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Date posted: October 22, 2011

Based on all the chapters of  Davidson’s Medicine- Fleshandbones
Candidates  preparing for competitive examinations are recommended to read the appropriate chapter from the text books  and then to asses themselves using these questions.  Otherwise it seems to difficult. Try to record your reasoning before checking the correct answer.

 CHAPTER – 11

Question 1. In humans

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

Question 2. In the chromosomal disorders

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

Question 3. In polycystic kidney disease

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

Question 4. The karyotype of a

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

Question 5. The following conditions arise as a result of the noted genetic abnormality

  • haemochromatosis-DNA point mutation (True)
  • Explanation: HFE gene
  • cystic fibrosis-DNA point mutation (False)
  • Explanation: Three base-pair deletion
  • Huntington’s disease-triplet repeat expansions (True)
  • Explanation: On 4p16
  • Down’s syndrome-chromosomal deletion (False)
  • Explanation: Chromosomal aneuploidy (trisomy 21)
  • DiGeorge syndrome-chromosomal microdeletion (True)
  • Explanation: The commonest microdeletion syndrome

Question 6. In autosomal dominant inheritance

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

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

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

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

  • cleft lip (False)
  • Explanation: Multifactorial disorder
  • sickle-cell anaemia (True)
  • Explanation: Autosomal recessive
  • retinitis pigmentosa (True)
  • cystic fibrosis (True)
  • Explanation: Autosomal recessive
  • familial hypercholesterolaemia (True)
  • Explanation: Autosomal dominant

CHAPTER – 12

Question 1. In the normal human heart

  • the atrioventricular (AV) node is usually supplied by the left circumflex coronary artery (False)
  • Explanation: Supplied by the right coronary artery in 90%
  • ß1-adrenoceptors mediate chronotropic responses (True)
  • Explanation: These receptors also mediate inotropic responses
  • pulmonary artery systolic pressure normally varies between 90 and 140 mmHg (False)
  • Explanation: Varies between 15 and 30 mmHg in health
  • the annulus fibrosus aids conduction of impulses from the atria to the ventricles (False)
  • Explanation: Restricts electrical connections between the atria and ventricles to the AV node
  • cardiac output is the product of heart rate and ventricular end-diastolic volume (False)
  • Explanation: The product of heart rate and ventricular stroke volume

Question 2. With regard to cardiovascular physiology

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

Question 3. In the normal electrocardiogram (ECG)

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

Question 4. In the normal ECG

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

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

  • the normal upper limit for the cardiothoracic ratio (CTR) on chest radiograph is 0.75 (False)
  • Explanation: The CTR should not be > 0.5
  • a negative exercise ECG excludes the diagnosis of ischaemic heart disease (False)
  • Explanation: False negative tests occur in 15-20%
  • a ‘step-up’ in oxygen saturation at cardiac catheterisation suggests an intracardiac shunt (True)
  • Doppler echocardiography reliably assesses pressure gradients between cardiac chambers (True)
  • Explanation: Pressure gradients can be extrapolated from measuring intracardiac flow velocities
  • radionuclide blood pool scanning accurately quantifies left ventricular function (True)
  • Explanation: Ejection fraction is usually measured using this technique

Question 6. The pain of myocardial ischaemia

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

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

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

Question 8. In the treatment of cardiac failure associated with acute pulmonary oedema

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

Question 9. Recognised features of severe cardiac failure include

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

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

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

Question 11. In the management of chronic heart failure

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

Question 12. Complications of systemic hypertension include

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

Question 13. Recognised causes of secondary hypertension include

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

Question 14. In the treatment of systemic hypertension

  • treatment has more effect on the risk of stroke than the risk of coronary heart disease (CHD) (True)
  • Explanation: 30% reduction in stroke, 20% in CHD
  • thresholds for treatment are higher in the elderly (False)
  • Explanation: Absolute risk is higher
  • treatment is less likely to be of benefit if cardiac or renal disease is present (False)
  • there are no proven benefits of therapy in patients aged over 70 years (False)
  • Explanation: Good evidence of efficacy in the elderly
  • moderation of alcohol consumption is likely to improve blood pressure control (True)
  • Explanation: Excessive consumption of alcohol is a significant factor in 10-15% of hypertensives

Question 15. Important explanations for hypertension refractory to medical therapy include

  • poor compliance with drug therapy (True)
  • inadequate drug therapy (True)
  • Explanation: Common particularly in asymptomatic patients
  • phaeochromocytoma (True)
  • Explanation: But rare
  • primary hyperaldosteronism (True)
  • Explanation: Conn’s syndrome is suggested by a hypokalaemic alkalosis
  • renal artery stenosis (True)
  • Explanation: May also develop during follow-up

Question 16. The auscultatory findings listed below are associated with the following phenomena

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

Question 17. Syncope

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

Question 18. Atrial fibrillation (AF) is

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

Question 19. In cardiac arrest

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

Question 20. Atrial tachycardia is typically associated with

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

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

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

Question 22. In ventricular tachycardia (VT)

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

Question 23. The following statements about atrioventricular block are true

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

Question 24. In the classification of anti-arrhythmic drugs, the following statements are true

  • class I agents inhibit the fast sodium channel (True)
  • Explanation: E.g. lidocaine (lignocaine)-like drugs
  • class II agents are ß-adrenoceptor antagonists (True)
  • class III agents prolong the action potential (True)
  • Explanation: E.g. amiodarone
  • class IV agents inhibit the slow calcium channel (True)
  • Explanation: E.g. verapamil, nifedipine
  • many anti-arrhythmic agents have actions in more than one class (True)
  • Explanation: E.g. sotalol and amiodarone

Question 25. The cardiac drugs listed below are associated with the following adverse effects

  • digoxin-acute confusional state (True)
  • Explanation: And lidocaine (lignocaine) therapy
  • verapamil-constipation (True)
  • Explanation: Calcium channel-blocking effect on smooth muscle
  • amiodarone-photosensitivity (True)
  • propafenone-corneal microdeposits (False)
  • Explanation: An adverse effect of amiodarone therapy
  • lidocaine (lignocaine)-convulsions (True)

Question 26. Amiodarone therapy

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

Question 27. Digoxin

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

Question 28. The risk of developing clinical evidence of coronary artery disease is

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

Question 29. In the investigation of suspected angina pectoris

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

Question 30. In the treatment of patients with angina pectoris

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

Question 31. The clinical features of acute myocardial infarction include

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

Question 32. In the treatment of acute myocardial infarction

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

Question 33. Drug therapies which improve the long-term prognosis after myocardial infarction include

  • aspirin (True)
  • Explanation: Vascular events are reduced by 25%
  • nitrates (False)
  • calcium antagonists (False)
  • ACE inhibitors (True)
  • Explanation: Limit infarct expansion
  • ß-blockers (True)
  • Explanation: Reduce mortality by 25%

Question 34. The following statements about the prognosis of acute myocardial infarction are true

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

Question 35. In intermittent claudication due to atherosclerosis

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

Question 36. Characteristic features of aortic dissection include

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

Question 37. In patients with significant mitral stenosis

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

Question 38. Recognised features of chronic mitral regurgitation include

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

Question 39. Clinical features suggesting aortic stenosis include

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

Question 40. Disorders associated with aortic regurgitation include

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

Question 41. In infective endocarditis

  • streptococci and staphylococci account for over 80% of cases (True)
  • Explanation: Streptococcus viridans alone accounts for 30-40% of cases
  • left heart valves are more frequently involved than right heart valves (True)
  • normal cardiac valves are not affected (False)
  • Explanation: About 30% have no identifiable predisposing cardiac lesion
  • glomerulonephritis usually occurs due to immune complex disease (True)
  • a normal echocardiogram excludes the diagnosis (False)
  • Explanation: Vegetations may be too small to be detected

Question 42. Central cyanosis in infancy is an expected finding in the following congenital heart diseases

  • persistent ductus arteriosus (False)
  • Explanation: With a left to right shunt
  • transposition of the great arteries (True)
  • Explanation: Usually due to a shunt through a ventricular septal defect
  • coarctation of the aorta (False)
  • Explanation: No shunt
  • Fallot’s tetralogy (True)
  • Explanation: Right to left shunt through a ventricular septal defect
  • atrial septal defect (False)
  • Explanation: Left to right shunt

Question 43. The following statements about persistent ductus arteriosus are true

  • blood usually passes from the pulmonary artery to the aorta (False)
  • Explanation: This only happens if the shunt reverses
  • the onset of heart failure usually occurs in early infancy (False)
  • Explanation: Typically presents with a murmur in an otherwise healthy infant
  • a systolic murmur around the scapulae is typical (False)
  • Explanation: Continuous ‘machinery’ murmur is typical (systolic and diastolic)
  • shunt reversal is indicated by cyanosis of the lower limbs (True)
  • Explanation: A rare sign
  • prophylactic antibiotic therapy to prevent endocarditis is indicated (True)

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

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

Question 45. In atrial septal defect

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

Question 46. In small ventricular septal defects

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

Question 47. Dilated (congestive) cardiomyopathy is

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

Question 48. Clinical features compatible with hypertrophic cardiomyopathy include

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

Question 49. Typical features of acute pericarditis include

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

Question 50. In pericardial tamponade

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

CHAPTER – 13

Question 1. Typical chest findings in a large right pleural effusion include

  • normal chest expansion (False)
  • Explanation: Expansion is reduced on the affected side
  • dull percussion note (False)
  • Explanation: Stony dull
  • absent breath sounds (True)
  • vocal resonance decreased (True)
  • Explanation: As is tactile vocal fremitus
  • pleural friction rub (False)

Question 2. Hypercapnia is a typical feature of

  1. pulmonary embolism (False)
  2. Explanation: Hyperventilation unless embolism is massive
  3. severe chest wall injury (True)
  4. Explanation: With type II respiratory failure
  5. salicylate intoxication (False)
  6. Explanation: Hyperventilation
  7. pulmonary fibrosis (False)
  8. Explanation: Hyperventilation and type I failure
  9. severe chronic bronchitis (True)
  10. Explanation: Type II respiratory failure may ensue

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

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

Question 4. The following statements about pulmonary function tests are true

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

Question 5. In a patient with severe acute breathlessness

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

Question 6. The following are recognised causes of haemoptysis

  • tuberculosis (True)
  • chronic obstructive pulmonary disease (False)
  • Explanation: Another cause should be sought
  • bronchiectasis (True)
  • Explanation: May be massive
  • Goodpasture’s syndrome (True)
  • Explanation: With associated renal disease
  • mitral stenosis (True)
  • Explanation: With pulmonary hypertension

Question 7. A pleural effusion with a pleural fluid:serum protein ratio of > 0.5 would be typical of

  • congestive cardiac failure (CCF) (False)
  • Explanation: Transudate in CCF
  • renal failure (False)
  • subphrenic abscess (True)
  • Explanation: Most frequently on the right
  • pneumonia (True)
  • Explanation: With polymorphonuclear leucocytes
  • nephrotic syndrome (False)
  • Explanation: Severe hypoalbuminaemia produces transudates

Question 8. The sleep apnoea syndrome is associated with

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

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

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

Question 10. In the treatment of acute COPD exacerbations associated with type II respiratory failure

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

Question 11. The following statements about oxygen are true

  • at sea level, the pressure of oxygen in inspired air is approximately 20 kPa (True)
  • Explanation: PaO2 declines with altitude
  • chronic domiciliary oxygen therapy is indicated only when PaO2 is < 6 kPa (False)
  • Explanation: Indicated when PaO2 < 7.3 breathing air
  • dissolved oxygen contributes to tissue oxygenation in anaemia (True)
  • Explanation: Also in other situations when Hb is maximally saturated
  • oxygen toxicity in adults can produce retrolental fibroplasia (False)
  • Explanation: Occurs only in neonates
  • central cyanosis unresponsive to 100% oxygen indicates right-to-left shunting of > 20% (True)
  • Explanation: Such shunts may be extra- or intrapulmonary

Question 12. In the management of chronic obstructive pulmonary disease

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

Question 13. Typical findings in severe chronic obstructive pulmonary disease include

  • elevation of the jugular venous pressure (True)
  • Explanation: A feature of right heart failure
  • tracheal descent on inspiration (True)
  • Explanation: Tracheal ‘tug’ due to mediastinal descent
  • indrawing of the intercostal muscles (True)
  • Explanation: A sign of hyperinflation
  • contraction of the scalene muscles (True)
  • Explanation: And other accessory respiratory muscles
  • pursed lip breathing (True)
  • Explanation: Decreases air trapping

Question 14. Typical pathological features of asthma include

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

Question 15. In the management of chronic persistent asthma

  • inhaled ß2-agonist use more than once per day is an indication for inhaled steroid therapy (True)
  • Explanation: Typically low-dose steroids
  • sodium cromoglicate therapy is often useful as an alternative to inhaled steroids in adults (False)
  • Explanation: But may be valuable in childhood
  • patients taking high doses of inhaled steroids should use a large-volume spacer device (True)
  • Explanation: Reduces oropharyngeal and gastric deposition
  • leukotriene antagonists are valuable substitutes for inhaled steroids (False)
  • Explanation: Use in addition to steroids and ß2-agonist
  • anticholinergic agents should be avoided (False)
  • Explanation: May be valuable

Question 16. Features compatible with severe acute asthma include

  • pulse rate = 120 per minute (True)
  • Explanation: But bradycardia may occur in life-threatening attacks
  • peak expiratory flow (PEF) rate = < 70% of expected (False)
  • Explanation: Usually < 50% of expected PEF
  • pulsus paradoxus (True)
  • Explanation: But may diminish in severe attacks
  • arterial PaO2 = 14 kPa while breathing air (False)
  • Explanation: PaO2 < 8 kPa in life-threatening attacks
  • arterial PaCO2 = 5 kPa (True)
  • Explanation: PaCO2 may remain normal until the late stages

Question 17. The initial management of severe acute asthma should include

  • 24% oxygen delivered by a controlled flow mask (False)
  • Explanation: High concentration, high flow should be used
  • salbutamol 5 mg by inhalation (True)
  • Explanation: Intravenous ß2-adrenoceptor agonists can also be used
  • ampicillin 500 mg orally and sodium cromoglicate 10 mg by inhalation (False)
  • Explanation: Of no proven value in acute attacks
  • hydrocortisone 200 mg i.v. or prednisolone 40 mg orally (True)
  • Explanation: Maintain corticosteroid therapy for at least 7 days in severe attacks
  • arterial blood gas analysis and chest radiograph (True)
  • Explanation: Exclude pneumothorax and ventilatory failure

Question 18. Typical clinical features of bronchiectasis include

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

Question 19. Cystic fibrosis is associated with

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

Question 20. In pneumonia, the following features are classically associated with the specific organisms noted

  • erythema nodosum and Mycoplasma pneumoniae (True)
  • hyponatraemia and Legionella pneumoniae (True)
  • contact with sick birds and Klebsiella pneumoniae (False)
  • Explanation: Chlamydia psittaci
  • abscess formation and Staphylococcus aureus (True)
  • haemolytic anaemia and Streptococcus pneumoniae (False)
  • Explanation: Mycoplasma

Question 21. A non-pneumococcal pneumonia should be considered if the clinical features include

  • respiratory symptoms preceding systemic upset by several days (False)
  • Explanation: The converse is typical of ‘atypical’ organisms
  • lobar consolidation (False)
  • rigors (False)
  • the absence of a neutrophil leucocytosis (True)
  • Explanation: Leucopenia can occur in severe pneumococcal infection
  • palpable splenomegaly (True)
  • Explanation: Rare in pneumococcal disease

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

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

Question 23. Typical features of primary tuberculosis include

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

Question 24. Recognised complications of post-primary tuberculosis include

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

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

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

Question 26. Recognised adverse reactions to antituberculous drugs include

  • streptomycin-renal failure (False)
  • Explanation: Causes vestibular disturbance and deafness
  • isoniazid-hypothyroidism (False)
  • Explanation: Polyneuropathy
  • rifampicin-optic neuritis (False)
  • Explanation: Ethambutol causes optic neuritis
  • pyrazinamide-hepatitis (True)
  • Explanation: And rifampicin
  • ethambutol-vestibular neuronitis (False)
  • Explanation: Streptomycin causes this

Question 27. Pulmonary infection with Aspergillus fumigatus is a recognised cause of the following

  • bullous emphysema (False)
  • Explanation: No association
  • mycetoma (True)
  • Explanation: Usually in a tuberculous cavity
  • necrotising pneumonitis (True)
  • Explanation: A severe, rapidly progressive illness
  • bronchopulmonary eosinophilia (True)
  • Explanation: Typically with wheeze, pulmonary infiltrates and peripheral eosinophilia
  • extrinsic allergic alveolitis (False)
  • Explanation: Type III and IV immune responses

Question 28. Bronchial carcinoma

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

Question 29. Non-metastatic manifestations of bronchial carcinoma include

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

Question 30. The following are contraindications to surgical resection in bronchial carcinoma

  • distant metastases (True)
  • malignant pleural effusion (True)
  • FEV1 < 0.8 litres (True)
  • ipsilateral mediastinal lymphadenopathy (False)
  • Explanation: But contralateral nodes are a contraindication
  • oesophageal involvement (True)

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

  • thymoma (True)
  • Explanation: May be associated with myasthenia gravis
  • retrosternal goitre (True)
  • Explanation: Anterior superior mediastinum
  • Pancoast tumour (False)
  • Explanation: Pulmonary apical mass
  • hiatus hernia (True)
  • Explanation: A retrocardiac opacity
  • neurofibroma (True)
  • Explanation: Can be multiple

Question 32. The following statements about sarcoidosis are true

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

Question 33. Typical features of cryptogenic fibrosing alveolitis include

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

Question 34. Clinical features compatible with a diagnosis of extrinsic allergic alveolitis include

  • expiratory rhonchi and sputum eosinophilia (False)
  • Explanation: Acute dyspnoea without wheeze is characteristic
  • dry cough, dyspnoea and pyrexia (True)
  • Explanation: Influenza-like symptoms may exist
  • end-inspiratory crepitations (True)
  • Explanation: Typically bilateral
  • FEV1/FVC ratio of 50% (False)
  • Explanation: Airway obstruction is absent
  • positive serum precipitin tests (True)
  • Explanation: May also be positive in healthy subjects

Question 35. The following statements about asbestos-related disease are true

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

Question 36. Characteristic features of pulmonary eosinophilia include

  • an association with ascariasis and microfilariasis (True)
  • Explanation: And Toxocara infestation
  • eosinophilic pneumonia without peripheral blood eosinophilia (False)
  • Explanation: Eosinophilia is necessary for the diagnosis
  • prominent asthmatic features (False)
  • Explanation: Wheeze may be absent
  • induction by exposure to drugs (True)
  • Explanation: Imipramine, phenylbutazone or others
  • opacities on chest radiograph (True)
  • Explanation: Pulmonary infiltrates and eosinophilia

Question 37. Clinical features characteristic of massive pulmonary embolism include

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

Question 38. Typical features of an empyema thoracis include

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

Question 39. The following statements about spontaneous pneumothorax are true

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

Question 40. The following are causes of an elevated hemidiaphragm

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

CHAPTER – 14

Question 1. The following statements about renal physiology in health are correct

  • each kidney comprises approximately 1 000 000 nephrons (True)
  • the kidneys receive approximately 5% of the cardiac output (False)
  • Explanation: 25% of the cardiac output
  • variations in the calibre of afferent and efferent arterioles control the filtration pressure (True)
  • the glomerular capillaries are supplied by the afferent arterioles (True)
  • the kidney produces erythropoietin (True)

Question 2. Microscopic haematuria would be an expected finding in

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

Question 3. Urinary protein excretion

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

Question 4. Typical features of the nephrotic syndrome include

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

Question 5. The following findings would support a diagnosis of pre-renal rather than established acute renal failure

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

Question 6. Typical causes of rapidly progressive glomerulonephritis include

  • post-infectious glomerulonephritis (True)
  • systemic vasculitis (True)
  • Explanation: Causes focal necrotising glomerulonephritis
  • Goodpasture’s disease (True)
  • IgA nephropathy (True)
  • Explanation: Including Henoch-Schönlein purpura
  • membranous glomerulonephritis (False)

Question 7. Typical biochemical features of chronic renal failure include

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

Question 8. Complications of chronic renal failure include

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

Question 9. The features of Alport’s syndrome include

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

Question 10. Characteristic features of minimal change nephropathy are

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

Question 11. In the treatment of minimal change nephropathy

  • therapy should be deferred pending renal biopsy in childhood (False)
  • Explanation: Diagnosis in children rarely requires histological confirmation
  • diuretics should be avoided to minimise the risk of renal impairment (False)
  • Explanation: Useful in management of oedema
  • high-dose steroids usually control proteinuria (True)
  • immunosuppressant therapy is indicated for frequent relapses (True)
  • Explanation: E.g. cyclophosphamide
  • impaired renal function commonly develops in the long term (False)
  • Explanation: Rarely, even in relapsing disease

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

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

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

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

Question 14. Causes of chronic interstitial nephritis include

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

Question 15. Chronic pyelonephritis in adults

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

Question 16. The clinical features of adult polycystic renal disease include

  • an autosomal recessive mode of inheritance (False)
  • Explanation: Autosomal dominant
  • cystic disease of the liver and pancreas (True)
  • Explanation: But liver function tests are normal
  • renal angle pain and haematuria (True)
  • Explanation: And hypertension and urinary tract infection
  • aortic and mitral regurgitation (True)
  • Explanation: Common but rarely severe
  • aneurysms of the circle of Willis (True)
  • Explanation: 10% will have a subarachnoid haemorrhage

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

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

Question 18. The typical features of acute pyelonephritis in adult females include

  • normal anatomy of the urinary tract (True)
  • Explanation: But ureteric obstruction may be a predisposing factor
  • vomiting, rigors and renal angle tenderness (True)
  • Explanation: With loin or epigastric pain
  • pyuria (True)
  • peritubular neutrophil infiltration (True)
  • loin pain and fullness in the flank (False)
  • Explanation: Suggest perinephric abscess

Question 19. In the treatment of renal calculi

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

Question 20. Recognised features of renal carcinoma include

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

Question 21. The typical features of benign prostatic hypertrophy include

  • peak incidence in the age-group 40-60 years (False)
  • Explanation: Aged over 60 years
  • acute urinary retention and haematuria (True)
  • Explanation: Sometimes precipitated by urinary tract infection
  • a response to a-adrenoceptor blocker therapy in > 50% of patients (True)
  • elevated serum prostate specific antigen (False)
  • Explanation: Suggests prostatic carcinoma
  • hard, nodular prostatic enlargement on rectal examination (False)
  • Explanation: Suggests prostatic carcinoma

Question 22. Typical features of prostatic carcinoma include

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

Question 23. Characteristic features of testicular tumours include

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

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