MCQs presented in CLS

Question 1

Which of the following is the most appropriate way to undertake DNA genetic diagnosis of Huntington’s disease?

A- RFLP (restriction fragment length polymorphism) analysis
B- PCR analysis
C- size estimation triplet repeat
D- Southern hybridisation
E- identification of gene-specific mutations

Answer 1

C

Question 2

The DNA approach to genetic disorders means that individuals who are at risk but clinically asymptomatic can be tested to determine if they will develop the disease. In this circumstance, which one of the following is the most appropriate reason for testing a 9 yo child?

A- informed consent can be obtained from the parents
B- parental anxieties can be relieved
C- In the case of autosomal recessive disorder, the child’s carrier status can be determined
D- Medical intervention can alter the disorder’s natural history
E- the child wants to be tested

Answer 2

D

Question 3

An 81 year old male presents with dyspnoea. He has a history of cigarette smoking and COPD, and an ejection systolic murmur. Transthoracic echocardiogram shows mild global LV dysfunction (LVEF 49%); aortic maximum velocity (Vmax) 3.4ms-1; PPG 51mmHg; MPG 32mmHg and aortic valve area (AVA) 1.2cm2.

Appropriate management is:
a. Referral for surgical aortic valve replacement

b. Palliative management due to age and comorbidities (COPD, cardiomyopathy)

c. Observation and repeat echocardiography

d. Referral for transcatheter aortic valve replacement (TAVI)

Answer 3

C

Question 4

Regarding acute severe aortic regurgitation, which of the following are incorrect:

a. Results in a severely dilated left ventricle

b. May be a life-threatening emergency

c. Infective endocarditis is an important cause to consider

d. Bradycardia may lead to patient deterioration

Answer 4

A (is seen in chronic)

Question 5

Secondary mitral regurgitation is related to

a. Endocarditis with leaflet perforation

b. Mitral valve prolapse

c. Left ventricular dysfunction and annular dilatation

d. Chordal rupture (‘flail leaflet’)

Answer 5

C

Question 6

An 87 year old man is admitted with a dense left hemiplegia and immobile. Which of the following strategies is the most effective for reducing the risk of developing a pressure ulcer in this patient?

A. Second-hourly turns

B. Assessment of pressure area risk by Norton Risk Assessment Score

C. Nutritional supplementation

D. Indwelling urethral catheterization

E.Pressure relieving mattress

Answer 6

A

Question 7

Which of the following treatments is most beneficial for venous ulcers?

A. Moist dressings

B. Compression

C. Keeping wound dry and exposed to air

D. Varicose vein surgery

E. Exercise

Answer 7

B

Question 8

What is the most common cause of chronic leg ulcers?

A. Skin Cancer

B. Arterial disease

C. Venous disease

D. Diabetes

E. Pressure ulcers

Answer 8

C

Question 9

Which of the following is NOT appropriate therapy for pyoederma gangrenosum

A. Compression

B. Topical tacrolimus

C. Skin grafting

D. Antibiotics

E. Moist wound dressings

Answer 9

C

Question 10

Which of the following features is NOT useful in distinguishing venous from arterial ulceration:

A.Ulcer shape

B. Ulcer depth

C. Presence of pain

D. ABPI

E. Amount of exudate

Answer 10

C

Question 11

A patient has cardiac resynchronisation therapy planned. Which of the following investigations will give the best prediction of whether a symptomatic response will be seen?

a. Cardiac MRI

b. Echocardiogram

c. Angiogram

d. CTCA

e. ECG

Answer 11

e

Question 12

Typical atrial flutter is caused by which mechanism?

a. Increased automaticity of atrial cells

b. Macro-reentry circuit in the atria

c. Micro-reentry circuit in the atria

d. Early after depolarisation

e. Ectopic atrial focus

Answer 12

b

Question 13

An 88 year old woman with a history of ischaemic heart disease, diabetes, hypertension and depression takes the following medications:

metoprolol 25 mg bd
simvastatin 40 mg daily
aspirin 100 mg daily
metformin 500 mg bd
indapamide 2.5 mg daily
irbesartan 8 mg daily
citalopram 20 mg daily
temazepam 10 mg nocte
Which of the following of her symptoms is most likely to be an adverse drug reaction?

A. Recurrent falls from metformin

B. Memory loss from aspirin

C. Muscle aches from temazepam

D. Confusion from indapamide

E. Leg swelling from citalopram

Answer 13

D - indapamide commonly causes hyponatraemia which causes delirium

Question 14

30 subjects undergo treatment for cancer. 9 subjects experienced cancer progression at 1 year. Select a true statement from below.

A. The risk of cancer progression on the treatment is 30%.

B. The odds of cancer progression on the treatment are 30%.

C. the NNT is 3.33.

D. The treatment is not effective.

Answer 14

A

Question 15

Censored observations…

A. can be included in the analysis if we use the correct statistical test.

B. ruin a perfectly good clinical trial.

C. can be excluded from the analysis without making any difference to the conclusions.

D. should be avoided under all circumstances.

Answer 15

A

Question 16

The following studies (Study A, B, C, D) assess the possible relationship between living near power lines and brain cancer.

Study A
The rate of brain cancer and the proportion of people living near power lines were determined in each Australian state. These rates and proportions were then compared between states.

Study B
A random sample of people were divided into two groups: those who lived near power lines versus those who lived far away. They were followed for ten years. The rates of brain cancer were compared between the two groups.

Study C
A random sample of adult patients who were in hospital over the previous year were divided into two groups: those diagnosed with brain cancer versus those who were not. The proportion of people who previously lived near power lines were compared between the two groups.

Study D
A random sample of people were asked whether they lived near power lines over the previous year and whether they had been diagnosed with brain cancer over the previous year. The rates of brain cancer were compared between those who lived near power lines versus those who lived far away.

List the studies in descending order of strength, i.e. highest quality study first, lowest quality study last.

a. A B C D

b. B C D A

c. C B A D

d. C B D A

Answer 16

B

Question 17

Which of the following features of clinical trial design may improve efficiency, i.e. less patients needed for the study?

a. stratification

b. allocation concealment

c. crossover

d. intention to treat analysis

Answer 17

C

Question 18

Covert Oxycodone 30 mg PO BD to CSCI of hydromorphone

Answer 18

1. Oxycodone oral morphine equivalent (OME) = 60 x 1.5 = 90 mg
2. OME to morphine SC = 90/3 = 30 mg
3. Morphine SC to Hydromorphone SC = 30/5 = 6 mg
4. Dose reduction when converting to SC = 6 x 2/3 = 4 mg

Question 19

52F presents with SOB on background resected left breast cancer. CT demonstrates large left sided pleural effusion. What is the next best step in management?
A- therapeutic pleural aspiration
B- diagnostic pleural aspiration
C-antibiotics
D-indwelling pleural catheter
E-intercostal catheter and talc pleurodesis

Answer 19

A: both obtains sample for diagnostic studies and also attempts to see if fluid drainage improves symptoms

Question 20

A man presents with 2 days of facial pain, redness and swelling. He is systemically well. What is the most appropriate treatment for his condition?
A- oral phenoxymethylpenicillin
B- oral clindamycin
C- IV flucloxacillin
D- IV vancomycin
D- oral amoxicillin + clavulanic acid

Answer 20

A - treatment for erysipelas = superficial infection of skin commonly in face caused by streptococci

Question 21

A patient presents with severe sepsis, hypotension and a painful, swollen red area on right arm. You suspect necrotising fasciitis. Confirmation of the diagnosis is best made by?

A- presence of crepitus on examination
B- clinical response to IV antibiotics
C- CT imaging of the arm
D- isolation of GAS on blood culture
E- surgical exploration

Answer 21

E

Question 22

Your local hospital guideline for empiric treatment of acute pyelonephritis (after cultures) recommends IV gentamicin 5 mg/kg LBW Q24H. Which of the following is the most relevant pharmacodynamic parameter to this dosing regimen of gentamicin?

A- Cmax/MIC
B- T > MIC
C- AUC/MIC
D- 0.7 x (Vd/CL)
E- All of the above

Answer 22

A - antibiotic activity of gentamicin (aminoglycaside) is concentration dependent and toxicity is dependent on the total exposure to drug, so aim for high concentration to promote killing and rapid clearance to avoid toxicity

(D is pharmacokinetic)

Question 23

An MSU positive for E.coli taken from a patient with pyelonephritis who has not responded to IV cefuroxime demonstrates to cepahlosporins + beta-lactams (I for co-amoxyclav). What is the most likely mechanism of resistance to cefuroxime?
A- reduced porin expression
B- enzyme-mediated hydrolysis
C- reduced target binding site affinity
D- efflux pump expression
E- ribosomal methylation

Answer 23

B (mechanism of ESBL)

Question 24

An MSU positive for E.coli taken from a patient with pyelonephritis who has not responded to IV cefuroxime demonstrates to cepahlosporins + beta-lactams (I for co-amoxyclav). What is the most likely mechanism of resistance to cefuroxime?
A- ampC
B- mecA
C- vanB
D- CTX-M
E- NDM

Answer 24

D (most common type of ESBL worldwide)

(ampC also correct but less common)

Question 25

67F 2 days dysuria and frequency without systemic involvement. Normal vitals. No drug allergies. Started empirically on trimethoprim, returned positive urine demonstrating broad penicillin resistance (I to co-amoxyclav), susceptibility to ertapenem, gentamicin, fosfomycin and mecillinam.
What is the best outpatient management?

A- OP IV gentamicin Q24H
B- IP IV gentamicin Q24H
C- IP IV ertapenem
D- OP fosfomycin
E- IP fosfomycin

Answer 25

D as treating ESBL+ cystitis (systemically well)

Question 26

85F presents with series on falls on background of cognitive decline and recurrent UTIs. Denies any LUTS. Oriented and normal vitals. Investigations are unremarkable except for E coli positive MSU pending sensitivities, with Leucs2+ and Nitrite+, urine WCC 120. What is best management?

A- Stat IV gent followed by Q8H cefuroxime
B- Oral trimethoprim
C- observe without antibiotics
D- observe without antibiotics and repeat MSU
E - IV Co-amoxyclav and repeat urine

Answer 26

C - asymptomatic bacteriuria

Question 27

50F undergoes renal transplantation with ATG induction. She is CMV seronegative but donor is CMV seropositive so is initiated on valganciclovir prophylaxis. After 2 months becomes neutropenic. What is the best method of prevention moving forward?

A- stop valganciclovir and switch to preemptive monitoring with a plan to start treatment when viral load climbs or becomes symptomatic
B- dose reduce valgancliclovir to 450 mg alt days
C- switch prophylaxis to marabivir
D- commence GCSF
E- check CMV IFN-gamma assay to guide duration of prophylaxis

Answer 27

A

Question 28

30M presents with 4/7 fever and sore throat with 48h itchy vesicular rash, dry cough and SOB. CXR demonstrates diffuse nodular opacities. What specific treatment is appropriate?
A- IV aciclovir
B- IV ceftriaxone
C- PO aciclovir
D- IV ganciclovir
E- IV liposomal amphoteracin

Answer 28

A - symptoms of chickenpox complicated by pneumonia

Question 29

60M with no PMHx presents with 2/7 headache and altered LOC. No recent travel. On exam she is febrile and drowsy. A CT-head is unremarkable. Her CSF demonstrates 10 lymphocytes, normal glucose and protein 0.5, Gram stain is negative. PCR is awaited.

What is the next most appropriate action?
A- Start IV aciclovir
B- Start IV meropenem
C- Start IV methylprednisone
D- Start IVIg
E- wait until PCR back

Answer 29

A

Question 30

60F presents with seizure and altered personality. One exam has normal vital signs, is confused and acting abnormally. Bloods are normal and tox screen negative.
Which of the following neuronal antibodies is most likely to be present?
A- anti-mGluR5
B- anti-GABABR
C- anti-Ma2/Ta
D- anti-NMDAR
E- Anti ANNA-1/Hu

Answer 30

D

Question 31

45M indigenous background is diagnosed with hodkin lymphoma and commenced on R-CHOP. Develops fever, vomiting and diarrhoea, cough, haemoptysis. Has transient infiltrates on serial CXR. Hb 107, WCC 4.5, PLT 112, Eosinophils 1.0.
What is the next step in management of this patient?
A- give platelet transfusion
B- Start IV meropenem
C- urgen bronchoscopy
D- start ivermectin
E- start Frusemide

Answer 31

D - reactivation of strongyloides infection

Question 32

72M with NHL on R-CHOP presents with fever, tachypnoea, tachycardia and hypotension. Hb 110, Plt 80, Neut 0.2. Which of the following is most appropriate?
A- Amoxicillin clavulanate
B- Ceftriaxone + roxithromycin
C- Ciprofloxacin
D- piperacillin tazobactam
E - vancomycin + gentamicin

Answer 32

D as beta lactam with anti-pseudomonal activity

Question 33

An ECG is shown demonstrating 2:1 atrial flutter entering into a wide complex tachycardia at 230 bpm. Which of the following is the most likely clinical history associated with this presentation?
A. 70M with prior MI on amiodarone
B. 55F with DCM on ARNI + bisoprolol
C. 44F with pAF on felcainide
D. 18M with history of recurrent SVT
E. 84M with dcPPM for mobitz II AV block

Answer 33

C - flecainide without AV nodal blocking agent increase risk of 1: 1 conduction of A flutter

Question 34

Which IV antiarrhythmic drug is contraindicated in management of acute VT?
A- lignocaine
B- Verapamil
C- procainamide
D- amiodarone
E- sotalol

Answer 34

B - negative ionotropic effect results in severe hypotension

Question 35

Which of the following is not a long-term treatment for scar-mediated VT?
A- amiodarone
B - ICD
C- sotalol
D- catheter ablation
E- mexilitene

Answer 35

B - does not treat VT, is prophylactic

Question 36

A 39 year old mechanic consults you because of concerns about his asthma. Several admissions to hospital in childhood, but none since. Uses Seretide dry powder inhaler (250/50ug), one puff bd. Had a week off work 9 months ago with a chest infection and asthma flare-up which gradually settled. However in the last 2 months has been a little more breathless and wheezy and is waking at night 1-2x per week. Uses salbutamol 2 or 3 times per day. FEV1 73% predicted with 16% improvement post bronchodilator.

Your recommendation:
a. Double the dose of Seretide

b. Change Seretide to metered dose inhaler + spacer

c. Add tiotropium mist inhaler

d. Add montelukast

e. Change to Symbicort SMART (single maintenance and reliever therapy)

f. Other

Answer 36

F - The question describes someone with poor asthma control. In this situation, it is important to first check inhaler technique and adherence to Seretide before increasing inhaler dose or switching to another formulation. Answers a, b, c and e would be reasonable alternatives once adherence and inhaler technique have been checked and optimised. Adding montelukast is unlikely to help unless there is a clear history of aspirin intolerance

Question 37

A 34 year woman, breastfeeding 6/12 child, is referred by a physician in a large regional town for management of severe asthma. Multiple admissions to hospital, including 3rd trimester of recent pregnancy. Multiple courses of oral prednisolone and recent weight gain. Wakes most nights with wheeze and cough. Allergic rhinitis, previous nasal polyps.

Current treatment Symbicort 400/12ug, ii bd, salbutamol 5-6 per day, oral prednisolone 10mg daily (last 8 weeks). Allergic to house dust mite and moulds, total IgE 520 kU/L, blood eosinophils 0.40 x 10^9/L. FEV1 61% predicted with no significant change after salbutamol.

Your recommendation:

a. Double the dose of Symbicort

b. Change to Seretide via a metered dose inhaler + spacer

c. Add montelukast

d. Refer to immunologist for allergen desensitisation

e. Methotrexate

f. Other

Answer 37

F - The first step would be to check inhaler technique and adherence to Symbicort. The dose of Symbicort is already high so there is not much value in pushing the dose higher. Switching to an alternative ICS/LABA combination metered dose inhaler via a spacer may help. Adding montelukast is unlikely to help unless there is a clear history of aspirin intolerance. Allergen desensitisation should not be initiated in someone with poorly controlled asthma. Methotrexate is too risky in someone who is breastfeeding.

Question 38

Which of the following is the single most useful test to perform in patients with suspected heart failure?
A- cardiac MRI
B- coronary angiogram
C- Chest x-ray
D- Echocardiogram

Answer 38

D

Question 39

Most drugs evaluated in HFpEF outcome studies failed to achieve their primary endpoint. Which of the following is an exception?
A- empagliflozin
B- candesartan
C- spirinolactone
D- digoxin

Answer 39

A

Question 40

A 55-year-old non-smoking male gentleman was referred with an abnormal chest radiograph and an 18-month history of progressive breathlessness. His previously unlimited exercise tolerance had diminished to 300 metres on level ground. He had no infective symptoms, haemoptysis, orthopnoea or paroxysmal nocturnal dyspnoea. He did not have any symptoms of an underlying connective tissue disease (for example Raynaud’s phenomenon, joint or muscle ache, skin tightening, rash, sicca symptoms, mucosal ulcers, alopecia or gastro-oesophageal reflux symptoms). There was no family history of pulmonary disease but his teenage son suffered with chronic aplastic anaemia.

What is the relevance of this patient’s family history? (multiple correct)

a. The absence of a family history of lung disease suggests that the aplastic anaemia affecting his son is not important​

b. Childhood aplastic anaemia has no relevance to adult respiratory disease

c. Childhood aplastic anaemia may be related to underlying dyskeratosis congenita (DKC)

d. The family may carry a genetic mutation in the telomerase complex​

Answer 40

The correct answers are (c) & (d)

The occurrence of childhood aplastic anaemia raises the possibility of an inherited bone marrow failure syndrome.
Dyskeratosis congenita is caused by mutations in genes encoding proteins involved in the maintenance of telomere length (e.g. telomerase) and manifests with a triad of mucocutaneous features in infancy: nail dystrophy, patchy skin hyperpigmentation and oral leukoplakia.
Aplastic anaemia complicates dyskeratosis congenita in the first or second decade of life.
Telomere shortening as a result of similar mutations has been associated with familial pulmonary fibrosis and emphysema.

Question 41

What full blood count and biochemistry abnormalities may be encountered in the context of telomere shortening? (multiple can be correct)

a. Anaemia

b. Microcytosis

c. Thrombocytopenia

d. Lymphopenia

e. Deranged liver function tests

Answer 41

The correct answers are (a), (c), (d) and (e)

The most common blood test abnormalities in the context of telomere shortening are:

Anaemia (28%)
Macrocytosis (24-45%)
Thrombocytopenia (9-55%)
Lymphopenia (8%)
Deranged liver function tests (4%)

Question 42

What other features raise the possibility of shortened telomeres in a patient with pulmonary fibrosis? (multiple can be correct)

a. Liver cirrhosis

b. Premature hair greying

c. Opportunistic infections

d. Emphysema

e. Osteoporosis

Answer 42

The correct answers are (a) – (e) (all are correct)

The clinical features of telomere shortening can involve multiple organs; the effects are in part dependent on the rapidity of tissue turnover.

Manifestations in rapid turnover tissues include:

Premature greying of the hair (20-30 years of age)
Aplastic anaemia, macrocytosis, thrombocytopenia, lymphopenia
B, T and NK cell immunodeficiency resulting in opportunistic infections
Manifestations in slow turnover tissues include:

Pulmonary fibrosis
Premature onset emphysema
Cirrhosis
Coronary artery disease
Osteoporosis
Additional manifestations include an increased risk of epithelial and haematological malignancies.

Question 43

What genetic phenomenon explains the occurrence of aplastic anaemia in the son and pulmonary fibrosis in the father?

a. Autosomal dominant inheritance

b. X-linked recessive inheritance

c. Mosaicism

d. Anticipation

Answer 43

The correct answer is (d)

The telomere complex mutations are inherited in an autosomal dominant fashion.
Shortened telomeres are carried in germ cells to offspring such that telomeres start from a shortened length in successive generations.
This leads to an anticipation effect with the onset of disease becoming earlier in successive generations.
Phenotype transition can occur, as exemplified in this case, with offspring presenting with haematological manifestations rather than respiratory disease – this explains the interesting occurrence of pulmonary fibrosis in this patient developing after the onset of haematological disease in his son.
The disease phenotype can also become more severe in successive generations.
This phenomenon raises important issues for genetic counselling in affected families.

Question 44

Which of the following features are shared between Idiopathic Pulmonary Fibrosis (IPF) and Rheumatoid Arthritis associated Interstitial Lung Disease (RA-ILD)? (multiple can be correct)

a. Usual interstitial pneumonia (UIP) radiological pattern

b. MUC5b genetic mutation

c. Association with a smoking history

d. Acute exacerbations

e. Response to anti-fibrotic therapy

Answer 44

The correct answers are (a), (b), (c) and (d)

The efficacy of anti-fibrotics in RA-ILD are not yet proven – the results of the TRAIL1 study are eagerly awaited. INBUILD [ahead of print] may provide some support for nintedanib in RA-ILD.
RA-ILD differs from other CTD-ILD in its predisposition to a UIP radiological/histological pattern.
A gain of function mutation in MUC5b is observed in ~50% of IPF patients. The same mutation has been found to increase the risk of ILD in RA.
The risk of RA-ILD is increased by a history of smoking. RA-ILD acute exacerbations are similar to acute exacerbations of IPF and have a high risk for mortality.

Question 45

Which of the following therapies does not have proven efficacy in systemic sclerosis associated interstitial lung disease?

a. Cyclophosphamide

b. Mycophenolate

c. Autologous stem cell transplantation

d. Nintedanib

e. Methotrexate

Answer 45

The correct answer is (e)

The pivotal Scleroderma Lung Study (SLS) trials confirmed the efficacy of cyclophosphamide and mycophenolate.
A number of recent trials have confirmed the efficacy of autologous stem cell transplantation in appropriately selected patients.
The SENSCIS trial recently confirmed the efficacy of nintedanib on rate of FVC decline in SSc-ILD.
Methotrexate has not been studied in SSc-ILD and would typically be avoided in SSc-ILD due to its risk of causing ILD.

Question 46

Which of the following therapies should be avoided in a patient with Idiopathic Pulmonary Fibrosis (IPF)? (multiple correct)

a. Pirfenidone

b. Nintedanib

c. Azathioprine

d. N-acetylcysteine

e. Mycophenolate

Answer 46

The correct answers are (c) and (e)

Both pirfenidone and nintedanib have proven efficacy in IPF.
N-acetylcysteine is not commonly used in IPF, however there may be efficacy in those who carry a mutation in TOLLIP.
The combination of azathioprine, prednisolone and n-acetylcysteine was shown to be harmful in those with IPF (PANTHER). Similar data exists for mycophenolate in IPF. Immunosuppression is therefore strongly discouraged in patients with IPF. The only exception may be in those with acute exacerbations of IPF where high dose corticosteroids might be utilized.

Question 47

A 45 year old lady presents with type 1 respiratory failure and the CT scan attached. She has no known medical history. Examination of the hands reveals erythematous lesions symmetrically over the meta-carpophalangeal joints. Her CK is not elevated. She is started on high flow oxygen therapy at 60% FiO2 and stabilized on the ward.
What is the most important next step in management of this patient?

a. Await ENA result

b. Await myositis panel result

c. Bronchoscopy with bronchoalveolar lavage

d. Commence immunosuppression

e. Start broad spectrum antibiotic therapy

Answer 47

The correct answer is (d)

This lady has a severe dermatomyositis associated interstitial lung disease. In this particular case the patient has an anti-MDA5 antibody which is typically amyopathic (hence the negative CK) and a pneumomediastinum (a common complication of this disease). The constellation of skin and lung findings is sufficient for the diagnosis and therefore the antibody panel is not necessary before the commencement of treatment.
A bronchoscopy is not required to make the diagnosis and would also be highly risky in the patient’s current clinical circumstance.

Question 48

Which of the following is a good prognostic feature in hypersensitivity pneumonitis?

a. Presence of honeycombing on CT

b. Identifiable antigen exposure

c. Shortened telomeres

d. Biopsy pattern of UIP

e. Negative serum precipitins

Answer 48

The correct answer is (b)

An identifiable exposure allows that patient to avoid/remove the exposure which is causing inflammation and fibrosis. An exposure is not identifiable in ~25% of patients with chronic hypersensitivity pneumonitis. The lack of an identifiable exposure is a poor prognostic feature.
The presence of honeycombing, UIP and shortened telomeres are poor prognostic features.
Serum precipitins may be useful in diagnosing HP, but are not contributory to prognostication. Serum precipitins may assist in defining an exposure.

Question 49

A 50 year old male smoker presents with dyspnoea and the attached chest x-ray. An intercostal catheter is inserted. A CT is performed.

The presence of which cells in a lung biopsy would confirm this man’s diagnosis?

a. Fibroblasts

b. LAM cells

c. Macrophages

d. CD1a+ Langerhans cells

e. Pneumocystis

Answer 49

The answer is (d)

This man has Langerhans cell histiocytosis as the cause of his cystic lung disease. Langerhans cells are dendritic cells which is diagnostic of this condition.
The CT demonstrates multiple irregularly shaped cysts within the lung. Sparing of the costophrenic recesses (not shown) is classic of this condition. Whereas in LAM the cysts are typically found in the costophrenic recesses - ‘LAMbs fall to the gullies’. The cysts in LAM typically have a smooth outline.

Question 50

An 80 year old lady presents to outpatients with chronic cough and dyspnoea and the attached chest CT. She has a past history of hypertension, dyslipidaemia, type 2 diabetes, chronic kidney disease and recurrent urinary tract infections.

Which of the below medications is the most likely cause?

a. Perindopril

b. Atorvastatin

c. Nitrofurantoin

d. Metoprolol

e. Metformin

Answer 50

The correct answer is (c)

This is a classic scan for nitrofurantoin induced lung disease. The RACP candidate would not be expected to know this classic scan appearance but should be aware of common causes of drug induced ILD (e.g. amiodarone, nitrofurantoin, methotrexate, newer biologic therapies).

Question 51

This 39 year old lady with a history of recurrent sinus infections presents with chronic dyspnoea and an abnormal chest CT. The below investigation results are obtained:

Lung function: FEV1 60%, FVC 80%, FEV1/VC 64%
ANA: 1:180 speckled
ENA: negative
Myositis panel: negative
ACE: elevated
ANCA: negative
RF: negative
Which of the following investigations should be performed next to diagnose this interstitial lung disease?

a. Surgical lung biopsy

b. EBUS-TBNA

c. Serum immunoglobulin levels

d. Bronchoalveolar lavage

e. CT guided percutaneous lung biopsy

Answer 51

The answer is (c)

This lady has Granulomatous Lymphocytic Interstitial Lung Disease (GLILD) associated with Common Variable Immunodeficiency (CVID). The history of recurrent sinus infections is the clue to this diagnosis. GLILD is a rare interstitial lung disease that can mimic sarcoidosis.
A bronchoalveolar lavage may be required to exclude atypical infection complicating this condition

Question 52

A 35 year old female with a history of previous pneumothorax and the attached CT has had progressive decline in her FEV1 over the last 5 years.

Which of the below therapies has proven efficacy in this condition to slow lung function decline?

a. Pirfenidone

b. Sirolimus

c. Inhaled corticosteroids

d. Mycophenolate

e. Oestrogen

Answer 52

The correct answer is (b)

This patient has lymphangioleiomyomatosis. The combination of pulmonary cysts and renal angiomyolipoma in a young woman is a classic presentation.
There are sporadic and tuberous sclerosis associated forms.
High VEGF-D levels may assist in diagnosis in difficult cases.
Rapamycin (mTOR inhibitor) has been shown to slow lung function decline in this condition.

Question 53

A 68 year old male presents with chronic cough and dyspnoea. His CT scan is reported as demonstrating bilateral lower zone ‘crazy-paving’. A bronchoalveolar lavage has returned ‘milky’ fluid which is periodic acid Schiff positive.

Presence of which of the below antibodies would be suspected?

a. Anti-GM-CSF

b. MPO-ANCA

c. PR3-ANCA

d. Anti-Jo1

e. Anti-MDA5

Answer 53

The correct answer is (a)

The features in this case are suggestive of Pulmonary Alveolar Proteinosis (PAP).
PAP results from the accumulation of surfactant in alveoli due to impaired clearance by alveolar macrophages. There are primary and secondary forms. The auto-immune (primary) form accounts for 90% of cases and is characterized by antibodies to GM-CSF.
The treatment options include whole lung lavage, immunomodulation and inhaled GM-CSF.

Question 54

TRAB antibodies should be measured in pregnant women with past history of Graves’ Disease. True or False?

Answer 54

True, Maternal TRAb serum concentration greater than 3 times the upper limit of the reference range in the third trimester is a risk factor for neonatal hyperthyroidism

Question 55

TPO antibodies should be measured in pregnant women to guide thyroid treatment.
True or False?

Answer 55

False

Question 56

T3 levels are important for transplacental transfer and fetal thyroid needs. True or False?

Answer 56

False

Question 57

When pregnant, women with hypothyroidism require thyroxine dose adjustment. True or False?

Answer 57

True

Question 58

Hypothyroidism in pregnancy is diagnosed as TSH >5 or TSH > pregnancy reference range and low T4. True or False?

Answer 58

True

Question 59

A 70 year old woman was admitted with an exacerbation heart failure and four days later had developed a purpuric rash on her legs and renal impairment. The most important first test is:

a. ANCA

b. Urine test for haematuria

c. A renal biopsy

d. Examination of her drug chart especially for medications containing an S group

Answer 59

b. Urine test for haematuria

If this is present, the person may have microscopic polyangiitis. If there is no haematuria, then this may be a reaction to a medication, such as furosemide in this case. Even though she may have been on this for years, an increase in dose may precipitate purpura. In this case, stop the furosemide and switch to bumetanide once a day.

Question 60

45F developed focal seizures with secondary generalization after a closed head injury in an MVA. She was started on lamotrigine monotherapy, which resulted in a significant decrease in seizure frequency but not complete control. Sometimes she misses a dose. The dose is uptitrated to the point she has developed side effects of mild blurred vision. She does not wish to stop lamotrigine.

Which of the following agents would be most appropriate to add as a second agent?

A- carbamazepine
B- Eslicarbazepine
C- levetiracetam
D- oxcarbazepine
E- Phenytoin

Answer 60

C- levetiracetam, is only agent that does not share mechanism of action with lamotrigine (binds SVA2 rather than blocking sodium channel)

Question 61

Recognised methods for managing ARDS include

a. Use of high frequency oscillation
b. Low PEEP and high tidal volumes
c. High Driving pressures
d. Prone ventilation
e. All of the above

Answer 61

d. Prone ventilation

Question 62

Use of long term oxygen therapy in chronic respiratory failure
a. Definitively increases physical activity
b. Reduces overall mortality when given nocturnally
c. Definitively increases physical activity
d. Should be administered for at least 15 hours per day to be effective
e. All of the above

Answer 62

d. Should be administered for at least 15 hours per day to be effective

Question 63

Non-invasive ventilation in neuromuscular disease

a. Is most effective when commenced electively for incipent respiratory failure as opposed for critically ill presentations in respiratory failure
b. Is most effective in motor neurone disease when commenced in patients with normal or mildly impaired bulbar function
c. Is most effective in patients with chest wall deformities
d. a,b,c above
e. None of the above

Answer 63

d. a,b,c above

Question 64

Management of respiratory failure should include

a. Use of cough assist devices when sputum clearance is impaired

b. Use of extracorporeal support when PEEP is greater than 10 cm H2O

c. Routine use of oxygen to improve mobility in exercise induced hypoxaemia

d. Regular use of oxygen therapy for nocturnal episodic hypoxaemia

e. a and c above

Answer 64

e. and c above

Question 65

Which of the following is not a cause of microcytic anaemia?
A- B thalassemia trait
B- alcohol excess
C- sideroblastic anaemia
D- lead poisoning
E- iron deficiency

Answer 65

B- alcohol excess
(lead poisoning interferes with heme synthesis)

Question 66

Which of the following iron study profiles is most consistent with iron deficiency anaemia?
A- normal serum Fe, normal transferrin, low Tsat
B- low serum Fe, Low transferrin, high Tsat
C- low serum Fe, High transferrin, low Tsat
D- low serum Fe, High transferrin, high Tsat
E- low serum Fe, high transferrin, normal Tsat

Answer 66

C: transferrin increases in iron deficiency anaemia and Tsat reduces

Question 67

65F is on prednisone for her PMR. She presents with lethargy and indigestion.
Hb 108 (115 - 165)
MCV 78 (80-100)
WCC 12.4 x 10^9 ( 3.5 -11)
Platelet 454 x 10^9
ESR 50 (0-20)

Serum iron 11.6 (5-30.4)
Transferrin saturations 16% (20-51)
Transferrin 1.6 (1.8 - 3.5)
Ferritin 200 (30-300)

What is the most likely cause of anaemia?
A- inflammation
B- alpha thalassemia trait
C- prednisone
D- Iron deficiency
E- immune mediated haemolysis

Answer 67

Inflammation
Low serum transferrin indicates inflammation, high transferrin indicates iron deficiency

Question 68

What is the pathophysiology of anaemia due to inflammation in someone on prednisolone for PMR?

A- prednisolone has decreased ferroprotin and reduced iron absorption and transferrin saturation

B- ineffective erythropoiesis has increased red blood cell breakdwon and hemolysis

C- cytokine-induced hepcidin increase has decreased ferroportin, reduced iron absorption and transferrin saturation

D- bleeding has caused a depletion in iron stores and reduced red cell synthesis

E- anti-gliadin antibodies have caused gastrointestinal inflammation leading to reduced iron absorption

Answer 68

C

Question 69

21F indonesian woman has been referred for investigation of anaemia. She has an older sister with anaemia, leg ulcers and splenomegaly requiring transfusion.

Hb 78, Hct 0.29, RBC 4.14, MCV 71
Reticulocytes: 200 (20-80)
Serum ferritin 378 (15-200)

Hb electrophoresis:
HbA2 1.95 (2-3.5)
HbF 0.3 (<1.1)
No abnormal bands seen

Which of the following is the most likely diagnosis?
A- beta0 thalassemia trait
B- Beta+ thalassemia trait
C- sickle-beta thalassemia
D- Alpha+ thalassemia trait (a-/aa)
E- Alpha0 thalassemia trait (–/aa)

Answer 69

E- Alpha0 thalassemia trait (–/aa)

HbA2 normal excludes beta thalassemia
No abnormal bands excludes sickle

Single a gene deletion is silent

Question 70

20M with the following results
Hb 115, MCV 62, PLT 390
Serum ferritin 295
Blood film show microcytes and occasional target cells
Hb electrophoresis:
HbA2 5.2 (1.8-3.5)
HbF 1.2 (0-2)
No abnormal bands
No HbH bodies seen

What is the most likely explanation for his anaemia:
A- iron deficiency anaemia
B- heterozygous beta thalassemia
C- homozygous beta thalassemia
D- homozygous sickle cell disease
D- alpha thalassemia trati

Answer 70

B
Increased HbA2 is suggestive of beta thalassemia. Homozygotes would rpesent in childhood

Question 71

Which of the followng combinations would cause the least concern for a couple presenting for genetic counselling?

     Female carrier/Male carrier A- beta thalassemia/beta thalassemia B - alpha0 thalassemia/ alpha0 thalassemia C- alpha+ thalassemia/ alpha0 thalassemia D- haemoglobin E/ beta thalassemia E- alpha0 thalassemia/ beta thalassemia

Answer 71

E
The imbalance between alpha and beta chains is the key determinant of disease severity in thalassemia. Co-inheritance of alpha and beta gene abnormalities reduces the imbalance as it reduces the excess of one type of chain over the other

Question 72

What is the cause of vaso-occlusive crises in sickle cell disease?
A- red cell membrane fragment occluding microvasculature
B- increased solubility of HbS compared to HbA at low temperatures
C- red cells clumping at sites of low pO2
D- obstruction of microvascular circulation due to inflexible red cells
E- hemoglobin not releasing oxygen due to high affinity

Answer 72

D

Question 73

41M present with fatigue, bruising, SOB. Generally unwell for weeks. Complete diet, no alcohol and no regular medications.
Hb 107, MCV 85, WCC 2.67, PLT 48
Which of the following would confirm bone marrow failure?
A- HbH inclusion in red cells
B- fragments on blood film
C- hypersegmented neutrophils
D- low platelet count
E- low reticulocyte count

Answer 73

E
Low reticulocytes indicate bone marrow hypofunction

Question 74

Pathophysiology of anaemia of chronic disease includes all except:
A- reduced absorption of iron from GI tract
B- increased production of immature red cells
C- reduced erythropoietin production
D- sequestration of iron in macrophages
E- increased hepcidin

Answer 74

B

Question 75

55F with SLE presents with 2/52 SOB and fatigue. She is pale with a palpable spleen.
Hb 70, Neuts 11.2, PLT 443, LDH 800
Bili 89
Spherocytes on blood film

What is the next best test to demonstrate cause of anaemia?
A- urinary haemosiderin
B- serum haptoglobin
C- unconjuagted bilirubin fraction
D- direct and indirect antiglobulin (coombs) test
E- peripheral blood flow cytometry

Answer 75

D

Question 76

22M has yellow sclera when he gets unwell.
Hb 122, MCV 88, PLT 295, WCC 9
Reticulocytes 5% (0.2-2), absolute 95 (20-80)
Peripheral blood film: anisocytosis, polychromasia, spherocytes
Bili 53

Which of the following tests would most likely confirm the diagnosis?
A- haemoglobin electrophoresis
B- red cell EMA quantification
C- direct and indirect antiglobulin (coombs) test
D- bone marrow aspiration and biopsy
E- red cell flow cytometry for CD59 and CD55

Answer 76

B - diagnostic for hereditary spherocytosis

Question 77

Which of the following states is true about hereditary spherocytosis?
A- red cells have an abnormality in membrane protein
B- red cells are deficient in a metabolic enzyme
C- it is X-linked
D- red cells have an abnormally high surface : volume ration
E- red cells have an increased sensitivity to lysis by complement

Answer 77

A

Question 78

The following are causes of microangiopathic haemolytic anaemia except:
A- paroxysmal nocturnal haemoglobinuria
B- dissemintated intravascular coagulation
C- prosthetic valve related haemolysis
D- Haemolytic uremic syndrome
E- thrombotic thrombocytopenic purpura

Answer 78

A- paroxysmal nocturnal haemoglobinuria

Question 79

What is most specific for intravascular haemolysis?
A- low haptoglobin
B- high reticulocytes
C- postive DAT for IgG
D- positive urinary hermosiderin
E- positive cryoglobins

Answer 79

D- positive urinary hermosiderin

Question 80

22F presents with GTCS preceded by confusion. She has a history of vitiligo.
WCC 11.5, Hb 92, PLT 19, MCV 78
Blood film: anisocytosis, poikilocystosis, schistocytes
Cr 101, Bili 37, LDH 662
PT 14 (11-15), INR 1.2, APTT 35.8 (31-39)

Which is the most diagnostic test that fist with her clinical presentation?
A- low ADAMTS13 level
B- low EMA by flow cytometry
C- low complement levels
D- low fibrinogen
E- low reticulocytes

Answer 80

low ADAMTS13 level (congenital TTP)

Question 81

78F presents with thyroiditis presents with bruising and fatigue. Low BMI. B12 deficiency is suspected.
WCC 3.1, Hb 108, MCV 103
Blood film: pancytopenia, hypersegmented neutrophils, oval macrocytes
B12 is 196 (150-700)

Which of the following confirms your suspicion?
A- low folate level
B- low homocysteine
C- low methylmalonic acid
D- low holotranscobalamin
E- low pyridoxine

Answer 81

low holotranscobalamin, active form of B12 taken up into cells and is more accutate than B12

MMA and homcysteine should increase in B12 deficiency

Question 82

What is the most specific test to determint he underlying cause of B12 deficiency?
A- parietal cell antibodies
B- anti-intrinsic factor antibodies
C- Anti-transglutaminsae antibodies
D- antigliadin antibodies
E- anti mitochondrial antibodies

Answer 82

anti-intrinsic factor antibodies

Question 83

77M evaluated for SOB and fatigue with progressive macrocytic anaemia over last 3 years.
Hb 85, MCV 108, WCC 3.43, PLT 136, reticulocytes 1.6% (0.2-2)
Blood film: mild polychromasia, round macrocytes, hypogranular neutrophils, hypogranular platelets

Which of the following genetic changes is most likely to be detected in his bone marrow biopsy?
A- t(9,22)
B- JAKV617F mutation
C- abnormalities of chromosome 7
D- C282Y mutation
E- HBB 6 Glu> Val substitution

Answer 83

abnormalities of chromosome 7

Question 84

75M with no co-morbidities presents with lymphadneopathy (1.5cm) and no splenomegaly. lymph 50, Hb110, PLT 160.
Weight is stable, no fevers or night weats. Peripheral blood flow cytometry shows CD5+CD19+CD23+ population with lambda light chain restriction.
The most appropriate initial approach is:
A- commence therapy with anti-CD2 mAb
B- confirm diagnosis with excisional biopsy of lymph node
C- confirm the diagnosis with a core biopsy of lymph node
D- do nothing immediately and observe
E- commence multi-agent chemotehrapy combined with an anti-CD20 mAb

Answer 84

D

Question 85

58F with CLL completed fludarabine based chemotherapy 3/12 ago. Now present with SOB and lethargy.
Na 135, K 3.4, Cr 120, Ur 14
Bili 43, ALP 50, GGT 38, ALT 40, AST 50
Hb 65, MCV 105, WCC 6, Lymph 2.1, PLT 148
Haptoglobin < 0.1, LDH 680, ferritin 30, Tsat 14%

What is the most appropriate next step:
A- perform B12 and folate assays
B- measure soluble transferrin receptors
C- perform DAT
D- refer gastroscopy and clonoscopy
E- commence treatment with IVIg

Answer 85

C

Question 86

Which of the following is not a known side effect of ibrutinib , the BTK inhibitor used in treatment of CLL?
A- an initial redistribution of lymphocytes
B- atrial fibrillation
C- tumour lysis syndrome
D- diarrhoea
E- increased bruising due to platelet dysfunction

Answer 86

C

Question 87

The Philadelphia chromosome/ BCR-ABL transcript is:
A- pathognomic of CML
B- necessary for the diagnosis of CML
C- not necessary for the diagnosis of CML

Answer 87

B

Question 88

Initiation of therapy for CML is:
A- observation of asymptomatic patient
B- Allogeneic bone marrow transplantation with curative intent
C- outpatient TKI therapy

Answer 88

C

Question 89

What is the unifying mechanistic principle of action of all diuretics?
A- prevent water reabsorption
B- prevent Na secretion
C- prevent Na reabsorption
D- cause K secretion

Answer 89

C

Question 90

Which of the following does not lead to hypokalaemia with metabolic alkalosis?
A- Bartter syndrome
B- Addison disease
C- Hyperaldosteronism
D- Chronic vomiting
E - diuretic abuse

Answer 90

Addison disease

Question 91

25F presents for investigation of infertility and a karyotype is reported as 45XO (Turner syndrome).
Which of the following conditions is associated with Turner syndrome and warrants commencement of regular screening?
A- aortic aneurysm
B - breast cancer
C- macular degeneration
D- myelodysplasia

Answer 91

Aortic aneurysm

Question 92

19M presents with 3rd episode lobar pneumonia due to S. pneumoniae in the last 2 years. He reports chronic sinus symptoms and frequent bronchitis, takes 4-6 Abs per year. He also reports intermittent non-bloody diarrhoea.
Preliminary immunodeficiency screening shows:
Pneumococcal IgG 14 (>16)
Pneumococcal IgG 2 (>5)
Total IgG 2.6 (7-16)
Total IgA < 0.07 (0.8 - 4.0)
Total IgM 2.5 (0.4 0 2.5)
CD4+ 1023 (500-1650)
CD8+ 477 (210 - 1200)
NK 135 (40-500)
CD19+ 0 (8-600)

What is the most likely diagnosis?
A- CVID
B- IgA deficiency
C- specific antibody deficiency
D- x-linked agammaglobulinaemia

Answer 92

x-linked agammaglobulinaemia

Question 93

71F with hypertension and 20-pack year smoker has abnormal kidney function on routine bloods. Her current medications are enalapril 10 mg OD and amlodipine 10 mg OD. BP 136/86.
Cr 168, eGFR 31, Na 138, K 4.7, Hb 116, CCa 2.45, PO4 1.3, ACR 11

In addition to monitoring kidney function, what additional strategy should be the focus of her management?
A- dietary potassium restriction
B- modification of CV risk
C- planning for dialysis access
D- reduction of proteinuria

Answer 93

modification of CV risk

Question 94

24F presents post marathon with confusion. She is disoriented to time and place, no focal neurology. Mild tachypnoea and myalgia in her legs. Nil other findings.
Na 122, K 3.6
Plasma osmo 256, urine osmo 432
Cr 79, glucose 4.8
What is the most appropriate way to manage her hyponatraemia?
A- fluid restrict
B- IV hypertonic saline
C- IV normal saline
D- oral demeclocycline

Answer 94

IV hypertonic saline

Question 95

25M undergoes GA + ORIF of fracture femur. Following induction with propofol and suxamethonium he developed tachycardia, tachypnoea, muscle rigidity and fever T41. He was treated with dantrolene for this episode of malignant hyperthermia and recovered. This is an AD disease.
What is the chance of this man’s cousin, ‘B’, is at risk of an episode of malignant hyperthermia?
A- 6.25%
B- 12.5%
C- 25%
D- 50%

Answer 95

12.5%

Question 96

Which investigation is the most specific for confirming a diagnosis of complement-mediated haemolysis?
A- direct antiglobulin (coombs)
B- free haemoglobin
C- haptoglobin
D- LDH

Answer 96

Free haemoglobin

Question 97

In a randomised control trial, the time from recruitment to the first CV event is measured.
What is the best term to express the result?
A- hazard ratio
B- incidence rate
C- odds ratio
D- relative risk

Answer 97

hazard ratio

Question 98

BCL-2 inhibitors have recently been shown to have therapeutic efficacy in blood cancers. What is the function of BCL-2 protein?
A- activates cell death receptors
B- activates cell survival proteins
C- activates effector caspases
D- inhibits cell apoptotic proteins

Answer 98

inhibits cell apoptotic proteins

Question 99

Molecular mimicry may account for the development of carditis in acute rheumatic fever. The streptococcal M protein and N-acetyl-beta-D-glucosamine share epitopes with which component of cardiac tissue?
A- actin
B- desmosomes
C- myosin
D- T-tubules

Answer 99

myosin

Question 100

Febuxostat is a newer urate-lowering therapy than allopurinol. Based on randomised control trial data in chronic gout, what is the main benefit of febuxostat 80 mg over allopurinol 300 mg daily?
A- faster resolution of tophi
B- fewer CV events
C- fewer flares of acute gout
D- lower serum uric acid

Answer 100

lower serum uric acid

Question 101

40F with GORD on high dose pantoprazole is admitted with severe HTN adn AKI. Has a history of raynaud’s, peripheral telangiectasia and grade III fundal hypertensive changes on exam.
Urinalysis is bland, normochromic normocytic anaemia tih PLT 115. Normal renal USS.
What is the most likely cause for her HTN and AKI?
A- acute interstitial nephritis
B- Conn syndrome
C- phaeochromocytoma
D- systemic sclerosis

Answer 101

systemic sclerosis

Question 102

71M has HTN, COPD, heavy smoker, CABG. Presents with 3/7 anuria and SOB. Meds include ramipril, atorvastatin, amlodipine, clopidogrel, aspirin, amoxicillin, pantoprazole, inhaled steroid. BP 200/105. ECG shows old anterior MI. Renal USS shows 6 cm right kidney and 11 cm left kidney, no urine in bladder. Cr 900. Started on urgent HD for APO.
What is the most likely diagnosis?
A- acute interstitial nephritis
B- aortic dissection
C- pyelonephritis
D- renal thromboembolism

Answer 102

renal thromboembolism

Question 103

75M presents with abrupt onset painless blurring in left eye lasting 20 minutes. Had a similar episode 1/52 ago. Right eye unaffected, neuro exam normal.
Which artery stenosis would be expected to cause this presentation?
A- basilar
B- left carotid
C- left vertebral
D- right carotid

Answer 103

Left carotid

Question 104

Pizotifen is a medication used in migraine prophylaxis. Apart from drowsiness, what is the most common adverse effect of pizotifen?
A- hepatitis
B- rash
C- rebound headache
D- weight gain

Answer 104

weight gain

Question 105

28F 36/40 pregnant presents with SOB, 1/52 lower limb swelling for 2 days. T 37.4, Bp 136/86, HR 98, Sats 98%RA. Left calf 2cm greater than right. ECG and CXR are normal.
What is the next most appropriate investigation?
A- CT-PA
B- D-dimer
C- echocardiogram
D- lower limb doppler ultrasound

Answer 105

lower limb doppler ultrasound

Question 106

You are trying to decide whether to institute a screening program for type 2 diabetes. You
find data indicating that a HbA1c of 6.4% (46 mmol/mol) or greater has a sensitivity of 40%
and a specificity of 80%. You estimate that the prevalence of undiagnosed type 2 diabetes in
your community is 20%.
What will be the ratio of true positives to false positives if you institute a screening program?
A- 1:1
B- 1:2
C- 1:4
D- 2:1

Answer 106

1:2

Question 107

52M T2Dm and HTN presents with sudden onset monocular vision loss 24 hours ago. Left optic disc swelling is seen on fundoscopy, visual acuity 6/6 right, 6/24 on left, colour desaturation on left, left relative afferent pupillary defect.
What is the most likely diagnosis?
A- carotid artery stenosis
B- central retinal artery occlusion
C- ischaemic optic neuropathy
D- occipital stroke

Answer 107

ischaemic optic neuropathy

Question 108

N-methyl-D-aspartate (NMDA) receptors are activated by which one of the following?
A- dopamine
B- glutamate
C- melatonin
D- noradrenaline

Answer 108

glutamate

Question 109

In patients undergoing acute rejection of renal allograft, biopsy specimens are likely to show predominant infiltration of the graft by which one of the following?
A- B-cells
B- Dendritic cells
C- macrophages
D- T-cells

Answer 109

T-cells

Question 110

Neurofibrillary tangles are typically seen in what type of dementia?
A- Alzheimer’s dementia
B- dementia with lewy bodies
C- frontotemporal dementia
D- Parkinson disease dementia

Answer 110

Alzheimer’s dementia

Question 111

Which antioxidant is required for the conversion of the paracetamol metabolist N-acetyl-p-benzoquinone imine (NAPQI) to non-toxic substance?
A- catalase
B- catechol-O-methyltransferase
C- glutathione
D- lipoic acid

Answer 111

glutathione

Question 112

By which mechanism does dobutamine predominantly increase cardiac output?
A- activation of cell surface dopamine receptors
B- inhibition of alpha-adrenoreceptros
C- reduction in breakdown of cAMP
D- stimulation of beta adrenoreceptors

Answer 112

stimulation of beta adrenoreceptors

Question 113

Which of the following is a minor criterion for the diagnosis of acute rheumatic fever?
A. Carditis.
B. Polyarthritis.
C. Prolonged PR interval.
D. Proteinuria.

Answer 113

Prolonged PR interval

Question 114

At initial diagnosis, which factor is most predictive of reduced survival in patients with
metastatic renal cell cancer?
A. Age < 60.
B. Chromophobe histology.
C. Eastern Cooperative Oncology Group (ECOG) performance status of 3.
D. Lung metastases

Answer 114

Eastern Cooperative Oncology Group (ECOG) performance status of 3.

Question 115

Which hormone released from intestinal L cells can lead to delayed gastric emptying,
increased post-prandial insulin release and improved satiety?

A. Cholecystokinin.
B. Gastrin.
C. Ghrelin.
D. Glucagon.
E. Glucagon-like peptide-1 (GLP-1).
F. Histamine.
G. Peptide YY.
H. Secretin.

Answer 115

Glucagon-like peptide-1 (GLP-1).

Question 116

Which hormone binds a plasma membrane-bound G-protein coupled receptor, leading to
increased glycogenolysis?

A. Cholecystokinin.
B. Gastrin.
C. Ghrelin.
D. Glucagon.
E. Glucagon-like peptide-1 (GLP-1).
F. Histamine.
G. Peptide YY.
H. Secretin

Answer 116

Glucagon

Question 117

Which neurological autoantibody target is associated with myasthenia gravis?

A. Acetylcholine receptor (AChR).
B. Amphiphysin.
C. Aquaporin 4 (AQP4).
D. Ganglioside M1 (GM1).
E. Glutamic acid decarboxylase (GAD).
F. Leucine-rich, glioma-inactivated 1 (LGI1).
G. Myelin-associated glycoprotein (MAG).
H. N-methyl-D-aspartate receptor (NMDAR).

Answer 117

Acetylcholine receptor (AChR)

Question 118

Which neurological autoantibody target is associated with neuromyelitis optica?

A. Acetylcholine receptor (AChR).
B. Amphiphysin.
C. Aquaporin 4 (AQP4).
D. Ganglioside M1 (GM1).
E. Glutamic acid decarboxylase (GAD).
F. Leucine-rich, glioma-inactivated 1 (LGI1).
G. Myelin-associated glycoprotein (MAG).
H. N-methyl-D-aspartate receptor (NMDAR).

Answer 118

Aquaporin 4 (AQP4)

Question 119

28F with SLE on hydroxychloroquine, known anti-phospholipid antibodies presents with unprovoked PE. Which of the following is the most appropriate management?
A- warfarin for 6/12 then stop
B- Warfarin for 6/12 then lifelong aspirin
C- warfarin lifelong aiming INR 2.5-3.5
D- warfarin for 6/12 then lifelong NOAC

Answer 119

warfarin lifelong aiming INR 2.5-3.5

Question 120

25F with SLE and class IV nephritis, previously managed with mycophenylate induction and on maintenance for 18 months presents with new hypertension and an increases in her urine protein:creatinine. A 24h urine protein was 970 mg with cellular casts. Which of the following is the most appropriate management?
A- arrange renal biopsy
B- commence gluco-corticoids and increased/different immunosuppression
C- consider egg collection or therapy with goserelin
D- all of the above

Answer 120

All of the above:
- in lupus renal pathology can change and may require different treatment
- also need to consider preserving fertility

Question 121

Vibrio cholerae causes diarrhoea by what mechanism?
A- hypermotility
B- inflammatory
C- malabsorption
D- osmotic
E- secretory

Answer 121

Secretory - upper small intestine cholera toxin binds and causes activation of chloride channel

Question 122

53M presents with 2/7 red hot swollen right knee. Started on Po cephalosporin day prior with no benefit. T 37.4, WCC 11.3.
Joint aspirate reveals 130,000 cells/mm3 95% neutrophils, negative gram stain, nil crystals seen.
What is the most appropriate initial management?
A- intra-articular steroids
B- IV flucloxacillin
C- PO cephalosporin
D- oral colchicine
E- surgical drainage of the knee

Answer 122

IV flucloxacillin

Question 123

Which of the following antibiotics is most likely to be equally effective administered orally at similar doses to IV administration?
A- flucloxacillin
B- penicillin VK
C- piperacillin/tazobactam
D- clindamycin
E- erythromycin

Answer 123

clindamycin

Question 124

72M admitted with 4 days of fever, cough and pharyngitis which started 4 days ago. His CXR shows no pneumonia. He spent the night in a 4-bedded room and tested positive for influenza A this morning. What is the most useful next course of action?
A- start amoxicillin 1 g IV Q8H
B- inhibit viral replication with a drug that inhibits influenza A M2 ion channel protein
C- vaccinate the man against seasonal influenza
D- vaccinate the other people in the room against seasonal influenza
E- treat the other patients in the room with oseltamivir

Answer 124

Treat the other patients in the room with oseltamivir (has been shown to prevent influenza illness)

Question 125

Regarding influenza illness, which of the following is true?
A- following exposure, illness usually develops after 5 days
B- the illness builds gradually, symptoms are worst after 5 days
C- the most severe symptoms result from cytokine release
D- fever is uncommon in adults
E- influenza leads to excess hospital admissions but not excess mortality

Answer 125

the most severe symptoms result from cytokine release

Question 126

32M returned from 8 weeks in India 16 days ago. Since arriving home he has fever, abdo pain, constipation and lethargy. GNB are grown in both aerobic and anaerobic blood culture samples 13 hours after being drawn. What is the most likely diangosis?
A- dengue
B- E. coli 0157
C- leptospirosis
D- malaria
E- typhoid

Answer 126

Typhoid

Question 127

23M presents 3/52 after 1 month holiday in Kenya and Tanzania. He has a 5 day history of fever, headaches and diarrhoea. GCS 15/15, T39, HR110, BP108/68, RR22. Normal exam. Hb94, PLT 88. Plasmodium falciparum seen on thin film with density of 15%.
What is the most appropriate initial treatment?
A- oral chloroquine
B- oral mefloquine
C- IV artesunate
D- oral quinine + doxycycline
E- Oral artemether-lumafamtrine

Answer 127

IV artesunate

Question 128

Tenofovir disoproxil fumarate is used in the management of HIV infection in combination with other antiretrovirals. What is the site of action of tenofovir in the HIV life cycle?
A- HIV binding and entry of cells
B- HIV protease activity
C- HIV reverse transcriptase activity
D- HIV viral assembly
E- integration of HIV DNA

Answer 128

HIV reverse transcriptase activity

Question 129

40M presents with 3 day history of fever, cough and sputum production and right lower lobe consolidation on x-ray. HE is HIV positive with CD4 count of 450 (650-2000). What is the most likely organism causing his penumonia?
A- MRSA
B- MAC
C- M. tb
D- Pneumocystis jirovecii
E- S. pneumoniae

Answer 129

E- S. pneumoniae

Question 130

33M presents with 20% body mass loss, fever and chills, several weeks of shortness of breath and dry cough with intermittent odynophagia. Examination confirms cervical and inguinal lyphadenopathy and oral thrush. He is febrile, tachypnoeic and hypoxis. Chest is clear. Sats on room air 92% decrease to 84% when walking. CXR shows diffuse alveolar infiltrates in the mid zones bilaterally. What is the most likely organism causing his pneumonia?
A- MRSA
B- MAC
C- M. tb
D- Pneumocystis jirovecii
E- S. pneumoniae

Answer 130

Pneumocystis jirovecii

Question 131

25F from Thailand presents with 2 weeks diplopia, headache and fevers. She has an enhancing lesion in the right mid brain. What is recommended management?
A- arrange brain biopsy to get micro
B- arrange brain biopsy and HIV test
C- arrange HIV test and treat for toxoplasma without brain biopsy if HIV positive
D- none of the above

Answer 131

arrange HIV test and treat for toxoplasma without brain biopsy if HIV positive

Question 132

44M presents with 2 weeks diarrhoea and abdo pain associated with increasing fatigue and weight loss. The diarrhoea is described as 2-3 watery bowel movements per day and occasional blood and mucus. He is Middle Eastern but born in Australia and has not recent travel history. He has no family history of GI or infectious disease. Examination is unremarkable. Bloods demonstrate iron deficiency anaemia, WCC 14, PLT 500. Alb 30. What is the next best test to investigate this case?
A- AXR
B- CT abdo
C- faecal MCS + c.diff toxin
D- Flexi sig + biopsy
E- intestinal USS

Answer 132

faecal MCS + c.diff toxin - always rule out infection

Question 132

44M presents with 2 weeks diarrhoea and abdo pain associated with increasing fatigue and weight loss. The diarrhoea is described as 2-3 watery bowel movements per day and occasional blood and mucus. He is Middle Eastern but born in Australia and has not recent travel history. He has no family history of GI or infectious disease. Examination is unremarkable. Bloods demonstrate iron deficiency anaemia, WCC 14, PLT 500. Alb 30. Stool culture is negative. What is the next best test to investigate this case?
A- colonoscopy and biopsy
B- CT scan of abdomen
C- MRE
D- flexible sigmoidoscopy and biopsy
E- faecal calprotectin

Answer 132

Flexible sigmoidoscopy and biopsy

Question 133

44M presents with 2 weeks diarrhoea and abdo pain associated with increasing fatigue and weight loss. The diarrhoea is described as 2-3 watery bowel movements per day and occasional blood and mucus. He is Middle Eastern but born in Australia and has not recent travel history. He has no family history of GI or infectious disease. Examination is unremarkable. Bloods demonstrate iron deficiency anaemia, WCC 14, PLT 500. Alb 30. Stool culture is negative. What is the most accurate test to investigate this case?
A- colonoscopy and biopsy
B- CT scan of abdomen
C- MRE
D- flexible sigmoidoscopy and biopsy
E- faecal calprotectin

Answer 133

Colonoscopy (will not miss Crohn’s as goes to terminal ileum)

Question 134

Which of the following is not a feature of inflammatory bowel disease?
A- granulomas
B- basal lymphoplasmacytosis
C- Paneth cell metaplasia
D- crypt arhcitecture disruption
E- intra-epithelial lymphocytosis

Answer 134

intra-epithelial lymphocytosis (a feature of microscopic colitis)

Question 135

What is the best initial treatment for mild to moderate flare of left sided ulcerative colitis?
A- 5ASA suppositories
B- 5ASA enema
C- oral 5ASA
D- corticosteroids
E- azathioprine
F- methotreaxate

Answer 135

5ASA enema

Question 136

A sigmoidoscopy demonstrates severe ulcerative colitis. The patient is started on corticosteroids, has an AXR every 2nd day and is on DVT prophylaxis. 3 days later his bowel chart shows 3 episodes of blood diarrhoea and his CRP >45. What is the next best step in managing this patient?
A- infliximab
B- increase in steroid dose
C- add azathioprine
D- start vedolizumab
E- add vancomycin
F- methotrexate

Answer 136

infliximab

Question 137

Which of the following medicine used for IBD is the most likely cause of acute pancreatitis?
A- 5ASA suppositories
B- oral 5ASA
C- corticoteroids
D- azathioprine
E- infliximab

Answer 137

Azathioprine is most likely (all others have a risk except supps)

Question 138

30F with 4 months of abo pain, diarrhoea, 5% weight loss, joint pain and rash. Sees her GP for painful red eye. Bloods show iron deficiency anaemia, low albumin, CRP 67. Negatievs tool sample for infection, WCC and RBCs present. Faecal calprotectin 897. What is the next best step in management of this patient?
A- flexible sigmoidoscopy
B- colonoscopy
C- MRE
D- CT
E- capsule endoscopy

Answer 138

colonoscopy

Question 139

54M with Crohn’s colitis involving 2/3 bowel for last 8 years. His last colonoscopy was Feb 2020. HE is asking whether he really needs another colonoscopy. Which if the following risk factors would not warrant annual colonoscopies?
A- PSC
B- family history of colon cancer in 1st degree relative at age 43
C- personal history of a polyp with low grade dysplasia in a colitic area
D- inflammatory pseudopolyps
E- colonic stricture on previous scopes

Answer 139

inflammatory pseudopolyps

Question 140

89M presents with 2 weeks fatigue, fever and night sweats. He weigh 55Kg and Cr 105. No antibiotic allergies. He is found to have E. faecalis native mitral valve endocarditis. This isolate is susceptible to amoxicillin and vancomycin and is high level gentamicin susceptible. There are no indications for surgery. What is the most appropriate antibiotic treatment?
A- amoxicillin alone for 4 weeks
B- amoxicillin + gentamicin 4 weeks
C- amoxicillin 4 weeks + gentamicin 2 weeks
D- amoxicillin + ceftriaxone 6 weeks
E- vancomycin + gentamicin 6 weeks

Answer 140

amoxicillin + ceftriaxone 6 weeks (display synergy, has renal impairment so cannot use gent)

Question 141

60F with cochlear implants present with 1 day history of headache, neck stiffness and light sensitivity. On examination, she is febrile, has nuchal rigidity, GCS 15 and no focal neurology. Which of the following is true?
A- ceftriaxone and vancomycin would be appropriate empiric treatment to cover Strep. pneumoniae, N. meningitidis and L. monocytogenes
B- If the CSF gram stain shows gram-positive diplococci, high dose benzylpenicillin should be used while awaiting culture and susceptibilities
C- A CSF white cell count of < 1000 rules out bacterial meningitis
D- this patient does not require a CT brain before undergoing lumbar puncture
E- dexamethasone is contraindicated in bacterial meningitis

Answer 141

This patient does not require a CT brain before undergoing lumbar puncture

Question 142

20M presents with 1 day history of fever, headache and neck stiffness. CSF shows 4000 white cells, 100% PMN, gram negative diplococci on gram stain. Which f the following is true?
A- this organism remains universally susceptible to penicillin
B- antibiotic prophylaxis is indicated for all involved healthcare workers
C- dexamethasone reduces mortality, hearing loss and neurologic sequelae in this condition
D- he is likely to have a non-blanching petechial rash
E- he should be managed in droplet precautions until he has received 24 hours of effective antibiotics

Answer 142

He should be managed in droplet precautions until he has received 24 hours of effective antibiotics

Question 143

50F with coeliac and autoimmune thyroiditis is being investigated for anaemia. Her blood film demonstrates occasional Howell-Jolly bodies. Current prevention of infection guidance would suggest she needs:
A- conjugate pneumococcal vaccine (PCV13) every 5 years
B- 23 valent polysaccharide vaccine (PPV23) every 5 years
C- lifelong PO amoxicillin OD
D- Polysaccharide ACWY meningococcal vaccine
E- PCV13 one dose followed by PPV23

Answer 143

PCV13 one dose followed by PPV23

Question 144

19M hospitalised with 2nd episode of pneumonia and is bacteraemic with S. pneumoniae. He reports background of chronic sinus symptoms, frequent bronchitis, takes at least 4 course antibiotics/year. Also reports intermittent non bloody diarrhoea.

Pneumococcal total IgG 14 (>16)
Pneumococcal total IgG2 2 (>5)
IgG 2.6 (7-16), IgA < 0.07 (0.8-4)
IgM 2.5 (0.4 - 2.5)
CD4 1023 (500-1650)
CD8 477 (210 -1200)
NK 135 (40-500)
CD19 0 (80-600)

What is the most likely diagnosis?
A- CVID
B- IgA deficiency
C- specific antibody deficiency
D- X-linked agammaglobulinaemia
E- X-linked hyper IgM syndrome

Answer 144

CVID

(not X-linked agammaglobulinaemia as produces IgG and IgM)

Question 145

Use of antibiotics (especially vancomycin and broad-spectrum) leads to an increase in the incidence of vancomycin-resistant Enterococcus (VRE).
What other factor contributes to colonisation with VRE?
A- antifungal
B- chronic immunosuppression
C- Clostridoides difficile infection
D- diabetes mellitus
E- residential care

Answer 145

residential care

Question 146

Which of the following antimicrobial agents mechanism of action involves binding to bacterial ribosome?
A- vancomycin
B- moxifloxacin
C- meropenem
D- metronidazole
E- linezolid

Answer 146

Linezolid

Question 147

Control of mycobacterium tuberculosis (MTB) replication is dependent on a number of critical factors including TNF alpha production and IFN gamma response. Which other immun effector plays a major role in controlling MTB replications?
A- B-cell
B- complement
C- NK-cell
D- neutrophil
E- T-cell

Answer 147

T-cell

Question 148

Th in vitro gamma interferon release assay Quantiferon TB Gold is commonly used in patients with suspected Mycobacterium tuberculosis (MTB). What is the main role of the Quantiferon Gold test?
A- detect exposure to MTB
B- determine extent of MTB disease
C- Determine response to MTB therapy
D- predict active MTB
E- rule out MTB

Answer 148

Detect exposure to MTB

Question 149

62F with several lymph nodes + mass seen on PET, no distant mets. ECOG 1. No contraindications to immunotherapy and no targetable mutation. Her biopsy demonstrates adenocarcinoma with high PDL1 (>50).
What is appropriate treatment?

Answer 149

Single agent pembrolizumab

Question 150

62F with several lymph nodes + mass seen on PET, no distant mets. ECOG 1. No contraindications to immunotherapy and no targetable mutation. Her biopsy demonstrates squamous cell with high PDL1 (>50).
What is appropriate treatment?

Answer 150

Single agent pembrolizumab

Question 151

62F with several lymph nodes + mass seen on PET, no distant mets. ECOG 1. No contraindications to immunotherapy and no targetable mutation. Her biopsy demonstrates adenocarcinoma with low PDL1 (<50).
What is appropriate treatment?

Answer 151

Chemotherapy and immunotherapy

Question 152

62M, ex-smoker presents with cough. Stage T3N2 adenocarcinoma is discussed at lung MDT. He is not a surgical candidate. Lung function is not good for radical dose radiotherapy.
How should he be managed?

Answer 152

Complete definitive chemoradiotherapy followed by 1 year of durvalumab

Question 153

Which of the following advserse events are more likely to occur when combination treatment dabrafenib (BRAF inhibitor) and trametinib (MEK inhibitor) is compared with dabrafenib alone?
A- fever
B- squamous cell carcinoma
C- basal cell carcinoma
D- alopecia
E- all the above adverse events are more likely to occur with combination treatment

Answer 153

fever

Question 154

Which of the following responses are associated with improved survival when using ipilimumab in metastatic melanoma?
A- immediate response in baseline lesions without the presence of new lesions
B- durable stable lesions
C- response after increase in total tumour burden
D- response in the presence of new lesions
E- all of the above

Answer 154

E

Question 155

With regard to immune related adverse events with ipilimumab which of the following have been reported to occur?
A- toxic epidermal necrolysis
B- Hypophysitis
C- gastrointestinal perforation
D- motor neuropathy
E- all of the above

Answer 155

E

Question 156

Which of the following side effects are noted to be more common with pembrolizumab than ipilimumab in the treatment of melanoma?
A- hypophysitis
B- colitis
C- fatigue
D- Type 1 diabetes
E- all of the above

Answer 156

Type 1 diabetes

Question 157

55M with metastatic melanoma is treated with ipilimumab. He has metastases to liver, para-aortic lymph nodes and lungs. A week after his 3rd cycle of ipilimumab, he complains of diarrhoea and abdominal discomfort. The diarrhoea is watery and occurs 3 times per day over 3 days. He was prescribed loepramide and reviewed 2 days alter, The diarrhoea is now occurring 7 times per day. Which if the following is the most appropriate next step?
A- continue loperamide and add codeine
B- discontinue ipilimumab
C- await stool culture results before deciding on definitive anti-microbial treatment
D- perform sigmoidoscopy to obtain a mucosal biopsy
E- start corticosteroids

Answer 157

start corticosteroids

Question 158

The mechanism of trastuzumab deruxtecan is to:
a. Bind to tumor cell via chemotherapy linker and deliver potent Herceptin molecule into cell

b. Link Herceptin to chemotherapy agent to topoisomerase 1 inhibitor causing cellular apoptosis

c. Bind to tumor cell via antibody molecule and internalise to release topoisomerase inhibiting drug

d. Bind to tumor cell via antibody molecule and internalise to release microtubule inhibiting drug

Answer 158

Bind to tumor cell via antibody molecule and internalise to release topoisomerase inhibiting drug

Question 159

Sacituzumab govitecan is used in the treatment of:
a. IDH-wild type glioblastoma

b. Metastatic endocrine receptor, progesterone receptor, HER2 ;breast cancer

c. IDH-mutant glioblastoma

d. Unresectable endocrine receptor, HER2- breast cancer

Answer 159

Unresectable endocrine receptor, HER2- breast cancer

Question 160

62M presents with tonic-clonic seizure. 3 days fever, headache, myalgia. On exam confused, low grade temp, pain on palpation of thighs with reduced lower limb power. Normal CT head.
CSF:
OP 310
Cell 90, lymphocytes
Protein 105, glucose 3.27
Gram negative

What is the most likely diagnosis?
A- progressive mutlifocal leukoencephalopathy
B- west nile virus encephalitis
C- Pneumococcal meningitis
D- Dengue fever
E- HSV encephalitis

Answer 160

B- west nile virus encephalitis (causes lower motor neruone signs)

Question 161

65M focal right arm and leg seizures, preceded by 1 week low grade fever and odd behaviour. No recent travel.
Confused, febrile and having visual hallucinations on exam. Normal neuro exam.
CSF:
- cell 150, lymphocytes
- protein 150, glucose 3.1
- gram and india ink negative
MRI head shows fronto-temporal enhancement.

Which of the following diagnostic studies should be performed next?
A- acute and convalescent HSV serology
B- ratio of CSF to serum HSV antibodies
C- brain biopsy
D- CSF PCR
E- EEG

Answer 161

D- CSF PCR, highly specific and sensitive

Question 162

20F presents with short term memory loss and GTCS. over 1 week progressed to agitation, hallucinations, catatonia, reduced level of consciousness.
Febrile T 39, HR 132, BP 128/84, dilated pupils.
MRI brain demonstrates signal changes in both temporal lobes.
CSF: cell 150, protein 68, HSV PCR negative, gram negative, oligoclonal bands positive.
EEG: diffuse slowing
No improvement with aciclovir or phenytoin.

Which is the next step in management?
A- add empiric antibiotics cover, awaiting culture
B- substitute aciclovir with foscarnet
C- consider steroids, Ig and PLAX
D- add oral thyroxine
E- start olanzapine and summon mental health team

Answer 162

C- consider steroids, Ig and PLAX