A 35 year old female presents with a 2 week history of fever and

By Denise Clark,2014-04-27 23:24
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A 35 year old female presents with a 2 week history of fever and

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


    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


     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


     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.


     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


     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


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


     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


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


    E. Most antimicrobial agents active against H. pylori are more effective at lower gastric pH.


    (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


Question 9

    Regarding pregnancy, which one of the following statements is true?

     thA. hypertension noted in the 18 week of gestation is most likely to be caused by pre-


    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



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. 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


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


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


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



     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.


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


     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.


     (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.


    (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


    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.


     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



E. Topoisomerase


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


    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.


     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


     There is an increased risk of developing prostate cancer with BRCA1 but it is


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


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.


     (reference NEJM 347, 4 July 25, 2002)

     40-60mg Prednisolone daily, 1000mg Methylpred in presence of visual


     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


     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

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