STG

Question 1

Glucose stimulated insulin secretion by the pancreas is augmented by which of the following? 
A. DPP4
B. GLP1
C. Leptin 
D. Somatostatin

Answer 1

GLP1

Question 2

Which of the following is not associated with bicuspid aortic valve disease?
A. Coarctation of the aorta
B. Atrial septa; defect
C. Aortopathy independent of valve stenosis
D. Aortic dissection

Answer 2

B - ASD

Question 3

Which of the following statement about HSV encephalitis is true?
A. It accounts for approximately 45% of identified cause of encephalitis
B. GIT symptoms are more common than other causes
C. Fever is les common than other causes
D. Occurs more commonly in younger patients

Answer 3

B. GIT symptoms are more common than other causes

Gastro symptoms are more common than with other causes (37% vs 19%)
Older age more common than in other causes (88% of HSV patients were older age group c.f. 64% for other causes).
Fever more common 80% vs 49%).

Question 4

Which one of the following statements regarding bevacizumab is CORRECT?
A. It improves survival when used as monotherapy in metastatic colorectal cancer
B. It is monoclonal antibody which targets epidermal growth factor receptor (EGFR)
C. It can be used in patients with a history of hypertension
D. It is a monoclonal antibody against RAF kinase

Answer 4

C. It can be used in patients with a history of hypertension

Bevacizumab is an mAb against vascular endothelial growth factor (VEGF). It has been shown to increase survival in metastatic colorectal cancer when used in combination with standard chemotherapy. Hypertension is a common side effect of bevacizumab and often requires treatment with anti-hypertensives but is not a contraindication to using bevacizumab (i.e. it can be managed with anti-HT meds)

Question 5

Which one of the following mechanisms is primarily responsible for the development of corticosteroid-induced osteoporosis?
A. Inhibition of bone formation
B. Inhibition of 25 OH vitamin D
C. Increased osteoclastic bone resorption
D. Secondary hyperparathyroidism

Answer 5

The main mechanism is inhibition of bone formation due to osteoblast and osteocyte apoptosis.

Osteoclastic bone resorption can be increased due to secondary hyperparathyroidism but this is not the main mechanism of bone loss. Corticosteroids do not cause hyperparathyroidism or affect vitamin D metabolism.

Question 6

Which of the following is TRUE in regards to antibiotic synergy?
A. The mechanism of antibiotic synergy with dual beta-lactams (ampicillin and ceftriaxone) in Enterococcus Faecalis endocarditis is thought to be related to differential targeting of penicillin bind proteins (PBP).
B. Antibiotic synergy is when two or more antibiotics are used simultaneously such that their effect is less potent than sum of each individual antibiotic.
C. Antibiotic synergy can also be seen with the use of antibiotics even if they test as resistant in vitro.
D. Combination of a beta-lactam and aminoglycoside does not demonstrate antibiotic synergy for Staphylococcus Aureus infective endocarditis.

Answer 6

A. The mechanism of antibiotic synergy with dual beta-lactams (ampicillin and ceftriaxone) in Enterococcus Faecalis endocarditis is thought to be related to differential targeting of penicillin bind proteins (PBP).

Third generation cephalosporins saturate the binding sites of PBP 2 and 3 allowing ampicillin to act on PBP 5, the major site of its activity against enterococcal species. Antibiotic synergy is when two or more antibiotics are used simultaneously such that their effect is more potent than the sum of each individual antibiotic. Antibiotics that organisms are considered intrinsically resistant to may still demonstrate antibiotic synergy in combination. Combination beta-lactam and aminoglycoside has shown evidence of synergy both in vitro and in vivo. The clinical benefit in Staphylococcus Aureus native valve endocarditis has not been show to outweigh the possible harm and is no longer recommended in guidelines. Aminoglycoside synergistic therapy for two weeks is recommended if appropriate for Staphylococcus Aureus prosthetic valve infective endocarditis.

Question 7

Which one of the following is NOT a recognised method of screening for frailty in older people?
A. Grip strength
B. Gait speed
C. BMI
D. Clinical Frailty Scale

Answer 7

C. BMI

You can have a high BMI and be frail

Question 8

Which one of the following statements about the potential sequelae of aneurysmal subarachnoid haemorrhage is TRUE?
A. Clinically significant hydrocephalus is a common complication.
B. The risk of re-rupture remains elevated for 2 weeks after the initial rupture if the aneurysm is not treated.
C. Delayed cerebral ischaemia develops in the vast majority of patients with angiographic vasospasm.
D. Blood pressure should be maintained at systolic less than 150mm Hg.

Answer 8

A. Clinically significant hydrocephalus is a common complication.

Question 9

Which one of the following is NOT a recognised radiological abnormality in psoriatic arthritis?
A. Calcification of peri-odontoid ligaments
B. Bone sclerosis
C. Juxta-articular new bone formation
D. Syndesmophytes

Answer 9

A. Calcification of peri-odontoid ligaments

Calcification of peri-odontoid ligaments is a feature of crowned dens syndrome, which is a lesion seen in CPPD.

Question 10

Which one of the following statements regarding biosimilars is CORRECT?
A.
Biosimilarity is based on comparable pharmacokinetic profiles.
B.
In psoriasis multiple switching between biosimilar TNF inhibitors is not associated
with reduced efficacy.
C.
Cetuximab and Panitumumab are biosimilars that bind to the epidermal growth
factor receptor.
D.
Development of auto antibodies to biosimilar agents predicts for increased adverse
effects related to these agents.

Answer 10

B.
In psoriasis multiple switching between biosimilar TNF inhibitors is not associated
with reduced efficacy.

Question 11

Which of the following anti-psychotic is LEAST LIKELY to cause extrapyramidal side effects?
A. Quetiapine
B. Olanzapine
C. Clozapine
D. Chlorpromazine

Answer 11

C. Clozapine

Question 12

Which of the following statements regarding transfusion associated graft versus host disease is TRUE?
A. It can be prevented if blood is leucodepleted at source
B. It is mediated by antibodies in donor plasma
C. It can be caused by human derived Factor VIII concentrate
D. It is mediated by donor derived immunocompetent T lymphocytes

Answer 12

D. It is mediated by donor derived immunocompetent T lymphocytes

TA-GVHD mediated by immunocompetent T lymphocytes from donor. Immunosuppressed patients at risk, also at risk if receive blood from close family member. Risk eliminated by irradiating blood products. Leucodepletion does not remove all lymphocytes.

Question 13

A 19-year-old ballet dancer attends your clinic with her mother for amenorrhea. She had normal menarche at age 13 but has not had a period for the past 6 months. Her BMI is 17kg/m2 and she has a fine covering of hair on her arms. Her GP does some blood tests which demonstrate the following; High normal serum oestrogen and progesterone levels. Low levels of FSH and LH. Her Prolactin and testosterone levels are normal. What is the most likely cause of her amenorrhea?
A. Secondary amenorrhea due to low body mass and excessive exercise
B. Concealed pregnancy
C. The combined oral contraceptive pill without sugar pills
D. Premature menopause

Answer 13

A 19-year-old ballet dancer attends your clinic with her mother for amenorrhea. She had normal menarche at age 13 but has not had a period for the past 6 months. Her BMI is 17kg/m2 and she has a fine covering of hair on her arms. Her GP does some blood tests which demonstrate the following; High normal serum oestrogen and progesterone levels. Low levels of FSH and LH. Her Prolactin and testosterone levels are normal. What is the most likely cause of her amenorrhea?
A. Secondary amenorrhea due to low body mass and excessive exercise
B. Concealed pregnancy
C. The combined oral contraceptive pill without sugar pills
D. Premature menopause

Question 14

A 38 year-old-man is going to Kenya to do some aid work. He comes to your clinic to ask about malaria prophylaxis advice. He has a long history of depression and is not currently on any treatment. He likes bushwalks and hikes and plans to spend a lot of time outdoors. He is otherwise well without any medical problems. What is the best choice for malaria prophylaxis?
A. Doxycycline
B. Chloroquine
C. Mefloquine
D. Atovaquone plus proguanil

Answer 14

Atovaquone plus proguanil is good prophylaxis against Plasmodium falciparum. This is a good choice for this man. Doxycycline is a reasonable option but can cause photosensitive dermatitis and may not be a good option for someone who will be spending a lot of time outdoors. Chloroquine is no longer suitable in most malaria-endemic areas due to resistance profile. Mefloquine can cause neuro-cognitive side effects and exacerbate pre-

Question 15

When aspirating a small effusion in the knee joint, where should the needle be inserted?

Answer 15

1cm medial to the junction of the upper and middle third of the patella

Question 16

Which one of the following is a feature of mitochondrial DNA disorder inheritance?
A. Paternal transmission of gene mutation
B. A mitochondrial gene mutation is present only in a proportion of the cell’s mitochondrial genome copies
C. There is a single copy of mitochondrial DNA in each cell
D. Point mutation is the type of defect identified in all mitochondrial gene mutations

Answer 16

B. A mitochondrial gene mutation is present only in a proportion of the cell’s mitochondrial genome copies

Mitochondria have their own chromosomes and these are passed on from a mother to all her children, but not from the father. These chromosomes contain only 37 genes that have a high and variable number of DNA copies and very little non-coding DNA and no introns. Many different mitochondrial mutations, including point mutations, deletions and duplications, alone or in combination, can result in a variety of different disorders. The relationship between genotype and phenotype is not straightforward, in part due to heteroplasmy, the tendency for a mitochondrial mutation to be present in only a proportion of the cell’s mitochondrial genome copies

Question 17

A 24-year-old male is brought into the emergency department by his friends from a new year’s party. He was reportedly drinking heavily and was noted to be increasingly drowsy and then had a tonic-clonic seizure. Bloods done show an acute kidney injury, severe metabolic acidosis and a significant osmolar gap of 25mOam/Kg. His urine is examined under the microscope and calcium oxalate crystals are seen. What is the likely toxic substance ingested in this case?
A. Ethanol
B. Methanol
C. Isopropyl alcohol
D. Ethylene glycol

Answer 17

D. Ethylene glycol

Ethylene glycol poisoning (anti-freeze). While all of the alcohols can cause neurological compromise and a metabolic acidosis with an osmolar gap – ethylene glycol breaks down into glycolic acid and oxalic acid which forms calcium oxalate crystals and acute renal failure.

Question 18

A 33-year-old woman with a background history of asthma suffers from disabling migraine headaches, lasting 2-3 days every 1-2 weeks and requiring the use of paracetamol, codeine and ibuprofen. What is the best option for migraine prophylaxis?
A. Propranolol
B. Topiramate
C. Valproate
D. Sumatriptan

Answer 18

B. Topiramate

Propranolol is relatively contraindicated given her previous history of asthma. Valproate should be avoided in women of childbearing age given risks of congenital malformations if taken during pregnancy. Sumatriptan is an acute migraine treatment and is not used for prophylaxis. Topiramate is one of many options for migraine prophylaxis and the best choice in this case.

Question 19

A diabetic man with severe peripheral neuropathy presents with a 3-month history of a plantar ulcer under the first metatarsophalangeal joint. The forefoot is swollen around this joint. There is purulent exudate. He is taking cephalexin prescribed by his general practitioner. Using a metal probe the examiner is able to probe to bone. A plain x-ray shows destruction of the first metatarsophalangeal joint consistent with destruction of the joint by infection. A deep swab from the ulcer is submitted for culture and Staphylococcus aureus and Pseudomonas aeruginosa are isolated.
How do you interpret the microbiology in this case?
A. A poly-microbial diabetic foot infection is confirmed
B. The organisms are of uncertain significance as the cause of the osteomyelitis
C. The patient has osteomyelitis caused by the organisms isolated
D. The result is not interpretable because of the antibiotic therapy

Answer 19

B. The organisms are of uncertain significance as the cause of the osteomyelitis

Swabs of ulcers are poorly predictive of the microorganisms in bone.

Question 20

A 34-year-old woman with type 1 myotonic dystrophy is 8 weeks pregnant. She attends your clinic for advice regarding the risk of myotonic dystrophy in her newborn. Which one of the following statements is CORRECT?
A. The chance of the baby being affected is 1 in 4
B. Her partner should be referred for genetic testing
C. If her baby does inherit the condition, the baby is at risk of being more severely affected than her
D. Only a male baby will be affected with this condition

Answer 20

C. If her baby does inherit the condition, the baby is at risk of being more severely affected than her

Myotonic dystrophy type 1 is a triplet repeat disorder, that it is autosomal dominant and not x-linked. It is caused by pathological expansion of a run of CTG repeats within the DMPK gene on chromosome 19. Expanded repeats
9
are unstable and prone to the genetic phenomenon called anticipation, where the offspring are more severely affected than the affected parent

Question 21

A 72-year-old man presents with a 3-month history of increasing fatigue, lethargy and generally feeling unwell. He has a history of well controlled Type 2 DM, hypertension and GORD. He notes a 6kg of unintentional weight loss. His MPO titre is highly positive.
On examination his BP is 150/95mmHg. UA shows Blood ++++ Protein +++
His blood test show serum creatinine 380umol/L and urea 22mmol/L
A renal biopsy is performed. Which one of the following histological findings are most likely?
A. Kimmelstiel-Wilson nodules with mesangial hypercellularity
B. Proliferative Glomerular nephritis with crescents and negative immunofluorescence
C. Sub-epithelial deposits with positive PLA2-receptor antibodies +
D. Membranoproliferative pattern with double contours

Answer 21

B. Proliferative Glomerular nephritis with crescents and negative immunofluorescence

This man has an ANCA associated renal vasculitis, which is usually pauci-immune with necrotising crescents

Question 22

A 39-year-old primigravida presents 3 weeks post normal vaginal delivery of a live male infant with central chest pain radiating down her left arm. She's been breastfeeding and caring normally for her infant. ECG shows 0.5mm ST elevation in Lead 3 and AVF without reciprocal ST depression. Initial troponin is normal and then rises to x20 upper limit of normal. Her chest pain settles with aspirin, nitrates and small dose of morphine. An ECHO demonstrates overall normal LV & RV function and she remains pain free. The most appropriate next step in her management would be?
A. Cardiac MRI 
B. Discharge for outpatient follow up 
C. Coronary angiogram 
D. CT coronary angiogram

Answer 22

B. Discharge for outpatient follow up

Dx is most likely coronary artery dissection diagnosed easily on CTCA without the risk of invasive angiogram

Question 23

Mycophenolate and pregnancy

Answer 23

• Increased risk of malformations and 1st trimester pregnancy loss
• External ear and other facial malformations such as cleft palate and lip