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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 – 15

Question 1. Type 1 insulin-dependent diabetes mellitus (IDDM) is associated with

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

Question 2. The following statements about type 2 diabetes mellitus (NIDDM) are true

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

Question 3. Secondary diabetes mellitus is associated with

  • thiazide diuretic therapy (True)
  • Explanation: Hypokalaemic alkalosis impairs insulin secretion
  • haemochromatosis (True)
  • Explanation: Pancreatic fibrosis
  • primary hyperaldosteronism (True)
  • Explanation: Conn’s syndrome produces a hypokalaemic alkalosis
  • pancreatic carcinoma (True)
  • Explanation: Islet cell destruction
  • thyrotoxicosis (True)
  • Explanation: Also occurs in phaeochromocytoma and acromegaly

Question 4. The physiological effects of insulin include

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

Question 5. In decompensated diabetes mellitus

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

Question 6. In the diagnosis of diabetes mellitus

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

Question 7. Typical presentations of diabetes mellitus include

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

Question 8. In the dietary management of diabetes mellitus

  • 90% of patients also require hypoglycaemic drug therapy (False)
  • Explanation: 50% of new diabetics can be controlled on diet alone
  • carbohydrate should provide 50% of the total calorie intake (True)
  • Explanation: Higher than that in the average UK diet
  • 10 g carbohydrate exchanges provide an ideal method of monitoring intake (False)
  • Explanation: Not advocated as the method takes no account of glycaemic effects or fat intake
  • fat intake should not exceed 35% of total calorie intake (True)
  • Explanation: UK national diet tends to higher proportion of fat
  • in obese patients, calorie intake should not exceed 750 kcal/day (False)
  • Explanation: Calorie restriction of 500 kcal/day is more realistic and sustainable

Question 9. Sulphonylurea drug therapy in diabetes mellitus

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

Question 10. Biguanide drug therapy in diabetes mellitus

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

Question 11. The following statements about other drug therapies in diabetes mellitus are true

  • thiazolidinediones enhance endogenous insulin sensitivity (True)
  • Explanation: Activate peroxisome proliferator-activated receptor ? (PPAR? agonists)
  • thiazolidinediones produce hyperinsulinaemia and hypoglycaemia (False)
  • Explanation: Insulin sensitivity in adipose tissue is only increased in patients with insulin resistance
  • thiazolidinediones are best prescribed in combination with biguanides, sulphonylureas or insulin True)
  • Explanation: Glitazones promote weight gain and fluid retention similar to sulphonylureas and insulin
  • meglitinides increase peripheral insulin sensitivity (False)
  • Explanation: Stimulate postprandial insulin secretion
  • alpha-glucosidase inhibitors induce carbohydrate malabsorption (True)
  • Explanation: Selectively inhibit intestinal disaccharidases producing flatulence and diarrhoea

Question 12. The following statements about insulin therapy are true

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

Question 13. Typical symptoms of hypoglycaemia in diabetic patients include

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

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

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

Question 15. Factors predisposing to frequent hypoglycaemic episodes in a diabetic patient include

  • delayed meals (True)
  • Explanation: Or inadequate size of meal
  • unusual exercise (True)
  • Explanation: Often unanticipated
  • excessive alcohol intake (True)
  • Explanation: A problem with patients on sulphonylurea drugs
  • development of hypoadrenalism (True)
  • Explanation: Increased sensitivity to insulin; weight loss and nocturia should signal the possibility
  • errors in drug administration (True)
  • Explanation: Inadvertent and occasionally even deliberate

Question 16. The typical clinical features of diabetic ketoacidosis include

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

Question 17. Expected findings in moderately severe diabetic ketoacidosis include

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

Question 18. In the management of diabetic ketoacidosis

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

Question 19. The clinical features of diabetic retinopathy include

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

Question 20. The following statements about the long-term complications of diabetes are correct

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

CHAPTER – 16

Question 1. The hypothalamic releasing factors listed below stimulate the pituitary gland to secrete the following hormones

  • dopamine-prolactin (False)
  • Explanation: Dopamine inhibits prolactin release; dopamine antagonists and TRH both stimulate prolactin release
  • somatostatin-growth hormone (False)
  • Explanation: Somatostatin inhibits growth hormone release
  • thyrotrophin-releasing hormone (TRH)-thyroid-stimulating hormone (TSH) and prolactin (True)
  • Explanation: In vivo significance of effect on prolactin is uncertain
  • gonadotrophin-releasing hormone (GnRH)-luteinising hormone (LH) and follicle-stimulating hormone (FSH) independently (True)
  • Explanation: Gonadal steroids and inhibin modify GnRH effects
  • corticotrophin-releasing hormone (CRH)-ß-lipotrophic hormone (LPH) and adrenocorticotrophic hormone (ACTH) (True)
  • Explanation: Arginine vasopressin also effects ACTH release

Question 2. Causes of hyperprolactinaemia include

  • oral contraceptive therapy (True)
  • Explanation: And pregnancy
  • chlorpromazine therapy (True)
  • Explanation: Dopamine antagonist like metoclopramide
  • primary hypothyroidism (True)
  • Explanation: High plasma TRH
  • hypothalamic disease (True)
  • Cushing’s disease (True)
  • Explanation: High plasma ACTH

Question 3. The clinical features of hyperprolactinaemia include

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

Question 4. The clinical features of acromegaly include

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

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

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

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

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

Question 7. Causes of hypopituitarism include

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

Question 8. Causes of diabetes insipidus (DI) include

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

Question 9. The typical features of cranial diabetes insipidus include

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

Question 10. The insulin tolerance test is

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

Question 11. The following statements about thyroid hormones are true

  • T3 and T4 are both stored in colloid vesicles as thyroglobulin (True)
  • Explanation: Thyroglobulin is synthesised within thyroid cells
  • T4 is metabolically more active than T3 (False)
  • Explanation: T4 should be regarded as a prohormone
  • T3 and T4 are mainly bound to albumin in the serum (False)
  • Explanation: Bound to thyroxine-binding globulin and also to pre-albumin
  • 85% of the circulating T3 arises from extra-thyroidal T4 (True)
  • Explanation: T4 is deiodinated in liver, muscle and kidney
  • conversion of T4 to T3 decreases in acute illness (True)
  • Explanation: Production of reverse T3 may increase

Question 12. The finding of reduced serum free T4 and thyroid-stimulating hormone (TSH) concentrations is compatible with the following conditions

  • hypopituitarism (True)
  • Explanation: With secondary hypothyroidism
  • primary hypothyroidism (False)
  • Explanation: Serum TSH would be elevated
  • nephrotic syndrome (False)
  • Explanation: Free T4 is normal but total T4 is often increased (high thyroxine-binding globulin (TBG) concentrations)
  • pneumonia (True)
  • Explanation: Sick euthyroid syndrome-total and free T4 may be reduced
  • pregnancy (False)
  • Explanation: Free T4 and TSH are normal; total T4 is often increased (high TBG concentrations)

Question 13. The following statements about thyrotoxicosis are true

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

Question 14. The clinical features of thyrotoxicosis include

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

Question 15. In the treatment of thyrotoxicosis

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

Question 16. The clinical features of primary hypothyroidism include

  • carpal tunnel syndrome and proximal myopathy (True)
  • Explanation: Both, however, are non-specific
  • cold sensitivity and menorrhagia (True)
  • Explanation: And infertility and impotence
  • deafness and dizziness (True)
  • Explanation: Perhaps due to oedema of the middle ear
  • puffy eyelids and malar flush (True)
  • Explanation: And rarely alopecia, vitiligo and dry hair
  • absent ankle tendon reflexes (False)
  • Explanation: Reflexes preserved with delayed relaxation

Question 17. Biochemical findings in primary hypothyroidism include

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

Question 18. The development of a goitre is associated with

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

Question 19. Thyroid carcinoma of

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

Question 20. The serum calcium concentration is typically increased in

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

Question 21. Typical clinical features of primary hyperparathyroidism include

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

Question 22. Typical biochemical findings in primary hyperparathyroidism include

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

Question 23. Causes of hypercalcaemia include

  • bone metastases (True)
  • Explanation: Often via production of osteoclast-activating factors
  • carcinomas secreting PTH-like peptides (True)
  • Explanation: Undetectable using standard PTH assays
  • severe Addison’s disease (True)
  • Explanation: Increased vitamin D synthesis with low PTH concentration
  • severe hypothyroidism (False)
  • Explanation: Hyperthyroidism is a rare cause
  • chronic sarcoidosis (True)
  • Explanation: Increased vitamin D production with low PTH concentration

Question 24. The following statements about adrenal gland physiology are true

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

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

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

Question 26. Adverse effects of oral corticosteroid therapy include

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

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

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

Question 28. Causes of primary adrenocortical insufficiency include

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

Question 29. Typical features of primary adrenocortical insufficiency include

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

Question 30. The typical features of phaeochromocytoma include

  • predominantly adrenaline rather than noradrenaline secretion (False)
  • Explanation: Noradrenaline is a precursor of adrenaline
  • episodic nausea with sweating and marked skin pallor (True)
  • Explanation: Catecholamine secretion
  • underlying malignant tumour in the majority (False)
  • Explanation: 90% are benign
  • presentation with hypertension and hypercalcaemia (True)
  • Explanation: Occurs in MEN type II syndrome
  • control of symptoms following propranolol therapy alone (False)
  • Explanation: Symptoms worsen due to unopposed a-adrenoceptor activity

Question 31. Causes of gynaecomastia include

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

Question 32. In cryptorchidism with inguinal testes in a child

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

Question 33. Causes of secondary amenorrhoea include

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

Question 34. The typical features of the menopause include

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

Question 35. Causes of hirsutism include

  • idiopathic familial hirsutism (True)
  • Explanation: Commonest cause and treated with anti-androgens (e.g. cyproterone)
  • polycystic ovarian syndrome (PCOS) (True)
  • Explanation: PCOS is associated with obesity and infertility; plasma LH:FSH ratio > 2.5:1
  • Cushing’s syndrome (True)
  • Explanation: Modest increase in adrenal androgen synthesis
  • autoimmune polyglandular syndrome (False)
  • Explanation: Primary adrenal, thyroid, parathyroid, gastric parietal and gonadal failure syndromes
  • ovarian tumour (True)
  • Explanation: Ectopic androgen production does not suppress with dexamethasone (unlike excessive androgen production in congenital adrenal hyperplasia)

CHAPTER – 17

Question 1. Causes of mouth ulcers include

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

Question 2. Causes of salivary gland enlargement include

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

Question 3. Recognised causes of dysphagia include

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

Question 4. Typical features of oesophageal achalasia include

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

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

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

Question 6. Oesophageal carcinoma in the UK is

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

Question 7. Typical features of oesophageal carcinoma at presentation include

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

Question 8. Factors associated with chronic peptic ulcer disease include

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

Question 9. Typical features of peptic ulcer dyspepsia include

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

Question 10. In the investigation and treatment of chronic dyspepsia

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

Question 11. Gastroduodenal haemorrhage in the UK is

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

Question 12. Typical features of major acute gastroduodenal haemorrhage include

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

Question 13. When acute gastroduodenal haemorrhage is suspected

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

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

  • oxygen should be administered if there are signs of hypovolaemia (True)
  • Explanation: Especially in patients with shock
  • transfusion requires whole blood rather than packed red cells (False)
  • Explanation: Colloid infusion and packed red cells are adequate for volume replacement
  • volume replacement with colloids is preferable to crystalloids (True)
  • Explanation: Crystalloids rapidly redistribute to the extravascular space
  • monitoring central venous pressure and/or urine output is advisable (True)
  • Explanation: Facilitates restoration of optimal circulating volume
  • surgical intervention should be considered if rebleeding occurs despite ulcer sclerotherapy (True)
  • Explanation: Consider surgical options in all patients with continuing bleeding

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

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

Question 16. Characteristic features of gastric outlet obstruction include

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

Question 17. Complications of partial gastrectomy include

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

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

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

Question 19. Carcinoma of the stomach is associated with

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

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

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

Question 21. In gluten enteropathy (coeliac disease)

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

Question 22. Causes of small bowel bacterial overgrowth (blind loop syndrome) include

  • diabetic autonomic neuropathy (True)
  • Explanation: Reduced small intestinal motility
  • chronic hypochlorhydria (True)
  • Explanation: E.g. long-term proton pump inhibitor therapy and pernicious anaemia
  • jejunal diverticulosis (True)
  • Explanation: Best demonstrated by barium meal
  • progressive systemic sclerosis (True)
  • Explanation: Reduced small intestinal motility
  • enterocolic fistula (True)
  • Explanation: E.g. Crohn’s disease

Question 23. Clinical features suggesting the carcinoid syndrome include

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

Question 24. Causes of acute pancreatitis include

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

Question 25. The following are characteristic of acute pancreatitis

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

Question 26. Adverse prognostic factors in acute pancreatitis include

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

Question 27. In the management of acute pancreatitis

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

Question 28. In the investigation of chronic pancreatic disease

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

Question 29. Features consistent with the diagnosis of chronic pancreatitis include

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

Question 30. Typical causes of chronic pancreatitis include

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

Question 31. Typical complications of chronic pancreatitis include

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

Question 32. The typical features of pancreatic carcinoma include

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

Question 33. Characteristic features of ulcerative colitis include

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

Question 34. Ulcerative colitis (UC) differs from Crohn’s colitis in that

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

Question 35. Recognised complications of ulcerative colitis include

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

Question 36. Characteristic features of Crohn’s disease include

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

Question 37. The typical clinical features of ileal Crohn’s disease include

  • association with tobacco consumption (True)
  • Explanation: In contrast to ulcerative colitis
  • presentation with bloody diarrhoea (False)
  • Explanation: Usually pain rather than diarrhoea unless there is rectal involvement also
  • presentation with subacute intestinal obstruction (True)
  • Explanation: With episodes of colicky pain
  • segmental involvement of the colon and rectum (True)
  • Explanation: In contrast to ulcerative colitis
  • inflammatory changes confined to the mucosa on histopathology (False)
  • Explanation: Inflammation is transmural

Question 38. The typical features of the irritable bowel syndrome include

  • nocturnal diarrhoea and weight loss (False)
  • Explanation: Such symptoms suggest organic pathology
  • onset after the age of 45 years (False)
  • Explanation: Typically affects females aged 16-45 years
  • history of childhood abdominal pain (True)
  • Explanation: Many also have dyspeptic and urinary symptoms
  • right iliac fossa pain and urinary frequency (True)
  • Explanation: Pain may be relieved by defaecation
  • abdominal distension, flatulence and pellety stools (True)
  • Explanation: May be tenesmus, mucus PR and diarrhoea

Question 39. The management of the irritable bowel syndrome should include

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

Question 40. Typical features of colonic diverticulosis include

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

Question 41. Typical features of colonic diverticulitis include

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

Question 42. Typical features of pseudomembranous colitis include

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

Question 43. Familial adenomatous polyposis is

  • inherited as an autosomal recessive trait (False)
  • Explanation: Autosomal dominant with a prevalence of 1 in 14 000
  • usually clinically apparent before the age of 10 years (False)
  • Explanation: Typically presents in the age group 20-40 years
  • likely to progress to carcinoma before the age of 40 years (True)
  • Explanation: Carcinoma is usually present when symptoms commence
  • associated with gastric and small bowel polyps (True)
  • Explanation: Also with lipomas, epidermoid cysts, osteomas and desmoid tumours
  • best treated with immunosuppressant therapy in patients aged < 20 years (False)
  • Explanation: Immunosuppressives have no role; prophylactic colectomy is warranted

Question 44. In colonic carcinoma

  • of the caecum, presentation with iron deficiency anaemia is typical (True)
  • Explanation: Non-specific presentation leads to diagnostic delay
  • obstruction is typically an early event in carcinoma of the sigmoid (True)
  • Explanation: Late event in right-sided tumours
  • metastatic spread is to the lungs rather than the liver (False)
  • Explanation: Portal venous dissemination to the liver is typical
  • concomitant multiple tumours are present in 20% of patients (False)
  • Explanation: Synchronous tumours occur in 2%
  • rising serum carcinoembryonic antigen (CEA) levels post-resection suggest recurrent tumour (True)
  • Explanation: But too insensitive for initial routine diagnostic purposes.

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