All online Quiz Week 30-44 Flashcards
Anthony is a 73 year-old man who presents to your general practice with shortness of breath. It has been present for 5-6 months and gradually worsening over that time. It is exacerbated by movement but is present to some degree, even at rest. It does not particularly bother him at night. He sleeps on 1 pillow. He coughs, particularly in the mornings. This is productive of yellow sputum and has been present for 4-5 years. He has had no fevers or night sweats and has not lost weight. There is no chest pain or tightness. He has no significant medical history. He is a Vietnam War veteran and has been smoking 20 cigarettes/day since age 20. He lives alone and avoids coming into town as much as possible. On examination, you notice a slim man. Jugular venous pressure is 3cm above the sternal notch at 45 degrees. His chest appears hyperinflated. Heart sounds are dual with no added sounds. There is widespread wheeze on examination of the lungs.
Which of the following is the most likely diagnosis?
A. Acute bronchitis
B. Acute coronary syndrome
C. Asthma
D. Chronic Obstructive Pulmonary Disease
E. Congestive heart failure
F. Pneumonia
Answer –> Chronic Obstructive Pulmonary Disease (COPD)
What does the following blood results indicate?
Elevated: RBC HGB HCT
Lowered: Lymph
Answer –> Polycythaemia
Increased numbers of red cells in Anthony’s blood are likely to reflect:
A. Excessive carbon monoxide exposure
B. Exogenous Erythropoietin administration
C. Haemoglobin chain abnormality
D. Peripheral endothelial dysfunction
E. Reduced pulmonary surface area for gas exchange
Answer –> Reduced pulmonary surface area for gas exchange
Anthony is quite worried that his symptoms might be due to carbon monoxide exposure.He had a friend die of a workplace accident at BHP in 1988 due to this.
How does excessive carbon monoxide exposure cause death?
A. CO alters CO2diffusion in the lungs
B. CO alters endothelial function
C. CO binds to Hb with a higher affinity than oxygen
D. CO binds to the red cell membrane
E. CO increases peripheral tissue pH
Answer –> CO binds to Hb with a higher affinity than O2
Sharon is a 52 year old woman with pernicious anaemia. On evaluation of her red blood cells, we notice a macrocytosis. The cause of this nuclear-cytoplasmic dyssynchrony is: A. Accelerated cytoplasmic maturation B. Accelerated nuclear maturation C. Decelerated cytoplasmic maturation D. Decelerated nuclear maturation E. Normal cytoplasmic maturation F. Normal nuclear maturation
Answer –> Decelerated nuclear maturation
Akshay is a 42 year-old man who presents to your practice complaining of tiredness, gradually worsening over the last 6 weeks. There are no other symptoms. He says he sleeps well, is a lifelong vegetarian, works as an administration officer for the local council. He walks for exercise and is happily married. Examination is entirely unremarkable. Full blood count demonstrates a microcytic hypochromic anaemia but is otherwise normal.
What is the most important diagnosis not to miss?
A. Depression
B. Dietary iron deficiency
C. Gastrointestinal cancer
D. Pernicious anaemia
E. Roundworm infestation
Answer –> Gastrointestinal cancer
Follow up iron studies confirm iron deficiency as the cause of Akshay’smicrocytic hypochromic anaemia. Why does iron deficiency cause a microcytic hypochromic anaemia? A. Accelerated cytoplasmic maturation B. Accelerated nuclear maturation C. Decelerated cytoplasmic maturation D. Decelerated nuclear maturation E. Normal cytoplasmic maturation F. Normal nuclear maturation
Answer –> Decelerated cytoplasmic maturation
Use the Bradford Hill criteria to examine the following information on the association between smoking and lungcancer.Considertheevidence and tick those for which you believe the evidence supports a causal relationship.
A. Most research shows that people smoked before they developed lung cancer.
B. Most research shows that smokers were 20-30 times more likely to develop lung cancer than non-smokers.
C. Most research shows that higher levels of smoking are associated with more cases of lung cancer.
D. Most research found that the associate between smoking and lung cancer is seen in men and women as well as other social and ethnic groups.
E. The full biological basis for how tobacco may cause lung cancer is not known.
F. Research has found that reducing the consumption of cigarettes reduces the risk of lung cancer. Furthermore, animal studies have shown that tobacco is carcinogenic to animals.
G. Numerous other diseases are associated with smoking.
Answer –> A,B,C,D,F,
What is the study design of:
Men and women who have had a heart attack are compared with those who have not had a heart attack and medical records are used to determine their use of anti-inflammatory medications.
Case-control study
What is the study design of:
Is obesity more common in men and women with arthritis?In a population survey of men and women in the Hunter, information on weight and the existence of medical conditions (such as arthritis) was collected by questionnaire. This study showed that people with arthritis were more likely to be obese than those within the normal weight range.
Cross sectional study
What is the study design of:
Does eating fish 3 or more times per week decrease the incidence of depression in men and women?
Men and women who eat fish 3 or more times per week are compared to those who consume less than this amount of fish. These people are followed for 5 years to determine if the incidence of depression is different between groups.
Cohort study
What is the study design of:
Does zinc supplementation improve glucose tolerance in men and women with type 2 diabetes?
400 men and women with type-2 diabetes are divided into to two groups of 200 people to determine if zinc supplementation improves glucose tolerance over a 6-month period.
RCT
You are a GP in Kotara, NSW. Baysan is a 19 year old woman referred in by her dentist following a planned wisdom tooth extraction that lead to persistent bleeding in the socket. The dentist is concerned that she may have a bleeding disorder. Baysan tells you she has always bruised easily but has never had bleeding into a joint as far as she’s aware. She’s never spoken to any doctors about her easy bruising before. She routinely experiences prolonged and heavy menstruation. On examination you notice widespread scattered petechiae.
Is the described pattern more likely to fit a:
A. Clotting factor disorder
B. Lack of skill of the dentist
C. Normal variant
D. Platelet disorder
E. Thrombotic disorder
Answer –> Platelet disorder
Ethan is a 13 year old boy who has a history of hemarthroses and spontaneous haematomas.
Is this described pattern more likely to fit a:
A. Clotting factor disorder
B. Normal variant
C. Platelet disorder
D. Thrombotic disorder
Answer –> clotting factor disorder
You are a gastroenterology registrar, monitoring the progress of Lucas, a 59 year old male inpatient with hepatic failure. His APTT and PT have recently become elevated, although his AST, ALT, GGT and ALP are stable. This is likely to reflect: A. Improving bone marrow function B. Improving liver function C. Deteriorating bone marrow function D. Deteriorating liver function E. Stable bone marrow function F. Stable liver function
Answer –> Deteriorating liver function
Fu is a 79 year old man with B- blood type. Assuming he needed blood and by some disaster it was unavailable, theoretically which type would be an acceptable substitute? A. A- B. AB+ C. B+ D. O- E. O+
Answer –> O-
Saanvi is a 15 year old girl who requires a plasma transfusion. She has a B+ blood type. Assuming B+ plasma was unavailable, which of the following would be an acceptable substitute? A. A- B. AB+ C. B- D. O- E. O+
Answer –> AB+
What do AST and ALT measure in a liver function test?
largely measure inflammatory processes within the liver
What do GGT and ALP measure in a liver function test?
a measure of liver obstruction.
What is the universal donor for blood?
O-
What is the universal donor for plasma?
AB+
Why is AB+ the universal plasma donor?
Plasma contains antibodies to cell surface markers not expressed by the donor. This is thought to be due to cross-reactivity with intestinal flora surface markers. The plasma of an AB+ person will not contain antibodies to either A, B, or the rhesus factor
E.g. –> A blood will contain antibodies to B, B to A, and O to both A and B. Negative rhesus factor donors will have antibodies to the Rhesus factor.
Which Immunoglobulin, present in secretions, is thought to coat microbes to prevent epithelial cell adherence, neutralise toxins and dampen inflammatory pathways that could otherwise lead to autoimmune processes? A. IgA B. IgD C. IgE D. IgG E. IgM
Answer –> IgA
Carly, aged 12 months, is receiving her scheduled vaccinations.
Which Immunoglobulin provides immediate response in response to the antigen stimuli?
A. IgA
B. IgD
C. IgE
D. IgG
E. IgM
Answer –> IgM
Which Immunoglobulin provides a long term protection against the given antigen, and can be used to measure immunity against the antigen? A. IgA B. IgD C. IgE D. IgG E. IgM
Answer –> IgG
Which immunoglobulin is classically implicated in the pathogenesis of anaphylaxis? A. IgA B. IgD C. IgE D. IgG E. IgM
Answer –> IgE
Adrian is a 32 year old man who lives in Australia and who has just been diagnosed with community acquired pneumonia. When the organism is identified, which of the following would be considered unusual? A. Group A Steptococci B. Haemophilus inlfuenza C. Moxarella catarrhalis D. Pneumocystis jiroveci E. Streptococcus pneumonia F. Staphylococcus aureus
Answer –> Pneumocystis jiroveci
Rocco, a 12 year old boy presents to the ED after a crash on his BMX bike, where he landed on the handlebars. He is complaining of abdominal pain and on exam he has a handlebar tattoo (see image). He has the following vital signs:
HR120BP110/70RR20T 37.1
What is the appropriate triage category for this boy?
A. 1
B. 2
C. 3
D. 4
E. 5
Answer –> 3 –> but most Eds would give a 2 because of the probable underlying injury
Which of the following internal organs is Rocco most likely to have injured? A. Liver B. Spleen C. Large intestine D. Left kidney E. Small intestine
Answer –> Spleen
An elevated serum lipase would raise suspicion of what kind of injury? A. Kidney B. Liver C. Pancreas D. Spleen
Answer –> Pancreas
Which of the following findings would most clearly indicate a hollow viscus (vs solid organ) injury had occurred?
A. Free peritoneal fluid on FAST scan (focused assessment with sonography for trauma)
B. Crepitus in the soft tissues around the site of injury
C. Rebound tenderness in all four abdominal quadrants
D. Radiolucent rim between the ribs and liver on lateral decubitus x-ray
Answer –> Radiolucent rim between the ribs and liver on lateral decubitus x-ray
Half an hour after Rocco’s arrival his vital signs are deteriorating. He has a HR of 145 and a BP of 100/50. You suspect intraperitoneal bleeding from a ruptured spleen.
How would Rocco’s cardiovascular systemfirstdetect acute loss of intravascular volume?
A. Decreased firing of baroreceptors
B. Decreased delivery of sodium to the distal tubule
C. Increased firing of baroreceptors
D. Increased levels of CO2 in peripheral tissues
Answer –> Decreased firing of baroreceptors
Rocco can increase his cardiac output by: (check all that apply)
A. Decreasing vagal nerve input to his heart
B. Increasing preload by venoconstriction
C. Increasing afterload by arteriolar constriction
D. Direct sympathetic nerve stimulation of the SA node
E. Release of circulating adrenaline from the adrenal medulla
Answer –> A,B,D,E
Vasoconstriction is accomplished by: (check all that apply)
A. Activation of sympathetic nerves innervating vasculature
B. Local response to increasing CO2 levels
C. Release of circulating adrenaline from the adrenal medulla
D. Withdrawal of parasympathetic nerve signals to vasculature
Answer –> A,C
Is there parasympathetic innervation of the vasculature?
No –> there is only sympathetic
Rocco is able to shift some fluid from the interstitial space to the intravascular space because: (check all that apply)
A. Decreasing capillary hydrostatic pressure alters the balance of starling force
B. Increasing capillary permeability allows free flow between the spaces
C. Increasing capillary oncotic pressure alters the balance of starling force
D. Sympathetic nerves activate a sodium-potassium ATPase in the capillary wall
Answer –> Decreasing capillary hydrostatic pressure alters the balance of starling force
Despite all these compensatory measures, perfusion to Rocco’s peripheral tissues becomes inadequate. As his cells are deprived of oxygen, what vital cellular process is unable to proceed? (check all that apply)
A. Utilisation of glucose via glycolysis
B. Reduction of NAD to NADH+
C. Conversion of pyruvic acid to lactic acid
D. Final reaction of electron transport chain
Answer –> D
No blood is available, so you replace Rocco’s lost volume with normal saline. His blood pressure returns to normal, however you have caused his haemoglobin to drop from 13.1 g/dL to 9.9 g/dL, thus reducing his oxygen carrying capacity.
Would giving 100% oxygen make up for this haemoglobin deficit?
A. Completely
B. Mostly
C. Only a bit
D. It’s a toxic waste of time
Answer –> It’s a toxic waste of time
Rocco is taken to theatre for an exploratory laparotomy. He is found to have a more extensive injury to the spleen than initially suspected, and the surgeon has no choice other than to perform a splenectomy.
When considering the long term consequences of splenectomy for Rocco, infection with which of the following organisms would be a particular concern?
A. Cryptosporidium
B. Influenza virus
C. Mycoplasma pneumonia
D. Streptococcal pneumonia
Answer –> Streptococcal Pneumonia
The spleen is normally involved with removing old worn out RBCs from the circulation. Rocco’s liver and lymph nodes will try to take up the slack, but patients without a spleen (or with a non-functioning spleen from something like sickle cell disease) have characteristic findings on their peripheral smear.
What changes would you observe in Brody’s RBCs on a peripheral blood smear? (check all that apply)
A. Poikilocytosis
B. Howell Jolly Bodies
C. Target cells
D. Acanthocytes
Answer –> A,B,C,D
Despite significant blood loss during surgery, Rocco recovers well and is keen to get back on his bike. He received perioperative IV iron during surgery, but when you see him for follow up you would like to check if his iron stores have been adequatelyreplenished.
Which of the following would indicate adequacy of iron stores?
A. Decreased TIBC (total iron binding capacity)
B. Normal serum iron
C. Increased soluble transferrin receptor
D. Normal serum ferritin
E. Normal haemoglobin
Answer –> Normal serum ferritin
You are a GP working in Jewells, NSW. Matilda Pryzbylski is a 17 year old girl who presents with her father, Sam. She’s developed an intensely itchy rash around her wrist. The rash has been gradually getting worse over the last few days. It’s never happened before. The distribution is limited to what you see in the picture, plus bilateral earlobes. It’s pruritic but not painful. She hasn’t tried new soaps, creams or sunscreen. She does wear earrings and a watch daily, and has had the same ones for several years. There is no other useful information on history. What is the pathogenesis of this rash most likely to be do you think? Image shows a rash localised under watch band A. Allergic contact dermatitis B. Atopic dermatitis C. Bacterial infection D. Fungal infection E. Irritant contact dermatitis F. Viral infection
Answer –> Allergic contact dermatitis
Which type of hypersensitivity reaction is allergic contact dermatitis? A. I B. II C. III D. IV
Answer –> IV (4)
Should Matilda continue wearing her watch and earrings?
A. Maybe, the choice is up to her
B. No, she is likely to develop anaphylaxis to repeated exposure
C. No, the reaction is unlikely to dissipate
D. Yes, it should dissipate with time
E. Yes, with some treatment to reduce the inflammation she can continue
Answer –> No, the reaction is unlikely to dissipate
Tony is a 23 year old man who comes to see you as his GP. He has developed skin lesions on his trunk and extensor surfaces of his limbs in the last fortnight. They are mildly itchy. He is otherwise well. Image displays thick, red, bumpy patches covered with silvery scales. Is this likely to be: A. Allergic contact dermatitis B. Atopic dermatitis C. Psoriasis D. Scarlet fever E. Urticaria
Answer –> Psoriasis
Tony’s Dad, Cameron, aged 70, is your next patient. He’s had this mark on his face for the last 3 months. It’s not itchy or painful, and hasn’t got better. He thinks it might be gradually getting bigger.
Image shows circular Raised erythematous border with hyperpigmented centre.
Is this most likely to be:
A. Infectious dermatosis
B. Inflammatory dermatosis
C. Malignant dermatosis
D. Self inflicted injury
Answer –> Malignant dermatosis
Hunter is a 11 year old boy brought by ambulance to the Emergency Department, where you are an intern. He was playing at a friend’s house when he became unwell, having difficulty breathing. His friend’s Mum called the ambulance. Hunter has a history of both asthma and anaphylaxis to peanuts.
Which of the following will help you distinguish between asthma and anaphylaxis?
A. Dual heart sounds, no murmur
B. Poor air entry
C. Reduced blood pressure
D. Widespread wheeze
E. Vomiting
Answer –> Vomiting
You are a GP in Jesmond, NSW. Yvette is a 40 year old woman who presents to you with the following rash. Rash displays erythematous distribution over cheeks and nose
Would you say that this distribution reflects:
A. Allergy
B. Melanoma
C. Photosensitivity
D. Psoriasis
E. Urticaria
Answer –> photosensitivity
You ask Yvette if she has sore joints. Arthritis or arthralgias are present in over 90% of patients with SLE.
If she has joint symptoms, are they likely to be:
A. Monoarticular
B. Morning stiffness which resolves with movement
C. Stiffness which gradually progresses as they day goes on
D. Unilateral
Answer –> Morning stiffness which resolves with movement
Her husband, Ray, has booked the next appointment. He shows you his feet below. He says it began overnight. The intense pain affects the erythematous area in the picture. He thinks it is hot too and he finds it painful to walk. This has never happened to him before. He has no significant medical history and apart from this, feels quite well. Image displays two feet --> one which is oedematous and erythematous, more red near big toe joint with a medial growth/protrusion Is this likely to be: A. Gout B. Osteoarthritis C. Pseudogout D. Rheumatoid Arthritis E. Septic Arthritis
Answer –> Gout
Gout is caused by: A. Deposition of crystals of calcium pyrophosphate dihydrate B. Hyperuricaemia C. Hypouricaemia D. Xanthine oxidase inhibition E. Xanthine oxidase potentiation
Answer –> Hyperuricaemia
Rheumatic Fever and Rheumatoid Arthritis have names which sound similar and they both occur in humans. Are they pathophysiologically similar conditions? A. No B. Sometimes C. Unsure D. Yes
Answer –> No
Many of the diseases you learned about last year resulted from immunologic processes gone wrong. Match the disease with the (oversimplified!) description of the primary pathologic process associated with it.
Graves disease
Hashimoto thyroiditis
Coeliac disease
Post-streptococcal glomerulonephritis
Allergic asthma
Type 1 diabetes mellitus
Antibody-receptor interaction resulting in activation of receptor
Immune complex (IgG, IgM and C3) deposition in tissue with associated inflammation
IgE mediated reaction to environmental trigger
T-cell mediated autoimmune process resulting in complete destruction of a specific cell type
Multiple autoantibodies causing generalized tissue inflammation usually progressing to loss of function
Autoimmune response triggered by environmental antigen resulting in reversible tissue damage
Answers:
Antibody-receptor interaction resulting in activation of receptor = Graves
Immune complex (IgG, IgM and C3) deposition in tissue with associated inflammation IgE mediated reaction to environmental trigger =Post-streptococcal glomerulonephritis
IgE mediated reaction to environmental trigger = Allergic asthma
T-cell mediated autoimmune process resulting in complete destruction of a specific cell type = Type-1 diabetes mellitus
Multiple autoantibodies causing generalized tissue inflammation usually progressing to loss of function = Hashimotos thyroiditis
Autoimmune response triggered by environmental antigen resulting in reversible tissue damage = Coeliac disease
Match the following patient presentations to consistent diagnosis:
Graves disease
Hashimotos thyroiditis
Coeliac disease
Post-streptococcal glomerulonephritis
Allergic Asthma
Type 1 diabetes mellitus
12 yo girl with shortness of breath, prolonged expiration with wheeze
32 yo woman with weight loss, shortness of breath on exertion, frequent bowel movements and anxiety
32 yo woman with weight gain, fatigue and constipation
12 yo girl with a swollen face, shortness of breath, widespread crackles on lung exam
32 yo woman with weight loss, fatigue and diarrhoea
12 yo girl with weight loss and excessive thirst
Answers
12 yo girl with shortness of breath, prolonged expiration with wheeze = allergic asthma
32 yo woman with weight loss, shortness of breath on exertion, frequent bowel movements and anxiety = Graves disease
32 yo woman with weight gain, fatigue and constipation = Hashimotos thyroiditis
12 yo girl with a swollen face, shortness of breath, widespread crackles on lung exam = Post-streptococcal glomerulonephritis
32 yo woman with weight loss, fatigue and diarrhoea = Coeliac disease
12 yo girl with weight loss and excessive thirst = Type 1 diabetes mellitus
Match the disease with the most commonly used confirmatory diagnostic test: Graves disease Hashimotos thyroiditis Coeliac disease Post-streptococcal glomerulonephritis Allergic Asthma Type 1 diabetes mellitus Tissue biopsy Positive Streptozyme Anti-TPO antibodies Presence of TSI immunoglobulin(anti TSH receptor) Immune testing not usually required with consistent clinical presentation Skin testing with suspected antigens
Answers:
Tissue biopsy = Coeliac disease
Positive Streptozyme = post- streptococcal glomerulonephritis
Anti-TPO antibodies = Hashimotos thyroiditis
Presence of TSI immunoglobulin (anti TSH receptor) = graves disease
Immune testing not usually required with consistent clinical presentation = type 1 diabetes
Skin testing with suspected antigens = Allergic Asthma
Match the causes of swelling in the following diseases:
Graves disease
Unrecognized coeliac disease
Post-streptococcal glomerulonephritis
Anaphylaxis
increased hydrostatic pressure due to volume overload
deposition of hyaluronic acid in skin tissue
increased capillary permeability
decreased plasma oncotic pressure
Answers:
increased hydrostatic pressure due to volume overload = Post-streptococcal glomerulonephritis
deposition of hyaluronic acid in skin tissue = Graves disease
increased capillary permeability = Anaphylaxis
decreased plasma oncotic pressure = Unrecognised Coeliac disease
In your working problem, Gulshan Behrooz was being treated for pharyngitis and had a reaction to penicillin. She became severely hypotensive. What type of shock did she have?
a. cardiogenic
b. distributive
c. septic
d. hypovolemic
e. obstructive
Answer –> distributive
If after admission to the ICU, Gulshan was noted to have decreased urine output, what serious renal complication would you be most worried about?
a. Post strep GN
b. Nephrolithiasis
c. Nephrotic syndrome
d. ATN (acute tubular necrosis)
Answer –> ATN (acute tubular necrosis)
Which of the following would be reassuring, that Gulshan’s low urine output was simply an appropriate response to hypotension rather than an indication of renal damage?
a. High urea/creatinine ration (>20:1)
b. Fractional excretion of sodium greater than 2%
c. Granular casts on urinalysis
d. Lack of urine output in response to fluid bolus
Answer –> High urea/creatinine ration (>20:1) (as urea retention is a reasonable response to hypovolaemic shock
Gulshan’s kidneys do sustain some damage and recover slowly. What blood test would give the best estimate of glomerular filtration rate?
a. Albumin
b. Creatinine
c. Urea
d. Potassium
Answer –> Creatinine
