbuminaemia produces transudates

Question 8. The sleep apnoea syndrome is associated with

obesity (True)
Explanation: Found in two-thirds of patients and may be associated with alcohol misuse
an increased risk of road traffic accidents (True)
Explanation: Increased threefold due to day-time sleepiness
nocturnal restlessness apparent to the patient (False)
a good response to inhaled bronchodilator therapy administered at bedtime (False)
Explanation: Ineffective; continuous positive airway pressure (CPAP) may be effective
nocturnal hypotension (False)
Explanation: Typically episodic hypertension

Question 9. The following disorders characteristically produce type I respiratory failure

kyphoscoliosis (False)
Explanation: Typically type II failure
Guillain-Barré polyneuropathy (False)
Explanation: Respiratory muscle paralysis causes type II failure
acute respiratory distress syndrome (ARDS) (True)
Explanation: Arterial PCO2 is typically normal
extrinsic allergic alveolitis (True)
Explanation: Ventilatory drive is usually maintained
inhaled foreign body in a major airway (False)
Explanation: Causes acute type II failure-asphyxia

Question 10. In the treatment of acute COPD exacerbations associated with type II respiratory failure
the inspired oxygen content should be at least 40% (False)
Explanation: Controlled oxygen therapy at about 24-28% is usual
nebulised doxapram improves small airways obstruction (False)
Explanation: A central respiratory stimulant
flapping tremor is a sensitive indicator of hypercapnia (False)
Explanation: It may be absent-blood gases are vital
corticosteroid therapy is usually contraindicated (False)
Explanation: May help relieve bronchospasm
BIPAP may be valuable if pH falls (True)
Explanation: But not all patients are candidates for such support

Question 11. The following statements about oxygen are true

at sea level, the pressure of oxygen in inspired air is approximately 20 kPa (True)
Explanation: PaO2 declines with altitude

By A. H.
chronic domiciliary oxygen therapy is indicated only when PaO2 is < 6 kPa (False)
Explanation: Indicated when PaO2 < 7.3 breathing air
dissolved oxygen contributes to tissue oxygenation in anaemia (True)
Explanation: Also in other situations when Hb is maximally saturated
oxygen toxicity in adults can produce retrolental fibroplasia (False)
Explanation: Occurs only in neonates
central cyanosis unresponsive to 100% oxygen indicates right-to-left shunting of > 20% (True) Explanation: Such
shunts may be extra- or intrapulmonary

Question 12. In the management of chronic obstructive pulmonary disease

influenza immunisation should only be offered once (False)
Explanation: Immunisation should be offered yearly
long-term antibiotic treatment decreases the frequency of exacerbations (False)
Explanation: This encourages drug resistance
regular inhaled steroids are of no proven value (True)
supplemental oxygen during air travel is necessary if the resting PaO2 < 9 kPa (True)
Explanation: PaO2 will be < 7 kPa in such a patient at altitude
long-term controlled oxygen therapy improves symptoms but not the prognosis (False)
Explanation: Survival has been demonstrated to improve

Question 13. Typical findings in severe chronic obstructive pulmonary disease include
elevation of the jugular venous pressure (True)
Explanation: A feature of right heart failure
tracheal descent on inspiration (True)
Explanation: Tracheal 'tug' due to mediastinal descent
indrawing of the intercostal muscles (True)
Explanation: A sign of hyperinflation
contraction of the scalene muscles (True)
Explanation: And other accessory respiratory muscles
pursed lip breathing (True)
Explanation: Decreases air trapping

Question 14. Typical pathological features of asthma include

eosinophilic bronchial infiltrate (True)
Explanation: And T lymphocytes
increased airway macrophages (True)
mucus gland hyperplasia (True)
Explanation: May contribute to development of fixed airways obstruction
epithelial shedding (True)
Explanation: A recognised feature in fatal asthma in particular
T lymphocyte activation and cytokine release (True)

Question 15. In the management of chronic persistent asthma

inhaled â2-agonist use more than once per day is an indication for inhaled steroid therapy (True)
Explanation: Typically low-dose steroids
sodium cromoglicate therapy is often useful as an alternative to inhaled steroids in adults (False)
Explanation: But may be valuable in childhood
patients taking high doses of inhaled steroids should use a large-volume spacer device (True)
Explanation: Reduces oropharyngeal and gastric deposition
leukotriene antagonists are valuable substitutes for inhaled steroids (False)
Explanation: Use in addition to steroids and â2-agonist
anticholinergic agents should be avoided (False)
Explanation: May be valuable

Question 16. Features compatible with severe acute asthma include

pulse rate = 120 per minute (True)
Explanation: But bradycardia may occur in life-threatening attacks

By A. H.
peak expiratory flow (PEF) rate = < 70% of expected (False)
Explanation: Usually < 50% of expected PEF
pulsus paradoxus (True)
Explanation: But may diminish in severe attacks
arterial PaO2 = 14 kPa while breathing air (False)
Explanation: PaO2 < 8 kPa in life-threatening attacks
arterial PaCO2 = 5 kPa (True)
Explanation: PaCO2 may remain normal until the late stages

Question 17. The initial management of severe acute asthma should include
24% oxygen delivered by a controlled flow mask (False)
Explanation: High concentration, high flow should be used
salbutamol 5 mg by inhalation (True)
Explanation: Intravenous â2-adrenoceptor agonists can also be used
ampicillin 500 mg orally and sodium cromoglicate 10 mg by inhalation (False)
Explanation: Of no proven value in acute attacks
hydrocortisone 200 mg i.v. or prednisolone 40 mg orally (True)
Explanation: Maintain corticosteroid therapy for at least 7 days in severe attacks
arterial blood gas analysis and chest radiograph (True)
Explanation: Exclude pneumothorax and ventilatory failure

Question 18. Typical clinical features of bronchiectasis include

chronic cough with scanty sputum volumes (False)
Explanation: Copious sputum production
recurrent pleurisy (True)
Explanation: Recurrent pneumonia
haemoptysis (True)
Explanation: Secondary to inflammatory bronchial change
finger clubbing (True)
crepitations on auscultation (True)
Explanation: In the presence of large amounts of secretions

Question 19. Cystic fibrosis is associated with

an incidence of 1 in 2500 live births (True)
Explanation: The commonest severe autosomal recessive disorder in Caucasians
a decreased sweat sodium concentration (False)
Explanation: Increased sweat sodium concentration
male infertility (True)
Explanation: Due to failure of development of the vas deferens
abnormal lung function at birth (False)
Explanation: It is normal; hence prospect for gene therapy
recurring pneumococcal pulmonary infections (False)
Explanation: Pseudomonas and staphylococcal sepsis

Question 20. In pneumonia, the following features are classically associated with the specific organisms noted
erythema nodosum and Mycoplasma pneumoniae (True)
hyponatraemia and Legionella pneumoniae (True)
contact with sick birds and Klebsiella pneumoniae (False)
Explanation: Chlamydia psittaci
abscess formation and Staphylococcus aureus (True)
haemolytic anaemia and Streptococcus pneumoniae (False)
Explanation: Mycoplasma

Question 21. A non-pneumococcal pneumonia should be considered if the clinical features include
respiratory symptoms preceding systemic upset by several days (False)
Explanation: The converse is typical of 'atypical' organisms
lobar consolidation (False)

By A. H.
rigors (False)
the absence of a neutrophil leucocytosis (True)
Explanation: Leucopenia can occur in severe pneumococcal infection
palpable splenomegaly (True)
Explanation: Rare in pneumococcal disease

Question 22. The following features suggest a poor prognosis in pneumonia

diastolic blood pressure of 90 mmHg (False)
Explanation: < 60 mmHg
confusion (True)
respiratory rate of 20 breaths per minute (False)
Explanation: > 30/min
blood urea of 9 mmol/l (True)
Explanation: > 7 mmol/l
white cell count of 3000 × 109/l (True)
Explanation: < 4000 × 109/l

Question 23. Typical features of primary tuberculosis include

a sustained pyrexial illness (False)
Explanation: Typically symptomless
caseation within the regional lymph nodes (True)
Explanation: Mediastinal, cervical or mesenteric nodes are most frequently involved
bilateral hilar lymphadenopathy on chest radiograph (False)
Explanation: Suggests sarcoidosis
erythema nodosum (True)
Explanation: Can also accompany pulmonary sarcoid
pleural effusion with a negative tuberculin skin test (False)
Explanation: A hypersensitivity phenomenon typically associated with positive tuberculin test

Question 24. Recognised complications of post-primary tuberculosis include

aspergilloma (True)
Explanation: Superinfection of a cavity
amyloidosis (True)
Explanation: Associated with chronic immune stimulation
massive haemoptysis (True)
bronchiectasis (True)
Explanation: Suggested by chronic productive cough
paraplegia (True)
Explanation: Due to vertebral or paraspinal abscess formation

Question 25. In the treatment of post-primary pulmonary tuberculosis

combination drug therapy is always indicated (True)
Explanation: Minimises resistance and reduces duration of treatment
sputum remains infectious for at least 4 weeks after the onset of therapy (False)
Explanation: Patients can be regarded as non-infectious after 2 weeks of therapy
at least 12 months' daily therapy is required for 100% effectiveness (False)
Explanation: 6- and 9-month regimes are of proven efficacy
isoniazid and pyrazinamide do not cross the blood-brain barrier (False)
Explanation: Hence their great value in the treatment of tuberculous meningitis
treatment failure is invariably due to multiple drug resistance (False)
Explanation: More often due to non-compliance

Question 26. Recognised adverse reactions to antituberculous drugs include

streptomycin-renal failure (False)
Explanation: Causes vestibular disturbance and deafness
isoniazid-hypothyroidism (False)
Explanation: Polyneuropathy

By A. H.
rifampicin-optic neuritis (False)
Explanation: Ethambutol causes optic neuritis
pyrazinamide-hepatitis (True)
Explanation: And rifampicin
ethambutol-vestibular neuronitis (False)
Explanation: Streptomycin causes this

Question 27. Pulmonary infection with Aspergillus fumigatus is a recognised cause of the following
bullous emphysema (False)
Explanation: No association
mycetoma (True)
Explanation: Usually in a tuberculous cavity
necrotising pneumonitis (True)
Explanation: A severe, rapidly progressive illness
bronchopulmonary eosinophilia (True)
Explanation: Typically with wheeze, pulmonary infiltrates and peripheral eosinophilia
extrinsic allergic alveolitis (False)
Explanation: Type III and IV immune responses

Question 28. Bronchial carcinoma

accounts for 10% of all male deaths from cancer (False)
Explanation: 50% of all male deaths from malignant disease
typically presents with massive haemoptysis (False)
Explanation: Streaking of sputum with blood in a smoker is more typical
histology reveals adenocarcinoma in 50% of patients (False)
Explanation: Squamous 35%, adenocarcinoma 30%
is associated with asbestos exposure (True)
Explanation: As is mesothelioma
is 40 times more common in smokers than in non-smokers (True)
Explanation: Smoking is the major aetiological factor

Question 29. Non-metastatic manifestations of bronchial carcinoma include

cerebellar degeneration (True)
Explanation: With ataxia and nystagmus
myasthenia (True)
Explanation: Eaton-Lambert syndrome
gynaecomastia (True)
Explanation: Usually bilateral
polyneuropathy (True)
Explanation: Usually distal sensorimotor
dermatomyositis (True)
Explanation: Skin rash and proximal myopathy

Question 30. The following are contraindications to surgical resection in bronchial carcinoma
distant metastases (True)
malignant pleural effusion (True)
FEV1 < 0.8 litres (True)
ipsilateral mediastinal lymphadenopathy (False)
Explanation: But contralateral nodes are a contraindication
oesophageal involvement (True)

Question 31. Mediastinal opacification on the chest radiograph is a typical feature of

thymoma (True)
Explanation: May be associated with myasthenia gravis
retrosternal goitre (True)
Explanation: Anterior superior mediastinum
Pancoast tumour (False)

By A. H.
Explanation: Pulmonary apical mass
hiatus hernia (True)
Explanation: A retrocardiac opacity
neurofibroma (True)
Explanation: Can be multiple

Question 32. The following statements about sarcoidosis are true

pulmonary lesions typically cavitate (False)
Explanation: Caseating granulomata (e.g. TB) are associated with cavitation
the tuberculin tine test is usually positive (False)
Explanation: Typically negative
erythema marginatum is a characteristic finding (False)
Explanation: Erythema nodosum is the typical skin lesion
spontaneous resolution is unusual (False)
Explanation: The normal course in stage I and stage II disease
hypercalcaemia suggests skeletal involvement (False)
Explanation: Due to increased vitamin D sensitivity

Question 33. Typical features of cryptogenic fibrosing alveolitis include

hypercapnic respiratory failure (False)
Explanation: Typically type I respiratory failure
positive antinuclear and rheumatoid factors (True)
Explanation: With or without evidence of connective tissue disease
finger clubbing (True)
recurrent wheeze and haemoptysis (False)
Explanation: Dyspnoea, dry cough and crackles
increased carbon monoxide transfer factor (False)
Explanation: Reduced

Question 34. Clinical features compatible with a diagnosis of extrinsic allergic alveolitis include
expiratory rhonchi and sputum eosinophilia (False)
Explanation: Acute dyspnoea without wheeze is characteristic
dry cough, dyspnoea and pyrexia (True)
Explanation: Influenza-like symptoms may exist
end-inspiratory crepitations (True)
Explanation: Typically bilateral
FEV1/FVC ratio of 50% (False)
Explanation: Airway obstruction is absent
positive serum precipitin tests (True)
Explanation: May also be positive in healthy subjects

Question 35. The following statements about asbestos-related disease are true
pleural plaques usually progress to become mesotheliomas (False)
Explanation: Often calcify
pleural effusions are always malignant (False)
Explanation: But malignancy should be excluded
finger clubbing and basal crepitations suggest pulmonary asbestosis (True)
Explanation: Although cryptogenic fibrosing alveolitis is possible
the FEV1/FVC ratio is typically decreased (False)
Explanation: A restrictive not an obstructive ventilatory defect
mesothelioma can only be reliably diagnosed at thoracotomy (False)
Explanation: Seldom necessary

Question 36. Characteristic features of pulmonary eosinophilia include

an association with ascariasis and microfilariasis (True)
Explanation: And Toxocara infestation
eosinophilic pneumonia without peripheral blood eosinophilia (False)

By A. H.
Explanation: Eosinophilia is necessary for the diagnosis
prominent asthmatic features (False)
Explanation: Wheeze may be absent
induction by exposure to drugs (True)
Explanation: Imipramine, phenylbutazone or others
opacities on chest radiograph (True)
Explanation: Pulmonary infiltrates and eosinophilia

Question 37. Clinical features characteristic of massive pulmonary embolism include

central and peripheral cyanosis (True)
Explanation: With profound hypoxaemia
pleuritic chest pain and haemoptysis (False)
Explanation: Suggests pulmonary infarction
breathlessness and syncope (True)
Explanation: Non-specific
tachycardia and elevated jugular venous pressure (True)
Explanation: Non-specific
Q waves in leads I, II and aVL on ECG (False)
Explanation: Classical ECG pattern is S1, Q3, T3

Question 38. Typical features of an empyema thoracis include

bilateral effusions on chest radiograph (False)
Explanation: Typically unilateral
a fluid level on chest radiograph suggesting a bronchopleural fistula (True)
Explanation: Or a recent diagnostic aspiration
persistent pyrexia despite antibiotic therapy (True)
Explanation: Suggests lung abscess, antibiotic resistance or hypersensitivity
recent abdominal surgery (True)
Explanation: Perhaps complicating subphrenic infection
bacteriological culture of the organism despite preceding antibiotic therapy (False)
Explanation: Frequently sterile post-antibiotic therapy

Question 39. The following statements about spontaneous pneumothorax are true
breathlessness and pleuritic chest pain are often present (True)
Explanation: A small pneumothorax may be asymptomatic
bronchial breathing is audible over the affected hemithorax (False)
Explanation: Diminished or absent breath sounds
absent peripheral lung markings on chest radiograph suggest tension (False)
Explanation: Mediastinal shift suggests tension
surgical referral is required if there is a bronchopleural fistula (True)
Explanation: Pleurectomy may also be necessary
pleurodesis should be considered for recurrent pneumothoraces (True)
Explanation: Particularly if bilateral

Question 40. The following are causes of an elevated hemidiaphragm

recurrent laryngeal nerve paralysis (False)
Explanation: Phrenic nerve paralysis
surgical lobectomy (True)
subphrenic abscess (True)
severe pleuritic pain (True)
Explanation: But underlying pathology should be sought
chronic severe asthma (True)

Module 14 (Chapter 14)

Question 1. The following statements about renal physiology in health are correct
each kidney comprises approximately 1 000 000 nephrons (True)
the kidneys receive approximately 5% of the cardiac output (False)

By A. H.
Explanation: 25% of the cardiac output
variations in the calibre of afferent and efferent arterioles control the filtration pressure (True)
the glomerular capillaries are supplied by the afferent arterioles (True)
the kidney produces erythropoietin (True)

Question 2. Microscopic haematuria would be an expected finding in

urinary tract infection (True)
renal papillary necrosis (True)
Explanation: Risk factors include diabetes mellitus, chronic non-steroidal anti-inflammatory drug (NSAID) misuse and
membranous glomerulonephritis (False)
Explanation: Typically proteinuria
infective endocarditis (True)
Explanation: Associated with a mesangiocapillary glomerulonephritis
renal infarction (True)
Explanation: May be frank haematuria

Question 3. Urinary protein excretion

in Bence Jones proteinuria is readily detectable by stick tests (False)
Explanation: Immunoelectrophoresis required
> 3.5 g/day is invariably due to glomerular disease (True)
Explanation: Often with oedema and hypoalbuminaemia
is greater in the night than during the day (False)
Explanation: Greater when the person is upright-'orthostatic proteinuria'
can be assessed by the albumin/creatinine ratio in a single sample (True)
Explanation: Easier to undertake than 24-hour collection
in early diabetic nephropathy typically comprises albumin predominantly (True)
Explanation: Microalbuminuria is a sensitive predictor

Question 4. Typical features of the nephrotic syndrome include

bilateral renal angle pain (False)
Explanation: Typically painless
generalised oedema and pleural effusions (True)
Explanation: Transudates
hypoalbuminaemia and proteinuria > 3.5 g/day (True)
Explanation: Serum albumin concentration < 30 g/l and urinary protein > 3.5 g/day
hypertension and polyuria (False)
Explanation: But may occur in chronic renal failure
urinary sodium concentration > 50 mmol/l (False)
Explanation: Marked sodium retention-urinary sodium < 10 mmol/l

Question 5. The following findings would support a diagnosis of pre-renal rather than established acute renal failure
oliguria < 700 ml per day (False)
Explanation: Pre-renal acute failure is not always oliguric
urine/plasma urea ratio > 10:1 (True)
Explanation: Indicating preservation of renal medullary function
a urinary osmolality > 600 mOsm/kg (True)
Explanation: Indicating preservation of renal medullary function
a urinary sodium concentration < 20 mmol/l (True)
Explanation: Indicating preservation of renal medullary function
hypertension rather than hypotension (False)
Explanation: Suggests primary renal disease

Question 6. Typical causes of rapidly progressive glomerulonephritis include

post-infectious glomerulonephritis (True)
systemic vasculitis (True)
Explanation: Causes focal necrotising glomerulonephritis

By A. H.
Goodpasture's disease (True)
IgA nephropathy (True)
Explanation: Including Henoch-Schönlein purpura
membranous glomerulonephritis (False)

Question 7. Typical biochemical features of chronic renal failure include

polycythaemia (False)
Explanation: Anaemia is atypical
hypophosphataemia (False)
Explanation: Hyperphosph ataemia
hypercalcaemia (False)
Explanation: Hypocalcaemia
metabolic acidosis (True)
Explanation: Resulting in hyperpnoea
impaired urinary concentrating ability (True)
Explanation: Hence polyuria; urinary diluting ability also impaired

Question 8. Complications of chronic renal failure include

macrocytic anaemia (False)
Explanation: Typically normocytic or microcytic
peripheral neuropathy (True)
Explanation: Can improve with haemodialysis
bone pain (True)
Explanation: Renal osteodystrophy with osteomalacia
pericarditis (True)
Explanation: Even haemorrhagic pericarditis with tamponade
metabolic alkalosis (False)
Explanation: Chronic metabolic acidosis

Question 9. The features of Alport's syndrome include

an autosomal dominant mode of inheritance (False)
Explanation: Autosomal recessive and X-linked modes
degeneration of the glomerular basement membrane (True)
mutation of genes encoding type IV collagen (True)
Explanation: Located at Xq22
association with progressive chronic renal failure (True)
Explanation: Second most common inherited form of chronic renal failure
association with high-tone deafness (True)
Explanation: Characteristic feature preceding severe sensorineural deafness

Question 10. Characteristic features of minimal change nephropathy are

occurrence in adults usually follows an acute infection (False)
Explanation: Usually children; accounts for 25% of nephrotic syndrome in adults
marked mesangial cell proliferation on renal biopsy (False)
Explanation: Minor or absent
nephrotic syndrome with unselective proteinuria (False)
Explanation: Selective proteinuria
hypertension and microscopic haematuria (False)
Explanation: Suggest an alternative cause
progression to chronic renal failure in patients not responding to corticosteroid therapy (False)
Explanation: Renal function is otherwise unimpaired

Question 11. In the treatment of minimal change nephropathy

therapy should be deferred pending renal biopsy in childhood (False)
Explanation: Diagnosis in children rarely requires histological confirmation
diuretics should be avoided to minimise the risk of renal impairment (False)
Explanation: Useful in management of oedema

By A. H.
high-dose steroids usually control proteinuria (True)
immunosuppressant therapy is indicated for frequent relapses (True)
Explanation: E.g. cyclophosphamide
impaired renal function commonly develops in the long term (False)
Explanation: Rarely, even in relapsing disease

Question 12. Typical features of acute post-infectious glomerulonephritis include

subendothelial immune deposits on the glomerular basement membrane (True)
bacterial rather than viral infections (True)
Explanation: Especially haemolytic streptococci; rare in the UK
diffuse glomerular involvement (True)
recurrent haemoptysis (False)
Explanation: Suggests Goodpasture's disease
a poor prognosis when the disease occurs in childhood (False)
Explanation: Usually resolves spontaneously, especially in children

Question 13. Typical features of acute interstitial nephritis (AIN) include

skin rashes, arthralgia and fever (False)
Explanation: Less than 30% of patients with drug-induced AIN have features of generalised hypersensitivity
peripheral blood eosinophilia (False)
Explanation: Eosinophilia occurs in 30% in the peripheral blood and 70% in the urine
renal biopsy evidence of an eosinophilic interstitial nephritis (True)
Explanation: And neutrophil or monocytic infiltrate
renal impairment typically follows withdrawal of the drug (False)
Explanation: Typically resolves
onset following antibiotic or anti-inflammatory drug therapy (True)
Explanation: E.g. penicillin or naproxen

Question 14. Causes of chronic interstitial nephritis include

Sjögren's syndrome (True)
Explanation: Also associated with sarcoidosis and systemic lupus erythematosus
Wilson's disease (True)
Explanation: And other heavy metal poisoning
sickle-cell nephropathy (True)
chronic transplant rejection (True)
analgesic misuse (True)
Explanation: Resulting in medullary ischaemia

Question 15. Chronic pyelonephritis in adults

accounts for the majority of patients with chronic renal failure (CRF) in the UK (False)
Explanation: Diabetes mellitus is the commonest cause
is usually attributable to vesicoureteric reflux in childhood (True)
Explanation: Other aetiological factors may also be important
has pathognomonic histopathological features on renal biopsy (False)
Explanation: Similar to chronic interstitial nephritis
is usually associated with demonstrable ureteric reflux (False)
Explanation: Reflux is often no longer demonstrable in adulthood
producing hypotension should be treated with oral sodium salts (True)
Explanation: As a result of a 'salt-losing' nephropathy

Question 16. The clinical features of adult polycystic renal disease include
an autosomal recessive mode of inheritance (False)
Explanation: Autosomal dominant
cystic disease of the liver and pancreas (True)
Explanation: But liver function tests are normal
renal angle pain and haematuria (True)
Explanation: And hypertension and urinary tract infection

By A. H.
aortic and mitral regurgitation (True)
Explanation: Common but rarely severe
aneurysms of the circle of Willis (True)
Explanation: 10% will have a subarachnoid haemorrhage

Question 17. Characteristic features of renal tubular acidosis (RTA) include

normal anion gap (True)
Explanation: Anion gap = plasma (Na+ + K+) - (Cl- + HCO3-) normally < 15 mmol/l
hyperchloraemic acidosis (True)
Explanation: increased chloride preserves anion gap
inappropriately high urinary pH > 5.4 (True)
Explanation: Even in presence of systemic acidosis
decreased glomerular filtration rate (GFR) (False)
Explanation: GFR is normal
normocytic normochromic anaemia (False)
Explanation: No features of uraemia

Question 18. The typical features of acute pyelonephritis in adult females include
normal anatomy of the urinary tract (True)
Explanation: But ureteric obstruction may be a predisposing factor
vomiting, rigors and renal angle tenderness (True)
Explanation: With loin or epigastric pain
pyuria (True)
peritubular neutrophil infiltration (True)
loin pain and fullness in the flank (False)
Explanation: Suggest perinephric abscess

Question 19. In the treatment of renal calculi

anuria indicates the need for urgent surgical intervention (True)
Explanation: Suggests total obstruction
the urine should be alkalinised if the stone is radio-opaque (False)
Explanation: Acidification with ammonium chloride may benefit
bendroflumethiazide (bendrofluazide) increases urinary calcium excretion (False)
Explanation: Decreases urinary calcium excretion by 30% in hypercalciuric patients
allopurinol increases urinary urate excretion in gouty patients (False)
Explanation: Decreases urinary urate and may reduce oxalate stone formation
renal pelvic stones require removal at open surgery (False)
Explanation: Fragmentation by lithotripsy and endoscopic removal is possible

Question 20. Recognised features of renal carcinoma include

persistent fever (True)
Explanation: Occurs in 20% and is due to increased interleukin release
bone metastases (True)
Explanation: Typically osteolytic metastases
haematuria (True)
Explanation: Due to blood clot or direct tumour obstruction of ureter
polycythaemia (True)
Explanation: Erythropoietin secretion
serum alphafetoprotein in high titre (False)
Explanation: Suggests hepatoma

Question 21. The typical features of benign prostatic hypertrophy include

peak incidence in the age-group 40-60 years (False)
Explanation: Aged over 60 years
acute urinary retention and haematuria (True)
Explanation: Sometimes precipitated by urinary tract infection
a response to á-adrenoceptor blocker therapy in > 50% of patients (True)

By A. H.
elevated serum prostate specific antigen (False)
Explanation: Suggests prostatic carcinoma
hard, nodular prostatic enlargement on rectal examination (False)
Explanation: Suggests prostatic carcinoma

Question 22. Typical features of prostatic carcinoma include

slowly progressive obstructive uropathy (True)
Explanation: As also benign prostatic disease
presentation with urinary frequency and nocturia (True)
Explanation: Or haematuria
preservation of the normal anatomy on digital rectal examination (False)
Explanation: Hard with obliteration of median furrow
local spread along the lumbosacral nerve plexus (True)
Explanation: And may involve ureters
osteolytic rather than osteosclerotic bone metastases (False)
Explanation: Osteosclerotic metastases

Question 23. Characteristic features of testicular tumours include

testicular pain in seminoma of the testis (False)
Explanation: Typically painless
secretion of alphafetoprotein and chorionic gonadotrophin by teratomas (True)
Explanation: Helps in the assessment of treatment response
absence of distant metastases (False)
peak incidence after the age of 60 years (False)
Explanation: Peak incidence aged 25-34 years
seminomas are both radio- and chemosensitive (True)
Explanation: Chemotherapy is given if disease is widespread

Module 15 (Chapter 15)

Question 1. Type 1 insulin-dependent diabetes mellitus (IDDM) is associated with
'insulitis'-T lymphocyte infiltrate of the islets of Langerhans (True)
Explanation: Patchy distribution in pancreas
feeding of cows' milk in early infancy (True)
Explanation: Cross-reactivity of antibodies to bovine serum albumin
destruction of over 70% of pancreatic beta cells (True)
Explanation: Symptoms occur only when 70-90% of beta cells have been destroyed
concordance rates in monozygotic twins of 35% (True)
Explanation: Indicating the importance of environmental factors
possession of HLA antigens DR3 and DR4 (True)
Explanation: Linkage with HLA-DQA1 and DQB1 genes encoded on the short arm of chromosome 6

Question 2. The following statements about type 2 diabetes mellitus (NIDDM) are true
there is clear evidence of disordered autoimmunity in most patients with type 2 diabetes mellitus (False)
Explanation: In contrast to type 1 diabetes mellitus
monozygotic twins show almost 100% concordance for type 2 diabetes mellitus (True)
Explanation: Compare 35% concordance in monozygotic twins with type 1 diabetes mellitus
patients with type 2 diabetes mellitus typically exhibit hypersensitivity to insulin (False)
Explanation: Variable insulin resistance
obesity predisposes to type 2 diabetes mellitus in genetically susceptible individuals (True)
Explanation: Especially if combined with underactivity
hypertension, hypercholesterolaemia and hyperinsulinaemia often coexist (True)
Explanation: Syndrome X (Reaven's syndrome) associated with macrovascular disease

Question 3. Secondary diabetes mellitus is associated with

thiazide diuretic therapy (True)
Explanation: Hypokalaemic alkalosis impairs insulin secretion
haemochromatosis (True)

By A. H.
Explanation: Pancreatic fibrosis
primary hyperaldosteronism (True)
Explanation: Conn's syndrome produces a hypokalaemic alkalosis
pancreatic carcinoma (True)
Explanation: Islet cell destruction
thyrotoxicosis (True)
Explanation: Also occurs in phaeochromocytoma and acromegaly

Question 4. The physiological effects of insulin include

increased glycolysis (True)
decreased glycogenolysis (True)
increased lipolysis (False)
Explanation: Decreased lipolysis and ketogenesis
increased gluconeogenesis (False)
Explanation: Decreased gluconeogenesis
increased protein catabolism (False)
Explanation: Decreased protein catabolism

Question 5. In decompensated diabetes mellitus

thirst results from the increased osmolality of glomerular filtrate (True)
Explanation: And produces an increase in plasma osmolality
hyperpnoea is the result of acidosis due to increased lactic and ketoacid production (True)
Explanation: Resulting in a metabolic acidosis
negative nitrogen balance results from the increased protein catabolism (True)
Explanation: Insulin deficiency increases protein degradation
lipolysis increases as a result of relative insulin deficiency (True)
Explanation: More profound ketogenesis occurs in type 1 diabetes mellitus
insulin deficiency inhibits the peripheral utilisation of ketoacids (False)
Explanation: Insulin deficiency increases ketoacid production

Question 6. In the diagnosis of diabetes mellitus

glycated haemoglobin (HbAlc) is a sensitive screening test (False)
Explanation: Too insensitive to detect all cases
absence of glycosuria excludes diabetes (False)
Explanation: Renal threshold may be high
glycosuria is usually due to a reduced renal threshold in young patients (True)
Explanation: But it should never be assumed to be so
2% of patients have significant diabetic complications at presentation (False)
Explanation: 20% have significant diabetic complications
random plasma glucose concentrations > 11 mmol/l are diagnostic (True)
Explanation: When symptoms suggest diabetes

Question 7. Typical presentations of diabetes mellitus include

weight loss (True)
Explanation: Catabolism
balanitis or pruritus vulvae (True)
Explanation: Predisposition to monilial infection
nocturia (True)
Explanation: Osmotic diuresis
limb pains with absent ankle reflexes (True)
Explanation: Small vessel disease and neuropathy
asymptomatic glycosuria in the elderly (True)
Explanation: Often detected on routine urine testing

Question 8. In the dietary management of diabetes mellitus

90% of patients also require hypoglycaemic drug therapy (False)
Explanation: 50% of new diabetics can be controlled on diet alone

By A. H.
carbohydrate should provide 50% of the total calorie intake (True)
Explanation: Higher than that in the average UK diet
10 g carbohydrate exchanges provide an ideal method of monitoring intake (False)
Explanation: Not advocated as the method takes no account of glycaemic effects or fat intake
fat intake should not exceed 35% of total calorie intake (True)
Explanation: UK national diet tends to higher proportion of fat
in obese patients, calorie intake should not exceed 750 kcal/day (False)
Explanation: Calorie restriction of 500 kcal/day is more realistic and sustainable

Question 9. Sulphonylurea drug therapy in diabetes mellitus

causes less weight gain than biguanide therapy (False)
Explanation: Causes more weight gain
increases hepatic gluconeogenesis (False)
Explanation: Stimulates pancreatic insulin secretion
decreases the number of peripheral insulin receptors (False)
Explanation: Such an action would produce insulin resistance
decreases hepatic glycogenolysis (True)
Explanation: Also decreases hepatic gluconeogenesis to reduce hyperglycaemia
causes alcohol-induced flushing (True)
Explanation: Disulfiram-like reaction

Question 10. Biguanide drug therapy in diabetes mellitus

is more likely to cause weight loss than weight gain (True)
Explanation: Sometimes a useful adjunct to calorie-restricted diets
Increases plasma immunoreactive insulin concentration (False)
Explanation: Hence does not cause hypoglycaemia in non-diabetics
Decreases pancreatic glucagon release (False)
Explanation: Increases the sensitivity of peripheral insulin receptors
Inhibits hepatic glycogenolysis (True)
Explanation: Thus limiting hyperglycaemia
Causes troublesome constipation (False)
Explanation: Causes diarrhoea which may limit drug compliance

Question 11. The following statements about other drug therapies in diabetes mellitus are true
Thiazolidinediones enhance endogenous insulin sensitivity (True)
Explanation: Activate peroxisome proliferator-activated receptor ã (PPARã agonists)
Thiazolidinediones produce hyperinsulinaemia and hypoglycaemia (False)
Explanation: Insulin sensitivity in adipose tissue is only increased in patients with insulin resistance
Thiazolidinediones are best prescribed in combination with biguanides, sulphonylureas or insulin (True)
Explanation: Glitazones promote weight gain and fluid retention similar to sulphonylureas and insulin
Meglitinides increase peripheral insulin sensitivity (False)
Explanation: Stimulate postprandial insulin secretion
Alpha-glucosidase inhibitors induce carbohydrate malabsorption (True)
Explanation: Selectively inhibit intestinal disaccharidases producing flatulence and diarrhoea

Question 12. The following statements about insulin therapy are true
Short-acting, regular insulin should be injected at least 30 minutes pre-prandially (True)
Explanation: Onset of effect at least 30 minutes after injection
the duration of action of short-acting regular insulin is 4-8 hours (True)
intermediate-acting isophane insulin action peaks at 1-3 hours (False)
Explanation: Isophane insulin action has an onset at 1-3 hours and lasts 7-14 hours
The standard UK solution strength is 100 units/ml (True)
Explanation: Different in other countries
Once absorbed, insulin has a plasma half-life of 2 hours (False)
Explanation: Plasma insulin has a half-life of 7 minutes

Question 13. Typical symptoms of hypoglycaemia in diabetic patients include

By A. H.
Feelings of faintness and hunger (True)
Explanation: But 50% of long-term type 1 diabetes mellitus patients have no symptoms
Tremor, palpitation and dizziness (True)
Explanation: Sympathetic nervous system activation
Headache, diplopia and confusion (True)
Explanation: Neuroglycopenia
Abnormal behaviour despite a normal plasma glucose (False)
Explanation: But plasma glucose concentration does not mirror cerebrospinal fluid glucose perfectly
Nocturnal sweating, nightmares and convulsions (True)
Explanation: Nocturnal hypoglycaemia may be difficult to recognise

Question 14. In the treatment of severe hypoglycaemia in a diabetic patient

patients should be taught to self-administer 50 ml of 50% glucose intravenously (False)
Explanation: Defined as hypoglycaemia requiring the assistance of another person for recovery
glucagon should be given intramuscularly (True)
Explanation: Diabetics and close family members should be taught the technique
the patient is more likely to have been taking metformin therapy alone rather than a sulphonylurea (False)
Explanation: Hypoglycaemia does not occur with biguanides
reversal of cognitive impairment is complete within 30 minutes of the restoration of normoglycaemia (False)
Explanation: Can take 60-90 minutes after normoglycaemia is restored
cerebral oedema should be considered if consciousness is not rapidly restored (True)
Explanation: Other possibilities include stroke, hypoglycaemia-induced seizures and alcohol intoxication

Question 15. Factors predisposing to frequent hypoglycaemic episodes in a diabetic patient include
Delayed meals (True)
Explanation: Or inadequate size of meal
unusual exercise (True)
Explanation: Often unanticipated
Excessive alcohol intake (True)
Explanation: A problem with patients on sulphonylurea drugs
Development of hypoadrenalism (True)
Explanation: Increased sensitivity to insulin; weight loss and nocturia should signal the possibility
Errors in drug administration (True)
Explanation: Inadvertent and occasionally even deliberate

Question 16. The typical clinical features of diabetic ketoacidosis include

Abdominal pain and air hunger (True)
Explanation: Due to the acidosis
Rapid, weak pulse and hypotension (True)
Explanation: Due to dehydration and acidosis
Profuse sweating with skin pallor (False)
Explanation: Suggests hypoglycaemia-skin is typically dry with loss of turgor in diabetic ketoacidosis
Vomiting and constipation (True)
Explanation: Due to ketosis and dehydration
coma with focal neurological signs (False)
Explanation: Suggests severe hypoglycaemia

Question 17. Expected findings in moderately severe diabetic ketoacidosis include

water deficit of at least 6 litres (True)
Explanation: Average deficit = 6 l (50% intracellular + 50% extracellular)
sodium and potassium deficits of at least 400 mmol (True)
Explanation: Chloride deficit similar
plasma bicarbonate less than 12 mmol/l (True)
Explanation: Check the arterial blood pH and PaCO2
absence of ketones in the urine (False)
Explanation: Absence of ketonuria suggests another cause for the metabolic acidosis
peripheral blood leucocytosis (True)

By A. H.
Explanation: Even in absence of infection due to acidosis

Question 18. In the management of diabetic ketoacidosis

intracellular water deficit is best restored using half-strength saline (0.45% saline) (False)
Explanation: Use isotonic solutions; change to 5% dextrose when blood glucose falls below 15 mmol/l
potassium should be given immediately anticipating a low serum potassium concentration (False)
Explanation: Avoid until the serum K+ result is available and do not give if the serum K+ > 5.5 mmol/l
bicarbonate infusion is rarely necessary in the absence of renal failure (True)
Explanation: Or in severe acidosis, i.e. pH < 7.0 (H+ concentration > 100 nmol/l)
5% dextrose solution should be avoided unless hypoglycaemia supervenes (False)
Explanation: Dextrose is used to correct intracellular fluid depletion and if blood glucose < 15 mmol/l
peripheral circulatory failure requires rapid volume replacement initially (True)
Explanation: Give plasma expander if blood pressure does not improve rapidly; monitor urine output and central venous

Question 19. The clinical features of diabetic retinopathy include

arteriolar spasm with arteriovenous nipping (False)
Explanation: Suggests hypertensive change
venous dilatation and increased venous tortuosity (True)
Explanation: Sausage-like venous 'beading'
soft and hard exudates (True)
Explanation: Soft exudates indicate retinal ischaemia; hard exudates indicate plasma leakage
retinal haemorrhages (True)
Explanation: Appearance of haemorrhages corresponds with their site in the layers of the retina
microaneurysms (True)
Explanation: Major risk factor for macrovascular disease

Question 20. The following statements about the long-term complications of diabetes are correct
cardiovascular disease accounts for 70% of all deaths associated with diabetes (True)
Explanation: Renal failure accounts for 10% of deaths associated with diabetes
the excess mortality associated with diabetes is mainly attributable to microvascular complications (False)
Explanation: Mainly macrovascular complications due to atherosclerosis
the frequency and severity of microvascular complications can be minimised by strict glycaemic control (True)
Explanation: Both in type 1 and type 2 diabetes
cardiovascular complications can be minimised by strict control of the blood pressure (True)
Explanation: Both in type 1 and type 2 diabetes
diabetic patients with hypercholesterolaemia and cardiovascular disease benefit from statin therapy (True)
Explanation: Both type 1 and type 2 diabetics at high risk from cardiovascular disease also benefit from angiotensin-
converting enzyme inhibitor therapy

Module 16 (Chapter 16)

Question 1. The hypothalamic releasing factors listed below stimulate the pituitary gland to secrete the following
dopamine-prolactin (False)
Explanation: Dopamine inhibits prolactin release; dopamine antagonists and TRH both stimulate prolactin release
somatostatin-growth hormone (False)
Explanation: Somatostatin inhibits growth hormone release
thyrotrophin-releasing hormone (TRH)-thyroid-stimulating hormone (TSH) and prolactin (True)
Explanation: In vivo significance of effect on prolactin is uncertain
gonadotrophin-releasing hormone (GnRH)-luteinising hormone (LH) and follicle-stimulating hormone (FSH)
independently (True)
Explanation: Gonadal steroids and inhibin modify GnRH effects
corticotrophin-releasing hormone (CRH)-â-lipotrophic hormone (LPH) and adrenocorticotrophic hormone (ACTH)
Explanation: Arginine vasopressin also effects ACTH release

By A. H.
Question 2. Causes of hyperprolactinaemia include
oral contraceptive therapy (True)
Explanation: And pregnancy
chlorpromazine therapy (True)
Explanation: Dopamine antagonist like metoclopramide
primary hypothyroidism (True)
Explanation: High plasma TRH
hypothalamic disease (True)
Cushing's disease (True)
Explanation: High plasma ACTH

Question 3. The clinical features of hyperprolactinaemia include

hypogonadism and galactorrhoea (True)
Explanation: Unilateral galactorrhoea suggests a breast tumour
infertility associated with secondary amenorrhoea (True)
Explanation: Typical
an increased likelihood of macroadenoma in males (True)
bitemporal hemianopia associated with microadenomas (True)
Explanation: Pressure effects are only associated with macroadenomas
prompt response to dopamine agonist therapy (True)
Explanation: E.g. cabergoline and quinagolide

Question 4. The clinical features of acromegaly include

arthropathy and myopathy (True)
Explanation: Also carpal tunnel syndrome
hypertension and impaired glucose tolerance (True)
Explanation: Both occur in 25%
goitre and cardiomegaly (True)
Explanation: Visceromegaly and hepatomegaly
increased sweating and headache (True)
Explanation: The commonest of all the symptoms
skin atrophy and decreased sebum secretion (False)
Explanation: The skin is thickened with increased sebum production

Question 5. Typical results of investigations in a patient with acromegaly include

failure of the plasma growth hormone (GH) to rise during a glucose tolerance test (GTT) (False)
Explanation: Failure to suppress plasma GH-may even rise; GH normally falls during the GTT
decreased serum prolactin (False)
Explanation: Increased serum prolactin occurs in 30%
increased serum insulin-like growth factor (IGF-1) (True)
abnormality of the pituitary fossa on plain radiograph (False)
Explanation: Rarely abnormal-MR scanning is used for preoperative assessment
tumour shrinkage in response to octreotide therapy (False)
Explanation: Somatostatin analogues reduce GH secretion but not tumour size

Question 6. Typical features of anterior pituitary hormone deficiency in adults include

loss of growth hormone function before luteinising hormone (True)
Explanation: Then loss of ACTH and finally loss of TSH
hypertension due to ACTH deficiency (False)
Explanation: Hypotension due to the effects of cortisol deficiency on the vascular bed and kidneys
skin pigmentation (False)
Explanation: Striking pallor due to the effects of â-LPH deficiency on melanocytes
myxoedema due to TSH deficiency (False)
Explanation: Unlike primary hypothyroidism, skin changes do not occur
dilutional hyponatraemia (True)
Explanation: Due to increased ADH release and ADH sensitivity induced by hypotension and cortisol deficiency-ADH
deficiency occurs if there is posterior pituitary damage

By A. H.

Question 7. Causes of hypopituitarism include

Kallmann's syndrome (True)
Explanation: GnRH deficiency associated with hypogonadotrophic hypogonadism and anosmia
craniopharyngioma (True)
Explanation: Any tumour close to the pituitary fossa including meningiomas
head injury (True)
Explanation: Including radiotherapy
Sheehan's syndrome (True)
Explanation: Post-partum necrosis of the pituitary gland
sarcoidosis (True)
Explanation: Also tuberculosis causing chronic basal meningitis

Question 8. Causes of diabetes insipidus (DI) include

congenital sex-linked recessive disorder (True)
Explanation: Nephrogenic DI; also congenital cranial DI-autosomal dominant
craniopharyngioma (True)
Explanation: Any tumour or radiotherapy close to the pituitary fossa
DIDMOAD syndrome (True)
Explanation: DI, diabetes mellitus, optic atrophy and deafness
severe hypocalcaemia (False)
Explanation: Severe hypokalaemia and hypercalcaemia
sarcoidosis (True)
Explanation: Also tuberculosis causing chronic basal meningitis

Question 9. The typical features of cranial diabetes insipidus include

serum sodium concentration > 150 mmol/l with urine specific gravity < 1.001 (False)
Explanation: Severe hypernatraemia only when water access denied
increased polyuria following corticosteroid therapy for hypopituitarism (True)
Explanation: Glucocorticoid insufficiency may mask diabetes insipidus
onset following basal meningitis or hypothalamic trauma (True)
Explanation: Or secondary to pituitary tumours or sarcoid
decreased renal responsiveness to ADH following carbamazepine therapy (False)
Explanation: Carbamazepine stimulates ADH release
unlike psychogenic polydipsia, the response to ADH is invariably normal (True)
Explanation: An effect of long-term overhydration in psychogenic polydipsia

Question 10. The insulin tolerance test is

mandatory to confirm the diagnosis of hypopituitarism (False)
Explanation: An ACTH stimulation test is often the more appropriate test
best terminated as soon as the plasma glucose falls below 2.4 mmol/l (True)
Explanation: Or if severe hypoglycaemic symptoms develop
contraindicated in ischaemic heart disease (True)
Explanation: Needs an adequate hypoglycaemic stimulus and runs the risk of hypoglycaemia
contraindicated in severe hypopituitarism (True)
Explanation: Plasma cortisol at 0800 hrs < 180 nmol/l
an unreliable test of hypothalamic function (False)
Explanation: Test of hypothalamic-pituitary-adrenal axis

Question 11. The following statements about thyroid hormones are true
T3 and T4 are both stored in colloid vesicles as thyroglobulin (True)
Explanation: Thyroglobulin is synthesised within thyroid cells
T4 is metabolically more active than T3 (False)
Explanation: T4 should be regarded as a prohormone
T3 and T4 are mainly bound to albumin in the serum (False)
Explanation: Bound to thyroxine-binding globulin and also to pre-albumin
85% of the circulating T3 arises from extra-thyroidal T4 (True)

By A. H.
Explanation: T4 is deiodinated in liver, muscle and kidney
conversion of T4 to T3 decreases in acute illness (True)
Explanation: Production of reverse T3 may increase

Question 12. The finding of reduced serum free T4 and thyroid-stimulating hormone (TSH) concentrations is
compatible with the following conditions
hypopituitarism (True)
Explanation: With secondary hypothyroidism
primary hypothyroidism (False)
Explanation: Serum TSH would be elevated
nephrotic syndrome (False)
Explanation: Free T4 is normal but total T4 is often increased (high thyroxine-binding globulin (TBG) concentrations)
pneumonia (True)
Explanation: Sick euthyroid syndrome-total and free T4 may be reduced
pregnancy (False)
Explanation: Free T4 and TSH are normal; total T4 is often increased (high TBG concentrations)

Question 13. The following statements about thyrotoxicosis are true

most patients have Graves' disease (True)
Explanation: 75% of cases
multinodular goitre is more common than uninodular goitre (True)
Explanation: 15% multinodular, 5% single nodule
amiodarone treatment should be considered as a possible cause (True)
Explanation: May also cause hypothyroidism
the thyroid gland is diffusely hyperactive in Graves' disease (True)
Explanation: A goitre is therefore usually present
there is an increased prevalence of HLA-DR3 in Graves' disease (True)
Explanation: And HLA-B8 and DR2

Question 14. The clinical features of thyrotoxicosis include

atrial fibrillation with a collapsing pulse (True)
Explanation: Or persisting resting sinus tachycardia
weight loss and oligomenorrhoea (True)
Explanation: Appetite is maintained
peripheral neuropathy (False)
Explanation: Muscular weakness may occur
proximal myopathy and exophthalmos (True)
Explanation: Occasionally with ophthalmoplegia
decreased insulin requirements in type 1 diabetes mellitus (False)
Explanation: Insulin requirements may increase

Question 15. In the treatment of thyrotoxicosis

propranolol should not be given in atrial fibrillation (False)
Explanation: Controls ventricular response rate
carbimazole blocks the secretion of T3 and T4 by the thyroid (False)
Explanation: Inhibits the iodination of tyrosine
persistent suppression of the serum TSH is an indication for surgery (False)
Explanation: TSH measurement alone should not guide therapy
serum TSH receptor antibodies usually persist despite carbimazole (False)
Explanation: But titres correlate poorly with disease activity
surgery is more likely to be necessary in young men than in women (True)
Explanation: Especially patients with large goiters

Question 16. The clinical features of primary hypothyroidism include

carpal tunnel syndrome and proximal myopathy (True)
Explanation: Both, however, are non-specific
cold sensitivity and menorrhagia (True)

By A. H.
Explanation: And infertility and impotence
deafness and dizziness (True)
Explanation: Perhaps due to oedema of the middle ear
puffy eyelids and malar flush (True)
Explanation: And rarely alopecia, vitiligo and dry hair
absent ankle tendon reflexes (False)
Explanation: Reflexes preserved with delayed relaxation

Question 17. Biochemical findings in primary hypothyroidism include

decreased serum free T4 and decreased serum TSH concentration (False)
Explanation: Decreased serum free T4 and increased serum TSH concentration
increased serum prolactin concentration (True)
Explanation: Rarely causing galactorrhoea
inappropriate ADH secretion (True)
Explanation: Producing hyponatraemia
increased serum alkaline phosphatase concentration (False)
Explanation: Serum lactate dehydrogenase and creatine kinase may be elevated
increased serum cholesterol concentration (True)
Explanation: And serum triglyceride levels

Question 18. The development of a goitre is associated with

Coxsackie B viral infection (False)
Explanation: May cause painful thyroiditis with transient hypothyroidism
dietary iodine deficiency (True)
Explanation: Hypothyroidism if iodine deficiency is severe
excess dietary calcium intake (False)
Explanation: No association
cranial irradiation (True)
Explanation: Secondary hypothyroidism
lithium carbonate therapy (True)
Explanation: Inhibits release of thyroid hormones

Question 19. Thyroid carcinoma of

lymphomatous type usually presents as a single 'hot' thyroid nodule (False)
Explanation: 'Hot' nodules are almost always benign
anaplastic type is usually cured by local radiotherapy (False)
Explanation: Radiotherapy provides brief symptomatic relief only
follicular type is best treated by 131I radio-iodine therapy alone (False)
Explanation: Total thyroidectomy, radio-iodine and long-term thyroxine
papillary type should be treated with total thyroidectomy (True)
Explanation: Papillary tumours are the most common cell type
medullary type secretes calcitonin causing severe hypocalcaemia (False)
Explanation: Rare despite high calcitonin levels; carcinoid syndrome can occur

Question 20. The serum calcium concentration is typically increased in

hypoalbuminaemia (False)
Explanation: 40% of calcium is protein-bound; normal after correction for serum albumin
pyloric stenosis (False)
Explanation: But metabolic alkalosis decreases the level of ionised calcium
carcinomatosis (True)
Explanation: Due to bone metastases (often microscopic)
hypoparathyroidism (False)
Explanation: Decreases serum calcium levels
chronic sarcoidosis (True)
Explanation: Increased vitamin D synthesis with decreased PTH concentration

Question 21. Typical clinical features of primary hyperparathyroidism include

By A. H.
recurrent acute pancreatitis and renal colic due to calculi (True)
Explanation: But 50% of patients are asymptomatic
hyperplasia of all the parathyroid glands on histology (False)
Explanation: Solitary parathyroid adenoma in 90%
osteitis fibrosa on bone radiographs at presentation (False)
Explanation: A relatively late feature
the complications of pseudogout and hypertension (True)
Explanation: And peptic ulceration and myopathy
nephrogenic diabetes insipidus (True)
Explanation: With characteristic polyuria

Question 22. Typical biochemical findings in primary hyperparathyroidism include

increased serum calcium and phosphate concentrations (False)
Explanation: Phosphate is usually low
decreased serum 1,25-dihydroxycholecalciferol concentration (False)
Explanation: Increased 1,25-dihydroxycholecalciferol concentration
hypercalciuria and hyperphosphaturia (True)
Explanation: Predisposing to stone formation
increased serum alkaline phosphatase with bony involvement (True)
Explanation: Indicating osteoblastic activity
increased serum calcium and PTH concentrations (True)
Explanation: Serum chloride concentration is usually elevated

Question 23. Causes of hypercalcaemia include

bone metastases (True)
Explanation: Often via production of osteoclast-activating factors
carcinomas secreting PTH-like peptides (True)
Explanation: Undetectable using standard PTH assays
severe Addison's disease (True)
Explanation: Increased vitamin D synthesis with low PTH concentration
severe hypothyroidism (False)

Explanation: Hyperthyroidism is a rare cause

chronic sarcoidosis (True)
Explanation: Increased vitamin D production with low PTH concentration

Question 24. The following statements about adrenal gland physiology are true
ACTH normally controls the adrenal secretion of aldosterone (False)
Explanation: Principally under control of angiotensin II
ACTH increases adrenal androgen and cortisol secretion (True)
Explanation: In the zona reticularis and zona fasciculata respectively
the plasma cortisol concentration normally peaks in the evening (False)
Explanation: Cortisol levels fall to a nadir at around midnight
hyperglycaemia increases the rate of cortisol secretion (False)
Explanation: Hypoglycaemia stimulates cortisol release
cortisol enhances gluconeogenesis and lipogenesis (True)
Explanation: Anti-insulin effects

Question 25. The typical clinical features of Cushing's syndrome include

generalised osteoporosis (True)
Explanation: Protein catabolism in bone
systemic hypotension (False)
Explanation: Hypertension may occur
hirsutism and amenorrhoea (True)
Explanation: Impotence in men
proximal myopathy (True)
Explanation: Muscle protein catabolism

By A. H.
hypoglycaemic episodes (False)
Explanation: Impaired glucose tolerance

Question 26. Adverse effects of oral corticosteroid therapy include

peptic ulceration (True)
Explanation: Decreases mucosal resistance
hypertension (True)
Explanation: Increased renal sodium reabsorption
avascular bone necrosis (True)
Explanation: Particularly likely to affect the femoral heads
pseudogout (False)
Explanation: Sometimes used to treat severe pseudogout
insomnia (True)
Explanation: Typical; causes day-night reversal of biorhythms

Question 27. In primary hyperaldosteronism (Conn's syndrome)

peripheral oedema is usually marked (False)
Explanation: Unlike oedema in patients with secondary hyperaldosteronism
proximal myopathy is due to hypokalaemia (True)
Explanation: Rarely hypokalaemic paralysis
polyuria and polydipsia are characteristic (True)
Explanation: Hypertension and hypokalaemia are also characteristic
diabetes mellitus is often present (False)
Explanation: Type 2 diabetes mellitus is, however, associated with primary hypoadrenalism
hypertension is associated with hyperreninaemia (False)
Explanation: Associated with renin suppression

Question 28. Causes of primary adrenocortical insufficiency include

haemochromatosis (True)
Explanation: Rare cause
autoimmune adrenalitis (True)
Explanation: Commonest cause
amyloidosis (True)
Explanation: Rare
sarcoidosis (False)
Explanation: May cause hypercalcaemia
tuberculosis (True)
Explanation: Now a rare cause

Question 29. Typical features of primary adrenocortical insufficiency include

anorexia, weight loss and diarrhoea (True)
Explanation: All features of glucocorticoid insufficiency
pigmentation of scars from surgery preceding hypoadrenalism (False)
Explanation: Only new scars become pigmented
vitiligo, weakness and hypotension (True)
Explanation: Vitiligo is seen in 10-20% of patients
increased insulin requirements in diabetic patients (False)
Explanation: Increased insulin sensitivity with hypoglycaemia
amenorrhoea and loss of body hair (True)
Explanation: Loss of adrenal androgen

Question 30. The typical features of phaeochromocytoma include

predominantly adrenaline rather than noradrenaline secretion (False)
Explanation: Noradrenaline is a precursor of adrenaline
episodic nausea with sweating and marked skin pallor (True)
Explanation: Catecholamine secretion
underlying malignant tumour in the majority (False)

By A. H.
Explanation: 90% are benign
presentation with hypertension and hypercalcaemia (True)
Explanation: Occurs in MEN type II syndrome
control of symptoms following propranolol therapy alone (False)
Explanation: Symptoms worsen due to unopposed á-adrenoceptor activity

Question 31. Causes of gynaecomastia include

androgen deficiency and/or excessive oestrogen production (True)
Explanation: E.g. hypogonadism or chronic liver failure
microprolactinoma or macroprolactinoma (True)
Explanation: Inhibition of LH/FSH secretion caused by prolactin
cimetidine therapy (True)
Explanation: Also spironolactone and anti-androgen therapy (e.g. cyproterone + GnRH analogues)
haemochromatosis (True)
Explanation: Hypergonadotrophic hypogonadism
human chorionic gonadotrophin-secreting tumour (True)
Explanation: Rare cause of excessive oestrogen production

Question 32. In cryptorchidism with inguinal testes in a child

the individual is usually otherwise normal (True)
Explanation: Chromosomal abnormalities are rare
hypogonadotrophic hypogonadism should be excluded (True)
Explanation: Occurs in the minority
the seminiferous tubules are typically normal (False)
Explanation: Sterility follows if bilateral
testicular interstitial cell function is usually normal (True)
Explanation: Secondary sexual characteristics are preserved
treatment with chorionic gonadotrophin or GnRH is contraindicated (False)
Explanation: Testicular descent ensues in 40%

Question 33. Causes of secondary amenorrhoea include

pituitary microprolactinoma (True)
Explanation: Suppression of LH and FSH secretion by prolactin
anorexia nervosa (True)
Explanation: Failure of gonadotrophin secretion
Cushing's syndrome (True)
Explanation: Associated with hyperprolactinaemia
renal failure (True)
Explanation: Or other severe systemic disease
Stein-Leventhal syndrome (True)
Explanation: Polycystic ovary disease

Question 34. The typical features of the menopause include

decreased plasma LH and FSH concentrations (False)
Explanation: Gonadotrophins elevated
hirsutism and clitoral hypertrophy (False)
Explanation: Features of androgen excess
bone fractures due to osteomalacia (False)
Explanation: Osteoporosis develops prematurely
superficial dyspareunia and dysuria (True)
Explanation: Due to oestrogen deficiency
normal age at onset 40 years (False)
Explanation: Normal menopause occurs at age 50-55 years

Question 35. Causes of hirsutism include

idiopathic familial hirsutism (True)
Explanation: Commonest cause and treated with anti-androgens (e.g. cyproterone)

By A. H.
polycystic ovarian syndrome (PCOS) (True)
Explanation: PCOS is associated with obesity and infertility; plasma LH:FSH ratio > 2.5:1
Cushing's syndrome (True)
Explanation: Modest increase in adrenal androgen synthesis
autoimmune polyglandular syndrome (False)
Explanation: Primary adrenal, thyroid, parathyroid, gastric parietal and gonadal failure syndromes
ovarian tumour (True)
Explanation: Ectopic androgen production does not suppress with dexamethasone (unlike excessive androgen
production in congenital adrenal hyperplasia)

Module 17 (Chapter 17)

Question 1. Causes of mouth ulcers include
gluten enteropathy (True)
Explanation: And systemic lupus erythematosus, Beh[sfgr ]et's syndrome, Reiter's syndrome
Crohn's disease (True)
Explanation: And ulcerative colitis
lichen planus (True)
Explanation: And pemphigoid and pemphigus
adverse drug reaction (True)
Explanation: Stevens-Johnson syndrome due to either drugs or infections
herpes simplex (True)
Explanation: Aphthous mouth ulcers are usually idiopathic rather than viral-induced

Question 2. Causes of salivary gland enlargement include

alcoholic liver disease (True)
Explanation: Also associated with malnutrition and autoimmune hepatitis
Sjögren's syndrome (True)
Explanation: Associated with dry mouth and keratoconjunctivitis sicca (dry eyes)
bacterial infection (True)
Explanation: May be associated with calculi in the parotid duct
sarcoidosis (True)
Explanation: Uveoparotid fever (Heerfordt's syndrome)
measles (False)
Explanation: Associated with mumps

Question 3. Recognised causes of dysphagia include

iron deficiency anaemia (True)
Explanation: Via formation of an oesophageal web-'sideropenic dysphagia'
pharyngeal pouch (True)
Explanation: May also be associated with regurgitation and recurrent aspiration
Barrett's oesophagus (False)
Explanation: Asymptomatic unless complicated by malignancy
myasthenia gravis (True)
Explanation: More commonly caused by stroke; typically worse with fluids than with solids
achalasia (True)
Explanation: Best diagnosed on oesophageal manometry

Question 4. Typical features of oesophageal achalasia include

recurrent pneumonia (True)
Explanation: Due to regurgitation and aspiration
spasm of the lower oesophageal sphincter (LOS) (False)
Explanation: Failure to relax the LOS with loss of ganglion cells in Auerbach's plexus on histology
heartburn and acid reflux (False)
Explanation: Acid reflux is prevented by the non-relaxing LOS
predisposition to oesophageal carcinoma (True)
Explanation: Even if the obstruction is treated
symptomatic response to pneumatic balloon dilatation (True)

By A. H.
Explanation: If this fails, Heller's myotomy may be indicated

Question 5. Gastro-oesophageal reflux disease is associated with the following factors

decreased intra-abdominal pressure (False)
Explanation: Associated with increased intra-abdominal pressure (e.g. pregnancy)
delayed gastric emptying (True)
prolonged oesophageal transit time (True)
Explanation: Delayed oesophageal clearance is more common in the elderly
increased lower oesophageal sphincter tone (False)
Explanation: Associated with decreased lower oesophageal sphincter tone
presence of a hiatus hernia (True)

Question 6. Oesophageal carcinoma in the UK is

associated with gluten enteropathy (True)
Explanation: Squamous rather than adenocarcinoma
more likely to be due to adenocarcinoma than squamous carcinoma (False)
Explanation: 80-90% are squamous cell
associated with Barrett's oesophagus (True)
Explanation: Adenocarcinoma is associated with chronic oesophagitis
more likely to arise in the upper third rather than the lower third of the oesophagus (False)
Explanation: 90% are in the lower two-thirds
associated with alcohol and tobacco consumption (True)
Explanation: And betel nut chewing in the East

Question 7. Typical features of oesophageal carcinoma at presentation include

acid reflux and odynophagia (False)
Explanation: More suggestive of reflux with oesophagitis and stricture formation
painless obstruction to the passage of a food bolus (True)
Explanation: Painless due to destruction of the mucosal innervation
nausea and weight loss (True)
Explanation: Weight loss relates to poor food intake
metastatic spread in the majority of patients (True)
Explanation: 75% have lymph node, liver and/or mediastinal spread
overall survival rates at 5 years of approximately 50% (False)
Explanation: 5-year survival is about 5%

Question 8. Factors associated with chronic peptic ulcer disease include

oral contraceptive therapy (False)
non-steroidal anti-inflammatory drug therapy (True)
Explanation: Plays a role in gastric ulcer
pernicious anaemia (False)
Explanation: Associated with achlorhydria-'no acid, no ulcer'
Helicobacter pylori - associated gastritis (True)
Explanation: Implicated in > 90% of instances
tobacco consumption (True)
Explanation: Associated with both gastric and duodenal ulcer recurrence rates

Question 9. Typical features of peptic ulcer dyspepsia include

pain relieved by eating (True)
Explanation: Hunger pain
well-localised pain relieved by vomiting (True)
Explanation: Perhaps with the 'pointing sign'
pain-free remissions lasting many weeks (True)
Explanation: Pain is characteristically periodic
nausea and epigastric pain (False)
Explanation: More suggestive of biliary colic; pain rarely lasts > 2 hours

By A. H.
absence of symptoms prior to acute perforation (True

Question 10. In the investigation and treatment of chronic dyspepsia

most patients aged < 55 years have an underlying peptic ulcer (False)
Explanation: Only about 20%; most have reflux dyspepsia or functional dyspepsia
25% of duodenal ulcers relapse unless H. pylori has been eradicated (False)
Explanation: 85% relapse if H. pylori has not been eradicated
magnesium-containing antacids produce constipation (False)
Explanation: Cause diarrhoea; aluminium-containing antacids cause constipation
bismuth compounds should not be used for maintenance therapy (True)
Explanation: Due to potential accumulation of bismuth, acid-lowering drugs are preferable
gastric ulcers associated with NSAID therapy are less likely to be associated with H. pylori gastritis than gastric ulcers
occurring in patients not taking NSAIDs (True)
Explanation: 30% of gastric ulcers are not associated with H. pylori (NSAID-induced ulcers)

Question 11. Gastroduodenal haemorrhage in the UK is

more often due to peptic ulcer than to oesophageal varices (True)
Explanation: Peptic ulcer 35-50%, varices < 5%
associated with a 5% mortality when due to chronic peptic ulceration (True)
Explanation: Higher mortality in the elderly and especially in patients who rebleed
a recognised complication of severe head injury (True)
Explanation: Cushing's stress ulcers
best investigated by endoscopy (True)
Explanation: Diagnostic yield reduces with time post-admission
significantly associated with anti-inflammatory drug therapy (True)
Explanation: 75% of patients with gastrointestinal bleed have recently taken NSAIDs (only 50% of 'controls')

Question 12. Typical features of major acute gastroduodenal haemorrhage include

severe abdominal pain (False)
Explanation: Typically pain-free
angor animi and restlessness (True)
Explanation: Sympathetic activation
syncope preceding other evidence of bleeding (True)
Explanation: Particularly in older patients
elevated blood urea and creatinine concentrations (False)
Explanation: Blood urea but not creatinine rises due to digestion of the blood in the gut
peripheral blood microcytosis (False)
Explanation: Only present if preceding iron deficiency

Question 13. When acute gastroduodenal haemorrhage is suspected

a pulse rate > 100/min is most likely to be due to anxiety (False)
Explanation: A sign of hypovolaemia
hypotension without a tachycardia suggests an alternative diagnosis (False)
Explanation: Bradycardia may occur in profound blood loss or in the elderly
the absence of anaemia suggests the volume of blood loss is modest (False)
Explanation: Haemoglobin concentration remains unaltered until haemodilution occurs
nasogastric aspiration provides an accurate estimate of blood loss (False)
Explanation: Monitoring the urine output as a measure of perfusion is important
endoscopy is best deferred pending blood volume replacement (True)
Explanation: Patients should first be haemodynamically stable if possible

Question 14. In resuscitating a patient with an acute gastrointestinal bleed

oxygen should be administered if there are signs of hypovolaemia (True)
Explanation: Especially in patients with shock
transfusion requires whole blood rather than packed red cells (False)
Explanation: Colloid infusion and packed red cells are adequate for volume replacement

By A. H.
volume replacement with colloids is preferable to crystalloids (True)
Explanation: Crystalloids rapidly redistribute to the extravascular space
monitoring central venous pressure and/or urine output is advisable (True)
Explanation: Facilitates restoration of optimal circulating volume
surgical intervention should be considered if rebleeding occurs despite ulcer sclerotherapy (True)
Explanation: Consider surgical options in all patients with continuing bleeding

Question 15. Perforation of a peptic ulcer is typically associated with

acute rather than chronic ulcers (False)
Explanation: 25% occur in acute ulcers
duodenal more often than gastric ulcers (True)
Explanation: Especially anterior wall ulcers
abdominal pain radiating to the shoulder tip (True)
Explanation: Diaphragmatic pain referred to one or both shoulder tips
the absence of nausea and vomiting (False)
Explanation: Vomiting is common
symptomatic improvement several hours following onset (True)
Explanation: But abdominal rigidity typically persists

Question 16. Characteristic features of gastric outlet obstruction include

metabolic acidosis (False)
Explanation: Hypokalaemic metabolic alkalosis
bile vomiting (False)
Explanation: Suggests more distal obstruction
urinary pH < 5 (True)
Explanation: Paradoxical aciduria due to renal tubular mechanisms
symptomatic relief after vomiting (True)
Explanation: Unusually, patients may feel like eating immediately after vomiting
absent gastric peristalsis (False)
Explanation: Often prominent gastric peristalsis and a succussion splash

Question 17. Complications of partial gastrectomy include

early satiety (True)
Explanation: Smaller stomach and loss of vagally mediated gastric relaxation
iron deficiency anaemia (True)
Explanation: Malabsorption is common and can produce folate, B12 and vitamin D deficiency
weight loss (True)
Explanation: Most patients will lose at least 5 kg
reactive hypoglycaemia (True)
Explanation: Late dumping syndrome with exaggerated insulin release
vomiting and diarrhoea soon after meals (True)
Explanation: Early dumping syndrome with the exaggerated release of upper gastrointestinal hormones

Question 18. The typical features of non-ulcer dyspepsia include

onset under the age of 40 years (True)
Explanation: Women are more commonly affected than men
nausea and bloating (True)
Explanation: Dysmotility state
weight loss and anaemia (False)
Explanation: Features suggesting serious underlying disease
constipation with pellety stools (True)
Explanation: Often associated with an irritable bowel syndrome
symptoms of anxiety and depression (True)
Explanation: Often associated with stressful life events and difficulties

Question 19. Carcinoma of the stomach is associated with

adenomatous gastric polyps (True)

By A. H.
chronic hypochlorhydria (True)
Explanation: Pernicious anaemia and partial gastrectomy
Helicobacter pylori infection (True)
Explanation: H. pylori may account for 60% of gastric carcinoma
Ménétrier's disease (True)
Explanation: Hypertrophic gastritis with protein-losing enteropathy
alcohol and tobacco consumption (True)

Question 20. Typical features of gastric carcinoma in the UK include

progression to involve the duodenum (False)
Explanation: Extraordinary but true
origin within a chronic peptic ulcer (False)
Explanation: But may present as a malignant ulcer
overall 5-year survival rate of 50% (False)
Explanation: 10% 5-year survival
folate deficiency anaemia on presentation (False)
Explanation: Iron deficiency anaemia is typical
supraclavicular lymphadenopathy (True)
Explanation: Virchow's node

Question 21. In gluten enteropathy (coeliac disease)

the peak at onset is 11-19 years (False)
Explanation: Peak incidence in the age groups 1-5 years and 40-59 years
there is a predisposition to gut lymphoma and carcinoma (True)
Explanation: Symptoms return without dietary indiscretion
the toxic agent is the polypeptide á-gliadin (True)
Explanation: A component of the gluten protein
gluten-free diets improve absorption but not the villous atrophy (False)
Explanation: Villous atrophy should resolve
serum anti-endomysium IgA antibody titres are characteristically elevated (True)
Explanation: Also antigliadin IgA antibody titres

Question 22. Causes of small bowel bacterial overgrowth (blind loop syndrome) include
diabetic autonomic neuropathy (True)
Explanation: Reduced small intestinal motility
chronic hypochlorhydria (True)
Explanation: E.g. long-term proton pump inhibitor therapy and pernicious anaemia
jejunal diverticulosis (True)
Explanation: Best demonstrated by barium meal
progressive systemic sclerosis (True)
Explanation: Reduced small intestinal motility
enterocolic fistula (True)
Explanation: E.g. Crohn's disease

Question 23. Clinical features suggesting the carcinoid syndrome include

facial blanching and sweating (False)
Explanation: Facial telangiectasia, flushing and wheezing
constipation (False)
Explanation: Diarrhoea is characteristic
intestinal ischaemia (True)
Explanation: Due to mesenteric infiltration and/or vasospasm
tricuspid valve dysfunction (True)
Explanation: And pulmonary stenosis
late occurrence of metastatic disease (False)
Explanation: Typically associated with widespread liver metastases

Question 24. Causes of acute pancreatitis include

By A. H.
measles (False)
Explanation: Mumps and Coxsackie B viral infections
hypothermia (True)
Explanation: And hyperlipidaemia
choledocholithiasis (True)
Explanation: 50% of cases are associated with biliary tract disease
azathioprine therapy (True)
Explanation: And thiazides and corticosteroids
alcohol misuse (True)
Explanation: Common cause in the UK

Question 25. The following are characteristic of acute pancreatitis

abdominal guarding develops soon after the onset of pain (False)
Explanation: Guarding occurs relatively late
normal serum amylase concentration in the first 4 hours after onset (False)
Explanation: Serum amylase rises and falls rapidly
persistent serum hyperamylasaemia suggests a developing pseudocyst (True)
Explanation: Or pancreatic abscess or non-pancreatic cause
hypercalcaemia 5-7 days after onset (False)
Explanation: Hypocalcaemia
hyperactive loud bowel sounds (False)
Explanation: Bowel sounds usually absent or diminished due to paralytic ileus

Question 26. Adverse prognostic factors in acute pancreatitis include

arterial hypoxaemia with a PaO2 < 8 kPa (True)
Explanation: Administer high-flow oxygen therapy
leucopenia with white blood cell count < 5 × 109/l (False)
Explanation: Poorer prognosis indicated by white blood cell count > 15 × 109/l
serum albumin < 30 g/l and serum calcium < 2 mmol/l (True)
Explanation: Reflect extent of peritoneal reaction
hypoglycaemia < 2.3 mmol/l (False)
Explanation: Hyperglycaemia > 10 mmol/l
blood urea > 16 mmol/l after rehydration (True)

Question 27. In the management of acute pancreatitis

early laparotomy is advisable to exclude alternative diagnoses (False)
Explanation: Diagnostic laparotomy is rarely required
opiates should be avoided because of spasm of the sphincter of Oddi (False)
Explanation: Effective pain relief is important
intravenous fluids are unnecessary in the absence of a tachycardia (False)
Explanation: Heart rate alone is a poor guide to volume losses
the urine output and PaO2 should be monitored (True)
Explanation: Shock and respiratory failure are serious complications
persistent elevation in the serum amylase suggests pancreatic duct obstruction (True)
Explanation: Resulting in pancreatic pseudocyst

Question 28. In the investigation of chronic pancreatic disease

glucose tolerance is typically normal in pancreatic carcinoma (False)
Explanation: Typically impaired glucose tolerance test (GTT)
duodenal ileus is a characteristic feature of chronic pancreatitis (False)
Explanation: Occurs in acute pancreatitis
transabdominal ultrasound scanning is more sensitive than CT (False)
Explanation: Pancreatic visualisation is superior with CT
endoscopic retrograde cholangiopancreatography (ERCP) can reliably distinguish carcinoma from chronic pancreatitis
Explanation: Surgery may be necessary
pancreatic calcification suggests alcohol as the cause (True)

By A. H.
Explanation: Biliary tract disease is rarely the cause

Question 29. Features consistent with the diagnosis of chronic pancreatitis include
abdominal or back pain persisting for days (True)
Explanation: Sometimes relieved by crouching or leaning forward
chronic opiate dependency (True)
Explanation: In 20%
increased sodium concentration in the sweat (False)
Explanation: Occasionally in cystic fibrosis
abdominal pain induced and relieved by alcohol intake (True)
pancreatic calcification on plain radiograph or ultrasound (True)
Explanation: But insensitive diagnostic tests

Question 30. Typical causes of chronic pancreatitis include

annular pancreas (False)
Explanation: Associated with pancreas divisum
alcoholism (True)
Explanation: Accounts for 70-80% of instances
gallstones (False)
Explanation: Common but not the cause of chronic pancreatitis
cystic fibrosis (True)
mumps (False)

Question 31. Typical complications of chronic pancreatitis include

pancreatic pseudocyst formation (True)
Explanation: Also associated with acute pancreatitis
obstructive jaundice (True)
Explanation: Due to stricture of the common bile duct as it passes the head of the pancreas
portal vein thrombosis (True)
Explanation: And splenic vein thrombosis leading to gastric varices
diabetes mellitus (True)
Explanation: Occurs in 30% overall
opiate drug dependence (True)
Explanation: May occur in up to 20% of patients

Question 32. The typical features of pancreatic carcinoma include

adenocarcinomatous histology (True)
Explanation: The vast majority
origin in the body of the pancreas in 60% of patients (False)
Explanation: Head of pancreas is the origin in 60% of patients
presentation with diabetes mellitus (True)
Explanation: Indicating advanced disease
back pain and weight loss indicate a poor prognosis (True)
Explanation: Even in the absence of metastatic spread
presentation with painless jaundice (True)
Explanation: Usually due to a tumour in the head of pancreas

Question 33. Characteristic features of ulcerative colitis include

invariable involvement of the rectal mucosa (True)
Explanation: Proctitis is a typical finding
segmental involvement of the colon and rectum (False)
Explanation: Suggests Crohn's disease
pseudopolyposis following healing of mucosal damage (True)
Explanation: Due to oedema and hyperplasia
inflammation extending from the mucosa to the serosa (False)
Explanation: Affects mucosa and submucosa only

By A. H.
enterocutaneous and enteroenteric fistulae (False)
Explanation: Suggest Crohn's disease

Question 34. Ulcerative colitis (UC) differs from Crohn's colitis in that
UC occurs at any age (False)
Explanation: Both have a peak incidence at the age of about 20 years
cessation of smoking is likely to reduce activity of Crohn's disease (True)
Explanation: Smoking exacerbates Crohn's disease but not ulcerative colitis
toxic dilatation only occurs in ulcerative colitis (False)
Explanation: Also occurs in severe Crohn's colitis
there is no association with aphthous mouth ulcers in UC (unlike Crohn's disease) (False)
Explanation: Occur in both
there is no involvement of the small bowel in UC (True)

Question 35. Recognised complications of ulcerative colitis include

pyoderma gangrenosum (True)
Explanation: Also occurs in Crohn's disease and rheumatoid arthritis
pericholangitis (True)
Explanation: Suggested by abnormal liver function tests
amyloidosis (True)
Explanation: Induced by many chronic inflammatory diseases
colonic carcinoma (True)
Explanation: Long-standing disease (> 10 years)
enteropathic arthritis (True)

Question 36. Characteristic features of Crohn's disease include

familial association with ulcerative colitis (True)
Explanation: And vice versa
onset after the age of 70 years (False)
Explanation: Early adult life most commonly
disease confined to the terminal ileum and colon (False)
Explanation: Affects any part of the alimentary tract
predisposition to biliary and renal calculi (True)
Explanation: Bile acid malabsorption and hyperoxaluria
giant cell granulomata on histopathology (True)
Explanation: Crohn's granulomata are non-caseating unlike those of tuberculosis Explanation: Large joints especially,
or spondyloarthritis

Question 37. The typical clinical features of ileal Crohn's disease include
association with tobacco consumption (True)
Explanation: In contrast to ulcerative colitis
presentation with bloody diarrhoea (False)
Explanation: Usually pain rather than diarrhoea unless there is rectal involvement also
presentation with subacute intestinal obstruction (True)
Explanation: With episodes of colicky pain
segmental involvement of the colon and rectum (True)
Explanation: In contrast to ulcerative colitis
inflammatory changes confined to the mucosa on histopathology (False)
Explanation: Inflammation is transmural

Question 38. The typical features of the irritable bowel syndrome include
nocturnal diarrhoea and weight loss (False)
Explanation: Such symptoms suggest organic pathology
onset after the age of 45 years (False)
Explanation: Typically affects females aged 16-45 years
history of childhood abdominal pain (True)
Explanation: Many also have dyspeptic and urinary symptoms

By A. H.
right iliac fossa pain and urinary frequency (True)
Explanation: Pain may be relieved by defaecation
abdominal distension, flatulence and pellety stools (True)
Explanation: May be tenesmus, mucus PR and diarrhoea

Question 39. The management of the irritable bowel syndrome should include
explanation and reassurance after a detailed clinical examination (True)
Explanation: Probably the most important therapeutic tools
barium enema and barium follow-through examinations in all patients (False)
Explanation: Investigations are important in older patients
evaluation of social and emotional factors (True)
Explanation: Anxiety and/or depression are often associated with refractory symptoms
referral for psychiatric assessment and therapy (False)
Explanation: Although occasionally psychiatric intervention may be necessary
dihydrocodeine for abdominal pain and diarrhoea (False)
Explanation: Use loperamide, a safer opioid that does not cross the blood-brain barrier

Question 40. Typical features of colonic diverticulosis include

predominant involvement of the right hemicolon (False)
Explanation: Sigmoid colon is most commonly involved
predisposition to the development of colonic carcinoma (False)
Explanation: No causative association
complications are more common in patients receiving NSAID therapy (True)
Explanation: Especially bleeding and perforation
reduction in the number of diverticula with a high-fibre diet (False)
Explanation: But symptoms may be improved
the absence of symptoms in the absence of complications (True)
Explanation: Such as acute diverticulitis

Question 41. Typical features of colonic diverticulitis include

severe rectal bleeding (True)
Explanation: Exclusion of malignancy may be necessary
chronic iron deficiency anaemia (False)
Explanation: But this may be a feature of chronic diverticulosis
septicaemia and paralytic ileus (True)
Explanation: With or without perforation
right iliac fossa pain (False)
Explanation: Left iliac fossa or hypogastric pain is typical
vesicocolic fistula (True)
Explanation: Or enterocolic or colovaginal

Question 42. Typical features of pseudomembranous colitis include

onset within two weeks of antibiotic therapy (True)
Explanation: Occurs from 4 days to 6 weeks post-antibiotics
normal appearance of the rectal mucosa (False)
Explanation: Usually appears as a non-specific proctitis
Clostridium difficile toxin in the stool (True)
presentation with abdominal pain and diarrhoea (True)
Explanation: And even bloody diarrhoea
clinical relapse despite prompt treatment (True)
Explanation: Treated with metronidazole or vancomycin

Question 43. Familial adenomatous polyposis is

inherited as an autosomal recessive trait (False)
Explanation: Autosomal dominant with a prevalence of 1 in 14 000
usually clinically apparent before the age of 10 years (False)
Explanation: Typically presents in the age group 20-40 years

By A. H.
likely to progress to carcinoma before the age of 40 years (True)
Explanation: Carcinoma is usually present when symptoms commence
associated with gastric and small bowel polyps (True)
Explanation: Also with lipomas, epidermoid cysts, osteomas and desmoid tumours
best treated with immunosuppressant therapy in patients aged < 20 years (False)
Explanation: Immunosuppressives have no role; prophylactic colectomy is warranted

Module 18 (Chapter 18)

Question 1. Bilirubin is
derived exclusively from the breakdown of haemoglobin (False)
Explanation: Also from catabolism of other haem-containing proteins (e.g. myoglobin)
bound in the unconjugated form to plasma â-globulin (False)
Explanation: Bound to albumin
conjugated in the microsomes of the hepatocytes (True)

Explanation: By enzymes of the smooth endoplasmic reticulum

reabsorbed in the small bowel as bilirubin diglucuronide (False)
Explanation: Only reabsorbed after metabolism to stercobilinogen
normally excreted as stercobilinogen in the faeces and as urobilinogen in the urine (True)
Explanation: And as the oxidation products stercobilin and urobilin

Question 2. The concentration of conjugated bilirubin in the

serum in haemolytic anaemia is typically increased (False)
Explanation: Unconjugated hyperbilirubinaemia
urine of healthy subjects is typically undetectable (True)
Explanation: As almost all bilirubin is unconjugated and albumin-bound
serum normally constitutes most of the total serum bilirubin (False)
Explanation: Most of the serum bilirubin is unconjugated
serum in Gilbert's syndrome is typically increased (False)
Explanation: Unconjugated bilirubin is increased
urine in viral hepatitis parallels that of urobilinogen (False)
Explanation: Urobilinogen is an unreliable indicator of hepatobiliary disease

Question 3. The serum alanine aminotransferase (ALT) concentration is

derived from a microsomal enzyme specific to hepatocytes (False)
Explanation: Neither ALT nor AST is specific to the liver
typically more than six times normal in alcoholic hepatitis (False)
Explanation: Not usually > three times normal
usually normal in both obstructive and haemolytic jaundice (False)
Explanation: May be elevated in either
likely to rise and fall in parallel with the serum bilirubin in viral hepatitis (False)
Explanation: Changes in serum ALT precede changes in the serum bilirubin
likely to increase in response to enzyme-inducing drug therapy (False)
Explanation: Only the gamma-glutamyl transferase levels increase

Question 4. The serum alkaline phosphatase concentration is

derived from the liver, bone, small bowel and placenta (True)
Explanation: Therefore not specific to liver disease
typically increased to more than six times normal in viral hepatitis (False)
Explanation: Not usually > 2.5 times normal
derived mainly from hepatic sinusoidal and canalicular membranes (True)
Explanation: Excess synthesis in cholestasis
of particular prognostic value in chronic liver disease (False)
Explanation: No prognostic value
increased more in extrahepatic than in intrahepatic cholestasis (False)
Explanation: No site-specific pattern

By A. H.
Question 5. In the investigation of suspected liver disease
ultrasonography reliably distinguishes solid from cystic masses (True)
ultrasonography reliably excludes liver disease (False)
Explanation: May appear normal in disease
normal liver function values exclude significant liver disease (False)
Explanation: May be normal in 10-15% of patients with cirrhosis
the mortality rate of percutaneous liver biopsy is about 5% (False)
Explanation: Approximately 0.05%
ascitic protein concentrations > 25 g/l are compatible with a diagnosis of carcinomatosis (True)

Explanation: And tuberculosis and hepatic vein obstruction; protein concentration < 30 g/l = transudate

Question 6. Characteristic features of Gilbert's syndrome include

an autosomal recessive mode of inheritance (False)
Explanation: Typically autosomal dominant
decreased hepatic glucuronyl transferase activity (True)
Explanation: Causing failure of bilirubin conjugation
unconjugated hyperbilirubinaemia < 100 µmol/l (True)
Explanation: And no abnormality of other liver function tests
serum bilirubin concentration increased by fasting (True)
Explanation: Sometimes used as a diagnostic test
increased serum bile acid concentrations (False)
Explanation: Unconjugated hyperbilirubinaemia is the sole abnormality

Question 7. Characteristic features of cholestatic jaundice include

dark green stools (False)
Explanation: Typically pale stools-steatorrhoea
dark brown urine (True)
Explanation: Due to conjugated bilirubinuria
unconjugated hyperbilirubinaemia (False)
Explanation: Conjugated hyperbilirubinaemia
serum alkaline phosphatase concentration > 2.5 times normal (True)
Explanation: Diagnostic feature
increased serum bile acid concentrations (True)

Question 8. Typical causes of extrahepatic cholestatic jaundice include

sclerosing cholangitis (False)
Explanation: Intrahepatic
primary biliary cirrhosis (False)
Explanation: Intrahepatic
cystic fibrosis (True)
Explanation: Common bile duct obstruction from chronic pancreatitis
alcoholic cirrhosis (False)
Explanation: Intrahepatic
non-alcoholic steatohepatitis (False)
Explanation: Rarely causes jaundice

Question 9. The following features suggest extrahepatic cholestasis rather than viral hepatitis
a palpable gallbladder (True)
Explanation: E.g. pancreatic carcinoma
right hypochondrial tenderness (False)
Explanation: Also common in acute hepatitis
serum alkaline phosphatase concentration > 2.5 times normal (True)
pruritus and rigors (True)
Explanation: Suggests obstruction with cholangitis
peripheral blood polymorph leucocytosis (True)
Explanation: Sometimes relative lymphocytosis in viral hepatitis

By A. H.

Question 10. The typical causes of macrovesicular steatosis include

alcohol misuse (True)
Explanation: Often asymptomatic
pregnancy (False)
Explanation: Microvesicular steatosis
Reye's syndrome (False)
Explanation: Microvesicular steatosis
severe malnutrition (True)
Explanation: Steatohepatitis (macrovesicular steatosis with hepatocyte necrosis) can be serious
diabetes mellitus (True)
Explanation: Common and benign

Question 11. The typical features of type A viral hepatitis (HAV) include
picornavirus infection spread by the faecal-oral route (True)
an incubation period of 3 months (False)
Explanation: 2-4 weeks
a greater risk of acute liver failure in the young than in the old (False)
Explanation: But children are more frequently infected
right hypochondrial pain and tenderness (True)
Explanation: Non-specific findings of acute hepatitis
progression to cirrhosis if cholestasis is prolonged (False)
Explanation: Chronic hepatitis does not occur

Question 12. The following statements about type A viral hepatitis are true
persistent viraemia produces the post-hepatitis syndrome (False)
Explanation: Viraemia is only transient in hepatitis A
relapsing hepatitis usually indicates a poorer prognosis (False)
Explanation: Spontaneous recovery is the typical outcome
the virus is not usually transmitted via infected blood (True)
Explanation: But a recognised rarity
drug-induced acute hepatitis produces similar liver histology (True)
Explanation: Serological investigations should help distinguish
travellers given immune serum globulin are protected for 3 months (True)
Explanation: Some will have natural endogenous protection

Question 13. Circulating hepatitis B surface antigen (HBsAg) is

detectable during the prodrome of acute type B hepatitis (True)
Explanation: A reliable marker of hepatitis B infection
a DNA viral particle transmissible in all body fluids (True)
Explanation: A DNA hepadna virus
likely to persist in about 50% of adults following acute type B hepatitis (False)
Explanation: Chronic carriage occurs in 5-10% of adults
invariably present in a patient with jaundice attributable to type B hepatitis infection (False)
Explanation: Alternative serological evidence of infection should be sought
commoner in asymptomatic subjects in the Western rather than the Eastern hemisphere (False)
Explanation: Carriage rates are highest in the Middle East and Far East

Question 14. The typical features of type B viral hepatitis (HBV) include
an incubation period of 1 month (False)
Explanation: Average incubation 3 months
history of exposure to unsafe sex or drug misuse (True)
Explanation: Or other exposure to blood or blood products
prodromal illness with polyrtharalgia (True)
Explanation: May cause serum sickness
hepatitic illness more severe than with type A virus (True)
Explanation: Hepatitis A is usually a mild illness

By A. H.
absence of progression to chronic hepatitis (False)
Explanation: And hepatic cirrhosis also occurs

Question 15. In hepatitis C (HCV)

a chronic carriage rate of > 50% is the rule (True)
Explanation: With varying degrees of severity
the infecting agent is an RNA flavivirus (True)
the disease does not progress to chronic hepatitis (False)
Explanation: Hepatitis C may progress to chronic disease
most patients experience the symptoms of acute hepatitis (False)
Explanation: Most patients are asymptomatic; incubation period is 2-26 weeks
the virus is responsible for 90% of all post-transfusion hepatitis (True)
Explanation: Although serological screening methods have greatly reduced this

Question 16. The typical features of acute (fulminant) hepatic failure include
onset within 8 weeks of the initial illness (True)
Explanation: Without evidence of pre-existing liver disease
hepatosplenomegaly and ascites (False)
Explanation: Suggest chronic liver disease
encephalopathy and fetor hepaticus (True)
Explanation: With confusion and asterixis (liver flap)
nausea, vomiting and renal failure (True)
Explanation: Renal failure is an ominous development
cerebral oedema without papilloedema (True)
Explanation: Occurs late, if at all

Question 17. Typical liver function values in acute hepatic failure include
hypoalbuminaemia (False)
Explanation: Serum albumin has a long half-life
hypoglycaemia (True)
Explanation: Impaired hepatic gluconeogenesis
prolonged prothrombin time (True)
Explanation: Useful in determining prognosis
serum alkaline phosphatase > 6 times normal (False)
Explanation: Typically not so elevated, unlike the serum transaminases
peripheral blood lymphocytosis (False)
Explanation: May be a polymorphonuclear leucocytosis

Question 18. The clinical features of autoimmune hepatitis include

an association with autoimmune thyroiditis (True)
Explanation: Type I autoimmune liver disease is associated with Graves' disease and Hashimoto's thyroiditis
acute onset simulating viral hepatitis in 25% of patients (True)
Explanation: Occurs in 25% of patients but symptoms and signs then persist
arthralgia, fever and amenorrhoea (True)
Explanation: And fatigue, anorexia and jaundice
spider telangiectasia and hepatosplenomegaly (True)
Explanation: And other signs of chronic liver disease
Cushingoid facies, hirsutism and acne (True)
Explanation: Altered steroid hormone metabolism

Question 19. The typical features of hepatic cirrhosis include

a small shrunken liver (True)
Explanation: Liver size reduces as disease progresses
painful splenomegaly (False)
Explanation: Painless splenomegaly due to portal hypertension
peripheral blood macrocytosis (True)
Explanation: Particularly in alcoholic liver disease

By A. H.
parotid gland enlargement (True)
Explanation: Particularly in alcoholic cirrhosis
central cyanosis (True)
Explanation: Hepatopulmonary syndrome associated with pulmonary telangiectasia

Question 20. Typical features of hepatic encephalopathy include

disordered sleep and loss of concentration (True)
Explanation: Grade 1
aggressive behaviour and personality change (True)
Explanation: Grade 2
yawning and hiccuping (True)
Explanation: And asterixis (hepatic flap)
drowsiness and disorientation (True)
Explanation: Grade 3
confusion progressing to coma (True)
Explanation: Grade 4

Question 21. Causes of ascites in the absence of intrahepatic liver disease include
congestive cardiac failure (True)
Explanation: Also constrictive pericarditis-transudate
nephrotic syndrome (True)
Explanation: Also protein-losing enteropathy-transudate
peritoneal tuberculosis (True)
Explanation: Also carcinomatosis-exudate
lymphatic obstruction (True)
Explanation: Chylous effusion
Budd-Chiari syndrome (True)
Explanation: Transudate associated with hepatic vein occlusion

Question 22. In the management of ascites due to hepatic cirrhosis

the dietary sodium intake should be restricted to 140 mmol/day (False)
Explanation: Restriction < 40 mmol/day is usually required
paracentesis and parenteral albumin replacement improve the survival rate (False)
Explanation: A palliative, symptomatic measure with no prognostic value
the daily calorie intake should be restricted to 1500 calories (False)
Explanation: Calorie restriction is neither required nor desirable
diuretic therapy should achieve a daily weight loss of at least 2.5 kg (False)
Explanation: Daily weight loss > 1 kg may precipitate renal impairment and/or encephalopathy
the protein intake should be at least 40 g/day unless encephalopathy is suspected (True)
Explanation: Restriction may be necessary to control encephalopathy

Question 23. Causes of portal hypertension include

alcoholic cirrhosis (True)
Explanation: Intrahepatic parenchymal
myeloproliferative disease (True)
Explanation: Intrahepatic pre-sinusoidal
hepatic schistosomiasis (True)
Explanation: Intrahepatic pre-sinusoidal; also sarcoidosis
abdominal trauma (True)
Explanation: Extrahepatic pre-sinusoidal (portal vein thrombosis)
hepatic vein obstruction (Budd-Chiari syndrome) (True)
Explanation: Extrahepatic post-sinusoidal

Question 24. Complications of portal hypertension include

variceal haemorrhage (True)
Explanation: Oesophageal, gastric, stomal and rectal varices
congestive gastropathy (True)

By A. H.
Explanation: Associated with hypergastrinaemia
hepatorenal failure (True)
Explanation: Associated with reduced renal blood flow
hepatic encephalopathy (True)
ascites (True)
Explanation: And hypersplenism

Question 25. In the management of acute variceal bleeding due to hepatic cirrhosis
the priority is to restore normovolaemia (True)
Explanation: Untreated, shock dramatically reduces liver blood flow and liver function
pharmacological therapy is more effective than variceal banding or sclerotherapy (False)
Explanation: Local measures stop bleeding in 80% of patients
somatostatin (octreotide) and vasopressin both reduce portal venous pressure (True)
Explanation: Constrict splanchnic arterioles; glyceryl trinitrate is given to reduce vasoconstriction
balloon tamponade is best undertaken after endoscopic confirmation of bleeding varices (True)
Explanation: Unless the patient is exsanguinating; 20% of patients are bleeding from non-variceal causes
transjugular intrahepatic portosystemic stent shunting (TIPSS) is contraindicated in hepatic failure (False)
Explanation: TIPSS is used when local measures fail and has replaced emergency shunt surgery

Question 26. Prevention of recurrent variceal bleeding is achievable using

somatostatin (octreotide) therapy (False)
Explanation: Somatostatin may be useful in acute bleeds
TIPSS (True)
Explanation: Also used in acute variceal bleeding
â-adrenoceptor antagonist (â-blocker) treatment (True)
Explanation: â-blockers reduce portal pressure
variceal banding (True)
Explanation: Better than sclerotherapy in the elective situation
sclerotherapy (True)
Explanation: Easier than banding in the emergency situation

Question 27. In primary biliary cirrhosis

middle-aged males are affected predominantly (False)
Explanation: Middle-aged females
pruritus is invariably accompanied by jaundice (False)
Explanation: May precede jaundice by months or years
osteomalacia and osteoporosis both occur as the disease progresses (True)
Explanation: Vitamin D malabsorption and hepatic osteodystrophy
rigors and abdominal pain are presenting features (False)
Explanation: Suggests obstruction of large bile duct
smooth muscle antibodies are present in high titres in the serum (False)
Explanation: High titres of antimitochondrial antibody

Question 28. The typical features of primary haemochromatosis include

association with an autosomal dominant pattern of inheritance (False)
Explanation: Inherited as an autosomal recessive gene located on chromosome 6
male predominance (True)
Explanation: 90% are males; females may be protected by menstruation and pregnancy
hepatic cirrhosis and diabetes mellitus (True)
Explanation: 'Bronzed diabetes'
congestive cardiomyopathy (True)
Explanation: May be a congestive cardiomyopathy
grey skin pigmentation due to ferritin deposition (False)
Explanation: Melanin not iron deposition

Question 29. The typical features of Wilson's disease include

haemolytic anaemia (True)

By A. H.
Explanation: Sometimes accompanying an acute hepatitis in children
acute hepatitis and chronic hepatitis (True)
Explanation: Or acute hepatic failure or cirrhosis
parkinsonian syndrome and hepatic cirrhosis (True)
Explanation: A variety of extrapyramidal syndromes may be seen
Kayser-Fleischer rings (True)
Explanation: Kayser-Fleischer rings are an important diagnostic clue
renal tubular acidosis (True)
Explanation: Copper is deposited in the liver and kidneys

Question 30. The typical features of alcoholic liver disease include

microvesicular steatosis (False)
Explanation: Macrovesicular steatosis is the earliest stage when abstinence will achieve a good prognosis
acute hepatitis and chronic hepatitis (True)
Explanation: 33% mortality if liver dysfunction is severe
hepatic cirrhosis (True)
Explanation: 50% 5-year survival after the initial presentation if abstinent
cholestatic jaundice (True)
Explanation: Often associated with tender hepatomegaly and abdominal pain
alcohol intake > 30 g/day for > 5 years (True)
Explanation: Usually associated with at least 50 g/day for at least 10 years

Question 31. The typical features of hepatocellular carcinoma include

fever, weight loss and abdominal pain (True)
Explanation: Abdominal pain and a cirrhotic liver suggest hepatoma
ascites and intra-abdominal bleeding (True)
Explanation: Tumours are vascular and spread locally
arterial bruit over the liver (True)
Explanation: There may also be a hepatic rub
rising serum á-fetoprotein titre (True)
Explanation: Rises in 90% of cases
surgically resectable disease in 50% of patients (False)
Explanation: Only 10% are suitable for surgery

Question 32. Pyogenic liver abscess is a recognised complication of

ascending cholangitis (True)
Explanation: Secondary to biliary obstruction
Crohn's disease (True)
Explanation: Secondary to portal pyaemia
pancreatitis (True)
Explanation: Acute pancreatitis
septicaemia (True)
Explanation: Infection via hepatic artery
subphrenic abscess (True)
Explanation: Direct local spread

Question 33. The typical features of pyogenic liver abscess include

obstructive jaundice and pruritus (False)
Explanation: Jaundice is usually mild and not often obstructive
tender hepatomegaly without splenomegaly (True)
Explanation: Splenomegaly suggests coexistent pathology
pleuritic pain and pleural effusion (True)
Explanation: May be right shoulder tip pain
multiple abscesses, especially in ascending cholangitis (True)
Explanation: Single lesions are more common in the right liver
Escherichia coli, anaerobes and streptococci present in pus (True)
Explanation: Multiple organisms in one-third of cases

By A. H.

Question 34. Gallstones are a recognised complication of

obesity (True)
Explanation: Increased hepatic cholesterol secretion
pregnancy (True)
Explanation: Increased hepatic cholesterol secretion and impaired gallbladder motility
chronic haemolytic anaemia (True)
Explanation: Pigment stones
terminal ileal disease (True)
Explanation: Pigment stones
rapid weight loss (True)
Explanation: Increased hepatic cholesterol secretion

Question 35. The typical clinical features of acute cholecystitis include

jaundice, nausea and vomiting (False)
Explanation: Jaundice occurs in less than 20% even in the absence of stones (Mirizzi's syndrome)
colicky abdominal pain in spasms lasting about 5 minutes (False)
Explanation: Pain is typically continuous for up to 6 hours
right hypochondrial tenderness worse on inspiration (True)
Explanation: Murphy's sign
air in the biliary tree on plain radiograph (False)
Explanation: May follow passage of a gallstone into intestine or biliary surgery
peripheral blood leucocytosis (True)
Explanation: May be absent in the elderly

Question 36. The post-cholecystectomy syndrome is characteristically associated with

patients with previous acalculous cholecystitis (True)
Explanation: Less common in patients with previous typical biliary colic and gallstones
females with a history of abdominal pain > 5 years in duration (True)
Explanation: Associated with the irritable bowel syndrome and functional dyspepsia
retained stones in the common bile duct (True)
Explanation: Hence the need to investigate this possibility
dysfunction of the sphincter of Oddi (False)
Explanation: This abnormality may not be causal and may in fact result from cholecystectomy
early postoperative complications (True)
Explanation: Suggest the possibility of a biliary stricture

Module 19 (Chapter 19)

Question 1. Peripheral blood lymphocytosis would be an expected finding in
brucellosis (True)
Explanation: Often with neutropenia
pneumococcal pneumonia (False)
Explanation: Polymorphonuclear leucocytosis
measles and rubella (True)
Explanation: Non-specific feature of many viral infections
Hodgkin's disease (False)
Explanation: Non-Hodgkin's lymphoma
chronic lymphatic leukaemia (True)
Explanation: Predominantly small lymphocytes

Question 2. Peripheral blood neutrophil leucocytosis would be an expected finding in

connective tissue disease (True)
Explanation: Or may be neutropenia in systemic lupus erythematosus
corticosteroid therapy (True)
Explanation: And lithium therapy
pregnancy (True)
Explanation: Variable, increases at delivery

By A. H.
whooping cough (False)
Explanation: Typically lymphocytosis
mesenteric infarction (True)
Explanation: And myocardial infarction

Question 3. Platelets
have a circulation lifespan of 10 hours in healthy subjects (False)
Explanation: 10-day lifespan
are produced and regulated under the control of thrombopoietins (True)
Explanation: By the megakaryocytes
contain small nuclear remnants called Howell-Jolly bodies (False)
Explanation: Found in red blood cells
decrease in number in response to aspirin therapy (False)
Explanation: May increase
release 5-hydroxytryptamine (5-HT, serotonin) and von Willebrand factor (vWF) (True)
Explanation: 5-HT (delta granules), and vWF and fibrinogen (alpha granules)

Question 4. The following statements about red blood cell morphology are true
hypochromia is pathognomonic of iron deficiency (False)
Explanation: Seen in other disorders of haemoglobin synthesis (e.g. thalassaemia)
polychromasia indicates active production of new red blood cells (True)
Explanation: Residual ribosomal material is stained faintly
poikilocytosis is invariably associated with anisocytosis (True)
Explanation: Sign of dyserythropoiesis
punctate basophilia is a typical feature of beta-thalassaemia (True)
Explanation: And lead poisoning
target cells are associated with hyposplenism and liver disease (True)
Explanation: And haemoglobinopathies

Question 5. Peripheral blood findings in dietary iron deficiency include

microcytosis (True)
Explanation: Microcytosis is the first sign
ovalocytosis (True)
Explanation: Sometimes poikilocytosis
mean corpuscular haemoglobin concentration < 50% of normal (False)
Explanation: Only in severe anaemia; hypochromia is due to microcytosis
Howell-Jolly bodies (False)
Explanation: Suggests hyposplenism
thrombocytosis (True)
Explanation: Thrombocytosis occurs even in the absence of bleeding

Question 6. In the treatment of iron deficiency anaemia with iron

folic acid should also be given if the anaemia is severe (False)
Explanation: Only if coexistent deficiency demonstrated
treatment is stopped as soon as haemoglobin normalises (False)
Explanation: Continue for 3 months to replenish stores
haemoglobin should rise by 1 g/l every 7-10 days (False)
Explanation: 10 g/l every 10 days unless there is malabsorption, bleeding or poor compliance
maximal reticulocyte count usually develops within 1-2 days (False)
Explanation: Peak reticulocyte count at 7-10 days
parenteral iron is usually more effective than oral iron (False)
Explanation: Oral iron is usually effective

Question 7. Hypochromic microcytic anaemia is a recognised finding in

haemolytic anaemia (False)
Explanation: Macrocytic with polychromasia
myelodysplastic syndrome (True)

By A. H.
Explanation: Typically a dimorphic red cell population
hypothyroidism (False)
Explanation: Typically macrocytic
beta-thalasaemia (True)
Explanation: And other thalassaemias
rheumatoid arthritis (True)
Explanation: Or a normochromic normocytic picture

Question 8. Normocytic normochromic anaemia is an expected feature of

alcoholic liver disease (False)
Explanation: Typically macrocytic
chronic renal failure (True)
Explanation: Erythropoietin deficiency
rheumatoid arthritis (True)
Explanation: Typically macrocytic
kwashiorkor (True)
Explanation: Protein-energy malnutrition
strict vegetarianism (False)
Explanation: Anaemia is rare in modest reductions of dietary vitamin B12 intake

Question 9. Macrocytic anaemia is a typical finding in

folic acid deficiency (True)
Explanation: With megaloblastic marrow
haemolytic anaemia (True)
Explanation: With polychromasia
alcohol misuse (True)
Explanation: With or without cirrhosis
primary sideroblastic anaemia (False)
Explanation: Dimorphic, with microcytic population
myelodysplastic syndrome (True)
Explanation: But variable red cell morphology

Question 10. Typical haematological findings in megaloblastic anaemia include

pancytopenia and oval macrocytosis (True)
Explanation: Commonly due to vitamin B12 deficiency
neutrophil leucocyte hypersegmentation (True)
Explanation: Shift to the right in the nuclear segmentation count (Arneth count)
anisocytosis and poikilocytosis (True)
Explanation: And red cell fragmentation
reticulocytosis and polychromasia (False)
Explanation: Features of bleeding or haemolysis
excess urinary urobilinogen and bilirubinuria (False)
Explanation: Bilirubinuria is not a feature of any anaemia

Question 11. Folate and vitamin B12 deficiency both typically produce
subacute combined degeneration of the spinal cord (False)
Explanation: Feature of vitamin B12 deficiency only
intermittent glossitis and diarrhoea (True)
Explanation: Glossitis less common in folate deficiency
mild jaundice and splenomegaly (True)
Explanation: Mild haemolysis
peripheral neuropathy (True)
marked weight loss (True)
Explanation: Partially dependent on underlying cause

Question 12. Characteristic features of Addisonian pernicious anaemia include

onset before the age of 20 years (False)

By A. H.
Explanation: Typically 45-65 years
gastric parietal cell and intrinsic factor antibodies in the serum (True)
Explanation: Found in 90% and < 50% respectively
increased serum bilirubin and lactate dehydrogenase concentrations (True)
Explanation: Mild haemolysis occurs
four-fold increase in the risk of developing gastric carcinoma (True)
Explanation: Associated gastric atrophy
Schilling test usually reverts to normal with intrinsic factor (True)
Explanation: Failure to correct suggests terminal ileal disease

Question 13. Causes of folic acid deficiency include

vegetarian diet (False)
Explanation: Caused by inadequate vegetable intake
gluten enteropathy (True)
Explanation: Characteristic finding
pregnancy (True)
Explanation: Increased requirements
haemolytic anaemia (True)
Explanation: Increased requirements
antibiotic therapy (False)
Explanation: Methotrexate and phenytoin may cause folate deficiency

Question 14. Characteristic features of primary aplastic anaemia include

peak incidence in the elderly (False)
Explanation: Peaks about 30 years of age
normocytic normochromic anaemia with thrombocytosis (False)
Explanation: Thrombocytopenia
bone marrow trephine is required to confirm the diagnosis (True)
Explanation: Diagnosis cannot be made on peripheral blood film alone
splenomegaly indicating extramedullary erythropoiesis (False)
Explanation: Splenomegaly occurs in under 10% of cases
pancytopenia (True)
Explanation: Typical

Question 15. Typical features suggesting intravascular haemolysis include

bilirubinuria and haemoglobinuria (False)
Explanation: Bilirubin is unconjugated therefore not found in urine
methaemalbuminaemia and haemosiderinuria (True)
Explanation: The latter always indicating intravascular haemolysis
increased serum haptoglobin concentration (False)
Explanation: Decreased serum haptoglobin
increased plasma haemoglobin concentration (True)
Explanation: Most is bound to serum haptoglobin
splenomegaly (True)
Explanation: Often with reticulocytosis

Question 16. Laboratory features suggesting haemolytic anaemia include

increased serum lactate dehydrogenase (LDH) concentration (True)
Explanation: Red cells are rich in LDH
conjugated hyperbilirubinaemia and bilirubinuria (False)
Explanation: Unconjugated hyperbilirubinaemia and excess urobilinogen in the urine
peripheral blood neutrophil leucocytosis (True)
Explanation: Also red cell abnormalities (e.g. spherocytes)
peripheral blood polychromasia and macrocytosis (True)
Explanation: Reflects reticulocytosis
bone marrow erythroid hyperplasia (True)
Explanation: With megaloblastic change if folate deficiency is also present

By A. H.
Question 17. Typical features of hereditary spherocytosis include
splenomegaly (True)
Explanation: Also pigment gallstones
intravascular haemolysis (False)
Explanation: Red blood cell destruction occurs in the spleen
decreased red blood cell osmotic fragility (False)
Explanation: Osmotic fragility is increased
transient aplastic anaemia (True)
Explanation: Often in association with parvovirus infection
deficiency of red cell spectrin (True)
Explanation: Red blood cell membrane protein

Question 18. The typical clinical features of sickle-cell anaemia include

haemolytic and aplastic crises (True)
Explanation: Often precipitated by viral infection
neonatal spherocytic haemolytic anaemia (False)
Explanation: Not until HbF levels fall after the age of 3 months
pulmonary, splenic and mesenteric infarcts (True)
Explanation: Causing pleuritic pain and also renal infarcts
splenomegaly with hypersplenism (False)
Explanation: Splenic atrophy and functional hyposplenism
bone necrosis and osteomyelitis (True)
Explanation: Painful bone infarcts

Question 19 In patients with sickle-cell disease, acute painful crises are likely to be precipitated by
high altitude (True)
Explanation: Decreased PaO2
pregnancy (True)
Explanation: May present as pseudo-toxaemia syndrome
dehydration (True)
Explanation: Rehydration is an essential component of therapy
systemic infection (True)
Explanation: Treat promptly to prevent sickle-cell crises
hypoxia (True)

Question 20. The typical features of the beta-thalassaemias include

macrocytic anaemia (False)
Explanation: Typically hypochromic microcytic anaemia
hepatosplenomegaly (True)
Explanation: In the 'major' (homozygous) form
pigment gallstones (True)
Explanation: Pigment gallstones can be associated with chronic haemolysis
neonatal haemolytic anaemia (False)
Explanation: Not until HbF synthesis declines
bone infarcts (False)
Explanation: Unlike sickle cell disease

Question 21. The typical features of autoimmune haemolytic anaemia include

peripheral blood spherocytosis and splenomegaly (True)
Explanation: Characteristic
haemoglobinuria and haemosiderinuria (True)
Explanation: Suggesting intravascular haemolysis
increased serum haptoglobin concentration (False)
Explanation: Decreased serum haptoglobin concentration
positive Coombs test (True)
Explanation: Warm usually IgG, cold usually IgM
association with lymphoproliferative disease (True)

By A. H.
Explanation: Chronic lymphatic leukaemia, lymphoma and also systemic lupus erythematosus

Question 22. The typical features of polycythaemia rubra vera include

peak prevalence aged > 40 years (True)
splenomegaly, leucocytosis and thrombocytosis (True)
Explanation: And elevated red cell mass
headaches, pruritus and peptic ulcer dyspepsia (True)
Explanation: But may be asymptomatic
decreased leucocyte alkaline phosphatase score (False)
Explanation: A feature of chronic myeloid leukaemia
increased blood viscosity associated with vascular disease (True)
Explanation: E.g. increased risk of stroke

Question 23. Acute lymphoblastic leukaemia (ALL)

has a peak prevalence in patients aged 20-30 years (False)
Explanation: Peaks in childhood
typically produces cytoplasmic Auer rods in blast cells (False)
Explanation: Acute myeloblastic leukaemia (AML)
has a median survival of 30 months with chemotherapy (True)
Explanation: AML has a 40% 5-year survival with chemotherapy
is the most common of all acute leukaemias (False)
Explanation: AML is four times more common than ALL
is a typical complication of multiple myeloma (False)
Explanation: May complicate myelofibrosis

Question 24. Clinical features of chronic myeloid leukaemia (CML) include

painful splenomegaly (True)
Explanation: Splenomegaly in 90% of cases
gout and arthralgia (True)
Explanation: Hyperuricaemia is often asymptomatic
generalised lymphadenopathy (False)
Explanation: Atypical feature
tendency to bleeding and bruising (True)
Explanation: Variable platelet dysfunction
median survival of 15 years with chemotherapy (False)
Explanation: Median survival 5 years

Question 25. The typical laboratory findings in chronic myeloid leukaemia include
leucoerythroblastic anaemia and thrombocytosis (True)
Explanation: Platelet count falls after blast transformation
peripheral blood neutrophilia, eosinophilia and basophilia (True)
chromosomal translocation q-22/q+9 (True)
Explanation: Philadelphia chromosome
increased neutrophil leucocyte alkaline phosphatase (LAP) score (False)
Explanation: Usually decreased LAP score
transformation to acute leukaemia (True)
Explanation: Transformation results to either ALL (30%) or acute myeloid leukaemia (AML) (70%)

Question 26. Typical features of chronic lymphocytic leukaemia include

onset in younger patients than in chronic myeloid leukaemia (False)
Explanation: Peak age 65 years
development of autoimmune haemolytic anaemia (True)
Explanation: Typically warm antibody
presentation with massive hepatosplenomegaly (False)
Explanation: Mild organomegaly only
lymphadenopathy associated with recurrent infections (True)
Explanation: Bacterial more than viral

By A. H.
median survival of 15 years following chemotherapy (False)
Explanation: Overall median survival 6 years

Question 27. The typical laboratory features in chronic lymphocytic leukaemia include
hyperuricaemia and thrombocytosis (False)
Explanation: Mild thrombocytopenia with urate usually normal
hypogammaglobulinaemia (True)
Explanation: Associated with a paraproteinaemia in 5%
peripheral blood lymphocytosis in the absence of lymphoblasts (True)
Explanation: Total WCC typically 50-200 × 109/l
positive Coombs test (True)
Explanation: May be associated with haemolysis
transformation to acute leukaemia (False)
Explanation: Transformation is rare

Question 28. Allogeneic bone marrow transplantation is particularly useful in the treatment of
multiple myeloma (True)
Explanation: Also useful in acute myelofibrosis
severe aplastic anaemia (True)
alpha-thalassaemia (True)
Explanation: All severe thalassaemias
severe combined immunodeficiency disorder (True)
chronic lymphocytic leukaemia (False)
Explanation: But useful in most other acute and chronic leukaemias

Question 29. Complications of allogeneic bone marrow transplantation include

acute graft-versus-host disease (True)
Explanation: Usually occurs 2-3 weeks after the graft and is associated with infection
severe infection (True)
Explanation: A major problem, especially with viruses and atypical microorganisms
infertility (True)
Explanation: Important given the age of many of the patients
pneumonitis (True)
malignant disease during long-term follow-up (True)

Question 30. The presence of lymphadenopathy and splenomegaly would be expected findings in
multiple myeloma (False)
Explanation: Neither is characteristic
chronic lymphocytic leukaemia (True)
Explanation: Mild splenomegaly, generalised lymphadenopathy
chronic myeloid leukaemia (False)
Explanation: Moderate to massive splenomegaly, no lymphadenopathy
infectious mononucleosis (True)
Explanation: Usually both mild
myelofibrosis (False)
Explanation: Splenomegaly without lymphadenopathy

Question 31. Recognised clinical features of multiple myeloma include

peak incidence between the ages of 30 and 50 years (False)
Explanation: Peak prevalence in males aged 60-70 years
secondary amyloidosis (True)
Explanation: Amyloidosis occurs in 10% of cases
median survival > 10 years with chemotherapy (False)
Explanation: Median survival of 40 months
recurrent infections and pancytopenia (True)
Explanation: Reduction of normal plasma cells causes immunodeficiency

By A. H.
increased serum calcium, urate and blood urea (True)
Explanation: All of which may be asymptomatic

Question 32. In differentiating multiple myeloma from a benign monoclonal gammopathy, the following findings
would favour the diagnosis of multiple myeloma
monoclonal gammopathy with normal serum immunoglobulin levels (False)
Explanation: Myeloma produces suppression of the other serum immunoglobulins
bone marrow plasmacytosis of > 20% (True)
Explanation: A diagnostic prerequisite
bilateral carpal tunnel syndrome (True)
Explanation: Amyloidosis also causes a restrictive cardiomyopathy
Bence Jones proteinuria (True)
Explanation: But the serum paraprotein may be undetectable
multiple osteolytic lesions on radiograph (True)
Explanation: Malignant infiltration is typically associated with a normal isotope bone scan

Question 33. The clinical features of Hodgkin's disease include

painless cervical lymphadenopathy (True)
Explanation: Usually painless
anaemia due to bone marrow involvement (False)
Explanation: Unlike non-Hodgkin's lymphoma
impaired T-cell function in the absence of lymphopenia (True)
Explanation: Lymphopenia suggests poor prognosis
fever and weight loss (True)
Explanation: Stage B
median survival > 10 years (True)
Explanation: Dependent on staging at presentation

Question 34. Typical characteristics of non-Hodgkin's lymphoma include

low-grade lymphomas rapidly produce symptoms due to high cell proliferation rates (False)
Explanation: Indolent and often asymptomatic course with low cell proliferation rates
bone marrow and splenic involvement are present from the onset (True)
Explanation: Typically extranodal at diagnosis
isolated involvement of gastric mucosa associated with Helicobacter pylori infection (True)
Explanation: MALToma may be cured by H. pylori eradication
the majority are T-cell rather than B-cell in origin (False)
Explanation: 70% are B-cell tumours
better prognosis in high-grade rather than low-grade lymphomas (True)
Explanation: Prognosis is also stage- and age-dependent

Question 35. Recognised causes of thrombocytopenia include

megaloblastic anaemia (True)
Explanation: Often with leucopenia
acquired immunodeficiency syndrome (True)
Explanation: Primary, or secondary to superimposed infections
disseminated intravascular coagulation (True)
Explanation: Increased peripheral consumption of platelets
von Willebrand's disease (False)
Explanation: The platelet count is normal
aspirin therapy (True)
Explanation: Also many commonly used drugs including heparin and â-blockers

Question 36. Typical features of idiopathic thrombocytopenic purpura include

IgG-mediated thrombocytopenia (True)
Explanation: Can therefore be transmitted transplacentally
peak prevalence in patients aged > 60 years old (False)
Explanation: Usually the young and commoner in females

By A. H.
prolongation of the bleeding time (True)
Explanation: Other clotting tests normal
splenomegaly (False)
Explanation: Suggests other causes of thrombocytopenia
prompt response to corticosteroid therapy (True)
Explanation: Particularly in children

Question 37. The prothrombin time is typically prolonged in

disorders of the intrinsic pathway (False)
Explanation: The extrinsic pathway
factor X deficiency (True)
Explanation: The Stuart-Prower factor
factor VII deficiency (True)
Explanation: First factor in extrinsic pathway
factor V deficiency (True)
Explanation: Also affects the activated partial thromboplastin time
factor XII deficiency (False)
Explanation: Disorder of the intrinsic pathway

Question 38. The activated partial thromboplastin time (APTT) is typically prolonged in
disorders of the extrinsic pathway (False)
Explanation: The intrinsic pathway
factor VII deficiency (False)
Explanation: Detected by prothrombin time
factor VIII or X deficiency (True)
Explanation: Factor X also influences prothrombin time
factor XIII deficiency (False)
Explanation: Specific assay to measure
factor IX, XI or XII deficiency (True)
Explanation: Initial factors in the intrinsic system

Question 39. Disseminated intravascular coagulation is a complication of

amniotic fluid embolism (True)
Explanation: Initiated by thromboplastin
incompatible blood transfusion (True)
Explanation: An unusual complication
hypovolaemic and anaphylactic shock (True)
Explanation: Endothelial injury
septicaemic shock (True)
Explanation: Exogenous endotoxins
carcinomatosis (True)
Explanation: Commonly bronchial carcinoma

Question 40. The bleeding time is characteristically prolonged in

ascorbic acid deficiency (False)
Explanation: Bleeding time is normal but petechial haemorrhages may occur
thrombocytopenia (True)
Explanation: Irrespective of its cause
haemophilia (False)
Explanation: No vessel wall or platelet defect
warfarin therapy (False)
von Willebrand's disease (True)
Explanation: Secondary decrease in factor VIII level with a qualitative platelet defect

Question 41. The following statements about severe haemophilia A are true
the disorder is inherited in an X-linked recessive mode (True)
Explanation: Prenatal diagnosis is possible

By A. H.
recurrent haemarthroses and haematuria are typical (True)
Explanation: Usually not apparent until the age of 6 months
activated partial thromboplastin time and prothrombin time are both prolonged (False)
Explanation: Only the activated partial thromboplastin time is prolonged
factor VIII has a biological half-life of about 12 days (False)
Explanation: Half-life is 12 hours
desmopressin therapy increases factor VIII concentrations (True)
Explanation: Desmopressin (DDAVP) therapy is useful to limit exposure to blood products

Question 42. The following statements about von Willebrand's disease are true
the disorder is inherited in an X-linked recessive mode (False)
Explanation: Autosomal dominant-gene locus on chromosome 12
it is characterised by a prolonged bleeding time (True)
Explanation: And secondary reduction in factor VIII levels
the von Willebrand factor (vWF) is synthesised by both platelets and endothelial cells (True)
vWF is a carrier protein which is bound to factor VIII (True)
deficiency of vWF is best treated by desmopressin (True)
Explanation: Desmopressin (DDAVP) therapy increases vWF concentrations

Question 43. Thrombophilia with a predisposition to recurrent venous thromboses is associated with
the antiphospholipid antibody syndrome (True)
Explanation: May present with recurrent spontaneous abortion
antithrombin deficiency (True)
Explanation: Decreased inactivation of factors IIa, VIIa, IXa, Xa, XIa, causing heparin resistance
factor V Leiden (True)
Explanation: Prolonged factor V activation; factor II Leiden increases plasma prothrombin levels
polycythaemia rubra vera (True)
Explanation: And chronic myeloid leukaemia-both are associated with thrombocytosis
protein C deficiency (True)
Explanation: And protein S deficiency-reduced inactivation of factors Va and VIIIa

Question 44. Indications for warfarin anticoagulation include

venous thromboembolism (True)
Explanation: Maintain the prothrombin ratio in the range 2.0-4.0
arterial embolism (True)
Explanation: Less effective in non-embolic peripheral vascular disease
myocardial infarction (False)
Explanation: Unless associated with mural thrombus
atrial fibrillation (True)
Explanation: Reduces the risk of arterial embolism
mechanical prosthetic heart valves (True)
Explanation: Reduces the risk of embolic clots and possibly endocarditis

Question 45. The hazards of blood transfusion include

urticaria (True)
Explanation: Allergic reaction
cardiac failure (True)
Explanation: Volume overload-in patients with previous CCF, give prophylactic diuretic therapy
development of Rhesus antibodies in a Rhesus-negative patient (True)
Explanation: Particularly important in women of child-bearing age
fever (True)
Explanation: Allergic reaction to one or more of the constituents of the transfusion
acute intravascular haemolysis (True)
Explanation: Major ABO incompatibility is the likeliest cause

Question 46. Clinical features suggesting an acute transfusion reaction include

onset within an hour of starting the transfusion (True)

By A. H.
Explanation: Delayed haemolytic transfusion reaction occurs 5-7 days after the transfusion
rigors and fever (True)
Explanation: Stop the transfusion immediately
chest and back pain (True)
sudden loss of consciousness (False)
Explanation: Unlikely in the absence of other premonitory changes
development of hypotension and shock (True)
Explanation: May be problematic in anaesthetised patients

Module 20 (Chapter 20)

Question 1. The following diseases are associated with antinuclear and/or rheumatoid factor antibodies
infective endocarditis (True)
Explanation: Chronic infections (e.g. tuberculosis, leishmaniasis and schistosomiasis)
autoimmune thyroiditis (True)
Explanation: Also found in myasthenia gravis
Sjögren's syndrome (True)

Explanation: And systemic lupus erythematosus, dermatomyositis and progressive systemic sclerosis
fibrosing alveolitis (True)
Explanation: And autoimmune hepatitis and sarcoidosis
ankylosing spondylitis (False)
Explanation: And, by definition, all the seronegative spondyloarthritides

Question 2. The biochemical features listed below characterise the following metabolic bone disorders
increased serum calcium, serum phosphate and serum alkaline phosphatase-osteoporosis (False)
Explanation: All three are normal in osteoporosis
normal serum calcium and serum phosphate but increased serum alkaline phosphatase-Paget's disease (True)
Explanation: Occasionally the serum calcium may be elevated if immobilisation is prolonged
normal serum calcium and serum alkaline phosphatase but decreased serum phosphate-osteomalacia (False)
Explanation: All three may be normal (see E)
decreased serum calcium, serum phosphate and serum alkaline phosphatase-metastatic bone disease (False)
Explanation: Increased calcium, normal or low phosphate, and high serum alkaline phosphatase
decreased serum calcium and serum phosphate but increased serum alkaline phosphatase-osteomalacia (True)
Explanation: But all three may be normal

Question 3. Presentation with acute monoarthritis suggests the possibility of

crystal arthritis (True)
Explanation: Gout and pseudogout
trauma (True)
Explanation: Trauma usually obvious
bacterial infection (True)
rheumatoid arthritis (False)
Explanation: Usually polyarticular in onset
enteropathic arthritis (True)
Explanation: Reactive arthritis following enterically or sexually acquired infection

Question 4. The following statements about infective arthritis are true

the onset is typically insidious (False)
Explanation: Onset usually acute, but less so in the elderly or the immunocompromised
pre-existing arthritis is a recognised predisposing factor (True)
Explanation: Also occurs after trauma or surgery
small peripheral joints are involved more often than larger joints (False)
Explanation: Large joints are most frequently affected
Haemophilus influenzae is the commonest causative organism in adults (False)
Explanation: H. influenzae is the main cause in children, streptococci and staphylococci in adults
joint aspiration should be avoided given the risk of septicaemia (False)
Explanation: Early joint aspiration is vital if the diagnosis is not to be delayed

By A. H.

Question 5. The following features of backache suggest mechanical or radicular pain rather than inflammatory pain
radiation of pain down the back of one leg to the ankle (True)
Explanation: Suggests lumbar nerve root compression
an elevated C-reactive protein (CRP) (False)
Explanation: Suggests an active inflammatory pathology
localised tenderness over the greater sciatic notch (True)
Explanation: Suggests lumbar nerve root compression
gradual mode of onset in an elderly patient (False)
Explanation: Suggests significant pathology even if there are no physical signs
back pain and stiffness exacerbated by resting (False)
Explanation: Suggests inflammatory disease

Question 6. The typical findings in fibromyalgia include

elevation of the ESR (False)
Explanation: A high ESR suggests another diagnosis
symptoms of fatigue and an irritable bowel (True)
Explanation: Typical of most psychosomatic disorders
coexistent anxiety and depression (True)
rapid, spontaneous resolution (False)
Explanation: Often very chronic
musculoskeletal pain without local tenderness (False)
Explanation: Multiple tender points are characteristic

Question 7. Shoulder pain is a recognised feature of

myocardial ischaemia (True)
Explanation: Either alone or associated with central chest pain
supraspinatus tendonitis (True)
Explanation: With characteristic painful arc on shoulder abduction
bronchial carcinoma (True)
Explanation: Suggests extra-pleural spread or bony metastases
pneumococcal pneumonia (True)
Explanation: Classically due to diaphragmatic irritation secondary to pleurisy
cervical spondylosis (True)
Explanation: Due to cervical nerve root compression

Question 8. In a patient with neck pain

aggravation by sneezing suggests cervical disc prolapse (True)
Explanation: Disc prolapse may also produce upper or lower limb neurological signs
radiation to the occiput suggests disease affecting the upper cervical vertebrae (True)
Explanation: Common in tension headache
associated bilateral arm paraesthesiae suggest angina pectoris as the most likely diagnosis (False)
Explanation: Suggest cervical radiculopathy
and otherwise normal joints, rheumatoid arthritis is excluded as a possible diagnosis (False)
Explanation: Rheumatoid arthritis typically involves atlantoaxial articulations

Question 9. The clinical features of primary (nodal) osteoarthrosis include

joint pain aggravated by rest and relieved by activity (False)
Explanation: More suggestive of an inflammatory arthritis such as rheumatoid arthritis
proximal interphalangeal and metacarpal-phalangeal joint involvement (False)
Explanation: Typically distal interphalangeal joint involvement
involvement of the hip, knee and spinal apophyseal joints (True)
a strong family history of Heberden's nodes (True)
microfractures of subchondral bone (True)

Question 10. Causes of secondary osteoarthritis include

acromegaly (True)

By A. H.
septic arthritis (True)
Explanation: And any joint previously traumatised
haemochromatosis (True)
Explanation: Also chondrocalcinosis and Wilson's disease
Perthes' disease (True)
Explanation: And most hip dysplasias
Ehlers-Danlos syndrome (True)
Explanation: Also other causes of hypermobility

Question 11. Criteria for the diagnosis of rheumatoid arthritis include

morning stiffness lasting more than 1 hour (True)
Explanation: American Rheumatism Association criteria (1998)
arthritis in both hip joints (False)
Explanation: Arthritis affecting three or more joint areas
the presence of rheumatoid nodules (True)
Explanation: Pathognomonic
symmetrical polyarthritis (True)
Explanation: Diagnosis of RA requires four or more of the criteria
radiological changes (True)
Explanation: In significant titres

Question 12. Common extra-articular manifestations of rheumatological disorders include

episcleritis and keratoconjunctivitis sicca in rheumatoid arthritis (True)
erythema nodosum in enteropathic arthritis (True)
enthesitis in ankylosing spondylitis (True)
Explanation: And Reiter's disease
alopecia in systemic lupus erythematosus (True)
Explanation: Also photosensitive skin rashes
retinitis pigmentosa in psoriatic arthritis (False)

Question 13. Typical features of active rheumatoid arthritis include

fever and weight loss (True)
Explanation: These also occur with minimal joint symptoms, making diagnosis difficult
macrocytic anaemia (False)
Explanation: Anaemia is classically normochromic and normocytic
anterior uveitis (False)
Explanation: Anterior uveitis is specifically associated with the seronegative spondyloarthritides
thrombocytopenia (False)
Explanation: Modest elevation in platelet count is common
generalised lymphadenopathy (True)
Explanation: Most obvious in nodes draining actively inflamed joints

Question 14. The typical pattern of synovial disease in rheumatoid arthritis includes
early involvement of the sacroiliac joints (False)
Explanation: More suggestive of a seronegative spondyloarthritis such as ankylosing spondylitis
symmetrical peripheral joint involvement (True)
Explanation: Characteristic pattern of onset
spindling of the fingers and broadening of the forefeet (True)
Explanation: Involvement of the proximal interphalangeal and metatarsophalangeal joints respectively
distal interphalangeal joint involvement of fingers and toes (False)
Explanation: More suggestive of osteoarthrosis or psoriatic arthritis
atlantoaxial joint involvement (True)
Explanation: Often not obvious clinically but can produce cord compression

Question 15. The following statements about rheumatoid arthritis are true
joint pain and stiffness are typically aggravated by rest (True)
Explanation: Early morning stiffness is a characteristic feature of all inflammatory arthritides

By A. H.
the rheumatoid factor test is positive in about 70% of patients (True)
Explanation: May be absent at disease onset and is not specific to rheumatoid arthritis
joint involvement is additive rather than flitting (True)
Explanation: The usual pattern; in palindromic arthritis flitting episodes are typical
associated scleromalacia typically produces painful red eyes (False)
Explanation: Scleromalacia is a painless wasting of the sclera unlike the rarer scleritis
sicca syndrome suggests the presence of an alternative diagnosis (False)
Explanation: Common in rheumatoid arthritis

Question 16. The clinical features of Felty&apos;s syndrome include

peak prevalence in the age group 20-30 years (False)
Explanation: Peak prevalence in the age group 50-70 years
previous long-standing rheumatoid arthritis (True)
negative rheumatoid factor test (False)
Explanation: Positive rheumatoid factor test
lymphadenopathy and splenomegaly (True)
Explanation: Characteristic
recurrent infections and leg ulcers (True)
Explanation: Characteristic

Question 17. In the treatment of rheumatoid arthritis

bed rest should be avoided because of bony ankylosis (False)
Explanation: Bed rest is of great value and without risk of bony ankylosis
splinting of the affected joints reduces pain and swelling (True)
Explanation: Reduces joint pain and may reduce contractures
associated anaemia responds promptly to oral iron therapy (False)
Explanation: Not usually iron-deficient and reflects disease activity
systemic corticosteroids are contraindicated (False)
Explanation: Low-dose steroids may lessen disease progression with only a small risk of side-effects
non-steroidal anti-inflammatory drugs retard disease progression (False)
Explanation: Not disease-modifying drugs, unlike gold, penicillamine and immunosuppressants

Question 18. Disease-modifying antirheumatic drugs (DMARD) in rheumatoid arthritis include

sulfasalazine (True)
Explanation: 50% of patients respond in 3-6 months
naproxen (False)
Explanation: None of the NSAIDs are DMARDs
D-penicillamine (True)
Explanation: Benefit may not be apparent for 3 months
sodium aurothiomalate (True)
Explanation: Adverse effects are common (e.g. proteinuria and marrow suppression)
azathioprine (True)
Explanation: Reserved for life-threatening or unresponsive disease

Question 19. A poorer prognosis in rheumatoid arthritis is associated with

insidious onset of rheumatoid arthritis (True)
Explanation: An explosive onset confers a relatively better prognosis
high titres of rheumatoid factor early in the course of the disease (True)
Explanation: Especially within 12 months of onset
early development of subcutaneous nodules and erosive arthritis (True)
Explanation: Indicates seropositive disease
extra-articular manifestations (True)
onset with palindromic rheumatism (False)
Explanation: The presence of periods of remission is a favourable sign

Question 20. Typical features of seronegative spondyloarthritis include

asymmetrical oligoarthritis (True)

By A. H.
Explanation: Axial joints are involved initially; only 10% of cases present with a peripheral arthritis
involvement of cartilaginous joints (True)
Explanation: E.g. the sacroiliac joints; involvement is rare in seropositive arthritides
enthesitis of tendinous insertions (True)
Explanation: Achilles tendonitis
scleritis and episcleritis (False)
Explanation: Typical ocular problem is acute anterior uveitis
mitral valve disease (False)
Explanation: An aortitis usually causing aortic regurgitation

Question 21. Features associated with ankylosing spondylitis include

peak onset in the second and third decades (True)
subcutaneous nodules (False)
Explanation: Nodules suggest seropositive arthritis, especially rheumatoid arthritis
HLA-B27 in at least 90% of affected patients (True)
Explanation: Identical twins homozygous for HLA-B27 may, however, be discordant for the disease
faecal carriage of specific Klebsiella species (True)
Explanation: Klebsiella carry an antigen similar to HLA-B27, suggesting a possible aetiology
family history of psoriatic arthritis and Reiter's syndrome (True)
Explanation: Familial aggregation of overlapping seronegative spondyloarthritides

Question 22. Features suggesting ankylosing spondylitis include

early morning low back pain radiating to the buttocks (True)
Explanation: Due to sacroiliitis and sometimes mistaken for lumbar disc disease
persistence of lumbar lordosis on spinal flexion (True)
Explanation: Lumbar lordosis may be lost in advanced disease
chest pain aggravated by breathing (True)
Explanation: Due to involvement of the costovertebral joints
'squaring' of the lumbar vertebrae on radiograph (True)
Explanation: Leading to the 'bamboo' spine appearance
erosions of the symphysis pubis on radiograph (True)
Explanation: Involvement of cartilaginous joints is a hallmark of the disease

Question 23. In the treatment of ankylosing spondylitis

systemic corticosteroid therapy is contraindicated (False)
Explanation: Can be invaluable in acute iritis
prolonged bed rest accelerates functional recovery (False)
Explanation: In contrast to rheumatoid arthritis, the patient with ankylosing spondylitis stiffens with bed rest
spinal radiotherapy modifies the course of the disease (False)
Explanation: Only to improve symptoms
spinal deformity is minimised with physiotherapy (True)
Explanation: Education regarding appropriate back exercises is vital
hip joint involvement augurs a poorer prognosis (True)
Explanation: As does extra-articular disease

Question 24. The typical features of reactive arthritis include

the development of anterior uveitis more often than conjunctivitis (False)
Explanation: Conjunctivitis is the classical ocular manifestation
non-specific urethritis and prostatitis (True)
Explanation: Cause dysuria, frequency and suprapubic discomfort
symmetrical small joint polyarthritis (False)
Explanation: Arthritis is asymmetrical, involving large or small joints
onset 1-3 weeks following bacterial dysentery (True)
Explanation: Similar delay following sexually acquired infections
keratoderma blenorrhagica and nail dystrophy (True)
Explanation: Similar to psoriatic skin and nail disease

By A. H.
Question 25. In Reiter's disease
a peripheral blood monocytosis is commonly found (False)
Explanation: Polymorphonuclear leucocytosis is typical in the acute phase
sacroiliitis and spondylitis develop in most patients (False)
Explanation: Occur in only 15% of patients
Salmonella or Shigella species can be cultured from joint aspirates (False)
Explanation: Organisms cause the preceding dysenteric illness
calcaneal spurs are not apparent radiologically (False)
Explanation: Appear on radiograph as a periostitis
arthritis resolves within 3-6 months of onset (False)
Explanation: 10% of patients have chronic active arthritis 20 years after onset

Question 26. Psoriatic arthritis is

usually preceded by the development of psoriasis (True)
Explanation: Occasionally there is no evidence of skin disease at onset
likely to develop in 25% of patients with psoriasis (False)
Explanation: Occurs in around 7% of patients
commoner in patients with psoriatic nail changes (True)
Explanation: Such as pitting and onycholysis
associated with a poorer prognosis than rheumatoid arthritis (False)
Explanation: Except for patients with arthritis mutilans
likely to respond to hydroxychloroquine (False)
Explanation: Should be avoided due to precipitation of an exfoliative dermatitis

Question 27. Recognised patterns of psoriatic arthritis include

asymmetrical oligoarthritis of the fingers and toes (True)
Explanation: Occurs in 40% of patients
distal interphalangeal joint involvement with nail dystrophy (True)

Explanation: Occurs in 15% of patients

sacroiliitis and spondylitis (True)
Explanation: Develops in 15% of patients-may be indistinguishable from ankylosing spondylitis
rheumatoid-like symmetrical small joint arthritis (True)
Explanation: Occurs in 25% of patients
arthritis mutilans with telescoping of the digits (True)
Explanation: Occurs in 5% of patients

Question 28. Diseases associated with seronegative spondyloarthritis include

Sjögren's syndrome (False)
Explanation: Either as a primary disorder or in association with some connective tissue diseases
Whipple's disease (True)
Explanation: Rare condition
coeliac disease (False)
Explanation: An association between coeliac disease and HLA-B8, DR17 and OQ2 but not HLA-B27
ulcerative colitis (True)
Explanation: Arthritis may precede evidence of ulcerative colitis or Crohn's disease
Behçet's disease (True)
Explanation: Suggested by orogenital ulceration and iritis (more common in Japan)

Question 29. Factors predisposing to hyperuricaemia and gout include

hypothyroidism (True)
Explanation: Diminished renal excretion of uric acid
severe exfoliative psoriasis (True)
Explanation: Increased purine turnover
chronic renal failure (True)
Explanation: Diminished renal excretion of uric acid
polycythaemia rubra vera (True)

By A. H.
Explanation: Increased purine turnover
therapy with loop diuretic agents (True)
Explanation: Diminished renal excretion of uric acid

Question 30. The clinical features of gout include

precipitation of an acute attack by allopurinol (True)
Explanation: Enzyme induction induces an acute attack
cellulitis, tenosynovitis and bursitis (True)
Explanation: Non-articular signs may predominate
the abrupt onset of severe joint pain and tenderness (True)
Explanation: Onset may be explosively sudden
serum urate levels fall during an acute attack (False)
Explanation: Serum urate is usually elevated but may be normal
loin pain and haematuria (True)
Explanation: Urate urolithiasis

Question 31. In the treatment of gout

NSAID therapy increases urinary urate excretion (False)
Explanation: Uricosuric drugs include probenecid, sulfinpyrazone and the NSAID azapropazone
salicylates control symptoms and accelerate resolution of the acute attack (False)
Explanation: Aspirin may worsen an acute attack by reducing renal urate excretion
allopurinol inhibits xanthine oxidase and hence urate production (True)
tophi should resolve with control of hyperuricaemia (True)
allopurinol or probenecid should be given within 24 hours of onset of the acute attack (False)
Explanation: Delay hypouricaemic therapy unless concomitant colchicine therapy is given

Question 32. In pyrophosphate arthropathy

calcium pyrophosphate dihydrate crystals are deposited in the synovial cells (False)
Explanation: Crystals are deposited in articular cartilage then shed into the joint space
haemochromatosis is a recognised predisposing factor (True)
the clinical appearances are similar to acute gout (True)
Explanation: Hence 'pseudogout'
the findings on synovial aspiration are indistinguishable from acute gout (False)
Explanation: Characteristic appearances of calcium pyrophosphate dihydrate (CPPD) crystals under polarising light
intra-articular corticosteroid injections are contraindicated (False)
Explanation: Such injections are often highly effective

Question 33. Osteoporosis is

usually associated with normal serum calcium, phosphate and alkaline phosphatase (True)
Explanation: Serum alkaline phosphatase may rise if fractures occur
more likely to occur if menopause is early (True)
Explanation: Accelerated bone loss occurs with oestrogen withdrawal
commonly asymptomatic (True)
Explanation: Pain only occurs after fracture
a typical complication of untreated Addison's disease (False)
Explanation: Occurs in states of corticosteroid excess
more common in patients with chronic high alcohol intake (True)
Explanation: Also associated with cigarette smoking

Question 34. Risk factors for osteoporosis include

gluten enteropathy (True)
Explanation: All causes of malabsorption including liver disease
rheumatoid arthritis (True)
Explanation: And ankylosing spondylitis
hyperparathyroidism (True)
Explanation: Multifactorial

By A. H.
anorexia nervosa (True)
Explanation: Multifactorial
hypogonadism (True)
Explanation: Improved by androgen replacement therapy

Question 35. Therapies useful in preventing recurrent vertebral fractures in osteoporosis include
regular exercise (True)
Explanation: Excessive exercise may be associated with low body weight and osteoporosis
oral phosphate supplementation (False)
Explanation: Unless the patient is hypophosphataemic from severe malnutrition
etidronate (True)
Explanation: Bisphosphonate therapy is the most effective and best evaluated
vitamin D and calcium supplementation (True)
Explanation: But this is less effective than bisphosphonate therapy
corticosteroid (False)
Explanation: Causes osteoporosis; androgen and oestrogen therapy are both effective

Question 36. In osteomalacia

the finding of a proximal myopathy suggests an alternative diagnosis (False)
Explanation: Characteristic; patients may have difficulty in standing up or in climbing stairs
bone involvement is characteristically painless (False)
Explanation: Pain may be generalised and severe
Chvostek's sign indicates that the underlying diagnosis may be hyperparathyroidism (False)
Explanation: Hypocalcaemia increases neuromuscular excitability (latent tetany)
due to renal disease, 25-hydroxycholecalciferol therapy is recommended (False)
Explanation: Give 1-á-hydroxycholecalciferol; renal 1-á-hydroxylation is impaired
pseudofractures on radiograph are pathognomonic (True)
Explanation: Looser's zones are translucent bands seen on radiograph

Question 37. Typical features of Paget's disease of bone include

onset before the age of 40 years (False)
Explanation: Onset usually over the age of 60 years
increased serum alkaline phosphatase and urinary hydroxyproline excretion (True)
Explanation: Increased bone turnover and osteoblast activity
presentation with severe bone pain, especially in elderly patients (False)
Explanation: Insidious asymptomatic progression; with nerve root and spinal cord compression
delayed healing of fractures (False)
Explanation: Fractures occur more commonly but usually heal normally
risk of development of osteogenic sarcoma (True)
Explanation: Rare complication suggested by bony expansion and localised pain

Question 38. In a male patient with prostate cancer and widespread metastatic bone disease
osteolytic deposits are characteristic (False)
Explanation: Prostatic secondaries are typically osteosclerotic
the plasma parathyroid hormone (PTH) concentration is typically elevated (False)
Explanation: Serum PTH is usually normal even when the serum calcium is high
bone pain is invariably present (False)
Explanation: Asymptomatic disease may be detected coincidentally on radiograph
the alkaline phosphatase is only elevated if pathological fracture occurs (False)
Explanation: Serum alkaline phosphatase is frequently elevated due to osteoblast activation
cyproterone acetate retards progress of the disease (True)
Explanation: Androgen deprivation therapy is of proven value in prostatic cancer

Question 39. Typical features of systemic lupus erythematosus (SLE) include

a higher prevalence in Caucasian than in African women (False)
Explanation: Afro-Caribbean females are particularly susceptible
onset usually in the fourth and fifth decades (False)

By A. H.
Explanation: Most commonly in the second and third decades
impaired function of suppressor T lymphocytes (True)
Explanation: Associated with polyclonal B lymphocyte activation
increased prevalence in women compared with men (True)
Explanation: Genetic factors appear to be of importance in aetiology
presentation with Raynaud's phenomenon in young men rather than young women (True)
Explanation: And in women aged > 30 years

Question 40. Characteristic clinical features of SLE include

Raynaud's phenomenon (True)
Explanation: Not, however, specific to SLE
alopecia (True)
Explanation: Occurs in at least 50% of patients
an erythematous photosensitive facial rash (True)
Explanation: Characteristic
absence of renal complications (False)
Explanation: Renal involvement is not infrequent and heralds a poor prognosis
neuropsychiatric symptoms (True)
Explanation: Especially depression and organic psychosis

Question 41. In the management of systemic lupus erythematosus, the following are of proven value
NSAIDs for renal involvement (False)
Explanation: NSAIDs may worsen renal function
corticosteroid therapy for cerebral involvement (True)
Explanation: High doses are often used initially, then reduced to as low a dose as possible on remission of disease
plasmapheresis for immune complex disease (True)
Explanation: Especially when combined with immunosuppressant drugs
hydroxychloroquine for skin and joint involvement (True)
Explanation: Beware retinal complications
long-term corticosteroid therapy during periods of remission to prevent relapse (False)
Explanation: Little evidence to suggest that this improves the long-term prognosis

Question 42. Recognised features of primary Sjögren's syndrome include

an increased incidence of lymphoma (True)
dryness of the eyes, mouth and vagina (True)
reduced lacrimal secretion rate (True)
Explanation: Demonstrable with the Shirmer test
more males affected than females (False)
Explanation: More females than males
a positive IgM rheumatoid factor in over 80% of patients (True)
Explanation: Not diagnostic of primary Sjögren's (sicca) syndrome

Question 43. The clinical features of progressive systemic sclerosis include

presentation with Raynaud's phenomenon (True)
Explanation: Raynaud's may precede other features by years
reflux oesophagitis and dysphagia (True)
Explanation: Gastrointestinal tract is involved in most patients
fibrosing alveolitis (True)
Explanation: Occurs in the majority of cases
ulceration, atrophy and subcutaneous calcification of the fingertips (True)
Explanation: 'Sausaging' of the fingers and sclerodactyly are also seen
anti-DNA antibodies and decreased serum complement levels (False)
Explanation: ANA only in 50%; anti-DNA antibodies are not seen and complement is normal

Question 44. In polymyositis

a normal serum creatine kinase does not exclude the diagnosis (True)
Explanation: Especially common in juvenile myositis

By A. H.
antinuclear (DNA) antibodies are characteristically absent (True)
Explanation: Similarly in polyarteritis nodosa
electromyography is helpful in differentiation from peripheral neuropathy (True)
underlying malignancy is usually present if weight loss is marked (False)
Explanation: Weight loss may occur in the absence of malignancy
an erythematous rash on the knuckles, elbows, knees and face is typical (True)
Explanation: Cutaneous features suggest dermatomyositis (Gottron's papules)

Question 45. Features of giant cell arteritis include

a predominance in females > 60 years of age (True)
pain in the jaw during eating (True)
Explanation: Due to claudication of the masseters
confluent involvement of affected arteries (False)
Explanation: Histological involvement is characteristically patchy
difficulty in rising from the seated position (False)
Explanation: Suggests proximal myopathy
weight loss with normochromic anaemia and high ESR (True)

Question 46. In polymyalgia rheumatica

antinuclear and rheumatoid factor antibodies are present in high titre (False)
Explanation: This finding would suggest an alternative diagnosis
temporal artery biopsy usually confirms the diagnosis (False)
Explanation: Biopsy is positive in < 40% of patients
response to oral corticosteroids typically occurs within 7 days (True)
Explanation: No such response should prompt a review of the diagnosis
corticosteroid therapy should be

Question 47. The features of classical polyarteritis nodosa include

increased prevalence in males (True)
Explanation: Male to female ratio is 2:1
an association with circulating immune complexes containing hepatitis B virus (True)
Explanation: HBV markers may only become apparent on follow-up
involvement of small arteries and arterioles (False)
Explanation: Systemic vasculitis affecting medium-sized arteries
multiple peripheral nerve palsies (True)
Explanation: Due to arteritis of the vasa nervorum
severe hypertension (True)
Explanation: Especially in association with renal involvement

Module 21 (Chapter 21)

Question 1. The following statements about the skin are true
the surface area of an adult is approximately 2 m2 (True)
Explanation: Comprising the epidermis, dermis and subcutis layers
the predominant cell of the dermis is the fibroblast (True)
keratinocytes comprise 10% of the epidermal cell mass (False)
Explanation: They comprise 95% of epidermal cells
Langerhans cells synthesise vitamin D in the epidermis (False)
Explanation: These are modified macrophages; keratinocytes synthesise vitamin D
eccrine sweat glands are innervated by the parasympathetic nervous system (False)
Explanation: They are innervated by cholinergic fibres of the sympathetic system

Question 2. In the terminology of skin lesions

papules are solid skin elevations > 20 mm in diameter (False)
Explanation: Papules < 5 mm in diameter
nodules are solid skin masses > 5 mm in diameter (True)
Explanation: Larger than papules
vesicles are fluid-containing skin elevations > 5 mm in diameter (False)

By A. H.
Explanation: Vesicles < 5 mm in diameter
petechiae are pinhead-sized macules of blood within the skin (True)
Explanation: They are not palpable
macules are small raised areas of skin of altered colour (False)
Explanation: Macules are flat, with altered skin colour or texture

Question 3. Typical features of melanocytic naevi include the following

usually present from birth (False)
Explanation: Most appear in early childhood
development after the age of 40 years (False)
Explanation: Should raise suspicion of malignancy
junctional naevi are smooth, papillomatous, hairy nodules (False)
Explanation: Not hairy and are macular
intradermal naevi are circular brown macules < 10 mm in diameter (False)
Explanation: They are nodular
30% life-time risk of malignant transformation (False)
Explanation: 6% in congenital melanocytic naevi

Question 4. Typical features of malignant melanoma include

changing appearance of a preceding melanocytic naevus (True)
Explanation: 30-50% develop in this way
diameter of the lesion > 5 mm (True)
Explanation: But smaller lesions may be malignant
irregular colour, border and elevation (True)
Explanation: Typically asymmetrical
personal or family history of melanoma (True)
Explanation: Risk is also increased with fair skin and blonde hair
painless, expanding, subungual area of pigmentation (True)
Explanation: Characteristically painless

Question 5. Characteristic features of eczema include

epidermal oedema and intra-epidermal vesicles (True)
Explanation: Epidermal oedema (spongiosis) and epidermal thickening (acanthosis)
delayed hypersensitivity reaction in seborrhoeic eczema (False)
Explanation: This is a feature of allergic contact eczema
increased serum IgA concentration in discoid eczema (False)
Explanation: Serum IgE concentrations are elevated
eyelid and scrotal oedema in allergic contact eczema (True)
Explanation: The initial eruption occurs at the contact site
occurrence in the flexures of the elbows and knees in pompholyx (False)
Explanation: Occurs on palms and plantar surfaces of hands and feet

Question 6. The following blistering eruptions are typically associated with mucosal involvement
dermatitis herpetiformis (False)
Explanation: An intensely itchy rash without oral mucosal involvement
bullous pemphigoid (False)
pemphigus (True)
Explanation: Often erosive and with mucosal involvement
toxic epidermal necrolysis (True)
porphyria cutanea tarda (False)

Question 7. The following are recognised causes of leg ulcers

leprosy (True)
Explanation: Typically painless
sickle-cell disease (True)
Explanation: And also cryoglobulinaemia
diabetes mellitus (True)

By A. H.
Explanation: Arterial and neuropathic aetiology
pyoderma gangrenosum (True)
Explanation: Associated with inflammatory bowel disease
syphilis (True)

Question 8. The following cause alopecia with scarring

tinea capitis (False)
alopecia areata (False)
discoid lupus erythematosus (True)
Explanation: Typically patchy
telogen effluvium (False)
androgenetic alopecia (False)
Explanation: Male-pattern baldness

Question 9. With regard to psoriasis

a child with one affected parent has a 50% chance of developing the disease (False)
Explanation: 15% if there is one affected parent
the cellular infiltrate is typically lymphocytic (True)
Explanation: Of helper type in the dermis
guttate psoriasis may be preceded by â-haemolytic streptococcal infection (True)
Explanation: Typically throat infection
nail pitting is associated with distal interphalangeal arthropathy (True)
Explanation: And onycholysis
about 5% of patients develop arthropathy (True)

Question 10. Typical features of psoriasis include

well-defined erythematous plaques with adherent silvery scales (True)
Explanation: Typically on the elbows, knees and lower back
epidermal thickening and nucleated horny layer cells (parakeratosis) (True)
Explanation: Also a dermal T lymphocyte infiltrate
induction of plaques by local trauma (True)
Explanation: Including surgical wounds (Köbner phenomenon)
an association with HLA Cw6 (True)
Explanation: Inheritance is probably polygenic
exacerbation by propranolol and lithium carbonate therapy (True)
Explanation: Also antimalarial drugs

Question 11. The characteristic clinical features of psoriasis include

sparing of the skin over the head, face and neck (False)
Explanation: The scalp is frequently involved
guttate psoriasis usually affects the elderly (False)
Explanation: Usually seen in children
nail changes with pitting and onycholysis (True)
Explanation: Also subungual hyperkeratosis
oligoarthritis particularly associated with nail changes occurring in 5% of cases (True)
Explanation: Perhaps mimicking rheumatoid arthritis
red non-scaly skin areas in the natal cleft and submammary folds (True)
Explanation: Axillary folds may be similarly affected

Question 12. The typical features of acne vulgaris include

involvement of pilosebaceous glands and their ducts (True)
Explanation: Ducts may be obstructed
distribution over the face and upper torso (True)
Explanation: Lesions elsewhere suggest an alternative diagnosis
infection with the skin commensal Propionibacterium acnes (True)
Explanation: Antibiotics are helpful
increased sebum production containing excess free fatty acids (True)

By A. H.
Explanation: Largely hormonally mediated
open and closed comedones, inflammatory papules, nodules and cysts (True)
Explanation: Seborrhoea (greasy skin) is often present also

Question 13. Therapies of proven value in acne vulgaris include

oral tetracycline or erythromycin therapy (True)
Explanation: For a minimum of 3 months
topical preparations of benzoyl peroxide and retinoic acid (True)
Explanation: Antibacterials such as chlorhexidine may also help
oral contraceptive pill (False)
Explanation: Unless given with cyproterone acetate
cyproterone acetate (True)
Explanation: Anti-androgen therapy often in combination with an oestrogen
oral isotretinoin (True)
Explanation: Reduces sebum secretion; highly teratogenic

Question 14. The characteristic features of rosacea include

predominantly affects adolescents (False)
Explanation: Commonest in middle age
increased secretion of sebum (False)
Explanation: Sebum secretion is normal
facial erythema, telangiectasia, pustules and papules (True)
rhinophyma, conjunctivitis and keratitis (True)
non-responsive to oral tetracycline therapy (False)
Explanation: Repeated courses may be necessary

Question 15. Medical conditions that cause pruritus include

oral contraceptives and pregnancy (True)
hypothyroidism and hyperthyroidism (True)
Explanation: Also caused by biliary obstruction
lymphoproliferative and myeloproliferative diseases (True)
iron deficiency anaemia (True)
Explanation: Also caused by chronic renal failure
opiate and antidepressant drug therapy (True)

Question 16. Skin diseases associated with marked pruritus include

cutaneous vasculitis (False)
Explanation: The rash is non-pruritic
lichen planus (True)
Explanation: Usually intensely itchy
atopic eczema (True)
Explanation: Classically pruritic
seborrhoeic keratosis (False)
Explanation: Non-pruritic
dermatitis herpetiformis (True)
Explanation: Associated with coeliac disease

Question 17. Skin diseases associated with blistering eruptions include

erythema multiforme (True)
Explanation: Perhaps with target lesions
dermatitis herpetiformis (True)
Explanation: Typically on extensor surfaces
pemphigoid (True)
Explanation: Tense blood-filled lesions
pemphigus vulgaris (True)
Explanation: Superficial flaccid lesions
guttate psoriasis (False)

By A. H.
Explanation: Small scaly raised lesions

Question 18. Skin diseases associated with photosensitivity include

variegate and hepatic porphyrias (True)
Explanation: Disordered haem metabolism
atopic eczema (True)
Explanation: Perhaps progressing to chronic actinic dermatitis
drug reactions to phenothiazine, thiazide and tetracycline (True)
Explanation: And also to amiodarone and enalapril therapy
pyoderma gangrenosum (False)
Explanation: Associated with inflammatory bowel disease
pityriasis rosea (False)
Explanation: Unaffected by sunlight

Question 19. Recognised causes of erythema multiforme include

herpes simplex infection (True)
Explanation: Also orf and other viruses
mycoplasmal pneumonia (True)
Explanation: Classical
sulphonamide therapy (True)
Explanation: Also penicillins and barbiturates
systemic lupus erythematosus (True)
Explanation: And other connective tissue disorders
bronchogenic carcinoma (True)
Explanation: And especially post-radiotherapy

Question 20. Recognised causes of erythema nodosum include

sarcoidosis (True)
Explanation: Also brucellosis
â-haemolytic streptococcal infection (True)
Explanation: Also mycoplasmal and chlamydial infections
inflammatory bowel disease (True)
Explanation: Also leukaemias and Hodgkin's disease
tuberculosis (True)
Explanation: Also leprosy
contraceptive drug therapy (True)
Explanation: Erythema nodosum can also be caused by some other drugs, e.g. iodides and sulphonamides

Question 21. The typical features of basal cell carcinoma include the following
predominantly affects the elderly (True)
Explanation: Rare in young adults
metastatic spread to the lungs if untreated (False)
Explanation: Spread by local invasion
occurrence in areas exposed to light or X-irradiation (True)
Explanation: Typically on the face or head
papule with surface telangiectasia or ulcerated nodule (True)
Explanation: With a rolled, pearly edge
unresponsive to radiotherapy (False)
Explanation: Radiosensitive but surgery is preferred

Question 22. The typical features of squamous cell carcinoma include

occurrence in areas exposed to light or X-irradiation (True)
Explanation: Typically in Caucasians living in equatorial regions
association with chronic immunosuppressant drug therapy (True)
Explanation: E.g. following organ transplantation
preceded by leucoplakia on the lips, mouth or genitalia (True)
Explanation: Or actinic keratosis on the skin

By A. H.
metastatic spread to the liver and lungs (False)
Explanation: Haematogenous dissemination is rare
unresponsive to radiotherapy (False)
Explanation: Radiosensitive but surgery is preferred

Module 22 (Chapter 22)

Question 1. The predominant segmental innervation of the following tendon reflexes is
biceps jerk-C5 (True)
supinator jerk-C6 (True)
Explanation: Same as the biceps jerk
triceps jerk-C7 (True)
Explanation: Finger flexion jerk-C8
knee jerk-L4 (True)
ankle jerk-S1 (True)

Question 2. A right homonymous hemianopia would be an expected finding in disorders of the

left optic tract (True)
Explanation: The optic tract runs between optic chiasm and lateral geniculate body
left optic radiation (True)
Explanation: Upper fibre damage causes lower field defect
optic chiasm (False)
Explanation: Midline lesions cause bitemporal hemianopia
right lateral geniculate body (False)
Explanation: Left lateral geniculate body
left optic nerve (False)
Explanation: Left monocular visual loss

Question 3. Features suggesting a 3rd cranial nerve palsy include

paralysis of abduction (False)
Explanation: Suggests 6th cranial nerve palsy
absence of facial sweating (False)
Explanation: Occurs in Horner's syndrome
complete ptosis (True)
Explanation: Paralysis of levator palpebrae superioris
pupillary dilatation (True)
Explanation: Impaired parasympathetic flow
absence of the accommodation reflex (True)
Explanation: And direct light response impaired

Question 4. Paralysis of the 4th cranial nerve produces

weakness of the inferior oblique muscle (False)
Explanation: Superior oblique
pupillary dilatation (False)
Explanation: No pupillary change
impaired downward gaze in adduction (True)
Explanation: May be difficult to detect clinically
elevation and abduction of the eye (True)
Explanation: Head may tilt towards normal side
nystagmus more marked in the abducted eye (False)
Explanation: Suggests internuclear ophthalmoplegia

Question 5. Paralysis of the 6th cranial nerve

produces impaired adduction of the eye (False)
Explanation: Impaired abduction
produces enophthalmos (False)
Explanation: May be a feature of Horner's syndrome
is a characteristic feature of Wernicke's encephalopathy (True)

By A. H.
Explanation: Usually bilateral, perhaps other ocular nerves also involved
results from disease of the upper pons (True)
Explanation: Infarction, haemorrhage or demyelination typically
is a recognised feature of posterior fossa tumour (True)
Explanation: May be 'false localising sign' in raised intracranial pressure

Question 6. Drooping of the upper eyelid results from a lesion of the

levator palpebrae superioris (True)
Explanation: Partial or complete ptosis
3rd cranial nerve (True)
Explanation: With pupillary dilatation
cervical sympathetic outflow (True)
Explanation: With pupillary constriction
7th cranial nerve (False)
Explanation: Orbicularis oculi may be affected
abducens nucleus (False)
Explanation: No ptosis, just a lateral rectus palsy

Question 7. Absence of pupillary constriction in either eye on shining a light into the right pupil suggests
bilateral Argyll Robertson pupils (True)
Explanation: Accommodation preserved
bilateral Holmes-Adie pupils (True)
Explanation: Defect is probably in the ciliary ganglia
right optic nerve lesion (True)
Explanation: An afferent defect
right oculomotor nerve lesion (False)
Explanation: Reaction in right eye only is impaired
bilateral Horner's syndrome (True)
Explanation: Both pupils may be small but response preserved

Question 8. Features of an intracranial lower motor neuron lesion of the facial nerve include
inability to wrinkle the forehead (True)
Explanation: Frontalis weakness
increased lacrimation on the affected side (False)
Explanation: Decreased due to involvement of nervus intermedius
upward deviation of the eye on attempted eyelid closure (True)
Explanation: Bell's sign
deafness due to loss of the nerve to the stapedius muscle (False)
Explanation: Produces hyperacusis
loss of taste over the anterior two-thirds of the tongue (True)
Explanation: Involvement of the chorda tympani

Question 9. Characteristic features of pseudobulbar palsy include

dysarthria (True)
Explanation: With dysphonia
dysphagia (True)
Explanation: Often with aspiration
emotional lability (True)
Explanation: Particularly in cerebrovascular disease
wasting and fasciculation of the tongue (False)
Explanation: Suggest lower motor neuron lesion, 12th nerve
absence of the jaw jerk (False)
Explanation: Jaw jerk is typically brisk

Question 10. The following statements about bladder innervation are correct
sacral cord lesions usually produce urinary retention (True)
Explanation: Parasympathetic innervation impaired

By A. H.
thoracic cord lesions produce urinary urge incontinence (True)
Explanation: And incomplete bladder emptying
pelvic nerve parasympathetic stimulation causes bladder emptying (True)
Explanation: Internal sphincter relaxation and detrusor contraction
pudendal nerve lesions produce automatic bladder emptying (False)
Explanation: Feature of spinal cord lesions
the L1-L2 segment sympathetic outflow mediates bladder relaxation (True)
Explanation: And internal sphincter contraction

Question 11. The following statements about the Glasgow coma scale are correct
the best response to an arousal stimulus should be measured (True)
Explanation: Test at least twice
appropriate motor responses to verbal commands = score 6 (True)
Explanation: No response to pain = 1
spontaneous eye opening = score 4 (True)
Explanation: No eye opening = 1
verbal responses with normal speech and orientation = score 5 (True)
Explanation: No speech = 1
the minimum total score = 3 (True)
Explanation: Maximum score = 15

Question 12. The diagnosis of brain death is supported by

pin-point pupils (False)
Explanation: Dilated and unreactive to light
absent corneal reflexes (True)
Explanation: A brain-stem reflex
absent vestibulo-ocular responses to caloric testing (True)
Explanation: 20 ml ice-cold water into each ear in turn
absence of spontaneous respiration (True)
Explanation: With PaCO2 > 6.7 kPa
preservation of the cough and gag reflexes (False)
Explanation: All brain-stem reflexes absent

Question 13. Typical features of prefrontal lobe lesions include

positive grasp reflex (True)
Explanation: And other 'primitive' reflexes
astereognosis (False)
Explanation: Suggests a parietal lobe lesion
sensory dysphasia (False)
Explanation: Posterior temporo-parietal lesion (Wernicke's area)
olfactory hallucinations (False)
Explanation: Temporal lobe sign
social disinhibition (True)
Explanation: Perhaps with antisocial behaviour

Question 14. Typical features of posterior parietal lobe lesions include

lower homonymous quadrantanopia (False)
Explanation: Contralateral to lesion
constructional apraxia (False)
Explanation: Non-dominant hemisphere
sensory inattention (False)
Explanation: Perhaps with sensory neglect
motor dysphasia (True)
Explanation: Broca's area in the inferior frontal lobe
agnosia and acalculia (False)
Explanation: Gerstmann's syndrome of the dominant angular gyral region

By A. H.
Question 15. In the evaluation of a patient with headache
thunderclap headache is invariably associated with subarachnoid haemorrhage (False)
Explanation: Only associated in 1 in 8 patients
patients with viral meningitis invariably display meningism (False)
Explanation: Meningism less common than in bacterial infection
the presence of concurrent focal limb weakness excludes migraine (False)
Explanation: Migrainous hemiparesis is well recognised
improvement with simple analgesia suggests tension headache (False)
Explanation: Tension headaches are typically poorly responsive
headache on waking suggests raised intracranial pressure (True)
Explanation: As does morning vomiting

Question 16. Migrainous neuralgia (cluster headache) is

more common in females than in males (False)
Explanation: Male to female ratio is 5:1
the commonest form of migraine (False)
Explanation: 10-50 times less common
associated with Horner's syndrome in some patients (True)
Explanation: And unilateral lacrimation
likely to be cured by prophylactic propranolol treatment (False)
Explanation: Prophylaxis may not be helpful
likely to respond well to sumatriptan therapy (True)

Question 17. In the evaluation of a patient with true vertigo

short-lived symptoms favour a labyrinthine cause (True)
Explanation: Persistent vertigo is more often central
the presence of nystagmus excludes viral labyrinthitis (False)
Explanation: Often present although transient
associated paroxysmal tinnitus suggests Ménière's disease (True)
Explanation: Exclude acoustic neuroma
positional vertigo fatigues rapidly when due to central cause (False)
Explanation: Tends to persist
temporal lobe epilepsy should be considered (True)
Explanation: But a rare cause

Question 18. Features suggesting vasovagal faint rather than epilepsy in a patient with a blackout include
an olfactory aura (False)
Explanation: But many patients are aware that something is about to happen
confusion following the event (False)
headache following the event (False)
Explanation: Also absence of injury or tongue-biting
memory loss surrounding the event (False)
tongue-biting (False)
Explanation: Also pallor rather than central cyanosis suggests fainting

Question 19. In the analysis of gait

circumduction of a leg suggests pyramidal weakness (True)
Explanation: Often with dragging of the affected foot
a high-stepping gait suggests foot drop (True)
Explanation: Perhaps with slapping steps
inability to walk heel-to-toe suggests cerebellar disease (True)
Explanation: Classically of the vermis
difficulty negotiating doorways suggests parkinsonism (True)
Explanation: Associated with festination
a waddling gait suggests proximal muscle weakness (True)
Explanation: Usually myopathic in nature

By A. H.
Question 20. Jerking nystagmus that changes in direction with the direction of gaze is
compatible with cerebellar hemisphere disease (True)
Explanation: Maximal on gaze towards lesion if cerebellar disease is unilateral
indicative of a brain-stem disorder (True)
Explanation: May be more marked in the abducting eye (ataxic nystagmus)
compatible with a vestibular nerve lesion (False)
Explanation: Typically present only when looking away from side of lesion
typically accompanied by vertigo and tinnitus (False)
Explanation: Suggests vestibulocochlear disease
likely to continue following closure of the eyes (True)
Explanation: Demonstrable using electronystagmography

Question 21. The characteristic features of trigeminal neuralgia include

pain lasting several hours at a time (False)
Explanation: Lancinating paroxysms lasting a few seconds
pain precipitated by touching the face and/or chewing (True)
Explanation: 'Trigger areas' may exist
absence of the corneal reflex (False)
Explanation: No abnormal signs
predominance in young females (False)
Explanation: Occurs in elderly subjects
response to anticonvulsants (True)
Explanation: E.g. carbamazepine

Question 22. The typical features of Ménière's disease include

sudden onset of vertigo, nausea and vomiting (True)
Explanation: May be disabling
progressive sensorineural deafness and tinnitus (True)
Explanation: Usually unilateral
jerking nystagmus and ataxic gait (True)
Explanation: Typically during attacks
nystagmus usually persists between attacks (False)
Explanation: Suggests benign positional vertigo
restoration of hearing following effective treatment (False)
Explanation: May delay progression but cannot restore auditory loss

Question 23. Typical causes of vertigo include

cardiac arrhythmia (False)
Explanation: Postural instability and syncopal symptoms
acoustic neuroma (True)
Explanation: Or other pathology of the 8th nerve
vestibular neuronitis (True)
Explanation: Usually associated with vertebral artery ischaemia
gentamicin drug therapy (True)
Explanation: And other ototoxic drugs
otitis media (True)
Explanation: With secondary labyrinthine inflammation

Question 24. Typical features of generalised epilepsy include

loss of consciousness accompanied by symmetrical EEG discharge (True)
Explanation: May follow focal EEG abnormality and symptoms-partial seizures
invariable presence of an aura (False)
Explanation: Often absent
lesion demonstrable on CT of the brain (False)
Explanation: Usually no obvious abnormality
induction by photic stimulation (True)
Explanation: TV or computer games may induce fits

By A. H.
induction by hyperventilation (True)
Explanation: Often used during the recording of an EEG

Question 25. The clinical features of tonic clonic seizures include

prodromal phase lasting hours or days (True)
Explanation: With vague irritability or lethargy
onset with an audible cry due to the aura (False)
Explanation: Audible cry may occur at the onset of the tonic phase
sustained spasm of all muscles lasting 30 seconds (True)
Explanation: Tonic phase
interrupted jerking movements lasting 1-5 minutes (True)
Explanation: Clonic phase
flaccid post-ictal state with bilateral extensor plantars (True)
Explanation: Variable duration

Question 26. The typical features of absence (petit mal) seizures include
loss of consciousness lasting up to 10 seconds (True)
Explanation: Sometimes with loss of posture
onset around age 25-30 years (False)
Explanation: Typically in childhood
synchronous three per second spike and wave activity on EEG (True)
Explanation: May be detected inter-ictally
later development of tonic clonic seizures in 40% of patients (True)
Explanation: May not occur until adulthood
sleepiness lasting several hours post-ictally (False)
Explanation: Rapid recovery although may occur very frequently

Question 27. The following statements about epilepsy are correct

treatment should be started following a single witnessed seizure (False)
Explanation: Await evidence of recurrent seizures
25% of patients will have a further seizure within 1 year of a first seizure (False)
Explanation: 70%, mostly in first 2 months
trigger factors for epilepsy include sleep deprivation and physical exhaustion (True)
Explanation: Also febrile illnesses and metabolic disturbances
the lifetime risk of a single seizure is 20% (False)
Explanation: 5%
sharp waves on EEG are highly specific for epilepsy (True)
Explanation: Only one in 1000 are false positives

Question 28. A patient with seizures in the UK can

drive a private car following a single seizure after 1 year free of recurrence (True)
hold a heavy goods vehicle licence if all seizures occurred before the age of 5 years (True)
Explanation: Providing no potentially epileptogenic brain lesion identified
drive a private car during the withdrawal of anticonvulsant therapy (False)
Explanation: Should stop driving for 6 months after their withdrawal
drive a heavy goods vehicle only if seizure-free for 5 years (False)
Explanation: 10 years
drive a private car if seizures have only occurred during sleep in the previous 3 years (True)

Question 29. The following statements about anticonvulsants are correct

plasma level monitoring is particularly useful in sodium valproate therapy (False)
Explanation: Phenytoin and carbamazepine
primidone is likely to cause sideroblastic anaemia (False)
Explanation: Megaloblastic anaemia
clonazepam is the first-line treatment of absence seizures (False)
Explanation: Ethosuximide
sodium valproate is the first-line treatment in primary generalised tonic clonic seizures (True)

By A. H.
carbamazepine is a recognised cause of hyponatraemia (True)
Explanation: Particularly in older patients

Question 30. Features suggesting epilepsy rather than a simple faint as the cause of blackouts include
impairment of vision heralding the attack (False)
Explanation: Suggests syncopal episode
tongue-biting during the attack (True)
Explanation: Not specific, especially in the elderly
eye-witness account of sustained jerking movements during the attack (True)
Explanation: Some jerking movements are common in simple faints
attacks aborted by lying supine (False)
Explanation: Suggests vasovagal syncope
attacks confined to the sleeping hours (True)
Explanation: May occur in blackouts due to bradycardias

Question 31. Clinical features of raised intracranial pressure include

tachycardia and hypotension (False)
Explanation: Bradycardia and hypertension
dizziness and lightheadedness (True)
Explanation: And vomiting
headache aggravated by bending and straining (True)
Explanation: And coughing
behavioural and personality changes (True)
Explanation: And impairment of conscious level
6th or 3rd cranial nerve palsies (True)
Explanation: 'False localising signs'

Question 32. The following statements about primary brain tumours are correct
meningiomas are the most common type in the middle-aged (True)
Explanation: 20% of all cerebral tumours
gliomas are the most common type in childhood (False)
Explanation: 40% of all cerebral tumours
most childhood brain tumours arise within the posterior fossa (True)
Explanation: They are usually cerebellar tumours
presentation with adult-onset partial seizures is typical (True)
Explanation: Indication for CT
acoustic neuromas usually present in the 6th and 7th decades (False)
Explanation: Fourth and fifth decades

Question 33. Typical causes of transient cerebral ischaemic attacks include

carotid artery stenosis (True)
Explanation: Usually contralateral motor, sensory, speech disturbance
atrial fibrillation (True)
Explanation: Bilateral events may occur
hypotension (True)
Explanation: Associated with standing
intracerebellar haemorrhage (False)
Explanation: Fixed deficit stroke
intracerebral tumour (False)
Explanation: Slowly progressive typically

Question 34. Clinical features suggesting lacunar stroke include

homonymous hemianopia (False)
Explanation: The optic pathway is only affected by larger lesions
motor or sensory dysphasia (False)
Explanation: Suggests cortical damage
facial weakness and arm monoparesis (True)

By A. H.
Explanation: Internal capsule lacuna
isolated hemiparesis or hemianaesthesia (True)
Explanation: Internal capsule lacuna
history of hypertension or diabetes mellitus (True)
Explanation: Account for > 80% of lacunar strokes

Question 35. The following statements about stroke are correct

65% of completed strokes are due to cerebral infarction (False)
Explanation: 85%
most strokes are complete in < 6 hours (True)
Explanation: Minority 'stutter' over a longer period
20% of cerebral infarcts are secondary to cardiogenic embolism (True)
Explanation: Another 20% are lacunar infarcts
following an ischaemic stroke, aspirin reduces the risk of death or further stroke by 25% (True)
Explanation: 75-150 mg daily
20% of patients with carotid territory symptoms have a major (> 70%) stenosis (True)
Explanation: Carotid endarterectomy may then be beneficial

Question 36. Clinical features suggesting intracerebral haemorrhage include

abrupt onset of severe headache followed by coma (True)
Explanation: Headache is not specific to haemorrhage
3rd cranial nerve palsy (True)
Explanation: In midbrain haemorrhage
retinal haemorrhages and/or papilloedema (True)
Explanation: With subhyaloid retinal haemorrhage
vomiting and neck stiffness (True)
Explanation: Raised ICP
tinnitus, deafness and vertigo (False)
Explanation: Suggest peripheral 8th nerve lesion

Question 37. Intracerebral abscess is a typical complication of

infective endocarditis (True)
Explanation: Often streptococcal in origin
bronchiectasis (True)
Explanation: Usually staphylococcal in origin
frontal sinusitis (True)
Explanation: Typically affects the frontal lobe
otitis media (True)
Explanation: Cerebellar or temporal
head injury (True)
Explanation: Typically staphylococcal in origin

Question 38. The typical features of an intracerebral abscess include

high fever, weight loss and peripheral blood leucocytosis (False)
Explanation: Usually there is no suggestion of infection
epilepsy persisting after successful treatment of the abscess (True)
Explanation: Prophylactic anticonvulsants should be considered
bradycardia and papilloedema (True)
Explanation: Raised intracranial pressure
headache, vomiting and confusion (True)
Explanation: With focal hemispheric signs
positive blood and CSF cultures (False)
Explanation: Lumbar puncture may be hazardous

Question 39. The typical features of adult tuberculous meningitis include

headache and vomiting (True)
Explanation: And general malaise

By A. H.
fever associated with neck stiffness (True)
Explanation: Fever often low-grade
cranial nerve palsies associated with coma (True)
Explanation: Cranial nerve lesions in 25% of cases
miliary tuberculosis is often present (True)
Explanation: Usual source of infection
CSF cell count > 400 neutrophil leucocytes per ml (False)
Explanation: Lymphocytic meningitis

Question 40. In the treatment of adult pyogenic meningitis

penicillin therapy should be given intrathecally initially (False)
Explanation: Intrathecal penicillin is both unnecessary and dangerous
chloramphenicol therapy should be considered for penicillin-allergic patients (True)
Explanation: Covers meningococci, pneumococci and Haemophilus
antibiotic therapy should not be given before CSF analysis has been undertaken (False)
Explanation: Start therapy if the diagnosis is likely, given the mortality and morbidity
parenteral fluid therapy should be instituted immediately (True)
Explanation: Septicaemic shock often complicates the disease
the onset of a purpuric rash suggests drug allergy is likely (False)
Explanation: Suggests meningococcaemia

Question 41. Recognised causes of viral meningitis include

herpes simplex (True)
Explanation: Sometimes with encephalitis
poliomyelitis (True)
Explanation: With subsequent anterior horn cell infection
arenavirus (True)
Explanation: Lymphocytic choriomeningitis
Coxsackie viruses (True)
Explanation: Common cause in UK
mumps virus (True)
Explanation: Usually self-limiting

Question 42. Typical features of adult viral encephalitis include

acute onset of headache and fever (True)
Explanation: Usually no prodrome
partial epilepsy and coma rapidly ensue (True)
Explanation: Occasionally a mild impairment of consciousness
decreased CSF glucose concentration (False)
Explanation: Suggests pyogenic infection
temporal lobe EEG abnormalities are pathognomonic of herpes simplex infection (False)
Explanation: Other viruses may cause this
meningism (True)
Explanation: In 75% of patients

Question 43. The typical features of multiple sclerosis include

invariable progression with relapses and remission (False)
Explanation: Only 25% of cases have a chronically progressive course
onset often occurs before the age of puberty (False)
Explanation: Rare in childhood
choreoathetosis and parkinsonism (False)
Explanation: No extrapyramidal features
urinary urgency, frequency and incontinence (True)
Explanation: In spinal involvement
epilepsy, dysphasia or hemiplegia (False)
Explanation: Epilepsy and hemiplegia are unusual

By A. H.
Question 44. Useful investigations in diagnosing multiple sclerosis include
visual and somatosensory evoked potentials (True)
Explanation: Can detect clinically silent lesions in 75% of patients
magnetic resonance brain scanning (True)
Explanation: MRI more sensitive than CT
CSF analysis for oligoclonal IgG bands (True)
Explanation: Occurs in 70-90% of patients between attacks
electroencephalography (False)
Explanation: Non-specific abnormalities
electromyography (False)
Explanation: Test of lower motor neuronal disease

Question 45. The typical features of idiopathic parkinsonism include

hypokinesia (True)
Explanation: Impaired fine finger movements
early-onset dementia (False)
Explanation: Cognitive impairment develops in about 30% of patients as the disease progresses
intention tremor (False)
Explanation: Resting tremor
'leadpipe' rigidity (True)
Explanation: Also 'cogwheel' rigidity if a tremor is prominent
normal eye movements (True)

Question 46. Clinical findings consistent with the diagnosis of idiopathic Parkinson's disease include
unilateral onset of the disorder (True)
Explanation: Typically arm tremor
emotional lability (False)
Explanation: Suggests underlying cerebrovascular disease
oculogyric crises (False)
Explanation: Suggests drug-induced extrapyramidal disease
extensor plantar responses (False)
Explanation: Suggests multisystems atrophy (MSA)
impaired voluntary eye movements (False)
Explanation: Impairment of conjugate eye movements suggests progressive supranuclear palsy

Question 47. In the management of Parkinson's disease

anticholinergic therapy is the best first-line therapy for hypokinesis (False)
Explanation: Principally useful for tremor
levodopa should be introduced as soon as the diagnosis is made (False)
Explanation: Early introduction means earlier waning of effect
hypersalivation invariably indicates overuse of levodopa (False)
Explanation: May be a sign of undertreatment causing hypokinesis
dopamine receptor agonists, unlike anticholinergics, do not cause confusion (False)
Explanation: Neuropsychiatric problems occur with both types of therapy
dyskinesia is a frequent dose-limiting side-effect of levodopa (True)
Explanation: Sustained-release preparations sometimes help

Question 48. The characteristic features of Huntington's disease include

autosomal recessive inheritance (False)
Explanation: Autosomal dominant transmission
clinical onset before the age of puberty (False)
Explanation: Onset in middle-aged subjects
progress of dementia arrested with tetrabenazine therapy (False)
Explanation: May help chorea
choreiform movements of the face and arms particularly (True)
Explanation: But become generalised
cardiomyopathic changes on echocardiography (False)

By A. H.
Explanation: Suggests Friedreich's ataxia

Question 49. The clinical features of motor neuron disease (MND) include
insidious onset in elderly males (True)
Explanation: Prevalence of 4 per 100 000
progressive distal muscular atrophy (True)
Explanation: Typically with absent reflexes
progressive bulbar palsy (True)
Explanation: Particularly tongue fasciculation
upper motor neuron signs in the lower limbs (True)
Explanation: Or in the upper limbs
lower motor neuron signs in the upper limbs (True)
Explanation: Or in the lower limbs

Question 50. The differential diagnosis in MND includes

syringomyelia (True)
Explanation: But no sensory signs in MND
diabetic amyotrophy (True)
Explanation: Look for evidence of diabetes mellitus
cervical myelopathy (True)
Explanation: Treatment may limit progression
paraneoplastic syndrome (True)
Explanation: Protean manifestations of a number of tumours
meningovascular syphilis (True)
Explanation: Check syphilis serology

Question 51. Typical features of cervical radiculopathy include

pathognomonic radiograph abnormalities of the cervical spine (False)
Explanation: Changes are usually degenerative and non-specific
radicular pain in the arm and shoulder (True)
Explanation: Follows the distribution of nerve root(s)
painful limitation of movements of the cervical spine (True)
Explanation: Only if due to disc prolapse or destructive pathology
C5-C7 sensory and/or motor loss in the upper limb (True)
Explanation: C5-C7 involvement with appropriate reflex loss
neurosurgical intervention is often required (False)
Explanation: Conservative management is usually adequate

Question 52. The following statements about spinal cord compression are correct
metastatic disease is a more common cause than primary tumour (True)
Explanation: Usually extradural deposits
the CSF protein concentration is likely to be normal (False)
Explanation: Typically elevated with xanthochromia (Froin's syndrome)
local spinal pain and tenderness usually precede motor weakness (True)
Explanation: Pain may follow nerve root distribution
urinary urgency is commonly the presenting feature (False)
Explanation: A late feature
myelography is the best and most appropriate investigation (True)
Explanation: MRI is now invaluable

Question 53. Recognised causes of paraplegia include

intracranial parasagittal meningioma (True)
Explanation: Important to remember if spinal investigations are normal
vitamin B12 deficiency (True)
Explanation: Rare in UK in this severity
tuberculosis of the thoracic spine (True)
Explanation: Associated with vertebral collapse (Pott's disease)

By A. H.
anterior spinal artery thrombosis (True)
Explanation: Sudden onset typically
spinal neurofibromas and gliomas (True)
Explanation: Intradural pathology accounts for 20% of cases of cord compression

Question 54. The typical features of syringomyelia include

slow insidious progression of the disease (True)
Explanation: Onset in third or fourth decade
dissociate sensory loss with normal touch and position sense (True)
Explanation: Leading to trophic ulceration
loss of one or more upper limb tendon reflexes is invariable (True)
Explanation: Damage to anterior horn cells
wasting of the small muscles of the hands (True)
Explanation: A common early feature
hyperreflexia of the lower limbs and extensor plantar responses (True)
Explanation: Pyramidal tract damage

Question 55. Recognised features of neurofibromatosis include

autosomal dominant inheritance (True)
Explanation: Central and peripheral forms occur
café-au-lait spots (True)
Explanation: And axillary skin freckling
association with multiple endocrine neoplasias (True)
Explanation: E.g. phaeochromocytoma
intraspinal and intracranial neuromas and meningiomas (True)
Explanation: At almost any site
nerve deafness (True)
Explanation: Acoustic neuroma

Question 56. The following statements about dementia are correct

20% of the population aged over 80 years suffer a dementing illness (True)
Explanation: Most commonly Alzheimer's disease
inheritance of the apolipoprotein å4 allele is associated with multi-infarct dementia (False)
Explanation: Risk of Alzheimer's increased four-fold
cerebral acetylcholinesterase inhibitors arrest progression of the disease (True)
Explanation: Particularly in Alzheimer's
Alzheimer's disease is characterised by the presence of neurofibrillary tangles (True)
Explanation: And amyloid-rich plaques
associated parkinsonism suggests possible Lewy body disease (True)
Explanation: Patients often made worse by levodopa therapy

Question 57. Recognised causes of a generalised polyneuropathy include

bronchial carcinoma (True)
Explanation: Typically sensory
rheumatoid arthritis (True)
Explanation: And systemic lupus erythematosus; also cause mononeuritis multiplex
vitamin B12 deficiency and folate deficiency (True)
Explanation: Also vitamin B1, B2, B6, A and E deficiency
amiodarone therapy (True)
Explanation: And numerous drugs
diabetes mellitus (True)
Explanation: And myxoedema

Question 58. Clinical features typical of the following polyneuropathies include

predominantly motor loss-lead poisoning (True)
Explanation: Look for haematological clues
predominantly sensory loss-post-inflammatory polyneuropathy (False)

By A. H.
Explanation: Motor weakness predominates
painful sensory impairment-alcohol misuse (True)
Explanation: Also autonomic neuropathy with local sympathetic neural dysfunction
sparing of the cranial nerves-sarcoidosis (False)
Explanation: The 7th nerve especially is commonly involved in neurosarcoid
prominent postural hypotension-diabetes mellitus (True)
Explanation: Suggests autonomic involvement

Question 59. The typical features of Guillain-Barré polyneuropathy include

onset within 4 weeks of an acute infective illness (True)
Explanation: 1-4 weeks, usually after viral infection
peripheral paraesthesiae (True)
Explanation: Paraesthesiae spread proximally
ascending flaccid paralysis with areflexia (True)
Explanation: Muscle wasting is usually absent
sparing of the respiratory and facial nerves (False)
Explanation: Cranial nerves involved in 30-40%
normal CSF protein concentration and cell count (False)
Explanation: CSF protein is elevated, cell count is normal

Question 60. Typical causes of proximal myopathy include

hypothyroidism (True)
Explanation: And also hyperthyroidism; both resolve with treatment
type 1 diabetes mellitus (False)
Explanation: Causes a variety of different peripheral nerve disorders
Cushing's syndrome (True)
Explanation: And also acromegaly
pernicious anaemia (False)
Explanation: Causes a peripheral neuropathy and spinal cord degeneration
chronic alcohol misuse (True)
Explanation: Often with a peripheral neuropathy

Question 61. Acute confusion in the elderly is likely to be the result of

an adverse drug reaction (True)
Explanation: E.g. opiates, levodopa
hypothermia (True)
Explanation: Check core temperature with a low-reading thermometer
bronchopneumonia (True)
Explanation: Consider the possibility of meningitis
myocardial infarction (True)
Explanation: More often asymptomatic in the elderly
cerebral infarction (True)
Explanation: CT to exclude subdural haematoma or tumour

Question 62. Recurrent dizziness in the elderly is likely to be the result of

an adverse drug reaction (True)
Explanation: Especially if associated with postural hypotension
postural hypotension (True)
Explanation: Absence of attacks when lying in bed is suggestive
Ménière's disease (True)
Explanation: Rare in the absence of hearing loss
vertebrobasilar insufficiency (True)
Explanation: Common and may be reproduced by head movements
sick sinus syndrome (True)
Explanation: Dizziness is more likely to occur with bradycardias than tachycardias
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