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1. Regarding oxalate renal stones, which statement is true: (A) (B) (C) (D) (E) Over 90% of oxalate comes from dietary absorption. The amount of free calcium within the gut is a major determinant of oxalate absorption. Low doses of ascorbic acid promote oxalate stone formation. Fat malabsorption contributes to uric stones but not oxalate stones. Hereditary hyperoxaluria is the most common cause of oxalate stones. 2. A 54 year old woman presents with a history of Raynaud’s phenomenon for many years, worsening symptoms of indigestion, and mild shortness of breath on exertion. On examination she had thickening of the skin over her fingers, extending to the metacarpophalygeal joints, with nailbed microangiopathy. Her blood pressure was normal, as was the cardiorespiratory examination. Which of the following statements is true: (A) (B) (C) (D) (E) Antitopoisomerase antibody is more likely to be positive than anti-centromere antibody. Her chance of surviving for a further ten years is less than 20%. She should be monitored for pulmonary hypertension. She is at high risk of developing malignant hypertension in the future. Treatment with D-pencillamine will prolong survival if respiratory complications develop. 3. A 50 year old woman has painless weakness of the shoulder girdle, hip girdle and trunk muscles. Electromyography of the weak muscles is performed. This shows no spontaneous activity and full motor recruitment patterns with many brief duration, highly polyphasic units. Which of the following diagnoses is consistent with these features? (A) (B) (C) (D) (E) post-polio syndrome limb girdle muscular dystrophy myophosphorylase deficiency acute polymyositis motor neurone disease 4. A 62 year old farmer has the following biochemistry: Creatinine 0.27 mmol/L Calcium 3.12 mmol/L Albumin 39 g/L PTH 1.0 pmol/L 1,25 dihydroxyvitamin D 240 pmol/L (0.06-0.12) (2.20-2.55) (39-48) (1.7-7.0) (40-140) The likely diagnosis is: (A) (B) (C) (D) (E) metastatic malignancy primary hyperparathyroidism humoral hypercalcaemia of malignancy Paget’s disease Sarcoidosis 5. A 30 year old woman has the following results on biochemistry: Bilirubin 8 umol/l (<20) ALP 350 U/L (30-120) ALT 260 U/L (<40) HBV surface antigen negative Anti-mitochondrial antibody negative Anti-smooth muscle antibody weakly positive This would be consistent with all of the following except: (A) (B) (C) (D) (E) alcoholic hepatitis autoimmune chronic active hepatitis chronic hepatitis C infection drug-induced cholestasis delta agent acute hepatitis 6. Recognised associations of acromegaly include all of the following except: (A) (B) (C) (D) (E) sleep apnoea colonic polyps hyperalosteronism hypercalciuria hypertension 7. Which of these is not a feature of primary hypothyroidism: (A) (B) (C) (D) (E) dilutional hyponatreamia U waves on electrocardiogram pituitary enlargement hyperprolactinanaemia joint effusions 8. Which statement regarding diabetic amyotrophy incorrect: (A) (B) (C) (D) (E) The degree of diabetic control is often unrelated to onset of this problem It is usually associated with intense pain, and often weight loss There is a cellular pleocytosis on CSF analysis Upper limb involvement is rare The long-term prognosis is generally good 9. Which is true of drug interactions involving the mixed function oxidase system: (A) (B) (C) (D) (E) metronidazole induces phenytoin metabolism carbemazepin inhibits phenytoin metabolism phenytoin has little interaction with warfarin both erythromycin and ciprofloxacin may inhibit theophylline metabolism allopurinol acts via the P450 system to alter azathioprine metabolism 10. In a normal pregnancy all the following statements regarding physiological changes are true except: (A) hypoalbuminaemia reflects significantly increased renal protein excretion (B) cardiac output increases by 40% by the second trimester (C) glomerular filtration rate increases by 50% due to increased glomerular pressure (D) mild leucocytosis can occur (E) mild respiratory alkalosis can occur 11. Which statement is always true about genetic polymorphism: (A) (B) (C) (D) (E) it is due to a variation in DNA sequence polymerase chain reaction testing is invariably required for detection it usually involves a clinically unimportant alteration in a gene any polymorphism is helpful in linkage studies tissues from two unrelated people can be distinguished using any polymorphism 12. A 32 year old man with Marfan’s syndrome presents with his wife who is pregnant, requesting information regarding transmission of the disorder to their child. You advise them that: (A) (B) (C) (D) (E) There is a 25% chance the child will be affected There is a 50% chance the child will be affected The risk of transmission depends of the gender of the child The risk of transmission depends on whether the father’s case is sporadic or inherited The husband should be analysed for mutations in the fibrillin gene 13. A 35 year old woman is brought into the emergency department after a seizure. She has ptosis and peripheral muscle weakness, with second degree AV block on ECG. She is diagnosed with KearnsSayre syndrome. Which feature in the family history would support this? (A) (B) (C) (D) (E) colonic cancer in the patient’s father ancestral consanguinity neuropsychiatric disease in the patient’s maternal relatives the patient and her brother having different fathers a strong family history of Parkinson’s disease 14. Two parents have a child born with severe neonatal hyperthyroidism. They are subsequently found to have mildly elevated calcium levels. What is the mode of inheritance: (A) (B) (C) (D) (E) Multifactorial Autosomal recessive Autosomal dominant X-linked Mitochondrial 15. Regarding genetic definitions which is incorrect: (A) Genetic anticipation refers to the progressively earlier appearance and increased severity of a disease in successive generations. (B) Heteroplasmy refers to the existence in the same cell of distinguishable (usually mutant and normal) copies of the mitochondrial chromosome (C) Imprinting is the differential expression of genes, depending on whether it has been inherited from the mother or father (D) Recombination is the reciprocal exchange or crossing over of genetic material between homologous chromosomes during mitosis (E) The amount of recombination between the loci estimates the genetic distance between these loci. 16. All of the following conditions classically result in nephrotic syndrome except: (A) (B) (C) (D) (E) HIV associated nephropathy Focal segmental glomerulosclerosis IgA nephropathy Minimal change disease Membranous nephropathy 17. Which is not associated with bladder carcinoma: (A) (B) (C) (D) (E) schistosomal infection positive family history dye exposure cyclophosphamide therapy cigarette smoking 18. Which of the following would occur in a compressive optic nerve lesion: (A) (B) (C) (D) (E) ataxic nystagmus enlarged blind spot normal visual evoked responses unaffected colour vision in that eye afferent pupillary defect 19. A 27 year old, otherwise fit man gives a history suggestive of recurrent tachyarrhythmias. During a previous anaesthetic he apparently arrested and required DC cardioversion. He now presents for an arthroscopy. His ECG is shown below. [FIGURE REQUIRED] The most likely diagnosis is: (A) (B) (C) (D) (E) Lown Ganong Levine syndrome Prolonged QT syndrome Wolff Parkinson White syndrome Sick Sinus syndrome Atrio-Ventricular (AV) nodal re-entrant tachycardia. 20. A fifty year old man suffers an acute myocardial infarction (MI). In which of the following conditions is temporary transvenous pacing most clearly indicated? (A) (B) (C) (D) (E) First degree heart block Mobitz type I second-degree AV block with normal haemodynamics Mobitz type II second-degree AV block Accelerated idioventricular rhythm Bundle branch block known to exist before the acute MI. 21. In transfusion practice, which is false: (A) (B) (C) (D) (E) Fever is usually due to anti-leucocyte antibodies Desmopressin (DDAVP) will raise levels of factor VIII in patients with mild haemophilia A Haemolytic reactions may be delayed for up to one week Severe anaphylaxis may be seen in IgA deficient individuals Patients on immunosuppression never have transfusion reactions 22. Which is not true of Hepatitis E virus? (A) (B) (C) (D) (E) It is a 34 nm single stranded RNA virus It is more common in IV drug abusers It can produce epidemic waterborne infections It will cause 10% of patients to develop chronic hepatitis. It is a nonenveloped HAV like virus 23. Which of the following are incorrectly paired? (A) (B) (C) (D) (E) Conn’s syndrome and metabolic alkalosis Uretero-colic anastomosis and hyperchloraemic acidosis Shock and metabolic acidosis Pancreatic fistula and metabolic acidosis Salicyclate poisoning and normoacidaemia 24. Pleural calcification is not a recognised result of: (A) (B) (C) (D) (E) Tuberculosis Chronic empyema Asbestosis Bagassosis Pleural Haemothorax 25. A patient is suffering from dystrophia myotonica is likely to suffer from: (A) (B) (C) (D) (E) Progressive external ophthalmoplegia Cataracts Symptoms that begin in childhood Fasiculations presenting in childhood Tendon reflexes that are retained despite muscle wasting 26. An unconscious man is brought to hospital as an emergency. He is a known methylated spirit drinker. If he is suffering from methyl alcohol poisoning, which is incorrect: (A) (B) (C) (D) (E) Kussmaul’s breathing (air hunger) would be expected as a prominent feature Papilloedema would be consistent with the condition The methyl alcohol would be metabolised to formaldehyde The plasma bicarbonate would be very low Heart block is possible. 27. Pulsus paradoxus is not found with: (A) (B) (C) (D) (E) Severe asthmatic attack Severe left ventricular failure Constrictive pericarditis Cardiac amyloidosis Cardiac sarcoidosis 28. A broad complex tachycardia is more likely to be supraventricular tachycardia with aberrant conduction than ventricular tachycardia if: (A) (B) (C) (D) (E) Cannon waves are seen in the neck waves Fusion beats are seen on the ECG The tachycardia is abolished by carotid massage There is a concordant pattern across the precordial leads The QRS duration is > 160 msec. 29. Signs of posterior inferior cerebellar artery thrombosis do not include: (A) (B) (C) (D) (E) Ipsilateral 5th nerve sensory loss Nystagmus to the side of the lesion Contralateral loss of pain in limbs and trunk Bulbar palsy CN IX palsy 30. Which of the following is the LEAST likely cause of massive haemoptysis: (A) (B) (C) (D) (E) Tuberculosis Bronchiectasis Emphysema Lung abscess Carcinoma 31. A 17 year old male experiences easy fatiguability and cramping pain of muscles with exercise during physical education classes. This condition does not improve with additional exercise, or with anti-inflammatory medications. He does not have problems with the activities of daily living. The best explanation is: (A) (B) (C) (D) (E) Duchenne muscular dystrophy Myasthenia gravis McArdle’s disease Amyotrophic lateral sclerosis Trichinosis 32. A 42 year old female complains of recent onset of easy bruising. The PT and PTT are normal, but her platelet count is only 10,000/microlitre. A bone marrow biopsy reveal a normocellular marrow with increased numbers of megakaryocytes. These findings most strongly suggest a diagnosis of: (A) (B) (C) (D) (E) Myeloproliferative disorder Drug reaction to recent antibiotic therapy Wiskott-Aldrich syndrome Epstein-Baarr virus infection Idiopathic thrombocytopenic purpura 33. Which of the following has an incubation period of less than 10 days? (A) (B) (C) (D) (E) Dengue fever Yellow fever Rickettsial infections Plague Leishmanisasis 34. Which of the following infectious diseases is incorrectly matched to its period of infectivity: (A) (B) (C) (D) (E) chicken pox: from appearance of rash until the last spot is crusted over rubella: 7 days before onset of rash until 4 days after onset of rash mumps: 3 days before until 7 days after salivary swelling scarlet fever: from appearance of rash until completion of 1 day’s penicillin measles: from onset of prodome until 4 days after onset of rash 35. which is false. Plasmodium falciparum (A) (B) (C) (D) (E) causes more severe disease in pregnancy is associated with recurrent relapses after initial treatment because of liver hypnozoites is the only malarial parasite causing greater than 20% parasitaemia infection is typically associated with thrombocytopaenia is the only cause of cerebral malaria 36. HIV positive patients may NOT receive: (A) (B) (C) (D) (E) Hepatitis B vaccination TY21a (oral typhoid vaccine) Hib vaccine Pneumovax Havrix (hepatitis A vaccine) 37. Allodynia is: (A) (B) (C) (D) (E) Pain caused by stimuli that are usually not painful The “burning’ sensation of causalgia Red flare with nerve damage Due to reflex sympathetic dystrophy Not associated with nerve damage 38. A celiac plexus block with alcoholwill probably not cause: (A) Hypotension (B) (C) (D) (E) Abdominal pain Constipation Paraplegia Pleuritic chest pain 39. Statistics – which is false: (A) Demonstrating that an intervention is beneficial when in reality it is not is an example of a type 1 error. (B) Failure to reject a false null hypothesis is usually the result of small study size. (C) 3 standard deviations above the mean should include 49.8% of observations. (D) Variance is equal to the square root of the standard deviation. (E) Blood groups are an example of nominal variables. 40. Which of the following cranial nerves does not contain both sensory and motor fibres: (A) (B) (C) (D) (E) II III VII IX X 41. Typical features of REM sleep do not include: (A) (B) (C) (D) (E) Increased sympathetic activity Recall of dreaming if awoke Penile flaccidity Increased tendon reflexes Maximal loss of muscle tone 42. Neuropathological changes commonly seen in Alzheimer’s disease do not include: (A) (B) (C) (D) (E) Sulcal widening Hirano Bodies Astrocytosis Thinning of corpus callosum Reduced dendritic branching 43. Volume of distribution: (A) (B) (C) (D) (E) Is not a theoretical concept Is equal to the mass of drug in the body at a given time divided by a person’s body weight When increased in volume corresponds to a longer duration of drug action Decreases with age Can be affected by physical illness 44. A 75 year old lady presents with sudden breathlessness and palpitations. On examination, she was observed to have an irregular heart beat with rate of 140 bpm, BP 150/84 and normal heart sounds. On auscultation of the chest, fine basal crepitations are heard. An ECG confirms AF and an old inferior MI. She is anticoagulated with heparin and given diuretics. Her heart rate remains rapid. What is the most appropriate management of the lady’s AF. (A) DCCV (B) (C) (D) (E) IV amiodarone IV betablocker IV digoxin Oral quinidine therapy 45. The term used to describe the genotype of a male for genes on the X chromosomes is: (A) (B) (C) (D) (E) homozygote heterozygote hemizygote heteroplasmy homogeneous 46. The Hardy-Weinberg principle can be used to calculate: (A) (B) (C) (D) The new mutation rate of a disease in a population The carrier frequency for an autosomal recessive disorder The degree of consanguinity in a family The risk that an offspring of a person affected with an autosomal dominant condition will be affected by the disease (E) The recombination fraction in a linkage study 47. The majority of cases of Down syndrome occur as a result of (A) (B) (C) (D) (E) non disjunction during maternal meiosis mosaicism of normal and trisomic cell lines unbalanced 14:21 translocations end to end fusions of two chromosomes 21 non disjunction during paternal meiosis 48. The explanation thought to be the most likely for the high incidence of carriers for cystic fibrosis (1 in 20) in the Northern European populations is: (A) (B) (C) (D) (E) a high mutation rate in the CFTR gene heterozygote resistance to chloride-secreting bacterial-induced diarrhoea repeated invasions by Vikings several separate loci for cystic fibrosis the cystic fibrosis mutation altering the proportion of normal mutation containing gametes 49. Stimulation of cholinergic vagal fibres in the SA node decreases heart rate. Which of the following statements most accurately describes the mechanism behind this? (A) Cholinergic vagal fibres decrease the contractility of the heart (B) Cholinergic vagal fibres increase the duration of the plateau phase of the action potential thereby increasing the muscle cell refractory period (C) Acetylcholine released from vagal fibres deactivates voltage-gated sodium channels in SA node (D) Acetylcholine released from vagal fibres increases K+ conductance in SA node cells (E) Non of the above 50. With respect to the human heart, which of the following statements is/are false? (A) The spread of excitation through the walls of the ventricles is from the endocardial surface outwards (B) Vagal stimulation decreases the force of ventricular contraction (C) Sympathetic stimulation increases the force of atrial contraction (D) The non-conducting fibrous skeleton of the heart including the ventricular valves plays a significant role in the electrical activity of the heart (E) At rest, denervation of the heart would result in a rise in heart rate 51. Which is correct. The functional residual capacity (FRC) in the lungs of a healthy adult of average size: (A) (B) (C) (D) (E) is about 1 litre becomes smaller if airflow resistance increases can be estimated using a helium dilution method has the effect of increasing fluctuations of alveolar gas concentrations during the breathing cycle is the volume at which some airways normally begin to close during expiration 52. In cancer of the cervix which is true (A) (B) (C) (D) (E) HSV has been identified as the aetiological agent The “pap smear test” is used to stage early disease Cells infected with HPV type 6 and type 11 have a high risk of progressing to cancer The HPV L1 and L2 genes act as oncogenes in the development of cervical cancer The HPV genome is often integrated into the cell’s chromosome 53. Which is incorrect. DNA (A) (B) (C) (D) (E) Contains the nucleotide bases adenine, cytosine, guanine and thymidine Is replicated in a semi-conservative manner Is replicated during the G2 phase of the cell cycle Is converted to RNA during transcription Is synthesised in a 5’ to 3’ direction 54. Which of the following are true of the tumour suppressor protein, p53 (A) (B) (C) (D) (E) p53 is activated in response to DNA damage Expression of the cyclin-dependent kinase inhibitor p21 is reduced when p53 is activated The MDM2 protein is a viral protein which complexes with p53 The p53 gene is the second most commonly mutated gene in human cancers Non of the above 55. Which subcellular compartment do the arrows point to in this electronmicrograph? (A) (B) (C) (D) (E) cytoplasm rough endoplasmic cisterna extracellular space nuclear matrix Non of the above 56. Which of the following are true of bacterial vaginosis: (A) (B) (C) (D) (E) It is always symptomatic It is associated with a non-odorous discharge Microscopy of the discharge shows “clue” cells It is a proven sexually transmitted disease It is not associated with post-partum endometritis 57. A 48 year old woman presented with a 10 day history of painful red nodules over her face, trunk, and limbs which rapidly enlarged before developing central ulceration. She was otherwise well with no complaints. She had received four days of oral flucloxacillin but otherwise was on no medication. There was no past medical history of note. Examination revealed deep cutaneous ulcers with purplish undermined edges and slough at the ulcer bases (fig 1). Ulcer swabs and blood cultures failed to grow any organisms. Chest radiography, full blood count, and biochemical profile were normal, but the C reactive protein was markedly raised at 380 mg/l. Complement C3 and C4 levels and IgG, IgA, and IgM titres were normal. Antinuclear antibodies, DNA antibodies (single and double strand), and neutrophil cytoplasmic antibodies were negative. Neutrophil function tests were normal (as assessed by respiratory burst chemiluminescence). A skin biopsy showed a predominantly neutrophilic infiltrate of the dermis with leucocytoclastic vasculitis. She was treated with 14 days of flucloxacillin and the ulcers healed over the next month. Two years later she developed diarrhoea after a chicken meal. After one week she again developed cutaneous ulcers over her face, trunk, and limbs. She presented six weeks later with weight loss, abdominal pains, multiple skin ulcers, and passing faeces through her vagina. On examination the skin lesions were as before, there was tenderness in left iliac fossa, and the rectovaginal fistula was present. Inflammatory markers were raised but ulcer, stool, and blood cultures were sterile. Which skin condition is not associated with the Gastrointestinal disease with which this patient suffers (A) (B) (C) (D) (E) Pyoderma gangrenosum Erythema nodosum Sweets syndrome Psoriasis None of the above 58. A 53 year old man complained of intermittent blurring of vision confined to the left eye over a period of 12 months. It did not stop him from reading or driving. There was no history of visual loss, eye pain or double vision. He had recently been diagnosed with hypertension and hypercholesterolaemia, for which he was treated with felodipine (5 mg once daily) and fluvastatin (40 mg once daily) respectively. He attended his optician who performed a visual field test (suprathreshold static perimetry, see figure below), on the basis of which referral to a neurologist was recommended. Clinical examination showed an uncorrected visual acutiy of 6/9 left, 6/6 right. Reading pseudoisochromatic (Ishihara) plates he scored 2/17 left, 14/17 right. Confrontation testing of the visual fields showed no field loss to stationary or moving targets, but a red pin appeared less read in the left temporal field compared with the left nasal field; no such temporal desaturation to red was noted on the right. There was no relative afferent pupillary defect and fundoscopy was normal. There was no neglect of visual stimuli. The rest of the neurological examination was normal. Ophthalmological examination showed normal appearances of the ocular media, retina and optic nerve, and the intraocular pressures were normal. What is the neuroanatomical correlate of this clinical finding? (A) Prechiasmal lesion (B) Postchiasmal lesion (C) Occipital lesion (D) Retinal lesion (E) Non of the above 59. A 16 year old girl was admitted because of low grade fever, headache, and nuchal rigidity. She complained of galactorrhoea during the preceding year and irregular menstruation since menarche at 13 years old. Physical examination was unremarkable except for the galactorrhoea. The diagnostic work-up for meningitis was negative. Cranial computed tomography and subsequent magnetic resonance imaging showed a large, possibly cystic, pituitary lesion (fig 1). The laboratory work-up showed a mild elevation of basal prolactin levels, 1.05 IU/l; evaluation of pituitary reserve showed normal thyrotrophin, luteinising hormone, and follicle stimulating hormone responses after stimulation. The α-subunit levels were 0.1 mIU/ml. Mild bilateral superior constriction was found on Goldman visual field examination. There were no findings suggestive of sarcoidosis (normal chest radiography, normal serum angiotensin converting enzyme levels). The most common condition associated with the above clinical picture is: (A) (B) (C) (D) (E) Primary hypophysitis Secondary Hypophysitis Pituitary Adenoma Lymphoma Craniopharyngioma 60. A 40 year old man, a non-smoker, was referred to us on account of chest radiograph abnormalities that had been discovered during the preoperative evaluation before an Achilles tendon repair. He had no respiratory complaints or significant past medical history. He had been working as a silver polisher for the last 20 years. His routine blood investigations were normal. The chest radiograph (fig 1) and the high resolution computed tomography (HRCT) lung scan (fig 2) are shown. Spirometry and arterial blood gases were normal. The most likely diagnosis is (A) Siderosis (B) Sarcoidosis (C) Hypersensitive pneumonitis (D) Tuberculosis (E) Vasculitis 61. A 24 year old woman was admitted to our hospital for a massive haemoptysis with abrupt onset. The average amount of blood expectorated was 200-250 ml in 24 hours. She was a non-smoking housewife living in a rural area. Her medical history was unremarkable except for the presence of recurrent oral and genital ulcers for three years, and skin lesions consistent with erythema nodosum had occurred one year previously. Her vital signs on admission were as follows: temperature 37°C, blood pressure 110/70 mm Hg, pulse rate 120 beats/min, and respiratory rate 28 breaths/min. Physical examination of the chest was normal. Admission laboratory values were as follows: leucocyte count 9.3 x 109/l, haemoglobin concentraion 120 g/l, packed cell volume 0.34, platelet count 42 x 10 9/l, erythrocyte sedimentation rate 44 mm/hour, alanine aminotransferase 48 IU/l (normal range 0-40 IU/l), aspartate aminotransferase 34 IU/l (normal range 0-40 IU/l). Serum electrolytes, renal function, urinalysis, prothrombin time, and activated partial thromboplastin time were all in the normal ranges. Her chest radiograph showed two rounded opacities bilaterally with fine margins with an average size of 3 x 5 cm (fig 1). Purified protein derivative by Mantoux testing was 17 mm. What is the most likely diagnosis? (A) Neoplasm (B) Hydatid disease (C) Fungal Infection (D) Behcets Disease (E) Tuberculosis 62. A 53 year old woman was referred to the general medical outpatient clinic. She had no relevant past medical history. Her main complaints were those of numbness and burning over her entire right forearm and hand. She felt that a recent cough had exacerbated the pain. In addition, she had burnt her right hand twice in the last month without even noticing. She denied any history of neck pain or stiffness and there was no history of spinal trauma. On examination she looked well and undistressed. There was nil of note on examination of the cardiorespiratory system or the abdomen. There were no palpable breast lumbs or lymphadenopathy. Examination of the cranial nerves and lower limbs was unremarkable and in particular there were no long tract signs. The left upper limb was normal from a neurological point of view. On neurological examination of the right upper limb, both the biceps and supinator jerks were absent. In addition there was grossly impaired sensation of pain over the C3-T2 dermatones. Light touch and vibration sense were preserved over this area. There was early wasting of the intrinsic hand muscles with an associated reduction in distal power. The tone was normal. MRI scan shown below What is the likely diagnosis? (A) Syringomyelia (B) Motor Neuron Disease (C) Cervical Spondylosis (D) Multiple Sclerosis (E) Intrinsic Spinal Cord Neoplasm 63. A 38 year old man presented with a history of episodic lower limb weakness lasting a few hours. The weakness was predominantly proximal and was preceded by cramps in the affected muscles. There were two such attacks separated by a one month period. He was perfectly normal between episodes. The weakness was unrelated to exertion or meals. The upper limbs, eyes, face, tongue, pharynx, larynx, diaphragm, and sphincters were spared. There were no sensory abnormalities. He did not have vomiting or diarrhoea, nor was he on any medication. He had had no major illness in the past. No other family member had a similar illness. His appetite was good and there was no change in his weight in recent years. His sleep was normal, so were his bowel and bladder habits. He did not have any addictions. On physical examination, the patient was afebrile and nervous. He had a heart rate of 120 beats/min and a blood pressure of 170/70 mm Hg. During the attack, there was a flaccid paraparesis with depressed tendon jerks. In the interattack period, strength was normal and the reflexes were brisk. His serum potassium concentration during the attack was 3.2 mmol/l, and after recovery 4.40 mmol/l (reference range 3.5-5.0 mmol/l). The concentration in urine was normal. Other electrolyte values were within normal limits. What further studies should be performed to establish the aetiology. (A) (B) (C) (D) (E) Serum diuretic level Aldosterone level Renin level Thyroid Function tests Genetic screen for periodic paralysis 64. A 50 year old woman was admitted with complaints of swelling and stiffness of right shoulder for three months. There was no history of trauma, fever, or any local injections. She did not drink alcohol and there was no history of any steroid intake. There was no past history of diabetes or syphilis. The swelling was minimally painful and only extremes of shoulder movements were painful. The swelling was fluctuant. There was no neurological deficit. Radiographic examination of the shoulder was done (fig1) followed by magnetic resonance imaging (MRI) of the cervical spine (fig 2). Given the changes shown in the above figures what is the most likely diagnosis (A) Charcots joints (B) Tuberculous arthritis (C) Septic arthritis (D) Metastatic Tumour (E) Vanishing Bone Disease (Gorhans Disease) 65. A 78 year old women was admitted to hospital with collapse and sudden onset left sided hemiplegia and a right sided ptosis. On admission she was drowsy. She had a left hemiplagia and right ptosis. When the right upper eyelid was passively raised, there was a fixed outward deviation of the right eye. Both pupils were of equal size and reacting to light. No diplopia or sensory signs were noted at presentation. Which is not true (A) Figures 1 and 2 show right sided partial ptosis and a divergent squint (B) Ipsilateral limb weakness is demonstrated (C) The diagnosis is that of a crossed hemiplegia involving the pons (3 rd CN and corticospinal tract at the level of the cerebral peduncles) (D) When the 4th nerve is involved in addition this may result in the patient being misdiagnosed with torticollis (E) The 3rd nerve nucleus (Motor nucleus and Edinger-Westphal) is located in the midbrain 66. A 23 year old man has had chronic diarrhoea, bloating and a 15 pound weight loss over the past year. His diarrhoea is improved by fasting and is worsened by eating fatty foods. He has no significant medical history. He takes no medications. The review of systems is remarkable for a skin rash over the extensor surface of his elbows and forearms. The patient’s vital signs are normal. He is 6 feet tall and weighs 68 kg (152 pounds). His skin is loose, with apparent loss of subcutaneous fat. He has an erythematous, serpiginous, scaling rash over the extensor surface of his right elbow. The abdominal examination is normal. He has no adenopathy. Evaluation shows normal electrolytes, an albumin of 3.1 g/dL, normal aminotransferases, amylase, lipase, and creatinine. The haemoglobin is 12 g/dL, with a mean corpuscular volume of 80 fL. The leukocyte count is 4500/μL. A 72 hour faecal fat collection shows 12 g of fat per 24 h on a 100 g fat diet. The most appropriate approach is: (A) (B) (C) (D) (E) Secretin test Small bowel biopsy Low fat diet supplemented with medium chain triglycerides Systemic corticosteroid therapy A course of broad spectrum antibiotic therapy 67. A 54 year old asymptomatic man volunteers to donate blood and is found to have elevated serum aminotransferase levels. He has no known medical problems and no history of hepatitis. He drinks no alcohol, takes no medications, and has not seen a physician in more than 10 years. He is active, works as a truck driver, and has noted no change in his physical condition. He has no family history of liver disease. The physical examination is remarkable for obesity. He is 5 feet 10 inches tall and weighs 100 kg. Laboratory studies Complete blood count Normal Aspartate aminotransferase 45 U/L (NL = <35 U/L) Alanine aminotransferase 85 U/L (NL = <35 U/L) Alkaline phosphatase 90 U/L (NL = <36-92 U/L) Gamma-Glutamyltransferase 125 U/L (NL = 5-40 U/L) Hepatitis serologies (anti-hepatitis A, hepatitis B surface antigen and antibody, anti-hepatitis B core antibody, and hepatitis C antibody) Negative Erythocyte sedimentation rate Normal Antinuclear antibody Negative Anti-smooth-muscle antibody Negative Total cholesterol 260 mg/dL (NL = <200 mg/dL) Low-density lipoprotein 225 mg/dL (NL = <130 mg/dL) Cholesterol Triglycerides 830 mg/dL (NL = <250 mg/dL) A liver biopsy specimen shows large droplet steatosis without a significant inflammatory reaction and no fibrosis. Ultrasonography shows a mildly enlarged fatty liver. The appropriate management of this patient would be: (A) (B) (C) (D) (E) Interferon therapy for presumed chronic non-B, non-C hepatitis Alcohol rehabilitation and counselling Weight loss and therapy for hyperlipidemia ERCP to evaluate the biliary tree Corticosteroid therapy 68. An 84 year old woman with a 10 year history of dementia is transferred from a nursing home to the hospital for evaluation of a new fever. She is being fed through a gastronomy tube, and she requires both an indwelling bladder catheter and a diaper. She has no known allergies. She has had three prior episodes of fever in the last six months. When she had a fever in the nursing home, she was given ciprofloxacin through the gastronomy tube. She has no advance directive, and her grandson, who has durable power of attorney, insists on full medical measures. On physical examination in the emergency room, the patient has a temperature of 38.8°C, pulse rate of 84/min, respiration rate of 24/min, and blood pressure of 94/48 mm/Hg. She is unresponsive. Her neck is supple, and her lungs are clear. There is an S4 gallop but no significant murmurs. The abdomen is soft and non-tender, with no masses or organomegaly. The extremities are warm but not swollen or red. Rectal examination is normal, and the stool is brown and negative for occult blood. The Foley catheter is filled with cloudy urine. In urinalysis and urine culture reports available from two days earlier, urinalysis showed trace protein, large leukocyte esterase, many leukocytes, rare erythrocytes, and copious bacteria, and urine culture showed Klebsiella pneumoniae. The susceptibility report was limited and indicated that the organism was susceptible to cefotaxime and resistant to ceftazidime, ciprofloxacin, tobracmycin, and tetracycline. Which of the following antimicrobial agents would be most likely to be effective for this woman? (A) (B) (C) (D) (E) Cefotaxime Aztreonam Imipenem Gentamicin Levofloxacin 69. A 34 year old man is evaluated because of a 4 day history of sore throat. He is able to swallow but indicates that the pain is significant. He has taken analgesics inconsistently. He has no febrile sensation or cough. On examination, he is afebrile. His pharynx is erythematous, but no plaques are visible, and he has no tender enlarged cervical lymph nodes. He is concerned about strep because he has small children, and they currently have symptoms of upper respiratory infection, including sore throat and fever. What would be the next appropriate step in managing this patient? (A) (B) (C) (D) (E) Get a rapid strep test and is positive start antibiotics Treat symptoms only Send off a throat culture and treat with antibiotics until result comes back Treat him and his children with antibiotics None of the above 70. With respect to infection with the human immunodeficiency virus which of these is incorrect: (A) Antiviral use in pregnancy and neonatally, elective caesarean delivery and avoidance of breast feeding have been effective interventions reducing vertical transmission. (B) Genetic susceptibility, not only to infection and progression, but to drug resistance, has been identified. (C) Methadone levels are unaffected by antiretroviral therapy. (D) Changes in body fat distribution (lipodystrophy syndrome) can induce buffalo hump, breast enlargement, abdominal paunch, face atrophy, and extremity wasting. (E) Levels of atorvastatin can increase six times with Lopinavir/Ritonavir (Kaletra). 71. After the introduction of highly active antiretroviral therapy (HAART) patients can develop an immune reconstitution syndrome. Which of these is incorrect: (A) The syndrome includes focal MAC, cryptococcal meningitis with marked CSF pleocytosis, mild herpes zoster, PML and CMV vitritis (B) HCV reactivated hepatitis and cryoglobulinaemia can result. (C) HAART should be stopped if PML manifests (MRI changes of enhancement). (D) MAC manifesting with focal adenitis should be treated with MAC specific therapy and perhaps steroids (E) Progression of TB can result. 72. Coeliac Disease or gluten sensitive enteropathy is characterised by malabsorption resulting from inflammatory injury to the mucosa of the small intestine after ingestion of wheat gluten or related proteins. In the autoimmune model of Coeliac Disease the environmental antigen, gliadin, in a genetically susceptible patient sets off an inflammatory process. Initially gliadin and transglutaminase form a complex; gliadin is deaminated and has increased avidity binding to DQ2. APC then present gliadin and gliadin-tissue transglutaminase complexes. Which is not true: (A) Coeliac Disease is related to an inappropriate T cell mediated response against ingested gluten in genetically predisposed people. (B) Only 50% of patients with Coeliac Disease have HLA DQ2. (C) α gliadin IgA antibodies are neither as specific nor sensitive as IgA antiendiomysial antibodies. (D) False negatives can occur in the setting of IgA deficiency. (E) Immunodeficiency is more common in patients with Coeliac Disease 73. The CXR shown is from a patient with scleroderma. Which is true: (A) This patient will probably not have anticentromere specific antibodies. (B) This patient will not respond to Prostacylin analogues or Bosentan. (C) This patient may have normal lung volumes with disproportionately reduced gas trasfer (↓DLCO) corrected for alveolar volume. (D) The degree of impairment of gas transfer is of no prognostic importance. (E) The problem is benign and of no clinical significance 74. The monitoring of patients with HIV includes both T cell subset and viral load analysis. Which is true: (A) (B) (C) (D) (E) The normal range for CD4 count is 300-1400/ml. CD4, CD8 and viral load are all independent predictors of clinical progression and survival. CD4 response generally mirroring RNA decay curve. CD4 cell count alone is used in the decision making process regarding antiviral treatment After achieving complete viral suppression with HAART for one year usually there is no further increase in CD4 count. 75. Behcet’s Disease is an inflammatory disorder of unknown cause characterised by recurrent aphthous ulcers, genital ulcers, uveitis and skin lesions. Which is not true: (A) (B) (C) (D) (E) Involvement of the GIT, CNS or large vessels can be life-threatening. Cases cluster along the ancient Silk Road and Turkey has the highest prevalence. Pathergy test can help the diagnosis. Erythema nodosum and superficial migratory thrombophlebitis are pathognomonic. Despite therapeutic intervention 25% of patients with ocular lesions eventually become blind. 76. Anthrax has three main clinical presentations: - cutaneous - inhalational - gastrointestinal Which is not true: (A) (B) (C) (D) (E) Anthrax is a gram-positive, spore-forming organism. Growth from blood culture is the most useful test for inhalational anthrax. Doxycydine and ciprofloxacin are effective agents for both prophylaxis and treatment. With respect to inhalational anthrax the usual clinical presentation is a pneumonitis. A widened mediastinum on CXR is a pathognomonic feature of inhaltional anthrax. 77. The diagnosis of common variable immunodeficiency (CVID) should be considered if either a male or female patient has a marked decrease in 2/3 major isotypes (IgM/C/A). Which is not true: Most patients with CVID are diagnosed in the 2nd-4th decade of life after several pneumonias. Viral, fungal and parasitic infections can be problematic. There is an association with autoimmunity and malignancy. The majority of patients have normal BtK gene, but reduced numbers of B cells and T cell functional abnormalities. (E) The hypogammaglobulinaemia of CVID is not easily distinguished from the hypogammaglobulinaemia associated with chronic lymphocytic leukaemia, penicillamine treatment and the immunodeficiency caused by hypercatabolsim of immunoglobulins. (A) (B) (C) (D) 78. With respect to the clinical utility of ANA/ENA, which is not true: (A) Anticentromere antibody is associated with the limited cutaneous variant of scleroderma. (B) Scl 70 detected by EIA, Immunoblot or CIEP is specific for DNA topoisomerase 1, has greater than 90% specificity but only 40% sensitivity for diffuse scleroderma. (C) The presence of Ribosomal P Antibody is reported to be associated with neuropsychiatric manifestations of SLE. (D) Anti-Smith (Sm) Antibodies are highly sensitive for SLE and are used to monitor disease activity. (E) ANAs are a screening tool for autoimmune connective tissues but of no use alone for prognosis and disease monitoring. 79. With respect to cryoglobulins and HCV which of the following is not true: (A) HCV is associated with type II and III cryoglobulinaemia. (B) HCV-associated cryoglobulins are associated with a vasculitis manifested as cutaneous lesions, peripheral neuropathy and mesangiocapillary glomerulonephritis. (C) Can cause hyperviscosity that responds to Inteferon α. (D) Can cause Raynaud’s phenomena. (E) Can induce immune complexes with HCV as the antigen, polyclonal anti-HCV antibodies and monclonal antibodies specific for IgG. 80. Raynaud’s phenomenon represents an episodic event of vasoconstriction of digital arteries, precapillary arterioles and cutaneous arteriovenous shunts. Which is not true: (A) Raynaud’s can be a primary or secondary phenomenon distinguished by such things as symmetry, necrosis/ulceration/gangrene, other clinical findings of a connective tissue disease, ANA, ESR, and nailfold capillaroscopy. (B) The median age of onset of primary Raynaud’s phenomenon is 14 years and a quarter have a family history. (C) 15-20% of patients with Raynaud’s phenomenon who have autoantibodies and abnormal nailfold capillaroscopy but do not initially meet the diagnostic criteria of a well defined connective tissue disease will ultimately do so, usualy with two years. (D) The DD can include cold agglutinins, cryoglobulinaemia and thoracic outlet syndrome. (E) Treatments include Calcium Channel and Blockers, Angiotensin II receptor antagonists, GTN and Prostastandin analogues. 81. Many patients are infected with both HIV and HBV. With respect to the management of HIV and Hepatitis B co-infection, which drugs would you predict to be effective in antiretroviral naïve patients for both viruses: (A) (B) (C) (D) (E) Zidovudine and Lamivudine Zidovudine and Efavirenz Tenofavir and Lamivudine Tenofavir and Efavirenz None of the above 82. Non-alcoholic Fatty Liver Disease is no longer considered a benign process and may progress to end-stage liver disease. Which is incorrect: (A) Obesity, insulin-resistant Type 2 Diabetes Mellitus, hyperlipidaemia and a family history of steatohepatitis are risk factors. (B) Often there are no symptoms or signs of liver disease and mild to moderately elevated levels of AST and ALT are the most common and often only laboratory abnormality. (C) The AST/ALT ration is usually less than one. (D) Histologically liver biopsies are distinct from liver damage resulting from alcohol abuse with steatosis, mixed inflammatory cell infiltrate, kepatocyte necrosis, Mallory’s hyaline and fibrosis. (E) The management is difficult but steps towards weight loss, improved serum glucose and lipid levels are important. 83. Periodic Fevers are defined as recurrences of fever that last from a few days to a few weeks separated by symptom-free periods. Many disorders including those inflammatory and neoplastic in nature can cause such fevers but recent interest has increased in the hereditary syndromes such as Familial Mediterranean Fever (FMF), Hyper IgD syndrome and the Tumour Necrosis Factor (TNF) receptor associated with periodic syndrome. Which is incorrect: (A) FMF can have associated serositis, scrotal involvement and erythema. (B) The genetic mutation associated with FMF (encoding the Pyrin gene) can be detected and helps with the diagnosis. (C) Colchicine has been shown to be of no benefit for patients with FMF. (D) With long term untreated patients with FMF and TNF receptor associated with periodic syndrome, the potential development of amyloidosis is a concern. (E) Hyper IgD syndromes can be associated lymphadenopathy, erythematous macules, abdominal pain, vomitting and arthralgias. 84. Peanut allergy in recent years has been of increased concern in the general community. Which is incorrect: (A) Early symptoms of food-induced anaphylaxis often include oral pruritis and tingling, pharyngeal pruritis, a sensation of tightening of the airways, abdominal pain, nausea, vomiting, flushing, urticaria and angioedaemia. (B) Biphasic reactions can occur in up to a third of patients with near fatal reactions. (C) Cross reactions can occur between other legumes and to tree nuts. (D) Treatment of an acute reaction includes intramuscular adrenaline. (E) Patients with a strong history of an allergy following the ingestion of a peanut product and evidence of peanut specific IgE (Skin Prick Test or RAST) should always have the diagnosis confirmed by oral challenge. 85. Thrombophyllias can adversely effect many pregnancy outcomes. Anticoagulation has been shown to be of benefit at least in some settings. Which is not true: (A) Although Warfarin is teratogenic between 6 and 12 weeks gestation, heparins do not cross the placenta. (B) Therapeutic doses of low molecular weight heparin contraindicate the use of regional anaesthesia and a switch to IV unfractionated heparin before delivery should be considered. (C) Aspirin can reduce the incidence of recurrent pre-eclampsia. (D) Antiphospolipid syndrome (thrombosis, recurrent miscarriage, antiphospholipid antibody positivity) is associated with venous thrombosis and often is associated with thrombocytosis. (E) Women with antiphospholipid antibodies have increased risk of uteroplacental insufficiency and pre-eclampsia. (F) Pregnancy outcomes in women with recurrent miscarriage associated with antiphospholipid syndrome are improved if aspirin and clexane are used 86. Lupus nephritis is a prototype of immune complex glomerulonephritis. Which is incorrect: (A) Within each of the WHO classes of lupus nephritis highly pleomorphic histological changes affecting the glomeruli tubules are observed. (B) Treatment of severe nephritis includes pulses with methylprednisolone, oral prednisone and cyclophosphamide. (C) Mycophenolate mofetil (a selective and reversible inhibitor of inosine monophosphate dehydrogenase – key enzyme in the de novo purine synthetic pathway) has been used for both initial treatment and as part of maintenance therapy. (D) Depressed serum complements and elevated titres of double-stranded DNA specific antibodies can alert physicians of renal involvement and should lead to careful review of a patient’s urinalysis. (E) ANA titres parallel the activity of lupus nephritis. 87. Mannose binding lectin (MBL) is a collagenous lectin found in serum. It binds to mannose and Nacetyl glucosamine residues when presented in the orientations and densities commonly found on micro-organisms. On binding it activates the complement system independently of antibodies. Which is incorrect: (A) MBL deficiency seems to have an important influence on the duration of febrile neutropenic episodes in children with malignancy. (B) Some variant alleles of MBL are associated with increased risk of HIV infection either directly or indirectly because of increased susceptibility to co-infections. (C) MBL is an acute phase protein that increases 2-3 fold after an inflammatory stimulus. (D) MBL appears to be an ancient mechanism of innate host defence. MBL-like systems seem to have been established for at least 300 million years. (E) Genetic deficiency in MBL is associated with resistance to meningococcal disease. 88. An orally absorbed drug is administered with grapefruit juice. As a result the area under concentration time curve (AUC) is increased. Which of the following is false: (A) (B) (C) (D) (E) The half-life of the drug is increased. The Cmax of the drug is increased. The drug is metabolised by cytochrome P450 3A4. First-pass metabolism is reduced. Co-administration of St John’s Wort may counteract some of the increase in AUC. 89. 60 patients are randomised to placebo or Wonder Treatment X to determine whether the new treatment is effective. The trial finds that the survival rate increases from 20 to 25% at one year (p=0.1). Which of the following is the best answer: (A) (B) (C) (D) (E) The new treatment should be rejected because the result is not statistically significant. This result is unlikely to have occurred by chance. There is a 9 in 10 chance that the difference in survival is real. The trial probably had sufficient power to detect a statistically significant difference at 5%. The trial has demonstrated the new treatment to be 5% better than placebo alone. 90. Regarding chemotherapy-induced toxicity, which of the following is false: (A) (B) (C) (D) (E) The side effects of 5-fluorouracil are schedule dependent. The haematologic toxicity of carboplatin can be predicted by renal function. Anthracycline cardiac toxicity is related to cumulative dose. Peripheral neuropathy is a side-effect of gemcitabine. Irinotecan-related diarrhoea may be ameliorated by atropine. 91 Regarding genetic polymorphisms and drug metabolism, which of the following is true: (A) Polymorphisms are unstable genetic variations with a frequency of >1%. (B) Rapid metabolisers of codeine have inadequate pain control due to a polymorphism of CYP 2D6. (C) A polymorphism of thiopurine methyltransferase increases the risk of complications from azathioprine. (D) 50% of Asians are slow acetylators. (E) Gene polymorphisms present in the population as a part of a normal distribution of gene variants. 92 A middle aged male presents with diarrhoea, flushing and wheeze and is found after extensive investigation to have malignant carcinoid. Which of the following is true: (A) (B) (C) (D) (E) He should be started on depot intramuscular octreotide to control his symptoms. The most likely cause of his wheeze is tricuspid incompetence. He should be started on subcutaneous octreotide to control his symptoms. Octreotide use will prolong his survival. Malabsorption is this syndrome is due to octreotide administration. 93 With respect to HER-2/neu oncoprotein, which is false: (A) (B) (C) (D) (E) It is overexpressed in 10-40% of human breast cancers. In tumours that are ER positive, the likelihood of response to a hormonal agent is reduced. In tumours that are ER positive, the duration of response to a hormonal agent is reduced. It does not have tyrosine kinase activity. It has similarity to the epidermal growth factor receptor. 94 With respect to BRCA 1/2 mutations, which is false: (A) (B) (C) (D) (E) Germline prevalence is 0.1-0.2% in the population. They account for 10% of all cases of ovarian cancer. They account for 70% of cases diagnosed in women younger than 40. Carriers of either BRCA1 or 2 have a 50-85% lifetime risk of breast cancer. BRCA2 carriers have a higher risk of ovarian cancer than BRCA1. 95 The most important prognostic feature of a local malignant breast mass is: (A) (B) (C) (D) (E) size fixation location ulceration hormone status 96 Which of the following is false regarding Pamidronate: (A) (B) (C) (D) (E) Can be associated ARF Can induce a fever Is standard of care for metastatic breast cancer with bony metastases Is standard of care for metastatic prostate cancer Can be associated with first dose “flu-like” illness 97 Which of the following is a tumour suppressor gene: (A) (B) (C) (D) (E) p53 c-myc c-erbB2 ras fos 98 Regarding hormonal therapy and cancer, which of the following is TRUE? a) Tamoxifen acts by blocking the membrane bound oestrogen receptor b) Anastrazole acts by blocking the membrane bound oestrogen receptor c) A flare of bone pain due to the use of goserelin to treat metastatic prostate cancer is due to the partial agonist effect of goserelin at the androgen receptor d) Failure to induce amennorhoea is an important predictor of relapse in pre-menopausal women who receive chemotherapy for early breast cancer e) Aromatase inhibition results in oestadiol levels being increased through negative feedback. 99 A 29 year old man with a 12 pack a year history of smoking presents with sharp pleuritic chest pains. On auscultation the chest sounds clear and there are no other signs on examination. His chest CT scans and serial lung function measurements are shown below. A. B. C. D. E. He should be reassured that his condition will resolve spontaneously. The smoking history, presentation and CT findings are typical of histiocytosis X. His presentation, progress and CT findings are typical of bronchoalveolar cell carcinoma. He should be treated with a combination of prednisone and cyclophosphamide. The presence of hypercalciuria will help determine the need for treatment. 100. A 45 year old accountant presents with sinusitis, chronic asthma and cough with expectoration of mucus plugs. His CXR and CT scans are shown below. Which of the following statements is false: A. He worked with a jack hammer for 6 months when aged 18 and has developed silicosis with progressive massive fibrosis. B. The differential diagnosis of his CT and CXR findings would include tuberculosis. C. The treatment of choice is a course of oral prednisone D. His serum IgE is likely to be elevated. E. This condition is frequently seen in patients with cystic fibrosis. 101. A 39 year old woman presented 4 years ago with a chronic cough. She had a history of winter bronchitis for some years and chronic sinusitis with no history of allergies, snoring or reflux. She is a non-smoker who is married but has no children because of infertility. She has a family history of breast cancer and colon cancer but no family history of respiratory disease. On examination she was not clubbed and her saturation were 98 % on room air. She had bibasal inspiratory coarse crackles nasal airflow. She has the following CT scan. The diagnostic test most likely to yield a positive result is: A. B. C. D. E. CF genotype testing A test of cilial function ANCA and serum immunoglobulins A CT of the sinuses A sweat test 102 A 17 year old schoolboy presents complaining of an inability to stay awake in class. He is overweight with a BMI of 30kg/m2. He reports occasional episodes of sleep-wake paralysis but denies cataplexy. His parents report intermittent snoring which is worse when he lies on his back. On examination he has a red swollen uvula and oedematous posterior pharynx and large prominent tonsils. Which of the following statements is false: A. The absence of cataplexy does not exclude a diagnosis of narcolepsy. B. He should be booked for a diagnostic sleep study followed the next day by a multiple sleep latency test (MSLT). C. A maintenance of wakefulness test (MWT) will help exclude the diagnosis of narcolepsy. D. The most likely diagnosis is obstructive sleep apnoea exacerbated by his obesity and large tonsils/ E. People with narcolepsy commonly present in their teens. 103. A 62 year-old man who is a retired boilermaker presents with the following CT scan and lung function. In retirement he is working four days a week as tennis coach and personal trainer. FEV1 FVC FEV1/VC% KCO TLC 3.16 L 101% predicted 3.92 L 98% predicted 80% predicted 92% predicted 5.87 L 89% predicted Which of the following statements is true? A. B. C. D. E. He has asbestosis. He is compensable under the Dust Diseases Act. He has developed mesothelioma. He has asbestos related pleural disease. It is likely that he had trivial exposure to asbestos during his working life. 104. A 52 year old female presents with breathlessness. She has the following lung function tests. FEV1 FVC FEV1/VC% PEFR (L/sec) 2.90 L 98% predicted 3.26 L 98% predicted 88% predicted 7.8 113% predicted KCO 2.5 TLC VC (slow) Inspiratory capacity Functional residual cap Residual volume 47% predicted 80% predicted 89% predicted 66% predicted 93% predicted 63% predicted Which of the following statements is true? A. B. C. D. E. Kyphoscoliosis with marked chest wall deformity could account for these lung function results. She requires tests of respiratory muscle strength. The next most helpful test would be a CT pulmonary angiogram. The next most helpful test is a high resolution CT scan with prone and supine view. These findings are consistent with diagnosis of chronic asthma with hyperinflation.