GP MCQ Paper 3

Created by sue_huxley 

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1. Which of the following thyroid function tests attracts a Medicare rebate as an initial investigation?
a. free T4 (thyroxine)
b. free T3 (tri iodothyronine)
c. TSH (thyroid stimulating hormone)
d. TSH receptor antibodies
e. thyroid tissue antibodies

1. C

2. On average, how quickly do thyroid function tests reflect a new equilibrium in a patient's health status after starting treatment with thyroxine?
a. within 24 hours
b. in one week
c. in two weeks
d. in six weeks
e. in six months

2. D

3. When is it appropriate to measure free T4 and TSH simultaneously,
a. in patients suspected of suffering dementia
b. when the tests are ordered to assist in the management of proven thyroid disease
c. in patients with psychiatric illness
d. in hospital inpatients
e. all of the above

3. E

4. Which of the following statements are true of free T3?
a. may be normal in patients with hypothyroidism
b. it is always high in hyperthyroidism
c. it is low in sick euthyroid syndrome
d. it is low in secondary hypothyroidism
e. all of the above

4. E

5. Which of the following can cause both hypothyroidism and hyperthyroidism?
a. thyroxine
b. the oral contraceptive pill
c. amiodarone
d. digitalis
e. non of the above

5. C

6. Autoimmune antibodies can occur in thyroid disease. In which conditions would a test for antibodies against thyroid peroxidase be useful?
a. thyroglossal cysts
b. thyroid cancer
c. Hashimoto's thyroiditis
d. goitre due to iodine deficiency
e. non of the above

6. C

7. A small amount of thyroglobulin is found in the circulation of normal people. When is it appropriate to measure thyroglobulin in blood?
a. when thyroglobulin is used as a marker for cancer recurrence in people who have had a total thyroidectomy followed by treatment with radioactive iodine for cancer
b. in hyperthyroidism (as a routine measurement)
c. in hypothyroidism (as a routine measurement)
d. to predict whether a baby will be born with hyperthyroidism when the mother has Graves' disease
e. to screen for hypothyroidism in neonates

7. A

8. What food component are people with coeliac disease unable to tolerate?
a. salicylates
b. amines
c. preservatives
d. gluten
e. starch

8. D

9. Which of the following basic foods contain the component that people with coeliac disease are unable to tolerate?
a. oats
b. wheat
c. barley
d. rye
e. all of the above

9. E

10. Diarrhoea is a common complaint in people with coeliac disease. Why does it occur?
a. the villi in the small bowel become atrophied, reducing surface area, leading to malabsorption
b. bile salts are not absorbed from the terminal ileum, which causes an osmotic diarrhoea in the colon
c. the colon is inflamed, leading to bloody diarrhoea
d. pancreatic enzymes are not manufactured in the pancreas, leading to malabsorption
e. the mechanism of the diarrhoea in coeliac disease is unknown

10.A

11. What part of the bowel is typically most affected in coeliac disease?
a. terminal ileum
b. colon
c. duodenum and jejunum
d. ileum and jejunum
e. the small bowel is always uniformly affected from duodenal cap to terminal ileum

11. C

12. Which of the following blood results would be most typical of coeliac disease?
a. normal folate and ferritin, low B12
b. normal folate and ferritin, high B12
c. low folate and B12, high ferritin
d. low ferritin, low folate, normal B12
e. normal ferritin, low B12 and low folate

12. D

13. Which of the following serological tests is the most sensitive and specific for coeliac disease?
a. IgG antigliaden antibody
b. IgA antigliaden antibody
c. IgA and IgG antiglyden antibody, in combination
d. endomysial antibody
e. smooth muscle antibody

13. D

14. Once a person has been shown to have coeliac disease how long should he or she continue on the prescribed diet?
a. 6 months
b. 1 year
c. until adulthood, if the patient is a child
d. until he or she feels better
e. forever

14. E

15. What other diseases are associated with coeliac disease?
a. lymphoma
b. carcinoma of the oesophagus
c. osteoporosis
d. osteomalacia
e. all of the above.

15. E

16. The majority of people who contract HIV have symptoms as a primary event. Which of the following options are true of primary HIV 1 infection?
a. if symptoms occur they occur within a few days of exposure
b. the time between exposure and the onset of symptoms is usually between two and four weeks
c. the acute illness usually lasts one to two days
d. the acute illness usually lasts a couple of months
e. the illness is always very mild and nonspecific

16. B

17. Which of the following symptoms or physical signs occur in more than 50% of cases of primary HIV 1 infection?
a. fever
b. muscle aches and pains
c. lymphadenopathy
d. pharyngitis
e. all of the above

17. E

18. What tests should be performed on a well patient with HIV at the time of the first presentation?
a. hepatitis B and C serology
b. Mantoux test
c. HIV antibodies
d. serological tests for toxoplasmosis, syphilis and cytomegalovirus
e. all of the above

18. E

19. Which of the following is the most useful means of monitoring HIV disease in order to make decisions about the timing of instigation of antiretroviral agents?
a. full blood count
b. HIV antibody titre
c. CD4 and T cell counts
d. total lymphocyte count
e. total white cell count

19. C

20. Which of the following malignancies is not common in people with HIV than in the general population?
a. non Hodgkin's lymphoma
b. carcinoma of the cervix
c. Kaposi's sarcoma
d. squamous carcinoma of the anus
e. hepatoma

20. E

21. Which one of the following options is the most likely explanation for this set of ophthalmic symptoms in an HIV patient: blurred vision, floaters and visual field defects?
a. Kaposi's sarcoma of the retina
b. fungal infection of the eye
c. cytomegalovirus retinopathy
d. glaucoma
e. herpes simplex keratitis.

21. C

22. Lactose intolerance is caused by a deficiency in the enzyme lactase in the small bowel mucosa. Which of the following options are likely to cause abdominal discomfort, flatulence and diarrhoea when consumed by a person with lactase deficiency?
a. a slice of cheddar cheese
b. 50 mL of low fat milk
c. 50 mL of full cream milk
d. 300 mL of low fat milk
e. a tub of yoghurt containing acidophilus

22. D

23. Your patient with coeliac disease has been totally compliant with his gluten free diet but is still suffering signs and symptoms of malabsorption. Which of the following foods can occasionally be responsible for continuing symptoms in coeliac disease?
a. potatoes
b. soy milk
c. yeast
d. malt
e. lecithin

23. B

24. Which of the following conditions has been associated with low folate levels in pregnant women?
a. Down syndrome
b. Turner's syndrome
c. spina bifida
d. cleft palate
e. eclampsia

24. C

25. Which one of the following foods is the best source of folate?
a. red meat
b. dark green leafy vegetables
c. corn
d. cod liver oil
e. cereals

25. B

26. Which of the following drugs can reduce body stores of folate.?
a. alcohol
b. phenytoin
c. salazopyrin
d. methotrexate
e. all of the above

26. E

27. Vitamin B12 deficiency is rarely dietary. Which of the following diets could, however, result in vitamin B12 deficiency?
a. a vegetarian diet that includes cheese and eggs.
b. a strict vegan diet that excludes any animal products
c. a gluten free diet
d. a lactose free diet
e. a diet deficient in fruit and vegetables

27. B

28. Which of the following symptoms and signs are diagnostic criteria for anorexia nervosa?
a. the patient most commonly is an adolescent at the time the illness commences
b. the patient, if female, has amenorrhoea
c. the patient's body mass index is less than or equal to 17.5
d. the patient's body weight is less than 85% of the expected weight
e. all of the above

28. E

29. How is body mass index defined?
a. (weight + height)/age
b. weight x 2/height
c. (weight)² /(height)²
d. weight/(height)²
e. (weight)²/height

29. D

30. What percentage (approximately) of Australian adolescent women have anorexia nervosa or bulimia nervosa?
a. 0.01
b. 0.1%
c. 1
d. 3
e. 10

30. D

31. What percentage of people with anorexia nervosa are male?
a. 0%
b. less than 1%
c. 1%
d. between 5 and 15%
e. more than 20%

31. D

32. When young patients initially present with marked weight loss they are often investigated for other illnesses, such as thyroid disease. Which abnormal thyroid function tests are consistent with a diagnosis of anorexia nervosa?
a. high T4, high T3 and low TSH
b. high T4, high T3 and high TSH
c. low T3, low T4 and normal or low TSH
d. low T3, low T4 and high TSH
e. none thyroid function tests are always normal in anorexia nervosa

32. C

33. Treatment of eating disorders is difficult, and about 20% of patients have lifelong difficulties with food. Treatment of the psychiatric component of the illness is usually based on a cognitive behavioural therapy approach. One of the following medications has been shown to be useful in the treatment of anorexia nervosa and bulimia. Which is it?
a. cisapride
b. motilium
c. prednisone
d. fluoxetine
e. ritalin.

33. D

34. A mother brings along her one year old boy who has a life long history of severe constipation. His motions, when passed, are thin and very hard. On examination, his abdomen is distended with faeces. Gentle inspection of the boy's rectum shows no abnormality. A barium enema arranged by the paediatrician shows a smooth 3 cm stricture in the rectum. What is the most likely diagnosis?
a. carcinoma of the colon
b. an ischaemic stricture
c. Hirschsprung's disease
d. anal stenosis
e. megarectum

34. C

35. A five year old boy presents with a history of daily stool soiling, associated with passage of hard, pellet like motions. His mother reports that he never passes a large motion, and never eats fruit or vegetables. On examination, there is distend sion of the boy's lower abdomen due to stool. On inspection, the rectum appears to gape and hard stool is visible. What is the most likely diagnosis?
a. Hirschsprung's disease
b. encopresis due to faecal impaction and overflow
c. sexual abuse
d. Crohn's disease
e. irritable bowel syndrome

35. B

36. How should this child be treated?
a. anal dilation is required
b. he should be treated with Lomotil to avoid soiling
c. he should be given a stool softener; he may also require a suppository to help keep the rectum empty, and should be `rewarded' for producing normal stools
d. a lateral sphincterotomy is required
e. psychotherapy is required for the whole family

36. C

37. A 65 year old woman presents with a history of gradually increasing constipation over the last year. She is uncomfortable in the abdomen and finds it hard to pass a motion. She has put on 5 kg, feels tired and has noticed some hair loss. A barium enema is normal. A test for an endocrine disease associated with constipation is abnormal. What is the most likely explanation for her symptoms?
a. Cushing's syndrome
b. hypothyroidism
c. hypoparathyroidism
d. Addison's disease
e. a prolactinoma

37. B

38. A number of different classes of laxatives are useful in the treatment of uncomplicated constipation. Which of the following are osmotic laxatives?
a. sorbitol
b. coloxyl
c. ford pills
d. psyllium
e. senna

38. A

39. Which of the following people should have a serum lipid estimation?
a. a man who presents with an episode of angina
b. a premenopausal woman who presents triglycerides? with angina
c. a postmenopausal woman who presents with angina
d. a 22 year old man with a family history of coronary heart disease in three first degree relatives under 40 years of age.
e. all of the above

39. E

40. It is common to see a variation in cho¬lesterol levels in one person over time, regard¬less of whether they alter their diet or level of exercise. What is the reason for this?
a. the usual reason is lack of standardisa¬tion in laboratory technique
b. the variation is due to the normal physiological variations in the serum cholesterol within an individual
c. in women the usual reason is the marked effect on lipids of the menstrual cycle
d. there is a very marked diurnal effect on lipids measurement should be at the same time every day
e. any variation in serum cholesterol and serum triglycerides is due to the saturated fat content of the last meal that has been consumed

40. B

41. There are a number of metabolic disorders that affect serum lipids. Which of the following elevate cholesterol to a greater degree than triglycerides?
a. pregnancy
b. hypothyroidism
c. nephrotic syndrome
d. cholestatic liver disease
e. all of the above

41. E

42. Your patient is a 55 year old man with a strong family history of heart disease in first degree relatives under the age of 60. He has mild hypertension, smokes and is mildly obese. His serum cholesterol is 6.2 mmol/L and his triglycerides are normal. His HDL cholesterol is less than 1.0 mmol/L and LDL cholesterol is more than 4.0 mmol/L. What is the appropriate management?
a. although a serum cholesterol of 6.2 mmol/L is elevated, the elevation is mild and it is not appropriate to treat him. Repeat the test in 12 months
b. this man has a number of risk factors, an elevated cholesterol, a low HDL choles¬terol and a high LDL cholesterol. He should be treated with a fibrate if a dietary trial is unsuccessful
c. this man has a number of risk factors, an elevated cholesterol, a low HDL cholesterol and a high LDL cholesterol. He should be treated with a statin if a dietary trial is unsuc¬cessful
d. he should try to modify his diet over the next 12 months and then have another serum lipid estimation
e. he should give up alcohol, which is likely to be the cause of this pattern of abnormality

42. C

43. You have a patient, 50 years of age, going through the menopause, who requests a general check up. Physical examination is normal except for a blood pressure of 145/90 mmHg. Her sister died of a myocar¬dial infarction at 60 years of age. Her fasting lipids are serum cholesterol 5 mmol/L ,serum triglycerides 4 mmol/L, HDL cholesterol is less than 1 mmol/L. She is not obese, her blood sugar is normal and she drinks no alcohol. What do you advise?
a. serum cholesterol is normal so no therapy is required
b. serum triglyceride is elevated and HDL cholesterol is reduced. If dietary modification is unsuccessful she should be treated with a statin
c. serum triglyceride is elevated and HDL cholesterol is reduced. If dietary modification is unsuccessful she should be treated with a fibrate or nicotinic acid
d. as this patient is female, no therapy is required because of the low risk of coronary artery disease
e. the lipid profile should be rechecked in one year.

43. C

44. Breast cancer usually, but not always, presents with a painless palpable lump. Which of the following can also indicate breast cancer?
a. nipple retraction
b. discharge from the nipple
c. a change in breast shape
d. pain without a palpable lump
e. all of the above

44. E

45. What is the triple test used in the assessment of breast lumps?
a. breast ultrasound, mammogra¬phy and fine needle aspiration biopsy
b. mammography, fine needle aspiration biopsy and plain x ray of the breast looking for calcification
c. clinical examination, mammo¬graphy and fine needle aspiration biopsy
d. clinical examination, mammo¬graphy and lumpectomy
e. clinical examination, mammography and wedge resection of the breast

45. C

46. Which of the following are true of the use of ultrasound in the diagnosis of breast lumps?
a. ultrasound is most useful in postmenopausal women
b. ultrasound is not useful in young premenopausal women
c. it is always a second line inves¬tigation to be used, if necessary, after mammography
d. it is the preferred first line imag¬ing technique for women under 35
e. it is only valuable in the assess¬ment of palpable lesions

46. D

47. What is the likelihood that at least one element of the triple test will indicate cancer in a woman with breast cancer?
a. 75%
b. 80%
c. 90%
d. 95%
e. over 99%

47. E

48. What is the most useful means of investigating a breast lump in a woman who is breastfeeding?
a. immediate ultrasound
b. immediate mammography
c. MRI
d. mammography after the baby is weaned
e. breast ultrasound after the baby is weaned

48. A

49. What is the best initial investi¬gation in a postmenopausal woman with a breast lump?
a. ultrasound
b. mammography
c. MRI
d. fine needle aspiration biopsy
e. thermography

49. B

50. In Australia, breast cancer accounts for 4% of all female deaths. The cumulative incidence is 1:13 women. Which of the following are risk factors for breast cancer?
a. a history of breast cancer in two first degree relatives
b. having no children
c. menopause after age 55
d. pregnancy after age 30
e. all of the above.

50. E

51. A 70 year old man presets to you with the complaint of pain and stiffness in his hips and shoulders over the last few weeks. He feels tired and unwell and has a low grade headache. On examination, his muscles are tender deep palpation around the shoulders and thighs. Examination of the left temple reveals a prominent artery and it is tender
What is the most likely cause of this man's muscle pain?
a. rheumatoid arthritis
b. osteoarthritis
c. cervical spondylitis
d. polymyalgia rheumatica
e. scleroderma

51. D

52. A 70 year old man presets to you with the complaint of pain and stiffness in his hips and shoulders over the last few weeks. He feels tired and unwell and has a low grade headache. On examination, his muscles are tender deep palpation around the shoulders and thighs. Examination of the left temple reveals a prominent artery and it is tender
Which one of the following investigations is most likely to help confirm your diagnosis?
a. x ray of the cervical spine drugs
b. electromyogram (EMG)
c. measurement of erythrocytv sedimentation rate (ESR)
d. full blood count
e. measurement of rheumatoid

52. C

53. A 70 year old man presets to you with the complaint of pain and stiffness in his hips and shoulders over the last few weeks. He feels tired and unwell and has a low grade headache. On examination, his muscles are tender deep palpation around the shoulders and thighs. Examination of the left temple reveals a prominent artery and it is tender
What specific syndrome does the examination of the man's temple suggest?
a. cerebral atherosclerosis
b. giant cell arteritis
c. polyarteritis nodosa
d. Takayasu's arteritis
e. tertiary syphilis

53. B

54. A 70 year old man presets to you with the complaint of pain and stiffness in his hips and shoulders over the last few weeks. He feels tired and unwell and has a low grade headache. On examination, his muscles are tender deep palpation around the shoulders and thighs. Examination of the left temple reveals a prominent artery and it is tender
What symptoms are consistent with this vascular abnormality?
a.. sudden loss of vision in one eye
b. claudication of the jaw on talk¬ing or chewing
c. transient ischaemic attacks
d. headache
e. all of the above

54. E

55. A 70 year old man presets to you with the complaint of pain and stiffness in his hips and shoulders over the last few weeks. He feels tired and unwell and has a low grade headache. On examination, his muscles are tender deep palpation around the shoulders and thighs. Examination of the left temple reveals a prominent artery and it is tender
What treatment would you commence this man on?
a. nonsteroidal anti inflammatory drugs
b. prednisolone (Panafcortelone, Solone) 10 mg/day
c. prednisolone 40 to 60 mg/day
d. cyclophosphamide (Cycloblastin, Endoxan Asta)
e. high dose aspirin

55. C

56. A 70 year old man presets to you with the complaint of pain and stiffness in his hips and shoulders over the last few weeks. He feels tired and unwell and has a low grade headache. On examination, his muscles are tender deep palpation around the shoulders and thighs. Examination of the left temple reveals a prominent artery and it is tender
A biopsy of the temporal artery performed after commencing treat¬ment confirms your diagnosis. How long should you continue therapy?
a. until the temporal artery has a normal appearance and feels normal to palpation
b. one month
c. six months
d. until blood tests have returned to normal
e. at least two years.

56. E

57. Approximately what percentage of cases of infertility are wholly or partially caused by abnormalities of the male partner's reproductive system?
a. 1
b. 5%
c. 10%
d. 33%
e. 50%

57. E

58. What is the frequency of infertility (absolute and relative) in the male population?
a. lin10
b. 1 in 25
c. 1 in 100
d. 1 in 1,000
e. 1 in 5,000

58. B

59. There are a number of possible causes of male infertility. The most common chromosomal abnormality is Klinefelter's syndrome. What is the karyotype in Klinefelter's syndrome?
a. 47 XXY
b. 47 XYY
b. 46 XX
d. 45 X
e. 47 YYY

59. A

60. Which of the following is a com¬mon clinical characteristic of Kline¬felter's syndrome?
a. short stature
b. gynaecomastia
c. large testicles
d. large hands
e. high, arched palate

60. B

61. What is the normal sperm count for a healthy male?
a. > 2 million/mL
b. > 10 million/mL
c. > 20 million/mL
d. > 100 million/mL
e. > 250 million/mL

61. C

62. What is the equation used to cal¬culate body mass index (BMI)?
a. weight (in kilograms) divided by the square of the height (in metres)
b. weight (in kilograms) divided by the height (in metres)
c. weight (in pounds) divided by the height (in inches)
d. weight (in pounds) divided by the square of the height (in inches)
e. weight (in grams) divided by the square of the height (in centimetres)

62. A

63. Which of the following is associated with a three to four fold increase in the risk of diabetes mellitus, stroke and ischaemic heart disease in men?
a. BMI greater than 10
b. BMI greater than 12
c. BMI greater than 20
d. BMI greater than 25
e. BMI greater than 28

63. E

64 . Which of the following patterns of distribution of body fat is associated with a higher risk of morbidity in over¬weight people?
a. a central distribution of fat, where the ratio of waist:hip circumference is >0.9 in women or >1.0 in men
b. a peripheral distribution of fat (arms and legs)
c. the absolute weight is the only important factor, the distribution is unimportant
d. weight distribution is only of importance in men, in whom a central distribution is associated with greater morbidity
e. weight distribution is only of importance in women, in whom a cen¬tral distribution is associated with greater morbidity

64. A

65. Which of the following medical conditions are associated with obesity?
a. hypothyroidism
b. polycystic ovary syndrome
c. Cushing's syndrome
d. hypothalamic injury.
e. all of the above

65. E

66. A young male patient presents with a stiff, painful back and evidence of some limitation of movement. After examining the patient, you suspect ankylosing spondylitis. Which one of the following is the most appropriate investigation?
a. HLA-B27 blood test
b. MRI of the spine
c. radionuclide bone scan
d. x ray of the lumbar spine including the sacroiliac joints
e. CT scan of the lumbar region

66. D

67. Which of the following are useful in alleviating the back pain of ankylosing spondylitis?
a. regular swimming
b. attention to posture
c. sleeping on a firm mattress
d. exercises to strengthen the back
e all of the above

67. E

68. Which one of the following is another of the so called seronegative forms of arthritis associated with HLA B27?
a. scleroderma
b. systemic lupus erythematosus
c. Sjiigren's syndrome
d. mixed connective tissue disease
e. psoriatic arthritis

68. E

69.The diagnosis of pulmonary embolus would be straightforward if all affected patients presented with short¬ness of breath, haemoptysis and pleuritic pain accompanied by a pleural rub. What are some of the less obvious signs or symptoms of pulmonary embolus?
a. tachycardia
b. tachypnoea
c. sweating
d. agitation
e. all of the above

69. E

70. Physical examination can be quite normal in a person with a pulmonary embolus. Which of the following would be your first line investigation if you had a high index of suspicion?
a. pulmonary angiogram
b. chest x ray
c. nuclear medicine ventilation perfusion lung scan and a recent chest x ray
d. respiratory function tests
e. blood gases

70. C

71. An ECG is an appropriate investigation in pulmonary embolus, although it is frequently normal or has very minor changes. Which of the following ECG abnormalities is regarded as the classic pattern for pulmonary embolus?
a. left bundle branch block
b. left axis deviation
c. S1, Q3, T3 pattern
d. S3, Ql, T1 pattern
e. bradycardia

71. C

72. Which of the following abnormalities on a chest x ray may be due to a pulmonary embolus?
a. no abnormality
b. atelectasis
c. a pleural effusion
d. an area of consolidation
e. all of the above

72. E

73. Radionuclide lung scans are the most useful test for the diagnosis of pulmonary embolus. What pattern of abnormality on the lung scan is indicative of a pulmonary embolus?
a. an area where there is no perfusion and no ventilation
b. an area that is being perfused but not ventilated
c. an area that is being ventilated but not perfused
d. an abnormal area that is normal on a chest x ray, regardless of whether the abnormality is of ventilation or perfusion
e. an area with no ventilation or perfusion abnormality

73. C

74. Immobility is the most commonly recognised risk factor for pulmonary embolus but there are a number of other important settings. Which of the following increase risk of pulmonary embolus?
a. pregnancy
b. postpartum period
c. oral contraceptive pill
d. varicose veins
e. all of the above

74. E

75. A 50 year old woman asks your advice about colonoscopy. Her 60 year old sister has just been diagnosed with bowel cancer. Her mother died of bowel cancer in her seventies. There is no other family history of malignancy. What would you advise her about her risk of bowel cancer?
a. there is no significant increase in risk
b. she should have faecal occult blood testing as her risk is increased
c. she should have a colonoscopy as her risk is increased
d. she should have a barium enema as her risk is increased
e. although her risk of bowel cancer is approximately doubled, the chance is still only 1 in 50, so screening is not appropriate

75. C

76. A 25 year old woman presents to you with symptoms of irritable bowel syndrome. She has occasionally seen blood on the toilet paper, in association with straining on defaecation. Her mother and her aunt both had bowel cancer diagnosed in their mid thirties. Her mother has also had a carcinoma of the endometrium. Her maternal grandmother developed breast cancer at 40. What would you do?
a. her chance of having bowel cancer at age 25 is for all practical purposes nil it is appropriate to treat her with fibre and antispasmodic medication
b. she has an increased risk of developing bowel cancer, but not until she reaches the age at which her mother and aunt were diagnosed, so she does not require any work up at this stage
c. there is no association between the three different types of malignancy in her family; only the family history of bowel cancer is important here, and a colonoscopy should be performed
d. she appears to belong to a hereditary nonpolyposis colon cancer (HNPCC) family; the three different malignancies are associated and her risk of colon cancer is greatly increased, so she should have a colonoscopy
e. she should have a set of faecal occult blood tests

76. D

77. A 50 year old man asks your advice about his risk of colon cancer. His uncle and grandfather both developed colon cancer in their seventies. What is his approximate risk?
a. 1 in 50
b. 1 in 25
c. 1 in 18
d. l in10
e. 1 in 8

77. C

78. What percentage of women who develop breast cancer have a family history?
a. 95%
b. 80%
c. 50%
d. 25%
e. 5%

78. E

79. It is estimated that 5% of women with breast cancer have a mutation in the BRCA1 gene. What is the lifetime risk of breast cancer in a woman with this mutation?
a. 100%
b. 85%
b. 50%
c. 33%
e. 25%

79. B

80. In which of the following cancers may a family history in a first degree relative potentially increase the lifetime risk in an individual?
a. melanoma
b. prostate cancer
c. non Hodgkin's lymphoma
d. lung cancer
e. all of the above

80. E

81. Thiazide diuretics have been a treatment for hypertension for many years. What metabolic side effects can they have?
a. hyperuricaemia
b. elevation of triglycerides
c. elevation of cholesterol
d. elevation of serum glucose
e. hypoglycaemia

81. E

82. Thiazide diuretics have been shown to:
a. reduce the risk of hypertensive people suffering a stroke
b. reduce the risk of hypertensive people suffering a myocardial infarction
c. increase the risk of hyperkalaemia
d. increase the risk of hyponatraemia
e. all of the above

82. E

83. Beta blockers are associated with which of the following side effects?
a. lassitude
b. bronchospasm
c. worsening of intermittent claudication
d. increase in serum triglycerides
e. all of the above

83. E

84. Which one of the following anti-hypertensive medications would you consider the most appropriate first line medication for a 65 year old woman with type 2 diabetes mellitus and blood pressure readings of 150/95 mmHg on three occasions? On examination there is no evidence of heart failure.
a. thiazide diuretic
b. beta blocker
c. angiotensin converting enzyme inhibitor (ACE inhibitor)
d. her blood pressure does not require treatment
e. prazosin

84. C

85. The angiotensin II receptor antagonists include irbesartan and losartan. Which of the following options is true of this class of medication?
a. angiotensin II receptor antagonists work only in people with an elevated serum renin
b. hypokalaemia can occur
c. hyperkalaemia can occur
d. a chronic nonproductive cough is a common side effect
e. angiotensin II receptor antagonists are markedly superior to ACE inhibitors in the control of hypertension

85. C

86. Calcium channel blockers are contraindicated in which of the following groups of patients?
a. hypertensive patients with diabetes mellitus
b. hypertensive patients with ischaemic heart disease
c. hypertensive patients with congestive heart failure
d. hypertensive patients who have peripheral vascular disease
e. none of the above

86. C

87. You have a 40 year old, moderately obese male patient who smokes and has a family history of ischaemic heart disease. His serum cholesterol and triglycerides are elevated and have not responded to dietary modification. His salt and alcohol intake are not excessive. You have seen him on three occasions and his blood pressure has been the same each time you've checked it. Which is the lowest blood pressure of those listed that would make you instigate treatment with an antihypertensive agent?
a. 160/100 mmHg
b. 155/100 mmHg
c. 150/98 mmHg
d. 140/95 mmHg
e. 125/85 mmHg.

87. D

88. A 35 year old man presents with sudden onset of severe right sided abdominal pain radiating into the right testicle. He says this is the worst pain he has ever experienced. He has been well in the past. You suspect renal colic. Which one of the following is most likely to help confirm your diagnosis at initial presentation?
a. physical examination if the patient has rebound tenderness he has renal colic
b. plain abdominal x ray a negative x ray excludes the diagnosis
c. urinalysis microscopic or macroscopic haematuria will be present
d. physical examination - the abdomen will be rigid over the part of the renal tract through which the stone is passing
e. straining of a spot specimen of urine for gravel, which is always present in renal colic

88. C

89. A 35 year old man presents with sudden onset of severe right sided abdominal pain radiating into the right testicle. He says this is the worst pain he has ever experienced. He has been well in the past. You suspect renal colic. You are still convinced your diagnosis is correct. Which one of the following investigations is the most sensitive and specific for renal tract stones?
a. nuclear medicine renal scan
b. micturating cystourethrogram
c. helical CT scan
d. urinary tract ultrasound
e. straining of a 24 hour urine specimen for gravel

89. C

90. A 35 year old man presents with sudden onset of severe right sided abdominal pain radiating into the right testicle. He says this is the worst pain he has ever experienced. He has been well in the past. You suspect renal colic. Further investigation confirms the presence of a 6 mm stone in the right ureter. What is this stone most likely to consist of?
a. calcium oxalate
b. uric acid
c. struvite
d. cystine
e. xanthine

90. B

91. Which of the following are risk factors for the development of this type of kidney stone?
a. alkaline urine
b. acid urine
c. hypercalcaemia
d. hypercalcuria
e. urinary tract infection

91. B

92. Calcium stones are the most common type of renal stone. Which of the following are helpful in preventing further calcium stone formation?
a. thiazide diuretics
b. limiting salt intake to less than 100 mmol per day
c. drinking sufficient water to pass 2 to 3 L of urine per day
d. limiting protein intake to 1 g/kg of body weight per day.
e. all of the above

92. E

93. A 25 year old man presents with a painful right knee and left ankle. He has a bilateral conjunctivitis and had a recent episode of dysuria with urethral discharge. What is the most likely diagnosis?
a. gonococcal arthritis
b. HIV related arthritis
c. rheumatoid arthritis
d. Reiter's syndrome
e. systemic lupus erythematosus (SLE)

93. D

94. A 30 year old man consults you with a story of increasing back pain over the last few years. The pain is felt in his lower back and can radiate down into both buttocks. He has also suffered attacks of pain in the right knee on occasion. On examination, the mobility of his back is reduced and he is tender over the sacroiliac joints. Which one of the following options is most likely?
a. rheumatoid arthritis
b. SLE
c. osteoarthritis
d. ankylosing spondylitis
e. Scheuermarm's disease

94. D

95. Which one of the following tests is most likely to help you confirm your diagnosis?
a. HLA 1327 it is positive in 99% of people who have the condition you have provisionally diagnosed
b. rheumatoid factor it is positive in 99% of the people who have the condi¬tion you have provisionally diagnosed
c. positive antinuclear antibody it is positive in 99% of the people who have the condition you have provision¬ally diagnosed
d. x ray of the back, showing widen¬ing of the sacroiliac joint and sclerosis of the joint margin
e. a mildly elevated ESR

95. D

96. Which of the following patterns of arthritis can be seen in association with psoriasis?
a. the arthritis can resemble rheumatoid arthritis, with symmetrical joint involvement in the hands
b. an arthritis mutilans affecting the hands, resulting in progressive destruction of joints
c. sacroiliitis
d. an asymmetrical arthritis affecting various joints in the hand, resulting in sausage shaped digits
e. all of the above

96. E

97. A 65 year old woman presents to you for the first time. She has mild osteoarthritis and a history of NSAID¬related gastric ulceration. At present she has symptoms consistent with a urinary tract infection. Her blood pressure is 120/95 mmHg and she has a systolic murmur, best heard in the aortic area, with radiation to the carotid arteries and into the apex of the heart. Her lung fields are clear and there is no evidence of congestive cardiac failure. There is no relevant history. Which one of the following is most consistent with these findings?
a. mitral incompetence
b. aortic stenosis
c. pulmonary stenosis
d. aortic incompetence
e. mitral valve prolapsed

97. B

98. A 65 year old woman presents to you for the first time. She has mild osteoarthritis and a history of NSAID-related gastric ulceration. At present she has symptoms consistent with a urinary tract infection. Her blood pressure is 120/95 mmHg and she has a systolic murmur, best heard in the aortic area, with radiation to the carotid arteries and into the apex of the heart. Her lung fields are clear and there is no evidence of congestive cardiac failure. There is no relevant history.Which one of the following is the most appropriate way of investigating this heart murmur?
a. chest x ray
b. coronary angiogram
c. echocardiogram
d. thallium scan
e. gated blood pool scan

98. C

99. A 65 year old woman presents to you for the first time. She has mild osteoarthritis and a history of NSAID-related gastric ulceration. At present she has symptoms consistent with a urinary tract infection. Her blood pressure is 120/95 mmHg and she has a systolic murmur, best heard in the aortic area, with radiation to the carotid arteries and into the apex of the heart. Her lung fields are clear and there is no evidence of congestive cardiac failure. There is no relevant history.What triad of symptoms is regarded as classical for this lesion?
a. atypical chest pain, orthopnoea and palpitations
b. orthopnoea, haemoptysis and hoarseness
c. angina, congestive cardiac failure and palpitations
d. angina, congestive cardiac failure and syncope
e. angina, orthopnoea and haemoptysis

99. D

100. A 65 year old woman presents to you for the first time. She has mild osteoarthritis and a history of NSAID¬related gastric ulceration. At present she has symptoms consistent with a urinary tract infection. Her blood pressure is 120/95 mmHg and she has a systolic murmur, best heard in the aortic area, with radiation to the carotid arteries and into the apex of the heart. Her lung fields are clear and there is no evidence of congestive cardiac failure. There is no relevant history. One year later your patient presents with chest pain consistent with angina. The investigation you performed 12 months ago confirmed your clinical impression. What should you do now?
a. arrange an exercise stress test as soon as possible
b. arrange an exercise thallium scan as soon as possible
c. arrange a gated blood pool scan to measure the ejection fraction from the left ventricle
d. consider the possibility that she will require a valve replacement in the near future and refer her for further investigation
e. provide her with a prescription for glyceryl trinitrate and see what happens over the next six months

100. D

101. The same patient is in atrial fibrillation. Auscultation of the heart is difficult and no definite heart murmurs are heard. Which one of the following is most likely to be present?
a. aortic stenosis
b. aortic incompetence
c. mitral stenosis
d. tricuspid stenosis
e. mural incompetence

101. C

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