GCUH RACP MOCK EXAM 2016/17

1. Which of the following is TRUE regarding oral factor Xa inhibitors used in treatment of non-valvular atrial fibrillation compared to warfarin:

a. They are more efficacious than warfarin in preventing thromboembolic complications with similar risk of intracerebral haemorrhage.

b. They are more efficacious than warfarin in preventing thromboembolic complications with lower risk of intracerebral haemorrhage.

c. They are as efficacious as warfarin in preventing thromboembolic complications with lower risk of intracerebral haemorrhage.

d. They have the same risk of intracerebral haemorrhage but do not require regular INR monitoring.

e. They are more efficacious than warfarin in preventing thromboembolic complications at the expense of increased risk of intracerebral haemorrhage.

2. Which diabetes medication has been shown to reduce cardiovascular events and improve survival in a cardiovascular outcome study?

a. Exenatideb. Empagliflozinc. Liraglutided. Gliclazidee. Sitagliptin

3. Which of the following would be the strongest indication to initiate germline genetic testing for Lynch Syndrome

a. First degree relative with colorectal cancer under 50 yearsb. Multiple colonic polyposisc. Colorectal tumour demonstrating microsatellite instability (MSI)d. Loss of staining for the MLH1 and PMSH2 proteins on tumour

immunohistochemistry (IHC)e. Loss of staining for the MSH2 and MSH6 proteins on tumour

immunohistochemistry

4. A 45-year-old woman has been found to have recurrent C. difficile infection. She is quite symptomatic with 12 loose stools daily, crampy abdominal pain and low-grade fevers. She has previously trialled a course of metronidazole and vancomycin. The next course of treatment being considered is a faecal transplant (donor not autologous). What is the likelihood of cure with this course of treatment?

a. 5%b. 10%c. 35%d. >75%e. 50%

5. A renal transplant recipient wishes to become pregnant. Which of these medications would you ensure the patient was not taking prior to conception?

a. Mycophenolate mofetilb. Prednisonec. Cyclosporine d. Tacrolimuse. Azathioprine

6. A 70 year old gentleman presents to the emergency department overnight with a 3 day history of severe diarrhoea. You are asked to admit him to the ‘twenty-four hour’ medical unit for intravenous rehydration. When you review him, he explains that he has metastatic melanoma and is currently receiving combination therapy with Ipilimumab (an anti-CTLA-4 antibody) and Nivolumab (an anti PD-1 antibody), having had his third dose only 3 days ago. He has no other medical history and takes no other medications, though he has just been given 2 tablets of loperamide. He is passing approximately 10 loose motions per day, the last several having scant blood. He is unsure if he has had any fevers, though his emergency observations have documented a temperature of 38.1 Celsius. Clinically he is dehydrated, with a pulse rate of 110 beats per minute and a blood pressure of 100/75mmHg. His biochemistry is pending, but his full blood examination is unremarkable, with a normal neutrophil count.

What is the most appropriate course of management for this gentleman?

a. Admission, intravenous fluids and low dose oral prednisoneb. Admission, intravenous fluids and intravenous broad-spectrum

antibioticsc. Admission and intravenous fluids with anti-diarrhoeal agents (e.g.

loperamide)d. Admission, intravenous fluids and high dose intravenous

corticosteroidse. Admission, intravenous fluids and infliximab

7. A test has a sensitivity of 95% and a specificity of 90%. It is used to screen the general population for a rare condition that has a prevalence of 1 in 100,000. What will the positive predictive value be nearest to?

a. 0.01%. b. 0.05%. c. 0.1%. d. 0.5%. e. 1%.

8. A 39 year old female presents with myalgia and weight loss. She has chronic cough and haemoptysis. She has also noticed a rash. On examination there is evidence of palpable purpura. ANCA PR3 and ANCA MPO are positive and an eosinophil count is normal. What is the most likely diagnosis?

a. Microscopic polyangiitisb. Granulomatosis with polyangiitis (GPA)c. Churg-Strauss syndromed. Goodpastures Syndromee. Polyarteritis Nodosa

9. Omalizumab is a recombinant monoclonal antibody against: a. Interleukin-4 b. Interleukin-13c. Mast cell tyrosine kinase d. Leukotriene A4hydroxylasee. IgE

10.Which of the following statements regarding von willebrand disease is correct?

a. types 1 and 3 are characterised by a quantitative abnormality in von willebrand factor

b. laboratory testing for vWF: Ag results in a clear distinction between normal individuals and patients with type 1 vWD

c. Plasma vWF: Ag levels are not affected by inflammation or infectiond. vWF is synthesised primarily by the livere. patients with most forms of vWD present with soft tissue and joint bleeding

11. A patient sustains an acute complete transection of the left optic nerve without any other damage.  What findings are present when you examine the patient’s pupils at rest in ambient light?

a. The left pupil is larger than the rightb. The left pupil is smaller than the rightc. The pupils are equal in sized. The left pupil is irregular in shapee. None of the above are correct

12. A 36year old woman presents with a 4 week history of anxiety, poor sleep, and sore eyes. She is a first time mother with a 7 month old daughter. Examination reveals HR 110 beats per minute, BP 120/70mmHg, tremor, lid retraction and mild exophthalmos. She has a small, smooth, non-tender goitre. Blood tests show TSH <0.05mU/L (0.4-5.0), T4 35pmol (8-25), FT3 20pmol/L (4-9.) What is the most likely diagnosis?

a. Panic attacksb. post partum-thyroiditisc. Hashimotos diseased. Graves diseasee. Toxic multinodular goitre

13. A 29-year-old woman was brought to hospital by ambulance. She had been found unconscious by her husband with imipramine tablets by her bed. On arrival in the emergency department she had a tonic–clonic seizure, which lasted for 2 minutes. She was otherwise fit and well.

Investigations

What is the most appropriate immediate treatment?

a. Amiodaroneb. DC cardioversionc. Lorazepamd. Phenytoine. Sodium Bicarbonate

14. A 45 year old male presents with RUQ pain and Jaundice. He is afebrile. He appears to be confused and is noted to have a hepatic flap. The patients history is unreliable and this appears to be his first presentation to the health service. His BP is 110/76mmHg, HR 101 beats per minute, oxygen saturations 98% RA. His chest is clear. He has no neck stiffness, rash and is not complaining of a headache.

Investigations are as follows:

Hb 111 (120-180)WCC 18 (3.5-11)Neut 16 (2-8)Bilirubin 120umol/L (<20)Albumin 30g/L (35-50)Prothrombin time 22 (12-15)INR 1.8 (0.0-1.2)AST 170 (<45)ALT 95 (<35)GGT 800 (<55)LDH 380 (120-250)Lipase 160

Hepatitis B & C serology negative

Urine <10 <10 <10

An abdominal USS was performed which showed a contracted gallbladder with trace pericholecystic fluid a bile duct diameter of 5mm. No stone or obvious mass was visualised. There was trace ascities. The portal vein is patent.

Beyond supportive therapy. Which additional treatment would be warranted in this patient?

a. Ceftriaxoneb. NACc. ERCPd. Prednisolonee. Cholecystectomy

15. The major benefit of treating patients with chronic kidney disease with erythropoietin stimulating agents is to

a. Reduce their cardiovascular riskb. Improve their cardiorespiratory function pre-transplantc. Reduce the amount of intravenous iron supplementation requiredd. Improve symptoms of anaemiae. There is no benefit to the use of these agents

16. 62 year old man presents for evaluation of exertional dyspnoea, NYHA classification class III. He has a background history of diabetes mellitus, hypertension and dyslipidaemia. He is currently on Perindopril, amlodipine, atorvastatin, metformin and basal bolus insulin. His transthoracic echo shows an ejection fraction of 40%, and moderate aortic stenosis with mean transaortic gradient of 30mmhg and transvalvular velocity of 3.1 m/sec. His coronary angiogram shows right dominant coronary circulation, 80% proximal LAD stenosis, 70 % mid RCA stenosis, and no significant stenosis of the left circumflex artery. What is the most appropriate management of this patient:

a. Percutaneous intervention of proximal LAD.b. Percutaneous intervention of LAD and RCA.c. Coronary artery bypass grafting of both vessels and aortic valve

replacement.d. Percutaneous intervention of both vessel and yearly monitoring of

aortic stenosise. Percutaneous intervention of both vessels and assessment for

transcatheter aortic valve replacement.

17.Which sign is not as helpful to differentiate between simple obesity and cushings syndrome?

a. Thin skinb. Proximal myopathyc. Buffalo humpd. Bruisinge. Supraclavicular fat pads

18.A 43-year-old man was admitted with a 4-day history of progressive leg weakness and poorly localised lower back pain. On examination, he had reduced tone in both lower limbs, with grade 4 power of flexion and extension of hips and knees bilaterally, and grade 3 power of foot dorsiflexion and plantar flexion bilaterally. His deep tendon reflexes in the lower limbs were absent, and the plantar responses were flexor. There was loss of all modalities of sensation in both feet in a stocking distribution. Examination of the upper limbs was normal. What respiratory function variable is it most important to measure regularly?

a. Forced expiratory volume in 1sb. Oxygen saturationc. Peak expiratory flowd. Respiratory ratee. Vital capacity

19.A 60-year-old woman was admitted with deterioration in her renal function. She had a history of type 2 diabetes mellitus, hypertension and chronic kidney disease stage 3a, with an estimated glomerular filtration rate (MDRD) of 45–60 mL/min/1.73 m2 (>60). She was taking perindopril for hypertension, and had recently started taking celecoxib for osteoarthritis. What best describes the mechanism of her celecoxib-induced deterioration in renal function?

a. Hypersensitivity reactionb. Inhibition of afferent arteriole vasodilationc. Interstitial nephritisd. Renal parenchymal infarctione. Renal tubular acidosis

20.A 49-year-old woman presents with 3 weeks of gradually progressive dysarthria, unsteadiness, and frequent falls. On examination she is found to have prominent nystagmus in all directions, with marked dysarthria. She also has truncal ataxia and dysmetria, which is more prominent in the upper than lower extremities. The patient has also been losing weight for the past 4 months. An MRI shows diffuse cerebellar atrophy, but no evidence of intracranial mass. Complete workup detects a pelvic mass originating in the ovary. Which of the following is correct regarding this condition?

a. A leptomeningieal biopsy will certainly demonstrate an infiltrative neoplasm

b. CSF cytology and flow cytology are very specific for the diagnosis of the condition

c. Anti-Tr antibodies are most likely to be positive in this patientd. It will improve with administration of hydrochlorothiazidee. Anti-Yo antibodies are likely to be positive in this patient

21.Which of the following is an indication for treatment in patients with chronic lymphocytic leukaemia?

a. Platelet count of 50 (140-400)b. Age < 60 yearsc. 17p deletion on FISH on bone marrow biopsyd. 3 lymph node masses > 3cm in maximum diametere. Peripheral blood lymphocyte count of 150 x 10’9L

22.Which one of the following statements concerning nausea while taking opioids is true:

a. Nausea to opioids is due to bowel distention and stimulation of the vagus nerve

b. Nausea to opioids is due to decreased bowel motility c. Nausea to opioids is usually accompanied with itching d. Nausea to opioids represents a drug allergy e. Nausea to opioids resolves in most patients within 7 days

23.Please review the pulmonary function test results below of a 75 year old gentleman who presents to your outpatient clinic with dyspnoea. He has been using a ventolin (salbutamol) puffer intermittently.

Which of the following tests would you perform next to assist in determining the cause of this patient’s dyspnoea?

a. CXRb. CT Chestc. Body mass indexd. Bronchodilator reversibility teste. V/Q Scan

24.A 56-year-old man presents with difficulty moving both hands for 6 months. He denies pain or swelling in any of his joints, and has no numbness or tingling in his hands. His hands do feel weak. He has a long history of hypertension, hyperlipidaemia, and type 2 diabetes mellitus, with more recent coronary artery disease and early chronic kidney disease. His physical examination is notable for difficulty flattening his hands against the surface of a table. No joint tenderness, redness, warmth, or swelling are noted. No thickening or nodulosis of the palmar fascia is palpable. His most recent HbA1c level is 8.2% (4.0–6.1). Which of the following is the most likely cause of his problem?

a. Carpal tunnel syndromeb. Complex regional pain syndromec. Diabetic chieroarthropathyd. Dupuytren’s Contracture

25. If the pre-test probability of a condition is known, which of the following is also needed to be able to estimate the post-test probability?

a. Sensitivity b. Specificity c. Accuracy d. Likelihood ratio e. Odds ratio

26.A 58 year old male was diagnosed with multiple myeloma. He was previously well with no medical history. He is worked up for autologous haematopoietic stem cell transplant, with melphalan conditioning. What is the most appropriate anti-fungal prophylaxis?

a. Posaconazoleb. Voriconazolec. No anti-fungal prophylaxisd. Fluconazolee. Liposomal amphotericin

27.Which of the following statements about chemotherapy is true?

a. Most chemotherapeutic agents produce neutropenia approximately two weeks after they are delivered

b. Chemotherapy cannot be delivered orallyc. Most chemotherapeutic agents are contraindicated in patients with

Chronic Kidney Disease Stage III or worsed. In most cases, chemotherapy should not be offered to patients over the

age of 70 yearse. Some side effects of chemotherapy can appear years after it is

delivered

28.Which of the following renal conditions are associated with the thrombospondin type-1 domain containing 7a antigen?

a. Membranous nephropathyb. Minimal change diseasec. Focal segmental glomerulosclerosisd. ANCA-associated vasculitise. Goodpasture’s Disease

29. 58 year old female presents with NYHA class IV dyspnoea. She underwent right and left heart catheterization for assessment. Cardiac catheterization results are: right atrial pressure 19 mmHg, RV end diastolic pressure is 21 mmHg, LV end diastolic pressure 23 mmHg, mean pulmonary artery pressure is 32 mmHg. There is discordance of LV and RV pressures on deep inspiration with systolic area index of 1.6. The most probable cause for the patient symptoms is:

a. Ischemic heart diseaseb. Infiltrative cardiomyopathy. c. Pulmonary hypertension. d. Previous radiotherapy to the chest.e. Anxiety

30.Once digoxin is started for the management of heart failure, when is the most appropriate time to measure its steady state concentration?

a. 12hb. 24hc. 2 daysd. 1 weeke. 2 weeks

31.70yr female presented with fatigue and atrial fibrillation. Her AF reverts spontaneously in ED. Her thyroid function is as stated: TSH <0.05mU/L (0.3-4.5), free T4 20pmol/L (7-17), free T3 8pmol/L (3.5-6). What is the most likely cause?

a. Graves diseaseb. Subacute thyroiditisc. Toxic multinodular goitred. Pituitary tumoure. Sick euthyroid

32.Prader-Willi syndrome is most commonly caused by which of the following mechanisms

a. Maternally derived deletion of 15q11b. Paternally derived deletion of 15q11c. Paternal uniparental disomy of Chromosome 15d. Mutations in the UBE3A genee. Imprinting defects

33.An 84-year-old man is admitted with melaena for the past 3 days and symptomatic anaemia. He has a mechanical heart valve and is on warfarin with an INR of 2.6 (0.9-1.2). He is also taking aspirin for secondary prophylaxis due to previous myocardial infarction. An upper endoscopy is performed and he is found to have 3 small and non-bleeding gastric ulcers. A proton pump inhibitor is added to his medication regimen. Which of the following is true?

a. Aspirin cannot be continued in this patient due to risk of future bleeding.

b. The risk of bleeding by continuing aspirin is worse than that of warfarin.c. The benefit of adding a PPI is more prominent with aspirin compared to

warfarin.d. Addition of a PPI will not alter the risk of bleeding in the future.

34.A thirty-five year old lady presents to the emergency department via ambulance. She reported to her partner prior to presenting to hospital self-administering paracetamol 16g, temazepam 100mg and diazepam 40mg four hours previous to presentation.

She has a history of depression and her supplied medication list includes:Citalopram 40mg dailyDiazepam 5-10mg tdsTemazepam 10mg nocte prn

She appears sedated with a GCS 5. Her blood pressure is 120/85mmHg, pulse rate 90 beats per minute and regular, respiratory rate 7, oxygen saturations 94% on room air. She is afebrile and has no localising signs of infection.

Which of the following interventions is LEAST appropriate at this stage:

a. Intubation and ventilationb. ECG to assess QT intervalc. Flumazenil 0.1-0.2mg IVd. Paracetamol concentration measuremente. Blood gas measurement

35.A 74-year-old man was referred to the outpatient clinic. He had fallen twice, and thought he had tripped over the carpet on both occasions. His wife reported that he had become quite anxious, especially when he had met with difficulty in completing their tax return. He had seemed more withdrawn than usual.

On examination, his mini-mental state examination score was 27/30. Examination of the limbs revealed normal tone, power grade 5/5, brisk lower limb reflexes, and an equivocal left plantar response.

MRI (T2 and FLAIR) images are shown below.

What is the most likely diagnosis?

a. Alzheimer’s disease b. Frontotemporal dementia c. Lewy body dementia d. Normal pressure hydrocephalus e. Vascular dementia

36.A Broca's (non-fluent, expressive) aphasia is characterized by all of the following except which?

a. Intact comprehension of speechb. Loss verbal output of speechc. A lesion in the posterior part of the (usually) left inferior frontal gyrusd. Damage to the inferior parietal lobulee. The patient being intensely frustrated

37.A 64 year old man with no significant past medical history attends pre-operative clinic and has screening blood tests done. A routine pre-surgical coagulation profile is displayed below.

PT 12 (normal range) INR 1.1 (0.9-1.2)APTT 85 (30-60) APTT (50% mix normal plasma) 77

The most appropriate next investigation to order is:

a. D Dimer b. Echis timec. A Bethesda assayd. Factor 8 concentrationse. Lupus anticoagulant

38.A patient has severe pain from locally advanced pancreatic cancer. The pain is eventually well controlled on 80mg/day of subcutaneous morphine infusion in hospital. It is intended to discharge the patient on oral controlled-release oxycodone. Which of the following is the equivalent dose?

a. Oxycodone CR 80mg BD b. Oxycodone CR 160mg BD c. Oxycodone CR 40mg BD d. Oxycodone CR 60mg BD e. Oxycodone CR 120mg BD

39.70 year old male with Parkinson disease and psychosis develops a psychotic episode in the ward. Which would be the most appropriate treatment to prevent further episodes?

a. Risperidoneb. Quetiapine c. Haloperidol d. Midazolam e. Diazepam

40.All of the following can increase the p50 (shift the oxygen-haemoglobin dissociation curve to the right) except?

a. Stored red blood cellsb. Hypoventilationc. Diabetic ketoacidosisd. Low affinity haemoglobin variante. Hyperthermia

41. In rheumatology, serology can be useful for the diagnosis and in some cases monitoring of disease activity. Which of the following auto-antibodies has a role in monitoring disease activity?

a. Anti-citrullinated peptide antibodies and rheumatoid arthritisb. Anti-double stranded DNA and SLEc. Anti-Jo antibodies and Anti-Synthetase Syndromed. Anti-Ro (SSA) in Sjogren’s Syndromee. Anti-SRP antibodies and myositis

42.Which of the following statements is INCORRECT?

a. A large sample will decrease the chance of type I error b. The power of a trial refers to the probability of correctly rejecting the

null hypothesis c. When comparing two samples, the null hypothesis states that the

population means from which the samples are drawn are not significantly different

d. Data are more likely to be normally distributed if the sample is large e. A type II error is failure to reject the null hypothesis when it is false

43.Which of the following is false regarding initiation of anti-retroviral therapy (ART) for HIV?

a. ART should be commenced when a patient’s CD4 count has declined to 350 cells per cubic millimetre.

b. A patient presenting with Pneumocystis jiroveci pneumonia and a CD4 count of 450 should be commenced on ART.

c. ART should be offered to a patient presenting with sero-conversion illness.

d. Efavirenz is no longer first-line treatment for HIV due to higher rates of CNS complications.

e. Two nucleoside reverse transcriptase inhibitors remains the most commonly used backbone for ART.

44.Which of the following statements about the immunotherapy agent, Pembrolizumab, is true?

a. Pembrolizumab blocks PD-1 (Programmed Cell Death 1 Receptor) located on T-lymphocytes

b. Pembrolizumab blocks PD-1 (Programmed Cell Death 1 Receptor) located on tumour cells

c. Pembrolizumab blocks PD-L1 (Programmed Death Ligand 1) located on T-lymphocytes

d. Pembrolizumab blocks PD-L1 (Programmed Death Ligand 1) located on tumour cells

e. Pembrolizumab activates PD-L1 (Programmed Death Ligand 1) located on tumour cells

45.A 85-year old lady is brought to the emergency department after having a syncopal episode at home. She is confused and unable to give a coherent history however she is adamant that she took “all her blood pressure pills” that morning. Her blood tests reveal serum sodium of 118 and a calculated serum osmolality that is low at 240. Urinary tests taken at the same show reveal that her urinary sodium is low at <10 with a high urinary osmolality of 350. What is the most likely cause of this patient’s hyponatraemia?

a. Thiazide diureticsb. SIADHc. Hypovolaemiad. Pseudohyponatraemiae. Primary polydipsia

46.Which of the following is least likely to occur when a T cell undergoes stimulation by an antigen without co-stimulation of CD28?

a. Proliferation of that T cell cloneb. Low level production of Th1 cell cytokinesc. Low level production of Th2 cell cytokinesd. Anergye. Apoptosis

47. 84-year-old female presents with chest pain. Her ECG shows inferior T wave inversion and troponin is elevated. Background history of hypertension, osteoarthritis, CKD, peripheral vascular disease and chronic airway disease. After discussion with her cardiologist, a non-invasive approach was decided on. Which of the following medications is not associated with a mortality benefit.

a. Aspirinb. Heparinc. Clopidogreld. Perindoprile. Atorvastatin

48.After a single dose, the area under the plasma concentration versus time curve (AUC) for a drug given orally is 300mgh/L. If given intravenously in a single dose, it is 500mgh/L. Which one of the following statements is true?

a. The oral bioavailability of the drug is 1.6b. 60mg of the drug given orally is equivalent to 100mg of the drug given

intravenously.c. 100mg of the drug given orally is equivalent to 60mg of the drug given

intravenously.d. The AUC for the drug given subcutaneously will be less than 300mgh/Le. None of the above.

49.30yr male with large space occupying lesion within the pituitary fossa with surrounding vasogenic oedema. He is commenced on dexamethasone 4mg TDS at presentation. Routine blood tests 7 days into admission show a Na+ 115mmol/L (135-145), osmolality 250mmol/L (275-295). His paired urine Na+ 30mmol/L and urine osmolality 600mmol/kg. Cortisol is found to be suppressed at <10nmol/L with normal thyroid function. He is clinically euvolemic and appears asymptomatic. What management will you institute to treat his hyponatraemia

a. Replace cortisol b. Fluid restrict c. Hypertonic salined. Salt tabletse. 1L normal saline over 24hr

50.Sheila and Alf are planning to have a child, but are concerned about having a child with spinal muscular atrophy. Sheila had a son with a previous partner that died from SMA. Alf has no family history of SMA. The carrier frequency of SMA in the general population is 1 in 50.

What is the risk to the couple of having a child affected with SMA?

a. ¼b. 1/50c. 1/100d. 1/200e. 1/300

51.Which of the following is the most appropriate use of TNF inhibitors in the treatment of inflammatory bowel disease

a. Perianal abscess with active Crohn’s disease proctitisb. Severe oral ulceration in a patient with Crohn’s diseasec. Discharging rectovaginal fistula due to refractory Crohns diseased. Relapsing ulcerative pancolitis requiring long term oral steroidse. Initial treatment of fulminant ulcerative colitis

52.Which of these anticonvulsant medications is likely to require maintenance dose increases during pregnancy?

a. Phenytoin due to changes in protein binding b. Valproate due to changes in protein bindingc. Lamotrigine due to changes in clearanced. Valproate due to changes in clearancee. Levetiracetam due to changes in volume of distribution

53.A 32-year-old man presented with a 3-week history of headaches, fever, sore throat, myalgia, anorexia and generalised non-pruritic rash. He had no other significant medical history and had not previously been given a blood transfusion.

On examination, vital signs were normal except for a temperature of 37.4°C. Enlarged non-tender lymph nodes were noted in the axillae, submandibular areas and both groins. Throat examination was normal. He had no meningeal signs and detailed cardiorespiratory, abdominal and neurological examinations were normal. Generalised maculopapular rash was noted.

Investigations:heterophil antibody test

negative

   

blood filmatypical lymphocytosis

What is the most likely diagnosis?a. Cytomegalovirus infectionb. Group A streptococcus infectionc. HIV seroconversiond. Secondary syphilis e. Toxoplasmosis

54.A lesion of the right (non-dominant) inferior parietal lobule could result in the following signs and symptoms:

a. Inability to recognise the left arm as belonging to him/her (asomatognosia)

b. Denial of illnessc. Homonymous left inferior quadrantopsia d. All of the above are correcte. Only a and c are correct

55.Which of the following statements regarding iron homeostasis is correct?

a. hepicidin production is not influenced by inflammationb. increases in dietary iron intake suppress hepcidin production c. most iron in food is ferrous (Fe2+) and is taken up by the intestinal

transporter DMT1d. hepcidin deficiency is feature of hereditary haemochromatosise. ferroportin mutations are not associated with disease in humans

56.Mrs JK is a 49 year old lady with asthma who presents with increasing dyspnoea, wheeze and a productive cough. Her current pulmonary function tests are shown below in addition to other investigations. She has been non-adherent to inhaler medication. She has no other significant medical issues.

Full blood count:Hb 118WCC 13.0

Neut 6.63 (51%)Lymph 2.34 (11%)Eosin 2.47 (19%)

Sputum MCS – normal respiratory flora, candida albicansSerum IgE 3390Aspergillus precipitins positiveCXR is unremarkable. There is evidence of mucus plugging on her chest CT.

Which of the following medications would be most appropriate in her treatment?

a. Fluconazoleb. Omalizumabc. Prednisoloned. Amoxycilline. An inhaled corticosteroid and long acting beta agonist

57.Which of the following combination of results would be most consistent with a diagnosis of scleroderma associated pulmonary arterial hypertension?

a. Anti-centromere antibodies, mPAP 30, PCWP 10, normal spirometryb. Anti-centromere antibodies, mPAP 40, PCWP 20, normal spirometryc. Anti-centromere antibodies, mPAP 22, PCWP 6, normal spirometryd. Anti-SCL70 antibodies, mPAP 30, PCWP 10, restrictive spirometry

e. Anti-SCL70 antibodies, mPAP 40, PCWP 25, normal spirometry

58.A 37-year-old male is seen for a sudden onset of pain and swelling in his great toe. Aspiration of the joint reveals a small amount of fluid with multiple monosodium urate crystals. The serum uric acid level is 9.2 mg/dL (reference range: 3.0–7.0 mg/dL), and renal function is normal. He is otherwise healthy and taking no medications. He notes that his father and grandfather have had gout. Genetic factors regulating which of the following processes are most likely contributing to hyperuricemia and gout in this patient?

a. Excessive cell death and cell turnoverb. Glomerular filtration of uric acidc. Purine metabolismd. Renal tubular handling of uric acide. None of the above

59.A 60yo man presents to the Emergency department with a two day history of fever, headache, malaise and a diffuse, maculopapular rash. He returned to Australia yesterday after having been travelling for work (a nurse for a relief agency) for the past two months- Sierra Leone 2 months ago, Middle East 4 weeks ago and the last two weeks in Papua New Guinea. Which of the following investigations are not indicated?

a. Malaria thick and thin filmb. Dengue virus serologyc. Ebola virus PCR d. Dengue virus NS1 e. Zika virus PCR

60.Which of the following is not a common side effect of immunotherapy agents (such as Pembrolizumab and ipilimumab)?

a. Hypothyroidismb. Hyperthyroidismc. Pneumonitisd. Cytopaeniase. Rash

61.A patient is referred to renal outpatients with rapidly worsening renal function over the past few weeks. Her most recent creatinine is 560, it had been normal 3 months ago. She is otherwise well however has been treated with multiple courses of antibiotics over the past year for presumed chest infections. Urine microscopy reveals microscopic haematuria. A kidney biopsy shows crescentic glomerulonephritis with no immune deposits seen on immunofluorescence. What is the most likely cause of this patient’s presentation?

a. Membranoproliferative glomerulonephritisb. IGA nephropathyc. Lupusd. Cryoglobulinaemiae. ANCA-associated vasculitis

62.Which of the following immunoglobulin classes is transferred across the human placenta?

a. IgAb. IgGc. IgEd. IgMe. IgG and IgA

63.52 year old female presents for evaluation of pulmonary hypertension. She underwent right heart catheterization. The results are: RA pressure is 16 mmHg, mean pulmonary artery pressure is 58 mmHg, pulmonary vascular resistance is 10 woods units, PCWP is 32 mmHg, and cardiac index is 1.8 L/min/m2. What is the most appropriate next step of treatment for this patient?

a. Treat left side heart failure.b. Start sildenafil.c. Start sildenafil and ambrisentan combination.d. Start diltiazem.e. Referral for psychiatric evaluation

64.The plasma concentration of a drug at steady state is mostly determined by the drug’s:

a. Volume of distribution (VD). b. Clearance (CL). c. Elimination rate constant (kel). d. Extent of protein binding. e. Elimination half-life (t½).

65.50yr male admitted electively for hernia repair. He is fasted pre-operatively, with 125mL/hr normal saline maintenance fluids. He frequently goes to the bathroom to pass urine. He becomes thirsty and hypernatremic, Na+ 146mmol/L (135-145). He is also found to be incidentally hypercalcaemic corrected calcium 2.65mmol/L (2.1-2.6), which medication is most likely to be responsible?

a. Aripiprazoleb. Lithiumc. Carbamazepined. Hydrochlorothiazidee. Frusemide

66.Which of the following hormone is most likely to increase food intake?

a. Adiponectinb. Ghrelinc. GLP 1d. Leptine. Peptide YY

67.Symptoms of Parkinson’s disease include all of the following except:

a. Symmetric tremor involves hands and headb. Axial and limb rigidityc. Bradykinesiad. Gait instability and postural dizzinesse. Cognitive impairment

68.A 48 year old male is diagnosed with moderate OSA with an Apnoea Hypopnoea index (AHI) of 27/hour and an Epworth Sleepiness Scale (ESS) of 19/24. He is commenced on treatment with CPAP at pressure 8cmH2O. He is reviewed 6 weeks later with the following download data

Usage days >/= 4 hours 30/30 days (100%) < 4 hours 0/30

Usage hours 220 Hours 19minsAverage usage 7 hours 21 mins

TherapyLeaks l/min Median 0.1 nax 6.1Events/hour AI 0.7 HI 0.1 AHI: 1.4Apnoea index: Central 0.4 Obstructive 0.3Cheyne- Stokes Respiration 0mins

He is still complaining of excessive daytime sleepiness with ESS 18/24. Which of the following is an appropriate course of action

a. Change to auto-PAP device and reassessb. Change to Bi-level device and reassessc. Commence treatment with dexamphetamined. Perform multiple sleep latency teste. Refer to psychiatrist for evaluation of depression

69.A 40 year old woman presents with fevers, severe abdominal pain and palpable purpuric lesions on her lower limbs. A CT abdomen demonstrates micro-aneurysms of the mesenteric arteries with necrosis and perforation of the small bowel and is she is taken to theatre. Histology reports a transmural inflammation of the mesenteric arterial wall in keeping with vasculitis. Urinalysis is negative for protein or blood and CXR is normal. 

CRP: 100 ESR: 45 ANA: 1:160 ANCA: negative 

What is the most likely diagnosis? 

a. Wegener’s granulomatosis b. Systemic Lupus Erythematosus c. Polyarteritis Nodosa d. Giant Cell Arteritis e. Microscopic Polyangiitis 

70.With regard to Zika Virus Disease:

a. Transmission occurs primarily through the bite of an infected Anopheles mosquito

b. The WHO recommends that men returning from areas where transmission of Zika virus is known to occur should wait at least 6 months before having condomless sex

c. Mortality in pregnant women is reported at approximately 4%d. It is caused by an alpha virus similar to Ross River Fever and

Chikungunya virusese. The risk of transmission to the unborn foetus is reduced through the

early administration of Normal Human Immunoglobulin (NHIG)

71.Jane is a 17year old woman that has just started her accelerated bachelor of science and is intending to enter medical school. She presents to the emergency department clinically well, but with colonoscopy and pathology reports that describes a small benign polyp that was snared from her descending colon. Jane is concerned that she has a familial syndrome that increases her risk of colon cancer. She tells you that a paternal cousin was diagnosed with colon cancer at the age of 27, as was his father at the age of 35. Her father was diagnosed with gastric cancer at the age of 55.

Which of the following statements about Jane is correct?

a. Jane likely has a familial syndrome and would benefit from referral to a medical oncologist for chemoprophylaxis

b. Jane likely has a familial syndrome but given she has had a normal colonoscopy she requires only routine follow-up.

c. Jane may have Lynch Syndrome (Hereditary Non-polyposis Colorectal Cancer) and should be referred to a clinical geneticist and begin colonoscopic screening earlier than the rest of the population

d. Jane may have Familial Adenomatous Polyposis Coli and should be referred to a clinical geneticist and have a prophylactic colectomy

e. Jane is unlikely to have a familial syndrome based on her history and colonoscopy report

72. In patients with unilateral renal artery stenosis which of the following is an indication for revascularization (as opposed to purely medical therapy)

a. Hypokalaemiab. Recurrent pulmonary oedemac. Metabolic alkalosisd. Severe hypertensione. Serum creatinine above 200

73.HLA-DR antigens are:

a. Present on the surface of all nucleated cellsb. Examples of class I antigens of MHC complexc. Expressed on T cellsd. Expressed on B cellse. Associated with β2-microglobulin on cell surface

74.20yr female on the combined oral contraceptive pill, presents with amenorrhoea for 3 months. Prolactin is found to be elevated at 2000 mU/L (<550). What should you test for next?

a. Prolactinomab. Pregnancyc. Macroprolactind. Marijuanae. GH and IGF-1

75.The following is true about alphafetoprotein except:

a. it can be elevated in pregnancyb. it can be elevated in gastric cancersc. it correlates well with size and staging of hepatocellular carcinoma d. it can be elevated in cirrhosis without HCCe. it is a good prognostic marker for follow up of hepatocellular carcinoma

76.A 21-year-old woman presents with multiple abnormal movements, including a moderate frequency rest and postural tremor and a twisting and in-turning of her right foot. Her history was also significant for depression with suicide attempt and significant anxiety. Her MRI is shown below. Laboratory tests show elevated liver enzymes. Which of the following statements is correct regarding the disorder depicted below?

a. It is autosomal dominant in inheritanceb. It results from a mutation in the gene encoding for the copper-binding

protein ceruloplasminc. Treatment include copper supplementationd. Treatment includes low zinc diete. Treatment includes low copper diet

77.Mr Smith is a 75 year old male ex-smoker. He presents to your clinic with dyspnoea. He has no history of occupational dust exposure. Autoimmune screening is negative. Chest auscultation reveals fine inspiratory crackles at the bases of both lung fields. His CT scan is shown below?

You decide to commence Mr Smith on nintedanib. You will advise Mr Smith of all of the following except?

a. The drug will reduce the rate of decline in FVCb. The most common side effect is diarrhoeac. The drug will result in a progressive improvement in FEV1d. The drug may reduce the risk of acute exacerbationse. The drug will not reverse the fibrosis

78.A 60 year old lady is evaluated for a 1 month history of fatigue and dyspnoea. She has a 10 year history of Raynaud’s phenomenon and severe gastro-oesophageal reflux for which she takes Pantoprazole 40mg daily

Bloods:ANA 1:320Anti-Centromere antibody positiveLung function tests reveal: FVC: 84% predicted DLCO: 44% predicted HRCT is shown below. 

 Which of the following is the most likely diagnosis: 

a. Interstitial lung disease b. Pulmonary hypertension c. Atypical pneumonia d. Left ventricular failure e. Pneumocystis infection

79.79yo man has been admitted for mild infective exacerbation of COPD and assessment for residential placement due to cognitive deterioration. He initially was treated with Augmentin by his GP before being referred to hospital as he was not coping at home. He has been commenced on intravenous pipercillin/tazobactam (Piptaz) and doxycycline. On day three of admission he develops profuse watery diarrhea, tachycardia, abdominal pain, raised WCC and impaired renal function. Faecal Clostridium difficile screen and toxin test return positive. Management includes:-

a. Start patient on oral Metronidazole and cease Piptaz.b. Commence patient on IV Metronidazole and oral vancomycin and

cease Piptaz.c. Commence patient on IV Metronidazole and oral vancomycin and

continue Piptaz.d. Commence patient on IV Vancomycin and continue Piptaz.e. Commence oral Vancomycin.

80.Chloe is a 70 year old woman who you are seeing in your general medical outpatients clinic for the first time. She had a mastectomy almost six years ago for a hormone-positive, early breast cancer, followed by adjuvant chemotherapy and then hormonal therapy with an aromatase inhibitor. Though she continued her yearly ultrasound and mammograms with her GP, she has not seen a specialist since she was first prescribed her aromatase inhibitor. Chloe is now complaining of pain in her back that has persisted after a particularly bumpy ride in a dune-buggy for her 70th birthday over one month ago. She is taking paracetamol to keep the pain under control, but is on no other medications (except for her aromatase inhibitor). Chloe is convinced it is due to her aromatase inhibitor, but she was told by her son-in-law, an oncology advanced trainee, that recent guidelines have recommended 10 years of aromatase inhibitor (rather than 5) following early breast cancer and so she feels as though she cannot stop. She had her last Bone Mineral Density scan done before starting her aromatase inhibitor; she does not know what the results were, but she remembers her oncologist shrugging at her after reading the report.

Your examination is unremarkable except for reproducible back pain in Chloe’s lumbosacral spine. There is no evidence of any locoregional disease recurrence. She denies any weight loss, change in appetite or pain elsewhere. She has not had any recent investigations.

How should Chloe be further investigated and counselled?

a. Chloe may have had an osteoporotic crush fracture in the setting of her aromatase inhibitor. She needs plain films of her lumbosacral spine, calcium and vitamin D studies, bone mineral density scan. She may require a bone scan subsequently if other investigations leave concern for malignancy. It is safe to discuss stopping the aromatase inhibitor and starting calcium/vitamin D replacement.

b. Chloe may have a pathological fracture either due to malignancy or osteoporosis. She needs an MRI of her spine, a bone mineral density scan and a baseline level of laboratory examinations. She should continue her aromatase inhibitor and start calcium and vitamin D.

c. Chloe likely has a malignant bony recurrence. She requires admission and imaging of her lumbosacral spine, with an aim to radiologically biopsy the affected area. She should continue her aromatase inhibitor until a diagnosis is made.

d. Chloe likely has a malignant bony recurrence. She needs a CT chest/abdomen/pelvis and possibly a biopsy depending on the distribution of her disease. She will likely need a change in her therapy.

e. Chloe likely has mechanical lower back pain from her buggy ride. She does not need further investigation at this stage however she should be followed up with her general practitioner closely. She should continue her aromatase inhibitor for the full 10 years, however if she has uncontrolled side effects she should return to discuss ceasing it.

81.Potential mechanisms for the benefit of oral bicarbonate therapy in patients with chronic kidney disease include each of the following except

a. Reducing the incidence and severity of hyperkalaemiab. Improving bone metabolismc. Improving nutritional status and muscle functiond. Reducing in the rate of progression of chronic kidney disease e. Reducing the patient’s serum phosphate

82.A defect in the RAG-1 or RAG-2 genes causes:

a. Hyper-IgM syndromeb. Common Variable Immunodeficiency (CVID)c. Severe Combined Immunodeficiency (SCID)d. Wiskott-Aldrich syndromee. X-linked agammaglobulinaemia

83.What of the following is true regarding hypertrophic cardiomyopathy:

a. The most common mode of inheritance is autosomal recessive.b. MYBPC3 mutation carries the worst prognosis.c. TNNI3 is the most common mutation.d. TNNT2 mutation is associated with sudden cardiac death without

significant septal hypertrophy.e. LAMP2 mutation is associated with late expression of hypertrophic

cardiomyopathy.

84.Which of the following medications used for hypertension can also be used for gout?

a. Losartan b. Hydrochlorothiazidec. Frusemided. Lisinoprile. Metoprolol

85.Which one of the following colonic polyps has the highest potential for malignant transformation?

a. Hyperplasticb. Tubularc. Villousd. Hamartomatouse. Peutz-Jegher

86.Which of the following is most likely to predict progression of osteoarthritis of the knee?

a. Low vitamin D levelb. Lower body mass indexc. Osteoarthritis in multiple jointsd. Regular running for exercisee. Younger age

87.45yo woman is brought in by Ambulance after collapsing at home. On arrival, paramedics found her to be febrile, hypotensive, hypoxic with a GCS of 11. In ED, the patient was in type 1 respiratory failure, GCS 11 and hypotensive. CXR showed extensive white out of bilateral lung fields. Her son gives the collateral history. She has no significant medical history except for uterine fibroids. She grew up in India and Thailand as a child and has recently returned to India to see her dying father. She returned three weeks ago. She complained of flu like symptoms approximately 10days ago and has been on a tablet by the GP but he is not sure which. She felt she was improving until approximately 36hrs ago. What should her initial antibiotic management be?

a. Benzylpenicillin and IV Azithromycinb. Ceftriaxone and IV Azithromycin. c. Ceftriaxone, Azithromycin and Vancomycind. Piptaz, Azithromycin and Vancomycine. Meropenem, Azithromycin and Vancomycin.

88.A previously fit 55 year old man is referred to the medical oncology clinic with a six week history of right upper quadrant and lower back pain, dry cough and six kilograms of weight loss. An ultrasound of his liver and biliary tree demonstrates innumerable hepatic hypodenisties throughout both lobes, up to 3cm in size. His extra-hepatic ducts and visualised pancreas and gallbladder are normal. Laboratory investigations reveal a normal renal function and full blood count, a PSA of 8ng/mL (<2ng/mL), a total bilirubin of 20μmol/L (<20μmol/L), normal ALP and GGT and AST and ALT less than 1.5x upper limit of normal. He has a 30 pack-year smoking history but does not drink any alcohol. Examination does not demonstrate any significant cardiorespiratory findings, but his liver edge is palpable and irregular and he has elicitable lower back pain without any firm neurological findings. Which of the following investigations would be most helpful in establishing a diagnosis?

a. A Positron Emission Tomography (PET) Scanb. Bronchoscopy and lavagec. Transrectal ultrasound and prostate biopsyd. Liver biopsye. Computerised Tomography (CT) Scan of the Chest, Abdomen and

Pelvis

89.A 45-year old female presented to the emergency department with a 2-week history of progressive lethargy and dyspnoea. She had no past medical history and was on no regular medications. She had suffered from a flu-like illness one month ago for which she did not seek medical attention. Her haemoglobin was found to be low at 65, bilirubin and LDH were elevated. She was thrombocytopaenic with a platelet count of 50.Her creatinine was markedly elevated at 500. Direct coombs testing was negative. Peripheral blood film revealed a high number of fragments. ADAMTS13 activity levels were normal at 100%. What is the most appropriate treatment for this patient’s condition?

a. IV Steroidsb. Plasma exchangec. Dialysisd. Eculizumabe. Rituximab

90.Which of the following regarding superantigens is most correct:

a. Bind to T-cell receptor and MHC II at usual peptide binding siteb. Results in massive production of IL-5c. Activate up to 20% T cellsd. Binds to MHC class I outside the peptide-binding groovee. Most common superantigens are gram negative bacteria

91. In a potential candidate for lung transplantation, infection due to which of the following microorganisms implies the worst prognosis for survival post transplantation:

a. Burkholderia cepacia complexb. Multi-resistant Pseudomonas aeruginosac. Non-tuberculous mycobacteriad. Aspergillus sp.e. Multi-resistant Staphylococcus aureus

92.An 82-year-old man with mild dementia was admitted following a syncopal episode. Two months previously, at the local memory clinic, he had been advised to take calcium and vitamin D, galantamine, simvastatin 20 mg at night, and aspirin. He had no other significant past medical history and had taken no drugs previously. 

The patient, his family and memory clinic staff felt that there had been intellectual and functional improvement since starting the medication. An ECG showed complete atrioventricular block. An ECG recorded before he had started taking medication had been reported as normal. On examination, he was alert, with warm peripheries and a blood pressure of 128/76 mmHg. 

What is the most appropriate long-term treatment strategy? 

a. change galantamine to memantine   b. change galantamine to rivastigmine   c. insert a permanent pacemaker   d. make no changes to current management   e. stop galantamine

93.A 70-year-old woman attended clinic for review with her husband. He reported that she was becoming very forgetful. She had also started to “see things, like the faces of little children who were not there”. She had first presented 1 year previously with features of parkinsonism, which had since responded poorly to levodopa. Her mini-mental state examination score was 20/30. What is the most likely diagnosis? 

a. Alzheimer’s disease   b. corticobasal degeneration  c. dementia with Lewy bodies   d. multiple system atrophy   e. vascular dementia 

94.Which of the following malignancies is most strongly associated with VTE?

a. Pancreatic cancerb. Breast cancerc. Prostate cancerd. Multiple myelomae. Hodgkins lymphoma

95.A 65 year old male in ICU after coronary artery bypass surgery complicated by multi-organ failure including anuric renal failure requiring continuous renal replacement therapy with unfractionated heparin in the circuit. After a week, his platelet count is noted to fall (baseline 300x109/Ldown to 30x109L). He is also noted to have right leg swelling. Duplex ultrasound confirms a venous thrombosis involving the distal femoral vein. His past medical history includes T2DM, IHD, HTN and dyslipidaemia. What is the immediate management?

a. Stop heparin, use enoxaparinb. Stop heparin, use warfarinc. Stop heparin, use danaparoidd. Stop heparin, use rivaroxabane. Stop heparin, arrange IVC filter

96.A 77-year-old man presented after a single episode of unilateral weakness of the left arm that lasted for 2 hours. On examination, his pulse was 80 beats per minute and regular, and his blood pressure was 170/100mmHg. There was no neurological deficit. His ABCD2 score was 6. He was give 300mg of aspirin while awaiting investigations. What is his chance of having stroke in the first week?

a. 5%b. 10%c. 20%d. 30%e. 40%

97.A 43-year-old woman was referred to hospital with a persistent headache of 4 days’ duration. It had come on gradually and had not been associated with vomiting. Her general practitioner had found her blood pressure to be elevated at 214/118 mmHg and had arranged emergency admission. She had no other significant medical history and was not taking any regular medication.

On examination, she appeared well. She had a round face and her body mass index was 32 kg/m2 (18–25). Her pulse was 90 beats per minute and her blood pressure was 218/116 mmHg. Peripheral pulses were normal with no radiofemoral delay. Heart sounds were normal. Fundoscopy showed grade 2 hypertensive changes but no papilloedema. Urinalysis showed blood negative, protein 2+, nitrites negative, leucocytes negative.

Investigations:

What is the most likely diagnosis?

a. Acute glomerulonephritisb. Cerebral tumourc. Cushings syndromed. Essential hypertensione. Phaeochromocytoma

98.A 78-year-old woman, who was bedbound because of end-stage Parkinson’s disease, was troubled by hallucinations. Her medication comprised co-beneldopa 125 mg four times daily and pramipexole 1 mg three times daily. There was no evidence that metabolic disturbance or infection had caused these new symptoms. What is the most appropriate first step in her management? 

a. reduce dose of co-beneldopa   b. reduce dose of pramipexole   c. start lorazepam   d. start quetiapine   e. start rivastigmine 

99.During pregnancy, many cardiovascular conditions are associated with an increased risk of maternal mortality. Which one of the following cardiovascular conditions is associated with the highest rate of maternal mortality?

Moderate to severe:

a. pulmonary hypertensionb. hypertrophic cardiomyopathyc. coarctation of the aortad. aortic regurgitation e. peripartum cardiomyopathy

100. Which of the following statements regarding Positron Emission Tomography Scanning (PET Scan) is false?

a. Not all tumours are avid on PET scanningb. A benign neoplastic lesion (such as a benign polyp) may be avid on

PET scanningc. FDG (flurodeoxyglucose) PET Scans can be affected by glycemic

control and exogenous insulin in Type I and Type II diabeticsd. Prostate Cancer is typically not avid on FDG (flurodeoxyglucose) PET

Scans, but it is possible to radiolabel PSA (prostate specific antigen) and use it as a radionucleotide

e. PET Scans have an advantage of other imaging modalities in that they can detect lesions smaller than 5mm, as long as the lesion in question takes up the injected radionucleotide

END OF PAPER