Question 1
Regarding hypertension, which one of the following statements is incorrect?
A.
Hypertension is a common transient complication of carotid endarterectomy
B.
populations following a diet low in dietary salt have negligible prevalence of
hypertension
C.
hypertension caused by fibromuscular dysplasia does not usually respond well to
single drug antihypertensive therapy
D.
with hypokalaemia, hyperreninaemia and low serum aldosterone is frequently seen in
Cushing’s syndrome
E.
with >30mM/24hr urinary potassium excretion when serum K is<3.5mM/L is suggestive
of primary aldosteronism
D


Up to 60% of Carotid EA get transient HT
In Cushing’s syndrome, K is low but both others are usually normal
Question 2
Which one of the following is incorrect with regards to MODY2?
A.
There is a defect in the glucokinase (GCK) gene on chromosome 7
B.
Inheritance is autosomal dominant
C.
It is associated with 60% reduction of insulin secretion
D.
There is a low incidence of microvascular complications
E.
It is often associated with the cluster of risk factors for macrovascular disease
E

MODY2 patients often have mild diabetes. Macro- and microvascular
complications are rare. There are more than 80 mutations on chromosome 7 in
the glucokinase gene, and it is an autosomal dominant disease.
Question 3
With regard to Cryptococcus neoformans infection in humans, which of the following is least
likely to be true?
A.
The ecological niche of C. neoformans var. neoformans (serotypes D and A) has not
been definitively identified
B.
The incidence in cryptococcosis in Australian aborigines is significantly higher (p<
0.05) than the incidence in the non-aboriginal population
C.
The incidence in HIV-infected patients has fallen dramatically in the last 5-10 years
D.
In immunocompetent patients, the infection is nearly always caused by C. neoformans
var. gattii (serotypes B or C)
E.
The cryptococcal latex agglutination antigen test is a sensitive and specific test for
infection even in patients with only pulmonary disease.
D


Although serotypes A and D is classically “associated” with pigeon droppings,
the organism is widespread in other organic material including plant matter,
insects etc.
Although var. gattii infection almost always (<90%) infects immunocompetent
hosts, these patients as a group are still most commonly suffer from var.
neoformans infection.
Question 4
Concerning fluid and electrolyte balance, which one of the following statements is incorrect?
A.
Thiazide diuretics act in the early distal tubule.
B.
In diabetic ketoacidosis urinary sodium concentration is typically <20mM/L
C.
non steroidal anti-infalmmatory drugs are a common cause of hyperkalaemic distal
renal tubular acidosis
D.
respiratory acidosis leads to a net decrease in urinary potassium excretion
E.
resistant hypokalaemia occurs with magnesium deficiency
B

there is salt wasting caused by osmotic effects of ketone bodies which drives
the hypovolaemia
Question 5
Which of the following is most correct regarding Clostridium difficile colitis?
A.
Culture of C. difficile from the stool is the most appropriate diagnostic test
B.
It is more common after the use of intravenous antibiotics as compared to oral
antibiotics
C.
Age is not a known risk factor
D.
Approximately 20% of patients will have relapse of disease after treatment cessation
E.
Vancomycin is superior to metronidazole in treatment efficacy, but less cost-effective
D

Culture has a controversial role; culture requires special media. The most
appropriate test is the detection of cytotoxin in the stool. Culture can be used to
facilitate diagnosis in uncertain cases.




More common after oral antibiotics, and can occur with even a single dose of
oral cephalosporin.
The following are known risk factors: elderly age, being bedridden, underlying
infection and use of antibiotics (~70% of cases are associated with clindamycin)
Recurrence occurs in 12-24% of cases. Recurrent disease is difficult to treat and
is characterised by frequent further recurrences.
Oral metronidazole and vancomycin are of equal efficacy, but metronidazole is
the recommended first-line treatment as it is more cost-effective, and due to
concerns regarding VRE
Question 6
Regarding bronchiectasis, which one of the following statements is correct?
A.
Immunoglobulin deficiency occurs in the majority of cases
B.
Bronchiectasis first presents in the lingula in cystic fibrosis
C.
Bronchiectasis is localised to a single lobe in Primary Ciliary Dyskinesia
D.
Bronchiectasis with dextrocardia suggests reverse beating of the cilia
E.
Bronchiectasis can be found in patients with normal ciliary beating
E
Question 7
Regarding Helicobacter pylori, which one of the following statements is correct?
A.
Eradication of H. pylori alone induces regression of gastric MALT lymphoma in the
majority of cases.
B.
Eradication of H. pylori improves symptoms in the majority of infected patients with
non-ulcer dyspepsia.
C.
Serologic testing is of use in determining the success of eradication of H. pylori in the
first 4 weeks after therapy, while the urea test may be falsely positive.
D.
Intestinal metaplasia is more likely in antral than in corpus-predominant H. pylori
gastritis.
E.
Most antimicrobial agents active against H. pylori are more effective at lower gastric
pH.
A
(reference NEJM 347, 15; Oct 10, 2002)
 but no long term data to confirm that remission of MALT is maintained
 only 9% with non-ulcer dyspepsia have improvement of symptoms
 serology of little use in follow-up, and urea test false negative in first 4 weeks
 only duodenal ulcer is more common in antral predominant

always combine antimicrobials with proton-pump inhibitors or ranitidine to
increase pH
Question 8
The cytokine released from Th2 (type 2) cells most responsible for production of IgE is:
A.
IL-4
B.
IL-5
C.
IL-6
D.
TGF-beta
E.
IL-10
A
Question 9
Regarding pregnancy, which one of the following statements is true?
A.
hypertension noted in the 18th week of gestation is most likely to be caused by preeclampsia
B.
hyperuricaemia associated with pre-eclampsia results from decreased proximal
tubular urate secretion
C.
renal transplant recipients intending to conceive should be converted from azathioprine
to an alternative immunosuppressive agent to avoid tetatogenic effects
D.
pre-eclampsia is less common in women with pre-existing renal impairment
E.
pregnancy does not provoke relapses of nephrotic syndrome in minimal change
disease
E
Question 10
Regarding cystic fibrosis, which one of the following statements is correct?
A.
Is uniformly fatal before the age of 35 years
B.
Is most common lethal inherited condition affecting Negroes
C.
Presents as meconium ileus in the majority of cases
D.
Is associated with an increased risk of pancreatic cancer
E.
D
In women only affects the respiratory tract
Question 11
Concerning systematic reviews and meta-analysis, which one of the following statements is
incorrect?
A. By combining data will increase the statistical power of results
B. If combining sufficient studies performed in different settings, will enhance the
transferability of the results
C. Can allow small biases to become exaggerated into apparent effect
D. Can be undertaken only using data from randomised controlled trials
E. Do not always provide the highest level of evidence
D
Question 12
Regarding clinical trials, which one of the following statements is correct?
A. A randomised controlled trial is the best design for establishing the burden of illness
within a population
B. A cross-sectional study is the usual design for establishing aetiology of illness
C. Coin tossing and allocation by day of week at presentation are both examples of
adequate randomisation methods.
D. Clinically important effects have a p value of <0.05
E. Publication bias is when results of a trial are reported and published more than once
in different journals
D
Question 13
In the setting of nosocomial candidaemia, which of the following is most likely to be true?
A.
Trauma is not a risk factor
B.
In Australia, infection is usually (>90%) caused by Candida albicans
C.
Transmission of Candida from health care worker’s hands to patients is an important
infection control issue
D.
Mucosal colonisation by Candida is not a significant predictor of invasive disease
E.
Antifungal prophylaxis in the ICU setting is an accepted preventative measure
C
Question 14
Concerning nephrotic syndrome, which one of the following statements is incorrect?
A.
membranous nephropathy is the most common cause of nephrotic syndrome in adults
B.
platelet aggregation is enhanced
C.
increased hepatic synthesis of high density lipoproteins (HDL) results in high circulating
levels of HDL
D.
may occur in HIV infection as a consequence of focal segmental glomerulosclerosis
E.
may accompany acute interstitial nephritis caused by non-steroidal anti-inflammatory
agents
C

HDL is lost in the urine; it is VLDL, IDL and LDL which rise
Question 15
With regard to invasive aspergillosis (IA) in organ transplant recipients, which of the
following is most likely to be correct?
A.
The chest X Ray is a clinically useful test for the diagnosis of pulmonary IA
B.
The presence of CMV disease is significantly associated with the likelihood of
developing IA
C.
Treatment of IA with lipid amphotericin preparations leads to better patient outcomes
than with conventional amphotericin B
D.
Autologous HSCT recipients experience a similar risk as allogeneic recipients of
developing IA
E.
In general, the isolation of Aspergillus from respiratory secretions is a good predictor of
invasive disease.
B
Question 16
Which one of the following is FALSE regarding absorption in the gut?
A.
Proteins are degraded to amino acids in the second part of the duodenum
B.
Lactose is hydrolysed by disaccharidases
C.
Chylomicrons are formed in the enteric mucosa
D.
There is a sodium-glucose cotransport pump in the small intestine
E.
B12 absorption occurs mainly in the terminal ileum
A


Proteins are acted upon by peptidases in the latter part of the duodenum
(pancreatic enzymes) and jejunum
Lactose is a disaccharide composed on glucose and galactose. The brush
border is abundant in disaccharidases



The apolipoproteins that bind to the fatty acids absorbed from the gut are
produced in the enterocyte's SER
The sodium-glucose pump is the basis for using glucose-salt mixtures in oral
rehydration fluids
B12 mainly absorbed in terminal ileum
Question 17
Regarding Thrombotic Thrombocytopaenic Purpura (TTP), which one of the following
statements is correct?
A.
The platelet thrombi contain fibrinogen (or fibrin).
B.
In most cases of idiopathic TTP the activity of a von Willebrand factor-cleaving
metalloprotease is suppressed.
C.
Clopidogrel is indicated as prophylaxis in familial cases.
D.
Plasma exchange is of no additional benefit over plasmapharesis alone in adult
idiopathic cases.
E.
Low-dose aspirin paradoxically reduces haemorrhagic complications.
B
(reference NEJM 347, 8; Aug 22, 2002)
 the platelet thrombi contain von Willebrand factor, but not fibrin. In DIC, the
platelet thrombi contain fibrin but not vWF.
 ADAMTS 13 activity < 5%
 clopidogrel rarely causes TTP
 must both replace the metalloprotease, and remove the antibodies directed
towards it
 aspirin is contraindicated in TTP because it provokes haemorrhage
Question 18
Regarding Inflammatory Bowel Disease, which one of the following statements is correct?
A.
Patients with ulcerative colitis are more likely than normal individuals to express variant
NOD2 (CARD 15) cytoplasmic protein.
B.
Early appendectomy is associated with a reduced incidence of ulcerative colitis.
C.
Smoking is protective against Crohn’s disease.
D.
In ulcerative colitis, Th1 helper-T-cells predominate in the mucosa.
E.
Cyclosporine is useful in the treatment of Crohn’s disease, even in the absence of
severe perianal disease.
B
(reference NEJM 347, 6; Aug 8 2002)
 Patients with Crohn’s disease are more likely than normal individuals to express
variant NOD2 (CARD 15) cytoplasmic protein


Smoking is protective against UC. Increases risk in Crohn’s
Th1 in Crohn’s, Th2 in UC
Question 19
Which one of the following statements concerning the regulation of parathyroid hormone
and vitamin D in chronic renal failure is correct?
A.
Hyperphosphataemia has no direct effect on parathyroid hormone synthesis and
secretion.
B.
Hypocalcaemia acts on a cytosolic calcium sensing receptor to increase parathyroid
hormone synthesis and secretion.
C.
1,25 hydroxyvitamin D acts on a cell surface vitamin D receptor to stimulate
parathyroid hormone synthesis and secretion.
D.
Hyperphosphataemia stimulates 1 hydroxylation of 25 hydroxyvitamin D.
E.
Parathyroid hormone stimulates 1 hydroxylation of 25 hydroxyvitamin D.
E



Hyperphosphataemia stimulates parathyroid hormone synthesis and secretion
directly, and indirectly via its effect to inhibit activation of 25 hydroxyvitamin D,
and by complexing with calcium to reduce circulating ionised calcium.
The calcium-sensing receptor is membrane-bound and the vitamin D receptor is
cytosolic; hypocalcaemia stimulates and vitamin D inhibits parathyroid hormone
synthesis and secretion.
PTH increases fractional excretion of phosphate (thus reducing
hyperphosphataemia) and also activates 25 hydroxyvitamin D.
Question 20
The most common intranuclear antigen targeted in the serum of patients with lupus nephritis
is:
A.
Sm
B.
dsDNA
C.
SSA
D.
RNP
E.
Topoisomerase
B
Question 21
With regards to prostate cancer, which one of the following statements is true?
A.
Maximum androgen blockade using an oral anti-androgen and a LHRH agonist
improves survival compared to bilateral orchidectomy alone for patients with metastatic
disease
B.
Populations screening using serum prostate specific antigen and digital rectal
examination to diagnose localised prostate cancer has reduced mortality.
C.
A PSA level of 4 ng/ml twelve months after radical prostatectomy indicates the patient
has been cured
D.
Men with BRCA1 gene mutation have a greater than 80% life-long chance of dying
prostate cancer.
E.
Long term LHRH agonist treatment for prostate cancer leads to an increased risk of
osteoporosis-associated bone fracture.
E




A large randomised trial published in N Engl J Med ~1998 showed no survival
benefit for MAB.
Trials are underway but no reduction in mortality has yet been shown for
prostate cancer screening.
PSA should fall to zero after prostatectomy and to about 0.5 after radical
radiotherapy
There is an increased risk of developing prostate cancer with BRCA1 but it is
small.
Question 22
Which one of the following factors does not significantly affect graft survival rates one year
after renal transplant in Australia?
A.
Donor Age
B.
Cause of renal disease
C.
Cold ischaemia time 24 - 48 hours
D.
Recipient age
E.
Steroid immunosuppression
E
Question 23
Regarding corticosteroid therapy in giant cell arteritis, which one of the following is most
correct?
A.
An initial dose of 20mg Prednisolone daily is adequate in biopsy-proven giant cell
arteritis in the absence of visual symptoms.
B.
Even after unilateral visual loss, it is reasonable to delay steroid administration for a
matter of hours to maximise the diagnostic yield from urgent temporal artery biopsy.
C.
In maintaining clinical remision, alternate day oral steroid therapy is as effective as
daily administration in suppressing symptoms.
D.
Elevation of erythrocyte sedimentation after an initial decline should prompt an
increase in steroid dose even without symptom recurrence.
E.
If bone mineral density is not reduced, calcium and Vitamin D supplementation is
adequate osteoporosis prophylaxis in a patient commencing steroid therapy.
E
(reference NEJM 347, 4 July 25, 2002)
 40-60mg Prednisolone daily, 1000mg Methylpred in presence of visual
symptoms
 very high incidence of contralateral blindness after unilateral visual loss, and
histopath still likely to be positive even after steroids
 use bisphosphonate if low BMD
Question 24
Regarding Hepatitis B therapy, which one of the following statements is correct?
A. Lamivudine therapy is associated with the development of genotype resistance in about
7% of patients after 1 year of therapy
B. After 4 years of therapy genotypic resistance occurs in about 40% of patients
C. Lamivudine cessation after 12 months in eAg negative hepatitis B is associated with
recurrence of hepatitis B viremia in 50% of cases.
D. In EAg positive HBV, seroconversion on lamivudine therapy is associated with
maintenance of a long term response in 50% of patients.
E. Lamivudine therapy is indicated in patients with decompensated HBV infection
E





Lamivudine therapy is associated with the development of genotype resistance
in 16-30% after 1 year
After 4 years of therapy genotypic resistance occurs in 70%
Lamivudine cessation after 12 months in eAg negative hepatitis B is associated
with recurrence of hepatitis B viremia in 85% of cases .
In EAg positive HBV, seroconversion on lamivudine therapy is associated with
maintenance of a long term response in 85% of patients.
Lamivudine therapy in patients with decompensated HBV infection improves
B/Albumin etc
Question 25
The principal cause of lactic acidosis and hepatic steatosis complicating therapy for HIV with
nucleoside analogue reverse transcriptase inhibitors (NRTI) is:
A.
Accumulation of toxic metabolites of the NRTI
B.
A combination of the NRTI and alcohol abuse.
C.
Hepatic toxicity from the NRTI
D.
Secondary to pancreatitis caused by NRTI induced hyperlipidaemia
E.
NRTI inhibition of mitochondrial DNA polymerase
E
Question 26
Concerning urolithiasis, which one of the following statements is incorrect?
A.
stones occur in 40% of patients with primary hyperparathyroidism
B.
Calcium oxalate stones are more common in patients with small bowel disease or ileal
bypass as a consequence of hyperoxaluria
C.
magnesium ammonium phosphate and calcium phosphate are the constituents of
struvite stones which form in response to chronic infection
D.
Stones in the renal pelvis commonly present with loin pain in the absence of frank
haematuria
E.
stones are more common in populations with higher consumption of animal protein
A


stones occur in ~10% of patients with primary hyperparathyroidism
frank haematuria mainly related to ureteric stones
Question 27
Regarding tinnitus, which one of the following statements is incorrect?
A.
tinnitus may be a complication of Aspirin therapy.
B.
low-pitched tinnitus is characteristic of Meniere’s disease.
C.
lateralised tinnitus is suggestive of acoustic neuroma.
D.
tinnitus associated with unilateral high-frequency hearing loss is suggestive of acoustic
neuroma.
E.
there is an association between tinnitus and tempero-mandibular joint dysfunction.
C
(reference NEJM 347, 12 Sept 19, 2002)
 long list of drugs cause tinnitus, including salicylates
 tinnitus is usually lateralised, but this is not helpful in differential diagnosis
Question 28
Dendritic cells provide the link between the innate and the adaptive immune systems
predominantly by which one of the following?
A.
Processing antigens and representing them on MHC class II antigens
B.
Expressing high concentrations of co-stimulatory molecules
C.
Secreting pro-inflammatory cytokines
D.
Secreting lymphocyte-specific chemokines
E.
Migrating from peripheral sites to lymph nodes upon antigen encounter
B
Question 29
A patient whose FT4 is recorded as 30 pmol/l and TSH <0.005 mIU/L has a thyroid
technetium scan. Uptake in the gland is not increased. Which one of the following could not
explain these results?
A.
Subacute thyroiditis
B.
Error in the endocrine laboratory
C.
Thyrotoxicosis factitia
D.
Iodine-induced thyrotoxicosis
E.
Follicular carcinoma of the thyroid.
E




In subacute thyroiditis there is inflammation and therefore no uptake
In thyrotoxicosis factitia, thyroid gland will be suppressed
uptake of technetium will be blocked by gland full of iodine
follicular carcinoma can occasionally cause thyrotoxicosis, in which a focal area
of increased uptake will be seen
Question 30
Regarding typhoid fever, which one of the following statements is incorrect?
A)
Is caused by the bacterium Salmonella enterica serotype typhimurium LT2.
B) Strains of the causative bacterium which express the polysaccharide capsular antigen
Vi are more infectious and more virulent than Vi-negative strains.
C) The Ty21a vaccine is taken orally, but should not be given to the
immunocompromised, or patients taking antibiotics.
D)
Chronic carriage is more common in patients with cholelithiasis.
E) Fluoroquinolones are more rapidly effective and are associated with lower rates of
stool carriage than trimethoprim-sulfamethoxazole.
(reference NEJM 347, 22; Nov 28, 2002)
 Salmonella enterica serotype typhi
Question 31
Which one of the following is the most reliable clinical predictor of progression of chronic
renal disease?
A.
Glomerular hypertension.
B.
Raised circulating renin.
C.
Proteinuria.
D.
Raised intrarenal angiotensin II concentration.
E.
Hyperlipidaemia
C
 Proteinuria is a hallmark of chronic renal disease and the rate of progression
tends to correlate with the severity of proteinuria
 Glomerular hypertension has been demonstrated in experimental animals to
contribute to disease progression, and by inference has been shown to exist in
some human diseases such as diabetes mellitus.
 Via a number of different mechanisms, angiotensin II has been shown to
accelerate disease progression in animal models, and ACE inhibitors and
angiotensin receptors to slow human progressive renal failure.
 Hyperlipidaemia has been shown to cause progression in various animal
models, and there is one meta-analysis and several poorly controlled clinical
studies which suggest that it is a factor in humans as well; however it has not
been the subject of a properly designed randomised control trial.
Question 32
Patients with avocado allergy are more likely than the general population to be allergic to
which one of the following?
A.
House dust mite
B.
Grass pollens
C.
Tree pollens
D.
Soy milk
E.
Latex
E
Question 33
Regarding the cystic fibrosis transmembrane receptor protein (CFTR), which one of the
following statements is correct?
A.
The protein functions as a potassium channel in lymphocytes
B.
There are more than 2,500 known mutations in the CFTR gene
C.
The incidence of mutations is higher in Australians of Asian descent than in those of
Southern European descent
D.
The protein is involved in Pseudomonas binding and ingestion
E.
The carrier rate in the northern Europeans is ~ 1: 2,500
D
Question 34
Regarding IgA negphropathy, which one of the following statements is incorrect?
A. The glomerular deposits of IgA are exclusively of the IgA1 subclass.
B.
A minority of patients with IgA nephropathy will eventually develop end-stage renal
disease.
C.
Of all the glomerulonephritides, IgA nephropathy is the most common cause of endstage renal disease in Australia.
D.
Corticosteroids have been shown to reduce levels of proteinuria.
E.
There is no evidence to suggest that dietary fish oil supplements are of any benefit in
preserving renal function.
E
(reference NEJM 347, 10; Sept 5, 2002)
 15-40% will eventually develop end-stage renal disease.
 Corticosteroids have been shown to reduce levels of proteinuria, although
whether they preserve renal function is debated
 meta-analysis of 4 RCTs of dietary fish oil supplementation suggests 75%
probability of benefit
Question 35
Which one of the following regarding portal hyptertension in cirrhosis is TRUE?
A.
Surgical risk in a cirrhotic patients is primarily determined by Child-Pugh classification,
type of surgery and type of anaesthesia
B.
In acute variceal bleeding, the addition of a somatostatin analogue to endoscopic
treatment has not been shown to be of additional value in controlling acute bleeding
C.
Vasopressin analogues such as terlipressin have therapeutic use in their ability to
decrease systemic vascular resistance
D.
Renal impairment in cirrhotic patients can be due to either hepatorenal syndrome or
organic renal disease - administration of terlipressin is equally effective in both cases
E.
Non-alcoholic steatohepatitis does not progress to cirrhosis and portal hypertension
A
 Risk of post-operative hepatic decompensation is determined largely by these 3
factors. The main principles involved here are: degree of hepatic reserve (ChildPugh class), and the degree of impairment to hepatic perfusion (determined by
type of surgey [ie worse if laparotomy or large blood loss] and anaesthetic
factors [eg- induction hypotension])
 addition of somatostatin analogue has benefit in controlling acute bleeding, but
no effect on long term outcome (NEJM 344:23-28, Jan 4 2001)
 vasopressin analogues act by improving renal perfusion: thus an increase in
systemic vascular resistance is required. Terlipressin also results in suppression
of endogenous vasoconstrictor activity and reduction in portal pressure
 terlipressin has been shown to only be useful in hepatorenal syndrome; leads to
significant improvement in renal function in hepatorenal syndrome only.
 though uncommon, it does. A significant proportion of people previously labelled
as ‘cryptogenic cirrhosis’ are now known to have suffered from NASH
Question 36
Regarding test specificity, which one of the following statements is correct?
A. Specificity is the probability that a person with a positive test result does have the
disease
B.
Specificity is a measure of the probability of correctly diagnosing a person without the
disease with a screening test
C.
Specificity is the proportion of patients with the target disorder who have a positive test
result
D.
Specificity is the probability that a person with a negative test result does not have the
disease
E.
Specificity is calculated by dividing the false positive results by the sum of the false
positive and true negative results.
B




A is the predictive value of a positive result
C is sensitivity
D is the predictive value of a negative result
Specificity is TN / (FP + TN)
Question 37
Regarding abnormal liver tests, which one of the following statements is correct?
A.
Aminotransferases are reduced in renal failure
B.
In HCV infection ALT/AST >1 is suggestive of cirrhosis
C.
In an individual with alcohol consumption of >60 g/day, an ALT>500 is consistent with
alcoholic hepatitis
D.
Paracetamol hepatotoxicity is increased by fasting as this reduces the levels of GSSG
E.
Valproate acid is associated with peroxisomal hepatotoxiciy and hence the ASTis
usually greater than the ALT
F.
AST/ALT>1 has high sensitivity for cirrhosis in cases where alcohol is not a cofactor
A





AST/ALT >1 suggestive of cirrhosis
alcoholic hepatitis is rarely associated with ALT>300. Consider paracetamol etc
Fasting reduces GSH
Valproate is associated with mitochondrial hepatotoxicity and hence AST is
greater
AST/ALT>1 in cases where alcohol is not a cofactor is relatively specific but not
sensitive
Question 38
The earliest serum abnormality of calcium and phosphate metabolism in chronic renal
failure is:
A.
Reduced 1,25 dihydroxyvitamin D.
B.
Elevated parathyroid hormone.
C.
Hyperphosphataemia.
D.
Hypercalcaemia.
E.
Hypocalcaemia.
B

High parathyroid levels are seen at a GFR as high as 70 mls/min, low vitamin D
levels from about 50 mls/min, hyperphosphataemia and hypocalcaemia from 25
mls/min and hypercalcaemia (due to treatment, tertiary hyperparathyroidism, or
with adynamic bone disese) is generally seen only in dialysis patients.
Question 39
With regards to germ cell tumour, which one of the following statements is true?
A.
A patient with a testicular mass and a serum alpha fetoprotein level of 200ng/ml most
likely has a seminoma
B.
Chemotherapy for good-prognosis germ cell tumour is associated with an 80% chance
of infertility.
C.
A man in whom the serum beta- HCG level falls from 1000ng/ml preoperatively to
200ng/ml two weeks after radical orchidectomy for testicular cancer is unlikely to have
metastatic disease.
D.
A patient with metastatic germ cell tumour to bone, liver and brain has a 40% chance
of cure with appropriate therapy.
E.
Primary mediastinal germ cell tumours have a better prognosis than testicular primary
germ cell tumours
D




If AFP is elevated the tumour must be non-seminoma. B-HCG may be
moderately elevated in seminoma (<100).
At least 30% of men who have had chemotherapy will sire children. Not all of
these try and so the infertility rate is probably less than 50%.
The half-life of BHCG is approximately 1 day (AFP is about 1 week). Two
weeks after orchidectomy the BHCG should be normal.
The prognostic factors for metastatic testicular cancer 1. Level of markers (AFP,
BHCG, LDH) 2. Site of primary (mediastinal primary have a worse prognosis) 3.
Presence of non-pulmonary visceral metastases. Even the worst prognostic
group has a cure rate of greater than 40%.
Question 40
Which one of the following is not characteristic of the hyperlipidaemia of chronic renal
failure?
A.
Low HDL cholesterol.
B.
Raised lipoprotein (a).
C.
Raised total cholesterol.
D.
Hyperhomocysteinaemia .
E.
Hypertriglyceridaemia
C

Unlike nephrotic syndrome in which hypercholesterolaemia is the major lipid
abnormality, total cholesterol levels tend to be normal in patients with chronic
renal failure.

Each of the other abnormalities is thought to contribute to the atherogenic profile
of uraemia.
Question 41
Regarding the use of lamivudine in the treatment of chronic hepatitis B, which one of the
following statements is NOT correct?
A.
The chance of HbeAg loss increases progressively with longer duration of therapy
B.
The greatest chance of response is seen in those with significantly elevated
transaminases
C.
It can be used in patients with decompensated cirrhosis
D.
The appearance of a resistant mutant is usually not associated with clinical
deterioration
E.
Lamivudine is effective at suppressing viral replication in patients with the pre-core
mutant HBV
D
Explanation:
 The percentage of patients who seroconvert their e antigen increases with
increasing duration of treatment. The relationship approximates a linear curve.
 If baseline ALT is <2 x normal, the effect of lamivudine is almost similar to
placebo. If >5x normal, the percentage of people who seroconvert is
approximately 4x placebo
 Whilst interferon is contraindicated in decompensated cirrhosis (because
interferon can cause a flare of disease), lamivudine does not cause a flare and
thus can be used in decompensated disease to good effect
 Monitoring serial LFTs is useful in assessing response to lamivudine- a sudden
rise in LFTs after successful control of transaminitis may indicate emergence of
a resistant virus. In patients who have had decompensated disease in the past,
the emergence of a resistant variant may even lead to rapid hepatic
decompensation
 Whilst interferon is not useful for precore mutant variant (ie- HBV that does not
produce e antigen), lamivudine is useful. The problem is that no serological or
biochemical end-point can be used reliably to determine whether or not
permanent suppression of virus replication has occurred. Cessation of
lamivudine in this group invariably leads to reactivations. Thus many must be
treated with lamivudine indefinitely
Question 42
The most common cause of new cases of endstage renal failure in Australia at present is:
A.
IgA disease.
B.
Insulin requiring Type 2 diabetes mellitus.
C.
Non –insulin requiring Type 2 diabetes mellitus.
D.
Polycystic kidney disease.
E.
Reflux nephropathy.
B




Diabetes mellitus accounted for 22% of new cases of endstage renal failure in
Australia in the year 2000; 50% of these were insulin-requiring Type 2 diabetes,
30% non-insulin requiring Type 2 and 20% Type 1.
Glomerulonephritis accounted for 30% of new cases, and of these IgA disease
for 25% (i.e. 7.5% of the total).
Hypertension was the single most common cause (14%) but included in this
group are probably a number with other diagnoses.
Polycystic kidney disease and reflux nephropathy accounted for 6% and 5%
respectively.
Question 43
Concerning the reporting of clinical trial results, which one of the following statements is
correct about relative risk ?
A.
Relative risk estimates the magnitude of an association between exposure and disease
B.
Relative risk is the absolute difference in event rates between 2 intervention or 2
treatment groups
C.
Relative risk is calculated as (control event rate – experimental event rate)/ experiment
event rate
D.
Relative risk is the most appropriate way to express results from a case control study
E.
Relative risk is identical to the odds ratio
A
Question 44
With respect to the management of meningitis, which of the following
statements is incorrect?
A. steroid therapy has been shown to be of benefit in the management of pneumococcal
meningitis
B. single-dose ciprofloxacin is an effective post-exposure prophylaxis for health-care
workers exposed to N meningitides
C. Ceftriaxone 1g IV bd is appropriate initial therapy for meningococcal meningitis.
D. penicillin is generally ineffective in eradicatng N menigitidis from the nasopharynx of
carriers and infected individuals
E. lumbar puncture can be safely performed in the absence of CT in cases of suspected
bacterial meningitis without neurological signs or diminished level of consciousness
C

Ceftriaxone 2g IV bd
Question 45
Regarding the incidence of disease, which one of the following statements is incorrrect?
A.
Type 1 diabetes occurs with higher incidence at increased latitudes.
B.
Type 1 diabetes occurs with higher incidence in households of lower socio-economic
indices.
C.
Crohn’s disease occurs with higher incidence at increased latitudes.
D.
British migrants to northern Australia have a similar incidence of multiple sclerosis to
Britons in the UK.
E.
The incidence of Non-Hodgkin’s lymphoma is increasing in developed countries.
D
(reference NEJM 347, 12; Sept 19, 2002)
 incidence of MS in British migrants declines towards Australian levels
Question 46
Which of the following statements about the anaemia of chronic renal failure is most
correct?
A.
Primarily due to erythropoietin resistance.
B.
Iron-responsive.
C.
Worsened by hypoparathyroidism.
D.
Primarily due to reduced red cell survival.
E.
Unrelated to CRP and IL6.
:B



In dialysis and pre-dialysis patients anaemia of chronic renal failure is
compounded by reduced iron availability; thus target serum feritin levels are
200-500 µg/L, and transferrin saturation 25-30%.
The anaemia is primarily due to erythropoietin deficiency, although
erythropoietin resistance and reduced red cell survival may contribute.
Hyperparathyroidism and inflammation (as evidenced by raised CRP and IL6
levels, for example) cause erythropoietin resistance.
Question 47
With respect to the management of septic shock, which one of the following
statements is correct?
A. Antithrombin III has been shown to be an effective intervention in meningococcal sepsis
B. activated protein C has not been shown to reduce mortality in septic shock
C. suboptimal adrenal responses to sepsis are commonly found in shocked patients
D. early dialysis (before strictly indicated as renal replacement therapy) has been shown to
improve outcome in sepsis
E. recombinant von Willebrand factor (rVWF) has been shown to reduce requirements for
inotropes in septic shock.
C

rVWF is complete bull
Question 48
Regarding renal sodium handling in chronic renal failure, which one of the folloing
statements is incorrect?
A.
There is increased proximal reabsorption in undamaged nephrons..
B.
There is a slow fall in sodium excretion following dietary sodium restriction.
C.
There is impaired natriuresis following sodium challenge.
D.
There is decreased fractional excretion of sodium.
E.
There is reduced distal tubular absorption in undamaged nephrons.
D



Fractional excretion of sodium (i.e. clearance of sodium in relationship to GFR)
actually increases in chronic renal failure, due to distal tubular processes in
undamaged nephrons.
This occurs even though proximal tubular reabsorption increases in undamaged
nephrons (glomerular tubular balance).
The kidney is slow to respond to changes (in either direction) in sodium load.
Question 49
With respect to ankylosing spondylitis which one of the following statements is incorrect?
A.
Sacro-iliitis is the pathologic hallmark and usually one of the first earliest
manifestations.
B.
The early lesion consists of subchondral granulation tissue that ultimately erodes the
joint
C.
Romanus lesion is an erosion of vertebral bodies at the disc margin
D.
Rheumatoid factor is positive in a low percentage (30%-40%) of patients
E.
The majority of patients express the HLA B27 gene product
D
Question 50
The acidosis of chronic renal failure is best explained by which one of the following?
A.
A urinary acidification defect.
B.
Bicarbonate wasting.
C.
Reduced titratable acid excretion.
D.
Excessive dietary loads.
E.
Reduced ammoniagenesis.
E




The mild, raised anion gap metabolic acidosis of chronic renal failure is
principally due to reduced whole kidney ammonia production, and to a lesser
extent reduced titratable acid excretion (the latter giving rise to the high anion
gap).
This occurs despite an increase ammoniagenesis and a modest increase in
titratable acid excretion in undamaged nephrons.
In general, distal tubular acidification of urine is maintained (except in specific
medullary diseases).
Mild increase in fractional excretion of bicarbonate occurs once GFR falls to <
25 mls/min.
Question 51
Concerning carriers of the BRCA1 gene mutation, which one of the following statements is
correct?
A.
who are female are at increased risk of breast and ovarian cancer
B.
who are male are at increased risk of breast cancer
C.
who are female should be offered Tamoxifen prophylaxis
D.
who are male are not at increased risk of prostate cancer
E.
who are male will not pass the mutation on to male offspring
A



male breast ca assoc with BRCA2
BRCA1 associated breast cancers tend to be ER negative
Autosomal dominant, not X-linked
Question 52
Which one of the following is not a recognized side effect of Cyclosporine?
A.
Tremor
B.
Hypertrichosis
C.
Leucopaenia
D.
Hypercholesterolaemia
E.
Hypertension
C
Question 53
Regarding the treatment of chronic hepatitis C with Pegylated interferon and Ribavirin,
which one of the following statements is correct?
A.
In genotype 3 infected patients, PEG/R is more efficacious than standard IFN/R
B.
In genotype 1 infected patients, PEG/R is more efficacious than standard IFN/R
C.
The cure rate for Genotype 3 HCV with PEG/R is less than 60%
D.
The cure rate for Genotype 1 HCV with PEG/R is better than 50%
E.
There is a dose-response relationship between genotype 3 and the cure rate with
IFN/R therapy
B





In genotype 3 infected patients there is no difference in efficacy between PEG/R
and IFN/R
In genotype 1 infected patients, PEG/R is 10% more efficacious than standard
IFN/R
The cure rate for Genotype 3 HCV with PEG/R approaches 80%
The cure rate for Genotype 1 HCV with PEG/R is ~50%
There is only a dose-response relationship between genotype 1 and the cure
rate with IFN/R therapy
Question 54
In the presence of normal endogenous and exogenous loads, the serum biochemical
abnormality which occurs earliest during the course of chronic renal failure is:
A.
Hyperphosphataemia
B.
Low serum bicarbonate.
C.
Hypocalcaemia.
D.
Hypermagnesaemia.
E.
Hyperuricaemia.
E
 Mild hyperuricaemia is one of the earliest biochemical abnormalities, occurring
with a GFR >25 mls/min; it tends to be of no clinical significance and does not
progress due to increased fractional excretion of uric acid.
 Under normal circumstances, hyperkalaemia is not seen until GFR falls to <5
mls/min.
 The other biochemical abnormalities are seen once GFR falls below 25 mls/min.
Question 55
A 42 year old lady presents with pneumonia. She has had recurrent otitis media for 7 years,
and this is her third bout of pneumonia in the last 2 years. High resolution CT scan shows
early bronchiectasis. Her IgA and IgM levels are below the limits of detection and the IgG
level is 2.4 g/L (NR 7.5 – 15 g/L). The most likely diagnosis is:
A.
Bence-Jones myeloma
B.
IgA deficiency
C.
Common Variable Immunodeficiency
D.
Bruton’s hypogammagobulinaemia
E.
Wiskott-Aldrich syndrome
C
Question 56
A 32 year old man presents to hospital with difficulty walking.
He was last well two weeks ago, at which time he developed a diarrhoeal illness that lasted
three days. Four days before presentation he developed back pain, which was followed by
pins and needles in his feet. In the following two days he developed weakness, at first
noticed when going up stairs, then slapping of his feet when he walked. The day before he
presented he developed deep aching in his thighs, pins and needles in his hands, and
difficulty holding small objects. He feels slightly breathless.
On examination there is symmetrical weakness of small hand muscles, wrist flexion, hip
extension, knee flexion and all movements at the ankle. All of the deep tendon reflexes
except the right triceps jerk are absent. There is reduction in sensation to pinprick below the
knee, and in the hands.
Nerve conduction studies reveal dispersed compound muscle action potentials with delayed
distal latencies in the median and common peroneal nerves. The median nerve SNAP is
absent, and F waves cannot be obtained in the ulnar or tibial nerves.
Which one of the following alternatives are you most likely to find on cerebrospinal fluid
examination?
A.
Glucose 4.5 mmol/L, protein 2000 mg/L, no red cells, 8 x 106/L mononuclear cells, no
polymorphs, cytology unremarkable
B.
Glucose 4.5 mmol/L, protein 200 mg/ L, no red cells, no mononuclear cells or
polymorphs, cytology unremarkable
C.
Lumbar puncture is unsafe and should not be performed because of the risk of spinal
herniation
D.
Glucose 5.0 mmol/L, protein 2000 mg/L, no red cells, 6x 10 6/L neutrophils, 160 x 106/L
mononuclear cells, cytology shows small lymphocytes and monocytes
E.
Glucose 2.0 mmol/L, protein 4800 mg/L, 13x 106/L neutrophils, 178 x 106/L
mononuclear cells, monomorphic population of atypical lymphatoid cells consistent with
lymphomatous infiltration
A



This patient presents with the typical clinical history and examination of GuillainBarre syndrome (acute demyelinating polyneuropathy) following a
Campylobacter jejuni infection. The nerve conduction studies show the typical
features of demyelinating polyneuropathy: dispersed and delayed CMAPs and
absent late responses (ie the F wave).
The CSF hallmark of GBS is “albumino-cytologic dissociation”, or an elevation in
CSF protein without a raised CSF cell count.
Answer b) is normal CSF; answer c) is not correct despite the back pain,
because there are no other features of a space occupying lesion in the spinal
column that could cause spinal herniation; answer d) is not correct as the cell
count is raised- this is more like the CSF that would be seen in HIV related
acute demyelinating neuropathy and answer e) is not correct because the
situation presented here (ie that of lymphomatous infiltration of the meninges
surrounding the spinal cord) would have normal results for the nerve conduction
studies presented.
Question 57
A 30 year man from the army presents to Emergency after a 10-day history of
pyrexia, lethargy, myalgia and most recently dry cough. He has no history of
smoking or illicit drug use but he sometimes binge-drinks alcohol. He has no
other significant co-morbidities.
On examination, he has a respiratory rate of 40 / min and saturation of 90%
on 6L of oxygen / min. He has a blood pressure of 90/40 mmHg and a pulse rate of
120 per minute. His ECG reveals only sinus tachycardia. He is pyrexial with a
temperature of 39.8ºC. He looks distressed with some diaphoresis.
Examination otherwise is unremarkable.
Chest X ray shows slight elevation and haziness of the right hemidiaphragm but no other
significant abnormalities.
Which one of he following investigations would be the LEAST useful in the immediate
management of this patient?
A.
Arterial blood gas
B.
Urea, creatinine and electrolytes
C.
Full blood count
D.
Serology for mycoplasma
E.
Urinary legionella antigen
D
Question 58
A 56 year old lady presents with increasing lethargy over 6-12 months. She was previously
active, and only recently ceased work as an accountant due to her tiredness. In the past few
weeks, she had become increasingly forgetful and even overtly confused at times. She has
noted some ankle swelling and abdominal distension, for which her local doctor had
commenced frusemide 20mg daily offering mild improvement. She is previously well, on no
regular medication s and does not smoke nor drink alcohol. On examination, she had pitting
oedema to the ankles and small amount of ascites. A few bruises and scratch marks were
also noted. Chest examination revealed a small right pleural effusion. Cardiac examination
revealed a normal JVP and normal cardiac auscultation. Her blood tests are as follows:
Hb
WCC
Plt
126
3.9
69
Na
K 3.5
Cl
Urea
Creat
142
ESR
BSL
22
4.2
Bili
ALP
GGT
Alb
Glob
INR
84
435
522
23
46
1.8
97
6.8
68
Which one of the following investigations is the next most appropriate to determine her
diagnosis?
A.
Echocardiogram and abdominal ultrasound
B.
Head CT and EEG
C.
ANA, ENA and anti-dsDNA
D.
Anti-mitochondrial antibody
E.
Bone marrow biopsy
D





Right heart failure and hepatic congestion are possible causes of her clinical
picture. However, her JVP is normal and her neurological symptoms are not
explained by this.
The neurological features are vague, and whilst CT might be done at some
stage, it would not address her deranged LFTs etc
ANA, ENA and anti-dsDNA are not relevant here
The features to note in the above picture are: age, gender, protracted history,
evidence of pruritis, oedema/ascites with a normal JVP, ‘cholestatic’ LFTs,
evidence of cirrhosis with low platelets, low albumin and coagulopathy. The
recent confusion etc is likely to be emerging hepatic encephalopathy. Antimitochondrial antibody is a helpful investigation in the initial work-up of
suspected PBC- present in 95% of cases. Titre of AMA does not correlate with
severity, stage or progression of disease
The low platelet count and coagulopathy may suggest a haematological
disease, but BMBx would not be helpful in assessing the whole clinical picture in
the first instance
Question 59
A 21 year-old woman presents for the second time in 48 hours with fever (38.5(C),
headache and constipation. She has been previously well until 3 days ago.
One month ago she returned from a tiger safari in northern India. Travel was by foot
including wading in fresh water. She recalls numerous mosquito, but no other insect bites.
She had received vaccinations (including typhoid) and malaria prophylaxis according to
current recommendations.
Examination reveals a tippable spleen, but no rash or neck stiffness. A full blood count
reveals thrombocytopaenia (Plt 90) but no leucocytosis. Routine biochemistry, including liver
function tests are normal. Initial thick and thin films reveal no malaria parasites.
With regard to this patient, which one of the following statements is most correct?
A.
Examination of the blood film for malaria parasites should be repeated after 24 hours.
B.
Pending serologic confirmation of rickettsial infection, empirical tetracycline
monotherapy should be commenced.
C.
The prolonged incubation period makes typhoid unlikely. A fluoroquinolone antibiotic
should only be commenced if serologic assay confirms this diagnosis.
D.
Penicillin alone is the appropriate empiric antibiotic therapy, pending serologic
confirmation of leptospirosis.
E.
Dengue fever is a possible diagnosis, but can only be confirmed by acute and
convalescent serology.
A
(reference NEJM 347, 7; Aug 15, 2002)
 this is a good story for vivax malaria (recurrent fever, thrombocytopaenia without
leukocytosis, splenomegaly) even with appropriate prophylaxis and negative
initial film
 the incubation period is too prolonged for rickettsia, no rash
 this is a classic history for typhoid, and appropriate incubation period. However,
serology is unreliable, diagnose by blood culture


leptospirosis is a reasonable consideration, but Penicillin alone not a reasonable
choice. Probably no empiric antibiotics are warranted at this stage.
The incubation period is too prolonged for Dengue. Thrombocytopaenia and
leukopaenia characteristic.
Question 60
A 54 year old male suffers an acute anterior myocardial infarction. After treatment with
primary angioplasty there is an uneventful initial recovery. Holter monitoring at 5 weeks
shows 5 beats in succession of ventricular tachycardia . The left ventricular ejection fraction
is 36% on gated heart pool scan.
The management of this patient should include which one of the following?
A.
Further Holter monitoring to assess recurrence of ventricular tachycardia
B.
Repeat coronary angiogram to assess patency of stent.
C.
Commencement of amiodarone
D.
Electrophysiological studies to assess inducibility of ventricular tachycardia
E.
Implantation of a cardioverter defibrillator
D
 MADIT and MUSTT trials have demonstrted the role of EPS in this situation.
 ICD needs to be implanted only if there is inducible VT.
 VT in this situation is not usually related to acute ischaemia and repeat
angiogram is not necessary, unless there are ischaemic symptoms.
 No need for amiodarone therapy. Amiodarone is less effective than ICD if VT is
inducible.
Question 61
A 24 yo female presents 1.5 hours after the reported ingestion of 60 x 500 mg (30 grams)
paracetamol following a fight with her boyfriend. She complains of nausea and epigastric
discomfort, and has vomited twice prior to arrival in the emergency department. Physical
examination reveals normal vital signs and mild epigastric tenderness. An ED resident asks
you for advice as to what to do next.
You would suggest (pick the most appropriate answer):
A.
Give 50 grams of activated charcoal orally and start N-acetylcysteine infusion
immediately as this is potentially a lethal ingestion
B.
Give 50 grams of activated charcoal orally, take blood for a serum pracetamol
concentration and start N-acetylcysteine infusion immediately
C.
Give 50 grams of activated charcoal orally and check serum paracetamol level 4 hours
post-ingestion and treat based on serum paracetamol level
D.
Give 50 grams of activated charcoal orally and check serum paracetamol 4 hours postingestion and urinary beta HCG level and treat based on serum paracetamol level
E.
Perform oro-gastric lavage followed by 50 grams of activated charcoal, check serum
paracetamol 4 hours post-ingestion and urinary beta HCG level and treat based on
serum paracetamol level.
D




There is no indication to treat a patient on history alone for paracetamol
poisoning if they present within 8 hours of ingestion as all patients will do well if
treatment is commenced within this window.
The risk of adverse reactions to NAC is up to 20% and unnecesary treatment of
patients may result in preventable morbidity. Also, reported ingested dose is not
always the same as true ingested dose.
Oro gastric lavage has not been shown to change outcome and may cause
more harm than good than charcoal alone.
Patients presenting within 2 hours of paracetamol ingestion may benfit from oral
activated charcoal as this has been shown to reduce a potentially toxic 4 hour
paracetamol level to a subtoxic one, thus resulting in prevention of need for
antidotal therapy.
Question 62
A 35 year old patient presents with palpitations, sweatiness and is generally unwell. She
had a recent URTI followed by neck soreness. On examination she has a small diffuse
goitre with slight tenderness. Her FT4 was 32 pmol/l and TSH <0.005 mIU/L.
Which one of the following statements is correct?
A.
An ESR of 97 is against the diagnosis of subacute thyroiditis.
B.
Undetectable thyroid stimulating immunogloblin levels excludes Graves’ disease.
C.
The presence of lid lag suggests Graves’ disease, rather than an alternative cause of
thyrotoxicosis.
D.
The presence of pretibial myxoedema suggests Graves disease.
E.
The presence of thyroid acropachy suggests subacute thyroiditis.
D





ESR is typically very high with subacute thryoiditis
20% of Graves’ disease patients have negative TSI
lid lag can be due to any cause of thyrotoxicosis
pretibial myxoedema is associated with Graves’
thyroid acropachy, or clubbing, is associated with Graves’
Question 63
A 38 year old builder presents with a long history of abdominal bloating and weight loss of
about 10kg over 12 months. He has also complained of recent onset of lower back pain. He
has been well previously, other than complaints of recurrent itchy skin ‘blisters’. Blood tests
are as follows:
Hb
101
MCV
Platelets
Blood film
Ferritin
102
121
Macrocytes, target cells, Howell-Jolly bodies
105
Na
K
Urea
Creatinine
Calcium
Phosphate
Albumin
Bilirubin
ALP
GGT
ALT
AST
138
4.1
6.7
112
1.71
0.68
28
18
200
34
28
25
Which one of the following statements about this patient is correct?
A.
The blood film is unlikely to be related to his presenting illness
B.
Colonoscopy and biopsy is the diagnostic investigation that should be performed next
C.
His skin lesions are likely to be photosensitive
D.
His back pain is most likely to be mechanical related to his occupation, and does not
require futher investigation
E.
Panendoscopy and biopsy is the diagnostic investigation that should be performed next
E




His blood film shows features consistent with several aspects of coeliac disease:
macrocytosis due to B12 malabsorption, target cells due to Fe deficiency and
Howell-Jolly bodies due to associated hyposplenism
The skin lesions are dermatitis herpetiformis, a pruritic vesicular rash that is not
photosensitive
Osteoporosis and vertebral crush fractures should be considered, despite his
age. His blood profile shows evidence of hypocalcaemia and raised ALP
suggesting increased bone turnover in response to poor calcium absorption
Villous atrophy in small bowel biopsies is the gold standard of diagnosis for
coeliac disease. Even though the clinical suspicion for coeliac disease is high,
biopsies are helpful as a baseline to document subsequent response to glutenfree diet
Question 64
A 40 yo female presents to hospital by ambulance following ingestion of 50 x 25 mg
amitriptylene tablets 45 minutes earleir. She is unconscious with a Glasgow coma score of
4, pulse 126 bpm, BP 80/60, temperature 35 deg C, finger stick blood sugar 6.3 mmol/L.
General physical exam is notable only for diminished bowel sounds and neurologic exam is
non-focal with 4mm bilateral pupils, generally decreased deep tendon reflexes and no
response to pain. She is intubated and ventilated in the emergency department and suffers
a self-limiting 20 second clonic generalised seizure post-intubation. A 12-lead ECG reveals
sinus tachycardia (rate 130/min), rightward axis, QRS duration 130 msec, and QTc 470
msec.
Which one of the following is correct?
A.
Phenytoin is the drug of choice to prevent seizures in this patient
B.
The QTc interval is the best indicator of cardiac toxicity in this patient
C.
A similar clinical picture may be seen after overdose with disopyramide
D.
Charcoal hemoperfusion will significantly enhance the elimination of cyclic
antidepressants in overdose
E.
The mechanism of cardiac toxicity in cyclic antidepressant poisoning is related to
blockade of potassium rectifier currents during the repolarization phase of the cardiac
action potential
C





Intravenous benzodiazepines are the drug of choice for recurrent seizures
following cyclic antidepressant overdose.
The QRS interval has some utility in predicting acute CAD toxicity. QRS >/= 100
msec predcits 30% risk of seizures and 50% of those with QRS > 160 msec will
develop vetricular arrhythmias.
A similar picture of toxicity ma be seen with any drug having class 1a
antiarrhythmic activity. This includes quinidine, quinine, disopyramide,
thioridazine, diphenhydramine. A simiar patter may also be seen with class 1c
agents such as flecanide.
Charcoal hemoperfucion will not enhance elimination of these agents as they
have very large volume of distribution and high protein binding.
Cardiac toxicity is related primarily to Na+ channel blockade which may be
overcome by boluses of IV sodium bicarbonate.
Question 65
A 30 year old woman with newly diagnosed HIV is noted to have abnormal white areas on
her tongue and buccal mucosa (as below). They cannot be removed with a swab.
Which one of the following is the most likely cause of these lesions?
A.
Cytomegalovirus
B.
Human papilloma virus
C.
Epstein-Barr virus
D.
Candida albicans
E.
Treponema pallidum
C
Question 66
A 20 year-old woman reports that her fingers have turned blue when exposed to cold
temperatures since she was a teenager. She takes propranolol as migraine prophylaxis.
Which one of the following statements is correct?
A.
In this patient, the presence of recurrent small, painful digital ulcers would suggest an
underlying connective tissue disorder.
B.
In this patient, Raynaud’s phenomenon is likely to be caused by the non-selective beta
blocker.
C.
If the ANA is positive 1:640, this patient is likely to have secondary Raynaud’s
phenomenon.
D.
The incidence of migraine in those with primary Raynaud’s phenomenon is not
significantly different from normal controls.
E.
Nifedipine has been shown to reduce the frequency of attacks only in secondary
Raynaud’s phenomenon.
A
(reference NEJM 347, 12; Sept 19, 2002)
 Trials do not support any association between beta-blockers and Raynaud’s
 30% positive predictive value of ANA for 2ary Raynaud’s
 There is an increased incidence of migraine in those with primary Raynaud’s
phenomenon.
 Nifedipine has been shown to be useful in both primary and secondary
Question 67
A 22 year old university student from China presents to the hospital emergency with a three
week history of headache and fevers. On examination she is febrile and confused with neck
stiffness. There are no focal neurologic signs. Physical examination is otherwise
unremarkable. She has recently travelled to China and has had a new sexual partner. She
keeps a cat.
LP reveals pressure 30cm H2O, Glucose 1.8mmol/l, Protein 2883mg/l, Polymorphs 0,
Mononuclear cells 94/ul, Red cells 13/ul. Aciclovir and ceftriaxone are commenced.
A contrast cerebral CT scan with sinus views and a CXR are normal. CSF culture is
negative at 48 hours. She remains unwell with fever, headache and becomes more
confused.
A repeat LP on day 4 reveals pressure 33cm H2O, Glucose 1.1mmol/l, Protein 4016mg/l,
Polys 0, Mononuclear cells 112/ul, Red cells 225/ul. CSF cryptococcal antigen is negative,
ZN stain is negative and mycobacterial and fungal cultures are pending. CSF PCR for HSV,
Enterovirus and M. tuberculosis are negative. HIV antibody and TPPA are negative.
Toxoplasma IgG antibody is positive.
The most appropriate next step in management would be:
A.
HIV PCR on CSF
B.
Treatment for Mycobacterium tuberculosis
C.
Treatment for Cryptococcus neoformans
D.
Serology for Bartonella henselae
E.
Treatment for Toxoplasma gondii
B
Question 68
A 28 yo female presents 4 hours after the ingestion of 20 x 240 mg verapamil SR tablets.
She is alert and orientated, well perfused with a pulse 66 bpm, BP 105/70.
The most appropriate immediate management is:
A.
give 50 grams of oral activated charcoal and observe for 6 hours. Medically clear the
patient if she is well at this time.
B.
give 50 grams of oral activated charcoal and a further 50 grams 6 hours later.
Medically clear the patient if she is well 24 hours post-ingestion.
C.
give 50 grams of oral activated charcoal and commence whole bowel irrigation with
polyethylene glycol-electrolyte solution and observe the patient for 12 hours. Discharge
if well at this time.
D.
give 50 grams of oral activated charcoal and commence whole bowel irrigation with
polyethylene glycol-electrolyte solution and observe for 24 hours. Discharge if well at
this time.
D



This is a potentially lethal overdose with patients becoming symptomatic as late
as 17 hours post-ingestion with inadequate GIT decontamination.
Whole bowel irrigation is rarley indicated in poisoning but this is one situation
where it should be attempted early BEFORE the development of an ileus to
clear the SR tablets from the gut.
Patients should be asymptomatic fot 24 hours prior to being medically cleared
from hospital.
Question 69
A 60 year old female presents with an 8 week history of diarrhoea. She has a background
history of hypertension, asthma and mild rheumatoid arthritis. Her medications are enalapril
and indomethacin prn. The diarrhoea is watery and non-bloody, and she passes between 510 motions per day. She has otherwise not had any other symptoms such as abdominal
pain, vomiting nor significant weight loss. Stool microscopy and culture have been
performed on several occasions: small numbers of both red and white cells occasionally,
and 1 of 5 samples yielded growth of Blastocystis hominis. Blood tests show a Hb 108
(normal MCV/MCH), albumin of 32, ESR 25, but otherwise normal LFTs, TFTs, Fe and
B12/folate. Colonoscopy was performed which was macroscopically normal, and one
random biopsy was normal. Which of the following statements regarding this patient is most
correct?
A.
Irritable bowel syndrome is the most likely diagnosis, as significant pathology on
colonoscopy has been excluded
B.
She should be treated with a prolonged course of metronidazole
C.
Repeat colonoscopy and biopsies of several areas of colon should be performed
D.
If admitted to hospital, she needs to be managed in isolation given her stool culture
result
E.
No further investigations are necessary
C
 Diarrhoea-predominant IBS is a possible diagnosis, but some features (such as
mild anaemia, positive microscopy), should prompt further investigation before
this diagnosis of exclusion is made.
 Blastocystis hominis is an intestinal protozoan, whose pathogenicity is unclear,
but probably does not have any clearly defined pathogenic potential and clinical
illness should not be attributed solely to this organism
 A highly possible diagnosis in this patient is microscopic colitis, which has not
been satisfactorily looked for thus far. She has several ‘risk factors’ for a
microscopic colitis (either lymphocytic colitis or collagenous colitis), including
age, gender and co-existent RA. Prolonged watery diarrhoea in a patient such
as this should prompt careful biopsy at several sites if the colonoscopy is
macroscopically normal. Right colon and rectum are good sights for biopsies.
Question 70
A 62 year old male was resuscitated from a cardiac arrest. Ventricular
tachycardia at a rate of 250 beats per minute was documented before
cardioversion. Serial cardiac enzymes were not elevated. ECG showed
evidence of old anterior myocardial infarction. Coronary angiogram showed
a left anterior descending artery totally occluded at its proximal aspect.
The other arteries were disease-free. There was moderate left ventricular
dysfunction with anterior wall aneurysm.
Which one of the following is the optimal management?
A.
Amiodarone
B.
Sotalol
C.
Implantation of cardioverter defibrillator
D.
Coronary artery bypass surgery
E.
Percutaneous intervention for the occluded left anterior descending artery
C



The optimum management of a patient with symptomatic ventricular
tachycardia, not related to a reversible cause, is implantation of a cardioverter
defibrillator (AVID Trial).
Antiarrhythmic drugs are inferior in efficacy to ICD (AVID trial).
Revascularisation has no role in this situation.
Question 71
A 34 year old man presents to hospital with six hours of weakness of his left side of the face
and left arm, and milder weakness of the left leg. Neck pain which developed after a
particularly vigorous cutback (ie whilst surfing).
He is a non- smoker, and has no personal history of hypertension, hypercholesterolaemia,
diabetes mellitus or ischaemic heart disease. He has no family history of stroke to his
knowledge.
Examination reveals a young man with left facial droop and left arm, and (milder) left arm
weakness. The right eyelid is ptosed, and the right pupil constricted and reactive.
Extraocular movements are full with no diplopia, and there is no detectable visual field
defect. There are no carotid or other bruits. Heart sounds are dual, and there are no added
sounds or murmurs. His apex beat is in the fifth intercostal space in the mid- clavicular line,
and the chest is clear.
Cerebral CT reveals loss of the normal grey / white differentiation in the right frontal lobe.
The most appropriate investigation to demonstrate the causative pathology is:
A.
Duplex ultrasound of the carotids
B.
Transoesophageal echocardiography
C.
MRI of the neck with MR angiography
D.
Angiography of the cerebral circulation
E.
Holter monitoring
C



1
This patient has sustained a stroke from dissection of the right carotid artery,
which probably occurred whilst he was surfing. Stroke from carotid dissection is
not usually caused by occlusion of the involved artery, but embolisation of
thrombus to a more distal artery1. Carotid dissection may be associated with
pain in the face, eye or neck ipsilateral to the dissection. A Horner’s syndrome
may occur with irritation of the sympathetic fibres around the internal carotid
artery. Occasionally ipsilateral palsies of lower cranial nerves may occur, which
can cause false localisation of a brainstem stroke.
After artery to artery embolism (from atherosclerosis), cardio- embolism, and
lacunar infarction, arterial dissection is next most common cause of stroke (the
most common of the uncommon causes, so to speak).
The best test for cervical arterial dissection is MR angiography, and MRI of the
neck to show the blood in the false lumen of the artery. Angiography may not
Warlow CP et al. (2001) Stroke: a practical guide to management 2nd ed.
show the characteristic elongated and tapering stenosis, ultrasound is too
insensitive, and both TOE and Holter monitoring are irrelevant in this case.
Question 72
An 11 year-old boy is noted to have a heart murmur and an unusual facial appearance
(pictured below). He has mild developmental delay. His attempt (in red) to copy an abstract
figure (in green) is illustrated below. There is a history of hypercalcaemia in infancy.
He undergoes left heart catheterisation (pictured below).
With regard to this patient, which one of the following statements is incorrect?
A.
He has Williams’ syndrome.
B.
There is a genetic defect in collagen metabolism
C.
The inability to copy figures is likely to reflect a specific visuo-spatial cognitive deficit.
D.
The abnormality in calcium metabolism is likely to have resulted from hypersensitivity
to and/or excess of Vitamin D.
E.
The cardiac catheter reveals supra-valvular aortic stenosis.
B

Elastin
Question 73
A 32 yo man with a history of heavy alcohol consumption presents to hospital complaining
of nausea, epigastric discomfort, and vomiting for 12 hours. Examination reveals well
perfused, alert and orientated but slightly agitated male patient with P 105 bpm, BP 100/50
mmHg, T 37.5 deg C and mild epigastric tenderness. IV normal saline is commenced and
routine bloods are drawn. Serum electrolytes reveal Na 146, K 3.0, Cl 101, Bic 10 mmol/L,
Urea 10.2 mmol/L, Creat 160 umol/L, BSL 4.0 mmol/L. Hb 145 g/L WCC 12.3, plt 240,000.
Liver function tests, amylase and lipase normal. Serum ethanol 20 mmol/L. Measured
serum osmolality 326 mosm/L.
Which one of the following statements is correct?
A.
the patient has a normal anion gap
B.
the patient has a significant omolar gap
C.
the patient should be commenced on an intravenous ethanol infusion
D.
the patient should be urgently haemodialysed
E.
the patient may complain of tinnitus on further questioning
E




The patient has an elevated anion gap of 35 with a normal osmolar gap
(2Na+Urea+gluc+EtOH level).
It is unlikely that he has a toxic alcohol ingestion in view of the normal osmolar
gap and the fact that he still has a detectable EtOH level which would inhibit the
metabolism of any toxic alcohol until the ethanol was metabolised first.
Hence he would not have an acidemia yet. Intravenous ethanol is not indicated
and hamodialysis is not required at this stage.
The patient may well complain of tinnitus on further questioning suggesting the
possibility of salicylate poisoning which can present with a mixed picture of
respiratory alkalemia with metabolic acidemia. Hemodialysis may well be
indicated after further biocemical assessment and estimation of serum salicylate
levels but is not required at this stage.
Question 74
A 35 year old female presents with a 2 week history of fever and fatigue and mild arthralgia.
Examination is unremarkable with the exception of fever 38C and proteinuria and
haematuria on dipstick urinalysis. Serum complement levels are as follows: C3 0.30
(reference range 0.83-1.70g/L); C4 0.15 (reference range 0.10-0.41g/L).
Which of the following is the most correct statement?
A.
Serum sickness is unlikely because the C4 level is normal.
B.
Repeated measurement of the C3 level is useful in monitoring disease activity.
C.
Urinary protein loss is the most likely cause of the low C3 level.
D.
A deficiency of phophatidyl inositol linkages is the cause of the low C3 and haematuria.
E.
A renal biopsy is the most appropriate next investigation.
B
Question 75
A 55 year old lady is found to be anaemic with a Hb of 97, MCV 115. Her past history
includes diabetes mellitus, partial gastrectomy for refractory peptic ulcer disease at age 20
and hypertension. She was found to be B12 deficient, and the following investigations were
performed subsequently.
Schilling test
Labelled B12 alone
Labelled B12 + intrinsic factor
4% of dose excreted at 24 hours
5% of dose excreted at 24 hours
C14 breath test
Early rise in labelled CO2
Which of the following is the most likely cause of her B12 deficiency?
A.
Pernicious anaemia
B.
Terminal ileal disease
C.
Bacterial overgrowth
D.
Dietary insufficiency
E.
Previous gastrectomy
C
 The C14 glycocholic acid breath test is also infrequently performed, but the main
principle here is to measure the amount of labelled CO2 in expired air after an
oral dose of the labelled glycocholic acid (a bile salt). Bacteria deconjugate the
bile salt subsequently releasing labelled CO2 in the breath. An early rise in the
breath radioactivity indicates either bacterial overgrowth in the small intestine or
rapid transit to colon. Hence, the picture given in the question is that of a
bacterial overgrowth syndrome.
The Schilling test is rarely performed, but the point of this question is to understand the
pathophysiology of disturbed B12 metabolism.
Schilling test simplified:
1. Oral load of radioactive cobalamin
2. IM injection of unlabelled cobalamin2
3. Measure proportion of radioactivity excreted in urine over the next 24 hours

If due to malabsorption (from any cause), the amount of radioactivity in the urine
will be low
4. Oral dose of radioactive cobalamin bound to intrinsic factor
5. Check urine radioactivity again

If the deficiency is due to intrinsic factor deficiency (from either pernicious
anaemia or surgery), the urine radioactivity will now be high

If it is still low, there may be:

Blind loop syndrome

Terminal ileal disease
2
The IM dose is to saturate the transcobalamin carriers, and FLUSH the radioactive cobalamin from the blood
and other tissue sites into the urine
6. Administer antibiotics

If it is due to blind loop, the antibiotics should correct the problem, and urine
radioactivity will then increase