BOF: 21

 

A 33-year-old female who has had multiple resections of the small bowel has been left with 90 cms of jejunum anastamosed to the colon. She is maintained on a diet high in polysaccharides and manages well on this diet. She is admitted to the ward with ataxia, blurred vision, ophthalmoplegia and nystagmus.

The likely cause of this complication is

a)      Thiamine deficiency

b)      Vitamin B 12 deficiency

c)      Magnesium deficiency

d)      L (+) lactic acidosis

e)      D (-) Lactic acidosis

Answer:

e)

In patients with a short small bowel and an intact colon, energy is absorbed from the colon by bacterial fermentation of polysaccharides to short chain fatty acid, which can be absorbed by the colonocytes. In rare instances mono and oligosaccharides may be metabolised to D (-) lactic acid by abnormal bacteria. The normal lactic acid produced by man is L (+) lactic acid. Absorption of D (-) lactic acid results in ataxia, blurred vision, ophthalmoplegia and nystagmus. Treatment is with broad-spectrum antibiotics such as neomycin or vancomycin, thiamine and a change in diet to one high in polysaccharides and low in mono and oligosaccharides.

 BOF: 22

A 28-year-old male presents with a painful swollen knee. He feels generally unwell and has fever. He has a psoriasiform rash on his glans penis and he also complains of low backache.

Six weeks previously he has had a self-limiting episode of diarrhoea.

In this patient

a)             Prompt treatment will reduce the chance of recurrence

b)            High dose steroids should be used without delay

c)             Prolonged antibiotic treatment will prevent the disease becoming chronic

d)            If the disease becomes chronic sulphasalazine and methotrexate are useful second line agents

e)             He has a greater than 50 % chance of developing erosive disease or spondylitis

Answer:

d)

This patient has developed reactive arthritis. If possible athrocenetesis should be preformed to exclude septic arthritis. Prednisolone does help to control symptoms in active disease but is not the drug of first choice. Non-steroidal anti-inflammatory drugs should be used. Antibiotics should be used if active infection is demonstrated but prolonged therapy is of no benefit. More than 50 % of patients will experience further episodes. Sulphasalazine and methotrexate are useful second line agents if the disease becomes chronic. About 15 % of patients go on to develop erosive disease or spondylitis.

 BOF: 23

A 35-year-old female presents with a mutilating arthritis of the hands with associated pitting of the nails.

In treating this patient

a)      Sulphasalazine is unlikely to be effective

b)      Methotrexate is unlikely to be effective

c)      Antimalarials are best avoided

d)      Tumour necrosis factor alpha antagonists are not effective

e)      Oral corticosteroids should be the drugs of first choice as they help the nail condition as well

Answer:

c)

 

The patient has psoriatic arthropathy. Treatment is usually with non-steroidal anti-inflammatory drugs although there is a risk of worsening the psoriasis. Sulphasalazine and methotrexate are useful in this condition. Tumour necrosis factor alpha antagonists are effective but are expensive to use. Steroids are seldom needed and may provoke worsening of the psoriases on withdrawal. Antimalarials are best avoided as they can cause an acute psoriatic skin reaction.

BOF: 24

A 45-year-old male presents with a sudden onset of pain and swelling of the metatarso-phalangeal joint of the right big toe.

In this patient

a)      A normal serum uric acid concentration excludes the diagnosis of gout

b)      The x-ray changes would be characteristic

c)      Synovial fluid analysis should be delayed to allow crystals to aggregate and become easier to visualise

d)      Fever, leucocytosis and elevated ESR would suggest septic arthritis

e)      The first attack is seldom associated with residual disability

Answer:

e)

In an acute attack of gout serum uric acid is raised in only about 60 % of patients. Similar x-ray changes may occur in inflammatory and degenerative arthritis. Synovial fluid analysis should be undertaken immediately following aspiration of joint fluid. The characteristic changes being the demonstration of needle shaped negatively birefringent crystals of mono-sodium urate in synovial fluid neutrophils by polarizing light microscopy. A raised ESR fever and leucocytosis can accompany very acute attacks of gout and do not necessarily indicate sepsis. The first attack of gout is seldom associated with residual disability. 

BOF: 25

A sixty five year old male who is on treatment for chronic heart failure with diuretics, angiotensin converting enzyme inhibitors, beta-blockers and spironolactone presents with sudden onset of pain and swelling of the metatarso-phalangeal joint of his right big toe. Aspiration of the joint demonstrates crystals of monosodium urate.

In this patient

a)      Moderate doses of aspirin would be beneficial

b)      Non-steroidal anti-inflammatory digs would be the drugs of first choice

c)      Highly selective cyclooxygenase 2 inhibitor should be used

d)      Colchicine would be the best choice

e)      Parenteral colchicine may be safely used to counter nausea and diarrhoea

Answer:

d)

 

This patient has gout. Aspirin unless used in high doses causes uric acid retention. Non-steroidal anti-inflammatory drugs would be contraindicated in view of the heart failure. Highly selective COX 2 inhibitors may not be used with co-existing heart failure. Intravenous colchicine is potentially hazardous.

BOF: 26

A 50-year-old female presents with a sudden onset occipital headache followed by a decreased level of consciousness. On examination she has neck stiffness and a positive Kernig’s sign. CT scanning shows blood in the sub-arachnoid and intraventricular space.

The patient improves initially but 10 days following admission her level of consciousness begins to deteriorate.

The next step in management would be:

a)      Decompression by lumbar puncture

b)      Lumbar puncture followed by high dose broad spectrum antibiotics until cultures are available

c)      High dose dexamethasone

d)      CT scan followed by a ventricular jugular shunt

e)      Cisternal puncture for decompression

Answer:

d)

The patient has had a sub-arachnoid haemorrhage. Deterioration coming on after an initial improvement is most likely due to the development of secondary hydrocephalus due to blockage of CSF flow by blood. The management would be CT scan to confirm the diagnosis followed by a procedure to drain CSF.

BOF: 27

A 60-year-old female presents with a severe left-sided temporal headache. The temporal artery is tender, pulsation is lost and the overlying skin is erythematous. The E.S.R. is 80 mm in the first hour.

In this patient

a)      A short course of high dose steroid should be prescribed

b)      The E.S.R. is not a reliable guide to use when reducing the dosage of steroids

c)      The headache subsides within hours of commencing the patient on high dose steroid

d)      Lifelong steroid treatment will be required

e)      As steroids may be harmful in elderly patients, treatment should be delayed until the results of temporal artery biopsy are available

Answer:

c)

The patient has temporal arteritis. The diagnosis is confirmed by biopsy but in view of the serious complications that may occur treatment with high-dose steroids should be started immediately. Reduction of steroid dosage is guided by the fall in the E.S.R. but the duration of treatment would be several months to years.

BOF: 28

A 30-year-old female presents with a history of weakness and fatigability of the ocular, bulbar and limb muscles. On examination she has bilateral ptosis and extra-ocular muscle weakness. Reflexes are preserved, there is no muscle wasting. The Edrophonium test is positive.

In this patient

a)      Thymectomy has no long term benefit

b)      If a thymoma is present the muscle weakness would improve

c)      In non-thymoma patients improvement will be seen in 60 % of patients

d)      The prognosis is worse as the patient is under 40 years of age

e)      Thymectomy should not be performed if the patient has positive receptor antibodies

Answer:

c)

In myasthenia gravis thymectomy offers long-term benefits. It improves the prognosis in patients below 40 years, in those with positive receptor antibodies and in those who have had the disease for less than 10 years. Following thymectomy 60 % of non-thymoma patients will improve. In thymoma although surgery is necessary as the tumour is potentially malignant, the myasthenia is unlikely to improve.

 BOF: 28

A 30-year-old female presents with a history of weakness and fatigability of the ocular, bulbar and limb muscles. On examination she has bilateral ptosis and extra-ocular muscle weakness. Reflexes are preserved, there is no muscle wasting. The Edrophonium test is positive.

In this patient

a)      Thymectomy has no long term benefit

b)      If a thymoma is present the muscle weakness would improve

c)      In non-thymoma patients improvement will be seen in 60 % of patients

d)      The prognosis is worse as the patient is under 40 years of age

e)      Thymectomy should not be performed if the patient has positive receptor antibodies

Answer:

c)

In myasthenia gravis thymectomy offers long-term benefits. It improves the prognosis in patients below 40 years, in those with positive receptor antibodies and in those who have had the disease for less than 10 years. Following thymectomy 60 % of non-thymoma

patients will improve. In thymoma although surgery is necessary as the tumour is potentially malignant, the myasthenia is unlikely to improve.

BOF: 29

A 70-year-old male is referred by his general practitioner as he has had a stroke. On examination the patient has left sided complete third nerve palsy with a contralateral hemiplegia. The lesion is likely to be in the

a)      The pons

b)      The medulla

c)      The mid-brain at the level of the inferior colliculus

d)      The mid-brain at the level of the superior colliculus

e)      The thalamus

Answer:

d)

The lesion involves the mid-brain at the level of the superior colliculus damaging the third nerve nucleus and the cerebral peduncles.

BOF: 30

A 30-year-old male presents with a chronic cough productive of copious amounts of thick yellow sputum and occasional haemoptysis. He also complains of bad breath and recurrent episodes of fever. On examination he has clubbing and on auscultation over the lung bases coarse crepitations are heard.

The test that would identify the cause of his condition would be:

a)      Sweat electrolytes

b)      Sinus x-ray

c)      Bronchoscopy

d)      High resolution CT scanning

e)      Bronchography

Answer:

d)

The patient has bronchiectasis. High resolution CT scanning would be the investigation of choice. It would show bronchial dilatation and wall thickening.

BOF 31

A 68-year-old female patient is seen on the ward. She complains of severe pain in her right eye. There is blurring of vision and she feels nauseated and has vomited several times. Earlier in the day she has undergone colonoscopy for evaluation of her long-standing Crohn's disease. The endoscopist has made a comment that the examination was difficult. What is the likely cause of her painful red eye?

a)      Anterior uveitis

b)      Acute conjunctivitis

c)       Episcleritis

d)       Sub-conjunctival haemorrhage

e)      Acute angle closure glaucoma

Answer

e)

Anticholinergic agents are sometimes used during endoscopy to cause smooth muscle relaxation to aid examination when difficulty is encountered. These agents cause pupillary dilatation thus precipitating acute angle closure glaucoma in susceptible patients. In patients with a history of glaucoma, glucagon is used instead of anticholinergics.  

BOF: 32

A 65-year-old male presents with a chronic cough. He is a heavy smoker of over 40 cigarettes a day. CXR shows a peripheral right-sided lesion, which on CT guided lung biopsy, is shown to be squamous carcinoma. No regional lymph nodes are involved. Lung function tests show a FEV1 of less than 1.5 litres.

The treatment most likely to benefit this patient would be:

a)      Surgery

b)      Chemotherapy

c)      High dose radiotherapy

d)      Combination chemotherapy and radiotherapy

e)      Combination chemotherapy and surgery

Answer:

c)

A FEV1 of less than 1.5 litres is not compatible with an active life following surgery. High dose radiotherapy can produce good results and is the treatment of choice in patients with poor lung function.

BOF: 33

A 45-year-old male homeless alcoholic has been referred to the medical ward after being brought in to casualty. He has a chronic cough productive of sputum, loss of weight, and night sweats. On examination he is unkempt and emaciated. His trachea is deviated to the left and there are crepitations over the apex of the left lung. CXR shows fibrosis and cavitation in the left apex.

The investigation most likely to confirm the diagnosis would be

a)      Sputum examination for acid and alcohol fast bacilli

b)      High resolution CT scan

c)      Fibreoptic bronchoscopy

d)      Mantoux test

e)      Gastric washings

Answer:

a)

The patient has a productive cough. The chances are that AAFB will be identified in these specimens. If sputum were not produced bronchoscopy would be preferred to gastric washings.

BOF: 34

A fifty –five year old male presents with a history of anorexia, nausea and vomiting and abdominal pain.

His skin is pigmented with pigmentation of palmar creases and sun exposed areas. He has a few patches of vitiligo. His blood pressure is low and there is a postural drop.

In this patient the blood urea and electrolytes are likely to show the following

a)      Decreased Na, Decreased K, Normal Urea

b)      Decreased Na, Increased K, Increased Urea

c)      Decreased Na, Increased K Normal Urea

d)      Increased Na, Decreased K, Increased Urea

e)      Decreased Na, Decreased K, Increased Urea

Answer:

b)

The patient has Addison’s disease. The Na will be low with and increase in K and increase in blood urea.

BOF: 35

A sixty-year-old female presents with a history of palpitations and swelling in the neck.

On examination of the pulse there is atrial fibrillation and in the neck there is a large multinodular goitre.

In this patient which one of the following are likely

a)      Eye signs are common

b)      Eye signs are rare

c)      Spontaneous remission is likely

d)      Long term antithyroid drugs are effective in controlling symptoms

e)      Thyroxine will help to reduce the size of the goitre

Answer:

b)

This patient has toxic multinodular goitre. In this condition eye signs are rare unlike Grave’s disease. Spontaneous remission is rare. Antithyroid drugs will increase the size of the goitre and are only used as a temporary measure prior to definitive treatment. Thyroxine will not reduce the size of the goitre.

BOF: 36

A sixty-year-old female presents with a history of nausea, lethargy and depression.

Her skin is pigmented and there is vitiligo. Her blood pressure is low and there is a postural drop. In this patient which one of the following are true

a)      Eosinopaenia is a feature

b)      The ESR is decreased

c)      Hyperglycaemia is a feature

d)      The heart size is small

e)      Hypokalaemia would occur

Answer:

d)

The patient has Addison’s disease. In this condition the heart size is small. The eosinophil count may be elevated, the ESR may be high, hypoglycaemia may be a feature, and hyperkalaemia would be a feature.

BOF: 37

A sixty-year-old man presents with a history of increased sweating. He also complains of headaches.

On examination the patient has large hands and the facial features are exaggerated with large nose, prominent jaw and thick lips.

In this patient which of the following may be used as a screening test

a)      Growth hormone level

b)      Glucose Tolerance Test

c)      Prolactin level

d)      Plasma Insulin-like Growth Factor levels

e)      Serum calcium

Answer:

d)

The patient has acromegaly. Plasma Insulin-like Growth Factor may be used as a screening test

BOF: 38

A fifty-five year old man is admitted with a history of fatigue, weight loss and jaundice. His alcohol intake is sixty units a week.

On examination he has clubbing, Dupuytren’s contracture, palmar erythema, flapping tremor, parotid enlargement, spider naevi, gynaecomastia, hepatosplenomegaly.

Which of the following signs is indicative of a poor prognosis:

a)      Clubbing

b)      Parotid Enlargement

c)      Gynaecomastia

d)      Flapping Tremor

e)      Splenomegaly

Answer:

d)

The patient has alcoholic liver disease with clinical evidence of cirrhosis. The features of a poor prognosis are hepatic encephalopathy, low serum albumin concentration, and low serum sodium and prolonged prothrombin time.

BOF: 39

A sixty-year-old man who is known to have ischaemic heart disease is admitted with a history of sudden onset abdominal pain, followed by watery diarrhoea and subsequent profuse rectal bleeding.

The likely diagnosis is

a)      Small bowel infarction

b)      Large bowel infarction

c)      Volvulus of the sigmoid colon

d)      Colon cancer with intussusception

e)      Ulcerative colitis

Answer:

b)

The history of pain flowed by diarrhoea and bleeding per rectum in a patient with known macro vascular disease is typical of large bowel infarction, which occurs in the region of the splenic flexure.

 BOF: 40

A thirty five year old female has had a right hemicolectomy and resection of 30 cms of terminal ileum for ileocaecal Crohn’s disease. She has persistent diarrhoea, which is not explosive. She does not have abdominal pain, bloating, or loss of weight. Investigations have failed to demonstrate evidence of recurrent Crohn’s disease.

Treatment that would relieve symptoms and give a clue to the underlying diagnosis would be:

a)      Loperamide

b)      Steroids

c)      Cyclical antibiotics

d)      Cholestyramine

e)      Tricyclic antidepressants

Answer:

d)

The patient has had resection of the terminal ileum and the cause of the diarrhoea is likely to be Bile Acid Malabsorption (BAM). Treatment with a Bile Acid Sequestrants such as Cholestyramine would relieve symptoms and point to the diagnosis.