Questions from Book

Question 1

Q1: In the treatment of acute coronary syndrome, which of following statements is false?

a) aspirin and clopidogrel do not provide enough anticoagulation, heparin should also be given
b) give 75mg aspirin
c) give 300mg clopidogrel in addition to aspirin
d) hypotension, asthma and bradycardia are main contraindicators to beta blockade
e) patients will likely continue taking a statin, beta blocker and ace inhibitor on discharge home

Answer 1

Give 75mg Aspirin

Question 2

Q4: 68 y/o man recently diagnosed with lung cancer admitted to emergency department with acute shortness of breath. Chest x-ray shows right upper zone collapse.

What do you expect to find on examination?

a) Trachea deviated to right, dull percussion right upper zone, reduced breath sounds
b) trachea deviated to right, dull percussion right upper zone, wheeze
c) trachea deviated to right, dull percussion resonant right upper zone, reduced breath sounds
d) trachea deviated to left, dull right upper zone percussion, reduced breath sounds
e) trachea deviated to left, percussion resonant right upper zone, wheeze

Answer 2

Trachea deviated to right, dull to percussion of right upper zone, reduced breath sounds on auscultation

Question 3

Q6: 45 year old man, heavy smoker, diagnosed with copd. No documented acute exacerbatons in past.

Which of following treatments is not suitable in management of COPD in this patient?

a) annual influenza and pneumoccocal vaccination
b) inhaled corticosteroids
c) short acting b2 agonist
d) short acting anti-cholinergic
e) smoking cessation

Answer 3

inhaled corticosteroids

Question 4

Q7: 35 y/o woman, admitted with acute onset shortness of breath. Past medical history of asthma. Pulse rate 120bpm, blood pressure 100/72mmHg, resp rate 30, Sao2 88% on room air.

Appears drowsy and exhausted and chest quiet on auscultation. Arterial Blood gases show ph 7.35, Pa02 5.2kpa, PaCo2 4.9kp and bicarbonate 24mmol/l

Which of following would not be appropriate in management of this case?

a) high flow 02
b) high dose nebulised beta 2 agonists
c) intravenous magnesium sulphate
d) leukotriene receptor antagonists
e) steroids

Answer 4

leukotriene receptor antagonists

Question 5

Q13: Which of following is not a preventable risk factor for coronary artery disease?

a) five cigarettes per day smoking history
b) high low density lipoprotein cholesterol levels
c) hypertension
d) obesity
e) 12 u/week alcohol history

Answer 5

12 u/week alcohol history

Question 6

Q14: 29 year old man with 1 week non productive cough, muscle ache, fever, vomit and diarrhoea. Temp 38.4, pulse 105, blood pressure 110/76, resp rate 22.

Examination - chest clear to both auscultation and percussion. Chest x-ray bilateral lung basal infiltrates.

Most likely causative organism

a) chlamydia pneumoniae
b) mycoplasma pneumoniae
c) legionella pneumophilia
d) staphyloccocus aureus
e) streptoccocus pneumoniae

Answer 6

legionella pneumophilia

Question 7

Q19: ECG - rate 88/min, regular rhythm, pr duration 0.26 seconds, qrs complex 0.08 seconds. QT interval 0.2 seconds. P waves only present before each QRS and that rhythm is regular.

Which of following would be best summary?

a) first degree heart block
b) left axis deviation
c) left bundle branch block
d) refuse to summarise
e) ventricular tachycardia

Answer 7

first degree heart block

Question 8

Q26: 74 year old man, shortness of breath, coughing up frothy white sputum which contains small amount of blood. Chest has diffuse crackles on inspiration which can discern a mid diastolic murmur and loud first heart sound. Chest x-ray confirms pulmonary oedema.

Most likely cause for symptoms

a) lower respiratory tract infection
b) mitral stenosis
c) non small cell carcinoma of lung
d) pulmonary embolism
e) small cell carcinoma of lung

Answer 8

mitral stenosis

Question 9

Q27: 62 year old man, shortness of breath on exertion, collapsing pulse and echo confirms aortic regurgitation.

Which of following is not associated with aortic regurgitation?

a) ankylosing spondylosis
b) aortic dissection
c) marfan syndrome
d) rheumatic fever
e) systemic lupus erythematosus (SLE)

Answer 9

systemic lupus erthematososus

Question 10

Q32: The left anterior descending coronary artery usually supplies

a) anterior wall of left ventricle and av node
b) anterior wall left ventricle and inter ventricular septum
c) anterior wall left ventricle, av node and iv septum
d) iv septum and inferior part of left ventricle
e) sa node, av node and inferior part left ventricle

Answer 10

anterior wall of left ventricle and iv septum

Question 11

Q39: 75 year old woman has mitral stenosis.

Which of following is not a sign of mitral stenosis?

a) bifid p wave
b) diastolic opening snap heart sound
c) double impulse apex beat
d) mid diastolic murmur
e) peripheral cyanosis

Answer 11

double impulse apex beat

Question 12

An anxious mum has read on internet about tetralogy of fallot.

Which of following does not fit diagnosis?

a) child small for his age
b) child is cyanotic
c) his pulse exhibits radio femoral delay
d) child exhibits loud systolic murmur
e) child can relieve symptoms by squatting

Answer 12

pulse has radio femoral delay

Question 13

Q3: 69 year old man with signs and symptoms saying heart failure.

Which of following is not a feature of heart failure?

a) hepatomegaly
b) non pitting oedema
c) pulsus alternans
d) raised jugular venous pressure
e) tricuspiid regurgitation

Answer 13

non pitting oedema

Question 14

Q7: 45 year old woman with type 1 diabetes and rheumatoid arthirits admitted with overdose of ibuprofen and has acute renal failure with creatinine level of 350umol/L.

She became breathless next day with airway clear. Resp rate 28/min and sats 86% on air. Hear bibasal creps in chest which is slightly dull to percussion at both bases. Pulse of 110bpm and blood pressure 125/80mmHg.

Urine output 120ml in last 10 hours and JVP is high.

What is most likely reason for her breathlessness

a) acute respiratory distress syndrome
b) aspiration
c) pleural effusion
d) pneumonia
e) pulmonary oedema

Answer 14

pulmonary oedema

Question 15

Q13: 52 year old man with chest pain. Most significant symptom towards diagnosis of acute coronary syndrome is

a) chest pain located just under left nipple near apex beat
b) past medical history of controlled angina
c) sharp chest pain
d) shortness of breath
e) tachycardia

Answer 15

past medical history of controlled angina

Question 16

Q16: 62 year old woman increasing shortness of breath over 2 weeks. Past medical history of breast cancer, ischaemic heart disease, previous MI with stent in left anterior descending artery and osteoarthiritis.

On examination reduced breath sounds at lung bases and dullness to percussion. Both legs swollen.

Chest x-ray demonstrates right sided pleural effusion. Aspiration of pleural cavity showed pleural fluid protein: serum protein ratio <0.5

What is most likely diagnosis?

a) congestive heart failure
b) metastatic lung cancer
c) rheumatoid disease
d) systemic lupus erythematosus
e) tuberculosis

Answer 16

congestive cardiac failure

Question 17

Q20 62 year old man with depression and cardiac arrhtyhmias. Recently discharged with chest pain.

During admission noted to have torsades de pointes.

What is torsades de pointes?

a) clinical sign associated with acute pericarditis
b) congenital facial sign associated with congenital heart defects
c) form of ventricular tachycardia that can self correct but also lead to sudden death
d) variation in QRS that changes in magnitude with inspiration and expiration
e) alternate t wave inversion

Answer 17

form of ventricular tachycardia that can self correct but also lead to sudden death

Question 18

Q24: find loud systolic murmur in 14 year old girl during preop assestment. Which of following signs or investigations do not help confirm diagnosis of coarctation of aorta?

a) ankle brachial pressure index
b) ecg
c) magnetic resonance angiography
d) radial pulse assymetry
e) radio femoral delay

Answer 18

ecg

Question 19

Q25: 28 year old woman with asthma and using salbutamol more. Currently on inhaled short acting beta 2 agonist and inhaled steroid 800ug/day and has been compliant.

What should you do?

a) add inhaled long acting beta 2 agonist
b) add leukotriene receptor antagonist
c) add oral steorid
d) increase dose inhaled steroid
e) prescribe inhaled short acting beta 2 agonist as regular therapy

Answer 19

add inhaled long acting beta 2 agonist

Question 20

Q29: 32 year old woman with 3 month history of non productive cough and breathless on exertion. Fatigue, weight loss and joint pain. Smokes 15 cigarettes a day. Not travelled abroad recently.

Examination - fine interstitial crackles on anterior chest wall. Multiple red lumps on both shins

Most likely diagnosis?

a) idiopathic pulmonary fibrosis
b) lung cancer
c) sarcoidosis
d) systemic lupus erythematosus
e) wegener granulomatosis

Answer 20

sarcoidosis

Question 21

Q32: 60 year old chinese man, 4 month history of weight loss. Cough productive of green sputum without blood. Reduced appetite, insomnia and night sweats.

Past history: hypertension and ischaemic heart disease. No smoking history.

Temp 36.4, pulse 67bpm, blood pressure 152/92 and resp rate 15/min. On exam - dullness to percussion over left upper lung zone.

Most likely diagnosis?

a) lung cancer
b) lung abscess
d) pulmonary infarction
e) tuberculosis
f) wegener granulomatosis

Answer 21

tuberculosis

Question 22

Q33: 27 year old woman with 3 month history of cough with blood, loss of weight and night sweats. Suspect tuberculosis.

Which of following chest x-ray findings is not consistent with tuberculosis?

a) cavitating lesion
b) consolidation of lobe
c) diffuse 1-2mm spots of increased opacity
d) perihilar ground glass changes
e) pleural effusion

Answer 22

perihilar ground glass changes

Question 23

Q36: 63 year old male smoker, on diuretics for essential hypertension, has chest pain.

On ECG notice T wave inversion.

Which of following does not cause t wave inversion?

a) hyperkalaemia
b) left bundle branch block
c) left ventricular hypertrophy
d) myocardial infarction
e) myocardial ischaemia

Answer 23

hyperkalaemia

Question 24

Q47: 43 year old woman with acute sharp central chest pain radiating to left arm worse on inspiration and at night. It is preventing her coughing which is prolonging chest infection.

Examination - chest exhibits vesicular breath sounds with bibasal crackles. ECG shows widespread concave ST elevation in sinus rhythm

Which of following most likely diagnosis?

a) acute pericarditis
b) cardiac tamponade
c) pulmonary embolism
d) STEMI
e) unstable angina

Answer 24

acute pericarditis

Question 25

Q3: In treatment of heart failure with atrial fibrillation, which of following statements about digoxin is false?

a) ace inhibitors and beta blockers more effective at extending survival
b) digoxin has secondary vagal effect that slows heart rate
c) digoxin is effective at treating symptoms
d) digoxin is obtained from foxgloves
e) digoxin is primarily chronotropic drug

Answer 25

digoxin is primarily chronotropic drug

Question 26

Q8: 44 year old man, 3 day history of shortness of breath and productive cough. Temp 38.2, pulse 90bpm, blood presure 130/86mmHg, resp rate 24, sats 94% on room air.

White cell count of 13.5 x 10 to the power of 6, CRP 45mmol/L, Na+ 136mmol/L, urea 9.2mmol/L and creatinine 110umool/L.

On examination dull sounds on percussion over right lower lobe. CXR shows right lower lung lobe consolidation.

Most appropriate management?

a) admission with empirical antibiotic treatment
b) admission for nebulised salbutamol and empirical antibiotic treatment
c) admission into ICU
d) home with inhaled salbutamol when stable
e) home with empirical antibiotic treatment when stable

Answer 26

home with empirical antibiotic treatment when stable

Question 27

Q9: 68 year old obese woman not coping at home and presents following fall. On examination weak regular pulse and ejection systolic murmur. Haemoglobin level is 13.2.

What is most likely wrong?

a) aortic stenosis
b) atrial fibrillation
c) cerebrovascular accident
d) gastointestinal bleed
e) mitral regurgitation

Answer 27

aortic stenosis

Question 28

Q16: 35 year old man increasing fatigue, snores, no weight loss, smokes 30 cigarettes a day, drinks 2 pints of beer every night and has BMI of 32.

Most likely differential diagnosis?

a) central sleep apnoea
b) chronic fatigue syndrome
c) idiopathic hypersomnolence
d) narcolepsy
e) obstructive sleep apnoea

Answer 28

obstructive sleep apnoea

Question 29

Q18: 65 year old man, chest pain, increasing shortness of breath and weight loss. Pain is dull and worse on inhalation. Lost 1 stone in 3 weeks. Never smoked.

Temp 36.8, pulse 80bpm, blood pressure 140/95 and resp rate 18. Examination dullness to percussion over left lower lung zone.

Most likely diagnosis?

a) bronchocaricnoma
b) mesothelioma
c) pneumoconiosis
d) pulmonary embolism
e) tuberculosis

Answer 29

mesothelioma

Question 30

Q19: 61 year old woman history of tight, sternal chest pain. Do not correspond to hard exercise. No cardiac history. ECG has not detected any abnormalities and 2 days have passed since last episode.

Which of following is next best step in her management?

a) 24 hour ecg
b) admit to ward
c) chest x-ray
d) echo
e) prescirbe home oxygen

Answer 30

24 hour ecg

Question 31

Q29: 23 year old student, cough productive of green sputum. Breathless on exertion. Average of five resp tract infections per year. As child could not tolerate daily.

On examination - finger clubbing is present and dullness to percussion of right upper lung zone with widespread bilateral wheeze.

What is most probably diagnosis

a) asthma
b) coaelic disease
c) cystic fibrosis
d) immotile cilia syndrome
e) pneumonia

Answer 31

cystic fibrosis

Question 32

Q31: 56 year old man diagnosed with sigmoid cancer. Acute onset shortness of breath, past medical history of COPD, hypertension, stroke and gout.

Temp 37.2, pulse 106bpm, blood pressure 110/74, resp rate 25/min and sats 87% on room air. No significant finding on chest exam.

ECG shows sinus tachycardia with no ST elevation. Plain chest x-ray shows small left pleural effusion.

Which of following is most appropriate diagnostic investigation

a) MRI of chest
b) d dimer level
c) CT pulmonary angiography
d) ventilation-perfussion scanning
e) echocardiography

Answer 32

CT pulmonary angiography

Question 33

Q35: 45 year old man with 4 month history of productive cough with exertional breathlessness. No haemoptysis or weight loss. 20 pack year smoking history. Examination - fine crackles heard throughout whole lung field.

Most likely diagnosis?

a) asthma
b) copd
c) cystic fibrosis
d) idiopathic pulmonary fibrosis
e) lung cancer

Answer 33

copd

Question 34

Q37: 54 year old woman with repeated incidents of burning chest pain. Mostly occurs when lying down in bed at night. Overweight with BMI of 40. Uses GTN spray but it doesn’t always help.

No shortness of breath or palpitations.

Most likely diagnosis?

a) angina
b) gastro-oesophageal reflux
c) myocardial infarction
d) pancreatitis
e) sleep apnoea

Answer 34

gastro-oesophageal reflux

Question 35

Q38: Which of following patients meets modified duke criteria for endocarditis?

a) one blood culture positive for gram neg bacilus, pyrexia of 38.5 and splinter haemorrhages and osler nodes
b) one blood culture positive for streptoccocus viridans and new soft pansystolic murmur loudest at apex
c) pyrexia of 38.5, iv drug use, osler nodes and splinter haemorrhages
d) two blood cultures positive for strep viridans and new crescendo descrendo ejection systolic murmur
e) two blood cultures positive for strep viridans, pyrexia at 38.5, splinter haemorrhages and osler node and new small cerebral absess

Answer 35

two blood cultures positive for strep viridans, pyrexia at 38.5, splinter haemorrhages and osler node and new small cerebral absess

Question 36

Q39: 78 year old woman with palpitations. Feels clammy to touch. Heart rate is 230bpm and regular. QRS complexes narrow and no p waves.

Most likely arrhythmia?

a) atrial fibrillation
b) atrial flutter
c) av node re entry tachycardia
d) sinus tachycardia
e) ventricular tachycardia

Answer 36

av node re entry tachycardia

Question 37

Q9: 68 year old woman, experiencing episodes of central choking chest pain and shortness of breath on exertion. ECG is normal, bloods as are bloods and CXR. Which of following will not help during next episode?

a) bisoprolol
b) GTN spray
c) morphine
d) oxygen
e) salbutamol nebulisers

Answer 37

salbutamol nebulisers

Question 38

Q11: 80 year old man attends GP for annual check for hypertension. Which of following is not sign of left ventricular hypertrophy?

a) inverted t waves
b) left axis deviation
c) pansystolic murmur
d) r wave in v6 >25mm
e) sum of magnitude of s wave in V1 and R wave in V5>35mm

Answer 38

pansystolic murmur

Question 39

Q12: 79 year old woman suddenly acute unwell after operation. Sudden onset of shortness of breath and chest tightness. Pain exacerbating by deep breathing.

Pasth istory of hypertension, hypercholesterolaemia and asthma. Temp 37.8, Pulse 108bpm, Blood Pressure 96/66mmHg, resp rate 26/min and saturations 89% on room air.

Chest clear to both auscultation and percussion. ECG shows sinus tachycardia without bundle branch block.

What is most likely diagnosis?

a) acute exacerbation of asthma
b) myocardial infarction
c) pneumonia
d) pneumothorax
e) pulmonary embolism

Answer 39

pulmonary embolism

Question 40

Q16: Examining tearful young child who has fractured her arm. On auscultation you hear ejection systolic murmur. No cyanosis.

Which of following prevents you reassuring her calm dad that his daughter has no serious heart problem?

a) history of cyanosis
b) fracture needs to heal first
c) second heart sound is split
d) murmur disappears on sitting up
e) murmur is soft

Answer 40

history of cyanosis

Question 41

Q21: 59 year old man admitted following fall. Complains of increased tiredness and jerking movement of his leg which led to his fall from staircase. He is a smoker. On arrival he has oxygen saturation level of 76% in air and arterial blood gas reading demonstrates ph 7.40, Pao2 6kpa, PaCo2 9.3kpa, Hco3 -35mmol/L on room air. Resp rate 20

What does this blood gas result show?

a) acute type 1 resp failure
b) acute type 2 resp failure
c) compensated chronic type 2 resp failure
d) metbaolic acidosis
e) resp alkalosis

Answer 41

compensated chronic type 2 resp failure

Question 42

Q33: 60 year old woman presents with chronic cough with thick, yellow sputum for past year. Sometimes sputum is blood tinged. Been prescribed multiple courses of antibiotics but did not seem to help. Past medical history of severe pneumonia that required admission to intensive care unit.

On chest exam, there are inspiratory crackles throughout lung fields with normal vesicular breath sounds.

Which of following is most likely differential diagnosis?

a) bronchial carcinoma
b) bronchieectasis
c) COPD
d) idiopathic pulmonary fibrosis
e) pneumonia

Answer 42

bronchiectasis

Question 43

Q35: 56 year old man has myocardial infarction the day after hernia repair. You request ECG and then compare it to pre admission trace. Notice ST segment changes in leads II, III and AVF.

In which part of myocardium is infarct?

a) anterior
b) anterolateral
c) anteroseptal
d) inferior
e) posterior

Answer 43

inferior

Question 44

Q37: 74 year old woman presents with acute right sided hemiparesis and is found to have left middle cerebral artery infarct on diffusion weighed MRI. It is her first stroke. Her past medical history is unremarkable.

Blood pressure is normal and ECG shows sinus rhythm with occasional ventricular ectopics. Blood tests show normal cholesterol and normal glucose. On carotid doppler she is found to have 85% stenosis on left carotid.

Which of following will not benefit her?

a) ace inhibitor
b) aspirin
c) left carotid endarterectomy
d) statin
e) warfarin

Answer 44

warfarin

Question 45

Q40: 52 year old woman presents with intermittent palpitations and breathlessness. Denies chest pain. ECG shows sinus tachycardia and she does not appear to be anaemia.

Which blood test would be of most use in confirming diagnosis?

a) haematinics
b) lactate
c) no blood test required
d) thyroid function tests
e) troponin

Answer 45

thyroid function tests

Question 46

Q2: 78 year old man taking warfarin for metallic aortic valve presents with 5 days of cough productive of purulent sputum, fever, anorexia and confusion. He is diagnosed with community acquired pneumonia and is admitted for antibiotic therapy.
Which of following antibiotics does not interact with warfarin?

a) ciprofloxacin
b) clarithromycin
c) gentamicin
d) metronidazole
e) rifampicin

Answer 46

gentamicin

Question 47

Q29: a 36 year old man has 1 month history of non productive dry cough. Has become more short of breath on exertion for past 2 weeks. He was known IV drug abuser. Chest auscultation is unremarkable.

CXR shows bilateral symmetricial interstitial infiltrates. Subsequent HIV test is positive

Which of following is most likely causative agent?

a) aspergillus fumigates
b) cytomegalovirus
c) histoplasma capsulatum
d) pneumocytis jirovecii
e) staphyloccocus aureus

Answer 47

pneumocytis jirovecii