The Royal Australian College of Physicians



The Royal Australian College of Physicians

2000 Written Examination

Paper 1 – Medical Sciences 2 hours

Paper 2 – Clinical Applications 3 hours

FRACP 2000 PAPER 1 – MEDICAL SCIENCES

Infectious Disease

1. An 18-year-old male presented with fevers and myalgia for 1 week. Examination reveals an inflamed throat an cervical lymphadenopathy. Paul-Bunnel test is negative on two occasions one week apart. Blood film shows numerous atypical lymphocytes and lymphocytosis. The most likely diagnosis:

a) EBV

b) CMV

c) Toxoplasmosis

d) HIV

e) Staphylococcus

(a)

2 Which of the following is most likely to result in transmission of Hepatitis C virus

a) Intravenous drug use

b) Vaginal delivery in a HepC Ab positive, PCR negative mother

c) Vaginal delivery in a HepC Ab positive, PCR positive mother

d) Multiple sexual partners without protection

e) Breast feeding with a HepC Ab positive, PCR negative mother

(?)

3. Which is the most likely mechanism of Strep, pneumoniae resistance?

a) Plasmid mediated βlactamase protein

b) Chromosome mediated βlactamase protein

c) Plasmid mediated penicillinase protein

d) Altered permeability of cell membrane to drug

e) Altered penicillin binding protein

(e)

4. A patient has a lump removed from his forearm. (photograph of histology shown). Histology shows central area of fibrinoid necrosis surrounded by pallisading histiocytes and a chronic inflammatory cell infiltrate. The nodule is most likely due to:

a) Sarcoid

b) Tuberculosis

c) Infected sebaceous cyst

d) Rheumatoid nodule

e) Gouty nodule

(d)

5. A 78 year old man presents with community acquired prostatitis. The most likely causative organism:

a) Staph. Aureus

b) E. coli

c) Proteus mirabilis

d) Pseudomonas spp

e) Chiamydia

(a)

6. The most important factor in the development of resistant herpes simplex virus is:

a) prolonged acyclovir prophylaxis

b) prolonged acyclovir treatment

c) size of herpetic lesions

d) degree if immunosupression

e) subtherapeutic doses

(d)

7. The organism most likely to cause nursing home acquired pneumonia:

a) Streptococcus pneumoniae

b) Haemophilus influenza

c) Branhamelia catarrhalis

d) Legionella pneumophilia

e) Staphylococcus aureus

(a)

8. The vaccine that is most likely to cause problems in an immunocompromised patient is:

a) HAV

b) HBV

c) Polio (sabin)

d) Tetanus toxoid

e) Influenza

©

PAPER 2 - CLINICAL APPLICATIONS

9. Patient with pancreatitis is on parenteral nutrition through a central line. He develops persistent fevers. Candida knizei is grown on blood cultures. Best initial treatment is:

a) Continue current treatment

b) Start fluconazole and keep intravenous lines in

c) Start fluconazole and remove lines

d) Start amphotericin and keep lines in

e) Start amphotericin and remove lines

(e)

10. An 80-year-old female from nursing home presents to Accident and Emergency department with a non-healing venous ulcer on the medial aspect of her leg. The ulcer is clean with no surrounding cellulites. Her MSU shows >100 white cells, no red cells. Urine culture grows E .coli > 105. What would you do for this woman’s urine result:

a) treat with antibiotics

b) treat with urinary alkalinisation

c) cranberry juice

d) no treatment

e) long-term prophylactic antibiotics

(?)

11. A 27-year-old male, visited Burma for 10 days, has been back for 2 days when he

presents to the emergency department with fever, rigors, headache, tachycardia, petechial rash on legsand torso (photo shown). Hb 14, WCC 3,4, platelet 60. Temp 38.90C. HR 90/min. Next investigation most likely to give diagnosis:

a) HIV Antibody

b) Thick and thin blood film

c) Dengue serology

d) Stool culture

e) Blood culture

(b)

12. A 54-year-old male with a history of chronic renal failure and diabetes was admitted with a perforated bowel secondary to diverticular disease. After laparotomy and lavage, blood culture grew Enterobacter sensitive to ceftriaxone. He was commenced on ceftriaxonde and metronidazole. Fevers pesisted and there was no improvement after 3 days. CT abdo shows no collection or abscess. Repeat blood cultures grow Enterobacter again. Next best action:

a) Continue on same antibiotics

b) Repeat laparotomy

c) Change to meropenem

d) Add vancomycin to existing regime

e) Cease ceftriaxone and add ampicilin and gentamicin to metronidazole.

©

13. A 46-year-old man presents with acute respiratory distress and has oral candidlasis. PO2 of 55 on ABG and diffuse bilateral pulmonary infiltrates on CXR. Sputum stains positive on silver stain. Best initial treatment.

a) IV ltraconazole

b) IV ltraconazole and prednisone

c) Amphotericin

d) IV cotrimoxazole

e) IV bactin(?) and prednisone

(e)

14. A patient is admitted with community acquired bacterial meningitis. Culture sensitivity is forthcoming. Ceftazidime and penicillin are started. Activity against which of the following organisms is the rationale for the addition of penicillin:

a) Pneumococcus

b) Klebsiella

c) Neiseria meningitis

d) Listeria monocytogene

e) E.coli

(?)

15. A 31-year-old Cambodian man presents with the nephrotic syndrome. Albumin 23, urine protein 7gm per day, serum creatinine 0.08. The investigation least likely to be helpful in the diagnosis is:

a) Hepatitis B antibody

b) Syphilis serology

c) Mantoux test

d) Malaria film

e) ANA

(?)

16. A 38-year-old man presents with fever and rigors. He had just returned from a trip to Africa 8 weeks ago. He took mefloquine for prophylaxis until two weeks after returning. His peripheral blood film now shows Plasmodium vivax in 1% of the red cells. What is the next best treatment?

a) doxycycline for 3 days

b) 3 days of chloroquine followed by 7 days doxycycline

c) one dose mefloquine followed by 14 days primaquine

d) 3 days choloroquine followed by 14 days primaquine

e) doxycycline stat

(?)

PAPER 1 - MEDICAL SCIENCES

Oncology:

1. A 48-year-old male on methotrexate for psoriasis received a course of co-trimoxazole for a urinary tract infection. He develops mucositis. His FBC shows mild pancytopenia. He is given folinic acid and he improves. The mechanism of folinic acid in this situation is:

a) reduced protein binding

b) inhibition of dihydrofolate reducatase

c) provides source of reduced folate

d) increased renal excretion of methotrexate

e) increased intracellular concentration of methotrexate.

©

2. Which is true regarding the G2 phase of the cell cycle?

| |DNA Replication |Microtubule Production |Other Protein Production |

|a) |Low |Low |Low |

|b) |Low |Low |High |

|c) |Low |High |High |

|d) |High |High |Low |

|e) |High |High |high |

©

3. Which is antineoplastic agent is least toxic to bone marrow?

a) Decreasing palatal oedema

b) Increasing functional residual capacity

c) Carboplatin

d) Etoposide

e) Vincristine

(?)

4. In a post menopausal woman with carcinoma of the breast whish of the following is first line hormonal treatment for breast cancer:

a) oestrogen

b) progesterone

c) androgens

d) anti-oestrogens

e) aromatase inhibitors

(?)

PAPER 2 - CLINICAL APPLICATIONS

5. A 71-year-old woman who lives alone presents to the emergency department following a 2 month history of increasing back pain. X-ray of thoracolumbar spine (shown) – crush fracture of one thoracic vertebrae and osteophytic lipping on other vertebrae (which appear very dense and opacified). Most likely diagnosis:

a) Myeloma

b) Breast cancer

c) Lymphoma

d) Pagets

e) Osteoporosis

(b)

6. The factor most associated with a poor prognosis in operable breast cancer is:

a) her-2-neu mutation

b) Hormone receptor status

c) Tumour grade

d) Nodal status

e) Tumour size

(?)

7. A change in which of the following protein or gene is responsible for drug resistance in tumours?

a) p-glycoprotein (MDR)

b) p53

c) Bc12

d) Cytochrome P450

e) Thiopurine S-menthyltransferase

(?)

8. The reason for frequent follow up of a patient after complete locally excised melanoma is for the early detection of which of the following:

a) new primary lesion

b) lymph node metastases

c) recurrence at primary site

d) systemic metastases

e) ??

(a)

PAPER 1 - MEDICAL SCIENCES

Gastroenterology

1. The most efficacious drug to prevent a gastric ulcer whilst using an NSAID is:

a) misoprostol

b) omeprazole

c) sucralfate

d) ranitidine

e) risprolol

(b)

2. The most important mechanism/cause of reflux oesophagitis is:

a) Sliding hiatus hernia

b) Smoking > 20 cigarettes per day

c) Increased frequently of transient lowering of oesophageal sphincter tone

d) Decreased oesophageal motility

e) Chronically decreased lower oesophageal sphincter tone

(?)

3. NSAID’s that are COX-2 specific have the greatest reduction in which adverse reaction compared to non-specific NSAID’s

a) renal failure

b) hypertension

c) gastroduodenal ulceration

d) rsh

e) headache

©

4. In the treatment of Hepatitis C with interferon-a which is the most predictive of a poor response to treatment (defined as a persistent elevation of ALT)

a) Age of patient

b) Pre-treatment ALT level

c) Presence of cirrhosis

d) Viral genotype

e) HCV RNA level (viral load)

(?)

5. Best indicator of acute exacerbation of chronic hepatitis B infection:

a) HepB SAg

b) HepB Sab

c) Hep B core 1gM

d) Hep B e Antigen

e) Hep B e Ab

(a)

PAPER 2 - CLINICAL APPLICATIONS

6 Young male intravenous drug user was found unconscious, hypotensive with a syringe lying next to the bed. Resuscitated by ambulance officers with CPR and Naloxone and brought to hospital in a stable condition. Two days later in hospital, LFT’s noted to be abnormal:

bilirubin 37

ALP 251

AST 12653

ALT 11982

GGT 192

The most likely cause of the abnormal LFT’s?

a) Acute hepatitis A

b) Acute hepatitis C

c) Ischaemic hepatitis

d) Drug induced

e) Liver abscess

©

7. A middle aged man with past history of heavy alcohol intake. He has not taken alcohol in the last two years. He presents with four weeks of increasing abdominal girth and leg swelling. He is afebrile, icteric, confused, has adcites and leg oedema, and a metabolic flap is present.

Bilirubin 35 ALT 90 Platelets 90

ALP 460 AST 85 INR 1.5

yGT 160

A CT of the liver is shown see NEXT PAGE:

What is the cause of his hepatic decompensation:

a) Hepatitis

b) Hepatocellular carcinoma

c) Portal vein thrombosis

d) Liver abscess

e) Metastatic disease

(?)

8. A 50-year-old male with epigastric pain. Abdominal ultrasound shows two large (3-4cm) cystic lesions. Endoscopy shows gastritis and biopsy is positive for H. pylori. Treatment with H2 antagonists fixes epigatric pain. LFT’s normal. Nil fevers, weight loss or RUO tenderness. Abdominal CT shows two large hypodense lesions on liver and some smaller ones peripherally. Most likely diagnosis:

a) liver metastasis

b) benign liver cysts

c) haemangiomas

d) liver abscesses

e) hyhdatid disease

(?)

9. A 36-year-old man with Crohn’s disease has 50 cm terminal ileum resected for iteitis. He presents with watery diarrhoea usually occurring in the morning. There is no blood or mucus with the stools. On examination there is no abdominal tenderness and stool microscopy is normal. What is the most appropriate management?

a) Metronidazole

b) Predniso(lo)ne

c) Azathioprine

d) Cholestyramine

e) Mesasal

(d)

10. Which of the following is most likely to delay the need for liver transplantation in primary biliary cirrhosis

a) methotrexate

b) surgery

c) ursodeoxycholic acid

d) Prednisone

©

11. Which of the following is the most accurate description of Hepatitis E virus infection?

a) Parenteral transmission, acute illness, no mortality

b) Enteric transmission, acute illness, increased mortality in pregnancy

c) Enteric transmission, chronic illness

d) Parenteral transmission, high mortality

e) Route of transmission unknown.

(?)

12. A middle aged woman presents with watery diarrhoea for two years. She denies laxatives use. There is no blood in the stools and no abdominal pain. There is no family history of colonic polyps. Urinary Ko 50 mmol/L, serum K0 3.1. ESR normal, FBC normal. (Colonoscopy shown; melanosis coli). What is the next appropriate step?

a) upper gastrointestinal endoscopy and biopsy

b) test stool and urine for laxative

c) xylose C14 breath test

d) antibiotics

e) small bowel enema

(b)

13. Repeat question on patient who needs radiolabelled hepatic scan.

14. A patient with Crohn’s disease presents with fever and abdominal discomfort. He takes sulindac 1 gm bd and prednisone 10 mg daily. On examination there is right iliac fossa tenderness. CT shown below

What is the next appropriate management:

a) IV hydrocortisone and IV antibiotics

b) IV antibiotics

c) Increase dose of Sulindac

d) Laparotomy

e) Increase Prednisone dose

(?)

15. A 63-year-old man has a 4-month history of low abdominal pain, increasing constipation and bright red bleeding. Double contrast barium enema shown – diverticular disease descending colon and narrow, irregular segment – 10 cm of sigmoid colon.

a) Ultrasound

b) CT scan

c) Colonscopy

d) High fibre diet and antispasmodics

e) Surgery

(?)

16. A 52-year-old lady presents with symptoms of gastritis. Endoscopy shows evidence of MALT lymphoma. H. pylori positive. Physical examination, CT chest/abdo/pelvis and galliumscan normal. Best initial treatment?

a) Combination chemotherapy

b) H. pylori eradication

c) Single agent chemotherapy

d) Irradiation

e) Gastrectomy

(b)

PAPER 1 - MEDICAL SCIENCES

Pharmacology

1. With the treatment of Chlamydia trachomatis, doxycycline for 7 days is used, but a single dose of azithromycin is used because of:

a) lower bacterial concentration in serum

b) high serum level

c) long intracellular half life

d) post dosage effect

e) lower renal clearance

©

2. Concerning a medication, which has been, commenced a once daily medication dose, with an elimination half-life of 48 hours. The drug will continue to accumulate for:

a) 2 days

b) 4 days

c) 10 days

d) 16 days

e) indefinitely

©

3. A drug is cleared 80% in the kidneys and 20% is metabolized in the liver. If the usual dose is 100 mg what dose should be given to a patient with 25% of renal function:

a) 80 mg

b) 20 mg

c) 40 mg

d) 25 mg

e) 60 mg

©

4. A patient is clinically stable on a fixed dose of Lithium carbonate. Which of the following is most likely to cause an increase in the lithlum level?

a) Cimetidine

b) Probenecid

c) Bendrofluozide

d) NSAID’s

e) Erythromycin

©

5. Five drugs with different log concentration and effect

Which drug has the most potency?

a) drug

b) drug B

c) drug C

d) drug D

e) drug E

(a)

6. Which of the following NSAID’s is most likely associated with haemorrhagic cystitis:

a) Sulindac

b) Naprosyn

c) Ketoprofen

d) Tiaprofenic acid

e) Piroxicam

(d)

7. Which causes the least reduction of protein binding of phenytoin?

a) Pregnancy

b) Chronic renal failure

c) Chronic liver failure

d) Warfarin

e) Carbamazepine

(e)

9. In a 70 kg person, which has the slowest clearance from plasma, given that:

|DRUG |Vd (L) |T½ (h) |

|Amiloride |1190 |21 |

|Amiodarone |4620 |600 |

|Dapsone |70 |22 |

|Tolbutamide |7 |6 |

|Trimethoprim |126 |11 |

a) Amiloride

b) Amiodarone

c) Dapsone

d) Tolbutamide

e) Trimethoprim

(b)

PAPER 2 - CLINICAL APPLICATIONS

10. A 53-year-old woman collapsed and was resuscitated by ambulance officers. She had a history of hay fever. She was started on Erythromicin four days ago for treatment of an upper respiratory tract infection. On arrival in the Emergency department an ECG showed prolonged QT interval. The Interaction with which of the following drug is the most likely cause of her collapse.

a) Asthma

b) Pulmonary embolus

c) Diastolic dysfunction

d) Myocardial ischaemia

e) Interstitial pulmonary fibrosis

©

11. An inadequately small response to codeine phosphate is likely due to which of the following phenotypes of polymorphic drug metabolizing enzymes?

a) Slow acetylator (N-acetyl transerase deficiency)

b) Poor metaboliser (cytochrome P450 2D6 deficiency)

c) Inadequate hydroxylation of mephenytoin

d) Atypical anticholinesterase

e) Rapid metaboliser (multiple copies of gene coding for cytochrome P450 2D6).

(b)

12. The reason why elderly people are more prone to adverse drug reactions compared to the young is due t which one of the following:

a) Altered pharmacokinetics

b) Altered phrmacodynamics

c) Reduced homeostatic mechanisms

d) Other co-morbidities

e) Polypharmacy

(e)

PAPER 1 - MEDICAL SCIENCES

Cardiology

1. The most specific finding for hypertrophic cardiomyopathy on M-mode echo is:

a) delayed closure of the aortic valve

b) anterior systolic mitral valve motion

c) ratio of the thickness of the septum to the posterior ventricular wall of greater than 1.3:1

d) LVOT obstruction

e) Reduced E-A ratio

©

2. What is the commonest complication related to coronary angiography

a) myocardial infarction

b) ventricular fibrillation

c) arterial false aneurysm

d) stroke

e) contrast reaction

© or (e)

3. Which of the following interventions would be least helpful in lowering blood pressure:

a) Weight reduction

b) Reduction in salt intake

c) A daily exercise program

d) Smoking cessation

e) Reducing ethanol consumption to less than 10 grams a day.

(d)

PAPER 2 – CLINICAL APPLICATIONS

4. A 35-year-old man presents with central chest pain worse on inspiration. BP 130/80: Temperature 37.80 C. JVP not elevated. No murmurs, no pleural rub. ECG shown opposite.

What is the likely diagnosis:

a) AMI

b) Pericarditis

c) Pulmonary embolism

d) Acute dissection

e) Pneumonia

(?)

6. A 62-year-old woman with history of essential hypertension has increasing exertional dyspnoea. She has no wheeze and respiratory examination is normal. Pulses are regular at 80/min. BP 170/90 mmHg, JVP not elevated, no oedema. Echo shows normal LV systolic function with mild left ventricular hypertrophy. Which of the following is the likely cause of her dyspnoea.

a) Asthma

b) Pulmonary embolus

c) Diastolic dysfunction

d) Myocardial ischaemia

e) Interstitial pulmonary fibrosis

(?)

6. What is the least likely finding with proximal aortic dissection:

ST-T changes on ECG

a) Aortic regurgitation

b) Chest pain

c) Hypotension

d) Difference in brachial blood pressures

(?)

7. The following cardiac Doppler flow pattern in the left ventricular outflow tract is due to which of the following:

a) Mitral stenosis

b) Aortic insufficiency

c) Aortic stenosis

d) Aortic regurgitation and aortic stenosis

e) Aortic stenosis and mitral regurgitation

(?)

8. A 57-year.old has exertional chest on moderate activity. He is hypertension which is treated with Captopril, and he takes ibuprofen for osteoarthritis. His body mass index is 30. W:H ratio 1.1. total cholesterol 6.0 triglyceride 2.0. HDL 0.7. LDE 4.0. random blood glucose 6.5. creatlinine 0.09. What is the next appropriate management?

a) Hypocaloric diet with weight loss of 2 kg. per week

b) Hypocaloric diet with weight loss of 0.5 kg per week

c) Reduced sucrose, reduced cholesterol diet

d) Low cholesterol with low intensity aerobic activity

e) Low cholesterol, hypocaloric diet with resistance exercises

9. A 60-year-old man is admitted to the surgical ward for a cholecystectomy. He has no symptoms attributed to cardiac diseases. You are asked to see him because his preoperative ECG was abnormal

The next most appropriate step is:

a) No further investigation

b) Exercise stress test

c) Dobutamine echo

d) Thallium scan

e) Coronary angiography

(a)

Respiratory Paper 1 - Medical Sciences

1. In a patient with idiopathic pulmonary fibrosis, which of the following cell types when found to predominate in the bronchioalveolar lavage, will be associated with the best response to treatment ?

a) CD8 lymphocytes

b) Macrophages

c) Neutrophils

d) CD4 lymphocytes

e) Eosinophils

(d)

2 A 67-year-old woman with severe COAD has an overnight sleep study. There is no evidence of obstructive sleep apnoea, but there are three episodes of recurrent desaturation of oxyhaemoglobin. The most likely cause:

a) SWS (slow wave sleep) related upper airway narrowing

b) REMS related increase in ventilation-perfusion mismatching

c) SWS related reduction in cardiac output

d) REMS related reduction in respiratory drive

(e)

3. What is the mechanism of nasal CPAP for obstructive sleep apnoea?

a) Decreasing palatal oedema

b) Increasing functional residual capacity

c) Augmenting the genioglossus muscle

d) Pneumatic splinting of the upper airway

e) Reducing the closure of the epiglottis

(d)

Paper 2 - CLINICAL APPLICATIONS

4. The next best management:

a) Volume infusion

b) Increase PEEP

c) Increase F102

d) Transfusion of packed red blood cells

e) Increase ventilation rate

(a)

5 A 43-year-old woman presents with increasing dyspnoea and wheeze. Spirometry shows limitation of flow during inspiration with a plateau effect on the inspiratory phase. (No spirometry shown). What is the likely cause?

e) Variable extrathoracic obstruction

f) Variable intrathoracic obstruction

g) Fixed intrathoracic obstruction

h) Fixed extrathoracic obstruction

i) Widespread intrapulmonary obstruction.

(?)

10. A 38-year-old woman presents with increasing shortness of breath while vacuuming. She arrived on a flight from London one week ago. Her spirometry FEV1 FVX 80%, (CXR shown: plate atelectasis right lower zone). ABG pH 7, 46, Pco2 28, PO2 8.

11. Ventilation- perfusion lung scan

12. High resolution chest CT

13. Lung function tests

14. Bronchoscopy

15. Echocardiogram

(a)

7. A 54-year-old man presents with a history of jfever an haemoptysis. The CXR shows right midzone and upper zone patchy opacification. No organisms are cultured from the sputum. What is the next appropriate step:

a) CT scan of the chest

b) Bronchoscopy

c) ZN stain of the sputum

d) Sputum culture

©

Paper 1 – Medical Sciences

Renal Medicine:

1. Which of the following least affects water resorption in the collecting tubules of the kidney?

16. ADH

17. Mineralocorticoid receptors

18. G protein

19. Aquaporin

20. Adenyl cyclase

2. A 25-year-old female presents to the Accident and Emergency Department with left-sided renal colic and macroscopic haematuria. She has had several similar presentations to other hospitals. On examination she has a temperature of 37.50C and there is left loin tenderness. Which of the following is least likely to cause this condition.

a) Goodpasture’s syndrome

b) Polycystic kidney disease

c) Narcotic abuse

d) LgA disease

e) Warfarin

?

3. In a pregnant woman which of the following best differentiate chronic hypertension from pre-eclampsia

a) proteinuria

b) BP less than 160 systolic

c) Onset of hyperiension before 15 weeks of pregnancy

d) Family history of hypertension

e) Haematuria

(?)

4. What is least likely to be seen in the renal pathology of Wegener’s granulomatosis?

a) Crescents

b) Focal necrosis

c) LgG

d) Lymphocytes

e) Macrophages

(?)

5. A patient with pancreatic insufficiency refuses to take pancreatic supplements. He later presents with renal calculi. Increased excretion of which of the following is the most likely cause of the renal calculi?

a) urate

b) phosphate

c) bicarbonate

d) oxalate

e) cysteine

(d)

Paper 2 - Clinical Applications

6. Previously person was found to have a BP of 170/105 on a routine insurance check up. He is on no medication and a normal diet. Serum K* 2.8, serum Na* 145, Cr 0.09, (Bicarb not given). Serum aidosterone 800. Serum renin 150. This clinical picture is most consistent with the following diagnosis:

a) essential hypertension

b) renovascular hypertension

c) Cushing’s syndrome

d) Conn’s syndrome

e) Licorice induced hypertension

(?)

7. A 46-year-old male presents to Accident and Emergency Department with right-sided abdominal pain. Several years ago he had a nephrectomy on the left side because of a staghom calculus. He has passed very little urine over the last twelve hours. His temperature is 37.40C, he is tender on the right side of the abdomen and right flank.

Urea is 32 mmol/L K* 5.1 mmol/L Bicarb 21 mmol/L

Creatinine 0.41 mmo/L Na* 128 mmol/L

Ultrasound of the right kidney shows a calculus in the pelvi-ureteric junction with dilated pelvicalyceal system. What is the next appropriat e management:

a) haemodialysis

b) retrograde cytoscopy and pyelogram

c) intravenous pyelogram

d) urgent percutaneous nephrostomy

e) lithotripsy

(d)

8. Woman with history of SLE and progressive glomerulonephritis, commenced on prednisone and cyclophospamide. One month after treatment commenced a painful rash develops.

The suppressed immunological effector function responsible is:

a) NK cell

b) Complement

c) Cell mediated immunity

d) Antibody

e) Phagocytic function

©

9. A 50-year-old male with a 5-year history of nephrolihiasis presents with a renal stone, which is composed of calcium oxalate. The serum Calcium 2.35, phosphate 1.4, urate 0.32, creatinine 0.08. Urine shows hypercalciuria and hyper uricaemia. Treatment least likely to help:

a) Low calcium diet

b) Thiazide diuretic

c) Allopurinol

d) High fluid intake

e) Alkalinisation of urine

(a)

10. A 23-year-old pregnant woman presents with a blood pressure of 145/90mmHg at 32 weeks gestation. Her prepregnancy BP was 125/70. Currently Cr normal. LFT normal, electrolytes normal, FBC normal, Urinalysis ***protein. She is otherwise well. Best management:

a) Chlorothiazide

b) Bed rest

c) Irbesartan

d) Enalapril

e) Methyidopa

(?)

11. Persistent depression of C3 is associated with which type of glomerulonephritis

12. MCGN

13. Membranous GN

14. SLE

15. Post infectious GN

16. IgA nephropathy

(?)

12. A 48-year-old man presents with increasing generalized oedema and proteinuria of 8g/24 hrs. He was previously treated for nephrotic syndrome with initially some response to steroid therapy. A renal biopsy was performed . (note trichrome stain)

What is the diagnosis?

a) Focal segmental glomenilosclerosis

b) Membranous

c) Post infectious?

d) IgA nephropathy

e) Amyhloid?

(?)

13. The least likely feature of cyclosporin induced renal disease:

a) Interstitial fibrosis

b) Arterial endothelial injury

c) Reduced uric acid excretion

d) Altered potassium secretion

e) Glomerulopathy.

Paper 1 – Medical Sciences

Immunology:

1. When a T-helper cell interacts with an APC an important mechanism of co-stimulation is binding of B7 to CD28. In the absence of this co-stimulatory signal what is the least likely response of the lymphocyte:

a) apoptosis of the T cell

b) activation of B lymphocytes

c) anergy

d) produce Th1 cytokines

e) produce Th2 cytokines

(b)

2. The large granular cells seen in the early response to virally infected cells are:

a) Naïve T cells

b) B lymphocytes

c) Memory CD4 cells

d) Memory CD8 cells

e) Natural killer cells

(e)

3. Cytokine regulation (especially IL-2) is least likely to be affected by:

a) Prednisone

b) Mycophenolate mofetil

c) Cyclosporin A

d) Tacrolimus

e) Rapamycin

(b)

4. Which of the following best distinguishes Th2 from Th1

a) IL-3 production

b) IL-5 production

c) Response to antigen by macrophages

d) Surface expression of MHC II

e) Surface expression of CD4

(b)

5. Which of the following is least important in the killing of gram-positive pyogenic infection:

a) complement mediated C3a C5a anaphylatoxin

b) opsonisation

c) complement mediated leukocytosis

d) C3a and C5a mediated chemotaxis

e) C5-9 membrane attack complex

(?)

6. The class or subclass of immunoglobulin which binds weakly in early response to Pneumococcal polysaccharide is:

a) IgE

b) IgG1

c) IgG3

d) IgM

e) IgA

(d)

Paper 2 – Clinical Applications

13. Two photographs shown.

14. Picture of foot with large blisters, surrounding erythema:

15. Immunoflourescence stain of skin biopsy showing line of C3 immunoflourescence at interface between dermis and epidermis. Which one of the following is involved in the pathogenesis of this condition:

a) immunoglobulin

b) CD4 + T cells

c) CD 8 + T cells

d) Masts cells

e) Monocytes

(a)

16. 35-year-old male with a fever, bilateral lower limb rash, bilateral ankle arthralgia.

ESR raised

CRP raised

Most likely cause?

a) Sarcold

b) TB

c) Lymphoma

d) Reither’s disease

e) SLE

(a)

17. The most useful test to prove anaphylaxis after dental surgery where penicillin was given prophylactically:

a) RAST

b) Serum tryptase

c) Skin testing

d) ??

e) ??

(b)

18. A 50-year-old man has a long history of chronic asthma and fleeting infiltrates in his lung. He presents with worsening of his asthma, fever and left foot drop. And…

WCC 18.0 IgE 1250 (0 – 2550)

Eosinophils 3.6 (0.05 – 0.25)

He responded poorly to predniso(lo)ne but improved after the addition of cyclophosphamide. The most likely diagnosis is:

a) allergic bronchopulmonary aspergillosis

b) chronic eosinophillic pneumonia

c) extrinsic allergic alveolitis

d) exacerbation of asthma

e) Churg-Strauss syndrome

(?)

19. A 64-year-old lady has symptoms of painful, blue fingers in cold weather. X-ray shown calcinosis in pulps of fingers. Which of the following test is most likely to be positive?

a) Anti RNP

b) Anti pm SCL

c) Anti-centromere

d) Anti topoisomerase (SCL 70)

e) Anti filaggrin

(?)

20. A 31-year-old man with HIV on zidovudine, smoker since the age of 17, denies asthma. He develops left sided chest pain and dyspnoea. PR 120, RR 28. Temp. 38.5 SaO2 96*, CXR 45% pneumothorax on the left. Most likely cause?

a) Smoking related disease

b) HIV related

c) Strep. Pneumoniae

d) Pneumocystis carinli

e) Antiretroviral therapy

Paper 1 – Medical Sciences

Neurology:

1. Strongest independent risk factor for stroke

a) age

b) hypertension

c) cigarette smoking

d) obesity

e) sedentary lifestyle

(a)

2. A 20-year-old female presents with two days of reduced visual acuity in the left eye. A visual evoked response was performed with the following result.

What is the diagnosis?

a) retinal artery occlusion

b) retinal detachment

c) optic neuritis

d) retinal migraine

e) cortical stroke

(?)

3. Which of the following conditions is electromyography /nerve conduction studies least useful?

a) radial nerve daisy

b) deep branch of the ulnar nerve palsy

c) sciatica

d) polymyositis

e) carpal tunnel syndrome

(?)

4. Concerning DNA testing for Huntington’s disease, the best clinical value of the test is

a) to investigate a child

b) to investigate someone presenting with a tremor

c) to predict the age of onset

d) to investigate before clinical symptoms become evident

e) if it only involves the collection of a blood test.

(?)

5. An abnormality of which of the following tests would confirm the diagnosis of motor neuron disease?

a) Sural nerve biopsy

b) MRI of brain and spinal cord

c) EMG

d) Nerve conduction study

e) CSF for protein concentration

(?)

6. A 21-year-old student presents with right wrist drop. The most likely cause is damage to:

a) Left internal capsule

b) Right brachial plexus

c) Left C7 cervical nerve root

d) Right radial nerve

e) Left extensor digitorum comminis muscle

(?)

Paper 2 – Clinical Applications

7. A 28-year-old male develops an acute demyelinating polyneuropathy. Two weeks prior to this he had an episode of diarrhoea in which Campylobacter was isolated from the stool. The most likely relationship between Campylobacter and polyneruopathy:

a) coincidental

b) Campylobacter toxin

c) Molecular mimicry between Campylobacter antigen and myelin

d) Direct damage to neural tissue by Campylobacter

e) Spinal abscess

(?)

8. A 65-year-old male has had a left sided transient ischaemic attack. Carotid dopplers reveal an 80% stenosis in the left internal carotid artery. Next best treatment is:

a) Carotid angioplasty

b) Carotid endarterectomy

c) IPA to carotid artery

d) Warfarin

e) Commence Ticlopidine

(?)

9. Predniso(lo)ne is not a recognized treatment of which of the following:

a) Myasthaenia gravis

b) Polymyositis

c) Guillain-Barre syndrome

d) Temporal arteritis

e) Multiple sclerosis

(?)

10. A 16-year-old woman presents with several blank spells. The electroencephalogram shows right temporal lobe sharp waves. (ECG described, not shown) What is the drug of choice in the treatment of this condition?

a) Carbemazepine

b) Phenytoin

c) Lamotrigine

d) Vigabatrin

e) Ethosuxamide

(?)

10. A 24-year-old male had had epilepsy for nine years attends a neurology clinic in January 2000 because he has had three seizures in the last week. He currently takes Phenytoin after failing a trial of Carbemazepine due to gastrointestinal side effects. He works as a barman, drinks 5 to 6 standard drinks a day, and smokes 15 cigarettes a day. He also uses marijuana on a recreational basis.

| |Phenyhtoin | |Phenytoin Level |

| |Dose | | |

|September5, 1999 |360mg |Well |Normal |

|September 26, 1999 |360mg |Seizures, presented to ED: |Low |

| | |Dose | |

|October 11, 1999 |400mg | | |

|December 14, 1999 |330mg |Vertigo, nausea |High |

|January 6, 2000 |330mg |Well |Normal |

| | |seizures | |

What is the cause of the pattern shown above:

a) excessive alcohol intake

b) cigarette smoking

c) illicit drug use inducing hepatic enzymes

d) noncompliance

e) reduced gastrointestinal absorption secondary to antacids

(?)

12. A 23-year-old female presents with a tremor, worse on movement. Her thyroid function tests are normal. Which of the following is least likely to be associated with her condition?

a) Improvement with a beta blocker

b) Improvement with alcohol

c) Family history

d) Improvement with L-dopa

e) Worsening with anxiety.

(d)

Paper 1 – Medical Sciences

Endocrinololgy:

1. Which one of the following is least likely to be raised in the third trimester of pregnancy?

a) Total iron binding capacity

b) FT4

c) Protactin

d) Cortisol

e) Alkaline phosphatase

(?)

2. Which of the following best describes relationship between insulin resistance and ischaemic heart disease?

a) confined to hypertension

b) confined to diabetes

c) confined to obesity

d) independent of cholesterol

e) only if low HDL

(?)

3. Concerning the sick euthyroid syndrome. The least likely finding in a patient who is critically ill and euthyroid is:

a) Raised FT4

b) Low T3

c) Raised T3

d) Low TSH

e) High TSH

(?)

4. Which of the following biochemical changes is most associated with obesity:

a) decreased leptin

b) increased C-peptide

c) increased LDL

d) reduced insulin receptor sensitivity

e) increased blood glucose level

(?)

5. Which of the following has the least direct effect on the parathyroid hormone production:

a) parathyroid hormone

b) phosphate

c) ionized calcium

d) 1.25 Vit DOH

e) calcium receptor

(?)

6. A 28-year-old woman present with galactorrhoea. She has a history of hypothyroidism and takes 0.1mg Thyroxine a day. She also takes lithium carbonate for bipolar disorder and has levels in mid-normal range. She takes Metoclopramide 10mg for nausea and Diazepam 5 mg at night. Serum prolactin 1,8000 (N600). He was given hydrocortisone and thyroxine.

Next best management:

a) transphenoidal pituitary resection

b) transfrontal pituitary resection

c) bromocriptine

d) testosterone

e) radiotherapy

(?)

8. A patient presents with calcium of 2.7 mmol/L following a routine blood test. He is asymptomatic. A 24 hour urinary calium excretion is low. PTH is within the normal range; 24-hr urinary creatinine clearance is normal. Renal ultrasound is normal. What is the next best test?

a) 1.25 vitamin D

b) test the urinary calcium of first degree relatives

c) bone scan

d) ultrasound of the neck

e) PTHrP

(?)

9. A 78-year-old female presents with several months of malaise and fatigue. There is a palpable 4 cm nodule in right upper pole of thyroid. Scan shown – toxic MNG with patchy uptake (? Cold predominant nodule in right upper pole. Clinically euthyroid. Blood tests reveal TSH 0.02 (low). FT4 23 (upper limit 19). Most likely diagnosis:

a) Thyroidities

b) Thyroid cysts

c) Thyroid cancer

d) Toxic multinodular goiter

e) Autonomous nodule

(?)

10. A 63-year-old woman has three weeks of fatigue, palpitations, tremulousness and weight loss of 2 kg. She has had no recent exposure to iodine. On examination she is thin, BP 150/86 mmHg. Pulse 80/min and regular. Respiratory, cardiovascular, and abdominal examination is normal. There is proximal weakness. Hb 130, platelets 236, WCC 3.5, TSH ................
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