BPT Trial Exam Questions 4 Flashcards
An 81 one year old gentleman is seen in primary care for review of his driver’s license. He is normally fit and well with no past medical history, nor is he on any regular medications. A blood pressure demonstrates a reading of 170/100, with a repeat reading 2 weeks later of 165/100. Which of the following statements is CORRECT regarding treatment of his high blood pressure?
A. Treatment not indicated given his age
B. Blood pressure reduction does not reduce his risk of heart failure
C. Blood pressure reduction to <150/90 will reduce his all cause mortality
D. Blood pressure to < 150/90 will reduce fatal and nonfatal strokes
Answer: C - Blood pressure reduction to <150/90 will reduce his all cause mortality
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Question based off the HYVET study which has got a good wikijournal article about. Aiming for BP < 150/90 decreased all cause mortality. Primary end point was reduction in fatal and nonfatal strokes, which had a HR of 0.7 but didn’t meet significant (?study terminated early) with a p value of 0.06. https://www.wikijournalclub.org/wiki/HYVET
A 50 year old woman is recently diagnosed with multiple myeloma. Her blood tests are as follows: Na 140 K 2.8 Chloride 120 Bicarbonate 12 Phosphate 0.4. Her urinary tests demonstrate an pH of 4, and a negative urinary anion gap. Which of the following is the most likely cause of her biochemical results:
A. Type 1 RTA
B. Type 2 RTA
C. Type 4 RTA
D. Renal light chain deposition disease
Answer: B - Type 2 RTA
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Lady has a normal anion gap metabolic acidosis. Anion gap is negative suggesting meaning that she is able to acidify the urine. Potassium is low. Therefore type 2 RTA which can be seen with MM, and is associated with proximal tubule dysfunction which is why phosphate low as well
A 25 year old man undergoes a renal transplant. Basiliximab is chosen for his induction regime. Which of the following describes the correct molecular target of basiliximab?
A. CD28
B. CD40
C. CD25
D. CD38
Answer: C - CD25
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Basiliximab is a monoclonal antibody against the alpha of the IL-2 receptor which is CD25
A 40 year old gentleman is followed up in renal clinic, now 10 months after a renal transplant for ESRF secondary to diabetes. His transplant was unremarkable in the postoperative period, and he has had no previous episodes of acute rejection. His immunosuppression consists of tacrolimus, mycophenolate, and prednisolone. Blood tests have demonstrated a rise in his creatinine from 80 to 150.
Urine cytology examination shows “decoy” cells, characterized by large nuclear inclusions that replace the normal chromatin. Further testing currently pending. What is the most appropriate management?
A. Pulse IV methyprednisolone
B. Reduce immunosuppression
C. IVIg
D. Leflunomide
Answer: B - reduce immunosuppression
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Person has BK nephropathy and management is based around decreasing immunosupression. General approach is to stop the antimetabolite (MMF or azathioprine) and to decrease the calcineurin drug aiming for a lower level with TDM. IV IG limited efficacy, and I’m not aware of leflunomide being used despite some evidence
Which of the following glomerulonephritides is LEAST likely to recur following renal transplant and cause graft failure?
A. IgA nepropathy
B. Focal and segmental glomerulosclerosis
C. Membranous nephropathy
D. Post-streptococcal glomerulonephritis
Answer: D - Post-strep GN
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Post-streptococcal GN doesn’t really recur
Which of the following has NOT been shown to delay progression to end stage renal failure?
A. Blood pressure control
B. Reduction of proteinuria
C. Alkali therapy
D. Low protein diet
Answer: D - low protein diet
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Low protein diet doesn’t do much. The others have been shown to delay progression to ESRF
A 40 year old female has end stage renal failure secondary to IgA nephropathy. She describes several month history of feeling fatigued. Blood tests show the following: Hb 90 Ferritin 200 Transferrin saturations of 18%. Which of the following is the most appropriate?
A. Red blood cell transfusion
B. Oral iron
C. IV iron
D. EPO
Answer: D - IV Iron
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Person has anaemia secondary to chronic kidney disease. Inflammatory condition that stops ferritin being adequately utilised.
Person has iron deficiency (look at KDIGO guidelines). First step should be replacing iron, and this should be IV as oral iron won’t work (won’t be absorbed due to lots of hepcidin, insufficient to replace usually losses).
Target ferritin > 300 and TF saturation >20%
A 70 year old female presents to hospital progressive behavioral disturbance. She has a medical history significant for dementia with lewy body diagnosed in the past year. On the wards, she is agitated, and crying out. In addition to nonpharmacological measures, which of the following would be most appropriate for her agitation?
A. Olanzapine
B. Quetiapine
C. Clozapine
D. Risperidone
Answer: B - Quetiapine
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Quetiapine least likely associated with EPSE
Which of the following is the strongest risk factor for delirium in hospitalised patients?
A. Use of restraints
B. Malnutrition
C. Addition of >3 medications in past 24 hours
D. Insertion of IDC
Answer: A - Use of restraints
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Physical restraints has the highest odds ratio to cause delirium out of those listed
A 40 year old female is admitted into hospital for progressive shortness of breath over the past 3 months. Her past medical history is notable for a longstanding history of allergic rhinitis, nasal polyps, and difficult to treat asthma. On examination, she is found to have an urticarial type rash as well bilateral pitting oedema. She also points out she has had numbness in the right leg, to which you find loss of sensation of her lateral leg as well as weakness in dorsiflexion and eversion. An xray demonstrates multiple chest opacities, seemingly in different areas to an xray her GP performed 2 weeks ago. Blockade of which of the following cytokines has been demonstrates to improve outcomes in this woman’s condition?
A. IL-6
B. IL-13
C. IL-1
D. IL-5
Answer: D - IL5
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Patient has eosinophilic granulomatosis with polyangiitis. IL-5 blockade using mepolizumab can be used
A 30 year old Turkish female presents to the emergency department with a febrile illness. She has been unwell in past 24 hours with fever, as well as chest pain which is worst on inspiration. Her ankle has become tender and has developed an erythema over the surrounding skin. Her past medical history is unremarkable except for a presentation 2 years ago where she had a fever and abdominal pain, with a subsequent normal laparotomy. She also reports a family history of fevers. Which of the following should be used first line in her condition?
A. Colchicine
B. Anakinra
C. Glucocorticoids
D. NSAIDS
Answer: A - Colchicine
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Patient has familial Mediterranean fever. Treatment is with colchicine
FMF an inflammasome driven condition with strong IL-1 effects.
Which is LEAST likely to cause drug induced lupus?
A. Procainamide
B. Methyldopa
C. Quinidine
D. Etanercept
Answer: D - Etanercept
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Etanercept least likely to cause drug lupus than the others
Drug induced lupus characterised by anti-histone antibodies
A 25 year old man with ankylosing spondylitis is reassessed in clinic 4-5 months after being commenced on infliximab. He describes minimal improvement in symptoms with an unchanged BASDAI score of 6. His ESR is 30 mm/hr with a CRP of 50 mg/L. Which one of the following is the least appropriate management?
A. Add methotrexate in combination with infliximab
B. Switch infliximab to the recombinant TNF inhibitor Etanercept
C. Switch infliximab to Il-17 inhibitor secukinumab
D. Switch infliximab to the IL-6 inhibitor tocilizumab
Answer: D - Switch infliximab to the IL-6 inhibitor tocilizumab
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Patient has ankylosing spondylitis which hasn’t responded to treatment with 1st TNF inhibitor. Different strategies exist, of which there is efficacy for all of them except for tocilizumab. Tocilizumab has not been shown to be useful ank spond
Which of the following causes of interstitial lung disease is typically upper lobe predominant?
A. Rheumatoid arthritis
B. Asbestosis
C. Hypersentivity pneumonitis
D. Methotrexate lung
Answer: C - Hypersensitivity Pneumonitis
Feedback Upper lobes (SCHART-S)
silicosis (progressive massive fibrosis), sarcoidosis
coal workers’ pneumoconiosis (progressive massive fibrosis)
histiocytosis
ankylosing spondylitis
allergic bronchopulmonary aspergillosis
radiation
tuberculosis
Lower lobes (RASCO)
rheumatoid arthritis asbestosis scleroderma cryptogenic fibrosing alveolitis other (drugs, e.g. busulphan, bleomycin, nitrofurantoin, hydralazine, methotrexate, amiodarone)
A 60 year old female was recently diagnosed with pulmonary arterial hypertension. During her right heart catheter study, a vasoreactivity test was performed with inhaled nitric oxide. Her mean pulmonary artery pressure fell from 60 to 40 mmHg with no fall in her cardiac output or systemic blood pressure. Which of the following is CORRECT regarding the use of nondihydropyridine calcium channel blockers (e.g. diltiazem)?
A. She is more likely to respond if her PAH is associated with a connective tissue disease rather than idiopathic
B. Calcium channel blockers have been shown to improve hemodynamics and functional quality of life, as well as improve mortality
C. Should be avoided if she is found to have inactivating mutations of BMPR2
D. She should be started on advanced therapy instead as her vasoreactivity test was negative
Answer: B - Calcium channel blockers have been shown to improve hemodynamics and functional quality of life, as well as improve mortality
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Calcium channel blockers have been shown to improve haemodyanmics, QOL as well as improve mortality in those who respond. Differemt types of group 1 PAH respond differently to calcium channel blockers. These include those with idiopathic and hereditary cases (mutations in BMPR2). Her vasoreactivty test is positive making d incorrect. Connective tissue disease associated PAH tends not to respond to calcium channel blockers
A 40 year old gentleman presents to the emergency department with abdominal pain shooting down to his groin. This is associated with new haematuria. He is given IVT and analgesia. Several hours later, a 6mm stone is passed which is sent to the lab for chemical analysis which reveals calcium oxalate. Which one of the following is NOT a risk factor for this man’s stone?
A. Thiazide diuretics
B. Restricting dietary calcium
C. Excess dietary oxalate
D. Metabolic acidosis
Answer: A - Thiazide Diuretics
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Thiazide diuretics are used to decreased calcium in the urinary tubules, hence used for prevention rather than a risk factor
A 30 year old man presents to hospital with 2 days of diarrhoea and crampy abdominal pain. It is blood-stained with occasional mucous, he is passing 10-12 motions per day and overnight. He has had similar but less severe episodes over the last 2 years but managed them at home. He denies and vomiting and has had no sick contacts.On examination he appears dehydrated. HR is is 100, BP is 105/80, temperature is 37.8. Hb 100 WCC 17 Platelets 300 CRP 20 Bedside flexible sigmoidoscopy is performed and shows severe inflammation uniformly from rectosigmoid proximally. Which of the following parameters is not included in the grading system to define severity in his condition? *
A. Temperature
B. Haemoglobin
C. Stool frequency
D. White cell count
Answer: D - WCC
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See Truelove and Witt’s criteria for severe acute ulcerative colitis. This is applied on admission and day 3 of therapy to guide escalation of treatment.
Severe: Stools per day >6 HR >90bpm Temperature >37.8 (this does seem to vary slightly on different guidelines) Hb <105g/L CRP >30
For this man his stool frequency, HR, BP and Hb all suggest severe disease. His CRP doesn’t, but this isn’t an option. WCC is not included in the criteria and is the correct answer for this question. An elevated WCC is however useful to define severe C. Difficile colitis.
A 40 year old man presents to you with dyspepsia and gnawing abdominal pain at night. Urea breath test is positive. The patient describes perioral swelling and wheeze when treated with a penicillin for leg cellulitis last year. What is the appropriate treatment regimen? *
A. Amoxycillin, clarithromycin and esomeprazole
B. Metronidazole, clarithromycin and esomeprazole
C. Colloidal bismuth subcitrate, tetracycline, metronidazole and esomeprazole
D. Metronidazole, levofloxacin and esomeprazole
Answer: B - Metronidazole, Clarithromycin and Esomeprazole
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You should be familiar with the ETG for questions like this. The first line therapies (and penicillin-free alternatives) are solid fodder for questions.
The first line treatment is esomeprazole 20mg BD, amoxycillin 1g BD and clarithromycin 500mg BD for 7 days.
The penicillin-free regimen substitutes metronidazole for penicillin.
Success rates are 85-90% with these reigmens. Nonadherence and primary resistance to clarithromycin (6-8%) are the most commmon reasons for treatment failure.
The patient from the above question (with H. pylori confirmed on breath test) completes his course of therapy as prescribed. He continues to have pain at night and reflux symptoms. His weight is stable. He sees you approximately 8 weeks after his last visit. You repeat urease breath testing, which is again positive. You refer him to Gastroenterology for endoscopy. What is the most appropriate regimen to commence him on whilst he is waiting?
A. Wait for endoscopy to guide sensitivities
B. Amoxycillin, levofloxacin and esomeprazole
C. Colloidal bismuth subcitrate, tetracycline, metronidazole and esomeprazole
D. No further treatment is necessary. The urease breath test has been repeated too soon and is likely a false positive.
Answer: C - Colloidal bismuth subcitrate, tetracycline, metronidazole and esomeprazole
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This questions speaks to a few issues. Endoscopy is probably reasonable in someone with persistent symptoms, but this referral might be a bit premature (in these questions you can assume red flags that aren’t mentioned aren’t present). Endoscopy and biopsy for H. pylori MCS should be done if they have failed TWO different treatment courses. In the first instance resistance to clarithromycin should be assumed and this should be substituted out. Thus, A is wrong.
The man is still allergic to penicillin and B is wrong. If he weren’t allergic, this would be an appropriate second line therapy.
C describes quadruple therapy which is used after failure of the first regimen and is the correct answer.
This man has had 2 weeks of treatment and returns another 6 weeks after that (total 8 weeks). Repeat urease breath test should be performed at least 4 weeks after completion of antibiotics, thus it has not been done prematurely and D is wrong. PPIs should be held in advance of the test because they can cause a false negative.
For drugs with low hepatic extraction ratio, doubling the hepatic extraction ratio will:
A. double the bioavailability
B. cause no difference to the bioavailability
C. half the bioavailability
D. decrease the bioavailability by 25%
Answer: B - cause no difference to the bioavailability
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Bioavailability = 1- hepatic extraction ratio
Low hepatic extraction ratio drugs:
- Poorly extracted by liver, nearly all the dose gets through the liver first pass
- Doubling or halving the minor proportion extracted by liver does not make any significant difference to bioavailability
High hepatic extraction ratio drugs
a) Mostly extracted through first pass through liver so that only a minor proportion reaches systemic circulation
b) Inducing or inhibiting the metabolising enymes only has small effect on hepatic extraction ratio and thus systemic clearance BUT major effect on proportion escaping extraction which is (1- hepatic extraction ratio) and thus major effect on bioavailability
A 32 year old caucasian male presents with a several-month history of lower back pain. You recall that most caucasian patients with ankylosing spondylitis are positive for HLA B27 and wonders whether to order this test. You then do a literature search and find that: a) 90% of caucasian patients with ankylosing spondylitis are HLA-B27 positive, and b) the background prevalence of HLA B27 among healthy caucasian male is about 10%. Given this patient’s history and physical examination, you estimate that his probability of having ankylosing spondylitis (the pretest probability) is only about 10%. Which one of the following values represents the positive predictive value of HLA B27 for ankylosing spondylitis in this case?
A. 50%
B. 10%
C. 90%
D. 25%
Answer: A - 50%
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Correct answer: a) 50%
The positive predictive value (PPV) is the probability that a patient with a positive test result actually has the disease. To calculate PPV, the easiest way is to construct a 2X2 table and one must know the sensitivity, specificity and pretest probability.
In this case:
- the sensitivity of HLA B27 is 90%
- the specificitis also 90% (given the 10% prevalence of HLA B27 in the general population, 90% of caucasians without the disease will be B27 negative)
- the pretest probability is 10%.
The 2X2 table (in a hypothetical population of 100) will look like this:
……………………. Disease Present Disease Absent
B27 positive……………. 9……………… 9
B27 negative …………… 1……………… 81
PPV: TP/ (TP+FP)
= 9/ (9+9) = 50%
The table shows that only 9 of the 18 patients who are B27 positive actually have the disease, thus the PPV is 50%.
Regarding anterior pituitary hormones, which of the following associations is incorrect?
A. ACTH release causes increased adrenal blood flow
B. Glucagon inhibits growth hormone release
C. Renal failure causes increased prolactin
D. Dopamine inhibits prolactin release
Answer: B - Glucagon inhibits growth hormone release
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Glucagon stimulates secretion of growth hormone, insulin and somatostatin. Other associations are correct. Notably, prolactin is excreted by a combination of renal and hepatic clearance and therefore accumulates in renal failure.
Which of the following factors cause an increase in gastric pH?
A. Vagal stimulation
B. Gastrin release
C. Histamine release
D. Secretin release
Answer: D - Secretin release
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Secretin release is stimulated by the presence of intraluminal acid and its actions include stimulating pancreatic bicarbonate secretion as well as inhibiting gastric acid and pepsin secretion and delaying gastric emptying.
Vagal stimulation increases both pepsin and acid output directly as well as decreasing pH indirectly stimulating gastrin secretion. Gastrin directly stimulates gastric acid. Histamine acts via H2 receptors to stimulate acid secretion
A 75 year old gentleman has been admitted to the intensive care unit with severe community acquired pneumonia requiring intubation and ventilation for 4 days. He has a background history of giant cell arteritis on high dose prednisolone, T2DM and hypertension. He has been on meropenem and vancomycin. However, he has now spiked a new temperature and preliminary blood culture results showed gram negative bacteria. What antibiotics should you consider?
A. Gentamicin
B. Trimethoprim/sulfamethoxazole
C. Ciprofloxacin
D. Pristinamycin
Answer: B - Bactrim
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Stenotrophomonas maltophilia is a gram negative bacterium naturally resistant to carbapenems, can be found in immunocompromised patients.
Which of the following oncovirus and malignancy associations are incorrect?
A. CMV and mucoepidermoid carcinoma
B. EBV and Post-Transplant Lymphoproliferative Disorder
C. HPV and Penile Carcinoma
D. HTLV and Primary Effusion Lymphoma
Answer: D - HTLV and primary effusion lymphoma
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Primary effusion lymphoma is caused by human herpes virus 8.
HTLV causes adult T cell leukemia
Which of these adverse effects is least associated with VEGF inhibitors?
A. Proteinuria
B. Bleeding
C. Cardiomyopathy
D. Bowel perforation
Answer: C - Cardiomyopathy
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VEGF inhibitors are used as targeted therapies for a variety of malignancies and affect angiogenesis which is essential for tumour growth. Common adverse effects includes bleeding and hypertension. A benign proteinuria has ben reported and there are case reports of bowel perforation. Cardiomyopathy is not a reported adverse effect and more associated with Her-2 blockers and anthracyclines.
