Download 2010 Westmead Hospital Trial Exam and Answers

WESTMEAD TRIAL EXAMINATION
PAPER 2
December 18, 2010.
100 Questions.
Time allowed: 3 hours
Instructions:
The following questions are A-type (single-best answer).
To answer these questions fill in ONE box on the answer sheet
provided, corresponding to the alternative which you consider to
be the best answer.
Do NOT mark any other box.
Each correct answer scores one mark and each incorrect
answer zero.
In the questions, values appearing within [ ] refer to normal
ranges.
When visual material has been turned on its side, an arrow on
the page indicates the orientation of the visual material.
This trial exam is dedicated to the advanced trainees of Westmead Hospital, as well as several
consultants at Blacktown Hospital, who all wrote these questions.
Thank you for your commitment to the education of our future specialists!
QUESTION 1.
The most important type of bias encountered in a case control study is
A.
B.
C.
D.
E.
Selection bias.
Recall bias.
Interviewer bias.
Misclassification bias.
Regression bias.
QUESTION 2.
A young male prisoner presents with acute hepatitis B. Which if the following is the most appropriate
management?
A.
B.
C.
D.
E.
Watch and wait.
Pegylated interferon for 48 weeks.
Entecaivr.
Tenofovir.
Hepatitis B immunoglobulin followed by vaccination at a later date.
QUESTION 3.
Which of the following statements regarding fluid restriction in ascites is correct?
A.
B.
C.
D.
E.
Fluid restrict all patients to < 1 litres per day.
No fluid restriction is appropriate.
Fluid restrict when serum sodium is < 130 mmol/L.
Fluid restrict when serum sodium is < 120 mmol/L.
Fluid restrict only patients with peripheral oedema and ascites.
QUESTION 4.
What percentage of patients with chronic pancreatitis will develop Type 2 diabetes?
A.
B.
C.
D.
E.
20%
50%
70%
95%
Very few, as the association is unusual.
QUESTION 5.
Hypercalcaemia can result in which of the following ECG abnormalities?
A.
B.
C.
D.
E.
Flattened T waves.
Prolonged QT interval.
Shortened QT interval.
Heart block.
Widened QRS.
QUESTION 6.
What is the commonest risk factor for developing aortic dissection?
A.
B.
C.
D.
E.
Age.
Hypertension.
Hyperlipidaemia.
Previous aortitis.
Aortic stenosis.
QUESTION 7.
Which of the following antihypertensives are contraindicated in pregnancy?
A.
B.
C.
D.
E.
Hydralazine.
Methydopa.
B blockers.
ACE inhibitors.
Ca channel blockers.
QUESTION 8.
What is the commonest immunosuppressant-related infection to occur in patients who have had a heart
transplant?
A.
B.
C.
D.
E.
Pseudomonas species.
Pneumocystis jeroviccii pneumonia (previously Pneumocystis carinii).
Varicella zoster virus.
Herpes simplex virus.
Cytomegalovirus.
QUESTION 9.
A 35-year-old Chinese woman presents with a non-productive cough and weight loss. She is a life-long
non-smoker and is otherwise well. A CXR and subsequent CT are performed.
A core biopsy is performed on the lung lesion. Pathology confirms an adenocarcinoma.
Immunohistochemistry shows the cells are positive for TTF-1 and CK-7. Mutational analysis is
performed and it is found that the tumour carries an epidermal growth factor receptor mutation
The most effective first line treatment is:
A.
B.
C.
D.
E.
Surgical resection followed by adjuvant chemotherapy.
Concurrent chemoradiotherapy.
Gefitinib.
Crizotinib.
Combination chemotherapy with a platinum based doublet.
QUESTION 10.
A 38 year old premenopausal women presents with a left breast lump. She undergoes imaging and a
subsequent biopsy, which confirms a malignancy. She subsequently undergoes a wide local excision and
axillary clearance; a summary of her pathology report is shown below.
35mm grade 3 invasive ductal carcinoma.
3/21 Lymph nodes involved with no extra nodal speed
The tumour is strongly positive for the Oestrogen and Progesterone receptor
HER-2 testing negative.
Which combination of adjuvant treatment is most appropriate?
A. Anastrozole and chemotherapy.
B. Tamoxifen and chemotherapy.
C. Tamoxifen and chemotherapy and radiotherapy.
D. Trastuzumab and chemotherapy.
E. Chemotherapy and radiotherapy.
QUESTION 11.
DNA damage is involved in the development of malignancies and can be manipulated in the treatment of
cancers. Regarding cellular responses to DNA damage and mechanisms of repair which of the following
is most correct?
A. Poly (adenosine diphosphate [ADP]–ribose) polymerase (PARP) plays a key role in homologousrecombination DNA repair.
B. The BRCA I and II genes play a key role in the repair of DNA single-strand breaks through base
excision repair.
C. p53 levels are decreased in response to DNA damage.
D. In response to DNA damage, p53 can induce G1 arrest and apoptosis.
E. Individuals with hereditary breast cancer who carry a BRCA1 mutation are unable to undertake
DNA repair.
QUESTION 12.
Bevacizumab is an anti–vascular endothelial growth factor (VEGF) antibody which is used in the
treatment of a number of malignancies. Regarding bevacizumab, which of the following is most correct?
A. It is contraindicated in adenocarcinoma of the lung because of the risk of haemoptysis.
B. In colorectal cancer, progression free survival is improved if it is used in combination with
cetuximab and chemotherapy.
C. It is associated with a lowering in blood pressure and carries a risk of postural hypotension
leading to syncope.
D. It carries a risk of thromboembolism.
E. In colorectal cancer, its benefit is limited only to those whose tumours do not have a K-RAS
mutation.
QUESTION 13.
Regarding adjuvant hormonal treatment in women with breast cancer post-definitive surgical resection,
which is the MOST correct statement?
A. Tamoxifen should be used in post-menopausal women and its mechanism of action is through
inhibition of the conversion of cholesterol to oestrogen.
B. Tamoxifen should be used in pre-menopausal women only and its anti-cancer mechanism of
action is the antagonist effect on the oestrogen receptor.
C. Tamoxifen could be used in either pre- or post-menopausal women and its mechanism of action is
the antagonist effect on the oestrogen receptor.
D. Aromatase inhibitors could be used in either pre- or post-menopausal women and its mechanism
of action is through inhibition of conversion of cholesterol to oestrogen.
E. Aromatase inhibitors should be used in post-menopausal women and its anti-cancer mechanism
of action is the antagonist effect on the oestrogen receptor.
QUESTION 14.
A 48-year-old female with metastatic breast cancer recently underwent bilateral pleurodesis for recurrent
symptomatic malignant pleural effusions. She was re-admitted with worsening of her dyspnoea. She has
no cough, sputum, fevers or chest pain. She is haemodynamically stable with a heart rate of 80/min and
oxygen saturation of 94% on RA. The physical examination is otherwise unremarkable.
Her
investigations are shown below.
Hb 89 g/L
WCC 10.0 x 109/L
Neutrophils 4.0 x 109/L
Plat 200 x 109/L
CRP 30 mg/L
Na 135 mmol/L
K 4.0 mmol/L
Ur 5.0
Creatinine 65 μmol/L
[115 – 155]
[4.1 – 11.0]
[2.0 – 8.0]
[150 – 400]
[ < 12]
[131 – 147]
[3.1 – 5.1]
[3 – 12]
[55 – 109]
CT pulmonary angiogram: negative for pulmonary embolus
The best management option for her dyspnoea is:
A. Start intravenous antibiotics, bronchodilators, steroids and transfuse one unit of packed red blood
cells.
B. Prescribe palliative oxygen therapy and PRN oral morphine.
C. Low dose oral morphine and simple hand-held or table-top fan.
D. Cardiothoracic review for further management.
E. Start on therapeutic enoxaparin twice daily and start chemotherapy.
QUESTION 15.
Which of the following statements is most correct?
A. Anti-EGFR therapies are the preferred 1st line treatment in East Asian non-smokers with non
small cell lung cancer (NSCLC).
B. Presence of K-ras mutation predicts response to anti-EGFR (epidermal growth factor receptor)
therapies in metastatic colorectal cancers.
C. BRAF mutation predicts response to BRAF inhibitors in the treatment of metastatic melanomas.
D. EGFR and K-Ras mutations usually co-exist in patients with NSCLC.
E. ELM4-ALK translocation predicts response to imatinib.
QUESTION 16.
A 62 year old woman with recurrent ovarian carcinoma presents with painful, distended abdomen, nausea
and vomiting for 3 days. Her husband noticed frequent jerky movements of her arms and legs and
intermittent disorientation and confusion.
Her bowels have not opened for 4 days and she feels constipated. She takes regular coloxyl and senna
tablets. She takes extended release oxycodone 30mg BD with 10 mg oxycodone (regular release)
breakthrough, needing 6 tablets per day extra per 24 hours. She has also been on regular
metoclopramide, four tablets per day, but continues to vomit 2 to 3 times per day.
Abdominal X-ray is shown below.
Her bloods show:
Na 139 mmol/L
K 2.9 mmol/L
Urea 8.9 mmol/L
Creatinine 220 μmol/L
[131 – 147]
[3.1 – 5.1]
[3 – 12]
[55 – 109]
Alb 26g/L
Bili 9 mmol/L
ALT 99 U/L
AST 106 U/L
GGT 255 U/L
ALP 125 U/L
[35-45]
[12-22]
[5-40]
[8-46]
[9-49]
[13-39]
Regarding her initial management, which is the most appropriate?
A. Ask nurse to insert an NGT and call for a Surgical consult and admission
B. Change her to 10mg SC morphine q4hourly regularly with hourly SC morphine breakthrough
C. Chart her for regular SC metoclopromide and IV ondansetron
D. Start her on hydromorphone 2mg SC q4hourly regularly with hourly PRN
E. Continue her usual medications and add Haloperidol PO.
QUESTION 17.
A 22 year old male presented to an emergency department with sudden onset rash and facial swelling
and progressive dyspnoea 45 minutes after an amoxicillin dose for pharyngitis. The salient clinical
findings were blood pressure of 85/40mmHg, pulse of 104 bpm, pulse oximetry 98% on room air, and
widespread urticaria with angioedema of the face and tongue. Which of the following statements is most
appropriate?
A.
B.
C.
D.
An elevated serum tryptase at presentation is specific for mastocytosis.
First-line therapy would be nebulised adrenaline 1:1000.
He will never be able to receive the penicillin-class of antibiotics again.
Skin prick tests detect soluble IgE and offer high negative predictive value for future
exposure to antibiotics.
E. He can be discharged without an adrenaline auto-injector.
QUESTION 18.
38 year old female presents with productive cough, dsypnoea and radiological evidence of unilobar
pneumonia. She has a 5 year pack-history of smoking. She had also been hospitalised for pneumonia 6
months ago. Over the intervening months, she has noticed increasing weight loss, frequent loose stools
with abdominal bloating and hand arthralgia. The full blood count and differential is normal. CRP 50. IgG
<0.5, IgA < 0.1 and IgM < 0.5. Urinalysis shows no protein. Stool microscopy is positive for giardia. The
most relevant investigation to assess her immunological status include:
A.
B.
C.
D.
E.
CD4+ T-cells.
Serum C3 and C4 .
CT chest.
Immunoglobulins subclasses.
ANA.
QUESTION 19.
Which of the following autoantibodies is best associated with scleroderma renal crisis?
A.
B.
C.
D.
E.
Th/To.
Centromere.
Pm-Scl.
RNP.
RNA Polymerase 3.
QUESTION 20.
The combination of dual positivity for cANCA and PR3 is best associated with:
A.
B.
C.
D.
E.
Inflammatory bowel disease
Rheumatoid vasculitis
Microscopic polyangiitis
Polyarteritis nodosa
Churg Strauss Syndrome
QUESTION 21.
Which of the statements about glomerulonephritis (GN) is most correct?
A.
B.
C.
D.
The peak incidence of Ig A nephropathy is in middle age males.
The commonest form of lupus nephritis is membranous nephropathy.
Prognosis is better for anti-GBM alone than anti-GBM plus ANCA.
Membranous GN associated with solid tumors is 20 times more common in patients
above 60 years of age compared to under 60 years.
E. The glomerular involvement pattern in scleroderma renal crisis has pathognomic
features.
QUESTION 22.
Which is the most effective measure of reducing cardiovascular outcome in patients with chronic kidney
disease.
A. initiation of statin in dialysis patients even without cardiovascular disease due to its
pleotrophic effects
B. correcting anaemia in end stage kidney disease to keep haemoglobin above 130 g/L
C. aggressive control of BP to <130/70
D. low salt diet
E. low protein diet to reduce proteinuria
QUESTION 23.
In patients with end stage renal disease, which of the following is FALSE?
A.
B.
C.
D.
E.
Choice of PD vs HD depends on patient decision.
PD depends on residual renal function.
Both PD inflow and outflow obstruction is usually due to fibrin clot.
PD membrane quality decline with time on dialysis.
There is more technical failure with HD than with PD.
QUESTION 24.
Regarding Metabolic bone disease in chronic kidney disease, which of the following is most correct?
A.
B.
C.
D.
E.
One of the action of bone derived FGF 23 is phosphoturic
Bisphosphonate is given routinely in CKD patients with osteoporosis.
It is a localized disease affecting the skeleton ranging high turnover to low turnover
disease.
In late stage of CKD, phosphate retention is due to impaired tubular function.
BMD is gold standard to diagnose bone disease in CKD.
QUESTION 25.
Which of the following statements about 1, 25-(OH)-Vitamin D is most correct?
A.
B.
C.
D.
E.
It increases calcium and reduces phosphate absorption from the gut.
It increases osteoblast activity in bone.
It reduces phosphate reabsorption from the kidney.
It has no effect on parathyroid hormone.
Production is reduced by inhibition of the 1 alpha hydroxylase enzyme.
QUESTION 26.
Which of the following statements is TRUE?
A.
B.
C.
D.
E.
In primary aldosteronism, there is hypokalemic metabolic alkalosis with increased
aldosterone and renin.
In severe vomiting, there is hypokalemic metabolic alkalosis and urinary chloride is usually
less than 20 mmol/L.
Bartter’s syndrome typically present in adulthood
The primary defect in type 2 Renal Tubular Acidosis is impaired distal acidification and
inability to excrete the daily acid load.
Type 1 RTA is usually associated with hypophosphatemia, hypouricemia, aminoaciduria
and renal glucosuria.
QUESTION 27.
Regarding maintenance immunosuppression in renal transplant recipients, which statement is FALSE?
A.
B.
C.
D.
E.
Tacrolimus is more diabetogenic than cyclosporine; however less association with
hypertension, hyperlipidemia, hyperuricemia.
A common side effect of mycophenolate is gastrointestinal intolerance.
Rapamycin (Sirolimus) is as nephrotoxic as cyclosporin or tacrolimus.
Tacrolimus is contraindicated in pregnancy.
OK T3 (Anti Tcell antibody) is associated with post transplant lymphoproliferative disorder
QUESTION 28.
Concerning patients with renal transplants, which statement is false?
A.
B.
C.
D.
E.
Survival of patients receiving an allograft from a living donor is superior to those who
receive a kidney from a deceased donor
Cardiovascular disease is the leading cause of death for adult renal allograft recipients
There is more disease recurrence rate with ANCA positive cresentric GN compared to Ig
A nephropathy.
Graft loss after 10 years is usually due to chronic allograft nephropathy.
Secondary hyperparathyroidism often persist after renal transplant and it is usually due to
nodular hyperplasia
QUESTION 29.
The JAK2 V617F mutation is most commonly found in:
A.
B.
C.
D.
E.
Chronic myelomonocytic leukaemia.
Primary myelofibrosis
Systemic mastocytosis
Polycythemia vera
Essential thrombocythemia
QUESTION 30.
In chronic lymphocytic leukaemia, which of the following is the strongest predictor of poor survival?
A.
B.
C.
D.
E.
Age > 65
del (13q14)
del (17p13)
lymphocyte count > 100
mutated IgVH (immunoglobulin heavy chain) status
QUESTION 31.
A 66 year old lady with rheumatoid arthritis is treated with etanercept for severe active disease. Which of
the following is the least common adverse effect of this treatment?
A Exacerbation of congestive heart failure
B. Disseminated tuberculosis
C. Demyelinating disorders
D. Lymphoma
E. Pulmonary fibrosis
QUESTION 32.
A 45 year old man from Samoa is evaluated because during the past 48 hours he has developed an
acute painful and swollen right first metatarsophalangeal joint. He has had attacks likes these every
month during the past year. On physical examination, his temperature is 38.8 deg Celsius with a blood
pressure of 150/95 mmHg and a BMI of 33. He is in distress because of a warm, red, exquisitely tender
toe.
Laboratory results show a serum uric acid level of 0.41 mmol/L, creatinine 180 mmol/L, CRP 67 mg/L.
Which of the following is the best therapy for this patient at this time?
A.
B.
C.
D.
E.
Allopurinol.
Colchicine every 6 hourly.
Prednisone.
Indomethacin.
A combination of allopurinol and colchicine.
QUESTION 33.
A 40 year old woman with a 2 year history of rheumatoid arthritis presents with dyspnoea of new onset
when she climbs the stairs at home. She also reports a dry cough over the last fortnight. She has an
active lifestyle and also cares for her 3 children. She has been taking methotrexate 20mg weekly with
folic acid supplements and states that her arthritis have never been better controlled.
Examination revealed a temperature of 37.8 deg Celsius with fine inspiratory crackles at both lung bases.
There is some tenderness on wrist flexion but otherwise no evidence of active synovitis.
Full blood counts and biochemistry are normal but the ALT and AST leves are 78 and 98 respectively.
Her chest X-ray is normal.
Which of the following is the next best step in this patient's management?
A.
B.
C.
D.
E.
Initiate prednisone therapy.
Order Xrays of her wrists.
Request for an ultrasound of the liver.
Stop the methotrexate.
Order HRCT chest scan.
QUESTION 34.
A 64 y.o male presented to the Outpatient clinic with worsening dyspnoea for investigation. No other
symptoms noted. He was saturating at 96% RA. Below are his pulmonary function test results.
The most likely cause of the ventilatory defect is:
A.
B.
C.
D.
E.
asthma
pulmonary fibrosis
kyphoscoliosis
obstructive sleep apnoea
bronchiectasis
QUESTION 35.
A 38 y.o man is admitted to hospital with right lower lobe pneumonia and is treated with appropriate
antibiotcs. After 6 days a progress CXR demonstrates a right pleural effusion. Which of the following
pleural fluid results is the best predictor of the need for pleural catheter insertion for drainage?
A.
B.
C.
D.
E.
Pleural/serum protien ratio <0.5
pH <7.3
Differential cell count demonstrating >90% neutrophils
Pleural/serum LDH ratio >0.6
Microscopy showing a positive gram stain
QUESTION 36.
A 60 year old sandblaster with a 60 pack-year history of cigarette smoking presents to the emergency
department with a one week history of increasing shortness of breath and productive cough.
His arterial blood gas on room air showed pH 7.41 (7.35-7.45) pO2 53 mmHg (72-100) pCO2 50mmHg
(35-45) BC 31mM (22-26) BE 5 (-3-3) O2 sat 91% Hb 15.7 g/dL
Which of the following describes best the above result:
The basis of his hypoxaemia appears to be:
A. acute alveolar hypoventilation and increased ventilation perfusion (VQ) mismatch
B. chronic alveolar hypoventilation and increased VQ mismatch
C. acute alveolar hypoventilation rather than increased VQ mismatch
D. chronic alveolar hypoventilation rather than increased VQ mismatch
E. normal alveolar ventilation and increased VQ mismatch
QUESTION 37.
Regarding the complications of OSA which of the following statements is true (one only):
A. All untreated OSA patients should not drive
B. CPAP has been shown to reduce BP in hypertensive OSA patients
C. There is good evidence that CPAP will significantly reduce oral hypoglycaemic and insulin use in
OSA NIDDM patients
D. There is no association with strokes and OSA
E. CPAP has been shown to reduce the LVEF in OSA CHF patients
QUESTION 38.
A 33 y. man has been commenced on quadruple anti-TB medications for pulmonary TB. During a routine
blood test at the Chest Clinic, thrombocytopenia is found. Which of the following medications is most
likely to be associated with this blood result:
A.
B.
C.
D.
E.
Isoniazid
Rifampicin
Ethambutol
Pyrazinamide
Pyroxidine
QUESTION 39.
In the last decade, the role of the inflammasomes has become central to our understanding of
inflammatory pathways. Which of the following statements best describes the inflammasomes?
A. A group of proteins that form a proteolytic cascade, which produce a membrane attack complex,
resulting in cell lysis
B. A group of transcription factors that translocate to the nucleus to stimulate gene expression upon
activation
C. A group of intracellular molecular platforms, activated upon cellular infection or stress, that trigger
the maturation of pro-inflammatory cytokines like IL-1β
D. A group of cell surface receptors that recognise pathogen-associated molecular patterns
(PAMPs) on the surface of bacteria
E. A group of cytokines that induce naïve T cells to differentiate into pro-inflammatory Th17 cells
QUESTION 40.
Apart from transferring an antibody into an animal model and observing uniform disease induction, which
of the following provides the most direct evidence that an antibody is directly pathogenic, as opposed to
epiphenomenal, in the pathogenesis of a disease?
A.
B.
C.
D.
E.
High sensitivity of the antibody for the disease
High specificity of the antibody for the disease
Response of the antibody-associated disease to plasma exchange
Response of the antibody-associated disease to anti-CD20 monoclonal therapy (rituximab)
High rates of neonatal disease in newborn infants from antibody-positive mothers
QUESTION 41.
B cells have a wide array of functions within the immune response to antigenic challenge, making them a
target of interest for many inflammatory and autoimmune diseases. Which of the following is not a key
function of B cells?
A.
B.
C.
D.
E.
Direct cellular killing
Antigen presentation
Production of pro-inflammatory cytokines
Differentiate into antibody-forming plasma cells
Activation of T cells
QUESTION 42.
Regulatory T cells (Tregs) are a subset of T cells controlled by the master transcription factor forkhead
box P3 (FOXP3). Which of the following best describes their general role in human immunity?
A.
B.
C.
D.
E.
Maintenance of self-tolerance to autoantigens centrally in the thymus
Maintenance of self-tolerance to autoantigens in the periphery
Regulation of IgE synthesis and parasitic immunity
Control of intracellular pathogens including mycobacteria
Production of IL-17 and control of extracellular pathogens
QUESTION 43.
Geoff is a healthy 23 year old non-smoker, referred to you for investigation of an intermittent dry nocturnal
cough, which has been present for 12 months. His past history is unremarkable aside from a childhood
eczema. There is a family history of atopy. The physical examination is unremarkable. His GP has
performed a chest X-ray which is normal. Which test is the next most appropriate?
A.
B.
C.
D.
E.
Spirometry & hypertonic saline broncho-provocation test
Sinus and chest computed tomography scan
Spirometry & methacholine broncho-provocation test
Spirometry alone
Spirometry & mannitol broncho-provocation test
QUESTION 44.
The flow-volume loop shown below is most consistent with which diagnosis?
A.
B.
C.
D.
E.
Unilateral vocal cord paralysis
Moderate chronic obstructive pulmonary disease
Tracheomalacia
Post-tracheostomy subglottic stenosis
Retrosternal goitre
QUESTION 45.
The following pulmonary function test most likely reflects which diagnosis?
A.
B.
C.
D.
E.
Severe chronic obstructive pulmonary disease
Bronchiectasis
Idiopathic pulmonary fibrosis
Kyphoscoliosis
Systemic sclerosis associated pulmonary fibrosis
QUESTION 46.
A 73 year old man with long-standing COPD is admitted to Westmead Emergency Department with
increased dyspnoea, after a lengthy ambulance ride. The patient is alert. The initial ABG demonstrates
the following:
ABG (8L/min O2 Hudson mask): pH 7.29; pCO2 65mmHg, pO2 105mmHg; HCO3 32; BE 3; SaO2 99%
The next most appropriate management step would be the institution of:
A.
B.
C.
D.
E.
Intubation and mechanical ventilation
Supplemental oxygen via Venturi mask
Non-invasive ventilation
Supplemental oxygen via nasal prongs
Continuous positive airway pressure
QUESTION 47.
A 67 year old Ukrainian man has recently retired after a long occupational history of quartzite mining and
sandstone masonry work for approximately 20 years, after which he worked in sales for a brief period. He
has travelled extensively within Eastern Europe recently. He presents with a history of chronic dyspnoea,
but subs cutely worsening over the past month. He reports a 11kg weight loss over this period, and has
had one episode of haemoptysis. His pulmonary function tests demonstrate a severe restrictive ventilator
defect, with a moderately decreased gas transfer capacity.
An HRCT chest demonstrates a left pneumothorax, with pleuro parenchymal bands, bilateral interlobular
septal thickening, calcified centrilobular nodules, and right sided mass like calcified consolidation with a
thick walled left upper lobe cavitating lesion.
The most likely diagnosis accounting for his acute symptoms is:
A.
B.
C.
D.
E.
Progressive massive silico-fibrosis
Small cell lung carcinoma
Active tuberculosis
Non-specific interstitial pneumonia
Emphysema
QUESTION 48.
What feature would be INCONSISTENT with “Farmer’s lung”?
A.
B.
C.
D.
E.
Hypersensitivity to Actinomycetes spp. in mouldy hay
Predominantrly airway, rather than alveolar, histologic changes
Restrictive ventilatory defect late in the disease
A variable degree of airway obstruction following antigen exposure
The acute form may present with a military nodular infiltrate
QUESTION 49.
A 66 year old female with a 30 pack-year history of smoking presents to Westmead Emergency with
dyspnoea. A chest X-ray shows hyperinflated lung fields, with a small 1cm right apical pneumothorax.
The next most appropriate management step is:
A.
B.
C.
D.
E.
Discharge with follow-up chest X-ray in 2 days
Admit for observation, with chest X-ray in 24 hours
Pleural aspiration in the 2nd intercostal space anteriorly along the mid-clavicular line
Insertion of a 10Fr intercostal catheter via Seldinger technique
Insertion of a 24Fr intercostal catheter via blunt dissection
QUESTION 50.
A 28 year old Indian man on a student visa presents to the Parramatta Chest Clinic for tuberculosis
screening as part of his onshore (TBU) application for permanent residency. His Mantoux test is positive
at 18mm, and a chest X-ray demonstrates minor left apical pleural thickening and a calcified nodule
adjacent to the left heart border. He is otherwise well.
At this point you would advise:
A.
B.
C.
D.
E.
6 months of isoniazid monotherapy
No specific measures
Single IM injection of streptomycin
9 months of isoniazid, rifampicin, pyrazinamide, ethambutol
Serial chest X-ray monitoring only
QUESTION 51.
Which one of the following physiological changes is least likely to be a cause of increased perioperative
mortality in elderly patients?
A.
B.
C.
D.
E.
Decreased compliance in left ventricular muscle.
Reduction in lung tidal volume
Reduced renal perfusion
Increased diastolic blood pressure
Autonomic dysregulation
QUESTION 52.
Which of the following statements is true about drug metabolism in the elderly?
A.
B.
C.
D.
E.
Hepatic blood flow is reduced leading to reduced drug metabolism.
There is increased biological activity of codeine.
Stomach acidity increases leading to impaired drug absorption.
The volume of distribution of fat soluble drugs decreases.
There is increased sensitivity to beta blockers.
QUESTION 53.
An 86 year old previously well male is discharged home after being admitted for a lacunar stroke. His stay
in hospital was complicated by episodes of delirium. One year ago, he slipped on a puddle outside his
home leading to a fractured neck of femur. For which of the following medications is there the strongest
evidence of benefit in those over the age of 80 ?
A.
B.
C.
D.
E.
Indapamide
Clopidogrel
Risperidone
Calcium
Atorvastatin
QUESTION 54.
What is the commonest cause of true syncope in elderly?
A.
B.
C.
D.
E.
Neurally mediated
Orthostatic hypotension
Cardiac arrhythmias
Structural cardio-pulmonary disease
Seizure
QUESTION 55.
Which of the following is least specific for the diagnosis of dementia?
A.
B.
C.
D.
E.
Memory impairment
Impairment of social or occupational functioning
Disturbance in executive functioning
Agnosia
Auditory hallucination
QUESTION 56.
In regards to malnutrition in older people, what is not part of the current definition?
A.
B.
C.
D.
E.
Body mass index (BMI)<18kg/m2
Unintentional weight loss>10% of body weight in previous 3-6 months
BMI <20kg/m2 and unintentional weight loss >5% in previous 3-6 months
BMI <25kg/m2 and unintentional weight loss of >5% in previous 3-6 months
BMI < 25 kg/m2 and any weight loss at all.
QUESTION 57.
Regarding Parkinsons disease, what nonmotor manifestation is likely to be responsive to dopaminergic
treatment?
A.
B.
C.
D.
E.
hallucinations
cognitive changes
mood disturbances
orthostatic hypotension
olfactory disturbance
QUESTION 58.
What intervention has been shown to reduce falls in older people?
A.
B.
C.
D.
E.
home hazard modification for older people without a history of falls
withdrawal of psychotropic medication
individual lower limb strength training
correction of visual impairment
nutritional supplements
QUESTION 59.
A 60 year old male presents with rash, dyspnoea, orthopnoea and peripheral oedema. Blood count
reveals leucocytosis predominantly comprised of mature eosinophils numbering 8x10^9/L, normochromic
anaemia, and normal platelet count.
No new medications are implicated. Extensive testing finds no parasitic infection, lymphadenopathy,
pulmonary infiltrate or connective tissue disease. Biopsy of the rash reveals non-specific dermatitis
change with marked eosinophilic infiltrate.
Bone marrow biopsy is hypercellular with increased eosinophils, no increase in blasts, no dysplasia, no
mast cells. Cytogenetic analysis was normal.
The most appropriate next step in management is:
A.
B.
C.
D.
E.
High dose corticosteroid with imatinib mesylate.
PCR for FIP1L1-PDGFRα fusion transcript
Initiation of mepolizumab
Commence enoxaparin 1mg/kg BD
FISH (fluorescence in situ hibridization) for t(9;22) on marrow
QUESTION 60.
An 84 year old woman presents to ED with pneumonia. She has been on prednisone and weekly MTX for
many years for rheumatoid arthritis. She is started on antibiotics and TED stockings. On the ward round
she is noted to be bleeding from venepuncture sites, and have widespread fresh eccymoses.
FBC: Hb 98 g/L, MCV 88fL, WBC 6.8 x10^9/L, Diff normal, Plt 430 x 10^9/L
PT 16s (NR 11-18), APTT 88s (NR 25-36), Fibrinogen 6 g/L (NR 1.8-4.4)
The next appropriate course of action would be:
A:
B:
C:
D:
E:
Transfuse 1 platelet pool.
High dose folinic acid.
Bethesda assay for FVIII inhibitor.
Check D Dimer level.
Perform mixing studies.
QUESTION 61.
Mutation in which gene has NOT been associated with Parkinson's disease? (familial or idiopathic form)
A. Alpha-synuclein
B. LRRK2
C. PPAR
D. PINK1
E. Glucocerebrosidase
QUESTION 62.
What is the biggest risk factor for formation of Barrett's oesophagus?
A: Alcohol
B: Smoking
C: Chronic reflux (for > 5yrs)
D: Higher socioecomonic status
E: Obesity
QUESTION 63.
A 34 yr old man presents with symptoms of dysphagia, food impaction and heartburn. His only past
medical history is that of asthma. He undergoes endoscopy which reveals the following appearance:
What is the best management?
A: Field ablation
B: Local resection
C: High dose PPI
D: Alcohol free diet
E: Ingested fluticasone propionate
QUESTION 64.
A 23yr old man of Irish decent presents with a 12 month history of weight loss and abdominal bloating.
Blood tests reveal a microcytic anaemia and you suspect coeliac disease. Examination reveals the
following rash.
The this rash is likely to be:
A: Erythema ab Igne.
B: Livido reticularis.
C: Porphyrea.
D: Dermatitis herpetiformis.
E: Acanthosis nigricans
QUESTION 65.
The young man in the above question goes on to have the following blood tests:
Tissue transglutamase Ab +
Anti gliadin IgA Ab: 0
Total IgA < 0
The next best management is:
A: Reassurance.
B: Commence gluten free diet and no further management
C: Psychiatry review
D: Commence gluten free diet and biopsy in four weeks
E: No dietary restrictions and biopsy.
QUESTION 66.
A 21 year old man presents with a 4 month history of complex partial seizures and decline in short term
memory. The seizures have been refractory to adequate doses of valproate, carbamezapine, and
phenytoin each tried separately as monotherpay. Below is a representative image from his brain MRI:
The next most appropriate management step is:
A.
B.
C.
D.
E.
Urgent lumbar puncture and commencement of IV acyclovir
Magnetic resonance venogram (MRV) and commencement of parenteral anticoagulation
Trial the above anticonvulsants as combination therapy
Trial another newer generation anticonvulsant
Arrange for anti-K channel antibody testing and start immunotherapy
QUESTION 67.
A 79 year old man presents with a 2 year history of gait difficulty causing falls, cognitive impairment
particularly affecting memory and visuospatial domains, and urinary incontinence. A representative
picture of his head CT is shown below:
The next most appropriate management step is:
A.
B.
C.
D.
A trial of donepezil
A trial of acetazolamide
CSF biochemical analysis, microscopy, and cytology
Supportive and multidisciplinary management including physiotherapy and lower limb muscle
strengthening
E. None of the above
QUESTION 68.
Whick of the following typically causes normal anion gap metabolic acidosis?
A.
B.
C.
D.
E.
Lactic acidosis.
Carbonic anhydrase inhibitors.
Ketoacidosis.
Methanol ingestions.
Ethylene glycol ingestion.
QUESTION 69.
Which of the following descriptions best fits the syndrome of thrombotic thrombocytopenic purpurahaemolytic uraemic syndrome (TTP-HUS):
A. Microangiopathic haemolytic anaemia with abnormal coagulation parameters.
B. Microangiopathic haemolytic anaemia with thrombocytopenia and glomerulonephritis.
C. Microangiopathic haemolytic anaemia with fluctuating neurologic abnormalities,
thrombocytopenia and fevers.
D. Anaemia with rapidly progressive glomerulonephritis and haemoptysis.
E. Anaemia with glomerulonephritis and purpuric rash, typically over the legs.
QUESTION 70.
A female patient presents with arthralgias, fevers, proteinuria, oral ulcers and a pericardial effusion. A
positive anti-nuclear antibody, at a titre of >2560, with a homogenous pattern is reported. Which of the
following tests is most likely to help you confirm the diagnosis:
A. Erythrocyte sedimentation rate (ESR)
B. Anti-neutrophil cytoplasmic antibodies
C. Anti-PR3 antibodies
D. ds-DNA antibodies
E. Interferon-gamma release assay
QUESTION 71.
In which of the following conditions is serum tryptase most like to be elevated:
A. Systemic mastocytosis
B. Polyarteritis nodosa
C. Systemic lupus erythematosus
D. Systemic sclerosis
E. Hypereosinophilic syndrome
QUESTION 72.
Common variable immunodeficiency (CVID) is one of the most common primary immune deficiencies,
patients present with recurrent sino-pulmonary infections. In the majority of cases no underlying cause is
identified. However, in recent years several defects have been reported.
Which of the following is one of the reported causes of CVID:
A. RAG-1 deficiency
B. CD19 deficiency
C. FOXP3
D. Deletions in chromosome 22q11.2.
E. Philadelphia translocation
QUESTION 73.
Gestational hypertension is best described as:
A. Hypertension with proteinuria in the latter part of pregnancy which should resolve by 12 weeks
postpartum.
B. Hypertension without proteinuria in the latter part of pregnancy which should resolve by 12 weeks
postpartum.
C. Hypertension without proteinuria in the latter part of pregnancy which lasts > 12 weeks
postpartum.
D. Hypertension with proteinuria at any stage of pregnancy.
E. New onset proteinuria after 20 weeks of gestation in a woman with preexisting hypertension.
QUESTION 74.
Type 4 Renal tubular acidosis is characterized by the presence of hyperkalaemia and metabolic acidosis.
Please, choose the correct statement:
A. Heparin and low molecular weight heparin have a direct toxic effect on the adrenal zona
glomerulosa cells causing primary aldosterone deficiency.
B. Administration of Trimethoprim causes hyporeninemic hypoaldosteronism, resulting in
hyperkalaemia.
C. The disorder is typically associated with a mild metabolic acidosis which may be due to
increased ammonium excretion by hyperkalemia.
D. The most common form of aldosterone resistance in adults is hyporeninemic
hypoaldosteronism, frequently observed among patients with mild to moderate renal
insufficiency, especially if due to diabetic nephropathy.
E. Patients with RTA type 4 typically have an inappropriately alkaline urine pH (pH ~7) and
low plasma bicarbonate concentration.
QUESTION 75.
A 26 year old South African female with TB-HIV co-infection is in her 1st trimester of pregnancy. Her CD4
count is 436, HIV viral load 51,000. She has smear-negative pulmonary tuberculosis confirmed on
sputum culture. An efavirenz-containing antiretroviral regimen is contraindicated because:
A. The risk of immune restoration inflammatory syndrome is unacceptably high.
B. The increased risk of hepatitis in her instance contraindicates non-nucleoside reverse
transcriptase inhibitor (NNRTI) use.
C. The risk of teratogenicity is too high.
D. Drug interactions between rifampicin and NNRTIs contraindicate this combination.
E. All of the above.
QUESTION 76.
A 55 year old man with splenectomy after a motor vehicle accident 12 years ago presents with fever,
headache and confusion. CSF examination reveals gram positive diplococci. Which of the following is
true regarding management?
A. Dexamethasone is contraindicated
B. 23-valent polysaccharide pneumococcal vaccine would not have decreased the likelihood of this
presentation due to widespread serotype replacement with subtype 19A
C. The mechanism if action of dexamethasone in this context is to improve CSF antibiotic
penetration
D. The addition of adjunctive dexamethasone may reduce the likelihood of unfavourable outcome or
death
E. Adjunctive dexamethasone should only be administered after antibiotics have been commenced
QUESTION 77.
A 32 year old male presents with fever and right upper quadrant pain. A CT scan is performed:
He is otherwise healthy with no significant co-morbidities. He has never engaged in male-to-male sexual
intercourse. He never consumes alcohol. He is of Australian ethnicity and has never travelled overseas
nor lived in rural areas.
His CT scan is shown below.
What is the most likely pathogen responsible for his illness?
A. Echinococcus granulosus
B. Escherichia coli
C. Entamoeba histolytica
D. Klebsiella pneumoniae
E. Staphylococcus aureus
QUESTION 78.
A 38 year old Sudanese female is referred by her LMO with chronic hepatitis B infection.
In determining the need for antiviral treatment, what is the most appropriate investigation?
A.
B.
C.
D.
E.
Abdominal ultrasound
Alpha foetoprotein
ALT and AST
Fibroscan
Liver biopsy
QUESTION 79.
The leading cause of mortality associated with fatty liver disease is:
A.
B.
C.
D.
E.
Diabetic nephropathy
Hepatocellular carcinoma
Myocardial infarction
Respiratory failure
Variceal bleeding
QUESTION 80.
What is the leading cause of hepatocellular carcinoma globally and in Australia?
A.
B.
C.
D.
E.
Chronic hepatitis C infection
Chronic hepatitis B infection
Alcohol
NASH
Smoking
QUESTION 81.
A 55-year-old man diabetic man requires antiretroviral therapy for recently diagnosed HIV complicated by
immunodeficiency.
Commencing which of the following agents is most strongly associated with increased cardiovascular
morbidity?
A.
B.
C.
D.
E.
Abacavir.
Efavirenz
Ritonavir
Tenofovir
Lopinavir
QUESTION 82.
Which of the following drugs is most associated with bone loss in patients with HIV commencing
antiretroviral therapy.
A.
B.
C.
D.
E.
Abacavir.
Efavirenz
Ritonavir
Tenofovir
Lopinavir
QUESTION 83.
A 55 year old man presents to hospital with pyelonephritis complicated by septic shock. He has recently
returned from a visit to relatives in India. Urine gram stain shows gram negative bacilli.
The most appropriate initial antibiotic therapy would be:
A.
B.
C.
D.
E.
Ampicillin and gentamicin
Ceftriaxone
Ceftriaxone and gentamicin
Meropenem
Ciprofloxacin
QUESTION 84.
A woman has endocarditis caused by Streptococcus Bovis.
Which of the following conditions is associated with this diagnosis:
A.
B.
C.
D.
E.
Periodontal disease
Urinary tract obstruction
Biliary tract obstruction
Colon cancer
Hepatoma
QUESTION 85.
A 45 old man presents three weeks after returning from a holiday in Thailand with a four day history of
headache, fever, generalised aches and pains and gastrointestinal upset with vomiting.
On examination he is unwell with temperature 39°C, pulse rate 99/min, BP 112/72 and respiration
21/minute. The physical exam was otherwise unhelpful with no rash, nuchal rigidity, pharyngitis, mouth
ulcers, lymphadenopathy, enlargement of the liver or spleen or abdominal tenderness.
He gives no history of animal contact, or intravenous drug use. He is heterosexual, without a regular
partner, reporting last sexual contact 2 months ago. There is no significant past medical history.
Full blood count revealed haemoglobin 158 g/litre, white cell count 2.4 x 109/l, neutrophils 1.2 x 109/l,
lymphocytes 1.0 x 109/l, with reactive lymphocytes present and platelets 78 x 109/l. Liver function tests
revealed bilirubin 11 umol/l, albumin 42 g/litre, AST 101 unit/litre, alkaline phosphatase 122 unit/litre, and
gamma GT 174 unit/litre. Chest x-ray and urinalysis were normal. HIV antibody, cytomegalovirus IgM, and
EBV IgM are negative, as are two malaria films, and blood culture at 48 hours.
Which would be the most important next investigation.
A.
B.
C.
D.
E.
HIV viral load.
Dengue serology
Stool culture for Salmonella
Malaria serology
Syphilis serology
QUESTION 86.
A 45 year old man has human immunodeficiency virus (HIV)/hepatitis B (HBV) co-infection. Liver biopsy
confirms active hepatitis with early fibrosis. Hepatitis B e antigen is negative and hepatitis B DNA is 2.4 x
104. The CD4 count is 630/microlitre (36%) and HIV viral load 2100 HIV RNA copies/ml. The HIV
genotype suggests a fully sensitive virus.
Which of the following statements is most correct?
A. He should be treated for his HBV infection; his HIV infection does not need treatment at this
stage.
B. He should be treated for his HIV infection; his HBV infection does not require treatment at this
stage.
C. He does not require treatment for either infection.
D. He should be treated for both infections.
E. Any treatment of his HBV is likely to be ineffective as he already has hepatic fibrosis.
QUESTION 87.
A 54 year old male presents complaining of periodic tight burning substernal chest pain. A stress
sestamibi shows hypoperfusion of cardiac muscle forming the diaghphramatic surface of the heart.
Which of the following coronary arteries is most likely occluded in this patient?
A.
B.
C.
D.
E.
Left main.
Acute marginal branches.
Left anterior descending.
Right coronary artery.
Left circumflex.
QUESTION 88.
A 53 year old diabetic female presents with ongoing chest pains and a concurrent troponin rise and is
diagnosed with a NSTEMI. An angiogram reveals an 70% lesion in the left main and 90% lesion in the
LAD. Which of the following treatment options would result in the least major adverse cardiovascular or
cerebrovascular events at 1 year?
A. Stenting of the left main lesion only.
B. Stenting of the both the lesions in the left main and in the LAD.
C. Coronary artery bypass grafting.
D. Stenting of the LAD and subsequent referral for surgery for the left main lesion.
E. Medical therapy.
QUESTION 89.
A 72 year old male is hospitalised after complaining of chronic fatigue and exertional dyspnoea. His left
ventricular pressure-volume curve is pictured below.
Normal
LV
Volume
Patient
Intraventricular
Pressure
Assuming that heart failure is responsible for this patient’s symptoms, which of the following is the most
likely cause of the patient’s condition?
A.
B.
C.
D.
E.
Viral myocarditis.
Previous high dose doxorubicin treatment .
Amyloidosis.
Alcoholic Cardiomyopathy.
Diphtheric myocarditis.
QUESTION 90.
In patients with Tetralogy of Fallot, some have relatively mild symptoms and experience only episodic
cyanosis and dyspnoea while some are cyanotic. The severity of symptoms in patients with this disorder
largely depends on the severity of:
A.
B.
C.
D.
E.
Aortic insufficiency.
Right ventricular hypertrophy.
Pulmonic stenosis.
Atrial septal defect.
Ventricular septal defect.
QUESTION 91.
A 48 year old woman presents to the emergency department with a 6 month history of fatigue and feeling
generally unwell. Three days ago, she developed a flu-like illness, and the last 24 hours has been
essentially bed bound at home, complaining of abdominal pain. Her concerned husband then called an
ambulance.
On assessment in the department, she was a thin woman with tanned skin, pale conjunctivae and
confused mentation. She was tachycardic with a pulse rate of 120 beats/minute, blood pressure was
80/45 mmHg, temperature 38.50C, and pulse oximetry 94% whilst breathing room air. Heart sounds were
dual with no murmurs, chest was clear to auscultation, and abdominal exam revealed generalised
tenderness without signs of peritonism and without organomegaly.
Urinalysis was essentially normal, except for a raised specific gravity. Fingerprick glucose was 4.8
mmol/L.
Apart from aggressive fluid resuscitation and the institution of antibiotics, the most appropriate
management in the acute setting whilst waiting for the results of blood tests is:
A.
B.
C.
D.
E.
Lumbar puncture with Gram stain and PCR for Neisseria meningitidis.
Intravenous hydrocortisone 200mg.
Urgent abdominal CT scan.
Urgent laparotomy.
Intravenous glucagon and dextrose.
QUESTION 92.
A 56 year old man is diagnosed with type 2 diabetes mellitus based on the results of two separate fasting
blood sugar levels. His body mass index is 32, and his blood pressure is 150/85 mmHg. Results of full
blood count, serum biochemistry and liver function tests are normal.
A recent random blood sugar level is 17.2 mmol/L, and HbA1c is 9.8.
The most correct statement is:
A. Caloric restriction and exercise should be the initial therapy, and are likely to result in
satisfactory glycaemic control.
B. Sulfonylureas are contraindicated given his obesity.
C. Metformin would be a good first line agent, but is unlikely to achieve acceptable
glycaemic control as a single agent.
D. He should be started on insulin alone as a first line agent.
E. He should be commenced on both insulin and an oral hypoglycaemic agent.
QUESTION 93.
A 56 year old man is admitted to hospital with right arm weakness. A CT brain reveals a small
haemorrhage in the left lentiform nucleus. His wife reports that his blood pressure control recently has
been poor.
He also has a history of chronic myeloid leukaemia, treated with imatinib (a tyrosine kinase inhibitor).
His only other medication is enalapril for hypertension.
Blood tests performed in hospital are shown below.
Current Admission.
Haemoglobin (g/L)
Three Months Ago.
126
138
23.4
8.3
18.0
5.1
0.3
0
721
345
3.5%
0.5%
[130 – 165]
White cell count (x 10^9/L)
[8 – 11.0]
Neutrophils (x 10^9/L)
[2 – 8.0]
Basophils (x 10^9/L)
[0 – 0.1]
Platelets (x 10^9/L)
[150 – 400]
Quantitative PCR for BCR-ABL
transcript [< 0.001%]
The most likely reason for his worsening full blood count parameters and rising BCR-ABL transcript is:
A.
B.
C.
D.
E.
Non-compliance with imatinib.
Emergence of resistance to imatinib.
A reactive phenomenon in the context of acute stroke.
Interaction between imatinib and enalapril.
Development of acute leukaemia.
QUESTION 94.
An 18 year old woman with menorrhagia and a 4 month history of fatigue is found to have the following
blood test results:
Haemoglobin
Mean cell volume
Ferritin
52 g/L
65 fL
< 3 μg/L
[120 – 155]
[79 – 98]
[15-250]
Apart from noticeable pallor and a mild tachycardia (heart rate 90 beats/minute), physical examination
is normal.
As well as control of her menorrhagia using hormonal therapy, the most appropriate management of
this situation is:
A.
B.
C.
D.
E.
Admission to hospital for blood transfusion.
Intravenous iron.
Oral iron.
Intramuscular iron.
Dietary measures to include increased red meat.
QUESTION 95.
Which of the following is the most common cause of thrombocytopenia in patients in intensive care:
A.
B.
C.
D.
E.
Heparin induced thrombocytopenia thrombosis syndrome (HITTS).
Sepsis.
Haemodialysis.
Gp IIIa/IIb inhibitor therapy.
Hypersplenism.
QUESTION 96.
A 63 year old man with hypertension presents with the acute onset of vomiting, right sided
dysdiadochokinesis, right sided facial numbness, and left arm and leg numbness. Nystagmus is present,
but otherwise horizontal and vertigal gaze are intact.
The most likely location of his neurological lesion is:
A.
B.
C.
D.
E.
Right motor cortex.
Right sensory cortex.
Left pons.
Right lateral medulla.
Right internal capsule.
QUESTION 97.
The most common cause of hypercalcaemia is:
A.
B.
C.
D.
E.
Primary hyperparathyroidism.
Tertiary hyperparathyroidism in the context of renal failure.
Multiple myeloma.
Secretion of parathyroid hormone related peptide (PTHrP).
Drugs.
QUESTION 98.
A 69 year old man with multiple myeloma undergoes treatment with chemotherapy and an autologous
stem cell transplant. He has an inpatient hospital admission lasting 26 days for his transplant. On
discharge from hospital, it is noted that he has a right foot drop.
Physical examination reveals weakness of ankle eversion and dorsiflexion. Ankle jerk is intact. He has an
area of sensory loss on the dorsum of his foot.
The most likely cause of his footdrop is:
A.
B.
C.
D.
E.
His thalidomide medication.
Peripheral neuropathy secondary to myeloma.
Vincristine chemotherapy.
Pressure on the L5-S1 nerve roots from a plasmacytoma.
Common peroneal nerve palsy secondary to pressure on the nerve whilst lying in bed.
QUESTION 99.
A 43 year old woman undergoes knee arthroscopy. Five days post-operatively, she develops pain and
swelling of the affected leg, and Doppler ultrasound reveals an occlusive thrombus of the peroneal,
tibial and popliteal veins. Veins above the knee are patent.
She has no personal or family history of venous thromboembolism or recurrent miscarriage.
Other testing reveals her to be heterozygous for the Factor V Leiden mutation.
What is the most appropriate duration of anticoagulation therapy for this woman?
A.
B.
C.
D.
E.
Anticoagulation is not indicated as the thrombus does not extend above the knee.
3 months of warfarin and then stop.
6 months of warfarin and then stop.
12 months of warfarin and then stop.
Indefinite anticoagulation is indicated given her Factor V Leiden status.
QUESTION 100.
A young man is found collapsed on a farm, and is brought to the local hospital.
He is covered in purpure and ecchymoses.
Selected laboratory results are shown below:
APTT
PT
Fibrinogen
Platelets
63s
32s
< 0.1
56 x 10^9/L
[28 – 34]
[14-18]
[0.6 – 1.5]
[150 – 400]
You suspect envenomation. Which creature is the most likely culprit?
A.
B.
C.
D.
E.
Funnel web spider.
Red back spider.
Wolf spider.
Brown snake.
Black snake (also called “red bellied black snake”).
Westmead Trial Exam, Paper 2, December 2010, Answers.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
B
A
D
B
C
B
D
E
C
B
C
D
C
C
C
D
E
a. An elevated serum tryptase at presentation is specific for mastocytosis
Serum tryptase is mast cell specific but can be raised in anaphylaxis, chronic renal failure
impairment of excretion, myeloid leukaemia and mastocytosis.
b. First-line therapy would be nebulised adrenaline 1:1000
Nebulised adrenaline is not evidence based. The best treatment in this scenario would be
intramuscular adrenaline 0.3mg given as the 1:1000 concentration
c. He will never be able to receive the penicillin-class of antibiotics again
He should avoid penicillin antibiotics( and probably cephalosporins as well) but will likely
tolerate penicllins given via a supervised desensitisation protocol. We usually avoid this
because of the availability of different antibiotic classes.
d. Skin prick tests detect soluble IgE and offer high negative predictive value for future
exposure to antibiotics
Skin prick tests trigger the wheal and flare reaction from IgE bound to mast cells. The
negative predictive value (remember it is population-sample dependent) is in the order
of 95-97%.
e. He can be discharged without an adrenaline auto-injector.
There is no role for auto-injectors when we have a clear drug trigger that is easily
avoided. Food triggers are difficult to avoid so generally patients with anaphylaxis are
issued with auto-injectors.
18 C
The clinical scenario is of antibody deficiency presenting with recurrent sino-pulmonary
infections. The most likely diagnosis is CVID.
a. CD4+ T-cells
CD4+ T-cell deficiency would be relevant considerations in fungal, pneumocystis
infections such as in HIV/AIDS.
b. Serum C3 and C4
This would be useful for screening an immune-complex disease such as SLE. This is not
the case in this scenario. Screening for complement deficiency would be better achieved
with CH50 or CH100.
c. CT chest
To exclude a thymoma as a cause of acquired immunodeficiency and
hypogammaglobulinemia (Good’s syndrome)
d. Immunoglobulins subclasses
Absent total IgG will make any measurement of subclasses useless
e. ANA
Arthralgias are frequent in CVID
19
E
Certain autoantibodies in scleroderma have correlation with clinical manifestations. 6
autoantibodies have been followed particularly well –
Scl-70/ Topoisomerase – associated with diffuse scleroderma, pulmonary fibrosis, cardiac
disease, renal crisis
RNA polymerase 3 – diffuse scleroderma, 25% of patients have renal crisis
Th/To – associated with limited systemic scleroderma and pulmonary hypertension
Pm-SCL – associated with scleroderma and myositis overlap
Centromere – associated with limited systemic scleroderma (classical CREST syndrome)
20
C
a. Inflammatory bowel disease
b. Rheumatoid vasculitis
Rheumatoid vasculitis is associated with positivity for Rheumatoid factor and CCP
autoantibodies. pANCA are common in RA and IBD but usually are directed with specificities
against other antigens such as lactoferrin or BPI ie atypical ANCA.
c. Microscopic polyangiitis
Tthe combination of the cANCA and PR3 and pANCA/MPO respectively are specific for
the ANCA-associated small vessel vasculitis. Typically, the pANCA/MPO combination is
more common in MPA and cANCA/PR3 is more common in Wegener’s.
d. Henoch Schonlein purpura
ANCA are not detectable in HSP
e. Takayasu arteritis
No autoimmune serology have been identified in TA.
21
D
Answer D
Explanations
a) Ig A nephropathy is most common primary GN in all ages; peak incidence in 2 nd or 3rd decade of life,
male: female = 2:1
b) Commonest form of lupus is diffuse proliferative GN
c) prognosis is better in Anti GBM plus ANCA compared to Anti GBM alone
d) Secondary GN is common in
Infections
viral - Hep B, C, HIV
bacterial - syphilis, mycobacteria - leprosy
parasitic - malaria, schistosomiasis, filariasis
Neoplasm
Solid tumours - lung, breast, GI, renal (22% in pt >60 yr; 1% in pt<60 yr)
Haematological - lymphoma usu NHL
e) Scleroderma renal crisis is not due to glomerular involvement. It is a thrombotic microangiopathy
similar to malignant nephrosclerosis, TTP/HUS, radiation nephritis, chronic transplantation rejection, and
the antiphospholipid antibody syndrome. Because of the similar renal histologic findings, renal biopsy
does NOT definitively establish the diagnosis. (ref: UpToDate)
22
D
a) There is no mortality benefit or better cardiovascular outcome with statin in dialysis patients (4 D trial).
CARI guidelines do not recommend initiating statin in dialysis patients without cardiovascular risk factors.
b) Consensus for Hb target in CKD is 110 +/- 10 g/L. Increased mortality with higher Hb.
c) BP > 140/90 is associated with worse CVS outcome however there is no evidence that aggressive BP
control improve further and in fact increase mortality. According KDOQI guidelines, target BP is to control
< 130/ 80 (level B evidence)
There are few negative RCT - CKD progression nor CVD risk reduced at lower target of BP
 AASK
 REIN 2
 ACCORD
d) Low salt diet is most cost effective intervention to improve CVS outcome in CKD patients. Salt
accelerates the rate of deterioration of renal function, aggravate proteinuria independeant of BP and blunt
the effect of ACE and ARB.
e) Reduction of proteinuria is associated with improve CVS outcome (level A evidence of using ACE and
ARB; KIDOQI). However low protein diet is not at all recommended for CKD patients as malnutrition itself
is associated with poor outcome.
23
Answer E
Choice between PD and HD depends on patients’ – clinical situation (eg, contraindication to PD or HD,
co-mobidities), feasibility (eg, distance from HD satellite centre) and patient’s choice.
PD depends on patient’s residual renal function. With time, PD membrane quality declines; average time
2- 3 years on PD.
There is more technical failure with PD especially within first 3 months of starting PD eg, kinking of
catheter, malposition, ect. Inflow problem is mainly due to kinking of catheter, outflow problem is mainly
due to omental wrapping and both inflow and outflow problem is usually due to fibrin clot
24
Answer A
FGF 23 is increasingly recognized in development of secondary hyperparathyroridism. It is bone derived
and cause phosphoturia.
Bone disease (Renal Osteodystrophy) in CKD patients has different spectrums ranging from high
turnover, low turnover or mixed turnover disease. Gold standard to diagnose bone disease in CKD is
bone biopsy. Bisphosphonates are not routinely given in CKD (risk of adynamic bone disease)
Metabolic bone disease in CKD is a systemic disease affecting the skeleton and vasculature; associated
with vascular and valvular calcification and worse cardiovascular outcome.
Normal kidneys filter large amounts of organic phosphate of which more than 90% is reabsorbed by the
renal tubules. In late renal dysfunction, more impaired in filtration leading to PO4 retention.
25
Answer E
Actions of 1, 25 (OH) vit D
1. increases calcium and phosphate absorption from GUT
2. increase osteoclast activity in BONE
3. increase calcium and phosphate reabsorption from KIDNEY
26
Answer B
In primary hyperaldosteronism, there is increased aldosterone but with reduced renin.
In patients with hypokalemic metabolic alkalosis,
Urinary chloride < 20 - vomiting
Urinary chloride > 40 - Bartter’s or Gitelman’s syndrome (tubular defect – increased excretion of
chloride even the body needs it)
Bartter’s syndrome, AR, presents in early childhood.
Gitelman’s syndrome, AR, presents in late childhood or adult.
Both associated with. However hypercalciuria with Bartter’s syndrome.
Bartter’s syndrome
Gitelman’s syndrome
AR
Presents in early childhood
Defect in thick ascending limb
Na – K – Cl co-transporter
AR
Presents in late childhood or adult
Defect in distal tubule
Na – Cl co transporter
Normotensive
Hypokalemic metabolic alkalosis
Hypercalciuria +/- hypomagnesemia
Normotensive
Hypokalemic metabolic alkalosis
Hypocalciuria + hypomagnesemia
Impaired concentration capacity
Reduced GFR or normal
Normal concentration capacity
Normal GFR
Secondary activation of RAA
Hyper reninemia and hyperaldosteronism
27
Answer C
Rapamycin (Sirolimus) is less nephrotoxic.
28
Answer C
Disease recurrence is common with FSGS, membranoproliferative GN, Ig A nephropathy, HUS, anti GBM
followed by ANCA positive GN.
29
D
30
C
31.
ANSWER: E
Serious infections are most frequently seen with anti-TNF therapy in RA, with a marked increase in
disseminated TB.
Anti-TNF agents may also exacerbate CHF, particularly in elderly patients.
Demyelinating syndromes, such as multiple sclerosis, optic neuritis or Guillain-Barre syndrome can also
occur.
Lymphoma is 2-5 times more common in patients with severe active RA than the general population.
32.
ANSWER: C
Colchicine should not be administered 6 hourly until relief occurs (as suggested by MIMS) because
diarrhoea is a terrible consequence to have with gout.
It is inappropriate to administer allopurinol in an acute attack.
Oral prednisone is the safest agent in this case in the presence of renal failure.
33.
ANSWER: D
Methotrexate-induced pulmonary injury is not uncommon in RA. Initial response should be to cease the
methotrexate.
34.
B
RFT Interpretation
1. Excellent test performance.
2. No comment re age, height, weight or race.
3. Pre flow volume curve is ‘stretched’ vertically and there is expiratory volume loss..
4. FEV1/FVC ratio within reference limits – an obstructive abnormality is excluded.
5. Pre-BD FEV1 56%.
6. Pre-BD FVC 53% – a restrictive abnormality is likely.
7. No functionally significant increases in FEV1 & FVC following bronchodilators.
8. TLC, RV & FRC are all decreased. Reduction in TLC confirms & quantifies severity of a
restrictive ventilatory defect.
9. DLCO is severely decreased consistent with diffuse pulmonary parenchymal or pulmonary
vascular disease.
Summary: A severe restrictive abnormality. No obstruction or significant bronchodilator
response. Diffusing capacity is severely decreased. Results are consistent with intrapulmonary lung restriction (Pulmonary Fibosis). Note that despite the abnormal RFT’s arterial
oxygenation is preserved.
Hypercapnea is a feature of extra-pulmonary restriction while hypo- or normocapnea tends to be the
finding in intra-pulmonary restriction.
A. Asthma - obstructive picture is seen rather than restrictive
C. Kyphoscoliosis – with this degree of restriction would likely see an abnormal blood gas with poor
oxygenation and hypercapnia.
D. OSA- could also demonstrate above picture but less likely in a non-obese male. Usually in obese
middle-age to older males.
E. Scleroderma - gives restrictive pattern in context of fibrosis as in B. But less likely in a middle-aged
male
35
Answer: E demonstrating infection (empyema).
A. Pleural/serum protien ratio <0.5 demonstrates more likely transudate rather than exudate
B. Should not use pH alone in determining requirements for drainage
C. Shows an early cellular response but microscopy is even more convincing of need to drain
D. Pleural/serum LDH ratio >0.6 demonstrates more likely exudate but microscopy more important
36
Answer: B chronic alveolar hypoventilation and increased VQ mismatch
37
Answer: B: Correct
D. False – there is an association
E. False – CANPAP study demonstrated increases LVEF
38
Answer: B Rifampicin.
39
C
a. A group of proteins that form a proteolytic cascade, which produce a membrane attack complex,
resulting in cell lysis
No, this is complement
b. A group of transcription factors that translocate to the nucleus to stimulate gene expression upon
activation
No, this is the role of critical transcription factors like NFkB
c. A group of intracellular molecular platforms, activated upon cellular infection or stress,
that trigger the maturation of pro-inflammatory cytokines like IL-1β
d. A group of cell surface receptors that recognise pathogen-associated molecular patterns
(PAMPs) on the surface of bacteria
No, this is the role of Toll like receptors
e. A group of cytokines that induce naïve T cells to differentiate into pro-inflammatory Th17 cells
No, Th17 cells are stimulated in response to infection by TGF-beta, IL-22, IL-23 and IL-6 (BPTs
don’t need to know this, but this has nothing to do with the question)
40
E
a. High sensitivity of the antibody for the disease
No, plenty of examples of sensitive, non-pathogenic antibodies (eg ANA in SLE)
b. High specificity of the antibody for the disease
No, plenty of examples of specific, non-pathogenic antibodies (eg Smith in lupus)
c. Response of the antibody-associated disease to plasma exchange
Partially correct, but diseases with non-pathogenic antibodies also improve with TPE (eg HUS,
lupus) as we remove lots of things in plasma other than antibodies (inflammatory cytokines,
complement)
d. Response of the antibody-associated disease to anti-CD20 monoclonal therapy (rituximab)
Partially correct, but many diseases with antibody signatures respond to rituximab even when
they are not pathogenic
e. High rates of neonatal disease in newborn infants from antibody-positive mothers
41
A
a. Direct cellular killing
No, this is the role of phagocytes, CD8+ cytotoxic T cells and NK cells
b. Antigen presentation
c. Production of pro-inflammatory cytokines
d. Differentiate into antibody-forming plasma cells
e. Activation of T cells
42
B
a. Maintenance of self-tolerance to autoantigens centrally in the thymus
No, this is mediated through the AIRE gene in the thymus
b. Maintenance of self-tolerance to autoantigens in the periphery
c. Regulation of IgE synthesis and parasitic immunity
No, this is Th2 cells
d. Control of intracellular pathogens including mycobacteria
No, this is Th1 cells
e. Production of IL-17 and control of extracellular pathogens
No, this is Th17 cells (the BPTs should know what a Th17 cell is)
43
Answer C.
Asthma is most likely diagnosis, and spirometry alone in this clinical scenario is likely to be normal, thus it
has a low negative predictive value for asthma. Normal spirometry on one occasion does not exclude
asthma. The most appropriate test here is the one with the highest NPV (i.e. we are looking to exclude
asthma in patient who is unlikely to have a documented variable obstructive ventilator defect) –
methacholine. Methacholine acts directly on airway smooth muscle, and is more likely to provoke
contraction than the indirect osmolar agents such as mannitol and hypertonic saline.
44
Answer A.
The pattern of the flow-volume loop is consistent with a variable extrathoracic obstruction. Unilateral vocal
cord paralysis is the only diagnosis listed here which can produce this – during expiration (above the xaxis), the positive intraluminal airway pressure merely pushes the paralysed cord to one side. During
inspiration, the negative airway pressure draws the cord inward, due to Bernoulli’s effect. COPD produces
expiratory flow limitation, not inspiratory, due to dynamic airway compression principally. Tracheomalacia
results in forced expiratory flow limitation due to the relative positive transmural tracheal pressure
collapsing the trachea (due to loss of cartilaginous support). Subglottic stenosis and a large retrosternal
goitre would be more likely to cause a fixed upper airway obstruction with both inspiratory and expiratory
flow limitation.
45
Answer D.
The above results demonstrate a severe restrictive ventilator defect, with a normal gas transfer capacity
(DLCO Adj). There is no functionally significant response to nebulised bronchodilators. COPD and
bronchiectasis cause obstruction, not restriction. The remaining three cause a restrictive ventilator defect,
but pulmonary fibrosis usually results in a decreased gas transfer capacity. Kyphoscoliosis is likely, given
the patient has small lung, but the lung parenchyma is normal.
46
Answer B
The patient most likely has acute-on-chronic hypercapnic ventilator failure as the degree of acidosis is not
as severe as one might expect from the marked elevation in the pCO2 and relatively normal (rather than
low) bicarbonate. This respiratory acidosis is most likely to have been precipitated by hyperoxia and
secondary depression of central ventilatory drive. Reduction of the FiO2 using controlled oxygen via
Venturi mask to SaO2 88-92% (or pO2 55-70mmHg) is the most appropriate initial step. If, following a
period of appropriately controlled oxygen therapy , the pCO2 is increasing further or acidosis worsening,
NIV could be instituted
47
Answer C.
Quartzite and sandstone mining are high risk occupations for the development of silicosis, especially in a
man of this age, where the use of personal protective equipment is likely to have been limited.The HRCT
demonstrates features of complicated silicosis i.e. progressive massive fibrosis with the formation of large
nodules or masses or mass-like consolidation associated with apical scarring, distortion of lung
architecture, and the development of adjacent bullae. Simple silicosis is more likely to present with
multiple small nodules, of a centrilobular or subpleural distribution, with lymph node calcification. However
PMF and small cell lung carcinoma are unlikely to result in an upper lobe cavitating lesion. TB is the main
consideration here in view of his cavitating upper lobe lesion haemoptysis, and weight loss, as silicotics
are at very high risk of developing both tuberculous and non-tuberculous mycobacterial disease – and he
has a history of exposure to areas with a moderate and increasing incidence. The CT appearance is
inconsistent with simple emphysema or NSIP.
48
Answer B.
Farmer’s lung as a variant of an extrinsic hypersensitivity pneumonitis to the thermophilic fungal species
Actinomycetes spores found in decaying organic matter. Alveolar walls are generally thickened, with
lymphocytic, plasma cell and eosinophilic infiltration, together with collections of histiocytes which may
form small granulomas. Fibrotic changes occur in advanced disease.
49
Answer C.
The patient has evidence of underlying lung disease, thus has a secondary spontaneous pneumothorax.
The patient is symptomatic (thus the size of the PTX here is irrelevant) and this mandates ICC insertion.
British Thoracic Society Guidelines recommend small bore drain insertion. See BTS Guidelines Online >
Pleural Disease > Spontaneous Pneumothorax > Flow chart on page i21.
50
Answer A.
The patient has latent tuberculosis infection. To reduce the risk of future reactivation 3 months of INH +
RIF dual therapy is advised or more commonly 6 months of isoniazid monotherapy. HIV, hepatitis and
LFT testing is required. There is no evidence of active TB here requiring 9 months of quad therapy. Serial
chest X-ray monitoring would be more appropriate only for older patients who are at heightened risk of
INH hepatotoxicity.
51
Answer: D.
Diastolic pressure is stable or decreased in elderly patients. All other changes are well-recognised
physiological changes of ageing.
52
Answer: A
Impaired hepatic blood flow in the elderly lead to impaired drug metabolism. Codeine is a prodrug which
needs to be converted in the liver to morphine to become biologically active. This process is impaired
leading to decreased biological activity. Stomach acidity decreases leading to impaired absorption of
certain drugs. The volume of distribution increases in fat soluble drugs. Beta blockers are less effective
due to less responsiveness of beta adrenergic receptors.
53
Answer: A
The HYVETS trial showed that indapamide was effective as secondary prevention in the treatment of
stroke patients over the age of 80. There is little evidence for the use of atorvastatin and clopidogrel in
those over the age of 80. There is no evidence of benefit of risperidone in any age group. The evidence
for calcium is somewhat sketchy and there is recent evidence of increased cardiovascular mortality in
those on calcium supplements.
54
Answer – a
55
Answer – e
56
answer: d
57
answer: c
58
answer: b (as per Cochrane review 2009)
59
answer B
Main references are UpToDate current edition and WHO 2008.
Hypereosinophilic syndromes are difficult to diagnose. They largely present with persistent eosinophilia
(>1.5x10^9/L), variable tissue infiltration and involvement, and exclusion of any secondary cause. Severe
eosinophilia of any cause may cause cardiomyopathy, skin or pulmonary involvement, and be a strong
thrombophilic risk.
The presentation above is of a man without a reactive cause, with tissue damage from hypereosinophilia
(cardiac and skin), but incomplete workup. Imatinib is indicated if there is a Philadelphia chromosome or
FIP1L1-PDGFRA (or several other tyrosine kinase fusions) but this hasn’t been proven so A is wrong.
Mepolizumab is an anti-IL5 with proven efficacy in steroid sparing activity in Lymphocytic HES (with no
FIP1L1 rearrangement, with or without a clonal T cell abnormality) so C is wrong. Though severe
thrombophilia (arterial and venous) may be seen with HES the current recommendation is against primary
prophylaxis so D is wrong. The t(9;22) is the Philadelphia chromosome which should be found on
conventional cytogenetics. If not then RT-PCR can identify BCR-ABL. FISH may have a role in some labs
but generally is not necessary if conventional cytogenetics are normal and PCR for BCR-ABL is available
(so E is unnecessary). B is the most correct answer as it identifies a treatable cause of HES.
In truth a patient presenting as above would be admitted, tests initiated rapidly, Parasitic infection
excluded ASAP, TTE performed and then receive a prednisone challenge while awaiting the results!
60
answer E
Acquired factor inhibitors are very rare, complicating the post-partum period, in RA patients, or
paraneoplastic syndromes. The presentation above is typical. They have a severe bleeding diathesis.
A is wrong as the platelet count is normal and there is no suggestion of a functional defect. B is for acute
MTX toxicity and rescue after high dose MTX. D-Dimer is either a screening tool for thrombosis but is
sometimes used to diagnose DIC – but acute DIC usually presents with low fibrinogen. C is appropriate
only if a FVIII inhibitor is detected. E is correct.
61
E
62
Ans: C: From PEP lecture.
63
E
Ans: The history and appearances are suggestive of eosinophilic oesophagitis. Recognised since 2005,
this consists of dense eosinophilic infiltration. Endoscopy may reveal the appearance above (though can
be normal) with eosinophilic infiltrate and > 20 eosinophils per hpf. Some may consider it “asthma of the
oesophagus”. It usually presents with longstanding intermittent dysphagia which is progressive but not
usually related to weight loss. Bolus impactions, vomiting and heartburn can also occur.
Treatment options include elimiation diet, ingested steroids and leukotriene inhibitor. Endoscopic
intervention may be required for bolus retrieval or stricture dilatation.
Ref: Vu Kwan's gastro lecture, PEP lecture.
64
D
65






E
Total IgA deficiency is common and if you don't have IgA antibodies, you won't have +ve IgA
antigliadins.
A biopsy is needed for diagnosis of coeliac disease if tTG-IgA (or EMA) is positive or IgA deficient
or high index of suspicion.
If the patient has been on gluten free diet, it may mask the coeliac disease.
Therefore, patient should have eg. 4 slices of bread per day for 1/12 prior to bx.
Biopsies should be taken from distal duodenem or jejunum on a patient on an adequate amount
of gluten.
NB: Immunosuppression may cause false negative serology and histology.
Ref: PEP lecture
66
Answer: E – This question refers to the important “hot” topic of immune mediated nonparaneoplastic limbic encephalitis. It is important to be aware of this because although rare, it is quite
treatable and should not be missed.
67
Answer: E – This classic clinical presentation along with dilated lateral ventricles and “tight”
cortical sulci on the CT are highly suggestive of normal pressure hydrocephalus and the next line of
management should be tailored for this – lumbar puncture as a therapeutic trial, or monitoring of CSF
pressure invasively, or brain MRI with CSF flow study, or surgery – not any of the above alternatives.
68 answer B
69
C
70.
Answer: D
The clinical scenario is most consistent with a diagnosis of SLE – fevers, arthralgias, proteinuria, oral
ulcers and a pericardial effusion. This is further supported by the high titre ANA with a homogenous
pattern. The patient already has 5 of the 11 ACR criteria for SLE.
Briefly the ACR criteria for SLE (require 4 out of 11):
1.Serositis – pleuritis or pericarditis
2.Oral ulcers
3.Arthritis
4.Photosensitivity
5. Heamatological disorder –cytopenia’s
6. Renal disease
7.ANA
8.Malar rash
9.Discoid lupus
10.Neurological disorder – seizures or psychosis
11. Diagnostic – positive anti-Smith Antibodies, Anti-ds-DNA
Anti-ds-DNA antibodies would be your next test. Positive dsDNA Abs are relatively specific for the
diagnosis of SLE approx. 97%.
With regards to the other answers you would expect the ESR to be elevated but this is a non-specific
marker of inflammation. ANCA and Anti-PR3 are both tests for a systemic vasculitis such as Wegener’s
granulomatosis. The interferon-gamma release assay )or Quantiferon-Gold Assay) would be used for
assessment of latent tuberculosis. The pericardial effusion and fevers may be seen in active TB but
overall the features are more in keeping with SLE.
71 Answer: A
Tryptase is produced by mast cells and to a lesser extent by basophils. It is relatively specific for mast
cells and so elevated levels are indicative of mast cell pathology. An elevated tryptase is one of the WHO
minor criteria for the diagnosis of systemic mastocytosis. Other causes of an elevated tryptase include:
anaphylaxis and less commonly AML and hypereosinophilic syndromes (myeloid variant)
72
Answer: B
The history gives the clue of sinopulmonary infections or “B-cell type infections” – so if you are not aware
of the defects you could look for ‘B-cell’ abnormalities.
The recognised defects linked to CVID include: ICOS - Inducible co-stimulator of activated T cells, TACI Transmembrane activator and calcium-modulator and cyclophilin ligand, BAFF-R - B cell activating factor
of the tumor necrosis factor family receptor and CD19.
With regard to the other answers: FOXP3 is the defect seen in IPEX is an X-linked immune dysregulatory
disorder that presents with a triad of enteropathy, autoimmune endocrinopathy, and dermatitis. FOXP3 is
required for the formation of regulatory T-cells.
Deletions in chromosome 22q11.2 is the defect seen in DiGeorge Syndrome – a disorder associated with
defective development of the pharyngeal pouch system: cardiac anomalies, hypoplastic thymus, and
hypocalcemia (resulting from parathyroid hypoplasia).
RAG1 deficiency is an autosomal recessive cause of severe combined immunodeficiency the defect
leads to defective V(D)J recombination.
Philadelphia chromosome or Philadelphia translocation is a specifi a chromosomal abnormality that is
associated with CML.
73
B
74
A
75
C
76
D
77
B
78
E
79
C
80
B
81
A: Abacavir – recent use of abacavir is associated with increased risk of myocardial infarction.
Ritonavir, lopinavir (Protease inhibitors) – can cause hyperlipidemia
82
D: Tenofovir - The initiation of tenofovir-containing ART regimens has been shown to
lead to initial, modest bone loss that subsequently stabilizes.
83.
D: High prevalence of ESBL producing gram negative colonisation in those from India. ESBLs are
enzymes that confer resistance to most beta lactam antibiotics including penicillins, cephalosporins and
the monobactam aztreonam. Carbapenems are the best antibiotics for infections caused by this
organisms.
84.
D The association between S. bovis bacteremia or endocarditis and colonic neoplasia has been
appreciated for many years. In different small studies of patients with S. bovis bacteremia or endocarditis,
colon cancer was noted in 16 to 32 percent of patients following a diagnostic work-up that was usually
initiated because of S. bovis infection . One of these reports compared the frequency of colon cancer in
patients with IE due to S. bovis or Enterococcus; the rate of colon cancer was significantly higher in
patients with S. bovis infection (18 versus 2 percent) Colonic polyps may be more common than colon
cancer (47 versus 16 percent in one report).
85
A – patient has primary HIV infection (seroconversion illness). Dengue would be the most likely
diagnosis if the patient presented in the first week after return, but after 14 days is not a consideration.
When acute retroviral syndrome is suspected, a plasma HIV RNA test should be used in conjunction with
an HIV antibody test to diagnose acute infection . Acute HIV infection is often defined by detectable HIV
RNA in plasma in the setting of a negative or indeterminate HIV antibody test. A low-positive HIV RNA
level (<10,000 copies/mL) may represent a false-positive test, since values in acute infection are
generally very high (>100,000 copies/mL). A qualitative HIV RNA test can also be used in this setting.
Patients diagnosed with acute HIV infection on the basis of either a quantitative or a qualitative HIV RNA
test should have confirmatory serologic testing performed at a subsequent time point .
86
A
Treatment Recommendations for HBV/HIV Coinfected Patients
• All patients with HBV should be advised to abstain from alcohol; should receive hepatitis A vaccine if found
not to be immune at baseline (i.e., absence of hepatitis A total or IgG antibody); should be advised on methods
to prevent HBV transmission (which do not differ from those to prevent HIV transmission); and should be
evaluated for the severity of HBV infection.
• If neither HIV nor HBV infection requires treatment: Monitor the progression of both infections. If
treatment becomes necessary for either infection, follow the guidelines listed in the scenarios below.
• If treatment is needed for HIV but not for HBV: The combination of tenofovir and emtricitabine or
tenofovir and lamivudine should be used as the NRTI backbone of an antiretroviral regimen, which will result
in treatment of both infections. To avoid development of HBV-resistant mutants, none of these agents should
be used as the only agent with anti-HBV activity in an antiretroviral regimen.
• If treatment for HBV is needed: Patients who need treatment for HBV infection should also be started on a
fully suppressive antiretroviral regimen that contains NRTIs with activity against both viruses: for example,
tenofovir plus either emtricitabine or lamivudine. The use of lamivudine, emtricitabine, or tenofovir as the only
active anti-HBV agent should be avoided because of the risk for resistance. If tenofovir cannot be used,
another agent with anti-HBV activity should be used in combination with lamivudine or emtricitabine for
treatment of HBV infection. Management of HIV should be continued with a combination regimen to provide
maximal suppression.
• Treating only HBV: In instances when HIV treatment is not an option or is not desirable, pegylated
interferon-alpha may be used for the treatment of HBV infection, as it does not lead to the emergence of HIV
or HBV resistance. Adefovir dipivoxil is active against HBV but not against HIV at the 10mg dose; however,
there is a theoretical risk for development of HIV resistance, as it has anti-HIV activity at higher doses and is
related to tenofovir. Because of the risk for HIV drug resistance, the use of emtricitabine, lamivudine,
tenofovir, or entecavir without a full combination antiretroviral regimen should be avoided.
• Need to discontinue emtricitabine, lamivudine, or tenofovir: Monitor clinical course with frequent liver
function tests and consider the use of interferon, adefovir dipivoxil, or telbivudine to prevent flares, especially
in patients with marginal hepatic reserve.
87
D.
Right Coronary artery
The R and L coronary arteries arise directly from the root of the aorta. Left main divide into the LAD and L
circumflex ahich supplies most of the anterior and left lateral surface of the heart. In 85-90% of cases, the
RCA gives rise to the PDA giving rise to a right dominant coronary circulation. The PDA supplies most of
the inferior wall of the left ventricle which forms the diaghphramatic surface of the heart. The RCA also
gives rise to the SA and AV nodal arteries in most patients. The LAD supplies the anterior 2/3 of the
interventricular septum via the septal branches and the anterior wall of the left ventricle (via the diagonal
branches) and part of the anterior papillary muscles. The left circumflex supplies the lateral and
posterosuperior walls of the left ventricle via the obtuse marginal branches. The left main gives rise to the
LAD and left circumflex and only gives rise to the posterior descending artery (PDA) in 10% of individuals.
The acute marginal branches arise from the RCA to supply the right ventricle and may provide collateral
circulation in patients with LAD occlusion.
88
Answer: B
Refer to the SYNTAX Trial
89
C. Amyloidosis
The patient’s LV diastolic pressure-volume curve show reduced LV compliance indicating that diastolic
dysfunction is contributing significantly to the patient’s congestive cardiac failure. Only amyloidosis can
cause restrictive cardiomyopathy. Diastolic dysfunction is the predominant mechanism of heart failure in
restrictive cardiomyopathy. Viral myocarditis, alcohol toxicity, certain chemotherapeutic agents and
diphtheric myocarditis result in dilated cardiomyopathy with systolic dysfunction as the main mechanism
of heart failure.
90
C. Pulmonic stenosis
Tetralogy of Fallot is typically characterised by:1. Pulmonary stenosis
2. Ventricular septal defect
3. Right ventricular hypertrophy
4. Overriding aorta (straddling VSD)
Major physiological problems in cyanotic Tetralogy of Fallot is right to left intracardiac shunting. The
degree of right to left shunting and associated cyanosis depends upon the degree of RV outflow
obstruction. In general the VSD in TOF is large and non restrictive permitting unrestricted flow between
the RV and LV thus is not one of the variables that determines the severity of hypoxaemia. If the
pulmonary stenosis is severe blood flows from RV to the LV (R to L shunt) across the VSD and causing
cyanosis. If the systemic vascular resistance exceeds tha pulmonary vascular resistance (determined by
the degree of pulmonary stenosis) the blood flows from LV to RV via the VSD and the to the pulmonary
vascular bed. These patient’s are acyanotic. Aortic insufficiency is generally not a presenting feature of
TOF. Patients with TOF generally do not have atrial septal defects.
91
B. I’m trying to suggest this lady has adrenal insufficiency, got the flu, and now has adrenal crisis.
92
C Generally OHG are tried first – this guy’s HbA1c is quite high, and he will likely need 2 agents.
Insulin should probably be witheld until it is shown he has suboptimal control on OHGs alone. Diet and
exercise are unlikely to be enough, tho obviously are important. Sulfonylureas are not absolutely
contraindicated.
93
A. This is a real patient that Anna and I saw today. I am trying to imply that he doesn’t take his
enalapril (that’s why his BP control is poor), so he may well be non-compliant with his imatinib. Imatinib
treatment of CML is a bit like HAART for HIV – you need a high level of compliance otherwise it doesn’t
work.
Resistance to imatinib does occur, but in the real world is still less likely than non-compliance.
Reactive phenomenon could possibly explain the FBC abnormalities, but not the rising PCR transcript.
Drug interaction would be an uncommon cause of imatinib failure; CYP 3A4 inducers could theoretically
do this. But enalapril isn’t that.
Acute leukaemia can occur in the context of CML. But again, this is less common than non-compliance
as a cause of imatinib failure.
94
C. This girl has iron deficiency anaemia secondary to blood loss. Her absorption of oral iron will
be excellent, and this is almost always sufficient (given adequate dosing) to treat the deficiency.
She does not require blood transfusion as her anaemia is compensated and she is not suffering heart
failure due to tissue hypoxia. Her Hb will increase rapidly with adequate oral iron.
Increased red meat alone will not be as good as a hefty dose of oral iron – if you fixed her menorrhagia, it
would eventually work, tho!
95
B
96
D – this is lateral medullary syndrome. (Not the pons, which would knock out eye movements).
Not cortical or internal capsule – notice crossed sensory loss.
97
A
98
E
99
B.
For a transient risk factor (surgery) 3 months is generally appropriate. Single FVL
mutation increases risk of recurrence, but not to the extent that indefinite anticoagulation is warranted.
She should have adequate thromboprophylaxis during future times of risk (e.g. surgery, immobility).
For asymptomatic calf DVTs, some people advocate careful watching and anticoagulate only on
extension. This woman is symptomatic – most people would anticoagulate her.
100.
D
This guy has got rampaging DIC. Always think snake bite when you see DIC, although
snake venom of course often contains neurotoxins as well. No spider that I know of has a toxin that
causes DIC.
Funnel web venom and redback venom are neurotoxic only. Wolf spiders aren’t really poisonous to
humans, although their bite can be painful and, of course, they are very scary.
So that leaves one of the snakes. You need to have some local knowledge – don’t worry, this question
would never make it into the real exam.
Brown snakes are much more venomous than black snakes. Black snakes don’t usually cause such a
profound picture of collapse and coagulopathy in humans (but remember, they are potentially very
dangerous to your dog.)